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

Role of Minimally Invasive Surgery in Management of Penetrating Abdominal Trauma in Children

INTRODUCTION

 Traditionally, exploratory laparotomy was used to treat penetrating abdominal trauma (PAT). At present, minimally invasive surgery (for diagnostic and therapeutic purposes) has developed and represents a rapidly evolving modality for dealing with PAT in stable children. In this article, we aim to present our experience, evaluate the effectiveness, and report the results of minimally invasive surgery (MIS) for PAT in stable pediatric patients.

MATERIALS AND METHODS

 This prospective study involved 117 hemodynamically stable pediatric cases of PAT (caused by gunshots, stab, and accidental stab), admitted, and managed according to the severity of injury. The information recorded for analysis included demographic data, the anatomical location of injury, the initial vital data and scoring systems, the organs affected, the procedures done, operative time, need for conversion to laparoscopic-assisted approach, length of hospital stay, complications, missed injury, and mortality rate.

RESULTS

 Among 117 pediatric patients with PAT, 15 cases were treated conservatively and 102 cases were managed by MIS. They were 70 males and 47 females with a mean age of 7.3 ± 0.6 years (range = 1-14 years). They included 48 cases of gunshot injury, 33 cases of abdominal stab, and 36 cases of accidental stab. Laparoscopy was diagnostic (DL) in 33.3% (n = 34) and therapeutic (TL) in 66.7% (n = 68) of cases. Of the 68 TL cases, we completely managed 59 cases (86.8%) by laparoscopy, while 9 cases (13.2%) were converted to limited laparotomy. The mean operative time was 17 ± 1 minutes (range = 12-25 minutes) for DL, 85 ± 9 minutes (range = 41-143 minutes) for complete TL cases, and 89 ± 3 minutes (range = 47-149 minutes) for laparoscopic-assisted procedures. For DL cases, the mean length of hospital stay was 2 ± 0.4 days, while for complete TL cases, it was 5.4 ± 0.83 days, and for laparoscopic-assisted cases, it was 5.8 ± 0.37 days. Postoperative complications occurred in eight cases (7.84%), with five cases (4.9%) required reintervention. No missed injury or mortality was recorded in the study. The patients were followed up for a median period of 52 months.

CONCLUSION

 For management of PAT in children, MIS has 100% accuracy in defining the injured organs with zero percent missed injuries.

Abdominal Self-Stabbing: An Uncommon Type of Sharp Abdominal Trauma

Abdominal self-stabbing, a type of sharp abdominal trauma, is a rare form of attempted suicide. Such cases are not commonly seen in the emergency department, but a prompt and well-reasoned decision is essential in the management of these patients. We report a case of a SI-ASW and a literature review to show the management of the aforementioned condition.

The role of diagnostic laparoscopy for trauma at a high-volume level one center

Background

The role of minimally invasive surgery in trauma has continued to evolve over the past 20 years. Diagnostic laparoscopy (DL) has become increasingly utilized for the diagnosis and management of both blunt and penetrating injuries.

Objective

While the safety and feasibility of laparoscopy has been established for penetrating thoracoabdominal trauma, it remains a controversial tool for other injury patterns due to the concern for complications and missed injuries. We sought to examine the role of laparoscopy for the initial management of traumatic injuries at our urban Level 1 trauma center.

Methods

All trauma patients who underwent DL for blunt or penetrating trauma between 2009 and 2018 were retrospectively reviewed. Demographic data, indications for DL, injuries identified, rate of conversion to open surgery, and outcomes were evaluated.

Results

A total of 316 patients were included in the cohort. The mean age was 34.9 years old (± 13.7), mean GCS 14 (± 3), and median ISS 10 (4–18). A total of 110/316 patients (35%) sustained blunt injury and 206/316 patients (65%) sustained penetrating injury. Indications for DL included evaluation for peritoneal violation (152/316, 48%), free fluid without evidence of solid organ injury (52/316, 16%), evaluation of bowel injury (42/316, 13%), and evaluation for diaphragmatic injury (35/316, 11%). Of all DLs, 178/316 (56%) were negative for injury requiring intervention, which was 58% of blunt cases and 55% of penetrating cases. There were no missed injuries noted. Average hospital length of stay was significantly shorter for patients that underwent DL vs conversion to open exploration (2.2 days vs. 4.5 days, p < 0.05).

Conclusion

In this single institution, retrospective study, the high volume of cases appears to show that DL is a reliable tool for detecting injury and avoiding potential negative or non-therapeutic laparotomies. However, when injuries were present, the high rate of conversion to open exploration suggests that its utility for therapeutic intervention warrants further study.

Selective nonoperative management of penetrating abdominal trauma at a level 1 Canadian trauma centre: a quest for perfection

Background

Many patients who sustain penetrating abdominal trauma can be managed nonoperatively. The Eastern Association for the Surgery of Trauma (EAST) has published guidelines on selective nonoperative management (SNOM), and this approach is well established. The purpose of this study is to assess the management of penetrating abdominal trauma, including the selection of patients for SNOM and the use of this approach, at a Canadian level 1 trauma centre.

Methods

We used the Hamilton Health Sciences trauma registry to compile data on patients aged 16 years and older who sustained penetrating abdominal trauma from Jan. 1, 2011, to Dec. 31, 2017. Hemodynamically stable, nonperitonitic patients without evisceration or impalement were considered potentially eligible for SNOM. We compared the SNOM group of patients with the immediate operative (IOR) group. Our primary outcome was SNOM failure; secondary outcomes included length of stay, repeat imaging, computed tomography (CT) protocol, laparoscopy in left thoracoabdominal trauma, and nontherapeutic and negative laparotomies.

