Wound Excision, Dressings and Delayed Primary Closure

(31-35)

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"The proper treatment of wounds is to be regarded as the most important requirement for the surgeon" Billroth, 1871.

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The basic principles of war wound management, known to military surgeons for centuries (16-18), and rightly emphasized by the ICRC (31-35), involve excision of all dead tissue and foreign materials, and the decompression of viable tissue affected by the injury. If this is well performed, infectious complications are prevented. After adequate wound excision, dry and bulky dressings are left undisturbed until the time of delayed primary closure 4-5 days later (31-34).

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In ICRC hospitals patients are not evacuated after initial surgery. This is particularly advantageous, for it gives the surgeon the best possible opportunity to improve his technique, by assessing the results of his initial excision when the dressings are removed.

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Penetrating Head Injuries (36)

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Surgeons in ICRC hospitals, like most military surgeons, usually have minimal previous neurosurgical experience, and moreover have no facilities for evacuation to neurosurgical units. The surgery recommended by the ICRC therefore focuses on haematoma evacuation and the prevention of brain abscess (36).

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Blood Transfusion (37-38)

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It has been observed that the patients requiring most blood in ICRC hospitals are those injured by

antipersonnel mines, who sustain large wounds mainly of the lower extremities (37-38), and who often undergo amputation. Surprisingly little has been written about transfusion requirements in war, which makes the ICRC experience all the more important.

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The ICRC recommendations are that when antipersonnel mines are used widely in a conflict, the

blood bank should expect to provide 100 units of blood for every 100 patients (37). For every 100 patients with an amputation, 345 units should be provided, and this requirement will continue long after hostilities have ceased (38).

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War Surgery and Anaesthesia (31, 39-50)

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The ICRC has published a practical field book, Surgery for Victims of War (31), loosely based on older military war surgery fieldbooks (18), summarising the experience of eminent specialists in various disciplines. This reflects the fact that ICRC hospitals have to serve both as field hospitals and as definitive centres combining primary, secondary and basic reconstructive surgery (20), for which problem area certain guidelines have been developed (39-40). A feature of note is that there are no facilities for prolonged, postoperative ventilation of patients: there is a correspondingly greater reliance on the use of ketamine and locoregional blocks for anaesthesia (41). On a personal level, individual surgeons and anaesthetists, on their return from postings to ICRC hospitals, have documented their experiences (42-50). All have benefited from such attachments.

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Vascular and Abdominal Injuries (51-56)

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The ICRC experience of vascular injuries reflects the fact that evacuation of the wounded to ICRC hospitals is by road, and is at best difficult, with over 60% of patients arriving more than 12 hours after injury (44, 51). This lag time between injury and treatment is the single most important prognostic variable for limb salvage.

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Revascularisation is only attempted in patients seen within 12 hours of injury, with primary amputation being almost inevitable in patients arriving after 12 hours (52-54).

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Penetrating abdominal injuries requiring laparotomy are dealt with in ICRC hospitals by established surgical techniques (31, 35, 55-56). The main area of controversy lies in the treatment of colonic injury by selective primary repair in up to half the patients, rather than by colostomy, especially if the injury to the left colon is minor, and resection and immediate ileocolic anastomosis for all right colon injuries. The guidelines for performing colostomy for transverse and left colonic injuries are: i. shocked patient; ii. other severe intra-abdominal injuries; iii. delay in presentation; and i v. marked faecal contamination (56).

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Limbs, Amputations and Mine Injuries (31, 57-67)

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Over 70% of all war wounded patients present with limb wounds. With so many limb injuries, surgical amputations of both lower and upper limbs at every level are common. Most of the severe limb injuries and traumatic amputations result from antipersonnel mines, which are widely used and very difficult to detect.

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The exceptionally high blood transfusion requirements for amputees (345 units for every 100 amputees) presents obvious logistic problems. In addition, war-injured patients with an amputation face more serious problems than non-amputees: their mortality is higher, they stay longer in hospital, the risk of infection is higher, and they undergo more surgical interventions (38).

Mines respect no ceasefire, they remain long after a conflict and they do not discriminate between the footstep of a child and that of a combatant. The ICRC has been forthright in its condemnation of the indiscriminate use of landmines: "Mines are the greatest violators of international humanitarian law, practising blind terrorism" (57-58).

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Three recognisable patterns of mine injury are seen in ICRC hospitals, and the ICRC has issued guidelines (31, 59-61), and produced an excellent video (62), Anti Personnel Mine Injuries - Surgical Management, to assist its surgeons in performing optimal amputations.

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The ICRC has also recently published a book, War Wounds of Limbs - Surgical Management (63), written primarily for the surgeon about to enter the field, which guides the surgeon through war wounds and mine injuries, the surgeon's role, methods of amputation, the complications and difficulties encountered and the rehabilitation of the patient.

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A recent review describes the ICRC method of using external fixation in combination with plaster splints or skeletal traction such that it can be "locked" or "unlocked" as required (64). This method eliminates many of the disadvantages of external fixation, in particular minimising delay in callus formation and pin problems.

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The ICRC has widely publicised the lessons it has learnt in war surgery specifically to educate medical and nursing personnel (65), both civilian and military, who may eventually have to face such problems themselves.

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Who would have imagined three years ago, for instance, that the civilian surgeons of Europe's largest University Teaching Hospital - in Sarajevo - would have had to familiarise themselves with these lessons?

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Moreover, such is the scale of the indiscriminate effects of antipersonnel mines on both individuals and communities that the ICRC is actively raising public awareness of this problem (66). It organised an international symposium on mine warfare and the effects of mines in Montreux in April 1993, since when a campaign to ban mines has commenced, and the United Nations is actively reviewing existing law, the 1980 United Nations Convention (67).