Middle East and North African (MENA) regions have engaged in many wars in the past few decades. Reference Willy, Hauer and Huschitt1 For instance, the Middle East has suffered from Arab-Israeli wars, the Lebanese civil war, the Iraqi War, and recently the Syrian armed conflict (SAC). Unstable political situations in MENA states, violence, and terrorist attacks were on the rise. There is a surge of preventable civilian mortality and morbidity in conflict and war, especially in MENA regions, and since 2011, the SAC has put many Syrian civilians’ lives in danger.
Bombings and terrorist attacks cause large numbers of causalities, which require urgent assessment and management. The continuous influx of injured people limits the tests that are possible to use and proves to be a challenge for medical teams. Reference Frykberg2
In the past century, plain radiography of the abdomen and diagnostic peritoneal lavage (DPL) were used to assess penetrating abdominal trauma. Those methods resulted in many false positive results, making DPL a controversial method of assessing penetrating trauma patients. Reference Biffl and Leppaniemi3 The Second World War gave way to laparotomy to increase the survival of such cases, which were previously managed by observation. Reference Ferrada and Birolini4
Damage control surgery (DCS) is a 3-phased technique of surgery used to save the lives of severely injured trauma patients. Phase I is based on “abbreviated laparotomy” that is done for hemorrhage and contamination control, followed by temporary abdominal closure. Phase II targets correcting hypothermia, coagulopathy, and acidosis in the intensive care unit (ICU), after which phase III of re-exploration is undertaken for definitive management of injuries and abdominal closure. Reference Chaudhry, Tiwari and Singh5
Damage control resuscitation (DCR) is a strategy for resuscitating patients from hemorrhagic shock to restore homeostasis. Efforts are focused on blood product transfusion in which the use of crystalloid are limited to avoid dilutional coagulopathy, hypotensive resuscitation until bleeding control is achieved, empiric use of tranexamic acid, correction of acidosis and hypothermia, and rapid surgical control of hemorrhage. Reference Cap, Pidcoke and Spinella6
Mandatory laparotomy is the main management for patients with penetrating abdominal trauma having a positive FAST (focused assessment with sonography in trauma), while immediate laparotomy must be conducted when hemodynamic instability is present. Reference Biffl and Leppaniemi3,Reference Kortbeek, Al Turki and Ali7 Otherwise, a computed tomography (CT) scan should be done to assess and find the injury. Reference Biffl and Leppaniemi3 Constant factors are thought to play a great role in defining the types of injuries such as the mechanism of injury; whether caused by high-velocity gunshots, mortars, shrapnel, or improvised explosive devices (IEDs). Reference Willy, Hauer and Huschitt1
The types of organ injuries relate to the mortality rate, Reference Payravi, Mortaz and Fazel8 and the number of injured organ systems affects the final health status. Reference Morris and Sugrue9
The experience gained during wars and terrorist attacks—regardless of differing battle environments—helps to get a clear vision of trauma injuries and their management. Reference Frykberg and Tepas10,Reference Hadden, Rutherford and Merrett11 While reviewing the literature, a single study regarding SAC was done in Syrian medical facilities, Reference Arafat, Alsabek and Ahmad12 while all other studies were conducted in non-Syrian institutions. Reference Aras, Altas and Yilmaz13-Reference Iflazoglu, Ureyen and Oner29 In this study, we present 898 wartime abdominal injuries, considering that the management of abdominal injuries remains a challenge despite the evolving medical technologies in diagnosis and therapy. Reference Biffl and Leppaniemi3,Reference Frykberg and Tepas10,Reference Vertrees, Greer and Pickett30
METHODS
Study Design and Data Sources
After obtaining the required permission and the ethics committee approval, we reviewed the operating room (OR) logs of patients who presented to the surgical emergency department (SED) at Al-Mouwasat University Hospital suffering from traumatic injuries and underwent surgical intervention, then we extracted data about patients who were subject to exploratory laparotomy due to war-related penetrating abdominal trauma. Some patients’ data were missing in the OR logs. So, we retrieved the missing data from the hospital’s archive. Patients who died in the SED before reaching the OR were not included in our study design because their data were not registered in OR logs.
