Clinical surgery-American
Local wound exploration remains a valuable triage tool for the evaluation of anterior abdominal stab wounds

Presented at the 60th Annual Meeting of the Southwestern Surgical Congress, April 1, 2008, Acapulco, Mexico.
https://doi.org/10.1016/j.amjsurg.2008.11.024Get rights and content

Abstract

Background

Recent guidelines do not support local wound exploration (LWE) or diagnostic peritoneal lavage (DPL) in the evaluation of patients with anterior abdominal stab wounds (AASWs), favoring computed tomography scanning or serial examinations. In patients without immediate indications for laparotomy, we hypothesized that LWE/DPL would identify patients requiring surgery while limiting unnecessary hospital admissions.

Methods

Patients sustaining penetrating trauma at our level I trauma center over a 3-year period were reviewed.

Results

During the study period, 139 patients with AASW followed our LWE/DPL algorithm. Fifty-six patients had LWE without fascial penetration: 46 were discharged immediately, 10 required admission. Fifty-eight patients had fascial penetration on LWE but negative DPL: 37 were observed for less than 24 hours, 19 were observed for more than 24 hours, and 2 patients developed peritonitis requiring exploration. Twenty-five patients had positive LWE/DPL: 13 had therapeutic laparotomy, 12 had nontherapeutic laparotomy.

Conclusions

Only 11% of patients with AASWs without overt indication for laparotomy require surgical care. LWE remains a valid method to exclude intra-abdominal injury and to eliminate hospitalization in more than one third of AASW patients.

Section snippets

Methods

Patients sustaining penetrating trauma at our American College of Surgeons–verified level I trauma center over a 3-year period were reviewed. AASW were defined as stab wounds between the costal margins, inguinal ligaments, and bilateral anterior axillary lines. Patients with thoracoabdominal, back, or flank wounds were excluded because diagnostics or interventions might be different. The management practice at our institution is directed by a LWE/DPL algorithm (Fig. 1). The technique of LWE has

Patient demographics

During the study period, 2,080 patients were evaluated for penetrating trauma, of which 192 sustained AASW. The majority (89%) were men, with a mean age of 32 ± .9 years. Forty patients underwent emergent surgery, 139 patients followed our LWE/DPL algorithm, and 13 patients underwent alternate management (Fig. 2). A total of 104 (54%) patients had a single stab wound whereas the remainder had multiple wounds.

LWE

Of the 139 patients undergoing LWE, 56 (40%) had no evidence of fascial penetration

Comments

In the past decade, there have been a number of reports advocating the nonsurgical management of penetrating trauma. The majority addressed gunshot8, 9, 10, 11 or stab wounds to the back or flank.12, 13, 14 Clearly, these mechanisms of injury differ from penetrating trauma to the anterior abdomen. Few reports in the past decade have addressed the diagnostic dilemma of determining which patients with AASW have intra-abdominal injuries mandating laparotomy. The goal of evaluation in the ED is

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