Anterior Abdominal Stab Wounds Research Articles

The use of CT Tractography in patients with Anterior Abdominal Stab Wounds

The use of CT Tractography in patients with Anterior Abdominal Stab Wounds

Discharge Stable Patients with Abdominal Stab Wounds and Negative CT

Historically, all patients with anterior abdominal stab wounds received exploratory laparotomies, and up to half of laparotomies in hemodynamically

Is computed tomography tractography reliable in patients with anterior abdominal stab wounds?

IntroductionThe current literature and guidelines recommend that determination of peritoneal violation is done first in cases of anterior abdominal stab wounds. The primary endpoint of this study was to determine the reliability of computed tomographic (CT) tractography to assess peritoneal violation in anterior abdominal stab wounds. The secondary endpoint is to compare local wound exploration between conventional CT and CT tractography in the evaluation of peritoneal violation. Material and methodsA total of 252 patients who were referred with anterior abdominal stab wounds were included in this prospective observational study. Three techniques (local wound exploration, conventional abdominal tomography, and CT tractography) were used to evaluate peritoneal violation. Sensitivity, specificity, positive predictive value (PPV), negative predictive value (NPV), and accuracy were calculated for each technique to determine peritoneal violation. ResultsThe results for the local wound exploration were 100% sensitivity, 100% specificity, 100% PPV, 100% NPV, and 100% accuracy. The results for CT tractography were 95% sensitivity, 100% specificity, 100% PPV, 80% NPV, and 96% accuracy. Conventional abdominal tomography results were 87% sensitivity, 50% specificity, 91% PPV, 40% NPV, and 82% accuracy. ConclusionLocal wound exploration is 100% effective in determining peritoneal violation with anterior abdominal stab wounds. CT tractography is better than conventional CT in detecting peritoneal violation. However, we do not recommend CT tractography in anterior abdominal stab wounds due to the false-negative results.

Small Bowel Injury after Penetrating Abdominal Trauma despite normal Pre-operative Computerised Tomography. A Case Report of a Successful Laparoscopic Repair

Background: The surgical management of a patient with a penetrating injury can be challenging. We present a case of a patient with a small bowel injury after penetrating abdominal trauma and its successful management despite normal Computerised Tomography (CT).Case and methods: A 39-year-old female, suffering from an anterior abdominal stab wound (AASW), was transferred to Accident and Emergency Department (A&E) after attempting to suicide with a knife. During transfer and on arrival at A&E patient was haemodynamically stable. Primary survey (ABCDE) revealed no concerning findings and abdominal examination revealed a 3cm horizontal wound 4cm above umbilicus. Abdomen was soft, mildly tender. Resuscitation and basic investigations were performed according to ATLS principles. Decision was to proceed with CT scan of the abdomen and pelvis (CTAP). After CTAP, patient became hypotensive and was resuscitated with 1 unit of RBCs and tranexamic acid. CTAP showed no intraperitoneal injury with no free intraperitoneal gas or fluid. Patient was reviewed by surgeons and decision was to proceed with Diagnostic Laparoscopy.Results: Laparoscopy revealed peritoneal penetration, abdominal muscle haematoma with haemorrhagic fluid in pelvis and sero-muscular tear of the proximal ileum. Sero-muscular tear was repaired laparoscopically with an uneventful post-operative period.Conclusion: Detailed clinical examination and experienced surgeon with advanced laparoscopic skills can result to a successful management of stable patients with anterior abdominal stab wounds, faster recovery and avoidance of unnecessary CT scans and laparotomies.

