Non-therapeutic operations for penetrating trauma: early morbidity and mortality

A characterization of trauma laparotomies in a scandinavian setting: an observational study

BACKGROUND

Despite treatment advances, trauma laparotomy continuous to be associated with significant morbidity and mortality. Most of the literature originates from high volume centers, whereas patient characteristics and outcomes in a Scandinavian setting is not well described. The objective of this study is to characterize treatments and outcomes of patients undergoing trauma laparotomy in a Scandinavian setting and compare this to international reports.

METHODS

A retrospective study was performed in the Copenhagen University Hospital, Rigshospitalet (CUHR). All patients undergoing a trauma laparotomy within the first 24 h of admission between January 1st 2019 and December 31st 2020 were included. Collected data included demographics, trauma mechanism, injuries, procedures performed and outcomes.

RESULTS

A total of 1713 trauma patients were admitted to CUHR of which 98 patients underwent trauma laparotomy. Penetrating trauma accounted for 16.6% of the trauma population and 66.3% of trauma laparotomies. Median time to surgery after arrival at the trauma center (TC) was 12 min for surgeries performed in the Emergency Department (ED) and 103 min for surgeries performed in the operating room (OR). A total of 14.3% of the procedures were performed in the ED. A damage control strategy (DCS) approach was chosen in 18.4% of cases. Our rate of negative laparotomies was 17.3%. We found a mortality rate of 8.2%. The total median length of stay was 6.1 days.

CONCLUSION

The overall rates, findings, and outcomes of trauma laparotomies in this Danish cohort is comparable to reports from similar Western European trauma systems.

Multi-center validation of the Bowel Injury Predictive Score (BIPS) for the early identification of need to operate in blunt bowel and mesenteric injuries

INTRODUCTION

The Bowel Injury Prediction Score (BIPS) is a tool for identifying patients at risk for blunt bowel and mesenteric injury (BBMI) requiring surgery. BIPS is calculated by assigning one point for each of the following: (1) WBC ≥ 17,000, (2) abdominal tenderness, and (3) injury grade ≥ 4 (mesenteric contusion or hematoma with bowel wall thickening or adjacent interloop fluid collection) on CT scan. A total score ≥ 2 is associated with BBMI requiring surgery. We aimed to validate the BIPS as a predictor for patients with BBMIs requiring operative intervention in a multi-center prospective study.

MATERIALS AND METHODS

Patients were prospectively enrolled at 15 U.S. trauma centers following blunt trauma with suspicion of BBMI on CT scan between July 1, 2018 and July 31, 2019. The BIPS was calculated for each patient enrolled in the study.

RESULTS

Of 313 patients, 38% had BBMI requiring operative intervention. Patients were significantly more likely to require surgery in the presence of abdominal tenderness (OR, 3.6; 95% CI, 1.6-8.0) and CT grade ≥ 4 (OR, 11.7; 95% CI, 5.7-23.7). Patients with a BIPS ≥ 2 were more than ten times more likely to require laparotomy than those with a BIPS < 2 (OR, 10.1; 95% CI, 5.0-20.4). The sensitivity, specificity, positive predictive value (PPV), and negative predictive value (NPV) of a BIPS ≥ 2 for BBMI requiring surgery was 72% (CI 0.6-0.8), 78% (CI 0.7-0.8), 67% (CI 0.6-0.8), and 82% (CI 0.8-0.9), respectively. The AUROC curve for BIPS ≥ 2 was 0.75. The sensitivity, specificity, PPV, and NPV of a BIPS ≥ 2 for BBMI requiring surgery in patients with severe alteration in mental status (GCS 3-8) was 70% (CI 0.5-0.9), 92% (CI 0.8-1.0), 82% (CI 0.6-1.0), and 86% (CI 0.7-1.0), respectively.

CONCLUSION

This prospective multi-center trial validates BIPS as a predictor of BBMI requiring surgery. Calculation of BIPS during the initial evaluation of trauma patients is a useful adjunct to help general surgeons taking trauma call determine operative versus non-operative management of patients with BBMI including those with severe alteration in mental status.

Expectant management in delayed presentation of war casualties with penetrating abdominal trauma

INTRODUCTION

While the management of acute civilian abdominal injuries is well established, The literature regarding the management of battle-related abdominal injuries presented in a delayed fashion is scarce. The objective of this study was to investigate the safety of non-operative management approach in delayed evacuation of battle-related abdominal injuries.

METHODS

Clinical records of thirty-seven hemodynamically normal patients with battle related injuries and Computed Tomography (CT) findings of penetrating abdominal trauma were retrospectively studied.

RESULTS

All 37 patients suffered penetrating abdominal injuries during the civil war in Syria. In this complex scenario, the casualties presented after a minimum 12-hour delay to our hospital. All patients had abnormal abdominal CT scans with no clinical peritoneal signs. Twenty-one [of the 37] patients exhibited 29 hard signs on CT scan. Of these, 17 patients were treated non-operatively and 4 underwent exploratory laparotomy (of which 2 were non-therapeutic). Sixteen patients exhibited a total of 75 soft signs on CT scan; 15 were treated non-operatively and one underwent non-therapeutic laparotomy. No complications were recorded in either the operative or non-operative groups. In total, 32 patients (86%) were treated non-operatively. Five patients (14%) underwent exploratory laparotomy (3 of which were non-therapeutic). Length of stay was dependent on the unique requirements of each individual patient as determined by the state department for returning across the border.

CONCLUSION

We propose that in battle related casualties, acute survivable penetrating abdominal trauma may be safely treated non-operatively in selected patients who are hemodynamically normal and in whom there is an absence of abdominal pain or tenderness on repeated clinical assessment.

Focused Assessment with Sonography in Trauma for Assessment of Injury in Military Settings: A Meta-analysis

Background

Non-invasive, rapid, and precise assessment of injury in the military settings is extremely important, yet difficult. Focused assessment with sonography in trauma (FAST) is being increasingly employed for assessing the location and severity of injury and guiding further treatment strategy. However, the evidence regarding the utility of FAST in the military settings is scattered.

Aims

To evaluate the diagnostic performance of FAST in the assessment of injury in the military settings.

Study Design

Meta-analysis.

Methods

We identified all relevant papers via the PubMed, EMBASE, and Cochrane Library databases. We evaluated the quality of included studies by the Quality Assessment of Diagnostic Accuracy Studies-2 tool. We pooled the area under the curve (AUC), sensitivity, specificity, positive and negative likelihood ratios, and diagnostic odds ratio as the effect sizes, followed by evaluating the heterogeneity among the studies by p value and I2.

