Abdominal wounds. Open injuries - abdominal wounds can be stab wounds (knife wounds) or gunshot wounds

Open injuries - abdominal wounds can be stab wounds (knife wounds) or gunshot wounds. In peacetime, stab wounds occur in most cases. Their course is much easier than closed injuries and especially gunshot wounds.

Gunshot wounds to the abdomen are the most severe type of injury due to the extent of tissue destruction and a large number of complications. Shrapnel wounds are the most severe.

Among gunshot wounds, wounds caused by shot from a hunting rifle at close range are dangerous. In such cases, fast and highly qualified surgical care is necessary. Small shot wounds from long distances are much less dangerous.

Open abdominal injuries are divided into two main groups - non-penetrating and penetrating. This is based on the preservation or violation of the integrity of the peritoneal covering of the abdomen. Penetrating injuries are more dangerous, but injuries of varying severity are possible within both groups. Penetrating wounds include favorable injuries to only the peritoneal layer; however, if the peritoneal cover is intact, damage to internal organs is possible. On average, penetrating abdominal wounds account for 75%, non-penetrating wounds - 25%.

Non-penetrating abdominal wounds. With non-penetrating abdominal wounds, in most cases the abdominal wall is damaged. However, damage to the abdominal organs is quite possible. These include extraperitoneal wounds of the colon, kidney vessels, as well as intraperitoneal bruises and ruptures of abdominal organs “at a distance”, from the indirect impact of a gunshot. In practice, all these injuries are usually interpreted as penetrating wounds.

Penetrating abdominal wounds. Penetrating abdominal wounds are rarely isolated. Combined organ injuries are more common. It is practically important that in only 50% of gunshot wounds the entry wound is localized on the abdominal wall; in the other half of the wounds, the entrance opening is found on the chest, in the lumbar, sacral region, on the buttock and thigh.

Intraperitoneal wounds are divided into injuries of hollow and parenchymal organs.

Diagnosis of damage to abdominal organs. With any damage to the abdominal organs, the risk of death cannot be ignored, so the diagnosis must be made as early as possible. The main task is not to recognize damage to one or another abdominal organ, but to establish indications for emergency surgical intervention. Under all conditions, the time factor plays a decisive role in saving the wounded with injuries to the abdominal organs.

Damage to the abdominal organs varies in nature, location and extent of damage, which leads to different clinical characteristics their. The severity of the condition is determined by shock, blood loss and peritonitis.

Shock is a characteristic condition of a patient with damage to the abdominal organs. It is observed in 72% of penetrating abdominal wounds. However, shock may be absent when there is obvious damage to the abdominal organs and develop when only the abdominal wall is damaged. The frequency of shock with injuries to the abdominal organs varies within a fairly wide range. In addition to the nature of the injury itself, the type of transport, the duration of transportation and the timing of admission to a medical institution, " great importance has the neuropsychic and physical condition of the victim at the time of injury. It largely determines the body’s response to injury, the clinical course of the injury and the effectiveness of therapeutic measures.

Bleeding is of great importance during shock. peritonitis, and, consequently, in the “outcomes of wounds. Accumulation of blood in the abdomen to one degree or another is noted in 80.4% of cases. The amount of blood spilled into the abdominal cavity serves as an indicator of the severity of the injury and its course.

With extensive destruction of the parenchymal organ and massive blood loss, collapse develops immediately after the injury. If blood loss is compatible with life, temporary compensation occurs after some time. When examining the victim, severe pallor, cold sweat, convulsive muscle twitching, frequent small pulse, and a sharp fall are noted. blood pressure. This is extreme internal bleeding. The compensation that develops is temporary and unstable.

Compensation for blood loss develops as a result of increased breathing, tachycardia with accelerated blood flow, contraction of peripheral arteries and veins with mobilization of blood from the depot and the entry of tissue fluid into the bloodstream. With small blood losses, compensatory mechanisms quickly restore vascular tone, blood volume and the speed of its circulation. In this restoration, the flow of fluid from the tissues plays a significant role. Determination of hemoglobin content and red blood cell count ib early dates does not give a complete picture of the degree of blood loss: blood thinning occurs later.

The hematocrit number is determined by centrifuging blood in capillary tubes. Normally healthy person red blood cells make up 42-46%, and plasma - 54-58% of blood volume. Determination of erythrocyte volume and specific gravity of blood is of great clinical importance. A decrease in the total volume of erythrocytes and a drop in the specific blood volume during blood loss occur quickly. 4-6 hours after the injury, a decrease in the volume of erythrocytes is noted, and the intensity of the decrease in their volume indicates the degree of blood loss.

Peritonitis develops to one degree or another with all injuries to the abdominal organs. Its development is most pronounced when hollow organs are damaged.

The examination of a newly arrived person wounded in the abdomen must begin with an assessment of his general condition and behavior.

There are no symptoms that indicate with absolute certainty that the abdominal organs are damaged. The diagnosis is made based on an assessment of general and local symptoms.

Symptoms of abdominal organ damage are numerous. They can be divided into two groups. The first group includes the initial symptoms of damage to the peritoneum, manifested in the form of defensive reactions. The second group includes symptoms characteristic of developing peritonitis.

Early symptoms lesions of the peritoneum are combined into syndrome of initial signs of peritoneal damage, This syndrome includes mainly three symptoms: tension of the abdominal wall, its non-participation in the act of breathing and the Shchetkin-Blumberg symptom.

Digital examination of the rectum is necessary in all cases. The presence of blood in the ampoule is an undoubted sign of damage to the rectum. In some cases, even with highly located wounds of the colon, blood is found on the finger. The presence of blood in the rectum is established more often than wound openings in it; the latter in some cases are inaccessible to the finger or are hidden in the folds of the mucous membrane and are not determined due to their small size. Damage to the rectum can be caused by fragments of broken pelvic bones. In such cases, digital examination reveals sharp bone fragments located in close proximity to the intestinal wall, or perforating it.

Tension of the abdominal wall, its non-participation in the act of breathing, a positive Shchetkin-Blumberg sign and pain in combination are the initial and reliable syndrome of peritoneal damage in abdominal injuries. In the presence of this syndrome, the indications for emergency surgical intervention cannot be disputed, and there is no reason to wait for the development of other symptoms.

Pain with abdominal injury is usually observed, but it does not always indicate organ damage abdominal cavity.

Trauma is an instantaneous act. It is more often perceived as a strong, deafening blunt blow. The pain develops somewhat later and can be very intense. In a state of shock, as well as with blood loss, perception pain reduced, and the more severe the state of shock, the less pronounced the pain symptom. Gradually progressing pain undoubtedly indicates the penetrating nature of the injury.

The frequency and filling of the pulse are the most reliable signs for assessing the general condition of the victim. In the first hours after an abdominal injury, the pulse can be reduced to 60-80 beats per minute. With the deterioration of the condition and the further development of peritonitis, an increase in heart rate appears, which steadily increases. An even more important symptom for assessing the condition of a wounded person is the degree of pulse filling; its completeness changes before the frequency. A rapidly progressing decrease in pulse filling indicates the severity of the wounded person's condition. Satisfactory pulse filling, even at a rate of 120 beats per minute, can be regarded as a favorable prognostic sign.

A high pulse rate is a sign of peritonitis, but often diffuse, when one cannot expect much from the operation. A significant pulse rate with a short period of time after injury is a poor prognostic sign. The opposite relationship, i.e., a moderate increase in heart rate for a significant period after injury, indicates a small lesion or a limited inflammatory process.

Dry tongue is often an early sign of peritonitis. However, the absence of dry tongue in no way speaks against incipient peritonitis. In some cases, the tongue of those wounded in the stomach remains wet for a long time.

The appearance of the oral mucosa and conjunctiva is of great diagnostic importance. The pallor of the mucous membranes indicates the degree of internal bleeding and the depth of shock. In more severe cases, the color of the mucous membrane takes on a cyanotic tint.

Percussion determination of hepatic dullness is important in the diagnosis of abdominal wounds. Its absence may be a sign of a penetrating injury. More accurate is an x-ray examination to determine the presence of free gas in the abdominal cavity. With injuries of the large intestine and stomach, the presence of free gas under the dome of the diaphragm is almost the rule.

Dullness of percussion sound in the sloping parts of the abdomen indicates the presence of free fluid in the abdominal cavity (blood, gastrointestinal contents, bile, urine, exudate). Most often, this symptom is observed with damage to the liver and spleen with extensive hemorrhage into the abdominal cavity.

Nausea and vomiting are common, but far from persistent symptoms. They usually appear when damage to the abdominal organs is beyond doubt. Retention of stool and gases during peritonitis is a very significant symptom, but late and rather prognostic, determining the course of diffuse peritonitis and indicating the development of paralysis of the intestinal muscles. In diagnostic terms, in the first 6-18 hours after injury, this sign is not of decisive importance.

The presence of blood in the urine is a definite sign of injury urinary tract. If the ureter is blocked by a clot or if it completely ruptures, there may be no blood in the urine. A reliable sign for diagnosis, but a very inconsistent one, is the discharge of urine from the wound. The beginning of urinary infiltration is determined above the pubis and in the perineal area.

In all cases when Clinical signs are insufficient to confirm or reject damage to the abdominal organs, doubts can be resolved in three ways: observation, surgical debridement and laparotomy. Monitoring the condition of the victim can resolve diagnostic issues and assess the condition. However, the dangers of waiting cannot be understated. You can observe, but you cannot passively wait for the development of symptoms, as you may miss the time for successful intervention.

The second option for solving diagnostic issues with open abdominal injuries is surgical treatment of the abdominal wall wound. However, practice shows that the course of the wound channel (in the muscles of the abdominal wall is easily lost during surgery, which can lead to erroneous diagnosis.

The surest way to resolve diagnostic doubts is a trial laparotomy. It must be borne in mind that an attempt to examine the abdominal cavity from a small incision, as a rule, is unsuccessful. Diagnostic laparotomy should be made from a midline incision of sufficient length; only under this condition does it become the most reliable and least traumatic.

Features of treatment of patients with combined abdominal injuries

Injuries to the abdominal organs are an absolute indication for emergency surgery, regardless of the nature of the other components of the associated injury. Only ongoing profuse intrapleural bleeding, massive rupture of lung tissue, bronchial rupture, and growing intracranial hematoma are competing diagnoses that force the initial operation to be performed on other than the abdominal organs.

Surgery for damage to the abdominal organs (if we are not talking about ongoing intra-abdominal bleeding) should be performed after obtaining the effect of a complex of anti-shock measures.

Pain relief in modern conditions should be general with the mandatory use of muscle relaxants.

Surgical access. An indispensable condition for the successful performance of surgery for injuries to the abdominal organs is a wide opening of the abdominal cavity. When analyzing tactical errors identified during such operations (using large clinical material from the N.V. Sklifosovsky Research Institute of Emergency Medicine), it was found that in 78% of cases these errors were due to insufficient incision of the abdominal wall. Narrow access does not allow for a full inspection and the necessary set of intra-abdominal manipulations, especially in the presence of intestinal bloating.

When operating for trauma to the abdominal organs, in all cases a universal approach should be used - wide median laparotomy. In the absence of clear data on the exact localization of intra-abdominal injuries, a mid-median laparotomy should be performed. The incision of the anterior abdominal wall, after preliminary revision, is expanded upward or downward if necessary.

If it is difficult to manipulate the damaged right lobe of the liver, spleen, or deep-lying parts of the diaphragm, the median laparotomy should be converted to a Rio Branca type incision. To do this, from the lower corner of the laparotomy wound, the incision is continued obliquely and upward, parallel to the course of the intercostal and lumbar nerves, while crossing the rectus abdominis muscle.

Great attention should be paid to careful isolation of the laparotomy wound to prevent its contamination with infected abdominal contents. After dissecting a well-separated aponeurosis, before opening the peritoneum (in cases where the operation is not performed for ongoing internal bleeding), we sutured a multilayer gauze napkin along the entire length of the aponeurosis to the edge of the aponeurosis with separate interrupted sutures, separating the subcutaneous fat layer and skin. On top of the napkin we place a sheet (or towel) folded several times, to which we fix the incised peritoneum with Mikulich clamps.

Revision of the abdominal cavity. When opening the abdominal cavity, sometimes an accumulation of gas or liquid contents is found in it, which indicates the nature of the damage. If there is a significant accumulation of blood, often indicating a rupture of the liver, spleen, mesentery small intestine, the blood is collected with a sterile scoop into a sterile vessel, adding the required amount of 4% sodium citrate solution to it. In the absence of damage to the hollow organs and signs of infection, the blood is reinfused after a hemolysis test (centrifugation). Detected effusion, pus, intestinal contents, and urine are removed using an electric suction, trying not to contaminate the circumference of the surgical field with them.

The absence of intestinal contents in the abdominal cavity does not always make it possible to exclude intestinal damage on this basis alone. In some cases, a neighboring intestinal loop is glued to the area of ​​\u200b\u200bthe rupture of the small intestine and, due to reflex paresis, the intestinal contents almost do not enter the abdominal cavity for some time. Therefore, with each emergency laparotomy, all parts of the intestine should always be thoroughly examined.

At closed injury abdomen, the small intestine is most often affected. If a defect in the intestinal wall is detected, the intestinal wound is closed with a slightly moistened tampon, which the assistant firmly holds together with the damaged loop of intestine, preventing the leakage of additional portions of intestinal contents. Every precaution is taken to ensure that ongoing exploration does not cause contamination of the rest of the abdominal cavity. When intestinal inspection, it is necessary to open the peritoneum, it is necessary to mobilize duodenum according to Kocher with a dissection of the peritoneum along the edge of the intestine and carefully examine the posterior wall. curled

Signs of damage to the duodenum are bile staining visible through the peritoneal layer, swelling, imbibition with blood, emphysema (gas bubbles) of the retroperitoneal tissue surrounding the intestine. Intraoperative injection of a methylene blue solution into the duodenum via a probe facilitates diagnosis. The presence of a hematoma in the pancreaticoduodenal zone and in the root of the mesentery of the transverse colon may be a sign of damage to the pancreas as well. In such cases, for a full revision, one should penetrate through the gastrocolic ligament into the omental bursa, dissect the peritoneum along the upper edge of the pancreas and examine it. The presence of a large hematoma in the area of ​​a particular kidney dictates the need to dissect the peritoneum to inspect the kidney and its vascular pedicle.

The presence of gas bubbles in the lateral sections of the retroperitoneal space and the dirty color of the hematoma present there suggest a rupture of the posterior wall of the ascending or descending colon. In such cases, it is necessary to dissect the peritoneum along the lateral canal and mobilize the mesoperitoneal portion of the intestine.

A large tense hematoma of the retroperitoneal space may be a consequence of a rupture, which is very rarely observed in blunt trauma.

After examining the intestines, bladder, examination and palpation of the entire liver, spleen, mandatory palpation of both domes of the diaphragm, a thorough inspection of the retroperitoneal space is carried out. Mesenteric hematomas, located near the intestinal wall, since these hematomas can be the result of a rupture of the intestinal wall in the area located between the two peritoneal layers. Failure to detect such a gap may cause the death of the patient.

Having ruled out the separation of the kidney from the vascular pedicle, the first step is to inspect the area of ​​transition of the iliac vessels into the small pelvis (there are known cases of rupture of these vessels due to a direct blow, pressing them against the relatively sharp bony edge of the innominate line).

In the presence of pelvic bone fractures, a large retroperitoneal hematoma sometimes occurs without damage to the great vessels.

Naturally, the data from the preoperative examination of the patient should largely guide the intraoperative search for pathology. However, the audit in all cases must be complete, otherwise serious collateral damage may remain undetected.

Damage to hollow organs.

In both closed and open trauma, the transverse colon is most often damaged, the second place in the frequency of damage is the sigmoid colon, the third is the ascending and descending colon. The rectum is damaged relatively rarely.

If an intramural hematoma of the colon is detected, the hematoma area should be immersed in a fold of the intestinal wall using gray-serous sutures.

For injuries that do not penetrate the intestinal lumen (rupture of the serous and muscular membranes), the wound is sutured with interrupted silk sutures or a continuous catgut serous-muscular suture.

Tactics for penetrating ruptures of the colon should be different depending on the period that has passed since the injury and the associated severity of the inflammatory reaction of the peritoneum.

During an operation performed in the first 6-7 hours after injury, in the absence of pronounced signs of purulent peritonitis, wounds that do not extend to the mesenteric edge of the intestine are subject to suturing (the crushed edges of the wound should be excised with puncture of the vessels of the submucosal layer). For wounds extending to the mesenteric edge, as well as for multiple wounds located on one intestinal loop, or for a long-term wound, the damaged section of the intestine should be resected with anastomosis using a hand suture (without suturing the mucosa!) end to end or mechanical anastomosis end to end or end to side.

Mechanical anastomosis can be performed using the KTs-28, SPTU, NZhKA devices or the Kanshin device. When resection of a damaged sigmoid colon, the device is inserted through the anus and an end-to-end anastomosis is performed according to the technique used for anterior resection of the rectum.

If it is necessary to resect the ascending or descending colon, the peritoneum should be cut along the entire length of the corresponding lateral canal along the intestine and the intestine should be bluntly separated from the posterior abdominal wall, thus giving the intestine greater mobility. The blood supply to the intestine is not impaired. To impart similar free mobility to the transverse colon, it is necessary to cross (between the ligatures) the gastrocolic ligament or separate the latter from the intestine along with the greater omentum.

The intestine is resected after clamping it with Kocher clamps. After this, having removed the clamp located at the adducting end of the intestine, a circular seromuscular (purse-string) catgut suture is applied, and the efferent end of the intestine is sutured with catgut thread, surrounding the clamp with stitches, as is done when suturing the duodenal stump during gastric resection. Having removed the Kocher clamp, the loose stitches of the thread are further relaxed and between them one or another stapler without a stop head is inserted into the intestinal lumen. At a distance of 5-10 cm from the end of the intestine, its wall is pierced with the rod of the apparatus and a thrust head is installed. Remove the clamp from the adducting end of the intestine, insert the head of the stapler into this end and tighten the purse-string suture.

After cutting off the excess threads of the purse-string suture, bring the heads of the apparatus together until a control hole appears on the rod of the stapler (when using the Kanshin apparatus, the heads are brought together until they stop). The stitching is performed and the device is removed. Tighten the stitches of the enveloping suture on the outlet loop, thus closing the intestinal lumen. A second (serous-muscular) row of suture is placed at one end of this thread. Additionally, several interrupted silk sutures are applied on top.

When using a stapler, a second row of anastomotic sutures is created. When applying an anastomosis using the Kanshina apparatus, you can limit yourself to 2-4 supporting seromuscular sutures placed outside the location of the compressive elements.

During an operation performed under conditions of peritonitis, suturing colon wounds and applying anastomosis too often lead to the development of suture failure, even when forming unloading intestinal stomas. In case of peritonitis, they try not to leave intestinal sutures in the abdominal cavity. The sometimes used suturing of an intestinal wound with suturing a loop of intestine into the wound of the abdominal wall in conditions of peritonitis rarely leads to success, since the sutures are cut after a few days, the abdominal wall wound suppurates and the intestine with an open fistula slips into the abdominal cavity.

Moving the intestine with a wound sutured in conditions of peritonitis into the retroperitoneal pocket, as a rule, also does not save the patient.

