Diagnosis and treatment of penetrating abdominal combat wounds

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BACKGROUND

The challenges of diagnosing abdominal combat injuries and determining the optimal scope of treatment at different stages of care for the wounded remain highly relevant [1]. At present, any surgeon may encounter a mine-blast abdominal injury and must be prepared to make critical decisions regarding the necessity of surgical intervention and, if indicated, the appropriate extent of the procedure.

During operations in emergency conditions and armed conflicts, healthcare professionals must consider not only standard medical indications but also medical-tactical factors. These factors are defined by the specific and often unique operational circumstances of the situation.

The variety of clinical cases precludes full standardization of diagnosis and treatment; however, general principles can still be identified.

A team of surgeons from the Federal Scientific and Clinical Center for Specialized Types of Medical Care and Medical Technologies of the Federal Medical Biological Agency of Russia (FSCC FMBA), operating as part of the consolidated medical detachment of the FMBA of Russia at the Medical and Sanitary Unit No. 125 (Kurchatov, Kursk Region), provided medical assistance to combat casualties from August to November 2024. This article presents our clinical experience, which we believe may offer valuable insights for a broad spectrum of healthcare practitioners. It is challenging to apply conventional scientific research methodology to the presented material due to its specific nature. In a combat environment, during simultaneous mass influxes of wounded and injured personnel, medical documentation was maintained in a reduced scope, and photographic documentation proved challenging. The specific characteristics of the operated patient cohort also impose limitations on the ability to track both short-term and long-term outcomes. To better reflect the nature of our data, we moved away from the conventional framework for reporting original research.

Aim: To analyze our own experience in providing medical care at a civilian hospital to patients with abdominal wounds sustained during a contemporary military conflict.

METHODS

Military personnel with combat-related injuries received medical care within several hours before admission, with the majority of cases occurring between 4 and 12 hours prior to arrival.

All those admitted had already undergone comprehensive initial stabilization at the level of the advanced medical team, in accordance with the Combat Trauma Treatment Guidelines of the Russian Ministry of Defense (anti-shock measures, respiratory restoration, fracture stabilization, etc.).

Before hospital admission, all wounded personnel received comprehensive early primary stabilization in the early post-injury period. This care was delivered either by the forward medical teams or at civilian medical facilities and was provided in accordance with the Ministry of Defence Guidelines for Combat Trauma Management. The stabilization protocol included essential interventions: anti-shock measures, restoration of airway patency and breathing, immobilization and stabilization of fractures, and other critical measures.

This study does not include patients who were brought to our stage of care with extremely severe injuries incompatible with life, or who were in a dying state. Furthermore, it does not include patients who had already undergone laparotomy due to ongoing bleeding. In all such cases, relaparotomy at Medical Unit No. 125 was not required.

This study examined the immediate clinical outcomes of diagnosis and surgical treatment in a cohort of 231 patients presenting with combat-induced penetrating abdominal injuries. All patients received surgical care delivered by surgeons affiliated with FSCC FMBA.

All injured patients were male, with a median age of 35 years (interquartile range: 26–43 years). Comorbidities were generally absent. The vast majority had a normal body mass index (BMI) and well-developed musculature.

Of the total cohort, 3 cases (1.3%) involved bullet wounds, and 228 cases (98.7%) resulted from mine blast injuries.

Upon admission, the majority of patients with penetrating abdominal trauma presented in stable or relatively stable condition, which made it possible to conduct their instrumental examination.

Routine laboratory tests demonstrated a median hemoglobin concentration of 118 g/L (interquartile range 99.5–133 g/L) and a median leukocyte count of 13.5 × 10⁹/L (range 9.8–17.45 × 10⁹/L).

Upon admission, a multidisciplinary team performed a clinical assessment, which included a comprehensive full-body physical examination in all wounded patients as part of the standard protocol.

In accordance with the clinical protocol, any minimal suspicion of internal organ injury mandated a non-contrast CT scan of the abdomen and pelvis to exclude or confirm potential intra-abdominal damage.

All diagnostic examinations were conducted with a surgeon on site, who simultaneously compared clinical findings with imaging results to facilitate accurate real-time interpretation. In cases of inconclusive CT findings with persistent clinical suspicion of abdominal trauma, bedside ultrasound using a high-end machine was performed, incorporating the FAST protocol to evaluate for intra-abdominal free fluid. Ultrasound was typically used to determine the layer of the anterior abdominal wall in which the fragment was located (which was sometimes impossible due to metal-induced imaging artifacts), to assess the extent of parenchymal organ damage (which was often challenging on non-contrast CT), and to monitor changes serially. Colonoscopy and gastroduodenoscopy were performed as clinically indicated. Endoscopic examination was required when fragments were located extraperitoneally adjacent to hollow organs. If the wound tract of the fragment did not traverse the abdominal cavity and no extraperitoneal injuries were present, the patient was placed under dynamic observation and managed conservatively.

Laparotomy was typically performed following confirmation of a penetrating abdominal wound and/or evidence of internal organ injury. Two primary surgical approaches were primarily employed: a single-stage surgical procedure or a multi-stage approach (Damage Control Surgery — DCS). To determine the surgical strategy, a classification system for surgical interventions in military field conditions (the Military Field Surgery — Surgical Strategy scale; (Table 1) was applied.

