Hey everyone! Welcome to a new series I’m calling Mangled Mondays.
The point of Mangled Mondays will be to give an injury profile every Monday. Not only is the alliteration fun, I know that I personally wish that I could personify Monday so that I could mangle it and then go back to bed.
(And yes, I know we’re starting this on a Friday, but that’s happening because… reasons.)
So without further ado I give you Mangled Mondays: Evisceration…
What Is It?
Evisceration, also known as disembowelment, is any form of injury that ends with your character’s insides on the outside, with their guts hanging out. Their bowels are literally in their lap.
The abdomen is essentially a madhouse of overpacking. The intestine, or small bowel, is approximately 25 feet of tightly bunched material that is held in place by a thick membrane called the peritoneum, which lines the abdominal cavity and is folded over those densely packed organs. When the peritoneum is ruptured, the guts come out.
The interesting thing about this injury is that the intestines themselves don’t even need to rupture for this to be an absolutely devastating and likely-to-be-deadly injury. Even if the bowels are miraculously intact, the odds of getting an infection are extremely high, and your character’s life is on the line.
Meanwhile, they have a problem: they have guts in their hands and they can’t get them back in!
If this injury is the result of some kind of fight, the character will be left vulnerable to additional injury, though an attack that leaves its victim extruding sausage into the open is likely to make the attacker think the job has been done. Either way, this character is instantly out of the fight, even if they retain strength; the horror of the injury is enough to disable them as a fighter.
In reality, in the majority of cases in which any part of the abdominal contents is welcomed to the outside world, what comes out is not actually an organ, but the omentum, a great protective apron of tough, fibrous tissue and fat that protects the underlying organs. However, characters with these injuries are still in deep trouble: 8 in 10 wounds with an evisceration will include another internal injury that requires surgical repair.
While some forms of evisceration are inherently lethal, including those with massive hemorrhage or where the entire abdominal contents are extruded and mangled or destroyed, it’s far more common for the protrusions through the abdominal wall to be fairly small, no more than a few inches.
In the former case, exsanguination (heavy blood loss) is the primary concern. In the latter, the real worry is infection.
Abdominal trauma in general is extremely prone to infection, because the gut is colonized with billions of bacteria. These are usually either neutral or beneficial to the body when they stay where they belong, but when they cross into the bloodstream, these bacteria can cause sepsis and death within days.
- Elvis has left the building.
- Erm, the bowels have left the abdomen. Or at least, something has left the abdomen; most often it’s the omentum.
- Protruding tissue may look gray or may be obvious loops of bowel; these look like raw sausage without the fennel.
How Does It Happen?
In order for matter to exit the abdominal cavity, it needs…
…a clear exit pathway. This typically involves a slashing injury to the abdominal wall, though it’s of course possible for the injury to come from a stab wound. Exit wounds from gunshots are also known to cause eviscerations.
Characters who aim to support a character with an evisceration have their work cut out for them.
First, they must get over their own emotions at the sight of their comrade with their “guts hanging out.” They may, in fact, need to be gutsy in how they handle the situation.
(I’m here Tuesdays and Thursdays, try the veal… or the sausage. Refunds can be requested from any reputable retailer.)
Next, bleeding must be managed as best it can be.
Characters with medical training will know that the exposed bowel must be kept wet, and so will use whatever’s handy as a wet dressing, soaking it with water (sterile for preference, distilled second, tap as a last resort) and applying it to the exposed tissue.
Afterwards, characters might use a piece of plastic, such as a plastic bag cut into a square and taped down on all sides, to protect the wound from contamination. (Given that we’re discussing a wound with the potential for perforated bowels, it may already be contaminated.)
Getting this character to a trauma surgeon is of the utmost importance, because characters simply don’t know what’s going on inside.
Surgery / Hospitalization
Trauma teams are going to be very concerned about patients with eviscerations, and the larger and more out-spilly the wound, the more concerned they will be.
The character will be given an overall trauma evaluation in the emergency department, where they will get IVs, blood products if they need them, and the first round of antibiotics. Then it’s a short, rapid trip to the operating room.
As a side note, in the US, stab wounds must be reported to local law enforcement. Relevant clothing will be preserved as evidence, and security will likely be close by until the police arrive.
In the operating room, the character will be anesthetized, and the abdomen will be opened to explore the wound. This is known as an exploratory laparotomy. An(other) incision will be made into the abdominal wall, which will likely run 4–6 inches in length, and surgeons will then examine the underlying tissue. Things that need stitches will be stitched.
If there is potential for the large or small bowel to be nicked, the character will undergo peritoneal lavage, meaning that sterile saline will be poured into the abdomen and then drained with suction and examined. Lavage is designed not only to flush out any free feces but also to examine whether (and how much) blood and fecal matter are in the abdomen.
After the repairs are made, the abdomen will be closed, first with a layer of sutures to close the peritoneum. Then the skin will be closed with a separate layer of sutures or staples.
The character will be in surgical ICU for a few days, and there’s a distinct possibility that they’ll need to return to the OR for further surgery if the abdomen continues to bleed or infection becomes apparent.
Colostomy & Ileostomy
In some cases, especially where the small intestine or colon has been significantly damaged, the character will be given a surgical hole through which to poop (defecate). If this is in the colon it’s a colostomy, an ileostomy if it’s in the small bowel. Fecal matter will thus drain into a bag rather than be excreted through the rectum and anus.
