Report “Wounds and injuries of the abdomen. Specialized medical care. Damage to large blood vessels in the abdomen

Each person must be prepared for any emergency situation. The rules for the provision of first aid are studied at the lessons of life safety at school. It is important not to get confused and try to remember everything that you know and can do.

If a we are talking about injuries to the limbs, the first step is to stop the bleeding and immobilize the limb. The situation is more complicated with abdominal wounds, chest or pelvis. About what should be the first aid for wounding the abdomen is described below.

There are the following wounds of the abdomen: non-penetrating and penetrating. Open wounds - deep wounds that penetrate deep abdominal cavity and entail trauma to the internal organs, in most cases - the intestines.

Penetrating wounds are terrible, because they can lead to the following damage: kidneys, liver, intestines, stomach. There is Great chance heavy bleeding both external and internal, and there is also the possibility that the content intestines will fall into the abdominal cavity. This will cause purulent inflammation (peritonitis). The first step is to stop the bleeding with pressure bandage. The wound around should be treated with iodine or brilliant green to prevent infection. Then an aseptic napkin and a pressure bandage are applied to the wound. It also happens that internal organs and intestines fall out of the wound. This fact immediately causes shock in the wounded. In this case, you also need to put an aseptic napkin on them and moisten it from time to time so that the organs do not dry out. It is impossible to put them back into the abdominal cavity. All manipulations should be carried out confidently, without fear of harming the victim.

If there is a wound in the stomach, help should be provided immediately. Foreign objects that enter the abdominal cavity should not be removed. It is necessary to twist a sausage from a bandage or cotton wool, and then build a kind of donut and fix objects with it so that they do not move.

In no case do not give the victim to drink, eat and medicine by mouth. You can only wet your lips with water. Transportation to the hospital is carried out in a semi-sitting position, legs bent at the knees. It is necessary to protect the victim from hypothermia and wrap in a warm blanket.

A wound in the abdomen certainly causes severe pain to the victim. In order to at least slightly alleviate his suffering, you should properly lay him down. It is necessary to lie on your back, bend your knees. This posture will allow the muscles of the abdominal wall to relax. Put a cold over the pressure bandage. It will help stop internal bleeding and reduce pain.

Non-penetrating wounds occur when the stomach hits a hard object, punches, kicks in the stomach. In such cases, you need to be afraid of internal bleeding, which appears as a result of rupture of blood vessels in the abdominal cavity, rupture of the spleen, liver, kidneys. If the intestine is torn, then this is fraught with inflammation of the peritoneum. Signs of such an injury to the abdomen are nausea, vomiting, abdominal pain, dizziness, and the abdomen becomes hard as a rock. The patient should be transported immediately to the hospital in order to provide medical assistance as soon as possible. It is impossible to give water, feed the victim, you can only apply cold to the abdomen, lay the patient on the stomach, bend the legs at the knees and try to bring the victim out of the state of shock.

When receiving a serious injury, very often the victim faints (on a short time passes out from pain, fear or excitement) or is in a state of shock. Shock is a rather serious condition that disrupts the proper functioning of the human body and can even lead to lethal outcome. It can develop due to the loss of a large amount of blood, severe pain. The patient in this state is covered with sticky cold sweat, is in a state of anxiety, speech may be slurred.

Penetrating wounds of the abdomen are accompanied by wounds of hollow or parenchymal organs, eventration of organs (prolapse of organs to the outside) and rarely only damage to the parietal peritoneum.

Clinically observed symptoms acute blood loss, traumatic shock, peritonitis. Gunshot wounds are very severe. The presence of a wound, pain in the abdomen, sharp pain on palpation and tension in his muscles, sharply severe symptom Shchetkin-Blumberg, the absence of abdominal breathing and intestinal motility indicate a penetrating injury to the abdomen.

Peritonitis develops rapidly. The tongue becomes dry, the body temperature rises, vomiting appears, a pronounced leukocytosis in the blood. At digital examination the rectum is determined by soreness and overhanging of the peritoneum in the Douglas space. Urination is delayed, diuresis is reduced.

First aid is to apply aseptic dressing, cold at the site of injury, the introduction of anti-shock drugs and hospitalization in the surgical department for emergency operation. In case of eventration of the internal organs, it is necessary to lay a bandage roller around the fallen organs and apply a wet bandage with saline solution on top.

In the treatment, a laparotomy is performed with a revision of the internal organs, their suturing and drainage of the abdominal cavity. Postoperative treatment is carried out in the intensive care unit. The patient should be in a semi-sitting position. The first days in the cavity of the stomach is a probe for the permanent removal of its contents. Within 5-7 days, it is necessary to take care of the drainages in the abdominal cavity.

Caring for a patient with abdominal trauma

In case of damage to the abdomen, the patient stays on strict bed rest. Before the operation, while monitoring the patient, he should not be given painkillers, drink or eat. Before the operation, active infusion therapy, measurement of blood pressure and body temperature, pulse counting, examination general analysis blood and urine.

In the postoperative period, the patient is placed in the intensive care unit. After coming out of anesthesia, he is given a half-sitting position in bed. The drainages are being taken care of, the quantity and quality of the allocated water through the drainages, daily diuresis are taken into account. Peritoneal dialysis is performed, pulse rate, blood pressure and body temperature are monitored, a bandage in the area of ​​​​the postoperative wound.

Prevention of postoperative thromboembolism and pulmonary complications is carried out. A day later, the patient is allowed to turn in bed, engage in respiratory exercises. The first day the patient entered the probe into the stomach. Initially conducted parenteral nutrition and on the 2nd day it is allowed to drink in fractional doses, it is possible to eat liquid food only from the 3rd-4th day with the resumption of intestinal motility.

The report "Injuries and injuries of the abdomen", presented at the plenum of the Board of the ROC in the framework of the international scientific and practical conference "Endovideosurgery in a multidisciplinary hospital" in St. Petersburg.

In conditions modern megacities the severity of wounds and injuries of the abdomen has increased, which is explained by the improvement prehospital care and a significant reduction in the delivery time of the victims to the hospital. Thanks to the widespread use of equipped resuscitation vehicles and helicopters for medical evacuation extremely severe victims, who had previously died, began to be delivered to specialized trauma centers. Accordingly, the complexity of the performed surgical interventions has also increased, which in last years led to the need to introduce the tactics of programmed multi-stage surgical treatment (MCL) or "damage control surgery". In the treatment of wounds and injuries of the abdomen, other new technologies (endovideosurgery, physical methods of hemostasis) began to be used, which significantly changed the surgical tactics and improved the outcomes of the treatment of this severe pathology.

CLASSIFICATION OF WOUNDS AND ABDOMINAL INJURIES

The classification of abdominal injuries is based on the general principles of the 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-cut, stab, cut, torn-bruised) and mechanical injury.

Abdominal injury may be penetrating(in case of damage to the parietal sheet of the peritoneum) and non-penetrating.

Penetrating wounds of the abdomen are tangents, blind and through. With non-penetrating wounds of the abdomen, in 10% of cases, damage to the abdominal organs and extraorganic formations was noted due to the energy of a side impact of a wounding projectile.

By type of damaged organs injuries 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 injury may be accompanied life-threatening consequences (continued intra-abdominal bleeding, eventration of internal organs, ongoing interstitial retroperitoneal bleeding). With late delivery of victims with abdominal injuries to medical institution(more than 12 hours) develop severe infectious complications- peritonitis, intra-abdominal abscesses, phlegmon of the abdominal wall and retroperitoneal space.

DIAGNOSTICS OF GUNSHOOT WOUNDS OF THE BODY

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

For the rest of those wounded in the stomach, the diagnosis is made on the basis of relative symptoms - ongoing intra-abdominal bleeding, which is noted in 60% of the wounded, and local signs. The diagnosis of a penetrating wound of the abdomen is easier to make with penetrating (usually bullet) wounds, when the comparison of the inlet and outlet creates an idea of ​​the course of the wound channel. Difficulties are caused by the diagnosis of a penetrating nature in multiple wounds, when it is difficult or impossible to determine the direction of the wound channel by the localization of the inlet and outlet holes. It should be borne in mind 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 chest, gluteal region, and upper third of the thigh.

For diagnosing penetrating gunshot wounds enii must be made abdominal x-ray in frontal and lateral projections.

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

If suspicion of a penetrating injury persists, use instrumental methods diagnosing a penetrating wound of the abdomen : clamp wound examination, progressive wound expansion, diagnostic peritoneal lavage, videolaparoscopy and diagnostic .

Examination of the wound with a clamp is the most simple method and at correct application can significantly reduce the duration of the examination of the wounded.

Clamp wound examination technique : in operating room, after treatment operating field, a curved clamp (Billroth type) is gently 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 mass, a conclusion is made about the penetrating nature of the wound. If the result is the opposite, further research of the wound channel is terminated due to the risk of causing additional damage. In this case, the so-called progressive expansion(i.e. revision) wounds of the abdominal wall. Under local anesthesia the wound is dissected in layers, the course of the wound channel is traced and it is established whether the parietal peritoneum is damaged or not.

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

Indications for the use of laparocentesis:

• - multiple injuries of the abdominal wall;
• - localization of the wound lumbar region or near the costal arch, where the implementation of a 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 is suspected according to the type of "side impact" (noted in 10% of the wounded with non-penetrating gunshot wounds of the abdomen).

