Page 141 - JSOM Winter 2021

further management to prevent desiccation and ischemia. The
presence of eviscerated abdominal contents does not imply
that sources of intra-abdominal or pelvic bleeding will be able
to be identified and controlled through the defect in the ab-
dominal wall. The CoTCCC does continue to make recom-
mendations to reduce the mortality from truncal hemorrhage,
especially when the source of hemorrhage is in the abdomen
or the pelvis, but these recommendations are distinct from the
recommendations for managing abdominal evisceration. Ac-
tive management of abdominal evisceration is recommended
to reduce hemorrhage, increase intra-abdominal organ via-
bility, reduce hypothermia, and reduce complications related
to sepsis. Photo courtesy Dr D Marc Northern

Background
Abdominal wounds have historically been responsible for
around 20% of all wounds presenting to a hospital in armed
conflict, with mortality due to these wounds dropping pro- wounding during the Operation Iraqi Freedom (OIF) and Op-
portionally as forward surgery and rapid transport became eration Enduring Freedom (OEF) era from 2001–2015. This is
6,7
increasing available. In 1875, Sir William MacCormac, likely due to the fact that “golden hour” MEDEVAC became a
surgeon-in-chief of the Anglo-American Ambulance in the Secretary of Defense mandate in Afghanistan in 2009, direct-
Franco-Prussion War, wrote, “Of penetrating wounds of the ing that every seriously injured combat casualty would arrive
abdomen, we saw but few, and the subjects of these died rapidly at a medical treatment facility with surgical capability within
of peritonitis and shock.” After a 54-day campaign in Metz, 1 hour of the MEDEVAC mission approval. This policy pro-
MacCormac noted, “As might be anticipated, the penetrating duced a significant reduction in Case Fatality Rate, with an
8
abdominal wounds were all fatal.” These pre–World War estimated 359 lives saved from 2009–2013. Clearly, early op-
12
(WW) I discussions led to debate in the surgical community erative management of the abdominally wounded combatant
whether there was value in laparotomy for war wounds of the is essential, and discussion during the OIF/OEF era centered
abdomen versus the orthodoxy of the time to manage abdomi- largely around damage control surgery vs. definitive laparot-
nal wounds as expectant. This viewpoint evolved somewhat in omy. During this same time period, De Robles and Ayuste
13
favor of laparotomy in WWI. In WWI, abdominal wounding published a review of 98 laparotomies performed for civilian
was recognized as a significant cause of mortality, with most stab wound victims with omental evisceration. Based on their
estimates ranging between 55% and 77% of patients dying findings that 81% of their patients had therapeutic laparotomy,
due their injuries. Abdominally wounded patients were still they recommended prompt operative management for any ab-
almost always triaged “expectant,” even if they were able to dominal trauma with omental evisceration. 14
9
reach a surgeon within 1 hour. Mortality was so high that in
Dr George G. Davis’s case series (N = 2,525 combat-wounded Infection, especially if associated with delayed presentation,
patients) under his care in a WWI evacuation hospital, he re- must be considered at all echelons of care. A study of 211
ported only one survivor of bayonet wounding to the abdo- predominantly host-nation injured patients cared for on the
men. He concluded that bayonet wounds of the abdomen are USNS Comfort during the first months of the Iraq War found
almost always lethal due to hemorrhage. 6 30% of abdominal injuries were infected, yielding an odds ra-
tio of 2.7 for an abdominal injury to develop an infection. 15
In WWII, mortality rates due to abdominal injury dropped
6,7
significantly to 18-36%. The Korean War and the US expe- The US Department of Defense Trauma Registry (DODTR)
rience in Vietnam saw even further decreases to 12%, and then provides additional recent evidence for the overall burden of
to as low as 4% mortality in one series in Vietnam. Hardaway’s abdominal evisceration in combat. Data from a 14-year pe-
study of 17,726 wounded American soldiers in Vietnam over riod during US combat operations reveal 26,548 abdominal
15 months, from March 1966 to July 1967, provided evidence procedures were performed, comprising 13% of combat sur-
to support improved survival due to wide availability of blood gery from 2002 to 2016. Of note, any trauma patient who
16
and blood products on the battlefield and rapid medical evacu- dies before reaching Role 2 care will likely not be found in
ation to surgical management. Notably, in patients who died the DoDTR. Therefore, the mortality rate for casualties with
10
of wounds (DOW), with abdominal wounding as their pri- abdominal eviscerations could potentially be higher than what
mary injury, 60% succumbed to hemorrhage, 25% to sepsis, has been published although the evisceration is unlikely to be
and 15% to pulmonary insufficiency. By the end of Vietnam, the proximate cause of death, but the hemorrhagic compo-
research was drawing a clear correlation between number of nent of this wounding pattern would contribute most to the
intraabdominal organs injured and mortality, with survivors mortality.
having an average of 1.8 injured organs. 7
In his review of patients from ongoing armed conflict in Nige-
In one review from OEF/OIF, abdominal wounds constituted ria, Olorundare studied 109 abdominal injuries over a 2-year
9.4% of 6,609 wounds recorded by the US Joint Trauma Reg- period from 2010 to 2012. Eviscerated bowels were present
istry; 81% of abdominal injuries were caused by explosions, in 34 patients (31%) and were largely due to ballistic wound-
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17% by gunshots, and 2% by motor vehicle collisions. Lit- ing (10:1 ratio of penetrating trauma to blunt trauma for all
tle was published on prehospital management of abdominal abdominal wounds). The case fatality rate was 10.8%, and
Abdominal Evisceration in Tactical Combat Casualty Care | 139