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l1G . I

.

A An

te rop os terio r ro en tgen og rain o f

th e

abdo m en dem ons tra tin g a la rge su bcu taneous co l-

le ction o f co n trast m ateria l.

B L ate ra l abdom in al

roen tgen ogram in the sam e p a tien t revea ling that

the co n tras t m a te ria l is conf ined

to the

abdomina l

wall an d do es n o t en ter th e per i toneal cav i ty .

Reproduced with pe rm issio n o ff. S i i ; . R e s . )

* From the Department of Surgery, The Johns H opk in s U n iv er sity a nd H osp ita l B a ltim ore Marylalld.

liBEl lilY 1966

41 4

PENETRAT ING W OUNDS O F THE ABDOM INA L W ALL

A N E \V D IA G N O S T IC T E C H N IQ U E

By \V IL L IA M P . C OR NE LL M.D .

a nd

PAUL A. EBERT, MI .

BALTIMORE MARYLAND

P

E N E T R A T IN G w oun ds o f the a b -

d om in al w a ll rep re sen t a d if lcu lt d iag -

nos t ic p ro b lem to the c lin ic ian rega rd ing

the p re sence o r absen ce o f in tra -ab dom ina l

i nju ry . Im m ed iate exp lo rato ry lapa ro tom v

has usu ally b een adv ised to de term in e if

an in ju ry ha s o ccu rred to the abd om in a l

con ten ts . T h is m e tho d of treatm en t has

p reven ted m o st o f the co m plica tion s o f

p en e tra ting abdo m ina l w ou nds , b u t has

re su lted in a la rge num ber o f u nnecessa ry

operat ions. A t the Jo hns H op k ins H o sp ita l

during th e p ast io years , on ly 40 pe r cen t

o f abdo m ina l stab w ou nds w ere sho w n at

the tim e o f su rge ry to have p ene tra ted . In

the p re sen t report a tech n iqu e is desc r ibed

b w h ich it can be de te rm in ed w h eth er

p en e tra tion in to the abd om in al cav ity h as

occurred .

M E T H O D

T h e pro ce d u re 1 w a s ca rried

ou t in each

case in the E m ergency R oo m , us ing s tan -

d ard roen tgeno grap h ic equ

i p m en t.

T h e

a rea a ro un d th e stab w ou nd is p rep a red

w ith sep tiso l and aqueou s zeph an im to

estab lish a ste r ile fie ld . A nu m ber 14

F rench ca the te r is in se rted th rou gh the

sk in w ou nd in to th e su bcu taneou s tissu e

w ithou t m ak ing an a ttem p t to

fin d the

trac t o r to pass the ca th ete r d irec tly in to

ti le peritoneal cav ity . T he sk in e dg es are

secured tig h tly a ro und the cathe te r w ith a

p urse s tr in g su tu re o f oo-s ilk . S ix ty to

eig h ty cub ic cen tim ete rs o f sod ium d ia tn i-

zoate hypaque 50 pe r cen t) w ith i cc. o f

m e th lene b lue is in jec ted in to the ca the ter

u nde r ca refu l ob serva tion to be certa in

tha t the so lu tio n do es no t leak ou t o f the

w ou nd on to the abd om in al w all. T h e

ca the ter is then clam p ed an d abdo m ina l

roen tg en ogram s a re m ade . B o th an te ro -

pos te rio r a lld la te ra l s tud ies a re ob ta ined

in th e recum b en t po sition . \\hen necessa ry ,

o b liqu e v iew s of th e abd om en

are in clude d

to c la rify th e loca t ion of con tras t m ate ria l.

In o rd er fo r a stu dy

to

b e co nsid ered

sa t i s fac to ry , it is necessa ry fo r a la rge

o paque a rea o f con tra st m a ter ia l to be seen

o n th e roen tg en og ram F ig .

i, J

an d

B .

T h is d iffusion o f co n trast m a ter ia l dem on -

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11G . 2 . A ) A nte rop oste rio r roen tgeno gram of the abdom en in recum b en t po sition dem on stratin g a la rge

qu n t i ty of con tras t m ate ria l in

th e

p er it on ea l c av it y, ou tlin ing the la rg e

an d

smal l bowel

and the un de r

su r face of the l iver and B th e sp len ic flexure. C C ontras t m ate rial ou tlin ing the righ t la te ra l pe rito neal

reflex io n and u nde rsu rfac e of

th e liv er and

D con tras t m ate ria l a roun d

th e

live r as w ell as

th e sp lee n

an d

sp len ic tlexure of the c o lo n .

\oI .

.

6,

No . 2

Penetrat ing

W o u n d s

of th e A bd om in a l \V all

41 5

stra tes tha t a su flic ien t quan tity is in jected

to fo llow tile tract of tile p ene tra tin g in jury

an d

enter

the pe rito nea l cav ity ,

if

su cil an

opening exists F ig .

2, z1-D ;

and 3 , an d

B .

Ihe m e thv len e b lu e

is

ad d ed

to p erm it

reco gn itio n at the tim e of lap a ro to n ly and

to fac ilita te in te rp re ta tion of tile roen t-

genogran ls .

