World Journal of Surgery

, Volume 37, Issue 5, pp 1162–1168

Patterns of Anterior Abdominal Stab Wounds and Their Management at Princess Basma Teaching Hospital, North of Jordan

Authors

    • Department of General SurgeryFaculty of Medicine Jordan University of Science and Technology (JUST)
  • Mohammad Bani-Yaseen
    • Princess Basma Teaching Hospital
  • Mohammad Khammash
    • Department of General SurgeryFaculty of Medicine Jordan University of Science and Technology (JUST)
  • Ghazi Qasaimeh
    • Department of General SurgeryFaculty of Medicine Jordan University of Science and Technology (JUST)
  • Fahmi Eqab
    • Department of General SurgeryFaculty of Medicine Jordan University of Science and Technology (JUST)
  • Hashem Jaddou
    • Department of Community MedicineJordan University of Science and Technology (JUST)
Article

DOI: 10.1007/s00268-013-1931-y

Cite this article as:
Omari, A., Bani-Yaseen, M., Khammash, M. et al. World J Surg (2013) 37: 1162. doi:10.1007/s00268-013-1931-y

Abstract

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.

Introduction

Penetrating abdominal injuries due to stab wounds are a frequent reason for admission to emergency departments of general hospitals. There is general agreement that patients with hemodynamic instability or organ evisceration should undergo immediate laparotomy without further investigation.

However, since the concept of conservatism was introduced by Shaftan [16], the trend of managing stable patients has shifted from mandatory exploration to a selective approach. On the one hand, it is well known that mandatory exploration of stable patients results in a high rate of nontherapeutic laparotomies with the inevitable laparotomy-related morbidity and mortality. On the other hand, missed intra-abdominal injury is associated with a significant increase in both serious complications and cost [7].

To enhance the sensitivity and specificity of clinical judgment in evaluating patients for possible serious intra-abdominal injury, additional diagnostic procedures and strategies have been advocated [4]. It seems, however, that there is still no universally acceptable management strategy, and therefore further study is warranted. Many publications reflect management protocols at high level trauma centers, but there is a paucity of research addressing this issue in general teaching hospitals. This is the first study on the management of abdominal stab wounds conducted in this part of the world.

The aim of the present study was to review the investigative tools used in patients with abdominal stab wounds presenting to our general hospital, hoping to guide the establishment of an evidence-based management algorithm for decreasing non-therapeutic laparotomies in busy general hospitals.

Materials and methods

This study was conducted at Princess Basma teaching hospital in North of Jordan, a medium-sized general teaching hospital serving more than a million local inhabitants and seven smaller district hospitals in the periphery. It is affiliated with the medical school of Jordan University of Science and Technology, and is used for training of medical students and general surgery residents.

All patients admitted to the ED between 1 January 2003 and 31 December 2009 with penetrating anterior abdominal stab wounds were included in this study. The medical records were reviewed to collect data regarding demography, site of wound, weapon used, investigations, management, complications, and follow-up.

The anterior abdomen was defined as the area between the two posterior axillary lines laterally, a line connecting both nipples superiorly, and the pelvic brim inferiorly. To specify the site of the wound over the anterior abdomen, we utilized the nine known surface anatomical regions, as shown in Fig. 1.
https://static-content.springer.com/image/art%3A10.1007%2Fs00268-013-1931-y/MediaObjects/268_2013_1931_Fig1_HTML.gif
Fig. 1

Distribution of stab wounds over the anterior abdomen

The strategy adopted in the hospital is described as follows:

After primary clinical evaluation, all hemodynamically unstable patients were assigned for urgent laparotomy, whereas stable patients including those with evisceration were managed according to the algorithm shown in Fig. 2.
https://static-content.springer.com/image/art%3A10.1007%2Fs00268-013-1931-y/MediaObjects/268_2013_1931_Fig2_HTML.gif
Fig. 2

Algorithm used for management of anterior abdominal stab wounds

All hemodynamically stable patients underwent local wound exploration (LWE) in the emergency department (ED) under local anesthesia.

Where the deep abdominal fascia was found to have been violated, the wound was considered penetrating and the patient was admitted to the hospital.