Results

Among the 39 papers, a total of six papers were included. The sample size ranged from 15 to 396. The AUC of FAST for assessing the injury was 0.85. The pooled sensitivity, specificity, positive and negative likelihood ratios, and diagnostic odds ratio were 0.66, 0.98, 33.1, 0.34, and 97, respectively. The heterogeneity among the studies was statistically significant (p=0.006, I2=78%).

Conclusion

FAST is potentially valuable for assessing injury in the military settings. Due to its high specificity, FAST may be appropriate to rule in significant injury. However, because of its poor sensitivity, the ability of FAST to rule out injury cannot be relied upon.

Avoiding delayed diagnosis of significant blunt bowel and mesenteric injuries: Can a scoring tool make the difference? A 7-year retrospective cohort study

INTRODUCTION

Significant blunt bowel and mesenteric injuries (sBBMI) are frequently missed despite the widespread use of computed tomography (CT). Early treatment improves the outcome related to these injuries. The aim of this study was to assess the prevalence of sBBMI, the incidence of delayed diagnosis and to test the performance of the Bowel Injury Prediction Score (BIPS), determined by the white blood cell (WBC) count, presence or absence of abdominal tenderness and CT grade of mesenteric injury.

PATIENTS AND METHODS

Single-centre, registry-based retrospective cohort study, screening all consecutive trauma patients admitted to Lausanne University Hospital Trauma Centre from 2008 to 2015 after a road traffic accident. All patients with reliable information about the presence or absence of sBBMI who underwent abdominal CT and for whom calculation of the BIPS was possible were included for analysis. The incidence of delayed (>24h after admission) diagnosis in the patient group with sBBMI was determined and the diagnostic performance of the BIPS for sBBMI was assessed.

RESULTS

For analysis, 766 patients with reliable information about the presence or absence of sBBMI were included. The prevalence of sBBMI was 3.1% (24/766). In 24% (5/21) of stable trauma patients undergoing CT, a diagnostic delay of more than 24h occurred. Abdominal tenderness (p<0.0001) and CT grade ≥4 (p<0.0001) were associated with sBBMI, whereas CT grade 4 alone (p=0.93) and WBC count ≥17G/l (p=0.30) were not. A BIPS ≥2 had a sensitivity of 89% (95% CI, 67-99), specificity of 89% (95% CI, 86-91), positive likelihood ratio of 8 (95% CI, 6.1-10), negative likelihood ratio of 0.12 (95% CI, 0.03-0.44), positive predictive value (PPV) of 19% (95% CI, 15-24) and negative predictive value (NPV) of 99.7% (95% CI, 98.7-99.9). CT alone identified 79% (15/19) and the BIPS 89% (17/19) of patients with sBBMI (p=0.66).

CONCLUSIONS

Diagnostic delays in patients with sBBMI are common (24%), despite the routine use of abdominal CT. Application of the BIPS on the present cohort would have led to a high number of non-therapeutic abdominal explorations without identifying significantly more sBBMI early than CT alone.

The diagnostic yield of commonly used investigations in pelvic gunshot wounds

BACKGROUND

Patients who sustain pelvic gunshot wounds (GSWs) are at significant risk for injury owing to the density of pelvic structures. Currently, the optimal workup for pelvic GSWs is unclear. The aims of this study were to determine the diagnostic yield of tests commonly used in the investigation of pelvic GSWs and to develop a diagnostic algorithm.

METHODS

All patients 15 years or older presenting to the Los Angeles County + University of Southern California Medical Center (January 2008 to February 2015) who sustained one or more pelvic GSWs were retrospectively identified. Patients' demographics, clinical assessment, investigations, procedures, and outcomes were abstracted. The diagnostic yield of computed tomographic (CT) scan, cystogram, gross inspection of the urine, urinalysis, endoscopy, and digital rectal examination (DRE) in the detection of clinically significant injuries to the pelvis were calculated.

RESULTS

Three hundred seventy patients were included. Patients with peritonitis, hemodynamic instability, an unevaluable abdomen, or evisceration were taken to the operating room for immediate laparotomy (n = 138 [37.3%]). All others (n = 232 [62.7%]) underwent CT scan and further investigations as indicated. The sensitivity, specificity, positive predictive value, and negative predictive value of the investigations were CT scan: 1.00, 0.98, 0.74, and 1.00; cystogram: 1.00 for all parameters; gross inspection of the urine: 1.00 for all parameters; urinalysis: 1.00, 0.71, 0.17, and 1.00; endoscopy: 1.00, 0.82, 0.75, and 1.00; and DRE: 0.77, 0.99, 0.77, and 0.99.

CONCLUSION

In the workup of pelvic GSWs, patients with hemodynamic instability, peritonitis, evisceration, or an unevaluable abdomen should undergo immediate laparotomy, while all others should undergo CT scan. Computed tomography-positive patients should be managed for their injuries. If the CT is negative, the likelihood of a clinically significant injury is very low. If the CT is equivocal for rectal or bladder injury, endoscopy or cystogram should be used to guide definitive management. There is no role for routine urinalysis or DRE. Further prospective validation of these findings is warranted.

LEVEL OF EVIDENCE

Diagnostic study, level III; therapeutic study, level IV.

Feasibility of selective non-operative management for penetrating abdominal trauma in France

INTRODUCTION

In France, non-operative management (NOM) is not the widely accepted treatment for penetrating wounds. The aim of our study was to evaluate the feasibility of NOM for the treatment of penetrating abdominal traumas at 3 hospitals in the Southeast of France.

METHODOLOGY

Our study was multicentric and retroprospective from January, 2010 to September, 2013. Patients presenting with a penetrating abdominal stab wound (SW) or gunshot wound (GSW) were included in the study. Those with signs of acute abdomen or hemodynamic instability had immediate surgery. Patients who were hemodynamically stable had a CT scan with contrast. If no intra-abdominal injury requiring surgery was evident, patients were observed. Criteria evaluated were failed NOM and its morbidity, rate of non-therapeutic procedures (NTP) and their morbidity, length of hospital stay and cost analysis.

