1. Stomach and Small Intestine Gastric wounds can be oversewn with a running single-layer suture line or closed with a stapler. If a single-layer closure is chosen, full- thickness bites should be taken to ensure hemostasis from the well-vascularized gastric wall.

2. Stomach and Small Intestine The most commonly missed gastric injury is the posterior wound of a totally penetrating injury. Injuries also can be overlooked if the wound is located within the mesentery of the lesser curvature or high in the posterior fundus. To delineate a questionable injury, the stomach can be digitally occluded at the pylorus while methylene blue-colored saline is instilled via a nasogastric tube.

3. Stomach and Small Intestine Alternatively, air can be introduced via the NG tube with the abdomen filled with saline

4. Stomach and Small Intestine Partial gastrectomy may be required for destructive injuries, with resections of the distal antrum or pylorus reconstructed using a Billroth procedure. Patients with injuries that damage both Latarjet nerves or vagi should undergo a drainage procedure

5. Small Intestine Small intestine injuries can be repaired using a transverse running 3-0 PDS suture if the injury is less than one- third the circumference of the bowel. Destructive injuries or multiple penetrating injuries occurring close together are treated with segmental resection followed by end-to-end anastomosis using a continuous, single-layer 3-0 polypropylene suture. Mesenteric injuries may result in an ischemic segment of intestine, which mandates resection.

6. Small Intestine Multiple studies have confirmed the importance of early total enteral nutrition (TEN) in the trauma population, particularly its impact in reducing septic complications. The route of enteral feedings (stomach vs. small bowel) tends to be less important, because gut tolerance appears equivalent unless there is upper GI tract pathology.

7. Small Intestine Although early enteral nutrition is the goal, evidence of bowel function should be apparent before advancing to goal tube feedings. Overzealous jejunal feeding can lead to small bowel necrosis in the patient recovering from profound shock. Patients undergoing monitoring for nonoperative management of grade II or higher solid organ injuries should receive nothing by mouth for at least 48 hours in case they require an operation.

8. Small Intestine Although there is general reluctance to initiate TEN in patients with an open abdomen, a recent multicenter trial demonstrates TEN in the postinjury open abdomen is feasible

9. Small Intestine For those patients without a bowel injury, TEN was associated with higher fascial closure rates, decreased complications, and decreased mortality. TEN in patients with bowel injuries does not appear to alter fascial closure rates, complications, or mortality; hence EN appears to be neither advantageous nor detrimental in these patientsOnce resuscitation is complete, initiation of TEN, even at trophic levels (20 mL/h), should be considered in all injured patients with an open abdomen.

10. Duodenum and Pancreas The spectrum of injuries to the duodenum includes hematomas, perforation (blunt blow- outs, lacerations from stab wounds, or blast injury from gunshot wounds) and combined pancreaticoduodenal injuries

11. Duodenum The majority of duodenal hematomas are managed nonoperatively with nasogastric suction and parenteral nutrition. Patients with suspected associated perforation, suggested by clinical deterioration or imaging with retroperitoneal free air or contrast extravasation, should undergo operative exploration. A marked drop in nasogastric tube output heralds resolution of the hematoma, which typically occurs within 2 weeks; repeat imaging to confirm these clinical findings is optional. If the patient shows no clinical or radiographic improvement within 3 weeks, operative evaluation is warranted.

12. Duodenum Small duodenal perforations or lacerations should be treated by primary repair using a running single-layer suture of 3-0 monofilament. The wound should be closed in a direction that results in the largest residual lumen. Challenges arise when there is a substantial loss of duodenal tissue

13. Duodenum Extensive injuries of the first portion of the duodenum (proximal to the duct of Santorini) can be repaired by debridement and end- toend anastomosis because of the mobility and rich blood supply of the distal gastric atrium and pylorus

14. Duodenum In contrast, the second portion is tethered to the head of the pancreas by its blood supply and the ducts of Wirsung and Santorini; therefore, no more than 1 cm of duodenum can be mobilized away from the pancreas, and this does not effectively alleviate tension on the suture line. Moreover, suture repair using an end-to-end anastomosis in the second portion often results in an unacceptably narrow lumen defects in the second portion of the duodenum should be patched with a vascularized jejunal graft.

15. Duodenum Duodenal injuries with tissue loss distal to the papilla of Vater and proximal to the superior mesenteric vessels are best treated by Roux- en-Y duodenojejunostomy with the distal portion of the duodenum oversewn

16. Roux-en-Y duodenojejunostomy

17. Duodenum Pyloric exclusion is used to treat combined injuries of the duodenum and the head of the pancreas as well as isolated duodenal injuries when the duodenal repair is less than optimal. The pylorus is oversewn through a gastrotomy, which is subsequently used to create a gastrojejunostomy. The authors frequently use needle-catheter jejunostomy tube feedings for these patients

18. Pyloric exclusion

19. Duodenum In particular, injuries in the distal third and fourth portions of the duodenum (behind the mesenteric vessels) should be resected, and a duodenojejunostomy performed on the left side of the superior mesenteric vessels.

