Experience with advanced surgery for the treatment of civilian gunshot injuries supports the changes in approach and indications for the treatment of war gunshot injuries. Eight patients with gluteal gunshot wounds are presented with typical war injuries. They were wounded during 1992 and 1993 in the war in Croatia and Bosnia and Herzegovina. Surgical complications were experienced in two cases. Complications developed in cases of colonic and rectal injuries for which advanced surgery was performed in the treatment of the war wound. Poor conditions for advanced surgery during war can change the final result, making the outcome of the war wound worse.
Civilian and war gunshot injuries can look similar or the same, but their outcome can be different. In the past, standard military surgical procedure was the treatment of choice for both of them. Advanced surgical procedures give civilian wounded persons the chance to be treated more comfortably. The use of advanced surgery in war requires delicacy and precision.
Materials and Methods
Eight patients with gluteal gunshot wounds above the greater trochanters are presented. They were wounded during the war in Croatia and Bosnia and Herzegovina between June 1992 and June 1993. They were treated at War Hospital Rama and Clinical Hospital Split, and all of them were surgically explored. There were five patients with colonic and rectal injuries. In three of them, standard military surgical management was performed. The main principles of such management are resection of the injured bowel and terminal colostomy. In two patients, advanced surgical management was done. This involves resection and primary repair of the bowel with or without proximal diverting colostomy. The different surgical attitudes and procedures in the two groups of patients are compared.
A 13-year-old boy was accidentally shot in the right gluteal region. The bullet passed through gluteal muscles, pubic bone, and soft tissues, resulting in complete rupture of femoral vascular fascicle (Abbreviated Injury Scale [AIS] score = 3). The vascular injury was manifested as extensive bleeding, shock syndrome, and absence of pulses in the right lower extremity. After hemostasis was achieved, the injured vessels were resected and reconstructed by saphenous vein graft. No complications developed.
A 5-year-old girl was accidentally shot in the lateral part of the right gluteal region. The bullet passed through the iliac bone and entered the peritoneal cavity. It resulted in segmental perforations of the small bowel and the peritoneal part of the rectum and contusion of the posterior wall of the urinary bladder. The bullet stopped in the left hip, fracturing the acetabulum and dislocating the hip (AIS score = 5). Shock developed. Diverting colostomy as well as suture closure of rectal and small bowel perforations were performed in the war hospital. Seven days later, a rectal fistula developed. We resected the fistula, reconstructed the rectum, and performed a Hartmann procedure. Reanastomosis was done 6 weeks later. Four weeks later, we closed the colostomy. The contusion of the urinary bladder was treated by catheterization. Hip dislocation was treated for 6 weeks by Bryant traction. The patient had temporary anal sphincter paresis and contracture of the left hip.
A 20-year-old male was wounded in military action. The bullet passed through the left gluteal region and into the retroperitoneal part of the rectum. It destroyed the anterior rectal wall and stopped in the left inguinal region. A large retroperitoneal hematoma formed, and the patient developed shock (AIS score = 3). A Hartmann procedure was performed. The rectum was reconstructed. The colon segments were reanastomosed 6 weeks later. No complications developed.
A 19-year-old soldier, wounded in fighting, developed the symptoms of hemorrhagic shock. The gunshot wound was located in the left gluteal region. The bullet destroyed the left colon (AIS score = 5). A left hemicolectomy and a bipolar colostomy were performed. Six weeks later, colon continuity was restored. No complications were encountered.
A 24-year-old civilian male was wounded in the left gluteal region. At the time of wounding, he was in prone position. The bullet passed longitudinally along the vertebral column and entered the peritoneal cavity through the posterior wall. It destroyed parts of the small bowel and the spleen (AIS score = 4). Hemorrhagic shock developed. Hemostasis was achieved by splenectomy. The small bowel was sutured. No complications ensued.
A 25-year-old soldier was wounded. The bullet passed through the left gluteal region and through the rectum at the level of rectosigmoidal flexion (AIS score = 5). A Hartmann procedure was performed. The bowel was reconstructed at 6 weeks. No complications developed.
A 12-year-old girl was accidentally shot. The bullet entered the posterolateral portion of the right gluteal muscle and destroyed the right hip. The bullet entered the abdominal cavity and transected the right colon (AIS score = 5). A right hemicolectomy and ileocolic anastomosis were performed. The right leg was placed in traction. Osteomyelitis of the acetabulum developed. The operative wound dehisced. Six days later, an anastomotic leak developed and was repaired. Daily dressing changes were performed. The patient was kept on antibiotic therapy for 6 months. She gradually improved but required plastic reparative surgery of the abdominal wall.