Selective non-operative management of anterior abdominal stab wounds with emphasis on the value of follow-up abdominal CT scanning

Background and aim Selective non-operative management of patients with penetrating abdominal stabs is the preferred treatment strategy. The present study aimed to assess the efficacy and safety of non-operative management with emphasis on the value of follow-up abdominal CT scanning in management of patients with penetrating anterior abdominal stab. Patients and methods This is a retrospective chart review of stable patients with anterior abdominal stab wounds. Patients were divided in terms of initial decisions into two groups: laparotomy group and non-operative management group. Abdominal CT scan was performed for patients in the non-operative management group on admission and follow-up CT scanning was performed in cases of clinical and/or biochemical deterioration. Results The laparotomy group included 82 patients and 68.2% of them had unnecessary laparotomies. The non-operative management group comprised 97 patients and 90.7% of them did not require subsequent laparotomy. Abdominal CT scan had a sensitivity of 88.9% and specificity of 100% in detection of intra-abdominal injuries. Follow-up CT scanning detected bowel injuries missed by initial CT scan in three patients. The non-operative management group had significantly lower post-operative complication rate than the laparotomy group (4.1% vs. 18.3%), with a significantly shorter length of stay. Conclusions Non-operative management is the optimal management strategy for stable patients with penetrating anterior abdominal stab to decrease unnecessary laparotomy rates, hospital stay and costs. Follow-up abdominal CT scanning facilitated the decision making for patients selected for non-operative management and is highly sensitive in the diagnosis of patients who require subsequent exploration.

Intra-abdominal insufflation as a diagnostic modality for penetrating anterior abdominal wall trauma in a busy urban center: a retrospective case-series

Background: The optimal algorithm for evaluating patients with anterior abdominal stab wounds (AASW) is not clear and has been a long standing controversy. Currently, the workup and management of penetrating anterior abdominal wall trauma may involve the decision to proceed immediately to surgery based on the presentation of the patient, or the work up may involve local wound exploration (LWE), focused abdominal sonography for trauma (FAST) exam, CT scan, or serial abdominal exams. Here we discuss an observational sign utilizing the Veress needle intra-abdominal insufflation test that can be used in conjunction with the current AASW algorithm, to rule in peritoneal violation. Methods: Eight patients admitted to our level 1 trauma center with penetrating AASW were evaluated using LWE, FAST, or CT scan followed by Veress needle insufflation and DL for suspected intra-abdominal injuries. These cases were retrospectively evaluated for the efficacy of Veress needle insufflation as an observational test for peritoneal violation. Results: Eight hemodynamically stable patients from December 2013 to June 2014 presented to our level one trauma center after sustaining penetrating AASW. All eight patients went to the operating room for Veress needle insufflation and DL. Upon intra-abdominal insufflation using a Veress needle to a target pressure of 15 mmHg, all patients with peritoneal violations [5] were found to have CO2 escape from their wounds. The remaining three patients with no violation to the peritoneum did not have any appreciable CO 2 escape. Conclusions: Utilizing our technique of intra-abdominal insufflation combined with monitoring for CO 2 escape, we were able to successfully identify all patients with peritoneal violation and rule out violation in those without peritoneal injuries. With further research, our technique can be used to safely, accurately and in a timely manner stratify patients for the need of further diagnostic and interventional procedures.

Diagnostic Accuracy of Abdominal wall Ultrasonography and Local Wound Exploration in Predicting the Need for Laparotomy following Stab Wound.

Screening of patients with anterior abdominal penetrating trauma in need for laparotomy is an important issue in management of these cases. This study aimed to compare the accuracy of abdominal wall ultrasonography (AWU) and local wound exploration (LWE) in this regard. This diagnostic accuracy study was conducted on ≥ 18 year-old patients presenting to emergency department with anterior abdominal stab wound and stable hemodynamics, to compare the characteristics of AWU and LWE in screening of patients in need of laparotomy. 50 cases with the mean age of 28.44 ± 7.14 years were included (80% male). Sensitivity, specificity and area under the receiver operating characteristic (ROC) curve of AWU were 70.58 (95% CI: 44.04 - 88.62), 93.33 (95% CI: 76.49 - 98.83), and 81.96 (95% CI: 69.91 - 94.01), respectively. These measures were 88.23 (62.25 - 97.93), 93.33 (76.49 - 98.83), and 90.78 (95% CI: 81.67 - 99.89) for LWE, respectively. The difference in overall accuracy of the two methods was not statistically significant (p = 0.0641). Based on the findings of the present study, AWU and LWE had the same specificity but different sensitivities in screening of anterior abdominal stab wound patients in need of laparotomy. The overall accuracy of LWE was slightly higher (91.48% versus 85.1%).

