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404 Graeme Pitcher · Craig Joseph
leukopenia, a small percentage of patients will develop intestinal perforations, usually in the second to fourth weeks of illness. Following a perforation, mortality rises
exponentially with delay to surgical intervention. Expeditious resuscitation and
urgent surgical exploration are required. Perforations may be minimally debrided
and simply closed. Multiple perforations may require segmental resection, typically of the terminal ileum. Primary anastomosis is deemed safe unless the patient
is physiologically compromised, in which case the bowel is best exteriorized as a
stoma. Appropriate antibiotic cover is vital to success. With increases in resistance
to amoxicillin and chloramphenicol, a quinolone antibiotic is a safer first choice in
very ill patients. The diagnosis may be confirmed by histology of the resected specimen, a positive blood culture, or positive serology in the form of a Widal test.
Sickle Cell Disease
Sickle cell disease (SCD) is an autosomal recessive hemoglobinopathy that is
relatively common in parts of Central Africa. Heterozygotes, who have only one
abnormal gene, have sickle cell trait (SCT), a beneficial condition that confers a
natural survival benefit against malaria. Unfortunately, individuals with a double
dose of hemoglobin S (HbS; i.e., SCD) have no such luck. The abnormal hemoglobin becomes unstable under conditions of low oxygen tension and aggregates
into large polymers. This results in distortion of the erythrocytes and a reduction
in their deformability. The disease is characterized by a chronic hemolytic anemia
and painful vaso-occlusive crises. Acute abdominal pain is a common mode of
presentation and may be difficult to differentiate from other surgical or urological
emergencies. Certain clues may point to a “sickle cell crisis”:
Pain occurs at multiple sites; typically the chest, back, and extremities.
The pattern of pain is similar to prior episodes.
Bowel sounds are preserved.
Improvement occurs with general supportive measures such as hydration,
oxygenation, and judicious use of analgesia.
A precipitating factor (trigger) is present (e.g., a respiratory tract infection).
Most sickle cell crises will settle on supportive therapy, but very rarely ischemic bowel perforations may require surgery, and massive splenic or hepatic sequestration crises may prove fatal. The usual commonly encountered surgical
pathologies also occur in this patient group, and abdominal computed tomogra phic (CT ) sc anning has proven to be a reliable modalit y that w ill ident ify mo st
surgical conditions, but ultimately clinical observation of the patient’s course
will determine the appropriate management. Diagnosis of SCD in suspected cases
is confirmed by observing sickled cells on a peripheral blood smear.
37.2 Africa 405
Conclusion
Acute abdominal conditions challenge surgeons in Africa not so much because of their disease diversity but in the challenge of treating the often very severely ill, neglected patient in poorly staffed and equipped conditions. Sophisticated
perioperative care, including intensive care, which has revolutionized the results
of the treatment of these patients in the West, is simply not present in the vast
majority of hospitals. Surgeons have to be innovative and in many instances must
tailor the patient’s treatment according to their facilities and circumstances.
Patients’ physiological reserves are frequently compromised by malnutrition and
severe infectious diseases, particularly tuberculosis and HIV/AIDS, and the pres-
sure is on the surgeon to “get it right the first time with the simplest and safest
operation.” There is no leeway for errors of operative strategy!
“After climbing a great hill, one only finds that there are many more hills to
climb.” (Nelson Mandela)
Penetrating Abdominal Trauma
Roger Sa adia
It is absolutely necessary for a surgeon to search the wounds himself, which
are not drest by him at first, in order to discover their nature and know their
e x t e n t . (A. Belloste, 1701)
General Principles
The crucial decision faced by the surgeon is whether an exploratory laparotomy is indicated. The decision to operate rests solely on the high likelihood that
a significant injury is present; it does not require a precise inventory of all the possible intra-abdominal visceral injuries. In penetrating trauma, the role of clinical
evaluation is primordial. Depending on the circumstances, it needs to be comple-
mented sometimes by adjunctive diagnostic measures.
The surgeon’s initial objective is to identify the patient requiring surgery
while avoiding unnecessary laparotomies. These are termed negative when no
injuries are present and nontherapeutic when the identified injuries would have
healed spontaneously if left alone (for example, a minor hepatic laceration associated with a small hemoperitoneum but no active bleeding).