Results

We included 191 patients with penetrating abdominal trauma; 123 underwent SNOM and 68 underwent IOR. Of the 68 patients in the IOR group, 4 underwent nontherapeutic laparotomies. Of the 123 patients in the SNOM group, this approach failed in 7 (5.7%). Patients who were successfully managed with SNOM had an average length of stay of 25.4 hours (7.9–43.0 h), with no repeat imaging in 34/35 (97.1%). Only 5 of the 47 patients with flank/back wounds had a CT scan that included luminal contrast. Only 3 of the 58 patients with left thoracoabdominal wounds underwent same-admission laparoscopy, all demonstrating diaphragmatic defects.

Conclusion

Our study demonstrates a high rate of compliance with the EAST SNOM guidelines, including minimal failure rate of SNOM and an efficient use of resources as demonstrated by reduced length of stay and minimal use of reimaging. We identified 2 opportunities for improvement: improved use of luminal contrast CT in patients with flank/back wounds and improved use of diagnostic laparoscopy in patients with left thoracoabdominal wounds.

Does computed tomography scan add any diagnostic value to the evaluation of stab wounds of the anterior abdominal wall? A systematic review and meta-analysis

BACKGROUND

The aim of this systematic review and meta-analysis was to evaluate whether computed tomography (CT) scan adds any diagnostic value in the evaluation of stab wounds of the anterior abdominal wall as compared with serial clinical examination (SCE).

METHODS

PubMed, EMBASE, Cochrane Library, and MEDLINE via Ovid were systematically searched for records published from 1980 to 2018 by two independent researchers (M.G., R.L.). Quality assessment, data extraction, and analysis were performed according to the Cochrane Handbook for Systematic Reviews of Interventions. Mantel-Haenszel method with odds ratio (OR) and 95% confidence interval (95% CI) as the measure of effect size was used for meta-analysis.

RESULTS

Three studies (1 randomized controlled trial and 2 observational studies) totaling 319 patients were included in the meta-analysis. Overall laparotomy rate was 12.8% (22 of 172 patients) in SCE versus 19% (28 of 147 patients) in CT. This difference was not significant (OR [95% CI], 0.63 [0.34-1.16]; p = 0.14). Negative laparotomy rate was 3.5% (6 of 172 patients) in SCE versus 5.4% (8 of 147 patients) in CT. The difference was not significant (OR [95% CI], 0.61 [0.20-1.83]; p = 0.37).

CONCLUSION

This meta-analysis compared SCE with CT scan in patients presenting with stab wounds of the anterior abdominal wall and provided level II evidence showing no additional benefit in CT scan. Further observational and experimental clinical studies are needed to confirm the findings of this meta-analysis.

LEVEL OF EVIDENCE

Systematic review and meta-analysis, level II.

Are we doing too many non-therapeutic laparotomies in trauma? An analysis of the National Trauma Data Bank

BACKGROUND

Exploratory laparotomy (EL) has been the definitive diagnostic and therapeutic modality for operative abdominal trauma in the US. Recently, many trauma centers have started using diagnostic laparoscopy (DL) in stable trauma patients in an effort to reduce the incidence of non-therapeutic laparotomy (NL). We aim to evaluate the incidence of NL in the trauma population in the US and compare the outcomes between DL and NL.

METHODS

Using ICD-9 codes, the National Trauma Data Bank (2010-2015) was queried for patients undergoing any abdominal surgical intervention. Patients were divided into two groups: diagnostic laparoscopy (DL) and exploratory laparotomy (EL). Hemodynamically unstable patients on arrival and patients with abbreviated injury score (AIS) > 3 were excluded. Patients in EL group without any codes for gastrointestinal, diaphragmatic, hepatic, splenic, vascular, or urological procedures were considered to have undergone NL. After excluding patients who were converted to open from the DL group, multivariate regression models were used to analyze the outcomes of DL vs NL group with respect to mortality, length of stay, and complications.

RESULTS

A total of 3197 patients underwent NL vs 1323 patients who underwent DL. Compared to DL group, the NL group were older (mean age: 35 vs. 31, P < 0.01). Rate of penetrating injury was 77% vs 86% for patients in NL vs DL. On multivariate analysis, NL was associated with increased mortality (OR 4.5, 95% CI 2.1-9.7), higher rate of complications (OR 2.2, 95% CI 1.4-3.3), and a longer hospital stay (OR 2.7, 95% CI 2.1-3.5). NL was also associated with higher rates of pneumonia, VTE, ARDS, and cardiac arrest.

CONCLUSION

With increasing experience in minimally invasive surgery, DL should be a part of the armamentarium of trauma surgeons. This study supports that in well-selected trauma patients DL has favorable outcomes compared to NL. These findings warrant further investigation.

Mandatory Laparotomy in Penetrating Abdominal Injuries with Omental Evisceration: Experience in a Major Trauma Center in the Philippines

BACKGROUND

Omental evisceration due to abdominal stab injuries connotes peritoneal penetration and translates to around 70% risk of intra-abdominal injury. Such cases are being managed with mandatory laparotomy at the Philippine General Hospital. This study aims to review the patient profile and laparotomy outcomes in such cases.

METHODS

This is a retrospective review of 98 consecutive laparotomies performed for patients with omental evisceration secondary to abdominal stab wounds between January 2004 to April 2018.

