initial exploration showed large volume blood and clot in pelvis thus the decision was made to convert to midline laparotomy.
The incision was carried down through the skin down to the fascia layer and into the abdomen. The blood was fully suctioned and a free bullet was removed from the pelvis. Attention was given to run the small bowel from the ligament of treitz to the cecum which showed proximal small bowel injury x 7 with injury to mesentery with venous bleeding. Attention was than given to examine the proximal rectum up to the left colon and splenic flexure to the transverse colon and the ascending colon and cecum and no pathology or injury was noted. The mesentery of the large bowel was examined and no injury was noted. The stomach was also free of an injury as well as the spleen and liver. We than made to decision to perform 2 segmental resections to incorporate all of the injuries to small bowel using GIA 80 staplers and performing side to side stapled anastomosis x 2. The staple line was oversewn with silk, and the mesenteric defect closed with silk suture as well. After a secondary review of the viscus was completed and no injury was noted the decision was made full irrigate the abdomen with 6 liters of irrigation given contamination from the bullet injuries to bowel. Aricpet irrigation was used as well and once the aspirate was clear a 19f blake drain was placed into the pelvis via RLQ incision. Drain secured with nylon suture. Once hemostasis was established, the fascia was closed with number 1 PDS both superiorly and inferiorly and tied to each other. The midline wound was irrigated and skin was closed with staples. Attention was than given to fully irrigate the 8 missle wounds in bilateral forearms and right thigh (2 cm missle wounds each) and close with skin staples. A sterile dressing was applied on all wounds. A incisional wound vac was placed over midline incision.
The incision was carried down through the skin down to the fascia layer and into the abdomen. The blood was fully suctioned and a free bullet was removed from the pelvis. Attention was given to run the small bowel from the ligament of treitz to the cecum which showed proximal small bowel injury x 7 with injury to mesentery with venous bleeding. Attention was than given to examine the proximal rectum up to the left colon and splenic flexure to the transverse colon and the ascending colon and cecum and no pathology or injury was noted. The mesentery of the large bowel was examined and no injury was noted. The stomach was also free of an injury as well as the spleen and liver. We than made to decision to perform 2 segmental resections to incorporate all of the injuries to small bowel using GIA 80 staplers and performing side to side stapled anastomosis x 2. The staple line was oversewn with silk, and the mesenteric defect closed with silk suture as well. After a secondary review of the viscus was completed and no injury was noted the decision was made full irrigate the abdomen with 6 liters of irrigation given contamination from the bullet injuries to bowel. Aricpet irrigation was used as well and once the aspirate was clear a 19f blake drain was placed into the pelvis via RLQ incision. Drain secured with nylon suture. Once hemostasis was established, the fascia was closed with number 1 PDS both superiorly and inferiorly and tied to each other. The midline wound was irrigated and skin was closed with staples. Attention was than given to fully irrigate the 8 missle wounds in bilateral forearms and right thigh (2 cm missle wounds each) and close with skin staples. A sterile dressing was applied on all wounds. A incisional wound vac was placed over midline incision.