Emergency treatment of violent trauma Clinical cases and surgical treatment of penetrating thoracoabdominal, perineal and anorectal trauma

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COD: 011-18 Categorie: ,

William Zuccon, Roberto Paternollo, Luca Del Re, Andrea Cordovana, Giovanni De Murtas, Giacomo Gaverini, Giulia Baffa, Claudio Lunghi

Ann. Ital. Chir., 2013 84: 11-18

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AIM: The Authors analyse clinical cases of penetrating thoracic, abdominal, perineal and anorectal injury and describe
the traumatic event and type of lesion, the principles of surgical treatment, the complication rate and follow up.
MATERIALS AND METHODS: In the last 24 months, we analyzed 10 consecutive cases of penetrating thoracic and abdominal
wounds [stab wound (n=7), with evisceration (n=4), gunshot wound (n=1)], and penetrating perineal and anorectal
wounds (impalement n=4). In addition, we report an unusual case of neck injury from a stab wound. All the
patients underwent emergency surgery for the lesions reported.
RESULTS: In 7 cases of perforating vulnerant thoracoabdominal trauma from stab wounds there was hemoperitoneum due
to bleeding from the abdominal wall (n=3), the omentum (n=1), the vena cava (n=1) and the liver (n=2). Evisceration
of the omentum was observed in 4 cases. In 2 cases laparoscopy was performed. In one case laparotomy and thoracoscopy
was performed. In a patient with an abdominoperineal gunshot wound, exploration was extraperitoneal. The 4 cases of
perineal and anorectal impalement were treated with primary reconstruction, while in one case a laparotomy was needed
to suture the rectum and fashion a temporary colostomy. In one case of anorectal injury rehabilitation resulted in a
gradual improvement of fecal continence, while in the patient with the colostomy follow up at 2 months was scheduled
to plan colostomy closure.
CONCLUSIONS: Based on the our clinical experience and the literature, in penetrating abdominal trauma laparotomy may
be required if patients are hemodynamically unstable (or in hemorrhagic shock), in patients with evisceration and peritonitis,
or for exploration of penetrating thoracoabdominal and epigastric lesions. In anterior injuries of the abdominal
wall from gunshot or stab wounds, laparotomy is indicated when there is peritoneal violation and significant intraperitoneal
damage. In patients with actively bleeding wounds of the abdominal wall muscles minimal laparotomy is often
necessary for control of hemorrhage and abdominal wall reconstruction to avoid herniation. If patients are asymptomatic,
in cases of anterior lesions the indications for diagnostic laparoscopy are uncertain. Selective conservative treatment is
reserved for asymptomatic patients who are hemodynamically stable. Further controlled studies are needed. Early surgery
for perineal and anorectal trauma, and also for complex injuries, is the gold standard for treatment.

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