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have a similar situation of a very long and widely open defect
of the heart, use a 2.0 stitch on a colt needle and rapidly
apply gure-of-eight sutures closing en masse from one side
to the other. The size of the needle is a great advantage for
stitching rapidly. On the other hand, you must keep in mind
that colt needles are usually cutting needles. Therefore, when
you insert the needle inside the myocardium, make sure that
it is in phase with the diastole, otherwise, if the tip is caught
inside the myocardium at the time of contraction, the myocardium will be “slashed”.
If the injury is near the coronary arteries, repair the defect
by inserting horizontal mattress sutures that pass beneath the
coronaries and around the injury, thereby controlling the
hemorrhage but not occluding the artery. It is convenient, but
not necessary, to use a double-arm suture (Fig. 42.7). In
practice there are cases, where the bleeding is so extensive
that it is difcult to apply these “fancy” sutures. Insert the
standard gure-of-eight sutures, making rather “loose” knots
just to approximate the wound edges and control most of the
bleeding. Next, you insert the recommended mattress sutures
under the coronaries, tie them up, and then remove the gureof- eight sutures. We have done this maneuver many times
without having any problems with the coronaries. This may
be so because our initial approximation is loose and at the
same time, our penetrating cardiac trauma patients are young
with “soft” coronaries, that can take a short interval of compression without being damaged.
Do not use skin staplers for denitive repair of the myocardium. First of all, it is impossible to use them in lacerations, where the gaping wound edges are not very close. Use
skin staplers as a temporary measure to control the bleeding
from “tiny defects” and then insert appropriate sutures at
your leisure.
Repair small needle puncture wounds of the coronary
arteries with a 6.0 or 7.0 polypropylene suture. Ligate distal
injuries. Proximal injuries to the coronary arteries may
devascularize signicantly large areas of the myocardium,
and you should contact the cardiothoracic surgeons for the
emergency aortocoronary bypass as soon as you control the
hemorrhage. This bypass should ideally be performed not
longer than 2–3h after the time of injury.
If you encounter injury to the atria, apply a small Satinsky
to control the bleeding and repair the defect with a continuous 5.0 Prolene suture (Fig.42.8). If needed, buttress your
sutures with small pieces of pericardium. During the repair,
your assistant should religiously control the Satinsky. You
should make sure that he does not apply any traction on the
wall of the atrium in his effort to facilitate your suturing, as
well as make sure that at no time, he lets the clamp fall free.
Both of the above can rip off the atrium and convert a repairable injury into a non-repairable one.
42.7.3 Closure
We feel that it is important to close the pericardium, as nonclosure or partial closure can lead to herniation of the heart
or technical problems during future sternotomies. Close the
pericardium with a running absorbable suture. Be particularly meticulous its proximal part as small gaps left behind
by inserting your stitches in big steps can lead to herniation
of the auricles. Leave a 2-cm gap at the distal (caudal) part of
Fig. 42.7 Horizontal
mattress sutures are inserted
to avoid the inclusion of the
coronaries
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Fig. 42.8 Suture of the cardiac atrium with Lahey in place
your closure. Insert a tube drain with its tip right at the front
of the gap. This will hopefully act as a safety valve and will
prevent the formation of a tension hemopericardium in case
of postoperative bleeding from the heart.
Sometimes it is not possible to close the pericardium
because of overdistension of the heart. This is usually related
to overtransfusion of uids. Ask your anesthetist to administer furosemide to your patient and attempt to close the pericardium after 20 min. In very rare cases, the pericardium
cannot be closed because of primary swelling of the cardiac
muscle, a situation that cannot really be dealt with acutely,
and in this case, you have to leave it open. Remember that
patients who were operated on for penetrating trauma to the
heart can be readmitted in the future with the same type of
injury. If you nd yourself in such a situation, be extremely
careful on opening the sternum, as in case the pericardium
was not closed during the initial operation, the anterior
aspect of the heart can be “stuck” to the back of the sternum
and can be inadvertently damaged.