R E S U L T S

T o th e

present time,

th e

studs has b een

performed in 40 patients. In one p atien t

ear ls

il l

th e se r ies the s tud y w as considered

un sa tisfac to ry fo r in terp re tation . A ll 1 2

p atien ts w ith ro en tgeno grap h ic ev id ence o f

co n trast m ate rial in the p eriton ea l cav i ty

h ad a de fin ite lace ra tion of

ti le peritoneum

a t th e tim e of lapa ro tom v . N o ne o f t ile 1 0

p a tien ts w h ose te st w as in te rp re ted as

n ega tive fo r pene tratio n in to th e ab dom ina l

cav i ty had p erfo ra tion of the pe ritoneum at

op era tion . T h e re w ere iH patients who ha d

no ro en tgenog raph ic ev id en ce of co n trast

m ateria l enterin g tile p eriton ea l cavit

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L

tha t d id no t have lapa ro tom v . T hese p a-

tien ts had no clin ica l ev idence of in tra -

ab d o m i n a l

in ju ry and were

d ischa rged a fte r

48 h ours o f o bse rv atio n . N one o f these p a-

tients sho w ed la te ev id en ce of in ju ry .

I IG . 4. A bdo m in a l roen tgenog ram fo llow ing in jec tion

of stab w ou nd . T h e con tras t m ate ria l d id n o t en te r

th e

pe rito nea l c av i ty

an d is seen in the rena l col-

lec ting sys tem

ar rows) .

41 6 Wi ll ia m P .r Cor ne ll and P au l A . E b ert

r

FEBRUAR\

1966

1 1G .

3.

Patien t

stabb ed ju st

abov e the d iaphragm w ith an ice p ick . In jec tio n

of

co n trast m ate ria l

d em o n -

stra ted in th e A ) an te rop oste rio r and B) la te ra l ro en tgenogram s tha t ne ithe r the peritoneum

no r

th e

p leura l spaces w ere en tered . T he hypaqu e is confin ed to the an te rio r m ed iastinum .

C O M M E N T

T here have b een n adv erse e ffec ts such

as in fec tion or n ecrosis o f the un de rly ing

t i s sues fo llo w in g in jectio n o f sod ium dia tri-

zoa te in to tile w oun ds. Pa tien ts com pla ined

of m in im al d is co m fort a t the tim e of in jec -

tion . T h e m a te ria l is co m ple te ly abso rb ed

fro m the tissues in 3 6 hou rs. O pac ifica tion

of the rena l co llectin g system is u sua lly

seen o n th e roen tgen ogram s, ind ica ting tile

rap id ity in w h ich th e con tra st

Illa te ria l is

abso rb ed F ig . 4 ). T ile re h av e been n o

fals e n ega tive o r fa lse pos itive interpreta-

tions of the tes t to d ate . lile s tud w as

con side red unsatisfac to ry in one pa tien t

ear ly in the se ries. If the study is pos itiv e

fo r pene tra tion o f the p er iton eu m or no t

sa tisfac to ry fo r in te rp reta tion , illl me dia t e

exp lo ra to ry laparo tom v is perfo rm ed . A l-

tho ugh w e have encoun tered no fa lse

neg ativ e exam in atio ns to

da te ,

it is o u r

p rac tice to ca rry ou t ear ly exp lo ra tion in

a ll pa tien ts w ith pene tratin g abdo m ina l

w o unds . If these early resu lts a re borne o u t

in ou r co n tinu ing expe rien ce , it m ay be

p ossib le to ca rry o u t a m ore co nserv ative

p rogram of m an ag em en t in p a tien ts w ith

negative stud ies .

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R E F E R E N C E

I. CO RN ELL

W . P .

EBERT,

P . A . an d

ZUIDEMA

G . D . X -ray d iagn osis o f p en etra ting w o und s o f

abdo m en . 7 .

Su rg . R es.,

1965

5, 142 145.

V O L . 96

N o. 2 P en etra tin g W o und s o f th e A b do m in a l W a ll

41 7

SUMMARY

O n the ba s is o f

preliminary results ob-

ta ined b y

inject ion

of w ou nds w ith rad io -

paque con tra st m a te ria l, w e can state th at

fa ilu re to d em ons tra te pene tra tion o f the

peri toneal cav ity is stro ng

ev ide nc e th a t

the pe ritoneum is no t pu nc tu red . T h is is a

con tinu in g stud y and a fu ll ev alu atio n o f a

m ore ex tensive ex pe rience w ill be th e sub-

jec t o f a su bsequ en t rep ort. T he tech n iqu e

as d escr ibed is sim p le to p erfo rm , sa fe fo r

th e p atien t, ap pea rs to b e re liab le an d is

a no the r ex am ple o f th e v alue o f d ia gn os tic

ro en tg en og rap h ic te ch n iq ue s in the trea t-

m e n t o f th e a cu te ly in ju re d p a tien t.

W illiam P. C orne ll, M .D .

D epartm en t o f Surgery

U niversity o f Pittsburgh

P ittsburg h , Penn sy lvan ia