Management Of Abdominal Stab Wounds Research Articles

Clinical decision making for abdominal stab wounds in high resourced but low volume centres require structured guidelines to be effective

The management of abdominal stab wounds (SW) has continued to evolve. The use of CT and laparoscopy has been advocated to reduce the rate of laparotomy. This study reviews our experience with SW in a high income, low volume setting. A retrospective study was undertaken from 2006 to 2020 at Waikato Hospital, New Zealand. All adult patients age > 16 years that were admitted following trauma were included. Seventy three cases of SW were included. Thirty two cases had indications for immediate laparotomy (peritonitis in 15, hemodynamic instability in 13, evisceration in 4). Twenty two underwent immediate laparotomy. Overall, 43 had a positive laparotomy. One had a negative laparotomy. Thirty seven cases had a CT. Laparoscopy was performed in 24 cases, with 23 demonstrating peritoneal breach. Subsequently 9 were converted to laparotomy whilst 15 had full laparoscopic exploration. The relative rarity of abdominal SW in our environment has resulted in a considerable degree of heterogeneity in our approach to this clinical dilemma. The simplified algorithm we have developed will hopefully facilitate clinical decision making in our institution.

Selective Nonoperative Management of Abdominal Stab Wounds with Isolated Omental Evisceration is Safe: A South African Experience

Selective nonoperative management of abdominal stab wound is well established, but its application in the setting of isolated omental evisceration remains controversial. The aim of the study is to establish the role of selective nonoperative management in the setting of isolated omental evisceration. A retrospective study was conducted over an 8-year period from January 2010 to December 2017 at a major trauma center in South Africa to determine the outcome of selective nonoperative management. A total of 405 consecutive cases were reviewed (91% male, mean age: 27 years), of which 224 (55%) cases required immediate laparotomy. The remaining 181 cases were observed clinically, of which 20 (11%) cases eventually required a delayed laparotomy. The mean time from injury to decision for laparotomy was <3 h in 92% (224/244), 3-6 h in 6% (14/244), 6-12 h 2% (4/244), and 12-18 h in 1% (2/244). There was no significant difference between the immediate laparotomy and the delayed laparotomy group in terms of length of stay, morbidity, or mortality. Ninety-eight percent (238/244) of laparotomies were positive and 96% of the positive laparotomies (229/238) were considered therapeutic. Selective nonoperative management for abdominal stab wound in the setting of isolated omental evisceration is safe and does not result in increased morbidity or mortality. Clinical assessment remains valid and accurate in determining the need for laparotomy but must be performed by experienced surgeons in a controlled environment.

Obesity May Not be Protective in Abdominal Stab Wounds.

Context:Current protocols for the management of abdominal stab wounds were established based on retrospective data from prior decades. Few have investigated whether higher body mass index (BMI) affects outcomes after these injuries.Aim:The aim was to determine the effects of obesity on outcomes in abdominal stab wound patients.Setting and Design:This was a retrospective cohort study at a Level I university-associated trauma center in the United States.Materials and Methods:We reviewed medical records of 100 adult patients admitted to our trauma center with abdominal stab wounds. Demographics, types of internal organ injury, gastrointestinal (GI) resection and repair, mortality, length of hospital stay (LOS), units of blood transfused within 24 h of admission, need and indications for exploratory laparotomy, surgical site infections (SSI), and need for re-operation were compared between obese and nonobese patients.Statistical Analysis:Categorical and continuous outcome variables were compared between the two groups using Chi-squared and independent-samples t-tests, respectively. BMI was evaluated as a predictor of outcomes using univariate and multivariate logistic regression.Results:Records of 100 adult abdominal stab wound patients were reviewed. Twenty-five patients were obese. The obese group was older (38.76 vs. 31.23, P = 0.018). Rates of therapeutic laparotomy were similar between obese and nonobese patients (20 [80.00%] vs. 64 [85.33%]). Obesity was associated with longer LOS (9.6 vs. 6.5, P = 0.026). In the multivariate analysis, increasing BMI was an independent predictor of need for GI resection (odds ratio: 1.10 [1.02–1.18], P = 0.018). One patient from the obese group died.Conclusions:Obese patients with abdominal stab wounds have longer LOS than nonobese patients. Increasing BMI was an independent predictor of need for GI resection.

