Anterior Abdominal Stab Wounds Research Articles

A clinical observation algorithm for anterior abdominal stab wound is safe in an Australian setting.

We previously published the outcomes associated with the use of diagnostic laparoscopy to determine peritoneal breach for AASW patients without an immediate indication for laparotomy. Although this pathway was 100% sensitive there was a 54% non-therapeutic laparotomy rate. Another option that has been extensively reported is the clinical observation algorithm (COA) however, majority of the data originate from high-volume centres. We hypothesized that a COA would also be a safe option in an Australian setting, and reduce the rate of non-therapeutic operative intervention in managing AASW. This was a prospective cohort study examining patients with AASW admitted to a level 1 trauma centre in Sydney, Australia, between June 2021 and August 2023. Patient, injury, management and outcome data were collected from electronic medical records and the hospital trauma registry. Data were then analysed to determine the diagnostic accuracy of the COA, complication rates and median hospital length-of-stay (LOS). A total of 48 patients presented with AASW. Of these patients, 11 (22.9%) proceeded to immediate laparotomy. Seven patients had a contraindication to COA and underwent diagnostic laparoscopy. Thirty patients were managed with the COA, with three (10%) patients subsequently requiring a laparotomy. Only one patient (3.3%) underwent a non-therapeutic laparotomy. There were no missed injuries. The COA sensitivity was 100%, specificity 92.7%, PPV 50% and NPV 100%. Patients managed with COA had no complications. Overall median hospital LOS was 1 day (1.0-2.3). A COA is a safe approach for evaluating patients with AASW in an Australian setting with adequate resources. It reduces the rate of non-therapeutic operative intervention and has acceptable outcomes compared with a diagnostic laparoscopy pathway.

The role of neutrophil-to-lymphocyte ratio, platelet-to-lymphocyte ratio, and systemic immune inflammation index in predicting the necessity for surgery and therapeutic surgery in patients with anterior abdominal stab wounds.

In this diagnostic accuracy study, we examined the effectiveness of neutrophil-to-lymphocyte ratio (NLR), platelet-to-lymphocyte ratio (PLR), and systemic immune inflammation index (SII) in predicting the need for surgical intervention in patients with anterior abdominal stab wounds (AASW) who exhibit unclear findings on physical examination yet remain hemodynamically stable. Over a 7-year period, patients with AASW were retrospectively analyzed. Patients were divided into two groups as surgical (SG) and nonsurgical group (nSG). The SG were also divided into two groups as therapeutic surgery (TS) group and the non-therapeutic surgery (nTS) group. The groups were compared in terms of NLR, PLR values and SII scores. In a retrospective analysis of 199 patients with AASW, NLR, PLR and SII obtained during clinical follow-up of patients with AASW in whom the necessity for immediate surgery was unclear significantly predicted therapeutic surgery (p<0.001 for all). These parameters did not show a significant difference in predicting the need for surgery at the admission. NLR showed an AUC of 0.971 and performed significantly better than PLR and SII (AUC=0.874 and 0.902, respectively) in predicting TS. The optimal cut-off value for NLR was 3.33, with a sensitivity of 98.2%, a specificity of 90%, and a negative likelihood ratio of 0.02. Time from admission to surgery was significantly shorter in the TS group (p=0.001). NLR, PLR and SII values may be useful in predicting therapeutic surgery during clinical follow-up in AASW patients with unclear physical examination findings and in whom immediate surgical decisions cannot be made.

Role of laparoscopy in management of patients with anterior abdominal stab wounds.