RESULTS

Almost all patients were male (99%) with a mean age of 32.1 years (range 14-70). The majority (81%) had a therapeutic laparotomy, and only 19 patients (19%) had a non-therapeutic laparotomy. The most commonly injured organs include the small bowel, stomach, colon, diaphragm, and liver. There was no significant difference in age, sex, duration of injury, systolic blood pressure and heart rate at presentation between the two groups. There were significantly more patients who presented with peritonism in the therapeutic laparotomy group compared to the non-therapeutic laparotomy group (82% vs 53%, p=0.005). Patients who presented with peritonism were six times more likely to have a therapeutic laparotomy. There was no significant difference between morbidity and mortality rates in the two groups. The length of hospital stay for the non-therapeutic laparotomy group was significantly shorter compared to the therapeutic laparotomy group (3.6 vs 5.7 days, p=0.006).

CONCLUSION

The rate of therapeutic laparotomy remains to be significantly higher among patients with omental evisceration. Hence, omental evisceration, particularly those associated with peritonism, should continue to prompt operative management.

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.

A study on initial outcome of selective non-operative management in penetrating abdominal injury in a tertiary care hospital in Bangladesh

Objectives

The aim of this study was to assess the initial outcome of non-operative, conservative management in selective penetrating abdominal injury in a tertiary care hospital.

Material and Methods

This was a cross sectional study done on purposively selected 36 patients with penetrating abdominal injuries of all ages admitted within 6 hours of the incident. All patients confirmed peritoneal breach and standard algorithm of management was followed. Closed monitoring was ensured with repeated investigations at regular intervals. Outcome parameters included surgical site infection (SSI), fever, hypothermia, wound dehiscence, fecal fistula, length of stay, pulmonary complication and death.

Results

A total of 36 patients with a mean age of 30 years (SD= 6.7), consisting all males, mostly (58%) from rural areas and 73% from low socioeconomic condition. Site of injury was noted in the epigastrium (42%) and right iliac region (22%). Among them, 33 (92%) patients were successfully managed with non-operative management and 3 (8%) patients needed laparotomy. Routine imaging and clinical observation could detect hollow viscus injury within 36 hours in 3 patients. Hospital stay was significantly lower ( <7 days) in conservative management.

Conclusion

Clinical examination alone and/or together with different diagnostic methods could reduce the number of negative laparotomies and associated morbidities. Single surgeon must closely monitor a patient of penetrating abdominal injury and take vital decisions from the time of admission until discharge.

Laparotomy for organ evisceration from abdominal stab wounds: A South African experience

INTRODUCTION

Organ evisceration following abdominal stab wound (SW) is currently considered as an absolute indication for mandatory laparotomy due to the high incidence of associated intra-abdominal injuries, but literature describing the spectrum of organ injury encountered is limited.

MATERIALS AND METHODS

We reviewed our experience of 301 consecutive patients who were subjected to mandatory laparotomy over an eight-year period at a major trauma centre in South Africa.

RESULTS

Of the 301 patients with organ evisceration, 92% were male (mean age: 28 years). Ninety per cent (270/301) of the laparotomies were positive (85% (229/270) therapeutic, 15% (41/270) non-therapeutic). The frequencies of eviscerated organs were small bowel (70%), large bowel (26%), and stomach 3%. Three (1%) patients had combined evisceration of more than one of the above organs. The most commonly injured organs were small bowel and large bowel. The mean length of hospital stay was nine days. Seven patients required intensive care admission. The morbidity rate was 21% and mortality was 2%.

CONCLUSIONS

The spectrum of injury associated with abdominal SW with organ evisceration is similar to smaller published series. Multiple organ injuries are common. The most commonly eviscerated organs were small bowel, large bowel and stomach, while the most commonly injured organs were small bowel and large bowel.

Comparison between isolated serial clinical examination and computed tomography for stab wounds in the anterior abdominal wall

OBJECTIVE

to compare abdominal computer tomography (CT) with isolated serial clinical exam (SCE) in the management of anterior abdominal stab wounds.

METHODS

randomized prospective study performed at Hospital de Pronto Socorro de Porto Alegre involving patients with anterior abdominal stab wounds without indication of immediate laparotomy; patients were divided in two groups: CT group and SCE group, In the SCE group, patients were followed up with serial clinical exam every 6 hours, Patients of CT group were submitted to abdominal computer tomography after initial evaluation.

RESULTS

66 patients were studied and 33 were included in each group, Of total, six were submitted to surgery, three of each group, In the SCE group, patients submitted to surgery in media waited 12 hours from arrival to diagnosis without any non-therapeutic surgeries, The remaining 30 patients of this group were discharged from hospital after 24 hours of observation, In the CT group, three patients showed alteration at CT and were submitted to laparotomy, one non-therapeutic, The others were discharged from hospital after 24 hours of observation, Abdominal computer tomography had a positive predictive value (PPV) of 67% and negative predictive value (NPV) of 100%, with 96% of accuracy, Isolated serial clinical exam showed PPV and NPV of 100% and 100% of accuracy.

CONCLUSION

selective management of anterior abdominal stabs is safe, when a rigorous selection of patients is observed, Isolated serial clinical exam may be performed without computer tomography, without increase of hospitalization time or morbidity, reducing costs, exposure to radiation, mortality and morbidity and non-therapeutic laparotomies.

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

BACKGROUND

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.

OBJECTIVES

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?

METHODS

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.

RESULTS

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.

DISCUSSION

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.

CONCLUSIONS

In stable AASW patients, a negative CT scan alone without an observation period is inadequate to exclude significant intraabdominal injuries.

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

BACKGROUND

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.

METHODS

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.

RESULTS

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.

CONCLUSION

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.

Selective Non-operative Management of Patients with Abdominal Trauma-Is CECT Scan Mandatory?