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

Under local anesthesia in the midline of the abdomen, 2–3 cm below the navel, an incision is made in the skin and subcutaneous tissue up to 1.5–2 cm long. To exclude a false positive result, clamps are applied to the bleeding vessels. In the upper corner of the wound, the aponeurosis of the white line of the abdomen is captured with a single-toothed hook and the anterior abdominal wall is pulled up. After that, at an angle of 45–60 °, the abdominal wall is pierced with careful rotational movements of the trocar (at the same time forefinger pushed forward to 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 intake of blood through the tube or, which happens much less often, the contents hollow organs(intestinal contents, bile or urine) confirms the diagnosis of a penetrating wound of the abdomen and is an indication for laparotomy. If nothing is excreted through the catheter, it is sequentially passed with the help of a trocar sleeve into the right and left hypochondria, into both iliac regions and the pelvic cavity. 10–20 ml of 0.9% sodium chloride solution are injected into these areas, after which the solution is aspirated with a syringe.

A contraindication to performing 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 doubtful (obtaining traces of blood on the tube, aspiration of pink fluid after the introduction physiological saline) is carried out diagnostic peritoneal lavage. The tube introduced into the small pelvis is temporarily fixed to the skin, and a standard amount (800 ml) of 0.9% sodium chloride solution is introduced into the abdominal cavity through it. After that, the tube is extended through the adapter with another long transparent tube, and its free end is lowered into the vessel to collect the outflowing liquid and dynamic observation. To objectify the results of diagnostic lavage of the abdominal cavity, a microscopic examination of the outflowing fluid is carried out: the content of erythrocytes in it in excess of 10000x1012/l is an indication for laparotomy.

If it is impossible to exclude the penetrating nature of the abdominal wound by other methods, perform laparoscopy, and in the event of an unstable state of the wounded or in the absence of the possibility of its implementation - laparotomy.

Indication for diagnostic laparoscopy when the abdomen is injured, it is impossible to exclude its penetrating nature. Contraindications to its implementation are established on the basis of the calculation of the WHC-EC index (Table 1, 2 of the Appendix). With a value of 6 or more points, due to the increased risk of complications from the main life-support systems during laparoscopy, the "traditional" one is performed. In cases where the values ​​of the WHC-EC index are less than 6 points, laparoscopy is performed. With values ​​of this index equal to 6 points, it is advisable to perform laparoscopy using a laparolift (gas-free laparoscopy) or "traditional" laparotomy.

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

Only if it is impossible to exclude the penetrating nature of the wound of the abdomen by these methods, it is permissible to perform diagnostic (explorative) laparotomy.

SURGICAL TACTICS FOR PENETRATING WOUNDS OF THE ABDOMEN

GENERAL PRINCIPLES OF SURGICAL TREATMENT OF ABDOMINAL INJURIES

The main method of treatment of penetrating wounds of the abdomen is the implementation of surgical intervention - laparotomy. In relation to gunshot wounds of the abdomen, surgery is called primary surgical treatment of the abdominal wound , and laparotomy is an operative approach to enable sequential surgical interventions on damaged organs and tissues (along the wound channel).

Preoperative preparation depends on general condition the wounded person and the nature of the injury. The duration of preoperative infusion therapy should not exceed 1.5–2 hours, and with continued internal bleeding, intensive antishock therapy should be carried out simultaneously with the implementation of urgent indications.

Laparotomy performed under endotracheal anesthesia with muscle relaxants. The standard and most convenient is the mid-median laparotomy, because. it allows not only to perform a full revision 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 a wound in the abdomen with damage to the organs of the abdominal cavity and retroperitoneal space is stop bleeding as soon as possible. The most common sources of bleeding are damaged liver, mesenteric and other blood vessels, kidneys, pancreas. If a significant amount of blood is detected in the abdominal cavity, it is removed using an electric suction into a sterile dish, then bleeding is stopped, and after establishing all intra-abdominal injuries and assessing the severity of the condition of the wounded, a decision is made on the extent of surgical intervention.

Surgical treatment of wounds parenchymal organs includes deletion foreign bodies, detritus, blood clots and excision of necrotic tissues. To stop bleeding and suture wounds of parenchymal organs, stabbing needles with threads from absorbable material (polysorb, vicryl, catgut) are used. Edges of gunshot defects hollow organs(stomach, intestine, bladder) are economically excised up to 0.5 cm around the wound. A sign of the viability of the wall of a hollow organ is a distinct bleeding from the edges of the wound. Failure to comply with this rule is accompanied by a high incidence of suture failure. All hematomas of the wall of hollow organs are subject to mandatory revision to exclude damage penetrating into the lumen. The suturing of hollow organs and the formation of anastomoses is performed using two-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).

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

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

Indications for insertion of tampons into the abdominal cavity with abdominal injuries are extremely limited:

• - uncertainty in the reliability of hemostasis (tight tamponade is carried out);
• – incomplete removal organ or the inability to eliminate the source of peritonitis (tampons are left in order to delimit the infectious process from the free abdominal cavity).

In some cases, the 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 the blood, bile or intestinal contents from the abdominal cavity, or when surgery was carried out against the background of peritonitis. In the latter case, antiseptics, heparin, anti-enzyme drugs are included in the composition of the lavage liquid. 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 in layers with the installation (if necessary) of drainage in the subcutaneous tissue. If laparotomy is performed under conditions of peritonitis, severe intestinal paresis, and also if repeated sanitation of the abdominal cavity is expected (including with MCL or damage control tactics), the peritoneum and aponeurosis are not sutured, only skin sutures are applied.

DAMAGE TO LARGE ABDOMINAL BLOOD VESSELS

Damage to the large blood vessels of the abdomen occurs in 7–11.0% of the wounded with penetrating gunshot wounds to the abdomen. At the same time, in most cases (90.3%), the abdominal organs are simultaneously damaged, and 75.0% of those wounded in the abdomen also have combined wounds of a different localization.

The condition of the majority of the wounded in this category (79.8%) is severe or extremely severe, which is determined both by the anatomical severity of the injuries and by 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 continued intra-abdominal bleeding and unstable hemodynamics, the wounded is temporarily - up to 20-30 minutes - aortic compression in the subdiaphragmatic region (with fingers, a tupfer or a vascular clamp) to prevent irreversible blood loss (Degiannis E., 1997). This maneuver is performed by access through the lesser omentum after mobilization of the left lobe of the liver (with abduction upward and laterally) and retraction of the stomach downward. The esophagus and paraesophageal tissue are retracted with fingers, which makes it possible to palpate the aorta.

In most cases, such clamping of the aorta is sufficient 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 the mesenteric vessels).

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

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

For revision abdominal aorta and its branches carried out rotation of internal organs to the right: the splenic-renal ligament is transected, 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 exfoliate in the medial direction over the left kidney.

With such retroperitoneal access, the entire abdominal aorta and its main branches (celiac trunk, superior mesenteric artery, left renal artery, iliac arteries).

If the aorta is injured below the infrarenal, then proximal control of bleeding can be achieved. transperitoneal access after retraction of the small intestine to the right, transverse colon up and descending colon to the left. The peritoneum is dissected longitudinally just above the aorta, the duodenum is mobilized upward. The upper limit of access is the left renal vein, which crosses the aorta in front.

Access to infrarenal inferior vena cava carried out after rotation of internal organs to the left: by dissecting the parietal peritoneum along the outer edge of the blind and ascending colon. Then the blind, ascending and mobilized hepatic flexure of the colon is exfoliated and retracted medially above the right kidney.

If necessary, selection suprarenal inferior vena cava also mobilization twelve duodenal ulcer according to Kocher with internal rotation of the duodenum and head of the pancreas, or median sternotomy and diaphragmatic incision may be necessary.

Damage suprarenal and retrohepatic divisions 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 divisions liver, despite clamping 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 for the implementation of MHL tactics or "damage control". If tamponade is ineffective, atriocaval shunting is performed, which is the only method of temporary hemostasis to eliminate damage to the proximal inferior vena cava and hepatic veins.

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

Iliac vessels are examined from direct access over the hematoma after providing 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 (clamping throughout, tight tamponade, the imposition of tourniquets and vascular clamps), a vascular suture (lateral or circular) is performed, and in case of a large defect, plasty with an autovein or a synthetic prosthesis is performed. In the absence of the possibility of restoring the integrity of a large blood vessel, its temporary prosthesis or ligation is carried out.

In a difficult surgical situation (development in a wounded terminal state, significant technical difficulties), as well as in the implementation of MHL tactics or "damage control" dressing is acceptable top mesenteric artery below the origin of the first small bowel branch, the inferior vena cava in the infrarenal region (below the confluence 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 the 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 prosthesis 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 experience of treating 206 wounded with damage to 275 large abdominal blood vessels 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, ligation of the vessels or tight tamponade of the wound was performed; restoration of vascular patency was achieved in 28.8% of cases (lateral suture - 11.5%, circular suture - 10.1%, vascular plasty - 7.2%). One of promising methods of temporary intraoperative hemostasis is endovasal balloon occlusion .

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

LIVER DAMAGE

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

The volume of surgical treatment of the wound of the liver depends on the degree of its 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 for the purpose of hemostasis, temporary compression of the liver, tight tamponade or hepatopexy (1.7%) is used - suturing the liver to the diaphragm (if the source of bleeding is multiple ruptures on its diaphragmatic surface).

With superficial small-scale 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 tamponing of the wound with a strand greater omentum on the leg.

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

At little damage gallbladder after surgical treatment of the wound, the defect is sutured and cholecystostomy is performed. With extensive damage, cholecystectomy is indicated, and with concomitant liver damage, drainage of the choledochus through the stump of the cystic duct is necessary.

In case of damage extrahepatic biliary tractsurgical tactics determined by the extent of the injury and the presence of damage to other organs of the abdomen. With a marginal wound of hepaticocholedochus, it is sufficient to perform external drainage of the duct through the wound. With a 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 applied as part of the MHL tactics (“damage control”). At isolated injury and stable condition wounded with a complete interruption of hepaticocholedochus, it is preferable to restore the passage of bile into the intestine by imposing a biliodigestive anastomosis with a Roux-enabled loop of the small intestine on submersible drainage.

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

Errors at surgical treatment liver injury: failure to conduct rapid temporary hemostasis in case of profuse bleeding from a liver wound by compression of the hepatic tissue around the wound (and hepatoduodenal ligament); attempts to stop bleeding from the depth of the wound channel by suturing the inlet (and outlet) holes.

The lethality at wounds of a liver reaches 12%.

SPLEEN DAMAGE

Spleen injuries occur in 6.5% of the wounded with penetrating gunshot wounds to the abdomen. Damage to the spleen in gunshot wounds, as a rule, is an indication for (97.0%). When dissecting the spleen and applying a clamp to the splenic pedicle, it is necessary avoid damage to the tail of the pancreas.

In rare cases superficial damage capsule or detachment of the ligaments of the spleen, it is possible to suturing it (with U-shaped sutures, with suturing a strand of the omentum on the leg) or using physical methods hemostasis (3.0%).

Most frequent complications of spleen injuries- secondary bleeding and abscesses of the left subdiaphragmatic space (5%). Splenectomy in the wounded older than 20 years is not accompanied by severe immunodeficiency.

Errors in the surgical treatment of wounds of the spleen: rough discharge of the spleen with damage to surrounding tissues - damage to the tail of the pancreas and fundus of the stomach is especially dangerous; irrational attempts to save the damaged spleen.

The lethality at wounds of a spleen makes 10%.

PANCREAS DAMAGE.

Pancreatic injuries occur in 5.7% of the wounded with penetrating gunshot wounds of the abdomen and, as a rule, are combined with damage to the surrounding organs of the pancreatoduodenal zone.

With 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 stitching (22.8%). In such cases, it is sufficient to drain the cavity of the stuffing bag with a tube that runs along the lower edge of the gland from the head to the tail and is removed retroperitoneally under the splenic flexure of the colon to the left side wall of the abdomen (a small incision in the peritoneum along the transitional fold at the splenic flexure of the colon is used to pass the drainage tube). daughter intestine).

At complete breaks 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 organs of the abdomen 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 stitching (or tight tamponade) of bleeding vessels, if possible, stitching the distal and proximal ends of the damaged Wirsung duct with adequate drainage of the omental sac. Despite the inevitability of post-traumatic pancreatitis, necrosis and sequestration of areas of the pancreas, the formation of pancreatic fistulas, the outcomes of treatment in such wounded are more favorable.

With extensive wounds of the pancreatic head, it can be resected with pancreatojejunostomy with the loop of the small intestine turned off according to Roux, but less traumatic intervention is more often performed: stitching or tight tamponade of the bleeding vessels of the gland and marsupialization with suturing of the gastrocolic ligament to the edges of the surgical wound.

During operations for injuries of the pancreas (regardless of the extent of damage), parapancreatic tissue should be infiltrated with a 0.25% solution of novocaine with antienzymatic drugs (kontrykal, gordox, trasilol), and the intervention should be completed with drainage of the omental sac, nasogastrointestinal intubation and unloading cholecystostomy.

AT postoperative period mandatory use of inhibitors of gland secretion (sandostatin or octreotide) and inhibitors of its enzymes (kontrykal), directed antibiotics (abaktal, metronidazole)

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

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

Mortality in pancreatic injuries is 24%.

GASTRIC DAMAGE

Injuries to the stomach occur in 13.6% of the 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 small omentum must be opened and inspected so as not to miss damage rear wall stomach. Gunshot wounds of the stomach should be sparingly excised, be sure to ligate the bleeding vessels. The defect of the stomach wall is sutured with a two-row suture in the transverse direction, especially in the outlet section (to prevent stenosis). Due to the abundant blood supply, gastric wounds heal well. In rare cases, with extensive damage to the organ, its atypical marginal resection is performed (1.5%).

The operation for wounds of the stomach ends with the obligatory introduction of a nasogastric tube for the purpose of decompression for 3–5 days, a probe is inserted into the small intestine for early enteral nutrition.

Most frequent complications of gastric injuries- bleeding, suture failure and the formation of intra-abdominal abscesses, peritonitis.

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

Mortality in gastric wounds is 6%.

DAMAGE TO THE DUODENUM

Duodenal injuries occur in 4.8% of the wounded with penetrating gunshot wounds of the abdomen and in 90% of cases are combined with damage to other organs. Of particular difficulty is the diagnosis of injuries of 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 two-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 Treitz ligament (terminal intestine) is transected. The wound opening in the intestine is sutured with a double-row suture, the retroperitoneal space is drained with a tube. With any suturing of wounds of the duodenum, its decompression with a nasogastroduodenal probe is necessarily carried out (for 5–6 days), a probe is inserted into the small intestine for early enteral nutrition.

With a 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 turn off (diverticulize) the duodenum by stitching and peritonizing the outlet section of the stomach, applying a bypass gastroenteroanastomosis.

With extensive damage to the intestine distal to the papilla of Vater, next intervention: an anastomosis is made between the proximal end of the duodenum and the Roux-enabled loop of the small intestine, the distal end of the duodenum is muffled. To prevent suture failure, the duodenum is also disconnected by stitching the outlet section of the stomach.

Considering that injuries of the duodenum often occur simultaneously with damage to the pancreas, the surgical tactics for these injuries is determined based on the characteristics and nature of the 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 an extremely serious condition of the wounded) MHL tactics are performed. In the course of the 1st intervention, only hemostasis and prevention of leakage of the contents of hollow organs into the free abdominal cavity are carried out: suturing the duodenal wall, external drainage of the bile and pancreatic ducts. After stabilization of the condition of the wounded, relaparotomy and pancreatoduodenal resection are performed.

Most frequent complications of duodenal injury- gastroduodenal bleeding, suture failure with the formation of duodenal fistulas and intra-abdominal abscesses, peritonitis.

Errors in the surgical treatment of wounds of the duodenum: failure to revise the retroperitoneal hematoma in the projection of the intestine, failure to revise the duodenum with bile stains under the parietal peritoneum; failure to drain the area of ​​damage to the intestine in the retroperitoneal space and failure to pass the probe into the small intestine for enteral nutrition; irrational surgical tactics for extensive damage to the intestine.

The lethality at wounds of a duodenum reaches 30%.

DAMAGE TO THE SMALL INTESTINE

Damage to the small intestine occurs in 56.4% of the wounded with penetrating gunshot wounds to the abdomen.

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

Resection of the small intestine is indicated for defects in its wall more than a semicircle; crushing and bruising of the intestine with a violation of the viability of the wall; detachment 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 acceptable in the absence of peritonitis, as well as after a high resection of the jejunum, when the danger to the life of the wounded person from the formation of a high small bowel fistula is higher than the risk of anastomosis suture failure. There is a high probability of anastomosis failure in the area of ​​poor blood supply - terminal department ileum 5–20 cm proximal to the ileocecal angle. The way to restore the patency of the intestine (anastomosis end to end - 42.0% or side to side - 55.2%) is determined by choice. However, for surgeons without much practical experience, side-to-side anastomosis is preferable, which is less likely to be accompanied by suture failure.

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

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

• - multiple nature of the wound of the intestine;
• - extensive damage to the mesentery;
• - pronounced phenomena of peritonitis with paresis of the intestine.

Preference is given to nasogastrointestinal intubation, if it is impossible, an intestinal probe is carried out through a gastrostomy, cecostomy or enterostomy.

Most frequent complications of small intestine injuries- failure of the sutures, acute, narrowing of the intestinal anastomosis with violation of the passage, the formation of intra-abdominal abscesses, peritonitis.

Errors in the surgical treatment of wounds of the small intestine: non-detection of intestinal wounds, especially in the mesenteric region; inadequate surgical treatment of gunshot wounds of the intestinal wall during their suturing; the formation of an anastomosis in the terminal ileum, which leads to suture failure; suturing several closely spaced wounds with bowel deformity instead of resection of a section of the bowel; 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.

Mortality in wounds of the small intestine reaches 14%.

COLON DAMAGE

Colon injuries occur in 52.7% of the wounded with penetrating gunshot wounds to the abdomen.

Sewing of the wound of the colon with a two-row suture (22.0%) is permissible only if it is small (up to 1/3 of the circumference of the intestine), early dates 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 injury. Nevertheless, it should be taken into account that up to 40% of operations for suturing gunshot wounds of the colon are accompanied by suture failure.

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

In the latter case, the discharge end of the intestine is muffled according to Hartmann or (with peritonitis) is displayed on the abdominal wall in the form of a colonic fistula.

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

In case of extensive wounds of the right half of the colon, a right-sided hemicolectomy is performed (5.9%). The imposition of ileotransverse anastomosis is possible only in the absence of peritonitis and stable hemodynamics; in other situations, the operation ends with the removal of the terminal ileostomy.

