286 Injury (1987) 18, 286-290 Printed in Great Britain

Disembowelment-a retrospective.study of patients suffering evisceration following penetrating abdominal injury

Peter Riley King Edward Vlllth Hospital, Durban, South Africa

Summary Details are presented of 104 patients admitted over a l-year period with evisceration following penetrating abdominal wounds. Stabbing was the most common cause of injury. Small bowel was the most commonly eviscerated organ, as well as the organ most frequently injured. Exploratory lapar- otomy was performed on all the patients who survived to reach the operating theatre. The negative laparotomy rate was 12 per cent, and a further 3 per cent had such mild visceral injuries that they did not require operative repair. For comparison a group of 111 patients admitted over the same period, but suffering only omental protrusion, was also examined. The rate of visceral injury in this group was slightly lower. Wound complications, including breakdown, were more commonly seen in the eviscerated patients, but the mortality was 8 per cent in both groups.

INTRODUCTION PENETRATING abdominal wounds are an extremely common indication for emergency admission in Dur- ban. Approximately one in eight of these patients arrives with evisceration. The frequency of this con- dition prompted the present study to discover whether evisceration results in morbidity and mortality over and above that sustained by patients not suffering this com- plication.

PATIENTS Between 1 January and 31 December 1982,799 patients with penetrating abdominal wounds were admitted to the general surgical service of King Edward VIIIth

Table 1. Causes of injury

Hospital, Durban. Forty-two (5 per cent) of these were due to gunshot, and most of the remainder to stabbing. One hundred and four of the patients presented with evisceration, and examination of the case records of this group provided the main material for this study. For comparison, the records were also examined of a further group of 111 patients who presented with omen- tal protrusion, but no evisceration.

Of the patients presenting with evisceration, 95 (91 per cent) were males. Their average age was 29 years (range 9-69). Many had consumed alcohol prior to admission, and some were belligerent and uncoopera- tive. An accurate history of the exact time or mode of the injury was often not available. Eighty-three per cent were admitted on a Friday, Saturday or Sunday, and 76 per cent between the hours of 1800 and 0600. The causes of injury are listed in Table I.

The time of injury was noted in 47 cases, and the average delay between injury and admission in these patients was just under 5 hours. Most patients were injured in the Durban area, although some received immediate attention (including intravenous infusion if judged necessary) from peripheral clinics before being dispatched to hospital by ambulance. Sixteen patients were transferred from rural hospitals.

The average pulse rate of the viscerated patients on admission was 90 beats/min, and the average systolic blood pressure was 115mmHg. Eleven patients were shocked, as defined by a systolic blood pressure below lOOmmHg, with a pulse rate of 100 or more. Four of

Patients with:

Evisceration Omental protrusion Cause of injury No. % No. %

Stab 98 94 109 98 Motor vehicle accident 2 2 - Hit by train 1 1 - Gored by cow 1 1 - Run over by tractor 1 1 Grenade explosion 1 1 -

Fall onto broken glass - - 1 1 Gunshot 1 1 Total 104 100 111 100

Riley: Evisceration after penetrating abdominal injury 287

R.loin 3 13 12 L. loin 2 6

Fig. 1. Site of evisceration (63 patients).

these patients died within 24 hours of admission. Haemoglobin level on admission were recorded in 96 patients, the average of this group being 12*4g/dl.

The site of evisceration was accurately described in only 63 cases, and the distribution of these is shown in Fig. 1. One patient suffered a wound from the umbili- cus to the right loin in a train accident. The organ most commonly eviscerated was small bowel (69 per cent), with large bowel and stomach seen less frequently (Table II). Eight patients had evisceration of more than one organ through one wound, and one patient came with small bowel eviscerated through a wound of the left loin, and omentum protruding through an epigas- tric wound. Twelve patients were recorded as having ‘massive disembowelment’-an imprecise term indicat- ing evisceration of multiple loops of bowel, often in- volving virtually the whole of the mobile part of the small bowel.

