eMedicine Specialties > Clinical Procedures > Soft Tissue Procedures

Abdominal Stab Wound Exploration

Author: Richard B Lawson, MB, BCh, Registrar, Department of Anesthesia, Johannesburg Hospital
Coauthor(s): Jacques Goosen, MB, ChB, (PRET), FCSSA, Principal Surgeon and Head, Trauma Unit, Johannesburg Hospital and University of the Witwatersrand
Contributor Information and Disclosures

Updated: Feb 25, 2009

Introduction

In the 19th century, penetrating abdominal wounds were managed nonoperatively. The associated morbidity and mortality rates were greater than 70%.1 Experience gained during World War I, World War II, and the Korean Conflict led to an aggressive approach of operative management for all penetrating abdominal wounds.2 This approach resulted in an unacceptably high frequency of laparotomy with findings negative for trauma. In 1960, Shaftan developed an approach of selective conservatism for penetrating abdominal injury and revolutionized abdominal stab wound management.3

The optimal method to determine the need for laparotomy has yet to be definitively established. Abdominal stab wound exploration forms part of a strategy developed by surgeons to allow a more selective approach. In asymptomatic patients with stab wounds to the anterior abdomen, 2 methods are widely used to help determine the need for laparotomy:

  • Abdominal stab wound exploration (Subsequent diagnostic peritoneal lavage [DPL], serial clinical evaluation, or both are used to further assess patients in whom an exploration cannot definitively exclude peritoneal penetration.)
  • Serial clinical evaluation

The objective is to reduce the number of patients with trivial or no intraperitoneal injury who are subjected to laparotomy. However, a high degree of diagnostic accuracy must be maintained to limit the frequency of missed injury. A reduction in unnecessary hospitalization is also targeted.

Investigators in this field are continuing to study other protocols and investigative tools. No protocol is currently universally accepted. Other modalities that have been studied include DPL alone, laparoscopy, CT, and ultrasonography. These strategies of selection for laparotomy are explored in greater detail below.

Abdominal stab wound exploration is a safe, rapid, and cost-effective tool in the management of asymptomatic patients who present with an anterior abdominal stab wound.4 This approach has no place in the treatment of patients who are unstable, who have peritonitis, or who have evisceration. Patients with peritonitis and those who are hemodynamically unstable should undergo mandatory laparotomy.

More than 25% of anterior abdominal stab wounds do not penetrate the peritoneal cavity.5,6 Local wound exploration allows the safe discharge of these patients from the emergency department. Only half of the wounds that penetrate the peritoneum cause damage that requires surgical intervention.1,7 The organs most commonly injured with anterior abdominal stab wounds are the small bowel, the liver, and the colon. Missed hollow viscus injuries are associated with significant morbidity and mortality.

The authors advocate abdominal stab wound exploration in asymptomatic patients who present with an anterior abdominal stab wound. An exploration with negative findings is reliable and highly sensitive. Abdominal stab wound exploration combined with further investigation, such as DPL or serial evaluation, achieves acceptable specificity rates. Minimizing the time taken to control ongoing intraperitoneal contamination is critical in penetrating stab wounds, and local exploration is a valuable first step in speeding up the decision-making process. When combined with DPL, abdominal stab wound exploration allows significant injuries that are not immediately apparent to be identified early.

Wound exploration can be performed successfully by surgeons or ED personnel who are trained in the procedure. This strategy aids with patient flow through a busy emergency department.

Flow chart illustrating the management options in...

Flow chart illustrating the management options in patients with a stab wound to the anterior abdomen. Red arrows highlight an approach that favors abdominal stab wound exploration.

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Flow chart illustrating the management options in...

Flow chart illustrating the management options in patients with a stab wound to the anterior abdomen. Red arrows highlight an approach that favors abdominal stab wound exploration.



Anatomy

An appreciation of the anatomy of the anterior abdominal wall at different levels is essential to understanding the procedure. The differences are highlighted in red on the diagrams below.

