Knife wound to the stomach: first aid and consequences. What organs can be affected by a stab wound to the stomach?

- a wide group of severe injuries, in most cases posing a threat to the patient’s life. They can be either closed or open. Open wounds most often occur as a result of knife wounds, although other causes are also possible (falling on a sharp object, gunshot wound). Closed injuries are usually caused by falls from a height, car accidents, work accidents, etc. The severity of damage for open and closed abdominal trauma may vary, but special problem represent closed injuries. In this case, due to the absence of a wound and external bleeding, as well as due to the traumatic shock accompanying such injuries or the serious condition of the patient, difficulties often arise at the stage of primary diagnosis. If an abdominal injury is suspected, urgent delivery of the patient to a specialized medical facility is necessary. Treatment is usually surgical.

ICD-10

S36 S30 S31 S37

General information

Abdominal trauma - closed or open injury to the abdominal area, both with and without violation of integrity internal organs. Any abdominal injury should be considered a serious injury that requires immediate examination and treatment in a hospital setting, since in such cases there is a high risk of bleeding and/or peritonitis, which pose an immediate danger to the patient’s life.

Classification of abdominal injuries

Colon rupture The symptoms resemble ruptures of the small intestine, however, tension in the abdominal wall and signs of intra-abdominal bleeding are often detected. Shock develops more often than with ruptures of the small intestine.

Liver damage occurs with abdominal trauma quite often. Both subcapsular cracks or ruptures and complete separation of individual parts of the liver are possible. In the vast majority of cases, such liver injury is accompanied by heavy internal bleeding. The patient's condition is serious, loss of consciousness is possible. With preserved consciousness, the patient complains of pain in the right hypochondrium, which can radiate to the right supraclavicular region. The skin is pale, pulse and breathing are rapid, blood pressure is reduced. Signs of traumatic shock.

Damage to the spleen– the most common injury in blunt abdominal trauma, accounting for 30% of the total number of injuries involving violation of the integrity of organs abdominal cavity. It can be primary (symptoms appear immediately after the injury) or secondary (symptoms appear days or even weeks later). Secondary splenic ruptures are usually observed in children.

With small ruptures, bleeding stops due to the formation of a blood clot. With major injuries, profuse internal bleeding occurs with accumulation of blood in the abdominal cavity (hemoperitoneum). The condition is serious, shock, drop in pressure, increased heart rate and breathing. The patient is bothered by pain in the left hypochondrium, which may irradiate to left shoulder. The pain is relieved by lying on the left side with the legs bent and pulled towards the stomach.

Damage to the pancreas. They usually occur with severe abdominal injuries and are often combined with damage to other organs (intestines, liver, kidneys and spleen). Possible concussion of the pancreas, its bruise or rupture. The patient complains of sharp pain in the epigastric region. The condition is serious, the stomach is swollen, the muscles of the anterior abdominal wall are tense, the pulse is increased, blood pressure is reduced.

Kidney damage It is quite rare in cases of blunt abdominal trauma. This is due to the location of the organ, which lies in the retroperitoneal space and is surrounded on all sides by other organs and tissues. When a bruise or concussion occurs, pain in the lumbar region, gross hematuria (excretion of bloody urine) and fever appear. More severe kidney injuries (crushed or ruptured) usually occur with severe abdominal trauma and are combined with damage to other organs. Characterized by shock, pain, muscle tension in the lumbar region and hypochondrium on the side of the damaged kidney, fall blood pressure, tachycardia.

Bladder rupture may be extraperitoneal or intraperitoneal. The cause is blunt trauma to the abdomen with a full bladder. An extraperitoneal rupture is characterized by a false urge to urinate, pain and swelling of the perineum. It is possible to pass a small amount of bloody urine.

Intraperitoneal rupture of the bladder is accompanied by pain in the lower abdomen and frequent false urge to urinate. Due to urine spilled into the abdominal cavity, peritonitis develops. The abdomen is soft, moderately painful on palpation, bloating and weakening of intestinal peristalsis are noted.

Diagnosis of abdominal trauma

Suspicion of abdominal injury is an indication for immediate delivery of the patient to the hospital for diagnosis and further treatment. In such a situation, it is extremely important to assess the nature of the damage as quickly as possible and, first of all, to identify bleeding, which may threaten the patient’s life.

Upon admission, in all cases, blood and urine tests are required, and the blood type and Rh factor are determined. Other research methods are selected individually, taking into account clinical manifestations and the severity of the patient's condition.

With the advent of modern, more accurate research methods, radiography of the abdominal cavity in abdominal trauma has partially lost its diagnostic value. However, it can be used to detect ruptures of hollow organs. Carrying out x-ray examination also indicated for gunshot wounds (to determine the location foreign bodies– bullets or shot) and if there is a suspicion of an accompanying pelvic fracture or chest injury.

An accessible and informative research method is ultrasound, which allows you to diagnose intra-abdominal bleeding and detect subcapsular damage to organs that may become a source of bleeding in the future.

If appropriate equipment is available, computed tomography is used to examine a patient with abdominal trauma, which allows a detailed study of the structure and condition of the internal organs, revealing even minor injuries and minor bleeding.

If a bladder rupture is suspected, catheterization is indicated - the diagnosis is confirmed by a small amount of bloody urine released through the catheter. In doubtful cases, it is necessary to perform ascending cystography, which reveals the presence of a radiopaque solution in the peri-vesical tissue.

One of the most effective diagnostic methods for abdominal trauma is laparoscopy. An endoscope is inserted into the abdominal cavity through a small incision, through which you can directly see the internal organs, assess the degree of their confirmation and clearly determine the indications for surgery. In some cases, laparoscopy is not only diagnostic, but also therapeutic technique, with which you can stop bleeding and remove blood from the abdominal cavity.

Treatment of abdominal injuries

Open wounds are an indication for emergency surgery. For superficial wounds that do not penetrate the abdominal cavity, the usual primary surgical treatment is performed with washing the wound cavity, excision of non-viable and heavily contaminated tissue and suturing. For penetrating wounds, the nature of the surgical intervention depends on the presence of damage to any organs.

Bruises of the abdominal wall, as well as ruptures of muscles and fascia are treated conservatively. Appointed bed rest, cold and physiotherapy. For large hematomas, puncture or opening and drainage of the hematoma may be necessary.

Ruptures of parenchymal and hollow organs, as well as intra-abdominal bleeding are indications for emergency surgery. Under general anesthesia A midline laparotomy is performed. Through a wide incision, the surgeon carefully examines the abdominal organs, identifies and repairs damage. In the postoperative period, in case of abdominal trauma, analgesics are prescribed and antibiotic therapy is carried out. If necessary, blood and blood substitutes are transfused during the operation and in the postoperative period.

Thank you

To understand the principles and mechanisms correct provision first aid, you need to know what penetrating injuries. The human body has cavities that are sealed and isolated from the external environment and other tissues of the body - abdominal, thoracic, articular and cranial. Inside the cavities are located vital organs, which for normal operation requires constancy of physical conditions and isolation from environment. That is why these organs are located in isolated and closed cavities, within which the necessary environment and conditions for their functioning are maintained.

Definition and classification of penetrating injury

Any injury during which the seal of any of the four body cavities is broken due to the entry of a foreign body into it is called penetrating. Due to the fact that there are four body cavities, penetrating wounds, depending on the location, can be as follows:
1. Penetrating head wound;
2. Penetrating injury to the chest cavity;
3. Penetrating abdominal wound;
4. Penetrating joint injury.

Penetrating wounds are always deep and can be inflicted by any relatively sharp and long object, for example, a knife, axe, arrow, harpoon, screwdriver, nail, chisel, etc. In addition, a penetrating wound is formed when a bullet, shell fragments, mine, stone or any other heavy object enters any cavity of the body.

The standards and rules for providing first aid for penetrating wounds are determined by which body cavity (abdominal, thoracic, cranial or joint) was damaged, and do not depend on what exactly it was caused by. Therefore, we will consider the rules of first aid for injuries of all four body cavities separately.

First aid in a critical situation begins with the fact that a penetrating wound must be recognized. To do this, you should know what type and location a penetrating wound may have.

What wound is considered penetrating?

Any wound on the abdomen, chest, head or joint area that is more than 4 cm deep should be considered penetrating. This means that if, by stretching the edges of the wound to the sides, you cannot clearly see its bottom, then it should be considered penetrating. You should not stick your finger inside the wound, trying to find its bottom, since in the absence of experience, in this way you can only deepen and widen the wound canal. Penetrating wounds from the outside may look like a very small hole, and therefore look harmless and safe. When you see such a wound located on the stomach, chest, head or joint, you should not be deceived, since it is very dangerous.

Penetrating wound into the chest cavity. Remember that a penetrating wound into the chest cavity can be located not only on the front surface of the chest, but also on the side, and on the back, and on the shoulders in the area of ​​the collarbones. Any opening on the body, located in the ribs or on the shoulders near the collarbones, should be considered a penetrating wound to the chest cavity and first aid should be provided according to the appropriate rules.

Penetrating injury to the abdominal cavity could be applied to any surface of the abdomen - side, front or back. This means that any wound located on the front or side wall of the abdomen, as well as on the area of ​​the back between the ribs and sacrum, is considered a penetrating wound into the abdominal cavity. Also, a penetrating wound into the abdominal cavity is considered to be a wound inflicted in the perineal area or in the upper part of the buttock. One should remember about the possible localization of a penetrating wound on the buttock and perineum, and when identifying a wound channel with a similar localization, first aid should always be provided, as for a penetrating wound of the abdominal cavity.

Penetrating wound to the head can be applied to any part of the skull. Therefore, a wound entrance located on any part of the skull (under the hair, on the face, in the nose, in the mouth, in the eye, on the chin, etc.) should be considered a penetrating head wound.

Penetrating joint injury can only be applied in the area of ​​large joints, for example, knee, hip, elbow, etc. A wound in the joint area in combination with pain during flexion and extension movements is considered penetrating.

First aid algorithm for penetrating wounds into the chest cavity

1. When you see a person with a penetrating wound to the chest cavity, you must call " ambulance", and then begin providing first aid. If calling an ambulance is impossible for some reason, or its arrival is expected in more than 30 minutes, then you should begin providing first aid, and then take the victim to the nearest hospital on your own ;
2. When starting first aid, a person with a penetrating chest wound should be prohibited from breathing deeply and speaking until he is in the hands of doctors;
3. If a person is unconscious, his head should be tilted back and turned to the side, since it is in this position that air can freely pass into the lungs, and vomit will be removed outward without threatening to clog the airways;
4. If there is any object in the wound (knife, axe, harpoon, arrow, chisel, nail, reinforcement, etc.), do not pull it out under any circumstances, as this may lead to additional damage to internal organs and, accordingly, to the death of the affected person within a short period of time (5 - 20 minutes). If the object protruding from the wound is long, try carefully cutting it off, leaving only a small part (about 10 cm above the skin). If an object protruding from a wound cannot be cut or shortened in other ways, then it should be left as it is;
5. Try to fix and stabilize the object in the wound so that it does not move or move. Fixing the object in the wound is necessary, since any movement of it can provoke additional trauma to the organs, which will significantly worsen the condition and prognosis of the injured person. To do this, you can cover a foreign object protruding in the wound with rollers of bandages or any fabric on both sides, and then secure the entire structure with a bandage, adhesive plaster or tape (see Figure 1). You can fix a foreign object in the wound in another way. To do this, you should first throw a loop of any dressing material(bandage, gauze, cloth). Then wrap the item tightly with dressing material and tie its ends. An object wrapped in several layers of dressing material will be well fixed. Moreover, the heavier or longer the object, the more layers of dressing material should be wrapped around it to fix it;

Figure 1 - Fixation and immobilization of a foreign object protruding from the wound.

6. If there is no foreign object in the wound, you should tightly cover its opening with your palm to block the access of air. If there are two openings on the body - an inlet and an outlet (the area can be 10 times larger than the inlet), then both of them should be covered. Then, if possible, you need to apply a sealing bandage to the wound. If it is impossible to apply a bandage, you will have to press the wound openings with your palms until the ambulance arrives or during the entire period of self-transportation of the victim to the nearest hospital;
7. To apply an airtight bandage, cover the wound with a clean piece of gauze (at least 8 layers) and place cotton wool on top. If there is no cotton wool or gauze, then simply place a piece of clean cloth on the wound. The gauze or cloth should be pre-lubricated with any ointment or oil so that it fits tightly to the skin. But if there is no oil or ointment, you don’t have to lubricate the fabric. An oilcloth, bag or piece of polyethylene should be placed on top of the fabric or cotton swab, which is tightly attached to the skin on all sides with tape, adhesive tape or a bandage (see Figure 2);

Figure 2 - The procedure for applying a sealed bandage to a penetrating wound of the chest cavity.

