AUTHOR AND EDITOR INFORMATION

Section 1 of 13  

• Authors and Editors
• Introduction
• Indications
• Relevant Anatomy
• Contraindications
• Workup
• Treatment
• Complications
• Outcome and Prognosis
• Future and Controversies
• Further Reading
• Multimedia
• References

INTRODUCTION

Section 2 of 13  

• Authors and Editors
• Introduction
• Indications
• Relevant Anatomy
• Contraindications
• Workup
• Treatment
• Complications
• Outcome and Prognosis
• Future and Controversies
• Further Reading
• Multimedia
• References

History of the Procedure

The management of penetrating abdominal trauma (PAT) has evolved greatly over the last century.

Prior to World War I, penetrating trauma was managed expectantly. During World War II, however, studies showed that early laparotomy improved survival. By the late 1950s, laparotomy was the standard treatment of patients with PAT. In 1960, Shaftan suggested the selective management of patients with abdominal stab wounds after observing an increased rate of laparotomies without identifiable injuries. More recently, expectant management has also been used in the treatment of specific gunshot wounds (GSWs) to the abdomen.

The introduction and refinement of diagnostic procedures and imaging studies, including peritoneal lavage, laparoscopy, CT scan, and focused ultrasound, have directed the evolution of PAT management.

Problem

Penetrating abdominal injury implies that either a GSW or a stab wound has violated the abdominal cavity.

Frequency

In the United States, suicide and homicide consistently rank in the top 15 causes of death. According to data published by the National Vital Statistics Reports, 30,318 people died of firearm injuries in 2002. Of these, 17,159 deaths were due to self-inflicted GSWs. Forty percent of homicides and 14% of suicides by firearm involved injuries to the torso.

Age-adjusted firearm death rates are 2-7 times higher for non-Hispanic black males as compared to males of other ethnicities. For non-Hispanic whites, most firearms deaths are due to suicide.
 
According to age-adjusted rates from 1990-1995, firearm mortality rates across the world vary widely, from 0.05 in Japan to 14.24 in the United States. Firearm associated homicide mortality is highest in Mexico at 10.35; firearm associated suicide is highest in the United States at 6.3. 

Pathophysiology

A GSW is caused by a missile propelled by combustion of powder. These wounds involve high-energy transfer and, consequently, can have an unpredictable pattern of injuries. Secondary missiles, such as bullet and bone fragments, can inflict additional damage. Military and hunting firearms have higher missile velocity than handguns, resulting in even higher energy transfer. Close-range shotgun injuries often cause significant tissue damage and should be considered high-energy transfer injuries as well.
 
Stab wounds are caused by penetration of the abdominal wall by a sharp object. This type of wound generally has a more predictable pattern of organ injury. However, occult injuries can be overlooked, resulting in devastating complications.

Clinical

Assessment of the patient begins at the scene of the incident by emergency medical service (EMS) personnel. Basic or advanced life support measures are applied at the scene and en route to the emergency department.

Upon arrival at the emergency department, communication of the incident history and the patient's vital signs to the emergency or trauma team is of paramount importance. Advanced trauma life support protocols are initiated. Airway protection and ventilatory support are followed by circulatory resuscitation with fluid infusion. Patients who present with hypotension are already in class III shock (30-40% blood volume loss), and they should receive blood products as soon as possible.
 
Physical examination includes inspection of all body surfaces, with notation of all penetrating wounds. Multiple wounds may represent entrance or exit wounds and must not be labeled as such, since multiple missiles or foreign objects may be retained within the body.

Examination of the abdomen in a patient who is awake may indicate peritoneal signs, such as pain and guarding and rebound tenderness, which necessitate exploration without delay. Abdominal distension in an unresponsive patient may indicate active internal bleeding that also requires exploration, especially in combination with hypotension.

Rectal examination is performed on all patients with PAT, as blood per rectum and high-riding prostate can indicate bowel injury and genitourinary tract injury, respectively. Notation of blood at the urethral meatus is also a sign of genitourinary tract injury.