The operation on the large intestine ends with its obligatory decompression by devulsion (stretching) of the anus or by a colonic probe inserted through the rectum, if the left half of the colon is injured, it is passed through the suture line.

Most frequent complications of colon injuries- failure of the sutures, the formation of intra-abdominal abscesses, peritonitis, retroperitoneal phlegmon.

Errors in the surgical treatment of wounds of the colon: non-detection of wounds of the intestine, especially in the region of the mesenteric region or retroperitoneally located areas; inadequate surgical treatment of wounds of the intestinal wall, which leads to the failure of the suture in the case of suturing the intestine or "failure" of the colostomy; incorrect surgical tactics with an attempt to suture extensive wounds of the intestine or the imposition of colonic anastomoses in case of gunshot wounds.

The lethality at wounds of a large intestine reaches 20%.

DAMAGE TO THE RECTUM

Damage to the rectum occurs in 5.2% of the wounded with penetrating gunshot wounds to the abdomen.

small wounds intraperitoneal department the rectum is sutured with a double-row suture (7.1%), then a double-barreled unnatural anus is superimposed on the sigmoid colon.

With extensive wounds of the rectum, a non-viable area is resected and the leading end of the intestine is brought out to the anterior abdominal wall in the form of a single-barreled unnatural anus. The outlet end is sutured tightly (Hartmann's operation).

When injured extraperitoneal region rectal surgery is performed in two stages. At the first, a double-barreled unnatural anus is superimposed on the sigmoid colon. Thereafter the abducting part of the rectum is washed with an antiseptic solution from stool. At the second stage, the ischiorectal space is opened by perineal access. The wound hole in the intestinal wall is sutured if possible, the sphincter is restored when it is damaged. Effective drainage of the pararectal space is mandatory.

Most frequent complications of rectal injuries- failure of the seams, the formation of intra-abdominal and intra-pelvic abscesses, peritonitis, retroperitoneal and intra-pelvic phlegmon.

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

Mortality in wounds of the rectum is 14%.

KIDNEY AND URETER DAMAGE

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

Surgical access to the damaged kidney is only median laparotomy . The kidney is exposed by dissecting the parietal peritoneum according to Mattox and turning the colon to the right or left, respectively.

Superficial wounds of the kidney that do not penetrate into pelvic system, are sutured absorbable suture material (15,9%).

With more massive wounds (penetrating into the pelvic system), especially if the hilum of the kidney is damaged, the vessels of the kidney are injured, nephrectomy (77,0%).

PeReBefore it is carried out, it is necessary to make sure that there is a second kidney! When the pole of the kidney is injured, in the absence of severe injuries to other organs and the state of the wounded is stable, it is possible to perform an organ-preserving operation - resection of the pole of the kidney (7.1%), which is necessarily supplemented by nephropyelo- or pyelostomy.

Ureteral injury occur in 1.7% of the wounded with penetrating gunshot wounds of the abdomen, but are often diagnosed late - already by the fact of the appearance of urine in the discharge from the drainage left in the abdominal cavity (attention is attracted by an unusual a large number of separable).

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). With extensive damage to the ureter, either the removal of the central end of the ureter to the abdominal wall, or its circular suture on the ureteral catheter (stent) with unloading nephropyelo- or pyelostomy, or nephrectomy is performed.

Most frequent complications of injuries of the kidneys and ureters- bleeding, suture failure with the formation of urinary streaks and retroperitoneal phlegmon, urinary fistulas, pyelonephritis.

Errors in the surgical treatment of injuries of the kidneys and ureters: failure to revise the kidney with a hematoma in its area; incorrect revision of the kidney through the mesentery of the intestine or without prior control of bleeding from renal vessels; inefficient drainage of the perirenal space; late diagnosis of ureter injury; excessive mobilization during suturing of the damaged ureter, leading to its stricture.

The lethality at wounds of kidneys 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, fragments of structures. 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, resembling symptoms of damage to the internal organs of the abdomen, can be provoked by fractures of the ribs, retroperitoneal hematoma in fractures of the pelvis and spine.

Closed trauma of the abdomen, accompanied by damage parenchymal organs, as well as the 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, an increase in heart rate and an increase in respiratory rate. Local symptoms due to intra-abdominal bleeding (tension of the muscles of the abdominal wall, peritoneal symptoms) are usually mild. In such cases, the most important clinical signs are dullness of percussion sound in the flanks of the abdomen, weakening of the noise intestinal peristalsis.

closed damage hollow organs quickly leads to the development of peritonitis, the main signs of which are in the abdomen, dry tongue, thirst, pointed facial features, tachycardia, chest type breathing, muscle tension of the anterior abdominal wall, widespread and severe pain on palpation of the abdomen, positive symptoms of peritoneal irritation, absence of intestinal peristalsis noises. Significant diagnostic difficulties arise in cases of closed ruptures of the retroperitoneally located sections of the colon and duodenum, pancreas. The clinical picture in this case is initially erased and appears only after the 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. Persistent symptoms in such cases, there are macro- and microhematuria, which may be absent if the vascular pedicle is separated 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 after 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 a phenomenon of overhanging the anterior wall of the rectum, the presence of blood in its lumen), tobladder atheterization(in the absence of independent urination) with a study of urine for the content of red blood cells.

Approximate ultrasound examination abdomen allows you to quickly and reliably identify hemoperitoneum, can be repeated many times during dynamic observation. The disadvantages of the method include its low sensitivity in case of damage to hollow organs, the subjectivity of the assessment of the identified findings. The abdomen is examined for fluid through right hypochondrium(Morrison space), left hypochondrium (around the spleen) and small pelvis. Ultrasound examination helps the surgeon to determine the indications for laparotomy in the wounded with abdominal trauma and unstable hemodynamics. A negative ultrasound result in the absence of clinical signs of closed damage to the internal organs of the abdomen and stable hemodynamics is the basis for refusing further diagnostics (if necessary, ultrasound is performed again). 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 with abdominal injuries has a number of limitations:

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

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

O main method instrumental diagnostics closed injury of the abdomen is laparocentesis. The technique of its implementation is the same as for abdominal wounds. The only feature is that in case of combined injuries of the abdomen and pelvis with a fracture of the bones of the anterior semicircle, 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 a closed abdominal injury can also be supplemented in doubtful cases. diagnostic lavage of the abdominal cavity, since for the diagnosis of damage to internal organs with closed injury of the abdomen, it is not the fact of the presence of blood in the abdominal cavity that is important, but its quantity. The threshold level of erythrocytes during diagnostic peritoneal lavage is not 10,000x10 12, as in wounds, but 100,000x10. 12

The presence of a small amount of blood in the abdominal cavity with a closed injury can be explained by inertial ruptures of the peritoneum, sweating of the retroperitoneal hematoma in pelvic fractures. Intense blood staining of the outflowing 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 the basis for performing a laparotomy). When the content of erythrocytes in the lavage fluid is from 100,000x10 12 to 750,000x10 12, diagnostic and therapeutic videolaparoscopy is performed.

Surgical treatment of injuries of internal organs with closed abdominal trauma.

At breaks liver, depending on the severity of the damage to the parenchyma, its 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. With inertial ruptures of ligaments with small tears spleen one should try to provide hemostasis by stitching or (better) coagulation and save the organ. Mesenteric ruptures guts may be accompanied by severe bleeding, and with extensive tearing of the intestine - necrosis of its wall. The presence of such ruptures of the mesentery with a closed abdominal injury indicates a significant traumatic effect. Retroperitoneal hematomas, identified during laparotomy, are subject to mandatory revision, except when they come from the area of ​​fractures of the pelvic bones.

TACTICS OF MULTI-STAGE SURGICAL TREATMENT ("DAMAGE CONTROL SURGERY") IN 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 intra-abdominal organs and massive blood loss, severe homeostasis disorders: pronounced acidosis(pH less than 7.2), hypothermia(body temperature less than 35°C), coagulopathy(RT more than 19 s and/or RTT 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 referred to as reduced laparotomy with programmed relaparotomy (SL–PR).

To specify indications for SL-PR tactics in case of gunshot wounds of the abdomen, the VPKh-CT scale (VPKh - Department of Military Field Surgery, CT - Surgical Tactics), which was developed on the basis of a statistical analysis of the results of treatment of 282 wounded in the abdomen, allows.

Shkala VPH-CT for gunshot wounds of the abdomen

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

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

Intervention on the abdominal organs should be minimal in volume and as fast as possible. Only parts of organs that are not completely torn off, which prevent effective hemostasis, are removed. Damaged hollow organs are either sutured with a single-row (manual or hardware) suture, or simply tied with gauze tape to prevent further leakage of the contents into the peritoneal cavity.

Temporary closure of the laparotomic wound it is carried out only by bringing together the edges of the skin wound with a single-row suture or by applying clamps (layer-by-layer suture of the abdominal wall is not performed!). In 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 laparotomic 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 WOUNDS AND INJURIES OF THE ABDOMINAL

All laparoscopies are divided into diagnostic and medicinal. The indication for diagnostic laparoscopy for abdominal injuries is the inability to exclude its penetrating nature. In case of closed abdominal injuries, the indication for performing diagnostic laparoscopy is the detection of erythrocytes in the outflowing fluid during diagnostic peritoneal lavage in the range from 100 to 750 thousand per 1 mm3. When the number of erythrocytes is more than 750 thousand in 1 mm3, an emergency laparotomy is indicated.