Evaluation and management of abdominal stab wounds: A Western Trauma Association critical decisions algorithm.

This is a recommended management algorithm from the Western Trauma Association addressing the management of adult patients with abdominal stab wounds. Because there is a paucity of published prospective randomized clinical trials that have generated Class I data, these recommendations are based primarily on published observational studies and expert opinion of Western Trauma Association members. The algorithm and accompanying comments represent a safe and sensible approach that can be followed at most trauma centers. We recognize that there will be patient, personnel, institutional, and situational factors that may warrant or require deviation from the recommended algorithm. We encourage institutions to use this as a guideline to develop their own local protocols.

Selective non-operative management of abdominal stab wounds is a safe and cost effective strategy: A South African experience.

INTRODUCTION Selective non-operative management (SNOM) of abdominal stab wounds is well established in South Africa. SNOM reduces the morbidity associated with negative laparotomies while being safe. Despite steady advances in technology (including laparoscopy, computed tomography [CT] and point-of-care sonography), our approach has remained clinically driven. Assessments of financial implications are limited in the literature. The aim of this study was to review isolated penetrating abdominal trauma and analyse associated incurred expenses. METHODS Patients data across the Pietermaritzburg Metropolitan Trauma Service (PMTS) are captured prospectively into the regional electronic trauma registry. A bottom-up microcosting technique produced estimated average costs for our defined clinical protocols. RESULTS Between January 2012 and April 2015, 501 patients were treated for an isolated abdominal stab wound. Over one third (38%) were managed successfully with SNOM, 5% underwent a negative laparotomy and over half (57%) required a therapeutic laparotomy. Over five years, the PMTS can expect to spend a minimum of ZAR 20,479,800 (GBP 1,246,840) for isolated penetrating abdominal stab wounds alone. CONCLUSIONS Provided a stringent policy is followed, in carefully selected patients, SNOM is effective in detecting those who require further intervention. It minimises the risks associated with unnecessary surgical interventions. SNOM will continue to be clinically driven and promulgated in our environment.

Selective Nonoperative Management of Abdominal Stab Wounds

Stab wounds (SW) to the abdomen traditionally require urgent exploration when associated with shock, evisceration, or peritonitis. Hemodynamically stable patients without evisceration may benefit from serial exams even with peritonitis. We compared patients taken directly to the operating room with abdominal SWs (ED-OR) to those admitted for serial exams (ADMIT). We retrospectively reviewed hemodynamically stable patients presenting with any abdominal SW between January 2000 and December 2012. Exclusions included evidence of evisceration, systolic blood pressure ≤110 mm Hg, or blood transfusion. NON-THER was defined as abdominal exploration without identification of intra-abdominal injury requiring repair. Of 142 patients included, 104 were ED-OR and 38 were ADMIT. When ED-OR was compared with ADMIT, abdominal Abbreviated Injury Score was higher (2.4 vs 2.1; P = 0.01) and hospital length of stay was longer (4.8 vs 3.3 days; P = 0.04). Incidence of NON-THER was higher in ED-OR cohort (71% vs 13%; P ≤ 0.001). In a regression model, ED-OR was a predictor of NON-THER (adjusted odds ratio 16.6; P < 0.001). One patient from ED-OR expired after complications from NON-THER. There were no deaths in the ADMIT group. For those patients with abdominal SWs who present with systolic blood pressure ≥110 mm Hg, no blood product transfusion in the emergency department and lacking evisceration, admission for serial abdominal exams may be preferred regardless of abdominal exam.

Prospective Evaluation of the Role of Computed Tomography in the Assessment of Abdominal Stab Wounds

