Penetrating Abdominal Injury

Is Exploratory Laparotomy Still the Standard Treatment?

Dr Annie NK ChiuUCHJHSGR21st Apr 2012

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)

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

Mechanism of Injury

Stab wound (SW) Gunshot wound

(GSW) Low-velocity High-velocity

Mechanism of Injury

Stab wound (SW)

Gunshot wound (GSW) Low-velocity High-velocity

Management of Abdominal Stab Wound

Initial Management

ATLS guidelinesAirwayBreathingCirculation

Initial Management

ATLS guidelinesAirwayBreathingCirculation

Circulation – significant amount of blood loss

Further Management

Does every patient need exploratory laparotomy?

Is Exploratory Laparotomy Mandatory?

Exploratory Laparotomy

Indications for immediate exploratory laparotomy:Haemodynamic

instabilityPeritonitisEvisceration

Is Exploratory Laparotomy Mandatory?

If patient has

• Stable haemodynamic, and

• No peritonitis

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

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

Background

Complications of unnecessary laparotomy ranges from 2.5% to 41%Visceral injuryWound infection IleusMyocardial infarctionPneumoniaDeath

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

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)

Patient selection criteria:Stable haemodynamicNo peritonitis

Close monitoringSerial physical examination and

reassessmentDiagnostic adjuncts

Selective Non-operative Management (SNOM)

Is it safe?

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%

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

Conclusions:

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

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 (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 (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 (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 (SNOM)

2002 2008

Rate of SNOM* 23.6% 37.0%

Rate of non-therapeutic laparotomy*

41.4% 31.8%

Rate of SNOM failure* 29.2% 19.5%

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

*p< 0.001

Pitfalls of Selective Non-operative Management (SNOM)

About 20% failure rateDelay in diagnosis and treatmentAssociated with increased morbidity,

mortality and longer hospital stayPatients 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

Level I trauma centreFacilities for close monitoringReadily available imaging facilitiesExperienced trauma radiologistExperienced trauma teamCapability to provide immediate surgical/

radiological intervention

Diagnostic Adjuncts

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)

An invasive procedurePositive test if

Free aspiration of blood/ GI contents/ bile

>100,000 RBC/mm3, 500 WBC/mm

3 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)

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)

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)

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

LWE DPL FAST CT scan Laparoscopy

Sensitivity (%) 71 87-100 46-85 94-97 50-100

Specificity (%) 77 52-89 48-95 95-98 74-90

NPV (%) 79 78-100 60-98 95-99 98-100

Penetrating Abdominal Trauma: Guidelines for Evaluation.

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

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 Wound

Abdominal stab wound

•Haemodynamic instability or

•peritonitis

Laparotomy

•Stable haemodynamic and

•No peritonitis

CT scan

Hollow organ injury Solid organ injury

Embolization

Negative

Observation

If haemodynamic instability or peritonitis

Left thoracoabdominal injury

No Yes

Laparoscopy

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

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