 

Table 1

The military field surgery outcome prediction scale

Factors	Values	Score
Systolic blood pressure below 70 mmHg upon admission	No Yes	0 1
Amputation of a limb segment, damage to the main blood vessel of a limb, chest injury requiring thoracotomy	No Yes	0 3
Volume of intrathoracic/abdominal blood loss at the start of surgery (ml)	Up to 1,000 1,000–2,000 More than 2,000	0 2 4
Presence of extensive tense retroperitoneal or intrapelvic haematoma	No Yes	0 2
Damage to a major abdominal or pelvic vessel, vertically unstable pelvic fracture with unstable haemodynamics	No Yes	0 3
Presence of a difficult-to-control source of bleeding	No Yes	0 2
Three or more damaged abdominal/pelvic organs, or two organs requiring complex surgical intervention	No Yes	0 2
Presence of diffuse peritonitis in the toxic phase	No Yes	0 2
Unstable haemodynamics during surgery requiring inotropic drugs	No Yes	0 6

Note. The index of lethal outcome probability is calculated by sequentially assessing the value of each clinical sign and summing the scores. If the scale index reaches 13 points or more, the probability of a lethal outcome rises to 92%. In such cases, abbreviated laparotomy is indicated. This procedure is performed for life-threatening conditions within the framework of the multi-stage approach surgical procedure (Damage Control Surgery, DCS).

 

A scale index value above 13 points is an indication for the use of the multi-stage approach surgical procedure.

In the absence of peritonitis and with a stable patient condition, a score of less than 13 points on the Military Field Surgery Outcome Prediction Scale indicated that a full-scope surgical intervention was feasible. Procedures included: segmental small bowel resection and anastomosis; hemicolectomy, typically with ileotransverse anastomosis for right-sided cases; hepatic resection; distal pancreatectomy, preferred over tight packing.

Indications for intestinal resection included either multiple injuries or a bowel tear involving more than half the circumference, in accordance with the established criteria of the American Association for the Surgery of Trauma (AAST).

Mechanical staplers were not used. All intestinal anastomoses were performed in a side-to-side configuration using a manually placed two-layer continuous suture. The bowel stump was closed with a continuous full-thickness suture, which was then inverted using a purse-string suture followed by a Z-pattern suture for secure closure.

In cases of gallbladder injuries, cholecystectomy was performed. This approach was preferred in the setting of unaltered anatomy, as the procedure was relatively quick and provided greater assurance of a successful outcome compared to suturing the defect with subsequent cholecystostomy.

Resection of hepatic segments and distal pancreatectomy were undertaken in the presence of substantial crushing injuries to the liver or pancreatic tissue. These procedures were specifically indicated when conventional haemostatic measures — including electrocoagulation and vessel ligation with sutures — failed to control active bleeding.

Retroperitoneal hematomas without reliable signs of retroperitoneal organ injury — as confirmed by unremarkable CT findings and absence of haematuria — and of non-tense character were not surgically evacuated.

In cases of extraperitoneal rectal injury, a double-barrel sigmoidostomy was performed. This included mandatory incision and drainage of the pararectal cellular space, primary suturing of the rectal defect whenever possible, and placement of surgical drains.

RESULTS

Abdominal combat trauma was suspected in 1359 patients. Following a comprehensive clinical examination, penetrating abdominal injury and internal organ damage were excluded in 1 128 cases (83%). During subsequent observation at the Medical and Sanitary Unit No. 125 (Kurchatov), none of the patients in this group required laparotomy.

In cases of bullet wounds, blast injuries, and wounds caused by large shrapnel fragments, the clinical and instrumental findings were unequivocal, leaving no doubt regarding the indications for laparotomy. The most challenging group involved patients with small-fragment abdominal injuries.

The wound tracks of fragments not exceeding 10–15 mm in maximum dimension could not be visualized on non-contrast CT scans. The absolute indication for surgical intervention was the presence of a foreign body (fragment) within the abdominal cavity. However, these fragments frequently became embedded in soft tissues, and in cases of multiple lesions, it was challenging to ascertain their trajectories. In each case, the surgeon systematically compared skin defects on the trunk with the topography of wounding elements visualized on CT scans to identify potential wound channels. Injuries to the intestine caused by small fragments were either glancing or puncture-type; furthermore, they were often contained (covered by adjacent tissue) and did not lead to significant amounts of free gas or fluid in the abdominal cavity. Lesions of parenchymal organs generally did not lead to clinically significant acute hemorrhage, and in certain cases bleeding was not present, especially when associated with combined injuries and traumatic shock. Collectively, the aforementioned factors led to extremely low sensitivity and specificity values for ultrasonography. Nevertheless, it is misleading to assert a limited diagnostic value of this modality, as it serves a supplementary diagnostic role, offering crucial insights into soft tissue injuries and structural alterations of parenchymal organs, including the liver, spleen, and kidneys. Colonoscopy was the primary diagnostic method in cases of suspected injury to the rectum and sigmoid colon. Laparoscopy was employed sparingly owing to the inability to perform a comprehensive intraoperative exploration and the potential risk of missing small bowel injuries. However, it was ideally suited for situations such as right-sided thoracoabdominal injuries with penetration of a small fragment through the right hemidiaphragm into the hepatic parenchyma, in the absence of signs of hemorrhage or other injuries on CT imaging. In most cases, such injuries required only hemostasis via coagulation and drainage. Furthermore, diagnostic laparoscopy may be utilized in rare cases of persistent diagnostic uncertainty to clarify the nature and extent of injuries.

During abdominal surgeries, we recovered 42 free-floating shrapnel fragments from artillery shells (Fig. 1) and undertook a study of their characteristics. The median weight of the fragments was 2.4 g, with an interquartile range of 0.8–5.3 g. All retrieved shrapnel fragments exhibited irregular shapes. The median maximum dimension was 15.5 mm, with an interquartile range of 8–22 mm. Notably, 21% of fragments had weights ranging from 0.16 to 0.35 g and a maximum length of 5–7 mm. X-ray fluorescence analysis of the chemical composition of the retrieved fragments was conducted.