8. If the victim receives assistance after more than 40 minutes from the moment of injury, the bandage is applied in the form of a U-shaped pocket. To do this, simply place a piece of polyethylene on the wound and attach it with tape or adhesive tape on three sides, leaving the fourth free. Through such a valve, air accumulated in the chest cavity will escape, but new portions will not be able to enter, which will prevent severe pneumothorax. Before applying polyethylene to the skin, if possible, it is recommended to lubricate its edges with any antibacterial ointment (for example, Levomekol, Baneocin, Sintomycin, etc.);
9. If the time of injury is unknown, then a U-shaped pocket is always applied;
10. After applying the bandage, the victim must be brought to a semi-sitting position, placing some support under his back, bending his knees and placing a cushion of clothing under them (see Figure 3);

Figure 3 - Correct position of a person during a penetrating wound in the chest cavity.

11. If possible, put cold on the bandage (ice in a bag or cold water in a heating pad);
12. Wait for the ambulance on site if its arrival is expected within half an hour from the time of the call. If the ambulance does not arrive within 30 minutes, you should transport the victim to the hospital yourself. Transportation is carried out on the floor sitting position.

First aid algorithm for penetrating wounds into the abdominal cavity

1. Once a person with a penetrating abdominal wound has been discovered, it should be assessed whether an ambulance will arrive within half an hour. If the ambulance arrives within 30 minutes, you should call it, and then begin providing first aid. If the ambulance does not arrive in the next half hour, then you should begin to provide first aid, and then independently transport the victim to the nearest hospital using any transport;
2. When starting to provide first aid, a person with a penetrating wound to the abdominal cavity should not be given anything to drink or eat, even if he urgently requests it. To quench thirst, you can only wet your lips with water or let the victim rinse his mouth;
3.
4. In the process of providing assistance, painkillers should not be administered to a person with a penetrating abdominal wound;
5. If there is any object in the wound (knife, axe, harpoon, pitchfork, chisel, nail, reinforcement, etc.), do not pull it out under any circumstances, as this may lead to additional damage to internal organs and, accordingly, to the death of the affected person within a short period of time (5 - 20 minutes). You can only try to carefully trim the object, leaving a small part sticking out from the wound - 10 cm above the skin. If it is impossible to cut or shorten an object in a wound in any other way, then you should leave it in this form;
6. The object in the wound should be fixed so that it does not move or shift during transportation or changes in the position of the victim’s body. In order to fix a foreign object in the wound, you need to take a long piece of dressing material, for example, bandages, gauze or any fabric (torn clothes, sheets, etc.). If the dressing is short, you should tie several pieces into one to get a strip of at least 2 meters in length. Then place a strip of dressing material over the object protruding from the wound, exactly in the middle, so that two long free ends are formed. Wrap these ends of the dressing tightly around the object and tie them together. An object wrapped in this way with several layers of dressing material will be well fixed;

7. After fixing the foreign object in the wound, the victim should be placed in a sitting position with legs bent at the knees. In this position, the victim is wrapped in blankets and transported while sitting;
8. If any object is missing from the wound, but internal organs have fallen out, do not under any circumstances try to set them back! Do not insert prolapsed organs into the abdominal cavity, as this can cause the victim to die very quickly from shock. In such a situation, you should carefully collect all the prolapsed organs in a clean cloth or bag and stick it with tape or adhesive tape to the skin in the immediate vicinity of the wound. In this case, internal organs should not be pressed or crushed. If there is nothing to stick a bag or cloth with organs to the skin, then you should isolate them from the external environment in another way. Rolls of bandages or cloth should be placed around the organs. Then a bandage should be made over the rollers, without pressing or squeezing the prolapsed organs;
9. After applying a bandage or fixing prolapsed organs, it is necessary to give the person a sitting position with bent legs, put cold on the wound and wrap the victim in blankets or clothes. Transport in a sitting position;
10. Until the person is taken to the hospital, the prolapsed organs should be moistened with water to keep them constantly moist. If the prolapsed organs are allowed to dry out, they will have to be removed because they will die;
11. If any object is missing from the wound, then apply a clean bandage made of sterile bandage, gauze or just cloth. To do this, 8–10 layers of gauze or bandage or a piece of fabric in two folds are applied to the wound so that they completely cover it. Then gauze or cloth is wrapped around the body. If there is nothing to tape gauze or fabric to the body, then you can simply stick it to the skin with tape, adhesive tape or glue;
12. If possible, apply cold to the bandage in the form of ice in a bag or ice water in a heating pad. After applying the bandage, the victim should be placed in a sitting position with his legs bent at the knees, and covered with blankets or clothes. The victim should be transported in a sitting position.

Important! Until a person with a penetrating wound to the abdominal cavity is taken to the hospital, it is strictly forbidden to give him water, food or administer painkillers.

First aid algorithm for penetrating wounds into the cranial cavity

1. Having discovered a person with a penetrating head wound, you should immediately call an ambulance, and then begin providing first aid;
2. If the ambulance cannot arrive within 30 minutes, then you should begin providing first aid, and then organize the delivery of the victim to the hospital on your own (by your own car, by passing transport, by calling friends, acquaintances, etc.);
3. If a person is unconscious, his head should be tilted back and turned to the side, since it is in this position that air can freely pass into the lungs, and vomit will be removed out without threatening to block the airways;
4. If there is any foreign object sticking out of your head (knife, rebar, chisel, nail, axe, sickle, etc.), under no circumstances touch or move it, much less try to pull it out. Any movement of an object in the wound can cause instant death;
5. In such a situation, you can only fix the object in the wound so that it cannot move while transporting the victim. To do this, make a long strip (at least 2 meters) of dressing material, which is tightly wrapped around the protruding object. In this case, the tape is thrown over the object exactly in the middle so that two long ends are formed. It is with these ends that the object is tightly wrapped. If there is no one long ribbon, then it should be made by tying several short bandages or pieces of fabric;
6. After fixing the foreign object, apply cold to the wound area and call an ambulance or independently deliver the victim to the nearest hospital. A wounded person must be transported in a sitting position, wrapped in blankets or clothes;
7. If there is no foreign object in the wound, then do not try to wash it, feel it, or reset the fallen tissue. In such a situation, you should only cover the head wound with a clean napkin or piece of cloth and apply a loose bandage. After this, it is necessary to give the victim supine position with his legs elevated and wrap him in blankets. Then you should wait for an ambulance or transport the person to the hospital yourself. Transportation is carried out in a lying position with the leg end raised.

Algorithm for providing first aid for penetrating wounds into the joint cavity

1. For any injury to the joint cavity, you should first call an ambulance, and then begin to provide first aid to the victim;
2. If the ambulance does not arrive within 30 minutes, then you should provide first aid to the victim, and then deliver him to the nearest hospital by your own means (by your car, by passing transport, etc.);
3. If a person is unconscious, his head should be tilted back and turned to the side, since it is in this position that air can freely pass into the lungs, and vomit will be removed out without threatening to block the airways;
4. If a penetrating wound into the joint cavity is detected, first of all, if possible, local anesthetics should be injected into the tissues surrounding the wound. For this you can use Novocaine, Lidocaine, Tricaine, Morphine, etc. For pain relief, use a disposable syringe to inject the entire solution from the ampoule with the existing medicine into the muscle tissue around the wound. Only after pain relief can first aid be continued;
5. If any foreign object is protruding from the wound, leave it and do not try to remove it;
6. If fragments of bones or pieces of torn muscles, tendons or ligaments protrude from the wound, then you should leave them alone and do not try to set or treat them;
7. If blood is oozing from a wound, do not stop it;
8. The skin around the wound should be washed with clean water or any antiseptic solution (for example, alcohol, Chlorhexidine, hydrogen peroxide, Furacilin, potassium permanganate, vodka, alcohol, cognac or any other alcohol-containing liquid). To wash the skin around the wound, you need to generously moisten a piece of bandage, gauze or cloth with an antiseptic or water and make a gentle wiping motion in the direction from the edge of the wound to the periphery. In this way, wipe all the skin around the wound;
9. Then apply a clean bandage made of bandage, gauze or a piece of cloth to the wound. The bandage should be applied in the position in which the joint is, without trying to straighten it;
10. After applying a bandage to the wound, the joint should be fixed (immobilized). To do this, apply any dense, stationary splint to the joint in the position in which it finds itself, for example, a stick, a metal pin, a wooden board, etc. Then this splint is tightly bandaged to the body above and below the wound, without changing the position of the joint (see Figure 4);

Figure 4 – Rule for immobilizing a joint using a splint.

11. If possible, apply cold to the skin slightly above the damaged joint;
12. The victim is wrapped in blankets and transported in a position convenient for him.

Before use, you should consult a specialist.

A knife wound is very dangerous; it is important to provide the victim with first aid correctly. Basic knowledge can be useful to anyone, because different things can happen, and untimely assistance can cause death.

Orthopedist-traumatologist: Azalia Solntseva ✓ Article checked by doctor

To the cervical region

If you receive a deep injury to the neck area, it is necessary to act more quickly than ever. In this case, first aid for stab wounds to the neck consists of:

1. It is necessary to immediately tilt the head towards the neck, in the direction where the severe cut is located.
2. Press your neck as close to your shoulder as possible. These steps should be performed to minimize blood loss.
3. Raise the arm that is on the opposite side of the neck wound.
4. Apply a dressing napkin to the wound site. If you don’t have one at hand, you can use a simple piece of crumpled clothing or any scrap of fabric. The material used should be bandaged to the raised shoulder.

If you are wounded in the area of ​​the Adam's apple, you should pierce the trachea with a knife in such a way as to reduce its length by a protrusion of two centimeters.

Similar actions should be done on one ring of the trachea, which is located below the Adam's apple. A tube open on both sides should be inserted into the resulting wound. This must be done to allow air to enter the lungs.

In the absence of a fracture, when the cartilage has simply shifted or sunk inward, everything possible should be done to prevent the victim from suffocating:

1. To do this, the victim is seated and leaned against the legs of the person who is providing assistance.
2. They throw their heads up.
3. Then they apply 4 gentle blows to the forehead with an open palm.
4. Next, the cartilage is palpated. The blows delivered should return them to their original position.

Video

Into the chest

If, when wounded in the chest, the victim fell and his heart stopped beating, then it is not at all necessary to immediately begin performing indirect massage.

There is a very good way to help the victim:

1. To do this, hit the area near the sternum and left nipple with the edge of your fist.
2. The blow should be applied lightly, but rather sharply.
3. This technique is called a precordial beat. When the action is completed, you should make sure whether the carotid artery pulse.
4. If it cannot be felt, then the procedure should be done one more time.
5. When the pulse is not palpable after the second time, you should do artificial respiration and indirect massage.

When blood bubbles begin to inflate from the wound and burst, but there is still not enough air, the hole must be closed. To do this, press your hand to the wound.

The rubberized side of an individual dressing bag is applied to the damaged area. If this is not nearby, then a plastic bag or thick paper will do.

You can fix the injury using:

• bandage;
• tape;
• patch;
• hands.

When stabbed in the lung area with a knife, it is necessary to insert a tube into the wound. This may be a catheter, a pen, or another suitable object; it should be washed before use.

At the same time, the air is deflated, and the lungs begin to slowly expand. Then the tube should be taken out and the wound should be sealed.

You can use:

• package;
• rubber;
• tape;
• bandage;
• piece of fabric.

Absolutely anything will do, as long as the material is clean.

How to help right away

1. First, you should thoroughly disinfect the wound. All knife wounds represent infected areas of skin. For this reason, they should be treated with any antiseptic that is at hand. It can be alcohol, brilliant green or vodka.
2. At first painful sensations, which arise from a knife wound, are very strong. They lead to shock or a shock state of the patient. At the same time, sweat appears on the face and it becomes pale. This is an indicator that the victim should be urgently hospitalized.
3. You cannot relieve pain with narcotic painkillers.
4. It is necessary to put an aseptic bandage on the treated wound.
5. You should apply something cold to the site of the knife wound.
6. Prolapse of organs from the abdominal cavity indicates a deep stab wound to the abdomen. Under no circumstances should they be put back on their own. They should be lined with cotton wool around the edges and covered with gauze on top. To fix prolapsed organs, it is necessary to use a wide bandage.