CECT scan is considered essential for selective non-operative management (SNOM) of patients with abdominal trauma. However, CECT has its own hazards and limitations. We evaluated the safety and efficacy of selective non-operative management of patients with abdominal trauma without the mandatory use of CECT scan in a prospective study. Patients with peritonitis and ongoing intra-abdominal bleed were excluded. Consenting FAST positive, hemodynamically stable patients with blunt and penetrating abdominal trauma between 18 and 60 years of age were included and admitted for SNOM and detailed ultrasonography of the abdomen (in all) with or without CECT abdomen (selectively). Eighty-four patients with abdominal trauma were admitted during the study period. Twenty-two patients did not satisfy the inclusion criteria and 18 required immediate laparotomy based on primary survey. Remaining 44 patients were admitted for SNOM: mean ± SD age of these patients was 27 ± 8.7 years; 40 (89 %) were males. Thirty-five patients (79.54 %) sustained blunt trauma (RTI = 16, Fall = 16, others = 3) while nine patients (20.45 %) sustained penetrating trauma. SNOM without CECT was successful in 36 (81.82 %) patients. Five (11.36 %) patients underwent delayed emergency laparotomy based on clinical and detailed USG evaluation. CECT was not done in these patients. Three patients underwent CECT for various reasons; however, they were managed with SNOM. Thus, SNOM without abdominal CECT was successful in 36 (81.82 %) patients. SNOM failed in five patients but abdominal USG was sufficient. SNOM can be practised safely in patients of abdominal trauma with limited use of CECT scan.

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.

Is non-operative approach applicable for penetrating injuries of the left thoraco-abdominal region?

Objectives

Currently, diagnostic laparoscopy (DL) is recommended for the left thoraco-abdominal region penetrating injuries (LTARP). However, organ and diaphragmatic injury may not be detected in all of these patients. Our aim is to focus on this LTARP patient group without any operative findings and to highlight the evaluation of diagnostic tools in the high-tech era for a possible selected conservative treatment.

Material and methods

The patients who were admitted to ED due to LTARP, and who underwent routine DL were evaluated retrospectively in terms of demographic, clinical, radiological, and operative findings of the patients.

Results

The current study included 79 patients with LTARP. In 44 of 79 patients, abdominal injury was not detected. In 30 patients an isolated diaphragmatic injury was revealed and in 4 patients a visceral injury was accompanying to diaphragmatic injury. Surgical findings revealed that the diaphragm was the organ most likely to sustain injury. In patients with more than one positive diagnostic findings need for surgery rate was 61.5%, however; in patients with one positive diagnostic finding (n = 53), positive surgical finding rate was only 35.8%, (p = 0.03). Regarding the combined use of all diagnostic tools in these patients; such as physical examination, plain chest X-ray, and computed tomography, when this method was used for pre-operative diagnosis, sensitivity was measured as 82.7%, specificity 84.1%, PPV 77.4% and NPV 88.1%.

Conclusion

Although DL is reliable for diagnosis of diaphragmatic and visceral injury in patients with LTARP. However, individual decision making for laparoscopic intervention is needed to prevent morbidity of an unnecessary operation under emergent setting due to high rates of negative intraabdominal findings.

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.

[Opportunities of endovideosurgical interventions in thoracic and abdominal trauma]

AIM

To analyze the results of laparo- and thoracoscopy in patients with thoracic and abdominal trauma in conditions of emergency hospital.

MATERIAL AND METHODS

For the period 2006-2013 we performed 56 laparoscopic and 15 thoracoscopic interventions in 67 patients with trauma. There were 80.6% of men and 19.4% of women aged 35±1.7 years. Abdominal, thoracic and thoraco-abdominal injuries were observed in 51 (76.1%), 14 (20.9%) and 2 (3%) patients. Abdominal or thoracic trauma alone was diagnosed in 41 (61.2%) cases and combined injury - in 26 (38.8%) patients. 37 (66%) interventions were performed laparoscopically. Conversion to laparotomy was observed in 19 (34%) cases. Mean volume of hemoperitoneum was 458 ml (range 100-1100 ml). In 11 (73.3%) patients thoracoscopic surgery was performed and conversion of access was applied in 4 (26.7%) cases.

RESULTS

No injuries of internal organs were observed in 19.6% and 13.3% of patients using laparo- and thoracoscopy respectively. So inadvisable open surgery was prevented although formal indications for laparo- and thoracotomy were present. In 25% and 20% of abdominal and thoracic damages respectively we avoided relatively unjustified laparo- or thoracotomy because of injuries were cured endoscopically. No one missed injury was observed. Postoperative complications were diagnosed in 5.6% of cases. Mortality rate was 15.6% in case of severe combined trauma. Mean hospital stay was 23.2 days (range 3-105).

CONCLUSION

Endoscopic techniques are perspective in treatment of thoracic and abdominal trauma. It allows to avoid inadvisable laparo- and thoracotomy in some cases and to improve results of treatment.

Scanning and War: Utility of FAST and CT in the Assessment of Battlefield Abdominal Trauma

OBJECTIVE

To determine utilization and accuracy of focused assessment with sonography for trauma (FAST) and computed tomography (CT) in a mature military trauma system to inform service provision for future conflicts.

BACKGROUND

FAST and CT scans undertaken by attending radiologists contribute to surgical decision making for battlefield casualties at the Joint Force, Role 3 Medical Treatment Facility at Camp Bastion (R3), Afghanistan.

METHODS

Registry data for abdominally injured casualties treated at R3 from July to November 2012 were matched to radiological and surgical records to determine diagnostic accuracy for FAST and CT and their influence on casualty management.