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

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

Coagulation of the liver wound. If liver wounds up to 1 cm deep with moderate bleeding are detected, monopolar electrocoagulation with an electrode with a spherical tip is used. In case of bleeding from liver wounds of stellate, irregular shape, as well as from liver wounds devoid of a capsule, the use of argon plasma coagulation should be considered the method of choice, which allows the formation of a reliable scab using a non-contact method. The operation ends with obligatory drainage of the subhepatic space and the pelvic cavity.

Coagulation of the wound of the spleen. The use of this method for injuries of the spleen is possible with the localization of the wound in the area of ​​attachment of the splenic-colic ligament and non-intense capillary bleeding. The most effective is the use of argon plasma coagulation, which allows non-contact formation of a reliable dense scab. Mandatory drainage of the left subdiaphragmatic space and the pelvic cavity.

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

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

Suturing the wound of the diaphragm. If a diaphragm wound is found, the pleural cavity is immediately drained on the side of the injury. The diaphragm is sutured from the side of the abdominal cavity: the 1st suture-holder is applied to the far edge of the wound. By traction by the suture-holder, the wound is sequentially sutured with Z-shaped intracorporeal sutures. The subdiaphragmatic space is drained on the side of the injury and the pelvic cavity.

Sewing of the wound of the stomach. The wound of the anterior wall of the stomach is sutured with a two-row suture: the 1st row is superimposed with Z-shaped intracorporeal sutures in the transverse direction through all layers of the stomach, the 2nd row - with gray-serous Z-shaped sutures. The tightness of the superimposed suture is checked by forcing air through a gastric tube and applying liquid to the suture line. Be sure to perform an audit of the posterior wall of the stomach. 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 in the posterior wall of the stomach, it is sutured in the manner described. The integrity of the gastrocolic ligament is restored with Z-shaped intracorporeal sutures. Thick silicone drains are placed in the right hypochondrium and the pelvic cavity.

Surgical interventions by laparoscopic method were performed in 104 wounded and injured. In all cases, the algorithm for diagnosing injuries to the abdominal organs included laparocentesis with peritoneal lavage according to the original technique. The proportion of diagnostic laparoscopies was 52.8%, the conversion rate was 18.6%. The frequency of transitions to laparotomy varied depending on the type of injury. So, with bullet wounds, it was 28.6%, shrapnel - 16.7%, stab wounds - 31.3%, and with closed injuries - 27.3%.

As a result of diagnostic interventions, it was possible to exclude the penetrating nature of bullet and shrapnel (18.1%, respectively) and stab and cut wounds in 20%, as well as damage to the internal organs of the abdomen in 43.6% of cases with 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, laparoscopically, it was possible to coagulate liver wounds (3.7%), suture wounds of the diaphragm and the anterior wall of the stomach equally by 5.5%, perform cholecystectomy (3.7%) with gallbladder rupture and in 11.1% of cases with damage to the spleen to 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.

POSTTRAUMATIC 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 the organs (mainly hollow) of the abdominal cavity.. Depending on the prevalence of the infectious process peritonitis may be local infectious complications (AI) if the inflammation of the peritoneum is limited, or to generalized AI (abdominal sepsis), if the infectious process extends to the entire peritoneum.

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

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

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

The most common option is secondary peritonitis, which combines all forms of inflammation of the peritoneum due to injuries and injuries or destruction of the abdominal organs or after a planned surgical intervention.

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

Depending on the prevalence of peritonitis there are two forms: local and widespread . Local subdivided into delimited(inflammatory infiltrate, abscess) and unlimited when the process is localized in one of the pockets of the peritoneum. 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 (diffuse) peritonitis(damage to more than two anatomical regions 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 combinations thereof) and pathological impurities (gastric and small intestine 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 the 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, a stormy clinical picture in the first hours is due to the development aseptic (chemical) peritonitis. Removal of aggressive contents from the abdominal cavity in a short time creates favorable conditions for stopping the pathological process.

It is also chemical in nature. urinary peritonitis that occurs when the bladder ruptures. It proceeds slowly, with erased clinical symptoms, so it is diagnosed late. Has a similar clinical course biliary and hemorrhagic peritonitis.

With low information content of non-invasive research methods, diagnostic laparoscopy, which in the vast majority of cases allows you to identify signs of peritonitis (cloudy exudate, fibrin overlay on the visceral peritoneum, outflow of bile, gastric or intestinal contents from damaged organs and other pathological changes) and determine the degree of its prevalence, and 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 a rapid onset, a vivid clinical picture, a severe course and unfavorable outcomes of anaerobic peritonitis.

Currently allocate four phases of the course of peritonitis (with and without abdominal sepsis):

1) absence of sepsis;

2) sepsis;

3) severe sepsis;

4) septic (infectious-toxic) shock.

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

• - the presence of multiple, poorly demarcated foci of destruction, making it difficult to immediately sanitize them;
• - 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 complexity of the differential diagnosis of aseptic forms of inflammation (sterile pancreatogenic peritonitis, intestinal dysbacteriosis) and the progression of infectious and inflammatory tissue destruction as the clinical picture of abdominal sepsis develops;
• - the rapid development of the syndrome of multiple organ failure and septic shock.

Frequency of post-traumatic peritonitis.

According to the "Experience of 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 stomach was 8.2-9.4%. At the same time, in seriously wounded with isolated, multiple and combined abdominal wounds, the incidence 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 from the number of deaths from abdominal injuries.

Surgery. The main method of treatment of peritonitis, which most influences the outcome, is a full-fledged, comprehensive surgical intervention aimed at: 1) eliminating or delimiting the source of peritonitis; 2) sanitation, drainage, decompression of the abdominal cavity; 3) prevention or treatment of intestinal failure syndrome. There is no discussion about the presence of a direct dependence of the frequency and severity of peritonitis on the time elapsed from the moment of injury to the start of the operation. Therefore, those wounded in the stomach should be delivered as soon as possible to the stage of medical care, where such an intervention can be performed on them.

Sequence of surgery for widespread peritonitis.

1. Access. The most rational access, providing maximum visibility and convenience in performing the subsequent stages of the operation, is median laparotomy. If necessary, access can be extended in the upper part, bypassing the xiphoid process on the left, in the lower part, by a cut to the pubic joint.
2. Removal of pathological content. According to the data of the war in Afghanistan in 1979-1989, along with blood and reactive effusion, 6.8% of the wounded found gastric contents in the abdominal cavity, 59.8% - intestinal contents, 2.8% - urine, 5, 7% - bile and 1.0% - purulent exudate.
3. Revision of the abdominal organs performed sequentially to identify the source of peritonitis.
4. Elimination or delimitation of 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.

H suturing 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 an obstructive resection of a hollow organ with the removal of the leading end in the form of a stoma or with its muffling and drainage of the leading section of the intestine (tactics for programmed relaparotomies). An exception is the suturing and anastomosis of the damaged initial part of the jejunum, in which the risk of developing failure is lower than the risk of forming a high small bowel fistula. With injuries to the right half of the colon, the possibility of imposing 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 is the removal of the adducting end of the intestine in the form of a single-barreled unnatural anus with plugging the discharge end.

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

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

Decompression of the small intestine is performed 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 conduct 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, one- or two-lumen soft silicone drains are brought to the source of peritonitis and to the most sloping places in the abdominal cavity: the pelvic cavity, lateral canals.
2. Closure of the laparotomic wound. When predicting a favorable course of peritonitis, layer-by-layer suturing of the wound of the abdominal wall 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.

With a probable unfavorable course of peritonitis after a single surgical correction, the tactics of programmed relaparotomy is recommended. In this case, temporary convergence of the edges of the wound is carried out by any of the existing methods.

Relaparotomy - repeated intervention on the abdominal organs, due to:

• - progression of peritonitis with the primary source not eliminated or with the appearance of new sources or tertiary peritonitis;
• - bleeding into the abdominal cavity or gastrointestinal tract;
• - inefficiency of treatment of the syndrome of intestinal insufficiency;
• - the occurrence or complication of the course 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 laparotomic wound;
• - elimination of the cause of repeated intervention on the abdominal organs (necrosequestrectomy, bleeding arrest, elimination of adhesive obstruction);
• - sanitation of the abdominal cavity with large volumes (5-10 l) of warm saline;
• – carrying out intestinal decompression;
• - re-draining of the abdominal cavity;
• – closure of the laparotomic wound. Its method depends on the decision on the further tactics of managing the wounded: surgical debridement, 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 during the transition to the tactics of programmed relaparotomies.

Programmed relaparotomy - repeated staged surgical intervention on the abdominal organs with an alleged unfavorable course of peritonitis due to the possible ineffectiveness of a single surgical intervention.

Indications for the tactics of programmed relaparotomy:

• - the impossibility of eliminating or delimiting the source of peritonitis with a single surgical correction;
• - the severity of the condition of the wounded, which does not allow to perform the necessary full volume of primary intervention;
• - the state of the laparotomic wound, which does not allow closing the defect of the anterior abdominal wall;
• – the impossibility of reducing the edges of the laparotomic wound due to the risk of developing the syndrome of intra-abdominal hypertension;
• - diffuse fibrinous-purulent or anaerobic peritonitis.

PRincuns performing 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;
• - control of the patency and correct position of the nasogastrointestinal probe for intestinal decompression;
• - correction of methods of drainage of the abdominal cavity;
• - temporary reduction of the edges of the laparotomic wound, determining the need, volume and timing of its processing, as well as the timing of the final closure of the abdominal cavity.