RESULTS

One hundred patients were included in the study. One patient died at admission. Twenty-seven were selected for NOM (20 SW and 7 GSW). Morbidity rate was 18%. Failure rate was 7.4% (2 patients) and there were no mortality. Seventy-two patients required operation of which 22 were NTP. In this sub-group, the morbidity rate was 9%. There were no mortality. Median length of hospital stay was 4 days for the NOM group and 5.5 days for group requiring surgery. Cost analysis showed an economic advantage to NOM.

CONCLUSION

Implementation of NOM of penetrating trauma is feasible and safe in France. Indications may be extended even for some GSW. Clinical criteria are clearly defined but CT scan criteria should be better described to improve patient selection. NOM reduced costs and length of hospital stay.

Penetrating neck injury: a review

Penetrating injury to the neck has inspired considerable controversy with regard to its management, owing to the large number of important, susceptible structures contained in this area. Mandatory exploration of all wounds has generally given way to selective operative management. Clinical assessment has, once again, become the prime diagnostic tool. This review describes the evolution of management and the value of various diagnostic modalities. It concludes with a summary of appropriate operative techniques.

Current management of penetrating torso trauma: nontherapeutic is not good enough anymore

A highly organized approach to the evaluation and treatment of penetrating torso injuries based on regional anatomy provides rapid diagnostic and therapeutic consistency. It also minimizes delays in diagnosis, missed injuries and nontherapeutic laparotomies. This review discusses an optimal sequence of structured rapid assessments that allow the clinician to rapidly proceed to gold standard therapies with a minimal risk of associated morbidity.

The principles of non-operative management of penetrating abdominal injury

The selective non-operative management of penetrating abdominal injury is gaining increasing acceptance. Recognition of the morbidity, mortality, and cost associated with non-therapeutic exploration has provided the impetus for selective management. This review describes the principles of, and evidence for, this strategy. Selective management is widely accepted for the treatment of stab wounds, but the selective management of ballistic injuries, particularly in the military setting, remains contentious. As a result, there are marked variations in the application of this practice. Computed tomography is a prerequisite for the selective management of ballistic injuries, and possibly also stab wounds. Failure of non-operative management, following stab wounds or gunshot wounds, is invariably apparent within 24 hours.

Non-operative management of abdominal gunshot wounds

Over the history of surgery, the management of abdominal gunshot wounds in the stable evaluable patient without peritonitis has evolved. While non-operative management has been widely accepted and employed for the management of abdominal stab wounds, recently it has been deemed a safe option for abdominal gunshot wounds as well. Selective non-operative management of penetrating abdominal trauma in the appropriate setting has been shown to decrease the rate of nontherapeutic laparotomy as well as the cost and total length of hospital stay, and potentially decrease short- and long-term morbidity. This review examines the background support for non-operative management of abdominal gunshot wounds while discussing patient evaluation, selection, and clinical management.

Selective non-operative management of abdominal gunshot wounds: survey of practise

BACKGROUND

There is a growing body of evidence attesting to the effectiveness and safety of selective non-operative management (SNOM) of abdominal gunshot wounds. However, much of the research which supports this conclusion has originated from a few centres, and the actual utilisation of SNOM by trauma surgeons is not known. We therefore conducted a survey to assess the acceptance of this strategy and evaluate variations in practise.

METHODS

Electronic questionnaire survey of trauma surgeons in the United States of America, Canada, Brazil, and South Africa. Responses were compared using Chi(2) and Fisher's exact tests.

RESULTS

183 replies were received. 105 (57%) respondents practise SNOM of abdominal gunshot wounds, but there are marked regional variations in the acceptance of this strategy (p<0.01). Respondents who had completed trauma (p<0.01) or critical care (p<0.01) fellowships, and those who practise in a higher volume centre (defined as >50 penetrating abdominal injuries seen per year) (p<0.01) are more likely to practise SNOM of gunshot wounds. Most surgeons who practise SNOM regard peritonitis, omental and bowel evisceration, and being unable to evaluate a patient as a contraindication to attempting non-operative management. Almost all regard CT as essential. Respondents' preparedness to consider SNOM is related to injury extent.

CONCLUSIONS

SNOM of abdominal gunshot wounds is practised by trauma surgeons in all four countries surveyed, but is not universally accepted, and there are variations in how it is practised.

Nontherapeutic laparotomy in combat casualties

BACKGROUND

The selective nonoperative management of ballistic abdominal injury remains contentious, particularly in the military setting. The exigencies of military practice have traditionally favored a more liberal approach to abdominal exploration. The driver for selective nonoperative management is the avoidance of morbidity incurred by nontherapeutic intervention. However, the incidence and complications of nontherapeutic laparotomy (NTL) in the military setting are not known.

METHODS

All UK military patients undergoing a laparotomy following battlefield trauma were identified from the UK Joint Theatre Trauma Registry. Procedures were classed as therapeutic laparotomy (TL) or NTL. Demographics, admission physiology, injury pattern, and mortality were compared, and complications in the NTL group were determined by Joint Theatre Trauma Registry and case record review.

RESULTS

Between March 2003 and March 2011, 130 (7.2%) of 1,813 combat wounded UK service personnel underwent a laparotomy. A total of 103 (79.2%) were considered TL, and 27 (20.8%) were NTL. There was no difference in demographic distribution or mechanism of injury. Patients undergoing TL were more likely to be hypotensive (systolic blood pressure, <90 mm Hg; p = 0.015) and have a reduced consciousness level (Glasgow Coma Scale [GCS] score ≤ 8; p = 0.006). There was a greater abdominal injury burden in the TL group (p < 0.001). There was no difference in severe extra-abdominal injury (Abbreviated Injury Scale [AIS] score ≥ 3), overall Injury Severity Score (ISS) and New ISS (NISS) scores, or mortality. Of the 27 patients who underwent NTL, 7 (25.9%) developed complications.

CONCLUSION

During the past decade, trauma laparotomy has become a relatively uncommon procedure. The NTL rate is also relatively low. This finding could be explained by the fact that selective nonoperative management is used more widely in the military setting than previously thought or that very few military injuries are amenable to nonoperative management. NTL is associated with a significant risk of complications and should therefore be minimized but not at the expense of missing a life-threatening intra-abdominal injury.

LEVEL OF EVIDENCE

Therapeutic study, level IV.

[A study of the predictive value of the primary review and complementary examinations in assessing the need for surgery in patients with stab wounds in the torso]

INTRODUCTION

Observation is the gold standard for stable patients with stab wounds. The aim of the study was to analyse the value of the primary review and complementary examinations to predict the need for surgery in stab wound patients in order to decrease observation times.

