209. Sacral Penetration with Fragment Coming Out at the Umbilicus

Corcoran, Francis P., Rit. 33809006 Age 29 ‘G’ Co 141 Inf.
Injured 1100 hrs. 25 Oct. 44 Shell frag.
3rd Bn Aid Sta 141 Inf 1115 hrs. Sulf dressing  
Co A Coll Sta 1145 hrs. 2 units plasma Redressed
M.S. gr ½ 1205 hrs.
Clr. Sta 111th Med Bn 1300 hrs. No treat  
11th Field Hosp 1315 hrs.    

Gen’l condition on admission poor. Shock severe. Abdomen rigid ++++--tender++++. Hematoma just below umbilicus. B.P. 50/30 P.130. Marked pallor.

Diagnosis: S.F.W. Pen. sacrum sv.

Preop Rx: 500 cc blood 1513 hrs. 1400 hrs. 500 cc blood B.P. 70/40 P. 120. 1435 hrs. 500 cc blood. Catheterized urine neg.

1515 hrs. B.P. 160/40 P. 112 1000 cc blood started
1550 hrs. B.P. 100/50 P. 104 1000 cc 5% glucose in Sal. Surgery began.
1605 hrs. B.P. 80/40 P. 100 500 cc blood Pt. turned on back.
1620 hrs. B.P. 110/78 P. 100 500 cc blood.
1635 hrs. B.P. 78/30 P. 100 1000 cc blood
1700 hrs. B.P. 90/28 P. 96  
1710 hrs. B.P. 104/38 P. 92 500 cc blood.
1735 hrs. B.P. 98/40 P. 84 500 cc blood. Pt. sucked out.
1805 hrs. B.P. 110/36 P. 100  

Pt. turned on left side. Wound of sacrum just to left of midline debrided. Wound was 4 cms. in diameter. Loose bone fragments excised. Feces and blood poured from this wound. Bleeding controlled and pt. turned on back. F.B. was subcutaneous in midline 5 cms. below umbilicus. Midline incision was made. F.B. removed (2x3x3 cms.). Peritoneal cavity was full of blood and fecal material which kept welling up as it was mopped out. Pelvis was exposed and the rectum was found to be torn across its posterior wall at the junction of the intra and extra peritoneal positions. The midsacral artery was actively bleeding. This was ligated. Bleeding at site of rectal tear was controlled. Hollow of sacrum was exposed retro-rectally as the missile directed upwards. Deep in pelvis when the rectum was packed off anteriorly, the sacral wd. could be seen. This tract was packed off temporarily. The small gut was explored. Two feet of ileum contained 8 perforations, three of which were complete transections. The mesentery supplying this loop of bowel was torn by the F.B. and was bleeding actively. Two feet of ileum were resected. End to end anastomoses done. Pelvic pack removed. Rectal tear closed with chromic catgut and the suture line was then turned extra peritoneally as a new pelvic floor was made over it. A penrose cigarette drain had been led from the retro-rectal space inferiorly and was delivered thru sacral wd. Pelvic floor closed over this drain. Sigmoid loop colostomy brought out thru left inguinal stab wd. 10 gms. sulf into peritoneal cavity (Bladder explored--neg.). Four retention silk sutures thru all layers. Abdomen closed in layers. Pt. turned on side and penrose drain which had been inserted from above was delivered thru sacral wd. This drain had been inserted from above. This did not transgress lumen of rectum but lies retro to rectum.

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