Resuscitate the patient, pass a nasogastric tube. Cover the exposed loops of gut with a warm saline pack or a towel.
If the patient’s gut is strangulating, immediately enlarge his wound under local infiltration anaesthesia (A 5.4) to relieve it.
If his gut is injured and leaking, you can, if necessary, close it temporarily with a non–crushing clamp, or resect it before anaesthetizing him. Gut is insensitive, so he will feel nothing. This will prevent later soiling of the wound.
Anaesthetize him—you will need good muscular relaxation. Paint his abdomen with some gentle antiseptic, such as chlorhexidine, and irrigate the exposed loops of his gut with quantities of saline.
Enlarge his wound in the most appropriate direction to make an incision which most nearly approximates to one of the standard ones, or do a separate standard laparotomy, taking care to miss nothing. You may find several other injuries. If necessary, revise the emergency closures that you did earlier. To do so, empty the injured section of gut, and apply soft clamps across its base to prevent it filling. Then undo any temporary sutures, freshen the edges of his gut, excise anydamaged areas, and do a formal closure or resection, as in Section 9.3.
Always try to close a patient’s peritoneum. Close the muscle layers as best you can, and leave his skin open for delayed primary suture. Excise the margins of the original wound.
If returning his viscera to his abdomen and closing it is difficult, try decompressing his small gut. Milk its contents proximally into his stomach, and keep aspirating all the time with a nasogastric tube.
If you cannot close his peritoneum (very unusual), try making long relieving incisions on the sides of his abdomen so thatyou can close his skin and subcutaneous tissues. Later, refer him for the repair of the muscles of his abdominal wall.
Alternatively: (1) Cover the wound with moist packs. The organs which present in it will granulate, and you can graft them about the fifth day. Refer him for a formal repair later. Or, (2) make an artificial peritoneum with strong, sterile cloth heavily coated with sterile vaseline, sewn to the margin of the defect. Granulations will slowly grow over it from the edges. Leave the cloth prosthesis in for several days and repeat the procedure as necessary. Graft the granulations with split skin, pending a formal repair.