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

The main directions of intensive care

1. Prevention and correction of the syndrome of intestinal insufficiency.
2. Directed (argued) anti-microbial therapy.
3. Active and passive immunotherapy.
4. Nutritional support (early enteral, total parenteral and mixed nutrition).
5. Respiratory therapy (IVL, VVL, including non-invasive ventilation of the lungs, sanitation FBS).
6. Adequate infusion-transfusion therapy.
7. Prevention of the formation of stress ulcers of the gastrointestinal tract.
8. Extracorporeal hemocorrection.
9. Control and correction of the level of glycemia.
10. Anticoagulant therapy.

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

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

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

Methods of treatment of intestinal insufficiency syndrome include selective decontamination of the gastrointestinal tract aimed at preventing the spread and local destruction of opportunistic bacteria of the intestinal microbiocenosis, as well as the elimination of toxins. It is carried out through the installed nasogastric or nasogastric tube by introducing 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 injections. The duration of selective decontamination is 7 days or more, depending on the dynamics of the process.

Abdominal injury may be open and closed. They occur when hitting the steering wheel or when injured by objects with sharp edges.
Closed abdominal trauma: with or without damage to internal organs.
Abdominal injury:
- penetrating wounds with or without damage to internal organs.
- non-penetrating wounds.
Reliable signs of a penetrating wound:
- prolapsed abdominal organs are visible in the wound.
- intestinal contents or bile flow from the wound.
During the first aid phase, abdominal trauma considered to be penetrating.
With a strong blow, there may be damage to the abdominal organs:
- parenchymal organs (liver, spleen, kidneys);
- hollow organs (stomach, intestines, bladder);
- large blood vessels (abdominal aorta, inferior vena cava) and vessels of organs (intestines, stomach, liver, spleen).
suspect damage to the hollow organs of the abdominal cavity possible if the following symptoms are present:
- strong acute (" dagger") pain;
- later - diffuse dull pain throughout the abdomen;
- vomiting, thirst;
- forced position on the side, legs tucked to the stomach ("embryo position");
- the abdomen may be swollen, painful, hard "like a board."
In case of damage (trauma) of hollow organs, their contents flow into the abdominal cavity and cause life-threatening inflammation of the abdominal cavity - peritonitis. 
Damage (trauma) parenchymal organs(liver, spleen, kidneys) and blood vessels of the abdominal cavity dangerously increasing latent blood loss.
suspect internal bleeding into the abdominal cavity if the following symptoms are present:
- pale, cold, moist skin;
- violation of consciousness from arousal to unconsciousness;
- frequent, shallow or irregular breathing;
- the pulse is quickened, it is difficult to determine due to a pronounced decrease in blood pressure;
- with very large blood loss, there may be a slowing of the pulse.
recognize damage to internal organs, especially in the first minutes after the injury, it is quite difficult and such victims require the fastest evacuation from the scene for a thorough examination and observation in a surgical hospital.
What is in our stomach?

First aid for abdominal trauma

Do not forget about the observance of the main principles of the provision of PP:
- make sure that there is no additional danger for yourself and the victim;
- call the ambulance service;
- if necessary, perform resuscitation or stop bleeding;
- inspect the victim for other, less dangerous injuries;
- provide first aid depending on the nature of the injuries found;
- prepare the victim for transportation;
- keep constant monitoring of his condition until the arrival of qualified medical personnel.
First aid for closed injury
Pulse at the wrist is palpable, affected in the mind, complaints of severe pain:
- lay on your back with a raised shoulder-head end and a roller under half-bent knees (photo 125).
- in case of vomiting - lay on one side.
- "cold" on the stomach.
The pulse on the wrist is not palpable:
- lay on your back, raising your legs 30-40 cm (photo 126).
- in case of vomiting - lay on one side.
- "cold" on the stomach.
- self-transportation to a medical institution is only allowed if the arrival of the ambulance is expected later than in 30 minutes!
First aid for abdominal wounds
- Give the victim a position in accordance with the severity of the injury.
Apply a sterile, wet dressing to the wound.

Forbidden!
- give water to the victim.
- Reposition prolapsed organs into the abdominal cavity.
- remove foreign bodies from the abdominal cavity.
- apply a pressure bandage to the prolapsed organs.
- apply "cold" to the prolapsed organs.

First aid algorithm

Indications:

Closed injury: severe pain in the abdomen, symptoms of shock. Muscle tension in the anterior abdominal wall.

Open injury: severe pain in the abdomen, symptoms of shock. Muscle tension in the anterior abdominal wall. A wound in the area of ​​the abdominal wall from which blood, feces, bile, urine flows, bowel loops fall out.

Assistance sequence:

Closed injury: cold on the stomach. Transport on a stretcher on the back. Place a roller with a diameter of 10-12 cm under the knees. Sodium etamsylate 2, 0. in / m, cardiomin 2.

It is forbidden! Administer pain medication. Give to drink.

Open injury: do not remove anything from the wound, do not set the intestines. Put a cotton-gauze bagel around the fallen out loops of the intestine. Apply a wide, non-tight bandage. Anesthetize with promedol 2% - 2. Transport on a stretcher on the back, under the knees with a roller with a diameter of 10 cm. Oxyenotherapy. Sodium etamsylate 2, cardiomin 2. It is forbidden! Give to drink.

First aid. At the MPP, bandages are corrected for those wounded in the stomach, antibiotics, tetanus toxoid, analgesics are administered, and, if indicated, cardiac drugs. In the cold season, the wounded must be warmed: overlaid with heating pads, wrapped in a blanket or sleeping bag. With penetrating wounds, especially in the case of life-threatening blood loss, the introduction of blood substitutes is necessary. Such wounded are subject to evacuation in the first place. After them, in the second turn, the wounded are evacuated, who, against the background of a relatively satisfactory state of health and a stable general condition, have a suspicion of a penetrating wound in the abdomen. At the MPP, only those who are agonizing are detained, who are treated symptomatically.

Qualified medical care. In omedb (omedo), the wounded in the stomach are divided into the following groups:

With symptoms of internal bleeding - immediately sent to the operating room in the first turn;

With penetrating wounds without signs of bleeding, as well as with clinically pronounced symptoms of peritonitis, they are sent to the anti-shock ward for intensive care and preparation for surgery in the second turn;

The wounded with a suspected penetrating nature of the wound of the abdomen are sent to the operating room in the second turn, where they perform progressive expansion of the wound or laparocentesis (laparoscopy). Depending on the result, either a laparotomy is performed for a penetrating wound of the abdomen, or, if necessary, only surgical treatment of the abdominal wall wound is performed;

Those who are agonizing are sent to the hospital department for symptomatic therapy.

In the event of a large number of wounded, when it is impossible to provide qualified assistance to all those wounded in the stomach within 3-4 hours, it is permissible to evacuate to the nearest medical facility those who do not have signs of internal bleeding.

Preoperative preparation depends on the general condition of the wounded and the nature of the injury. For carrying out infusion-transfusion therapy, catheterization of the central veins is necessary. It is based on intravenous infusions of crystalloid and colloid solutions with broad-spectrum antibiotics. The duration of preoperative infusion therapy should not exceed 1.5-2 hours. With ongoing internal bleeding, intensive antishock therapy should be carried out simultaneously with the operation.

Laparotomy produced under endotracheal anesthesia with muscle relaxants. The incision of the abdominal wall should provide the possibility of a detailed examination of all parts of the abdominal cavity. The most convenient median approach, as it allows you to perform a complete revision of the abdominal cavity and retroperitoneal space, if necessary, can be extended in the proximal or distal directions, supplemented by transverse incisions.

The loops of the intestine that fell out through the wound or a strand of the greater omentum are washed with an antiseptic solution. The intact intestine is set into the abdominal cavity, expanding, if necessary, the wound of the abdominal wall. To prevent the outflow of intestinal contents, the intestinal walls penetrating into the lumen of the wound are closed with elastic intestinal sphincter, followed by their suturing. The modified area of ​​the omentum is subject to resection.

After opening the abdominal cavity, the surgical aid is carried out in the following sequence: 1) identifying the source with a temporary or final stop of bleeding; 2) systematic revision of the abdominal organs; 3) intervention on damaged organs; 4) intubation of the small intestine (according to indications); 5) sanitation, drainage of the abdominal cavity and retroperitoneal space; 6) closing the wound of the abdominal wall; 7) surgical treatment of entry and exit wounds.

The main principle of surgical intervention for abdominal wounds with damage to the organs of the abdominal cavity and retroperitoneal space is to stop bleeding as soon as possible. Its most frequent sources are damaged liver, spleen, mesenteric and other large abdominal vessels, kidneys, pancreas. An important method of treating traumatic shock in these wounded is the reinfusion of blood that has poured into the abdominal cavity. Seemingly uncontaminated blood is collected by suction, after which it is filtered (perhaps through several layers of gauze) and reinfused. In case of damage to hollow organs, kidneys and ureters, it is advisable to transfuse canned blood or its erythrocyte-containing components. In the absence of blood supplies and severe blood loss, reinfusion of autologous blood under the cover of antibiotics is justified even in the case of injury to hollow organs. A contraindication to reinfusion is massive contamination with the contents of hollow organs of blood poured into the abdominal cavity.

