eMedicine Specialties > Trauma > Abdominal Trauma

Abdominal Trauma, Penetrating: Follow-up

Author: Katie Jo Stanton-Maxey, MD, Resident Physician, Department of Surgery, Indiana University School of Medicine
Coauthor(s): H Scott Bjerke, MD, FACS, Clinical Associate Professor, Department of Surgery, Indiana University School of Medicine, Medical Director of Trauma Services, Methodist Hospital, Clarian Health Partners, Inc
Contributor Information and Disclosures

Updated: Jun 12, 2007

Outcome and Prognosis

The outcome for patients with PAT varies greatly depending on the extent of injury and the interventions required for repair.

In a series by Nicholas of 250 patients with PAT and positive laparotomies, the overall survival was 86.8%.1 Mortality was found to be associated with the number of organs injured, vascular injury, and the need for damage-control surgery, emergency department thoracotomy, or operating room thoracotomy. While damage-control surgery has been used with some success in the management of patients with extensive abdominal trauma, it is associated with significant morbidity, including sepsis, intra-abdominal abscess, and gastrointestinal fistula, according to Nicholas.1

Future and Controversies

Management of the patient with PAT continues to evolve. After many years of obligatory exploration, expectant management of selected patients has become commonplace. Much of the present controversy involves the determination of patients or, more specifically, the injury patterns suitable for this type of management. Several different methods have been used to establish the injuries present and therefore the need for operative intervention in patients with PAT. Most trauma centers use an algorithm with multiple diagnostic modalities whose uses are based on the pattern of injuries and the clinical status of the patient.

Laparoscopy

Laparoscopy was first used in cases of PAT in the late 1970s. However, the technique was not widely used until much later after equipment had been improved and surgeon experience had grown. Diagnostic laparoscopy can be used to determine the need for laparotomy in patients with penetrating injury patterns. Multiple studies have shown a reduction in unnecessary laparotomies in patients with a penetrating mechanism but no identifiable organ injury who underwent diagnostic laparoscopy.

A retrospective study of 344 patients with abdominal exploration for PAT revealed 44 laparoscopies, half of which were negative for penetration and resulted in avoidance of laparotomy.2 A prospective study of 99 patients with abdominal trauma who underwent laparoscopy showed that diagnostic laparoscopy was negative in 62% of the patients with PAT. The use of diagnostic laparoscopy reduced the rate of unnecessary laparotomy from 78.9% to 16.9% in this group of patients with PAT.3

The successful incorporation of diagnostic laparoscopy into the management of patients with PAT depends on the selection of hemodynamically stable patients, the availability and ease of use of quality laparoscopic equipment, and the experience of the surgeon in using the technique for diagnostic purposes in traumatic injuries. 
 
CT scan

Triple-contrast helical CT has been evaluated as a diagnostic modality in hemodynamically stable patients with penetrating torso trauma. Oral, intravenous, and rectal contrasts are administered, and the images are reviewed for evidence of peritoneal penetration and visceral injuries.

Findings consistent with peritoneal penetration include a wound tract outlined by hemorrhage, air, or bullet or bone fragments that clearly extend into the peritoneal cavity; the presence of intraperitoneal free air, free fluid, or free contrast material; and intraperitoneal organ injury.

In a prospective study of 200 patients, CT was found to be 97% sensitive and 98% specific for peritoneal violation.4 Laparotomy based on CT findings in 38 of these patients was considered therapeutic in 87%, nontherapeutic in 8%, and negative in 5%. These results were comparable to others obtained with the use of clinical examination, DPL plus local wound exploration, and DPL alone.5,6,7 Patient selection is extremely important when considering CT as a diagnostic adjunct in patients with PAT.

The availability and quality of the CT scan and the experience of the examining radiologist are also key considerations.

Ultrasound

Ultrasonography has been widely used in the assessment of patients with blunt trauma, but it has only recently been used in the assessment of patients with penetrating injuries.

