Table of Contents  

Al-Ozaibi, AlSuwaidi, Al-Zarouni, Hussein, Khalil, Al-Mazrouni, and Badri: Penetrating abdominal stab wounds – current practice and recommendations

Introduction

The management of penetrating abdominal stab injuries is the subject of some controversy; most surgeons recommend explorative laparotomy in all patients, but this is associated with a high percentage of unnecessary laparotomies and many post-operative complications. The current recommendation is selective non-operative management for stable patients without signs of generalized peritonitis,1 which is effective in decreasing the rate of non-therapeutic laparotomy. Despite this, some centres still practise mandatory exploration for all cases, believing that the incidence of missed intra-abdominal injuries is higher than the rate of complications of negative laparotomy.

Method

This is a retrospective study of patients admitted to Rashid Hospital with isolated abdominal stab wounds between January 2011 and December 2015. The demographic data that were collected were age, sex and length of hospital stay, and specific clinical findings included vital signs, Glasgow Coma Scale score, abdominal tenderness (either localized or generalized), evisceration and local wound exploration (LWE) result. The use of imaging diagnostic tests [ultrasonography and computerized tomography (CT)] and their accuracy in pre-operative diagnosis, the type of surgery performed and the operative findings were also collected. Patients were included if they had penetrating injuries and fulfilled conservative management criteria (i.e. were haemodynamically stable, had localized tenderness and no evisceration). Exclusion criteria were patients who were haemodynamically unstable, with evisceration and generalized tenderness.

Results

A total of 66 patients with abdominal stab injuries were admitted between January 2011 and December 2015. The mean age of the patients was 28 years; 62 (94%) were men and four (6%) were women. The most common site of injury was the left upper quadrant. Stab wounds associated with the least injury were in the back, followed by the right upper quadrant (RUQ). Eight patients had stab injuries in the RUQ (Table 1), two of whom were successfully treated conservatively; the remaining six underwent surgery (two had a diaphragm injury, one a colon injury and three had a small liver laceration).

TABLE 1

Site of stab injury

Site of injury Number of patients
Left upper quadrant 10
RUQ 8
Umbilical region 8
Back 8
Left iliac fossa 7
Right iliac fossa 5
Epigastrium 5
Right lumbar 5
Left lumbar 4
Multiple 6
Total 66

The characteristics of the patients’ injuries are shown in Figure 1. Of the 66 patients, 22 had non-penetrating injuries. Patients with no penetration and no other associated injuries were treated with wound closure and observed in the emergency department for 4 hours before being discharged.

FIGURE 1

Characteristics of injuries.

HMJ-666-fig1.jpg

A total of 44 patients had penetrating injuries with a breach of the peritoneum. Seven of these patients had evisceration of either the omentum or bowel (all were associated with significant intra-abdominal injuries that required surgery; Figure 2), eight cases had generalized tenderness that necessitated exploratory laparotomy (all were therapeutic) and the remaining 29 had localized tenderness and were eligible for conservative management.

FIGURE 2

Injury showing evisceration.

HMJ-666-fig2.jpg

Twenty-nine patients fulfilled the inclusion criteria for conservative management; six were treated conservatively and were followed up by serial clinical examinations at 4, 8, 12 and 24 hours after arrival by the surgical on-call team. All the patients did well and none required surgery. They were discharged within 2–3 days and 1-year follow-up for all revealed no complications. CT was performed in each patient and revealed fluid collection, fat stranding or solid organ laceration; none required surgery. The mean hospital stay was 3 days.

Of the 23 patients who had surgery, 13 underwent diagnostic laparoscopy and 10 direct exploratory laparotomy. Of those who had diagnostic laparoscopy, four converted to laparotomy because of a bowel injury, one had a diaphragm injury that was repaired and eight were non-therapeutic. Among the 10 patients who underwent direct exploratory laparotomy, five procedures were therapeutic and five were non-therapeutic. The decision to perform laparotomy and not diagnostic laparoscopy was in seven cases based on the CT findings of suspected intra-abdominal injury and in three cases on the surgeon’s preference. In summary, a total of 13 (57%) patients underwent non-therapeutic procedures and 10 (43%) therapeutic procedures. The mean hospital stay for those who underwent diagnostic laparoscopy was 2 days and for those who underwent laparotomy was 5 days (Table 2).

TABLE 2

Mean hospital stay

Management Mean hospital stay (days)
Conservative 3
Non-therapeutic diagnostic laparoscopy 2
Non-therapeutic laparotomy 5

A positive FAST (focused assessment with sonography for trauma) scan was helpful in the diagnosis of penetration but was poor in identifying injuries that required intervention. On the other hand, a negative FAST scan did not exclude significant injuries. Abdominal CT was highly sensitive in the evaluation of the injuries; it was helpful in diagnosing peritoneal violation and bowel, intra-abdominal organ and diaphragm injury (Figure 3).

