Potential spectrum of accompanied penetrating abdominal intra-peritoneal injuries with bowel evisceration: Surprises awaiting the trauma Surgeon in resource limited settings.

doi:10.21203/rs.3.rs-1937316/v1

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Potential spectrum of accompanied penetrating abdominal intra-peritoneal injuries with bowel evisceration: Surprises awaiting the trauma Surgeon in resource limited settings.

https://doi.org/10.21203/rs.3.rs-1937316/v1

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Penetrating abdominal injuries involves violation of the peritoneal cavity and injuries to solid organs, and other intra-peritoneal viscera such as major blood vessels and hollow organs. Typically such injuries arise from Gunshot wounds or stab wounds. With increase in crime rates and motor traffic accidents in urban areas, the trauma surgeon in civilian urban centers faces spectrum of injuries similar to his colleague in war torn areas. Potential spectrum of penetrating abdominal injuries is wide and accurate diagnosis in resource limited centers is challenging. Majority of injuries are concealed and diagnosed intra-operatively and dealt with relatively junior trauma surgeons in emergency settings in remote limited settings. Computed Tomography (CT) scans and Magnetic Resonance imaging (MRI) facilities are scarce in resource limited settings. Haemo-dynamic states of penetrating abdominal injuries patients presenting in emergency departments necessitate urgent surgical exploration and management with minimal room for full radiological work-up. Evisceration of bowels mandate laparotomy due to wide spectrum of accompanied intra-peritoneal injuries. Four cases of penetrating abdominal injuries are presented with modes of assault ranging from Gunshot injuries to stab wounds with broken bottles to highlight the intra-abdominal spectrum of injuries, challenges in diagnosis and emergency managements done in a resource limited setting.

General Surgery

Bowel evisceration

laparotomy

stab wounds

Gunshot wounds

abdomen

The abdomen is the most injured area in trauma patients⁽¹⁾, with abdominal trauma leading in morbidity and mortality in all age groups in the world⁽²⁾⁽³⁾. However, identifying life threatening intra-peritoneal injuries due to trauma is a challenge⁽²⁾. Stab wounds and Gunshot wounds are the most common causes of penetrating abdominal injuries^(4)(5)(3)(6). Stab wounds are more common but with low mortality rates⁽⁷⁾⁽⁶⁾. Males predominance is seen in penetrating abdominal injuries ^{(2)(3)(2)(8–10)}. The violation of abdominal cavity results in the small bowel (50%), large bowel (40%), liver (30%), and intra-abdominal vasculature (25%) constituting the higher spectrum percentage of intra-peritoneal viscera injury⁽⁴⁾. Intra peritoneal spectrum of injuries is unpredictable as initial primary assault maybe further complicated by secondary injuries arising from either bone or bullet fragments⁽⁴⁾⁽⁵⁾. Concealed injuries further contribute to morbidity and mortality of victims⁽⁴⁾⁽³⁾. Presentation of the injuries varies depending on the type of penetrating object or ballistic kinetic energy involved⁽⁴⁾, viscera involved and number of wounds⁽⁵⁾. Immediate surgical exploration is warranted in haemo-dynamically unstable patients presenting with hypotension, signs of poor end organ perfusion, weak pulse, tachycardia and peritonism with high index of potential vascular injury⁽⁵⁾. Standard radiological pre-operative assessment involves chest and abdominal roentgenography, triple contrast computed tomography scans, retrograde urethrograms and cystograms to rule out injuries ranging from diaphragmatic involvement to bladder injuries⁽⁵⁾. Surgical management of patients depends on mechanism of injury, haemo-dynamic state and accompanying injuries. High kinetic energy injuries such as gunshot wounds almost always necessitate exploration due to vast spectrum of accompanying intra-peritoneal injuries. Stable hemodynamic stab wounds patients may not always necessitate surgery^(5)(7)(11). Four selected cases of penetrating abdominal traumas are presented to highlight the spectrum of injuries, diagnostic challenges and emergency surgical management.

2.1 Case one:

A 26 years old male was referred to our center with history of penetrating abdominal injury on the left lumbar region of his abdomen. He arrived at our center 12 hours post injury. The referral clinical notes stated his blood pressure was 76/48mmHg and no urine collected on urinary bag through urethral catheter. Amount of intravenous fluids given was not documented.

On admission his Glasgow coma scale was 15/15; he was severely pale, not jaundiced, not cyanosed, ill-looking, in-distress. His vital signs on admission were Blood pressure 94/46mmHg, pulse rate 117 beats per minute regular with weak volume, respiratory rate 22 cycles per minute, temperature 35.9^o and oxygen saturation 94% on room air. On systemic examination of other systems were normal except for the abdomen where he had oedematous gangrenous small bowel evisceration of about 12cm long on his left lumbar abdominal area through a 2cm diameter stab wound. He had muscle guarding and tender abdomen on palpation. On admission the patient did not reveal the true mode of his injury and claimed he fell on bathroom tiles. His haemoglobin level was 10.4g/dL. Blood grouping and crossmatch was done and Intravenous fluids Normal saline and a unit of blood was transfused and patient was taken for emergency explorative laparotomy.