Forbidden:

1. With such a wound, it is forbidden to feed the patient, give him medications through the mouth.
2. You cannot probe or probe the wounded area.
3. You cannot remove an object from a wound that is left there.

Damaged heart muscle

Such an injury is very dangerous. But there is always a chance of survival.

The most important thing is not to try to get an object that is sticking out of the wound.

You should not do this even if clothes are stuck in it. And all because it helps control bleeding. There are no immediate first aid actions in this case.

1. It is important to fix the object in the wound and not touch it. To do this, you can use an adhesive plaster, clothing or bandage.
2. The victim should move as little as possible.
3. If the object was nevertheless removed from the wound, then you should immediately insert your fingers into the wound site in order to plug the hole.
4. You should immediately call an ambulance or take the victim to a doctor.

There are many cases in domestic surgery where people were able to survive such damage. There were situations when the victim remained alive after a gunshot wound to the heart and damage to the aorta.

The described rules should be applied in case of damage to any part of the body - they are universal.

Video

Soft tissue damage

1. When wounding soft tissues in the area with a knife inside His wrists should be covered with the lapel of his shirt or jacket; he can put his hand behind his belt, in his bosom, or in an inner pocket.
2. The wounded area is pressed firmly against the chest in order to reduce blood loss.
3. When the skin in the area of ​​the fingers or the back of the hand is cut, you need to unclench your fist and make a “boat” or “rib” with your palm.
4. You can also squeeze a piece of fabric or any clothing in your fist. This will help reduce blood flow.
5. If soft fabrics are wounded in the area of ​​the elbow, the wound should be pulled together or clamped. The hand can be squeezed tightly at the elbow.
6. With your injured hand, you can grab the pocket or lapel of your jacket. You can place an oblong object under the elbow bend. It could be a knife. In this case, it should be placed with the handle in the fold with the blade away from the body. This is necessary to prevent re-injury to the arm and reduce blood loss.

Features of treatment

The first stage of treatment for an incised wound is to stop the bleeding. In conditions medical institution For this purpose, an electrocoagulator is used, especially severe cases– placing a ligature (suture) on the vessel.

The next stage is treatment with disinfectant solutions. To do this, you can use a solution of chlorhexidine or hydrogen peroxide. Do not use substances containing alcohol, as this may cause burns to damaged tissues.

In some cases, in addition to stopping bleeding, suturing is necessary. This minor operation is performed to speed up wound healing, reduce cosmetic defect and reducing trauma to surrounding tissues.

Typically, sutures are placed under local anesthesia with catgut or synthetic thread. After 7-10 days, the sutures applied are removed.

Another component of treatment for an incised wound is antibiotic therapy.

When choosing antibacterial agent you must adhere to the following rules:

• the spectrum of action of the antibacterial agent should be as wide as possible in order to prevent the infectious process in the wound and the generalization of infection;
• the form of release of the drug should be convenient for the patient to ensure the greatest adherence to therapy;
• the dose should be sufficiently effective, but not maximum, to avoid side effects.

There are many ointments of complex action that have antibacterial, wound-healing and anti-edematous effects. In most cases, the use of ointment and a protective bandage (gauze, plaster or combination) provides fast recovery initial integrity of the skin.

Wound in the back

Injuries to the back of the chest may result in lung damage, which can be detected by X-ray. The wound in the central part of the back may go through the spine with a cut spinal cord. In this case, paralysis and numbness of the body below the level of damage are observed.

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Abdominal injuries occur due to the following reasons:

• blunt trauma: for example, in a car collision, hitting the steering wheel of a car, explosion, pinching, jolt, gunshot wound
• penetrating abdominal wounds: stab wound, bullet wound, impalement type wound
• Iatrogenic: laparoscopy, puncture of intra-abdominal organs

Pathogenesis

Tear, perforation, rupture of abdominal organs: spleen, liver, mesentery, kidney, diaphragm, stomach, duodenum (usually retroperitoneal wall), small intestine, large intestine, bladder, pancreas, gall bladder.

Injury to blood vessels, tear, or rupture of the mesentery results in intra-abdominal bleeding.

When perforation of intestinal loops, injury to the gallbladder or bile ducts occurs, peritonitis occurs.

Video: Bayan Yesentaeva hospitalized with stab wounds

Symptoms

Abdominal wounds - photo

The symptoms of abdominal wounds vary greatly, from minor to severe pain. You can detect a visible site of damage, hematoma, swelling, bleeding, wound. Clinic present acute abdomen, signs of shock.

Diagnosis of abdominal wounds

Anamnesis (drawing up a picture of the damage and the severity of the damage) and clinical examination: examination of the abdominal area, visible places injuries, penetrating wounds of the abdomen (do not probe), hematomas, dullness in the lateral parts of the abdomen, tense muscles of the abdominal wall, bowel sounds.

In the absence of symptoms, subsequent short-term monitoring + ultrasound.

X-ray for abdominal injury: overview image of the abdominal cavity standing or lying on the left side (foreign bodies, organ displacement, free air), if possible, computed tomography.

Examination of the chest (accompanying injuries, such as rupture of the diaphragm, bronchi, esophagus).

In patients with polytrauma, the skull bones, axial skeleton, lower and upper extremities (according to the clinic) are additionally examined.

Ultrasound of the abdominal cavity: free fluid (bleeding), wounds, ruptures of organs (spleen, liver, pancreas).

Laboratory examination for abdominal injury: urgent indicators for preparation (blood picture, coagulation factors, electrolytes, liver, renal parameters, pancreatic enzymes, blood type, Rh factor), order the required volume of blood, urinary status.

Peritoneal lavage for abdominal injury (indicated for blunt trauma, rarely performed today): performed using a puncture 2 transverse fingers below the navel, a catheter is inserted into the pelvis, then about 1 liter of Ringer's solution is injected, followed by suction, it is examined for presence of blood, bile, feces, if necessary, bacteriological examination, determination of lipase, amylase, hematocrit.

Video: “Dumb and Dumber”: Motorola terrorist shoots Russian “volunteer” in the stomach

Lavage is not performed when intestinal obstruction or adhesions due to the risk of perforation. With adhesions, a false negative result is possible due to the presence of cameras.

For penetrating wounds or an unclear clinical picture, diagnostic laparotomy is always indicated.

Differential diagnosis

• accompanying injuries in polytrauma with pain spreading to the abdominal wall
• bruises, hematomas of the anterior abdominal wall
• vertebral fractures, chest injuries (basal rib fractures)
• retroperitoneal hematomas
• contusions and ruptures of the diaphragm
• urinary tract injuries

Treatment

Treatment at home, Traditional treatment

Emergency treatment of abdominal injuries: stabilization of the function of vital organs, sterile closure of the wound or prolapsed intestine, foreign bodies are not removed at the preclinical stage, transportation to the clinic.

Surgical treatment is indicated for any penetrating wound, blunt trauma with intraperitoneal bleeding, or organ damage.

In case of a penetrating wound, wound inspection, laparotomy (not in the area of ​​the primary wound), inspection of internal organs and perforation sites, and tetanus prevention are carried out. The perforation site is sutured, local bleeding is stopped, and bactericidal rinsing with tauroline solution is performed. active antibiotic), wound drainage. In case of crushing of the intestine: resection of the damaged area.

The prognosis for abdominal injuries depends on the patient's condition (degree of shock) and the extent of the injury.

Complications of abdominal wounds

• bleeding, shock, life-threatening
• bowel prolapse
• intestinal obstruction (also a few days after injury, as a consequence of a covered mesenteric hematoma and subsequent intestinal necrosis)
• post-traumatic cholecystitis
• accompanying injuries in polytrauma: rib fractures, pneumothorax, contusion, rupture of the diaphragm, vertebral fractures, injury cervical spine spine, pelvic fractures, retroperitoneal hematomas, skull fractures, cranial bleeding

Report “Wounds and Abdominal Injuries”, presented at the plenum of the board of the Russian Society of Survivors within the framework of the international scientific and practical conference “Endovideosurgery in a multidisciplinary hospital” in St. Petersburg.

In the conditions of modern megacities, the severity of wounds and abdominal injuries has increased, which is explained by the improvement prehospital care and a significant reduction in the time it takes to deliver victims to the hospital. Thanks to the widespread use of equipped ambulances and helicopters for medical evacuation, extremely serious victims who previously died were transported to specialized trauma centers. Accordingly, the complexity of the surgical interventions performed has increased, which in recent years has led to the need to introduce the tactics of programmed multi-stage surgical treatment (MST) or “damage control surgery”. In the treatment of wounds and injuries of the abdomen, other new technologies began to be used (endovideosurgery, physical methods of hemostasis), which significantly changed surgical tactics and improved the outcomes of treatment of this severe pathology.

CLASSIFICATION OF WOUNDS AND INJURIES OF THE ABDOMEN

The classification of abdominal injuries is based on general principles classification of surgical trauma.

Stand out gunshot injuries(bullet, shrapnel, mine blast wounds and mine blast injuries) and non-gunshot abdominal injuries- non-gunshot wounds (stab wounds, stab wounds, cuts, lacerations and bruises) and mechanical injuries.

Abdominal injuries may be penetrating(if the parietal layer of the peritoneum is damaged) and non-penetrating.

Penetrating abdominal wounds are tangents, blind And end-to-end. With non-penetrating abdominal wounds, in 10% of cases, damage to the abdominal organs and extra-organ formations was noted due to the energy of the side impact of the wounding projectile.

By type of damaged organs wounds and mechanical injuries of the abdomen can be without damage to the abdominal organs, with damage to hollow (stomach) and parenchymal organs (liver), with damage to large blood vessels and their combination.

Abdominal injuries may be accompanied life-threatening consequences (continuing intra-abdominal bleeding, eventration of internal organs, continuing interstitial retroperitoneal bleeding). When victims with abdominal injuries are delivered late to a medical facility (more than 12 hours), severe infectious complications develop - peritonitis, intra-abdominal abscesses, phlegmon of the abdominal wall and retroperitoneal space.

DIAGNOSIS OF GUNSHOT WOUNDS OF THE ABDOMEN

Diagnosis of the penetrating nature of an abdominal wound is not difficult when there are absolute signs of a penetrating wound: loss of abdominal organs from the wound (eventration), leakage of intestinal contents, urine or bile.

For the rest of those wounded in the abdomen, the diagnosis is made on the basis of relative symptoms - ongoing intra-abdominal bleeding, which is observed in 60% of the wounded, and local signs. The diagnosis of a penetrating abdominal wound is easier to make with penetrating (usually bullet) wounds, when a comparison of the entrance and exit holes creates an idea of ​​the course of the wound canal. Difficulties are caused by the diagnosis of a penetrating nature in case of multiple wounds, when it is difficult or impossible to determine the direction of the wound channel by localizing the entrance and exit holes. It should be taken into account that often (up to 40% or more) there are penetrating wounds of the abdomen with the location of the entrance wound not on the abdominal wall, but in the lower parts of the chest, gluteal region, and upper third of the thigh.

For diagnosing penetrating gunshot wounds must be done X-ray of the abdomen in frontal and lateral projections.

belly (FAST - Focused Assessment with Sonography in Trauma) allows you to detect the presence of free fluid in the abdominal cavity (if its amount is more than 100-200 ml). Negative ultrasound result in the absence clinical signs a penetrating abdominal wound and stable hemodynamics is the basis for refusing further diagnostics (if necessary, ultrasound is repeated). In all other cases a negative ultrasound result does not exclude the presence of abdominal injuries

If suspicion of a penetrating wound persists, use instrumental methods diagnosis of penetrating abdominal wound : examination of the wound with a clamp, progressive widening of the wound, diagnostic peritoneal lavage, video laparoscopy and diagnostic.

Examination of the wound with a clamp is the most simple method and when used correctly, it can significantly reduce the duration of examination of the wounded.