An important adjunct in the management of abdominal gunshot wounds, the role of computed tomography (CT) in the diagnostic workup of abdominal stab wounds remains controversial. To prospectively compare CT against serial physical examination in the evaluation of patients who have sustained a stab wound to the abdomen. Prospective single-center observational study of all patients sustaining abdominal stab wounds from March 1, 2009, through March 31, 2011. Patients who were hemodynamically unstable, unevaluable, peritonitic, or eviscerated proceeded directly to laparotomy (n = 249). The remainder underwent CT evaluation. The impact of CT findings and physical examination on the decision to operate was analyzed. Diagnostic accuracy of CT vs physical examination in determining the need for therapeutic laparotomy. A total of 249 patients were enrolled (94% male; mean [SD]: age, 30.8 [12.9] years [range, 16-87 years]; systolic blood pressure, 128 [28] mm Hg; Glasgow Coma Scale score, 14 [2]; Injury Severity Score, 6.8 [6.5]). Forty-five patients (18.1%) underwent immediate laparotomy, 27 (10.8%) had superficial injuries allowing immediate discharge, and the remaining 177 (71.1%) underwent CT. Of these, 154 (87.0%) were successfully observed, with 20 (11.3%) requiring laparotomy, 2 (1.1%) thoracotomy, and 1 (0.6%) sternotomy. Of the 20 laparotomies, 16 (80.0%) were therapeutic. All patients who underwent therapeutic laparotomy did so based on their physical examination. The most common finding leading to laparotomy was the development of peritonitis in 70%. The CT scan findings did not alter clinical decision making. The sensitivity and specificity of physical examination were 100.0% and 98.7%, respectively, while those of CT were 31.3% and 84.2%, respectively. In this prospective evaluation of abdominal stab wound management, serial physical examination was able to discriminate between patients requiring a therapeutic laparotomy and those who could be safely observed. A physical examination-based diagnostic algorithm was effective and decreased radiation burden in the management of abdominal stab wounds.

Non-operative management of abdominal gunshot wounds

Over the history of surgery, the management of abdominal gunshot wounds in the stable evaluable patient without peritonitis has evolved. While non-operative management has been widely accepted and employed for the management of abdominal stab wounds, recently it has been deemed a safe option for abdominal gunshot wounds as well. Selective non-operative management of penetrating abdominal trauma in the appropriate setting has been shown to decrease the rate of nontherapeutic laparotomy as well as the cost and total length of hospital stay, and potentially decrease short- and long-term morbidity. This review examines the background support for non-operative management of abdominal gunshot wounds while discussing patient evaluation, selection, and clinical management.

Penetrating abdominal injuries in adults seen at two teaching hospitals in Ghana

The incidence of penetrating abdominal injuries (PAI) has increased in the West African sub-region. To determine the pattern and management outcome of penetrating abdominal injuries (PAI) in the two main teaching hospitals in Ghana. A prospective and retrospective descriptive study. Komfo Anokye Teaching Hospital (KATH), Kumasi and Korle-Bu Teaching Hospital (KBTH), Accra. Relevant details of all adult patients admitted with penetrating abdominal injuries over a 11-year period were recorded at KATH and KBTH in Accra. The study in KATH was prospective pro forma based and that in the KBTH was a retrospective case review of all penetrating abdominal injuries. There were 411 patients, mostly men (M: F-8:1). The peak age of patients was 20-29 years, 164 patients (39.9%). Abdominal stab wound injuries accounted for 251 (61.1%). Three hundred and thirty - one patients (80.5%) had an emergency laparotomy. Twelve patients required 16 emergency thoracotomies. The small bowel (23.2%), stomach (12.9%), colon (10.2%), the liver (10.0%), were the most commonly injured organs. In 92 patients (29.0%) no significant intra-abdominal injury was detected at laparotomy Stab wounds are the main penetrating abdominal injuries seen mostly among young male adults in Ghana. Management was by a mandatory laparotomy after clinical assessment. The overall mortality was 4.4%. Selective non-operative management of abdominal stab wounds is possible.

Selective non-operative management of penetrating abdominal injury in Great Britain and Ireland: Survey of practice