METHODS

A retrospective study of stab wound patients recorded in a database. Clinical and diagnostic workup parameters were analysed. The main variable was the need for surgery.

RESULTS

A total of 198 patients were included between 2006 and 2009, with a mean injury severity score (ISS) of 7.8±7, and 0.5% mortality. More than half (52%) of the patients suffered multiple wounds. Wound distribution was 23% neck, 46% thorax and 31% abdomen. Surgery was required in 73 (37%) patients (59% immediate, 27% delayed and 14% delayed). The need for surgery was associated with a lower revised trauma score (RTS), evisceration, active bleeding, and fascial penetration. Initial and control haemoglobin levels were significantly lower in patients who required surgery. A positive computerised tomography (CT) scan was associated with surgery. There were complications in 18% of patients, and they were more frequent in those who underwent surgery. There was no difference in complication rates between immediate and delayed (P=.72). Surgery was finally required in 10% of the patients with no abnormalities in the primary review and diagnostic workup, and 6% of those developed complications.

CONCLUSION

None of the parameters studied could individually assess the need for surgery. Primary and secondary reviews were the most important diagnostic tool, but CT scan should be used more often. An observation period of 24 hours is recommended in torso penetrating wounds.

Selective non-operative management of penetrating abdominal injury in Great Britain and Ireland: survey of practice

BACKGROUND

The selective non-operative management of penetrating abdominal injury is gaining increasing acceptance. In Great Britain and Ireland, the management of trauma remains the responsibility of general surgeons. This study appraises the acceptance and utilisation of selective non-operative management strategies by British and Irish general surgeons, compared with trauma surgeons in the United States of America.

METHODS

Electronic questionnaire survey of British and Irish consultant general surgeons and trauma surgeons in the United States of America.

RESULTS

139 British and Irish general surgeons and 75 US trauma surgeons completed the survey. 84.3% of British and Irish general surgeons and 94.4% of US trauma surgeons practise selective non-operative management of abdominal stab wounds, and 14.0% and 74.3% practise selective non-operative management of abdominal gunshot wounds. The management of those British and Irish surgeons who do practise selective non-operative management is broadly similar to that of US trauma surgeons, with the exception of the use of laparoscopy to examine the left hemidiaphragm following thoracoabdominal injuries, which is employed by fewer British and Irish general surgeons than US trauma surgeons.

CONCLUSIONS

The selective non-operative management of abdominal stab wounds is generally accepted by British and Irish general surgeons. In contrast, few British and Irish surgeons are comfortable with non-operatively managing patients with abdominal gunshot wounds, reflecting both the rarity of this type of injury, and surgeons' training and experience. This proportion is unlikely to change until the management of torso trauma is recognised as a specialty, and services are concentrated in regional centres.

Negative Laparotomy in Trauma: Are We Getting Better?

One of the trauma surgeons’ daily challenges is the balancing act between negative laparotomy and missed abdominal injury. We opted to characterize the indications that prompted a negative trauma exploratory laparotomy and the rate of missed abdominal injuries in an effort to optimize patient selection for laparotomy. At the Los Angeles County + University of Southern California Medical Center, negative laparotomies and missed injuries are consecutively captured and reviewed at the weekly mortality + morbidity (MM) conferences. All written reports of the MM meetings from January 2003 to December 2008 were reviewed to identify all patients who underwent a negative laparotomy or a laparotomy as a result of an initially missed abdominal injury. Over the 6-year study period, a total of 1871 laparotomies were performed, of which 73 (3.9%) were negative. The rate of missed injuries requiring subsequent laparotomy was 1.3 per cent (25 of 1871). The negative laparotomy rate and the rate of missed injuries did not vary significantly during the study period (2.8 to 4.7%, P = 0.875, and 0.7 to 2.9%, P = 0.689). Penetrating mechanisms accounted for the majority of negative laparotomies (58.9%). The primary indication for negative laparotomy was peritonitis (54.8%) followed by hypotension (28.8%) and suspicious computed tomographic scan findings (27.4%). The complication rate after negative laparotomy was 14.5 per cent, and of these, 10.1 per cent were directly related to the procedure. A low but steady rate of negative laparotomies and missed abdominal injuries after trauma remains. Negative laparotomies and missed abdominal injuries when they occur are still associated with significant complication rates and a prolonged length of stay.

Prospective evaluation of selective nonoperative management of torso gunshot wounds: when is it safe to discharge?

BACKGROUND

Selective nonoperative management (NOM) has been increasingly used for torso gunshot wounds (GSWs). The optimal observation time required to exclude a hollow viscus injury is not clear. The purpose of this study was to determine the safe period of observation before discharge.

METHODS

All patients aged 16 years and older sustaining a torso GSW undergoing a trial of NOM were prospectively enrolled (January 2009 to January 2011). Patient demographics, initial computed tomography (CT) results, time to failure of NOM, operative procedures, and outcomes were collected. Failure of NOM was defined as the need for operation.

RESULTS

A total of 270 patients sustained a GSW to the torso. Of those, 25 patients (9.3%) died in the emergency department and were excluded leaving 245 patients available for the analysis. Mean age was 26.5 years ± 9.9 years (16-62 years), 92.7% (227) were men, and mean Injury Severity Score scale was 13.8 ± 11.3 (1-45). Overall, 115 patients (46.9%) underwent immediate exploratory laparotomy based on clinical criteria (72.2% had peritonitis, 27.8% hypotension, 10.4% unevaluable, and 4.3% evisceration), and 130 patients (53.1%) underwent evaluation with CT for possible NOM. Of those, 39 patients (30.0%) had a positive CT and were subsequently operated on. All had significant intra-abdominal injuries requiring surgical management. A total of 91 patients (70.0%) underwent a trial of NOM (47 had equivocal CT findings and 44 had a negative examination). Of these, 8 patients (8.8%) failed NOM and underwent laparotomy (all had equivocal CT scans). Two patients had a nontherapeutic laparotomy; the remainder had stomach (50.0%), colon (25.5%), and rectal (12.5%) injuries. The mean time from admission to development of clinical or laboratory signs of NOM failure was 2 hours:43 minutes ± 2 hours:23 minutes (0 hour:31 minutes-6 hours:58 minutes). All patients failed within 24 hours of admission.

CONCLUSION

In the initial evaluation of patients sustaining a GSW to the torso, clinical examination is essential for identifying those who will require emergency operation. For those undergoing a trial of NOM, all failures occurred within 24 hours of hospital admission, setting a minimum required observation period before discharge.

