Skip to main content
Log in

Management Guidelines for Penetrating Abdominal Trauma

  • Surgical Symposium Contribution
  • Published:
World Journal of Surgery Aims and scope Submit manuscript

Abstract

Introduction

The optimal management of patients with penetrating abdominal injuries has been debated for decades, since mandatory laparotomy (LAP) gave way to the concept of “selective conservatism.”

Materials and Methods

A comprehensive literature review was performed and summarized.

Results

A proposed management guideline for patients with penetrating abdominal trauma was created.

Conclusion

Indications for immediate laparotomy (LAP) include hemodynamic instability, evisceration, peritonitis, or impalement. Selective nonoperative management of stable, asymptomatic patients has been demonstrated to be safe. Adjunctive diagnostic testing—ultrasonography, computed tomography, local wound exploration, diagnostic peritoneal lavage, laparoscopy—is often used in an attempt to identify significant injuries requiring operative management. However, prospective studies indicate that these tests frequently lead to nontherapeutic LAP, and are not cost-effective.

This is a preview of subscription content, log in via an institution to check access.

Access this article

Subscribe and save

Springer+ Basic
EUR 32.99 /Month
  • Get 10 units per month
  • Download Article/Chapter or Ebook
  • 1 Unit = 1 Article or 1 Chapter
  • Cancel anytime
Subscribe now

Buy Now

Price excludes VAT (USA)
Tax calculation will be finalised during checkout.

Instant access to the full article PDF.

Fig. 1
Fig. 2

Similar content being viewed by others

References

  1. Shaftan GW (1960) Indications for operation in abdominal trauma. Am J Surg 99:657–664

    Article  CAS  PubMed  Google Scholar 

  2. Leppaniemi A, Salo J, Haapiainen R (1995) Complications of negative laparotomy for truncal stab wounds. J Trauma 38:54–60

    Article  CAS  PubMed  Google Scholar 

  3. Renz BM, Feliciano DV (1996) The length of hospital stay after an unnecessary laparotomy for trauma: a prospective study. J Trauma 40:187–190

    Article  CAS  PubMed  Google Scholar 

  4. Biffl WL, Kaups KL, Cothren CC et al (2009) Management of patients with anterior abdominal stab wounds: a Western Trauma Association multicenter trial. J Trauma 66:1294–1301

    Article  PubMed  Google Scholar 

  5. Biffl WL, Kaups KL, Pham TN et al (2011) Validating the Western Trauma Association algorithm for managing patients with anterior abdominal stab wounds: a Western Trauma Association multicenter trial. J Trauma 71:1494–1502

    Article  PubMed  Google Scholar 

  6. Berg RJ, Karamanos E, Inaba K et al (2014) The persistent diagnostic challenge of thoracoabdominal stab wounds. J Trauma Acute Care Surg 76:418–423

    Article  PubMed  Google Scholar 

  7. Burlew CC, Moore EE, Moore FA et al (2012) Western Trauma Association critical decisions in trauma: resuscitative thoracotomy. J Trauma Acute Care Surg 73:1359–1363

    Article  PubMed  Google Scholar 

  8. Nicol AJ, Navsaria PH, Hommes M et al (2014) Sternotomy or drainage for a hemopericardium after penetrating trauma: a randomized controlled trial. Ann Surg 259:438–442

    Article  PubMed  Google Scholar 

  9. Shanmuganathan K, Mirvis SE, Chiu WC et al (2004) Penetrating torso trauma: triple-contrast helical CT in peritoneal violation and organ injury- A prospective study in 200 patients. Radiology 231:775–784

    Article  CAS  PubMed  Google Scholar 

  10. Moore EE, Marx JA (1985) Penetrating abdominal wounds: rationale for exploratory laparotomy. JAMA 253:2705–2708

    Article  CAS  PubMed  Google Scholar 

  11. Uribe RA, Pachon CE, Frame SB et al (1994) A prospective evaluation of thoracoscopy for the diagnosis of penetrating thoracoabdominal trauma. J Trauma 37:650–654

    Article  CAS  PubMed  Google Scholar 

  12. Murray JA, Demetriades D, Asensio JA et al (1998) Occult injuries to the diaphragm: prospective evaluation of laparoscopy in penetrating injuries to the left lower chest. J Am Coll Surg 187:626–630

    Article  CAS  PubMed  Google Scholar 

  13. Friese RS, Coln CE, Gentilello LM (2005) Laparoscopy is sufficient to exclude occult diaphragm injury after penetrating abdominal trauma. J Trauma 58:789–792

    Article  PubMed  Google Scholar 

  14. Himmelman RG, Martin M, Gilkey S et al (1991) Triple-contrast CT scans in penetrating back and flank trauma. J Trauma 31:852–856

    Article  CAS  PubMed  Google Scholar 

  15. Boyle EM Jr, Maier RV, Salazar JD et al (1997) Diagnosis of injuries after stab wounds to the back and flank. J Trauma 42:260–265