Al-Mouwasat University Hospital is a teaching hospital linked to the faculty of medicine in Damascus University. The hospital has 850 beds, 60 in the SED.
Our population was the patients who came to the SED at Al-Mouwasat University Hospital requiring exploratory laparotomy due to high-velocity gunshot and explosive device injuries between April 1, 2011 and December 31, 2017. However, data on laparotomies during the period from August 23, 2011 to June 2, 2012 were missing because of the war damage to record storage, so we excluded them.
Data Analysis
We collected data from patients’ records, sorted it into tables created with Microsoft Excel 2016, and arranged it in 7 categories: injury type, age, gender, admission date, affected organs, treatment, and death (mortality).
We analyzed data using Microsoft Excel 2016 and Google sheets; calculations were compared using means and percentages (Table 1; Figure 1).
TABLE 1 Rates of Numbers of Organs/Organ Systems Injured per Patient in 873 Patients Who Had a Complete Laparotomy, in Addition to the Rates of the Mechanism of Injury in Each Group of Patients
Abbreviation: POMR, perioperative mortality rate.
FIGURE 1 Number of All Patients Who Presented to the Surgical Emergency Department at Al-Mouwasat Hospital, and the Number of Penetrating Abdominal Injuries Requiring Exploratory Laparotomy from April 1, 2011 to December 31, 2017. *The data from August 23, 2011 to June 2, 2012 were missing.
RESULTS
Description of the Sample
From April 1, 2011 to December 31, 2017, 7826 patients arrived at SED at Al-Mouwasat University Hospital because of traumatic injuries. A total of 898 (11.5%) had a war-related penetrating abdominal injury requiring exploratory laparotomy. Distribution of patients during years (2011-2017) is demonstrated in Figure 1.
Exploratory laparotomy was performed on patients having a penetrating abdominal injury with hemodynamic instability, positive FAST showing free fluid, or positive findings on abdominal CT scan. A total of 898 patients underwent exploratory laparotomies, 873 (97.2%) patients underwent complete laparotomies with well-known intra- and extra-abdominal injuries, while 25 patients (2.8%) had fulminant hemorrhage and death that impeded full exploration of the abdomen.
Among all patients who had an exploratory laparotomy (n = 898), 680 (75.7%) patients were males. The age distribution peaks in the second decade of life (Figure 2). Women (aged between 18 and 60 years old), elderly (> 60 years), and children (< 18 years) constitute 51.2% of patients, while 48.8% were men (18-60 years old).
FIGURE 2 Distribution of 898 Patients Who Had Laparotomies by Age and Sex.
The major cause of injury was shrapnel from explosive devices (47% of patients who underwent an exploratory laparotomy n = 898), while gunshots were responsible for 36.1%. However, the type of projectile was undetermined in 16.9% of patients.
Abdominal Injuries in Detail
Of patients who had complete laparotomies (n = 873), the 3 most common organs affected by abdominal penetrating injuries were the small intestines (including duodenum, jejunum, and ileum) in 36.4% of patients, the large intestines (ascending, transverse, descending, sigmoid colons and the upper third of rectum) in 33% of patients, and the liver in 22.9%. The rates of spleen, stomach, and pancreas injuries are shown in Figure 3.
FIGURE 3 Rate of Intra-abdominal Organ Injuries, and Concomitant Organ System Injuries in 873 Patients Who Had a Complete Laparotomy. SI: small intestines; LI, large intestines; LVR, liver; SPL, spleen; S, stomach; P, pancreas; CI, concomitant injuries; V, vascular; GU, genitourinary; Th, thoracic; MS, musculoskeletal; Gyn, gynecologic; Neu, neurologic; Others, other extra-abdominal Injuries.
A percentage of 42.8% of patients had other concomitant injuries, including, from the most common to the least, vascular, genitourinary, thoracic, musculoskeletal, gynecological, neurological, and other extra-abdominal injuries (Figure 3).