Transverse section of the anterior abdominal wall...

Transverse section of the anterior abdominal wall above the arcuate line.

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Transverse section of the anterior abdominal wall...

Transverse section of the anterior abdominal wall above the arcuate line.


Transverse section of the anterior abdominal wall...

Transverse section of the anterior abdominal wall below the arcuate line.

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Transverse section of the anterior abdominal wall...

Transverse section of the anterior abdominal wall below the arcuate line.


Boundaries of the anterior abdomen:

  • Costal margins (superior)
  • Inguinal ligaments (inferior)
  • Anterior axillary lines (lateral)

  • Boundaries of the anterior abdominal wall.

    Boundaries of the anterior abdominal wall.

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    Boundaries of the anterior abdominal wall.

    Boundaries of the anterior abdominal wall.

Indications

Abdominal stab wound exploration is indicated in a patient who presents with a stab wound to the anterior abdomen, normal vital signs, no signs of peritonitis, and no evidence of evisceration.


Stab wound to the anterior abdomen.

Stab wound to the anterior abdomen.

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Stab wound to the anterior abdomen.

Stab wound to the anterior abdomen.


Some authors advocate local exploration of wounds only anterior to the midaxillary line. If the wound tracks anteriorly and the end point of the tract is not accurately determined, the patient undergoes diagnostic peritoneal lavage (DPL). If the wound tracks posteriorly and is not obviously superficial, the patient is investigated as for a penetrating flank wound. This often involves a triple-contrast CT scan.8

Special circumstances involve patients with additional injuries that require operative intervention and cases in which the offending weapon or object is retained.

  • If the patient has additional injuries that require operative intervention, a wound exploration may be performed in the operating room before the other procedure is commenced.
  • If the object has been retained and the surgeon strongly suspects that the peritoneum has not been breached, the object may be removed in the operating room and the wound locally explored. In such cases, the surgeon should be prepared to immediately convert to laparotomy, if necessary.

Contraindications

Abdominal stab wound exploration is contraindicated if immediate laparotomy is indicated. The situations in which immediate laparotomy is indicated include the following:

  • Unstable patient
  • Peritonitis
  • Evisceration (This remains controversial; see paragraph 3 in Selecting Candidates for Laparotomy section.)
  • Blood on rectal examination or blood in nasogastric tube aspirate suggests intra-abdominal injury (A low threshold for operative intervention is suggested.)

Other contraindications to abdominal stab wound exploration include the following:

  • Lower chest wounds: Exploration of these wounds carries a high risk of iatrogenic pneumothorax.
  • Flank and back wounds: Some authors advocate exploration of these wounds if they are suspected to be superficial. However, this expectation may be unreliable, and the strong musculature makes the tract difficult to predict or to follow. Local wound exploration may result in further injury or a restart of hemorrhage that had stopped.
  • Patient refusal or uncooperative patient.

Relative contraindications include the following:

  • Obesity
  • Multiple abdominal stab wounds

More on Abdominal Stab Wound Exploration

Overview: Abdominal Stab Wound Exploration
Treatment & Medication: Abdominal Stab Wound Exploration
Multimedia: Abdominal Stab Wound Exploration
References
Further Reading
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References

  1. Cayton CG, Nassoura ZE. Abdomen. In: Ivatury RR, Cayton CG. Textbook of Penetrating Trauma. Chap 24. Baltimore, Md: Williams & Wilkins; 1996:281-99.

  2. Lee WC, Uddo JF Jr, Nance FC. Surgical judgment in the management of abdominal stab wounds. Utilizing clinical criteria from a 10-year experience. Ann Surg. May 1984;199(5):549-54. [Medline].

  3. Shaftan GW. Indications for operation in abdominal trauma. Am J Surg. May 1960;99:657-64. [Medline].

  4. Feliciano DV, Bitondo CG, Steed G, Mattox KL, Burch JM, Jordan GL Jr. Five hundred open taps or lavages in patients with abdominal stab wounds. Am J Surg. Dec 1984;148(6):772-7. [Medline].