Technique for examining a wound with a clamp : in the operating room, after processing the surgical field, a curved clamp (Billroth type) is carefully inserted into the wound and released from the hand. If the instrument falls into the abdominal cavity without effort under the influence of its own weight, a conclusion is drawn about the penetrating nature of the wound. If the result is the opposite, further examination of the wound channel is stopped due to the risk of causing additional damage. In this case, the so-called progressive expansion(i.e. revision) of a wound of the abdominal wall. Under local anesthesia the wound is dissected layer by layer, the course of the wound canal is traced and it is established whether the parietal peritoneum is damaged or not.

Laparocentesis to determine the penetrating nature of gunshot wounds of the abdomen is performed relatively rarely (in 5% of those wounded in the abdomen).

Indications for the use of laparocentesis:

• – multiple wounds of the abdominal wall;
• – localization of the wound in the lumbar region or near the costal arch, where progressive expansion of the wound is technically difficult;
• – in case of difficulty in the progressive expansion of the wound, since the course of the wound channel due to primary and secondary deviations can be complex and tortuous;
• – with non-penetrating gunshot wounds of the abdomen, when damage to the abdominal organs of the “side impact” type is suspected (noted in 10% of wounded with non-penetrating gunshot wounds of the abdomen).

Laparocentesis technique according to the method of V.E. Zakurdaeva.

Under local anesthesia, an incision of the skin and subcutaneous tissue up to 1.5–2 cm long is made in the midline of the abdomen 2–3 cm below the navel. To exclude false positive result Clamps are applied to the bleeding vessels. IN top corner wound, a single-pronged hook grasps the aponeurosis of the white line of the abdomen and the anterior abdominal wall is pulled upward. After this, the abdominal wall is pierced at an angle of 45–60° with careful rotational movements of the trocar (at the same time forefinger pushed forward towards the tip to prevent excessively deep insertion of the trocar). After removing the stylet, a transparent polyvinyl chloride tube with holes at the end is inserted into the abdominal cavity. The flow of blood through the tube or, which is much less common, the contents of hollow organs (intestinal contents, bile or urine) confirms the diagnosis of a penetrating abdominal wound and is an indication for laparotomy. If nothing is released from the catheter, it is sequentially carried out using a trocar sleeve into the right and left hypochondrium, into both iliac regions and the pelvic cavity. 10–20 ml of 0.9% sodium chloride solution is injected into the indicated areas, after which the solution is aspirated with a syringe.

A contraindication to laparocentesis is the presence of a scar on the anterior abdominal wall after a previously performed laparotomy. In such cases, an alternative diagnostic technique is microlaparotomy(access to the abdominal cavity for insertion of the tube is through a 4–6 cm long incision made away from the postoperative scar, usually along the semilunar line or in the iliac region).

If the result of laparocentesis or microlaparotomy is questionable (obtaining traces of blood on the tube, aspiration of pink fluid after administration of saline), diagnostic peritoneal lavage. A tube inserted into the pelvis is temporarily fixed to the skin, and a standard amount (800 ml) of 0.9% sodium chloride solution is injected into the abdominal cavity. After this, the tube is extended through an adapter with another long transparent tube and its free end is lowered into a vessel to collect the flowing liquid and dynamic observation. To objectify the results of diagnostic lavage of the abdominal cavity, a microscopic examination of the flowing fluid is performed: the content of red blood cells in it in an amount exceeding 10,000x1012/l is an indication for laparotomy.

If it is impossible to exclude the penetrating nature of the abdominal wound using other methods, perform laparoscopy, and in the case of an unstable condition of the wounded or in the absence of the possibility of performing it - laparotomy.

Indication for diagnostic laparoscopy When the abdomen is wounded, it is impossible to exclude its penetrating nature. Contraindications to its implementation are established based on the calculation of the VPC-EC index (Table 1, 2 of the Appendix). If its value is 6 or more points, due to the increased risk of complications from the main life-supporting systems during laparoscopy, “traditional” is performed. In cases where the VPC-EC index is less than 6 points, laparoscopy is performed. With values ​​of this index equal to 6 points, it is advisable to perform laparoscopy using laparolift (gasless laparoscopy) or “traditional” laparotomy.

A feature of laparoscopic revision of the abdominal cavity for abdominal wounds is a thorough examination of the parietal peritoneum in the area of ​​localization of the abdominal wall wound, which in most cases makes it possible to exclude or confirm the penetrating nature of the wound. If it is confirmed, an inspection of the abdominal organs is necessary, assessing the damage and making a decision either to perform therapeutic laparoscopy or to switch to traditional laparotomy (conversion). In the absence of damage, diagnostic laparoscopy for penetrating wounds necessarily ends with the installation of a control one in the pelvic cavity.

Only if it is impossible to exclude the penetrating nature of the abdominal wound using these methods is it permissible to perform diagnostic (exploratory) laparotomy.

SURGICAL TACTICS FOR PENETRATING ABDOMINAL WOUNDS

GENERAL PRINCIPLES OF SURGICAL TREATMENT OF ABDOMINAL TRAUMA

The main method of treating penetrating abdominal wounds is surgical intervention - laparotomy. In relation to gunshot wounds of the abdomen, surgical intervention is called primary surgical treatment of abdominal wounds , and laparotomy is a surgical approach to ensure the possibility of sequential surgical interventions on damaged organs and tissues (along the wound canal).

Preoperative preparation depends on general condition the wounded and the nature of the injury. Duration of preoperative infusion therapy should not exceed 1.5–2 hours, and if internal bleeding continues, intense antishock therapy should be carried out simultaneously with execution for urgent indications.

Laparotomy performed under endotracheal anesthesia with muscle relaxants. The standard and most convenient is midline laparotomy, because it allows not only to perform a full inspection of the abdominal organs and retroperitoneal space, but also to carry out the main stages of surgical intervention. If necessary, the incision can be extended in the proximal or distal directions, or supplemented with a transverse approach.

The main principle of surgical intervention for abdominal wounds with damage to the abdominal organs and retroperitoneal space is stop bleeding as quickly as possible. The most common sources of bleeding are damaged liver, mesenteric and other blood vessels, kidneys, and pancreas. If a significant amount of blood is detected in the abdominal cavity, it is removed using electric suction into a sterile container, then the bleeding is stopped, and after all intra-abdominal injuries have been established and the severity of the wounded person’s condition has been assessed, a decision is made on the extent of surgical intervention.

Surgical treatment of wounds parenchymal organs includes removal of foreign bodies, detritus, blood clots and excision of necrotic tissue. To stop bleeding and suturing wounds of parenchymal organs, piercing needles with threads made of absorbable material (Polysorb, Vicryl, catgut) are used. Edges of gunshot defects hollow organs(stomach, intestines, bladder) are sparingly excised up to 0.5 cm around the wound. A sign of the viability of the wall of a hollow organ is clear bleeding from the edges of the wound. Failure to comply with this rule is accompanied by a high rate of failure of sutures. All hematomas of the walls of hollow organs are subject to mandatory revision to exclude damage penetrating into the lumen. Suturing of hollow organs and the formation of anastomoses is performed using double-row sutures: the 1st row is applied through all layers with an absorbable thread, the 2nd - gray-serous sutures made of non-absorbable material (prolene, polypropylene, nylon, lavsan).

A mandatory element of surgical intervention for injuries of the abdominal organs is abdominal lavage a sufficient amount of solutions (at least 6–8 l).

The operation for a penetrating abdominal wound is completed by inserting tubes into the abdominal cavity through separate incisions (punctures) in the abdominal wall. One of the drains is always installed in the pelvic area, the rest are brought to the sites of injury.

Indications for inserting tampons into the abdominal cavity for abdominal wounds are extremely limited:

• – uncertainty about the reliability of hemostasis (tight tamponade is performed);
• – incomplete removal of the organ or inability to eliminate the source of peritonitis (tampons are left in place for the purpose of delimiting infectious process from the free abdominal cavity).

In some cases, drains left in the abdominal cavity serve not only to control the amount and nature of discharge from the abdominal cavity, but also to perform postoperative lavage abdominal cavity. Its implementation is indicated in cases where intraoperative sanitation failed to completely wash blood, bile or intestinal contents from the abdominal cavity or when surgery was carried out against the background of peritonitis. In the latter case, the composition of the lavage fluid includes antiseptics, heparin, and antienzyme drugs. Lavage is performed fractionally (usually 4–6 times a day) with a sufficient volume of liquid (1000–1200 ml).

Suturing the surgical wound the anterior abdominal wall after laparotomy is performed layer by layer with the installation (if necessary) of drainages in the subcutaneous tissue. If laparotomy is performed in conditions of peritonitis, severe intestinal paresis, and also if repeated sanitation of the abdominal cavity is expected (including with MHL or “damage control” tactics), suturing of the peritoneum and aponeurosis is not performed, only skin sutures are applied.

DAMAGE TO LARGE ABDOMINAL BLOOD VESSELS

Injuries to large blood vessels of the abdomen occur in 7–11.0% of patients with penetrating gunshot wounds of the abdomen. Moreover, in most cases (90.3%), the abdominal organs are simultaneously damaged, and 75.0% of those wounded in the abdomen also have associated injuries of a different location.

The condition of the majority of the wounded in this category (79.8%) is severe or extremely serious, which is determined by both the anatomical severity of the injuries and acute blood loss. Only in 14.0% of these wounded does it not exceed 1 liter, in 41.0% it varies from 1 to 2 liters and in 45.0% of the wounded it exceeds 2–2.5 liters.

With ongoing intra-abdominal bleeding and unstable hemodynamics in the wounded, temporary - up to 20–30 min - aortic compression in the subdiaphragmatic region (with fingers, a tuffer or a vascular clamp) to prevent irreversible blood loss (Degiannis E., 1997). This maneuver is performed through the lesser omentum after mobilizing the left lobe of the liver (with upward and lateral abduction) and pulling the stomach downwards. The esophagus and paraesophageal tissue are retracted with the fingers, which allows the aorta to be felt.

In most cases, such clamping of the aorta is enough to find the source of bleeding and eliminate it by applying a clamp, stitching or tight tamponade (damage to the liver, spleen or pancreas, injury to mesenteric vessels).

In specialized multidisciplinary centers, the method of temporary endovascular occlusion with balloon probes of various designs can be effectively used for temporary hemostasis from large abdominal vessels.

Stopping bleeding from large abdominal vessels(abdominal aorta and inferior vena cava, iliac vessels, portal vein) requires the use of special technical techniques.

For revision abdominal aorta and its branches carried out rotation of internal organs to the right: the splenorenal ligament is divided, then the parietal peritoneum is dissected (from the splenic flexure of the colon along the outer edge of the descending and sigmoid colon). These formations bluntly peel off in the medial direction above the left kidney.

With this retroperitoneal approach, the entire abdominal aorta and its main branches (celiac trunk, superior mesenteric artery, left renal artery, iliac arteries) become accessible.

If the aorta is injured below the infrarenal region, proximal bleeding control can be achieved transperitoneal access after retracting the small intestine to the right, the transverse colon upward and the descending colon to the left. The peritoneum is incised longitudinally just above the aorta, and the duodenum is mobilized superiorly. Upper limit access - left renal vein, crossing the aorta anteriorly.

Access to infrarenal portion of the inferior vena cava carried out after rotation of internal organs to the left: by dissecting the parietal peritoneum along the outer edge of the cecum and ascending colon. Then they are peeled off and retracted medially over right kidney cecum, ascending and mobilized hepatic flexure of the colon.

If necessary, selection suprarenal portion of the inferior vena cava The duodenum is also mobilized according to Kocher with internal rotation of the duodenum and the head of the pancreas, or a median sternotomy and dissection of the diaphragm may be necessary.

Damage suprarenal and retrohepatic sections of the inferior vena cava, as well as hepatic veins refers to the most difficult situations with a mortality rate of 69.2% and is diagnosed by ongoing bleeding from posterior sections liver, despite compression of the hepatoduodenal ligament, i.e. hepatic artery and portal vein.

In this case, stopping the bleeding with tight tamponade of the wound is indicated to implement the MHL or “damage control” tactics. If tamponade is ineffective, atriocaval shunting is performed, which is the only method of temporary hemostasis to eliminate damage to the proximal parts of the inferior vena cava and hepatic veins.

An effective and safe method of temporary hemostasis in case of damage to the suprarenal portion of the inferior pudendal vein is its endovascular occlusion with a double-balloon probe while maintaining blood flow, inserted through the great saphenous vein of the thigh.

Iliac vessels are inspected from direct access over the hematoma after ensuring proximal control of hemostasis by retracting the small intestine to the right and dissecting the peritoneum above the aortic bifurcation.