In the case of a nonpenetrating stab wound as proved by LWE, patients were discharged home with clear instructions to return immediately if required; these patients were also scheduled for an outpatient visit at the next surgical clinic.

Patients who could not be fully evaluated for reasons of agitation, obesity, or indeterminate fascia wounds were admitted for further investigation and observation. The fascia defects were closed in all cases.

Eviscerated omentum or intestine in stable patients was washed with saline and reduced into the abdomen, the fascia was closed, and the patient was admitted to the surgical ward for observation. Before transfer to the ward, focused abdominal sonography for trauma (FAST) was done and if positive, a decision for (LAP) was made. A positive ultrasound examination was defined as more than 500 ml blood detected in the peritoneal cavity. A computed tomography (CT) scan was ordered only for obese, agitated, or FAST equivocal patients, or where a retroperitoneal injury was suspected. The CT study was considered positive when more than 350 ml of blood was present in the peritoneal cavity.

Patients selected for nonoperative management were admitted to the hospital and monitored with repeat clinical assessments (RCA) and laboratory investigations (mostly hemoglobin concentration measurements) every 4 h for 24 h.

In all FAST negative or mildly positive studies (presence of a small amount of blood in the peritoneal cavity), patients were further observed. Deterioration of vital signs, worsening of the peritoneal signs, a drop in hemoglobin concentration, and leukocytosis were all indications for surgical intervention. Patients who remained hemodynamically and clinically stable were discharged from the hospital after a normal meal and bowel motion.

According to the type of management, each patient was placed in one of three categories for statistical analysis:
  1. 1.

    Immediate laparotomy: This group consisted of patients thought to have significant injury by clinical criteria on initial evaluation.

     
  2. 2.

    Delayed laparotomy: These patients were not thought to have indications for exploratory laparotomy on initial evaluation but later developed criteria for exploration during observation.

     
  3. 3.

    No laparotomy: This group included patients thought to have no indication for surgery on initial examination and who were eventually discharged from hospital without exploration.

     
According to the intraoperative findings, laparotomies were divided into the following three groups:
  1. 1.

    Therapeutic

     
  2. 2.

    Non-therapeutic

     
  3. 3.

    Negative

     

A laparotomy was considered therapeutic when the patient was found to have an intraperitoneal injury that required definitive treatment. A laparotomy was defined as non-therapeutic if an insignificant lesion was found that, in retrospect, did not require surgery, such as a minor liver, mesenteric, or omental injury that was no longer bleeding. When no injured intra-abdominal structure was found, the laparotomy was described as negative.

After discharge from the hospital, all patients were followed up in the clinic weekly for a month or longer if required.

Ethics approval for the present study was granted by the institutional review board (IRB) of North of Jordan.

Statistical analysis

Data were analyzed with the Statistical Package for Social Sciences software, SPSS (SPSS Inc., Chicago, IL) version 16.

Results

A total of 393 patients were received in the ED with anterior abdominal stab wounds during the study period. Of these, 26 patients were hemodynamically unstable and required emergency surgery. In another 114 patients, wounds were found to be non-penetrating following LWE and were treated in the ED, after which the patients were discharged home with an appointment to attend the next surgical clinic. The remaining 253 hemodynamically stable patients with penetrating wounds were included in our analysis.

The majority (93 %) of these patients were males. The mean age was 24.4 years (± .4 years) with a range of 9–67 years. Kitchen knives were used in 91 % the cases. The most common site (32 %) of injury was the left upper quadrant (Fig. 1).

Focused abdominal sonography for trauma was performed on all the 253 patients, and it showed signs of intra-abdominal injury in 70 (27.6 %) patients. There were no signs of injury in 150 (59.2 %) patients, and the findings in the remaining 33 (13 %) patients were inconclusive for reasons of obesity, irritability, agitation, or non-compliance. A laparotomy was performed for all 70 FAST-positive patients with 63 (90 %) therapeutic explorations. The 150 patients with negative ultrasonic findings were managed conservatively. Repeat clinical assessment of these patients identified 28 (18.6 %) with deteriorating signs of peritonitis, while the remaining 122 patients could be discharged 24–48 h after admission and were followed up in the surgical clinic with no missed serious injuries. Laparotomy performed on the patients with deteriorating peritoneal signs was therapeutic in 20 (71.4 %) of the 28 cases. As shown in Table 1, the sensitivity of FAST as a diagnostic test for therapeutic exploration was 75.9 %, specificity was 94.9 %, positive predictive value was 90 %, and negative predictive value was 86.7 %.
Table 1