On closing the sternotomy, if you are not experienced
with the procedure, you will see that getting the needle and
the wire through the sternum may be quite taxing. Insertion
of the needle can be facilitated by applying the needle holder,
not in the recommended junction of the middle and distal
third of the needle, but rather at the junction of the proximal
and middle third and advancing in a vertical direction rather
than the usual rotational movement. As pressure is applied
with the needle on the sternum, it is not uncommon for the
sternum to give way and the needle to go through suddenly,
damaging underlying structures. Use a soup spoon with the
concavity facing upward, applied under the sternum at the
expected point of penetration. This will safeguard against
inadvertent injury of mediastinal structures. Control the
bleeding from the edges of the divided sternum by applying
E. Degiannis et al.
bone wax or electrocautery. Make sure that you apply only as
much wax as necessary, as the excess application is related to
an increased risk of infection of the sternum. Approximate
the edges of the divided sternum well, as good approximation is also of paramount importance to avoid sternal infection. If you cannot insert your stitches through the sternum,
you can always “wrap” them around both halves of the sternum. If there is difculty in approximating the two halves of
the sternum, ask an assistant or the anesthetist to place both
his/her hands behind the patient’s scapulae facing upward.
Then apply force upward and medially, approximating the
two sternal edges and giving you the opportunity to tie your
sutures under less tension. If irrespective of your efforts you
cannot close the sternum, take a large abdominal swab, cover
it with an adhesive sterile surgical drape (e.g., Steri-Drape®,
and Opsite®), and insert it in the area of the gaping sternum.
Apply another adhesive sterile surgical drape on the anterior
chest wall and refer the patient for closure of the sternum to
a more experienced colleague or another hospital when the
patient is physiologically stable.
Use a subxiphoid pericardial window in cases where
you cannot exclude pericardial blood collection clinically
or via investigations. On performing the pericardial window, start with a 5-cm incision from the xiphisternum distally and open the linea alba. Restrain yourself from
opening the peritoneum. The plane to work is that of the
preperitoneal fat. Insert your scissors cephalad in the preperitoneal fat space under the xiphisternum in a horizontal
plane and open its limbs. You will then see the pericardium
right in front of you. Raise the pericardium with two
Burkett’s and divide it in between. If there is any blood,
aspirate it and proceed with a sternotomy. Recently, a few
publications are suggesting that in the case of delayed presentation, simple insertion of a pencil drain is sufcient if
there is no bleeding after the aspiration. The pencil drain is
removed in 48h. If bleeding recurs during this period, they
recommend proceeding with the sternotomy. We are cautious with this practice as we cannot exclude secondary
hemorrhage after the 48h period, as well as the development of constrictive pericarditis. In case the patient undergoes a laparotomy and haemopericardium has to be
excluded, the pericardial sac can be approached via an
incision of the central tendon of the diaphragm on which
the heart normally “sits”.
Before discharging your patient, make sure that there is
no injury to the cardiac septa or the valves. Daily auscultate
your patient’s precordium for murmurs, and even if they are
absent, do a cardiac echo before discharge.
Important Points
• In the physiologically grossly unstable patient, proceed
with left anterolateral thoracotomy.
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365
• The best access to the heart is via a median sternotomy, but
is more time-consuming than an anterolateral thoracotomy.
• Always consider the possibility of a second posterior
wound.
• On inspecting the posterior aspect, replace the heart in the
pericardial sac as soon as it develops bradycardia.
• Check if the coronaries are included in your stitches.
Suggested Reading
Degiannis E, Smith MD.Pot pouri of heuristics in penetrating trauma to
the chest. ANZ J Surg. 2008;78(12):1103–5.
Degiannis E, Zinn RJ. Pitfalls in penetrating thoracic trauma (les-
sons we learned the hard way…). Ulus Travma Acil Cerrahi Derg.
2008;14(4):261–7.
Degiannis E, Bowley DM, Westaby S.Penetrating cardiac injury. Ann
R Coll Surg Engl. 2005;87(1):61–3.
Degiannis E, Loogna P, Doll D, Bonanno F, Bowley DM, Smith
MD.Penetrating cardiac injuries: recent experience in South Africa.
World J Surg. 2006;30(7):1258–64.
