Laparotomy questions

Dani · Nov 8, 2011

I have a few questions basically.

A bullet wound through the abdomen that perforated the colon and small intestines and nicked a small artery (but not any other major organs) - would this automatically call for a laparotomy? Or would laproscopy be an option?

In both cases, is the risk of peritonitis 24-48 hours?

Is it possible peritonitis would not develop at all?

During the 24-48 hours, how do they know the risk has been reduced? Is it just time in general or the way the patient is healing/blood work etc?

Thanks so much in advance for your responses.

crunchyblanket · Nov 8, 2011

If the bullet perforates the colon, infection is highly likely. Intestinal bacteria and fecal matter is released into the abdominal cavity, and you'll be very lucky to avoid peritonitis. The risk is reduced depending on how large the perforation is, and therefore how much intestinal matter is released.

Perforation is considered an emergency, and sepsis would likely set in within the first 24-48 hours without intervention. Usually, they'll perform an exploratory laparotomy to find the site of the perforation and close it up, followed by a peritoneal wash and a course of strong antibiotics.

The patient would be closely monitored for infection - obvious signs are fever, high white blood cell count (a full blood count test would detect this) and abdominal rigidity, which would indicate the presence of gas and/or pus.

Dani · Nov 8, 2011

crunchyblanket said:
If the bullet perforates the colon, infection is highly likely. Intestinal bacteria and fecal matter is released into the abdominal cavity, and you'll be very lucky to avoid peritonitis. The risk is reduced depending on how large the perforation is, and therefore how much intestinal matter is released.

Perforation is considered an emergency, and sepsis would likely set in within the first 24-48 hours without intervention. Usually, they'll perform an exploratory laparotomy to find the site of the perforation and close it up, followed by a peritoneal wash and a course of strong antibiotics.

I've tried to keep this as realistic as possible without being too detrimental to the story. He was shot in the abdomen and no miracles occurred. I didn't say where he was shot specifically, I wanted to keep it vague because I don't want a lot of emo drama with it, but still wanted realism.

Would it be too miracle-ish for him not to suffer from peritonitis or sepsis (sic?)? The bullet went through and through. It was close range (point blank) from a police issue hand gun. The paramedics arrived within ten minutes and he was taken immediately to hospital. He didn't lose consciousness, nor did he suffer from shock.

crunchyblanket said:
The patient would be closely monitored for infection - obvious signs are fever, high white blood cell count (a full blood count test would detect this) and abdominal rigidity, which would indicate the presence of gas and/or pus.

When would they decide he was out of the woods? Would he show sings of improvement or is it just a matter of 'this much time has elapsed without symptoms?

Thanks again for your help -=).

crunchyblanket · Nov 8, 2011

He was shot in the abdomen and no miracles occurred. I didn't say where he was shot specifically, I wanted to keep it vague because I don't want a lot of emo drama with it, but still wanted realism.

It would be possible to be shot in the abdomen/torso and have no major organs hit - it's unusual, as far as I know, but it does happen.

Would it be too miracle-ish for him not to suffer from peritonitis or sepsis (sic?)?

If the doctors are prompt, it's perfectly possible for him to 'get away with it', so to speak. If there's an intestinal perforation and they seal it up, and wash out the abdominal cavity pretty quickly, the chances of infection are lessened. Of course, if there's no intestinal perforation to start with, you've only got wound infection to contend with, as opposed to organ rupture.

When would they decide he was out of the woods? Would he show sings of improvement or is it just a matter of 'this much time has elapsed without symptoms?

When we're monitoring patients for infection, we'll usually run a blood culture, which takes (for us) 48 hours. This determines the presence of bacteria in the blood. Sometimes, we'll do a wound swab too, which takes 24 hours (again, this is in our lab, times may vary) If a patient is making a good recovery - full mobility, no fever (apyrexial), good haemoglobin and white blood cell levels, they'll usually be discharged. For trauma cases, I would say the minimum observation period would be 48 hours.

Dani · Nov 8, 2011

crunchyblanket said:
It would be possible to be shot in the abdomen/torso and have no major organs hit - it's unusual, as far as I know, but it does happen.