Intra-operative findings were oedematous gangrenous small bowel evisceration of about 12cm long on his left lumbar abdominal area 2cm diameter stab wound, massive retroperitoneal haematoma of about 2.5 liters with active oozing of blood from retroperitoneal space, multiple mesenteric lacerations with mesenteric haematoma, jejunal perforations at 80cm from ligament of Treitz, a longitudinal infra renal inferior vena cava laceration about 2cm long. The spleen, liver, Gastrium, large colon and kidneys were normal.

The eviscerated bowels were reduced and resected and primary anastomosis done. Lacerated jejunal segment was also resected and primary anastomosis done. Retroperitoneal haematoma was evacuated and bleeding from the inferior vena cava was controlled by applying pressure by index fingers supra and infra segment of the lacerated inferior vena cava segment and repaired by Nylon 6 − 0 by continuous suturing. Intra-operative blood pressure was ranging as low as 60/30mmHg. The mesenteric lacerations were repaired by vicryl No. 2. Intra-operatively we estimated the patient had lost about 4.5 liters of blood in total from the haematoma evacuated and bleeding from the actual surgery. There was still some diffuse oozing from the mesentery. We packed the abdomen with two abdominal mops, inserted two abdominal drains, repaired abdominal stab wound and closed up the abdomen for continual resuscitation in intensive care unit. The surgery took 6 hrs. He received a total of 6 units of blood. Post operatively on day one the patient’s abdominal drain totaled 900mls of hemorrhagic fluid. No anticoagulants were instituted as prophylaxis for embolism in fear of massive intra-peritoneal bleeding as not all bleeders were arrested during initial index damage control surgery. The patient improved clinically. He revealed he was stabbed by a standard 10 inch screw driver during a street quarrel (Fig. 1). On day five post operatively the patient had an acute onset of chest pain, developed difficulty in breathing and succumbed to cardiac arrest. Postmortem was not performed. We suspected patient had developed pulmonary embolism which lead to his death.

2.2 Case two

41 years old man was brought at our center with history of being assaulted by a broken beer bottle in a bar fight 4 hours post injury. He was clinically stable with a blood pressure of 110/60mmHg, pulse rate of 80beats/min, oxygen saturation of 99%, and temperature of 36.9 C. On examination he had a Glasgow Coma Scale of 15/15, moderately pale, not jaundiced nor cyanosed. Per abdomen he had an evisceration of omentum and part of transverse colon. (Fig. 2 (a) and (b)). He was wheeled into the operating theater for emergency explorative laparotomy. Abdomen was opened through extended midline incision. Intra-operative findings were evisceration of omentum and part of the transverse colon through a 4 by 5 cm anterior abdominal wall defect, a 2cm jejunal traumatic perforation 20cm from ligament of Treitz, and a 1cm transverse colon serosal tear. Bowel traumatic perforations were repaired with vicryl no. 2 − 0 and anterior abdominal wall defect with vicryl no 2. He received two units of whole blood. He was instituted on I/V ceftriaxone 1g od and metronidazole 500mg 8hrly post-operative. Post-operative recovery was uneventful. He was discharged fourth day post operatively. Patient was reviewed 4 weeks post discharge faring well.

2.3 Case three

36 years old man was brought to our center with history of gunshot injury to the abdomen 4 hours prior admission. He was conscious, Glasgow coma scale 15/15, moderately pale, oxygen saturation 99% on room air. His blood pressure was 148/67mmHg and pulse rate of 87beats/min. Per abdomen he had two wounds on left lumbar area 3 cm in diameter with smooth margins entry wound with blood oozing and small bowel evisceration of about 4cm and right lumbar area, a rouged edged wound 2 by 3 cm exit wound. Abdomen was opened through extended midline incision. Intra operative findings were complete jejunal transections at 90cm and 110cm from ligament of Treitz and 0.5cm perforation at 120cm. The rectus abdominis muscle on left lumbar area were transected with ruptured peritoneal fascia. About 20cm of jejunum was resected and end to end anastomosis done. Rectus abdominis muscle was repaired with its underlying fascia. Abdomen closed and he was instituted on I/V ceftriaxone 1g od and metronidazole 500mg 8hrly post-operative. Post-operative recovery was uneventful.

