Abdominal Stab Wound Exploration Technique
- Author: Juan L Poggio, MD, MS, FACS, FASCRS; Chief Editor: Erik D Schraga, MD more...
Obtain informed consent for the procedure.
Gather and check equipment.
Position the patient supine and elevate the operating table or stretcher to an appropriate height.
Shave and prepare the area around the stab wound. The maintenance of a sterile field is essential (see the video below).
Local wound exploration requires an operator and an assistant. Both the operator and assistant should scrub, as for any surgical procedure.
Liberally infiltrate local anesthetic with epinephrine around the wound, using standard surgical technique. Adequate hemostasis is necessary to facilitate direct visualization of the tract of the wound and to prevent further hemorrhage in wounds that penetrate the peritoneum. Also, the wound may need to be extended, which may result in further bleeding. For both these reasons, lidocaine with epinephrine is preferred as the anesthetic agent. Achieving poor hemostasis has been associated with subsequent false-positive diagnostic peritoneal lavage (DPL) results and unnecessary laparotomy. Do not exceed the maximum dose of lidocaine.
Most stab wounds are small and need to be extended with a scalpel to allow visualization of the underlying fascia. To optimize subsequent wound healing and cosmetic result, midline wounds should be extended vertically and lateral wounds should be extended horizontally (see the videos below) along natural skin lines. The required length of extension is determined by the depth of subcutaneous fat. Wounds heal from the sides rather than the ends; hence, lengthening the wound does not affect the repair process.
The assistant uses the retractors to visualize the depths of the wound (see video below). Diathermy is a useful aid in the maintenance of hemostasis.
Appreciation of the anatomy of the anterior abdominal wall at different levels is essential. The procedure cannot be safely completed if you do not know which layer you are exploring and what lies immediately beneath it (see video and images below).
Further explore the wound under direct vision, taking care to identify the fascial layers and the musculature. Breach of the anterior rectus fascia requires extension of the fascial defect. This can be achieved with a scalpel, with dissecting scissors, or with diathermy. This allows inspection of the underlying muscle and the posterior layer of the rectus sheath. There is no posterior layer of rectus sheath below the arcuate line, but the rectus fascial defect is still extended to allow inspection of the underlying muscle and transversalis fascia.
The goal of exploration is to determine the end point of the tract (see video below). This is not always easy, especially in more lateral wounds. The fascial planes are more difficult to identify laterally. Following the tract through muscle can be challenging. If the posterior rectus fascia or transversalis fascia is adequately visualized and is intact, the patient does not have an intra-abdominal injury. After adequate wound care, the patient can be discharged from the emergency department.
If the posterior rectus fascia or the transversalis fascia is penetrated, the local wound exploration findings are positive (see video below). The frequency of peritoneal injury is high in patients with positive findings. Assessing the integrity of the parietal peritoneum itself is technically difficult, and exploring at this level risks converting a nonpenetrating wound into a wound that breaches the peritoneum. If breach of the peritoneum cannot be confidently excluded, the patient requires further assessment and investigation.
Patients who require further investigation may undergo DPL. The wound should be temporarily packed with dry gauze and a sterile dressing until the lavage is completed. This packing helps prevent further hemorrhage into the peritoneum from the wound. A DPL with positive findings further delineates patients who are more likely to have an intra-abdominal injury that requires surgical intervention. The stomach and bladder must be decompressed before DPL.
The wound is then thoroughly irrigated with saline and closed in layers. Hemostasis and sound surgical technique prevent subsequent wound complications. The sheath is closed with strong absorbable suture (PDS 0 or Vicryl 0). Muscle need only be repaired if the defect is large. If muscle repair is necessary, interrupted absorbable sutures (Vicryl 2-0) are used (see video below). In individuals who are obese, the subcutaneous fat can be approximated with absorbable sutures. The wound edges rarely require debridement before skin closure. The skin is closed with skin clips, interrupted nonabsorbable sutures, or continuous subcuticular sutures. Some authors have advocated suturing the surgical extension wound but leaving the stab wound to heal by secondary intention to minimize the risk of infection. Unless the wound is markedly contaminated, this is unnecessary.