In case of peritonitis, the damaged area of ​​the antimesenteric wall of the colon should be brought out to the anterior abdominal wall (through a special incision) in the form of a colostomy, using the techniques recommended when applying a double-barreled unnatural anus. The incision in the abdominal wall should be small, corresponding to the folded intestinal loop being brought out. A rubber tube with a dense rod inserted into it should be placed under the intestinal loop.

If the inactive part of the intestine is damaged, it should be mobilized, since the intestine must be brought out without any tension.

In case of a wound involving the mesenteric part of the intestine, the intestinal tube must be crossed and both ends brought to the anterior abdominal wall through two narrow counter-openings. However, with simple suturing of the intestinal walls to the edges of the skin in conditions of peritonitis, the sutures can quickly cut through. As a result, the removed intestine can sink into the abdominal cavity. To prevent such a serious complication, we have developed a special tactic for removing the intestine.

In case of peritonitis, before crossing (or resection) the intestine, we clamp it with Kocher clamps and cross it along the edge of the clamp. To prevent intestinal contents from contaminating the surgical field when removing the intestine, we temporarily suture both ends of it. It is possible to cross the intestine with an LVCA device with silicone gaskets. After this, we wipe the sections of intestine to be excreted with iodonate solution. The intestine should be removed (through a small counter-aperture) at least 5-6 cm above the skin level.

We surround the removed end of the intestine freely, without squeezing its lumen, with several rounds of a gauze swab, the width of which should correspond to the length of the removed section of the intestine. To ensure that the coupling created around the intestine remains solid, we fix the surface of the gauze with separate sutures to the underlying layers. Then we remove the temporary suture from the removed intestine, open the intestine and sew it circularly in the form of a rosette to the upper edge of the gauze sleeve.

We emphasize once again that the gauze sleeve should not interfere with the patency of the removed intestine.

Thus, the intestine is fixed not to the skin, but high above it to the gauze. We do not remove the muff for a long time until the intestine fuses with the anterior abdominal wall.

When the fistula formed in this way begins to function, then in the first days the removed intestine is immersed in a plastic bag of a colostomy bag along with a gauze sleeve.

When performing the operation, it is important that the hole in the abdominal wall strictly corresponds to the diameter of the removed intestine. If there is an excessive opening, the intestine will not fuse well with the abdominal wall and eventration of other intestinal loops may occur next to it. If the opening is too narrow, in addition to compressing the lumen, the outflow of blood from the intestine will be impaired; the resulting pronounced swelling of the intestinal wall will contribute to the gradual traction of additional sections of the intestine from the abdominal cavity outward.

If increasing edema of the removed intestine is detected in the postoperative period, it is necessary to slightly expand the hole in the abdominal wall under local anesthesia (this fully applies to the removal of the proboscis of the small intestine).

If there are the above indications for resection of the colon in conditions of peritonitis (after resection), instead of performing an anastomosis, it is necessary to bring both ends out using the method described above. Leaving the tightly sutured end of the intestine in the abdominal cavity during peritonitis is dangerous.

If the rectum is damaged in conditions of peritonitis, it is necessary to cross sigmoid colon and bring both ends out separately, since the imposition of a double-barreled unnatural anus does not completely exclude the possibility of intestinal contents entering the rectum. It is advisable to connect the edges of the wound of the rectum disconnected in this way with several sutures, fixing to one of them the end of a double-lumen silicone tube intended for aspiration with rinsing. In case of peritonitis, the wound area and tube must be fenced off from the abdominal cavity with tampons.

In some cases, similar tactics can be used when the damage is localized in other sedentary parts of the colon, if mobilization of the colon turns out to be difficult. In this case, the operation must be combined with the intersection of the mobile part of the intestine above the area of ​​​​damage to bring both ends out using the method described above.

2. Damage to the small intestine. Surgical tactics for injuries to the small intestine should not differ significantly from the tactics described above, which we recommend for injuries to the large intestine. Thus, with intervention performed before the development of peritonitis (for the small intestine in the first 18 hours, and sometimes longer), one can resort to suturing wounds or resection of the intestine with anastomosis. In contrast to injuries to the large intestine, the small intestine is sometimes torn off from the mesentery for some extent, which serves as an indication for resection of a section of the intestine deprived of blood supply.

In the presence of purulent peritonitis, suturing wounds of the small intestine, and especially anastomosis, almost always ends with an unfavorable outcome. Thus, out of 16 victims in whom a small intestinal anastomosis was performed in our institute under conditions of peritonitis, 12 died due to failure of the sutures. Therefore, in cases of severe purulent peritonitis, we consider it necessary to remove intestinal stomas if not only the colon, but also the small intestine is damaged.

This tactic is unlikely to raise objections from anyone if the terminal ileum is damaged, since one can live with a permanent terminal ileostomy for many years. At the same time, a complete high small intestinal fistula would seem to be incompatible with life and should quickly lead to exhaustion, irreversible electrolyte changes and death of the patient. However, as a number of our observations have shown, a technically correctly applied artificial end fistula of even the initial part of the small intestine when carrying out special measures and well-organized care for the patient not only does not lead to death, but in case of severe peritonitis caused by damage to the intestine, it is the only remedy saving the patient's life. The afferent and efferent ends of the transected small intestine should be brought out in the form of two proboscis through counter-apertures located at a short distance from each other and fixed to gauze couplings, as described above (see section “Injuries to the colon”).

A soft (preferably thin-walled silicone) tube must be inserted into the outlet loop of the transected intestine, which is subsequently used to dispose of the chyme released from the upper stoma. An ordinary medical tube made of red rubber is not suitable for this purpose, since with peritonitis it can cause a through bedsore of the small intestine, which we observed in our practice.

When, after a decrease in the manifestations of peritonitis under the influence of therapy, the upper fistula begins to function, the contents obtained from it are repeatedly injected into the lower fistula throughout the day. The longer the proboscis of the superior fistula is extended, the more convenient it is to collect its discharge into a film colostomy bag. For ease of disposal of chyme, a soft tube inserted into the outlet loop of the intestine can be connected to a hose coming from a funnel mounted on a medical stand (Fig. 40).

After the elimination of severe paresis of the gastrointestinal tract, the patient can begin to be fed liquid food, continuing to introduce into the lower stoma all the contents secreted by the upper fistula. If peritonitis can be managed, then after some time (3 weeks after surgery) the continuity of the digestive tract can be restored surgically.

Duodenal ruptures are discussed in the section on injuries to retroperitoneal organs.

3. Stomach ruptures. Gastric injuries from blunt trauma are very rare and usually involve the cardia or body of the stomach. In practice, we most often have to deal with knife and gunshot wounds of this organ. Gastric rupture can occur when the diaphragm ruptures simultaneously. The gastric wound must be sutured with a double-row hand suture.

4. My gallbladder is also damaged. Tears in the serous membrane of the gallbladder are sutured with a thin thread on an atraumatic needle. If there is a through rupture, a typical cholecystectomy should be performed. Uncomplicated cholecystectomy does not require tampons. However, a silicone tube with side holes should be installed to the bed of the removed gallbladder, passing its end to the omental opening. The second end of the tube is brought out through a puncture in the abdominal wall.

If there is no discharge, the tube is removed 2 days after surgery.

5. Damage to the bladder. Such injuries, often combined with pelvic bone fractures, can usually be diagnosed before surgery. During the period anti-shock measures There should be a permanent catheter in the damaged bladder.

If there is a wound to the intra-abdominal part of the bladder, before suturing it, it is necessary to carefully examine the internal surface of the organ to exclude additional damage. If the wound does not extend to the extraperitoneal part of the bladder, then it can be sutured with a double-row suture (suturing the submucosal layer) without applying an epicystostomy, limiting the use of a permanent catheter in the early postoperative period.

Wounds of the extra-abdominal part of the bladder, in addition to suturing, require an epicystostomy and mandatory drainage of the peri-vesical tissue. Instead of the Buyalsky-McWhorter drainage of the peri-vesical tissue used in the past with a rubber tube passing through the obturator foramen, you can use a double-lumen silicone non-absorbent drainage, carried out through a puncture of the abdominal wall, or a drainage with a microchannel for lavage. Constant aspiration in the postoperative period will prevent the development of urinary leaks.

Damage to parenchymal organs.

1. Damage to the spleen. If with knife wounds it is sometimes possible to suture the spleen wound, then for ruptures caused by blunt trauma, as a rule, splenectomy should be performed. In the absence of contraindications, reinfusion of blood spilled into the abdominal cavity is performed.

2. Liver damage. Closed liver injuries are usually divided into injuries without breaking the integrity of the capsule (bruise, subcapsular hematoma, deep hematoma of the liver) and with breaking the integrity of the capsule (rupture, separation of part of the organ, crushing), indicating whether the injury is accompanied by parenchymal bleeding or bleeding from large vessels .

The most common ruptures of liver tissue (usually the upper surface) are observed. In 20% there are crush injuries, in 25% there are subcapsular and intrahepatic hematomas.

The main goal of surgery for liver damage is to stop bleeding and remove non-viable liver tissue.

Superficial (up to 1-2 cm deep) cracks that do not cause bleeding do not require sutures. Deeper injuries that do not project onto the passage of the main hepatic vessels are sutured with interrupted catgut sutures, having previously ligated the detected bleeding vessels. It is advisable to capture the area of ​​the well-supplied greater omentum placed on the wound into the sutures (an isolated flap of the omentum should not be used, since, by becoming necrotic, it can contribute to the development of infection).

When applying sutures, a large curved stabbing needle is used, which allows the entire thickness of the edges and the bottom of the wound to be sutured. Leaving unsutured cavities (“dead spaces”) leads to the formation of intrahepatic hematomas, which subsequently cause severe complications. To prevent the seams from cutting through, they are tightened and tied only after all the seams have been completely applied. The assistant brings the edges of the wound together with his fingers, and the surgeon ties the sutures one by one, not tightening them too tightly.

If there are crushed edges of the wound, they are excised according to the type of surgical treatment, removing all non-viable tissue. Bleeding vessels and open intrahepatic bile ducts ligated.

If it is not possible to quickly stop massive bleeding from the vessels of the liver, the hepatoduodenal ligament should be clamped by inserting a finger into the omental foramen. By reducing the degree of clamping, bleeding hepatic vessels are detected and ligated. The period of switching off the liver from the blood circulation should not exceed 10 minutes. If there is a rare need to extend this period, it is necessary to periodically stop the clamping, restoring the patency of the portal vein and hepatic artery for some time.

A wide wound resulting from excision of crushed tissue often cannot be sutured using the method described above. After thorough hemostasis, the wound can be covered with a large omentum, fixing it to the edges of the wound with loosely tightened sutures and placing a perforated (preferably double-lumen) silicone tube under the omentum for the outflow of blood and bile in the postoperative period.

The use of gauze tampons for liver ruptures, which was very popular in the past, has now changed dramatically. It is tampons that very often turn out to be the main cause of severe postoperative complications (recurrent bleeding, suppuration) and death of the patient. Packing with gauze can be used as a last resort only if it is impossible to stop the bleeding by other methods. At the same time, temporary intraoperative use of tampons moistened with hot isotonic sodium chloride solution is a convenient and rational technique.

The recent enthusiasm for wide resections and lobectomies for liver trauma should be treated critically, without excessively expanding the scale of the operation, especially in patients with concomitant trauma. We must strive to remove non-viable tissue and stop bleeding. Lobectomy to achieve this goal becomes necessary in a very small number of victims. Selective angiography provides great assistance in determining the extent of intervention.

The operation ends with the obligatory placement of silicone drainage to the liver brine, which is removed only after the flow of discharge through it has completely stopped.

Damage to retroperitoneal organs.

1. Damage to the duodenum. The rupture of the retroperitoneal part of the duodenum most often has a transverse direction. Sometimes there is a complete transverse rupture of the intestine.

After economical excision of the wound edges, a double-row suture is applied. In case of a complete circular rupture, an end-to-end anastomosis is performed. The peritoneum above the intestine is sutured, if possible peritonesizing the suture line. A double-lumen silicone tube is installed into the retroperitoneal space through the incision of the peritoneum on the side of the intestine for continuous aspiration with lavage. The free end of the tube is brought out through a puncture of the abdominal wall to the right of the midline incision. It is necessary to ensure that the drainage tube does not come into contact with the suture line on the intestine. A decompression probe is inserted into the duodenum transnasally (or gastrostomy style).

If the surgeon is unsure of the reliability of the sutures placed on the duodenum, in addition to draining the retroperitoneal tissue and applying a microgastrostomy with insertion into the duodenum of a relatively soft drainage tube with side holes, it is necessary to cross the initial section of the jejunum and, stepping back 50-70 cm from the intersection, apply a Y-shaped anastomosis according to Roux. The free end of the transected intestine should be brought out in the left hypochondrium in the form of an end stoma (jejunostomy according to Meidl). The jejunostomy allows for complete enteral feeding, bypassing the duodenum, and at the same time utilizing the chyme aspirated from the duodenum.

If there is a large defect in the duodenal wall, which is difficult to sutured in the usual way, this defect can be anastomosed with a loop of the jejunum in the early stages.

With intervention performed at a later date, when phlegmon of the retroperitoneal tissue is detected, simply suturing the intestinal wound or anastomosing it with the jejunum is not promising and the prognosis, as a rule, is unfavorable. As an operation of desperation, it can be recommended to insert a non-absorbing double-lumen tube into the intestine through the wound for constant aspiration in the postoperative period. The intestinal wound should be sutured with a double-row suture up to the tube.

A second drainage tube (double-lumen for long-term aspiration with lavage) is installed in the area of ​​the suppurating retroperitoneal hematoma. The posterior layer of the peritoneum is carefully sutured (preferably with reinforcement of the suture line with an omentum) and a Meidl jejunostomy is applied.

In the absence of a special double-lumen hose, you can use two simple rubber tubes, the ends of which are placed on two branches of a glass tee. In the machine of the tube through which air will be sucked, several small side holes are cut. When washing, periodically turning off the electric suction, you can use a suction tube to pour liquid through it into various parts of the abdominal cavity from a vessel mounted on a high stand.

Any sterile liquid available in the operating room (solutions of furatsilin, novocaine or isotonic sodium chloride solution) is suitable for washing, which, in order not to cause hypothermia of the patient, must first be warmed to body temperature.

Neither when washing nor when draining the abdominal cavity should you wipe the peritoneum with gauze. When washing, light gentle underwater wiping of the contaminated visceral and parietal peritoneum can only be done with fingers in a rubber glove, while removing loosely fixed contaminated fibrin deposits from the peritoneum, lightly “rinsing” the intestinal loops in large quantities liquids. We specifically draw attention to this issue due to the fact that if the peritoneum is injured, peritonitis will be much more severe.

The abdominal wall should be pierced not perpendicularly, but obliquely, so that the tube penetrates into the abdominal cavity in the desired direction without bending at an acute angle. The skin near the tube is stitched with a strong thread and the tube is secured with it, onto which you can also put a rubber clamp.

It is permissible to install gauze tampons into the abdominal cavity only to stop persistent capillary bleeding and in extremely rare cases, for special indications, when, for example, they are used to fence off an unreliably sutured wound of the disconnected rectum.

In case of peritonitis, it is also necessary to drain the stomach and the initial part of the jejunum. For this purpose, a relatively thin probe with numerous side holes is inserted transnasally into the stomach. Having felt the probe with his hand through the wall of the stomach, the surgeon helps guide it into the duodenum. B. A. Voikov’s (1972) proposal to install several thin-walled metal rings in the lumen of the probe, giving these areas rigidity, can help in passing the probe into the jejunum. By grasping these dense areas with your fingers through the wall of the stomach and then the intestines, the probe can easily be passed below the level of the Treitz ligament.

The side holes in the wall of the probe allow aspiration both from the jejunum and simultaneously from the stomach and duodenum.

Suturing a laparotomy wound. It is necessary to suture a laparotomy wound in the presence of complete muscle relaxation. First, 2-3 interrupted sutures are placed on the aponeurosis in the navel area and only then the peritoneum is sutured with a continuous catgut thread. To suturing the aponeurosis, it is necessary that its edges be well separated from the subcutaneous fat layer, since poor contact of the aponeurotic tissue being sutured and interposition of adipose tissue create the risk of eventration occurring in the postoperative period.

One of the reasons for eventration is also the suturing of the median aponeurosis alone without passing the needle lateral to the zone of fusion of the anterior and posterior walls of the rectus abdominis sheath. The median aponeurosis, especially with its considerable width, is relatively easily stratified in the transverse direction, but in the area of ​​its division into the anterior and posterior walls of the rectus abdominis sheath there is a complex interweaving of fibers that prevents the cutting of the thread.

When suturing the aponeurosis below the navel, in the area where the posterior wall of the rectus sheath is absent, during surgery for trauma, taking into account the inevitable bloating of the abdomen in the postoperative period, it is advisable to apply 8-shaped sutures, which are less prone to eruption.

In case of an underdeveloped subcutaneous fat layer and moderate contamination of the abdominal cavity, it is recommended to apply loop-shaped (vertical mattress) Donati sutures to the skin, with the help of which the subcutaneous fat layer and skin are simultaneously sutured with removable sutures. To reliably eliminate the cavity in the subcutaneous fat layer, it is necessary to capture the aponeurosis in the suture. The knot, unlike a regular skin suture, is placed at the suture line itself, and not at the place where the needle is inserted.

With pronounced, especially excessive development of the subcutaneous fat layer in patients with damage to the hollow organs of the abdomen, there is always a high risk of suppuration of the laparotomy wound. One of the most effective methods to prevent suppuration in such cases is drainage of the subcutaneous fat layer according to Redon with constant aspiration in the early postoperative period. At the same time, wound secretion (blood, tissue fluid) is evacuated from the sutured wound, which serves as a good breeding ground for microorganisms and is one of the main factors contributing to the development of postoperative suppuration. No "graduates" can ever provide complete removal contents inevitably accumulating in the wound. The vacuum created in the wound during prolonged aspiration also contributes to the closure of its walls, acting as a wall; syringe sterile liquid towards the wound; it is easy to rinse the ring drainage. When removing the ring drainage, one of its ends is crossed at the level of the skin, i.e., proceed as when removing skin sutures.

Features of treatment in the postoperative period. Victims operated on in the absence of peritonitis, if other components of the combined injury allow, should be activated early in bed, allowing them to sit up 1-2 days after surgery.

The timing of feeding depends on the location of intra-abdominal damage and on the rate of reverse development of postoperative paresis of the stomach and intestines. Suturing early damage to the ileum and colon allows (in the absence of pronounced paresis) to prescribe small portions of fluid the very next day after surgery. If drinking during the first day does not cause congestion and vomiting, then you can start feeding liquid food.

General therapeutic measures and infusion therapy are carried out taking into account the nature of the entire amount of damage according to generally accepted indications in surgery.

When using a modified Redon drainage (or ring drainage), by puncturing a rubber tube, a sterile liquid (furatsilin solution, etc.) is injected with a syringe 2-3 times a day, thus washing the main drainage channel. If a wound is contaminated, an antibiotic or antiseptic solution can be injected temporarily to create exposure, while pinching the hose through which suction is carried out.

Redon drainage should be removed no earlier than 2 days after surgery.

Within the framework of this book, it is not possible to cover in detail the entire range of therapeutic measures. carried out during peritonitis. For traumatic peritonitis, treatment is not fundamentally different from the treatment of other diffuse peritonitis, including peritonitis of appendicular origin.

A patient with peritonitis in the postoperative period should be in a position with the head end of the bed elevated. Unfortunately, this well-known requirement of surgery is very often neglected. Removal of small intestinal contents through a transnasal tube in this position of the patient should be carried out through prolonged aspiration with weak vacuum.

