“Management of penetrating chest injuries : An integrative insight” – Prof. Siddharth Lakhotia, Dr. Ashish Sharma and Prof. Shivji Gupta

Commentary

Since antiquity, human kind has faced the challenges of traumatic wounds inflicted either as a result of weaponry attacks or accidental injuries. Management of such cases require a sound understanding of the anatomy and physiology of the organ or structure involved, along with a proficient surgical expertise and a diligent temperament to plan and deal with the situation effectively. Present video clearly demonstrates the value of these attributes in saving the lives of patients enduring with life-threatening penetrating injuries of the thoracic region. However, it is pertinent to note that the management of trauma and wounds has also been a part of traditional medicinal practices prevalent across the globe since long. In traditional Indian system of medicine (i.e. Ayurveda) also, surgery has been an integral branch since beginning and the ancient Indian surgeons, namely Sushruta and others, have also shared their views about the ways to manage these kinds of cases in their respective literary compilations. Sushruta Samhita, the compendium written by Sushruta, which is based primarily on the principles and practices of surgery, contains two chapters dedicated to the features and management of penetrating injuries resulting from the weapons and foreign bodies (made up of metals and other materials) [1]. Vagbhata has also described about these in specific chapters in the foremost section i.e. sootrasthana of his compilations [2-3].

As per Sushruta, the term “shalya” is used to denote something which moves swiftly and/or causes pain or injury to the body [4].

‘शल’ ‘श्वल’ आशुगमने धातूः; तयोराद्यस्य शल्यमिति रूपम् ||…सर्वशरीराबाधकरं शल्यं ||
                                                                                 [Su. Soo. 26/3-4]

Though the definition includes both endogenous and exogenous causes; the term shalya, with reference to traumatic injuries, is however used for foreign bodies or weapons especially the arrows (barbed or smooth) and other penetrating weapons (like spear etc.) made up of metals. Other sharp and pointed objects like horns, bones and wooden armatures have also been mentioned as potential cause of injury [5]. The last part of the present video demonstrates cases of penetrating injuries inflicted off arrow and bull-horn.

The forms and shapes of a shalya or foreign body may be of any sort, but some characteristic features have been described in Ayurveda. About the penetrating ends of shalya or foreign body, Vagbhata has mentioned that their pointed ends can either be round in shape or angulated; may be biangular (prithu or dvyasram), triangular (triputam or tryasram), or quadrangular (chatushkonam or chaturasram). The course of shalya inside the body has also been described to be either in upward (urdhwa), downward (adhah) or sideward (tiryak) direction in a straight (riju gati) or curved fashion (vakra gati) [6-7].

त्रिविधा हि गतिः शल्यानामुर्ध्वमधस्तिर्यक् च | सा पुनः प्रत्येकमृजुवक्रभेदेन द्विधा ||
समासतश्चतुर्विधं शल्यं भवति | वृत्तद्वित्रिचतुरस्रभेदेन ||           [A.S. Soo. 37/2 & 5]

वृत्तं पृथु चतुष्कोणं त्रिपुटं च समासतः |                            [A.H. Soo. 28/18]

Sushruta, on the other hand, has described the ends of shalyas to be either smooth (shlakshna) or barbed (karni) and their course inside the body has been categorized into upward (urdhwa), downward (urdhwa), sideward (tiryak), backward (riju) and frontward (arwachina) depending on the direction of their entry [8].

स च द्विविधः कर्णी श्लक्ष्णश्च ||…सर्वशल्यानां तु महतामणूनां वा पञ्चविधो गतिविशेष
ऊर्ध्वमधोऽर्वाचीनस्तिर्यगृजुरिति ||                            [Su. Soo. 26/7-8]

The iron rod injuring the chest in the present video can be categorized as a triangular (tryasram or triputam) shalya which, after entering from the front part of the chest, has followed a curved course (vakra gati) inside the body, before exiting through the back above the left scapular region (i.e. in urdhwag fashion according to Sushruta). Also, due to the force of trauma (as explained in video), a part of the rod got curved on itself; thus making it simulating a karni (barbed) shalya.

As mentioned earlier, management of penetrating traumas require a thorough understanding of the case to devise an appropriate treatment strategy. The ancient Indian surgeons also narrated the same concept and advised to first assess the case in terms of depth and fixity of shalya inside the body. On the basis of these, the shalyas were categorized as avabaddha (impacted or fixed) and anavabaddha (loose) types [9].

शल्यं द्विविधमवबद्धमनवबद्धं च ||            [Su. Soo. 27/3]

When, after entering into the body, the shalya or foreign body gets lodged into deeper tissues like muscles, bones etc. in such a way that it becomes fixed and difficult to extract, it is termed as avabaddha shalya or impacted foreign body. The anavabaddha shalya, on the other hand, is not impacted and is easily extractable. Apart from this, shalyas have also been categorized into arwachina and parachina types, based on the depth of penetration inside the body. If, with respect to the entry wound, the shalya has penetrated more than half of the dimension of the concerned body part, it is considered to be parachina whereas, the term arwachina is used if it does not cross the halfway mark. This concept of arwachina and parachina shalya is important as it directs the path of extraction of the lodged foreign body. Sushruta has advised that the arwachina shalya should be extracted through the wound of entry itself (termed as pratiloma aaharana) while the parachina shalya should be extracted through the exit wound (termed as anuloma aaharana) so as to minimize the chances of injury to the vital structures in vicinity while extraction [10].