FIGURE 3

Computerized tomography scan showing signs of penetration.

HMJ-666-fig3a.jpgHMJ-666-fig3b.jpg

Discussion

Few studies of the management of abdominal stab injuries have been conducted in the Gulf and Middle East. Current recommendations and guidelines state that shock, evisceration and generalized peritonitis warrant immediate laparotomy following penetrating abdominal stab injuries.1 Anterior abdominal stab wound victims can undergo serial clinical assessments (SCAs)1 with the aim of avoiding unnecessary laparotomy. Wounds without penetration of the posterior fascia on LWE can be sutured and the patient safely discharged from the emergency department.

Common evaluation strategies include LWE, SCAs, FAST scans and CT. LWE should be performed by a well-trained surgeon. The Western Trauma Association found that only 4% of decisions were based on FAST, and 23% of patients with normal FAST findings required therapeutic laparotomy.2 Patients should not be discharged from the emergency department based solely on a normal FAST.

Computerized tomography is a highly sensitive diagnostic modality and should be considered for use in patients selected for non-operative management to facilitate initial management decisions. CT findings are considered positive for peritoneal violation if intraperitoneal free air or fluid is present, or if intraperitoneal organ, mesenteric or vascular injury is present. The use of oral, intravenous and rectal contrast can improve the sensitivity of CT in detecting intra-abdominal injuries.

Herfatkar et al.3 reviewed 100 patients with stab wounds to the anterior abdominal wall who were selected for non-operative management, and were followed up with SCAs at admission and at 4, 8, 12 and 24 hours post admission. A total of 8% of patients needed laparotomy only after 12 hours. The authors concluded that SCAs are safe and decrease the cost and duration of hospitalization in stable patients. Those physicians who have missed injuries will declare themselves in the first 12 hours. Another study comparing the conservative and surgical management of stable patients with penetrating abdominal stab wounds4 showed that conservative management with physical examination can decrease the rate of laparotomies performed and the length of hospital stay, and help to start oral feeding earlier. Selective non-operative management of penetrating abdominal solid organ injuries has a high success rate, a low complication rate and leads to significantly shorter hospital stay than surgery.5 Isolated solid organ injury may benefit from advanced endovascular and percutaneous interventions to facilitate its management.6

In our centre we do not commonly practise the selective non-operative management strategy. In our study only six patients with penetrating injuries were managed non-operatively and followed up with SCAs. All of these patients showed good recovery and none needed surgery. The SCAs were found to be effective in making a decision about when to operate on a patient with a penetrating abdominal injury, but a larger study is required to obtain more accurate results. The majority of patients with penetrating abdominal trauma managed non-operatively could be discharged after 24 hours of observation after reliable abdominal examination, but in our study the mean hospital stay for such patients was 3 days.

The site of the stab injury is also helpful in making a decision about conservative management. Eastern Association for the Surgery of Trauma guidelines recommend that isolated injury to the RUQ may be managed without laparotomy if the patent’s vital signs are stable, with reliable examination, and there is minimal tenderness.7 In our study we found that back-stab injuries were associated with the least intra-abdominal injury. Of the eight patients with back-stab injuries, only one (12%) had a significant injury that required laparotomy; however, of the eight patients with RUQ injuries, three (37%) had significant injury requiring intervention – two of these had diaphragmatic injury. We concluded that back injuries can be managed safely by selective non-operative management and diagnostic laparoscopy is advisable in RUQ injuries, both diagnostic and therapeutic.

Current guidelines for the management of evisceration state that laparotomy should be performed.8 There remains a conflict regarding conservative management in these cases. In one study,8 54% of patients with evisceration did not have any intra-abdominal injuries during laparotomy, but Nagy et al.9 found that 78% of their patients had an intra-abdominal injury that required repair. In our study 100% of the cases of evisceration were associated with intra-abdominal injuries requiring repair and, therefore, exploratory laparotomy is highly recommended in such cases.

Reports of the incidence of unnecessary laparotomy range from 23% to 53% for patients with stab injury.10 Sanei et al.11 found that 82% of laparotomies in patients who had no signs of peritoneal irritation were negative. Complications (e.g. small bowel obstruction, pneumothorax, ileus, wound infection, myocardial infarction, visceral injury and death) develop in 2.5–41% of all trauma patients undergoing unnecessary laparotomy.12 In our study 57% of patients who were candidates for selective non-operative management underwent unnecessary surgery and 43% underwent therapeutic surgery.

