Gunshot wounds to the abdomen. Medical care for gunshot wounds of the abdomen. Rectal injuries

Surgical intervention, performed no later than 10-12 hours from the moment of injury, can save a person with a penetrating wound to the abdomen and damage to internal organs. If the patient is not provided with full-fledged surgical care in a timely manner, then death becomes almost inevitable. It is important for a gunshot wound to the abdomen to quickly and correctly assess the nature of the wound and provide first aid.

Symptoms of non-penetrating wounds

In some cases, gunshot non-penetrating wounds of the abdomen without extraperitoneal damage to organs are classified as minor injuries. The lightest - with a trajectory of a bullet or projectile or their fragments at the end, perpendicular to the surface of the abdomen. In this case, the foreign body can get stuck in the abdominal wall without damaging the peritoneum. With oblique wounds of the abdominal wall, which can be caused by shells or their fragments, there may be severe bruises of the small or large intestine, followed by necrosis of a section of their wall and perforative peritonitis. For gunshot wounds abdominal wall symptoms of shock and symptoms of a penetrating injury to the abdomen may be observed. Therefore, any wound should be considered as potentially penetrating. Wounded with non-penetrating wounds require urgent evacuation to medical institution in order to establish the true nature of the injury.

Symptoms of penetrating wounds

In most cases, penetrating wounds of the abdomen are accompanied by injuries of organs abdominal cavity(liver, spleen, stomach, intestines, mesentery, bladder, combined with injury to the spine and spinal cord).

The clinic and symptoms of penetrating gunshot wounds of the abdomen are determined by a combination of three pathological processes: shock, bleeding and perforation or through violation of the integrity of the wall of the cavity or tubular organ(intestine, stomach, bladder), as a result of which a communication is established between the cavity of the organ and its environment. In the first hours after the injury, the clinic of blood loss and shock dominates. After 5-6 hours from the moment of injury, peritonitis develops.

Symptoms of penetrating wounds of the abdomen: prolapse of the viscera from the wound or outflow from the wound canal of fluids corresponding to the contents of the abdominal organs. In such cases, the diagnosis of a penetrating wound of the abdomen is established at the first examination.

First aid

In order to make right action for first aid in case of injury to the abdomen, it is necessary to correctly assess the severity and nature of the injury . Bullet or shrapnel wounds, penetrating the body, cause damage to the latter, which have certain differences from other body injuries: the wounds are usually deep, often contaminated with tissue fragments, shells, bone fragments, and the injuring object often remains inside the body. These features of a gunshot wound should be taken into account when providing first aid to the victim. The severity of the injury should be assessed by the location and type of the inlet, the behavior of the victim and other signs.

In case of injuries of the abdominal organs, the victim is seated on the floor sitting position. Warning wound infection: disinfect the edges of the wound, apply a sterile napkin. With severe blood loss - antishock therapy.

At the slightest suspicion of the penetrating nature of the wound, it is necessary:

Inject morphine.
Close the wound with a dry aseptic bandage.
Give the wounded absolutely no drink and no food.
To ensure the fastest and smoothest possible transportation.

In case of loss of entrails:

Cover the entire abdominal wall, immobilizing (especially when bowel loops, omentum fall out of the wound) with a wide aseptic bandage moistened with a solution of furacilin or vaseline oil. It is impossible to set the fallen organs into the abdominal cavity.
Place a roll of gauze bandages around the fallen organs. Put on top of the rollers aseptic bandage, trying not to press the fallen organs. Bandage the bandage to the stomach.
Apply cold to the bandage.
Introduce analgesics, cardiac drugs, tetanus toxoid and morphine hydrochloride.
If necessary, wrap the wounded in a warm blanket.
Provide gentle transportation of the wounded on a stretcher.
Call " ambulance”, ensuring the delivery of the victim in a supine position with bent knees, under which a roller from a blanket should be placed.

Important! It is forbidden to drink or feed the wounded. To quench the feeling of thirst, you need to moisten your lips.

Treatment

The most frequent complications in the postoperative period in those wounded in the abdomen are peritonitis and pneumonia. The main signs of peritonitis are abdominal pain, 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 irritation of the peritoneum, the absence of noises of intestinal peristalsis.