In this retrospective cohort study, we assessed the utility of laparoscopic surgery for diagnostic and therapeutic purposes in patients with anterior abdominal stab wounds (AASWs). We also investigated patient characteristics that might suggest a greater suitability of laparoscopic interventions. Over a 25-year span, we analyzed AASW patients who had operations, categorizing them based on the presence of significant intra-abdominal injuries and whether they received laparoscopic surgery or laparotomy. We compared variables such as preoperative conditions, surgical details, and postoperative outcomes. We further evaluated the criteria indicating the necessity of direct laparotomies and traits linked to overlooked injuries in laparoscopic surgeries. Of 142 AASWs surgical patients, laparoscopic surgery was conducted on 89 (62.7%) patients. Only 2 (2.2%) had overlooked injuries after the procedure. Among patients without significant injuries, those receiving laparoscopic surgery had less blood loss than those receiving laparotomy (30.0 vs. 150.0ml, p = 0.004). Patients who underwent laparoscopic surgery also had shorter hospital stays (significant injuries: 6.0 vs. 11.0days, p < 0.001; no significant injuries: 5.0 vs. 6.5days, p = 0.014). Surgical complications and overlooked injury rates were comparable between both surgical methods. Bowel evisceration correlated with higher laparotomy odds (odds ratio = 16.224, p < 0.001), while omental evisceration did not (p = 0.107). Laparoscopy is a safe and effective method for patients with AASWs, fulfilling both diagnostic and therapeutic needs. For stable AASW patients, laparoscopy could be the preferred method, reducing superfluous nontherapeutic laparotomies.

MANAGEMENT OF PENETRATING WOUNDS OF ABDOMEN, A REVIEW

The small colon, big bowel, liver, and intra-abdominal vasculature are the most often injured organs in penetrating abdomen wounds. The treatment of individuals with penetrating abdominal has evolved during the past few years. The best way to treat abdominal stab wounds is still debatable. The objective is to locate injuries and treat them in a way that is both safe and economical. Local wound exploration (LWE), diagnostic peritoneal lavage (DPL), laparotomy, and computed tomography (CT) imaging are all common evaluation procedures. It has been demonstrated that clinical practice guidelines enhance healthcare delivery. Although they are rare, anterior abdominal stab wounds provide a problem for trauma management in both rural and urban areas. These clinical practice recommendations place a lot of emphasis on choosing the diagnostic and therapeutic methods that are the most trustworthy, safe, effective, and affordable. The guidelines will include evidence-based suggestions for treating patients who present to both rural and urban hospitals with anterior abdominal stab wounds. In this article we explain the types of the abdominal stab wounds and state the approaches which can be used to manage the abdominal stab wounds and the followed guidelines for ideal management.

Laparotomy for Abdominal Stab Wound With Combined Omental and Organ Evisceration: 10-Year Experience From a Major Trauma Centre in South Africa.

Combined omental and organ evisceration following anterior abdominal stab wound (SW) is uncommon and there is a paucity of literature describing the management and spectrum of injuries encountered at laparotomy. A retrospective study was undertaken on all patients who presented with anterior abdominal SW involving combined omental and organ evisceration who underwent laparotomy over a 10-year period from January 2008 to January 2018 at a major trauma centre in South Africa. A total of 61 patients were eligible for inclusion and all underwent laparotomy: 87% male, mean age: 29years. Ninety-two percent (56/61) had a positive laparotomy whilst 8% (5/61) underwent a negative procedure. Of the 56 positive laparotomies, 91% (51/56) were considered therapeutic and 9% (5/56) were non-therapeutic. In addition to omental evisceration, 59% (36/61) had eviscerated small bowel, 28% (17/61) had eviscerated colon and 13% (8/61) had eviscerated stomach. A total of 92 organ injuries were identified. The most commonly injured organs were small bowel, large bowel and stomach. The overall complication rate was 11%. Twelve percent (7/61) required intensive care unit admission. The mean length of hospital stay was 9days. The overall mortality rate for all 61 patients was 2%. The presence of combined omental and organ evisceration following abdominal SW mandates laparotomy. The small bowel, large bowel and stomach were the most commonly injured organs in this setting.

Evaluation of diagnostic laparoscopy for penetrating abdominal injuries: About 131 anterior abdominal stab wound.

