Penetrating Abdominal Trauma: When NOT to rush to the OR.

As a senior surgical resident, when I hear 19 year old male with a single GSW to the abdomen – my heart skips a beat, the adrenaline surges and thoughts of rushing off to the OR run through my head.  However as I have learned during my time on this service, many patients in this situation can be best treated with non-operative management. 

One hundred years ago, all patients with penetrating trauma to the abdomen underwent a mandatory laparotomy. .  In these patients, it was noted that many had no intra-abdominal injuries and no therapeutic intervention was required after laparotomy was completed.  However this group did have to bear the increased costs and risks of surgery and postoperative complications including small bowel obstructions, ileus, wound infection, myocardial infarction, pneumonia, and even death.  Over the last century, much research has been done in this field, which has resulted in practice guidelines to limit non-therapeutic laparotomies

Many factors need to be weighed when non-operative management is considered.  Patient selection is key.  This approach is not appropriate for patients with hemodynamic instability or if patients are demonstrating sigs of peritonitis.  In this group, immediate operative exploration is mandated.  Non-operative management is best utilized in a stable patient with no significant abdominal exam findings distant to the site of trauma.  Other considerations are mechanism of injury – stab wound versus gunshot wound versus a shotgun wound and region of abdomen at risk by the trauma.  Nonoperative management usually entails a diagnostic workup followed by a 24-hour period of abdominal exams at which time if the patient remains with a benign clinical exam and is able to tolerate PO is discharged home.

A single experienced clinician should optimally complete the initial physical exam and subsequent serial exams.  Local wound exploration can be completed at the bedside to assess for fascial penetration.  Studies have shown in patients with stab wounds with no fascial penetration, it was safe to discharge these patients home without additional observation.  Controversy exists over the management of patients with omental evisceration in patients with stab wounds.  The conservative approach would be to take the patient to the operating room to explore for further injuries, however a single institution series did demonstrate success with nonoperative management with serial abdominal exams and undergoing operative intervention only with signs of peritonitis. 

Additional information can be gathered by CT Triple contrast, CTA, DPL, cystoscopy, and proctoscopy.  The goal of these studies is to evaluate for violation of the peritoneum and the presence of hollow viscus or solid organ injury that would require operative intervention.  CT Triple contrast evaluates the retroperitoneal colon for injury which if missed can lead to severe delayed complications.  CTA can evaluate for blush in solid organs, which may require IR guided therapies.  DPL has been shown to have greater than 95% sensitivity and specificity at detecting intra-abdominal injuries by noting the presence of blood, feces, bile, and food particles. 

Location of injury is paramount with injuries in the right upper quadrant having the highest success of nonoperative management.  The presence of the liver in the RUQ, limits the deleterious effects of an anterior/superior diaphragm injury and access to hollow viscera.  Many studies have demonstrated that patients with penetrating trauma secondary to a GSW or stab wound limited to the liver can be successfully management with serial hemaglobins, abdominal exams, and possible intervention with angiography.  Ongoing studies are looking to expand this management style to isolated renal injuries.     

Most important take away point is each patient is unique and the clinician must apply his/her experience and prudent judgment to each situation.  Also plans are fluent and require continued reassessment of the patient and clinical situation, a patient that was initially appropriate for non-operative management may develop into an operative candidate during their hospital course.

Eastern Association for Surgery of Trauma (EAST) Recommendations:

a. Patients who are hemodynamically unstable or who have diffuse abdominal tenderness should be taken emergently for laparotomy (level 1).

b. Patients who are hemodynamically stable with an unreliable clinical examination (i.e., brain injury, spinal cord injury, intoxication, or need for sedation or anesthesia) should have further diagnostic investigation performed for intraperitoneal injury or undergo exploratory laparotomy (level 1).

c. A routine laparotomy is not indicated in hemodynamically stable patients with abdominal SWs without signs of peritonitis or diffuse abdominal tenderness (away from the wounding site) in centers with surgical exper- tise (level 2).

d. A routine laparotomy is not indicated in hemodynamically stable patients with abdominal GSWs if the wounds are tangential and there are no peritoneal signs (level 2).

e. Serial physical examination is reliable in detecting signif- icant injuries after penetrating trauma to the abdomen, if performed by experienced clinicians and preferably by the same team (level 2).

f.  In patients selected for initial NOM, abdominopelvic CT should be strongly considered as a diagnostic tool to facilitate initial management decisions (level 2).

g. Patients with penetrating injury isolated to the right upper quadrant of the abdomen may be managed without laparotomy in the presence of stable vital signs, reliable examination, and minimal to no abdominal tenderness (level 3).

h. The majority of patients with penetrating abdominal trauma managed nonoperatively may be discharged after 24 hours of observation in the presence of a reliable abdominal examination and minimal to no abdominal ten- derness (level 3).

i.  Diagnostic laparoscopy may be considered as a tool to evaluate diaphragmatic lacerations and peritoneal penetration (level 2).

Source:

Como JJ, Bokhari F, Chiu WC et al. Practice management guidelines for selective nonoperative management of penetrating abdominal trauma. The Journal of Trauma. 2010;68(3):721-733.

 

from Dr. Purvi Patel