A 20-year-old soldier was shot in the right gluteal region. The projectile passed through subcutaneous tissue and stopped at the base of the penis. A contusion of the anterior urethra caused hematuria (AIS score = 3). Simple perineal extraction of the bullet and catheterization of the urinary bladder were performed. The patient had a good result.
Gluteal gunshot wounds may include injuries not observed at first examination. Physicians who perform first aid on the battlefield can easily overlook secondary injuries. Many of those reported here were unrecognized and were discovered only later. The types of injuries initially treated and the surgical procedures performed are listed in Table I.
The reconstruction of a projectile's trajectory and its final intracorporeal location are very important in planning treatment. Different injured tissues far away from the gluteal region show the importance of being aware of possible injuries along the trajectory. Surgical complications are listed in Table II. They were observed in two patients on whom advanced surgery was performed (not in our hospitals).
Gluteal gunshot wounds include injuries of different tissues, and they require different surgical procedures. The AIS scores of these patients ranged from 3 to 5.1-3 Most of these injuries were initially encountered with varying symptoms caused by hemorrhage. The abdominal wall findings as well as the absence of pulses at the lower extremities were important in making diagnoses. The findings of abdominal tenderness or gross blood in the urine or rectum are highly predictive of major injury. Every patient with a transpelvic bullet trajectory warrants exploration.4 The entrance wound site has a critical role in determining the likelihood of serious injury associated with penetrating gluteal wounds.5 Gunshot wounds penetrating above the greater trochanters indicate the need for angiography, and this study should be part of the protocol for the management of penetrating injuries in the gluteal region.6 Sigmoidoscopy is selectively performed in patients who sustain gunshot wounds to the buttocks when the presence of rectal injury is in doubt.7 However, physical reexamination is much more important when there is a lack of advanced diagnostic equipment.
In this group of patients, there were no complications when the standard principles of military injury management were used. The complications appeared in those cases in which the surgeon, in war conditions, performed modern, advanced, and selective management. Both patients had AIS scores of 5. They were treated using standard war injury management.
Some clinicians do not adhere to the standard military surgical principles for the treatment of civilian rectal injuries (colostomy, repair, irrigation, drainage, and antibiotics) and perform selective management with excellent results, low morbidity, and no mortality. They consider that the complications in 5 of 52 patients were not related to the rectal injury.8 Canadian surgeons consider colostomy the appropriate treatment for colon injuries. Primary repair has definitely established a foothold at all levels of Canadian general surgery practice.9 Well-chosen personnel educated in war surgery are always important for successful diagnoses and treatment. They have to accept the relation between modern concepts and the probabilities of their successful use in war. There are situations in which the surgeon must be flexible in the choice of treatment, and the time interval between sustaining the wound and surgery is an important factor. 10,11
The standard principles of wound management must not be forgotten. In the treatment of anorectal injuries, it is important to perform terminal sigmoid colostomy, repair of rectal injury (intraperitoneal or, if possible, extraperitoneal), sphincter muscle approximation, and presacral drainage.12 Fecal diversion and presacral drainage are the mainstays of therapy for extraperitoneal rectal injuries. The importance of distal rectum irrigation has not been established. Primary repair of the rectum has no effect on morbidity and mortality.13 Rectourethral fistula should be managed by colonic diversion and resection of the fistula using posterior transsphincteric anterior rectal wall advancement.14,15 In civilian practice, this type of fistula is treated by primary closure of the fistula, and proximal diverting colostomy is frequently used. The principle of complete diversion of intestinal contents is usually used in reexploration.12 The most frequent indications for reexploration are dehiscence of the anastomosis, missed perforation, and subsequent perforation of blast injury.12 It looks like a paradox that even serious complications cannot make the surgeon abstract to modify the treatment.
When standard principles of war wound management were used, there were no complications in all cases of gluteal gunshot injuries. Neither significant morbidity nor mortality was noted. Two months of treatment and the possibility of stoma complications are far preferable to the failure of healing of a primary colon or rectal anastomosis. Advanced surgical principles and experiences in civilian surgery cannot always be applied in war. Because of the nature of war, even experience in war surgery cannot be transferred from one war to another with any guarantee of success.
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Guarantor: Zoran Vukic, MD MA
Contributor: Zoran Vukic, MD MA
Department of Pediatric Surgery, Clinical Hospital Split, 21000 Split, Spinciceva 1, Croatia.
This manuscript was received for review in January 1999. The revised manuscript was accepted for publication in June 1999.
Copyright Association of Military Surgeons of the United States Mar 2000
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