The answer to this question is often obtained in the operating room, although in the modern combat support hospital, you will usually have access to a CT scanner and may know the answer ahead of time. The bigger issue to address remains: does this patient need to go to the operating room? A combat casualty that presents with a penetrating mechanism and a wound that violates the peritoneal cavity requires abdominal exploration, period. Hemodynamic stability may buy you time to better evaluate the situation with adjunctive studies. Yet, the bottom line for the unstable patient with a suspicion of intra-abdominal trauma based on injury pattern and mechanism remains that if the pattern and mechanism point to the abdomen, then a laparotomy is in order. You will figure out what is damaged in the operating room, and preoperative imaging will add little benefit. In fact, “stable” is often really a misnomer for the combat casualty with a penetrating wound to the abdomen. They may appear clinically well for the moment, but that can change quickly. Unfortunately, you will likely encounter a situation where a patient with a penetrating abdominal wound has to wait in line for the operating room either from a mass casualty event or expended resources. Don’t forget this patient – assign a nurse or medic to reevaluate him frequently in your absence, as they may push themselves to the “front of the line.” In fact, repeat triage is standard and a mandatory part of mass casualty management.

Trust your physical exam and clinical judgment ; you will rarely regret it. If the patient is awake and alert, do a careful physical exam of the abdomen. In these mostly young and healthy patients, the abdominal exam is highly reliable for identifying peritonitis. If you push on their belly in two separate places and they have a clear severe pain reaction, that is peritonitis. No CT scan is needed to “confirm” your exam or to look for other abdominal injuries. Your careful exploration should be better than any CT scan. If they are not examinable, then you have to rely on injury patterns and possible imaging studies but should have a low threshold for exploration.

In contrast, if one is located in a remote area, has a hemodynamically normal patient with an isolated penetrating wound to their abdomen, and is able to reliably and expeditiously (i.e., make it to a higher level of care within 60 minutes) transfer a patient, then it is reasonable to delay an operation until they reach the more secure and better resourced combat support hospital. This would allow the forward surgical team to remain equipped to treat a truly unstable patient. Communication with the gaining institution is paramount with all transfers, so they know exactly what type of injured patient they are receiving.

Make a big enough midline incision so that you may adequately explore all quadrants of the peritoneal cavity. You will likely encounter lots of blood and contamination and perhaps a large retroperitoneal hematoma, but don’t let this affect you. Have a systematic approach to packing the abdomen and exploring it one area at a time. Control hemorrhage first and then spend time controlling contamination. Many of these casualties will require a “damage control” approach to treatment. We found it useful to have an egg timer in the room that was set for 45 min. When that timer went off, we knew it was time to start “cleaning up” and ready the patient for transport to the ICU. You want to be fast, but not furious. Calm and focused gets you out of the OR faster and safer than panicked and hurried. Don’t get in such a hurry that you miss a major injury that will lead to the patient’s demise. A small missed injury may be forgivable when you go back later and find it, but a major missed injury is a mistake that may not give you another chance.

We employ two useful techniques to quickly control contamination from bowel injuries. In the umbilical tape approach , mesenteric windows are created on the proximal and distal sides of the injury, which the tape is then passed through and tied (Fig. 7.1). This works well when you have focal areas of injury, but is not as effective when you have a long segment of injured small bowel or colon that is laden with succus or stool. The second approach requires the use of gastrointestinal anastomotic stapling devices. In this approach we rapidly create mesenteric windows on both sides of the injury and then fire the staplers through the windows effectively closing and dividing the bowel at these points. We then fire additional staplers across the mesentery of the injured bowel, staying close to the bowel wall and using vascular loads. You can resect injured segments of small bowel in less than 60 seconds using this technique. Alternatively, you can take the mesentery with the serial creation of windows and placement of clamps. To make this maneuver faster, take large bites of the mesentery with each clamp (3–4 cm) for en masse ligation and only clamp the proximal side. Use your hand to control bleeding from the distal side until the specimen is excised.

Colonic resection in mobile areas can be accomplished almost as quickly with the same techniques. Injuries to the colon at points of retroperitoneal fixation such as the ascending and descending colon simply require a moderate amount of mobilization to achieve the same end. You can also employ the use of atraumatic bowel clamps to assist when there are multiple areas of contamination to deal with or to close small anterior holes. In the “damage control” setting, this is all that is initially required. A quick washout and temporary abdominal closure is all that remains between the patient and critical care in the ICU. Do not get bogged down by small bleeders in this situation. Just focus on getting your cold, coagulopathic, and acidotic casualty to the ICU where these problems, also known as the lethal triad, can more effectively be addressed.