 

Fig. 1. Characteristics of the retrieved fragments. The high silicon content in modern NATO fragmentation ordnance results in high brittleness, leading to the generation of numerous small shrapnel fragments.

 

A detailed characterization of the combat-related abdominal injury observed is presented in Table 2. The pattern of associated injuries was stratified according to the need for specialist input, including thoracic surgery, trauma surgery, vascular surgery, urology, neurosurgery, and maxillofacial surgery. All procedures were performed during a single surgical session, with multidisciplinary teams operating sequentially or, where feasible, in parallel.

 

Table 2

Characteristics of injuries

Type of injury	Number of Cases (n=231) (%)
Isolated injuries	40 (17.3)
Combined injuries	191 (82.7)
Chest injuries	117 (50.6)
Fractures of limb bones	102 (44.2)
Traumatic amputations of limb segments	9 (3.9)
Pelvic bone injuries	38 (16.5)
Injuries to major limb arteries requiring vascular reconstruction	10 (4.3)
Injuries to urogenital organs	36 (15.6)
Retroperitoneal hematoma	30 (13)
Injuries to the brain or spine and spinal cord requiring neurosurgical intervention	25 (10.8)
Injuries to the facial part of the skull and/or neck	23 (10)
Injuries requiring involvement of 3 surgical specialties	78 (33.8)
Injuries requiring involvement of 4 surgical specialties	12 (5.2)
Injuries requiring involvement of 5 surgical specialties	5 (2.2)
Injuries requiring involvement of 6 surgical specialties	1 (0.4)

 

The structure and frequency of injuries to the abdominal viscera are presented in Table 3.

 

Table 3

Injuries to abdominal organs in abdominal wounds

Organ	Incidence of Injury (n=231) (%)
Stomach including cases where the stomach was the only injured organ in the abdominal cavity	13 (5.6) 4 (1.7)
Duodenum including cases where the duodenum was the only injured organ	4 (1.7) 0
Small intestine including cases where the small intestine was the only injured organ in the abdominal cavity	97 (42) 44 (19)
Сolon, including cases combined with small intestine injury сases where the large intestine was the only injured organ in the abdominal cavity	91 (39.4) 35 (15.2) 32 (13.9)
Rectum including cases where the rectum was the only injured organ	5 (2.2) 4 (1.7)
Pancreas including cases where the pancreas was the only injured organ in the abdomen	3 (1.3) 0
Liver including cases where the liver was the only injured organ in the abdominal cavity	45 (19.5) 22 (9.5)
Gallbladder including cases where the gallbladder was the only injured organ in the abdominal cavity	5 (2.2) 0
Spleen including cases where the spleen was the only injured organ in the abdominal cavity	40 (17) 16 (7)
Injury to a single abdominal organ including cases with additional urogenital injuries	122 (52.8) 21 (9)
Injury to two abdominal organs including cases with additional urogenital injuries	61 (26.4) 6 (2.6)
Injury to three abdominal organs including additional damage to the urogenital system	24 (10.4) 2 (0.9)
Injury to four or more abdominal organs including additional damage to the urogenital system	7 (3) 1(0.4)
Penetrating abdominal wound without damage to intra-abdominal organs, comprising: isolated lacerations of the intestinal mesentery isolated injuries to the kidneys and bladder no detectable intra-abdominal injuries	17 (7.4) 6 (2.6) 6 (2.6) 5 (2.2)

 

We briefly illustrate the diagnostic challenges associated with penetrating abdominal injuries using clinical case examples. In all cases, the injuries were incurred within 6 hours prior to admission.

Clinical case # 1

A penetrating abdominal wound resulting from a fragment approximately 5 mm in maximum dimension occurred during artillery shelling. The entry wound (approximately 5 mm in diameter) was located along the anterior axillary line, overlying the splenic flexure of the colon. Abdominal examination revealed a non-distended, soft, and non-tender abdomen. Computed tomography demonstrated the absence of pneumoperitoneum and free fluid in the abdominal cavity. However, the metallic fragment was precisely visualized adjacent to the splenic flexure of the colon (see Fig. 2), providing the indication for exploratory laparotomy. Intraoperatively, no pathological contents were identified in the abdominal cavity. During mobilization of the splenic flexure of the colon, examination revealed that the fragment had perforated the colonic wall and was located in the pericolonic adipose tissue immediately posterior to the bowel wall. The perforations were punctate, measuring less than 5 mm in diameter. The entry wound on the anterior wall of the transverse colon was concealed by an epiploic appendage. The defects were repaired using a two-layer interrupted suture with Vicryl 3/0. Following systematic intraoperative inspection of the abdominal cavity, no additional injuries were identified. The surgical intervention was terminated with insertion of a passive drain into the left lateral paracolic gutter, followed by meticulous multilayer closure of the laparotomy wound in anatomical layers. The present case demonstrates the imperative need for comprehensive evaluation of the posterior colonic wall in the setting of an anterior wall injury, due to the significant risk of transmural perforation. Following successful surgical intervention, the patient was transferred to a higher echelon of care with stable hemodynamic parameters. According to the available data, the case concluded with full recovery.

 

Fig. 2. CT scan demonstrating a penetrating injury to the splenic flexure of the colon. Axial view shows transmural perforation of the colonic wall at the splenic flexure, with no evidence of free intraperitoneal gas or fluid. In this and all subsequent figures, the foreign body (metallic fragment) is outlined with a dotted line.