Diagnostic laparoscopy may be considered as a tool to evaluate diaphragmatic lacerations and peritoneal penetration in an effort to avoid unnecessary laparotomy.7 This should be strongly considered in patients with penetrating trauma to the thoracoabdominal area, as it has been shown to be 96.8% sensitive and 87.5% specific for diaphragmatic injuries.13 Cherry et al.14 reported that laparoscopy prevented 60.9% of non-therapeutic laparotomies. The possibility of missing an injury during laparoscopy is a concern, but the risk is negligible if performed by a surgeon well trained in laparoscopy. In our study diagnostic laparoscopy was performed in 15 cases and it prevented unnecessary laparotomy in 11 (73%); none of these patients had missed injuries. Hospital stay was decreased in those who underwent diagnostic laparoscopy compared with those who were treated conservatively or underwent unnecessary laparotomy.

Our recommendations for management of penetrating stab wounds are shown in Figure 4. These differ from the current guidelines in that we recommend diagnostic laparoscopy if there are signs of free fluid, organ injury, contrast extravasation or bowel wall thickening on abdominal CT, even if the patient is a candidate for selective non-operative management.

FIGURE 4

Recommendations for management of a penetrating stab wound.

HMJ-666-fig4.jpg

Conclusion

Selective non-operative management for stable patients without signs of peritonitis is an effective tool in decreasing unnecessary laparotomies, but should be practised in a specialized trauma centre and performed by experienced clinicians. It should preferably be performed by the same team as a significant number of patients are found to have intra-abdominal injuries that necessitate surgical repair. The uses of triple-contrast abdominal CT is recommended in preference to the intravenous contrast alone as it can reduce the rate of negative findings at laparotomy. Diagnostic laparoscopy is safe and decreases both non-therapeutic laparotomy rates and hospital stay.

References

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Biffl WL, Moore EE. Management guidelines for penetrating abdominal trauma. Curr Opin Crit Care 2010; 16:609–17. http://dx.doi.org/10.1097/MCC.0b013e32833f52d2

2. 

Biffl WL, Kaups KL, Cothren CC, et al. Management of patients with anterior abdominal stab wounds: a Western Trauma Association multicenter trial. J Trauma 2009; 66:1294–301. http://dx.doi.org/10.1097/TA.0b013e31819dc688

3. 

Herfatkar MR, Mobayen MR, Karimian M, Rahmanzade F, Baghernejad Monavar Gilani S, Baghi I. Serial clinical examinations of 100 patients treated for anterior abdominal wall stab wounds: a cross sectional study. Trauma Mon 2015; 20:e24844. http://dx.doi.org/10.5812/traumamon.24844

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Paydar S, Salahi R, Izadifard F, et al. Comparison of conservative management and laparotomy in the management of stable patients with abdominal stab wound. Am J Emerg Med 2012; 30:1146–51. http://dx.doi.org/10.1016/j.ajem.2011.08.012

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Demetriades D, Hadjizacharia P, Constantinou C, et al. Selective non-operative management of penetrating abdominal solid organ injuries. Ann Surg 2006; 244:620–8.

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Como JJ, Bokhari F, Chiu WC, et al. Practice management guidelines for selective non-operative management of penetrating abdominal trauma. J Trauma 2010; 68:721–33. http://dx.doi.org/10.1097/TA.0b013e3181cf7d07

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Arikan S, Kocakusak A, Yucel AF, Adas G. A prospective comparison of the selective observation and routine exploration methods for penetrating abdominal stab wounds with organ or omentum evisceration. J Trauma 2005; 58:526–32. http://dx.doi.org/10.1097/01.TA.0000152498.71380.3E

9. 

Nagy K, Roberts R, Joseph K, An G, Barrett J. Evisceration after abdominal stab wounds: is laparotomy required? J Trauma 1999; 47:622–4. http://dx.doi.org/10.1097/00005373-199910000-00002

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Friedmann P. Selective management of stab wounds of the abdomen. Arch Surg 1968; 96:292–5. http://dx.doi.org/10.1001/archsurg.1968.01330200130028

11. 

Sanei B, Mahmoudieh M, Talebzadeh H, Shahabi Shahmiri S, Aghaei Z. Do patients with penetrating abdominal stab wounds require laparotomy? Arch Trauma Res 2013; 2:21–5. http://dx.doi.org/10.5812/atr.6617

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Renz BM, Feliciano DV. Unnecessary laparotomies for trauma: a prospective study of morbidity. J Trauma 1995; 38:350–6. http://dx.doi.org/10.1097/00005373-199503000-00007

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Friese RS, Coln CE, Gentilello LM. Laparoscopy is sufficient to exclude occult diaphragm injury after penetrating abdominal trauma. J Trauma 2005; 58:789–92. http://dx.doi.org/10.1097/01.TA.0000158243.78299.B5

14. 

Cherry RA, Eachempati SR, Hydo LJ, Barie PS. The role of laparoscopy in penetrating abdominal stab wounds. Surg Laparosc Endosc Percutan Tech 2005; 15:14–7. http://dx.doi.org/10.1097/01.sle.0000153732.70603.f9




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