RESULTS

A total of 468 casualties met inclusion criteria, of whom 85.0% underwent FAST and 86.1% abdominal CT; 159 (34.0%) had abdominal injuries. For detection of intra-abdominal injury, FAST sensitivity (Sn) was 0.56, specificity (Sp) 0.98, positive predictive value (PPV) 0.87, negative predictive value (NPV) 0.90, and accuracy (Acc) 0.89. For CT, Sn was 0.99, Sp 0.99, PPV 0.96, NPV 1.00, and Acc 0.99. Forty-six solid organ injuries were identified in 38 patients by CT; 17 were managed nonoperatively. A further 61 patients avoided laparotomy after CT confirmed extra-abdominal wounds only. The negative laparotomy rate was 3.9%.

CONCLUSIONS

FAST and CT contribute to triage, guide surgical management, and reduce nontherapeutic laparotomy. When imaging is available, these data challenge current doctrine about inadvisability of nonoperative management of abdominal injury after combat trauma.

The predictive value of physical examination in the decision of laparotomy in penetrating anterior abdominal stab injury

A selective conservative treatment for penetrating anterior abdominal stab injuries is an increasingly recognized approach. We analyzed patients who followed-up and treated for penetrating anterior abdominal stab injuries. The anterior region was defined as the area between the arcus costa at the top and the mid-axillary lines at the laterals and the inguinal ligaments and symphysis pubis at the bottom. An emergency laparotomy was performed on patients who were hemodynamically unstable or had symptoms of peritonitis or organ evisceration; the remaining patients were followed-up selectively and conservatively. A total of 175 patients with purely anterior abdominal injuries were included in the study. One hundred and sixty-five of the patients (94.29%) were males and 10 (5.71%) were females; the mean age of the cohort was 30.85 years (range: 14-69 years). While 16 patients (9%) were made an emergency laparotomy due to hemodynamic instability, peritonitis or evisceration, the remaining patients were hospitalized for observation. During the selective conservative follow-up, an early laparotomy was performed in 20 patients (12%), and a late laparotomy was performed in 13 patients (7%); the remaining 126 patients (72%) were discharged after non-operative follow-up. A laparotomy was performed on 49 patients (28%); the laparotomy was therapeutic for 42 patients (86%), non-therapeutic for 4 patients (8%), and negative for 3 patients (6%). A selective conservative approach based on physical examination and clinical follow-up in penetrating anterior abdominal stab injuries is an effective treatment approach.

Peritoneal Breach as an Indication for Exploratory Laparotomy in Penetrating Abdominal Stab Injury: Operative Findings in Haemodynamically Stable Patients

Introduction. Management of haemodynamically stable patients with penetrating abdominal injuries varies from nonoperative to operative management. The aim was to investigate whether peritoneal breach when used as an indication for exploratory laparotomy appropriately identified patients with intra-abdominal visceral injury. Methods. We conducted retrospective cohort study of all patients presenting with PAI at a major trauma centre from January 2007 to December 2011. We measured the incidence of peritoneal breach and correlated this with intra-abdominal visceral injury diagnosed at surgery. Results. 252 patients were identified with PAI. Of the included patients, 71 were managed nonoperatively and 118 operatively. The operative diagnoses included nonperitoneal-breaching injuries, intraperitoneal penetration without organ damage, or intraperitoneal injury with organ damage. The presenting trauma CT scan was reported as normal in 63%, 34%, and 2% of these groups, respectively. The total negative laparotomy/laparoscopy rate for all patients presented with PAI was 21%, almost half of whom had a normal CT scan. Conclusion. We found that peritoneal breach on its own does not necessarily always equate to intra-abdominal visceral injury. Observation with sequential examination for PAI patients with a normal CT scan may be more important than exclusion of peritoneal breach via laparoscopy.

The management of penetrating abdominal stab wounds with organ or omentum evisceration: The results of a clinical trial

OBJECTIVE

The therapeutic approach to abdominal penetrating stab injuries has changed over the years from routine laparotomy to non-operative treatment. In case of organ or omental evisceration, although the laparotomy need is greater, non-operative treatment may be applied in selected cases. The aim of our study was to assess the follow-up and treatment outcomes of patients with organ or omental evisceration due to penetrating abdominal injuries.

MATERIAL AND METHODS

Patients with organ or omental evisceration due to penetrating abdominal stab injuries were prospectively evaluated between April 2009 and July 2012. Emergent laparotomy was performed in cases that were hemodynamically unstable or had signs of organ evisceration or peritonitis, while other patients were managed conservatively. Patients' follow-up and treatment outcomes were assessed.

RESULTS

A total of 18 patients with organ or omental evisceration were assessed. Six (33.3%) patients underwent emergent laparotomy, and 12 (66.7%) patients underwent conservative follow-up. Three patients in the emergent laparotomy group had signs of organ evisceration, and 3 had signs of peritonitis; five of these 6 patients underwent therapeutic laparotomy and 1 negative laparotomy. In the non-operative follow-up group, therapeutic laparotomy was carried out in a total of 7 patients, 4 being early and 3 late, due to development of peritonitis, whereas 5 (27.8%) patients were managed non-operatively.

CONCLUSION

Although organ or omental eviscerations due to penetrating abdominal stab injuries have a high rate of therapeutic laparotomy, selective conservative therapy is a safe method in selected cases.