 

Clinical case # 2

Penetrating abdominal injury caused by a 5 mm metallic fragment, acquired during artillery shelling. CT imaging revealed no free intraperitoneal gas or fluid. The indication for surgery was the intra-abdominal topography of the retained foreign body, as confirmed by CT (Fig. 3). During intraoperative exploration of the abdominal cavity, the fragment was found located within the muscular layer of the small intestine, with the mucosa remaining intact. The foreign body was carefully extracted, and the resulting intestinal wound was closed using a two-layer interrupted suture in a transverse orientation. The operation was completed with placement of a drain in the pelvic cavity and layered closure of the laparotomy incision. The patient was evacuated to the next level of care in a stable condition. Based on available follow-up data, the patient returned to active duty.

 

Fig. 3. Penetrating injury of the jejunum. (а) Axial computed tomography (CT) scan showing a metallic fragment; (b) Intraoperative photograph demonstrating the wound site. The foreign body was located within the muscular layer of the intestinal wall, with the mucosal lining remaining intact.

 

Clinical case # 3

Penetrating trauma secondary to an artillery attack. Clinical examination revealed a solitary entrance wound at the level of the eighth rib along the left anterior axillary line. CT imaging confirmed the presence of a metallic fragment embedded in the subcutaneous tissues, approximately 3 cm deep, without penetration beyond the soft tissue layer. However, CT imaging demonstrated that the fragment had fractured into multiple pieces upon impact with the rib, and one of the fragments was identified in the omental bursa (Fig. 4). No pneumoperitoneum or free intraperitoneal fluid was observed. Exploratory laparotomy was performed, and intraoperative exploration revealed no evidence of pathological contents within the peritoneal cavity. During intraoperative exploration, it was found that the fragment had transfixed the transverse colon. The perforations were punctate and measured less than 5 mm in diameter. They were closed with interrupted two-layer sutures using Vicryl 3/0, applied sequentially to both the anterior and posterior walls of the colon to ensure watertight closure. The omental bursa was opened, and the fragment was identified on the anterior surface of the pancreatic body. However, no parenchymal bleeding from the pancreas was noted. The fragment was gently removed. Subsequently, the abdominal cavity and omental bursa were thoroughly lavaged and irrigated with warm saline solution. Drains were placed in the omental bursa and pelvis. Given the risk of pancreatitis and intestinal anastomotic dehiscence, the operation was completed with provisional closure of the laparotomy wound, with closure limited to the skin layer using interrupted sutures. In the immediate postoperative period, there were no signs of pancreatitis, as indicated by normal serum amylase levels. The patient was transferred to the next stage of medical care in a stable condition. Based on postoperative follow-up data, the case resulted in a full recovery.

 

Fig. 4. Shrapnel-induced penetrating abdominal wound with fragmentation occurring along the wound track.

 

In the presented cases, there is no doubt that the injuries sustained would have led to intestinal contents spilling into the peritoneal cavity and subsequent peritonitis within a short period of time. Precise early topographic diagnosis facilitated the identification and surgical repair of injuries, thereby preventing the development of an abdominal catastrophe. Furthermore, the third case illustrates the distinctive characteristics and insidious nature of modern ballistic projectiles. A single entry wound, with the shrapnel fragment lodged in the soft tissues and no free fluid or gas in the abdominal cavity, simulates a non-penetrating injury. Nevertheless, this cursory assessment may result in serious clinical consequences.

Clinical case # 4

The injury was sustained as a result of an attack by an unmanned aerial vehicle (UAV). There was an open fracture of the left forearm bones and a shrapnel wound of the chest with an entry point at the level of the sixth intercostal space along the mid-axillary line, complicated by hemopneumothorax. At the preceding stage of care, the patient underwent drainage of the left pleural cavity. CT imaging showed no significant free fluid in the abdominal cavity, but of particular concern was the presence of a metallic fragment in the retroperitoneal space at the level of the ThXII vertebra (Fig. 5). The shrapnel wound track was presumed to traverse the spleen, although CT imaging showed no conclusive signs of splenic injury. Ultrasonography corroborated the initial clinical suspicion: splenic parenchymal architecture was disrupted, with a minimal volume of free intraperitoneal fluid present. Subsequently, exploratory laparotomy was performed. Approximately 200–300 mL of blood was found in the abdominal cavity. During splenic mobilization, complete penetration of the spleen was observed, with a wound channel measuring approximately 1 cm in diameter. This finding prompted urgent splenectomy. No other intra-abdominal injuries were noted. The operation was completed by drainage of the splenic bed followed by layered closure of the laparotomy wound. Based on follow-up data, the patient achieved full recovery. In the present case, most likely due to centralization of circulation during traumatic shock, the splenic injury was not associated with massive hemorrhage in the early post-injury period; however, it posed a significant risk of profuse hemorrhage.

 

Fig. 5. CT imaging of a patient with a thoracoabdominal penetrating injury. (а) Penetration of the spleen by a small fragment; the trajectory extends from the pleural cavity through the diaphragm; (b) The fragment is lodged in a paravertebral location. Surgical exploration confirmed a complete penetrating tract through the spleen. However, no significant active hemorrhage was observed. Only a small volume of free blood was present in the peritoneal cavity.

 

In addition to centralization of blood flow, the high temperature of the injurious elements may induce a coagulation effect.

Clinical case # 5

As a result of artillery fire, the patient suffered a penetrating injury from a large shrapnel fragment. The fragment completely transected a substantial portion of liver segment VI (Fig. 6), resulting in traumatic loss of hepatic tissue.

 

Fig. 6. Penetrating abdominal injury caused by a large shrapnel fragment. (а) Computed tomography (CT) demonstrates a linear wound tract. The fragment is located within the soft tissues of the thoracic wall. (b, c) Surgical exploration revealed a completely transected fragment of hepatic segment VI. No evidence of hemorrhage or biliary leakage from the resection margin was noted. The peritoneal cavity was free of blood.

