PENETRATING ABDOMINAL INJURIES

This extends the general method for abdominal injuries in Section 66.1. Much of the section on blunt injuries (66.3), and eviscerating injuries (66.4), also applies.

If a knife, or any other penetrating object, is still in place, leave it there until you reach the theatre, as in Figs. 66-5 and 66-6.

Work out the track of the wound. Wounds can enter a patient’s abdomen from his back, his chest, his buttocks, or his thigh.

If he might have a thoraco–abdominal injury, examine him for a haemothorax, or a haemopneumothorax (65.4).

Look for blood in the patient’s urine and gastric aspirate. If he has haematuria, do an intravenous pyelogram.

THE CONSERVATIVE TREATMENT OF PENETRATING ABDOMINAL INJURIES

In the absence of any of the indications for laparotomy listed in Section 66.3, you may be able to manage a patient with a stab wound conservatively.

Record his pulse and blood pressure half hourly. Watch him closely. Operate if he shows signs of bleeding or peritoneal irritation.

THE OPERATIVE TREATMENT OF PENETRATING ABDOMINAL INJURIES

LOCAL TREATMENT When you operate, explore the patient’s stab wound in the theatre and excise it down to his peritoneum. Open up the plane between his transversus and his peritoneum over a reasonable area and look at it.

If his peritoneum is intact, close his wound by immediate or delayed primary suture.

If his peritoneum has been opened, do a laparotomy, through a standard incision, and examine any organ which might have been injured.

If a plug of omentum protrudes through the wound, enlarge it, explore it, and make sure there are no injured viscera underneath.

If you have to get into his abdomen in a hurry, make a long midline or paramedian incision.

CAUTION! As a general rule, don’t try to explore the abdomen by extending the wound from the original injury. You will run into anatomical difficulties. Make a separate laparotomy incision.

Continue as with a laparotomy for a blunt injury, as described in the next section.

Always try to close the patient’s peritoneum. Close the muscle layers as best you can. If necessary, you can close them as a single layer. if the skin wound of the original injury was contaminated, leave it open for delayed primary suture.

If you cannot close the peritoneum, goto Section 66.4.