If there are no conditions in the medical institution for constant clear monitoring of the level of electrolytes in the body’s media and in the lavage fluid, we do not recommend resorting to the use of classical peritoneal dialysis. In such cases, it is more advisable to remove toxic products from the body through forced diuresis.

Microirrigators introduced into the abdominal cavity must be used for periodic exposure to antibiotic solutions.

New antibiotics are currently the most popular wide range actions. However, although penicillin has long been considered an insufficiently effective means of influencing the microflora sown during peritonitis, when administered into the abdominal cavity (at intervals of 3-4 hours) up to 24,000,000-30,000,000 units per day with simultaneous intramuscular injection 8000000-16000000 units per day, we have repeatedly achieved cure for patients with severe peritonitis.

Conventional methods of bacterial diagnostics without the use of special media and complex anaerobic chambers, unfortunately, do not provide a complete picture of the association of microorganisms that cause peritonitis, as a result of which there is no information on sensitivity to antibiotics in the treatment of peritonitis. Therefore, focusing only on determining the sensitivity to the sown form of microorganisms is not always correct.

In any case, large doses of penicillin in the treatment of peritonitis often give a clear positive effect, which is not always explained by the sensitivity data obtained.

Benzylpenicillin can be combined with semisynthetic penicillins.

Whatever antibiotics are used, they should be introduced into the abdominal cavity in significant dilution, in a large amount of solvent, firstly, so that the solution penetrates into all parts of the abdominal cavity, and secondly, so that an excessively high concentration of the antibiotic does not cause irritation of the peritoneum. In the Fowler position, exudate and fluid injected into the abdominal cavity gradually flow down to the pelvis. To actively remove exudate using the through drainage described above, constant aspiration is connected to one end of it, carried out using an electric vibration suction. In this case, air enters through the second end of the drainage tube, preventing adjacent formations from being sucked into the side drainage holes. Without turning off the suction, the drainage tube is periodically flushed with sterile liquid.

When treating severe peritonitis, the entire range of modern means should be used. At the N.V. Sklifosovsky Research Institute of Emergency Medicine we use forced diuresis, drainage of the thoracic lymphatic duct in the neck with the return of purified lymph to the bloodstream. We individually prescribe infusion therapy, immune therapy, parenteral nutrition, including a complete complex of amino acids, and fat emulsions. We perform electrical stimulation of intestinal peristalsis, and when severe paresis decreases, we prescribe early, slow administration of corrective drugs through a probe into the jejunum. saline solutions, close in concentration to intestinal chyme, we introduce nutritional mixtures. Patients are treated with hyperbaric oxygen therapy, physiotherapy and etc.

Treatment of local complications. When a laparotomy wound suppurates (as with almost any other wounds suppurates), we abandoned the traditional separation of the wound edges with packing. Instead, we install a double-lumen silicone drainage along the entire length of the festering wound, the wide channel of which has small side holes. We insert an injection needle connected to a medical dropper system into the narrow channel of the tube. Using a glass adapter, we connect the wide channel of the tube with a hose going to a container with negative pressure.

In the absence of a special double-lumen drainage tube, you can use a regular silicone tube by inserting a fairly dense thin microirrigator into its lumen. In this case, tightness is achieved by passing the microirrigator into the tube through a glass tee with a rubber coupling, as shown.

If the cavity of the festering wound is relatively small, constant aspiration (using an electric vibration suction) is carried out through a wide channel of a double-lumen tube, while a constant drip infusion of sterile liquid is carried out through a thin channel. Continuous washing of the drainage tube prevents its clogging: the exudate, as it accumulates, is immediately removed along with the washing liquid through a system of tubes into a hermetically sealed glass vessel.

With large purulent cavities and tissue detachment, evacuation of exudate from the resulting lateral spurs may not be sufficient. In these cases, we use fractional rinsing not only of the drainage tube, but also of the purulent cavity itself, periodically filling it with a rinsing solution.

The method becomes especially important in patients with concomitant trauma, when the patient’s immobility due to the presence of fractures of the spine, limbs, and prolonged coma greatly complicates the use of the tampon method of treatment, which requires frequent changes of dressings.

When aspirating treatment of abdominal ulcers, it is advisable to use a non-conventional electric vibrator pump, which produces a vacuum of about 120-140 cm of water. Art., and an aspirator created on its basis by L.L. Lavrinovich, which allows one to very accurately regulate the vacuum parameters. At a vacuum exceeding 50 cm of water. Art., suction of the intestinal wall to the holes of the drainage tube can lead to perforation and the development of an intestinal fistula.

In the absence of an aspirator with an adjustable vacuum level, it is advisable to insert a non-suction drainage tube into the cavity of the intra-abdominal abscess, the design of which is described above.

We have repeatedly successfully used aspiration with lavage in case of an intestinal fistula opening into the abscess of the abdominal cavity. The double-lumen drainage tube should have a slightly larger diameter than usual.

If failure of the sutures of a sutured intestinal wound or anastomotic sutures occurs in the postoperative period, emergency relaparotomy is indicated. Symptoms of this complication are often erased and most often manifest themselves as increasing intoxication, tachycardia, diffuse abdominal pain, intestinal paresis in the absence of muscle tension and with a vaguely expressed Shchetkin-Blumberg symptom.

The tactics for failure of sutures should be the same as for the primary operation performed for intestinal damage in the late stages, with peritonitis already developed. We emphasize once again that in case of purulent peritonitis one should not resort to suturing intestinal defects. During peritonitis, only intact intestinal loops should remain in the abdominal cavity.

In conclusion, we emphasize that the treatment of suppurative processes using the method of hermetic drainage with washing and aspiration requires known experience and an extremely conscientious attitude to their duties by all medical personnel involved in the treatment of the patient.

Abstract of the dissertationin medicine on the topic Gunshot wounds of the abdomen. Features, diagnosis and treatment at the stages of medical evacuation in modern conditions

As a manuscript

GUNSHOT WOUNDS OF THE ABDOMEN. FEATURES, DIAGNOSIS AND TREATMENT AT THE STAGES OF MEDICAL EVACUATION IN MODERN

CONDITIONS

St. Petersburg 2015

The work was carried out in the Federal State Budgetary Military educational institution higher vocational education"Military medical Academy named after S.M. Kirov » RF Ministry of Defense

Scientific consultant:

Doctor of Medical Sciences Professor Samokhvalov Igor Markellovich

Official opponents:

Efimenko Nikolay Alekseevich - Corresponding Member of the Russian Academy of Sciences, Doctor of Medical Sciences, Professor, Institute for Advanced Training of Physicians of the Federal State Institution Medical Educational and Scientific Clinical Center named after. P.V. Mandryk, Ministry of Defense of the Russian Federation, Department of Advanced Training Surgery, Head of the Department;

Singaevsky Andrey Borisovich - Doctor of Medical Sciences, State Budgetary Educational Institution of Higher Professional Education "North-Western State medical University them. I.I. Mechnikov Ministry of Health of Russia", Department of Faculty Surgery named after. I.I.Grekova, professor of the department;

Ergashev Oleg Nikolaevich - Doctor of Medical Sciences, Professor, State Budgetary Educational Institution of Higher Professional Education "First St. Petersburg State Medical University named after. acad. I.P. Pavlov of the Ministry of Health of Russia", Department of Hospital Surgery No. 2 named after. acad. F.G. Uglova, professor of the department

Lead organization:

State Budgetary Institution St. Petersburg Research Institute of Emergency Medicine named after I.I. Dzhanelidze

The defense will take place on October 12, 2015 at 14:00 at a meeting of the council for the defense of doctoral and candidate dissertations D 215.002.10 on the basis of the Federal State Budgetary Educational Institution of Higher Professional Education "Military Medical Academy named after S.M. Kirov" of the Ministry of Defense of the Russian Federation (194044, St. Petersburg, Academician Lebedev St. , d.6). The dissertation can be found in the fundamental library and on the website vmeda.org. Federal State Budgetary Educational Institution of Higher Professional Education "Military Medical Academy named after S.M. Kirov"

Scientific secretary of the dissertation council, Doctor of Medical Sciences, Professor Sazonov A.B.

GENERAL DESCRIPTION OF WORK

The relevance of research. Gunshot wounds to the abdomen have remained a pressing problem in military field surgery for many decades. In war, the proportion of abdominal wounds in the overall structure of wounds is relatively small (4-7%) (Zuev V.K. et al., 1999; Zhianu K. et al., 2013; Hardaway R.M., 1978; Jackson D.S., et al. , 1983; Rhee P., et al., 2013; Rich N.M., 1968; Schoenfeld A.J., et al., 2011). However, the close dependence of the outcomes of abdominal wounds on the timing of the start and quality of surgical treatment creates great organizational difficulties, the same for peacetime and wartime, especially with a massive intake of wounded. To this day, with abdominal wounds, high postoperative mortality (12-31%) and a high incidence of complications (54-81%) remain (Bisenkov J1.H., Zubarev P.N., 1997; Kuritsyn A.N., Revskoy A. K., 2007; Murray S.K., et al., 2011).

The experience of local wars has shown that conventional weapons, as they improve, cause injuries of particular severity. Accordingly, new approaches to treatment are required. This fully applies to the most severe category of combat trauma - gunshot wounds to the abdomen (Zubarev P.N., Andenko S.A., 1990; Efimenko N.A. et al., 2000, Samokhvalov I.M., 2012; Morris D.S., Sugrue W.J. , 1991; Sharrock A.E., et al., 2013; Smith I.M., et al., 2014). The specific features of gunshot wounds determine the relatively greater severity of functional disorders, the more frequent development of complications and, as a result, more high level lethality.

As a rule, a significant portion of military personnel wounded in the stomach are recognized by military medical commissions as unfit or partially fit for further service in the Armed Forces. Adverse outcomes are caused by dysfunctions of vital functions important organs and systems in those wounded in the stomach. The prognosis is largely determined by the clinic of the early postoperative period, which largely depends on the nature of the injury and the initial state of the victim’s body at the time of injury (Bulavin V.V. et al., 2013; Polushin Yu.S., Shirokov D.M., 1992; Champion H.R., et al., 2010).

A person’s presence in unfavorable climatic and geographical conditions characteristic of Afghanistan (mountainous desert terrain with a hot climate) led to very significant functional and adaptive changes in the body, aggravating the severity of the wound process (Aleksanin S.S., 1990; Novitsky A.A., 1992 ). However, to date, deviations from the normal functioning of vital organs and systems in patients wounded in the abdomen in the early postoperative period remain poorly understood.

Degree Designed™ Topics. The relevance and practical significance of this study is due to the need to generalize

And scientific analysis organization of the provision of surgical care to those wounded in the abdomen in Afghanistan and the North Caucasus in comparison with data from the experience of the Great Patriotic War and other military conflicts.

Surgical interventions for abdominal wounds have not yet been fully assessed in terms of their adequacy depending on the volume and nature of damage to internal organs. There is no clear understanding of the possible connection between the nature of surgical interventions and the characteristics of postoperative complications that arise. No analysis has been carried out of the effectiveness of using modern methods of treating the wounded in the postoperative period. Those available to the surgeon at the stage of providing qualified medical treatment have not been determined. medical care factors predicting the course and outcome of the postoperative period.

Purpose of the study. Based on a study of the experience of providing surgical care to those wounded in the abdomen during the war in Afghanistan and Chechnya, and an in-depth study of pathophysiological changes in the body of the wounded, develop recommendations for improving the provision of medical care to the wounded with gunshot wounds to the abdomen.

Research objectives:

1. To study the frequency and nature of combat injuries to the abdomen received in military conflicts using modern means of combat destruction.

2. Determine the characteristics of the organization staged treatment wounded in the stomach during the war in Afghanistan in comparison with the surgical experience of military conflicts in the North Caucasus.

3. Investigate the results of diagnostics of penetrating abdominal wounds and injuries to internal organs in non-penetrating abdominal wounds based on clinical and laboratory data and the use of invasive methods (laparocentesis, diagnostic laparotomy).

4. To study the frequency and nature of injuries to internal organs in modern combat abdominal trauma, as well as methods for eliminating damage at the stages of medical evacuation.

5. To study disturbances of homeostasis in those wounded in the stomach during the war in Afghanistan in the dynamics of a traumatic disease.

6. Analyze the frequency, nature and causes of postoperative complications for gunshot wounds of the abdomen and methods for their correction.

7. Develop methods for objectively assessing the severity of damage to internal organs and predicting treatment outcomes for gunshot wounds of the abdomen.

Scientific novelty. A comprehensive, multifaceted study of modern combat injuries to the abdomen received when using new means of combat destruction was carried out on significant material (2687 wounded during the entire period of the war in Afghanistan and 1294 wounded in Chechnya).

It has been established that all gunshot wounds to the abdomen are severe injuries in terms of the scale and number of injuries to the abdominal organs

cavities. Bullet wounds turned out to be more severe than shrapnel wounds.

The results of treatment of the wounded at the stages of medical evacuation using the achievements of modern clinical surgery were studied. It has been established that the diagnosis of injuries to the abdominal organs at the stages of medical evacuation presents particular difficulties in non-penetrating abdominal wounds and mine-explosive injuries. The role of laparocentesis and other methods of objective diagnosis of combat injuries to the abdomen have been studied and indications have been developed.

Methods for assessing the severity of damage to the abdominal organs and a scale for predicting the course of traumatic illness in those wounded in the abdomen are proposed.

A detailed study of homeostasis disorders in those wounded in the abdomen was carried out, which makes it possible to study the pathogenesis of the development of complications. The structure and timing of the development of postoperative complications in patients wounded in the abdomen, and the features of their course, were studied.

Theoretical significance of the work:

The frequency, structure and characteristics of gunshot wounds to the abdomen in Afghanistan and counter-terrorism operations in the North Caucasus were studied;

The nature and features of providing surgical care to those wounded in the abdomen at the stages of medical evacuation, especially those associated with aeromedical evacuation, are determined;

Features identified diagnostic measures when examining this category of wounded, it was found that it is particularly difficult to diagnose damage to internal organs in non-penetrating abdominal wounds and mine-explosive trauma;

It has been established that the negative course of the wound process is due to the multiple and combined nature of the wound;

The revealed multiplicity and severity of the nature of injuries to internal organs determine the variety of surgical interventions;

The factors influencing the nature of the postoperative period in the wounded, the nature of postoperative complications and outcomes were identified;

The “local norm” of physiological and laboratory parameters has been studied, which is the basis for determining the same indicators in the wounded;

The pathophysiological changes in the body of the wounded in the dynamics of the course of a traumatic disease were studied;

The structure and timing of postoperative complications were determined;

The main measures of postoperative therapy were studied, the indications, content and features of long-term intra-aortic therapy were determined;

The main ways to improve treatment outcomes for victims with abdominal wounds at the stages of medical evacuation have been identified;

Practical significance of the work:

An assessment is made of the frequency, structure and nature of gunshot wounds to the abdomen in modern local conflicts and an analysis of the frequency of development, structure of complications and causes of mortality in this group of wounded is carried out;

It has been established that the severity of the condition of those wounded in the abdomen, the presence of multiple and combined injuries in many of them, increases the importance of objective diagnostic methods at the stages of medical evacuation;

It has been shown that when there is a massive intake of wounded, it is necessary to isolate from them a group of those wounded in the abdomen, requiring wait-and-see tactics;

It was determined that when calculating the possibilities of providing qualified surgical care to the wounded in modern warfare the duration of laparotomy should be estimated at approximately 3 hours;

It has been established that due to the worsening of intra-abdominal injuries in modern combat abdominal trauma, the proportion of wounded people requiring complex surgical interventions increases, which must be taken into account when training surgeons sent to the combat zone;

Indications for the early use of long-term aortic regional therapy have been formulated. It has been established that it is advisable to start it no later than the first three days after injury, with a duration of up to 4-5 days, with the introduction of up to 50% of the infusion volume into the aorta;

It was revealed that during dynamic observation in the immediate postoperative period of patients wounded in the abdomen, the following indicators are of particular importance for the prognosis and early detection of complications: levels of urea and creatinine, myoglobin content, testosterone activity and the content of medium molecular polypeptides.

Provisions submitted for defense.

1. Gunshot wounds to the abdomen account for 4-7% of the combat combat surgical trauma. Penetrating abdominal wounds received using modern weapons are considered severe injuries due to the extent of damage to internal organs and their combined nature.

2. Due to the severity of intra-abdominal injuries, the complexity surgical interventions with combat trauma to the abdomen increases significantly, which increases the requirements for the training of military field surgeons.

3. The severity of damage to internal organs during combat injuries to the abdomen and profound metabolic disorders in the body of the wounded cause an increase in the frequency of postoperative complications.

4. The use of a prognostic model of the outcome of abdominal wounds and a scoring of the severity of damage to internal organs during mass admission of wounded allows us to improve triage and development of surgical tactics.

5. Optimization of the provision of surgical care to those wounded in the abdomen is carried out taking into account the conditions of the military conflict, the timing of evacuation,

potential of medical units and medical institutions for the provision of surgical care, the possibility of promoting medical reinforcement groups.

Methodology and research methods. The structure and organization of the work were determined by its goal, which was to solve the problem of improving treatment outcomes for wounded people with gunshot wounds by studying the characteristics of these wounds, summarizing treatment experience and developing a system of measures to improve the provision of surgical care at the stages of medical evacuation.

The object of the study is the system of providing assistance to those wounded in the abdomen during the stages of medical evacuation in Afghanistan and the North Caucasus. The subject of the study is wounded with gunshot wounds to the abdomen. The work uses systematic and scientific approaches that involve taking into account the clinical, laboratory, instrumental, structural, morphological and surgical aspects of the problem in their relationship with the identification of the main and essential provisions (fundamentals), the formulation and solution of complementary research problems using the scientific apparatus in its implementation. To establish cause-and-effect relationships, formal-logical, general scientific and specific (statistical, biochemical, immunological, structural-morphological and clinical) research tools and methods were used.

The degree of reliability of the research results. During the study, a complex of modern and original methods and methods of collection and processing was used primary information, formation of representative samples with selection of objects of observation. The reliability of scientific statements, conclusions and practical recommendations is ensured by a structural-system approach, the vastness and diversity of the analyzed material over a long period and the use of adequate methods of mathematical and statistical data processing. Based on a fairly large amount of factual material, the issues of treatment of gunshot wounds of the abdomen were considered from statistical, structural-morphological, pathogenetic and surgical positions, which made it possible to substantiate, develop and implement fundamental treatment methods in the dynamics of the development of traumatic disease in this category of wounded.

Testing and implementation of work results. The research materials were discussed at the All-Union Anniversary Scientific Conference dedicated to the 180th anniversary of the birth of N.I. Pirogov and the 150th anniversary of the beginning of his scientific and pedagogical activities at the Medical-Surgical Academy of Russia (Leningrad, 1991), at the conference "Current Problems multiple and combined injuries" (St. Petersburg, 1992), All-Army Scientific and Practical Conference "Current problems of providing medical care to the lightly wounded, slightly ill and easily injured, their treatment and medical rehabilitation"(St. Petersburg, 1993), scientific conference "Current problems clinical diagnostics"(St. Petersburg, 1993), at the anniversary scientific and practical conference of the 32nd Central Naval Hospital "Problems of clinical and naval medicine" (Moscow, 1993), at

35th (Washington, USA, 2004) and 36th (St. Petersburg, 2005) International Congresses on Military Medicine, at the International Congress on Wound and Explosive Ballistics (Pretoria, South Africa, 2006), All-Russian Scientific Conference with international participation “Modern military field surgery and injury surgery”, dedicated to the 80th anniversary of the Department of Military Field Surgery named after S.M. Kirov (St. Petersburg, 2011), All-Russian Scientific Conference "Emergency Medical Care" - 2013 (St. Petersburg, 2013), All-Russian Scientific Conference with international participation "Emergency Medical Care" - 2014 (St. Petersburg, 2014).