 

Following laparotomy, surgical exploration revealed a detached fragment of liver parenchyma within the peritoneal cavity. Notably, there was no evidence of intra-abdominal haemorrhage or biliary leakage. Detailed inspection of the hepatic resection margin demonstrated a desiccated cut surface, confirming the absence of active bleeding and bile duct leakage.

Additional hemostasis was achieved using bipolar coagulation. The operation was completed by placement of a drain in the liver resection site and layered closure of the laparotomy wound. Based on available data, the patient made a full recovery.

As statistical data show, liver injuries are rarely associated with clinically significant bleeding. However, notable exceptions exist, reflecting the variable clinical course of such injuries.

Clinical case # 6

Thoracoabdominal injury caused by a small metallic shrapnel fragment. Physical examination revealed an entry wound at the sixth intercostal space along the right mid-axillary line. Imaging studies (CT scan) demonstrated that the fragment had traversed the diaphragm and penetrated into the central region of the right liver lobe (Fig. 7). Intraoperative findings revealed a hepatic defect in segments VII–VIII, measuring 4×5 cm, despite the small shrapnel size. Active hemorrhage was noted, which failed to be controlled by bipolar electrocoagulation. Surgical repair was performed using U-shaped mattress sutures, reinforced with Teflon felt pads placed beneath the sutures to prevent pull-through and ensure reliable hemostasis.

 

Fig. 7. Penetrating thoracoabdominal trauma caused by a small shrapnel fragment. (а) Computed tomography reveals a small shrapnel fragment lodged within the central hepatic segments. (b, c) Intraoperative findings demonstrate a substantial laceration of the diaphragmatic surface of the liver. The laceration was repaired using U-shaped mattress sutures, reinforced with Teflon felt pads to ensure hemostasis and prevent suture pull-through. During the postoperative period, a laparotomy was undertaken due to the development of intra-abdominal bleeding. A temporary abdominal closure technique was employed, with primary closure limited to the skin layer only. The patient remained hemodynamically stable and was transferred to the next level of care. Follow-up data confirmed full recovery.

 

A comprehensive analysis of the performed surgical interventions is presented. The distribution of procedures by type and frequency, including those involving abdominal and retroperitoneal organs, is summarized in Table 4.

 

Table 4

Surgical interventions on abdominal cavity and retroperitoneal space organs in patients with abdominal trauma

Type of surgical intervention	Number of operated patients (absolute numbers and %)
Small bowel resection with entero-entero anastomosis which included resection of two intestinal segments with the formation of two anastomoses	44 (19) 2 (0.9)
Right hemicolectomy with ileotransverse anastomosis with some cases additionally involving small bowel resection and dual entero-entero anastomosis	15 (6.5) 3 (1.3)
Right obstructive hemicolectomy with nasointestinal intubation	2(0.9)
Left hemicolectomy with creation of a terminal transverse colostomy with a subset of cases involving concomitant small bowel resection and subsequent entero-enteral anastomosis	12 (5.2) 2 (0.9)
Resection of the transverse colon with terminal transverse colostomy with some cases including small bowel resection and entero-enteral anastomosis	5 (2.2) 2(0.9)
Obstructive resection of the sigmoid colon or rectum with terminal colostomy, including cases with: resection of the sigmoid colon combined with small bowel resection and entero-enteral anastomosis anterior resection of the rectum abdominoperineal resection	19 (8.2) 1 (0.4) 2 (0.9) 1 (0.4)
Double-barreled (loop) sigmoidostomy	2 (0.9)
Splenectomy in some cases, it was the only surgical procedure in the abdominal cavity	38 (16.5) 16 (7)
Resection of two or more liver segments	3 (1.3)
Cholecystectomy	5 (2.2)
Distal pancreatic resection	2 (0.9)
Laparotomy with minimal damage control: hemostasis via coagulation/suturing/tamponade and repair of hollow organ injuries	93 (40.3)
Laparotomy with thorough abdominal exploration, removal of all free intra-abdominal foreign bodies (bone/metal fragments), and placement of abdominal drains	3 (1.3)
Laparoscopy, including procedures involving hemostasis of hepatic injuries	7 (3)

 

Among patients with penetrating abdominal trauma, a rare subset of «lucky» wounds was identified (n = 5, 2.2%), characterized by the absence of visceral injuries despite a proven wound tract through the abdomen or free intra-abdominal fragments. Surgical management included laparotomy in 3 patients and laparoscopy in 2 patients. These patients were managed with a high degree of clinical vigilance, given the substantial risk of overlooking a minor lesion or perforation in the small or large bowel. Consequently, all surgical procedures were routinely completed with placement of abdominal drains to monitor for potential postoperative leakage.

In most cases, splenic injuries necessitated splenectomy. However, spleen preservation was achieved in 2 patients. In one case, a small foreign body had perforated the splenic capsule and was lodged within the parenchyma at a depth of no more than 2 mm. Following removal of the foreign fragment, the resulting punctate defect in the splenic capsule was treated with bipolar electrocoagulation and subsequently covered with an absorbable hemostatic sponge. In another case, the spleen sustained a tangential injury with a wound diameter not exceeding 15 mm. Reliable hemostasis was achieved through monopolar electrocoagulation of the capsular vessels, followed by application of a hemostatic sponge.