An individual approach is required to stop bleeding from large abdominal vessels(abdominal aorta and inferior vena cava, iliac vessels, portal vein, vessels of the kidney, spleen). After temporary compression, the aorta is isolated from the esophagus: the left triangular ligament is dissected, the left lobe of the liver is retracted to the right side, and a vascular clamp or tourniquet is applied to the abdominal aorta. For revision of the aorta and its branches, left iliac vessels, extraperitoneal parts of the left half of the colon, left kidney, adrenal gland and ureter, the parietal peritoneum is dissected along the left lateral canal along the outer edge of the descending and sigmoid colon, and sometimes the spleen. These formations are exfoliated in the medial direction along with the mesenteric vessels, and, if necessary, with the tail of the pancreas and mobilization of the splenic flexure of the colon. Access to the inferior vena cava, right iliac vessels, extraperitoneal parts of the right half of the colon, right kidney, adrenal gland and ureter is carried out by dissecting the parietal peritoneum along the right lateral canal. Then, the blind, ascending and mobilized hepatic flexure of the colon is peeled off, and if necessary, the duodenum is mobilized according to Kocher.

After exposing the vessels and temporarily stopping the bleeding (cross-clamping, tight tamponade, applying tourniquets and vascular clamps), a vascular suture is applied, both lateral and circular anastomosis, and in case of a large defect, autovenous plasty. In the absence of ischemia or the impossibility of restoring the integrity of a large vessel, rigid clamps are applied with ligation or stitching of the damaged vessel. In a difficult situation (development of a terminal state), ligation of the inferior vena cava below the confluence of the renal veins, the superior mesenteric artery below the origin of the first small intestinal branch, as well as one of the ducts of the portal vein (superior, inferior mesenteric, splenic veins) is acceptable. When ligating two or more mesenteric arteries, in all cases it is necessary to control the state of the intraparietal circulation of the intestine. In case of development of necrosis, it is resected. Be sure to drain the damaged area.

Gunshot wounds of all abdominal organs are subject to surgical treatment. , which is a mandatory and important stage of the operation. During surgical treatment of parenchymal organs, visible necrosis is excised, foreign bodies, blood clots are removed, since failure to do this leads to the development of severe complications (repeated bleeding, the formation of purulent foci). Stopping bleeding, suturing wounds of parenchymal organs is carried out using piercing needles and threads from absorbable material (polysorb, vicryl, catgut).

In case of gunshot defects of hollow organs (stomach, intestine), economical excision of wall tissues up to 0.5 cm around the wound is performed. When carrying out surgical treatment, it is taken into account that a sign of the viability of the wall of a hollow organ is a distinct bleeding from the edges of the wound. Failure to comply with this rule is accompanied by a high incidence of suture failure and the development of life-threatening complications. All hematomas of the wall of hollow organs are subject to mandatory revision to exclude damage penetrating into the lumen. Suturing and formation of anastomoses on hollow organs are performed in 2 rows. The first row of sutures is applied through all layers, using absorbable threads (Polysorb, Vicryl, Polydiaxonone, catgut), the second - serous-muscular - from non-absorbable material (Prolene, polypropylene, capron, lavsan).

At liver injury the volume of surgical interventions depends on the degree of damage to it, while the general principles are a reliable stop of bleeding and a complete surgical treatment of the liver wound. For peripheral ruptures, suturing with U- or Z-shaped sutures from absorbable material, plugging the liver wound, and omentohepatopexy are used. With deep, especially central damage to the organ, preference is given to atypical or anatomical resections with obligatory drainage of the biliary tract, regardless of the presence or absence of bile leakage from the liver wound. With crushing of the lobe, as well as multiple ruptures of both lobes, liver resection or lobectomy is indicated. In critical situations, for the purpose of hemostasis, tight tamponade or compression of the liver with a bandage and tampons is used by fixing them to the ligamentous apparatus. The wound area should be drained with a tube brought out in the right hypochondrium.

Bleeding from a wound spleen usually requires removal of the organ. Be sure to drain the left subdiaphragmatic space with drainage in the left hypochondrium.

When bleeding from a wound kidneys suturing small, non-penetrating wounds into the abdominal system. For more massive wounds, pole resection or wedge-shaped resection is indicated, supplemented by nephropyelo- or pyelostomy for wounds penetrating the pelvicalyceal system. Nephrectomy is performed with central ruptures or irreparable damage to the vessels of the leg, and you should first make sure that there is a second kidney. Be sure to perform drainage of the retroperitoneal space.

When ureteral injury its mandatory revision is carried out throughout its entire length. In this case, either a small (up to 1/3 of the circumference) wound defect is sutured, or the damaged edges are resected and the anastomosis is applied in the absence of tension. It is advisable to use a ureteral catheter (stent) for suturing and resection of the ureter. With extensive damage and the impossibility of restoring the integrity of the ureter, either the central end of the ureter is removed to the abdominal wall, or an unloading pyelo-, pyelonephrostomy is performed. In all cases, drainage of the retroperitoneal space is performed.

Bleeding from small superficial wounds pancreas stop stitching. In such cases, it is sufficient to drain the cavity of the stuffing bag with a tube, which is carried along the lower edge of the gland from the head to the tail, bringing it retroperitoneally under the splenic flexure or the initial section of the colon to the left side wall of the abdomen along the midaxillary line. For supply-and-flow drainage, a second tube is additionally inserted into the hermetically sutured omental bag, which is passed from the right hypochondrium towards the first, through the gastrocolic ligament. With extensive head injuries or the inability to stop bleeding from the pancreatic wound, tamponade and marsupialization are performed - suturing the gastrocolic ligament to the edges of the surgical wound. With complete ruptures distal to the passage of the mesenteric vessels, resection of the body or tail of the pancreas is acceptable. You should always infiltrate the parapancreatic tissue with a 0.25% solution of novocaine with anti-enzymatic drugs (contrical, gordox, trasilol). With severe damage to the pancreas, the operation must be completed with nasogastrointestinal drainage and unloading cholecystostomy.

When injured stomach crushed edges of the wound are economically excised and the wall defect is sutured in the transverse direction. The operation ends with obligatory drainage of the stomach for the purpose of decompression within 3-5 days. In rare cases, with extensive damage to the organ, its marginal (atypical) resection is performed.

Wounds on the anterior wall duodenum, covered with peritoneum, sutured in the transverse direction; when suturing an extensive wound defect (up to ½ of the circumference of the intestine), an unloading gastrojejunostomy should be applied. If damage to the retroperitoneal part is detected, the intestine is mobilized according to Kocher, the wound opening is sutured, and the retroperitoneal space is drained with a tube. With a pronounced narrowing and deformation of the intestine as a result of suturing, the operation of choice is the operation of switching off (diverticulization) by flashing and peritonizing the outlet section of the stomach and applying a bypass gastroenteroanastomosis. Plastic surgery of an extensive defect of the duodenum with a loop of the small intestine (or Roux-en-y) is allowed; accordingly, an unloading entero-enteroanastomosis according to Brown is applied between the inlet and outlet sections of the intestinal loop, and with the Roux method, the continuity of the small intestine is restored using the “end-to-side” method. The retroperitoneal space is drained, and a nasogastroduodenal probe is inserted into the intestinal lumen.

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 performed, and with concomitant liver damage, it is necessary to use drainage of the choledochus through the stump of the cystic duct according to Halsted. In all cases, the subhepatic space is drained with a tube.

For minor damage extrahepatic bile ducts after suturing the wound defect, a cholecystostomy is applied, or cholecystectomy and drainage of the choledoch through the stump of the cystic duct according to Halsted is performed, or external drainage of the choledoch with a T-shaped drainage is performed. Drainage of the subhepatic space is mandatory.

Surgical tactics for wounds of the small and large intestines depends on the nature of the injury, the severity of blood loss, the presence and phase of peritonitis.

When injured small intestine suturing wounds or resection of the intestine is used. An indication for suturing is the presence of one or more wounds located at a considerable distance from each other, when their size does not exceed the semicircle of the intestine. Resection of the small intestine is indicated for defects in its wall greater than a semicircle, with crush and bruises of the intestine with a violation of the viability of the wall, with separation and rupture of the mesentery with impaired blood supply, with multiple wounds located in a limited area and complete rupture of the intestine. The imposition of a primary anastomosis after resection of the small intestine is permissible in the absence of peritonitis, as well as after resection of the small intestine, when the danger to the life of the wounded person from the formation of a high small bowel fistula exceeds that in the event of failure of the anastomotic sutures. In conditions of diffuse peritonitis in the toxic or terminal phase, anastomosis is not applied to the small intestine, and the leading and abducting ends of the small intestine are brought to the abdominal wall in the form of fistulas. The operation after interventions on the small intestine (suturing several wounds or resection) is completed by its obligatory drainage with a two-channel silicone probe. Preference should be given to nasogastrointestinal intubation, retrograde drainage of the small intestine is preferred when removing a caudal enterostomy.