Patients with an exploration with negative findings may be discharged home. Antibiotics are not required. Routine surgical wound care is provided.
The critical concept is to determine the end point of the tract under direct vision.
Ensure good lighting.
Ensure hemostasis and adequate anesthesia.
Extend the wound to allow good visualization.
Use retractors and a trained assistant.
Use a hemostat or other instrument as a guard to cut onto when exploring the depths of the wound. This assists with accuracy of dissection and prevents extending the wound at a deeper level than anticipated.
The exploration usually takes 10-15 minutes. Meticulous dissection ultimately saves time.
The exploration of an abdominal wound in patients who are markedly obese can be particularly challenging. In these patients, consider performing the procedure in the operating room with the patient under general anesthesia.
Do not probe the wound with a finger or blunt object, as this can cause further hemorrhage, give a false impression of the tract, distort the anatomy of the wound, and introduce infection into the depths of the wound.
Diathermy simplifies the exploration because it helps maintain hemostasis.
When doubt exists, prudence involves further investigation, observation, or consideration for exploratory laparotomy.
Cayton CG, Nassoura ZE. Abdomen. Ivatury RR, Cayton CG. Textbook of Penetrating Trauma. Chap 24. Baltimore, Md: Williams & Wilkins; 1996. 281-99.
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. 1984 May. 199(5):549-54. [Medline].
Shaftan GW. Indications for operation in abdominal trauma. Am J Surg. 1960 May. 99:657-64. [Medline].
Sanei B, Mahmoudieh M, Talebzadeh H, Shahabi Shahmiri S, Aghaei Z. Do patients with penetrating abdominal stab wounds require laparotomy?. Arch Trauma Res. 2013 Spring. 2(1):21-5. [Medline]. [Full Text].
Paydar S, Salahi R, Izadifard F, Jaafari Z, Abbasi HR, Eshraghian A, et al. Comparison of conservative management and laparotomy in the management of stable patients with abdominal stab wound. Am J Emerg Med. 2011 Nov 17. [Medline].
Berardoni NE, Kopelman TR, O'Neill PJ, August DL, Vail SJ, Pieri PG, et al. Use of computed tomography in the initial evaluation of anterior abdominal stab wounds. Am J Surg. 2011 Dec. 202(6):690-6. [Medline].
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. 1984 Dec. 148(6):772-7. [Medline].
Cothren CC, Moore EE, Warren FA, Kashuk JL, Biffl WL, Johnson JL. Local wound exploration remains a valuable triage tool for the evaluation of anterior abdominal stab wounds. Am J Surg. 2009 Aug. 198(2):223-6. [Medline].
Leppäniemi AK, Voutilainen PE, Haapiainen RK. Indications for early mandatory laparotomy in abdominal stab wounds. Br J Surg. 1999 Jan. 86(1):76-80. [Medline].
Biffl WL, Kaups KL, Cothren CC, Brasel KJ, Dicker RA, Bullard MK. Management of patients with anterior abdominal stab wounds: a Western Trauma Association multicenter trial. J Trauma. 2009 May. 66(5):1294-301. [Medline].
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].
Thal ER. Evaluation of peritoneal lavage and local exploration in lower chest and abdominal stab wounds. J Trauma. 1977 Aug. 17(8):642-8. [Medline].
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. 2007 Aug. 77(8):614-20. [Medline].
Barry P, Shakeshaft J, Studd R. Abdominal Injuries. Sherry E, Templeton J, Trieu L, eds. Trauma. New York: Oxford University; 2003. 213-26.
Thal ER. Commentary. Ivatury RR, Cayton CG, eds. Textbook of Penetrating Trauma. Baltimore, Md: Williams & Wilkins; 1996. 307-8.
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. 1983 Oct. 198(4):411-9. [Medline].