When immediate operative intervention is not requisite, further evaluation ensues with laboratory testing and diagnostic and imaging studies.

INDICATIONS

Section 3 of 13  

• Authors and Editors
• Introduction
• Indications
• Relevant Anatomy
• Contraindications
• Workup
• Treatment
• Complications
• Outcome and Prognosis
• Future and Controversies
• Further Reading
• Multimedia
• References

GSWs are associated with a high incidence of intra-abdominal injuries. Nearly all patients with GSWs require laparotomy. Recent reports of nonoperative management of GSWs to the abdomen are discussed later in this article.

Stab wounds are associated with a significantly lower incidence of intra-abdominal injuries; therefore, expectant management is indicated in hemodynamically stable patients. Many protocols have been developed for determination of abdominal wall penetration of stab wounds to the torso (see Media file 1).

RELEVANT ANATOMY

Section 4 of 13  

• Authors and Editors
• Introduction
• Indications
• Relevant Anatomy
• Contraindications
• Workup
• Treatment
• Complications
• Outcome and Prognosis
• Future and Controversies
• Further Reading
• Multimedia
• References

Each area of the torso has anatomical boundaries, as follows:

• Thoracoabdominal area – Nipples to the 12^th rib, between anterior axillary lines
• Abdomen – Nipples to anus, between anterior axillary lines
• Flank – Between ipsilateral anterior and posterior axillary lines
• Back – Below the tip of the scapula, between posterior axillary lines

CONTRAINDICATIONS

Section 5 of 13  

• Authors and Editors
• Introduction
• Indications
• Relevant Anatomy
• Contraindications
• Workup
• Treatment
• Complications
• Outcome and Prognosis
• Future and Controversies
• Further Reading
• Multimedia
• References

Patients without recordable cardiac activity upon presentation should not be further resuscitated.

WORKUP

Section 6 of 13  

• Authors and Editors
• Introduction
• Indications
• Relevant Anatomy
• Contraindications
• Workup
• Treatment
• Complications
• Outcome and Prognosis
• Future and Controversies
• Further Reading
• Multimedia
• References

Lab Studies

All patients should undergo certain basic laboratory testing, as follows:

• Complete blood count (CBC) provides a baseline value for later comparison, even though it may not reveal the extent of active bleeding.
• Basic chemistry profile (BMP) also reveals any baseline renal insufficiency or electrolyte abnormalities.
• Coagulation studies (PT/INR + PTT) may suggest development of coagulopathy.
• Arterial blood gas (ABG) provides important information regarding acid-base balance and, thus, the hemodynamic stability of the patient.
• Urine dipstick may reveal occult blood indicative of genitourinary tract injuries. Female patients should have urine pregnancy testing. 

Patients who arrive in shock should be typed and crossed for 4-8 units packed red blood cells.  

Ethanol and drug screens are also standard practice in trauma patients. Studies have shown that even brief intervention and counseling in patients at the time of admission for trauma injury has positive outcomes.

Imaging Studies

Many imaging modalities can be useful in the evaluation of a patient with PAT.

Plain radiograph

Chest radiograph is obtained on all patients because penetration of the chest cavity cannot be ruled out, even with abdominal stab wounds or even-numbered GSWs. Chest radiograph can reveal hemothoraces/pneumothoraces or irregularities of the cardiac silhouette, which can be a sign of cardiac injury or great vessel injury. Air under the diaphragm indicates peritoneal penetration. Abdominal radiographs in 2 views (ie, AP, lateral) are also obtained on all patients with GSWs to help determine missile trajectory and to account for retained missiles in patients with odd-numbered GSWs.
 
Ultrasound

The focused assessment with sonography for trauma (FAST) uses 4 views of the chest and the abdomen (ie, pericardial, right upper quadrant, left upper quadrant, pelvis) to evaluate for pericardial fluid indicative of cardiac injury and for free peritoneal fluid. Free fluid in the abdomen can be a sign of hemorrhage secondary to liver or splenic laceration or, less commonly, of spillage secondary to hollow viscus injury.
 
