Nonoperative Management of Penetrating Injuries to

Authors: Elizabeth Benjamin Demetrios Demetriades

Publish Date: 2015/04/08

Volume: 1, Issue: 2, Pages: 102-106

PDF Link

Abstract

Contemporary management of penetrating abdominal trauma includes potential nonoperative management in a select group of patients Patients with hemodynamic instability or peritonitis after penetrating abdominal trauma require immediate laparotomy Stable evaluable patients without peritonitis however may be selected for a protocol of serial abdominal and laboratory examinations Crosssectional imaging is a useful adjunct for trajectory mapping especially after gunshot wounds Although many patients may be successfully managed without operation a subset of patients selected for nonoperative management will develop clinical signs of intraabdominal injury and required delayed laparotomy Protocols of selective nonoperative management after penetrating abdominal trauma have been shown to be safe The desire to avoid the morbidity of nontherapeutic laparotomy however must continue to be weighed against the risk of missed intraabdominal injury and the institutional feasibility of strict adherence to a protocol of serial examinationsThe traditional teaching of mandatory surgical exploration for penetrating abdominal trauma was challenged in the 1960s with the publication of the high nontherapeutic laparotomy rates associated with this practice 1 The idea of selective nonoperative management of penetrating abdominal trauma initially gained support in patients with stab wounds however contemporary evaluation of abdominal gunshot injuries is also included in this algorithmA large percentage of patients with abdominal stab wounds have no clinically significant intraabdominal injury Demetriades et al prospectively analyzed 467 patients with abdominal stab wounds and known peritoneal penetration and found that 276  of patients had no significant intraabdominal injury 2 In a Western Trauma Association multicenter study of 359 patients with anterior abdominal stab wounds only 36  of patients underwent a therapeutic laparotomy 3 The authors concluded that in the absence of hypotension peritonitis or evisceration patients with anterior abdominal stab wounds could be observed for potential nonoperative management These recommendations were validated in a followup study with no morbidity or mortality incurred by delayed operative intervention 4•• Similar results have been reported after abdominal gunshot wounds In a prospective study including 1856 patients a policy of mandatory laparotomy after abdominal gunshot wound would have resulted in a nontherapeutic laparotomy rate of 47  5 Given these high rates of potential nontherapeutic intervention the role of selective nonoperative management has been expanded to include both abdominal stab and gunshot woundsThe balance between nontherapeutic intervention and the morbidity of missed injury remains the cornerstone principle of selective nonoperative management Similar to selective nonoperative management of solid organ injury after blunt trauma not all patients selected for observation after penetrating abdominal trauma will avoid an operation The critical component to safe selective nonoperative management is frequent and reliable physical examination The potential morbidity of a nontherapeutic laparotomy is easily outweighed by the morbidity or potential mortality of a missed intraabdominal injury Patients should be observed in a monitored setting with serial exams ideally by the same experienced team in the absence of narcotics antibiotics or anesthesia Hemodynamic and laboratory data including white blood cell count lactate and serial hemoglobin are monitored Changes in the physical exam or hemodynamics should prompt critical reevaluation for potential operative intervention Although recent literature supports an observation period of 12–24 h the majority of patients requiring laparotomy after penetrating abdominal trauma will manifest clinical symptoms within 4–6 h 6•• 7 8Hemodynamic instability and diffuse peritonitis following penetrating abdominal trauma remain absolute indications for exploratory laparotomy In contrary to the localized tenderness that can be caused by the soft tissue damage of a superficial wound tract diffuse peritonitis after penetrating abdominal trauma is associated with a high therapeutic laparotomy rate even in the hemodynamically stable patient In a review of 139 consecutive hemodynamically stable peritonitic patients after penetrating abdominal trauma 97  had intraabdominal injury on laparotomy 9 In addition 39  required blood transfusion and 25  developed intraoperative hypotensionAs accurate physical examination over time is imperative for safe nonoperative evaluation of a patient with penetrating abdominal trauma altered level of consciousness need for general anesthesia or inability to perform reliable serial exams is a contraindication for selective nonoperative managementAlthough injuries will rarely be missed with a policy of uniform laparotomy after penetrating trauma the potential morbidity of nontherapeutic laparotomy is as high as 20  10 11 with the later complications of hernias and bowel obstructions likely underreported Nontherapeutic laparotomy has also been associated with increased hospital length of stay and cost 5 12 With the advent of selective nonoperative management for penetrating abdominal trauma the reservation lies in the patient that converts from the nonoperative to operative arm and whether or not the delay in operation contributes to patient morbidity and mortality Delayed intervention however when following a protocol of serial abdominal and laboratory examinations has not been shown to result in significant adverse outcome due to the prompt identification of clinical deterioration 4•• 10 13 14 15 16••

Keywords: