What is the management of evisceration?

Management of Evisceration

Patients with bowel evisceration should undergo immediate operative intervention. 1

Definition and Immediate Management

• Evisceration refers to the protrusion of internal organs outside their normal anatomical compartment, typically through a defect in the body wall 2, 3
• When evisceration occurs, it represents a surgical emergency requiring prompt intervention to prevent complications such as strangulation, infection, and organ necrosis 3, 4

Management Algorithm

Initial Assessment and Stabilization

• Assess hemodynamic status immediately - evisceration often accompanies other significant injuries 1
• Do not attempt to reduce eviscerated organs in the emergency department 2
• Leave eviscerated organs in place and cover with moist, sterile saline-soaked gauze 2
• Initiate fluid resuscitation and antibiotic therapy to prevent infection 1

Definitive Management

1. Hemodynamically unstable patients:

   • Immediate operative intervention is mandatory 1
   • Damage control techniques should be considered, particularly with associated injuries and physiologic derangement 1

2. Hemodynamically stable patients:

   • Despite stability, immediate operative intervention is still required for evisceration 1
   • Current guidelines clearly state that evisceration is an absolute indication for operative management, regardless of hemodynamic status 1

3. Operative approach:

   • Laparotomy is typically required for abdominal evisceration 1
   • For penetrating trauma with evisceration, patients should be taken directly to the operating room without delay for CT scanning 1
   • Primary repair should be performed whenever technically possible 1

Special Considerations

Organ-Specific Management

• Bowel evisceration: Requires careful inspection for viability, repair of any perforations, and thorough abdominal exploration to identify other injuries 3, 5
• Lung evisceration: Requires immediate surgical intervention with retrieval of the eviscerated lung and thoracic wall repair 2
• Liver evisceration: Extremely rare but requires careful reduction and repair of the abdominal wall defect 4

Common Pitfalls

• Attempting to reduce eviscerated organs outside the operating room can lead to further injury and contamination 2, 3
• Delayed surgical intervention significantly increases mortality - a fourfold increase when delay exceeds 24 hours for hollow viscus injuries 1, 6
• Non-therapeutic laparotomy carries risks, but these are outweighed by the risks of missed injuries in cases of evisceration 1, 6

Follow-up Care

• Monitor for signs of infection, wound dehiscence, and other post-operative complications 4
• Consider nutritional support to aid healing, particularly in patients with pre-existing malnutrition 4
• Resume normal activities gradually, typically after 3-4 months for major abdominal trauma 1

Conclusion

Evisceration represents a true surgical emergency requiring immediate operative intervention regardless of hemodynamic status or associated injuries. The primary goals are to return the eviscerated organs to their normal anatomical position, repair any injuries, and close the defect to prevent further complications.