Navsaria PH, Nicol AJ. Haemopericardium in stable patients after
penetrating injury: is subxiphoid pericardial window and drainage
enough? A prospective study. Injury. 2005;36:745–50.
Saadia R, Levy RD, Degiannis E, Velmahos GC. Penetrating cardiac
injuries: clinical classication and management strategy. Br J Surg.
1994;81(11):1572–5.
Vassiliu P, Yilmaz T, Degiannis E.On the ideal emergency thoracotomy
incision. World J Surg. 2014;38(4):1001–2.
Velmahos GC, Degiannis E, Souter I, Saadia R.Penetrating trauma to
the heart: a relatively innocent injury. Surgery. 1994;115(6):694–7.
Velmahos GC, Degiannis E, Souter I, Allwood AC, Saadia R.Outcome
of a strict policy on emergency department thoracotomies. Arch
Surg. 1995;130(7):774–7.
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ElminSteyn
43
43.1 Pathophysiology
The overall incidence of diaphragmatic perforations from
penetrating thoracoabdominal injuries (as reported by
Murray et al.) is 42% (59% for gunshot wounds, 32% for
stab wounds). Although diaphragmatic injuries are commonly associated with penetrating truncal injuries, they are
notoriously difcult to diagnose and frequently missed,
especially in patients presenting with a seemingly simple
hemopneumothorax. The height of the diaphragm varies
with breathing, the highest point extending to the level of the
fth intercostal space during maximum expiration, which is
why both anterior and posterior chest wounds may cause diaphragmatic (and abdominal) injuries. Missed injuries, however small, have a risk of late herniation, often presenting
after many years with incarcerated or strangulated intestines
in the chest. This tendency of abdominal viscera to herniate
through a small defect in the chest cavity is due to the constant movement of the diaphragm (which is said to be the
reason for not healing) and the intermittent negative pressure
in the chest compared to the constant positive pressure of the
abdominal cavity. Right-sided penetrating injuries are usually associated with liver injuries, which are more likely to
be treated with a non-operative approach. As the liver acts as
a barrier preventing intestinal loops from herniating through,
right-sided diaphragmatic lacerations, if small, rarely require
repair.
After recovery from the index injury, the patient with an
undiagnosed diaphragmatic defect may be asymptomatic for
many years, while gradual herniation of abdominal contents
into the chest cavity takes place. Late presentation is typically with obstruction of the incarcerated intestine, complicated by strangulation, gangrene, and possibly intra-thoracic
perforation of the stomach, small bowel, or colon. Herniation
may be massive, leading to lung compression, cardiac tam-
E. Steyn (*)
Department of Surgery, Faculty of Medicine and Health Sciences,
University of Stellenbosch, Cape Town, South Africa
e-mail: esteyn@mweb.co.za; esteyn@sun.ac.za
ponade, or diaphragmatic splinting. Smaller hernias are also
capable of signicant complications, as they present with
vomiting and pain, but minimal abdominal signs, leading to
late diagnosis, signicant hypovolemia, and even septic
shock. The reported morbidity and mortality rates of latepresenting diaphragmatic hernias are 30% and 10%,
respectively.
43.2 Clinical Assessment
Penetrating torso injuries caused by stabs or gunshots potentially may involve the diaphragm as well as adjacent structures in the chest or abdominal cavities. No signs or
symptoms are specic to diaphragmatic injury, and no noninvasive investigation can reliably exclude a small diaphragmatic defect.
Clinical assessment should rst be directed at abnormalities of the airway, breathing, and circulation. Attention
should be paid to possible signs of injury on the opposite side
of the diaphragm, i.e., penetrating chest injuries require
appropriate assessment of the abdomen and penetrating
abdominal injuries mandate a clinical and radiological
assessment of the chest. The incidence of associated injuries
is high, typically presenting with peritonism or a hemopneumothorax. However, in a review of patients with proven penetrating diaphragmatic injuries, 31% had no abdominal
tenderness, 40% had a normal chest roentgenogram, and
only 49% had an associated hemopneumothorax (Murray
etal. 1997).