While FAST has been found to be 94-98% specific for abdominal injury in PAT, its sensitivity of 46-67% is not good.8,9 The rapidity with which FAST can be performed in the trauma setting is useful; however, the need for further testing to rule out occult injury in the event of a negative FAST limits its overall use.

 


More on Abdominal Trauma, Penetrating

Overview: Abdominal Trauma, Penetrating
Workup: Abdominal Trauma, Penetrating
Treatment: Abdominal Trauma, Penetrating
Follow-up: Abdominal Trauma, Penetrating
Multimedia: Abdominal Trauma, Penetrating
References
Further Reading
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References

  1. Nicholas JM, Rix EP, Easley KA, Feliciano DV, Cava RA, Ingram WL, et al. Changing patterns in the management of penetrating abdominal trauma: the more things change, the more they stay the same. J Trauma. Dec 2003;55(6):1095-108; discussion 1108-10. [Medline].

  2. Simon RJ, Rabin J, Kuhls D. Impact of increased use of laparoscopy on negative laparotomy rates after penetrating trauma. J Trauma. Aug 2002;53(2):297-302; discussion 302. [Medline].

  3. Taner AS, Topgul K, Kucukel F, Demir A, Sari S. Diagnostic laparoscopy decreases the rate of unnecessary laparotomies and reduces hospital costs in trauma patients. J Laparoendosc Adv Surg Tech A. Aug 2001;11(4):207-11. [Medline].

  4. Shanmuganathan K, Mirvis SE, Chiu WC, Killeen KL, Scalea TM. Triple-contrast helical CT in penetrating torso trauma: a prospective study to determine peritoneal violation and the need for laparotomy. AJR Am J Roentgenol. Dec 2001;177(6):1247-56. [Medline].

  5. Feliciano DV, Burch JM, Spjut-Patrinely V, Mattox KL, Jordan GL Jr. Abdominal gunshot wounds. An urban trauma center's experience with 300 consecutive patients. Ann Surg. Sep 1988;208(3):362-70. [Medline].

  6. Demetriades D, Velmahos G, Cornwell E 3rd, Berne TV, Cober S, Bhasin PS. Selective nonoperative management of gunshot wounds of the anterior abdomen. Arch Surg. Feb 1997;132(2):178-83. [Medline].

  7. Kelemen JJ, Martin RR, Obney JA, Jenkins D, Kissinger DP. Evaluation of diagnostic peritoneal lavage in stable patients with gunshot wounds to the abdomen. Arch Surg. Aug 1997;132(8):909-13. [Medline].

  8. Udobi KF, Rodriguez A, Chiu WC, Scalea TM. Role of ultrasonography in penetrating abdominal trauma: a prospective clinical study. J Trauma. Mar 2001;50(3):475-9. [Medline].

  9. Boulanger BR, Kearney PA, Tsuei B, Ochoa JB. The routine use of sonography in penetrating torso injury is beneficial. J Trauma. Aug 2001;51(2):320-5. [Medline].

  10. Cox EF. Blunt abdominal trauma. A 5-year analysis of 870 patients requiring celiotomy. Ann Surg. Apr 1984;199(4):467-74. [Medline].

  11. Fabian TC. Abdominal trauma including indications for celiotomy. 1996;441-59.

  12. Jacobs LM, et al. Advanced Trauma Operative Management: Surgical Strategies for Penetrating Trauma. Connecticut: Cine-Med Inc; 2004.

  13. Mattox KL, Feliciano DV, Moore EE. Trauma. 4th ed. New York: McGraw-Hill; 1999.

  14. Morris JA Jr, Eddy VA, Rutherford EJ. The trauma celiotomy: the evolving concepts of damage control. Curr Probl Surg. Aug 1996;33(8):611-700. [Medline].

  15. Murphy SH. National Vital Statistics Reports. Deaths, final data for 1998. 2000;Available at: http://www.cdc.gov/nchs/data/nvsr/nvsr48/nvs48_11.pdf. [Full Text].

  16. Pourmoghadam KK, Fogler RJ, Shaftan GW. Ligation: an alternative for control of exsanguination in major vascular injuries. J Trauma. Jul 1997;43(1):126-30. [Medline].

