Penetrating Abdominal Injury

1. Penetrating Abdominal Injury Is Exploratory Laparotomy Still the Standard Treatment? Dr Annie NK Chiu UCH JHSGR 21st Apr 2012

2. 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

3. Penetrating Abdominal Injury (PAI) • An injury that occurs when an object pierces the skin and enters the tissue of the abdomen

4. Mechanism of Injury • Stab wound (SW) • Gunshot wound (GSW) • Low-velocity • High-velocity

5. Mechanism of Injury • Stab wound (SW) • Gunshot wound (GSW) • Low-velocity • High-velocity

6. Management of Abdominal Stab Wound

7. Initial Management • ATLS guidelines • Airway • Breathing • Circulation

8. Initial Management • ATLS guidelines • Airway • Breathing • Circulation • Circulation – significant amount of blood loss

9. Further Management Does every patient need exploratory laparotomy?

10. Is Exploratory Laparotomy Mandatory?

11. Exploratory Laparotomy • Indications for immediate exploratory laparotomy: • Haemodynamic instability • Peritonitis • Evisceration

12. Is Exploratory Laparotomy Mandatory? • If patient has • Stable haemodynamic, and • No peritonitis

13. 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

14. 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

15. 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

16. 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

17. Selective Non-operative Management (SNOM) • Patient selection criteria: • Stable haemodynamic • No peritonitis • Close monitoring • Serial physical examination and reassessment • Diagnostic adjuncts

18. Selective Non-operative Management (SNOM) Is it safe?

19. 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

20. 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

21. 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

22. 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

23. 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

24. 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

25. 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

26. 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

27. Diagnostic Adjuncts

28. 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

29. 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

30. 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

31. 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

32. 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

33. Investigations Penetrating Abdominal Trauma: Guidelines for Evaluation. Krin C, Brohi K, London UK www.trauma.org

34. 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

35. 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

36. 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

37. 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.

38. Thank you