After exposing the vessels and temporarily stopping the bleeding (over-clamping, tight tamponade, application of tourniquets and vascular clamps), a vascular suture (lateral or circular) is performed, and in case of a large defect, plastic surgery with an autologous vein or a synthetic prosthesis is performed. If it is not possible to restore the integrity of a large blood vessel, temporary prosthetics or ligation is performed.

In a difficult surgical situation (development of terminal state, significant technical difficulties), as well as when implementing MHL tactics or “damage control” bandaging is acceptable top mesenteric artery below the origin of the first small intestinal branch, the inferior vena cava in the infrarenal region (below the entry of the renal veins into it), as well as one of the three main tributaries of the portal vein (superior or inferior mesenteric, splenic veins). In case of ligation of the hepatic artery or large mesenteric vessels, a planned relaparotomy (preferably video laparoscopy) may be required as a “second look operation” to control the condition of the ischemic areas of the abdominal organs. If it is impossible to restore the abdominal aorta, common or external iliac artery, portal vein, temporary vascular prosthetics is necessarily performed.

Ligation of the inferior vena cava in the suprarenal region above the confluence of the renal veins (as well as ligation of the aorta) is incompatible with life. Ligation of one of the hepatic veins, as a rule, does not cause negative consequences.

According to our analyzed experience of treating 206 wounded with damage to 275 large blood vessels of the abdomen mortality amounted to 58.7%, incl. more than half of the wounded (59.0%) died from blood loss during the operation and within 1 day. after her. The nature of surgical intervention on the vessels was as follows: in 45.8% of the wounded, vascular ligation or tight wound tamponade was performed; restoration of vascular patency was achieved in 28.8% of cases (lateral suture - 11.5%, circular suture - 10.1%, angioplasty - 7.2%). One of A promising method of temporary intraoperative hemostasis is endovasal balloon occlusion .

Due to the extremely serious condition of the wounded and ongoing profuse intraoperative bleeding, in a quarter of cases of intervention (25.4%), the operation was reduced to attempts to temporarily stop the bleeding with death on the table. 92.0% of the wounded who survived surgery developed severe complications, including in 18% of cases requiring relaparotomy.

LIVER DAMAGE

Liver injuries occur in 22.4% of patients with penetrating gunshot wounds to the abdomen.

The extent of surgical treatment of a liver wound depends on the degree of damage. A way to significantly reduce the intensity of bleeding from a liver wound is temporary (up to 20 minutes) clamping of the hepatoduodenal ligament with a tourniquet or vascular clamp.

In critical situations with extensive liver damage, temporary compression of the liver, tight tamponade or hepatopexy (1.7%) - suturing the liver to the diaphragm (if the source of bleeding is multiple ruptures on its diaphragmatic surface) is used for the purpose of hemostasis.

In case of superficial small fragment wounds without signs of bleeding, the liver suture is not performed (13.8%). Small bleeding wounds of the liver are sutured with U-shaped sutures made of absorbable material (84.5%) with packing of the wound with a strand greater omentum on a leg.

In case of extensive organ damage, atypical liver resection is performed (9.5%). In this case, external decompression of the biliary tract (cholecystostomy or choledochostomy) is mandatory.

For minor damage gallbladder After surgical treatment of the wound, the defect is sutured and cholecystostomy is performed. In case of extensive damage, cholecystectomy is indicated, and in case of concomitant liver damage, drainage of the common bile duct through the stump of the cystic duct is necessary.

In case of damage extrahepatic biliary tract Surgical tactics are determined by the extent of the wound and the presence of damage to other abdominal organs. In case of a marginal wound of the hepaticocholedochus, it is sufficient to perform external drainage of the duct through the wound. In case of complete interruption of the common bile duct, especially in the case of damage to other abdominal organs and severe concomitant trauma, an end hepaticostomy is performed as part of the MHL tactics (“damage control”). In case of isolated injury and stable condition of the wounded with a complete interruption of the hepaticocholedochus, it is preferable to primary restore the passage of bile into the intestine by applying a biliodigestive anastomosis with a loop of the small intestine disconnected by Roux on a submersible drainage.

Most Frequent complications of liver injuries- secondary bleeding, intra-abdominal abscesses (1–9%), biliary fistulas (3–10%), liver cysts, hemobilia and biliary peritonitis.

Mistakes in surgical treatment of liver wounds: failure to carry out rapid temporary hemostasis in case of profuse bleeding from a liver wound by compression of the liver tissue around the wound (and the hepatoduodenal ligament); attempts to stop bleeding from the depths of the wound canal by suturing the inlet (and outlet) opening.

Mortality from liver injuries reaches 12%.

DAMAGE TO THE SPLEEN

Injuries to the spleen occur in 6.5% of patients with penetrating gunshot wounds to the abdomen. Damage to the spleen from gunshot wounds is usually an indication (97.0%). When isolating the spleen and applying a clamp to the splenic pedicle, it is necessary Avoid damage to the tail of the pancreas.

In rare cases of superficial damage to the capsule or separation of the ligaments of the spleen, it may be sutured (U-shaped sutures, with a strand of the omentum on the pedicle sutured) or the use of physical methods hemostasis (3.0%).

Most Frequent complications of splenic wounds- secondary bleeding and abscesses of the left subphrenic space (5%). Splenectomy in wounded patients over 20 years of age is not accompanied by severe immunodeficiency.

Mistakes in surgical treatment of spleen wounds: gross isolation of the spleen with damage to surrounding tissues - damage to the tail of the pancreas and the fundus of the stomach is especially dangerous; irrational attempts to preserve the damaged spleen.

The mortality rate for splenic injuries is 10%.

DAMAGE TO THE PANCREAS.

Injuries to the pancreas occur in 5.7% of patients with penetrating gunshot wounds of the abdomen and, as a rule, are combined with damage to surrounding organs of the pancreaticoduodenal zone.

For superficial non-bleeding (usually shrapnel) wounds of the gland, suturing is not required (71.3%). Bleeding from small wounds of the pancreas is stopped by diathermocoagulation or suturing (22.8%). In such cases, it is sufficient to drain the cavity of the omental bursa with a tube that runs along the lower edge of the gland from the head to the tail and is brought out retroperitoneally under the splenic flexure of the colon onto the left side wall of the abdomen (to pass the drainage tube, a small incision of the peritoneum is used along the transitional fold at the splenic flexure of the colon). colon).

In case of complete ruptures of the pancreas distal to the passage of the superior mesenteric vessels, resection of the damaged part of the body and tail of the pancreas can be performed, usually together with the spleen (5.9%). At the same time, such a volume of surgery, especially when other abdominal organs are injured, with a combined nature of the injury in conditions of massive blood loss, often leads to death. Therefore, in case of severe injury to the gland, it is more rational to perform suturing (or tight tamponade) of the bleeding vessels, and, if possible, suturing the distal and proximal ends of the damaged Wirsung duct with adequate drainage of the omental bursa. Despite the inevitability of post-traumatic pancreatitis, necrosis and sequestration of areas of the pancreas, and the formation of pancreatic fistulas, treatment outcomes in such wounded patients are more favorable.

In case of extensive wounds of the head of the pancreas, its resection can be performed with pancreatojejunostomy with a loop of the small intestine disconnected according to Roux, but more often a less traumatic intervention is performed: suturing or tight tamponade of the bleeding vessels of the pancreas and marsupialization with suturing of the gastrocolic ligament to the edges of the surgical wound.

During operations for wounds of the pancreas (regardless of the extent of damage), infiltration of the parapancreatic tissue with a 0.25% solution of novocaine with antienzyme drugs (contrical, gordox, trasylol) should be performed, and the intervention should be completed by drainage of the omental bursa, nasogastrointestinal intubation and unloading cholecystostomy.

In the postoperative period, it is necessary to use inhibitors of gland secretion (sandostatin or octreotide) and inhibitors of its enzymes (contrical), targeted antibiotics (abactal, metronidazole)

Most Frequent complications of pancreatic injuries- formation of pancreatic fistulas (6%) and intra-abdominal abscesses (5%), post-traumatic pancreatitis, retroperitoneal phlegmon, arrosive bleeding, formation of pancreatic pseudocysts.

Mistakes in surgical treatment of pancreatic wounds: failure to inspect the retroperitoneal hematoma in the projection of the pancreas, failure to inspect the pancreas in the presence of bile stains under the parietal peritoneum; improper drainage of the area of ​​pancreatic injury; attempts to perform extensive reconstruction of the damaged gland in an extremely serious condition of the wounded; non-use of sandostatin (octreotide) in the postoperative period.

The mortality rate for pancreatic injuries is 24%.

STOMACH DAMAGE

Stomach injuries occur in 13.6% of wounded with penetrating gunshot wounds of the abdomen and, as a rule, are combined with damage to other organs. For any injury to the stomach The cavity of the lesser omentum must be opened and inspected so as not to miss damage to the posterior wall of the stomach. Gunshot wounds of the stomach should be excised sparingly, always ligating the bleeding vessels. The gastric wall defect is sutured with a double-row suture in the transverse direction, especially in the outlet section (to prevent stenosis). Thanks to the abundant blood supply, stomach wounds heal well. In rare cases, with extensive damage to an organ, atypical marginal resection is performed (1.5%).

Surgery for gastric wounds ends with the mandatory insertion of a nasogastric tube for the purpose of decompression for 3–5 days; a tube is inserted into the small intestine for early enteral nutrition.

Most Frequent complications of stomach wounds- bleeding, failure of sutures and the formation of intra-abdominal abscesses, peritonitis.

Mistakes in surgical treatment of gastric wounds: viewing damage to the posterior wall of the stomach; inadequate debridement wounds of the stomach wall, which leads to suture failure; poor-quality hemostasis, accompanied by gastric bleeding in the postoperative period; failure to drain the stomach with a probe.

The mortality rate for stomach injuries is 6%.

DAMAGE TO THE DUODENUM

Injuries to the duodenum occur in 4.8% of patients with penetrating gunshot wounds of the abdomen and in 90% of cases are combined with damage to other organs. Particularly difficult is the diagnosis of injuries to the retroperitoneal part of the intestine (not recognized in 6% of cases). Indications for mandatory mobilization and revision of the duodenum are retroperitoneal hematoma in the projection of the intestine, the presence of bile and gas in the hematoma or in the free abdominal cavity.

Wounds on the anterior wall of the duodenum are sutured with a double-row suture in the transverse direction (70% of all operations for wounds of the duodenum). To eliminate damage to the retroperitoneal part of the duodenum, the intestine is mobilized according to Kocher (descending and lower horizontal part of the intestine) or the ligament of Treitz is transected (terminal part of the intestine). The wound hole in the intestine is sutured with a double-row suture, and the retroperitoneal space is drained with a tube. With any suturing of wounds of the duodenum, it is necessary to decompress it with a nasogastroduodenal tube (for 5–6 days), and a tube is inserted into the small intestine for early enteral nutrition.

In case of pronounced narrowing and deformation of the intestine as a result of suturing the wound (more than half the circumference), the operation of choice is to disconnect (diverticulize) the duodenum by suturing and peritonizing the outlet of the stomach and applying a gastrojejunostomy.

In case of extensive damage to the intestine distal to the papilla of Vater, the following intervention is performed: an anastomosis is performed between the proximal end of the duodenum and the loop of the small intestine disconnected by Roux, the distal end of the duodenum is plugged. To prevent suture failure, the duodenum is also disconnected by suturing the gastric outlet.

Considering that injuries to the duodenum often occur simultaneously with damage to the pancreas, surgical tactics for these injuries are determined based on the characteristics and nature of damage to both organs. In case of severe injury to the duodenum, head of the pancreas and common bile duct, pancreaticoduodenal resection is performed or (in the extremely serious condition of the wounded) MHL tactics are performed. During the first intervention, only hemostasis is carried out and the contents of hollow organs are prevented from leaking into the free abdominal cavity: suturing the duodenal wall, external drainage of the bile and pancreatic ducts. After stabilization of the wounded person, relaparotomy and pancreaticoduodenectomy are performed.

Most Frequent complications of duodenal injuries- gastroduodenal bleeding, failure of sutures with the formation of duodenal fistulas and intra-abdominal abscesses, peritonitis.