Treatment includes reoperation for peritonitis and subsequent conservative treatment, opening of abscesses of the abdominal cavity, surgery intestinal fistulas and others recovery operations on the gastrointestinal tract.

With combined radiation injuries surgical treatment of gunshot wounds of the abdomen begins at the stage of qualified medical care and is necessarily combined with the treatment of radiation sickness. Operations should be simultaneous and radical, since as radiation sickness develops, the risk increases sharply infectious complications. In the postoperative period, massive antibiotic therapy, blood transfusion and plasma substitutes, the introduction of vitamins, etc. are indicated. With combined combat injuries of the abdomen, the terms of hospitalization should be extended.

The prognosis for gunshot wounds of the abdomen is unfavorable.

Abdominal injury is a dangerous pathological condition in which there is high probability damage to internal organs. Wounds in the abdomen, especially penetrating, are characterized by a strong pain syndrome, due to which the patient suffers shock. In the abdominal cavity there are large, and organs, with the defeat of which it is almost impossible to stop the bleeding, which often leads to death. That is why you should be aware of how first aid is provided for wounding the abdomen.

Types of injuries

The nature of early medical care largely depends on the type of damage in the abdominal (abdominal) region. The greatest danger is characterized by open wounds, as they are accompanied by bleeding, penetrating damage to organs, rupture of tissues and blood vessels. In most cases, open abdominal injuries occur due to punctures, cuts, less often animal bites, and gunshot wounds.

With closed abdominal injuries, there is no penetration of a foreign body into the tissues, but this does not mean that the lesion is less dangerous. With severe bruises, a fracture of the ribs is possible with further penetration of fragments into nearby organs. Also, closed injuries may be accompanied by internal bleeding, ruptures of organs, large vessels.

Bruising of the abdominal wall is considered the least dangerous pathology. With minor trauma and no complications pathological manifestations pass in 2-3 weeks. At the site of impact, pain is noted, and hematomas may appear.

Thus, abdominal injuries are open and closed, and pose a significant threat to the health of the victim.

Clinical picture

Before assisting the patient, it is important to determine the severity of the lesion. To do this, you need to learn about the symptoms that bother the patient. Abdominal injuries are accompanied by a wide range of clinical manifestations, which determine the nature of the lesion.

Symptoms of abdominal wounds:

. With open injuries, tissue is damaged, which causes bleeding at the site of injury. The color of the blood varies depending on the nature and depth of the injury. With shallow lesions, the blood is usually bright red, indicating a violation of the integrity of the arterial vessels. Abundant hemorrhage indicates damage to the parenchymal organs, which include the pancreas, liver, spleen.
Pain syndrome. The intensity and localization depend on where the damage is located, whether the internal organs are affected. It is important to note that in some patients, pain does not occur immediately, which is quite dangerous, since pain may be absent even if the internal organ is damaged and internal bleeding.
. In the affected area, the skin, as a rule, swells, acquires a bluish tint. This indicates a violation of the blood supply in this area. Often occurs with bruises caused by blows with a blunt object, falls, squeezing.
Loss of consciousness. The symptom indicates serious damage to the abdominal organs. Most often, loss of consciousness leads to violations of the integrity of the liver, as this develops intense bleeding, and the patient's condition worsens significantly. At the same time, pallor skin, cold sweat, sometimes chills.
Bloating. Indicates damage to the pancreas. Injury to this organ is a rare occurrence that usually occurs simultaneously with damage to other abdominal organs. In addition to bloating, the victim has tension in the abdominal muscles, increased heart rate.
Nausea and. It occurs in almost any abdominal injury. Occur due to functional disorders caused by mechanical action on internal organs. Vomiting attacks can be multiple, while the consistency and content of vomit should be taken into account.

In general, abdominal injuries are accompanied by various symptoms, with which you can determine the severity of the lesion.

First aid

Before proceeding to help the victim, you need to call an ambulance. It is recommended to do this even in the absence of symptoms of severe injuries or damage to internal organs. It is extremely difficult to diagnose complications on your own, and therefore only a qualified physician can do this. In the future, they move on to helping the victim.