Selective nonoperative management of torso gunshot wounds: when is it safe to discharge?

BACKGROUND

For patients sustaining torso gunshot wounds (GSWs) who undergo a trial of nonoperative management (NOM), the optimal observation time required to exclude a hollow viscus injury before discharge is unknown. The purpose of this study was to analyze a continuous series of patients undergoing NOM after sustaining a GSW to the torso to determine the safe period of observation before discharge.

METHODS

This is a retrospective analysis of a continuous series of patients assessed at a Level I Trauma Center undergoing NOM of their torso GSWs from 2005 to 2007. After Institutional Review Board approval, injury demographics, operative procedures, time to operation, computed tomographic imaging results, and outcomes were abstracted.

RESULTS

During the 3-year study period, a total of 863 patients sustained a GSW to the torso. Of these, 61 patients (7.1%) died in the emergency department and 15 (1.7%) did not have admission data. After excluding these patients, a total of 787 patients were available for analysis. Mean age was 26.2 +/- 9.7 years (range, 16 - 87 years), 93.6% were male, and mean Injury Severity Score was 10.7 +/- 10.6. Overall, 151 patients (19.2%) underwent immediate exploratory laparotomy, based on clinical criteria, and 636 patients (80.8%) underwent a trial of NOM. Of these, patients, 29 (4.6%) failed and were subsequently taken to the operating room. Two patients had a negative laparotomy; the remaining had colon or rectal (58.6%), small bowel (24.1%), stomach (17.2%), and bladder (6.9%) injuries requiring repair. All patients developed clinical or laboratory evidence of a missed injury by 24 hours of observation.

CONCLUSION

For patients undergoing NOM of their torso GSWs, all patients who failed and required a laparotomy did so within 24 hours of admission. Patients undergoing selective NOM required a minimum of 24 hours of close observation before discharge.

Practice management guidelines for selective nonoperative management of penetrating abdominal trauma

BACKGROUND

: Although there is no debate that patients with peritonitis or hemodynamic instability should undergo urgent laparotomy after penetrating injury to the abdomen, it is also clear that certain stable patients without peritonitis may be managed without operation. The practice of deciding which patients may not need surgery after penetrating abdominal wounds has been termed selective management. This practice has been readily accepted during the past few decades with regard to abdominal stab wounds; however, controversy persists regarding gunshot wounds. Because of this, the Eastern Association for the Surgery of Trauma Practice Management Guidelines Committee set out to develop guidelines to analyze which patients may be managed safely without laparotomy after penetrating abdominal trauma. A secondary goal of this committee was to find which diagnostic adjuncts are useful in the determination of the need for surgical exploration.

METHODS

: A search of the National Library of Medicine and the National Institutes of Health MEDLINE database was performed using PubMed (www.pubmed.gov).

RESULTS

: The search retrieved English language articles concerning selective management of penetrating abdominal trauma and related topics from the years 1960 to 2007. These articles were then used to construct this set of practice management guidelines.

CONCLUSIONS

: Although the rate of nontherapeutic laparotomies after penetrating wounds to the abdomen should be minimized, this should never be at the expense of a delay in the diagnosis and treatment of injury. With this in mind, a routine laparotomy is not indicated in hemodynamically stable patients with abdominal stab wounds without signs of peritonitis or diffuse abdominal tenderness. Likewise, it is also not routinely indicated in stable patients with abdominal gunshot wounds if the wounds are tangential and there are no peritoneal signs. Abdominopelvic computed tomography should be considered in patients selected for initial nonoperative management to facilitate initial management decisions. The majority of patients with penetrating abdominal trauma managed nonoperatively may be discharged after 24 hours of observation in the presence of a reliable abdominal examination and minimal to no abdominal tenderness. Diagnostic laparoscopy may be considered as a tool to evaluate diaphragmatic lacerations and peritoneal penetration in an effort to avoid unnecessary laparotomy.

Injury location dictates utility of digital rectal examination and rigid sigmoidoscopy in the evaluation of penetrating rectal trauma

Penetrating pelvic injuries (specifically rectal) pose a difficult diagnostic challenge. Although management of these injuries, once recognized, can be straightforward, the consequences of a missed injury can be devastating. The purpose of this study was to evaluate the utility of digital rectal examination (DRE) and rigid sigmoidoscopy (RS) as screening tests for penetrating rectal injuries. Patients with full-thickness penetrating rectal injury over a 10-year period were identified. All underwent DRE and RS before exploration. Injury location was classified as intraperitoneal (IP) or extraperitoneal (EP). Overall sensitivities for DRE and RS were calculated as well as sensitivities for RS in the identification of IP versus EP injuries. Seventy-seven patients were identified. Overall sensitivity for DRE and RS was 51 per cent (95% CI: 37-65%) and 78 per cent (95% CI: 65-92%), respectively. Sensitivity of RS for identification of rectal injury based on anatomic distinction was 58 per cent (95% CI: 30-86%) for IP and 88 per cent (95% CI: 75-100%) for EP injuries. Anatomic location determines the value of preoperative screening tests for identification of penetrating rectal injuries. RS proved better than DRE for diagnosis. The greatest benefit was observed with EP injuries. The possibility of a missed IP injury associated with a negative screen should prompt exploration if clinical suspicion is high.

Use of laparoscopy in evaluation and treatment of penetrating and blunt abdominal injuries

Use of laparoscopy in penetrating trauma has been well established; however, its application in blunt trauma is evolving. The authors hypothesized that laparoscopy is safe and feasible as a diagnostic and therapeutic modality in both the patients with penetrating and blunt trauma. Trauma registry data and medical records of consecutive patients who underwent laparoscopy for abdominal trauma were reviewed. Over a 4-year period, 43 patients (18 blunt trauma / 25 penetrating trauma) underwent a diagnostic laparoscopy. Conversion to laparotomy occurred in 9 (50%) blunt trauma and 9 (36%) penetrating trauma patients. Diagnostic laparoscopy was negative in 33% of blunt trauma and 52% of penetrating trauma patients. Sensitivity/specificity of laparoscopy in patients with blunt and penetrating trauma was 92%/100% and 90%/100%, respectively. Overall, laparotomy was avoided in 25 (58%) patients. Use of laparoscopy in selected patients with blunt and penetrating abdominal trauma is safe, minimizes nontherapeutic laparotomies, and allows for minimal invasive management of selected intra-abdominal injuries.