Mistakes in surgical treatment of duodenal wounds: failure to inspect the retroperitoneal hematoma in the projection of the intestine, failure to inspect the duodenum with bile stains under the parietal peritoneum; failure to drain the area of ​​intestinal injury in the retroperitoneal space and failure to insert a probe into the small intestine for enteral nutrition; irrational surgical tactics for extensive intestinal injuries.

Mortality from duodenal injuries reaches 30%.

SMALL INTESTINE DAMAGE

Injuries to the small intestine occur in 56.4% of patients with penetrating gunshot wounds of the abdomen.

For wounds of the small intestine, suturing of wounds (45.0%) or resection of a section of intestine (55.0%) is used. Suturing is possible in the presence of one or several wounds located at a considerable distance from each other, when their size does not exceed the semicircle of the intestine. The intestinal wound, after economical excision of the edges, is sutured in the transverse direction with a double-row suture.

Resection of the small intestine is indicated for defects of its wall larger than a semicircle; crushes and bruises of the intestine with disruption of the viability of the wall; separation and rupture of the mesentery with impaired blood supply; multiple wounds located in a limited area. The imposition of a primary anastomosis after resection of the small intestine is permissible in the absence of peritonitis, as well as after high resection of the jejunum, when the danger to the life of the wounded from the formation of a high intestinal fistula is higher than the risk of failure of the anastomotic sutures. There is a high probability of anastomotic failure in the area of ​​poor blood supply - the terminal section ileum 5–20 cm proximal to the ileocecal angle. The method of restoring intestinal patency (end-to-end anastomosis - 42.0% or side-to-side - 55.2%) is determined by choice. However, for surgeons who do not have much practical experience, it is preferable to perform a side-to-side anastomosis, which is less often accompanied by suture failure.

In conditions of diffuse peritonitis in the toxic or terminal phase, an anastomosis is not performed, and the afferent and efferent ends of the small intestine are brought to the abdominal wall in the form of fistulas (2.8%).

The most important element of the operation is small bowel intubation. Indications for its implementation are:

• – multiple nature of intestinal injury;
• – extensive damage to the mesentery;
• – pronounced symptoms of peritonitis with intestinal paresis.

Preference is given to nasogastrointestinal intubation; if this is not possible, an intestinal tube is passed through a gastrostomy, cecostomy or enterostomy.

Most Frequent complications of small intestinal injuries- failure of sutures, acute, narrowing of the area of ​​intestinal anastomosis with disruption of passage, formation of intra-abdominal abscesses, peritonitis.

Mistakes in the surgical treatment of small intestinal wounds: failure to detect intestinal wounds, especially in the mesenteric region; inadequate surgical treatment of gunshot wounds of the intestinal wall when suturing them; the formation of an anastomosis in the terminal ileum, which leads to suture failure; suturing several closely spaced wounds with intestinal deformation instead of performing resection of a section of intestine; failure to perform nasogastrointestinal intubation in the presence of peritonitis; layer-by-layer suturing of the abdominal wall with severe intestinal paresis, which is accompanied by abdominal compartment syndrome.

The mortality rate for injuries of the small intestine reaches 14%.

COLON DAMAGE

Injuries to the colon occur in 52.7% of patients with penetrating gunshot wounds of the abdomen.

Suturing a colon wound with a double-row suture (22.0%) is only permissible if it is small in size (up to 1/3 of the circumference of the colon), early stages surgery (up to 6 hours after injury), the absence of massive blood loss, peritonitis, as well as damage to other abdominal organs and severe concomitant trauma. However, it should be taken into account that up to 40% of suturing operations for gunshot wounds of the colon are accompanied by suture failure.

If these conditions are absent, either removal of the movable damaged section of the intestine is performed in the form of a double-barreled unnatural anus, or its resection and formation of a single-barrel unnatural anus (50.4%).

In the latter case, the efferent end of the intestine is plugged according to Hartmann or (in case of peritonitis) brought to the abdominal wall in the form of a colonic fistula.

If the free edge of the intraperitoneally located parts of the colon is injured (if there is doubt about the outcome of suturing or large size wound defect - up to half the circumference of the intestine), it is possible to perform extraperitonealization of a section of the intestine with a sutured wound (21.7%). Extraperitonealization technique consists of temporarily removing a sutured damaged loop of the colon into an incision in the abdominal wall, which is sutured to the aponeurosis. The skin wound is loosely packed with ointment bandages. In the case of a successful postoperative course, after 8–10 days the loop of intestine can be immersed in the abdominal cavity or the skin wound can simply be sutured. With the development of failure of the intestinal sutures, a colonic fistula is formed.

For extensive wounds of the right half of the colon, a right hemicolectomy is performed (5.9%). Application of ileotransverse anastomosis is possible only in the absence of peritonitis and stable hemodynamics; in other situations, the operation ends with the removal of an end ileostomy.

Colon surgery ends with its mandatory decompression by devulsion (stretching) of the anus or a colonic probe inserted through the rectum; if the left half of the colon is injured, it is passed beyond the suture line.

Most Frequent complications of colon wounds- failure of sutures, formation of intra-abdominal abscesses, peritonitis, retroperitoneal phlegmon.

Mistakes in surgical treatment of colon wounds: failure to detect intestinal wounds, especially in the mesenteric region or retroperitoneal areas; inadequate surgical treatment of wounds of the intestinal wall, which leads to failure of the suture in the case of suturing the intestine or “failing” of the colostomy; incorrect surgical tactics with an attempt to suturing extensive wounds of the intestine or applying colonic anastomoses for gunshot wounds.

Mortality from colon injuries reaches 20%.

RECTAL INJURY

Injuries to the rectum occur in 5.2% of patients with penetrating gunshot wounds of the abdomen.

Minor wounds intraperitoneal section the rectum is sutured with a double-row suture (7.1%), then sigmoid colon a double-barreled unnatural anus is applied.

In case of extensive wounds of the rectum, a resection of the non-viable area is performed and the adducting end of the intestine is removed to the anterior abdominal wall in the form of a single-barreled unnatural anus. The outlet end is sutured tightly (Hartmann procedure).

When wounded extraperitoneal section rectal surgery is performed in two stages. In the first, a double-barrel unnatural anus is placed on the sigmoid colon. After that the abductor part of the rectum is washed with an antiseptic solution from feces. At the second stage, the ischiorectal space is opened using the perineal approach. If possible, the wound hole in the intestinal wall is sutured, and the sphincter is restored if it is damaged. Effective drainage of the pararectal space is mandatory.

Most Frequent complications of rectal injuries- failure of sutures, formation of intra-abdominal and intra-pelvic abscesses, peritonitis, retroperitoneal and intra-pelvic phlegmon.

Mistakes in surgical treatment of rectal wounds: inadequate surgical treatment of wounds of the intestinal wall, which leads to suture failure in case of intestinal suturing; refusal to form an unnatural anus; incorrect surgical tactics with an attempt to suturing extensive wounds of the intestine and applying colonic and rectal anastomoses on an unprepared intestine; ineffective drainage of the pararectal space.

The mortality rate for rectal injuries is 14%.

DAMAGE TO THE KIDNEYS AND URETERS

Kidney damage occur in 11.9% of wounded with penetrating gunshot wounds of the abdomen.

Surgical access to a damaged kidney is only midline laparotomy . Exposure of the kidney is performed by cutting the parietal peritoneum according to Mattocks and rotating the colon to the right or left, respectively.

Superficial wounds of the kidney that do not penetrate pelvic system, are sutured absorbable suture material (15.9%).

For more massive wounds (penetrating the pelvic system), especially with damage to the hilum of the kidney, injury to the vessels of the kidney, it is indicated nephrectomy (77,0%).

PeReBefore performing it, you need to make sure that there is a second kidney! If the pole of the kidney is injured, in the absence of severe damage to other organs and the wounded person is in a stable condition, it is possible to perform organ-preserving surgery - kidney pole resection (7.1%), which is necessarily supplemented by nephropyelo- or pyelostomy.

Ureteral injuries occur in 1.7% of wounded with penetrating gunshot wounds of the abdomen, but are often diagnosed late - already by the appearance of urine in the discharge through the drainage left in the abdominal cavity (attention is drawn unusually a large number of separated).

In case of damage to the ureter, suturing the lateral(up to 1/3 of the circle) defect or resection of damaged edges and anastomosis on the ureteral catheter(stent). In case of extensive damage to the ureter, either the central end of the ureter is brought out onto the abdominal wall, or its circular suture is performed on a ureteral catheter (stent) with unloading nephropyelo- or pyelostomy, or nephrectomy is performed.

Most Frequent complications of wounds of the kidneys and ureters- bleeding, failure of sutures with the formation of urinary leaks and retroperitoneal phlegmon, urinary fistulas, pyelonephritis.

Mistakes in surgical treatment of wounds of the kidneys and ureters: failure to perform an inspection of the kidney due to a hematoma in its area; improper inspection of the kidney through the mesentery or without prior control of bleeding from the renal vessels; ineffective drainage of the perinephric space; late diagnosis of ureteral injury; excessive mobilization when suturing a damaged ureter, leading to its stricture.

The mortality rate for kidney injuries reaches 17%.

DIAGNOSIS AND SURGICAL TREATMENT OF CLOSED ABDOMINAL INJURIES

Closed abdominal injuries occur in car accidents, falls from a height, compression of the torso by heavy objects, or debris from buildings. Recognition of intra-abdominal injuries is especially difficult when there is a combination of a closed abdominal injury with damage to the skull, chest, spine, and pelvis. With concomitant severe traumatic brain injury, the classic symptoms of an acute abdomen are masked by general cerebral and focal neurological symptoms. Against, clinical picture, reminiscent of symptoms of damage to the internal organs of the abdomen, can be provoked by rib fractures, retroperitoneal hematoma due to fractures of the pelvic bones and spine.

Closed abdominal injury accompanied by damage parenchymal organs, as well as blood vessels of the abdomen (more often with ruptures of the mesentery), is manifested by symptoms of acute blood loss: pallor of the skin and mucous membranes, a progressive decrease in blood pressure, increased heart rate and increased respiratory rate. Local symptoms caused by intra-abdominal bleeding (tension of the abdominal wall muscles, peritoneal symptoms) are usually mild. In such cases, the most important clinical signs are dullness of percussion sound in the flanks of the abdomen and weakening of the sounds of intestinal peristalsis.

Closed damage hollow organs quickly leads to the development of peritonitis, the main signs of which are abdominal pain, dry tongue, thirst, pointed facial features, tachycardia, breast type breathing, muscle tension of the anterior abdominal wall, widespread and sharp pain on palpation of the abdomen, positive symptoms of peritoneal irritation, absence of intestinal peristalsis sounds. Significant diagnostic difficulties arise in cases of closed ruptures of retroperitoneal parts of the colon and duodenum, pancreas. The clinical picture is initially blurred and appears only after development severe complications(retroperitoneal phlegmon, peritonitis, dynamic intestinal obstruction).

Closed damage kidney accompanied by pain in the corresponding half of the abdomen and lumbar region with irradiation to groin area. Constant symptoms in such cases are macro- and microhematuria, which may be absent when the vascular pedicle is torn off from the kidney or the ureter is ruptured.

Closed abdominal trauma may be accompanied by subcapsular ruptures of the liver and spleen. In these cases, bleeding into the abdominal cavity may begin a considerable time (up to 2-3 weeks or more) after the injury as a result of rupture of the organ capsule from the pressure of the hematoma formed under it (two-stage ruptures of the liver and spleen).

In all cases, examination for suspected abdominal trauma should include digital rectal examination(you are the phenomenon of overhang of the anterior wall of the rectum, the presence of blood in its lumen), Toatherization of the bladder(in the absence of independent urination) with a urine test for red blood cell content.

Approximate ultrasound examination abdomen allows you to quickly and reliably identify hemoperitoneum and can be repeated many times during dynamic observation. The disadvantages of the method include its low sensitivity for injuries of hollow organs and the subjectivity of assessing the identified findings. The abdomen is examined for fluid through the right hypochondrium (Morrison's space), left hypochondrium (around the spleen), and the pelvis. Ultrasound examination helps the surgeon determine the indications for laparotomy in patients with abdominal trauma and unstable hemodynamics. A negative ultrasound result in the absence of clinical signs of closed injury to the internal organs of the abdomen and stable hemodynamics is grounds for refusing further diagnostics (if necessary, ultrasound is repeated). In all other cases a negative ultrasound result does not exclude the presence of damage to the abdominal organs, which requires the use of other research methods.