The management of hemodynamically stable patients with anterior abdominal stab wounds (AASW) is debated. Mini-invasive techniques using laparoscopy and non-operative management (NOM) have reduced the rate of nontherapeutic laparotomies after AASW leading to unnecessary morbidity. The aim of this study was to determine with a systematic diagnostic laparoscopy of peritoneal penetration (PP), patients who do not require abdominal exploration in the management of stable patient with an AASW. All patients with AASW were retrospectively recorded from 2006 to 2018. Criteria of inclusion were AASW patients who underwent a systematic diagnostic laparoscopy. Criteria of exclusion were patients with an evisceration, impaling, clinical peritonitis, and hemodynamic instability. If no PP was detected, laparoscopy was terminated. If defects of peritoneum were found, a laparotomy was performed looking for diagnosis and treatment of intra-abdominal injuries. On 131 AASW patients, 35 underwent immediate emergency laparotomy, 96 underwent diagnostic laparoscopy, 47 were positive (PP) and had an intra-abdominal exploration by laparotomy, 32 (68.1%) had intra-abdominal injuries which required treatment. All patients with an intra-abdominal injury had a positive diagnostic laparoscopy. For the 49 patients with a negative laparoscopy, the mean hospital stay was 1.6days with ambulatory care for some patients. No patient presented a delayed injury. Non-therapeutic laparotomy rate was 15.6%. For patients who did not have an intra-abdominal injury the morbidity rate was low (3%). Our study shows that diagnostic laparoscopy was safe, with a low duration of hospitalization, a possible ambulatory care and had an excellent ability to screen the patients who did not need a abdominal exploration. This management can avoid many unnecessary laparotomies with an acceptable rate of negative laparotomy, without any delayed diagnosis of intra-abdominal injuries and with a low morbidity rate.

Injuries Sustained During Incarceration Among Prisoners

BackgroundThe U.S. prison population has increased substantially in recent years, and violent injury is common among prisoners. We sought to describe injury patterns and other characteristics of prisoners who presented to a trauma center after injury. Because penetrating trauma from an improvised weapon (e.g., shank) is frequent, we also sought to compare characteristics and outcomes of prisoners and non-prisoners who sustained an anterior abdominal stab or shank wound (AASW). MethodsWe analyzed injured adult prisoners who presented to a Level 1 trauma center between February, 2011, and April, 2017. We described characteristics of the injured prisoners and their hospitalizations. We compared prisoners who sustained an AASW to a random sample of non-prisoners with the same mechanism of injury using the chi-square test, Student's t-test, and logistic and Poisson regression. ResultsOf 14,461 hospitalized injured adults, 299 (2.0%) were injured while incarcerated. 185 (62%) encounters involved interpersonal violence and 36 prisoners (12%) presented with self-inflicted injuries. 98 (33%) had a psychiatric disorder. Among 33 prisoners and 66 non-prisoners who sustained an AASW, prisoners were less likely to have undergone a laparotomy [14/33 (42%) vs 44/66 (67%); RR 0.64 (95% CI 0.41-0.98)] or sustained an injury requiring operative intervention [2/33 (6%) vs 23/66 (35%); RR 0.17 (95% CI 0.04-0.69)]. ConclusionsMany injured prisoners have psychiatric illness, are involved in interpersonal violence, or harm themselves. Among hospitalized patients, abdominal stab/shank wounds sustained in prison are less likely to result in significant injuries or operative intervention than similar wounds in non-prisoners.

Should the management approach to the anterior abdominal stab wound be different in patients with self-inflicted abdominal injury?

BackgroundSelf-inflicted injury is a leading cause of death worldwide. It is hypothesized that due to instincts for self-preservation, the severity of abdominal injury would be decreased following suicidal self-stabbing in comparison to stab wounds from assault, and therefore a more conservative management might be considered. MethodsAll patients with isolated abdominal stab wound (SW) admitted to 19 Trauma Centers in Israel between the years 1997 and 2018 were included in the study. Patients with self-inflicted abdominal SW (Group I) were compared to victims with abdominal SW following assault (Group II). ResultsGroup I included 9.4% (314/3324) of patients eligible for this study. Compared to Group II, Group I patients were older (median: 39 years, IQR 28,52 vs. 24 years, IQR 19,33; p<0.001), had more females (28.7% vs 4.9%, p <0.001), had longer length of hospitalization (median: 3 days vs. 2 days; p<0.001), underwent surgery more frequently (55.4% vs. 37.4%; p<0.001), and had higher mortality (2.9% vs. 0.7%; p=0.003). Possible covariates for mortality were examined and following logistic regression, self-inflicted injury remained associated with higher death rates compared to assault (OR 4.027, CI95% 1.380, 11.749; p=0.011). ConclusionIn this study, patients with isolated self-inflicted abdominal injuries had higher mortality and more frequently underwent abdominal surgery.