CT scan 

CT scan is used in the evaluation of patients with stab wounds to the flank and the back and in the evaluation of selected patients with abdominal stab wounds and GSWs. Triple contrast (ie, oral, intravenous, rectal) is often used to maximize the sensitivity of this study for peritoneal penetration and intra-abdominal organ injury.

Specific signs of peritoneal penetration include a wound tract outlined by hemorrhage, air, or bullet or bone fragments that clearly extend into the peritoneal cavity; the presence of intraperitoneal free air, free fluid, or bullet fragments; and obvious intraperitoneal organ injury.
 
Intravenous pyelogram

This study is more often used intraoperatively to assess contralateral renal function in a patient with kidney damage necessitating nephrectomy.

Diagnostic Procedures

In patients with PAT, a limited number of procedures are necessary for diagnosis and/or treatment.

Nasogastric intubation

All patients undergoing endotracheal intubation require decompression of the stomach to decrease the risk of aspiration. Blood in the nasogastric tube can indicate upper gastrointestinal injury.
 
Foley catheterization

Catheter insertion is required to monitor the fluid resuscitation status of the patient with PAT. The presence of blood in the urine is a sign of genitourinary tract injury.

Diagnostic peritoneal lavage

Diagnostic peritoneal lavage (DPL) can be performed via either a closed method (ie, small skin puncture with blind insertion of catheter over guidewire) or an open method (ie, insertion of catheter under direct vision after exposure of the peritoneum through a small infraumbilical incision).

Aspiration of gross blood is positive for peritoneal penetration and organ injury. If aspiration is negative, 1 liter of sodium chloride is administered through the catheter and then retrieved by gravity siphonage. The fluid is then evaluated for the presence of red blood cells (>10,000/mm³), white blood cells (>500/mm³), bile, fibers, or particles, any of which indicate peritoneal penetration and organ injury.

While very sensitive and specific, DPL requires a fair amount of time to perform, and it has been supplanted in many institution protocols by FAST, CT scan, and/or laparoscopy.

Tube thoracostomy

Patients with penetrating wounds to the thoracoabdominal area may require chest tube placement. Absent or significantly decreased unilateral breath sounds necessitate immediate tube thoracostomy to relieve hemothorax/pneumothorax. In other patients, hemothorax/pneumothorax will be identified on chest radiograph.

A large-bore (38-40F) chest tube should be placed in the midaxillary line at the fifth intercostal space. Time permitting, liberal local anesthesia is preferred in the patient who is awake. The tube is placed to 20-cm wall suction, and, postprocedure, chest radiograph is performed to confirm placement.   

Rigid sigmoidoscopy

Patients with blood on rectal examination who are otherwise being managed expectantly (mostly stab wounds) should undergo rigid sigmoidoscopy to rule out rectal injury.

TREATMENT

Section 7 of 13  

• Authors and Editors
• Introduction
• Indications
• Relevant Anatomy
• Contraindications
• Workup
• Treatment
• Complications
• Outcome and Prognosis
• Future and Controversies
• Further Reading
• Multimedia
• References

Medical therapy

Resuscitation of the patient with PAT begins immediately upon arrival. At least 2 large-bore peripheral intravenous catheters should be secured; central venous access may be necessary. Fluids should be administered rapidly. Normal saline or Ringer’s lactate solution can be used for crystalloid resuscitation. Patients arriving in shock or with obvious significant bleeding should receive blood products as quickly as possible. Arterial access for continuous blood pressure monitoring is standard. Efforts should be made to limit hypothermia, including warm blankets and prewarmed fluids. Antibiotics should be administered to patients undergoing exploration.