Role of laparoscopy in penetrating abdominal trauma: a systematic review

BACKGROUND

Debate remains regarding the optimum role of laparoscopy in the setting of trauma although it can offer advantages over traditional exploratory laparotomy. Laparoscopy can be a screening, diagnostic or therapeutic tool in trauma. The purpose of this review is to evaluate the role of laparoscopy in penetrating abdominal trauma

METHODS

The PUBMED database was searched with the keywords "Laparoscopy AND Trauma". Additional citation searching and searching of the grey literature was conducted. Relevant studies were chosen on the basis of the defined inclusion and exclusion criteria and quality was assessed where appropriate using the Downs and Black checklist

RESULTS

In total, 51 studies were included in the analysis of which only 13 were prospective. In most studies, laparoscopy was used as a screening, diagnostic or therapeutic tool. In total, 2569 patients underwent diagnostic laparoscopy (DL) for penetrating abdominal trauma (PAT), 1129 (43.95 %) were positive for injury. 13.8 % of those with injury had a therapeutic laparoscopy. In total 33.8 % were converted to laparotomy, 16 % of which were non-therapeutic and 11.5 % of them were negative. 1497 patients were spared a non-therapeutic laparotomy. Overall, 72 patients suffered complications, there were 3 mortalities and 83 missed injuries. Sensitivity ranged from 66.7-100 %, specificity from 33.3-100 % and accuracy from 50-100 %. 23 of the 50 studies reported sensitivity, specificity and accuracy of 100 %, including the four most recent studies. In general the quality of the reported studies was poor. When used for cohort studies, the mean Downs and Black checklist score was 13.25 out of a possible total of 28.

CONCLUSIONS

In summary, laparoscopy in PAT may have an important role in a selected subgroup of patients, with surgeon expertise also an important factor. Laparoscopy has screening, diagnostic and therapeutic roles, particularly where diaphragm injury is suspected. It is extremely sensitive in determining need for laparotomy but detects hollow visceral injuries less reliably. It has potential as a therapeutic tool in centres with appropriate expertise. The development of specific guidelines or protocols may increase the value of laparoscopy in trauma but this would require more evidence of a higher quality.

Patterns of anterior abdominal stab wounds and their management at Princess Basma teaching hospital, North of Jordan

BACKGROUND

With the progressive use of new diagnostic techniques, the management of penetrating abdominal stab wounds is changing. Most studies have been conducted in well-equipped trauma centers in developed countries, and there is a paucity of reports from general teaching hospitals with limited resources. We reviewed the assessment of anterior abdominal stab wounds in patients presenting to our hospital hoping to establish an evidence-based algorithm for managing such patients in busy general hospitals.

METHODS

The medical records of all 393 patients treated at our hospital for anterior abdominal stab wounds over a 7-year period were reviewed. Information regarding age, gender, site of the stab wound, management, and complications were analyzed.

RESULTS

Twenty-six patients with hemodynamic instability at presentation underwent urgent laparotomy (LAP); 24 (92.3 %) of those procedures were therapeutic. Local wound exploration (LWE) proved that 114 (31 %) of all hemodynamically stable patients had no abdominal fascia penetration and consequently could be discharged home from the emergency department (ED). A total of 253 patients were found to have fascial penetration, and all were admitted for repeat clinical assessments (RCA) and imaging studies. A total of 121 (48 %) of the patients underwent abdominal exploration with 102 (84 %) therapeutic LAP procedures.

CONCLUSIONS

Hemodynamic instability and evisceration should continue to prompt urgent LAP. For stable patients, a sequence of LWE followed by focused abdominal sonography for trauma and computed tomography scanning for unclear cases primed by RCA was found to be efficient in limiting hospital admissions and reducing the rate of non-therapeutic LAP.

Is laparoscopy equal to laparotomy in detecting and treating small bowel injuries in a porcine model?

AIM: To evaluate the safety and effectiveness of laparoscopy compared with laparotomy for diagnosing and treating small bowel injuries (SBIs) in a porcine model.

METHODS: Twenty-eight female pigs were anesthetized and laid in the left recumbent position. The SBI model was established by shooting at the right lower quadrant of the abdomen. The pigs were then randomized into either the laparotomy group or the laparoscopy group. All pigs underwent routine exploratory laparotomy or laparoscopy to evaluate the abdominal injuries, particularly the types, sites, and numbers of SBIs. Traditional open surgery or therapeutic laparoscopy was then performed. All pigs were kept alive within the observational period (postoperative 72 h). The postoperative recovery of each pig was carefully observed.

RESULTS: The vital signs of all pigs were stable within 1-2 h after shooting and none of the pigs died from gunshot wounds or SBIs immediately. The SBI model was successfully established in all pigs and definitively diagnosed with single or multiple SBIs either by exploratory laparotomy or laparoscopy. Compared with exploratory laparotomy, laparoscopy took a significantly longer time for diagnosis (41.27 ± 12.04 min vs 27.64 ± 13.32 min, P = 0.02), but the time for therapeutic laparoscopy was similar to that of open surgery. The length of incision was significantly reduced in the laparoscopy group compared with the laparotomy group (5.27 ± 1.86 cm vs 15.73 ± 1.06 cm, P < 0.01). In the final post-mortem examination 72 h after surgery, both laparotomy and laparoscopy offered a definitive diagnosis with no missed injuries. Postoperative complications occurred in four cases (three following laparotomy and one following laparoscopy, P = 0.326). The average recovery period for bowel function, vital appearance, and food re-intake after laparoscopy was 10.36 ± 4.72 h, 14.91 ± 3.14 h, and 15.00 ± 7.11 h, respectively. All of these were significantly shorter than after laparotomy (21.27 ± 10.17 h, P = 0.004; 27.82 ± 9.61 h, P < 0.001; and 24.55 ± 9.72 h, respectively, P = 0.016).

CONCLUSION: Compared with laparotomy, laparoscopy offers equivalent efficacy for diagnosing and treating SBIs, and reduces postoperative complications as well as recovery period.

Evolution-based algorithm for the management of penetrating abdominal stab injury

PURPOSE

As an increasing amount of penetrating abdominal stab injuries has been observed in the last few decades, it is important to evaluate the adequacy of the medical systems and surgical education and training to handle this type of injury. The aim of this study was to analyze the outcome of patients with penetrating abdominal stab injuries admitted to the Emergency Unit and to evaluate the effects of using a new treatment algorithm.