Selective nonoperative management of penetrating torso injury from combat fragmentation wounds

BACKGROUND

Historically, military surgical doctrine has mandated exploratory laparotomy for all penetrating fragmentation wounds. We hypothesized that stable patients with abdominal fragmentation injuries whose computerized tomography (CT) scans for intraperitoneal or retroperitoneal penetration disclosed nothing abnormal, can be safely observed without therapeutic laparotomy.

METHODS

We retrospectively studied all hemodynamically stable patients with penetrating fragmentation wounds to the back, flank, lower chest, abdomen, and pelvis evaluated by abdominal physical examination (PE), CT, or ultrasound treated during a 6-month period at one combat support hospital. Sensitivity, specificity, and positive and negative predictive values were calculated comparing each positive test to laparotomy and each negative test to successful nonoperative management.

RESULTS

One hundred forty-five patients met study criteria. Based on CT scans, 85 (59%) patients were managed nonoperatively; 60 (41%) underwent laparotomy. Forty-five of 60 (75%) of laparotomies were therapeutic. CT scan for intraperitoneal or retroperitoneal penetration that disclosed nothing abnormal was 99% predictive of successful nonoperative management. In detecting intra-abdominal injury requiring laparotomy, sensitivity for each method was 30.2% (PE), 11.7% (ultrasound), and 97.8% (CT) (p < 0.05). Specificity was 94.8% (PE), 100% (ultrasound), and 84.8% (CT). The areas under the receiver operating characteristic (ROC) curves were 0.565 (PE), 0.543 (ultrasound), and 0.929 (CT) (p < 0.0001). All patients with a positive ultrasound (n = 4) underwent therapeutic laparotomy.

CONCLUSION

PE alone was unreliable in stable patients with abdominal fragmentation injuries. The clinical value of ultrasound results was limited, likely because the majority of these stable patients did not have injuries associated with the large accumulation of peritoneal fluid. CT scan safely and effectively analyzed nonoperative management of penetrating abdominal fragmentation injuries and should be the diagnostic study of choice in all stable patients without peritonitis with abdominal, flank, back, or pelvic combat fragmentation wounds.

Selective non-operative management of solid organ injury following abdominal gunshot wounds

BACKGROUND

The objective of this study was to evaluate the outcome of patients sustaining a torso gunshot wound with documented solid organ injury. Our hypothesis was that the non-operative management of isolated solid organ injuries is a safe management option for a select group of patients.

METHODS

A retrospective review of a prospectively collected database was conducted to identify all patients sustaining a torso gunshot resulting in a solid organ injury undergoing non-operative management over a 5-year period (12/1999-01/2005). Patient demographics, injury details, diagnostic imaging, outcome and follow-up were reviewed.

RESULTS

Of 644 gunshot wounds to the torso, 144 (22%) underwent non-operative management. Thirteen of these patients (9%) had 16 solid organ injuries (10 liver, 4 kidney and 2 spleen). CT characterisation of the isolated solid organ injury ranged from AAST Grade I-IV. One of 13 patients failed non-operative management and subsequently underwent laparotomy, which was non-therapeutic. Clinical follow-up was available in all patients for an average of 101 days (median 27, range 6-473). The organ salvage rate was 100%.

SUMMARY

In select haemodynamically stable patients without peritonitis able to undergo serial clinical examination, solid organ injury is not a contra-indication to non-operative management. In the appropriate setting, non-operative management of solid organ injury after gunshot wounding is associated with a high rate of success and organ salvage.

The nonoperative management of penetrating abdominal trauma

The management of penetrating injuries to the abdomen has evolved back to a selective nonoperative approach. Using clinical examination for screening, evaluable patients without hemodynamic instability or peritonitis can safely undergo a trial of nonoperative management. For stab wounds, this involves serial clinical examination with delayed laparoscopic evaluation of the diaphragm for left thoracoabdominal injuries and CT scanning for suspected solid-organ injuries. The same contraindications to nonoperative management apply to gunshot injuries. Gunshot injuries undergoing nonoperative management require detailed trajectory imaging with CT. The presence of peritoneal violation without definite organ injury requires serial clinical examination. Isolated solid-organ injury is not an absolute contraindication to nonoperative management and may benefit from advanced endovascular and percutaneous interventions to facilitate management. Selective nonoperative management of both stab wounds and gunshot injuries is safe and has been shown to decrease the rate of unnecessary laparotomy, length of hospital stay, and management costs.

Colon and rectal injuries

PURPOSE

This study was designed to develop treatment algorithms for colon, rectal, and anal injuries based on the review of relevant literature.

METHODS

Information was obtained through a MEDLINE ( www.nobi.nih.gov/entrez/query.fcgi ) search, and additional references were obtained through cross-referencing key articles cited in these papers.

RESULTS

A total of 203 articles were considered relevant.

CONCLUSIONS

The management of penetrating and blunt colon, rectal, and anal injuries has evolved during the past 150 years. Since the World War II mandate to divert penetrating colon injuries, primary repair or resection and anastomosis have found an increasing role in patients with nondestructive injuries. A critical review of recent literature better defines the role of primary repair and fecal diversion for these injuries and allows for better algorithms for the management of these injuries.

Management of cervical stab wounds in low volume trauma centres: systematic physical examination and low threshold for adjunctive studies, or surgical exploration

INTRODUCTION

In Nordic countries penetrating neck injuries (PNIs) are infrequent and management has traditionally been guided by surgeons' preferences. Some form of selective non-operative approach is currently practised in most urban trauma centres.

OBJECTIVE

To examine demographic features and treatment outcome of non-ballistic penetrating neck injuries in southern Finland and provide management guidelines for centres with low volume of penetrating neck trauma.

MATERIALS AND METHODS

Retrospective analysis of 85 platysma penetrating neck injuries in two southern Finland hospitals (Helsinki University Central Hospital, HUCH and Tampere University Hospital, TaUH) was carried out using the ICD-10 based hospital databases to identify PNI-patients.

RESULTS

The incidence of admitted patients with penetrating neck injuries was 1.3/100000/year. Fifty-two (61%) injuries were caused by random acts of violence, 28 (38%) were self-inflicted and 5 (6%) were accidents. Of all 85 patients, 52 (61%) underwent operative exploration with a negative exploration rate of 65%. Hard signs for vascular or aerodigestive trauma were present in 23 (27%) patients and all of these were operated with a negative exploration rate of 30%. Two patients had no hard signs on physical examination but were operatively explored and significant injuries were found in both patients. The hospital mortality rate was 0% and the overall complication rate for operated patients was 7.7%.

