Because a hole in the stomach is never just a hole.
The Setup
Blunt trauma loves the liver. Sharp trauma loves the stomach.
And when the stomach gets hit, it doesn’t quietly leak, it erupts.
You see the bile-stained field, the smell of acid and food debris, the moment where the abdominal cavity becomes a toxic soup.
And you know instantly: this isn’t just a repair, this is a race.
The Mechanisms That Make It Ugly
Gastric injuries usually arrive as:
- Penetrating trauma: Stabs, gunshots, shrapnel
- Blunt trauma: Deceleration, seatbelt compression, handlebar impacts
- Blast trauma: Intra-abdominal overpressure with gastric rupture
The stomach is surprisingly tough, but once it’s breached, contamination is instant and complete.
Unlike the small bowel, gastric contents are acidic, enzymatic, and bacteria-rich, a perfect recipe for peritonitis.
Find It Fast
Most gastric injuries don’t bleed you dry, they poison you slow.
That’s why exposure is everything.
Incision: Long midline laparotomy, always.
Then:
- Evacuate debris and gastric content immediately.
- Identify the wounds (especially in penetrating trauma).
- Trace bullet/stab paths through lesser sac, spleen, pancreas, diaphragm, and liver, gastric injuries never travel alone.
If the wound is posterior, open the lesser sac.
If anterior, lucky day; it usually declares itself.
Classify It in Your Head (Not on Paper)
Forget fancy grading systems in the chaos.
Ask yourself:
- Small or large?
- Anterior or posterior?
- Through-and-through or contained?
- Single or multiple?
That’s all you need to plan the next move.
Control Contamination
Before anything else:
- Suck. Irrigate. Suction again.
- Decompress the stomach with an NG tube (if not already in).
- Pack around to localise contamination, avoid spreading it to the pelvis or paracolic gutters.
Then, when the field is clean enough to see, repair.
Repair. Simple Works!
Small perforations / clean edges:
Two-layer closure, inner absorbable (e.g., 3-0 Vicryl) full-thickness, outer seromuscular imbrication (e.g., PDS).
Always test with saline distension, check for air leaks.
Larger or devitalized wounds:
- Debride edges until viable.
- Two-layer closure, or
- If extensive, wedge resection or gastric antrectomy (rare in trauma but sometimes needed).
Massive tissue loss, posterior wall destruction, or delayed presentation with necrosis?
→ Controlled drainage + diversion (feeding jejunostomy, NG, and drains).
Don’t reconstruct an acid volcano.
Always Look for Friends
Gastric injuries rarely travel solo.
You must actively search for companions:
- Diaphragm: Left-sided tears, always check with nasogastric insufflation under saline.
- Spleen: Especially with posterior upper gastric injuries.
- Pancreas: Bullet paths through lesser sac.
- Liver: Tangential upper gastric entry wounds.
Miss one, and your patient will remind you later, in the form of an abscess, leak, or fistula.
Drain Intelligently
A drain is not a crutch, it’s insurance.
Place dependent drains near repair, ideally in the left subhepatic space or subphrenic region.
Never leave untested closures unguarded.
Nutrition: The Forgotten Lifeline
Don’t let fear of feeding starve your patient.
If the stomach is intact and bowel viable, start enteral feeds early.
If high-risk repair or contamination → feeding jejunostomy now, not later.
You’ll thank yourself when the leak becomes a nutritional marathon.
When You Shouldn’t Close
If the patient is dying:
- Pack.
- Drain.
- Get out.
Damage control trumps elegance.
You can’t fix mucosa in a corpse.
Pitfalls and Painful Lessons
- Missing posterior injuries = abscess within days.
- Overzealous debridement = anastomotic leaks.
- No drain + occult leak = septic crash on day 3.
- Tight closure with swelling = gastric outlet obstruction.
You earn these lessons once, if you’re lucky enough to keep the patient.
Postoperative Vigilance
Watch for:
- Persistent NG output (suggests leak or obstruction)
- Fever, tachycardia, rising WCC → suspect abscess or leak
- CT with oral contrast if suspicion persists
- Don’t hesitate to drain collections early
And remember, gastric leaks are rarely small problems. They spiral.
In Summary
Do:
- Debride gently
- Two-layer closure
- Drain wisely
- Check neighbours
- Feed early (if safe)
Don’t:
- Chase perfection in the unstable
- Forget to test your closure
- Close tight without thinking
And From the Patient’s Side…
They won’t remember the acid smell, or the frantic packing, or the cold rush of saline in a desperate washout.
They’ll wake up weeks later with scars they can’t explain, but alive.
For them, it was an instant.
For you, it was the longest hour of the night, standing between contamination and catastrophe.
Because trauma surgery isn’t about making things look neat.
It’s about making sure they wake up again.
