During a 23-year interval, 83 patients with wounds of the portal and/or superior mesenteric veins underwent emergency laparotomy. Six (7%) of the injuries were due to blunt trauma, while penetrating wounds accounted for the remaining 77 (93%). With one exception, associated organ injuries were routinely present and involved 120 other major vascular structures in 59 (71%) of the patients. Five patients with both portal and superior mesenteric vein injury and 3 others with isolated portal venous injury exsanguinated before repair could be accomplished.Lateral phleborrhaphy gave survival in 24 of 34 patients so treated. End-to-end reanastomosis of the portal vein was successful in only 1 of 3 patients on whom it was attempted, while the single portacaval shunt led to a metabolic death. Of the initial 17 patients having vein ligation as a desperation measure, there were 7 survivors. Subsequent immediate application of this technique whenever lateral repair was impossible or impractical was successful in 17 of 20 so managed.Death resulted from hemorrhagic shock (20), its attendant coagulopathy (7), or renal failure (2) in 29 patients. Two deaths were the result of failure to over-transfuse appropriately when portal venous ligation or thrombosis with its attendant splanchnic sequestration led to significant peripheral hypovolemia. The overall mortality rate was 41%, with individual mortality rates of 46 % and 27 % for the portal and superior mesenteric veins, respectively. There was no survival if both veins had been injured.

Over a 20-year interval, 167 patients sustained acute full-thickness abdominal wall loss due to necrotizing infection (124 patients), destructive trauma (32 patients), or en bloc tumor excision (11 patients). Polymicrobial infection or contamination was present in all but five of the patients. Of 13 patients managed by debridement and primary closure under tension, abdominal wall dehiscence occurred in each. Only two patients survived, the 11 deaths being caused by wound sepsis, evisceration, and/or bowel fistula. Debridement and gauze packing of a small defect was used in 15 patients; the single death resulted from recurrence of infectious gangrene. Pedicled flap closure, with or without a fascial prosthesis beneath, led to survival in nine of the 12 patients so-treated; yet flap necrosis from infection was a significant complication in seven patients who survived. The majority of patients (124) were managed by debridements, insertions of a fascial prostheses (prolene in 101 patients, marlex in 23 patients), and alternate day dressing changes, until the wound could be closed by skin grafts placed directly on granulations over the mesh or the bowel itself after the mesh had been removed. Sepsis and/or intestinal fistulas accounted for 25 of the 27 deaths. Major principles to evolve from this experience were: 1) insertion of a synthetic prosthesis to bridge any sizeable defect in abdominal wall rather than closure under tension or via a primarily mobilized flap; 2) use of end bowel stomas rather than exteriorized loops or primary anastomoses in the face of active infection, significant contamination, and/or massive contusion; and 3) delay in final reconstruction until all intestinal vents and fistulas have been closed by prior operation.

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