[German education for treatment of penetrating gut traumata in army service]

[Approach to liver, spleen and pancreatic injuries including damage control surgery of terrorist attacks]

BACKGROUND

Terrorist attacks have outreached to Europe with more and more attacks on civilians. Derived from war surgery experience and from lessons learned from major incidents, it seems mandatory for every surgeon to improve understanding of the special circumstances of trauma following a terrorist attack and its' management.

METHOD

A short literature review is followed by outlining the damage control surgery (DCS) principle for each organ system with practical comments from the perspective of a specialized hepatobiliary (HPB) surgery unit.

CONCLUSION

Every surgeon has to become familiar with the new entities of blast injuries and terrorist attack trauma. This concerns not only the medical treatment but also tailoring surgical treatment with a view to a lack of critical resources under these circumstances. For liver and pancreatic trauma, simple treatment strategies are a key to success.

[The value of thoracoscopy in thorax trauma]

A hemodynamically stable patient presenting with persistent bleeding through his chest tube (ICD) is a classic indication for early thoracoscopic intervention in trauma. The source of bleeding and air leaks can be identified and often treated: bleeding and perforated pulmonary segments can be resected, and chest wall bleeding may be coagulated or sutured. Injuries to the diaphragm are difficult to diagnose, as they might not be seen in conventional trauma imaging without gross herniation of intra-abdominal contents into the thoracic cavity. Identifying the site of diaphragm perforation can give useful hints in thoracoabdominal trauma, identifying injured cavities and localizing the bullet or stab tract. Most often, diaphragmatic defects may be closed during diagnostic thoracoscopy as well. Non- or partially drainable hemothorax is another indication for thoracoscopy. Coagulated blood can be mechanically mobilised, and aspirated or primary bleeding may be stopped. Effective lavage and a high-performance suction device are required. Correct placement of the drainage is part of optimized therapy, along with inspection of all intrathoracic organs and surfaces. Furthermore, surgical and anaesthesiological teamwork and experience are prerequisites for the fast, professional application of a minimally invasive thoracoscopic approach in chest trauma patients. Diagnostically and theurapeutically, thoracoscopy plays an important role in the trauma setting--in the case of hemodynamically stable patients.

[Procedures of temporary wall closure in abdominal trauma and sepsis]

Temporary abdominal closure methods differ mainly between vacuum-assisted and conventional approaches. Each method has its indications. Vacuum-assisted methods seem to be superior especially for trauma indications--in terms of lethality, the possibility of secondary closure during primary hospital stay, and frequency of enterocutaneous fistulas. Skin-only closure might be used as a short-term application (e.g. when damage control closure is needed), and the Bogota bag silo gives space to protruding bowels in pending or manifest abdominal compartment syndrome. Temporary fascial mesh closure enables repetitive laparotomies through the mesh, thus sparing the fascia. For that reason it is to be preferred, especially for its good practicability in clinical situations and on mission abroad.

[Penetrating injuries to the pelvis]

As criminality and weapon use increase, general and military surgeons are increasingly confronted with penetrating pelvic injuries both at home and on peacekeeping missions. Penetrating injuries to the iliac vascular axis are associated with considerable mortality, and thus the majority of these emergency patients arrive in a state of deep hypovolemic shock. Concomitant bowel injuries are present in one of five cases, resulting in contamination of the damaged area. Surgical options are simple lateral repair, ligation of the veins, temporary shunt insertion, and prosthetic graft interposition in the injured artery. In extremis ligation of the common or external iliac artery may be the only option to save the patient's life. Surgeons must be aware that damage control surgery and related methods may be needed early on to enable patient survival.