An experience with 31 patients who developed major bleeding diatheses during laparotomy was reviewed. Management of the initial 14 patients was by standard hematologic replacement, completion of all facets of operation, and then closure of the peritoneal cavity, usually with suction drainage; only one patient survived. The subsequent 17 patients had laparotomy terminated as rapidly as possible to avoid additional bleeding. Major vessel injuries were repaired; ends of resected bowel were ligated; and holes in other gastrointestinal segments and the bladder were closed by purse-string sutures. One patient had a ureter ligated. Laparotomy pads (4-17) were then packed within the abdomen to effect tamponade, and the abdomen was closed under tension without drains or stomata. Following correction of the coagulopathy, the abdomen was re-explored at 15 to 69 hours in the 12 survivors. Definitive surgery then was completed: bowel resection and reanastomosis; ureter reimplantation; drains for bile, pancreatic juice, and urine; and stomata for bowel or urine diversion or decompression. Eleven of 17 patients, deemed to have a lethal coagulopathy, survived. This technique of initial abortion of laparotomy, establishment of intra-abdominal pack tamponade, and then completion of the surgical procedure once coagulation has returned to an acceptable level has proven to be lifesaving in previously non-salvageable situations.

Antibiotic prophylaxis for surgery has appeared indicated whenever likelihood of infection is great or consequences of such are catastrophic. For better clarification, a prospective, randomized, double-blind study was run on 400 patients undergoing elective gastric, biliary, and colonic operations. There were four treatment categories, with antibiotic being instituted 12 hours preoperatively, just prior to operation, after operation, or not at all. During operation, samples of blood, viscera, muscle, and fat were taken for determination of antibiotic concentration. Both aerobic and anareobic cultures were also taken of any viscus entered, peritoneal cavity, and incision. Similar cultures were run on all postoperative infections. Results demonstrated that the incidence of wound infection could be reduced significantly by the preoperative administration of antibiotic in operations on the stomach (22% to 4%), on the biliary tract (11% to 2%), and large bowel (16% to 6%). Less impressive results were obtained for peritoneal sepsis. Initiation of antibiotic postoperatively gave an almost identical infection rate as if antibiotic had not been given (15% and 16%, respectively).

During a 44 month trial, 268 patients with wounds of the colon were entered into a prospective, randomized, nonblinded study. Consideration for primary closure demanded that: preoperative shock was never profound, blood loss was less than 20% of estimated normal volume, no more than two intra-abdominal organ systems had been injured, fecal contamination was minimal, operation was begun within eight hours, and wounds of colon and abdominal wall were never so destructive as to require resection. Once such criteria had been satisfied, colon wound management was dictated by last digit in the randomly assigned hospital number; odd indicated primary closure; even, exteriorization of the wound or primary closure with protection by a proximal vent. Results obtained in 139 determinant patients eligible for randomization revealed that primary closure (67 patients) had a lower infection rate of the incision (48% vs S7%, p > 0.05) and a still lower infection rate for the abdomen proper (15% vs 29%, p < 0.05) on comparison to the 72 patients with a randomized colostomy. Morbidity otherwise for the randomized colostomy was tenfold greater than if a primary closure had been performed. Average postoperative stay was six days longer (p < 0.01) if a colostomy had been created, exclusive of subsequent hospitalization for colostomy closure; while the total extra cost for management of the colon wound by colostomy was approximately $2,700.00. Although immediate mortalities were identical, one late death occurred following colostomy closure. These data not only confirm the safety of primary closure for colon wounds in selected cases, but also indicate that such should become the preferred method of treatment whenever specific criteria have been met.

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Previous studies have demonstrated that administered antibiotics must be active against major anticipated pathogens and must have reached sufficient concentrations in the tissue or body fluid at risk by the time of bacterial challenge if prophylactic therapy is to be maximally effective in reducing the infection rate of potentially contaminated surgery. The need for continuing antibiotic prophylaxis beyond the day of operation, however, has been uncertain. In a prospective, randomized, double-blind study of 220 patients undergoing elective gastric, biliary or colonic surgery, perioperative administration of cefamandole plus five days of placebo was compared to perioperative plus five days of postoperative antibiotic therapy; no significant difference was found between the groups in the rate of infection of wound (6 and 5%, respectively), peritoneum (2% each) and elsewhere (6% and 5%). In another prospective, randomized, nonblind study of 451 determinant cases of 1,624 patients undergoing emergency laparotomy, cephalothin was instituted preoperatively but after peritoneal contamination had occurred (i.e., abdominal trauma, etc.); continued postoperative antibiotic again failed to reduce further the wound and peritoneal infection rates, as noted on comparing perioperative therapy alone (infection rates 8 and 4%, respectively) with perioperative plus 5-7 days of postoperative treatment (10% and 5%, respectively). Analysis of these data, as well as of the extra expenses incurred by 463 patients because of infection in a previous prophylactic antibiotic study, revealed an average additional expenditure of $2,686.00 for each instance of postoperative infection of the wound and/or peritoneum; whereas savings of $300.00 per patient at risk were obtained whenever appropriate prophylactic antibiotic had been given.

During a 23-year interval, 83 patients with wounds of the portal and/or superior mesenteric veins underwent emergency laparotomy. Six (7%) of the injuries were due to blunt trauma, while penetrating wounds accounted for the remaining 77 (93%). With one exception, associated organ injuries were routinely present and involved 120 other major vascular structures in 59 (71%) of the patients. Five patients with both portal and superior mesenteric vein injury and 3 others with isolated portal venous injury exsanguinated before repair could be accomplished.Lateral phleborrhaphy gave survival in 24 of 34 patients so treated. End-to-end reanastomosis of the portal vein was successful in only 1 of 3 patients on whom it was attempted, while the single portacaval shunt led to a metabolic death. Of the initial 17 patients having vein ligation as a desperation measure, there were 7 survivors. Subsequent immediate application of this technique whenever lateral repair was impossible or impractical was successful in 17 of 20 so managed.Death resulted from hemorrhagic shock (20), its attendant coagulopathy (7), or renal failure (2) in 29 patients. Two deaths were the result of failure to over-transfuse appropriately when portal venous ligation or thrombosis with its attendant splanchnic sequestration led to significant peripheral hypovolemia. The overall mortality rate was 41%, with individual mortality rates of 46 % and 27 % for the portal and superior mesenteric veins, respectively. There was no survival if both veins had been injured.

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.