CT scan for abdominal injuries has a number of limitations:

• — not performed in hemodynamically unstable wounded;
• - has low specificity for injuries of hollow organs;
• - requires the use of contrast to clarify the nature of damage to parenchymal organs;
• — there is subjectivity in the quick assessment of identified findings;
• — repeated use during dynamic observation is difficult.

The absence of identified injuries to the abdominal organs on CT is not a basis for 100% exclusion of the diagnosis of abdominal trauma!

ABOUT main method instrumental diagnostics closed abdominal trauma is laparocentesis. The technique for carrying it out is the same as for abdominal wounds. The only peculiarity is that in case of combined injuries of the abdomen and pelvis with a fracture of the bones of the anterior semi-ring, laparocentesis is performed at a point 2 cm above the navel to prevent the stylet from passing through the preperitoneal hematoma and obtaining a false positive result.

Laparocentesis performed to diagnose closed abdominal trauma can also be supplemented in doubtful cases diagnostic lavage of the abdominal cavity, since for the diagnosis of damage to internal organs during a closed abdominal injury, it is not the fact of the presence of blood in the abdominal cavity that is important, but its quantity. The threshold level of erythrocyte content when performing diagnostic peritoneal lavage is considered not 10,000x10 12, as for wounds, but 100,000x10. 12

The presence of a small amount of blood in the abdominal cavity during a closed injury can be explained by inertial ruptures of the peritoneum, sweating of the retroperitoneal hematoma during fractures of the pelvic bones. Intense blood staining of the flowing fluid (the content of red blood cells in the lavage fluid is more than 750,000x1012 is a sign of the accumulation of a significant amount of blood in the abdominal cavity and is considered a reason for performing laparotomy). When the content of red blood cells in the lavage fluid is from 100,000x10 12 to 750,000x10 12, diagnostic and therapeutic video laparoscopy is performed.

Surgical treatment of internal organ injuries due to closed abdominal trauma.

For ruptures liver, depending on the severity of the damage to the parenchyma, suturing or atypical resection is used (preferably with tamponade with a strand of the greater omentum). Extensive liver injury with damage to large vessels may require the use of tight tamponade as part of the MHL tactics. For inertial ligament ruptures with small tears spleen an attempt should be made to ensure hemostasis by suturing or (better) coagulation and preserve the organ. Mesenteric tears guts may be accompanied by severe bleeding, and with extensive avulsions of the intestine - necrosis of its wall. The presence of such mesenteric ruptures in a closed abdominal injury indicates a significant traumatic effect. Retroperitoneal hematomas, identified during laparotomy, are subject to mandatory revision, with the exception of cases when they come from the area of ​​pelvic bone fractures.

TACTICS OF MULTISTAGE SURGICAL TREATMENT (“DAMAGE CONTROL SURGERY”) FOR WOUNDS AND INJURIES OF THE ABDOMEN

In case of extremely severe wounds and injuries of the abdomen with damage to large blood vessels and (or) with multiple damage to intra-abdominal organs and massive blood loss, severe disturbances of homeostasis: severe acidosis(pH less than 7.2), hypothermia(body temperature less than 35°C), coagulopathy(RT more than 19 s and/or PTT more than 60 s) to save the life of the wounded, MHL or “damage control” tactics are undertaken, which in relation to abdominal injuries is designated as abbreviated laparotomy with programmed relaparotomy (SL-PR).

The VPH-CT scale (VPH - Department of Military Field Surgery, HT - surgical tactics), which was developed on the basis of a statistical analysis of the results of treatment of 282 wounded in the abdomen, allows us to specify the indications for the SL-PR tactics for gunshot wounds of the abdomen.

ShkAla VPH-HT for gunshot wounds of the abdomen

FAToTORs	ZnAhenAnde	BAll
SBP upon admission -<70 мм рт.ст.	No	0
Avulsion of a limb segment, damage to the main vessel of the limb, chest injury requiring thoracotomy	No	0
Volume of intracavitary (chest and abdomen) blood loss at the beginning of surgery, ml	1000	0
The presence of an extensive retroperitoneal or intrapelvic hematoma	No	0
Damage to a large vessel in the abdomen or pelvic area	No	0
Presence of a difficult-to-remove source of bleeding	No	0
The presence of three or more damaged organs of the abdomen and pelvis or two requiring complex surgical interventions	No	0
Presence of diffuse peritonitis in the toxic phase	No	0
Unstable hemodynamics during surgery, requiring the use of inotropic drugs	No	0

If the scale index value is 13 points or more, the probability of death is 92%, therefore abbreviated laparotomy with programmed relaparotomy is indicated.

Methodology for performing the 1st stage of the SL-PR tactics for wounds and abdominal injuries is as follows. Ensures fast temporary hemostasis by ligating the vessel, temporary intravascular prosthesis or tight wound tamponade (depending on the source of bleeding).

Intervention on the abdominal organs should be minimal in volume and as fast as possible. Only incompletely severed sections of organs that interfere with effective hemostasis are removed. Damaged hollow organs are either sutured with a single-row (manual or hardware) suture, or simply bandaged with gauze to prevent further leakage of contents into the peritoneal cavity.

Temporary closure of the laparotomy wound is carried out only by bringing together the edges of the skin wound with a single-row suture or applying clamps (layer-by-layer suture of the abdominal wall is not performed!). In case of severe intestinal paresis, to prevent abdominal compartment syndrome, the abdominal cavity can be delimited from the external environment by sewing a sterile film into the laparotomy wound.

The use of SL-PR tactics in 12 wounded with extremely severe abdominal wounds in the North Caucasus made it possible to reduce mortality from 81.3 to 50%.

ENDOVIDEOSURGERY FOR ABDOMINAL WOUNDS AND INJURIES

All laparoscopies are divided into diagnostic And medicinal. The indication for diagnostic laparoscopy for abdominal wounds is the inability to exclude its penetrating nature. In case of closed abdominal injuries, the indication for diagnostic laparoscopy is the detection of erythrocytes in the flowing fluid during diagnostic peritoneal lavage in the range from 100 to 750 thousand per 1 mm3. If the number of red blood cells exceeds 750 thousand per 1 mm3, emergency laparotomy is indicated.

Features of surgical technique during diagnostic laparoscopy in the wounded. The sequence of laparoscopic exploration of the abdominal cavity is determined by the mechanism of injury. With closed abdominal injuries, damage to parenchymal organs is primarily excluded. A feature of laparoscopic revision of the abdominal cavity for stab and shrapnel wounds of the abdomen is a thorough revision of the parietal peritoneum, which in most cases makes it possible to exclude the penetrating nature of the wound. With through bullet wounds of the abdomen, even if the penetrating nature of the wound is excluded, a thorough inspection of the abdominal cavity is necessary in order to exclude damage to internal organs due to a side impact. In all cases, diagnostic laparoscopy of the abdominal cavity ends with the installation of drainage in the pelvic cavity.

Features of surgical technique during therapeutic laparoscopy in the wounded. The main types of operations are: stopping bleeding from shallow ruptures or wounds of the liver and spleen; splenectomy in the presence of a shallow wound with moderate bleeding and failure of physical methods of hemostasis; cholecystectomy for avulsions and injuries of the gallbladder; suturing small wounds of hollow organs and diaphragm.

Coagulation of a liver wound. When liver wounds up to 1 cm deep with moderate bleeding are detected, monopolar electrocoagulation is used with an electrode with a spherical tip. For bleeding from stellate, irregularly shaped liver wounds, as well as from liver wounds lacking a capsule, the method of choice should be the use of argon plasma coagulation, which allows a non-contact method to form a reliable scab. The operation ends with mandatory drainage of the subhepatic space and the pelvic cavity.

Coagulation of a splenic wound. The use of this method for splenic injuries is possible when the wound is localized in the area of ​​attachment of the splenic-colic ligament and there is mild capillary bleeding. The most effective is the use of argon plasma coagulation, which allows the non-contact formation of a reliable dense scab. Drainage of the left subphrenic space and the pelvic cavity is mandatory.

Splenectomy. The position of the wounded person is on the right side with the head end raised. To insert the laparoscope, a 10 mm port is installed below the navel. Additionally, two 10 mm and 5 mm ports are installed in a fan-shaped manner under the costal arch. First, the splenic flexure of the colon is mobilized and the splenocolic ligament is incised. Then, after bipolar coagulation, the gastrosplenic ligament is sequentially dissected to the point where the short gastric arteries pass through it, which are intersected after preliminary clipping. After mobilization, the splenic artery and vein are clipped as distally as possible. The phrenosplenic ligament is divided bluntly and the spleen is placed in a plastic container. The wound in the area of ​​the 10 mm port is expanded with a three-leaf retractor to a diameter of 20 mm. Then, using a Luer lock, the spleen is removed from the abdominal cavity in portions. The abdominal cavity is sanitized, hemostasis is controlled, and the left subdiaphragmatic space and the pelvic cavity are drained with thick silicone drains.

Cholecystectomy. The technique of this intervention for wounds and avulsions of the gallbladder is similar to that for diseases of the gallbladder.

Suturing the diaphragm wound. If a wound to the diaphragm is detected, drainage of the pleural cavity on the side of the injury is immediately performed. Suturing of the diaphragm is carried out from the abdominal cavity: the 1st suture-holder is applied to the far edge of the wound. By applying traction to the stay suture, the wound is sequentially sutured with Z-shaped intracorporeal sutures. The subphrenic space on the injured side and the pelvic cavity are drained.

Suturing a gastric wound. The wound of the anterior wall of the stomach is sutured with a two-row suture: the 1st row is applied with Z-shaped intracorporeal sutures in the transverse direction through all layers of the stomach, the 2nd row is applied with gray-serous Z-shaped sutures. The tightness of the applied suture is checked by pumping air through a gastric tube and applying liquid to the suture line. An inspection of the posterior wall of the stomach is required. To do this, after preliminary coagulation, the gastrocolic ligament is dissected for 5 cm, the stomach is lifted with a fan-type retractor, and the cavity of the lesser omentum is examined. If there is a wound to the posterior wall of the stomach, it is sutured in the described manner. The integrity of the gastrocolic ligament is restored with Z-shaped intracorporeal sutures. Thick silicone drains are installed in the right hypochondrium and pelvic cavity.

Surgical interventions were performed laparoscopically on 104 wounded and injured patients. In all cases, the algorithm for diagnosing injuries to the abdominal organs included laparocentesis with peritoneal lavage using the original method. The share of diagnostic laparoscopy was 52.8%, the conversion rate was 18.6%. The rate of conversion to laparotomy varied depending on the type of injury. Thus, for bullet wounds it was 28.6%, for shrapnel wounds - 16.7%, for stab wounds - 31.3%, and for closed injuries - 27.3%.

As a result of diagnostic interventions, it was possible to exclude the penetrating nature of bullet and shrapnel wounds (18.1% each, respectively) and in 20% - stab wounds, as well as in 43.6% of cases - damage to the internal organs of the abdomen during a closed injury. The most common type of therapeutic laparoscopy was splenectomy - 27.4% (11 for closed trauma and 3 for shrapnel wounds). In other cases, the laparoscopic method was used to coagulate liver wounds (3.7%), suturing wounds of the diaphragm and the anterior wall of the stomach equally in 5.5%, performing cholecystectomy (3.7%) in case of gallbladder avulsion and in 11.1% of cases with In case of damage to the spleen, stop bleeding using argon-enhanced plasma coagulation.

Thus, in the treatment of victims, diagnostic laparoscopy was more often used, which made it possible to avoid unnecessary laparotomies in more than half of the cases.

POST-TRAUMATIC PERITONITIS

Peritonitis in wounds and injuries is an infectious complication, the pathogenetic essence of which is inflammation of the peritoneum, which develops as a result of damage to organs (mainly hollow) of the abdominal cavity. Depending on the prevalence of the infectious process peritonitis may be related to local infectious complications (IO) if the inflammation of the peritoneum is limited, or generalized IO (abdominal sepsis), if the infectious process spreads to the entire peritoneum.

Modern views on the etiology and pathogenesis of peritonitis, classification, diagnosis, surgical treatment and intensive care are presented in the practical guide “Peritonitis” edited by V.S. Savelyev, B.R. Gelfand and M.I. Filimonova (M., 2006).

The etiological classification distinguishes between primary, secondary and tertiary peritonitis.

Primary peritonitis may complicate the course of tuberculosis and other rare infections and is not found in injury surgery.