Preoperative details

Surgical intervention begins with preparation of the patient in the operating room. The patient is placed in the supine position with arms extended. The entire chest, abdomen, and pelvis, including the upper thighs, are prepped and draped. This allows for access to the chest, should the injury tract extend above the diaphragm, and to the vasculature of the groins, should reconstruction become necessary. Fluids and blood products should be readily available (and administered via warm lines), and warming devices should be placed on the patient’s upper and/or lower extremities. Entering the abdominal cavity can release tamponade, resulting in a precipitous drop in blood pressure, so the anesthesia team must be informed when the midline incision is made. 

Intraoperative details

Essential components to the trauma laparotomy include control of bleeding, identification of injuries, control of contamination, and reconstruction (if possible). Initial control of bleeding is accomplished with 4 quadrant packing using laparotomy pads. The abdominal wall is retracted, the falciform ligament is taken down, and packs are placed above the liver and the spleen and in both sides of the pelvis after the bowel is swept cephalad. Once anesthesia has been given time to catch up with fluid resuscitation, the packs are removed one quadrant at a time, starting away from the sites of apparent bleeding. All areas are examined for injuries; each solid organ and the entire bowel are inspected. Contamination is controlled with the use of clamps, staples, or suture closures. Depending on the character of the defect(s), resection may be necessary. If the patient is stable enough to continue the operation, reconstruction may then be performed.

Occasionally, patients with PAT develop such significant metabolic acidosis and coagulopathy that proceeding with the reconstruction phase of the laparotomy is not possible. In these cases, the operation is considered damage-control surgery, and the abdomen is closed rapidly. Often, a temporary closure with an intravenous fluid bag or mesh (occasionally with a vacuum dressing) is used, as the patient has undergone massive fluid resuscitation and the bowel has become quite edematous, precluding primary closure of the abdomen. The patient is then transported to the intensive care unit for continued resuscitation and warming. Reconstruction then takes place upon return to the operating room in 24-48 hours.
 
In patients with PAT, the possible patterns of intra-abdominal injuries are countless. A brief description of specific organ injuries and the intraoperative approach to their management are outlined below.

Diaphragm

Penetrating injuries to the diaphragm are graded as follows: (I) contusion; (II) laceration, <2 cm; (III) laceration, 2-10 cm; (IV) laceration, >10 cm; and (V) total tissue loss, >25 cm². Lower grade injuries may be repaired either via laparotomy or with laparoscopic or thoracoscopic techniques.

Essential components of repair include an airtight closure with nonabsorbable suture and liberal saline lavage of the hemithorax if there has been a concomitant bowel injury with soilage of the field. The closure may be running or interrupted, and a chest tube is often placed for drainage. Large defects may require placement of a prosthetic patch.  

Liver

Liver injuries are also classified by grade. Components of the different grades pertinent to penetrating injuries include the following: (I) nonbleeding capsular tears, <1 cm deep; (II) lacerations, 1-3 cm deep and <10 cm long; (III) laceration, >3 cm deep; (IV) parenchymal disruption involving 25-75% of a lobe or 1-3 segments; (V) parenchymal disruption of >75% of a lobe or >3 segments or juxtahepatic venous injury; and (VI) hepatic avulsion. 

Operative management of liver injuries can involve many techniques, including simple packing or wrapping, local hemostasis, and resectional debridement. Knowledge of hepatic anatomy is crucial, because exposure and vascular control are necessary for the safe repair of injuries. Packing may successfully control minor hemorrhage; however, packs may need to be left in place and the abdomen closed temporarily. After resuscitation is complete, the patient may return to the operating room for removal of the packs, at which point bleeding is most often resolved.

Several hemostatic agents have been used in liver repair, including thrombin, fibrin sealant, collagen/gel preparations, electrocautery, argon beam and radiofrequency coagulation, omental packing, or even intrahepatic balloon tamponade as in the case of through-and-through injuries. Resectional debridement is much less commonly required in the treatment of penetrating liver injuries but may be accomplished with finger fracture, cautery, sutures, clips, or stapler device.
 