The research results have been introduced and used in scientific, pedagogical and medical work at the departments of military field, naval surgery, surgery No. 2 for advanced training of doctors (with a course of emergency surgery) of the Military Medical Academy, at the St. Petersburg Research Institute of Emergency Medicine named after I. AND. Dzhanelidze, in the 442 district military clinical hospital named after. Z.P. Solovyov, and were also used in the medical practice of the central hospital of the 40th army (Kabul) and the medical battalion (Bagram) during the war in Afghanistan, in the 236th and 1458th military hospitals of the North Caucasus Military District, 66th MoSN during counter-terrorism operations in Chechnya.

The research materials were used in writing: sections of the textbook on military field surgery (2008), the National Guide to Military Field Surgery (2009), the manual “Military Field Surgery of Local Wars and Armed Conflicts” (2011), manual “Wounds by non-lethal kinetic weapons” (2013), “Instructions for military field surgery of the Ministry of Defense of the Russian Federation (2013), “Experience in medical support for troops in an internal armed conflict in the North Caucasus region Russian Federation in 1994-1996 and 1999-2002”, volume 2 “Organization of surgical care” (2015).

The dissertation materials were used to carry out research work on research topics VMA.02.05.01.1011/0206 Code “Trauma-1” “Study of damaging effects, diagnostic features and surgical treatment when injured by non-lethal kinetic weapons"; Research work on topic No. 35-89-v5. “Pathogenesis of hemodynamic disorders when hit by high-velocity projectiles”; Research work on topic No. 16-91-p1. “Traumatic illness in the wounded”; Research work on topic No. 22-93-p5.. “Gunshot wounds of the abdomen, features of the course and treatment, prediction of outcomes.”

The organization and conduct of the dissertation research was approved by the Ethics Committee at the Federal State Budgetary Educational Institution of Higher Professional Education "Military Medical Academy named after S.M. Kirov" of the Ministry of Defense of the Russian Federation (protocol No. 156 of December 23, 2014)

Personal participation of the author in the study. The author personally defined the goal and objectives, developed the methodology and stages of a comprehensive scientific study to solve the problem of improving treatment results for those wounded in the stomach. Collection, systematization, logical construction work and analysis of the results obtained with their subsequent mathematical and statistical processing, scientific principles, conclusions and practical recommendations were formulated. The author of the dissertation was directly involved in the surgical treatment of those wounded in the abdomen in Afghanistan and the North Caucasus and carried out the planning, organization and implementation scientific research in military field conditions, he personally developed medical histories of the wounded, created a database and statistically processed the results obtained.

Scope and structure of work. The dissertation is presented on 389 pages of typescript and consists of an introduction, 8 chapters, a conclusion, conclusions and practical recommendations. The work used 293 domestic and 287 foreign sources. The dissertation contains 83 figures and 74 tables.

Materials and methods of research. To determine the characteristics of gunshot wounds to the abdomen in a local war, an in-depth analysis of 3136 case histories of 2687 wounded in the abdomen in Afghanistan was carried out. The protocols of surgical interventions were studied according to entries in the operating logs of medical institutions of the 40th Army, as well as protocols of pathological autopsies, minutes of meetings of military medical commissions, lists of the wounded who were undergoing treatment and rehabilitation in garrison and district hospitals (from the archives of the Military Medical Museum of the Russian Defense Ministry).

An analysis of the provision of surgical care for gunshot wounds of the abdomen in armed conflicts in the North Caucasus was carried out based on the results of a study of 575 case histories of those wounded in the abdomen in the first (1994-1996) - and 719 case histories in the second (1999-2002) armed conflicts on the territory of the Chechen Republic and the Republic of Dagestan .

Case histories were analyzed using a special card with coding of general data (population, age, medical institution, duration of treatment, outcome, expert opinion, circumstances of injury, nature of the wounding projectile, characteristics of the entrance and exit holes), injuries to the internal organs of the abdomen and other anatomical areas, treatment first aid, delivery times and duration of surgery, surgical intervention, complications, reoperations, symptoms and severity of the condition, postoperative treatment.

The array for statistical analysis of the nature of combat wounds of the abdomen included 1855 wounded with penetrating wounds of the abdomen (1404) and with thoracoabdominal wounds (451) (Table 1). The age of the wounded ranged from 18 to 51 years. In the vast majority of cases (92%) these were young people aged 18-25 years.

Table 1.

Characteristics of gunshot wounds to the abdomen in Afghanistan

Nature of injury Observations

Abs.h. % Of mix died (%)

Penetrating abdominal wounds 1404 52.8 28.4

Thoracoabdominal wounds 451 16.8 40.7

Non-penetrating abdominal wounds 655 24.4 1.1

Mine-explosive injury with damage to abdominal organs 97 3.6 40.2

Wounds of the pelvis with damage to the rectum 68 2.5 33.8

Injuries of the pelvis with damage to the bladder 12 0.4 8.3

TOTAL 2687 100.0 24.2

When comparing our data with the figures from the annual reports of the medical service of the 40th Army, it was stated that the analysis included the medical histories of 89.6% of wounded with penetrating abdominal wounds and 96% with thoracoabdominal wounds for all years of the war in Afghanistan. Consequently, the presented statistical information most fully reflects the problems of organizing and providing assistance to those wounded in the stomach. According to reports from the 40th Army, the proportion of abdominal injuries among other combat wounds ranges from 3.5% (1982) to 7.8% (1980), with an annual average of 5.8%.

In most cases, the wound was caused by bullets (60.2%), much less often by shrapnel (39.8%). Isolated penetrating abdominal wounds were observed only in 28.5% of cases. The multiple nature of the injury (two or more bullets or shrapnel affecting one anatomical area) was noted in 2.4% of cases, and the combined nature (injuries within two or more areas) - in 39.3%.

The work was based on retrospective clinical and statistical studies of a group of wounded in the abdomen (2,687 wounded according to materials from the war in Afghanistan) and a comparative retrospective study of the results of staged treatment of wounded in the abdomen (a group of 2,687 wounded in Afghanistan and a group of 1,294 wounded in the North Caucasus) - Table 2.

Table 2.

Arrays of wounded Research conducted

2687 wounded in the abdomen in Afghanistan Clinical and statistical characteristics of combat abdominal wounds

2687 wounded in the abdomen in Afghanistan Study of the nature of medical care and treatment during the stages of medical evacuation, study of postoperative complications

1294 wounded in the abdomen in the North Caucasus Comparative analysis of the organization of surgical care

88 wounded in the abdomen in Afghanistan (control - 98 healthy military personnel who served a year in Afghanistan) An in-depth study of the effect of a gunshot wound to the abdomen on the degree and nature of changes in functional systems ah body of the wounded

1855 wounded in the abdomen in Afghanistan Development of a method for objective assessment of the severity of damage to abdominal organs

1855 wounded in the abdomen in Afghanistan Creation of a scale for predicting the course of traumatic disease with gunshot wounds to the abdomen

In addition, to study the effect of a gunshot wound to the abdomen on the degree and nature of changes in the functional systems of the body of the wounded, an in-depth examination of homeostasis parameters was performed in 88 wounded in the abdomen in Afghanistan. By the nature of the injury, the frequency and nature of damage to the abdominal organs, the presence of associated injuries, the severity of the condition, the frequency of shock, and the course of the postoperative period, they corresponded to the group of those wounded in the abdomen, analyzed from medical histories.

Taking into account the climatic and geographical features of Afghanistan: high summer temperatures and temperature changes in the mountains during the day, increased solar radiation, low humidity, low atmospheric pressure in mid-mountain conditions, and, consequently, reduced partial pressure of oxygen in the air, as well as the characteristics of the professional activities of military personnel who are in an unusual habitat for them (excessive psycho-emotional and physical exercise), to determine the “local norm,” 98 healthy military personnel who served in Afghanistan for one year were previously examined.

In the wounded, the study of clinical and laboratory parameters was carried out according to a single scheme in dynamics on the 1st, 3rd, 5th, 7th, 10th and 15th days after surgery.

opinions. A physical examination was performed, and clinical blood and urine tests were performed. The volume of circulating blood and its components were studied using the plasma-hematocrit method with Evans blue dilution. The study of central hemodynamics indicators: heart rate, stroke volume, stroke index, minute volume of blood circulation, cardiac index, reserve coefficient was carried out using the method of integral rheography of the body according to M.I. Tishchenko. The state of systemic arterial tone to assess the degree of centralization of blood circulation was determined by the coefficient of integral tonicity. The state of the respiratory system was assessed based on direct examination of arterial and venous blood gases using the Astrup micromethod. At the same time, to assess the state of the respiratory function of the lungs, the respiratory frequency, respiratory intensity indicator and coefficient respiratory changes stroke volume. To characterize water balance, the volume of extracellular fluid and the balance indicator were determined. The saturation of hemoglobin in arterial and venous blood with oxygen was studied using an OSM-2 hemoximeter (Radiometer). The metabolic state was assessed by indicators of the acid-base state of the blood, the content of pyruvic and lactic acids in the blood serum; the state of the “lipid peroxidation - antioxidants” system; content of enzymes that reflect functional state individual organs, systems and the body as a whole. The content of potassium, sodium, chlorine, total protein, urea, creatinine, bilirubin, glucose ions in the blood serum: the activity of alanine aminotransferase, aspartate aminotransferase, alkaline phosphatase was determined on a Technicon analyzer. The level of potassium and sodium ions in erythrocytes and urine was studied using flame photometry, the levels of urea and creatinine in urine, and the content of total lipids - using Lachema kits. When assessing the immunological status of the wounded body, the absolute and relative numbers of lymphocytes and their subpopulations, the reaction of inhibition of lymphocyte migration, the content of immunoglobulins and the level of circulating immune complexes in the blood serum were studied. Using the radioimmune method using kits from Sorin and Radiopreparat, the levels of adrenocorticotropic and somatotropic hormones, cortisol, aldosterone, antidiuretic hormone, renin, testosterone, insulin, glucagon, calcitonin, triiodothyronine, thyroxine were determined.

In addition, on a sample of 1,855 wounded in the abdomen in Afghanistan, a method was developed to objectively assess the severity of damage to the abdominal organs and a mathematical analysis was carried out with the creation of a scale for predicting the course of traumatic disease in gunshot wounds of the abdomen

Statistical processing was carried out at Research Laboratory-2 of the Military Medical Academy with technical assistance from Ermakova G.Yu. and Kulikova V.D. using the BMDP application package for ID, 2D, 3D, 7M, 2R programs. Analysis of statistical patterns in all cases was carried out using Student's t-test and Fisher's F-test. Differences

considered reliable at p< 0,05. Данные в таблицах приведены в виде М ± шх, где М - среднее значение показателя, шх - ошибка среднего значения.

RESULTS OF OWN RESEARCH

Features of clinnnkn and diagnosis of combat abdominal trauma. Modern combat gunshot wounds of the abdomen in most cases (87.1%) are accompanied by severe symptoms, often accompanied by shock (82.2%), and have a characteristic location of the wound openings (74.5%). Diagnosis of penetrating abdominal wounds does not cause difficulties in the presence of absolute signs - prolapse of internal organs (10.8%) - strands of the greater omentum (6.9%), loops of the small intestine (3.9%), large intestine (1.3% ), liver (1.0%), in some cases, spleen, stomach, as well as when the contents of the stomach and intestines, bile, and urine leak. The leakage of abdominal contents into the wound was detected infrequently: intestinal contents - in 24 cases, gastric contents - in 4, urine - in 4 cases and bile - in 2 (total 3.3%). Blood flow from the wound was detected in 63.3% of the wounded.

Diagnostic difficulties most often arise with non-penetrating abdominal wounds (24.4% of total number wounded in the abdomen, in 9.2% - with damage to intra-abdominal organs), the location of the entrance holes in the chest and pelvis (30.2%), with damage to the rectum and bladder (8.2%), mine-explosive injury ( 3.6%). In some cases, diagnostic errors are due to insufficient examination of the wounded (2.9%).

Plain radiography of the abdominal cavity was performed in 42.5% of the wounded, and it was possible to localize foreign bodies(bullets, fragments), diagnose fractures of ribs, pelvic bones.

An important method in the diagnosis of injuries to the abdominal organs was laparocentesis. The indication for it was the absence of a clear clinical picture when the inlet openings are located, both in the abdomen and neighboring areas. Significantly more often (p<0,05) лапароцентез использовался при сочетанных ранениях. Так, если при проникающих ранениях живота его выполняли у 11,5% раненых, то при торакоабдоминапьных ранениях - у 25,7%. При лапароцентезе у раненых с проникающими ранениями живота в 70,9% из общего числа случаев его использования получена кровь, еще в 16,2% - окрашенная кровью жидкость, в 3,9% - кишечное содержимое. В 7,2% использовано продленное наблюдение с оставлением трубки в брюшной полости. Чувствительность лапароцентеза при огнестрельных ранениях живота, определяемая долей пострадавших, у которых достоверно установлен положительный результат, составила 92,3%. Специфичность метода, зависящая от достоверности данных об отсутствии признака повреждения у пациентов, у которых он действительно отсутствовал, была на уровне 96,0%. Диагностическая точность, определяемая отношением истинных результатов

to all indicators, that is, the frequency of correct detection of both positive and negative test results in all victims combined was 93.5%. Thus, laparocentesis has been an effective diagnostic method for penetrating abdominal wounds.

In 9 wounded people, at the stage of specialized medical care in Afghanistan, laparoscopy with a rigid endoscope was performed for diagnostic purposes, the effectiveness of which, according to the state of the art of those years, was equivalent to laparocentesis. In the second Chechen conflict, at the stage of specialized care, laparoscopy using the CST-EC kit was performed on 46 wounded with penetrating abdominal wounds (Boyarintsev V.V., 2004, Sukhopara Yu.N., 2001).

During the period of military conflicts in Afghanistan in the North Caucasus, ultrasound and computed tomography were not used to diagnose abdominal wounds in advanced medical institutions. However, based on our data, we can assume that screening ultrasound diagnostics (especially in the modern version of the abbreviated RABT study) is indicated at least in all cases of laparocentesis used for penetrating abdominal wounds (11.5% ).

Most of the wounded with penetrating abdominal wounds were admitted in a state of shock; stable hemodynamics was only in 17.8% of cases. Considering that CT examination is performed only in the stable condition of the wounded, the possibility of its use is available in no more than a fifth of the wounded with penetrating abdominal wounds.

Organization of provision, timing and content of medical care for abdominal wounds. The conditions of local wars determined both the nature of gunshot wounds to the abdomen and the peculiarities of providing medical care and evacuation of these wounded.

In Afghanistan, first aid to those wounded in the stomach was in most cases provided within 10-15 minutes in the form of mutual aid or by a sanitary instructor, paramedic, and often a doctor. In particular, an aseptic dressing was applied to almost all the wounded. Promedol from a syringe tube was administered if there were signs of a penetrating wound in the abdomen (69.4%). Some of the wounded who were in a state of shock began intravenous infusion of blood substitutes (18.8%). 3.9% of all wounded received antibiotics at the prehospital stage. First aid to those wounded in the stomach in conflicts in the North Caucasus was the same in scope as in Afghanistan.

Comparative characteristics of first medical aid in Afghanistan and Chechnya are presented in Table 3. Noteworthy is the improvement in the provision of prehospital care to the wounded in Chechnya through such important measures as infusion therapy and antibiotic prophylaxis (r<0,05).

The main means of delivering those wounded in the abdomen to the stage of providing surgical care was a helicopter, which made it possible to significantly reduce delivery times - more than 90% of them arrived at the stage of providing medical care.

assistance within three hours after injury. During the Great Patriotic War, only 16.9% of those wounded in the stomach were admitted to medical battalions at the same time (Banaitis S.I., 1949).

Table 3.

The nature of first medical aid for those wounded in the stomach in military conflicts (%)

Events Afghanistan (1979-1989) Chechnya (1994-1996) Chechnya (1999-2002)

Aseptic dressing 100.0 98.0 99.0

Infusion therapy 18.8 23.5 51.6

Administration of antibiotics 3.9 51.9 74.1

Pain relief 100.0 100.0 100.0

An equally important indicator influencing the outcome of abdominal injury is the time elapsed from the moment of injury to the start of surgery. The distribution of the wounded depending on the timing of the start of the operation is presented in Table 4.

Table 4.

The time period from the moment of injury to the start of surgery for those wounded in the abdomen.

Time from the moment of injury to the start of the operation (1) Afghanistan Chechnya (1994-1996) Chechnya (1999-2002)

Number of wounded (%) Of which died (%) Number of wounded (%) Of which died (%) Number of wounded (%) Of which died (%)

G< 3 час 41,6 35,4 41,9 13,6 47,2 20,4

3 <1:<6 час 36,6 31,8 32,3 15,7 30,3 9,1

6 < г< 12 час 12,2 25,1 13,5 13,6 14,2 19,4

12<г<24 час 6,7 30,2 7,1 16,7 5,5 0

1 >24 hours 2.9 30.4 5.2 11.8 2.8 0

Total 100.0 32.4 100.0 13.0 100.0 17.1

Within 6 hours, in all conflicts studied, almost 80% of those wounded in the abdomen were operated on. Moreover, postoperative mortality among the wounded in Chechnya was 2-3 times lower than in Afghanistan (p<0,05).

It should be clarified that at the stage of providing qualified surgical care (MSC), the heads of departments of garrison hospitals and senior residents of district hospitals worked, and in the hospitals of the 1st echelon of specialized surgical care - reinforcement groups from the Military Medical Academy and central military hospitals.

A significant indicator reflecting the severity of the injury and the qualifications of surgeons and anesthesiologists-resuscitators is the duration of the surgical intervention. On average, it was 3.4 ± 0.1 hours, varying from 10 minutes for those who died on the table, when they only had time to open the abdominal cavity, to 15 hours for severe combined wounds.

The distribution of those wounded in the abdomen by frequency of medical evacuation stages is presented in the table. 5.

Table 5.

Organization of the provision of surgical care to those wounded in the abdomen in military conflicts (% of admissions to the stages of medical evacuation)

Evacuation stage Afghanistan Chechnya (1994-1996) Chechnya (1999-2002)

Qualified surgical care 72.6 83.2 56.2

1st echelon of specialized surgical care 27.4 16.8 43.8

2nd echelon of specialized surgical care 88.3 76.9 68.9

3rd echelon of specialized surgical care 5.8 23.7 19.5

In all analyzed military conflicts, more than half of those wounded in the abdomen received qualified surgical care, which reflects the desire for early laparotomy to stop intra-abdominal bleeding and prevent peritonitis.

In Afghanistan, echeloned specialized care for those wounded in the abdomen was provided in the Kabul Army Hospital, 340 District Clinical Military Hospital (64.9% of those wounded in the abdomen passed through this hospital), as well as in all district and central clinical military hospitals. Evacuation to the stage of specialized medical assistance

cabbage soup was carried out by An-26 "Spasatel", Il-18 and Tu-154 "Sanitar", Il-76 "Scalpel" aircraft.

