Injuries to the stomach and small bowel are common in penetrating abdominal trauma.
The incidence of gastrointestinal injury following gunshot wounds that penetrate the peritoneal cavity is over 80%. Thus, exploratory laparotomy is warranted on virtually all gunshot wounds that penetrate the peritoneal cavity. The incidence of hollow viscus injury (HVI) secondary to stab wounds that have penetrated the peritoneal cavity is much less, which in most series is about 30%. Thus, a selective approach to operative exploration has been advocated following stab wounds.
Blunt injuries to the stomach and small bowel are much less common than penetrating injury, but collectively compromise the third most common type of blunt abdominal injury. 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. In contradistinction to some of the diagnostic difficulties with stomach and small bowel injuries, 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 and subsequent late death.
Intestinal injuries were reported early in the medical literature (see Chapter 1). Small bowel perforation from blunt trauma was first recognized by Aristotle.1 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.2
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. Although still controversial, in 1901 President William McKinley, shot in the abdomen by an assassin, underwent expeditious transport and surgical repair of several gastric wounds. However, a wound to the pancreas was overlooked, and McKinley died 8 days later.
A laparotomy for intestinal perforation at the start of World War I carried a mortality rate of 75–80%, almost equal to the mortality rate of nonoperative management. However, in the later part of World War I, operative management was recognized as the preferred management for penetrating abdominal trauma.
In World War II, prompt evacuation, improvements in anesthesia, and better understanding and treatment of shock led to mortality rates of 13.9% for jejunal or ileal injuries and 36.3% if multiple injuries were present.3 Further improvements in mortality were ...