METHODS

From January 2009 to April 2009, a standardized education and training system for the surgical team was implemented in order to improve the emergency medical care system. From April 2009 to April 2011, 106 patients with the diagnosis of a penetrating abdominal stab injury were prospectively included in the study.

RESULTS

The cohort included 98 males and the mean age was 29.40 ± 10.9 years. Eighty-two percent of the patients were managed conservatively, whereas 18 % underwent surgery. Based on the surgical outcomes of the patients, the rate of negative, non-therapeutic, and therapeutic laparotomies was 5, 11, and 84 %, respectively. No statistically significant difference between patients who did and did not receive surgery was observed with regards to blood pressure, temperature, hematocrit, hemoglobin, and C-reactive protein (CRP) values. However, a statistically significant difference was observed in the pulse rate, leukocyte, and neutrophil counts. The mortality and morbidity rates were 0.94 and 3.77 %, respectively.

CONCLUSIONS

Selective non-operative management, which has been standardized in trauma centers, may be carefully utilized in order to treat penetrating abdominal stab wounds with caution in well-equipped medical centers with well-trained staff.

Selective nonoperative management of anterior abdominal stab wounds: 1992-2008

BACKGROUND

The use of selective nonoperative management for anterior abdominal stab wounds has evolved into a readily accepted practice. Multiple reports have shown this strategy to be both safe and effective. However, there is a paucity of long-term studies.

METHODS

A retrospective review was performed of all trauma patients presenting for anterior abdominal stab wounds at a Level I trauma center during a 17-year time period. Primary outcomes were the percentage of patients undergoing an exploratory laparotomy and the negative laparotomy rate.

RESULTS

A total of 7,033 patients sustained a stab wound with 1,961 involving the anterior abdomen. The percentage of patients undergoing exploratory laparotomy decreased during the study period from 64.8% to 37.6% (overall 45.8%). The negative laparotomy rate decreased from 21.3% to 8.6% (overall 18.7%). The negative laparotomy rate of patients who underwent exploratory laparotomy immediately did not change over time (13.8%), whereas the negative laparotomy rate of those patients who underwent exploratory laparotomy in a delayed fashion decreased from 25.0% to 6.25%. The overall mortality was 1.9%, with 6.2% mortality for patients undergoing an immediate laparotomy, 0.7% for patients undergoing a delayed laparotomy, and 0.0% for patients managed nonoperatively (p<0.04). The mean length of hospital stay was 6.6 days±0.5 days, with a mean of 9.4 days±0.9 days in patients undergoing an immediate laparotomy, 8.1 days±0.5 days in patients undergo a delayed laparotomy, and 3.8 days±0.2 days in patients managed nonoperatively (p<0.001).

CONCLUSIONS

Selective nonoperative management for stab wounds to the anterior abdomen is associated with a decreased operative rate and decreased negative laparotomy rate over time. Selective nonoperative management is both safe and effective for anterior abdominal stab wounds.

Abdominal Trauma in Combat

Evaluating and managing patients with abdominal trauma remains one of the most challenging, resource-intensive and satisfying aspects of combat care. It demands a thorough understanding of the pathophysiology of trauma and shock, excellent clinical acumen and the ability to think and operate rationally in a chaotic milieu.

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 (<12h) there is little additional morbidity. Recognition of the need for surgical intervention after 12h 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 12h 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 12h. These patients are at risk of delay associated morbidity. There are particular anatomical sites and structures which are prone to error.

Has the Pendulum Swung Too Far? The Impact of Missed Abdominal Injuries in the Era of Nonoperative Management

Nonoperative management for traumatic injuries has significantly influenced trauma care during the last decade. We undertook this study to assess the impact of nontherapeutic laparotomies for suspected abdominal injuries compared with delayed laparotomies for questionable abdominal injuries for patients with abdominal trauma. The records of patients admitted to the trauma service between 2002 and 2007 who underwent laparotomies deemed nontherapeutic or delayed were retrospectively reviewed. Demographics, severity of injury, management scheme, and outcome data were analyzed. Sixteen patients underwent delayed laparotomies, whereas 26 patients incurred nontherapeutic laparotomies. Injury severity scores, Glasgow coma scale scores, abdominal abbreviated injury scale score (AIS), and age were similar for both populations. Delayed laparotomies occurred an average of 7 ± 9 days postinjury. Intensive care unit length of stay (26 ± 24 vs 10 ± 6 days), hospital length of stay (40 ± 37 vs 11 ± 10 days), ventilator days (31 ± 29 vs 11 ± 10), and number of abdominal operative procedures (1.9 ± 1.5 vs 1 ± 0) were significantly higher in the delayed laparotomies group versus the nontherapeutic laparotomies group, respectively. Delayed diagnosis of intra-abdominal injuries yielded a significantly increased morbidity and mortality. During the evolving era of technological imaging for traumatic injuries, we must not allow the nonoperative pendulum to swing too far.

The utility of diagnostic laparoscopy in the evaluation of anterior abdominal stab wounds

BACKGROUND

To assess if diagnostic laparoscopy (DL) is superior to nonoperative modes (serial abdominal examination with/without computed axial tomography [CAT] and diagnostic peritoneal lavage) in determining the need for therapeutic laparotomy (TL) after anterior abdominal stab wound (ASW).

METHODS

Retrospective review of ASW patients. Patients were divided into group A (DL/exploratory laparotomy) to identify peritoneal violation (PV) and group B (initial nonoperative modes).

