Abdominal gunshot wounds require laparotomy and few if any diagnostic tests are indicated. Anteroposterior and lateral films of the abdomen will enable the surgeon to reconstruct the path of the missile and anticipate the internal injuries. ( CDFjgure.,9) A single-shot intravenous pyelogram is advocated when renal injury is suspected in order to verify the presence of two kidneys, should nephrectomy be required. Shotgun wounds are difficult to evaluate. Distribution of the pellets may correlate with the depth of penetration since wide scatter implies a greater distance between gun and victim with lower-speed lower-energy pellets. Injuries covering 25 cm or less demand exploration, whereas scatter over more than 25 cm suggests that the patient can be evaluated with serial physical examinations ( G]eZ§L®L§./,. 1993). Superficial bullet tracts that do not violate the peritoneum may have significant tenderness upon palpation. Lateral radiographs, tractotomy, and diagnostic peritoneal lavage are useful adjuncts in assessing these questionable cases.
CD Figure 9. This patient suffered a close-range shotgun injury. He presented with an expanding hematoma in the left groin and a palpable thrill. The small area of scatter is associated with internal injury. A lateral film (a) may demonstrate the depth of penetration. The abdomen, perineum, and femoral vessels must be evaluated. Since this patient has hard signs of vascular injury, operative exploration of the groin, laparotomy, and rigid sigmoidoscopy are indicated. The preoperative chest radiograph (b) reveals pellets in the right ventricle and the pulmonary vasculature. These have embolized from the wound and indicate femoral vein injury. Pellets may also travel through a patent foramen ovale into the arterial tree or distally via an arterial injury.
Flank and back injuries are difficult to assess. Unstable patients receive a laparotomy. In stable patients, abdominal radiographs including a lateral view aid in assessing the tract of the projectile. Formal wound exploration, followed by diagnostic peritoneal lavage if the fascia is violated, determines the need for operation. A CT scan with triple contrast (intravenous, oral, and rectal) can evaluate the retroperitoneum, but hollow viscus injuries may still be missed. Suprapubic penetration may lead to pelvic visceral and extraperitoneal vascular injury without hypotension or peritoneal signs. With pelvic or perineal injury, rigid sigmoidoscopy may reveal rectal injuries below the peritoneal reflection, leading to repair and/or diversion.
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