CONCLUSIONS

Trauma centres managing PNIs infrequently should have an individually tailored management protocol for penetrating neck injury patients. If mandatory exploration is not practised, a systematic physical examination should be the mainstay of diagnostic work up but the threshold for adjunctive studies should be low. Although not evident by the current data, protocol-based management could be useful in decreasing treatment variation and enhancing residency training.

Unnecessary laparotomy by using physical examination and different diagnostic modalities for penetrating abdominal stab wounds

BACKGROUND

The modern management of penetrating abdominal trauma has decreased the incidence of unnecessary laparotomy by using selective non-operative management protocols. However, the real benefits of physical examination and different diagnostic methods are still unclear.

METHODS

From January 2000 to April 2003, we prospectively collected data on 117 patients with penetrating stab wounds to the thoracoabdominal, anterior abdominal, and back regions who had non-operative management. Clinical examination was the primary tool to differentiate those patients requiring operation. Findings of physical examination, ultrasound, computed tomography, endoscopy, echocardiography, diagnostic peritoneal lavage, and diagnostic laparoscopy were reviewed. The number of therapeutic, non-therapeutic, and negative laparotomies were recorded.

RESULTS

Non-operative management was successful in 79% of patients. There were 11 early (within 8 hours of admission) and 14 delayed (more than 8 hours after admission) laparotomies performed, depending on the results of various diagnostic procedures. Non-operative management failed in 21% of patients, and the rate of non-therapeutic laparotomy in early and delayed laparatomy groups was 9% and 14% respectively. There was no negative laparatomy.

CONCLUSIONS

The use of physical examination alone and/or together with different diagnostic methods allows reduction of non-therapeutic laparotomies and elimination of negative laparatomies.

Diagnostic and therapeutic laparoscopy for stab wounds of the anterior abdomen

BACKGROUND

At present, laparoscopy is used mainly as a diagnostic tool in patients with abdominal stab wounds.

PATIENTS AND METHODS

Thirty-two hemodynamically stable patients with isolated stab wounds of the anterior abdomen, thought to be penetrating, were prospectively selected to undergo treatment via a laparoscopic approach. When possible, parenchymal wounds were coagulated or sealed, and wounds to the intestines were sutured or stapled.

RESULTS

The results of laparoscopy were negative in 6 (18.8%) of the cases: nonpenetrating wounds in 4 cases and nonsignificant organ injury in 2 cases. A hemoperitoneum was identified in 13 (40.6%) of the cases, and significant organ injuries in 26 (81.3%) of the cases: stomach, 2; small bowel, 5; colon, 2; pancreas, 1; vascular injuries, 4; liver, 5; mesentery, 9. Laparoscopy was therapeutic in 20 (62.3%) of the cases. Conversion to open surgery was required in 6 (18.8%) of the cases. No injuries were missed, and no mortality occurred. Postoperative complications developed in 2 (6.2%) of the cases. The mean hospital stay was 4 days, with no late complications.

CONCLUSIONS

Laparoscopy can avoid a number of unnecessary laparotomies and can treat most of the lesions found in hemodynamically stable patients with anterior abdominal stab wounds.

[Abdominal wound injuries: diagnosis and treatment. Report of 79 cases]

INTRODUCTION

- Traditionally, penetrating abdominal wounds justify routine laparotomy. However, this policy can be adapted to mechanism of injury (stab or firearm) and accuracy of imaging procedures if they eliminate visceral injury thus allowing close follow up.

PATIENTS AND METHODS

Retrospective study of 79 patients (May 1995-May 2002) with a penetrating abdominal wound: (47 (59%) stab wounds and 32 (41 %) firearm wounds). Correlation between imaging and surgical findings, treatment, post-operative course were studied.

RESULTS

Sixty-eight patients were operated on from the outset, and 11 underwent close follow-up. Of the 11 patients who had follow-up, (9 after stab wound and 2 after firearm wound), two had to be operated (1 in each group). Correlation between imaging and surgical findings was good in 34 (72%) patients after stab wound and in 21 (80%) after firearm wound; the mean number of visceral injuries was 1 and 3 respectively. Six patients (8%) died (mortality: 2% and 16% respectively), 12 (15%) had postoperative complications.

CONCLUSION

Penetrating abdominal stab wounds can be treated by close follow-up if imaging excludes visceral injury. Firearm wounds still justify routine laparotomy due to both multiplicity of visceral injuries and bad prognosis.

Plaies abdominales avec épiplocèle

INTRODUCTION

The abdominal stab wound with omentum evisceration, represent 4 to 20% of abdominal injuries. It causes a problem of therapeutic indication between selective and mandatory laparotomy. The goal of this work is to give some answers to this dilemma.

MATERIAL AND METHODS

A retrospective study from 1992 to 2000, concerning 75 patients presenting an omentum evisceration. Where there were 71 men et four women, the mean age was 25 years old. All the abdominal injuries are exclusively by the stab wound. These 75 patients were divided into three groups: group I: 24 patients (32) were immediately operated ahead of the existence of severity elements; group II: 18 (24%) patients had an isolated omentum evisceration without any elements of severity were operated immediately; group III: 33 (44%) were placed under clinical, radiological and ultrasound control.

RESULTS

We have found four cases of negative laparotomy (16,7%) in group I, and 14 (77,8%) in group II. Five secondary laparotomies (15%) were performed in group III. Among the 51 patients (Group II and Group III) nine (17%) had visceral injuries... In all of the three groups, there was a high frequency of intestinal organs injuries, there was no mortality and 12% of morbidity.

CONCLUSION

The isolated omentum evisceration is a penetrating injury of the abdominal wall but not synonym with visceral injuries, the interventionists authors had a high rate of negative laparotomy. However the selective authors in the asymptomatic patients under clinic examination appears logical: we believe that the laparoscopic diagnostic and therapeutic in doubtful cases can resolve this problem.

Technology-driven triage of abdominal trauma: the emerging era of nonoperative management

Selective nonoperative management of blunt or penetrating abdominal trauma is safe, has eliminated the complications associated with nontherapeutic laparotomies, and is cost-effective. Appropriately selected investigations, such as focused abdominal sonography for trauma, diagnostic peritoneal lavage, spiral computed tomography (CT) scan, diagnostic laparoscopy, or thoracoscopy and angiography, play a critical role in the triage of patients. Future technological advances, such as improvement of the ultrasonic hardware and software that provide automated interpretation and the availability of portable CT scan machines in the emergency room, may improve the speed and accuracy of the initial evaluation. Improvement of the optical system of minilaparoscopes may allow reliable bedside laparoscopy for suspected diaphragmatic injuries.