Associated injuries were recorded in 50 patients, and the frequency with which different regions were injured is listed in Table lZZ.

Table II. Organ eviscerated (84 patients)

Organ No. of patients

Small bowel only Colon only Stomach only More than one of

above*

58 (69%) 14 (17%) 4 (5%)

8 (9%)

*Also includes one patient in whom a partially severed segment of liver was eviscerated.

Tab/e i/L Associated injuries (eviscerated patients)

Site No. of patients

Head 12 (12%) Thorax 33 (32%) Upper limbs ‘17 (16%) Lower limbs 5 (5%)

The group of 111 patients with omental protrusion was almost identical with respect to age, pulse rate and percentage who were shocked on admission. This group contained a slightly higher percentage of females (13 per cent), and the average systolic blood pressure when first seen was higher at 124 mmHg. Five of the 11 who were shocked on admission died.

MANAGEMENT Of the patients suffering evisceration, 103 underwent laparotomy. The exception was a patient who was admitted in extremis and died before reaching the operating theatre. One patient also underwent thoraco- tomy. Preoperative investigations were in almost all cases confined to estimations of haemoglobin, and a chest radiograph in those with chest injuries in order to determine the need for intercostal drainage. In one patient for whom no operating theatre was immediately available, the stab wound was enlarged under local anaesthesia in the admission ward to relieve constric- tion of the eviscerated bowel. The average delay be- tween admission and start of operation was 3 hours, meaning that the average delay between injury and operation was 8 hours for those patients whose time of injury was recorded.

Of the patients arriving with omental protrusion, 108 were submitted to laparotomy. One died before reaching the operating theatre, and two were managed conservatively, with the protruding omentum being amputated under general anaesthesia in one and re- placed under local anaesthesia in the other.

The injuries of organs found in the two groups are listed in Tuble IV. Twelve of the patients with eviscera- tion were found to have no visceral injury, compared with 22 of the patients with omental protrusion. Re- spectively 3 and 5 patients in each group had only slight visceral injuries which required no surgical repair.

Resection of short lengths of small bowel was per- formed in 14 of the patients. In 12 this was done at the original operation; according to the surgeons’ notes, 10 of these resections were required because of muItipIe wounds of the bowel itself, or mesenteric wounds that interrupted the blood supply to a segment. In only 2 of the cases for which initial resection was performed was the bowel said to be infarcted. In the 2 patients in whom later resection was performed, the resected seg- ments were said to be gangrenous, although one of the two was a loop in which seven wounds had been closed at the initial operation. Two of the patients requiring resection at first operation came from the group de- scribed as having ‘massive disembowelment’.

Resection of small bowel was performed in only 2 of the patients who suffered omental prolapse-in both cases because of the severity of the wound of the affected segment,

Perioperative antibiotics were given to 74 of the patients with evisceration. The usual practice was for metronidazole and an aminoglycoside to be adminis- tered with either cephalothin or a penicillin, continuing for 48 hours unless the clinical condition of the patient indicated the need for longer treatment.

Abdominal drains were inserted at the discretion of the individual surgeon-the most common indications being wounds of the liver, or wounds of large bowel that were left inside the abdomen after repair.

288 Injury: the British Journal of Accident Surgery (1987) Vol. 18/No. 4

Table IV. Injuries of organs in two groups

Patients with:

Organ Evisceration Omental protrusion No. % No. %

No visceral injury Minimal injury (no

operative repair required)

12 12 22 20

3 3 5 5

Small bowel 59 57 30 28 Large bowel 27 26 17 16 Stomach 20 19 22 20 Mesentery and

mesocolon 15 14 8 7 Liver 10 10 10 9 Diaphragm 5 5 23 21 Spleen 2 2 5 5 Gallbladder 2 2 - -

Duodenum 2 2 1 1 Kidney 2 2 - -

Aorta 1 1 2 2 Bladder 1 1 - -

Pancreas - 2 2 Inferior vena cava - - 2 2

COMPLICATIONS AND MORTALITY Post-operative complications Excluding the patients who died within the first 24 hours, the frequency of complications is shown in Table V. Pneumonia was the most common problem in both groups. Wound infections were the second most common complication, but were more frequent in the eviscerated patients; three wounds burst in this group, and breakdown of the exteriorized colonic repairs occurred in five; neither of these latter two complica- tions was seen in the group with omental protrusion. The incidence of infective complications was the same in the patients treated with antibiotics as in those not so treated.