BackgroundThe selective non-operative management of penetrating abdominal injury is gaining increasing acceptance. In Great Britain and Ireland, the management of trauma remains the responsibility of general surgeons. This study appraises the acceptance and utilisation of selective non-operative management strategies by British and Irish general surgeons, compared with trauma surgeons in the United States of America. MethodsElectronic questionnaire survey of British and Irish consultant general surgeons and trauma surgeons in the United States of America. Results139 British and Irish general surgeons and 75 US trauma surgeons completed the survey. 84.3% of British and Irish general surgeons and 94.4% of US trauma surgeons practise selective non-operative management of abdominal stab wounds, and 14.0% and 74.3% practise selective non-operative management of abdominal gunshot wounds. The management of those British and Irish surgeons who do practise selective non-operative management is broadly similar to that of US trauma surgeons, with the exception of the use of laparoscopy to examine the left hemidiaphragm following thoracoabdominal injuries, which is employed by fewer British and Irish general surgeons than US trauma surgeons. ConclusionsThe selective non-operative management of abdominal stab wounds is generally accepted by British and Irish general surgeons. In contrast, few British and Irish surgeons are comfortable with non-operatively managing patients with abdominal gunshot wounds, reflecting both the rarity of this type of injury, and surgeons’ training and experience. This proportion is unlikely to change until the management of torso trauma is recognised as a specialty, and services are concentrated in regional centres.

An audit of failed non-operative management of abdominal stab wounds

Selective non-operative management based on clinical assessment has been shown to be a generally safe approach in the management of penetrating stab wounds of the torso. However there will be a subset of patients who fail selective non-operative management. This audit focuses on the failures. Methods The metropolitan surgical service in Pietermaritzburg covers 3 hospitals. At the weekly metropolitan morbidity and mortality meeting all trauma patients are reviewed. All cases of failed selective non-operative management of penetrating abdominal stab wounds are discussed. Failed non-operative management is usually defined as any patient who ultimately requires surgical exploration. We do not subscribe to this as we feel as long as the need for surgical intervention is recognised within a short period of time (<12 h) there is little additional morbidity. Recognition of the need for surgical intervention after 12 h would be regarded by us as failed non-operative management as we feel the risk of delay associated morbidity begins to increase significantly after this time. Results A total of 340 patients with a penetrating anterior abdominal stab wound were managed over the 2 year period under review. A total of 192 (56%) of these patients were subjected to mandatory laparotomy. Of these mandatory laparotomies 98% were positive. The remaining 148 (44%) patients were observed. Of the 148 observed patients a total of 30 (20%) subsequently underwent surgery. A total of 13 patients were only taken to surgery after 12 h of observation. In this group of 13 patients the average delay between admission and recognition of injury was 40 h. There were six gastric injuries, one pyloric and pancreatic injury, two gallbladder injuries, one liver, one colon and two small bowel injuries. There were no deaths. 9 patients recovered with no additional morbidity. In the remainder, morbidity included, relaparotomy (1), open abdomen (1), renal failure (1) and prolonged stay in ICU (3). Conclusion Clinical assessment accurately predicts the need for mandatory laparotomy following a stab wound to the torso. In patients who do not meet the indications for mandatory laparotomy and who are subjected to non-operative management 20% will come to surgery. A subgroup may only be recognised as requiring surgery after more than 12 h. These patients are at risk of delay associated morbidity. There are particular anatomical sites and structures which are prone to error.

Non-operative management of abdominal stab wounds--an analysis of 186 patients.

The modern management of abdominal stab wounds remains controversial and subject to continued reappraisal. In the present study we reviewed patients with abdominal stab wounds to examine and validate a policy of selective non-operative management with serial physical abdominal examination in a busy urban trauma centre with a high incidence of penetrating trauma. Over a 12-month period (2005), the records of all patients with abdominal stab wounds were reviewed. Patients with abdominal stab wounds presenting with peritonitis, haemodynamic instability, organ evisceration and high spinal cord injury underwent emergency laparotomy. No local wound exploration, diagnostic peritoneal lavage or ultrasound was used. Haematuria in patients without an indication for emergency surgery was investigated with a contrasted computed tomography (CT) scan. Patients selected for non-operative management were admitted for serial clinical abdominal examination for 24 hours. Patients in whom abdominal findings were negative were given a test feed. If food was tolerated, they were discharged with an abdominal injury form. One hundred and eighty-six patients with abdominal stab wounds were admitted. There were 171 (91.9%) males, with a mean age of 29.5 years. Seventy-four patients (39.8%) underwent emergency laparotomy. There were 5 negative laparotomies (6.8%). The remaining 112 patients (60.2%) were assigned for abdominal observation. One hundred (89.3%) of these patients were successfully managed non-operatively. The remaining 12 patients underwent delayed laparotomy, which was negative in 2 cases (16.7%). Non-operative management was successful in 53.8% of patients overall. The overall sensitivity and specificity of serial abdominal examination was 87.3% and 93.5%, respectively. Serial physical examination alone for asymptomatic or mildly symptomatic patients with abdominal stab wounds enables a significant reduction in unnecessary laparotomies.