    Article  PubMed  Google Scholar 

  16. Ramirez RM, Cureton EL, Ereso AQ et al (2009) Single-contrast computed tomography for the triage of patients with penetrating torso trauma. J Trauma 67:583–588

    Article  PubMed  Google Scholar 

  17. Thompson JS, Moore EE, Van Duzer-Moore S et al (1980) The evolution of abdominal stab wound management. J Trauma 20:478–484

    Article  CAS  PubMed  Google Scholar 

  18. Nance FC, Wennar MH, Johnson LW et al (1974) Surgical judgment in the management of penetrating wounds of the abdomen: experience with 2,212 patients. Ann Surg 179:639–646

    Article  PubMed Central  CAS  PubMed  Google Scholar 

  19. Cornell WP, Ebert PA, Greenfield LJ et al (1965) A new nonoperative technique for the diagnosis of penetrating injuries to the abdomen. J Trauma 7:307–314

    Article  Google Scholar 

  20. Thal ER (1977) Evaluation of peritoneal lavage and local exploration in lower chest and abdominal stab wounds. J Trauma 17:642–648

    Article  CAS  PubMed  Google Scholar 

  21. Aragon GE, Eiseman B (1976) Abdominal stab wounds: evaluation of sinography. J Trauma 16:792–797

    Article  CAS  PubMed  Google Scholar 

  22. Oreskovich MR, Carrico CJ (1983) Stab wounds of the anterior abdomen: analysis of a management plan using local wound exploration and quantitative peritoneal lavage. Ann Surg 198:411–419

    Article  PubMed Central  CAS  PubMed  Google Scholar 

  23. Ivatury RR, Simon RJ, Weksler B et al (1992) Laparoscopy in the evaluation of the intrathoracic abdomen after penetrating injury. J Trauma 33:101–106

    Article  CAS  PubMed  Google Scholar 

  24. Livingston DH, Tortella BJ, Blackwood J et al (1992) The role of laparoscopy in abdominal trauma. J Trauma 33:471–478

    Article  CAS  PubMed  Google Scholar 

  25. Rehm CG, Sherman R, Hinz TW (1989) The role of CT scan in evaluation for laparotomy in patients with stab wounds of the abdomen. J Trauma 29:446–450

    Article  CAS  PubMed  Google Scholar 

  26. Rozycki GS, Ochsner MG, Schmidt JA et al (1995) A prospective study of surgeon-performed ultrasound as the primary adjuvant modality for injured patient assessment. J Trauma 39:492–500

    Article  CAS  PubMed  Google Scholar 

  27. Demetriades D, Rabinowitz B (1987) Indications for operation in abdominal stab wounds: a prospective study of 651 patients. Ann Surg 205:129–132

    Article  PubMed Central  CAS  PubMed  Google Scholar 

  28. Henneman PL, Marx JA, Moore EE et al (1990) Diagnostic peritoneal lavage: accuracy in predicting necessary laparotomy following blunt and penetrating trauma. J Trauma 30:1345–1355

    Article  CAS  PubMed  Google Scholar 

  29. Leppaniemi AK, Haapiainen RK (1996) Selective nonoperative management of abdominal stab wounds: prospective, randomized study. World J Surg 20:1101–1106

    Article  CAS  PubMed  Google Scholar 

  30. Tsikitis V, Biffl WL, Majercik S et al (2004) Selective clinical management of anterior abdominal stab wounds. Am J Surg 188:807–812

    Article  PubMed  Google Scholar 

  31. Leppaniemi AK, Voutilainen PE, Haapiainen RK (1999) Indications for early mandatory laparotomy in abdominal stab wounds. Br J Surg 86:76–80

    Article  CAS  PubMed  Google Scholar 

  32. Nagy K, Roberts R, Joseph K et al (1999) Evisceration after abdominal stab wounds: is laparotomy required? J Trauma 47:622–624

    Article  CAS  PubMed  Google Scholar 

  33. Rosenthal RE, Smith J, Walls RN et al (1987) Stab wounds to the abdomen: failure of blunt probing to predict peritoneal penetration. Ann Emerg Med 16:172–175

    Article  CAS  PubMed  Google Scholar 

  34. Schnuriger B, Inaba K, Barmparas G et al (2010) Serial white blood cell counts in trauma: do they predict a hollow viscus injury? J Trauma 69:302–307

    Article  PubMed  Google Scholar 

  35. Inaba K, Okoye OT, Rosenheck R et al (2013) Prospective evaluation of the role of computed tomography in the assessment of abdominal stab wounds. JAMA Surg 148:810–816

    Article  PubMed  Google Scholar 

  36. Udobi KF, Rodriguez A, Chiu WC et al (2001) Role of ultrasonography in penetrating abdominal trauma: a prospective clinical study. J Trauma 50:475–479

    Article  CAS  PubMed  Google Scholar 

  37. Murphy JT, Hall J, Provost D (2005) Fascial ultrasound for evaluation of anterior abdominal stab wound injury. J Trauma 59:843–846

