66.2 Penetrating abdominal injuries

If a patient has an abdominal skin wound the important questions to decide are: (1) Has it entered his peritoneal cavity? (2) Has it done any damage which requires surgery? Knives, bullets, or the horn of an animal can all penetrate the abdomen. It is the depth of a wound that matters, not its length. More severe injuries are often multiple and may penetrate a patient’s thorax as well as his abdomen, as with the arrow in Fig. 66-6. Stab wounds and bullet wounds differ.

Stab wounds from knives and daggers follow a predictable path; only the organs through which the weapon passes are injured, and a laparotomy may not be necessary.

Bullets may follow an unpredictable path, may change direction, and cause widespread damage. The higher their velocity the worse this is. Bullets almost always cause serious visceral injuries, so operate on all bullet wounds.

Figure 66.5: A PENETRATING ABDOMINAL INJURY, illustrating the value of making a separate incision which enables you to see the track of the knife. Note that the knife was left in place until the patient reached the theatre. Kindly contributed by Peter Bewes.

If you select patients with penetrating wounds wisely, and observe them all carefully, about a third of them will not need a laparotomy. Be guided by the nature of the injury and the force used. If you try to treat a patient conservatively, monitor him carefully. Increasing pain, shock, and signs of peritonitis will tell you when to operate. Time is critical. Few patients survive if peritonitis has been developing for 16 hours, but most will live if you can operate in the first 6 hours.

Before starting to operate on a patient with a bullet wound, think carefully about the structures that it may have injured in its path between entering and leaving the abdomen. If it remains inside, see where it is in at least two X–rays taken from different directions. A patient may be grateful for the time you spend reviewing his anatomy.

AMOS (6 years) was playing on a child’s slide. He went down on his front, feet first, and subsequently complained of abdominal pain. There was a small lacerated wound on his abdominal wall near his umbilicus. The signs of general peritonitis developed and laparotomy showed a splinter of wood 15 cm long and 3 cm wide, which had entered his abdomen and penetrated the anterior wall of his stomach. This was removed and he recovered.