Abdominal stab wounds: diagnostic peritoneal lavage criteria for emergency room discharge.

To prospectively evaluate a method for management of abdominal stab wounds that allows for immediate emergency room discharge. Anterior abdominal stab wound patients were prospectively placed in a study trial during a 48-month period. Consent was obtained for all patients before study entry. Anatomic boundaries for abdominal stab wounds were costal margins, inguinal ligaments, and anterior axillary lines. Hemodynamically stable patients with negative physical examinations were entered in the study and evaluated with closed diagnostic peritoneal lavage (DPL). Patients with DPL results less than 1000 RBCs/mm3 were sent home. Patients with DPL results greater than 1000 RBCs/mm3 (including gross blood) were admitted for observation. Hemodynamically stable patients with evisceration and no abdominal tenderness had the viscera replaced in the emergency room. Eviscerated patients did not undergo DPL and were admitted for observation. Patients that presented with hemodynamic instability or peritonitis were not entered in the study and underwent immediate surgical intervention. Ninety hemodynamically stable patients were entered in the study. Forty-four (49%) patients had DPL < 1000 RBCs/mm3, 34 of which were discharged home. Of the 10 admissions that qualified for discharge, 4 were admitted due to elevated ethanol levels and no family assistance, 3 were admitted to psychiatry, and 3 required other surgical procedures. No patient with DPL < 1000 RBCs/mm3 required laparotomy or had complications associated with their stab wounds. Thirty-eight (42%) patients were observed because DPL counts were greater than 1000 RBCs/mm3. Eight (21%) of these patients developed positive physical examinations that prompted exploratory laparotomy, of which five (63%) were therapeutic. There were no complications associated with delayed laparotomy. Four (4%) patients had DPL results greater than 500 WBCs/mm3, all of which underwent immediate exploratory laparotomy. Four (4%) patients presented with evisceration, one of which underwent therapeutic laparotomy. Abdominal stab wound patients that are hemodynamically stable can be safely sent home from the emergency room when DPL counts are less than 1000 RBCs/mm3. Observation of hemodynamically stable patients allows for low laparotomy rates with minimal morbidity.

The efficacy of serial physical examination in penetrating abdominal trauma

Over a 10-year period we reviewed the records of 370 consecutive patients with potentially penetrating abdominal wounds (48 gunshot and 322 stab wounds). Selective non-operative management for abdominal stab wounds was introduced, guided by serial physical examination. In our study the terms therapeutic and non-therapeutic laparotomies were used, the latter comprising negative as well as insignificant findings. Initially diagnostic peritoneal lavage and local wound exploration were used, but these methods were later abandoned. Mortality was 10.2% and morbidity 25% in the group of gunshot wounds and 1.2% and 8.6% in the group of stab wounds. During this period the rate of laparotomies for stab wounds decreased from 55% to 30%, while the rate of non-therapeutic laparotomies decreased from 24% to 0% in the last year. Delayed laparotomy did not cause death or increase morbidity. Our results support the concept of selective non-operative management of abdominal stab wounds using repeated physical examination. Peritoneal perforation and haemoperitoneum should not be an indication for routine laparotomy.

Laparoscopy in the Evaluation of Abdominal Stab Wounds

A retrospective study was designed to compare the accuracy and potential advantages of laparoscopy vs. laparotomy in the management of abdominal stab wounds. Thirty-five patients with abdominal stab wounds and scheduled for abdominal surgical exploration based on clinical evaluation were included. Hemodynamically unstable patients were excluded from the evaluation, laparotomy being performed immediately. Laparotomy was performed in 18 and laparoscopy in 17 patients. Penetrating wounds were observed in 65% of the patients (66.6% for laparotomy and 64.7% for laparoscopy). The diagnostic accuracy of laparoscopy was 100%, and laparotomy 89%. Four patients operated on by laparoscopy were converted to laparotomy (22%): in 2 patients to ascertain the origin of hemorrhage, and in 2 patients to suture a bowel laceration. No mortality was noted. Morbidity was observed in 4 patients managed by laparotomy: delirium tremens; pulmonary infection; missed small bowel injury, and stress bleeding ulcus. The postoperative hospital stay was significantly shorter for the patients explored by laparoscopy than for those explored by laparotomy (5.6 vs. 10.2 days, p = 0.02). We conclude that laparoscopy is a safe and accurate method for the evaluation of abdominal stab wounds. It avoids unnecessary laparotomy in 78% of cases. It led to less morbidity and shorter hospital stay than laparotomy. Further evaluation is required to determine the potential to treat major acute lesions by laparoscopy.