    Article  PubMed  Google Scholar 

  38. Feliciano DV, Bitondo-Dyer CG (1994) Vagaries of the lavage white blood cell count in evaluating abdominal stab wounds. Am J Surg 168:680–683

    Article  CAS  PubMed  Google Scholar 

  39. Fang JF, Chen RJ, Lin BC (1998) Cell count ratio: new criterion of diagnostic peritoneal lavage for detection of hollow organ perforation. J Trauma 45:540–544

    Article  CAS  PubMed  Google Scholar 

  40. Otomo Y, Henmi H, Mashiko K et al (1998) New diagnostic peritoneal lavage criteria for diagnosis of intestinal injury. J Trauma 44:991–997

    Article  CAS  PubMed  Google Scholar 

  41. McAnena OJ, Marx JA, Moore EE (1991) Contributions of peritoneal lavage enzyme determinations to the management of isolated hollow visceral abdominal injuries. Ann Emerg Med 20:834–837

    Article  CAS  PubMed  Google Scholar 

  42. Jaffin JH, Ochsner MG, Cole FJ et al (1993) Alkaline phosphatase levels in diagnostic peritoneal lavage fluid as a predictor of hollow visceral injury. J Trauma 34:829–833

    Article  CAS  PubMed  Google Scholar 

  43. Leppaniemi A, Haapiainen R (2003) Diagnostic laparoscopy in abdominal stab wounds: a prospective, randomized study. J Trauma 55:636–645

    Article  PubMed  Google Scholar 

  44. O’Malley E, Boyle E, O’Callaghan A et al (2013) Role of laparoscopy in penetrating abdominal trauma: a systematic review. World J Surg 37:113–122

    Article  PubMed  Google Scholar 

  45. Sumislawski JJ, Zarzaur BL, Paulus EM et al (2013) Diagnostic laparoscopy after anterior abdominal stab wounds: worth another look? J Trauma Acute Care Surg 75:1013–1018

    Article  PubMed  Google Scholar 

  46. Fakhry SM, Broenstein M, Watts DD et al (2000) Relatively short diagnostic delays (<8 hours) produce morbidity and mortality in blunt small bowel injury: an analysis of time to operative intervention in 198 patients from a multicenter experience. J Trauma 48:408–415

    Article  CAS  PubMed  Google Scholar 

  47. Martin RR, Burch JM, Richardson R et al (1991) Outcome for delayed operation of penetrating colon injuries. J Trauma 31:1591–1595

    Article  CAS  PubMed  Google Scholar 

  48. Clarke DL, Allorto NL, Thomson SR (2010) An audit of failed non-operative management of abdominal stab wounds. Injury 41:488–491

    Article  CAS  PubMed  Google Scholar 

  49. Nance FC, Cohn I Jr (1969) Surgical judgment in the management of stab wounds of the abdomen: a retrospective and prospective analysis based on a study of 600 stabbed patients. Ann Surg 170:569–580

    Article  PubMed Central  CAS  PubMed  Google Scholar 

  50. Moore EE, Moore JB, Van Duzer-Moore S et al (1980) Mandatory laparotomy for gunshot wounds penetrating the abdomen. Am J Surg 140:847–851

    Article  CAS  PubMed  Google Scholar 

  51. Renz BM, Feliciano DV (1994) Gunshot wounds to the right thoracoabdomen: a prospective study of nonoperative management. J Trauma 37:737–741

    Article  CAS  PubMed  Google Scholar 

  52. Demetriades D, Hadjizacharia P, Constantinou C et al (2006) Selective nonoperative management of penetrating abdominal solid organ injuries. Ann Surg 244:620–628

    PubMed Central  PubMed  Google Scholar 

  53. Navsaria PH, Nicol AJ (2009) Selective nonoperative management of kidney gunshot wounds. World J Surg 33:553–557

    Article  PubMed  Google Scholar 

  54. Navsaria PH, Nicol AJ, Krige JE et al (2009) Selective nonoperative management of liver gunshot injuries. Ann Surg 249:653–656

    Article  PubMed  Google Scholar 

  55. Jansen JO, Inaba K, Resnick S et al (2012) Selective non-operative management of abdominal gunshot wounds: survey of practice. Injury Int J Care Injured 44:639–644

    Article  Google Scholar 

Download references

Author information

Authors and Affiliations

Authors

Corresponding author

Correspondence to Walter L. Biffl.

Rights and permissions

Reprints and permissions

About this article

Check for updates. Verify currency and authenticity via CrossMark

Cite this article

Biffl, W.L., Leppaniemi, A. Management Guidelines for Penetrating Abdominal Trauma. World J Surg 39, 1373–1380 (2015). https://doi.org/10.1007/s00268-014-2793-7

Download citation

  • Published:

  • Issue Date:

  • DOI: https://doi.org/10.1007/s00268-014-2793-7

Keywords

Navigation