Emergency War Surgery NATO Handbook: Part IV: Regional Wounds and Injuries: Chapter XXIX: Wounds of the Abdomen
United States Department of Defense
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Distal Esophagus, Diaphragm, Stomach, Spleen, and Kidney
The principles for dealing with injuries to organs in the left upper quadrant of the abdomen are simple. Careful exploration should assure integrity of the diaphragm, the anterior and posterior wall of the stomach, and the esophageal hiatus. The surgeon must palpate the kidney and search for a retroperitoneal hematoma. Perforations of the stomach should be closed primarily with minimal, if any, debridement. Injuries to the lower esophagus should be closed primarily after adequate mobilization. All injuries of the diaphragm should be closed with a single layer of interrupted heavy, nonabsorbable sutures. Large injuries to the diaphragm with herniation of abdominal contents should be repaired transabdominally after the abdominal viscera have been returned to their normal location. The most common error made in the treatment of diaphragmatic injuries is missed diagnosis. All patients with gastric injuries should be treated with nasogastric suction until normal bowel function returns. Enough gastric distention to disrupt a gastric repair is common in patients who are evacuated by air in the early postoperative period.
The diagnosis of renal injury depends on a high index of suspicion, hematuria, or evidence of fragments traversing the kidney. Penetrating injuries of the kidney should be explored and hemostasis obtained. In some cases, a nephrectomy is necessary to achieve hemostasis. Gerota's fascia, if intact, can effectively tamponade hemorrhage in the case of blunt injury to the kidney. In blunt trauma, this fascia should not be opened as hemorrhage is usually self limited.
The spleen should be inspected, but should not be mobilized unless there is evidence of bleeding. In civilian practice, the spleen is infrequently removed because of trauma. If hemorrhage can be controlled quickly and simply with confidence that it will not recur, the spleen can be preserved in combat surgery. If there is extensive injury to the spleen, the organ should be removed. The major difference between the management of civilian and combat injuries to the spleen is in the management of moderate injuries. If a moderate amount of effort is needed to secure hemostasis, it is best to remove the spleen of a combat casualty. The combat surgeon has neither the time required to preserve the moderately-injured spleen, nor the certainty of close personal postoperative observation required for such conservatism. Patients who have undergone splenectomy should be given antibiotic prophylaxis beginning at the time of surgery. This should be continued through the convalescent period. The patient should be vaccinated against those organisms which cause overwhelming sepsis as soon as possible.
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