Diffuse peritonitis was identified in 15 patients (6.5%). All had sustained injuries ≥12 hours before admission. In all cases, a single-stage surgical procedure was applied, with minimization of the surgical volume during the initial stage. Formation of anastomoses was not performed in this group. Intestinal resections took place only if defects could not be repaired by suturing. Patients with peritonitis were usually in severe or critical condition, making further evacuation impossible in the early postoperative period. We performed programmed relaparotomies in 8 patients one day postoperatively. A positive trend in peritonitis progression was observed. All patients achieved clinical stabilization, and they were successfully evacuated to the next stage of care.

Among all surgically managed injured patients, relaparotomy was required in 6 cases (2.6%) during the early postoperative period due to intra-abdominal hemorrhage.

At our stage of providing medical care, no fatalities were recorded.

DISCUSSION

Contemporary battlefield trauma is characterized by combined injury patterns, which often complicates the identification of the dominant injury. Among military patients undergoing surgery for penetrating abdominal wounds, 41.5% sustained concomitant injuries involving three or more surgical specialties. Experience from the Great Patriotic War (1941–1945) showed that for injuries requiring specialized specialists, direct evacuation to hospitals with appropriate departments (bypassing intermediate stages) was crucial for ensuring favorable treatment outcomes. The consolidated medical unit of the FMBA of Russia operated as a fully multidisciplinary team, integrating physicians and nurses from various specialties. This approach demonstrably improved patient outcomes, including reduced complication rates, faster recovery times, and improved survival rates.

The majority of hospital admissions involved patients injured during artillery shelling and unmanned aerial vehicle (UAV) attacks. Patients injured by NATO fragmentation munitions typically present with multiple small entry wounds and retained high-velocity shrapnel. The small size and high penetrating capability of the fragments often result in complex internal injuries requiring extensive surgical exploration. The enhanced tissue penetration and fragmentation pattern are linked to the unique chemical composition of modern NATO projectiles. Specifically, their silicon content — a key factor in steel fragility — is 3–5 times greater than in older munitions. This results in more numerous and smaller shrapnel fragments upon detonation. During surgical extraction of shrapnel fragments, we identified an unexpected elemental composition: while chromium and manganese (common alloying elements) were anticipated, the presence of iridium — a rare platinum-group metal — represented a novel finding. An extensive literature review revealed no previously documented cases of iridium incorporation into steel alloys. Iridium, a rare and expensive platinum-group metal, exhibits extreme hardness and a high melting point. Historically, its incorporation into munitions was considered impractical due to its high cost. This is demonstrated by Case 4, where a shrapnel fragment fragmented during tissue penetration upon impact with a rib. The resulting smaller fragment propagated along the wound tract, inflicting secondary damage to adjacent internal organs. The irregular shape of the projectile significantly influences the trajectory of the wound tract, resulting in a curvilinear course. Based on clinical observations, the combined physical and material properties of modern shrapnel fragments contribute to highly unpredictable migration patterns within tissue.

Small shrapnel fragments frequently cause subtle injuries to intra-abdominal organs. These lesions commonly present with minimal clinical symptoms and inconspicuous imaging findings in the first few hours’ post-injury, but can rapidly progress to life-threatening complications such as peritonitis, hemorrhage, or multi-organ failure, resulting in high mortality if not promptly diagnosed and treated. Despite significant advances in trauma management, mortality rates in patients with gunshot-induced peritonitis remain high [1]. Prompt detection and timely surgical intervention are critical for reducing mortality and improving patient survival rates. Accurate diagnosis of such injuries is not possible without high-resolution CT, advanced ultrasound imaging, and endoscopy. In the early stages, these lesions typically have minimal impact on the overall clinical severity of the trauma patient, but may rapidly worsen if undetected. In a typical case of isolated abdominal injury from a small shrapnel fragment, the patient presents 4–6 hours post-injury. The individual is ambulatory and asymptomatic, with unremarkable physical examination findings, normal laboratory parameters, and no pathological changes identified on ultrasound or plain abdominal radiography.

However, CT imaging confirmed that the shrapnel fragment had penetrated the abdominal cavity. Subsequently, the patient underwent laparotomy. During the procedure, the surgeon identified localized injuries to the intestinal wall without full-thickness disruption, covered punctate perforations (partially covered by adjacent mesenteric tissue), and tangential tears of the mesentery. When such abdominal injuries coexist with wounds to other anatomical regions — particularly the chest, extremities, head, spine, pelvis, or external genitalia — the concomitant injuries typically dominate the initial clinical presentation. This may mask subtle signs of intra-abdominal pathology, delaying its timely recognition. However, without timely treatment, the patient’s condition deteriorates significantly after 12 hours post-injury, as secondary peritonitis develops. This complication ultimately determines the clinical outcome.

Prior to World War I, laparotomy was generally avoided in combat-related penetrating abdominal gunshot wounds, even after the advent of anesthesia. It was believed that preserving life in cases of internal organ injury was impossible. Advances in medical technology at the beginning of the 20th century led to a change in this situation.

V.A. Opel, the founder of the staged treatment concept for battlefield casualties, wrote that only laparotomy could prevent a fatal outcome, resulting in 20–30% survival rates [3]. The staged treatment approach for abdominal injuries was formally endorsed at the 14th Congress of Russian Surgeons (December 16–19, 1916). This system established a clear sequence of care: initial temporary wound dressing at the battlefield; analgesia and fluid resuscitation at the regimental aid station; followed by organized evacuation and definitive surgical intervention (laparotomy) at divisional medical facilities or Red Cross hospitals. Subsequently, particularly with the advent of antibiotics, military medical services adopted an aggressive surgical approach for all types of abdominal trauma. This resulted in an unusually high rate of unnecessary laparotomies, which carried a 20–30% complication rate, primarily involving postoperative infections [4]. Over time, analysis of extensive clinical data demonstrated that even when injuries were present, performing definitive surgical intervention before stabilizing the casualty — particularly in facilities with inadequate logistical and staffing support — resulted in high mortality rates.

