83

MC Vol.17-No.4-2011 ( 83-86 ) Laghari H.Z. et al

Quarterly Medical Channel www.medicalchannel.pk
PENETRATING INJURY TO SOLID
ABDOMINAL ORGANS
ABSTRACT:
Background: Trauma is leading cause of death in young adult in UK. Penetrating
abdominal injury implies either Gunshot wound or stab wound. Stabbing are more
common than Gun Shot. Stabbing involves the transfer of low level of energy, with
damage confined to the course of the wound track; tissue away from the tract is
unaffected unless transaction of neurovascular supply occurs.
Methodology:
Study Design: Prospective Descriptive
Setting: Department of Surgery at Liaquat University of Medical & Health Sciences,
J amshoro.
Sample Size: 50 patients of penetrating abdominal trauma followed up for 3 months.
Results: The age of the patients ranged from 7 to 65 years with mean age of 30 years.
Out of these 50 patients, 4 (8%) patients were females and 46 (92%) male. Majority
of the patient had firearm injuries 68% while stab injuries were only seen in 32% of cases
(Table I). Mean lapse time between trauma and surgical intervention was 4.25 hours. A
total of thirteen patients (26%) were having hepatic injury with other associated injuries
to other abdominal organs. Out of these, eleven patients (22%) had gunshot injuries, and
two (4%) got stab injury. Hepatic trauma varied from a small laceration to complete
shattering of the liver lobe
Conclusion: Liver is the most commonly injured solid organ in which coupting suturing
is sufficient in 50% of the patients. Splenectomy still is safe option to deal with splenic
trauma in our set up. In cases of pancreatic trauma peri-pancreatic drainage is an
acceptable and safe option. Resection of the pancreas is not a desirable emergency
procedure.
Keywords: abdominal injury, gun shot, stab wound, visceral injury
INTRODUCTION
With advancing mechanization and increasing lawlessness in society, extensive trauma has
emerged as a serious health hazard.
1
Incidence of penetrating trauma to the abdomen has
increased significantly in the last few years due to increased terrorism in our society.
Previously, penetrating injuries were occurring in rural areas of the Pakistan due to tribal
clashes resulting in gunshot. But now firearms are increasing in urban areas too, due to
spread of high velocity weapons after Afghan War.
1, 2
Healthy young males are the usual victims of such type of violence. These injuries result
in the loss of precious lives, hard earned money and many working hours of potentially
the most useful member of the society
.2
Penetrating trauma to the abdomen is a
potentially lethal injury and requires high level of suspicious, early diagnosis and
appropriate management. Even when the patient with penetrating abdominal injury
reaches the hospital, controversy exists in the management and up to now the trauma
surgeons have not decided whether exploratory laparotomy is mandatory or not.
A quick swift diagnosis of internal injuries and their prompt treatment remains a major
M E D I C A L M E D I C A L M E D I C A L M E D I C A L M E D I C A L
C H A N N E L C H A N N E L C H A N N E L C H A N N E L C H A N N E L
ORI
Original Article
1. ZAMEER HUSSAIN LAGHARI,
2. AFZAL JUNEJO,
3. QAMBAR HUSSAIN LAGHARI,
Corresponding author:
DR. ZAMEER HUSSAIN LAGHARI,
FCPS
Registrar
Department of Surgery,
Liaquat University of Medical &
Health Sciences, J amshoro
1. Registrar
Department of Surgery,
Liaquat University of Medical &
Health Sciences, J amshoro
2. Associate Professor
Department of Surgery,
Liaquat University of Medical &
Health Sciences, J amshoro
3. Resident
Department of Surgery,
Liaquat University of Medical &
Health Sciences, J amshoro
84
MC Vol.17-No.4-2011 ( 83-86 ) Laghari H.Z. et al
Quarterly Medical Channel www.medicalchannel.pk
challenge for the attending surgeons in case of penetrating injury
of the abdomen because current diagnosis pre-operatively in relation
to the extent of internal damage is not possible frequently. Surgeons
started operating on abdomen more regularly at the end of 19
th
and
early 20
th
century but in cases of trauma such operations were
associated with frightful mortality of up to 80%.
