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Practice Management Guidelines for Selective Nonoperative Management of Penetrating Abdominal Trauma

Como, John J. MD; Bokhari, Faran MD; Chiu, William C. MD; Duane, Therese M. MD; Holevar, Michele R. MD; Tandoh, Margaret A. MD; Ivatury, Rao R. MD; Scalea, Thomas M. MD

Journal of Trauma-Injury Infection & Critical Care: March 2010 - Volume 68 - Issue 3 - pp 721-733
doi: 10.1097/TA.0b013e3181cf7d07
Clinical Management Update

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.

From the Division of Trauma, Critical Care, and Burns (J.J.C.), Department of Surgery, MetroHealth Medical Center, Cleveland, Ohio; Department of Surgery (F.B.), Stroger Hospital of Cook County, Chicago, Illinois; Department of Surgery (W.C.C., T.M.S.), R Adams Cowley Shock Trauma Center, University of Maryland Medical Center, Baltimore, Maryland; Department of Surgery (T.M.D., R.R.I.), Virginia Commonwealth University Medical Center, Richmond, Virginia; Department of Surgery (M.R.H.), Mount Sinai Hospital, Chicago, Illinois, and Department of Surgery (M.A.T.), Upstate Medical Center, Syracuse, New York.

Submitted for publication June 4, 2007.

Accepted for publication December 14, 2009.

Presented at the 22nd Annual Meeting of the Eastern Association for the Surgery of Trauma, January 13-17, 2009, Lake Buena Vista, Florida.

Address for reprints: John J. Como, MD, 2500 MetroHealth Dr., Suite H945, Cleveland, OH 44109; email: jcomo@metrohealth.org.

© 2010 Lippincott Williams & Wilkins, Inc.