A total of 56.4% of patients had multiple injuries, while 34.6% had isolated injuries. Considering the injury of each of the following organs: small intestines, large intestines, liver, spleen, stomach, pancreas, or other intra-abdominal injuries (ie, mesenteric, omental injuries) as 1 organ injury, and each vascular, genitourinary, thoracic, musculoskeletal, gynecological, neurological, or other extra-abdominal injuries (ie, wounds) as 1 organ system injury (Table 1). The rest 9% of patients (n = 79) had neither intra- nor extra-abdominal injuries.
For instance, of the patients who had exploratory laparotomies (n = 898), 92 patients (10.2%) had negative laparotomies (there was no intra-abdominal organ injury, despite the penetrating injury of the abdomen). However, 13 patients (14.1%) had concomitant extra-abdominal injuries (Table 2).
TABLE 2 Rates of Deaths Due to Fulminant Hemorrhage, Deaths With Diagnosed Injuries, and Negative Laparotomies in All Patients Who Had Laparotomies (898 Patients) in Addition to the Rates of the Mechanism of Injury in Each Group of Patients
Abbreviation: POMR, perioperative mortality rate.
Perioperative Mortality Rate
Of patients who had exploratory laparotomies (n = 898), 58 patients (6.5%) died in the operating or recovery room. Twenty-five patients (2.8%) died because of fulminant hemorrhage before getting their abdomen fully explored, so their injuries remained unknown, while 33 patients (3.7%) died with diagnosed injuries (Table 2).
Seven percent (14 deaths/200 patients) of patients who had a liver injury died in the perioperative period. Thus, liver injuries were associated with the highest perioperative mortality rate (POMR) of intra-abdominal organ injury, while the remaining intra-abdominal organ injuries POMRs ranged from 3.1% to 3.8%. The highest POMR of other concomitant injuries was due to musculoskeletal injuries (POMR: 18.2%; 8 deaths/44 patients), followed by vascular injuries (POMR: 11.8%; 20 deaths/170 patients) (Figure 4).
FIGURE 4 Perioperative Mortality Rate of Abdominal Organ Injuries, and Concomitant Organ System Injuries* in 873 Patients Who Had a Complete Laparotomy. SI, small intestines; LI, large intestines; LVR, liver; SPL, spleen; S, stomach; P, pancreas; V, vascular; GU, genitourinary; Th, thoracic; MS, musculoskeletal; POMR, perioperative mortality rate. *The POMRs of gynecological, neurological, and other extra-abdominal concomitant injuries were not shown because of the lack of sufficient sample size.
The POMR increased when more organs/organ systems were injured reaching a peak at 3 organs/organ systems injuries with a POMR of 8.3% (12 deaths/145 patients). Afterward, POMR slightly decreased at 4 organs/organ systems injuries (POMR 8%; 4 deaths/50 patients), and decreased clearly afterward (Table 1).
The type and the number of organs/organ systems injured affected mortality rates. For instance, among the patients who died because of isolated injuries (n = 7), 3 patients had vascular injuries (presenting as retroperitoneal hematoma), two patients sustained liver injuries, and 2 patients died because of severe musculoskeletal injuries. While among patients who sustained multiple injuries (n = 26), the main cause of death was liver and vascular injuries with or without concomitant intra or extra-abdominal injuries (n = 8). The remainder of deaths (n = 18) were caused by various combinations of injuries (ie, intestinal, vascular, musculoskeletal, splenic, genitourinary, hepatic, thoracic, gastric, and neurological injuries, arranged by their incidence rates).
Negative laparotomies had a POMR of 2.2% (2 deaths/ 92 patients), in which deaths were attributed to severe musculoskeletal injuries (Table 2).
Specific Details About Organs/Organ Systems Injuries
Small Intestines (Duodenum, Jejunum, and Ileum)
Three hundred eighteen patients had small bowel injuries; the POMR was 3.5% (11 deaths/318 patients). A total of 58.7% of the patients had multiple small intestine (SI) injuries, and 14.8% of these patients had an accompanying mesenteric injury. Repair procedures included primary repair, resection of the involved segment and anastomosis, a combination of these 2, and sometimes ileostomy was performed.
