Penetrating abdominal injury
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Penetrating Abdominal Injury. Is Exploratory Laparotomy Still the Standard Treatment?. Dr Annie NK Chiu UCH JHSGR 21st Apr 2012. Outline. Definition of penetrating abdominal injury (PAI) Mechanism of penetrating injury Stab wound Gunshot wound Management Exploratory laparotomy

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Penetrating abdominal injury

Penetrating Abdominal Injury

Is Exploratory Laparotomy Still the Standard Treatment?

Dr Annie NK Chiu

UCH

JHSGR

21st Apr 2012


Outline

Outline

  • Definition of penetrating abdominal injury (PAI)

  • Mechanism of penetrating injury

    • Stab wound

    • Gunshot wound

  • Management

    • Exploratory laparotomy

    • Selective non-operative management

    • Diagnostic adjuncts

  • Summary


Penetrating abdominal injury pai

Penetrating Abdominal Injury (PAI)

  • An injury that occurs when an object pierces the skin and enters the tissue of the abdomen


Mechanism of injury

Mechanism of Injury

  • Stab wound (SW)

  • Gunshot wound (GSW)

    • Low-velocity

    • High-velocity


Mechanism of injury1

Mechanism of Injury

  • Stab wound (SW)

  • Gunshot wound (GSW)

    • Low-velocity

    • High-velocity


Management of abdominal stab wound

Management of Abdominal Stab Wound


Initial management

Initial Management

  • ATLS guidelines

    • Airway

    • Breathing

    • Circulation


Initial management1

Initial Management

  • ATLS guidelines

    • Airway

    • Breathing

    • Circulation

  • Circulation – significant amount of blood loss


Further management

Further Management

Does every patient need exploratory laparotomy?


Is exploratory laparotomy mandatory

Is Exploratory Laparotomy Mandatory?


Exploratory laparotomy

Exploratory Laparotomy

  • Indications for immediate exploratory laparotomy:

    • Haemodynamic instability

    • Peritonitis

    • Evisceration


Is exploratory laparotomy mandatory1

Is Exploratory Laparotomy Mandatory?

  • If patient has

  • Stable haemodynamic, and

  • No peritonitis


Background

Background

  • Before World War I, PAI was managed expectantly and mortality rate was high

  • Exploratory laparotomy was accepted as the standard treatment for PAI and studies showed improved survival


Background1

Background

  • High incidence of non-therapeutic or negative laparotomy

    • Incidence of unnecessary laparotomy for patients with stab wound 23% to 53%

Friedmann P. Selective management of stab wounds of abdomen. Arch Surg 1968;96:292-295


Background2

Background

  • Complications of unnecessary laparotomy ranges from 2.5% to 41%

    • Visceral injury

    • Wound infection

    • Ileus

    • Myocardial infarction

    • Pneumonia

    • Death

Como JJ MD et al. Practice Management Guidelines for Selective Nonoperative Management of Penetrating Abdominal Trauma. J Trauma 2010;68:721-733


Background3

Background

  • In 1960, Shaftan published a report on selective non-operative management (SNOM) for patient with abdominal trauma, including both blunt and penetrating injury.

  • 125 out of 180 patients (63% penetrating injury) were managed without laparotomy, no mortality or morbidity in this group of patients.

Shaftan GW. Indications for operation in abdominal trauma. Am J Surg 1960;99:657-664


Selective non operative management snom

Selective Non-operative Management (SNOM)

  • Patient selection criteria:

    • Stable haemodynamic

    • No peritonitis

  • Close monitoring

  • Serial physical examination and reassessment

  • Diagnostic adjuncts


Selective non operative management snom1

Selective Non-operative Management (SNOM)

Is it safe?


Selective non operative management snom2

Selective Non-operative Management (SNOM)

  • Comparing two policies: exploratory laparotomy vs SNOM

  • 600 patients with abdominal SW

  • 60% of patients were treated non-operatively

  • 3 patients had delayed laparotomy within 24 hours without mortality

  • Unnecessary laparotomy rate decreased from 67% to 25%

  • Conclusions:

  • Decision of laparotomy based on clinical status decreased unnecessary laparotomy, complication rate and length of hospital stay

Nance FC, Cohn I Jr. Surgical management in the management of stab wounds of the abdomen: a retrospective and prospective analysis based on a study of 600 stabbed patients. Ann Surg 1969;170:569-580


Selective non operative management snom3

Selective Non-operative Management (SNOM)

  • Prospective study of 651 patients with anterior abdominal SW

  • 306 patients (47%) were managed conservatively

  • 11 patients (3.6%) need subsequent operations without mortality

  • Unnecessary laparotomy rate 5%

  • Conclusions:

  • Many anterior abdominal SW can be safely managed non-operatively

  • The decision for operative or conservative management should be based on clinical criteria

Demetriades D, Rabinowitz B. Indications for operation in abdominal stab wounds. A prospective study of 651 patients. Ann Surg 1987; 205:129-132


Selective non operative management snom4

Selective Non-operative Management (SNOM)

  • Prospective study of 230 patients with penetrating injuries to the back (97% stab wound)

  • 195 patients (85%) were managed conservatively

  • 5 patients required subsequent operations without mortality

  • Unnecessary laparotomy rate 2.6%

  • Conclusions:

  • Penetrating injuries to the back should be assessed in the same way as anterior abdominal injury

  • The decision for operative or conservative management should be based on clinical criteria

Demetriades D et al. The management of penetrating injuries to the back. A prospective study of 230 patients. Ann Surg 1988; 207:72-74


Selective non operative management snom5

Selective Non-operative Management (SNOM)

  • Prospective study of 152 patients with penetrating abdominal solid organ injuries (29.6% stab wound)