38
To fulfill this ideal requirement of timely necessary surgery with a zero rate
of unnecessary laparotomies, numerous algorithms, some very complicated,
have been devised incorporating various diagnostic tests. Not a single one is
foolproof or has gained universal acceptance. In fact, the most experienced
trauma surgeon does perform, from time to time, an unnecessary laparotomy;
while such surgery is attended by some morbidity, this is a fair price to pay for
not missing a significant intra-abdominal injury, provided that the frequency of
such laparotomies is not unreasonably high.
In civilian practice, there are two main mechanisms of penetrating abdominal trauma: st ab w ou nds an d gunshot injuries. Owing to surgical tradition, these
two categories have been treated differently, with mandatory surgery advocated
Roger Saadia
University of Manitoba and Health Sciences Centre, Winnipeg, MB, Canada R3M 3G5
M. Schein et al. (eds.), Schein’s Common Sense Emergency Abdominal Surger y,
DOI: 10.1007/978-3-540-74821-2_38, © Springer-Verlag Berlin Heidelberg 2010
407
408 Roger Saadia
for gunshot wounds. More recently, there has been a tendency to apply the same
management principles irrespective of the injury mechanism.
After penetrating abdominal trauma, two possible clinical pictures can be
found, in isolation or in combination: hypovolemic shock and peritonitis. The former is the result of bleeding from an injured solid organ (e.g., spleen, liver) or a
sizable vessel. The latter is the consequence of soiling of the peritoneal cavity
caused usually by an injured hollow viscus (gut, biliary system, urinary bladder).
Abdominal Stab Wounds
“Though shock may be temporarily alleviated by transfusion, it cannot be arrested
or overcome; resuscitation divorced from surgery is folly.” (William Heneage Ogilvie,
18 87–19 71)
The diagnosis of a stabbed abdomen is straightforward in the majority of
cases: there is a visible wound on the abdominal wall, and the patient or witnesses usually confirm the circumstances of the assault. Do not be taken in by
“fishermen’s tales” about how long the steak knife was but remember instead the
adage: “Treat the patient not the weapon.”
It bears repeating that clinical evaluation of the patient (supplemented by
an upright chest X-ray) is the most important step in the diagnostic workup.
There are scenarios mandating an exploratory laparotomy without the need for
additional confirmatory diagnostic procedures. The only required tests are those
preparatory for a laparotomy (basic blood work, blood group and match, and
when necessary electrocardiogram [EKG], bHCG, etc.).
The following are indications for immediate surgery:
Hemodynamic instability in the absence of an associated extra- abdominal
injury that could, by itself, account for shock. Aggressive fluid resuscitation must
be started immediately. (Patients in extremis should be transferred expeditiously
to the operating room since emergency room thoracotomy is not a useful maneuver in this context; as for emergency room laparotomy, it is extremely efficient in
transferring the patient’s total blood volume from the abdomen to the floor.)
Peritonitis is frequent, and there is little diagnostic value in eliciting tender-
ness and even guarding on abdominal palpation in the immediate vicinity of the
laceration. Signs of peritonitis need to be found at a distance from the wound to
confidently establish the diagnosis. Always ensure that the bladder is empty before
you prod for abdominal tenderness (these patients often arrive to the emergency
room with a bladder ready to burst, courtesy of overenthusiastic paramedics).
38 Penetrating Abdominal Trauma 409
The demonstration of free intraperitoneal air on the upright chest X-ray.
Abdominal X-rays are unnecessary in stabbed abdomens except for the lateral
decubitus film in a patient who cannot sit up for a chest X-ray.
Omental or intestinal evisceration. A laparotomy is advisable because of
the high likelihood of visceral injury. Even if the laparotomy turns out to be negative, it would have served the double purpose of reducing safely the herniated
viscera and allowing for a meticulous closure of the lacerated abdominal wall,
preventing hernia formation.
A retained stabbing instrument. This could be tamponading a sizable
blood vessel and therefore should be removed in the operating room.
Abdominal Stab Wounds: When to Observe? How to Investigate?
Reading the standard textbooks, one gets a little confused about how to manage the asymptomatic patient with, typically, an anterior abdominal wall laceration. In about one-third of patients, the wound does not extend into the peritoneal
cavity, and in another third it does, but there are no significant visceral injuries.
Exploring all these patients would not be a good idea.