What is the diagnostic value of computed tomography tractography in patients with abdominal stab wounds?

Computed tomography (CT) tractography is a promising technique; it is a CT performed after an entire stab wound tract with a water-soluble contrast agent in patients with abdominal stab wounds. The aim of the current study was to investigate the diagnostic value of CT tractography and to compare with other radiodiagnostic tools in patients with abdominal stab wounds. All of the patients with anterior abdominal stab wounds were retrospectively reviewed between January 2012 and December 2014. Included in this study for statistical analyses were patients who had contrast-enhanced (oral and intravenous, not rectal) abdominal CTs alone or had contrast-enhanced abdominal CTs combined the CT tractographies and laparotomies in the first 24h. These patients were divided two groups: the CT scan group (patients who had abdominal CTs alone) and the CT tractography group (patients who had CT tractographies). Both groups underwent laparotomies. The endpoint of this study was to determine whether CT tractography predicted peritoneal violation, not requiring therapeutic laparotomy. The gold standard of diagnosis peritoneal violation was considered laparotomy (therapeutic or not therapeutic). A total of 102 patients with anterior abdomen stab wounds who had laparotomies were enrolled and 29 (27%) of the patients were excluded for several causes in the study period. Finally, 73 of the patients were enrolled in this study for statistical analyses. The diagnostic performance of a CT tractography in detecting peritoneal violation resulted in 100% sensitivity, 100% specificity, 100% positive predictive values (PPV), 100% negative predictive values (NPV), and 100% accuracy. A CT tractography combined with an abdominal CT scan seems successful in detecting peritoneal violation in hemodynamically stable patients with abdominal stab wounds. Certainly, randomized controlled trials are required on this topic to recommend this as a routine diagnostic procedure.

Serial Clinical Examinations of 100 Patients Treated for Anterior Abdominal Wall Stab Wounds: A Cross Sectional Study.

Background:The current approach in stab wounds of the anterior abdominal wall is still unclear.Objectives:The goal of this study was to evaluate serial clinical examinations of patients with abdominal wall stab wounds referred to Poursina Hospital in Rasht.Patients and Methods:In a cross sectional study, 100 cases with stab wounds to the anterior abdominal wall were examined serially (admission time, 4, 8, 12, and 24 hours) after wound exploration. Serial hemoglobin test was performed every 8 hours. Laparotomy was performed in cases who were not hemodynamically stable or who showed symptoms of peritonitis. The results were analyzed with SPSS software version 21.Results:Ninety-one men (91%) and 9 women (9%) with mean age of 27 ± 10.7 years were included. Coexisting injuries were prevalent in 12 cases. The duration of hospitalization was 1 day in 31%, 2 days in 30%, 3 - 4 days in 32% and more than 5 days in 7%. Late laparotomy was performed 12 hours after admission in 8% of patients due to peritonitis. There was visceral damage in these cases. No mortality occurred. The cost and duration of hospitalization was significantly higher in cases with coexisting injuries and those who underwent laparotomy.Conclusions:It seems serial clinical examinations are safe and decrease the cost and duration of hospitalization in stable patients with anterior abdominal wall stab wounds.

Benefits of CT tractography in evaluation of anterior abdominal stab wounds

IntroductionThe study aimed to identify the presence of peritoneal penetration in management of anterior abdominal stab wound by using computed tomography (CT) tractography. Material and methodsHemodynamically stabile, CT tractography-performed patients who were admitted to our emergency clinic with anterior abdominal stab wounds between the years 2012 and 2014 were included in this study, and all images were evaluated in terms of peritoneal penetration and possible intra-abdominal injury. ResultsIn the study CT tractography identified necessity of laparotomy accurately in 90% of the patients, and none of the patients without peritoneal penetration needed surgical treatment in their follow-up. ConclusionThe procedure may be used for some selected cases of hemodynamically stable patient with anterior abdominal stab wounds to abstain from local wound exploration.

The spectrum of injuries resulting from posterior abdominal stab wounds: a South African experience.