In 1952, Academician P.A. Kupriyanov and colleagues, based on their analysis of World War II experience, emphasized that in cases of gunshot abdominal injuries, every surgeon must determine the need for surgical intervention on a case-by-case basis, considering specific medical-tactical and battlefield conditions. Surgery undertaken with the best intentions — to save a life — but without assessing the casualty’s physiological stability or conducting a sober evaluation of the extent and severity of injuries, may be performed at the patient’s expense. Refraining from surgery, however, is psychologically more difficult than proceeding with the intervention [5].

In 1993, M.F. Rotondo and colleagues introduced the key principles of the “Damage Control” (DC) strategy, designed to reduce the volume of surgical procedures during the initial phase of trauma care. This approach has since gained widespread acceptance in trauma surgery, particularly for severely injured patients [6, 7]. Limiting surgical interventions at the stage of advanced surgical care to the management of life-threatening conditions — specifically hemorrhage control, temporary closure of hollow viscera, and debridement of non-viable tissue — is a cornerstone of the modern military medical doctrine.

Our own experience has shown that in many admitted casualties, formal medical indicators and the medical-tactical situation allowed for complete repair of existing injuries. There were no compelling grounds for applying damage control surgery (DCS) principles or minimizing surgical interventions. The military trauma prognosis scale is notable for its simplicity and is well-suited for use in emergency response operations and mass casualty events. However, it fails to capture the full spectrum of injuries seen in modern armed conflicts. Specifically, the scale fails to account for traumatic brain injury, spinal cord trauma, maxillofacial injuries, and neck trauma. Thoracic injuries, even those not requiring thoracotomy, can substantially worsen the patient’s clinical condition. A similar pattern is observed with pelvic injuries: even with an intact pelvic ring, such trauma, as our clinical experience shows, significantly influences the systemic inflammatory response. It is challenging to standardize the full range of possible clinical scenarios. Therefore, each surgeon must make individual decisions, balancing the need to address life-threatening injuries against the risk of inflicting additional surgical trauma that could prove fatal.

Our clinical experience demonstrates that employing a dynamic decision-making approach to select between a single stage surgical procedure and a multi — stage approach significantly improved immediate postoperative outcomes. Specifically, this strategy resulted in zero mortality in the early postoperative phase among our operated casualties, and all patients were successfully stabilized and evacuated to higher levels of care.

Special emphasis should be placed on the management of laparotomy incision closure. The multi-stage approach requires temporary abdominal closure. This is justified by two key factors: the requirement for staged relaparotomies to monitor intra-abdominal pathology, and the prevention of abdominal compartment syndrome (ACS), a condition that can lead to organ dysfunction and worsen patient outcomes. Temporary abdominal closure may be accomplished using various techniques. The most technically advanced method is vacuum-assisted closure (VAC) therapy. However, its implementation was impractical in our field setting due to patient transport requirements and an insufficient supply of portable suction units. In cases of peritonitis, multiple organ injuries, anastomosis construction, or anticipated risk of postoperative complications, we performed skin-only closure. However, routine application of temporary abdominal closure in all trauma patients carries the risk of late-onset complications. This approach requires subsequent surgical intervention. Failure to do so will result in the inevitable development of an incisional hernia. Given the availability of effective non-invasive diagnostic tools — including laboratory tests, ultrasound imaging, and computed tomography (CT) — the routine uses of revision relaparotomy in patients demonstrating no clinical or laboratory signs of postoperative complications offers no clinical benefit. However, if the aponeurosis is not sutured within the first few days, its edges may significantly separate, making their approximation difficult. Therefore, in cases where we were confident in the reliability of the performed operation, we performed layered wound closure including the aponeurosis.

LIMITATIONS OF THE STUDY

A limitation of our study was that, when attempting to track long-term outcomes, we encountered several difficulties and lacked complete information on the subsequent fate of the operated patients, which prevents a comprehensive evaluation of the obtained experience.

The lack of direct communication between specialists providing care at different stages introduces uncertainty, hinders continuity of care, and impedes the determination of optimal treatment strategy.

We also excluded from the study wounded patients who were delivered with significant combined injuries and who died within 2-3 hours of admission.

CONCLUSION

The management of modern combat trauma usually necessitates a multidisciplinary surgical approach owing to the complex and often multisystem nature of injuries. Penetrating abdominal wounds caused by contemporary fragmentation munitions frequently exhibit an ambiguous clinical presentation during the initial post-injury hours. Early identification of these injuries is particularly challenging yet critically important, since timely diagnosis and appropriate intervention exert a significant influence on both patient survival rates and long-term clinical outcomes. In small-fragment wounds, a blurred clinical and instrumental picture is often observed during the first hours post-injury. However, according to our experience, combat penetrating abdominal trauma is not accompanied by injuries to any anatomical structures in only 2.2% of cases.

Classical signs of abdominal injury, such as the presence of free gas or fluid in the peritoneal cavity, may initially be absent. However, their subsequent appearance indicates a significant worsening of the prognosis for the wounded patient. In modern military conflicts, surgical services must detect and treat internal organ injuries early — before peritonitis onset. In cases of suspected abdominal injury, routine performance of native CT scanning in all patients, supplemented by endoscopic examination when clinically indicated, enables highly accurate diagnosis and identification of the subset of casualties requiring emergency laparotomy.