Large Intestines (Ascending, Transverse, Descending, Sigmoid Colons, and the Upper Third of Rectum)
A total of 288 patients had large intestine (LI) injuries (POMR: 3.1%, 9 deaths/288 patients). Most of the LI injuries were single. Operative approaches were primary repair, resection and anastomosis, and ileostomy or colostomy.
Liver
Two hundred patients had liver injuries (POMR: 7.0%; 14 deaths/200 patients). Twelve patients had accompanying gallbladder injuries. A total of 66.4% of injuries were in the right lobe, 26.5% in the left lobe, and in 7.1% of patients both lobes were injured. Most of the liver injuries were managed by debridement and hemostatic maneuvers such as sutures and hemostatic agents (ie, dressings and Gelfoam).
Spleen
One hundred thirty patients had splenic injuries, ranging from a minor laceration to complete rupture (POMR: 3.8%; 5 deaths/130 patients). Surgical management included 2 main procedures, splenectomy, and hemostatic maneuvers.
Stomach
A total of 119 patients had gastric injuries (POMR: 3.4%; 4 deaths/119 patients). Isolated gastric injuries exceeded multiple ones. Almost all gastric perforations were treated with 1 or 2-layer continuous sutures, rarely resection of the injured part and anastomosis were needed.
Pancreas
Twenty-eight patients had pancreatic injuries (POMR: 3.2%; 1 deaths/28 patients). The injury site varied between the head, neck, body, and tail of the pancreas. Treatment included mainly 2 options depending on the severity of the injury, primary repair, and debridement and resection of the injured part.
Vascular Injuries
A total of 170 patients had vascular injuries (POMR: 11.8%; 20 deaths/170 patients). The most common presentation of vascular injuries was a retroperitoneal hematoma, which was seen in 106 patients, 13 of them died. Primary repair and ligation of the bleeding vessel were the main management options.
Genitourinary
A total of 143 patients had genitourinary (GU) tract injuries (ie, kidneys, ureters, bladder, urethra, vas deferens, testes, and penis). POMR: 3.5%, 5 deaths/143 patients. Two patients had an injury to the adrenal gland. Primary repair, hemostatic agents, partial and total nephrectomy, nephrostomy, orchiectomy, and suprapubic catheter were performed to manage different types of GU injuries.
Thoracic
Ninety-eight patients had thoracic injuries (POMR: 4.1%; 4 deaths/98 patients). The major type of injury was diaphragmatic perforation; other types included rib fractures and lung injuries. Almost all patients were managed by primary repair and chest tube placement.
Musculoskeletal
Forty-four patients had limb injuries (ie, muscle lacerations and bone fractures)(POMR: 18.2%, 8 deaths/44 patients). The management included sutures, external fixation, or amputation of the injured limb.
Other Injuries
Four patients had neurological injuries (1 died), 7 female patients had uterine and ovarian injuries (no deaths), and 5 patients had other extra-abdominal injuries (ie, wounds), no deaths were reported either.