Diaphragmatic injury may be suspected based on the predicted trajectory of the injury, or abnormal ndings involving
both cavities. All stab wounds below the tip of the scapula at
the back or below the nipple line in front should be considered as possibly involving the diaphragm and could be associated with intra-abdominal injuries. All gunshot injuries of the
torso have the potential to traverse the diaphragm. Stab
wounds of the chest accompanied by local subcostal tenderness (not necessarily including peritonism or generalized ten-
© The Author(s), under exclusive license to Springer Nature Switzerland AG 2023
E. Degiannis et al. (eds.), Penetrating Trauma, https://doi.org/10.1007/978-3-031-47006-6_43
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E. Steyn
derness) warrant laparotomy or laparoscopy. In patients with
lower chest injuries, repeated clinical assessment may not be
sufcient to identify all cases of diaphragmatic penetration. It
is estimated that 30% of such injuries are missed on routine
evaluation, and therefore laparoscopic or thoracoscopic
assessment is strongly recommended (McDonald etal. 2018).
Right-sided penetrating injuries of the chest and diaphragm are inevitably associated with liver injury, and the
clinical ndings may vary from massive hemorrhage into the
chest or abdomen to benign liver injury amenable to selective
nonoperative management. As most of the small penetrating
right-sided diaphragmatic injuries are effectively sealed off
by the liver, the risk of late intestinal herniation is small.
Clinical assessment of right-sided injuries should be focused
on the identication of ongoing bleeding and possible retroor intraperitoneal visceral perforation.
43.3 Radiological Assessment
Chest radiographs are notoriously unreliable for the diagnosis
of acute penetrating diaphragmatic injuries. The sensitivity of
preoperative chest X-ray and computed tomography (CT)
was 86 and 100% in the presence of visceral herniation and
14 and 0% in the absence of a visceral hernia (Tiberio).
According to Murray etal., normal chest radiographs were
found in 40% of patients with diaphragmatic injuries. In the
presence of gunshot wounds on the trunk, the likelihood of a
diaphragmatic injury is determined by the estimated trajectory of the projectile. This requires radiological assessment of
the chest, abdomen, and pelvis as indicated, with metal markers (such as paper clips) identifying the entrance and exit (if
present) wounds. Gunshot injuries should always be assessed
to nd wounds in pairs (or to pair an entrance wound and a
retained bullet), although it should be kept in mind that bullets do not always travel in straight lines. Lodox® scanning is
useful for rapidly identifying the location of retained bullets
and foreign bodies in all types of penetrating injuries.
phragm are unlikely to be identied by ultrasonography at the
time of acute presentation. FAST may indirectly demonstrate
the presence of a diaphragmatic injury by diagnosing pleural
uid associated with a penetrating abdominal injury or intraperitoneal uid in the presence of a penetrating chest injury.
43.6 Diagnostic Peritoneal Lavage (DPL)
DPL is rarely used, although it may be one of the more sensitive tests for breach of the diaphragm in the absence of other
intra-abdominal injuries. Modalities such as abdominal and
chest X-rays, FAST, and Computed Tomography are considerably less reliable than DPL in demonstrating a penetrating diaphragmatic injury. A positive DPL in a patient with isolated
penetrating chest injury is conclusive evidence that the diaphragm has been traversed. Contrary to the applications of
DPL in blunt abdominal trauma, in the presence of a supradiaphragmatic wound, very small amounts of blood in the peritoneal lavage uid should be considered signicant. Therefore,
a more sensitive criterion such as 10,000 RBC/mm3 should be
used. DPL may be false negative if the penetrating chest
wound extends directly into the lesser sack. Drainage of lavage
uid from the chest tube indicates a positive result.
43.7 Computed Tomography (CT)
CT is a poor diagnostic tool to demonstrate penetrating diaphragmatic injury in the absence of herniation but may provide
indirect evidence of the injury trajectory or injuries above and
below the diaphragm. Multidetector CT (MDCT with 64-slice
technology or more) has a sensitivity of 87.2% to demonstrate
diaphragmatic injury and accurately rules out diaphragmatic
injury with a specicity of 72.4%. The overall accuracy is
reported as 77% (Stein etal. 2007). When MDCT is equivocal,
further investigation is required to evaluate the diaphragm.