When injured colon the presence of a wound more than ½ of the circumference of the intestine, the destruction or disruption of the blood supply to the segment of the intestine serve as an indication for resection of the damaged segment and the formation of a single-barreled unnatural anus from the leading section of the intestine; the discharge end of the intestine is muffled according to Hartmann, or it is brought to the abdominal wall in the form of a colonic fistula. The presence of diffuse peritonitis is a contraindication to suturing even a small wound defect; in such cases, either crossing the lumen of the intestine and its mesentery at the site of injury and performing the Hartmann operation, or removing the movable damaged area in the form of an unnatural anus of the “double-barreled” type, is permissible. Suturing is permissible only in the presence of an isolated small (up to 1/3 of the circumference of the intestine) wound, the absence of massive blood loss, as well as severe damage to other organs and anatomical regions; if there is doubt about the final outcome or a larger size of the wound defect (up to ½ of the circumference of the intestine), extraperitonization of the movable part of the colon with a sutured wound is indicated. Under extraperitonization understand the temporary removal through a separate incision of the abdominal wall of the loop of the colon with a sutured wound, which is placed under the skin; with a successful postoperative course, after 10 days, the bowel loop is immersed in the abdominal cavity; with the development of insolvency of the intestinal sutures, a colonic fistula is formed. If the mesoperitoneal section is damaged, either the wound is sutured and an unloading proximal abduction colostomy is applied, or the intestinal lumen and its mesentery are crossed at the wound site, mobilization and the Hartmann operation is performed. With extensive wounds of the right half of the colon, it is permissible to perform a right-sided hemicolectomy: the imposition of a primary ileotransverse anastomosis is indicated in the absence of pronounced inflammatory changes in the abdominal cavity, characteristic of the toxic or terminal phase of peritonitis and stable hemodynamics; in other situations, the operation ends with the removal of the ileostomy. The removal of the damaged segment of the colon with an extensive wound on the abdominal wall is not recommended because of the highest mortality.

When injured intra-abdominal rectum There are 2 operating options available. With a small wound the wound defect is sutured, and from a separate incision of the abdominal wall in the right iliac region, an unnatural anus is applied to the sigmoid colon (in the form of a "double-barrel"). With extensive wounds of the rectum resection of the non-viable area and removal of the adducting end of the intestine to the anterior abdominal wall in the form of a single-barreled unnatural anus are performed; the outlet end is sutured tightly (Hartmann's operation). Injury to the extraperitoneal rectum impose an unnatural anus (in the form of a "shotgun") on the sigmoid colon. The outlet part of the rectum is washed with an antiseptic solution, after which the ischiorectal space is opened with perineal access; if possible, the wound opening is sutured or the sphincter is restored; drainage of the pararectal space in case of extraperitoneal injury is mandatory. It is better to use a double-lumen tube, which is brought to the damaged area.

In all cases, operations on the colon should end with decompression of the gastrointestinal tract. Preference should be given nasogastrointestinal intubation using double lumen silicone probes. When applying an ileo- or cecostomy, retrograde drainage of the small intestine is performed through the removed intestinal fistula. It is mandatory to simultaneously drain the colon through the anus with a silicone probe (single or double lumen), especially in cases of suturing a defect in the intestinal wall or applying a primary anastomosis. At the end of the operation, devulsion of the anus is performed.

At small intraperitoneal bladder injury after surgical treatment of the wound, it is sutured with double-row sutures without capturing the mucous membrane. After that, bladder drainage is established with a permanent catheter. In the case of extensive and multiple wound defects, cystostomy and drainage of paravesical tissue are performed according to Buyalsky-McWorter (through the obturator foramen) or Kupriyanov (under the pubic symphysis). At extraperitoneal bladder injuries produce extraperitoneal access to the bladder, if possible, suturing wound defects. The operation is completed with the imposition of a cystostomy and drainage of paravesical tissue.

An important point of the surgical stage of treatment is sanitation of the abdominal cavity. Allocate primary and final sanitation. The primary is carried out after the evacuation of the exudate, intestinal contents from the abdominal cavity, the final - after the elimination or delimitation of the source of peritonitis. The best bactericidal properties are oxygenated (0.06% -0.09%) or ozonized (4-6 mg / l) isotonic sodium chloride solution, however, depending on the equipment and capabilities of the military medical institution, a sterile one can be used for lavage of the peritoneal cavity. saline or antiseptic solutions: furatsilina (1:5000), chlorhexidine (0.2%).

Each laparotomy for a penetrating abdominal injury should end with drainage of the abdominal cavity. Drainages are carried out through separate incisions (punctures) of the abdominal wall, while one of them must be installed in the cavity of the small pelvis.

Surgical wounds of the anterior abdominal wall after laparotomy are sutured tightly. In the case of laparotomy against the background of diffuse peritonitis, severe intestinal paresis, the need for repeated sanitation of the abdominal cavity, the aponeurosis is not sutured, but only skin sutures are applied. After that, surgical treatment of input and output wounds is performed.

After the operation, the wounded are placed in the intensive care unit to continue treatment with the participation of an anesthesiologist-resuscitator, and after waking up, without an endotracheal tube and with restored natural breathing, they are transferred to the hospital ward. In the first 2–3 days of the postoperative period, parenteral nutrition is carried out by intravenous administration of protein solutions (plasma, albumin), concentrated glucose solutions (20–40%) with insulin and vitamins with a total volume of up to 4–6 l / day. In the following days, the volume of infusions is reduced and gradually switched to enteral nutrition. With intestinal paresis, constant aspiration of gastric and intestinal contents through probes is provided, epidural anesthesia is performed, and intestinal function is stimulated.

Antibiotics are administered intramuscularly, intravenously, endolymphatic and additionally intraperitoneally through established drains.

In some cases, it becomes necessary to perform an early (in 12–24 hours) programmed relaparotomy, the purpose of which is a control examination of the internal organs and sanitation of the abdominal cavity. The indications for such an operation are: performing a primary operation against the background of diffuse purulent peritonitis, the forced use of methods for temporarily stopping bleeding, and a high probability of failure of the intestinal sutures.

After the operation, the wounded in the stomach are not transportable for 7-10 days if the evacuation is carried out by road, and up to 3-4 days - by air.

The most common complication (more than 60% of their total number) in those wounded in the stomach in the postoperative period is peritonitis. Postoperative peritonitis most often develops due to the failure of intestinal sutures or anastomoses, local delimited peritonitis (abscesses) as a result of inadequate sanitation or inadequate drainage of the abdominal cavity. Diagnosis of peritonitis in those wounded in the abdomen is difficult and responsible, since the outcome often depends on the early detection of complications. The basis of diagnosis is the deterioration of the general condition, the progression of intoxication and intestinal paresis, which are often supported by x-ray and laboratory data (an increase in leukocytosis and a shift of the leukocyte formula to the left). Laparoscopy is highly informative in terms of diagnosing this complication, while one should not forget about the adhesive process and the possibility of additional iatrogenic injuries. If peritonitis is detected, urgent relaparotomy is performed and its source is eliminated with a full range of detoxification measures (forced diuresis, peritoneal and intestinal lavage, enterosorption, endolymphatic administration of antibiotics, drainage of the thoracic duct). In some cases, after relaparotomy, there is a need for program sanitation of the abdominal cavity, the indications for which are the impossibility of performing a single thorough intraoperative lavage. This situation, as a rule, occurs when there is significant fecal content in the abdominal cavity. In such cases, after sanitation of the abdominal cavity, only skin sutures are applied to the edges of the surgical wound. These wounded, after stabilization of hemodynamic parameters in the immediate postoperative period, should be transferred to a specialized hospital in the first place.

The next severe postoperative complication in those wounded in the abdomen is early adhesive intestinal obstruction, occurring, as a rule, for 3-5 days. The clinical picture of obstruction is characterized by the appearance of cramping abdominal pain, nausea, vomiting, bloating, cessation of gas, stool or intestinal contents, a change in the shape of the abdomen (Val's symptom). In these cases, conservative therapy is first performed: drainage and gastric lavage, an enema, a warming compress on the abdomen, sacrospinal, and even better, epidural blockade at the level of the lower thoracic spine. If these procedures do not lead to the desired effect and intoxication increases, they resort to relaparotomy and removal of the obstacle that caused difficulty in the passage of intestinal contents, drainage of the small intestine with a nasogastrointestinal probe.

At eventrations, the causes of which are most often peritonitis, suppuration of the surgical wound and errors in suturing the abdominal wall, the wounded person needs urgent surgical intervention. Under general anesthesia, the prolapsed intestinal loops are set into the abdominal cavity, the small intestine is intubated, the abdominal cavity is sanitized and drained. To prevent re-eventration, the wound is sutured through all layers with mattress sutures, a wide bandage of a towel or sheet is applied to the abdomen. With diffuse purulent peritonitis, the surgical wound of the abdomen is closed only with skin sutures.

For prevention pneumonia the wounded should be in bed with a raised head end, breathing exercises and vibration massage are systematically performed after the administration of analgesics.

Specialized medical care wounded in the stomach is in hospitals intended for the treatment of wounded in the chest, abdomen and pelvis (VPTAG). At this stage of evacuation, the wounded are mainly delivered, who have already been provided with qualified surgical care.

One of the main tasks in the provision of specialized care is the treatment of emerging postoperative complications: diffuse peritonitis, intra-abdominal abscesses, early adhesive intestinal obstruction, secondary bleeding, eventration of internal organs, phlegmon of the abdominal wall and retroperitoneal space, intestinal fistulas and urinary streaks. In the conditions of modern warfare, the wounded in the stomach or pelvis, who need urgent operations and anti-shock treatment, can be delivered to a specialized hospital directly from the centers of mass destruction, bypassing the stage of providing qualified medical care.

In TTMZ, the treatment of the wounded continues due to complications that have arisen in them: adhesive disease, intestinal and urinary fistulas, etc.

Guidelines for military surgery