DISCUSSION
The medical staff usually deals with penetrating abdominal injuries sustained by civilians. These injuries are mostly stab wounds, traffic accidents, and low-velocity gunshot wounds. However, during wars and armed conflicts, injuries and trauma are different, and they comprise high-velocity gunshot wounds and explosive device injuries. In those exceptional situations, the civilian trauma teams providing damage control resuscitation and damage control surgery to civilians suffer from some extra difficulties, most importantly the large influx of critically traumatized patients and the relative lack of adequately experienced staff to deal with such cases. This is compounded or exacerbated by high-velocity weapon systems, high order explosives, and other lethal weapon systems designed for killing of populations and deployed by state level militaries and armed groups. War injuries convey a higher mortality rate mainly due to the major energy transmitted to tissues. Reference Lamb and Garner31
During the SAC, our hospital was one of the major medical centers to handle emergencies in Damascus. The medical staff in our hospital had to manage new cases of penetrating injuries to large numbers of civilians. This constitutes a challenge for the medical establishment. To our knowledge, 18 studies about Syrian war victims’ injuries were published from 2011 to 2015. Reference Arafat, Alsabek and Ahmad12-Reference Iflazoglu, Ureyen and Oner29 However, all these studies were relatively in a short period of time, the shortest study was 1 mo long and the longest was 27 mo long. Two studies were concerned with abdominal penetrating injuries; Arafat et al. conducted a study in Damascus-Syria and reviewed abdominal trauma victims for 9 months, Reference Arafat, Alsabek and Ahmad12 and Iflazoglu et al. studied mortality in penetrating abdominal firearm injuries. Reference Iflazoglu, Ureyen and Oner29 Other studies were about the orthopedic trauma, Reference Duramaz, Bilgili and Bayram15 pediatric trauma, Reference Er, Corbacioglu and Guler16 vascular trauma, Reference Hornez, Boddaert and Baudoin19,Reference Salamon, Lerner and Rothem28 hospital costs, Reference Karakuş, Yengil and Akkucuk21 trauma care, Reference Mowafi, Hariri and Alnahhas23 intensive care units, Reference Ozdogan, Karateke and Ozdogan24 posttraumatic growth, Reference Rizkalla and Segal26 head and neck injuries and patterns of trauma. Reference Aras, Altas and Yilmaz13,Reference Biswas, Waksman and Baron14,Reference Gurler, Coskun and Oner17,Reference Hasanin, Mukhtar and Mokhtar18,Reference Hornez, Ramiara and Mocellin20,Reference Kocamer Şimşek, Dokur and Uysal22,Reference Qasaimeh, Shotar and Alkhail25,Reference Ronen, Assadi and Sela27 We reviewed the characteristics of penetrating abdominal injuries endured by civilian victims at the emergency department of our hospital from April 2011 to December 2017 (76 months). These victims arrived at the emergency department within several minutes to an hour after injury from different regions of Damascus and the nearby suburbs. The waiting time from arrival at the hospital to entry into OR depended on the patients’ influx and the nature of massive attacks, but typically it did not exceed 30 min to perform the operation in unstable critical patients.
During the SAC, some attacks were perpetrated in residential neighborhoods, schools, and markets, especially in Damascus city. Consequently, women, children, and the elderly accounted for almost half the victims (51.2%) in our sample, which shows that a higher percentage of men were injured in comparison with the general population gender/age distribution in Syria (2018) according to Syrian Central Bureau of Statistics 32 : Men (20-60 years) 22%; women (20-60 years), elderly(>60 years), and children (<20 years) 78%, simply because men are more likely to be outdoors due to local traditional customs and war condition, therefore, they were more prone to injury. In contrast with other studies, the elderly, children, and women casualties do not usually exceed 15% of total victims. Reference Hornez, Ramiara and Mocellin20,Reference Karakuş, Yengil and Akkucuk21 This difference is related to the differences in the sample of civilian patients. Al-Mouwasat University Hospital is located in urban Damascus and serves a mainly civilian population; injured soldiers were typically transported to military or field hospitals.
There are 2 main types of attacks: gunshots and explosions. The explosive injuries are those caused by mortars, shrapnel, and IEDs. Explosive attacks often result in more civilian casualties than gunshots. Reference Bala, Rivkind and Zamir33
In our study, explosive devices accounted for 47% of injuries and gunshots accounted for 36.1%, while 16.9% of injuries had unknown causes due to the lack of patient records. These results are in accordance with a previous study conducted in Damascus Hospital, where explosive devices resulted in 56.5% of total injuries and gunshots resulted in 43.5%. Reference Arafat, Alsabek and Ahmad12 However, the findings of the current study differ from those published by Iflazoglu et al., where shrapnel resulted in 40% and bullets resulted in 60% of injuries. This difference is due to the fact that the majority of their sample were males 95.8%, Reference Iflazoglu, Ureyen and Oner29 probably male combatants are more likely to be injured in battle by gunshots.