The spectrum of injury associated with anterior abdominal stab wounds (SWs) is well established. The literature on the spectrum of organ injury associated with SWs to the posterior abdomen, however, is limited. We reviewed our experience of 105 consecutive patients who had established indications for laparotomy managed over a 4-year period in a high volume trauma service in South Africa. Of the 105 patients, 97 (92%) were male and the overall mean age was 24 years. Fifty-seven patients (54%) had immediate indications for laparotomy. The remaining 48 patients (46%) initially underwent active clinical observation and the indications for laparotomy became apparent during the observation period. Of the 105 laparotomies performed, 94 (90%) were positive and 11 (10%) were negative. Of the 94 positive laparotomies, 92 were therapeutic and 2 were non-therapeutic. A total of 176 organ injuries were identified: 50 (53%) of the 94 patients sustained a single organ injury while the remaining 44 (47%) sustained multiple organ injuries. The most commonly injured organs were the colon (n=63), spleen (n=21) and kidney (n=19). The pattern of intra-abdominal injuries secondary to SWs to the posterior abdomen is different to that seen with the anterior abdomen. Colonic injury is most commonly encountered, followed by injuries to the spleen and kidney. Clinicians must remain vigilant because of the potential for occult injuries.

International Association of Trauma and Surgical Intensive Care Symposium: Penetrating Trauma. Update on Penetrating Trauma.

Significant advances in the management of penetrating trauma have taken place over the past decade. Military experience has demonstrated the benefits of changes in our prehospital management and resuscitation strategies, and improving technology has allowed an evolution in diagnostic and therapeutic paradigms. In the end, however, there are fundamental principles that continue to guide how we approach the patient with penetrating injury. The trauma victim who suffers cardiopulmonary arrest is likely to die without immediate intervention. Dr. Civil and colleagues provide an overview of resuscitative thoracotomy in penetrating trauma, including indications, technical considerations, and outcomes. In addition, they discuss issues such as training, personnel, and location— pointing out that the capabilities in urban trauma centers in the US are not necessarily duplicated in hospitals worldwide. This is certainly a consideration in designing an institutional protocol for managing patients in extremis. Penetrating neurotrauma can be immediately lethal or leave the victim with devastating disability. Rosenfeld and colleagues provide an overview of penetrating and blast injury to the central nervous system. Blast injury and its sequelae are being seen with increasing frequency in the aftermath of military conflict. The authors emphasize the importance of aggressive resuscitation and correction of coagulopathy, and highlight the need for early operative intervention in order to optimize outcomes. On the other hand, they offer criteria for nonoperative management of penetrating injuries to the brain and spinal cord. Finally, the importance of early decompression for blast injuries is highlighted. In his paper on penetrating cervical trauma, Dr. Feliciano reviews the signs and symptoms of significant vascular or aerodigestive injury, and emphasizes that early operative intervention is most appropriate in symptomatic patients. Among patients without symptoms, he points out that serial clinical evaluation is accurate and that CT scanning does not improve on the accuracy. On the other hand, as he points out, CT scanning is likely to obviate the need for invasive testing in the patient with ‘‘soft’’ signs or equivocal exam findings. Finally, he offers valuable technical tips for the surgical management of cervical injuries. In ‘‘Laparoscopy in penetrating abdominal trauma,’’ Uranues and colleagues describe the benefits of employing technological advances in the diagnosis and management of abdominal trauma. As surgeons gain experience with laparoscopy, it can be relied upon to facilitate diagnosis of significant abdominal and thoracoabdominal injuries— particularly diaphragmatic lacerations, small intestinal perforation, and mesenteric hemorrhage. The reduced surgical morbidity and length of stay, and cost-effectiveness of this approach compared with laparotomy, make a compelling argument for laparoscopy as the preferred approach in the stable patient. This paper highlights the importance of trauma surgeons’ acquisition and maintenance of skills in the elective surgical realm, so that they may be applied in the emergency situation. A different, even less-invasive, approach to penetrating abdominal trauma is described by Biffl and Leppaniemi. The authors offer evidence that, in patients with anterior abdominal stab wounds, performing additional testing & Walter L. Biffl walter.biffl@dhha.org