20. Colon and Rectum three methods for treating colonic injuries are used: primary repair, end colostomy, and primary repair with diverting ileostomy.

21. Colon and Rectum Primary repairs include lateral suture repair or resection of the damaged segment with reconstruction by ileocolostomy or colocolostomy. All suturing and anastomoses are performed using a running single-layer technique The advantage of definitive treatment must be balanced against the possibility of anastomotic leakage if suture lines are created under suboptimal conditions

22. Colon and Rectum Alternatively, although use of an end colostomy requires a second operation, an unprotected suture line with the potential for breakdown is avoided. Numerous large retrospective and several prospective studies have now clearly demonstrated that primary repair is safe and effective in virtually all patients with penetrating wounds

23. Colon and Rectum Colostomy is still appropriate in a few patients, but the current dilemma is how to select which patients should undergo the procedure. Currently, the overall physiologic status of the patient, rather than local factors, directs decision making. Patients with devastating left colon injuries requiring damage control are clearly candidates for temporary colostomy. Diverting ileostomy with colocolostomy, however, is used for most other high-risk patients.

24. Colon

25. A.The running, single-layer suture is started at the mesenteric border. B. Stitches are spaced 3 to 4 mm from the edge of the bowel and advanced 3 to 4 mm, including all layers except the mucosa. C. The continuous suture is tied near the antimesenteric border.

26. Rectal injuries Rectal injuries are similar to colonic injuries with respect to the ecology of the luminal contents, overall structure, and blood supply of the wall, but access to extraperitoneal injuries is limited due to the surrounding bony pelvis. Therefore, indirect treatment with intestinal diversion usually is required. The current options are loop ileostomy and sigmoid loop colostomy.

27. Rectal injuries For sigmoid colostomy, technical elements include: (a) adequate mobilization of the sigmoid colon so that the loop will rest on the abdominal wall without tension, (b) maintenance of the spur of the colostomy (the common wall of the proximal and distal limbs after maturation) above the level of the skin with a one-half- inch nylon rod or similar device, (c) longitudinal incision in the tenia coli, and (d) immediate maturation in the OR

28. Loop colostomy will completely divert the fecal flow

29. Rectal injuries If the injury is accessible (e.g., in the posterior intraperitoneal portion of the rectum), repair of the injury should also be attempted. However, it is not necessary to explore the extraperitoneal rectum to repair a distal perforation.

30. Rectal injuries If the rectal injury is extensive, another option is to divide the rectum at the level of the injury, oversew or staple the distal rectal pouch if possible, and create an end colostomy (Hartmann’s procedure).

31. Rectal injuries Extensive injuries may warrant presacral drainage with Penrose drains placed along Waldeyer’s fascia via a perianal incision In rare instances in which destructive injuries are present, an abdominoperineal resection may be necessary to avert lethal pelvic sepsis.

32. Complications Complications related to colorectal injuries include intraabdominal abscess, fecal fistula, wound infection, and stomal complications. Intra-abdominal abscesses occur in approximately 10% of patients, and most are managed with percutaneous drainage. Fistulas occur in 1% to 3% of patients and usually present as an abscess or wound infection with subsequent continuous drainage of fecal output; the majority will heal spontaneously with routine care

33. Stomal complications Stomal complications (necrosis, stenosis, obstruction, and prolapse) occur in 5% of patients and may require either immediate or delayed reoperation. Stomal necrosis should be carefully monitored, because spread beyond the mucosa may result in septic complications, including necrotizing fasciitis of the abdominal wall.

34. osteomyelitis. Penetrating injuries that involve both the rectum and adjacent bony structures are prone to development of osteomyelitis. Bone biopsy is performed for diagnosis and bacteriologic analysis treatment entails longterm IV antibiotic therapy and occasionally debridement.

35. Damage Control Surgery Indications to limit the initial operation and institute DCS techniques include a combination of refractory hypothermia (temperature <35°C), profound acidosis, (arterial pH <7.2, base deficit <15 mmol/L), refractory coagulopathy

36. Damage Control Surgery The second key component of DCS is limiting enteric content spillage. Small GI injuries (stomach, duodenum, small intestine, and colon) may be controlled using a rapid whipstitch of 2-0 polypropylene. Complete transection of the bowel or segmental damage is controlled using a GIA stapler, often with resection of the injured segment. Alternatively, open ends of the bowel may be ligated using umbilical tapes to limit spillage.