According to studies conducted on war injuries in Afghanistan and Iraq, abdominal injuries constitute only 2% and 6.9% of the total war injuries, respectively. Reference Belmont, Goodman and Zacchilli34,Reference Peoples, Gerlinger and Craig35 Whereas, abdominal injuries sustained by Syrian refugees in Turkey and Jordan account for 8% of the injuries. Reference Hornez, Ramiara and Mocellin20,Reference Karakuş, Yengil and Akkucuk21 In our study, abdominal injuries constitute 11.5% of total reported injuries and this percentage is higher than the ones reported in similar studies. Reference Hornez, Ramiara and Mocellin20,Reference Karakuş, Yengil and Akkucuk21,Reference Belmont, Goodman and Zacchilli34,Reference Peoples, Gerlinger and Craig35 A possible explanation for this result might be that only civilians were included in our study and they were not wearing any means of protection at the time of injury, unlike soldiers who often wear body armor.
The initial diagnosis was based mainly on the scenario of the attack, physical examination, and rapid investigations, such as FAST. CT was performed when possible and was especially ordered for stable conditions. The final diagnosis was determined in the OR.
In our study, negative laparotomy presented in 92 patients (10.2%) of the total performed laparotomies (n = 898), and 85.9% of them (n = 79) had neither intra-abdominal nor extra-abdominal injuries at the time of the procedure, while the remaining 14.1% (n = 13) had extra-abdominal injuries. Negative laparotomy percentages resemble the reported values during the Lebanese war, in the study conducted in Damascus Hospital and in the study conducted in Turkey (9.7%, 8.3%, and 7%, respectively). Reference Arafat, Alsabek and Ahmad12,Reference Iflazoglu, Ureyen and Oner29,Reference Nassoura, Hajj and Dajani36
Physical examination is the cornerstone in making an early diagnosis. Reference Almogy, Mintz and Zamir37 Factors influencing the diagnosis and the severity of the damage include firearm type, firearm-to-target distance, number of heard gunshots, the mass of missiles, and distance from the explosion’s epicenter. Reference Bala, Rivkind and Zamir33,Reference Sampalis, Denis and Frechette38
However, important information may frequently be forgotten or missed. In such situations, X-ray and FAST are useful diagnostic procedures for detecting any abnormal fluid or air in the pleural and abdominal cavities and may help in choosing the most suitable procedure for each case. Reference Biffl and Leppaniemi3 CT has a limited role in the diagnosis of penetrating abdominal injuries, because of its low sensitivity for hollow visceral and diaphragmatic injuries. However, it is useful for evaluating patients with a high clinical suspicion of solid organ and retroperitoneal injuries. Reference Ferrada and Birolini4
By following the previous protocol, of 873 patients who had complete laparotomies, 34.6% had 1 injured organ, 56.4% had 2 or more injured organs, and 9% had neither intra- nor extra-abdominal injuries. Although explosions may affect multiple body parts, gunshots cause more severe abdominal injuries, and the pattern of intra-abdominal injury after explosions resembles the pattern of injury caused by gunshots. Reference Bala, Rivkind and Zamir33 Explosive device injuries can be classified into 4 categories: primary, secondary, tertiary, and quaternary. Primary injuries are due to high-order explosives and affects mainly gas-filled structures such as lungs, gastrointestinal tract, and middle ear. Secondary injuries are caused by flying debris, weapon casings, and content fragments and mainly cause penetrating trauma. Tertiary injuries are caused by blast wave and sudden forceful push against fixed objects leading to fractures, amputation of limbs, solid organ injuries, and traumatic brain injuries. Quaternary injuries include other injuries that are not classified above, such as burns, inhalational injury, and radiation illness. Reference Cubano and Butler39
Previous authors showed that explosive assaults could have multiple entry sites to the abdomen. Reference Almogy, Belzberg and Mintz40 They have also revealed previously, that the penetrating projectiles result in the majority of intra-abdominal injuries after explosive attacks. Reference Almogy, Mintz and Zamir37
Penetrating abdominal trauma resulting from gunshots and explosions causes characteristically high-grade damage to abdominal organs with large surface areas, such as the small and large intestines and the liver. Hollow viscera are the most commonly injured organs in penetrating injuries. Reference Ferrada and Birolini4,Reference Iflazoglu, Ureyen and Oner29,Reference Almogy, Mintz and Zamir37
Our findings are consistent with these results; because the most damaged intra-abdominal organs reported in our study are small and large intestines (36.4% and 33%, respectively), followed by the liver (22.9%).