Laparoscopy vs Laparotomy in the Management of the Anterior Abdominal Stab Wounds According to 2018 WTA Algorithm: Systematic Review

Laparoscopy vs Laparotomy in the Management of the Anterior Abdominal Stab Wounds According to 2018 WTA Algorithm: Systematic Review

ROLE OF LAPAROSCOPY TO OBVIATE LAPAROTOMY IN VIOLATING ABDOMINAL STAB WOUNDS IN HEMODYNAMICALLY STABLE PATIENT

Background: Abdominal trauma one of the main series proplem faced in emergency room it is management is directly related to the incidence of morbidity and mortality Laparoscopy approach has gained wide acceptance among all surgeon.Aim of the work: To study role of laparoscopy in management of violating abdominal stab wounds in hemodynamically stable patients regarding current applications, advantages, disadvantages and future developments. Patients and methods: This prospective nonrandomized clinical study included 80 patients who presented to Ain Shams emergency unit with anterior abdominal stab wound(s) during the period from January 2018 till January 2019. Informed consent regarding conservative management or the need for diagnostic laparoscopy / laparotomy was obtained from all patients.Results: In our study results of 80 patients showed 15 patients (18.8%) were negative without intraabdominal lesion.65 patients (81.3%) had positive finding 46 patients (57.5%) were managed by laparoscopy and 19 patients (23.8%) were converted to open surgery.46 patients were managed by laparoscopy 12 (15%) patients underwent repair of serosal and small tears with simple intracoporcal suturing.10 patients (12.5%) with omental injury, cauterization was done to the 8 patients and clipping of omental bleeder in 2 patients was done.8 patients (10%) with gastric tear were repaired by intracoporial suturing.11 patients (13.8%) with liver injury, haemostasis was done by cauterization and gel foam.5 patients with left colonic and sigmoid injuries underwent lap. colostomy.Conclusion: Exploratory laparoscopy applied to carefully selected hemodynamically stable penetrating trauma patients proved to be safe and technically feasible. It also reduced the negative and non-therapeutic laparotomies and offered profound therapeutic potential and cost effectiveness. So 61 patients (76.3%) ovoid unnecessary laparotomy [15 negative (8.8%) + 46 (57.5%) underwent laparoscopic management] so it's proved to both diagnostic and therapeutic role

CT tractography in anterior abdominal stab wounds: a proposed algorithm.

This study evaluates the accuracy of IV contrast-enhanced computed tomography (CT) tractography in the detection of peritoneal violation in anterior abdominal stab wounds (AASW) and its impact on the management algorithm. This prospective study included 61 patients who presented to Kasr Alainy Hospital with AASW. According to the IV contrast-enhanced CT tractography, they were classified into penetrating, equivocal and non-penetrating injuries. The former two were subjected to diagnostic laparoscopy (DL), while the non-penetrating group was subjected to serial abdominal examination (SAE). The accuracy of CT tractography to detect peritoneal violation was assessed by correlating its findings with management outcome. CT tractography stratified the injuries into non penetrating (54.1%), equivocal (14.8%) and penetrating (31.1%). All non-penetrating stabs were managed successfully by SAE. DL proved negative for peritoneal violation in all equivocal injuries and positive in all injuries designated as penetrating. Consequently, sensitivity, specificity, positive and negative predictive values and accuracy of CT tractography in detecting peritoneal violation was 100%. No missed injuries were encountered in this study. IV contrast-enhanced CT tractography is an effective tool in the evaluation of patients with AASW. Patients with negative tractography can be safely managed by SAE. Positive tractography accurately indicates peritoneal violation which warrants further management. Patients with equivocal findings were all negative for peritoneal violation by laparoscopy, therefore, they might be reallocated for frequent SAE to reduce the rate of non-therapeutic interventions.

Management of an Anterior Abdominal Stab Wound in a Hostile Abdomen

Management of an Anterior Abdominal Stab Wound in a Hostile Abdomen

Diagnostic laparoscopy in penetrating abdominal trauma.