Action algorithm:

Reception comfortable position. The victim is given the most comfortable position for him. It is best if the person with the wound lies down. When vomiting, be sure to turn the patient's head to the side to prevent suffocation. If the injury to the abdomen is caused by a fall on sharp object, the patient should not be removed or repositioned.
Air access. The patient is provided with an influx of oxygen. If the wound is received indoors, open the windows, carefully ventilating the room. It is recommended to remove clothing from the victim if it interferes with normal breathing.
Preservation of consciousness. It is not recommended that the patient lose consciousness before the arrival of doctors. It is necessary to maintain it in a conscious state through dialogue. The victim is asked about the symptoms present in him, reassure. This allows not only to preserve the consciousness of the patient, but also to distract him from pain, to prevent panic attacks.
. Before stopping the bleeding, it is necessary to clean the edges of the wounds from possible contamination. It is best to remove dirt from affected tissues with cotton swab or cotton swab. At the same time, it is strictly forbidden to try to place any object in the wound channel in order to assess the depth of damage.
Stop bleeding. In the presence of open wound it is necessary to cover it with an antiseptic dressing or lotion. If there are no disinfectants at hand, clothes and clean handkerchiefs are used to stop bleeding. treat the wound itself antiseptics Not recommended.
. It is strictly forbidden to give the victim any anesthetics. decline pain syndrome blurs the overall clinical picture, which can lead to misdiagnosis. In addition, with wounds to the abdomen, it is possible to save the victim from pain only with the help of potent drugs.

It is important to remember that in no case should a victim with a stomach injury be allowed to drink or eat, even if he himself asks for it. The load on the internal organs in this state is not permissible. After providing the measures described above, it is recommended to apply cold to the affected area. This will reduce pain sensitivity, and to some extent alleviate the condition of the victim before the ambulance arrives.

In general, first aid for abdominal wounds is to keep the patient conscious, prevent complications and bleeding.

Wounds with penetration of foreign objects

With open penetrating injuries of the abdomen, it often happens that at the site of tissue rupture remains foreign object. These include various tools, reinforced concrete fittings, edged weapons, bullets, nails, and other objects. In this case, the algorithm for providing assistance changes.

First of all, the severity of the condition of the victim is assessed. If the patient's condition is difficult, first of all it turns out urgent care during which doctors are called. In other cases, calling medical staff is the first step in helping the victim.

If the patient has lost consciousness, he is placed on his back, his head is thrown back and turned to the side. In this position, free access is provided, and vomit, in the case of a reflex urge, leaves the body without obstacles.

It is strictly forbidden to remove a foreign body from the abdomen. First, because of this, bleeding increases. Secondly, during the extraction, damage to organs is possible, which will lead to the death of the victim. If possible, the foreign body can be cut off a little so that it does not interfere with the transportation of the patient.

If the object stuck in the stomach is long, it is immobilized. This is done with a bandage or gauze. The object is carefully wrapped, and the ends are fixed around the torso of the victim. Before the arrival of the ambulance, the patient is covered with a warm blanket, his condition is monitored. Giving food and liquids to drink is prohibited.

If the wound was caused by a gunshot, attention should be paid to the presence of a bullet exit hole. If it is found, in this place, as well as on the inlet, superimposed antiseptic dressing or compress. If a bullet wounds several, each is subject to processing.

Prolapse of internal organs

Such a pathology is possible with large lacerated or incised wounds. First of all, it is estimated how quickly the arrival of doctors is possible. If the doctors are expected to arrive within 30 minutes, then an ambulance is first called, and then proceed to emergency measures.

If organs prolapse, you should not try to put them back into the abdominal cavity. It with highly likely will lead to infection. In addition, it is impossible to properly assemble organs inside the abdominal cavity in the absence of special knowledge.

The fallen organs are carefully moved towards each other, so that the area occupied by them is minimal. Subsequently, they are placed in a plastic bag or fabric bag, and applied near the wound. If it is impossible to isolate the fallen organs, they are carefully wrapped with a bandage and tied to the abdominal cavity. During any manipulations with the organs, excessive pressure or compressing them should not be exerted.

After performing the above procedure, the patient is transferred to a sitting position. In the same position, he is transported to the nearest medical facility. Before the arrival of doctors, the fallen organs are regularly wetted clean water to prevent them from drying out.