Sensitivity, specificity, positive and negative predictive values of the tests used in selecting patients for therapeutic laparotomy

Test

No. of patients

Sensitivity (%)

Specificity (%)

Positive predictive value (%)

Negative predictive value (%)

PTP (%)

FAST

220

75.9

94.9

90

86.7

29

CT

33

94.7

85.7

90

92.3

55

RCA

163

100

93

68

100

13

PTP pre-test probability (the number [percentage] of patients who had therapeutic laparotomy after any of the three tests), FAST focused abdominal sonography for trauma, CT computed tomography, RCA repeat clinical assessment

Computed tomography scan was performed on the 33 patients with no conclusive ultrasonic findings. These CT studies identified 20 (60.6 %) patients with positive signs of organ injury, and all underwent laparotomy. Of these 20 patients, laparotomy was therapeutic for 18 (90 %). The remaining 13 CT negative patients were managed conservatively; ten of them were discharged 24 h later and were followed up in the surgical clinic. Laparotomy performed on the other 3 patients was therapeutic in one patient. As shown in Table 1, the sensitivity of CT as a diagnostic test for therapeutic explorations was 94.7 %; specificity, 85.7 %; positive predictive value, 90 %; and negative predictive value, 92.3 %.

Repeat clinical assessment (RCA) was carried out for the 163 FAST and CT scan negative patients. The majority (81 %) of them remained clinically stable and were discharged with no serious complications or missed internal organ injuries.

Of the 31 patients who showed deterioration in peritoneal signs, a total of 21 (68 %) patients underwent therapeutic LAP; most of them had intestinal perforations and diaphragmatic wounds.

Sensitivity and specificity of RCA was 100 and 93 %, respectively (Table 1).

In general, analysis of the data showed that 102 (84 %) of all laparotomies were therapeutic, 13 (11 %) were nontherapeutic, and 6 (4 %) were negative.

Further analysis indicated that conservative management was successful in 132 of 253 hemodynamically stable patients (52 %) (Table 2). Findings at both immediate and delayed laparotomy confirmed that the small intestine was most commonly injured by penetrating stab wounds, followed by the liver (Table 3). Small mesenteric hematomas or minor bleeds from the liver, the kidney, the spleen or the abdominal wound were found at the non-therapeutic LAP, most of which had stopped by the time of surgery.
Table 2

Classification based on the type and the result of laparotomy

Type of management

No. of patients (%)

Therapeutic LAP

Hospital days

Immediate laparotomy

26 (9)

24 (92)

7.75 (5–15)

Delayed laparotomya

121 (43)

102 (84)

3.7 (2–7)

Non-laparotomy

132 (47)

1.6 (1–2)

Total patients

279 (100)

126

3.08 (1–15)

aDelayed laparotomy was performed within 24 h of admission

Table 3

Organs injured by stab wounds in 126 therapeutic laparotomies

Organ injured

No.

%

Small bowel

30

18

Liver

27

16

Stomach

17

10

Mesentery (bleeding)

15

9

Retroperitoneum (bleeding)

13

8

Spleen

13

8

Colon

12

7

Diaphragm

11

7

Abdominal wall (significant bleeding)

9

5

Kidney

7

4

Major abdominal vessels

5

3

Pancreas

4

2

Gallbladder

2

1

Ureter

1

1

Total

166

 

On reviewing records for complications, we found that 12 patients of the non-laparotomy group developed wound site infection and were treated as outpatients, but none of them required readmission for any missed intra-abdominal injury.

Records of patients in the delayed laparotomy group showed that 2 patients developed intra-abdominal sepsis, one with wound dehiscence; another 7 patients had surgical site infections and were treated successfully. Hospital records also showed that 3 patients developed intestinal obstruction within the first year postoperatively and underwent surgical adhesiolysis.

Discussion

Since the introduction of conservative management of stab wounds to the abdomen in the early 1960s, there have been numerous attempts to improve diagnostic accuracy and enable timely decisions that should prevent avoidable mortality and morbidity without excessive use of costly and risky diagnostic procedures [1, 2].

