66.9 Small gut injuries
Penetrating injuries from bullets or knives can make holes in a patient’s small gut and its mesentery. Blunt injuries either tear or burst it by pressing it against his spine.
Figure 66.15: PENETRATING INJURIES OF THE GUT AND MESENTERY may be bullet holes (A) with a similar wound on the other side of the patient’s gut. The mucosa protrudes through the wound and there may be little leakage. Close wounds transversely (B) to avoid stenosis. If the wound is on the edge of the gut (C) there may be only one wound. Wounds close to the mesenteric border (D) may be easily missed. If several injuries occur together, or the omentum is injured, excise the injured segment, and anastomose the gut (F). You can suture small tears in the mesentery (G), especially if they run in the direction of the vessels perpendicular to the gut. If the tear is near the edge of the mesentery the circulation to the gut may be impaired (I), so resect the segment (j). The anastomotic arterial arcades (K) are some distance from the gut. Beyond them the arteries are end arteries, so that injuring them may kill the gut they supply. This is a composite diagram. If all these injuries occurred in the same loop, most surgeons would excise the loop altogether.The lower diagram shows the method of repairing a laceration (L), trimming it (M), inserting the sutures (N), and finally sewing it up transverse to the axis of the gut (O).
A patient’s abdomen becomes tender after an abdominal injury. You may have difficulty deciding how much of this tenderness is caused by bruising of his abdominal wall, and how much by peritonitis from a ruptured gut. If you are in doubt, the decision not to operate is much more dangerous.
Provided the small gut is viable, it has remarkable powers of repair. Although it may look very deformed and constricted at the end of the operation, it may be quite normal some months later. Although resecting gut does not increase mortality in skilled hands, it does so in less skilled ones. The main danger is a leak, because of poor technique, or sloughing of its wall. If you have a choice, repairing gut is safer than resecting it. IF IN DOUBT OPERATE