Prolapse of organs in open wounds of the abdomen - serious complication requiring special first aid.

While watching the video, you will learn about first aid for wounding the abdomen.

Wounds in the abdominal region are a serious pathology, which, if not treated in time, leads to the death of the patient. Knowledge of the rules of first aid significantly increases the likelihood of survival of the victim and prevents irreversible consequences for good health.

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 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 - spilled Blunt pain all over the stomach;
- 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, is quite difficult and such victims require speedy 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 it's missing 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 medical institution admissible only if the ambulance is expected to arrive later than 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.
- impose pressure bandage on 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.

Article content: classList.toggle()">expand

Any injury to the abdomen is always considered dangerous, since internal organs may be affected, and it is impossible to determine this at first glance, as well as assess the severity of the injury.

Therefore, the first aid to the victim is always the same, regardless of the type of injury (gunshot, knife, etc.). But providing assistance in the presence of a foreign body or protruding organs has some differences from the general algorithm.

Brief instructions for assistance

Especially important point when injured in the abdomen, which must be taken into account when providing first aid, is that the victim is strictly forbidden to give food and drink, even if he asks for it. It is only allowed to wet his lips with clean water and, if necessary, you can rinse your mouth without swallowing water.

Oral medications, including painkillers, should also not be given. As for painkillers, they cannot be given to a person on their own when the abdomen is wounded.

First aid for a wound in the abdomen is as follows:

First aid for penetrating wounds of the abdomen

If a person has a wound in the abdomen, it is important to immediately assess the situation. If an ambulance can arrive at the scene within half an hour, then the first thing to do is call the doctors and then proceed to provide first aid.

If the ambulance can get to the victim for a long time, you should immediately begin first aid measures, and then take the person to the nearest clinic on your own.

If a person is unconscious, this does not interfere with first aid, especially in the case of an open penetrating wound to the abdomen or any other part of the body. You should not try to bring him to his senses, you just need to lay him on a flat surface, bend your knees, put a roller of clothes under them and tilt the person’s head back, turning it to the side to ensure free passage of air.

No need to feel the wound on the stomach, and even more so try to find out its depth. by dipping a finger or hand into it. In case of a gunshot wound, the victim should be examined and determined possible presence bullet exit hole. If it is available, it must also be processed, as well as the input, and a bandage should be applied. If there are several wounds in the abdomen, then everything will be treated, starting with the largest and most dangerous injuries.

It is important to stop if it is profuse, for which it is necessary to correctly determine its type, after which the wounds should be treated and cleaned of dirt and blood.

For cleaning, you need to use a clean cloth, gauze, bandages soaked in hydrogen peroxide, any solution of an antiseptic or potassium permanganate (furatsilina). In the absence of such drugs, you can use any alcoholic beverage.

Cleaning of the wound is carried out in the direction away from the edges of the damage around the entire perimeter. The cloth should be soaked in the solution abundantly. In some cases, one treatment may not be enough for a complete cleaning. In this case, you will need another piece of cloth or bandage soaked in an antiseptic solution.

Can't fill antiseptic preparations into the wound, as well as water and other liquids. Contaminants should be removed only from the surface of the skin surrounding the wound and its edges.

If possible, the skin around the wound should be treated with brilliant green or iodine to prevent secondary infection. After that, you need to apply a bandage and deliver the victim to the clinic. During transport, an ice pack or other source of cold may be applied over the dressing.

Algorithm of actions in case of injury in the presence of a foreign body

First aid in this case is carried out according to the general algorithm, but it is important to take into account special points, as well as pay attention to a number of rules, non-observance of which can lead to the death of the victim.

In case of a gunshot wound, if a bullet remains in the wound, in no case should you try to remove it yourself, as this can lead to the onset of serious bleeding that threatens the life of a person.

The ban on extraction also applies to any other object in the wound, primarily to the one that was injured. Therefore, in no case should the knife be removed as part of first aid when knife wound in the abdomen or abdominal cavity. The traumatic object closes the damaged vessels, pinching them and holding back the bleeding. They can only be removed in the hospital, in the operating room, where doctors can provide assistance in any situation.

