Emergency War Surgery NATO Handbook: Part IV: Regional Wounds and Injuries: Chapter XXX: Reoperative Abdominal Surgery

Specific Reasons for Reoperations: Missed Intra-Abdominal Injury

United States Department of Defense

Three factors influence the failure to identify and treat significant intra-abdominal injury: the adequacy of the operative incision, the necessity for complete systematic exploration, and the failure to explore by dissection the hidden areas of the abdomen when indicated. The operative incision must be adequate in size as well as in position. A generous midline incision is best for exposure because of the facility with which it can be made and closed. Quadrant incisions are generally not as good unless the course of the wounding agent is known with absolute certainty, a situation that seldom prevails. Systematic exploration requires an adequate incision. An incision that admits only one of the surgeon's hands into the abdomen is inadequate for complete exploration. Changes in the location of certain intra-abdominal organs during changes in body position and respiration may be responsible for injuries distant from the external wounds and are an additional reason for systematic, complete examination of all organs. The most commonly overlooked injuries at celiotomy are those of the retroperitoneal structures, the fixed portions of the colon, and the viscera bordering the lesser sac. These areas can be inspected adequately only by intraoperative dissection, which should be done when there is any likelihood that injury to these organs has occurred.

Intra-abdominal injury can be overlooked when a missile penetrates the abdomen through an entrance site other than the anterior abdominal wall. When the patient, who has undergone operative treatment of thigh, buttock, chest, or flank wounds, develops signs of peritonitis, an intraperitoneal wound must be suspected. Abdominal roentgenography may be of help by identifying free air or a previously unrecognized intra-abdominal metallic fragment. This examination should be done in all such cases to assure early detection of these hidden wounds.

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Operational Medicine 2001

Health Care in Military Settings

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