Spleen

Penetrating injuries to the spleen can cause significant bleeding. Irreparable vascular injuries, including total avulsion and extensive lacerations, are indications for splenectomy. Splenectomy may also be necessary for less substantial injuries for the patient in extremis. Time permitting, the spleen is completely mobilized, and care should be taken not to injure the pancreas. If there is a reparable laceration, digital pressure should be applied at the hilum and interrupted pledgeted splenorrhaphy performed.

Kidney

Injuries to the kidney are also graded according to severity, as follows: (I) contusion; (II) lacerations, <1 cm; (III) lacerations, >1 cm; (IV) lacerations to the collecting system; and (V) vascular avulsion.

As with spleen injuries, the kidney is salvaged with renography, using pledgeted sutures and wrapping, and capsular reapproximation if at all possible. If nephrectomy is deemed necessary because of the severity of injury or instability of the patient, an intraoperative intravenous pylorogram is performed to confirm function of the contralateral kidney.

Stomach

Exposure and thorough inspection of the stomach is necessary to evaluate and treat penetrating injuries to the stomach. This is facilitated by opening of the gastrocolic ligament, which allows entrance into the lesser sac. Injuries extending into the lumen may be repaired quickly with a stapling device.

Duodenum

Injuries to the duodenum are graded as follows: (I) hematoma; (II) partial thickness laceration; (III) laceration disrupting <50% circumference of D1, D3, D4, or 50-75% circumference of D2; (IV) laceration disrupting 50-100% circumference of D1, D3, D4, or >75% circumference of D2, or involving the ampulla or distal common bile duct; and (V) massive disruption of the duodenopancreatic complex or devascularization of the duodenum.

The Kocher maneuver is used to mobilize the duodenum, along with the pancreatic head and distal common bile duct, so that penetrating injuries can be fully explored. Primary repair of injury is the goal, with protection of the repair using closed-suction drainage.  Diversion procedures are often used for protection. Duodenal diverticulartization diverts biliary and pancreatic secretions using T-tube drainage and gastric decompression with a gastrostomy. Pyloric exclusion involves closure of the pylorus with nonabsorbable suture with bypass via gastrojejunostomy; the pylorus opens spontaneously in 4-6 weeks. Grade V injuries require pancreaticoduodenectomy, which is often done as a staged procedure in the unstable trauma patient.
 
Pancreas

Pancreatic injuries are graded according to the presence or absence of ductal injuries. Grades I and II include superficial or major laceration or contusion without ductal injury, respectively. Grade III injuries are distal transections without duct injury or tissue loss. Grade IV lacerations involve proximal transection or parenchymal injury involving the ampulla. Grade V injuries are massive disruptions of the pancreatic head.

After hemorrhage is controlled and the pancreas is exposed, the extent of the injury must be identified. Debridement must be selective to preserve as much endocrine and exocrine function as possible. Grade I and II injuries can be managed conservatively, but Grade III injuries are best treated with distal pancreatectomy and splenectomy. Grade IV injuries require near total pancreatectomy with reconstruction of pancreatic drainage into the gastrointestinal tract with either Roux-en-Y pancreaticojejunostomy or pancreaticogastrostomy. If the patient is too unstable, wide drainage of pancreatic tissue without anastomosis may be necessary. 

Small bowel

Control of contamination is of high priority with penetrating injuries to the small bowel. Clamps or staples may be used for temporary control as the entire length of the small bowel is examined.

If less than 50% of the bowel circumference is disrupted, the defect can be closed in a transverse fashion with sutures or staples.

If there is a single defect larger than 50% circumference, there are multiple defects in a short segment of bowel, or there is a devascularizing injury to the mesentery, resection of the involved segment is appropriate. Side-to-side stapled anastomosis can be accomplished quickly.

In the unstable patient, a damage-control procedure may be performed, with control of contamination and resection of devitalized segments without anastomosis. The patient returns to the operating room within 24-48 hours for reexploration, resection of any further devitalized segments, and restoration of continuity with one or more anastomoses. 

Colon

The management of colonic injuries depends on the extent of the defect, the amount of contamination, and the stability of the patient. Primary repair may be considered if the patient is hemodynamically stable and if the injury is fairly small with minimal fecal contamination.

