Safety of incidental appendectomy.

Reports in the surgical literature are conflicting as to whether appendectomy "in passing" during laparotomy for trauma or for some other disease state does or does not significantly increase patient morbidity or mortality. A chart survey of all appendectomies (342 for acute appendicitis and 146 as incidental procedures) performed on the trauma service of Grady Memorial Hospital over a 40 month period appeared to indicate that the wound infection rate (6.8 percent) was the same as that for acute simple or suppurative appendicitis (6.7 percent), whereas the intraabdominal sepsis rate (17.5 percent) paralleled that for more advanced gangrenous or perforative appendicitis (18.6 percent). Since the validity of a retrospective review is always open to question, a prospective, randomized trial was carried out only on patients with a negative abdominal exploration for trauma over a 22 month interval at the same trauma service. An odd second from the last digit hospital number dictated appendectomy, provided the appendix was readily accessible; an even digit in the same locus dictated retention of the appendix. In no patient did intraperitoneal sepsis develop, regardless of the procedure chosen. Wound infection rates were 1.8 percent for appendectomy (1 of 56), if local anatomic considerations precluded an easy appendectomy (0 of 45), and 3.6 percent for the control subjects without appendectomy (3 of 83). There were no deaths. These data cast considerable doubt on the reliability of retrospective reviews and support the generally accepted dictum that incidental appendectomy, especially in the trauma patient, can be a relatively innocuous procedure.

Injury to the popliteal artery.

During a 32 year period, 164 patients with 165 popliteal artery injuries were treated. One hundred twenty-five injuries were due to penetrating trauma, and 40 to blunt force. During the first decade reviewed, with ligation the main method of management, the amputation rate was 74 percent. Almost routine attempts at vascular repair over the ensuing 10 years reduced the amputation rate to 28 percent. During the final 12 years, six amputations were required for 81 injuries, thereby producing an amputation rate of only 6 percent. From this experience, the following principles of management have evolved: (1) early diagnosis is best accomplished by a careful history and detailed physical examination, not by arteriography; (2) thrombectomy followed by distal heparinization before repair is the best method for guaranteeing an adequate arterial outflow tract and thus successful revascularization; (3) resection of all injured vessels with reconstitution of continuity by the use of an interposed saphenous vein graft is often warranted to avoid tension; (4) popliteal vein repair should be performed when practical; and (5) subperiosteal fibulectomy-fasciotomy should be done routinely immediately after vascular repair.

Management of acute full-thickness losses of the abdominal wall.

Over a 20-year interval, 167 patients sustained acute full-thickness abdominal wall loss due to necrotizing infection (124 patients), destructive trauma (32 patients), or en bloc tumor excision (11 patients). Polymicrobial infection or contamination was present in all but five of the patients. Of 13 patients managed by debridement and primary closure under tension, abdominal wall dehiscence occurred in each. Only two patients survived, the 11 deaths being caused by wound sepsis, evisceration, and/or bowel fistula. Debridement and gauze packing of a small defect was used in 15 patients; the single death resulted from recurrence of infectious gangrene. Pedicled flap closure, with or without a fascial prosthesis beneath, led to survival in nine of the 12 patients so-treated; yet flap necrosis from infection was a significant complication in seven patients who survived. The majority of patients (124) were managed by debridements, insertions of a fascial prostheses (prolene in 101 patients, marlex in 23 patients), and alternate day dressing changes, until the wound could be closed by skin grafts placed directly on granulations over the mesh or the bowel itself after the mesh had been removed. Sepsis and/or intestinal fistulas accounted for 25 of the 27 deaths. Major principles to evolve from this experience were: 1) insertion of a synthetic prosthesis to bridge any sizeable defect in abdominal wall rather than closure under tension or via a primarily mobilized flap; 2) use of end bowel stomas rather than exteriorized loops or primary anastomoses in the face of active infection, significant contamination, and/or massive contusion; and 3) delay in final reconstruction until all intestinal vents and fistulas have been closed by prior operation.

Experiences in the management of pancreatic trauma.

A 30-year experience in the management of 283 consecutive patients with acute pancreatic trauma was reviewed. Of these injuries 224 were penetrating; 59 were from blunt trauma. Diagnosis was made by laparotomy in all patients, although elevated serum amylase suggested this injury in 23 (56%) of 41 patients with nonpenetrating injuries. Operative measures were initially involved with correction of associated injury when present (961 organ injuries in 278 patients: 3.5 injuries per patient). During the earlier years, Penrose drains were placed to the site of injury. Significant pancreatic complications (fistula in 13, suppurative pancreatitis or abscess in six, pseudocyst in three) were noted in 19 (46%) of the 41 patients so managed. Routine sump drainage dramatically reduced the incidence of pancreatic complications to 2% in the 198 patients having external drainage alone. Distal resection was performed in 29 patients, without later pancreatic insufficiency. Most disappointing were the results from Roux-en-Y internal drainage: fistula developed in five and lethal bacterial pancreatitis in three of the seven patients so treated. Five patients died from exsanguination during exploration for major vascular trauma, and all three patients undergoing pancreaticoduodenectomy succumbed within 20 hours after operation. The overall mortality was 13.8%, with only seven deaths out of the last 100 patients treated. Profound hemorrhagic shock and its complications (19), suppurative pancreatitis (eight), and post-traumatic respiratory insufficiency (three) accounted for 30 of the 39 fatalities.