Selective surgery for abdominal stab wounds

"Awake" laparoscopy for the evaluation of equivocal penetrating abdominal wounds

BACKGROUND

Diagnostic laparoscopy is useful for the assessment of equivocal penetrating abdominal wounds, and has become the modality of choice for the evaluation of such wounds at our institution. We hypothesised that, in appropriate patients, diagnostic "awake" laparoscopy (AL) could be performed under local anaesthesia in the emergency department (ED), allowing for expedited discharge and potential cost savings.

METHODS

Selected haemodynamically stable patients with penetrating abdominal injury underwent AL. Suitability for AL was at the discretion of the attending surgeon. Identification of peritoneal penetration by AL led to exploratory laparotomy in the operating room. Patients with no evidence of peritoneal penetration were discharged from the ED (ALneg). These patients were matched to a cohort of 24 patients who underwent diagnostic laparoscopy in the OR which was negative for peritoneal penetration (DLneg). Length of stay and hospital charges were compared.

RESULTS

Over a 30-month period, 15 patients underwent AL without complication. No peritoneal penetration was found in 11 patients. The remaining four patients underwent exploratory laparotomy, of which two were positive for intra-abdominal injury. Mean time to discharge was 7h in the ALneg group versus 18 h in the DLneg group (p=0.0003). Cost savings on hospital charges averaged 2227 US dollars per patient in the ALneg group compared with the DLneg group.

CONCLUSIONS

AL may be safely performed in the ED, allowing for expedited patient discharge. Cost savings are achieved by the avoidance of charges inherent to diagnostic laparoscopy performed in the operating room.

Unnecessary laparotomy by using physical examination and different diagnostic modalities for penetrating abdominal stab wounds

BACKGROUND

The modern management of penetrating abdominal trauma has decreased the incidence of unnecessary laparotomy by using selective non-operative management protocols. However, the real benefits of physical examination and different diagnostic methods are still unclear.

METHODS

From January 2000 to April 2003, we prospectively collected data on 117 patients with penetrating stab wounds to the thoracoabdominal, anterior abdominal, and back regions who had non-operative management. Clinical examination was the primary tool to differentiate those patients requiring operation. Findings of physical examination, ultrasound, computed tomography, endoscopy, echocardiography, diagnostic peritoneal lavage, and diagnostic laparoscopy were reviewed. The number of therapeutic, non-therapeutic, and negative laparotomies were recorded.

RESULTS

Non-operative management was successful in 79% of patients. There were 11 early (within 8 hours of admission) and 14 delayed (more than 8 hours after admission) laparotomies performed, depending on the results of various diagnostic procedures. Non-operative management failed in 21% of patients, and the rate of non-therapeutic laparotomy in early and delayed laparatomy groups was 9% and 14% respectively. There was no negative laparatomy.

CONCLUSIONS

The use of physical examination alone and/or together with different diagnostic methods allows reduction of non-therapeutic laparotomies and elimination of negative laparatomies.

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

OBJECTIVE

To prospectively evaluate a method for management of abdominal stab wounds that allows for immediate emergency room discharge.

METHODS

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.

RESULTS

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.

CONCLUSION

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.

Conservative management of penetrating torso trauma

Trauma has evolved as a specialty of its own over the past two decades, and has been the subject of much research and a huge number of trials, many of which are ongoing. As a result, it is now possible to apply an evidence-based practice to many trauma scenarios. The management of penetrating injuries to the chest or abdomen has traditionally followed a policy of emergency surgery as the first course of action. This has now shown to be unnecessary in many cases, particularly with the advances in diagnostic tests and imaging modalities. A large number of cases of penetrating torso trauma may require an operation at some stage, but obtaining the clearest diagnostic picture and optimizing the clinical condition of the patient before this undertaking will result in improved outcome. A selective approach to emergency surgery, with its attendant difficulties, is now recommended

Evisceration after abdominal stab wounds: is laparotomy required?