When determining the extent of surgical intervention, the surgeon must balance medical and medico-tactical indications based on the operational context. Careful assessment of the patient’s overall condition is crucial, as excessive surgical trauma may worsen outcomes. However, reduced-volume primary surgery with a multi-stage approach is indicated for only a subset of combat casualties.

Optimal outcomes in modern combat trauma care require bringing multidisciplinary high-tech medical services closer to the battlefield and enhancing collaboration between military and civilian healthcare systems to ensure continuity of care.

ADDITIONAL INFORMATION

Author contributions: A.V. Smirnov, treatment of the wounded, performing operations, general concept, collection and analysis of material, writing the article, editing; Yu.V. Ivanov, I.L. Anyushin, treatment of the wounded, performing operations, collection and analysis of material, editing; V.Yu. Gritsun, A.A. Keshvedinova, V.R. Stankevich, S.V. Deryabin, treatment of the wounded, performing operations and participation in the collection and discussion of material; E.A. Velichko, participation in the analysis of the material; N.A. Soloviev, R.I. Khabazov, A.V. Troitsky, general supervision and participation in the discussion of the material. Thereby, all authors provided approval of the version to be published and agree to be accountable for all aspects of the work in ensuring that questions related to the accuracy or integrity of any part of the work are appropriately investigated and resolved.

Acknowledgements: The authors thank the entire staff of Medical Unit No. 125 who participated in providing care to the wounded. Special thanks go to R.N. Dolgikh for invaluable assistance in organizing surgical care; M.V. Khruslova for her significant organizational contribution and assistance in collecting data; and the surgeons of the Federal Scientific and Clinical Center of the Federal Medical and Biological Agency of Russia who operated on the wounded: I.A. Beloglyadov, D.G. Demidov, E.A. Epifantsev, Yu.S. Nazarov, V.I. Sychev, and R.S. Chaikin.

Consent for publication: Not applicable.

Ethics approval: The study was approved by the local ethics committee of the Federal Scientific and Clinical Center of the Federal Medical and Biological Agency of Russia (protocol No. 9/2025 dated September 15, 2025).

Funding sources: State assignment of the Federal Medical and Biological Agency of Russia.

Disclosure of interests: The authors declare no conflict of interests.

Statement of originality: The authors did not utilize previously published information (text, illustrations, data) in conducting the research and creating this paper.

Data availability statement: The editorial policy regarding data sharing does not apply to this work, data can be published as open access.

Generative AI: Generative AI technologies were not used for this article creation.

About the authors

Alexander V. Smirnov

Federal Scientific and Clinical Center for Specialized Types of Medical Care and Medical Technologies

Author for correspondence.
Email: smirnov.av@fnkc-fmba.ru
ORCID iD: 0000-0003-3897-8306
SPIN-code: 5619-1151

MD, PhD, Assistant Professor

Russian Federation, Moscow

Yury V. Ivanov

Federal Scientific and Clinical Center for Specialized Types of Medical Care and Medical Technologies

Email: ivanovkb83@yandex.ru
ORCID iD: 0000-0001-6209-4194
SPIN-code: 3240-4335

MD, PhD, Professor

Russian Federation, Moscow

Ivan L. Anyushin

Federal Scientific and Clinical Center for Specialized Types of Medical Care and Medical Technologies

Email: Myneo@yandex.ru
ORCID iD: 0009-0001-9109-1440

MD

Russian Federation, Moscow

Aishe A. Keshvedinova

Federal Scientific and Clinical Center for Specialized Types of Medical Care and Medical Technologies

Email: aishe1998@mail.ru
ORCID iD: 0000-0002-0045-2715
SPIN-code: 1577-0901

MD

Russian Federation, Moscow

Vladimir R. Stankevich

Federal Scientific and Clinical Center for Specialized Types of Medical Care and Medical Technologies

Email: v-stankevich@yandex.ru
ORCID iD: 0000-0002-8620-8755
SPIN-code: 5126-6092

MD, PhD

Russian Federation, Moscow

Vladimir Yu. Gritsun

Federal Scientific and Clinical Center for Specialized Types of Medical Care and Medical Technologies

Email: ords1313@gmail.com
ORCID iD: 0000-0001-7647-9853

MD

Russian Federation, Moscow

Sergey V. Deryabin

Federal Scientific and Clinical Center for Specialized Types of Medical Care and Medical Technologies

Email: Deryabin@mail.ru
ORCID iD: 0000-0003-2754-4836
SPIN-code: 4929-0910

MD

Russian Federation, Moscow

Evgeny A. Velichko

Federal Scientific and Clinical Center for Specialized Types of Medical Care and Medical Technologies

Email: velichko_eugen@mail.ru
ORCID iD: 0000-0002-0297-8155
SPIN-code: 9817-2850

MD, PhD, Assistant Professor

Russian Federation, Moscow

Nikolay A. Soloviev

Federal Scientific and Clinical Center for Specialized Types of Medical Care and Medical Technologies

Email: my_docs@mail.ru
ORCID iD: 0000-0001-9760-289X
SPIN-code: 8024-7220

MD, PhD

Russian Federation, Moscow

Robert I. Khabazov

Federal Scientific and Clinical Center for Specialized Types of Medical Care and Medical Technologies

Email: khabazov119@gmail.com
ORCID iD: 0000-0001-6801-6568
SPIN-code: 8264-7791

MD, PhD

Russian Federation, Moscow

Aleksandr V. Troitsky

Federal Scientific and Clinical Center for Specialized Types of Medical Care and Medical Technologies

Email: dr.troitskiy@gmail.com
ORCID iD: 0000-0003-2143-8696
SPIN-code: 2670-6662

MD, PhD, Professor

Russian Federation, Moscow

References

Supplementary files