  17. Thal ER. Operative exposure of abdominal injuries and closure of the abdomen. In: Wilmore DW, Cheung LY, Harken AH, Holcroft JW, Meakins JL, eds. Scientific American Surgery. New York: Scientific American; 1996: revised 1997.

  18. Weigelt JA, Thal ER, Carrico JC, eds. Operative Trauma Management Atlas. Stamford, Conn: Appleton & Lange; 1997.

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Further Reading

Lawson R, Goosen J. Abdominal Stab Wound Exploration. eMedicine from WebMD. Updated May 31, 2007. Available at: http://www.emedicine.com/proc/topic82869.htm.

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Keywords

gunshot wound, GSW, gut shot, stab wound, missile injury, celiotomy, diagnostic peritoneal lavage, DPL, diagnostic laparoscopy, intra-abdominal injuries, intraabdominal injuries, advanced trauma life support, ATLS

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Contributor Information and Disclosures

Author

Katie Jo Stanton-Maxey, MD, Resident Physician, Department of Surgery, Indiana University School of Medicine
Katie Jo Stanton-Maxey, MD is a member of the following medical societies: Alpha Omega Alpha
Disclosure: Nothing to disclose.

Coauthor(s)

H Scott Bjerke, MD, FACS, Clinical Associate Professor, Department of Surgery, Indiana University School of Medicine, Medical Director of Trauma Services, Methodist Hospital, Clarian Health Partners, Inc
H Scott Bjerke, MD, FACS is a member of the following medical societies: American Association for the History of Medicine, American Association for the Surgery of Trauma, American College of Surgeons, Association for Academic Surgery, Eastern Association for the Surgery of Trauma, Midwest Surgical Association, National Association of EMS Physicians, Pan-Pacific Surgical Association, Royal Society of Medicine, Southwestern Surgical Congress, and Wilderness Medical Society
Disclosure: Nothing to disclose.

Medical Editor

Ernest Dunn, MD, Program Director of General Surgery, Director of Trauma and Critical Care, Clinical Associate Professor, Department of Surgery, Methodist Hospitals of Dallas, University of Texas Southwestern
Ernest Dunn, MD is a member of the following medical societies: American College of Surgeons, American Medical Association, Association for Academic Surgery, Society of Critical Care Medicine, and Texas Medical Association
Disclosure: Nothing to disclose.

Pharmacy Editor

Francisco Talavera, PharmD, PhD, Senior Pharmacy Editor, eMedicine
Disclosure: Nothing to disclose.

Managing Editor

Robert L Sheridan, MD, Assistant Chief of Staff, Chief of Burn Surgery, Shriners Burns Hospital; Associate Professor of Surgery, Department of Surgery, Division of Trauma and Burns, Massachusetts General Hospital and Harvard Medical School
Robert L Sheridan, MD is a member of the following medical societies: American Academy of Pediatrics, American Association for the Surgery of Trauma, American Burn Association, and American College of Surgeons
Disclosure: Nothing to disclose.

CME Editor

Paolo Zamboni, MD, Professor of Surgery, Chief of Day Surgery Unit, Chair of Vascular Diseases Center, University of Ferrara, Italy
Paolo Zamboni, MD is a member of the following medical societies: American Venous Forum and New York Academy of Sciences
Disclosure: Nothing to disclose.

Chief Editor

John Geibel, MD, DSc, MA, Professor, Department of Surgery, Section of Gastrointestinal Medicine and Department of Cellular and Molecular Physiology, Yale University School of Medicine; Director of Surgical Research, Department of Surgery, Yale-New Haven Hospital
John Geibel, MD, DSc, MA is a member of the following medical societies: American Gastroenterological Association, American Physiological Society, American Society of Nephrology, Association for Academic Surgery, International Society of Nephrology, New York Academy of Sciences, and Society for Surgery of the Alimentary Tract
Disclosure: AMGEN Royalty Other; AstraZeneca Grant/research funds Other

 
 
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