Abdominal injuries

Low-velocity injuries to both large and small bowel can usually be managed by primary repair, or by resection and anastomosis. Most civilian penetrating injuries do not require colostomy, although high-velocity missile injuries require more extensive debridement. AK47 injuries are characterized by multiple perforations, while M-16 injuries result in large contiguous areas of devascularization mandating stoma creation ( Bel|amy alDd...Zajtchuk 199!). If extensive contamination has occurred, a second-look laparotomy after 24 to 48 h should be considered.

Most low-velocity missile injuries to the liver can be managed by drainage alone, hepatorrhaphy with ligation of vessels, or omental packing. High-velocity injuries result in more extensive damage, requiring radical debridement, possible segmentectomy or hepatectomy, or 'damage control' (packing with plans for a second-look operation). Transection of the extrahepatic biliary ducts can be managed by primary repair or biliary bypass. Postoperatively the patient should be monitored for possible abscess formation, bile leak, or cholangitis. Pancreatic injuries can be usually managed by resection and/or drainage. Complex pancreaticoduodenal injuries may require pancreaticoduodenectomy or duodenal exclusion. Octreotide to decrease pancreatic secretions may reduce the risk of pancreatic fistula formation, and has been suggested as an unproven adjunct.

Intra-abdominal vascular injuries are best managed by primary repair. Although contamination is generally a contraindication to prosthetic grafts, they have been used successfully when primary repair or the use of autogenous material is not possible. Infrarenal caval injuries can be ligated, repaired, or patched with saphenous vein. Injuries at the level of or above the renal veins require repair and carry a high mortality. Temporary vascular control may be achieved using shunts or a caval-axillary vein bypass with heparin-bonded tubing. As a final tool, circulatory arrest may be necessary.

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