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
1. |
Necessity for rapid evacuation, with minimal stops, to the Forward Operating Centre. |
2. |
Resuscitation, if necessary, at the ADS, continued as an in-ambulance drip transfusion, but full resuscitation only just before operation. |
3. |
Operation preferably carried out at the CCS level. |
4. |
Operate without delay but only when optimum resuscitation by blood, plasma, and serum has been achieved. |
5. |
Urgent operation without full resuscitation is called for in continued intra-abdominal haemorrhage, traumatic amputation, and severe muscle injuries. |
6. |
Utilisation of an experienced senior surgeon for the diagnosis and listing of cases. |
7. |
Auscultation of the abdomen to eliminate possibility of intestinal injury and so save laparotomy. |
8. |
Use of the X-ray especially to localise foreign bodies in cases of diaphragmatic and retro-peritoneal injury, with a view to saving laparotomy. |
9. |
Routine catheterisation for diagnosis of urological injuries. |
10. |
Careful investigation with rectal examination for possible abdominal injury in wounds of the pelvis and buttocks. |
11. |
Provision of a suction apparatus. |
12. |
Provision of electric lighting-generally by mobile plants. |
13. |
Operation undertaken when the systolic B.P. reached 100 mm. Hg. and is rising. (80 mm. is the minimum level of operatability.) page 275 |
14. |
The necessity for highly trained anaesthetists and best available apparatus for these cases. |
15. |
The ample provision of young, well-trained surgeons in Mobile Field Surgical Units for attachment to forward operating units. |
16. |
Laparotomy preferably by a mid-line incision. Loin incisions for localised and renal injuries. |
17. |
Orderly examination of the abdominal organs. |
18. |
Simple, generally one layer, suture, of small intestine injuries. Resection avoided if at all possible. |
19. |
Exteriorisation of all severe lesions of the colon through a separate small incision. |
20. |
Suture of small simple wounds of the right colon. Drainage by Paul's tube, with early secondary closure, of more severe lesions. |
21. |
Proximal colostomy for lower sigmoid and all rectal injuries. |
22. |
Free perineal drainage for lower rectal wounds. |
23. |
Formation of spur for colostomy with care to prevent injury to the mesentery by the clamp during later closure. |
24. |
Conservative treatment of lesser liver and kidney injuries, the large majority of the cases. |
25. |
Nephrectomy when a wound of the colon complicates an open renal injury. |
26. |
Conservative treatment of the late abdomen. |
27. |
Drainage instituted when in doubt, and definitely for wounds of the colon, pancreas, duodenum, biliary passages, bladder, and retro-peritoneal injuries. |
28. |
Thoraco-abdominal exploration, unless the intestine is involved, preferably through the chest. |
29. |
Resuscitation just as necessary after operation as before operation. |
30. |
Gastric suction instituted till peristalsis definitely reestablished. |
31. |
Intravenous fluid given freely, 8 to 10 pints daily, after operation to combat dehydration and prevent the onset of anuria. |
32. |
Water given by mouth early and light nourishment, when possible, after forty-eight hours. |
33. |
Patient nursed in horizontal position following operation. |
34. |
Post-operative administration of plasma and later of high protein and vitamin diet. |
35. |
Administration of penicillin parenterally in all cases and also local application to the peritoneum and the wound. page 276 |
36. |
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. |
37. |
Closure of colostomy wounds as soon as possible. |
38. |
Conservative treatment of late sepsis with drainage of established abscesses. |
39. |
Burst wound always associated with infection of the wound and also of the peritoneum. |
40. |
Provision of body armour to protect the abdomen and chest is recommended. |
Statistics (New Zealand figures in Italy)
1. |
The mortality covering all cases was 50 per cent. |
2. |
The mortality covering abdominal cases operated on was 36 per cent. |
3. |
The mortality covering thoraco-abdominal cases operated on was 42·6 per cent. |
4. |
Cases operated on at CCS level, 96 per cent. |
injury to— | |
Small intestine | 56 |
Colon | 62 |
Stomach | 12 |
Duodenum | 3 |
Rectum | 10 |
Bladder | 10 |
Liver | 39 |
Kidney | 5 |
Anal canal | 1 |
Urethra | 2 |
Spleen | 16 |
Gall bladder | 3 |
Bowel | 3 |
Other | 4 |
Penetrating abdomen | 16 |
Penetrating abdominal wall | 11 |
Two hollow visci | 31 |
Thoraco-abdominals | 33 |
Hollow and solid visci | 11 |
Two solid visci | 4 |
More than two organs | 12 |
Colostomy | 52 |
Colostomy (probable) | 14 |
Colostomy and cystostomy | 3 |
Colostomy, double | 1 |
Cystostomy, suprapubic | 1 |
Cystostomy, suprapubic (prob) | 5 |
—— | |
76 |
complications— | |
Burst abdomen | 2 |
Nephrectomy | 2 |
Haematoma, extra-peritoneal | 2 |
Ventral hernia | 1 |
Faecal fistula | 1 |
Abscess, intra-peritoneal | 1 |
Abscess, retro-peritoneal | 2 |
Abscess, retro-pleural | 1 |
Abscess, subphrenic | 1 |
accidental injuries invalided to nz— | |
Laceration liver | 1 |
Rupture spleen | 1 |
Stricture rectum | 1 |
Rupture bladder | 2 |
Penetrating abdomen | 282 |
Penetrating abdomen with lesion of— | |
Liver | 57 |
Spleen | 21 |
Kidney | 28 |
Bowel | 85 |
Bladder | 14 |
Colon | 69 |
Stomach | 39 |
Perforating abdomen | 73 |
Abdominal wall | 133 |
Contusions, etc., of abdomen | 41 |