Impact of body mass index on injury in abdominal stab wounds: implications for management

BackgroundAlthough it is assumed that obese patients are naturally protected against anterior abdominal stab wounds, the relationship has never been formally studied. We sought to examine the impact of body mass index (BMI) on severity of sustained injury, need for operation, and patient outcomes. Materials and methodsWe conducted a review of all patients presenting with abdominal stab wounds at an urban level I trauma center from January 2000–December 2012. Patients were divided into groups based on their BMI (<18.5, 18.5–29.9, 30–35, and >35). Data abstracted included baseline demographics, physiologic data, and characterization of whether the stab wound had violated the peritoneum, caused intra-abdominal injury, or required an operation that was therapeutic. The one-sided Cochran–Armitage trend test was used for significance testing of the protective effect. ResultsOf 281 patients with abdominal stab wounds, 249 had complete data for evaluation. Chest and abdomen abbreviated injury scale trends decreased with increasing BMI, as did overall injury severity score, the percent of patients severely injured (injury severity score ≥25), and length of intensive care unit stay. Rates of peritoneal violation (100%, 84%, 77%, and 74%; P = 0.077), visceral injury (83%, 56%, 50%, and 30%; P = 0.022), and injury requiring a therapeutic operation (67%, 45%, 40%, and 20%; P = 0.034) all decreased with increasing BMI. Patients in the thinnest group required an operation three times more often than those in the most obese. ConclusionsIncreased BMI protects patients with abdominal stab wounds and is associated with lower incidence of severe injury and need for operation. Heavier patients may be more suitable to observation and serial examinations, whereas very thin patients are more likely to require an operation and be critically injured.

Conservative Management of Anterior Abdominal Penetrating Trauma

Background Selective conservative management of abdominal penetrating trauma can significantly minimize the morbidity and length of hospitalization by decreasing the rate of unnecessary laparotomies. Objectives In the present study, we reported the outcome of newest guidelines of our trauma center in one year. Patients and Methods All patients with anterior abdominal stab wounds who were referred to Rajaiee trauma center between September 2012 and September 2013 were enrolled. Patients without shock, peritonitis, and evisceration who did not require emergency operation were planned for nonoperative management with serial physical examinations, blood cells count, and radiographic investigations. Outcome of nonoperative management was described in order to reveal the advantages and disadvantages of our current guideline. Results Among 45 patients who underwent nonoperative management, 27 cases (60%) required laparotomy due to peritonitis or shock. Rate of unnecessary nontherapeutic operations was 49.2%. Conclusions Minimizing diagnostic procedures such as diagnostic peritoneal lavage and computed tomography can significantly increase the rate of unnecessary operations leading to longer hospitalizations and operation-related morbidity. To reduce the failure rate of nonoperative management and nontherapeutic surgeries, modifications in current guidelines should be made.

To Scan or Not to Scan, That is the Question

Background Selective conservative management of abdominal penetrating trauma can significantly minimize the morbidity and length of hospitalization by decreasing the rate of unnecessary laparotomies. Objectives In the present study, we reported the outcome of newest guidelines of our trauma center in one year. Patients and Methods All patients with anterior abdominal stab wounds who were referred to Rajaiee trauma center between September 2012 and September 2013 were enrolled. Patients without shock, peritonitis, and evisceration who did not require emergency operation were planned for nonoperative management with serial physical examinations, blood cells count, and radiographic investigations. Outcome of nonoperative management was described in order to reveal the advantages and disadvantages of our current guideline. Results Among 45 patients who underwent nonoperative management, 27 cases (60%) required laparotomy due to peritonitis or shock. Rate of unnecessary nontherapeutic operations was 49.2%. Conclusions Minimizing diagnostic procedures such as diagnostic peritoneal lavage and computed tomography can significantly increase the rate of unnecessary operations leading to longer hospitalizations and operation-related morbidity. To reduce the failure rate of nonoperative management and nontherapeutic surgeries, modifications in current guidelines should be made.

Efficacy of computed tomography for abdominal stab wounds: a single institutional analysis.