The medical institution of the 1st echelon stage of specialized medical care, which received those wounded in the stomach in the first conflict in Chechnya, were: 236 VG (65.98%), 696 MOSN (33.72%) and the Republican Hospital (0.30%) ; in the second conflict: 1458 VG (55.26%), 236 VG (37.47%), VG Buinaksk) (6.47%) and Republican Hospital (0.8%). 80.38% of those wounded in the stomach in the first conflict and 80.53 % - in the second. In medical institutions of the 3rd echelon of specialized medical care (Military Medical Academy, central military hospitals), 23.68% of those wounded in the stomach in the first conflict and 19.05% in the second continued to receive treatment.

General features of combat abdominal trauma in modern military conflicts. Early evacuation of the wounded in the abdomen resulted in the delivery of wounded with severe injuries to the abdominal organs, and in almost 60% of cases more than one organ was damaged.

In Afghanistan, with penetrating abdominal wounds, injuries to hollow organs predominated (63.4%), followed by simultaneous injuries to hollow and parenchymal organs (24.9%), injuries to parenchymal organs (11.7%). In the group of thoracoabdominal wounds, the sequence was reversed: injuries to parenchymal organs were predominant (46.7%), followed by simultaneous injuries to hollow and parenchymal organs (42.9%), injuries to hollow organs - 9.2%.

In both conflicts in Chechnya, the distribution of injuries to internal organs due to penetrating wounds of the abdomen was identical: injuries to hollow organs also predominated (45.9% and 50%), followed by simultaneous injuries to hollow and parenchymal organs (19.6% and 30.1%) , damage to parenchymal organs (19.1% and 24.0%).

Moreover, only a third of those wounded with bullet wounds of the abdomen (33.1%) and in 44.3% of cases with shrapnel wounds of the abdomen had damage to one internal organ; the majority of those wounded in the abdomen in modern military conflicts had damage to 2 or more internal organs ( table 6).

Bullet wounds of the abdomen cause more severe damage to internal organs compared to shrapnel wounds, and also damage them in greater quantities, which causes a more serious condition of such wounded people, necessitates the use of large-scale surgical procedures, leads to a more frequent development of severe infectious complications and, as consequence, to a higher mortality rate. In a comparative analysis of the nature of the damaging effect of 5.45 mm and 7.62 mm caliber bullets, we were unable to identify the predominant damaging effect of any of these wounding projectiles.

The distribution of combinations of abdominal wounds with injuries to other anatomical areas is presented in Table. 7.

Table 6.

Frequency of internal organ injuries from bullet and shrapnel wounds of the abdomen in Afghanistan (%)

Quantity Frequency at Frequency at

damaged bullet wounds shrapnel wounds

organs (n=1128) (n=726)

Total 100.0 100.0

Table 7.

Frequency of combined injuries to various anatomical areas (and mortality rate) in penetrating abdominal wounds in Afghanistan

Anatomical region Injury rate (%) Deaths (%)

Head, including injuries to the skull and brain 8.6 32.5

Eyes 2.9 26.4

ENT organs 0.8 53.3.

Maxillofacial region 7.2 27.8

Chest, including thoracoabdominal wounds 37.1 35.5

Spine, including those with spinal cord injury 9.2 39.4

Pelvis, including damage to the pelvic bones 20.3 37.8

Limbs, including with separation of a limb segment with damage to the main vessel 35.7 31.1

Most often, when the abdomen was wounded, the chest was simultaneously damaged, then the limbs and pelvis. Injuries to two areas occurred in 40.7% of cases, three - in 20.8%, four - in 8.8%, five or more - in 1.2% of cases.

Mortality in combined injuries, when the severity of damage to the abdominal organs (calculated using a refined objective scale - see below) exceeded the severity of damage to organs in other areas, was 28.8%. When the severity of injuries was equivalent, the mortality rate was 58.7%. In cases where the severity of damage exceeded other areas, the mortality rate was even higher - 76.9%. The overall mortality rate for isolated penetrating abdominal wounds was 24.8%, for combined ones - 33.8% (p<0,05).

An intraoperative diagnosis of peritonitis was established in 42.3% of the wounded, and for penetrating abdominal wounds this diagnosis was established in 47.6%, and for thoracoabdominal wounds - in 25.7%. The presence of peritonitis at the time of the first operation predetermined the highest mortality rate in this group - 28.5% (in the absence - 14.7%) (p<0,05), так и более тяжелое послеоперационное течение. О тяжести поступивших раненых говорит и то, что 11,8% из них умерли на операционном столе и в первые сутки после операции, несмотря на проводимую интенсивную терапию.

The nature of modern combat trauma to the abdominal organs, features of surgical tactics and treatment. Considering the similar frequency and nature of damage to internal organs in abdominal wounds during the war in Afghanistan and counter-terrorism operations in the North Caucasus, the analysis of injuries to internal organs and surgical interventions on them will be carried out mainly on the basis of more thoroughly studied clinical material obtained in Afghanistan (Table 8 ).

Table 8.

Frequency of damage to abdominal organs in military conflicts (%)

Organ Afghanistan Chechnya (1994-1996) Chechnya (1999-2002)

Stomach 17.6 13.0 12.3

Duodenum 4.3 3.6 2.5

Small intestine 46.0 49.2 41.5

Colon 47.3 45.8 48.0

Rectum 7.9 9.6 7.9

Liver 31.5 24.9 26.9

Spleen 12.9 15.6 10.7

Pancreas 7.4 3.4 8.6

Kidneys 13.3 13.4 16.8

Bladder 4.2 6.5 6.0

Ureter 4.1 1.7 1.0

Large blood vessels 11.1 18.8 12.0

Injuries to the small (41-49%) and large intestine (47-48%), liver (25-32%), stomach (12-18%), kidney (13-17%) and spleen (11-17) were more common. %). In 11-19% of cases of combat wounds of the abdomen, damage to large blood vessels.

The nature of modern combat injuries to the abdominal organs and the features of operations used at the stages of medical evacuation were studied in detail.

The main operation (81.4%) for gastric wounds is suturing the wounds with a double-row suture. In case of extensive damage, gastrectomy had to be performed (1.8%), but the effectiveness of this operation in military field conditions is low (mortality rate - 100%). When suturing gastric wounds, the main attention must be paid to carefully stopping bleeding from the vessels of the gastric wall, since if this condition was violated, secondary gastric bleeding developed in the wounded (14.6%). When revising the stomach, it is necessary to examine its posterior wall, since 52.2% of gastric wounds are through. After surgery, gastric decompression with a probe is required for at least 3-5 days.

In case of suspected injury to the duodenum, revision of its retroperitoneal part after mobilization according to Kocher is indicated. Most often, duodenal wounds after excision were sutured with a double-row suture with mandatory drainage gastrointestinal tract nasogastrointestinal probe, however, in 1/5 of cases of suturing intestinal wounds in the postoperative period, suture failure was detected. It is difficult to identify an unambiguous reason for this (insufficient surgical treatment, poor drainage, etc.) in a retrospective analysis. In case of pronounced narrowing of the sutured intestine, a gastroenteroanastomosis should be performed. Extensive damage to the duodenum and surrounding organs is accompanied by high mortality (77.8%).

For single wounds of the small intestine measuring no more than half the circumference of the intestine, they were sutured with a double-row suture after excision of the wound edges. In case of detection of multiple wounds in a limited area of ​​the intestine, its complete breaks and crushing, separation from the mesentery, doubt about its viability after ligation of the mesenteric vessels, resection of a section of the small intestine was performed (performed in 55% of the wounded). It should be borne in mind) that the wounded do not tolerate organ resection well and the mortality rate after resection of the small intestine is directly proportional to the volume of intervention (with resection of a segment of the small intestine up to 100 cm, 29.8% of the wounded died, 100 - 150 cm - 37.5%, over 150 cm - 55.6%). Although failure of small intestinal anastomoses was detected somewhat more often after anastomosis of the "end-to-end" type (10.3%) than "side-to-side" (6.1%) , these differences were not significant (p>0.05).

In case of injuries to the colon, the choice of surgical tactics was determined not only by the nature of the damage to the wall, but also by a number of other factors, namely: the overall severity of the injury (the presence of injuries to other abdominal organs and associated injuries), the degree of blood loss, the timing of the operation and the presence of

what is peritonitis? Under any circumstances, primary colon anastomoses should not be used (attempts to perform them were accompanied by failure in 66.4% and mortality rate of 71.4%). Indications for the operation of suturing wounds of the colon are limited (spot size of the wound, absence of other injuries and blood loss, early stages of intervention in the absence of signs of peritonitis), and the results (7.1% of failure and 31.0% of deaths) are inferior to those obtained with a safer operation - extraperitonealization of sutured intestinal wounds (2.6% of suture failures and 31.7% of deaths). For extensive injuries to the colon, depending on their location, a right-sided hemicolectomy or (for injuries to the left half of the intestine) a Hartmann-type operation is performed. After these interventions, mortality reached 50-60%, but this was primarily due to the massive anatomical damage to organs and blood loss. In extremely serious condition of the wounded with multiple and combined injuries and in conditions of wound peritonitis, removal of the damaged part of the intestine to the abdominal wall was performed as the most gentle intervention.

If a rectal injury was detected, an unnatural anus was placed on the sigmoid colon, the peri-rectal tissue was drained, the rectal wound was washed and, if possible, sutured. The results of these operations in Afghanistan were as follows: 63.8% infectious complications and 43.0% deaths.

In case of liver injuries, crushed liver tissue was removed (5%) followed by suturing of the wound (84.5%). When suturing liver wounds, pedunculated omentum, round ligament of the liver, and hemostatic drugs were used to tamponade them for the purpose of hemostasis. In case of extensive liver destruction, extrahepatic drainage was performed. biliary tract, as well as supra- and subhepatic space (76.9%). The mortality rate for liver injuries was 36.8%.

In case of injury to the spleen, the main operation remains splenectomy (87.5%), and only with minor damage to its capsule is suturing indicated (6.3%). In all these cases, drainage of the left subphrenic space is necessary.

Tactics for wounding the pancreas are based on the presence or absence of damage to its ducts, but in most cases (81.6%) it comes down to the introduction of antiproteolytic enzymes under the capsule of the gland, removal of its non-viable areas (the tail of the gland) and drainage of the omental bursa.

When the kidneys are injured, the main operation remains nephrectomy (72.3%), since most often they are destroyed, but suturing of superficial wounds of the kidney is also possible (14.2%), as well as resection of its pole (3.3%).

In case of injury to the bladder, the wound was sutured, followed by long-term catheterization, a cystostomy was applied, and in case of damage to its extraperitoneal part, drainage of the paravesical space was performed.

The main surgical intervention for injuries to large abdominal vessels was ligation (54%), but whenever possible their restoration was undertaken (28.2%). In every fourth wounded person (24.5%), death from blood loss on the operating table did not allow vascular surgery to be performed. In 7.2% of cases, bleeding was stopped by tight wound tamponade. The overall mortality rate for injuries to abdominal vessels was 58.7%; 28.6% died on the first day after surgery. The complication rate for injuries of large vessels was 91.7%.

Thoracoabdominal wounds accounted for 24.4% of all penetrating abdominal wounds, the mortality rate for them was 40.7%. Regarding chest wounds, in the vast majority of cases (90.2%) they were limited to drainage pleural cavity on the damaged side using two tubes. Indications for thoracotomy (9.8%) were ongoing intrapleural bleeding, valvular pneumothorax, not amenable to conservative treatment and injury to the mediastinal organs. In 5.8% of cases of thoracoabdominal injuries, when there was a suspicion of injury to the heart and large vessels of the chest, surgical intervention began with thoracotomy. In the remaining 94.2% of cases, laparotomy was performed first. Only in 2.7% of cases was thoracolaparotomy performed, which has no advantages over separate approaches due to greater trauma. In 2.2% of the wounded, thoracotomy was performed with the aim of suturing a wound on the posterodiaphragmatic surface of the liver, which could not be sutured through the laparotomy approach. Suturing of the lung wound was performed in 8.7% of the wounded, marginal resection in 4.4%, lobectomy in 0.4%, and pneumonectomy in 1.1%. Heart wounds were sutured in three wounded people. Blood evacuated from the pleural cavity was reinfused in 40.2% of the wounded in a volume of 100 to 7500 ml, on average 1200+70 ml.

Features of mine-explosive injuries to the abdomen. Damage from explosive munitions in Afghanistan amounted to 11.1% (298 wounded), in Chechnya (1994-1996) - 22.7% (129 wounded) and in Chechnya (1999-2002) - 24.2% (173 wounded). With penetrating abdominal wounds, mine-explosive wounds accounted for 6.7%, with non-penetrating wounds - 0.8%. Blast injury occurred in 3.6% of those injured in the abdomen in Afghanistan and 2.2% and 3.7%, respectively, in the Chechen conflicts.

Diagnosis and treatment tactics for mine-explosive wounds (direct contact with explosive ammunition) with penetration of fragments into the abdominal cavity did not differ from the diagnosis and treatment of other penetrating abdominal wounds. The main thing is that mine-explosive wounds to the abdomen were always accompanied by damage to other areas of the body, including the separation of limb segments in half of the wounded. Mortality from mine-explosive abdominal wounds was 29.3% (9.9% of all deaths with penetrating abdominal wounds).

Much more difficult in diagnostic terms were the wounded with explosive (mine-explosive) trauma, accompanied by damage to the abdominal organs. Distinguishes them from wounded with mine-explosive wounds

There is a frequent lack of damage to the skin of the abdominal area. Typically, mine-explosive trauma to the abdominal organs was observed during explosions of equipment without penetration of the armored wall, due to the shielded effect of the explosion energy with damage to the wounded on it or inside it.

Considering the complexity and little-studied nature of the pathology, the medical histories of 97 wounded with mine-explosive abdominal trauma were specially analyzed, which accounted for 3.6% of all those wounded in the abdomen. In 78.4% the injuries were multiple, and in 89.7% they were combined. Damage to one anatomical area was observed in 10.3%; two - 26.8%; three - 39.8%; four - 17.5%; five - 6.2%. The distribution of these combinations is presented in Table 9.

Table 9

Distribution of damage to anatomical areas in mine-explosive abdominal trauma (%)

Anatomical region Frequency of injury

Head 55.7

Spine 9.3

Limbs 58.8

Severation of a limb segment occurred in 8.2% of the wounded. In the majority of wounded, the severity of intra-abdominal injuries prevailed over the severity of damage in other anatomical areas, but in 16.5% of cases it was equivalent to the severity of damage to other areas, and in 3.1%, the severity of damage to other areas exceeded the severity of damage to the abdomen.

An undoubted diagnosis of injuries to the abdominal organs was established in 32% of cases, therefore laparocentesis was used for diagnosis in 68% of cases, including in 7% with prolonged observation: in this case, blood or blood-stained fluid was obtained in 98.5% of cases.

During laparotomy, damage to internal organs was not detected in 10.4% of cases, however, preperitoneal hematomas and tears in the mesenteries of the small and large intestine were detected. Damage to one organ was found in 46.9%, two - in 22.9%, three - in 11.5%, four - in 7.3%, seven - in 1%. Parenchymal organs were damaged more often (79.4%) than hollow organs (34%), because parenchymal organs have greater inertia. Most often (54.2%) with a mine-explosive injury to the abdomen, the spleen was damaged, as the most vulnerable organ. Its complete destruction was found in more than half of the cases, damage to only the spleen capsule was found in 7.7% of the wounded. Liver damage was detected in 37.5% of the wounded, while the right lobe, being more massive, was damaged four times more often than the left. In one case, extensive liver damage was combined with

rupture of the portal and inferior vena cava (fatal outcome). Mine-explosive liver injury was characterized by superficial linear ruptures, and only 14.3% of victims were found to have deep cracks in the hepatic parenchyma. Kidney damage was found in 11.5% of the wounded, and the right kidney was damaged twice as often as the left. Kidney destruction was recorded in 20% of cases of kidney damage. The pancreas was damaged in 10.3% of the wounded, and its tail was more often damaged. The small intestine was damaged in 20.6% of the wounded. Bruises of its wall and damage to the serous membrane amounted to 80%, penetrating ruptures - 20%. Damage to the colon was found in 19.6% of the wounded. In 80% these were bruises of the intestinal wall and ruptures of its serous membrane, and complete ruptures of its wall amounted to 20%. Half of all lesions were located in the area of ​​the cecum and transverse colon. The rectum was damaged in 3.1% of the wounded. The bladder is damaged in 2.1% of cases. Damage to large abdominal blood vessels was detected in 3.1% (there was one case of rupture of the inferior vena cava, rupture of the portal vein and rupture of the left iliac vein). Hematomas and ruptures of the intestinal mesentery were recorded in 38.2% of the wounded; in all cases of mine blast trauma to the abdomen, ruptures of the parietal peritoneum were found.

Peritonitis developed in 14.4% of the wounded. Complicated postoperative course was observed in 84.9% of the wounded. The mortality rate for mine-explosive abdominal trauma was 40.2%.

Features of combat non-penetrating abdominal wounds. Non-penetrating wounds accounted for 24.4% of all abdominal wounds in Afghanistan, 21.6% in Chechnya (1994-1996) and 25.0% in Chechnya (1999-2002), that is, they practically remained at the same level.

In 17.3% of wounded with non-penetrating wounds In cases of suspected damage to the abdominal organs, laparocentesis was used, of which 58.4% had long-term follow-up. Based on clinical symptoms and results of laparocentesis, laparotomy was performed in 10.0% of patients with non-penetrating abdominal wounds. During surgery, 9.2% of the total number of wounded with non-penetrating abdominal wounds were found to have damage to internal organs: liver - 1.7%, spleen - 2.0%, kidneys - 2.4%, pancreas - 0.2%, small intestines - 1.7%, colon - 3.4%, including rectum - 0.3%, bladder 0.2%. Damage to one abdominal organ was observed in 75% of victims, two - in 20%, three - in 5%. For injuries to the parenchymal organs of the abdominal cavity, the most typical were subcapsular hematomas, ruptures, and cracks; for hollow organs - bruises, subserous hematomas, ruptures of the visceral peritoneum. There were also complete ruptures of the intestinal and stomach walls. In cases where during laparotomy there were no injuries to the internal organs of the abdominal cavity (0.8%), hemorrhages occurred in the form of preperitoneal and retroperitoneal hematomas, which caused peritoneal symptoms.

Characteristics of homeostasis disorders in combat wounds of the abdomen. A gunshot wound to the abdomen was a trigger for the development of pathophysiological changes in all life support systems of the body. A study of the parameters of the circulatory system revealed prolonged changes in the blood volume and, especially, its globular component, directly proportional to the severity of the injury, despite intensive infusion-transfusion therapy. The direction of these changes fully corresponded to the nature of the postoperative period. The content of erythrocytes, hemoglobin level and hematocrit were correlated with the course of the postoperative period. Depending on the severity of the postoperative period, the shock and cardiac indices and heart rate changed throughout the entire observation period. At the same time, an electrocardiographic study revealed disturbances in repolarization processes in the myocardium and left ventricular ischemia.

Shifts in the circulatory system were accompanied by changes in respiratory system: Tachypnea and an increase in the coefficient of respiratory changes in stroke volume were observed. These disturbances, in turn, affected the gas composition of the blood: a decrease in the arteriovenous oxygen difference and hemoglobin saturation with oxygen was recorded.