  • Liver 73%, kidney 30.3% and spleen 30.3%

  • 41 patients (27%) with solid organ injuries managed without laparotomy

  • 4 patients had angiographic embolization

  • 3 patients had delayed laparotomy, recovered without complications

  • Conclusions:

  • In appropriate environment, penetrating abdominal solid organ injuries can be managed by SNOM

Demetriades D et al. Selective nonoperative management of penetrating abdominal solid organ injuries. Ann Surg 2006; 244: 620-628


Selective non operative management snom6

Selective Non-operative Management (SNOM)

  • 13030 patients with stab wound in 2002-2008

  • 72.2% patients managed in level I trauma centre

Outcome of selective non-operative management of penetrating abdominal injuries from the North American National Trauma Database. Br J Surg 2011;99(1) 1550165


Selective non operative management snom7

Selective Non-operative Management (SNOM)

*p< 0.001

Outcome of selective non-operative management of penetrating abdominal injuries from the North American National Trauma Database. Br J Surg 2011;99(1) 1550165


Pitfalls of selective non operative management snom

Pitfalls of Selective Non-operative Management (SNOM)

  • About 20% failure rate

  • Delay in diagnosis and treatment

  • Associated with increased morbidity, mortality and longer hospital stay

  • Patients with high injury severity score (ISS) and the need of blood transfusion were more likely to fail SNOM

Outcome of selective non-operative management of penetrating abdominal injuries from the North American National Trauma Database. Br J Surg 2011;99(1) 1550165


Prerequisites for snom

Prerequisites for SNOM

  • Level I trauma centre

  • Facilities for close monitoring

  • Readily available imaging facilities

  • Experienced trauma radiologist

  • Experienced trauma team

  • Capability to provide immediate surgical/ radiological intervention


Diagnostic adjuncts

Diagnostic Adjuncts


Local wound exploration lwe

Local Wound Exploration (LWE)

  • To look for penetration of anterior rectus fascia

  • Decision for laparotomy based on penetration of anterior fascia results in negative laparotomy rate up to 50%

Como J.J. MD et al. Practice management guidelines for selective nonoperative management of penetrating abdominal trauma. J Trauma 2010; 68:721-733


Diagnostic peritoneal lavage dpl

Diagnostic Peritoneal Lavage (DPL)

  • An invasive procedure

  • Positive test if

    • Free aspiration of blood/ GI contents/ bile

    • >100,000 RBC/mm3, 500 WBC/mm3 or bacteria present on Gram staining

Henneman P.L. MD et al. Diagnostic peritoneal lavage: Accuracy in predicting necessary laparotomy following blunt and penetrating trauma. J Trauma 1990;30(11): 1345-1355


Focused assessment sonography in trauma fast

Focused Assessment Sonography in Trauma (FAST)

  • In blunt abdominal trauma, sensitivity 81% to 88%, specificity 97% to 100%

  • In PAI, sensitivity 48% and specificity 98%

  • Not reliable for determining surgical exploration

Rozycki GS et al. A prospective study of surgeon-performed ultrasound as primary adjuvant modality for injured patient assessment. J Trauma 1995;39:492-500

Soffer D et al. A prospective evaluation of ultrasonography for the diagnosis of penetrating torso injury. J Trauma 2004;56:953-959


Computed tomography ct

Computed Tomography (CT)

  • Contrast-enhanced CT

    • Intravenous +/- oral and rectal

  • Positive CT:

    • free gas or fluid, contrast extravasation, visceral injury

  • Sensitivity 94.90%; specificity 95.38%

  • Overall accuracy 94.70%

  • PPV 84.51%

  • NPV 98.62%

Goodman CS et al. How well does CT predict the need for laparotomy in hemodynamically stable patients with penetrating abdominal injury? A review and Meta-analysis. AJR 2009;193:432-437


Diagnostic laparoscopy dl

Diagnostic Laparoscopy (DL)

  • Good for evaluation for peritoneal penetration and diaphragmatic injury

  • Rate of unnecessary laparotomy ranges from 27.6% to 45% even peritoneal penetration confirmed

Friese RS et al. Laparoscopy is sufficient to exclude occult diaphragm injury after penetrating abdominal trauma.Trauma 2005;58:789-792

Como J.J. MD et al. Practice management guidelines for selective nonoperative management of penetrating abdominal trauma. J Trauma 2010; 68:721-733


Investigations

Investigations

Penetrating Abdominal Trauma: Guidelines for Evaluation.

Krin C, Brohi K, London UK www.trauma.org


Investigations1

Investigations

  • CT is recommended as a diagnostic tool to facilitate management decisions

  • Experienced trauma radiologist for interpretation of images for more accurate diagnosis

  • Diagnostic laparoscopy has a role in evaluation of diaphragmatic injury

Como J.J. MD et al. Practice management guidelines for selective nonoperative management of penetrating abdominal trauma. J Trauma 2010; 68:721-733


Management of abdominal stab wound1

Management of Abdominal Stab Wound

Abdominal stab wound

  • Haemodynamic instability or

  • peritonitis

  • Stable haemodynamic and

  • No peritonitis

CT scan

Laparotomy

Negative

Hollow organ injury

Solid organ injury

Left thoracoabdominal injury

No

Yes

Embolization

Observation

Laparoscopy

If haemodynamic instability or peritonitis


Summary

Summary

  • Patients with abdominal SW who are haemodynamically unstable or who have peritonitis should have immediate exploratory laparotomy.

  • Exploratory laparotomy used to be the standard treatment for PAI


Summary1

Summary

  • For haemodynamically stable patients without peritonitis, SNOM reduces unnecessary laparotomy and its complications.

  • SNOM can be practiced in level I trauma centre with dedicated trauma team, facilities and resources for close monitoring.


Thank you

Thank you


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