There are several diagnostic tools to support the decision for abdominal stab wounds. The aim of this study is to evaluate the ability of computed tomography (CT) to facilitate decisions on the initial management in patients with anterior abdominal stab wounds. The medical records of all 118 patients who sustained abdominal stab wounds from March 2004 to January 2012 were reviewed retrospectively. The average age of patients was 41 years, and 84 (71%) patients were male. Ten patients underwent an immediate laparotomy due to hemodynamic instability, peritonitis, or definite evisceration. The other 108 patients underwent CT scans, and 91 patients had positive CT findings, leading to performance of laparotomy in 82 patients. One patient underwent a non-therapeutic laparotomy. Seventeen patients had negative CT results; however, seven patients underwent early laparotomy according to the attending surgeon's decision using serial physical examination or other diagnostic tools. The sensitivity of the CT scan was 94.2%, and the positive-predictive value was 98.8%. CT can be used efficiently along with physical examination as an initial diagnostic tool in patients with abdominal stab wounds. However, there can be missed injuries, then surgeon should consider other diagnostic methods.

Diagnostic laparoscopy after anterior abdominal stab wounds

The National Institute of Medicine's report Hospital-Based Emergency Care: At the Breaking Point highlighted the critical issue of emergency department overcrowding. At our institution, patients with anterior abdominal stab wounds (AASW) have been managed with a protocol that uses diagnostic laparoscopy (DL) after positive result on local wound exploration. Patients with negative DL result are eligible for discharge directly from the recovery room. The purpose of this study was to evaluate the use of DL for AASWs in light of the recommendations that suggested serial abdominal examination (SAE) is preferred to determine the need for laparotomy. Patients admitted to a Level 1 trauma center from January 2010 through August 2012 with AASWs were included (contemporary period to Western Trauma Association study). Information regarding baseline characteristics, diagnostic workup, injury management, and outcomes were retrospectively reviewed and compared with the SAE AASW algorithm. A total of 158 patients with AASWs were evaluated using our institutional algorithm. Thirty-eight patients (24%) went directly to the operating room for peritonitis, shock, or evisceration; 120 underwent local wound exploration; 99 had positive result (82%). Twenty-eight patients had immediate laparotomy owing to worsening clinical examination findings. Seventy had DL, and 19 of these patients were discharged home from the recovery room, with a mean length of stay of 6.4 hours. When comparing patients managed using the DL algorithm to those managed using the SAE-based algorithm, the nontherapeutic laparotomy rate was lower, although not statistically significant. However, the DL algorithm produced a significantly higher percentage of patients discharged directly home following local wound exploration. With some trauma centers suffering from emergency department overcrowding and constrained resources, DL may offer an alternative to SAE to efficiently use available resources. Both SAE and DL are safe and offer similar therapeutic laparotomy rates. The method used to evaluate patients after AASW should be tailored to institutional needs and resources. Therapeutic/care management, level IV.

Evaluating the Role of Computed Tomography

Inaba and colleagues1 performed a prospective evaluation of their algorithmfor themanagementof asymptomatic abdominal stabwounds. Theyhave shown that routine computed tomographic scanning adds nothingtotheevaluationand, in fact, physical examination is more accurate than computed tomography in predicting theneed for a therapeutic laparotomy. Iwould like to commend the authors on objectively evaluating the way they manage patients and coming to the conclusion that their algorithm is not supportedby their findings. There are other aspects of their data that suggest that further change in management may be indicated. For instance, in their algorithm, patients who are intoxicated or otherwise unexaminable go directly to the operating room. This is owing to the inability to perform serial examinations. Itwouldbehelpful if theauthorsprovideddataon the negative laparotomy rate in the patients who had no objective evidence of intraabdominal injury. It is possible that allowing intoxication to resolve or performing computed tomographyor serial examinations in stable patientswould also be a reasonable approach. Theauthorsalsostatedthat theyobservepatientswith thoracoabdominal wounds for the development of peritonitis. If peritonitis does not develop, they routinely perform laparoscopy to rule out diaphragm injuries. However, in this series, all of the results of thoracoscopies performed for this indication were negative for diaphragm injuries. This finding suggests that the algorithm could be modified. The authors’ algorithm also did not include local wound exploration. When local wound exploration conclusively excludes fascial penetration, patients canusually be discharged without an observation period.2 This would further facilitate careful observation of the patients who need it and expedite discharge of those who do not. Finally, the authors did not provide important details concerning how the patients are observed. It is not clear who is examining these patients, how frequently, and in what setting. Many level 1 trauma centers routinely have periods when all manpower is focused on critically injured patients. Also in light of the 80-hour work week and increasing frequency of shift work, it is possible that subtle changes in the physical examination could be missed. It is important to realize that observation of stable stab wound patients may not be feasible in all settings because it is resource intensive. AlthoughtheUniversityofSouthernCaliforniagroup isnot the first to report the success of observing patients with anterior abdominal stabwounds,3 this contribution remains importantbecause it represents anexampleofhowcritically analyzing an established center’s data can change practices. The question remains: have they changed enough?

