Introduction
History of the Procedure
The management of penetrating abdominal trauma (PAT) has evolved greatly over the last century.
Prior to World War I, penetrating trauma was managed expectantly. During World War II, however, studies showed that early laparotomy improved survival. By the late 1950s, laparotomy was the standard treatment of patients with PAT. In 1960, Shaftan suggested the selective management of patients with abdominal stab wounds after observing an increased rate of laparotomies without identifiable injuries. More recently, expectant management has also been used in the treatment of specific gunshot wounds (GSWs) to the abdomen.
The introduction and refinement of diagnostic procedures and imaging studies, including peritoneal lavage, laparoscopy, CT scan, and focused ultrasound, have directed the evolution of PAT management.
Problem
Penetrating abdominal injury implies that either a GSW or a stab wound has violated the abdominal cavity.
Frequency
In the United States, suicide and homicide consistently rank in the top 15 causes of death. According to data published by the National Vital Statistics Reports, 30,318 people died of firearm injuries in 2002. Of these, 17,159 deaths were due to self-inflicted GSWs. Forty percent of homicides and 14% of suicides by firearm involved injuries to the torso.
Age-adjusted firearm death rates are 2-7 times higher for non-Hispanic black males as compared to males of other ethnicities. For non-Hispanic whites, most firearms deaths are due to suicide.
According to age-adjusted rates from 1990-1995, firearm mortality rates across the world vary widely, from 0.05 in Japan to 14.24 in the United States. Firearm associated homicide mortality is highest in Mexico at 10.35; firearm associated suicide is highest in the United States at 6.3.
Pathophysiology
A GSW is caused by a missile propelled by combustion of powder. These wounds involve high-energy transfer and, consequently, can have an unpredictable pattern of injuries. Secondary missiles, such as bullet and bone fragments, can inflict additional damage. Military and hunting firearms have higher missile velocity than handguns, resulting in even higher energy transfer. Close-range shotgun injuries often cause significant tissue damage and should be considered high-energy transfer injuries as well.
Stab wounds are caused by penetration of the abdominal wall by a sharp object. This type of wound generally has a more predictable pattern of organ injury. However, occult injuries can be overlooked, resulting in devastating complications.
Presentation
Assessment of the patient begins at the scene of the incident by emergency medical service (EMS) personnel. Basic or advanced life support measures are applied at the scene and en route to the emergency department.
Upon arrival at the emergency department, communication of the incident history and the patient's vital signs to the emergency or trauma team is of paramount importance. Advanced trauma life support protocols are initiated. Airway protection and ventilatory support are followed by circulatory resuscitation with fluid infusion. Patients who present with hypotension are already in class III shock (30-40% blood volume loss), and they should receive blood products as soon as possible.
Physical examination includes inspection of all body surfaces, with notation of all penetrating wounds. Multiple wounds may represent entrance or exit wounds and must not be labeled as such, since multiple missiles or foreign objects may be retained within the body.
Examination of the abdomen in a patient who is awake may indicate peritoneal signs, such as pain and guarding and rebound tenderness, which necessitate exploration without delay. Abdominal distension in an unresponsive patient may indicate active internal bleeding that also requires exploration, especially in combination with hypotension.
Rectal examination is performed on all patients with PAT, as blood per rectum and high-riding prostate can indicate bowel injury and genitourinary tract injury, respectively. Notation of blood at the urethral meatus is also a sign of genitourinary tract injury.
When immediate operative intervention is not requisite, further evaluation ensues with laboratory testing and diagnostic and imaging studies.
Indications
GSWs are associated with a high incidence of intra-abdominal injuries. Nearly all patients with GSWs require laparotomy. Recent reports of nonoperative management of GSWs to the abdomen are discussed later in this article.
Stab wounds are associated with a significantly lower incidence of intra-abdominal injuries; therefore, expectant management is indicated in hemodynamically stable patients. Many protocols have been developed for determination of abdominal wall penetration of stab wounds to the torso (see Media file 1).
Relevant Anatomy
Each area of the torso has anatomical boundaries, as follows:
- Thoracoabdominal area – Nipples to the 12th rib, between anterior axillary lines
- Abdomen – Nipples to anus, between anterior axillary lines
- Flank – Between ipsilateral anterior and posterior axillary lines
- Back – Below the tip of the scapula, between posterior axillary lines
Retroperitoneal organs include the duodenum, pancreas, kidneys, ureters, urinary bladder, ascending and descending colon, major abdominal vessels, and rectum.
Contraindications
Patients without recordable cardiac activity upon presentation should not be further resuscitated.
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
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].
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].
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].
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].
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].
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].
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].
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].
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].
Cox EF. Blunt abdominal trauma. A 5-year analysis of 870 patients requiring celiotomy. Ann Surg. Apr 1984;199(4):467-74. [Medline].
Fabian TC. Abdominal trauma including indications for celiotomy. 1996;441-59.
Jacobs LM, et al. Advanced Trauma Operative Management: Surgical Strategies for Penetrating Trauma. Connecticut: Cine-Med Inc; 2004.
Mattox KL, Feliciano DV, Moore EE. Trauma. 4th ed. New York: McGraw-Hill; 1999.
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].
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].
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].
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.
Weigelt JA, Thal ER, Carrico JC, eds. Operative Trauma Management Atlas. Stamford, Conn: Appleton & Lange; 1997.
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.
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