Complications of Negative Laparotomy for Truncal Stab Wounds

In a retrospective study of 459 patients undergoing mandatory explorative laparotomy for truncal stab wounds, 172 (37%) negative laparotomies were identified, divided in two groups: group I (n = 147) without, and group II (n = 25) with associated extra-abdominal injuries or surgical procedures other than laparotomy. One patient (0.6%) died of associated mediastinal vascular injuries. The overall postoperative morbidity rate was 21%, 17% in group I, and 44% in group II (p < 0.001). The excess morbidity in group II was caused by pulmonary complications associated with a thoracic injury or procedure. In group I, the complications were not severe, prolonging the mean hospital stay by 4.6 days. It is concluded that mandatory laparotomy for truncal stab wounds leads to an unnecessary operation in about 40% of cases, with a 20% morbidity rate associated with the laparotomy itself. Although the complications are not severe, the results should be assessed against the safety and accuracy of the selective management of abdominal stab wounds.

Management of Stab Wounds to the Pregnant Uterus

Only 18 cases of stab wounds to the pregnant uterus have been reported to date. This paper presents an additional case--a patient at 26 weeks' gestation with multiple voluntary stab wounds to the abdomen and lower chest resulting in fetal death. The literature is reviewed and management of abdominal stab wounds in pregnancy is discussed.

Surgical judgement in the management of abdominal stab wounds: W.C. Lee, J.F. Uddo, and F.C. Nance. Ann Surg 199:549–554, (May), 1984

Surgical judgement in the management of abdominal stab wounds: W.C. Lee, J.F. Uddo, and F.C. Nance. Ann Surg 199:549–554, (May), 1984

Surgical judgment in the management of abdominal stab wounds. Utilizing clinical criteria from a 10-year experience.

A 10-year retrospective study of patients with stab wounds to the abdomen managed under a protocol of selective management has been performed. Patients were assessed on the basis of clinical presentation and physical examination, with minimal diagnostic studies. Peritoneal lavage was not utilized in the evaluation of the patients. Two hundred and nineteen such patients were identified. One hundred and eleven of these patients were treated nonoperatively. Ninety patients were treated by immediate laparotomy. Eighteen patients, initially observed, underwent delayed laparotomy. One patient, not explored despite clear-cut indications for laparotomy, died of sepsis, emphasizing the need for strict adherence to the stated protocol. The negative or unnecessary laparotomy rate was 7.8%. The false-negative examination rate was 5.5%. Overall mortality rate was 2.3%. The accuracy of careful clinical evaluation and observation is comparable to, or better than, any other method currently available to identify intra-abdominal injuries in patients with abdominal stab wounds. The study suggests that selective management of stab wounds of the abdomen may be safely practiced in a smaller community hospital.

Conservative management of penetrating abdominal wounds.

CRITERIA for exploration of the abdomen in acute injuries have not been well defined. It is generally accepted that gunshot wounds of the abdomen should be explored as soon as the patient's condition permits. However, there has not been general agreement in the management of abdominal stab wounds. Penetration of the abdominal wall has been suggested as the major criterion. Various x-ray diagnostic aids to determine if penetration exists have been proposed; these include injection of radiopaque material through a catheter placed deep into the wound, diagnostic peritoneal lavage, and probing of the wound. 1-3 However, none of these methods has met with universal acceptance. During the past eight years, the Department of Surgery of Cook County Hospital has maintained a policy of exploring only those abdominal stab wounds with physical findings suggestive of intraperitoneal injury. The present communication details experience with evaluation and treatment of stab wounds of the