The utility of laparoscopic evaluation of the parietal peritoneum in the management of anterior abdominal stab wounds

BackgroundTrauma centres vary in their approaches to managing stable patients with anterior abdominal stab wounds (AASWs), with no approach yet proven superior. We sought to evaluate the performance of screening laparoscopy (i.e., parietal peritoneal penetration or not) in determining which patients should undergo laparotomy. MethodsWe conducted a retrospective case series study, including all patients with an AASW who presented to U.C. Davis Medical Center from January 2003 through March 2009. We collected data from medical records using a standardised, pre-tested instrument. Among laparoscopically screened cases, we determined the test characteristics of peritoneal penetration for detecting intra-abdominal injury. We sub-classified injuries as “requiring treatment” (e.g., full-thickness enterotomy or active haemorrhage) or not. ResultsOf 358 patients with AASWs, 163 underwent screening laparoscopy. Seventy-eight of the 163 (48%) had no peritoneal penetration and six (4%) had peritoneal penetration but a low-risk wound; none of these 84 underwent laparotomy nor had a missed injury. Of 79 patients with peritoneal penetration who underwent laparotomy, 61 had an intra-abdominal injury, of whom 42 were treated intraoperatively. Among these 42, 30 had an injury “requiring treatment.” The PPV of peritoneal penetration for an injury requiring treatment was 38% (30/79) (95% CI 27–50%), NPV 100% (84/84) (95% CI 95–100%), sensitivity 100% (30/30) (95% CI 88–100%), and specificity 63% (84/133) (95% CI 54–71%). The negative and positive likelihood ratios were 0 (95% CI 0–0.4) and 2.7 (95% CI 2.2–3.4), respectively. ConclusionsScreening laparoscopic evaluation of the parietal peritoneum results in a negligible rate of missed injury and an approximately 40% rate of finding an injury requiring treatment.

Anterior abdominal stab injury: a comparison of self-inflicted and intentional third-party stabbings

BackgroundThere is minimal literature comparing self-inflicted (SI) with non–self-inflicted (NSI) anterior abdominal stab wounds (AASW). MethodsAdult patients treated at a level 1 trauma center from 2006 through 2011 with an AASW were reviewed. ResultsThere were 215 patients with an AASW; 20% were SI. NSI patients had more nonabdominal injuries (47% vs 16%, P < .01) and disposition directly to the operating room (45% vs 26%, P = .02). Intra-abdominal injury rates were similar. One hundred twenty-eight patients had isolated AASWs; 28% were SI. SI patients had higher admission rates (86% vs 63%, P = .01). One hundred three patients had isolated stable/asymptomatic AASWs; 31% were SI. SI patients had more admissions (84% vs 52%, P < .01), had higher intensive care unit admission rates (23% vs 5%, P = .01), longer LOS (3.2 vs 1.4, P < .01), and higher hospital charges ($18,000 vs $11,000, P < .01). The rates of intra-abdominal injury were again similar. ConclusionsControlling for extra-abdominal injuries, SI AASW patients have similar rates of intra-abdominal injury but use more resources.