If the patient has multiple injuries; if the patient has required significant blood product resuscitation; if the patient is acidotic, hypothermic, and coagulopathic; and/or if there is a large defect (>50% of the circumference) and considerable fecal spillage, then a diverting colostomy should be performed.

Postoperative details

Patients should be monitored closely in the surgical intensive care unit after trauma laparotomy. Many patients will remain intubated and require ventilatory support. Attention should be paid to warming the patient, to continuing fluid and blood product resuscitation, to replacing electrolytes, and to monitoring drain outputs. Patients with evidence of ongoing bleeding may benefit from angiographic evaluation for possible embolization; some require reexploration for control of hemorrhage. Patients who have undergone damage-control procedures and/or who have temporary abdominal closures must return to the operating room within 24-48 hours for definitive repair.  

Follow-up

For excellent patient education resources, visit eMedicine's Wounds Center. Also, see eMedicine's patient education article Puncture Wound.

COMPLICATIONS

Section 8 of 13  

• Authors and Editors
• Introduction
• Indications
• Relevant Anatomy
• Contraindications
• Workup
• Treatment
• Complications
• Outcome and Prognosis
• Future and Controversies
• Further Reading
• Multimedia
• References

Early postoperative complications include ongoing bleeding, coagulopathy, and abdominal compartment syndrome. The latter is treated with opening of the abdomen and temporary closure.

Later complications include acute respiratory distress syndrome, pneumonia, sepsis, intra-abdominal fluid collections, wound infections, and enterocutaneous fistulae.

Late complications include small bowel obstruction and incisional hernias.

OUTCOME AND PROGNOSIS

Section 9 of 13  

• Authors and Editors
• Introduction
• Indications
• Relevant Anatomy
• Contraindications
• Workup
• Treatment
• Complications
• Outcome and Prognosis
• Future and Controversies
• Further Reading
• Multimedia
• References

The outcome for patients with PAT varies greatly depending on the extent of injury and the interventions required for repair.

In a series by Nicholas of 250 patients with PAT and positive laparotomies, the overall survival was 86.8%.¹ Mortality was found to be associated with the number of organs injured, vascular injury, and the need for damage-control surgery, emergency department thoracotomy, or operating room thoracotomy. While damage-control surgery has been used with some success in the management of patients with extensive abdominal trauma, it is associated with significant morbidity, including sepsis, intra-abdominal abscess, and gastrointestinal fistula, according to Nicholas.¹

FUTURE AND CONTROVERSIES

Section 10 of 13  

• Authors and Editors
• Introduction
• Indications
• Relevant Anatomy
• Contraindications
• Workup
• Treatment
• Complications
• Outcome and Prognosis
• Future and Controversies
• Further Reading
• Multimedia
• References

Management of the patient with PAT continues to evolve. After many years of obligatory exploration, expectant management of selected patients has become commonplace. Much of the present controversy involves the determination of patients or, more specifically, the injury patterns suitable for this type of management. Several different methods have been used to establish the injuries present and therefore the need for operative intervention in patients with PAT. Most trauma centers use an algorithm with multiple diagnostic modalities whose uses are based on the pattern of injuries and the clinical status of the patient.

Laparoscopy

Laparoscopy was first used in cases of PAT in the late 1970s. However, the technique was not widely used until much later after equipment had been improved and surgeon experience had grown. Diagnostic laparoscopy can be used to determine the need for laparotomy in patients with penetrating injury patterns. Multiple studies have shown a reduction in unnecessary laparotomies in patients with a penetrating mechanism but no identifiable organ injury who underwent diagnostic laparoscopy.