Assistance in the presence of organs falling out of the wound

The general algorithm for providing first aid in this case is also relevant, but has some special points that must be observed. First of all, if internal organs are visible when injured in the abdomen, it is necessary to evaluate general situation, such as how quickly an ambulance can get to the scene.

If a team of doctors can reach the victim within half an hour, then the first thing to do is call an ambulance, and then begin first aid measures. If doctors need more time, they should immediately begin to provide assistance, and then deliver the person to the clinic in their own or passing transport.

If a person with a wounded abdomen is unconscious, it is necessary to tilt his head back and turn slightly to the side so that air can freely enter the lungs.

If the internal organs have fallen out of the wound on the abdomen, in no case should you push them back and try to push them back into the abdominal cavity. If there are several organs that have fallen out (or the intestines have fallen out), it is necessary to move them as close as possible to each other so that the area occupied by them is minimal. After that, as carefully and very carefully as possible, all organs should be placed in a piece of clean tissue or a clean bag, the edges of which must be glued with a plaster or ordinary tape to the victim's skin around the wound.

It is very important to isolate the prolapsed organs from any environmental influences and protect them from possible damage.

If it is impossible to isolate the fallen organs in this way, the procedure is carried out a little differently. You should prepare several rollers from a clean cloth or bandages, cover the fallen organs with them and cover them on top with a piece of gauze or a clean cloth. After that, it is necessary to carefully and not tightly fasten the structure to the body of the victim at the site of the injury.

It is very important to take into account that the internal organs, when applying such a bandage, should not be squeezed even slightly, since this can lead to many complications.

After fixing the prolapsed organs in any of these ways, the victim should be given a normal sitting position, while his legs should be half-bent at the knees. Cold should be applied to the wound, but it is important that the ice pack be wrapped in a cloth or towel. After this, the victim must be wrapped in a blanket (this is mandatory). Transportation of a person with such a wound should be carried out in a sitting position.

During transportation to the clinic, it is important to constantly moisten the fallen organs with clean water, preventing them from drying out. If the organs are placed in a bag, then water can be poured inside from a conventional syringe. If they are in a fabric or under a special bandage, then it will be enough to periodically soak the dressing with water, preventing drying.

It is important to remember that the drying of the surface of the internal organs, caught in the air, will lead to their necrosis, due to which doctors will be forced to remove them. With necrosis of vital organs, death occurs.

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. For penetrating wounds, especially 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 the operation in the second stage;

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 assistance within 3-4 hours qualified assistance all those wounded in the stomach, evacuation to the nearest medical facility of those who do not have signs of internal bleeding is acceptable.

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 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 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, taken to right side left lobe liver, carry out the imposition of a vascular clamp or tourniquet on 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 sections of the right half of the colon, right kidney, adrenal gland and ureter is carried out by dissection of 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, mobilization is performed. duodenum 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 inability to restore integrity large vessel resort to the imposition of rigid clamps with ligation or stitching of the damaged vessel. AT difficult situation(development 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 mandatory and milestone operations. During surgical treatment of parenchymal organs, excision of visible necrosis is performed, removal foreign bodies, blood clots, 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 perform 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 amount of surgical intervention depends on the degree of its damage, general principles at the same time, there is 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 lesions organ preference is given to atypical or anatomical resections with mandatory drainage 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 perform suturing of small, non-penetrating cavity system wounds. For more massive wounds, pole resection or wedge resection, supplemented by nephropyelo- or pyelostomy with wounds penetrating into the pyelocaliceal 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.

At little 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. 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; when in doubt about the final outcome or larger size wound defect (up to ½ of the circumference of the intestine), extraperitonization of the movable 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 perform suturing of the wound defect and from a separate incision of the abdominal wall in the right iliac region carry out the imposition of an unnatural anus on 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, colon surgery should end with decompression. 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 ozonated (4-6 mg / l) isotonic solution sodium chloride, however, depending on the equipment and capabilities of the military medical institution for lavage of the peritoneal cavity, you can use a sterile 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. 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.

Most frequent complication(more than 60% of their total number) in the wounded in the stomach in 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 the wounded in the stomach is difficult and responsible, since early detection complications often depend on the outcome. 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 (increased leukocytosis and shift 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 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. Clinical picture obstruction is characterized by the appearance cramping pains in the abdomen, 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 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 providing 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