  5. Markovchick VJ, Moore EE, Moore J, Rosen P. Local wound exploration of anterior abdominal stab wounds. J Emerg Med. 1985;2(4):287-91. [Medline].

  6. Thal ER. Evaluation of peritoneal lavage and local exploration in lower chest and abdominal stab wounds. J Trauma. Aug 1977;17(8):642-8. [Medline].

  7. Barry P, Shakeshaft J, Studd R. Abdominal Injuries. In: Sherry E, Templeton J, Trieu L, eds. Trauma. New York: Oxford University; 2003:213-26.

  8. Thal ER. Commentary. In: Ivatury RR, Cayton CG, eds. Textbook of Penetrating Trauma. Baltimore, Md: Williams & Wilkins; 1996:307-8.

  9. Oreskovich MR, Carrico CJ. Stab wounds of the anterior abdomen. Analysis of a management plan using local wound exploration and quantitative peritoneal lavage. Ann Surg. Oct 1983;198(4):411-9. [Medline].

  10. Burnweit CA, Thal ER. Significance of omental evisceration in abdominal stab wounds. Am J Surg. Dec 1986;152(6):670-3. [Medline].

  11. Nagy K, Roberts R, Joseph K, An G, Barrett J. Evisceration after abdominal stab wounds: is laparotomy required?. J Trauma. Oct 1999;47(4):622-4; discussion 624-6. [Medline].

  12. Demetriades D, Rabinowitz B. Indications for operation in abdominal stab wounds. A prospective study of 651 patients. Ann Surg. Feb 1987;205(2):129-32. [Medline].

  13. Arikan S, Kocakusak A, Yucel AF, Adas G. A prospective comparison of the selective observation and routine exploration methods for penetrating abdominal stab wounds with organ or omentum evisceration. J Trauma. Mar 2005;58(3):526-32. [Medline].

  14. Thompson JS, Moore EE, Van Duzer-Moore S, Moore JB, Galloway AC. The evolution of abdominal stab wound management. J Trauma. Jun 1980;20(6):478-84. [Medline].

  15. Bull JC Jr, Mathewson C Jr. Exploratory laparotomy in patients with penetrating wounds of the abdomen. Am J Surg. Aug 1968;116(2):223-8. [Medline].

  16. Petersen SR, Sheldon GF. Morbidity of a negative finding at laparotomy in abdominal trauma. Surg Gynecol Obstet. Jan 1979;148(1):23-6. [Medline].

  17. Rosemurgy AS 2nd, Albrink MH, Olson SM, Sherman H, Albertini J, Kramer R, et al. Abdominal stab wound protocol: prospective study documents applicability for widespread use. Am Surg. Feb 1995;61(2):112-6. [Medline].

  18. American College of Surgeons. Abdominal Trauma. In: Advanced Trauma Life Support for Doctors: Student Course Manual. 6th ed. Chicago Ill: American College of Surgeons; 1997:167.

  19. Gonzalez RP, Turk B, Falimirski ME, Holevar MR. Abdominal stab wounds: diagnostic peritoneal lavage criteria for emergency room discharge. J Trauma. Nov 2001;51(5):939-43. [Medline].

  20. Wilson RF, Walt AJ. General Considerations in Abdominal Trauma. In: Wilson RF, Walt AJ, eds. Management of Trauma: Pitfalls and Practice. 2nd ed. Baltimore, Md: Williams & Wilkins; 1996:411-31/20.

  21. Thacker LK, Parks J, Thal ER. Diagnostic peritoneal lavage: is 100,000 RBCs a valid figure for penetrating abdominal trauma?. J Trauma. Apr 2007;62(4):853-7. [Medline].