OBJECTIVES

To determine the incidence of intra-abdominal injury requiring laparotomy after an abdominal stab wound with evisceration. To identify clinical signs that increase the likelihood of an intra-abdominal injury in the presence of such a wound.

METHODS

Information was collected prospectively over an 8-year period on all patients who presented to our urban level I trauma center with an abdominal stab wound and evisceration. This information included which organ eviscerated, presence of other indications for laparotomy, organs injured, and postoperative complications. All comparisons used the Fisher's exact chi2.

RESULTS

A total of 81 patients were admitted with evisceration after an abdominal stab wound. Sixty-one patients (75%) had eviscerated omentum, 18 patients (22%) had eviscerated small bowel, and 2 patients (2%) had eviscerated colon. Sixty-two patients (76%) had evisceration as the sole indication for laparotomy, the remaining 19 patients (24%) had another indication such as hypotension or peritonitis. Overall, 63 patients (78%) had an intra-abdominal injury that required repair. This was true regardless of organ eviscerated (omentum = 77% vs. viscus = 80%, not significant) or clinical presentation (no other indication = 76% vs. another indication = 84%, not significant).

CONCLUSION

The majority of patients who present with an evisceration after a stab wound to the abdomen require a laparotomy. This is true regardless of what has eviscerated or the presence of other clinical indications to operate. Evisceration should continue to prompt operative intervention.

Unnecessary laparotomies for trauma: a prospective study of morbidity

OBJECTIVE

Despite advances in diagnostic techniques, unnecessary laparotomies (no repairs/no drains) are still performed in trauma centers. The true risks of such procedures are unclear. Our hypothesis was that the overall incidences of complications after an unnecessary laparotomy for trauma that have been reported in the literature were significant underestimates because of flaws in study design. To test our hypothesis, a prospective study to record all perioperative complications in patients undergoing an unnecessary laparotomy for trauma was performed.

DESIGN

Prospective case series.

MEASUREMENTS AND MAIN RESULTS

The main outcome measures were perioperative complications. An unnecessary laparotomy was performed in 254 patients who sustained trauma. The mechanism of injury was a penetrating wound in 98% of the patients. Complications occurred in 41.3% of the patients (n = 105) and included atelectasis (15.7%), postoperative hypertension that required medical treatment (11.0%), pleural effusion (9.8%), pneumothorax (5.1%), prolonged ileus (4.3%), pneumonia (3.9%), surgical wound infection (3.2%), small bowel obstruction (2.4%), urinary infection (1.9%), and others. Complication rates for patients who did (n = 111) and did not (n = 143) have an associated injury were 61.3% and 25.9%, respectively (p = 0.0001). Complications occurred in 19.7% of 81 patients who did not have an associated injury and who did not have intraperitoneal or retroperitoneal penetration. The mortality rate for the entire series was 0.8% and was unrelated to the unnecessary laparotomies.

CONCLUSIONS

Unnecessary laparotomies for trauma result in a significant morbidity when complications are recorded prospectively. Current efforts to reduce the incidence of these unnecessary procedures without increasing that of missed injuries are obviously worthwhile.

Management of penetrating back trauma

The best management plan for patients with stab wounds of the posterior abdomen who have no obvious indication for operation is a selective one. Repeated physical examination is the mainstay of treatment, as indicated by many authors. Other special studies, such as DPL, angiography, intravenous pyelography, and contrast CT scanning, are indicated on a case-by-case basis, but as yet lack convincing justification for routine use.

Emergency care of the injured child

Emergency care of the injured child can be rapid and efficient if the treatment facility is properly prepared to manage children. At Ochsner Foundation Hospital, a mobile tool cabinet is used to store the materials needed for standard pediatric emergency care. The initial evaluation involves rapid assessment of pulmonary function and cardiac action and control of external hemorrhage. Secondary evaluation covers all other areas of the body, with possible problems assessed in descending order of seriousness. In many cases, after initial care and stabilization, the severely injured child should be transported to a pediatric intensive care or trauma unit for definitive treatment.