A retrospective study of 344 patients with abdominal exploration for PAT revealed 44 laparoscopies, half of which were negative for penetration and resulted in avoidance of laparotomy.² A prospective study of 99 patients with abdominal trauma who underwent laparoscopy showed that diagnostic laparoscopy was negative in 62% of the patients with PAT. The use of diagnostic laparoscopy reduced the rate of unnecessary laparotomy from 78.9% to 16.9% in this group of patients with PAT.³

The successful incorporation of diagnostic laparoscopy into the management of patients with PAT depends on the selection of hemodynamically stable patients, the availability and ease of use of quality laparoscopic equipment, and the experience of the surgeon in using the technique for diagnostic purposes in traumatic injuries. 
 
CT scan

Triple-contrast helical CT has been evaluated as a diagnostic modality in hemodynamically stable patients with penetrating torso trauma. Oral, intravenous, and rectal contrasts are administered, and the images are reviewed for evidence of peritoneal penetration and visceral injuries.

Findings consistent with peritoneal penetration include a wound tract outlined by hemorrhage, air, or bullet or bone fragments that clearly extend into the peritoneal cavity; the presence of intraperitoneal free air, free fluid, or free contrast material; and intraperitoneal organ injury.

In a prospective study of 200 patients, CT was found to be 97% sensitive and 98% specific for peritoneal violation.⁴ Laparotomy based on CT findings in 38 of these patients was considered therapeutic in 87%, nontherapeutic in 8%, and negative in 5%. These results were comparable to others obtained with the use of clinical examination, DPL plus local wound exploration, and DPL alone.^{5, 6, 7} Patient selection is extremely important when considering CT as a diagnostic adjunct in patients with PAT.

The availability and quality of the CT scan and the experience of the examining radiologist are also key considerations.

Ultrasound

Ultrasonography has been widely used in the assessment of patients with blunt trauma, but it has only recently been used in the assessment of patients with penetrating injuries.

While FAST has been found to be 94-98% specific for abdominal injury in PAT, its sensitivity of 46-67% is not good.^{8, 9} The rapidity with which FAST can be performed in the trauma setting is useful; however, the need for further testing to rule out occult injury in the event of a negative FAST limits its overall use.

FURTHER READING

Section 11 of 13  

• Authors and Editors
• Introduction
• Indications
• Relevant Anatomy
• Contraindications
• Workup
• Treatment
• Complications
• Outcome and Prognosis
• Future and Controversies
• Further Reading
• Multimedia
• References

Lawson R, Goosen J. Abdominal Stab Wound Exploration. eMedicine from WebMD. Updated May 31, 2007. Available at: http://www.emedicine.com/proc/topic82869.htm.

MULTIMEDIA

Section 12 of 13  

• Authors and Editors
• Introduction
• Indications
• Relevant Anatomy
• Contraindications
• Workup
• Treatment
• Complications
• Outcome and Prognosis
• Future and Controversies
• Further Reading
• Multimedia
• References

Media file 1:  Management of penetrating abdominal trauma.
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Media file 2:  Penetrating abdominal trauma. Small bowel anastomosis, step 1: the gastrointestinal anastomotic stapler is inserted into the bowel.
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Media file 3:  Penetrating abdominal trauma. Small bowel anastomosis, step 2: the gastrointestinal anastomotic stapler is fired inside 2 bowel loops.
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Media file 4:  Penetrating abdominal trauma. Small bowel anastomosis, step 3: the TA stapler is fired across 2 bowel ends.
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Media file 5:  Penetrating abdominal trauma. A defect in the mesentery is approximated to prevent internal herniation.
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Media file 6:  Penetrating abdominal trauma. Tangential gunshot wound to the liver.
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Media file 7:  Penetrating abdominal trauma. Strangulated small bowel in a patient with a previous gunshot wound to the abdomen.
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Media file 8:  Penetrating abdominal trauma. Blind loop syndrome in a patient with a previous gunshot wound to the abdomen and side-to-side anastomosis.
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REFERENCES

Section 13 of 13

• Authors and Editors
• Introduction
• Indications
• Relevant Anatomy
• Contraindications
• Workup
• Treatment
• Complications
• Outcome and Prognosis
• Future and Controversies
• Further Reading
• Multimedia
• References