Many diagnostic strategies, such as local wound exploration, diagnostic peritoneal lavage and abdominal ultrasonography, contrast-enhanced computed tomography, and laparoscopy [4] have been used to safely reduce the incidence of nontherapeutic LAP.

In busy general hospitals where other medical emergencies are dealt with, the strategy should be safe, reproducible, applicable, and less costly. In the present study, only 37 % of all patients with abdominal stab wounds reporting to the ED underwent LAP, which means that most of the patients could be safely managed conservatively.

Our data show that 24 (92.3 %) of the patients presenting with hemodynamic instability had therapeutic LAP, a finding supported by several other studies [3, 4, 8, 9]. Also in the present study, 14 (88 %) of the 16 hemodynamically stable eviscerated patients ultimately underwent operation, and 11 (79 %) of those LAPs were therapeutic. This finding is also in line with the uniform agreement that evisceration is an indication for immediate LAP regardless of what has eviscerated, as the rate of organ injuries in such patients has been reported to be 70–80 % [5, 915].

However, there is some debate regarding omental evisceration, and recent reports have shown that nontherapeutic LAPs are encountered more after omental evisceration than after organ evisceration [1517].

Indeed, the present study cannot settle this argument as the number of eviscerated patients is small: only two patients with omental protrusion could be discharged without LAP.

Local wound exploration is one of the screening tools used to test the integrity of the abdominal fascia. Given the high sensitivity, specificity and cost effectiveness of the test [18], it is clear that it should be especially useful in district hospitals of developing countries where conservation of resources is of prime concern.

In the present study, 114 (42.7 %) of all hemodynamically stable patients were discharged from the ED without a single missed intra-abdominal organ injury. A few wound infections were managed successfully on an outpatient basis. This finding is supported by the 40–59 % discharge rate reported in other studies [9, 18]. However, it is worth noting that the LWE test should be executed by an experienced clinician and the tract should be followed to the posterior abdominal fascia. Moreover, our data showed that the majority of patients (63 %) who had a positive LWE were managed conservatively, stressing the significance of LWE as a step in a strategy rather than a solo indication for or against operative abdominal exploration.

Although the management of blunt abdominal trauma has definitely improved with the introduction of ultrasonography, its use in patients with penetrating abdominal trauma is still debatable [9, 19].

In the present study, the sensitivity, specificity, positive and negative predictive values for FAST were 76, 95, 90, and 87 %, respectively (Table 1). Thus it appears that a positive FAST is a good guide for selecting patients for LAP in penetrating abdominal stab wounds, and a negative study is also a valuable indicator for conservative management of such patients.

The high sensitivity and specificity of FAST in the present study is in line with many other studies, and it is therefore considered a valuable method for detecting intra-abdominal injury [1921].

Although we used a single-contrast CT scan for evaluating patients whose assessment with FAST was difficult, our study showed that CT had a sensitivity of 95 % and a specificity of 87 %.

For the 20 patients with positive diagnostic studies, LAP was therapeutic in 18 (90 %), and of the 13 patients with negative studies, 10 were discharged home without missed injuries or major complications. Only 3 patients of those considered negative by the test were operated due to deterioration of peritoneal signs and just one of them had a positive LAP. These results are in line with many other studies that show the sensitivity of CT in such cases to be 98–100 %, with a specificity of 81–96 % [2226].

Our data show that RCA has a specificity of 93 %, suggesting its great potential to facilitate safe hospital discharge. Moreover, RCA had a 100 % sensitivity, indicating its value in detecting patients who were in need of therapeutic exploration in spite of a negative FAST study or CT scan (Table 1).

It is worth noting that the majority of patients undergoing therapeutic LAP in this series were found to have bowel perforations, so we think, like others, that the results can be improved by the use of other tests, such as a triple contrast tomography [2731].

Conclusions

This study confirms that patients who present to the ED with hemodynamic instability or evisceration should undergo urgent LAP. For stable patients, a strategy of LWE, FAST, or CT scan (in difficult cases) with RCA is safe and applicable at general hospitals and can significantly reduce the rate of nontherapeutic LAP.

Copyright information

© Société Internationale de Chirurgie 2013