Gunshot Wounds of an Abdomen- a Single-Institution Experience

A 16-year-old patient was transported by ambulance because of an abdominal injury caused by a firearm, shot from a gun. The patient was conscious, oriented, afebrile, tachycardic, and hypotensive with a tension of 80/40 mmHg. The skin was extremely pale and discolored. Physical examination recorded gunshot wounds, the entry wound was located in the right para umbilical and the exit wound was in the left sacral region.

The patient was clinical, laboratory, and ultrasound examined and immediately transferred to the intensive care unit. Laboratory values on admission were: red blood cells 2.1, leucocytes 15.6, Hemoglobin 54, hematocrit 19, and platelets 89. Ultrasound findings (FAST) revealed the presence of free fluid in the abdomen without lesions of solid organs. After emergency resuscitation and blood transfusion, urgent surgical intervention was done. The patient's condition was very poor and additional diagnostic procedures will contribute to faster deterioration of the patient.

During the operation, multiple injuries of the mesocolon transversum (Figure 1a,b) and mesentery of the small intestine, laceration of the D3 duodenum as well as retroperitoneal hematoma at the level of the femoral fossa on the right were recorded. After the opening of the retroperitoneum, injuries of the v.cava inferior in the form of a 2cm long laceration and a 3,5 cm long laceration of the right v.iliaca communis were recorded (Figure 1c). The primary suture of injured blood vessels was done. The duodenum was then mobilized by Koher's maneuver to find the laceration of the duodenum in the D3 area below the ampulla of Water (Figure 1d), and the primary suture of the duodenum was done (Figure 1e). Injuries of the mesocolon transversum and mesentery of the small intestine are treated with single sutures. Two drains were placed, the first one in the right paracolic, and the second one in the recto-vesical space (Figure 1f). The patient spent 5 days in the intensive care unit, treated with triple antibiotic therapy, analgesics, and proton pump inhibitors. On the sixth and seventh postoperative days, the drains were removed. The passage of the gastrointestinal system was established on the third postoperative day, and the 10th day after the intervention he was discharged from the hospital. During two controls, color Doppler examinations, blood vessels were normal. A month after the surgical intervention, a gastroscopy was performed, and the examination was normal.

A 12-year-old patient was brought to the hospital with a penetrating abdominal injury inflicted by an automatic rifle. The patient was confused, with no verbal communication, extremely pale, and drenched in a cold sweat. Physical examination recorded an entry wound in the epigastric area left of the xiphoid, and an exit wound in the left paravertebral area (Figure 2a).

The patient was transferred to the intensive care unit, blood was taken for laboratory analysis and blood tests. The patient was extremely hypotensive with a blood pressure of 70/30 mm Hg and a surgeon decided to do an urgent surgical intervention only after transfusion of 2 units of blood. After opening the abdomen, the following injuries were recorded: injury of the anterior and posterior walls of the stomach in the length of 6cm on the front wall and about 15cm on the back wall, a complete transection of the pancreas and conquassation of two-thirds of the pancreas in the body and tail area, conquassation of the spleen with transsection of the splenic vein and artery (Figure 2b), lesion of the left kidney with transection of the renal vein and artery (Figure 2c), transsection of the left ureter, lesion of the left lobe of the liver and complete transection of the left m.quadratus lumborum. About 1,800 ml of blood was evacuated from the abdominal cavity. Due to complete devascularisation, a splenectomy was performed, followed by a nephrectomy with ureterectomy, partial pancrectomy of the distal part of the pancreas, suture of the head of the pancreas, and stomach suture (Fig,2d). Drains were placed in retroperitoneal, left paracolic, and rectovesical space. During the surgical intervention, the patient received six units of blood. After the surgery, he was transferred to the intensive care unit. His condition was stable until the nineteenth postoperative day when he deteriorated rapidly due to a massive abdominal hemorrhage due hemorrhagic pancreatitis, located at the site of the confluence of the left renal artery in the aorta. During the second operation, three drains were placed in the abdominal cavity, as well as intestinal adhesiolysis. Twenty-four days after the surgery, intestinal contents appeared on the drain and another operation followed. The anastomotic leak was on the anterior wall of the stomach. Lavage of the abdominal cavity was done, with the gastrostomy and gastroplasty by Mikulić and with placing an open abdomen system ABTHERA. Twenty-five days after the last intervention, intestinal contents were again in the drain and reoperation was done. The colonic gangrene in the area of the hepatic flexure was found, with subsequent right hemicolectomy, Brooke ileostomy, and the open ABTHERA system was again installed. Twenty-eighth postoperative day after this intervention, the bile content was verified on the drains, which indicated the presence of an intestinal fistula. A new surgical procedure was performed, the ABTHERA system was removed, a protective Stamm-Kaden gastrostomy was performed, drains were replaced, the abdomen was closed with tension, and in the upper part of the wound Vacuum-assisted wound closure system (VAC) was placed. Finally, after 2 weeks VAC was extracted, and a contrast passage of the gastroduodenal was performed, as well as fiberoptic pan endoscopy. The patient was discharged from the hospital for home treatment after 128 days. Six months after discharge, the patient was hospitalized again for ileus, due to small intestinal adhesions. Surgery was performed, with the partial resection of the ileum and T-T anastomosis due to ileum injury during adhesiolysis. The postoperative days went smoothly. He has been operated 6 times. Today, he comes regularly for check-ups, his general condition is good and his local findings are normal.