3
Results of
laparotomy improved after world war-II because of the experience
gained to deal with war injuries. In recent years, there is marked
improvement in the management of abdominal trauma not only
because of improved safety of surgery and aftercare but also
because of availability of better diagnostic tools. Despite these
advancements the incidence of preventable deaths is not uncommon
following penetrating abdominal trauma.
4
The aim of this study
was to evaluate the pattern of various injuries to solid organs
sustained by patients of penetrating abdominal trauma.
MATERIAL AND METHODS
This prospective descriptive study comprises a total of fifty (50)
patients with abdominal trauma who were brought to the Department
of Surgery from casualty department of Liaquat University Hospital
J amshoro / Hyderabad from J anuary 2009 to December 2010.
Patients were received in the emergency department where the
injuries were assessed and resuscitation immediately started according
to the Advanced Trauma Life Support guidelines. The resuscitative
measures included provision of two venous accesses with 18 G
I/V canula and infusion of crystalloids like Ringer lactate, 0.9%
isotonic saline and Colloids e.g. Haemaccel and transfusion of
fresh blood. Once the patient become haemodynamically stable,
then they were shifted to surgical unit there they were also
resuscitated and blood sample was drawn for blood grouping and
cross matching. A detailed history along with thorough examination
of patient was carried out in ward in every case. Baseline
investigations including blood CP, blood sugar, urea, creatinine,
electrolytes, plain x-ray abdomen, ultrasound abdomen and peritoneal
tapping were performed. Patients having no clinical and diagnostic
evidence of peritoneal penetration or visceral trauma were closely
monitored. While patients with signs of peritoneal irritation, peritoneal
breach on wound exploration, intraperitoneal blood loss, evisceration
and free gas beneath diaphragm underwent for laparotomy.
RESULTS:
The age of the patients ranged from 7 to 65 years with mean age
of 30 years. Out of these 50 patients, 4 (8%) patients were
females and 46 (92%) male. Majority of the patient had firearm
injuries 68% while stab injuries were only seen in 32% of cases
(Table I). Mean lapse time between trauma and surgical intervention
was 4.25 hours.
One patient (3.3%) of firearm injury with suspected visceral
injury underwent laparotomy but no visceral injury was found to
any viscus because peritoneum was not breached and the bullet
FIGURE / TABLE 1 CAUSES OF PENETRATING
ABDOMINAL TRAUMA N = 50
FIGURE/ TABLE II: COMPLICATIONS
TABLE III: DISTRIBUTION OF HEPATIC INJURIES
N=13
TABLE IV: SOLID ORGAN INVOLVEMENT
85
MC Vol.17-No.4-2011 ( 83-86 ) Laghari H.Z. et al
Quarterly Medical Channel www.medicalchannel.pk
had passed through anterior abdominal wall. Another one case
(3.3%) with firearm injury had a suspected hepatic injury and on
USG; there was minimal fluid around the liver with no subcapsular
hematoma or echo texture difference of liver parenchyma. This
patient was treated conservatively and patient did well and was
discharged afterwards, he also had associated right-sided
pneumothorax for which chest intubation was done. Tube was
removed after 72 hours. Nine patients (18%) developed wound
infection. Four patients (8%) had abdominal dehiscence. One
patient (3.3%) developed gangrene of the ileostomy and two (4%)
developed faecal fistula that was of low output and successfully
healed conservatively in four weeks (Table II). The average hospital
stay was 9 days in those who presented early and were operated
within 6 hours of injury. The patient who presented late had more
prolonged convalescence and the average hospital stay in those
patients increased to 16 days.
