Abstract

Author as a trauma surgeon with Sri Lanka army has treated 21 soldiers during December 1999 to May 2001 at Military Hospital, Palaly, Jaffna who only sustained shrapnel injuries reaching liver substance through lower part of right thorax. Injuries were a result of soldier anticipating enemy with gun pointing forward when shrapnel from above ground blasts enter chest wall through weaker flanks of flak jackets. During ATLS assessment they had insertion of a chest drain to right side performed. This 21 patients qualified for thoracotomy on grounds of initial drainage or ongoing drainage as per ATLS guidelines. The group in study did not have abdominal distension and had only mild right hypochondrial tenderness. Chest X-ray revealed right haemothorax and some shrapnel in the liver substance which was confirmed on abdominal X-Ray. Although qualified for thoracotomy these patients underwent exploratory laparotomy first. After control of bleeding and mobilization of liver, diaphragmatic lacerations were repaired and liver lacerations managed with gelfoarm packs and sutures. Three of the patients had large liver lacerations and required damage control surgeries which were successful. Thoracotomy was not required in any. Understanding of exact mechanism of injury through knowledge of the profession is vital for effective assessment in trauma. Awareness and accurate assessment of described thoraco-abdominal injuries contributed to optimum management with exploratory laparotomy and avoid thoracotomy, a second major operation.