  22. Demetriades D, Hadjizacharia P, Constantinou C, Brown C, Inaba K, Rhee P, et al. Selective nonoperative management of penetrating abdominal solid organ injuries. Ann Surg. Oct 2006;244(4):620-8. [Medline].

  23. Enderson BL, Maull KI. Missed injuries. The trauma surgeon's nemesis. Surg Clin North Am. Apr 1991;71(2):399-418. [Medline].

  24. Alzamel HA, Cohn SM. When is it safe to discharge asymptomatic patients with abdominal stab wounds?. J Trauma. Mar 2005;58(3):523-5. [Medline].

  25. Tsikitis V, Biffl WL, Majercik S, Harrington DT, Cioffi WG. Selective clinical management of anterior abdominal stab wounds. Am J Surg. Dec 2004;188(6):807-12. [Medline].

  26. Navsaria PH, Berli JU, Edu S, Nicol AJ. Non-operative management of abdominal stab wounds--an analysis of 186 patients. S Afr J Surg. Nov 2007;45(4):128-30, 132. [Medline].

  27. Martin RR, Burch JM, Richardson R, Mattox KL. Outcome for delayed operation of penetrating colon injuries. J Trauma. Dec 1991;31(12):1591-5. [Medline].

  28. Aragón GE, Eiseman B. Abdominal stab wounds: evaluation of sinography. J Trauma. Oct 1976;16(10):792-7. [Medline].

  29. Weinberg JA, Magnotti LJ, Edwards NM, Claridge JA, Minard G, Fabian TC, et al. "Awake" laparoscopy for the evaluation of equivocal penetrating abdominal wounds. Injury. Jan 2007;38(1):60-4. [Medline].

  30. Leppäniemi A, Haapiainen R. Diagnostic laparoscopy in abdominal stab wounds: a prospective, randomized study. J Trauma. Oct 2003;55(4):636-45. [Medline].

  31. Soffer D, McKenney MG, Cohn S, Garcia-Roca R, Namias N, Schulman C. A prospective evaluation of ultrasonography for the diagnosis of penetrating torso injury. J Trauma. May 2004;56(5):953-7; discussion 957-9. [Medline].

  32. Blackbourne LH, Soffer D, McKenney M, Amortegui J, Schulman CI, Crookes B. Secondary ultrasound examination increases the sensitivity of the FAST exam in blunt trauma. J Trauma. Nov 2004;57(5):934-8. [Medline].

  33. 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].

  34. Murphy JT, Hall J, Provost D. Fascial ultrasound for evaluation of anterior abdominal stab wound injury. J Trauma. Oct 2005;59(4):843-6. [Medline].

  35. Rehm CG, Sherman R, Hinz TW. The role of CT scan in evaluation for laparotomy in patients with stab wounds of the abdomen. J Trauma. Apr 1989;29(4):446-50. [Medline].

  36. Salim A, Sangthong B, Martin M, Brown C, Plurad D, Inaba K, et al. Use of computed tomography in anterior abdominal stab wounds: results of a prospective study. Arch Surg. Aug 2006;141(8):745-50; discussion 750-2. [Medline].

  37. Ertekin C, Yanar H, Taviloglu K, Güloglu R, Alimoglu O. Unnecessary laparotomy by using physical examination and different diagnostic modalities for penetrating abdominal stab wounds. Emerg Med J. Nov 2005;22(11):790-4. [Medline].

  38. Sugrue M, Balogh Z, Lynch J, Bardsley J, Sisson G, Weigelt J. Guidelines for the management of haemodynamically stable patients with stab wounds to the anterior abdomen. ANZ J Surg. Aug 2007;77(8):614-20. [Medline].

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Further Reading

Cayton CG, Nassoura ZE. Abdomen. In: Ivatury RR, Cayton CG, editors. Textbook of Penetrating Trauma. 1st ed. Baltimore, Md: Williams & Wilkins, 1996:281-299.