43.4 Contrast Studies
Contrast studies outlining the stomach or colon may occasionally be useful to diagnose diaphragmatic rupture due to
blunt trauma in the acute setting but are of no value in the
early identication of the typical acute penetrating injury.
43.5 Ultrasound
Focused Abdominal Sonography for Trauma (FAST) is commonly utilized in trauma cases and may demonstrate uidlled intestinal loops in the chest cavity after blunt
diaphragmatic disruption. Penetrating injuries of the dia-
43.8 Magnetic Resonance Imaging (MRI)
MRI is able to demonstrate the diaphragm and may be used in a
stable patient with equivocal ndings and no indication for laparotomy, or for late diagnosis. MRI is unsuitable for acutely
injured patients who require monitoring and resuscitation.
There is little evidence of the value of MRI investigation to conrm penetrating diaphragmatic injuries in the acute setting.
43.9 Laparoscopy
Diagnostic laparoscopy provides the most reliable tool for
detecting occult diaphragmatic injuries among patients who
have no other indications for formal laparotomy. Patients
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369
with penetrating wounds of the anterior or posterior left lower
chest, without clinical or radiological evidence of
diaphragmatic perforation, should have a laparoscopic assessment of the left diaphragm. Diagnostic laparoscopy and
video-assisted thoracoscopy signicantly improve the rate of
diagnosis of occult injuries. Laparoscopic examination of the
diaphragm in high-risk cases reduces the risk of negative or
nontherapeutic laparotomies. Friese etal. report the specicity, sensitivity, and negative predictive value of laparoscopy
as 100%, 87.5%, and 96.8%, respectively, and conclude that
in asymptomatic hemodynamically normal patients with penetrating thoracoabdominal injury, laparoscopy alone is sufcient to exclude diaphragmatic injury. Penetrating
diaphragmatic injury, once diagnosed laparoscopically, may
be amenable to laparoscopic repair. However, laparoscopic
assessment for visceral injuries below the diaphragm is not
universally reliable. In the early post-injury stage, a laparoscopically diagnosed diaphragmatic injury requires conversion to a laparotomy to safely rule out occult visceral injury,
especially of the transverse colon, the lesser sac, pancreas,
duodenum, or posterior aspect of the stomach. When a laparoscopic inspection is done semi-electively for a stable patient
who remains entirely asymptomatic, the likelihood of missed
abdominal visceral injury becomes very small.
43.10 Thoracoscopy andVideo-Assisted
Thoracoscopic Surgery (VATS)
VATS has been used for patients with penetrating chest
trauma to visualize the diaphragm when an injury is suspected and laparotomy is not clinically indicated. Out of 171
patients undergoing VATS assessment of a hemidiaphragm,
60 patients (35%) were found to have a diaphragmatic injury
(Freeman et al. 2001). The true value of thoracoscopy or
laparoscopy for the assessment of left-sided diaphragmatic
injury lies in its high negative predictive value.
Fiber-optic thoracoscopy has been demonstrated to be useful for the diagnosis of diaphragmatic injuries in children.
43.11 Treatment
43.11.1 Surgery
All left sided diaphragmatic injuries require early detection
and repair. As the diaphragm is in constant motion, injuries
are unlikely to heal spontaneously. Occasionally, in stable
patients with no overt abdominal ndings on CT, penetrating
thoraco- abdominal injuries may be managed with a selective
non- operative approach. But once stabilized, high-risk injuries will require thoracoscopic or laparoscopic assessment of
the diaphragm. Penetrating injuries, especially gunshot injuries, often require laparotomy for hemodynamic instability
or the presence of visceral injury. Damage control principles
are applied in circumstances of hemodynamic instability;
however, a quick inspection and repair of the diaphragm is
prudent, especially for larger defects. The choice of surgical
approach to suspected or known penetrating diaphragmatic
injuries is based on injury trajectory, diagnostic procedure
(laparoscopy or thoracoscopy), whether the diagnosis is
made late or early, and surgeon’s choice. In most cases, a
laparotomy is the preferred option. Other intra-abdominal
injuries requiring repair or resection may distract attention
from a seemingly minor injury of the diaphragm, therefore
the left diaphragm should routinely be inspected.