This is especially common if the colon itself has been injured by the evisceration.
The character will be given ice chips on the first day and likely clear fluids by the second or third day. They will also likely have a tube running from the nose to the stomach for the first two days after surgery, which is hooked up to suction; this is to drain the stomach of bodily fluids.
Characters may be eating solid food as soon as three days after the surgery.
The wound will likely have a small tube in place which will provide suction on the wound to help drain any fluid that accumulates as part of the healing process; this fluid is called serosanguinous fluid and is an orangey yellow. The drain will likely be removed after 2 days.
The dressings will be changed every four to 48 hours, especially if they soak through; earlier on, dressing changes will be more frequent.
Characters with a colostomy will be taught how to clean the stoma (opening) with warm water, and will be instructed on how feces collects into the bag.
In the Austere Environment
Outside of a hospital environment, the best that can be done is to gently push the relevant pieces of abdominal contents back into the wound, stitch the wound closed, wait, and hope. Antibiotics, if available, should be used.
This will only be realistically survivable if the character comes to Death’s door, knocks, and waits patiently while Death herself deliberates; that is, the character will almost invariably become septic, or incredibly sick with infection.
The Rocky Road to Recovery
Characters will be able to use all four limbs, and walking is possible beginning a few hours after surgery.
As anyone who has strained a muscle doing sit-ups or yoga can tell you, a surprising number of actions involve the core muscles of the abdomen. It will take a few weeks for the abdominal muscles to heal, much less the skin, and everything from leaning over to making a bowel movement and coughing can cause pain and discomfort; ability to run, move heavy weights, etc., will take some weeks to return.
Amazingly enough, intestines are quick-healing, and the muscle damage is reparable. Characters who don’t need permanent colostomies will have avoided having any significant long-term consequences, other than a wicked scar.
Features of Recovery: Hospital Stay
Features of Recovery: PT/OT
There are two main focuses of physical therapy after laparotomy: walking, and core strength. The first is accomplished with assistance: first, if needed, a walker, then an assistant or a steady pole, until finally the character will simply walk as they did before, if more slowly.
Core strength is compromised by the injury to the abdominal muscles, from both the wound and the surgery, and will take some time to return. However, once the wound is no longer at risk of ripping open, strength will be rebuilt with exercises like crunches, planks, side planks, and something called a Superman, where the character lies prone (on their belly) with their arms and legs extended and raises one arm-and-opposite-leg pair at a time.
The New Normal
Other than a permanent scar on the abdomen, characters may not have any significant changes to their lifestyle after their surgical wounds heal.
Characters who suffer any kind of insult to the intestines are at risk of a complication known as adhesions, which are essentially large pockets of scar tissue, which typically develop years after the injury itself. Adhesions are mostly benign, but they can cause frequent constipation or even bowel obstruction as they pinch off an area of small or large intestine, and are the most common cause of such symptoms in developed nations.
In severe cases, adhesions can strangle the bowel. On the vascular side, this strangulation causes obstruction of blood flow to the bowel and can cause death of the tissue. But it can also cause the bowel to swell with feces and rupture, which can cause lethal bleeding. If the character doesn’t bleed to death, they may succumb to infection.
If these adhesions become problematic, they may need to be surgically removed – a process that can cause additional adhesions down the line.
Total Recovery Time (Typical)
Suture and wound healing: 6 weeks
Full strength: 12 weeks
The abdomen is lined with four layers of protection for the underlying organs. The skin is what we all know it to be. The fat is a yellow layer whose thickness varies based on body type, but which may have substantial thickness and weight in heavier characters. The muscles are bright pink and will bleed, and the peritoneum is thick, white, and fibrous. (If the evisceration is small, it’s the omentum, the outer layer of the peritoneum, that will come out.)
If the bowel or intestine is pierced, the viewer will be able to see brown material ooze from the nicked sections.
In addition to the coppery stench of blood, this character will smell strongly of feces if the colon or small bowel is pierced.
Imagine the sound of wet meat hitting concrete. That’s about what a disembowelment will sound like.
In addition to the pain, characters who are being disemboweled may feel a sliding or falling feeling as their bowels come out.
If the bowels are stuffed back in, they’ll feel a significant amount of pressure and pain during the push.
A laparotomy is known between colleagues as a “lappy,” with the specific procedure – exploratory laparotomy – being known as an “ex lap.”
Exploring the small or large intestine for damage and necrosis (tissue death) is known as “running the bowel.”
When attempting to put them back into place, surgeons might be said to be “playing Hide the Sausage” with the intestines. Note that this will not be said in front of the patient unless they’re under anesthesia, as it’s somewhat less than polite.
- Eviscerations are rapidly lethal when large portions of bowel are removed or damaged, as bleeding can be significant.
- On the smaller end of the scale, it’s possible that only the omentum, the flap that covers and protects the intestines, protrudes through the skin.
- The risk of infection is great if the wound is not properly managed. (See the entry on Sepsis.)
- Eviscerated bowel must be kept moist to prevent additional damage.
xoxo, Aunt Scripty
This post is an excerpt from Blood on the Page Volume One: A Writer’s Compendium of Injuries. The book details thirty-one injuries with which to maim, mangle, and maul your characters, as well as nine indispensable articles of Wound Wisdom covering everything from burn stages to suture selection.
The book will be out 10/23, just in time for NaNoWriMo!