A pronounced activation of lipid peroxidation and a simultaneous decrease in the activity of the antioxidant defense system were revealed. Along with the activation of the lipid peroxidation system, an increase in the level of free fatty acids, which have a pronounced membrane-destructive effect, was observed. Depending on the severity of the postoperative period, the content of aspartate and alanine aminotransferases increased in the blood serum. Activation of the kallikrein-kinin system was noted with a slight increase in the content of proteolysis inhibitors. The postoperative period in those wounded in the abdomen was accompanied by activation of the central and peripheral parts of the hypothalamic-pituitary-adrenal system. Cortisol levels were significantly increased on the first day, and the increase in ACTH levels was longer lasting. The level of somatotropic hormone was significantly increased throughout the observation period. At the same time, a pronounced decrease in hormone levels was observed thyroid gland(T3, T4), as well as testosterone, especially in the group with an unfavorable outcome. Fluctuations in the levels of insulin and glucagon, as well as the level of glucose regulated by these hormones, were noted. Blood loss, hemodilution, increased catabolic processes in the body, as well as a decrease in synthetic processes caused hypoproteinemia, especially due to a decrease in albumin and prealbumin. A characteristic feature of hypoproteinemia in the wounded was that it was persistent and difficult to correct, which in turn influenced the nature of wound healing and the course of the postoperative period. Confirmation of protein catabolism was an increase in the concentration of urea and creatinine in the blood serum, as well as their excretion in the urine. Protein catabolism was accompanied by

This is due to a significant increase, depending on the course of the postoperative period, in the content of medium molecular polypeptides. Impaired stability of cell membranes, a decrease in oncotic pressure caused by albumin deficiency, and peculiarities of the reaction of the neurohumoral system led to early and serious shifts in water-electrolyte metabolism. Against the background of tissue hypoxia and metabolic disorders, there was an accumulation of osmotically active substances, and the change endocrine regulation led to the redistribution of fluid in the spaces of the body and even greater disruption of metabolic processes. A decrease in cellular immunity in the early stages after injury has been established.

In general, the pathophysiological changes identified in the wounded in a combat situation corresponded to similar reactions accompanying a traumatic illness in victims with mechanical trauma in peacetime. Regardless of option clinical course these changes are observed in all those wounded in the abdomen and can be considered as a traumatic disease in the wounded, which is influenced by the syndrome of “ecological-professional stress” and the morphological features inherent in a gunshot wound. Therefore, approaches to the treatment of such wounded in general should correspond to the approaches developed in the treatment of traumatic illness in peacetime, taking into account the longer time frame for the onset of long-term adaptation in the wounded.

Postoperative complications and features of intensive care of combat wounds of the abdomen. The war in Afghanistan was characterized by a large number of postoperative complications (82.7%). In Chechnya, as a result measures taken, the frequency of complications decreased significantly (in the first conflict - 48.6%, in the second - 43.8%), but also did not differ significantly from the data of the Great Patriotic War (59.5% according to A.I. Ermolenko, 1948). The frequency of complications correlated with the amount of blood loss and the number of damaged organs, as well as the severity of damage to abdominal organs.

An in-depth study of the nature and severity of complications among abdominal wounded patients in Afghanistan was conducted. Complications developed in 77.0% of those who survived and in 98.8% of those who died from the total number of those wounded in the abdomen. By their nature, complications can, with a certain degree of convention, be divided into two groups:

General complications from the functional systems of the body (in 68.7% of the wounded), caused by the injury itself and its consequences (anemia, myocardial ischemia, pneumonia, acute renal failure, spicy liver failure);

Complications directly related to the abdominal injury and the surgical intervention performed (48.3%): suppuration postoperative wounds, phlegmon of the abdominal wall and retroperitoneal space, abdominal abscesses, progressive peritonitis, acute intestinal obstruction, failure of sutured wounds of hollow organs and anastomoses, etc.

As a result of acute blood loss, 52.3% of the wounded were found to have posthemorrhagic anemia, which, as a rule, was persistent, especially with blast wounds, and was difficult to correct, despite blood transfusion therapy. The state of anemia and the resulting hypoxia led to varying degrees the severity of metabolic and then ischemic changes in the myocardium in 49.8% of all wounded. Acute renal failure was observed in 7.7% of the wounded. More often it developed with kidney injuries (18.8%), especially if blood reinfusions were performed in this situation: from 1.0 l to 2.5 l - in 26.3%, and over 2.5 l - in 36.4 %. Acute liver failure complicated the course of the postoperative period in 4.7% of cases, and with liver injuries it developed somewhat more often (6.6%). Contusions of the lungs or direct damage to the lung tissue during thoracoabdominal wounds, prolonged mechanical ventilation, congestion in the lungs as a result of being in a forced position led to pneumonia in 33.1% of cases, and with penetrating abdominal wounds it was diagnosed in 29.3% of the wounded, and with thoracoabdominal wounds wounds - in 44.9%. Gastrointestinal bleeding detected in 5.3% of the wounded. Acute intestinal obstruction was diagnosed in 7.5% of the wounded; it was dynamic in 1.1% of cases, mechanical in 6.4%.

Failure of sutured gastric wounds was detected in 1.5% of cases, small intestinal wounds - in 1.7%, small intestinal anastomoses - in 1.9%, colon wounds - in 0.9%, colon anastomoses - in 0.5%, colostomy - in 2.5%, extraperitoneal colon - in 1.1%. Intestinal eventration developed in 6.4% of the wounded. Gastrointestinal fistulas occurred in 5% of the wounded. In 16.0% these were gastric fistulas, in 52.0% - small intestinal and 31.0% - colonic. Suppuration of postoperative wounds was detected in 29.4% of the wounded. More often they developed in wounds of the rectum (48.4%), colon (38.2%) and small intestine (36.5%), which is explained by the nature of the microflora entering the wound. Abdominal wall phlegmon was detected in 3.7% of the wounded. Phlegmons of the retroperitoneal space were found in 4.3% of the wounded; much more often they were diagnosed with injuries of the ureter (18.2%), rectum (16.1%) and colon (8.1%). Progressive peritonitis in the postoperative period occurred in 18.6% of the wounded, and in the surviving wounded it developed in 6.5% of cases, in the subsequently deceased - in 43.3%. Intra-abdominal abscesses were diagnosed in 9% of the wounded, their number varied from one to eight. Multiple abscesses occurred in 55.1% of cases.

A feature that created additional difficulties in diagnosing postoperative complications was the simultaneous presence of concomitant (background) complications in 4.5% of those wounded in the abdomen in Afghanistan. infectious diseases: 2.6% have infectious hepatitis, 0.8% have typhoid fever, 0.8% have malaria, 0.2% have dysentery and amoebiasis.

The high frequency of intra-abdominal complications led to the fact that in 14.7% of cases of abdominal wounds, sanitary relaparotomy was performed, which

agrees with the data of G.A. Kostyuk (1998). In survivors it was performed in 8.7% of cases (once - in 6.7%, twice - in 1.4%, and three times or more - in 0.6%), in deceased - in 27.9% of cases (once - in 19.1%, twice - in 6.4% and three times or more - in 1%).

Intensive therapy began from the moment the wounded were delivered to the stage of providing qualified or specialized care (Table 10).

Table 10.

Frequency of use of intensive care methods for those wounded in the abdomen in _ military conflict (%)__

Treatment method Afghanistan Chechnya 1994-1996 Chechnya 1999-2002

Epidural anesthesia 41.2 12.6 13.3

Intra-aortic therapy 11.8 7.8 3.5

Hemosorption 10.7 3.9 -

HBO 17.4 19.7 4.8

UV blood 2.1 13.9 6.2

Plasmapheresis, hemodialysis - 5.5 3.6

In 18..% of the wounded in Afghanistan, infusion therapy was started even before admission to the stage of qualified medical care. The volume of infusions in the wounded varied from 250 to 4000 ml (982 + 42 ml), the average values ​​for survivors were 967 ± 52 ml and the number of deaths was 1005 + 57, that is, they were almost the same. The volume of infusion therapy during surgery averaged 4059 + 83 ml (Table 11).

The volume of infusion therapy on the first day after surgery varied from 200 ml to 10 l, on average 2740+39 ml; in the following days this volume gradually decreased. During 10 days of intensive therapy, the total volume of transfused solutions and blood in the group with a complicated course of the postoperative period was 43.7 + 5.8 l, with blood and erythromass - 7.21 + 1.32 l, dry and native plasma, albumin solutions and protein - 4.28±0.64 l, artificial colloids - 6.64+0.64 l, crystalloids - 11.15+1.64 l, preparations for parenteral nutrition - 13.6+1.37 l and 2 % soda solution -0.78±0.19 l. In the group of wounded with an uncomplicated course of the postoperative period, the volume of transfused solutions was 1.8 times less, and in the group of deceased it was 1.3 times more.

After the operation, mechanical ventilation was continued in 33.5% of all those wounded in the abdomen (in 25.3% of those who survived and in 54.6% of those who died), while with the duration of mechanical ventilation up to 12 hours, 42.8% of the wounded died, from 12 to 24 hours - 78.5%, and over 24 hours - 80.7%.

All wounded were administered antibiotics, including intramuscularly - 86.5% of the wounded, intravenously - 76.5%, intraperitoneally - 65.3%, orally - 31.5%, intra-aortically - 11.8%, endolymphatic - 0.3% .

Table 11

Volume and composition of infusions administered during surgery

Infusion devices Survivors Deceased

M+t tt-tah p M+t tt-tah p

Automatic blood (reinfusion), l 0.91±0.06 0.10-6.80 152 1.81+0.09 0.10- 12.5 136

Donor blood, l 1.17±0.03 0.20 - 6.00 645 2.04+0.06 0.25 - 7.20 441

Erythrocyte mass, l 0.28+0.02 0.25 - 0.30 3 1.37±0.72 0.60 - 2.80 3

Albumin, 10% solution, l 0.17+0.01 0.05-0.75 139 0.23 ±0.01 0.05 - 0.60 110

Dry plasma, l 0.71±0.04 0.10 - 8.00 227 0.95±0.05 0.15-5.09 215

Protein, l 0.37+0.02 0.20-1.50 98 0.47±0.03 0.20 - 1.50 89

Colloidal solutions, l 0.77±0.02 0.15-4.65 800 1.23±0.04 0.10-6.00 434

Saline solutions, l 0.83+0.02 0.10-5.20 775 1.14±0.03 0.10-9.30 392

5% glucose solution, l 0.66+0.01 0.20 - 2.60 674 0.92±0.05 0.25 - 9.04 323

20% glucose solution, l 0.47+0.03 0.20 - 2.00 66 0.58+0.01 0.10-3.20 66

Amino acid solutions, l 0.51±0.03 0.20 - 1.00 18 0.53±0.05 0.40-1.10 14

Solutions of hydrolysates, l 0.56±0.08 0.40 - 0.90 8 0.42±0.02 0.40 - 0.45 3

2% sodium bicarbonate solution, l 0.28+0.01 0.06 - 0.80 189 0.42+0.02 0.10-2.09 220

Intraoperative lavage of the abdominal cavity for the purpose of its sanitation was performed in 80% of the wounded, and postoperative peritoneal perfusion continued sanitation of the abdominal cavity in 63.6%.

Long-term intra-aortic regional therapy using fractional and drip methods was used in 11.8% of the wounded (130 observations) in different terms: immediately after surgery and with the development of intra-abdominal complications. For comparative analysis effectiveness of the method, we selected a group of wounded who did not receive intra-aortic therapy (Table 12).

Table 12

Comparative characteristics of the use of intra-aortic therapy in patients wounded in the abdomen

Number of damaged abdominal organs<3 >3

Use of intra-aortic therapy Yes No Yes No

Number of observations in the group 80 105 50 68

Severity of damage (VPH-P scale), points 8.8±2.6 6.6±3.9 16.0±4.2 17.1±4.7

Colon damage, (%) 68.6 35.2 82.0 64.7

Frequency of peritonitis, (%) 56.9 35.2 62.0 52.9

Number of relaparotomies, (%) 40.7 11.4 56.0 23.5

Frequency of defects, (%) 20.9 5.7 24.0 17.6

Mortality, (%) 39.5 21.0 64.0 67.6

Intra-aortic therapy was used in more severe categories of wounded, often due to postoperative complications that had developed. It has been established that it is most beneficial to begin on days 1-3 after surgery; with less effect, the method has an effect at a later date, already due to postoperative complications that have developed. The optimal duration of intra-aortic therapy seems to be 4-5 days.

Outcomes of treatment of those wounded in the abdomen. The immediate outcomes of treatment of those wounded in the abdomen in Afghanistan and Chechnya are presented in Table 13.

7.1% of wounded soldiers and sergeants and 31.5% of officers and warrant officers returned to duty after penetrating abdominal wounds. The average treatment period was 74.1+1.7 days.

There is a significant, almost two-fold, decrease in mortality among those wounded in the stomach in Chechnya compared to the war in Afghanistan. This was the result of the work carried out based on the analysis of Afghan surgical experience. During the Great Patriotic War, the mortality rate for penetrating abdominal wounds was 70% (at the final stage of the war - 34%) (Banaitis S.I., 1949).

In 41.4% of deaths, the cause of death was acute massive blood loss. Thus, 38.2% of the deceased died on the first day, 44.3% of them on the operating table, as a rule, due to the exceptional severity of the wounds and irreversible blood loss. Progressive peritonitis, leading to multiple organ failure, caused the death of 40.2% of the wounded. Among

other causes of death - thromboembolism pulmonary artery, posthypoxic decortication, severe exhaustion after complete spinal cord interruption, anaerobic infection, fat embolism, gastrointestinal bleeding.

Table 13.

Immediate outcomes of treatment of those wounded in the abdomen (%)

Treatment outcome Afghanistan Chechnya (1994-1996) Chechnya (1999-2002)

Vacation, further fate unknown 10.4 31.2 25.9

Fit for service 6.0 12.8 19.3

Unfit for service in peacetime 34.8 19.1 12.3

Unfit for exclusion from military registration 17.4 16.7 15.1

Transferred to another medical institution. - 6.5 8.8

Civilians - 0.7 1.5

Died 31.4 13.0 16.1

Total 100.0 100.0 1000

Directions for improving the results of treatment of combat abdominal trauma. Based on the fundamental principles of modern military medical doctrine and the analysis of the organization of care for those wounded in the abdomen in the context of military conflicts of recent decades, one should be guided by the following provisions when providing care to the wounded with a combat abdominal injury.

1. It is necessary to reduce as much as possible the number of stages of medical evacuation that a person wounded in the abdomen goes through. This allows you to extremely reduce the time from the moment of injury to laparotomy. In this case, air transport (helicopters) should be widely used for priority evacuation of those wounded in the stomach from the battlefield (the place of injury) directly to the stage of qualified or specialized medical care.

2. If possible, those wounded in the abdomen should be evacuated directly to the stage of providing specialized medical care. In Afghanistan, 92.1% of those wounded in the abdomen were taken to a surgeon (mainly to the stage of qualified surgical care - in 72.7% of cases) within three hours from the moment of injury. In the North Caucasus, in conditions of a smaller evacuation shoulder, a significant part of those wounded in the stomach - 44.4% and 48% (1st and 2nd conflict, respectively) were delivered from the battlefield directly to advanced multidisciplinary military hospitals. However, average

At the same time, the evacuation time increased slightly: 81.3% of the wounded were delivered within three hours from the moment of injury. Considering that the mortality rate among those wounded in the abdomen in the North Caucasus has decreased by half, the time factor is inferior to the importance of the factor of primary intervention in more favorable conditions (specialist surgeons with better training, equipment and medical supplies operate; the level of anesthesiological and resuscitation care is also much higher) .

3. The optimal organization of providing surgical care to those wounded in the abdomen in a military conflict is a multifactorial management task, the parameters of which are the conditions of the conflict and the possible timing of evacuation of the wounded, the capabilities of medical institutions to provide surgical care (qualification of surgeons and anesthesiologists-resuscitators, medical supplies, workload of operating rooms tables and intensive care units, etc.). The best option decision making is the early evacuation of those wounded in the abdomen to advanced multidisciplinary hospitals. When organizing the distribution of evacuation flows, it is necessary to regulate them in such a way that no more than two or three wounded people in the stomach are admitted to one medical institution at a time. This will make it possible to provide timely assistance to a larger number of such wounded people. If the evacuation of those wounded in the stomach is constantly delayed, and the conditions for providing assistance in advanced medical units are acceptable, the right solution is to advance medical reinforcement groups to the medical department (omedo, omedb).

4. A difficult problem is the organization of surgical care for those wounded in the abdomen (as well as other seriously wounded) during mobile combat operations. Attempts to deploy reinforcement groups to constantly redeployed advanced medical units (MOFN) in the North Caucasus to provide specialized assistance there were unsuccessful. In such situations, it is optimal to use multi-stage surgical treatment tactics according to medical and tactical indications.

5. The organization of providing surgical care to those wounded in the abdomen and other seriously wounded places special demands on advanced multidisciplinary military hospitals (3rd level) of the echeloned stage of providing specialized medical care in terms of personnel (the presence of reinforcement groups from central hospitals), equipment (similar to peacetime trauma centers) , the possibility of rapid delivery of the wounded and their further evacuation (a helipad nearby and the presence of an airfield receiving military transport aircraft nearby). The use of air ambulance transport for the evacuation of those wounded in the stomach from a zone of military conflict to the rear of the country makes it possible to reduce the period of their temporary inability to transport, to reduce the load on medical institutions in the operational zone with seriously wounded (which is extremely important in conditions of constant mass arrival of the wounded).

6. When providing surgical care to those wounded in the abdomen, the maneuver using the forces and means of the medical service can be carried out by predicting the outcome, identifying a group of wounded people in need of

symptomatic treatment and objective assessment of the severity of damage to internal organs.

In order to simplify the sorting of such a complex and specific group of wounded as penetrating abdominal wounds, based on the use of the method of linear discriminant analysis, the problem of predicting the outcome upon admission of the wounded was solved. 1855 cases of abdominal wounds with a mortality rate of 31.4% were used as a training sample. Based on the medical histories, 178 indicators were selected, the determination of which is possible upon admission of the wounded. When selecting indicators, preference was given to those with individual values ​​of which the mortality or complication rate exceeded 50%. The solution to the situational problem was obtained in the form of an equation, which is an algebraic sum of the products of variables and coefficients. Subsequently, the equation was converted into the form of a prognostic table (Table 14).

Table 14.

Values ​​of variables for dividing abdominal wounded patients into groups with favorable and unfavorable outcomes

Indicator name Indicator value Points

Systolic blood pressure 0-50 0

Pulse rate 70 -80 17

Eventration of internal organs no 8

Combined injury of the brain or spinal cord no 17

To identify a group of survivors in 95%, the threshold value is 39, and 99% - 35. At the same time, the deceased are identified in 27.7% and 18.9%, respectively, which allows the first threshold to be recommended for use in case of mass admission of wounded to the stage of qualified surgical care , and the second - with a limited number of wounded. Based on the data in the table, in the absence of spinal cord injury and prolapse of internal organs, wounded patients with a systolic blood pressure value above 50 mm Hg are promising. and a pulse rate of up to 120 beats per minute, but in the presence of combined injuries or prolapse of internal organs, these values ​​change.

The existing scoring scale for the severity of damage in case of gunshot wounds VPH-P (OR) (Gumanenko E.K., 1992) has a significant drawback for the abdominal organs - it reflects the severity of damage to organs on average, regardless of the characteristics and nature of their damage. Using the methodology for creating this scale based on 1855 case histories, we additionally carried out calculations in points to create a refined scale of injuries to the abdominal organs (Table 15). It turned out that in a number of cases the scores turned out to be different from the VPH-P (OR) “Belly” scale.