Left-sided stab wounds to the lower chest in patients who
are awake and orientated and have no clinical evidence of
abdominal injury, can be managed with chest drainage (if
indicated) and serial abdominal assessment. In the absence
of clinical or radiological abnormality of the abdomen, the
need for laparoscopic inspection of the diaphragm remains.
Should there be an indication for thoracoscopy (VATS), such
as evacuation of a clotted hemothorax, the diaphragm can be
easily assessed via this route.
It must be emphasized that in the acutely presenting
patient, any penetrating diaphragmatic injury diagnosed thoracoscopically or laparoscopically usually mandates laparotomy to exclude subdiaphragmatic visceral injuries.
Intra-operatively, the left diaphragm is visualized by
pressing down the stomach and transverse colon, while the
assistant robustly retracts the left upper abdominal wall and/
or sternum. Once the diaphragmatic perforation has been
identied, it is brought into vision using Babcock or Allis
forceps and repaired in a single full-thickness layer with a
nonabsorbable suture.
Should there be contamination or blood clots in the
chest, the pleural cavity can usually be accessed via the
opening in the diaphragm (which may be enlarged if
required) and copious lavage with warm physiological
saline should be performed. A chest drain should be placed,
if not already present. If the lung is collapsed or signicantly atelectatic, it may be manually expanded (Valsalva
maneuver) by the anesthesiologist as the nal diaphragmatic suture is closed. Active bleeding or a signicant air
leak from the lung or bronchus may require thoracotomy or
rarely, sternotomy.
Late-presenting diaphragmatic herniation with incarcerated intra-abdominal structures may be approached from the
chest or the abdomen. An abdominal approach is recommended as an ischemic small- or large bowel may require
resection. A thoracic approach could facilitate the release of
pleural and lung adhesions to the herniated viscera. A thorough pleural washout and adequate drainage should be provided, together with broad-spectrum antimicrobial therapy if
visceral perforation or ischemia was present.
Post-operative management is as for all trauma laparotomies; depending on the nature and extent of the other inju-
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ries, early ambulation, adequate pain control, and frequent
chest physiotherapy should contribute to a rapid recovery
(Figs.43.1, 43.2, and 43.3).
Fig. 43.1 A stab wound of the left lower chest presenting acutely with
visceral herniation into the chest
E. Steyn
Fig. 43.3 Continuous suture repair of the diaphragm while pulling the
laceration downward and into view
Important Points
• Penetrating diaphragmatic injuries are diagnostically
challenging and need to be actively sought and excluded.
• Invasive diagnostic procedures such as laparoscopy or
thoracoscopy are the most sensitive modalities to den-
itively exclude small penetrating diaphragmatic
injuries.
• High-resolution CT scanning and FAST may identify
high-risk cases by implicating the trajectory on both sides
of the diaphragm. Although rarely utilized, a positive
DPL (indicating the presence of red cells) in the presence
of a penetrating chest wound, is diagnostic.
• Early diagnosis and surgical repair of all left-sided dia-
phragmatic hernias are essential to reduce the morbidity
and mortality of late complications.
Fig. 43.2 The left diaphragm wound was enlarged to allow the reduction of colon
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Meyer DM, Wait MA, DiMaio M. Indications for using video-
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Approach toThoracoabdominal Injury
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EliasDegiannis, ThorstenHauer, andDietrichDoll
44
Thoracoabdominal injuries in penetrating trauma are very
important for two reasons. Firstly, they are characterized by
high morbidity and mortality due to the signicant physiological impact on the patient. Secondly, it is often difcult to
come to a conclusive decision on which cavity needs to be
operated on, or, if both cavities have to be opened, which one
takes priority. Therefore, it is difcult to give clear-cut guidelines, but certain aspects can render the decision-making
process more error-proof. Having said that, the surgeon
should still have the exibility to move from one cavity to
the other if his initial decision was wrong or if life- threatening
developments present intraoperatively from the other cavity.