A total of thirteen patients (26%) were having hepatic injury with
other associated injuries to other abdominal organs. Out of these,
eleven patients (22%) had gunshot injuries, and two (4%) got stab
injury. Hepatic trauma varied from a small laceration to complete
shattering of the liver lobe. (Table III) Grade I injuries were
observed in 7 (54%) patients, there was no vigorous hemorrhage
and patients were managed by simple coopting sutures. Grade II
injury were found in only 2 (15%) patients and he was managed
by applying figure of eight suture starting from depth and reinforced
by gelatin sponge. Grade III injuries were seen in 4 (31%) patients,
liver was partially shattered in all cases and they were managed
by removal of all devitalized tissue by finger fracture method and
suture ligation of the bleeding vessels was done.
Right sided pneumothorax was found in one case due to gunshot
injury to right hypochondriac region, ultrasound revealed free
fluid around the liver, no subcapsular hematoma or echo texture
difference of liver parenchyma. The patient was haemodynamically
stable and was treated conservatively; chest intubation was done
for pneumothorax. Three patients (6%) had renal injury due to
firearm (Table IV). Out of these one patient required surgery and
2 had through and through penetration of bullet from the middle
and lower 1/3 of the right kidney. Debridement & Pyelonephrostomy
was performed in these cases. Four patients (8%) had injury to
pancreas due to firearm. Tail of the pancreas was injured in one
(2%) patient, distal pancreatectomy and splenectomy was performed
in this patient. Another patient had an injury to the body of
pancreas left to the mesenteric vessels and was managed by
suture and lesser sac was drained with tube drain. Another 2 (4%)
patients had also injury to the tail of pancreas which were managed
conservatively Four patients (8%) had firearm injury in the left
hypochondriac region; on investigation left hemi-diaphragmatic
perforation was found in all cases. Two of these patients had
associated hepatic and gastric injuries. In these patients diaphragms
were repaired by interrupted non absorbable sutures. Eight patients
(16%) were reported with history of splenic injury due to gunshot
trauma injury. In all these patient spleen was badly shattered.
Splenectomy was performed in all the cases including 5 patients
having associated injury of transverse colon in 2 cases, in which
exteriorization of colon was done in the form of colostomy and
3 patients with jejunal perforation which were repaired primarily.
DISCUSSION
The age frequency in the current study ranges from 7 to 65 years
with mean age of 30 years that is almost similar with a study by
Udobi

et al in 2001
4
they reported a figure of 30 years. While it
is lower i.e. 23 years in a study by khoury et al in 1996 in USA
5
.
More recently another study conducted at Department of General
Surgery, University Hospital Girona, Spain by Rodrguez-Hermosa
J I, has given a median age of 35 years.
6
In this study one patient had negative laparotomy because bullet
passed through the anterior abdominal wall without breaching the
peritoneum. One patient with firearm injury was treated
conservatively as he was haemodynamically stable and did not
reveal any evidence of visceral injury, the most important thing
in the conservative management of the patient was repetitive
examination and continuous eye on the vitals and abdominal signs
of the patient. His duration of stay in hospital was 4 days;
shorter than the patient with negative laparotomy i.e. 7 days.
In this study 48 patients (96%) underwent for laparotomy which
is almost same as compared to studies reported by Ijaz Ahmad
1
in 1992 in which of 148 cases (98%) were operated and AFA
Khan
7
in which 73 cases (96%) in 1999 were operated. Liver
injuries constituted the main bulk of injuries 26.6% (n=13) to the
solid organs whereas A.K Leppaniemi et al
5
in 1999 in a series
of 209 cases depicted a figure of 22% while in other study by
I.M. Bain et al
50
in 1996 calculated a figure of 30%, 29.1% and
30.7% in their small series of 10, 24 and 13 cases respectively.
However AFA Khan et al
7
in their study of 37 cases noted 14.5%
liver injuries.
Our approach is comparable with Athar et al
8
who observed that
finger fracture technique in some and perihepatic packing in rapidly
exsanguinating patients are the viable options for injured liver.
However on the contrary few authors recommends that although
non-operative management of liver injuries has been common
practice a management plan that involves a multimodal surgical
strategy is essential.