Penetrating abdominal trauma is uncommon in Australia. There are multiple potential approaches to the patient without an indication for immediate laparotomy. This study examined the management of patients with a penetrating anterior abdominal injury in a Level 1 trauma centre, and in particular investigated the outcomes of those patients who underwent diagnostic laparoscopy. A retrospective review was undertaken of all patients presenting to a Level 1 trauma centre with an anterior abdominal stab wound over a 15-year period. Patient demographic, injury, examination, treatment and outcome data were extracted. These data were analysed using SPSS PASW version 20. A total of 318 patients were identified. Immediate laparotomy was performed in 121 of those patients. Of the remaining 197 patients, 146 underwent diagnostic laparoscopy. Peritoneal breach was identified in 87 patients, 79 of whom then had exploratory laparotomy. The laparotomy was therapeutic in 36 of 79 patients (45.6%). Multiple stab wounds were an independent predictor of therapeutic laparotomy (hazard ratio 2.39, 95% CI 1.16-4.93). Diagnostic laparoscopy was 100% sensitive, 60.9% specific and had a negative predictive value of 100% and a positive predictive value of 40%. Non-therapeutic laparotomy was associated with a median length of stay of 5.5 days and a complication rate of 9.3%. Diagnostic laparoscopy to detect peritoneal breach is a safe approach in the management of anterior abdominal stab wounds. However, utilizing peritoneal breach as an indication for laparotomy is associated with a moderate incidence of non-therapeutic laparotomy. Measures to decrease the negative laparotomy rate should be considered.

Nonoperative management of solid abdominal organ injuries: From past to present.

Today, a significant proportion of solid abdominal organ injuries, whether caused by penetrating or blunt trauma, are managed nonoperatively. However, the controversy over operative versus nonoperative management started more than a hundred years ago. The aim of this review is to highlight some of the key past observations and summarize the current knowledge and guidelines in the management of solid abdominal organ injuries. A non-systematic search through historical articles and references on the management practices of abdominal injuries was conducted utilizing early printed volumes of major surgical and medical journals from the late 19th century onwards. Until the late 19th century, the standard treatment of penetrating abdominal injuries was nonoperative. The first article advocating formal laparotomy for abdominal gunshot wounds was published in 1881 by Sims. After World War I, the policy of mandatory laparotomy became standard practice for penetrating abdominal trauma. During the latter half of the 20th century, the concept of selective nonoperative management, initially for anterior abdominal stab wounds and later also gunshot wounds, was adopted by major trauma centers in South Africa, the United States, and little later in Europe. In blunt solid abdominal organ injuries, the evolution from surgery to nonoperative management in hemodynamically stable patients aided by the development of modern imaging techniques was rapid from 1980s onwards. With the help of modern imaging techniques and adjunctive radiological and endoscopic interventions, a major shift from mandatory to selective surgical approach to solid abdominal organ injuries has occurred during the last 30-50 years.

CT for Anterior Abdominal Stab Wounds: Does a Negative Scan Rule out Peritoneal Violation?

Journal of the American College of Surgeons 227(4):p S260, October 2018. | DOI: 10.1016/j.jamcollsurg.2018.07.533

Outcomes and Costs-of-Care of the Selective Management of Anterior Abdominal Stab Wounds: A Single-Center Experience

Outcomes and Costs-of-Care of the Selective Management of Anterior Abdominal Stab Wounds: A Single-Center Experience

The spectrum of injuries resulting from abdominal stab wounds with isolated omental evisceration: A South African experience

IntroductionThe spectrum of injury associated with anterior abdominal stab wounds (SWs) is well established. The literature in the specific setting of isolated omental evisceration is limited. Materials and methodsWe reviewed our experience of 244 consecutive patients with established indications for laparotomy over an eight year period at a major trauma centre in South Africa. ResultsOf the 244 patients (93% male, mean age: 27 years), 224 (92) underwent immediate laparotomy (IL). Twenty were initially observed and eventually required a laparotomy (delayed laparotomy, DL). The mean time from injury to decision for laparotomy was <3 h in 92% (224/244), <6 h in 6% (14/244), <12 h 2% (4/244) and <18 h in 1% (2/244). Ninety-eight per cent (238/244) of laparotomies were positive and 96% of the positive laparotomies (229/238) were considered therapeutic. The mostly commonly injured organ encountered on laparotomy were small bowel, stomach and colon. ConclusionsThe most commonly injures encountered are intestinal and gastric. Clinicians must remain vigilant as injuries may be subtle.