2.4 Case four

33 years old female was admitted at our center with history of being stabbed with a knife on his abdomen. She arrived with Glasgow coma scale of 15/15, Blood pressure 140/70mmHG, pulse rate of 80beats/min. Per abdomen examination she had evisceration of small bowel from her left hypochondriac area lying on anterior abdominal wall. (Fig. 3 (a) and (b)). Abdomen was opened through extended midline incision. Intra-operative findings were 3 by 3 cm defect on the left hypochondriac area, with evisceration of small bowel. Two traumatic perforations along the greater curvature approximately 2 by 2cm on the gastrium, multiple traumatic perforations on the jejunum from 50cm to 120cm from the ligament of Treitz with complete transection at 100cm mark with haemoperitoneum of approximately 300mls. Gastric perforations were repaired with vicryl 2 − 0 and jejunum resected 45cm from ligament of Treitz to 130cm mark. Abdomen closed in layers. She was instituted on I/V ceftriaxone 1g od and metronidazole 500mg 8hrly post-operative. Post-operative recovery was uneventful.

Penetrating abdominal trauma involves external objects/ballistics violating anterior abdominal wall into the peritoneal cavity⁽⁴⁾. The increase in violence among the civilian populations has increased the spectrum of trauma injuries resembling those seen in war zones. ⁽⁵⁾, thus making the urban trauma surgeon working in civilian populations facing similar trauma cases as his colleague in war zones. This has been due to the availability of weapons, and presence of military conflicts⁽⁴⁾⁽⁵⁾. However spectrum of injuries in war zones is different as most assaulting objects are high velocity ballistics⁽⁶⁾The trauma surgeon is facing a wider spectrum of intra-abdominal injuries due to a wide range of instruments/weapons available among the civilian population. Nyongole et al found 69% of penetrating abdominal trauma patients were due to assaults⁽²⁾.The most common causes of penetrating abdominal injuries faced by the trauma surgeon are stab wounds (31%), gunshot wounds(64%), shotgun wounds (5%)⁽⁴⁾⁽⁵⁾ and industrial accidents⁽⁴⁾, with gunshot wounds having a wider spectrum of intra-peritoneal organ injuries and most often require exploration ⁽⁵⁾. The four cases presented ranged from gunshot injury, stab wounds by knife, screw driver and broken bottle. All cases were results from assaults and conflicts.

The pattern of intra-peritoneal organs injury involves small bowel (50%), colon (40%), liver (30%), and intra-peritoneal vasculature (25%) injuries⁽⁴⁾⁽⁵⁾. Close contact trauma inflicted wounds have greater kinetic energy thus inflict wider spectrum of intra-peritoneal injury⁽⁴⁾⁽⁵⁾. Magnitude of injury depends on viscera affected, nature of assaulting object and the quantity of energy transmitted⁽⁴⁾. Spectrum of injuries can be increased by injuries from patients own bone fragments or bullets fragments⁽⁴⁾⁽⁵⁾. The pattern of injuries from the cases presented ranged from Inferior Vena Cava injury, small bowel, gastric and large bowel traumatic perforations. The spectrum of injuries seen, vasculature trauma was diagnosed intra-operative as seen in case one as the pre-operative diagnostic radiological modalities such as Focused Assessment with Sonography in Trauma (FAST) are limited in diagnosis of vessel injury. Advanced imaging technology increases diagnostic accuracy of injuries⁽⁵⁾.

Diagnosing full extent of intra-peritoneal injuries from clinical assessment is difficult as injuries are concealed as peritonism and hypovolemic shock may still occur in conscious individuals⁽⁴⁾. Standard pre-operative radiological assessment includes x-rays, CT scans, and MRI due to the wide spectrum of injuries⁽⁴⁾⁽⁵⁾.

However even with clinically stable patients without any signs of peritonism might still require advance radiological investigations to diagnose concealed intra-peritoneal viscera injury⁽⁴⁾. Preferred radiological diagnostic tool is the triple contrast CT scan⁽⁴⁾. This is not always available in all limited resource centers.

The standard management protocol for penetrating abdominal trauma is laparotomy⁽⁵⁾. From a clinical standpoint surgical indications for exploration are hemodynamic unstable patient, development of signs of peritonism and unresolving diffuse abdominal pain⁽⁴⁾. However for patients who are haemodynamically stable, with no signs of peritonism and have been evaluated with triple contrast CT scan, laparotomy maybe withheld and observed^(5)(11). Care should be taken as medication may affect blood pressure values with patients with higher pain threshold withstanding clinical signs and symptoms of peritonitis⁽⁷⁾ .However there is a high incidence of intra-peritoneal viscera injury with patients presenting with bowels eviscerations thus mandating exploration^{(12)(13)(14)(15)(9)}. This was the observation in all the four cases presented as all had intra-peritoneal organs eviscerations and had accompanying viscera injuries which needed theraupetic surgical repair (Fig. 1–4). Bowel eviscerations occurs post recent laparotomy in wound dehiscence and penetrating abdominal trauma due to slash or stab wounds to the anterior abdominal wall⁽¹⁶⁾. Kong et al found the most commonly eviscerated organs were small bowel (70%), large bowel (26%), and Gastrium 3%(13). In our cases three patients had small bowel evisceration with other intra-peritoneal viscera injury. Only (1%) of the patients by Kong et al had combined evisceration of more than one intra-peritoneal viscera⁽¹³⁾. One case in our cases series had combined omentum and transverse colon evisceration. He had sustained anterior abdominal wall umbilical area broken beer bottle stab wound. However combined omental and viscera evisceration post anterior abdominal stab wound is uncommon⁽⁹⁾.

