Exploratory Laparotomy in a Hemodynamically Stable Patient for an Abdominal Gunshot Wound

Abstract

Gunshot wounds to the abdomen are one of the most classic trauma cases a surgeon will come across in their career. The high velocity of a bullet can cause massive internal and external trauma to the abdomen. Exploration of the small bowel using laparotomy is often indicated after a penetrating traumatic injury or when peritoneal signs are present. This video article shows the most common techniques for performing an exploratory laparotomy. In this case, the abdomen was explored and was revealed to show a through-and-through gunshot wound to the jejunum, as well as a partial-thickness tear of the proximal cecum; the abdomen was explored for any smaller bleeds or leaks, and the abdomen was closed.

Keywords

Trauma, penetrating, peritonitis, emergency, open.

Case Overview

Background

An exploratory laparotomy is a significant procedure that can be used for a variety of presentations and problems such as generalized peritonitis of unknown origin, perforated ulcers, or penetrating trauma. It is an ideal way to visualize the entire contents of the abdominal cavity to assess for a variety of gastrointestinal and vascular injuries. In this case, exploration of the abdominal cavity showed a through-and-through penetrating injury to the jejunum and partial tear of the cecum. This technique allows for the identification of any unknown intra-abdominal injuries, while also providing the surgeon access to repair them.

Focused History of the Patient

The history associated with penetrating abdominal trauma consists of evidence of foreign body penetration into the abdomen such as a bullet or knife wound. The stability of the patient is one of the most important aspects to consider when any trauma presents; the patient’s airway, breathing, and circulation must all be prioritized. In this case, the patient was found to be in stable condition with no alarming vital signs. Pain may be localized to the area surrounding the site of injury or may present as diffuse abdominal tenderness. Pain is usually described as sudden onset and agonizing without the help of analgesics. One of the key diagnostic features to examine for are signs of peritonitis. Penetrating trauma can injure or rupture internal organs leading to inflammation of the peritoneal cavity. 

Physical Exam

Most patients with penetrating abdominal injuries will usually present with an open wound usually accompanied by active bleeding and erythema. The amount of damage is often dependent on the source of trauma and amount of energy transferred from the penetrating object, and diffuse abdominal tenderness. The abdomen should be examined for signs of peritonitis. Peritonitis can present in a variety of ways including diffuse abdominal tenderness with voluntary or involuntary guarding, rebound tenderness, and rigidity. It has been established that rigidity is highly specific for the diagnosis of peritonitis.¹

Options for Treatment

The mainstay of treatment for penetrating abdominal trauma with signs of peritonitis is an open laparotomy.² Patients with abdominal gunshot wounds with signs of peritonitis should be emergently taken to the operating room for an open laparotomy, which allows maximum visibility and accessibility to the contents of the abdominal cavity in order to look for potential sources of bleeding or leakage of bowel contents. If the patient is stable and there are no signs of peritonitis, it may open the option to perform imaging that would reveal damage or bleeding, which would allow the surgeon to perform a more minimally invasive laparoscopic examination and repair of the abdominal contents; however, studies suggest that open laparotomy should still be used as the mainstay of treatment.³

Rationale for Treatment

The ultimate goal of this procedure is to methodically examine the contents of the abdominal cavity for diagnostic and therapeutic purposes in a penetrating traumatic injury. Injured vascular structures can cause massive internal bleeding that can lead to exsanguination and eventually death. Damage to gastrointestinal structures can cause peritonitis if not treated, can lead to further damage to the bowel, sepsis, and eventually death. It is also important to fix the structures that were damaged in order to allow the best return to normal function.

Discussion

Here we present the case of a man that presented to the ED with a gunshot wound to the abdomen and signs of peritonitis. He was emergently taken to the OR where an exploratory laparotomy was performed. A midline abdominal incision was performed, and access to the abdominal cavity was achieved. The entire contents of the abdomen were explored and examined for signs of traumatic injury. Upon exploration of the abdominal contents, jejunal perforation was observed. That portion of the small bowel was removed, and an antiperistaltic stapled side-to-side functional end-to-end anastomosis was performed. After that, a partial cecectomy was done to repair a partial tear of the cecum that had been observed. Before closing, a final exploration of the abdominal contents was performed for reassurance. Upon successful completion of the operation, the patient was given an NG tube, extubated in the OR, released to the PACU, and eventually to the floor for observation. Due to the emergent nature of the case, a postoperative x-ray was performed to make sure instruments or lap pads were not left in the abdomen.

This case is noteworthy due to the classic appearance of penetrating abdominal trauma and peritonitis indicating an exploratory laparotomy. Several studies have been conducted on the management of gunshot wounds to the abdomen. In 1980, a study found that out of 245 subjects who had penetrating gunshot wounds to the abdomen and lower chest, 156 had signs of peritonitis, of which 96% were found to have visceral damage on laparotomy.⁴ Of those with intra-abdominal injury, 17% didn’t have any impressive clinical findings. This study concluded by recommending exploratory laparotomy for gunshot wounds to the abdomen with peritoneal violation.⁴

There is currently some debate as to the role an exploratory laparotomy has in the medical management of abdominal trauma. The principle of selective nonoperative management (SNOM) has become indicated for abdominal trauma without signs of peritonitis.⁵ When determining a treatment plan for penetrating abdominal trauma, it is necessary to consider the source of the trauma. Abdominal wounds associated with stab injuries are more appropriately treated with SNOM, while gunshot wounds possess a greater amount of kinetic energy and can therefore cause more damage and should be treated with an open laparotomy.⁶ According to a review of 1,856 patients with abdominal gunshot wounds, it is safe to use SNOM or diagnostic laparoscopy at a Level I trauma center that has a greater level of expertise and access to resources than other facilities.⁷ Gunshot wounds to the abdomen are of particular significance due to their association with higher rates of complications and increased number of days spent in intensive care units when compared with gunshot wounds in other locations.⁸

Postoperative care for exploratory laparotomies due to trauma range depending on the amount of damage that was observed. Perioperative antibiotics for unclean surgical sites often include the use of a first- or second-generation cephalosporin. Many patients also experience substantial pain and require analgesics, but these should be titrated to the lowest effective dose due to their association with constipation. Nausea and vomiting may also need to be treated prophylactically due to the use of general anesthesia. There is always a risk of complications. Common complications from exploratory laparotomies include bowel ischemia and necrosis, perforation, incarceration, and anastomotic leak, all of which are associated with high 30-day mortality.⁹ Other common complications that have lesser 30-day mortality include ileus and obstruction, abscess, herniation, and phlegmon.⁹

Equipment

The following is a partial list of equipment that was used during this procedure:

• Allis forceps
• Electrocautery
• Balfour retractor
• Large Richardson retractor
• Suture scissors
• LigaSure
• GIA Surgical stapler
• Babcock forceps
• Mayo scissors
• Malleable retractor
• DeBakey forceps

Disclosures

Nothing to disclose.

Statement of Consent

The patient referred to in this video article has given their informed consent to be filmed and is aware that information and images will be published online.