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World Journal of Surgery

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01-06-2015 | Surgical Symposium Contribution

Management Guidelines for Penetrating Abdominal Trauma

Authors: Walter L. Biffl, Ari Leppaniemi

Published in: World Journal of Surgery | Issue 6/2015

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.

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

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

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

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 66:1294–1301CrossRefPubMed

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 71:1494–1502CrossRefPubMed

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

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

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

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 231:775–784CrossRefPubMed

10.

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

11.

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

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 187:626–630CrossRefPubMed

13.

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

14.

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

15.

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

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 67:583–588CrossRefPubMed

17.

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

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 179:639–646CrossRefPubMedCentralPubMed

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 7:307–314CrossRef

20.

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

21.

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

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 198:411–419CrossRefPubMedCentralPubMed

23.

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

24.

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

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 29:446–450CrossRefPubMed

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 39:492–500CrossRefPubMed

27.

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

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 30:1345–1355CrossRefPubMed

29.

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

30.

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

31.

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

32.

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

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 16:172–175CrossRefPubMed

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 69:302–307CrossRefPubMed

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 148:810–816CrossRefPubMed

36.

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

37.

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

38.

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

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 45:540–544CrossRefPubMed

40.

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

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 20:834–837CrossRefPubMed

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 34:829–833CrossRefPubMed

43.

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

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 37:113–122CrossRefPubMed

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 75:1013–1018CrossRefPubMed

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 48:408–415CrossRefPubMed

47.

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

48.

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

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 170:569–580CrossRefPubMedCentralPubMed

50.

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

51.

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

52.

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

53.

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

54.

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

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 44:639–644CrossRef

Title: Management Guidelines for Penetrating Abdominal Trauma
Authors: Walter L. Biffl
Ari Leppaniemi
Publication date: 01-06-2015
Publisher: Springer International Publishing
Published in: World Journal of Surgery / Issue 6/2015
Print ISSN: 0364-2313
Electronic ISSN: 1432-2323
DOI: https://doi.org/10.1007/s00268-014-2793-7

At a glance: The STEP trials

Springer Medicine

Management Guidelines for Penetrating Abdominal Trauma

Abstract

Introduction

Materials and Methods

Results

Conclusion

At a glance: The STEP trials

Springer Medicine

Abstract

Introduction

Materials and Methods

Results

Conclusion

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