The total severity of damage to the abdominal organs in the study group of wounded varied from 0 to 48 points and averaged 9.69 +0.17 points. A study was conducted of the dependence of the mortality rate, as well as the incidence of various postoperative complications, on the severity of damage to the abdominal organs according to the modified VPH-P (OR) “Belly” scale. A directly proportional relationship was found (p<0,05). Установлена также прямая коррелятивная связь уточненной шкалы ВПХ-П (ОР) «Живот» со шкалой Е.Мооге и соавт., 1989, 1990, 1992 (г=0,82) (р<0,005).

Therefore, during laparotomy in patients wounded in the abdomen, the severity of damage to the abdominal organs should be roughly assessed according to a refined scale for assessing the severity of injuries to internal organs. With a score above 10, the likelihood of developing postoperative complications sharply increases (from 33.3% to 66.7%), which expands the indications for the use of shortened laparotomies.

In addition, informative prognostic factors are the volume and nature of the contents of the abdominal cavity, the number of damaged organs, the presence of peritonitis, the duration of surgery, and the severity of associated injuries. The “critical organ,” that is, the organ whose injury significantly increases the incidence of complications, is the colon. The identified prognostic factors must be taken into account when choosing surgical tactics - full intervention or shortened laparotomy.

The described approaches to the objectification of surgical tactics, formulated on the basis of an analysis of the experience of the Afghan war, were tested by the author while working in groups to strengthen the stage of providing qualified surgical care in the North Caucasus.

Refined abdominal organ injury severity scale 1

Table 15.

Spleen

Pancreas

Duodenum

[for gunshot injury

Nature and location of damage

Edge, tangent, surface

Deep, more than 3 cm

Crush

Gate, destruction

Superficial

Gate, destruction

Parenchyma

Wall contusion, non-penetrating wound

Blind wound

Through wound

Wall contusion, non-penetrating wound Blind wound

Severity in points

Through wound

Small intestine

Wall contusion, subserous hematoma, non-penetrating wound. Blind wound, through wound, single. Multiple wounds in a limited area

Multiple wounds at a considerable distance from each other

Complete break, crushing of the small intestine. Separation of the small intestine from the mesentery_

Colon

Wall contusion, subserous hematoma

Non-penetrating wound

Blind wound, through wound

Complete colon break

Crush

Rectum

Intraperitoneal section

Extraperitoneal section

Bladder

Intraperitoneal section

Extraperitoneal section

(Note: Only the most severe damage to the abdominal organ is taken into account when calculating points, i.e. the more severe damage absorbs the less severe damage).

1. Gunshot wounds of the abdomen remain a pressing problem in military field surgery. According to the experience of the war in Afghanistan, with a frequency of 5.8% in the overall structure of surgical sanitary losses, abdominal wounds are characterized by a high frequency of shock (82.2%) and postoperative complications (82.7%). The frequency of abdominal wounds in the North Caucasus was 4.5% in the first and 4.9% in the second armed conflict.

2. Modern combat wounds of the abdomen are characterized by frequent simultaneous damage to several intra-abdominal organs (57.0%) and significant severity of their damage (average value of 9.7 points on the revised VPH-OR scale), the predominance of wounds combined in localization (71.2%) . The most severe combat injuries to the abdomen occurred with mine-explosive trauma (14.6 points, 89.7% of combined injuries, mortality - 40.2%).

3. The widespread use of aviation means for evacuating the wounded from the battlefield has made it possible to significantly reduce the time required for the start of surgical treatment. In Afghanistan, 92.2% of those wounded in the abdomen were admitted within the first three hours from the moment of injury (27.3% went straight to the stage of specialized care). In the North Caucasus, 81.3%) of the wounded were admitted within the first three hours, including 44.4% and 48.0% (in the 1st and 2nd conflicts, respectively) - immediately to advanced multidisciplinary military hospitals.

4. Diagnosis of combat wounds of the abdomen in Afghanistan only in 12.1% of cases was based on absolute signs of the penetrating nature of the wound. For the majority of the wounded, the diagnosis was established based on relative criteria: peritonitis (87.1%), blood loss and shock (82.2%), the presence of wounds on the abdominal wall (74.5%) and a number of other indicators. In 15% of cases of penetrating abdominal wounds, laparocentesis was used to clarify the diagnosis (diagnostic accuracy of the method is 93.5%). In the North Caucasus, in military hospitals of the 1st echelon, the use of laparoscopy began, which has significant prospects for providing specialized care for penetrating abdominal wounds.

5. With non-penetrating combat wounds of the abdomen, amounting to 24.4%, to clarify the diagnosis, it was necessary to perform a laparotomy in every tenth of this group, since it was impossible to exclude intra-abdominal injuries by other means. At the same time, injuries to the abdominal organs were discovered during laparotomy only in half of the cases (56.2%). The remaining wounded were found to have hemorrhages under the parietal peritoneum, ruptures of the visceral peritoneum, and hematomas of the mesenteries of the small intestine and colon.

6. Bullet wounds of the abdomen (50-61% in the general structure) are more severe than shrapnel wounds, both in terms of the severity of organ damage and in the frequency and severity of postoperative complications. According to the nature of the wound channel, penetrating bullet wounds of the abdomen were through in 68% of cases, blind - in 32%. Shrapnel wounds were blind in 96%, in

4% - through. With gunshot penetrating wounds of the abdomen, the small (56.4%) and large intestine (52.7%) were more often damaged; with thoracoabdominal wounds, the liver (60.7%) and spleen (33.4%) were damaged.

7. The organization of the provision of surgical care to those wounded in the abdomen should be carried out taking into account medical and tactical conditions, timing of evacuation of the wounded, the capabilities of medical units and medical institutions to provide surgical care (qualification of surgeons and anesthesiologists-resuscitators, medical supplies, loading of operating tables and intensive care units and etc.). When treating abdominal wounds during the evacuation stages, the simplest and most reliable surgical techniques should be used. Expanding the scope of surgery is associated with an increased risk of complications and a poor prognosis. It is necessary to individualize surgical tactics in accordance with the general condition of the wounded and the nature of the injury; if indicated, reduce the volume of intervention (the first phase of multi-stage surgical treatment).

8. With gunshot wounds to the abdomen, a complex set of pathophysiological processes develops in the body of the wounded, caused by the wound and acute blood loss. In the wounded with an uncomplicated course of the traumatic disease, the average volume of blood loss was 763 ml, in those with a complicated course - 1202 ml, in the deceased - 1918 ml. In case of an unfavorable course, significant circulatory disorders were noted from the first day, characterized by a more pronounced decrease in stroke and cardiac indices than in subsequently recovered wounded patients, and the development of secondary tissue hypoxia. Changes in the respiratory system were characterized by tachypnea, an increase in the coefficient of respiratory changes in stroke volume, a decrease in the arteriovenous oxygen difference and hemoglobin oxygen saturation.

9. Gunshot wounds to the abdomen were accompanied by activation of the central and peripheral parts of the hypothalamic-pituitary-adrenal system. The level of cortisol was significantly increased on the first day, the increase in the content of adrenocorticotropic hormone was longer lasting. The level of somatotropic hormone was significantly increased throughout the observation period. There was a marked decrease in the levels of thyroid hormones and testosterone.

10. The high incidence of postoperative complications in those wounded in the abdomen (82.7%) is due to the severity of modern combat injuries, as well as due to operations performed even on extremely seriously wounded patients. The most common complications were: progressive peritonitis (18.6%), gastrointestinal bleeding (14.6%), intra-abdominal abscesses (9%), acute intestinal obstruction (7.5%). Relaparotomies for various postoperative complications were performed in 14.7% of the wounded (mortality rate - 59%).

11. Developed prognostic models for the outcome of abdominal wounds and a refined scoring of the severity of injuries to internal organs are

are a constructive basis for medical triage and differentiated treatment tactics at the stages of medical evacuation.

12. Thanks to the widespread implementation of the results of studying the surgical experience of the Afghan war and improved training of surgeons, the mortality rate for penetrating abdominal wounds decreased from 31.4% (war in Afghanistan) to 13.0% in the 1st conflict and 16.1% - in the 2nd conflict in the North Caucasus.

1. The severity of the condition of those wounded in the abdomen, the presence of multiple and combined injuries in many of them, increases the importance of objective diagnostic methods at the stages of medical evacuation.

An indication for progressive expansion of the wound is the presence of dubious relative signs of a penetrating nature in a single abdominal wound. The indication for laparocentesis in modern combat trauma of the abdomen is the presence of questionable relative signs of damage to intra-abdominal organs in the following cases: multiple wounds of the abdominal wall; localization of gunshot wounds in adjacent areas (chest, pelvis); non-penetrating abdominal wounds; mine blast injury with closed abdominal injuries. At the stage of providing specialized care to the wounded in a stable condition, laparoscopy may be used instead of laparocentesis.

2. In the event of a massive influx of wounded, it is possible to isolate from them a group of those wounded in the abdomen requiring wait-and-see tactics (with a mortality rate of 95%) based on a combination of the following indicators: the presence of eventration of internal organs and associated injury to the brain or spinal cord, pulse over 120 beats/min , systolic blood pressure below 50 mm Hg. Art. They are given symptomatic therapy, and surgical treatment is carried out when hemodynamic parameters are stabilized.

3. When calculating the possibilities of providing qualified surgical care to the wounded in modern war, the duration of laparotomy should be estimated at approximately 3 hours.

4. During laparotomy, the severity of damage to each abdominal organ should be roughly assessed according to the updated scale for assessing the severity of damage to internal organs. With a score above 10, the likelihood of developing postoperative complications sharply increases, which expands the indications for the use of abbreviated laparotomies.

5. In the complex treatment of those wounded in the abdomen, especially with damage to the colon, as well as in the presence of gunshot peritonitis, early use of long-term aortic regional therapy is indicated. It is advisable to start it no later than the first three days after injury, lasting up to 4-5 days and introducing up to 50% of the infusion volume into the aorta.

6. During dynamic observation in the immediate postoperative period of patients wounded in the abdomen, the values ​​of the following indicators are of particular importance for predicting complications: levels of urea and

creatinine, myoglobin content, testosterone activity, content of medium molecular weight lipids.

7. Due to early evacuation and worsening intra-abdominal injuries in modern combat abdominal trauma, the proportion of wounded who require complex surgical interventions increases, which must be taken into account when training surgeons sent to the combat zone.

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480 rub. | 150 UAH | $7.5 ", MOUSEOFF, FGCOLOR, "#FFFFCC",BGCOLOR, "#393939");" onMouseOut="return nd();"> Dissertation - 480 RUR, delivery 10 minutes, around the clock, seven days a week and holidays

Averkin Oleg Olegovich. Diagnosis and tactics of surgical treatment of gunshot wounds of the abdomen at the stage of specialized care: dissertation... Candidate of Medical Sciences: 14.00.27 / Averkin Oleg Olegovich; [Place of defense: State educational institution of higher professional education "Moscow State Medical and Dental University"]. - Moscow, 2004. - 148 p.: ill.

Introduction

Chapter 1. Modern ideas about the diagnosis and surgical treatment of gunshot wounds of the abdomen and their complications (literature review) 9 pp.

Chapter 2. General characteristics of the material and research methods 37 pages.

Chapter 3. Diagnosis of gunshot wounds to the abdomen 52 pp.

Chapter 4. Surgical tactics for treating gunshot wounds of the abdomen 76 p.

Chapter 5. Analysis of postoperative complications of gunshot wounds. 111 pp.

Conclusion 125 pp.

References 138 pages.

Introduction to the work

Gunshot wounds to the abdomen are among the most severe

wartime and peacetime damage. They are characterized by special

severity, often accompanied by bleeding, infection of the abdominal

cavity and the development of a state of shock. Combination of organ injuries

abdominal cavity with damage to adjacent thoracic organs

cells of the retroperitoneal space and pelvis significantly aggravate the course

wound process (Alisov P.G., Eryukhin I.A., 1998, Gumanenko E.K., 1999,

Revskoy A.K., Lyufing A.A., Voinovsky E.A. 2000).

Improvement of modern firearms, changes

ballistic properties of wounding projectiles, increased frequency of local conflicts

and terrorist attacks led to an increase in the number and severity

combat abdominal injury.

The frequency of gunshot penetrating wounds of the abdomen was in

WWII period - 5.0%, during combat operations in Vietnam - 18.0%, during

war in Afghanistan - 7.1%.

In Chechnya, during the first military campaign, there were gunshot wounds

the belly accounted for 2.3%, in the second military company 4.8% (Bryusov P. G.,

Fragile V.I., 1996, Efimenko N.A., Gumanenko E.K., Samokhvalov I.M.,

Trusov A. A. 2002).

These statistics indicate the need for an accurate diagnosis of combat abdominal trauma in order to determine tactics, scope, surgical intervention, as well as predict possible complications. Radiation diagnostic methods allow these issues to be resolved quickly and reliably (Ermolov A. S., Abakumov M. M., 1996).

However, even at the stage of providing specialized medical care (SMC), polyposition radiography, fistulography, angiography, ultrasonography, spiral computed tomography are often

are used, isolated from each other, or are generally unclaimed.

The lack of a unified, clear, comprehensive approach to diagnosis at the stage of providing specialized surgical care often leads to the wrong choice of treatment tactics and complications.

According to many authors, based on their own observations, they came to the conclusion that it is necessary to improve the clinical radiological diagnostic algorithm for gunshot wounds of the abdomen. Existing methods of radiation diagnostics, as well as the emergence of new high-precision radiological methods, help improve the quality of treatment.

In this regard, there is a need to improve the algorithm for complex radiation diagnostics for combat abdominal trauma, which will optimize surgical tactics, increase the effectiveness of treatment and reduce the number of deaths and postoperative complications.

Purpose of the study.

Optimization of diagnostics and tactics of surgical treatment in conditions of local conflict at the stage of specialized medical care.

Research objectives;

To study the scope and result of surgical treatment for gunshot wounds of the abdomen in conditions of local conflict.

To develop an algorithm for radiological diagnostics for gunshot trauma to the abdomen.

Based on the results of diagnostics and treatment, develop and justify tactics for providing surgical care for gunshot injuries to the abdominal organs.

IV. To determine the optimal volume of surgical treatment depending on the damaged organ, taking into account the immediate and long-term results of treatment.

Main provisions submitted for defense:

1. Use of modern instrumental research methods
(CT, videolaparoscopy) for gunshot wounds of the abdomen, based on
of the proposed algorithm is a highly informative diagnostic
technique.

2. When conducting local combat operations, use the stage
Qualified medical care (QMC) is not advisable. Stage
specialized medical care should be as much as possible
close to the battlefield. Surgical interventions for everyone
wounded with gunshot wounds to the abdomen should be carried out at the stage
specialized assistance. This will allow for highly accurate
diagnostic studies, make an accurate diagnosis and timely
perform the optimal volume of surgical interventions.

3. The success of surgical treatment for gunshot trauma to the abdomen depends
from informative diagnosis and early surgery.

Scientific novelty of the research:

An analysis of the information content, sensitivity and specificity of the main types of radiation diagnostics was carried out. The results were studied depending on tactics and surgical interventions for modern gunshot wounds of the abdomen at various stages of evacuation in a local conflict.

The diagnostic algorithm for gunshot wounds of the abdominal organs at the stage of specialized medical care has been improved.

Based on modern radiological diagnostic methods, the optimal tactics for surgical treatment of gunshot trauma to the abdomen have been developed.

The expediency of the fastest possible evacuation of the wounded to the stage of specialized medical care has been established.

Practical value of the work:

The work studied a combat injury to the abdomen received in a local

conflict, diagnostics and surgical treatment at stages

medical evacuation.

The need to reduce the stages of surgical treatment has been demonstrated.

assistance and preoperative and postoperative diagnostics

according to an improved diagnostic algorithm.

The sequence of application of radiation methods has been clarified and expanded

diagnostics in wounded with a gunshot wound to the abdomen.

Depending on the damage to various abdominal organs

optimal surgical treatment tactics have been proposed.

Implementation of research results:

The results of the work and the main provisions of the dissertation are used in the practical activities of the surgical and diagnostic departments of the Main Clinical Hospital of the Ministry of Internal Affairs of the Russian Federation, the Main Military Clinical Hospital of the Internal Troops of the Ministry of Internal Affairs of the Russian Federation, the Main Military Clinical Hospital named after. N.N. Burdenko, City Clinical Hospital No. 50 and No. 81, as well as in the educational process of the Department of Surgical Diseases and Clinical Angiology and the Department of Radiation Diagnostics and Radiation Therapy of the State Educational Institution of Higher Professional Education "MGMSU" of the Ministry of Health of the Russian Federation.

Approbation of work:

The main results of the dissertation work were reported at the scientific conference dedicated to the 60th anniversary of the State Clinical Hospital of the Ministry of Internal Affairs of the Russian Federation (Moscow, 2002), the European Congress of Radiologists (Vienna, 2003), and the conference of surgeons of the North-Western region (Petrozavodsk, 2003). ).

Modern ideas about the diagnosis and surgical treatment of gunshot wounds of the abdomen and their complications (literature review)

In modern local wars, the frequency of gunshot wounds to the abdomen in the structure of combat losses ranges from 3.5 to 20%. Approximately half of the casualties are fatally wounded and bleed to death on the battlefield.

Currently, the ballistic properties of wounding projectiles are being improved, which leads to an increase in the severity of injuries. Gunshot wounds of the abdomen and pelvis currently remain the most severe injuries in war and peacetime. During the period of hostilities in the Republic of Afghanistan, during the armed conflict in North Ossetia, they constituted the majority. During the Chechen campaign of 1994-1996. During different periods of combat operations, gunshot wounds ranged from 6.2 to 48.1%.

The frequency of damage to individual abdominal organs with penetrating gunshot wounds varies. Liver damage is the most common (26-38%). In second place are injuries to the small intestine (26%), third - to the stomach (19%) and colon (16%). Trauma to the large intestine occurs 2-3 times less often than to the small intestine due to the peculiarities of the anatomical location, and its left half is the most susceptible to injury. With gunshot wounds to the abdomen, the stomach is damaged less frequently than the intestines. This fact is explained by the close relationship of the stomach with neighboring parenchymal and hollow organs. Damage to the intestinal mesentery accounts for 9%, spleen - 7%, kidneys and diaphragm - 5%, pancreas and duodenum - 2.5-3.5%. Injury to other organs due to penetrating wounds is even less common. High mortality (33%) of gunshot wounds of the abdomen was typical for injuries with damage to the inferior vena cava and extrahepatic bile ducts.

57% of those wounded in the stomach have damage to two or more organs. Injuries to the hollow organs of the abdomen are combined with injuries to: mesentery (26.6%), liver (17.2%), diaphragm (5.1%), spleen (4.8%), pancreas (4.5%), large vessels (4.5%), chest (2.6% ), pelvic bones (1.4%), skull (1.3%).

Abdominal wounds are combined with chest wounds in 37.1% of cases, with extremities - 35.7%, with pelvis - 20.3%. Complications in the postoperative period occur in 82.7% of the wounded.

