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INTRODUCTION

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Injuries to the stomach and small bowel are very common in penetrating abdominal trauma. The incidence of gastrointestinal injury following gunshot wounds (GSW) that penetrate the peritoneal cavity is in excess of 80%. Thus, exploratory laparotomy is reasonable on virtually all gunshot wounds that penetrate the peritoneal cavity. The incidence of hollow viscus injury (HVI) secondary to stab wounds was traditionally about 30%, but now as our population has become more obese, is closer to 20%. Thus, a selective approach to operative exploration has been advocated following stab wounds.1

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Blunt injuries to the stomach and small bowel on the other hand are much less common than penetrating injuries, but collectively compromise the third most common type of blunt abdominal HVI. The increasing use of computed tomography (CT) for diagnostic evaluation of the patient with blunt abdominal trauma and selective nonoperative management of solid organ injuries have contributed to some of the difficulties and controversies in the management of HVIs following blunt trauma.

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Over the last several decades, the evaluation and management of the trauma patient has been evolving constantly. With the evolution of better CT scans and ultrasound, the complications and the frequency of nontherapeutic laparotomy have been reduced.2

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When necessary, the operative repair of stomach and small bowel injuries is relatively straightforward. The key to the successful management of stomach and small bowel injuries is prompt recognition and treatment, thus decreasing the likelihood of abdominal septic complications such as inflamed bowel that does not heal and results in anastomotic breakdown, fistulae, intra-abdominal abscesses, and subsequent late death.

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HISTORICAL PERSPECTIVE

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Intestinal injuries were reported early in the medical literature (see Chapter 1) and small bowel perforation from blunt trauma was first reported by Aristotle.3 Hippocrates was the first to report intestinal perforation from penetrating abdominal trauma. In 1275, Guillaume de Salicet described the successful suture repair of a tangential intestinal wound. Reports of attempted surgical repair of gastric and intestinal wounds appeared in the literature with heightened interest and controversy during the American Civil War, the Spanish-American War, the Russo-Japanese War, and other military conflicts. However, the dismal results of surgical intervention lead to abandonment of laparotomy even with obvious intestinal injury during these military campaigns.4

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By the late 19th century, improved surgical techniques led to renewed interest in laparotomy and repair of penetrating abdominal injuries. Theodore Kocher was the first surgeon to report successful repair of a gunshot wound of the stomach. In 1881, President Garfield was shot in the lumbar spine and the bullet was lodged near his liver. At that time the common practice was to retrieve the bullet with an unsterile finger. President Garfield eventually died 80 days later. However, 2 days after President Garfield was shot, a miner was shot in the abdomen in Tombstone Arizona. This patient was saved by Dr George ...

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