1. Nicholas JM, Rix EP, Easley KA, Feliciano DV, Cava RA, Ingram WL, et al. Changing patterns in the management of penetrating abdominal trauma: the more things change, the more they stay the same. J Trauma. Dec 2003;55(6):1095-108; discussion 1108-10. [Medline].
2. Simon RJ, Rabin J, Kuhls D. Impact of increased use of laparoscopy on negative laparotomy rates after penetrating trauma. J Trauma. Aug 2002;53(2):297-302; discussion 302. [Medline].
3. Taner AS, Topgul K, Kucukel F, Demir A, Sari S. Diagnostic laparoscopy decreases the rate of unnecessary laparotomies and reduces hospital costs in trauma patients. J Laparoendosc Adv Surg Tech A. Aug 2001;11(4):207-11. [Medline].
4. Shanmuganathan K, Mirvis SE, Chiu WC, Killeen KL, Scalea TM. Triple-contrast helical CT in penetrating torso trauma: a prospective study to determine peritoneal violation and the need for laparotomy. AJR Am J Roentgenol. Dec 2001;177(6):1247-56. [Medline].
5. Feliciano DV, Burch JM, Spjut-Patrinely V, Mattox KL, Jordan GL Jr. Abdominal gunshot wounds. An urban trauma center's experience with 300 consecutive patients. Ann Surg. Sep 1988;208(3):362-70. [Medline].
6. Demetriades D, Velmahos G, Cornwell E 3rd, Berne TV, Cober S, Bhasin PS. Selective nonoperative management of gunshot wounds of the anterior abdomen. Arch Surg. Feb 1997;132(2):178-83. [Medline].
7. Kelemen JJ, Martin RR, Obney JA, Jenkins D, Kissinger DP. Evaluation of diagnostic peritoneal lavage in stable patients with gunshot wounds to the abdomen. Arch Surg. Aug 1997;132(8):909-13. [Medline].
8. Udobi KF, Rodriguez A, Chiu WC, Scalea TM. Role of ultrasonography in penetrating abdominal trauma: a prospective clinical study. J Trauma. Mar 2001;50(3):475-9. [Medline].
9. Boulanger BR, Kearney PA, Tsuei B, Ochoa JB. The routine use of sonography in penetrating torso injury is beneficial. J Trauma. Aug 2001;51(2):320-5. [Medline].
10. Cox EF. Blunt abdominal trauma. A 5-year analysis of 870 patients requiring celiotomy. Ann Surg. Apr 1984;199(4):467-74. [Medline].
11. Fabian TC. Abdominal trauma including indications for celiotomy. 1996;441-59.
12. Jacobs LM, et al. Advanced Trauma Operative Management: Surgical Strategies for Penetrating Trauma. Connecticut: Cine-Med Inc; 2004.
13. Mattox KL, Feliciano DV, Moore EE. Trauma. 4^th ed. New York: McGraw-Hill; 1999.
14. Morris JA Jr, Eddy VA, Rutherford EJ. The trauma celiotomy: the evolving concepts of damage control. Curr Probl Surg. Aug 1996;33(8):611-700. [Medline].
15. Murphy SH. National Vital Statistics Reports. Deaths, final data for 1998. 2000;Available at: http://www.cdc.gov/nchs/data/nvsr/nvsr48/nvs48_11.pdf. [Full Text].
16. Pourmoghadam KK, Fogler RJ, Shaftan GW. Ligation: an alternative for control of exsanguination in major vascular injuries. J Trauma. Jul 1997;43(1):126-30. [Medline].
17. Thal ER. Operative exposure of abdominal injuries and closure of the abdomen. In: Wilmore DW, Cheung LY, Harken AH, Holcroft JW, Meakins JL, eds. Scientific American Surgery. New York: Scientific American; 1996: revised 1997.
18. Weigelt JA, Thal ER, Carrico JC, eds. Operative Trauma Management Atlas. Stamford, Conn: Appleton & Lange; 1997.

Article Last Updated: Jun 12, 2007