Of all gunshot wounds, it is necessary to distinguish thoracoabdominal wounds (TAR) separately. These injuries account for 10-12%. The most important and characteristic feature of TAR is the multiplicity of injuries and in more than 1/3 of them there is injury to two, three or more organs of the thoracic and abdominal cavities, not counting the diaphragm. With this type of injury, the liver is most often damaged (31.0%). Especially with right-sided injuries, liver damage reaches 95%. Other organs of the abdominal cavity and retroperitoneal space are affected: kidneys (10.8%); spleen (18.1-22.4%), stomach (19.8%), intestines (16.6-10.7%), pancreas (6.1%)

When providing assistance to those wounded in the abdomen, the time elapsed from the moment of injury to the start of surgical treatment plays an important role. This factor is one of the decisive ones in choosing the tactics and scope of surgical treatment provided. In this regard, there is a direct relationship: the higher the evacuation speed and the higher the quality of medical care, the fewer deaths. According to literature data, during large-scale combat operations, some of the wounded were delivered to the hospital only 8 hours after being wounded. During this period, peritonitis and septic shock often developed. As a result, some surgeons regarded gunshot wounds of the abdomen, from which more than 6 hours had passed, as gunshot peritonitis.

Reducing the time from the moment of injury and delivery to the stage of qualified assistance, on the one hand, improves the results of treatment of a number of victims, on the other hand, it increases mortality. During the Second World War, 16.9% of the wounded were delivered within three hours of injury. At the initial stages of providing assistance to the wounded in Afghanistan, the victims reached the stage of specialized care after 8-12 hours. In the conditions of modern local war, with the widespread use of aviation, the time it takes to deliver the wounded to the stage of qualified and specialized care has been significantly reduced. In local conflicts in the North Caucasus in 1994-96, victims were transported to medical institutions on average after 2.5±0.4 hours. In the armies of foreign countries there are standards for the provision of medical care. First medical aid is provided within 30 minutes to 1 hour, and qualified medical assistance is provided within 4-5 hours.

General characteristics of the material and research methods

When characterizing victims with gunshot wounds of the abdominal organs, the following qualification criteria were identified: age, time of delivery to the stage of qualified medical care (QMC), volume of medical care provided at the prehospital stage, type and trajectory of the wounding projectile, number of damaged anatomical areas, severity of the condition.

All the wounded were males between 18 and 45 years old. Most often, injuries to the internal organs of the abdomen occurred in the age group from 20 to 29 years (44.5%). Gunshot wounds to the abdomen predominated among rank and file employees of the Ministry of Internal Affairs and military personnel of the Ministry of Defense.

The delivery time for the wounded to qualified medical care varied from 15 minutes to 8 hours (Table 2).

In most cases, victims (46.4%) arrived at the stage of qualified medical care 2 hours after being injured. The wounded were transported from the battlefield to the hospital emergency department, where they received qualified medical care. 32 people were evacuated by army air ambulance and 78 people by motor transport. The use of aviation contributed to reducing the time it took to deliver the wounded to the hospital to 1 hour.

The wounding projectile in most cases was a bullet. Along the trajectory, bullet wounds were distributed as follows: through wounds - 33, blind - 24, tangential - 2. Penetrating gunshot wounds of the abdomen were identified in 108 wounded, non-penetrating in two.

In the examined contingent of wounded, combined gunshot wounds predominated (68.2%). The combination of gunshot wounds to the abdomen in combination with injuries to other anatomical areas was varied (Table 5). Thus, victims with injuries to three or more anatomical areas predominated (29.3%). Among this category of wounded, the following types of injuries were more common: stomach + chest + limbs - six wounded, stomach + head + chest + limbs - four wounded, thoracoabdominal wound + limbs - eight wounded.

In case of gunshot penetrating wounds of the abdomen, the colon (52.7%), small intestine (39.1%), liver (44.7%), and spleen (33.8%) were more often injured than other organs.

The severity of the condition of the wounded was largely determined by the volume of blood loss. The volume of blood loss upon admission to the CMP stage was assessed based on changes in hemodynamic parameters (shock index), by assessing blood concentration parameters (hematocrit, hemoglobin) and by the volume of circulating blood. At the same time, a relationship was noted between the nature of the injury and blood loss. To objectively assess the severity of the condition of the wounded, we used the VPH-P(SP) scale developed at the Department of Military Field Surgery of the Military Medical Academy (E.K. Gumanenko et al. 1996). When using this scale, a point assessment is made of the 12 most significant and easily identifiable characteristics. Severity scores are calculated taking into account the likelihood of death and complications. The VPH-P(SP) scale differs from other scales (CRAMS, TRISS, ARASN P) in its ease of use, is focused on the analysis of combat trauma, clinical signs that do not require additional equipment for their determination, and has a high degree of reliability.

Using the VPH - ShchSP scale), we obtained the following data: at the stage of the emergency medical treatment, 35 wounded were in a state of moderate severity (from 14 to 21 points), 57 wounded were in a serious condition (from 21 to 31 points), in an extremely serious condition with the possibility of death in the near future 18 wounded (from 32 to 45 points).

There were no wounded in critical condition (more than 45 points) at the ILC stage; apparently, these wounded died and were not transferred to the next stage of evacuation. At the stage of specialized surgical

Diagnosis of gunshot wounds to the abdomen

The wounded were delivered to the stage of qualified medical care (QMC), in most cases, 1-2 hours after the injury (83.7%). Diagnosis of gunshot wounds to the abdomen was based on a clinical and instrumental examination of the wounded, the purpose of which was to identify, first of all, injuries that were subject to emergency surgical intervention. First of all, the nature (penetrating or non-penetrating) and severity of the injury were determined.

The presence of a wound in the abdominal wall did not always make it possible to establish the penetrating or non-penetrating nature of the damage, especially with extensive hematomas, tortuous or too long courses of the wound canal. The appearance of the wound in gunshot wounds of the abdomen did not always make it possible to determine the true severity of the wound and the nature of intra-abdominal injuries. However, based on the location of the wounds and the direction (projection) of the wound canal (for penetrating wounds), damage to a particular organ was roughly judged (Fig. 1).

In cases of severe combined abdominal injuries with injuries to the head, spine, chest, difficulties arose when the symptoms of an “acute abdomen” were absent, and injuries to other anatomical areas were accompanied by a more severe pain syndrome and were determined during external examination.

Usually, to establish a diagnosis of a penetrating abdominal wound, an examination of the localization of the wound was performed, and an assessment was made of the general and local signs of injury present in the wounded person, both of which were considered depending on the time that had passed since the injury was received.

Absolute signs of penetrating abdominal wounds were present in 14 (12.7%) wounded patients. These were wounds with wide gaping wounds of the abdominal wall, prolapse of the greater omentum and intestinal loops into the wound, or the appearance of intestinal contents and bile in the wound. With combined gunshot penetrating wounds of the abdomen, with damage to the organs of the urinary system, leakage of urine from the wound was observed.

Depending on the nature of the injury, gunshot injuries were distinguished, accompanied by clinical internal bleeding (54 wounded), or a picture of damage to a hollow organ (56 wounded).

Damage to the liver, spleen, mesenteric vessels, and kidneys was manifested by symptoms of acute blood loss: pallor of the skin and mucous membranes, a progressive decrease in blood pressure, increased heart rate and respiration, dullness of percussion sound in sloping areas of the abdomen, tension of the abdominal wall, weakening or absence of intestinal peristalsis sounds. Symptoms characteristic of a penetrating abdominal injury, accompanied by internal bleeding and shock, were the following: deterioration in the quality of the pulse, increasing hypotension, pallor of the skin and mucous membranes, lack of response to intensive infusion and transfusion therapy. The appearance of these signs was caused by pathological changes occurring in the body, which led to disruption of compensation mechanisms. In three wounded, symptoms indicating the presence of bleeding into the abdominal cavity were not pronounced.

Damage to the hollow organs was accompanied by clinical manifestations characteristic of peritonitis: abdominal pain, dry tongue, thirst, pointed facial features, rapid pulse, chest type of breathing, widespread and sharp pain determined by palpation of the abdomen, tension in the muscles of the abdominal wall, positive symptoms of peritoneal irritation , absence of peristaltic noise.

In 22 wounded with thoracoabdominal wounds, the clinical picture of injuries to the abdominal organs predominated. There were 20 wounded with signs of damage to parenchymal and hollow organs, and 14 of them had symptoms of internal bleeding. There were two wounded with predominant symptoms of damage to both cavities (thoracic and abdominal). These wounded showed signs of respiratory distress, gunshot peritonitis, massive blood loss and shock.

Based on clinical manifestations, the severity of the condition of the wounded and the prognosis for further treatment were assessed. At the CMP stage, 18 (16.3%) people were in extremely serious condition, 57 (51.8%) were in serious condition, and 35 (31.9%) were in moderate condition.

Given the low information content of physical research methods, laboratory and instrumental research methods acquired leading importance in the diagnosis of abdominal wounds. These research methods made it possible to more accurately establish a diagnosis and select appropriate treatment tactics.

For gunshot wounds of the abdomen, at the stage of providing qualified medical care, simple and informative laboratory tests were carried out, such as a general clinical analysis of blood and urine. These studies were performed from the moment of admission and over a period of 2-3 days or more often depending on the patient’s condition. In blood tests, after 6-8 hours, there was an increase in the number of leukocytes above 9.0x10/9/l with a band shift of more than 5% in 72 (65.5%) of the wounded. Which indicated the beginning of the development of a nonspecific inflammatory process caused by gunshot damage. In the analyzes of 54 (49.1%) wounded, the hemoglobin level (below 130 g/l) and the number of red blood cells (below 4.5x10/12/l.) were below normal. Changes in red blood parameters confirmed the clinical picture of ongoing or existing internal bleeding.

A general clinical urine test allowed us to determine whether there was damage to the urinary tract. With gunshot wounds of the urinary system, eight of the 11 victims had signs of myco- and gross hematuria.

Surgical tactics for treating gunshot wounds of the abdomen

Sorting of the wounded at the stages of emergency medical care and emergency medical care was carried out on the basis of: - The results of the survey, general examination and external examination - Familiarization with the accompanying medical documents - The results of diagnostic studies The priority of medical care depended on the severity, nature of the injury, and the degree of hemodynamic stability. When triaging wounded patients with gunshot wounds to the abdomen, priority for surgical treatment was given to victims with a favorable treatment prognosis.

According to the variety of clinical manifestations of gunshot wounds to the abdomen, the wounded were distributed as follows:

1. Wounded with signs of bleeding into the abdominal cavity or into the pleural cavity (with thoracoabdominal wounds) or with signs of acute massive blood loss - 54 (49.1%) people.

2. Wounded with injuries to the abdominal organs, with pronounced signs of shock, but without signs of ongoing bleeding - 3 (2.7%) people.

3. Wounded with injuries to the abdominal organs, but without signs of shock and ongoing bleeding, with positive peritoneal symptoms - 28 (25.5%) wounded.

4. Wounded with injuries to the abdominal organs, but without signs of shock and ongoing bleeding, with unexpressed symptoms of damage to the abdominal organs - 23 (20.9%) wounded.

5. Wounded without signs of penetrating wounds - 2 (1.8%) wounded.

Therapeutic and diagnostic tactics for the wounded of each group had their own characteristics, determined by the urgency of the surgical intervention and the condition of the wounded.

The wounded of the first group were sent to the operating room first. The surgical intervention was also an anti-shock measure; it was carried out against the background of intensive infusion-transfusion therapy. All 54 wounded patients with signs of bleeding underwent upper-median laparotomy in the 1st turn, the source of bleeding was eliminated, and the further extent of surgical treatment depended on the damaged organ.

The victims of the second group (three people) were sent to the anesthesiology and intensive care unit, where anti-shock measures and intensive infusion-transfusion therapy were carried out for 1.5-2 hours. When their condition improved, blood pressure stabilized and it rose above 80 mmHg, they underwent diagnostic laparoscopy, determined the severity of the injury, and then performed abdominal surgery. This category of wounded was admitted from the anesthesiology and resuscitation department to the operating room in the 1st turn.

Those wounded in the abdomen without signs of intra-abdominal bleeding and without severe symptoms of shock, but with positive peritoneal symptoms, received preoperative infusion-transfusion therapy for an hour, after which they underwent surgery. They also tried to send these wounded people to the operating room in the 1st turn.

In those wounded in the abdomen with unexpressed symptoms of damage to internal organs, laparocentesis or diagnostic laparoscopy was performed according to indications in order to clarify the nature of the injury. If damage to the abdominal organs was detected, the wounded person was sent to the operating room in the 1st or 2nd stage, depending on the workload of the operating room.

The non-penetrating nature of the wound was established in 2 wounded. These wounded, after preoperative preparation, underwent primary surgical treatment of gunshot wounds of the abdomen in the 2nd stage.

Early surgery was the main condition for a favorable outcome. At the same time, for 26 (23.6%) wounded in the stomach, due to the severity of the condition, laparotomy was a serious test and required adequate preoperative preparation. The exception was 54 (49.1%) wounded with ongoing intra-abdominal and external bleeding, who received infusion-transfusion therapy in conjunction with surgery. The duration, volume and content depended on the degree of impairment of hemostasis, the effectiveness of the therapy and the general condition of the wounded. However, the duration of preparation did not exceed 1.5 hours. If during this time homeostasis indicators did not tend to improve, then this was considered a poor prognostic sign and the risk of surgical intervention increased.

- a wide group of severe injuries, in most cases posing a threat to the patient’s life. They can be either closed or open. Open wounds most often occur as a result of knife wounds, although other causes are also possible (falling on a sharp object, gunshot wound). Closed injuries are usually caused by falls from heights, car accidents, work-related accidents, etc. The severity of damage for open and closed abdominal injuries can vary, but closed injuries are a particular problem. In this case, due to the absence of a wound and external bleeding, as well as due to the traumatic shock accompanying such injuries or the serious condition of the patient, difficulties often arise at the stage of primary diagnosis. If an abdominal injury is suspected, urgent delivery of the patient to a specialized medical facility is necessary. Treatment is usually surgical.

ICD-10

S36 S30 S31 S37

General information

Abdominal trauma is a closed or open injury to the abdominal area, either with or without violating the integrity of the internal organs. Any abdominal injury should be considered a serious injury that requires immediate examination and treatment in a hospital setting, since in such cases there is a high risk of bleeding and/or peritonitis, which pose an immediate danger to the patient’s life.

Classification of abdominal injuries

Colon rupture The symptoms resemble ruptures of the small intestine, however, tension in the abdominal wall and signs of intra-abdominal bleeding are often detected. Shock develops more often than with ruptures of the small intestine.

Liver damage occurs with abdominal trauma quite often. Both subcapsular cracks or ruptures and complete separation of individual parts of the liver are possible. In the vast majority of cases, such liver injury is accompanied by heavy internal bleeding. The patient's condition is serious, loss of consciousness is possible. With preserved consciousness, the patient complains of pain in the right hypochondrium, which can radiate to the right supraclavicular region. The skin is pale, pulse and breathing are rapid, blood pressure is reduced. Signs of traumatic shock.

Damage to the spleen– the most common injury in blunt abdominal trauma, accounting for 30% of the total number of injuries involving violation of the integrity of the abdominal organs. It can be primary (symptoms appear immediately after the injury) or secondary (symptoms appear days or even weeks later). Secondary splenic ruptures are usually observed in children.

With small ruptures, bleeding stops due to the formation of a blood clot. With major injuries, profuse internal bleeding occurs with accumulation of blood in the abdominal cavity (hemoperitoneum). The condition is serious, shock, drop in pressure, increased heart rate and breathing. The patient experiences pain in the left hypochondrium, possibly radiating to the left shoulder. The pain is relieved by lying on the left side with the legs bent and pulled towards the stomach.

Damage to the pancreas. They usually occur with severe abdominal injuries and are often combined with damage to other organs (intestines, liver, kidneys and spleen). Possible concussion of the pancreas, its bruise or rupture. The patient complains of sharp pain in the epigastric region. The condition is serious, the stomach is swollen, the muscles of the anterior abdominal wall are tense, the pulse is increased, blood pressure is reduced.

Kidney damage It is quite rare in cases of blunt abdominal trauma. This is due to the location of the organ, which lies in the retroperitoneal space and is surrounded on all sides by other organs and tissues. When a bruise or concussion occurs, pain in the lumbar region, gross hematuria (excretion of bloody urine) and fever appear. More severe kidney injuries (crushed or ruptured) usually occur with severe abdominal trauma and are combined with damage to other organs. Characterized by shock, pain, muscle tension in the lumbar region and hypochondrium on the side of the damaged kidney, drop in blood pressure, tachycardia.

Bladder rupture may be extraperitoneal or intraperitoneal. The cause is blunt trauma to the abdomen with a full bladder. An extraperitoneal rupture is characterized by a false urge to urinate, pain and swelling of the perineum. It is possible to pass a small amount of bloody urine.

Intraperitoneal rupture of the bladder is accompanied by pain in the lower abdomen and frequent false urge to urinate. Due to urine spilled into the abdominal cavity, peritonitis develops. The abdomen is soft, moderately painful on palpation, bloating and weakening of intestinal peristalsis are noted.

Diagnosis of abdominal trauma

Suspicion of abdominal injury is an indication for immediate delivery of the patient to the hospital for diagnosis and further treatment. In such a situation, it is extremely important to assess the nature of the damage as quickly as possible and, first of all, to identify bleeding, which may threaten the patient’s life.

Upon admission, in all cases, blood and urine tests are required, and the blood type and Rh factor are determined. Other research methods are selected individually, taking into account the clinical manifestations and severity of the patient’s condition.

With the advent of modern, more accurate research methods, radiography of the abdominal cavity in abdominal trauma has partially lost its diagnostic value. However, it can be used to detect ruptures of hollow organs. X-ray examination is also indicated for gunshot wounds (to determine the location of foreign bodies - bullets or shot) and if there is a suspicion of concomitant pelvic fracture or chest injury.

An accessible and informative research method is ultrasound, which allows you to diagnose intra-abdominal bleeding and detect subcapsular damage to organs that may become a source of bleeding in the future.

If appropriate equipment is available, computed tomography is used to examine a patient with abdominal trauma, which allows a detailed study of the structure and condition of the internal organs, revealing even minor injuries and minor bleeding.

If a bladder rupture is suspected, catheterization is indicated - the diagnosis is confirmed by a small amount of bloody urine released through the catheter. In doubtful cases, it is necessary to perform ascending cystography, which reveals the presence of a radiopaque solution in the peri-vesical tissue.

One of the most effective diagnostic methods for abdominal trauma is laparoscopy. An endoscope is inserted into the abdominal cavity through a small incision, through which you can directly see the internal organs, assess the degree of their confirmation and clearly determine the indications for surgery. In some cases, laparoscopy is not only a diagnostic, but also a therapeutic technique, with which you can stop bleeding and remove blood from the abdominal cavity.

Treatment of abdominal injuries

Open wounds are an indication for emergency surgery. For superficial wounds that do not penetrate the abdominal cavity, the usual primary surgical treatment is performed with washing the wound cavity, excision of non-viable and heavily contaminated tissue and suturing. For penetrating wounds, the nature of the surgical intervention depends on the presence of damage to any organs.

Bruises of the abdominal wall, as well as ruptures of muscles and fascia are treated conservatively. Bed rest, cold and physiotherapy are prescribed. For large hematomas, puncture or opening and drainage of the hematoma may be necessary.

Ruptures of parenchymal and hollow organs, as well as intra-abdominal bleeding are indications for emergency surgery. A midline laparotomy is performed under general anesthesia. Through a wide incision, the surgeon carefully examines the abdominal organs, identifies and repairs damage. In the postoperative period, in case of abdominal trauma, analgesics are prescribed and antibiotic therapy is carried out. If necessary, blood and blood substitutes are transfused during the operation and in the postoperative period.