Diagnostic procedures are sometimes advocated. Diagnostic peritoneal la-
vage is cumbersome and lacks accuracy; it is attended by a high rate of nontherapeutic laparotomies. Exploration of the wound under local anesthesia aims at
identifying a breach of the parietal peritoneum. It is often difficult to determine
with certainty the extension of the track: try it in an obese or combative patient in
the rough-and-tumble atmosphere of a busy emergency department! Laparoscopy
is a logistically demanding test since it requires general anesthesia. Here also, its
main value is to ascertain intraperitoneal penetration. Do not be fooled by overconfident minimally invasive surgeons; a negative laparoscopic assessment of the
peritoneal cavity cannot exclude a small intestinal laceration with minimal spillage
or assess the retroperitoneum. In addition, postprocedure clinical or radiological
abdominal assessments are made unreliable. About the selective role of laparoscopy for a suspected diaphragmatic injury, see the section on “difficult scenarios”.
There remain two (we believe, complementary) approaches to the asymptomatic patient with an anterior abdominal stab wound: clinical reassessment
and helical computed tomography (CT) scanning.
1. Serial clinical reassessment of the patient
This policy has been dubbed “selective conservatism” and has proved its
worth in many centers. The patient is admitted, kept nil per os and given an intravenous infusion. The vital signs and urine output are closely monitored. The
410 Roger Saadia
abdomen is re-examined at frequent intervals, checking for the development of
peritonitis; the initial area of tenderness around the wound can be circumscribed
with a marker, and spreading tenderness is watched for over the observation
period. Analgesia, antibiotics, or nasogastric decompression are not required. If,
after an observation period of 18–24 hrs, no signs of hypovolemia or peritonitis
are elicited, it is highly unlikely that a significant intra-abdominal injury is present. A very good indicator of this is a patient angrily demanding a meal tray. In
applying this policy, keep an open mind at all times and do not persevere stubbornly with nonoperative management in the face of even subtle deterioration.
Having to operate in a delayed fashion in a well-monitored patient is not a sign
of personal failure but a tribute to your clinical acumen. An occasional unneces-
sary laparotomy will be performed; this is nothing to be ashamed of, and when
in doubt it is safer to err on the side of surgical exploration.
2. Abdominal CT scan
In recent years, both the access to CT scanning and the quality of the images have
improved dramatically. In many centers, the asymptomatic stabbed patient is often
sent to the scanner by the emergency physician before the surgeon is even consulted.
Whatever seasoned trauma surgeons may think of this practice, the train has long
since left the station. Undoubtedly, this investigation is often valuable, even though its
shortcomings in early intestinal perforation are well known. Some patients are shown
to have only a superficial wound with greater ease and accuracy than by local tract
exploration. They can be safely discharged from the emergency department. A small
minority of asymptomatic patients are diagnosed with a significant visceral injury
(which would have eventually declared itself under observation). Their trip to the operating room is thereby expedited. The remaining majority of the patients with a negative or equivocal CT scan need to be admitted and observed as described.
The primacy of clinical evaluation is unquestioned. However, as in the
management of acute appendicitis (> Chap. 28), its interplay with the judicious
use of the CT scanner can refine one’s decision making a little further.
Gunshot Abdominal Wounds: Dogma Versus Modern Imaging
“It is highly desirable that anyone engaged in war surgery should keep his idea
fluid and so be ready to abandon methods which prove unsatisfactory in favour of
others which, at first, may appear revolutionary and even not free from inherent
danger.” (H.H. Sampson, 1940)
Traditional wisdom inherited from war experience has held that an explor-
atory laparotomy is always indicated in patients with abdominal gunshot wounds
38 Penetrating Abdominal Trauma 4 11
irrespective of their clinical condition. This policy has been predicated on the
higher likelihood of significant intra-abdominal injuries in gunshot than in stab
wounds. This premise, if true, implies merely that shock and peritonitis are more
frequently associated with the former than with the latter. Decision making is then
ea sy. What about the benign-looking abdomen with a gunshot wound that is en-
countered now not that infrequently in many large urban trauma centers? There is
accumulating evidence to suggest that initially asymptomatic gunshot victims can
be managed safely along the same broad lines as stabbed patients. While the role
of initial and serial clinical reassessments is here again very important, we contend
that an early CT scan of both the abdomen and chest is mandatory, not only in
asymptomatic patients but in all gunshot victims who are stable enough to go to
the scanner. Bullets tend to travel longer distances than the length of a knife blade.
Imaging of the whole torso is essential to document the trajectory of the bullet,
which could extend beyond the confines of the abdominal cavity. A missing bullet
should prompt the search for an extra-abdominal location or a hidden exit wound.