Second operations were required in 22 of the patients with evisceration but replacement of exteriorized colon or closure of a colostomy accounted for 1.5 of these. The totals for second operations and replacements of the colon in the omental protrusion group were respec- tively 7 and 5 (Table Vl).

Hospital stay The average stay in hospital of the surviving eviscerated patients was 19 days (median 12), while that of the patients with omental protrusion was 11 days (median

9).

Mortality Eight (8 per cent) of the eviscerated patients died, and nine (8 per cent) of those with omental protrusion died. Details of the eviscerated patients who died are pre- sented in Table VII. The causes of death in the omental protrusion group were broadly similar-six died within 24 hours of admission, and one at 28 hours as a result of severe injuries. The remaining two patients died, one at 3 days and one at 14 days, apparently as a result of severe sepsis.

Table V. Complications

Eviscerated Omental protrusion

group group

Infections Chest 18 18 Wound 16 7 Peritonitis 2 4 Urinary tract 1

Wound dehiscence 3 -

Breakdown of exteriorized colon repair 5 -

Renal failure 1 Delirium tremens 2 1 Abortion - 1

Table VI. Conditions requiring second operations

Eviscerated Patients with patients omental protrusion

Replacement of exteriorized colon or colostomy 15 5

Laparotomy for: Bleeding 1 1 Peritonitis 2 Burst abdomen 2 Intestinal obstruction

due to adhesions 1 Repair of incisional

hernia 1 Uterine evacuation - 1 Total 22 7

Riley: Evisceration after penetrating abdominal injury

Table VII. Causes of death (eviscerated patients)

289

Sex, age, Condition on cause of admission, organs wound injured Surgical treatment

Time of injury to

death Complications, cause of death

F, 14, stab Not shocked, wounds Laparotomy, suture of of stomach, stomach and duodenum and kidney duodenum, feeding

jejunostomy

M, 30, stab Grossly shocked, Laparotomy multiple deep stabs of neck, trunk, abdomen and limbs

M, 30, stab Not shocked, wounds Laparotomy, repair of stomach, small and plus exteriorization of large bowel repaired colon

M, 19, stab Not shocked, multiple Laparotomy and small bowel wounds repair

M, 24, stab Shocked, multiple stabs of chest and abdomen

M, 35, motor Grossly shocked, accident multiple injuries

M, 37, stab Grossly shocked, wounds of liver, major haemoperitoneum

F, 37, stab Shocked, wounds of stomach, penetrating head injury

Thoracolaparotomy, massive bleeding as abdomen opened

Died before reaching theatre

Laparotomy, suture and drainage of liver

Laparotomy, repair of stomach

c. 17hr

c. 8hr

10 days

6 days

c. 4hr

c. 2hr

c. IOhr

9 days

Sudden collapse and cardio- respiratory arrest on ward post- operatively. Appears to have had inadequate replacement of initial blood loss

Transferred from outlying hospital. Profuse bleeding. Died on table shortly after com- mencement of operation

Developed adult respiratory distress syndrome. Gradual deterioration and death despite intensive care

Volvulus of previously eviscerated loop of bowel, with peritonitis. Re-laparotomy day 5, but patient already very ill and continued to deteriorate

Major vascular injury, air embolism

Multiple severe injuries

Transferred from outlying hospital. Uncorrectable hypovolaemia before reaching hospital

Died as a result of cerebral damage from head injury

DISCUSSION Most series of penetrating abdominal wounds collected elsewhere in the world show a higher proportion of gunshot wounds than we find in our practice, presum- ably reflecting relative ease of access to particular types of weapons. Evisceration is rare through the small wounds usually caused by the relatively low-velocity gunshot wounds in civilian practice here.

