CHAPTER VI.
LAPAROTOMY FOR TRAUMATISM.
‘The indications for laparotomy following traumatism are as follows:
Perforating gunshot wounds,
Perforating stab wounds likely to have wounded a viscus,
Contusions of the abdomen presenting symptoms of dangerous lesions of abdominal viscera or vessels; not always definite, but operate at once if you find these appearances following contusions:
(a) The abdominal walls are resistant some distance from the in- jury; @ progressive meteorism reaching the hepatic region; dullness over the ilinc fosse or the flanks, indicating hemorrhage.
(b) The pulse is weak and rapid, and growing worse.
(©) The general condition of the patient is alarming, pallor, pain, excitement or delirium, subnormal temperature.
But whether it be an open wound or a contusion, do not wait for the symptoms of peritonitis, for it will then likely be too late, The operation is delicate and dangerous in the hands of the unskilled, and yet the patient's life depends upon It. There is no time to send for a Specialist unless he is right at hand, and, as Vewu says, it is better for the patient to be operated on early by an inexperienced surgeon than to be operated on too late by the best surgeon in the land. It i¢ an intervention in which one never knows what he is going to find.
‘The steps of the operation are:
(2) A laparotomy.
(2) Search for the hemorrhage if there is blood in the abdomen,
(3) Search for visceral injuries,
Gencral anesthesia is indispensable, and ether is preferable unless compelled to operate in close quarters by lamp light. Every precau- tion must be taken not to aggravate shock; the limbs should be wrayged and the chest protected. The whole anterior abdominal wa wo oe
469
(1) Laparotomy- Whatever be the site of the wound or © make an incision in the middle line; below the umbilicus, us above, if the injury points to the epigastrium. “The incision. should be about three inches long. It may be necessary to ex Divide the skin and fatty tissues and catch up the bleeding
Open the sheath of the rectus and look for the linea alba, but if nol
readily found, go through the muscle; it docs not greatly m
expose the subperitoneal fatty ti Tt may be quite thick.
cavity by reason of its (ranspareney. Catch up the peritoneum with secting forceps and incise the thus formed, with the the scalpel turned away from th dominal cavity, that the bowel be wounded (Fig. 438). Ei: small opening thus created, and di the assistant to seize the lips of the peritoneal wound with fore Pay no attention to the blood which may pour out, but rapidly to elongate the peritoneal wound with the scissors, the bowel with the left index finger (Fig. 339). Remember the toncum envelops the bladder, so do not open the peritoneum @e to the pubes, although the skin wound should be carried thus far | order to give the best view (Fig. 340). aml Carefully catch up the lips of the peritoneal wound with which may also serve as retractors; such control of the p also facilitate ts suturing at the end of the operation. be necessary to push the anesthesia « little if there ism
Mi
Pro, y98-—Inchnng Wp fold of *Seewecum Yoke)
CONTROL OF THE HEMORRHAGE. ant
(2) Locale and check the hemorrhage. Do not be in a burry to put a hand in the cavity but observe closely, sponging gently. The character of the fluids may be helpful in diagnosis. The examining
finger may detect lesions, or the injured viscera may push up into the wound,
fosing peony oping tthe alec oY So ee Ny a gg i
The hemorrhage may come from the following: (a) omentum; (b) mesentery; (c) the vascular organs, liver, spleen, kidney; (d) the vessels of the posterior abdominal wall.
(a) The great omentum should be gently lifted out of the cavity. Tt may contain a hematoma and the divided vessels be hard \o Wd,
TAPAROTOMY FOR TRAUMATINM,
47?
‘Tic them with No. 2 catgut. If the omentum is torn and
resect the injured portion (Fig.414). It may be split; the lange veas opened must be tied; the small will be controlled by the continue suture, which should reunite the edges of the wound. If the omenty |
Flo j4o Brianne the wecing ward tee zaben the bieler aman abe wonndel. (onthe is detached from the greater curvature, the stomach should be ome and the pmentum sutured thereto.
(b) The hemorrhage from the mesentery may be arrested Ps | same manner, though one may not find it until in the course apecting the gut. Mesenteric wounds often exist without jajury, In suturing tbe tear, the needle must be passed close
TREATMENT OF WOUNDS OF THE INTESTINE. 473
edges of the wound so that no vessel may be wounded or included in the tie,
Tf its attachment to the bowel is disturbed for, say, more than three inches or if it is necessary to tie a branch as large as the radial, the integrity of the corresponding section of gut is compromised and it will be advisable to resect. If unable to do that, treat it as the doubt- ful bowel is treated in strangulated hernia (see page 539)-
(©) If the hemorrhage proceeds from a wound of the liver, spleen, or kidney, tampon methodically and firmly with sterile gauze,
If the liver is ruptured extensively and tamponade has no effect, try deep suturing. If this does not succeed, the wound is probably be- yond surgical aid.
If the spleen is extensively Jacerated, remove it. (See page 482.)
