Minimally Invasive Surgery

in Trauma and Gunshot Wounds

A. Rakhlin, M.D.
Department of Surgery
 Two uses: slim and none
 Blunt trauma
 Hemodynamically stable patients
 stable for CT’s as well as interventional radiologic procedures
 Hemodynamically unstable patients
 Need laparotomy, not laparoscopy
 Penetrating trauma
 Knife wounds
 Limited application for diagnostic laparoscopy – judge penetration
into abdominal cavity (esp in chest knife wounds), run the bowel
 Bullets
 Usually damage is too widespread for laparoscopy
Gunshots and Injuries
 GUNSHOT INJURIES
WOUNDING VARIABLES
 BULLET SIZE
 BULLET VELOCITY

 BULLET SHAPE

 BULLET SPIN

 BULLET TRAVEL DISTANCE

 TYPE OF TISSUE STRUCK

 GUNSHOT INJURIES

KE = ½ MV2

High Velocity
>2000 fps
Low Velocity
<1000 fps

Bullet mass is also important

YAW (non-rifled)

TUMBLE

DEFORMATION

FRAGMENTATION
 GUNSHOT INJURIES
 TISSUE CHARACTERISTIC

1. LESS DAMAGE WITH:

ELASTICITY AND DENSITY
(EXAMPLE: LUNGS)

2. MORE DAMAGE WITH:

ELASTICITY AND DENSITY
(EXAMPLE: LIVER; SPLEEN;
BRAIN)
 GUNSHOT INJURIES: 3 phases
 Sonic Pressure Wave
 Preceeds the bullet
 Very short duration
 Usually no significant damage
 Permanent Cavity
 Tissue directly destroyed by the bullet
 Possible to have small entry wound and large permanent
cavity
 Temporary Cavity
 Transient expansion of tisssues as bullet releases its
kinetic energy
 Can be up to 30 times the size of bullet
 GUNSHOT INJURIES
 Additional considerations
 As the bullet enters, it creates negative pressure
 Pulls contaminated residue from outside
 Especially wadding in shotgun injuries

 Missile Embolization – if no exit wound found – x-

ray survey
 Lead Poisoning
 Esp if bullet

is in synovial
fluid
Extremity gunshot injuries: bone
 From direct cavity or permanent cavity
 Damage varies considerably depending on velocity
and bone type
 Extremity gunshot injuries:
vascular
 Varies from intimal disruption to complete
laceration
 Vessel may temporarily contract
 Partial laceration will not contract – extensive
blood loss
Location of wound Incidence (%)
Lateral thigh 1
Medial or posterior thigh 7–9
Popliteal fossa 9–10
Calf or leg 18–22
Upper arm or shoulder 9–10
Medial or posterior upper arm 6–8
Forearm or antecubital fossa 17–22
 Extremity gunshot wound
injuries: Vascular
 Investigations
 Physical exam – pulses, blood pressure differential.
 10% of patients with normal exam have occult vascular
injury
 High index of suspicion – angiogram
 May reveal intimal flaps, other injuries
 Low threshold for fasciotomies
 Time to treatment
 6 hrs of ischemic time
 Temporary cavity – extensive muscle damage
 Extremity gunshot wounds:
neurological damage
 70-90% recovery within 3 months if:
 Neuropraxia – stretching, no actual disruption of the nerve
 Axonotmesis – disruption of axon and myelin sheaths, but
with preservation of connective tissue
 Generally 1 mm/day
 Neurotmesis – complete severance of nerve
 25% of patients recover after nerve repair
 Late sequalae – reflex sympathetic dystrophy
 Pain, swelling, vasomotor dysfunction in extremity
 Treatment varies from sympathetic blocks to acupuncture
 Rates of cure variable
 Gunshot Wounds to Abdomen
 Maryland medical journal - 1884
 “Professor Kocher of Berne declares that,
considering the impossibility of recovery in
cases of gun-shot wounds to stomach when
active measures are not taken, it is the duty
of the surgeon to perform laparotomy
whenever injury of this kind is suspected.”
 Still true in 2009
 Gunshot wound: abdomen
 Unless a rare case – do not pass “Go”, do not
collect $200 – proceed directly to OR
 Rare cases – BB guns, tangential wounds to
flank
 CT scan, check for free air, free fluid, consider
contrast per rectum to r/o colon injury
 Abdomen starts at nipples
 Hence earlier remark on utility of laparoscopy in
chest injury
 30% of GSW to hips are associated with
intraabd injury
 Gunshot wounds: In the OR
 Complete survey, prep from neck to
thighs, left arm out
 Pack four quadrants
 “Damage control laparotomy” in unstable
patient
 Close all visceral injuries
 Pack all solid organ injuries
 May perform quick splenectomy
 Pack retroperitoneum
 Get out for ICU resuscitation
 Deadly triad
 Hypothermia, coagulopathy,
acidosis
Abdomen won’t close?
 Abdominal compartment syndrome
 Extensive damage and resuscitation
 Open abdominal dressing
 VAC, Bogota bag, vicryl mesh

VAC
Abdomen won’t close?

Bogota bag
Abdomen won’t close?

Zipper closure
 Individual organ treatment
 Intestines
 Stomach, small bowel – freshen up edges, primary
repair, resection if multiple wounds in close
proximity to each other
 Large bowel – conservative – diversion, ostomy

 Spleen – splenectomy, splenorrhaphy if fesible

 Liver – dreaded injury. Treatment depends on
intraop findings – deep sutures, hepatectomy,
arterial devascularization, veno-venous bypass
 Individual organ treatment
 Retroperitoneum
 Upper
retroperitoneum
 Great vessels (that’s
why left arm was
abducted),
 Duodenum, Pancreas
 Books have been
written on
duodenal and
pancreatic injuries.
Duodenal Exclusion
Questions?