Experience of treating gunshot wounds of large vessels in Afghanistan.

The problem of treating injuries of large vessels in times of peace has been sufficiently well developed both in theoretical and practical aspects. In times of war, however, due to the large numbers of the wounded, a shortage of expert angiosurgeons, and multiple gunshot wounds, many theoretical tenets lose their academic regularity. The present study is based on the experience of treating 302 patients wounded during the Afghanistan war (1981-1985). Most of the injuries were to the vessels of the extremities. The gunshot wounds were complex. They included extensive destruction of tissue in the damaged segments of the extremities with simultaneous damage of large veins (42.0% of the cases), nerves (45.5%), and bones (47.4%). Multiple-vessel injuries were encountered in 4% of the cases, with combined injuries comprising 17.5%. Most of the wounded (83.7%) were in a state of shock, with 6.4% in a terminal condition. The blood loss amounted to 15% to 65% of the total volume. Ninety percent of the wounded were admitted to hospitals in the first 6 hours. A two-stage method was used to treat 71 of the wounded. The method included temporary bypass of the injured arteries and veins while evacuating the wounded and during surgery. Two hundred ninety-five wounded underwent vessel surgery. Out of the total number of injuries of arteries and veins, vessel sutures were used in 36.9% and 35.9% of the cases, vessel plastics in 41.4% and 7.1% of the cases, and vessel ligation in 21.7% and 60.0% of the cases, respectively. Surgery was completed by fixing the bone fragments externally with the help of special devices using the Ilizarov method. Amputation was performed in 13.9% of the cases. In 7.3% of the cases amputation was performed according to primary indications (no reconstructive surgery attempted on the vessels). In 6.6% of the cases extremities were amputated during the early postoperative period as a result of vessel thrombosis and an increase of tissue ischemia. The mortality rate after vessel surgery was 5.3%. We believe that for patients with gunshot wounds involving vessel injuries, early one-time reconstruction of the destroyed anatomical structures should be performed.

Operative videothoracoscopy in the surgical treatment of penetrating firearms wounds of the chest.

We prospectively analyzed our experience with operative videothoracoscopy (OVT) performed in a field military hospital in cases of penetrating firearms wounds of the thorax (PFAWT) sustained in Chechnya. From February to April 1996, we treated 206 wounded patients, of whom 37 (18.0%) had sustained chest injuries. PFAWT were present in 23 soldiers, accounting for 62.2% of all chest injuries. Twelve injuries were confined to the thorax, eight patients had associated injuries, and three soldiers had thoracoabdominal injuries. Nineteen patients had pleural drainage performed during medical evacuation. The thoracic injuries were right-sided (17), involved bullets or shell splinters (23); were through and through (16), represented solitary wounds (19), and were associated with internal organ injuries (21). Fifteen patients had indications for OVT when they were delivered from the battle-field 1.5 to 22 hours after injury. All patients manifested signs of hemorrhagic shock and hemodynamic instability. Indications for OVT were ongoing intrapleural bleeding (6), clotted hemothorax (6), or marked air leakage (3) preventing lung inflation with the OP-02 apparatus (field modification). OVT revealed 12 lung wounds, nine of which were multiple wounds, pleural bleeding in 6 patients, clotted hemothorax in 11 patients, and foreign bodies in 5 patients. Two patients underwent thoracotomy, one for suspicion of heart injury and the second because we could not adequately visualize and control bleeding revealed at OVT to be from the intercostal artery in the left costovertebral angle. Eight of 23 patients had no indication for operative videothoracoscopy and were managed with continued pleural aspiration and drug therapy. Wedge resection of the lung using an Endo-GIA-30 stapler was necessary in two patients because of parenchymal destruction and bleeding. Evacuation of clotted blood by fragmentation and aspiration was satisfactory in all cases. Satisfactory manual suturing of selected lung injuries was obtained largely with intracorporeal knot tying. The duration of the procedures ranged from 40 to 90 minutes. No morbidity nor mortality was encountered in patients undergoing OVT. Postoperative pain was minimized by using OVT placement of catheters in the chest wall soft tissue with local administration of 2% Trimecain. Patients were able to stand in 10 to 12 hours and to walk by the end of the first postoperative day. All patients who underwent OVT were evacuated without drains by the third or fourth postoperative day, all tolerating sitting and standing positions. We conclude that early OVT in the military field hospital for continued bleeding, clotted hemothorax, and continued major air leakage has several advantages in military patients with PFAWT: early definition and management of organ injury; identification and control of bleeding in most instances; earlier and more accurate assessment for thoracotomy; vigorous lavage and removal of projectiles such as bone fragments and evacuation of clotted hemothorax; early debridement with suture closure of the thoracic wall canal; and minimal postoperative pain with dramatically reduced suppurative sequelae and bronchopleural fistulae.