The following course of action may be followed for
patients presenting with thoracoabdominal injury:
• Once the patient has arrived at the resuscitation room,
place the bullet wound markers on the wounds and proceed with AP and lateral X-rays of the chest and abdomen.
This will give you an idea of the trajectory and apart from
conrming the thoracoabdominal nature of the injury, this
information will also help you to see if the bullet crossed
the midline (if there is no obvious entry and exit wound).
• Insert an intercostal drain (ICD) at the side of the injured
chest cavity, if you have not already done so on admission
to the resuscitation area.
• Do an e-FAST to make sure that the ICD is serving its
purpose and the pleural cavity has been properly evacu-
E. Degiannis (*)
Department of Surgery, University of the Witwatersrand Medical
School, Johannesburg, South Africa
e-mail: degiannis@yebo.co.za
T. Hauer
Department of Surgery, Berlin Military Hospital, Berlin, Germany
e-mail: thorstenhauer@bundeswehr.org
D. Doll
Medical Faculty, Saarland University, Homburg, Germany
Department of Colorectal Surgery, St. Mary’s Hospital,
Vechta, Germany
ated, also assessing the pericardiac cavity for cardiac tamponade and the peritoneal cavity for free uid.
A CT scan and laparoscopy in the physiologically stable
patient can help with the diagnosis of the above as well as the
diagnosis of diaphragmatic injury. Patients with clinical
signs of peritonitis will have to be operated on without any
further investigations of the abdomen.
On deciding if only one cavity or both should be opened,
it is important to remember that 85% of patients with penetrating chest trauma only require an insertion of an ICD.
Assuming that we have a functioning ICD, the chance
of blood migrating from the thoracic cavity via the diaphragmatic defect to the abdomen and resulting in a large
hemoperitoneum is small. On the other hand, it is quite
feasible for intraperitoneal uid to be sucked into the chest
through the diaphragmatic defect and present itself as an
ICD output.
Considering the point made above, it is clear how useful
it would have been to be able to close the communication
between these two cavities and assess them separately.
Unfortunately, this is usually not possible preoperatively.
Therefore, we have to rely on our “good clinical judgment”—be exible and convert from one cavity to the other
if the intraoperative ndings do not t the physiological status of the patient, or if developments at the other cavity
become clinically evident during the operation. So, it is
important to close the diaphragmatic defect during the operation as soon as possible, so that we can monitor the true
amount of blood originating from each of the two cavities—
chest via the ICD and abdomen. Remember that there will be
times when we will have to perform a pericardial window on
a patient who is undergoing a laparotomy; in the presence of
gross contamination of the peritoneal cavity, try, if possible,
intraoperative e-FAST so that you avoid infection spreading
in the pericardial sac. Importantly, the anesthesiologist is
“the surgeon’s best friend.” He does not only contribute in
keeping the patient alive, but he can also draw your attention
to any signicant increase in the ICD output, difculties
© The Author(s), under exclusive license to Springer Nature Switzerland AG 2023
E. Degiannis et al. (eds.), Penetrating Trauma, https://doi.org/10.1007/978-3-031-47006-6_44
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while ventilating the patient, and unexplained physiological
instability.
From experience, it is evident that in the majority of cases,
the best bet is to start by opening the abdominal cavity. Even
though there is no “silver bullet,” we recommend the following in an attempt to standardize the operative approach:
• Small amounts of ICD output combined with a large
amount of intraperitoneal uid on e-FAST (or other inves-
tigations): Operate on the abdomen.
• Large amount of ICD output combined with large amount
of intraperitoneal uid on e-FAST (or other investiga-
tions): Operate on the abdomen with an open mind to shift
to the chest.
• Small amount of ICD output combined with a small
amount of intraperitoneal uid on e-FAST (or other investigations): Operate on the abdomen.
• Large amount of ICD output combined with a small
amount of intraperitoneal uid on e-FAST (or other investigations): Operate on the chest.
Quite often you may nd that you were wrong and, unfor-
tunately, even with extensive experience in trauma and gut
feeling, you could be let down. On the other hand, intraoperative alertness and exibility can save the day and your
patients’ lives.
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