If the doctors are prompt, it's perfectly possible for him to 'get away with it', so to speak. If there's an intestinal perforation and they seal it up, and wash out the abdominal cavity pretty quickly, the chances of infection are lessened. Of course, if there's no intestinal perforation to start with, you've only got wound infection to contend with, as opposed to organ rupture.

When we're monitoring patients for infection, we'll usually run a blood culture, which takes (for us) 48 hours. This determines the presence of bacteria in the blood. Sometimes, we'll do a wound swab too, which takes 24 hours (again, this is in our lab, times may vary) If a patient is making a good recovery - full mobility, no fever (apyrexial), good haemoglobin and white blood cell levels, they'll usually be discharged. For trauma cases, I would say the minimum observation period would be 48 hours.

I think you're quite possibly the best human being ever =). Thanks for your answers and your time in responding. It's very much appreciated.

GeorgeK · Nov 8, 2011

Dani said:
I have a few questions basically.

A bullet wound through the abdomen that perforated the colon and small intestines and nicked a small artery (but not any other major organs) - would this automatically call for a laparotomy? Or would laproscopy be an option?

In both cases, is the risk of peritonitis 24-48 hours?

Is it possible peritonitis would not develop at all?

During the 24-48 hours, how do they know the risk has been reduced? Is it just time in general or the way the patient is healing/blood work etc?

Thanks so much in advance for your responses.

Laparoscopic vascular surgery is not something that you are likely to find at any typical hospital and most arteries in the viscera are not likely to stop bleeding on their own. The standard in most places will be a CT (since the patient is not in shock) followed by an exploratory laparotomy. Since the surgery is also involving unprepped perforated bowel, don't be surprised when the patient wakes up with a colostomy. They'll reverse it in about 3 months. Also although the abdominal wall will be closed, the skin might not be. There will be several drains. There's a bunch of variables but antibiotics and watchful waiting is not in his future.

It is theoretically possible to survive without treatment. Appendicitis left untreated has a 25% survival rate, but a very morbid 2-5 year recovery. Realistically without treatment he'll get a more and more swollen and painful abdomen over the next 3-5 days. Then when the bacteria hit the bloodstream the pain will lessen as he loses lucidity and consciousness and probably die in 1-2 days.

Dani · Nov 8, 2011

GeorgeK said:
don't be surprised when the patient wakes up with a colostomy.

I had COMPLETELY forgotten about this and I meant to ask about it! Awesome. Thanks so much! (LOL I was actually doing a google search on colostomy and gunshots when I got the notification of this reply.)

GeorgeK said:
They'll reverse it in about 3 months. Also although the abdominal wall will be closed, the skin might not be. There will be several drains. There's a bunch of variables but antibiotics and watchful waiting is not in his future.

He wouldn't receive antibiotics? How long would the drains be in and the skin be opened? Would he remained hospitalized while that was open?

GeorgeK said:
It is theoretically possible to survive without treatment. Appendicitis left untreated has a 25% survival rate, but a very morbid 2-5 year recovery. Realistically without treatment he'll get a more and more swollen and painful abdomen over the next 3-5 days. Then when the bacteria hit the bloodstream the pain will lessen as he loses lucidity and consciousness and probably die in 1-2 days.

No worries, he's treated right away. He's in hospital. He's had the exploratory laparatomy (I researched this part pretty well) and he's in recovery. I just need the rest of my story in the proper setting. (which is either at home, recovering, or in hospital recovering).

GeorgeK · Nov 8, 2011

Oh, he'd get antibiotics, just not ONLY antibiotics. If you had to pick either surgery or antibiotics, surgery would be the better option, but they'd still use antibiotics. The drains will be in until they are draining normal amounts of normal looking fluids. In a best case scenario three days. The skin if left open woul not be closed. It would be allowed to close by secondary intent and would go home on dressing changes, moist fresh gauze repacked into the wound 2-3 times a day until it's all dry, probably 1-3 weeks.

Dani · Nov 8, 2011

Thank you both so much for your help. This community is beyond awesome and helpful. I appreciate your time =).

Laparotomy questions

Dani

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crunchyblanket

the Juggernaut of Imperfection

Dani

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crunchyblanket

the Juggernaut of Imperfection

Dani

Cuddly sweet teddy bear!

GeorgeK

ever seeking

Dani

Cuddly sweet teddy bear!

GeorgeK

ever seeking

Dani

Cuddly sweet teddy bear!