(d) Ti the vessels of the posterior abdominal wall are involved or the splenic, mesenteric, or renal, it will often be very difficult to find the starting-point of the hemorrhage, for it is in the midst of a great clot. Begin by applying a large compress to the suspected point and make firm pressure. Following this, rapidly wipe out all the clots and reapply the compress, Raise its edge gradually and as each bleeding point appears, clamp it, It will often be impossible to ligate at that depth and forceps are left attached, The forceps are to remain twenty-four to thirty-six hours, These must be removed without violence, .
(3) Wounds of the intestine: Do not forget that intestinal perfora- tions are often multiple, are usually so after gunshot wounds, so that it fs absolutely necessary to inspect the whole intestine that no wound may be overlooked.
(A) Examination of the Bowel.—The procedure must be methodical. Do not pick up first one segment and then another indiscriminately; in this way one part may be examined several times and another part not at all.
Begin by picking up with forceps any part of the bowel that may present; these forceps will serve as a starting-point and landmark. It will not hurt the bowel with its pressure, aa it includes in its hold only the serous and muscular coats (Fig. 341).
Begin at this point, then, pulling up to view segment alter veyrmcn,
LAPAROTOMY FOR TRAUMATISM. and as it is inspected, returning it to the cavity. The be attended with difficulty especially if one is compelled t late, when peritonitis has begun and the partially p is greatly distended. Tf several folds of the bowel should there is difficulty in returning them, the procedure as d page 116 will be helpful.
Vo. 341. —Ramining the bowel, (Veaw.)
Begin by lifting up the abdominal wall by means of the ret Cover the refractory mass with a wide compress and them tuck border of the compress into the wound, gradually working it i abdominal cavity. It will carry the bowel along, ‘Then withdraw the compress.
Examining thus the small intestine, one of its fixed po finally be reached, either the cecum or the duodenum; return the to the forceps and work in the other direction.* d siterdits in eaiitg the lajoice rey Be groslylocreased) a Bat the following case:
‘On December 31, 107, 9 colored man was brought to the City
wound in the back, the bullet entering the right lumbar foches [rom the middle fine, Progressive abdominal
REPAIK OF INTESTINAL WOUNDS. ATS
Whenever a perforation is found, it must be repaired before looking further,
(B) Repair of the Intestinal Wound.—When an intestinal wound is located, seize its edges with two forceps, Including only the serous and muscular coats, draw the part outside the cavity and isolate it with compresses and then suture.
(a) Non-perforating wounds are sufficiently repaired by two or three Lembert sutures.
(b) Small perforating wounds, such as bullet wounds, must be re
P10. 542.—Tho inclusive suture passed: tiet and Lembert suture passed; Lembert tied.
paired by suture in two layers (Fig. $42). With fine silk, No. 1, make a suture which includes all three coats, serous, muscular and mucous (Pig. 343). If the wound is longer than two-thirds of an inch, use two such sutures, etc. These sutures are to be covered in and buried by the second layer, which involves only the serous coat
no perforation, No opening in the posterior abdominal wall could be found be- low the level of the umbilicus, The incision was extended and the examining finger located a tear behind the stamach. At this time the patient’s condition grew so bad it was necessary to cease the search and before the abdomen could be completely closed, he died. b ppstunrien sevesied a long tear in the transverse perlon of the duodenum.
‘The bullet had struck the trinsverse process of a lumbar vertebra, had deflected to the feft, wounding the ascending veoa cava and the duodenum, and had lodged im the anterior abdominal wall. “The blood escaping from the vena cava had not emptied into the abdomen, but had followed the vein along the spine and had flooded. the posterior
mediastinum.
476 LAPAROTOMY FOR TRAUMATISM,
(Lembert suture). In introducing them, begin at least one-half ine back of the first line and use either a continuous or interrupted satay ig. 344).
Ps, 545 —The Sint layer Fie 1 er 4, iis Toelele alt coats wet, ‘Meabeny” sureas ‘ane
(c) Large Perforating Wounds.—If the wound i an incised ant suture without refreshing the edges, but if it is contused or lacerate, (Fig. 345) it will be necessary for repair to trim away to the soum tissue; but take care not to diminish the caliber of the gut.
7
an
Fee 345-—Trieuning away thee braieed tienes. (Vem)
As before, beginning at one angle, introduce the first fine of th suture, incloding all the coats, and using, if possible, = con! suture (Fig. 346).
AFTER-TREATMENT OF LAPAROTOMY FOR TRAUMATISM. 477
The second line of (Lembert or sero-serous) sutures must begin and end one-half inch beyond the limits of the first and the needle must be entered far enough away from’ the first line that the peritoneal surfaces may be well apposed and the first layer completely covered (Fig. 347)-
(C) Resection of the Gut—If the wound involves more than two- thirds of the circumference or if there is a contusion of the whole or a large part of the segment, it will be necessary to resect and do a circular enterorrhaphy or some other form of anastomosis. If the operator cannot undertake that, then the gut ‘must be treated as in the gangrene of strangu- lated hernia, making an artificial anus (see page $19). For resection of gut, see page 575.
Drain the peritoneal cavity with a Micu- licz drain where there is oozing, and with a drainage-tube if infection is feared (see