Burnweit CA, Thal ER. Significance of omental evisceration in abdominal stab wounds. Am J Surg. 1986 Dec. 152(6):670-3. [Medline].
Nagy K, Roberts R, Joseph K, An G, Barrett J. Evisceration after abdominal stab wounds: is laparotomy required?. J Trauma. 1999 Oct. 47(4):622-4; discussion 624-6. [Medline].
Nicholson K, Inaba K, Skiada D, Okoye O, Lam L, Grabo D, et al. Management of patients with evisceration after abdominal stab wounds. Am Surg. 2014 Oct. 80(10):984-8. [Medline].
Demetriades D, Rabinowitz B. Indications for operation in abdominal stab wounds. A prospective study of 651 patients. Ann Surg. 1987 Feb. 205(2):129-32. [Medline].
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. 2005 Mar. 58(3):526-32. [Medline].
Como JJ, Bokhari F, Chiu WC, Duane TM, Holevar MR, Tandoh MA. Practice management guidelines for selective nonoperative management of penetrating abdominal trauma. J Trauma. 2010 Mar. 68(3):721-33. [Medline].
Bautz PC. Management of stab wounds in South Africa. ANZ J Surg. 2007 Aug. 77(8):611-2. [Medline].
Jansen JO, Inaba K, Rizoli SB, Boffard KD, Demetriades D. Selective non-operative management of penetrating abdominal injury in Great Britain and Ireland: Survey of practice. Injury. 2011 Apr 27. [Medline].
Rezende-Neto JB, Vieira HM Jr, Rodrigues Bde L, Rizoli S, Nascimento B, Fraga GP. Management of stab wounds to the anterior abdominal wall. Rev Col Bras Cir. 2014 Jan-Feb. 41(1):75-9. [Medline].
Rosemurgy AS 2nd, Albrink MH, Olson SM, Sherman H, Albertini J, Kramer R. Abdominal stab wound protocol: prospective study documents applicability for widespread use. Am Surg. 1995 Feb. 61(2):112-6. [Medline].
Thompson JS, Moore EE, Van Duzer-Moore S, Moore JB, Galloway AC. The evolution of abdominal stab wound management. J Trauma. 1980 Jun. 20(6):478-84. [Medline].
American College of Surgeons. Abdominal Trauma. Advanced Trauma Life Support for Doctors: Student Course Manual. 6th ed. Chicago Ill: American College of Surgeons; 1997. 167.
Gonzalez RP, Turk B, Falimirski ME, Holevar MR. Abdominal stab wounds: diagnostic peritoneal lavage criteria for emergency room discharge. J Trauma. 2001 Nov. 51(5):939-43. [Medline].
Wilson RF, Walt AJ. General Considerations in Abdominal Trauma. Wilson RF, Walt AJ, eds. Management of Trauma: Pitfalls and Practice. 2nd ed. Baltimore, Md: Williams & Wilkins; 1996. 411-31/20.
Thacker LK, Parks J, Thal ER. Diagnostic peritoneal lavage: is 100,000 RBCs a valid figure for penetrating abdominal trauma?. J Trauma. 2007 Apr. 62(4):853-7. [Medline].
Nagy KK, Roberts RR, Joseph KT, Smith RF, An GC, Bokhari F. Experience with over 2500 diagnostic peritoneal lavages. Injury. 2000 Sep. 31(7):479-82. [Medline].
Cha JY, Kashuk JL, Sarin EL, Cothren CC, Johnson JL, Biffl WL. Diagnostic peritoneal lavage remains a valuable adjunct to modern imaging techniques. J Trauma. 2009 Aug. 67(2):330-4; discussion 334-6. [Medline].
Enderson BL, Maull KI. Missed injuries. The trauma surgeon's nemesis. Surg Clin North Am. 1991 Apr. 71(2):399-418. [Medline].
Bull JC Jr, Mathewson C Jr. Exploratory laparotomy in patients with penetrating wounds of the abdomen. Am J Surg. 1968 Aug. 116(2):223-8. [Medline].