In addition to operating quickly and efficiently, one must again consider their location when deciding how best to do damage control. Operating in the far forward setting mandates only doing damage control surgery as the subsequent operation will be at a higher echelon of care typically only 1–2 h of transport away. There, a second look if only to wash out an opened abdomen is expected; but certainly a second look to look for occult injuries, to mature ostomies, or to put the bowel back in continuity is the norm. Transferring out of the combat theater often takes much longer, and as such, the patients should be hemodynamically normal and their injuries much more stabilized to tolerate the trip that may be several hours away.

You must expose the entire stomach and use both inspection and palpation to evaluate for injuries. Your high-risk areas for a missed injury are high at the gastroesophageal junction or along the lesser curve. If there is a hole in the stomach, then always find the other hole or explore it well enough to convince yourself 100% that there isn’t another one. There is a classic triad of injuries here that include the stomach, the spleen, and the diaphragm so one should look for these associated injuries. Retract the left lobe of the liver anteriorly and open the avascular gastrohepatic ligament to examine the lesser curve. The lesser sac should always be opened and inspected, which allows evaluation of both the pancreas and the posterior stomach. Divide several inches of the gastrocolic ligament along the greater curve at the midpoint to enter the lesser sac. Retract the greater curve anteriorly and to the right to examine the posterior stomach, and insert your entire hand into the lesser sac to palpate for injuries. Squeeze the stomach or insufflate with air via the nasogastric tube to look for extravasation of fluid or food particles.

Most nondestructive injuries to the body of the stomach can be managed through simple mobilization of the organ and closure of the hole with a single firing of a TA or GIA stapler. Injuries involving the lesser and greater curvatures of the stomach may be addressed by a wedge resection of the injury using two firings of a gastrointestinal anastomotic stapling device. The stomach possesses a tremendous amount of redundancy, which is to the surgeon’s advantage. Destructive injuries to the greater curvature may be managed using a sleeve gastrectomy technique as long as a reasonable lumen is preserved (Fig. 7.2). The patient may lose some weight in the long run, but they will be alive.

Severe injuries to the antrum may require antrectomy and reconstruction. Our advice here is to keep the procedure simple and complete. Beware of leaving retained antrum on the duodenal side of the resection if you plan on using a Billroth II or Roux-en-Y reconstructions. Take only what you need to take since the indication for resection is trauma. Our preferred reconstruction is gastrojejunostomy with Braun enteroenterostomy because of its simplicity. Utilize GIA staplers as much as you can, but sutured anastomoses can be quite useful in the setting of edematous bowel and where staplers are not available. Injuries to the gastroesophageal junction can be quite complex and difficult to treat. Utilize gastroesophageal anastomosis only when absolutely necessary as this anastomosis can be difficult to construct and comes with a high risk of leak. The circular stapling device can simplify this problem, but nondestructive injuries are probably best managed with primary closure (over a bougie dilator); nasogastric decompression; buttressing of the esophageal repair with by the surrounding muscle, fascia, or pericardium; and closed suction drainage. Assess any potential damage to the vagus nerves that may require you to perform a pyloroplasty , although this is rarely needed. Don’t waste time on steps like this in the damage control setting. You do not need to leave drains at the initial damage control procedure if you have adequate closure of the defect and are planning a vacuum type temporary closure and second look operation. A closed suction drain should be left adjacent to your repair prior to fascial closure or at your last exploration prior to placing the patient in the evacuation chain. Eventually this patient may need feeding tube placement also.

For these types of combat injuries, you must identify the obvious injuries and then diligently search for the less obvious ones. Pinhole-sized enterotomies from fragment wounds may look like a speck on the serosal surface or a tiny hematoma that you would otherwise leave alone. The other common area for missed injury is a perforation into the mesenteric border, which may look like a small mesenteric hematoma or discoloration at the bowel margin. Firmly grasp and elevate the bowel as you run it. Milk each segment manually to observe for spillage or leakage of air. Even though you may be in damage control mode, take the 5 min to slowly and carefully run the entire small bowel . Explore any area of question on the serosal surface or at the mesenteric border. If you are still not sure if there is an injury, you can insufflate air or saline via a 20-gauge needle into that segment of bowel while occluding proximally and distally. Oversew any areas of concern as you proceed along the bowel. When you identify an injury or serosal tear that requires repair, do not proceed with a plan to come back and fix it after running the rest of the bowel. Either repair it right away, or mark it with a suture to repair later. In the heat of battle, there are many distractions that could result in you forgetting about the injury, with disastrous consequences.