Prognosis of intra-peritoneal injuries depends on extent of trauma, time of presentation, intestinal contents peritoneal cavity contamination, haemorrhage, wide spectrum of organ injury, female sex⁽⁵⁾, accompanying brain trauma, or bleeding disorders increases the mortality rate⁽⁴⁾.

Inferior vena cava injuries are rare vascular injuries due to its retro-peritoneal location and buffer from intra-peritoneal organs. In our case the assaulting weapon was a long 10 inch screw driver which could transverse through the anterior abdominal wall and cushioning intra-peritoneal organs to reach the inferior vena cava.

It is however the most injured intra-abdominal vascular structure constituting to 25% of abdominal vascular injuries⁽¹⁷⁾. The most often injured segment of the inferior vena cava is the infra-renal segment (39%)⁽¹⁸⁾. Mortality rates are high (65%) due to insufficient fluid replacement, challenges in diagnosis and skillset in management⁽¹⁸⁾, with little improvements over the last four decades⁽¹⁷⁾.

Inferior vena cava injuries are generally diagnosed intra-operatively and are accompanied with other peritoneal organs injuries with retro-peritoneal haematoma⁽¹⁹⁾. This was also the observation in our case as the IVC lesion was concealed by a huge retroperitoneal haematoma. They are normally overlooked when accompanied with other intra-peritoneal injuries.

Laparotomy is the standard modality for the management of eviscerated intra-peritoneal viscera in penetrating abdominal injuries. There is always accompanied injury of peritoneal viscera or the eviscerated bowels. In our cases series reported all had presented with bowel evisceration from penetrating abdominal injury either from stab wounds or gunshot. Intra-operative findings revealed injury to the eviscerated organs with accompanied intra-abdominal viscera. Pre-operative diagnosis of entire spectrum of all intra-peritoneal injuries is difficult in resource limited settings as sophisticated radiological investigations are not available such as MRI and triple contrast CT scan. In our cases due to the nature of presentation of the patients having bowels eviscerations with perforations, our patients were wheeled straight into operating room for surgical interventions. Full radiological work up is not always possible in emergency limited resource setup. In our cases no abdominal radiological workup was ordered due to obvious nature of eviscerated bowels on anterior abdominal wall. Advocating for CT scanning/MRI imaging of abdomen would be time consuming, financially restrictive, worsening haemodynamically state due to continual intra-peritoneal haemorrhage in an otherwise obvious absolute indication for exploration. In resource limited settings we advocate for explorative laparotomy in eviscerated intra-peritoneal viscera for surgical reduction of contents into peritoneal cavity through an extended midline incision, exploration of injury to peritoneal viscera and repair, cleaning/irrigation of violated contaminated peritoneal cavity and repairing anterior abdominal wall defect.

Ethics approval and consent to participate

Written informed consent was obtained from the patient for writing of this case series; additionally, accompanying images have been censored to ensure that the patient cannot be identified. A copy of the consent is available on record. Approval to publish was obtained from relevant authorities.

Consent for publication

Written informed consent was obtained from the patient for publication for this case series.

Availability of data and materials

All data and materials pertaining to this case series can be made available on request.

Competing interest

The authors declare they have no competing interests. All authors of the manuscript have read and agreed to its contents.

Funding

No funding was obtained for this case series.

Authors’ contributions

All authors made a significant contribution to the work reported, whether that is in the conception, study design, execution, acquisition of data and interpretation, or in all these areas; took part in drafting, revising or critically reviewing the article; gave final approval of the version to be published; have agreed on the journal to which the article has been submitted; and agree to be accountable for all aspects of the work.

Acknowledgement

The authors would like to thank the patient for permission to share their medical history for educational purposes and publication.

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Potential spectrum of accompanied penetrating abdominal intra-peritoneal injuries with bowel evisceration: Surprises awaiting the trauma Surgeon in resource limited settings.

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Abstract

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1. Introduction

2. Case Presentations

2.1 Case one:

2.2 Case two

2.3 Case three

2.4 Case four

3. Discussions

4. Conclusion

Declarations

References

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