RESULTS

Seventy-three patients met inclusion criteria. In group A (n = 38), 29 patients (76%) had PV by DL and underwent exploratory laparotomy. Only 10 (35%) underwent TL (sensitivity for PV = 100%; specificity and positive predictive value of PV in determining need for TL = 29% and 33%, respectively). In group B (n = 35), 7 patients (20%) underwent TL, yielding an improved specificity (96%) and positive predictive value (88%).

CONCLUSIONS

We find no role for DL in the evaluation of ASW patients solely to determine PV.

Evaluation of selective treatment of penetrating abdominal trauma

OBJECTIVE

In penetrating abdominal trauma, diagnostic imaging and the application of selective clinical management may avoid negative celiotomy and improve outcome.

DESIGN

We prospectively observed patients with penetrating abdominal trauma over 15 months and recorded demographics, presentation, imaging, surgical procedure, and outcome. Patients who underwent immediate laparotomy were compared with patients who were observed and/or had a computed tomography (CT) scan. Outcomes of negative versus positive and immediate versus delayed celiotomy were compared. Chi-square and Student t tests were used. A p value of less than 0.05 was considered significant.

SETTING

A level 1 trauma center.

PARTICIPANTS

Adult patients who presented with penetrating abdominal injury.

RESULTS

In all, 100 consecutive patients (mean age, 32 years) were included (male:female, 91:9; gunshot wound:stab wound, 65:35). Overall, 60 immediate and 10 delayed laparotomies were performed; 30 patients did not undergo surgery. Predictors of immediate celiotomy were hypotension (p = 0.03), anteriorly located entrance wounds (p = 0.0005), and transaxial wounds (p = 0.03). Overall morbidity and mortality was 32% and 2%, respectively. The negative celiotomy rate was 25%. Patients with a positive celiotomy had higher morbidity (p = 0.006) and longer hospital length of stay (p = 0.003) compared with negative celiotomy. A CT scan was employed in 32% of patients, with 100% sensitivity and 94% specificity. Delayed celiotomy (10%) did not adversely impact morbidity (p = 0.70) and was 100% therapeutic, with no deaths.

CONCLUSION

Nonselective immediate celiotomy for penetrating abdominal trauma results in a high rate of unnecessary surgery. Hemodynamically stable patients can safely be observed and/or have contrast CT scans and undergo delayed celiotomy, if indicated. This selective treatment had no adverse effect on patient outcomes and can potentially improve overall outcome.

Role of laparoscopy in the management of visceral injuries following abdominal stab wounds

BACKGROUND

Laparoscopy offers several advantages in the treatment of abdominal stab wounds. In this paper, we report our experience during 2004, where hemodynamically stable patients with stab wounds were managed laparoscopically.

PATIENTS AND METHODS

Between January and December 2004, 8 hemodynamically stable patients (7 men, 1 woman) underwent laparoscopy for anterior abdominal stab wounds. Median age was 28.5 years (range, 17-55). All patients underwent an abdominal computed tomography (CT) prior to the laparoscopy.

RESULTS

Exploration of the wound under aseptic conditions, carried out as a part of the physical examination, confirmed peritoneal penetration in 7 of the 8 cases. Abdominal CT revealed positive findings in 7 (87.5%) cases. Laparoscopy was performed after a median time of 60 minutes (range 30-90). Laparoscopic exploration evidenced peritoneal penetration in 100% of the cases and visceral lesions in 87.5% of the cases. All visceral injuries were managed laparoscopically. Median operative time was 135 minutes (range, 45-200). Operative mortality was 0% and early morbidity was 12.5%. Median hospital stay was 5 days (range, 1-11). After a median follow-up of 12 months (range, 1-28), 1 patient complained of persistent chest pain and a ventral hernia at the site of the abdominal stab wound was diagnosed in another patient.

CONCLUSIONS

Laparoscopy should be included in management algorithms in patients with anterior abdominal stab wounds who are hemodynamically stable. In addition to its diagnostic ability, this study demonstrates that laparoscopy can be an effective management modality with minimal morbidity and no mortality.

The impact of published recommendations on the management of penetrating abdominal injury

Background

In patients with penetrating abdominal injury (PAI), haemodynamic instability and peritonitis are indications for laparotomy, but it remains uncertain whether laparotomy is indicated for evisceration, retained foreign body and pneumoperitoneum. In 1989, a review of 107 patients with PAI revealed a 78·5 per cent laparotomy rate, with 35 per cent considered unnecessary. The aim of this study was to review current practice in the same hospitals.

Methods

A retrospective review included case notes from 224 patients with PAI presenting to three hospitals between 2001 and 2005.

Results

Some 206 patients (92·0 per cent) were male and the mean age was 30·5 years. Aetiologies were stabbing (96·4 per cent), impalement (2·7 per cent) and gunshot wound (0·9 per cent). Laparotomy was performed in 48 patients (21·4 per cent), and was positive in 33 and unnecessary or negative in 15. Haemodynamic instability and peritonitis were strong indicators of positive laparotomy; seven of 13 laparotomies for evisceration alone were negative, as were two of four for retained foreign bodies.

Conclusion

The laparotomy rate fell from 78·5 to 21·4 per cent over 25 years. The rate of unnecessary or negative laparotomy did not change. Isolated evisceration and retained foreign body remain relative indications.

Advances in Abdominal Trauma

Emergency practitioners routinely encounter patients who suffer from abdominal trauma, be it blunt or penetrating. These injuries are often confounded by altered mental status, distracting injuries, or lack of historical information, and may present challenges in management. However, in the last several years new approaches to the diagnosis and management of abdominal trauma, including bedside ultrasound, newer generation computed tomography scans, laparoscopy, and the ability for selected nonoperative management expedite identification of life threatening injury and offer new options in treatment.