Feasibility and Usability of Intraoperative Fluorescent Angiography With Indocyanine Green in Penetrating Abdominal Trauma

The surgical management of penetrating bowel and intestinal injuries has been the topic of debate since before the second world war [1-3]. The injury is most often inflicted via a gunshot or knife stabbing. Different classifications systems have been proposed to help determine the best operative option: (i) Flint Grading System (FGS); (ii) Penetrating Abdominal Trauma Index (PATI); (iii) Colonic/Rectal Injury Scale (CIS/RIS); and (iv) destructive/non-destructive colonic injuries; (v) Stone and Fabian's criteria [2,3,10-14].

Principally, a penetrating injury of the intestine can be managed by: (i) primary repair (suturing the hole in the intestine); (ii) primary diversion (the intestine, above the injury, is brought through the abdominal wall as a "stoma") or (iii) an abbreviated primary operation (laparotomy, where large bleeding is stopped and destroyed tissue is removed) and planned reoperation, within 24-48 hours, for definitive treatment (final treatment, for example reconnecting intestinal ends). The concept of abbreviated primary operation, also known as "damage control surgery", is today well established in trauma care [4-6]. A damage control operation with regards to intestinal injury, entails a primary resection/removal of the affected intestinal segment in which the remaining intestinal ends are closed off and not surgically connected (anastomosed) in the first operation.[4-9]. The abdomen is left "open" (the incision through the abdominal wall is not sutured closed but covered with a temporary dressing), and a relaparotomy (re-operation) is conducted once the patient is stabilized (at the end of which the abdominal wall is closed), usually after 24-48 h [4-9]. During the re-laparotomy, the intestines will then either be anastomosed (re-connected), or a stoma will be created if the intestine is deemed too damaged to be re-connected [4-9].

Non-destructive colonic injuries (Flint grades 1 & 2 and CIS grades I to III) are generally treated with primary repair, which involves the identification, debridement and single-layer suture repair of perforation and then dressing the repaired site with omentum (an intra-abdominal layer of fat and vessels) [1,2,10,12]. Primary repair is generally considered the better option in this setting [1-3,28].

Destructive colon wounds (Flint grade 3 or CIS grades IV and V) encompass those injuries that require segmental resection (parts of the large intestine have to be removed) due to extensive damage or loss of blood supply or both [10,12]. The management of destructive colon wounds is less clear and is still debatable. However, primary repair has been deemed as a safe option, while primary diversion has been opted for in particular cases [1-3,9,11,29-33]. In unstable patients; those with hypovolemic shock (large blood loss), blood-poisoning due to intestinal content leaking into the abdominal cavity, systemic hypothermia (low body temperature), and complex intra-abdominal injuries; an abbreviated laparotomy is considered to be an appropriate course of action [7,11,30,32-34].

In colonic trauma, the anastomosis leak rate (the connection between to intestinal ends breaks down) is reported between 4-27% [34-37]. A leak in the sight of intestinal connection is a severe complication which greatly increases the length of hospitalization, increases patient morbidity and has a significant negative impact on patient's recovery. The mortality rate for an anastomotic leak around 10-15% [38,39]. Factors associated with anastomotic failure include co-morbid immune-compromising disorders such as diabetes mellitus, acquired immunodeficiency syndrome, cirrhosis and a transfusion requirement of more than six units of blood [36]. Other potential risk factors appear to be shock, significant associated injuries, and delay of operation [35,36].