Emergency treatment of violent trauma: clinical cases and surgical treatment of penetrating thoracoabdominal, perineal and anorectal trauma.

AIM The authors analyse clinical cases of penetrating thoracic, abdominal, perineal and anorectal injury and describe the traumatic event and type of lesion, the principles of surgical treatment, the complication rate and follow up. MATERIALS AND METHODS In the last 24 months, we analyzed 10 consecutive cases of penetrating thoracic and abdominal wounds [stab wound (n=7), with evisceration (n=4), gunshot wound (n=1)], and penetrating perineal and anorectal wounds (impalement n=4). In addition, we report an unusual case of neck injury from a stab wound. All the patients underwent emergency surgery for the lesions reported. RESULTS In 7 cases of perforating vulnerant thoracoabdominal trauma from stab wounds there was hemoperitoneum due to bleeding from the abdominal wall (n=3), the omentum (n=1), the vena cava (n=1) and the liver (n=2). Evisceration of the omentum was observed in 4 cases. In 2 cases laparoscopy was performed. In one case laparotomy and thoracoscopy was performed. In a patient with an abdominoperineal gunshot wound, exploration was extraperitoneal. The 4 cases of perineal and anorectal impalement were treated with primary reconstruction, while in one case a laparotomy was needed to suture the rectum and fashion a temporary colostomy. In one case of anorectal injury rehabilitation resulted in a gradual improvement of fecal continence, while in the patient with the colostomy follow up at 2 months was scheduled to plan colostomy closure. CONCLUSIONS Based on the our clinical experience and the literature, in penetrating abdominal trauma laparotomy may be required if patients are hemodynamically unstable (or in hemorrhagic shock), in patients with evisceration and peritonitis, or for exploration of penetrating thoracoabdominal and epigastric lesions. In anterior injuries of the abdominal wall from gunshot or stab wounds, laparotomy is indicated when there is peritoneal violation and significant intraperitoneal damage. In patients with actively bleeding wounds of the abdominal wall muscles minimal laparotomy is often necessary for control of hemorrhage and abdominal wall reconstruction to avoid herniation. If patients are asymptomatic, in cases of anterior lesions the indications for diagnostic laparoscopy are uncertain. Selective conservative treatment is reserved for asymptomatic patients who are hemodynamically stable. Further controlled studies are needed. Early surgery for perineal and anorectal trauma, and also for complex injuries, is the gold standard for treatment.