Alzamel HA, Cohn SM. When is it safe to discharge asymptomatic patients with abdominal stab wounds?. J Trauma. 2005 Mar. 58(3):523-5. [Medline].
Tsikitis V, Biffl WL, Majercik S, Harrington DT, Cioffi WG. Selective clinical management of anterior abdominal stab wounds. Am J Surg. 2004 Dec. 188(6):807-12. [Medline].
Navsaria PH, Berli JU, Edu S, Nicol AJ. Non-operative management of abdominal stab wounds--an analysis of 186 patients. S Afr J Surg. 2007 Nov. 45(4):128-30, 132. [Medline].
Clarke DL, Allorto NL, Thomson SR. An audit of failed non-operative management of abdominal stab wounds. Injury. 2010 May. 41(5):488-91. [Medline].
Martin RR, Burch JM, Richardson R, Mattox KL. Outcome for delayed operation of penetrating colon injuries. J Trauma. 1991 Dec. 31(12):1591-5. [Medline].
Plackett TP, Fleurat J, Putty B, Demetriades D, Plurad D. Selective nonoperative management of anterior abdominal stab wounds: 1992-2008. J Trauma. 2011 Feb. 70(2):408-13; discussion 413-4. [Medline].
Aragón GE, Eiseman B. Abdominal stab wounds: evaluation of sinography. J Trauma. 1976 Oct. 16(10):792-7. [Medline].
Demetriades D, Hadjizacharia P, Constantinou C, Brown C, Inaba K, Rhee P. Selective nonoperative management of penetrating abdominal solid organ injuries. Ann Surg. 2006 Oct. 244(4):620-8. [Medline].
Salim A, Sangthong B, Martin M, Brown C, Plurad D, Inaba K. Use of computed tomography in anterior abdominal stab wounds: results of a prospective study. Arch Surg. 2006 Aug. 141(8):745-50; discussion 750-2. [Medline].
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. 1989 Apr. 29(4):446-50. [Medline].
Weinberg JA, Magnotti LJ, Edwards NM, Claridge JA, Minard G, Fabian TC. "Awake" laparoscopy for the evaluation of equivocal penetrating abdominal wounds. Injury. 2007 Jan. 38(1):60-4. [Medline].
Lin HF, Wu JM, Tu CC, Chen HA, Shih HC. Value of diagnostic and therapeutic laparoscopy for abdominal stab wounds. World J Surg. 2010 Jul. 34(7):1653-62. [Medline].
Leppäniemi A, Haapiainen R. Diagnostic laparoscopy in abdominal stab wounds: a prospective, randomized study. J Trauma. 2003 Oct. 55(4):636-45. [Medline].
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. 2004 May. 56(5):953-7; discussion 957-9. [Medline].
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. 2004 Nov. 57(5):934-8. [Medline].
Udobi KF, Rodriguez A, Chiu WC, Scalea TM. Role of ultrasonography in penetrating abdominal trauma: a prospective clinical study. J Trauma. 2001 Mar. 50(3):475-9. [Medline].
Murphy JT, Hall J, Provost D. Fascial ultrasound for evaluation of anterior abdominal stab wound injury. J Trauma. 2005 Oct. 59(4):843-6. [Medline].
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. 2005 Nov. 22(11):790-4. [Medline].
Petersen SR, Sheldon GF. Morbidity of a negative finding at laparotomy in abdominal trauma. Surg Gynecol Obstet. 1979 Jan. 148(1):23-6. [Medline].
Ertan T, Sevim Y, Sarigoz T, Topuz O, Tastan B. Benefits of CT tractography in evaluation of anterior abdominal stab wounds. Am J Emerg Med. 2015 Sep. 33 (9):1188-90. [Medline].
Ahmed BA, Matheny ME, Rice PL, Clarke JR, Ogunyemi OI. A comparison of methods for assessing penetrating trauma on retrospective multi-center data. J Biomed Inform. 2009 Apr. 42(2):308-16. [Medline].