Free fluid on abdominal computed tomography without solid organ injury after blunt abdominal injury does not mandate celiotomy

BACKGROUND

Mandatory celiotomy has been proposed for all patients with unexplained free fluid on abdominal computed tomography (CT) scanning after blunt abdominal injury. This recommendation has been based upon retrospective data and concerns over the potential morbidity from the late diagnosis of blunt intestinal injury. This study examined the rate of intestinal injury in patients with free fluid on abdominal CT after blunt abdominal trauma.

METHODS

This study was a multicenter prospective series of all patients with blunt abdominal trauma admitted to four level I trauma centers over 22 months. Data were collected concurrently at the time of patient enrollment and included demographics, injury severity score, findings on CT scan, and presence or absence of blunt intestinal injury. This database was specifically queried for those patients who had free fluid without solid organ injury.

RESULTS

In all, 2,299 patients were evaluated. Free fluid was present in 265. Of these, 90 patients had isolated free fluid with only 7 having a blunt intestinal injury. Conversely, 91% of patients with free fluid did not. All patients with free fluid were observed for a mean of 8 days (95% confidence interval 6.1 to 10.4, range 1 to 131). There were no missed injuries.

CONCLUSIONS

Free fluid on abdominal CT scan does not mandate celiotomy. Serial observation with the possible use of other adjunctive tests is recommended.

Impact of recent trends of noninvasive trauma evaluation and nonoperative management in surgical resident education

BACKGROUND

The use of ultrasonography and nonoperative management of solid organ injury has become standard practice in many trauma centers. Little is known about the effects of these changes on resident educational experience.

METHODS

We retrospectively reviewed resident evaluation of abdominal trauma and trauma operative experience as reported to the residency review committee between 1994 and 1999.

RESULTS

A total of 4,052 patients underwent one or more of three diagnostic modalities. The nontherapeutic laparotomy rate as a result of positive diagnostic peritoneal lavages decreased from 35% to 14%. Although resident operative trauma experience was stable because of increases in operative burns and nonabdominal trauma, the number of abdominal procedures declined.

CONCLUSION

Noninvasive diagnostic tests have allowed more rapid trauma evaluation and fewer nontherapeutic laparotomies. As nonoperative experience grows, the opportunity for operative experience decreases. These trends may adversely affect the education of residents and suggest that novel approaches are needed to ensure adequate operative experience in trauma.

Conservative management of penetrating torso trauma

Trauma has evolved as a specialty of its own over the past two decades, and has been the subject of much research and a huge number of trials, many of which are ongoing. As a result, it is now possible to apply an evidence-based practice to many trauma scenarios. The management of penetrating injuries to the chest or abdomen has traditionally followed a policy of emergency surgery as the first course of action. This has now shown to be unnecessary in many cases, particularly with the advances in diagnostic tests and imaging modalities. A large number of cases of penetrating torso trauma may require an operation at some stage, but obtaining the clearest diagnostic picture and optimizing the clinical condition of the patient before this undertaking will result in improved outcome. A selective approach to emergency surgery, with its attendant difficulties, is now recommended

Non-operative treatment of abdominal gunshot injuries

BACKGROUND

Non-operative treatment is a management option that challenges the traditional mandatory laparotomy for abdominal gunshot injuries.

METHODS

All published relevant clinical reports were retrieved by searching through the Medline database and manually. The theoretical arguments in favour of non-operative management as well as the results of the reviewed reports are analysed and evaluated.

RESULTS AND CONCLUSION

Patients with proven non-penetration of the abdominal cavity can be offered conservative treatment with a satisfactory outcome. Greater caution should be exercised in the presence of a documented visceral injury until the safety of this option has been established by further clinical trials.

Complications after negative laparotomy for trauma: long-term follow-up in a health maintenance organization

OBJECTIVE

To assess short-term and long-term complication rates after trauma laparotomy in a group of health maintenance organization (Kaiser Permanente) patients.

DESIGN

Retrospective cohort study of patients belonging to Kaiser Permanente.

MATERIALS AND METHODS

Eighty Kaiser patients who underwent a negative or nontherapeutic laparotomy for trauma at a Level I trauma center (University of California, Davis Medical Center (UCDMC)) between April 1989 and May 1994 were identified. Demographic data, past medical history, mechanism of injury, indications for surgery, findings at laparotomy, and short-term complications were abstracted from the UCDMC record. Long-term complications were taken from the Kaiser record.

MEASUREMENTS

Long-term complications, including small bowel obstruction, hernia, and cosmesis. Short-term complications, including pneumonia, cellulitis, wound infection, prolonged ileus, and urinary tract infection.

RESULTS

The single death in the early postoperative period was not related to the laparotomy. Mean follow-up was 36 +/- 2 months (median, 36 months); 86% had follow-up of at least 1 year. The incidence of short-term complications was 43% in patients with associated extra-abdominal injuries and 20% in patients without associated extra-abdominal injuries (p = 0.17). On long-term follow-up, there were no small bowel obstructions, incisional hernias, or cosmetic problems requiring correction. One patient developed a stitch abscess 6 weeks after the operation.

CONCLUSIONS

The incidence of long-term complications after negative or nontherapeutic laparotomy for trauma is low.

Complications of negative laparotomy for truncal stab wounds

In a retrospective study of 459 patients undergoing mandatory explorative laparotomy for truncal stab wounds, 172 (37%) negative laparotomies were identified, divided in two groups: group I (n = 147) without, and group II (n = 25) with associated extra-abdominal injuries or surgical procedures other than laparotomy. One patient (0.6%) died of associated mediastinal vascular injuries. The overall postoperative morbidity rate was 21%, 17% in group I, and 44% in group II (p < 0.001). The excess morbidity in group II was caused by pulmonary complications associated with a thoracic injury or procedure. In group I, the complications were not severe, prolonging the mean hospital stay by 4.6 days. It is concluded that mandatory laparotomy for truncal stab wounds leads to an unnecessary operation in about 40% of cases, with a 20% morbidity rate associated with the laparotomy itself. Although the complications are not severe, the results should be assessed against the safety and accuracy of the selective management of abdominal stab wounds.