War Surgery and Medicine
SUMMARY OF IMPORTANT ASPECTS OF THE TREATMENT OF ABDOMINAL INJURIES — Statistics (New Zealand figures in Italy)
SUMMARY OF IMPORTANT ASPECTS OF THE TREATMENT OF ABDOMINAL INJURIES
Necessity for rapid evacuation, with minimal stops, to the Forward Operating Centre.
Resuscitation, if necessary, at the ADS, continued as an in-ambulance drip transfusion, but full resuscitation only just before operation.
Operation preferably carried out at the CCS level.
Operate without delay but only when optimum resuscitation by blood, plasma, and serum has been achieved.
Urgent operation without full resuscitation is called for in continued intra-abdominal haemorrhage, traumatic amputation, and severe muscle injuries.
Utilisation of an experienced senior surgeon for the diagnosis and listing of cases.
Auscultation of the abdomen to eliminate possibility of intestinal injury and so save laparotomy.
Use of the X-ray especially to localise foreign bodies in cases of diaphragmatic and retro-peritoneal injury, with a view to saving laparotomy.
Routine catheterisation for diagnosis of urological injuries.
Careful investigation with rectal examination for possible abdominal injury in wounds of the pelvis and buttocks.
Provision of a suction apparatus.
Provision of electric lighting-generally by mobile plants.
Operation undertaken when the systolic B.P. reached 100 mm. Hg. and is rising. (80 mm. is the minimum level of operatability.)page 275
The necessity for highly trained anaesthetists and best available apparatus for these cases.
The ample provision of young, well-trained surgeons in Mobile Field Surgical Units for attachment to forward operating units.
Laparotomy preferably by a mid-line incision. Loin incisions for localised and renal injuries.
Orderly examination of the abdominal organs.
Simple, generally one layer, suture, of small intestine injuries. Resection avoided if at all possible.
Exteriorisation of all severe lesions of the colon through a separate small incision.
Suture of small simple wounds of the right colon. Drainage by Paul's tube, with early secondary closure, of more severe lesions.
Proximal colostomy for lower sigmoid and all rectal injuries.
Free perineal drainage for lower rectal wounds.
Formation of spur for colostomy with care to prevent injury to the mesentery by the clamp during later closure.
Conservative treatment of lesser liver and kidney injuries, the large majority of the cases.
Nephrectomy when a wound of the colon complicates an open renal injury.
Conservative treatment of the late abdomen.
Drainage instituted when in doubt, and definitely for wounds of the colon, pancreas, duodenum, biliary passages, bladder, and retro-peritoneal injuries.
Thoraco-abdominal exploration, unless the intestine is involved, preferably through the chest.
Resuscitation just as necessary after operation as before operation.
Gastric suction instituted till peristalsis definitely reestablished.
Intravenous fluid given freely, 8 to 10 pints daily, after operation to combat dehydration and prevent the onset of anuria.
Water given by mouth early and light nourishment, when possible, after forty-eight hours.
Patient nursed in horizontal position following operation.
Post-operative administration of plasma and later of high protein and vitamin diet.
Administration of penicillin parenterally in all cases and also local application to the peritoneum and the wound.page 276
Evacuation from the forward operating centre to be delayed (especially in cases of wound sepsis) till full stability has been reached. Responsibility of survival placed on the forward surgeon.
Closure of colostomy wounds as soon as possible.
Conservative treatment of late sepsis with drainage of established abscesses.
Burst wound always associated with infection of the wound and also of the peritoneum.
Provision of body armour to protect the abdomen and chest is recommended.
Statistics (New Zealand figures in Italy)
The mortality covering all cases was 50 per cent.
The mortality covering abdominal cases operated on was 36 per cent.
The mortality covering thoraco-abdominal cases operated on was 42·6 per cent.
Cases operated on at CCS level, 96 per cent.
|Penetrating abdominal wall||11|
|Two hollow visci||31|
|Hollow and solid visci||11|
|Two solid visci||4|
|More than two organs||12|
|Colostomy and cystostomy||3|
|Cystostomy, suprapubic (prob)||5|
|accidental injuries invalided to nz—|
|Penetrating abdomen with lesion of—|
|Contusions, etc., of abdomen||41|