3,6
Splenic injuries constituted 16%. The incidence is lower 7.2% in
study of A F A Khan et al
7
in 1999 and just 7% in a study by
Ijaz
1
.

As we did Splenectomy in all patients we think operative
procedure for the management of splenic trauma requires some
more efforts towards salvage.
Pancreatic trauma constituted 8% of the injuries. Madiba et al
9
in 1995 quoted the incidence of about 10% of the abdominal
injuries but Ijaz et al in 1996 mentioned a figure of 6.1%. Gupta
et al
10
in 2008 in India mentioned a figure of 1-12% as the
pancreas is surrounded by major abdominal organ and blood vessels,
associated injuries are consequently frequent. In current study all
the pancreatic injuries are coupled with other abdominal organ
injuries (100%). In pancreatic trauma improved evaluation and
more aggressive surgical intervention is desired than exploration
and drainage.
11
The pattern of internal organ injuries in our study is comparable
with the other series. The Similarity among these depicts the
pattern of injury depending upon the site and depth of organ and
the trajectory of the missiles. Prevalence of injuries to small gut,
colon, liver and spleen can thus be explained.
CONCLUSION
Intestine, liver, spleen and stomach found to be most frequently
injured abdominal organs in this study. After debridement simple
reconstructive procedure of repair are adequate in most of the
cases. The delay between the time of injury and the initiation of
treatment is responsible for the unfavorable outcome. Persistent
sepsis is responsible for higher mortality.
86
MC Vol.17-No.4-2011 ( 83-86 ) Laghari H.Z. et al
Quarterly Medical Channel www.medicalchannel.pk
REFERENCES
1. Ahmed I. Abdominal Trauma. A Prospective Study. Pak J Surg
1996:8; 37-42.
2. Schmelzer TM, Mostafa G, Gunter OL Jr, Norton HJ, Sing RF.
Evaluation of selective treatment of penetrating abdominal trauma. J
Surg Educ. 2008 Sep-Oct; 65(5):340-5.
3. McAnena OJ; Moore EE; Marx JA. Peritoneal Lavage enzyme
determination following blunt and penetrating abdominal trauma. J
Trauma 1998: 31(8); 1161.
4. Fraga GP, Bansal V, Fortlage D, Coimbra R. A 20-year experience
with portal and superior mesenteric venous injuries: has anything
changed? Eur J Vasc Endovasc Surg. 2009 Jan;37(1):87-91.
5. Khoury G, Sfeir R, Khalifeh M, Nabbout G. Penetrating trauma to the
abdominal vessels. Cardiovasc-Surg 1996; June 4(3): 405-07.
6. Rodrguez-Hermosa JI, Roig J, Sirvent JM, Codina-Cazador A, Girons
J, Puig J,Osorio M. Gastric perforations from abdominal trauma. Dig
Surg. 2008; 25(2):109-16.
7. Noor MA, Ather MH. Difference in the outcome of patients managed
with isolated renal injury and co-existent abdominal organ injury. J
Ayub Med Coll Abbottabad. 2003 Jan-Mar; 15(1):29-32.
8. Mallik ZU, Hanif MS, Tariq M. Mass casualty management after a
suicidal attack on a religious procession in Quetta, Pakistan. J Coll
phys surg Pakistan; 2006; 16 (4): 253-56.
9. Madiba TE, Mokoena TR. Favorable prognosis after surgical drainage
of gunshot, stab or blunt trauma of the pancreas. Br J Surg 1995; 82:
1236-39.
10. Gupta V, Wig JD, Garg H. Trauma pancreaticoduodenectomy for
complex pancreaticoduodenal injury. Delayed reconstruction. JOP. 2008
Sep 2; 9(5):618-23.
11. Bala M, Rivkind AI, Zamir G, Hadar T, Gertsenshtein I, Mintz Y, et
al. Abdominal trauma after terrorist bombing attacks exhibits a unique
pattern of injury. Ann Surg. 2008 Aug; 248(2):303-9.