सर्वशल्यानां तु महतामणूनां वा द्वावेवाहरणहेतू भवतः- प्रतिलोमोऽनुलोमश्च ||

तत्र प्रतिलोममर्वाचीनमानयेत्, अनुलोमं पराचीनम् ||                [Su. Soo. 27/6]

In other cases, where due to loss of momentum owing to the resistance offered by the body tissues, a pointed or barbed-end shalya is not able to come out of the body but is just visible under the skin (may be, by a raised prominence), the shalya can be taken out via anuloma aaharana by making a wound by giving an incision over the skin (at the raised area) and cutting off the barbed end [10].

उत्तुण्डितं  छित्त्वा निर्घातयेच्छेदनीयमुखम् ||        [Su. Soo. 27/6]

However, exception has been added for the foreign bodies lodged in or piercing through certain important regions like abdominal cavity (kukshi) and the axillary (kaksha), intercostal (parshukantara) and thoracic (vaksha) regions which have been advised to be brought out with utmost caution, through its entry wound only. Further, it is advised to cut off the pointed or barbed end of foreign body using a sharp instrument, if the need arises, to make it easily extractable through the entry wound [10].

छेदनीयमुखान्यपि कुक्षिवक्षःकक्षावङ्क्षणपर्शुकान्तरपतितानि च हस्तशक्यं यथामार्गेण हस्तेनैवापहर्तुं प्रयतेत || हस्तेनैवापहर्तुमशक्यं विशस्य शस्त्रेण यन्त्रेणापहरेत् ||     [Su. Soo. 27/6]

Explaining the process in his commentary, Chakrapani has also clarified that a foreign body with a smooth end may be extracted with caution through the entry wound without injuring the neighboring structures but a barbed-end foreign body needs either the barbed end to be cut off or to be manipulated in such a way that it can be extracted safely through the entry wound, especially when lodged in places like abdominal, thoracic or inguinal regions.

The iron rod pierced in the chest of the patient in the present video is an example of parachina avabaddha shalya pierced through the thoracic and axillary region, the piercing end of which has become barbed or karni after being rolled on itself due to the force of trauma. This rolled on (barbed or karni) part had to be cut off using an electrical cutter, so as to take out the rod cautiously from the entry wound. This is exactly in accordance to the above mentioned management principles advocated by Sushruta wherein a karni shalya lodged in vaksha, parshukantara and kaksha region must be taken out of the entry wound by pratiloma aaharana by cutting off its barbed end by using a sharp surgical instrument. Further, simultaneous implementation of resuscitation measures to prevent the shock, which is a basic part of management of such cases, was also advised by Sushruta and can be seen in the present video also [11].

शीतलेन जलेनैनं मूर्च्छन्तमवसेचयेत् | संरक्षेदस्य मर्माणि मुहुराश्वासयेच्च तम् ||
                                                                   [Su. Soo. 27/7]

After removing the shalya, Sushruta has advised to ensure the hemostasis. After this, the wound must be cleaned (or debrided if necessary) and antiseptic measures should be adopted to prevent infection and wound should be allowed to heal by secondary intention. In that era, thermal cauterization (agnikarma) was a useful and effective tool for hemostasis, debridement and antisepsis [12].

ततः शल्यमुद्धृत्य निर्लोहितं व्रणं कृत्वा स्वेदार्हमग्निघृतप्रभृतिभिः संस्वेद्यावदह्य प्रदिह्य सर्पिर्मधुभ्यां बद्ध्वाऽऽचारिकमुपदिशेत् ||                         [Su. Soo. 27/8]

In the present video, the surgeon also narrates the same steps of ensuring hemostasis, cleaning by peroxide, dressing with antiseptics (povidone iodine solution) and leaving the wound for secondary healing.

Towards the end of the video, the surgeon or the narrator is shown to be exclaiming over the fact that patient, in spite of a fatal injury of such a magnitude, was not only able to survive but was also drinking tea and water on the very evening of the operative day and was walking the very next day. This really seems like a miracle because such cases usually, as the narrator said, succumb to death either at the site or during transportation to hospital and hence, the whole team deserves lot of applauses for managing the patient so well. However, the survival and the rapid mobilization of the patient point towards two very important principles told by Sushruta. In his treatise, Sushruta has clearly emphasized the role of maintaining hemodynamic state of the patient by hemostasis and other measures [13].

देहस्य रुधिरं मूलं रुधिरेणैव धार्यते | तस्माद्यत्नेन संरक्ष्यं रक्तं जीव इति स्थितिः ||
[Su. Soo. 14/44]

Also, in case of penetrating trauma to the organs of abdominal or thoracic cavity, he has mentioned that the chances of survival are good if the natural processes of alimentary, urinary and respiratory tracts are intact [14].