Non-operative management of isolated single abdominal stab wound: is it safe?

This is a retrospective review of prospectively collected data on our hospital, a Level 1 trauma centre, where stable patients with single abdominal stab wounds are considered for non-operative (conservative) management if they fulfil the criteria with the aid of computed tomography. The aim is to review our current approach in managing these patients. Patients' data were obtained from January 2005 to June 2016. All injuries classed as assault or self-harm by sharp object in Injury Severity Score body region 4 were included. Patients were excluded from this study if they had haemodynamic instability, peritonism, significant findings on computed tomography, intoxicated, sustained head injury, sedated and intubated or evisceration of bowel, impalement of the stabbed object, potential thoraco-abdominal injury and multiple stab wounds. The patients were divided into non-operative and delayed operative groups for analysis. One hundred and sixty-six of the 313 patients who presented with abdominal stab wounds matched our criteria. One hundred and sixty-three patients (98.2%) from the non-operative group were discharged without complications following period of observation, while three patients underwent operative intervention following trial of non-operative management. The mean length of stay for the successful non-operative group and the group which required delayed operative intervention were 2.8 and 6 days, respectively. No morbidity or mortality was recorded in either group. Our observational study showed that in a Level 1 trauma centre, patients with single anterior abdominal stab wound and normal vital signs can potentially be safely managed with non-operative approach provided that these patients are cooperative for close observation.

Accuracy of Computed Tomography in Diagnosis of Intra-abdominal Injuries in Stable Patients With Anterior Abdominal Stab Wounds: A Systematic Review and Meta-analysis.

Workup for patients presenting to the emergency department (ED) following an anterior abdominal stab wound (AASW) has been debated since the 1960s. Experts agree that patients with peritonitis, evisceration, or hemodynamic instability should undergo immediate laparotomy (LAP); however, workup of stable, asymptomatic or nonperitoneal patients is not clearly defined. The objective was to evaluate the accuracy of computed tomography of abdomen and pelvis (CTAP) for diagnosis of intraabdominal injuries requiring therapeutic laparotomy (THER-LAP) in ED patients with AASW. Is a negative CT scan without a period of observation sufficient to safely discharge a hemodynamically stable, asymptomatic AASW patient? We searched PubMed, Embase, and Scopus from their inception until May 2017 for studies on ED patients with AASW. We defined the reference standard test as LAP for patients who were managed surgically and inpatient observation in those who were managed nonoperatively. In those who underwent LAP, THER-LAP was considered as disease positive. We used the Quality Assessment Tool for Diagnostic Accuracy Studies (QUADAS-2) to evaluate the risk of bias and assess the applicability of the included studies. We attempted to compute the pooled sensitivity, specificity, positive likelihood ratio (LR+), and negative likelihood ratio (LR-) using a random-effects model with MetaDiSc software and calculate testing and treatment thresholds for CT scan applying the Pauker and Kassirer model. Seven studies were included encompassing 575 patients. The weighted prevalence of THER-LAP was 34.3% (95% confidence interval [CI]= 30.5%-38.2%). Studies had variable quality and the inclusion criteria were not uniform. The operating characteristics of CT scan were as follows: sensitivity= 50% to 100%, specificity= 39% to 97%, LR+= 1.0 to 15.7, and LR-= 0.07 to 1.0. The high heterogeneity (I2 >75%) of the operating characteristics of CT scan prevented pooling of the data and therefore the testing and treatment thresholds could not be estimated. The articles revealed a high prevalence (8.7%, 95% CI= 6.1%-12.2%) of injuries requiring THER-LAP in patients with a negative CT scan and almost half (47%, 95% CI= 30%-64%) of those injuries involved the small bowel. In stable AASW patients, a negative CT scan alone without an observation period is inadequate to exclude significant intraabdominal injuries.

Use of CT scanning in patients with Anterior Abdominal Stab Wounds

Use of CT scanning in patients with Anterior Abdominal Stab Wounds