The male preponderance of the patients in this study, and their usual arrival at night time and at weekends, accords with the findings in other series (Harriman et al., 1972; Donaldson et al., 1981; Cayten et al., 1982). It has also been shown elsewhere that a high proportion of emergency service patients have consumed alcohol or are frankly inebriated (Harriman et al., 1972; Holt et al., 1980).

The average delay between injury and admission is greater than that recorded in other series (Harriman et al., 1972; Wilder and Kudchadkar, 1980; Cayten et al., 1982). This presumably reflects difficulties in com- munication .and transport, and the distance which some patients travelled to reach hospital.

The high mortality of the patients who were shocked on admission confirms the findings of other authors that this is in itself an important pointer to serious injury (Donaldson et al., 1981). The measurement of haemo- globin was often falsely reassuring in patients who had bled and were still hypovolaemic.

With regard to the organ eviscerated, it seems likely

that this is determined mainly by the site and size of the wound in the abdominal wall and the relative mobility of the adjacent viscera. In this respect it is interesting that, in the group with omental protrusion, there was a greater proportion of low chest stabs, as indicated by the number of diaphragmatic injuries. As Sandrasagra (1977) has pointed out, ‘In expiration the diaphragm is closely applied to the lower part of the chest wall and. . . penetrating wounds of the lower chest are therefore likely to pass directly through the diaphragm into the abdominal cavity’.

Selective conservatism in the management of pa- tients with penetrating abdominal wounds was first proposed by Shaftan in 1960. Since then this subject has been discussed by many authors, without any final agreement because of the difficulty of early distinction between patients with and without important visceral injury. Patients with evisceration and omental protru- sion, where mentioned, are all felt to warrant lapar- otomy, but the actual incidence of visceral injury in these patients has not been examined previously.

With only 15 per cent of the eviscerated patients in this study escaping important visceral injury, the case for laparotomy in all cases in this group is upheld. The argument is less strong in the omental protrusion group, 25 per cent of whom suffered no major damage of an organ.

The relative frequency of injuries to different viscera broadly follows that found in other series of patients

290 Injury: the British Journal of Accident Surgery (1987) Vol. 18/No. 4

with stab wounds (Donaldson et al., 1981; Cayten et this study is hard to explain; it may relate to the timing al., 1982), except for a lower incidence of liver injuries of the commencement of treatment; from the informa- in the present series. Presumably this reflects the fact tion available in the patients’ case records it was in most that evisceration is usually blocked by the liver itself cases impossible to be certain when the patient actually when wounds penetrate it directly on entering the received the first dose of antibiotic. abdomen. The identical mortality rates in the two groups sug-

The stated reason for most resections of the bowel in gest that the severity of the initial injuries in the two the eviscerated patients was the degree of injury result- groups was similar, and that while disembowelment ing directly from laceration of the bowel itself or of its results in increased morbidity, it makes little difference mesentery. This does not, however, explain the seven to mortality as long as effective treatment is given. Nor

times greater frequency of bowel resection in these is there any evidence that the extent of evisceration

patients, when small bowel injuries were only twice as makes any difference; of the patients suffering ‘massive

common as in the omental protrusion group. It seems disembowelment’ only one died, and that was due to likely that vascular compromise due to evisceration, exsanguination from multiple wounds and not as a which rarely on its own damaged the bowel sufficiently result of the evisceration. to require resection, when combined with laceration may damage the affected bowel beyond repair. Fluorescein was not used in any of these cases in order to determine viability.

With regard to complications, it is noteworthy that important wound complications were also more com-

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Paper accepted 12 October 1986.

Requests for reprints should be addressed IO: Peter Riley, Terracotta, Wellhouse Lane, Burgess Hill, Sussex.