One of the limitations on our study was the inability to collect data of patients who arrived dead or died in the SED and never made it to the OR, due to the collection of our data from the OR logs, this may be a potential confounder for our results, as their injury types were not identified. For instance, the injury types of those victims may have been significantly different from those who survived long enough to undergo surgery. However, our accessible data showed that 6.4% (n = 58) of the patients (n = 898) died in the operating or recovery room, 43% of them suffered from severe major uncontrolled hemorrhage. The most common risk factors of death were musculoskeletal, vascular, and hepatic injuries. Deaths were high in patients with multiple intra- and extra-abdominal injuries having a POMR of 5.3% (26 deaths/492 patients having multiple injuries) compared with patients who had isolated injuries (POMR: 2.3%; 7 deaths/302 patients having isolated injuries) especially patients with 3 injured organs (8.3% POMR; 12 deaths/145 patients). This correlation was previously mentioned by Morris and Sugrue in Afghanistan, Reference Morris and Sugrue9 they noted that the mortality rate was highest when the injuries affected 3 abdominal organs.
The most prevalent cause of preventable death in trauma patients is hemorrhage. Reference Teixeira, Inaba and Hadjizacharia41 Abdominal structure injuries are a significant source of bleeding, and they have important practical difficulties for suitable diagnosis and treatment, particularly when there are concomitant lesions. Reference Teixeira, Inaba and Hadjizacharia41,Reference Parreira, Oliari and Malpaga42 In our sample, the highest POMR of other concomitant injuries was due to musculoskeletal injuries, probably because of the duration of surgical management in which the patients enter the trauma triad of death (hypothermia, acidosis, and coagulopathy). This triad must be aggressively addressed by all damage control resuscitation and surgical interventions from point of injury to surgical intervention. This will require a rethink and new approach from surgeons and anesthetists, especially when prehospital and theater duration is prolonged, and when multiple surgical teams are collaborating to repair concomitant injuries.
CONCLUSIONS
Civilians are the weakest part of any armed conflict, and penetrating abdominal injuries are common among them. Our study is one of the few in the literature concerned with civilians sustaining war-related injuries. The most commonly affected organs due to abdominal penetrating trauma are small and large intestines, followed by the liver. The most common risk factor of death is musculoskeletal, vascular, and hepatic injuries.
The number and type of injured organs and their relation to mortality should be considered during the surgical management of penetrating abdominal injuries, especially when the patient has 3 injured organs.
Acknowledgments
We express our sincere gratitude to the medical staff at Al-Mouwasat University Hospital for working under pressure and lack of sufficient resources for many years, and their dedication to save patients’ lives under all circumstances. We thank Dr. Subhi Albahri and Dr. Ammar Raiy in the administration of Al-Mouwasat University Hospital for their kind cooperation and support, and we thank Lamia Kouba and Younis Hajeer for the linguistic revision.
Funding
No funding was received in support of this work.
Ethical Approval and Consent to Participate
Ethical Approval upon data access and Consent to participate was given from the general board of Al-Mouwasat University Hospital “number 5920”.
Competing Interests
The authors declare that they have no competing interests.
Authors’ Contributions
The study was designed and supervised by B. Alsaid and S. Sara. The literature search was done by M. Alhimyar. M. Alhimyar, A. Alnweilaty, E. Alhasan, M. Bathich, K. Turkmani, Z. Salhoum, A. Ahmad, and T. Ahmad collected the data. A. Alnweilaty, E. Alhasan, and M. Alhimyar analyzed the data. Figures were done by A. Alnweilaty. T. Ahmad, E. Alhasan, Z. Salhoum, A. Alnweilaty, M. Bathich, M. Alhimyar, K. Turkmani, and B. Alsaid wrote the manuscript. T. Ahmad, M. Alhimyar, A. Alnweilaty, E. Alhasan, and K. Turkmani revised the manuscript. S. Sara coordinated with the hospital staff. All authors have read and approved the final version submitted.