The most common option is secondary peritonitis, which unites all forms of inflammation of the peritoneum due to wounds and injuries or destruction of the abdominal organs or after planned surgery.

Tertiary peritonitis develops in the postoperative period in the wounded and injured with a pronounced depletion of anti-infective defense mechanisms and with the addition of bacteria with low pathogenicity or fungal microbiota to the infectious process. This nosological form is identified if, after an adequately performed surgical intervention for secondary peritonitis and full initial antibiotic therapy after 48 hours, no positive clinical dynamics are observed and the process of peritoneal inflammation becomes sluggish, recurrent.

Depending on the prevalence of peritonitis There are two forms of it: local and widespread . Local divided into delimited(inflammatory infiltrate, abscess) and unbounded when the process is localized in one of the peritoneal pockets. With this form of peritonitis, the task of the operation is to eliminate the source of peritonitis, sanitize the affected area and prevent further spread of the process. At widespread (spread) peritonitis(affecting more than two anatomical areas of the abdominal cavity) requires extensive sanitation with repeated washing of the entire abdominal cavity.

The clinical course of peritonitis depends on the nature of the inflammatory exudate (serous, purulent, fibrinous, hemorrhagic or their combinations) and pathological impurities (gastric and small intestinal contents, feces, bile, urine), coming from the hollow organs of the abdomen. The microbiological characteristics of the exudate are essential: aseptic, aerobic, anaerobic or mixed. The nature of the pathological contents of the abdominal cavity determines qualitative differences in the clinical course of peritonitis and significantly affects the prognosis.

In case of damage to the upper parts of the digestive tract: stomach, duodenum, jejunum and pancreas, the rapid clinical picture in the first hours is due to the development aseptic (chemical) peritonitis. Removing aggressive contents from the abdominal cavity in a short time creates favorable conditions for stopping the pathological process.

Chemical in nature is also urinary peritonitis, which occurs when the bladder ruptures. It proceeds slowly, with blurred clinical symptoms, so it is diagnosed late. Has a similar clinical course bile and hemorrhagic peritonitis.

If the information content of non-invasive research methods is low, diagnostic laparoscopy, which in the vast majority of cases makes it possible to identify signs of peritonitis (turbid exudate, fibrin overlay on the visceral peritoneum, leakage of bile, gastric or intestinal contents from damaged organs and other pathological changes) and determine the degree of its prevalence, and also in some cases eliminate the source of peritonitis, sanitize peritoneal cavity and adequately drain it ( laparoscopic sanitation of the abdominal cavity).

Diagnosis fecal peritonitis due to abundant contamination of the exudate with the contents of the terminal ileum or colon, it determines the rapid onset, vivid clinical picture, severe course and unfavorable outcomes of anaerobic peritonitis.

Currently there are four phases of peritonitis (with and without abdominal sepsis):

1) absence of sepsis;

2) sepsis;

3) severe sepsis;

4) septic (infectious-toxic) shock.

AbdOmAndnAlbusth sepsis has a number of distinctive features that determine treatment tactics:

• – the presence of multiple, poorly demarcated foci of destruction, making their immediate sanitation difficult;
• – long-term existence of synchronous or metachronous infectious and inflammatory foci;
• – means of drainage or artificial delimitation of inflammatory foci become sources of potential endogenous and exogenous reinfection;
• – the difficulty of differential diagnosis of aseptic forms of inflammation (sterile pancreatogenic peritonitis, intestinal dysbacteriosis) and the progression of infectious-inflammatory tissue destruction as the clinical picture of abdominal sepsis develops;
• – rapid development of multiple organ failure syndrome and septic shock.

Frequency of post-traumatic peritonitis.

According to the materials of “Experience in medical support for troops in operations in the North Caucasus in 1994–1996 and 1999–2002,” the incidence of peritonitis in those wounded in the abdomen was 8.2–9.4%. At the same time, in seriously wounded patients with isolated, multiple and combined abdominal wounds, the frequency of widespread peritonitis was 33.5%, abdominal abscesses - 5.7% and retroperitoneal phlegmon - 4.5%. Abdominal sepsis with multiple organ failure was the cause of death in 80.2% of the wounded of those who died from abdominal wounds.

Surgery. The main method of treating peritonitis, which has the greatest impact on the outcome, is a full-fledged, comprehensive surgical intervention aimed at: 1) eliminating or limiting the source of peritonitis; 2) sanitation, drainage, decompression of the abdominal cavity; 3) prevention or treatment of intestinal failure syndrome. There is no debate about the direct dependence of the frequency and severity of peritonitis on the time elapsed from the moment of injury to the start of surgery. Therefore, those wounded in the abdomen should be transported as quickly as possible to the stage of medical care, where such intervention can be performed.

Sequence of surgery for widespread peritonitis.

1. Access. The most rational access, providing maximum visibility and ease of performing subsequent stages of the operation, is midline laparotomy. If necessary, access can be extended in the upper part by bypassing the xiphoid process on the left, in the lower part - by making an incision to the pubic symphysis.
2. Removing pathological contents. According to the war in Afghanistan 1979–1989, along with blood and reactive effusion, gastric contents were found in the abdominal cavity in 6.8% of the wounded, intestinal contents in 59.8%, urine in 2.8%, 7% - bile and 1.0% - purulent exudate.
3. Revision of abdominal organs performed sequentially to identify the source of peritonitis.
4. Eliminating or limiting the source of peritonitis- the most important and responsible part of the surgical intervention. In all cases, the question of choosing the method of operation is decided individually, depending on the severity of inflammatory changes in the wall of a hollow organ, the degree of its blood supply, and the general condition of the wounded.

N placement of sutures and anastomoses of hollow organs is contraindicated in conditions of severe peritonitis, questionable blood supply, in severe or extremely serious condition of the wounded. The operation of choice in such cases is obstructive resection of a hollow organ with removal of the adducting end in the form of a stoma or with plugging it and draining the adducting part of the intestine (tactics for programmed relaparotomies). The exception is suturing and anastomosing the damaged initial section of the jejunum, in which the risk of developing insolvency is lower than the risk of forming a high small intestinal fistula. In case of injuries to the right half of the colon, the possibility of applying a primary anastomosis depends on the nature of the destruction and the degree of blood supply to the intestinal wall. If the left half of the colon is damaged, the most reliable way is to remove the leading end of the intestine in the form of a single-barrel unnatural anus with plugging of the leading end.

If it is impossible to radically remove the source of peritonitis, the affected organ is delimited with gauze tampons from the free abdominal cavity, while the tampons are removed through separate incisions of the abdominal wall in its most sloping places.

1. Sanitation abdominal cavity is carried out with large volumes of warm saline solution, sufficient for mechanical removal of exudate and all pathological impurities.
2. Drainage of the small intestine indicated in the presence of loops of the small intestine sharply distended by the contents, with a flabby, edematous, sluggish peristalsis, with dark spots (subserous hemorrhages) of the intestinal wall.

Decompression of the small bowel is carried out by placing a nasogastroduodenal tube (50–70 cm distal to the ligament of Treitz). The main goal is emptying and prolonged drainage of the initial section of the jejunum. It is mandatory to insert a separate probe into the stomach.

The duration of drainage of the small intestine is determined by the restoration of intestinal motility and can be up to 3–4 days.

1. Abdominal drainage. Traditionally, single or double-lumen soft silicone drains are placed to the source of peritonitis and to the most sloping areas of the abdominal cavity: the pelvic cavity, lateral canals.
2. Closure of the laparotomy wound. If a favorable course of peritonitis is predicted, layer-by-layer suturing of the abdominal wall wound is performed. If there is intestinal paresis accompanied by visceral, in order to decompression In the abdominal cavity, only the skin and subcutaneous tissue are sutured.

In case of probable unfavorable course of peritonitis after a single surgical correction, the tactics of programmed relaparotomies are recommended. In this case, temporary rapprochement of the wound edges is carried out using any of the existing methods.

Relaparotomy - repeated intervention on the abdominal organs due to:

• – progression of peritonitis when the primary source is not eliminated or when new sources appear or tertiary peritonitis;
• – bleeding into the abdominal cavity or gastrointestinal tract;
• – ineffectiveness of treatment of intestinal failure syndrome;
• – the occurrence or complication of a concomitant disease requiring urgent surgical intervention
• – a complication resulting from a violation of surgical technique.

Principles of performing relaparotomy:

• – access – removal of sutures from the laparotomy wound;
• – elimination of the cause of repeated intervention on the abdominal organs (necrosequestrectomy, stopping bleeding, eliminating adhesive obstruction);
• – sanitation of the abdominal cavity with large volumes (5-10 l) of warm saline solution;
• – carrying out intestinal decompression;
• – drainage of the abdominal cavity;
• – closure of the laparotomy wound. Its method depends on the decision on further tactics for managing the wounded: surgical treatment of the edges, layer-by-layer suturing of the wound or suturing only the skin and subcutaneous tissue with a predicted favorable course of peritonitis, or temporary reduction of the wound edges when moving to the tactics of programmed relaparotomies.

Programmed relaparotomy – repeated staged surgical intervention on the abdominal organs in the event of an expected unfavorable course of peritonitis due to the possible ineffectiveness of a single surgical intervention.

Indications for programmed relaparotomy tactics:

• – impossibility of eliminating or limiting the source of peritonitis with a single surgical correction;
• – the severity of the wounded person’s condition, which does not allow performing the required full scope of primary intervention;
• – the condition of the laparotomy wound, which does not allow closing the defect of the anterior abdominal wall;
• – impossibility of closing the edges of the laparotomy wound due to the risk of developing intra-abdominal hypertension syndrome;
• – diffuse fibrinous-purulent or anaerobic peritonitis.

PRintsSPHow to perform programmed relaparotomies:

• – staged removal or delimitation of the source of peritonitis (necrosequestrectomy, delayed operations on hollow organs, etc.);
• – repeated sanitation of the abdominal cavity with warm saline solution;
• – monitoring the patency and correct positioning of the nasogastrointestinal tube for intestinal decompression;
• – correction of methods of drainage of the abdominal cavity;
• – temporary reduction of the edges of the laparotomy wound, determination of the need, volume and timing of its treatment, as well as the timing of the final closure of the abdominal cavity.

Intensive therapy of widespread peritonitis (abdominal sepsis) . Intensive therapy is a mandatory component of the treatment program for abdominal sepsis.

Main areas of intensive care

1. Prevention and correction of intestinal failure syndrome.
2. Directed (reasoned) antimicrobial therapy.
3. Active and passive immune-oriented therapy.
4. Nutritional support (early enteral, total parenteral and mixed nutrition).
5. Respiratory therapy (ventilation, intravenous ventilation, including non-invasive ventilation, sanitation FBS).
6. Adequate infusion and transfusion therapy.
7. Prevention of the formation of stress ulcers of the gastrointestinal tract.
8. Extracorporeal hemocorrection.
9. Control and correction of glycemic levels.
10. Anticoagulant therapy.

A special area of ​​intensive care is the treatment intestinal failure syndrome, which can clinically manifest itself as intestinal paresis and early adhesive intestinal obstruction.

At intestinal paresis enteral lavage is performed through a gastric and intestinal tube, drug or physiotherapeutic stimulation of intestinal motility, dynamic monitoring of the condition of the abdominal organs using laboratory and ultrasound diagnostics. The lack of effect of the treatment within 8-12 hours is an indication for relaparotomy.

At early adhesive intestinal obstruction Activities aimed at stimulating intestinal motility are removed from the treatment program. The indication for relaparotomy is the lack of effect from the therapy within 8-12 hours. The obligatory stage of relaparotomy is total nasointestinal intubation. The probe is removed no earlier than after 7 days.

Treatment methods for intestinal failure syndrome include selective decontamination of the gastrointestinal tract, aimed at preventing the spread and local destruction of opportunistic bacteria of intestinal microbiocenosis, as well as removing toxins. It is carried out through an installed nasogastric or nasogastrointestinal tube by administering a combination of drugs:

• – tobramycin (gentamicin) - 320 mg/day or ciprofloxacin - 1000 mg/day;
• – polymyxin E (colistin) or M - 400 mg/day;
• – amphotericin B - 2000 mg/day;
• – fluconazole - 150 mg/day.

The daily dose is divided into four administrations. The duration of selective decontamination is 7 days or more, depending on the dynamics of the process.

The article was prepared and edited by: surgeon