Furthermore, a bullet entering the abdomen can significantly damage bony structures (thoracolumbar spine, pelvis, hip, etc.). The information gleaned from these
images is often invaluable despite the occasional “scatter” caused by a retained
metal fragment. Sometimes, it will be seen that the missile’s trajectory is tangen-
tial, missing the peritoneal cavity: a laparotomy can be avoided, but semielective
debridement of the abdominal wall may prove necessary in some of these cases.
Difficult Scenarios: The CT Scan Reigns Supreme
Stab wounds to the lower chest, the flank, or the perineum pose the problem
of possible but clinically occult injury to intra-abdominal viscera.
The diaphragm: an isolated diaphragmatic laceration is often at first clini-
cally silent but is sometimes complicated by a secondary diaphragmatic hernia.
This complication is more likely to occur on the left than on the right side, which
is relatively shielded by the bulk of the liver. Little is known about the natural
history of diaphragmatic wounds, but very small ones are probably often missed
with impunity. It is, however, standard of care to look for them whenever a stab
wound is located in the lower chest or upper abdomen (especially on the left side).
In this scenario, if there are no other clinical reasons to operate, then a thoracoscopy or a laparoscopy should be performed during the patient’s hospital stay to
check the integrity of the diaphragm; if a laceration is identified, it should be repaired at laparotomy. Reconstructed coronal CT scan views of the diaphragmatic
domes can also be very helpful and may supplant laparoscopy in the future.
The flank: a stab wound to the flank can involve the retroperitoneal
portion of the duodenum or colon. Peritoneal signs are present only at a late
stage (sometimes too late, associated with advanced retroperitoneal infection).
412 Roger Saadia
Therefore, a CT scan must always be obtained early (there is no more need for a
combined contrast enema). An injury to the kidney is often benign and is usually associated with frank hematuria. The possibility of a ureteric injury is more
serious and must be entertained in the presence of microscopic hematuria. The
CT scan has now supplanted the intravenous pyelogram (IVP) as the screening
investigation of choice in suspected injuries to the urinary tract.
The perineum: abdominal penetration must always be suspected. A digital
rectal exam looking for rectal bleeding is a mandatory component of the clinical examination. A CT scan is helpful and may need to be supplemented by a
rectosigmoidoscopy.
Patients with multiple stab or gunshot wounds to both the chest and ab-
domen may constitute a dilemma in the choice or sequencing of the operations
if both the chest and abdomen are possible candidates for the source of severe
hemorrhage; this is particularly the case if the patients are unstable and unfit
for transfer to the CT scanner. Alternatively, one can come across a patient with
a high epigastric stab wound and hypotension in whom the possibility of a cardiac tamponade should be entertained. In these cases, an ultrasound scan in the
emergency room (FAST, focused abdominal sonography for trauma) may help
formulate a logical management plan. FAST is used more frequently in blunt
trauma and is discussed in > Chap. 39.1.
What to Do When CT Scanning Is Not Available?
Some of you readers from developing countries may not have unrestricted
access to emergency CT scans. The great majority of penetrating trauma victims can be managed by the combination of three diagnostic modalities: clinical
examination, upright chest X ray, and, yes, exploratory laparotomy, the last resorted
to more liberally whenever in doubt. Keep the threshold for intervention low. The
acceptable price to pay, in this context, is a higher rate of unnecessary laparotomies
rather than missed injuries. In patients with a flank injury or hematuria, a one-shot
IVP in the emergency room is easy to perform and very useful (especially in confirming the presence of a functioning kidney on the uninjured side).
Conclusion
Clinical evaluation (including vital sign assessment and abdominal examination) retains to this day its primacy in the management of penetrating abdominal trauma. There are clear-cut clinical scenarios requiring immediate laparotomy.
In other situations, clinical observation remains extremely valuable. In recent
years, abdominal CT scanning has established itself as the best diagnostic adjunct.
Know when to operate and when not to (> Fig. 38.1).
38 Penetrating Abdominal Trauma 413
Fig. 38.1. “Let’s be conservative!”
“Failure to promptly recognize and treat simple life-threatening injuries is the
tragedy of trauma, not the inability to handle the catastrophic or complicated
injury.” (F. William Blaisdell)
Blunt Trauma and Rx of Specific
Injuries
Roger Sa adia
39
M. Schein et al. (eds.), Schein’s Common Sense Emergency Abdominal Surger y,
DOI: 10.1007/978-3-540-74821-2_39, © Springer-Verlag Berlin Heidelberg 2010
415
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