Kirby R, Viswanathan S, Jiang R. Diagnostic and Therapeutic techniques. In: Sherry E, Trieu L, Templeton J, editors. Trauma. 1st ed. New York: Oxford University Press, 2003. p.715-716.

Back and flank wounds
Coppa GF. Back and Flank. In: Ivatury RR, Cayton CG, eds. Textbook of Penetrating Trauma. 1st ed. Baltimore, Md: Williams & Wilkins, 1996:300-308.

Diagnostic peritoneal lavage

Marx J. Diagnostic Peritoneal Lavage. In: Ivatury RR, Cayton CG, editors. Textbook of Penetrating Trauma. 1st ed. Baltimore, Md: Williams & Wilkins, 1996:335-343.

Wilson RF, Walt AJ. General Considerations in Abdominal Trauma. In: Wilson RF, Walt AJ. Management of Trauma: Pitfalls and Practice. 2nd ed. Baltimore, Md: Williams & Wilkins; 1996:411-431/20.

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Keywords

abdominal stab wound exploration, local wound exploration, LWE, rectus fascia, rectus sheath, transversus abdominis muscle, transverse abdominal muscle, back stab wound, flank stab wound, stabbing, penetrating wound, nonpenetrating wound, penetrating abdominal trauma, diagnostic peritoneal lavage, DPL, peritoneal wound, midline wound, lateral wound, wound exploration, laparotomy

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Contributor Information and Disclosures

Author

Richard B Lawson, MB, BCh, Registrar, Department of Anesthesia, Johannesburg Hospital
Richard B Lawson, MB, BCh is a member of the following medical societies: South African Medical Association
Disclosure: Nothing to disclose.

Coauthor(s)

Jacques Goosen, MB, ChB, (PRET), FCSSA, Principal Surgeon and Head, Trauma Unit, Johannesburg Hospital and University of the Witwatersrand
Disclosure: Nothing to disclose.

Medical Editor

Erik D Schraga, MD, Consulting Staff, Department of Emergency Medicine, Mills-Peninsula Emergency Medical Associates; Consulting Staff, Permanente Medical Group, Kaiser Permanente, Santa Clara Medical Center
Disclosure: Nothing to disclose.

Pharmacy Editor

Mary L Windle, PharmD, Adjunct Assistant Professor, University of Nebraska Medical Center College of Pharmacy, Pharmacy Editor, eMedicine
Disclosure: Pfizer Inc Stock Investment from financial planner; Avanir Pharma Stock Investment from financial planner ; WebMD Salary and stock Employment and investment from financial planner

Managing Editor

Luis M Lovato, MD, Associate Clinical Professor, David Geffen School of Medicine at UCLA; Director of Critical Care, Department of Emergency Medicine, Olive View/UCLA Medical Center
Luis M Lovato, MD is a member of the following medical societies: Alpha Omega Alpha, American College of Emergency Physicians, and Society for Academic Emergency Medicine
Disclosure: Nothing to disclose.

CME Editor

Gil Z Shlamovitz, MD, Assistant Professor of Emergency Medicine, University of Connecticut School of Medicine; Attending Physician, Emergency Department, Windham Community Memorial Hospital, Willimantic, CT; Attending Physician, Emergency Department, Hartford Hospital, Hartford, CT
Gil Z Shlamovitz, MD is a member of the following medical societies: American Academy of Emergency Medicine and American College of Emergency Physicians
Disclosure: Nothing to disclose.

Chief Editor

Rick Kulkarni, MD, Medical Director, Assistant Professor of Surgery, Section of Emergency Medicine, Yale-New Haven Hospital
Rick Kulkarni, MD is a member of the following medical societies: Alpha Omega Alpha, American Academy of Emergency Medicine, American College of Emergency Physicians, American Medical Association, American Medical Informatics Association, Phi Beta Kappa, and Society for Academic Emergency Medicine
Disclosure: WebMD Salary Employment

 
 
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