Evaluation of Selective Treatment of Penetrating Abdominal Trauma

• Published in: Journal of surgical education Vol. 65; no. 5; pp. 340 - 345
• Main Authors: Schmelzer, Thomas M., MD, Mostafa, Gamal, MD, Gunter, Oliver L., MD, Norton, H. James, PhD, Sing, Ronald F., DO
• Format: Journal Article
• Language: English
• Published: United States Elsevier Inc 01-09-2008
• Subjects: abdominal injuries; Abdominal Injuries - surgery; Abdominal Injuries - therapy; Adult; Algorithms; computed tomography; Female; Humans; Laparoscopy - statistics & numerical data; Length of Stay; Male; nonoperative management; penetrating trauma; penetrating wounds; Practice Based Learning and Improvement; Prospective Studies; prospective study; Surgery; Time Factors; Trauma Centers - statistics & numerical data; Treatment Outcome; Wounds, Penetrating - surgery; Wounds, Penetrating - therapy; computed tomography; penetrating wounds; prospective study; nonoperative management; abdominal injuries; Practice Based Learning and Improvement; penetrating trauma
• ISSN: 1931-7204; 1878-7452
• DOI: 10.1016/j.jsurg.2008.06.008

Objective In penetrating abdominal trauma, diagnostic imaging and the application of selective clinical management may avoid negative celiotomy and improve outcome. Design We prospectively observed patients with penetrating abdominal trauma over 15 months and recorded demographics, presentation, imaging, surgical procedure, and outcome. Patients who underwent immediate laparotomy were compared with patients who were observed and/or had a computed tomography (CT) scan. Outcomes of negative versus positive and immediate versus delayed celiotomy were compared. Chi-square and Student t tests were used. A p value of less than 0.05 was considered significant. Setting A level 1 trauma center. Participants Adult patients who presented with penetrating abdominal injury. Results In all, 100 consecutive patients (mean age, 32 years) were included (male:female, 91:9; gunshot wound:stab wound, 65:35). Overall, 60 immediate and 10 delayed laparotomies were performed; 30 patients did not undergo surgery. Predictors of immediate celiotomy were hypotension (p = 0.03), anteriorly located entrance wounds (p = 0.0005), and transaxial wounds (p = 0.03). Overall morbidity and mortality was 32% and 2%, respectively. The negative celiotomy rate was 25%. Patients with a positive celiotomy had higher morbidity (p = 0.006) and longer hospital length of stay (p = 0.003) compared with negative celiotomy. A CT scan was employed in 32% of patients, with 100% sensitivity and 94% specificity. Delayed celiotomy (10%) did not adversely impact morbidity (p = 0.70) and was 100% therapeutic, with no deaths. Conclusion Nonselective immediate celiotomy for penetrating abdominal trauma results in a high rate of unnecessary surgery. Hemodynamically stable patients can safely be observed and/or have contrast CT scans and undergo delayed celiotomy, if indicated. This selective treatment had no adverse effect on patient outcomes and can potentially improve overall outcome.