स्वमार्गप्रतिपन्नास्तु यस्य विण्मूत्रमारुताः | व्युपद्रवः स भिन्नेऽपि कोष्ठे जीवति मानवः ||
                                                                             [Su. Chi. 2/55]

In this patient also, the bleeding was already ceased by the time the patient arrived in the hospital. Further, and most importantly, the breathing was somehow maintained, though on a single lung only. Also, there were no other vital injuries except the patient was in shock which was very well managed by the experienced team members.

In conclusion, it can be said that although the technological advances in the field of surgery, medicine and anaesthesia has made it possible to manage even the impossible of the cases successfully with rapid recovery and mobilization of the patient, the basic principles of management have remained the same from the ages of Sushruta and Vagbhata to the present times. The concept and principles of surgery and trauma management told by Sushruta and other ancient Indian Surgeons thousands of years ago, still hold valid in present era and hence, should be duly acknowledged and followed.

References

1. Shastri AD, editor. Ayurveda Tattva Sandeepika Hindi commentary on Sushruta Samhita of Sushruta, Sootra Sthana: Chapter 26 & 27. Reprint ed. Varanasi: Chaukhamba Sanskrit Sansthan; 2009:138-46p.
2. Chhangani GS. Arthprakashika Hindi commentary on Ashtanga Sangraha of Vagbhata, Sootra Sthana: Chapter 37. Reprint ed. Varanasi: Chaukhamba Sanskrit Sansthan; 2005:307-12p.
3. Gupta AD, editor. Vidyotini Hindi Commentary on Ashtanga Hridayam of Vagbhata, Sootra Sthana: Chapter 28. Reprint ed. Varanasi: Chaukhambha Prakashan; 2011:208-14p.
4. Shastri AD, editor. Ayurveda Tattva Sandeepika Hindi commentary on Sushruta Samhita of Sushruta, Sootra Sthana: Chapter 26, Verse 3-4. Reprint ed. Varanasi: Chaukhamba Sanskrit Sansthan; 2009:138p.
5. Shastri AD, editor. Ayurveda Tattva Sandeepika Hindi commentary on Sushruta Samhita of Sushruta, Sootra Sthana: Chapter 26, Verse 6-7. Reprint ed. Varanasi: Chaukhamba Sanskrit Sansthan; 2009:139p.
6. Chhangani GS. Arthprakashika Hindi commentary on Ashtanga Sangraha of Vagbhata, Sootra Sthana: Chapter 37, Verse 2 & 5. Reprint ed. Varanasi: Chaukhamba Sanskrit Sansthan; 2005:308-9p.
7. Gupta AD, editor. Vidyotini Hindi Commentary on Ashtanga Hridayam of Vagbhata, Sootra Sthana: Chapter 28, Verse 18. Reprint ed. Varanasi: Chaukhambha Prakashan; 2011:210p.
8. Shastri AD, editor. Ayurveda Tattva Sandeepika Hindi commentary on Sushruta Samhita of Sushruta, Sootra Sthana: Chapter 26, Verse 8. Reprint ed. Varanasi: Chaukhamba Sanskrit Sansthan; 2009:139p.
9. Shastri AD, editor. Ayurveda Tattva Sandeepika Hindi commentary on Sushruta Samhita of Sushruta, Sootra Sthana: Chapter 27, Verse 3. Reprint ed. Varanasi: Chaukhamba Sanskrit Sansthan; 2009:142p.
10. Shastri AD, editor. Ayurveda Tattva Sandeepika Hindi commentary on Sushruta Samhita of Sushruta, Sootra Sthana: Chapter 27, Verse 6. Reprint ed. Varanasi: Chaukhamba Sanskrit Sansthan; 2009:143p.
11. Shastri AD, editor. Ayurveda Tattva Sandeepika Hindi commentary on Sushruta Samhita of Sushruta, Sootra Sthana: Chapter 27, Verse 7. Reprint ed. Varanasi: Chaukhamba Sanskrit Sansthan; 2009:143p.
12. Shastri AD, editor. Ayurveda Tattva Sandeepika Hindi commentary on Sushruta Samhita of Sushruta, Sootra Sthana: Chapter 27, Verse 8. Reprint ed. Varanasi: Chaukhamba Sanskrit Sansthan; 2009:143p.
13. Shastri AD, editor. Ayurveda Tattva Sandeepika Hindi commentary on Sushruta Samhita of Sushruta, Sootra Sthana: Chapter 14, Verse 44. Reprint ed. Varanasi: Chaukhamba Sanskrit Sansthan; 2009:73p.
14. Shastri AD, editor. Ayurveda Tattva Sandeepika Hindi commentary on Sushruta Samhita of Sushruta, Chikitsa Sthana: Chapter 2, Verse 55. Reprint ed. Varanasi: Chaukhamba Sanskrit Sansthan; 2009:23p.

Original video link – https://www.youtube.com/watch?v=QeknY30NvSU