Surgical registrars are often taught a specific approach to a patient with penetrating abdominal wounds. Below is a short summary of an approach taught by the College of Surgeons in Australia:
- If the patient is unstable he goes to theatre.
- If the patient is stable, the wound can be explored in ED under local, and if the tract is found to have penetrated the anterior sheath, the patient is booked for a laparoscopy to determine if the wound has breached the peritoneum.
- If the wound did not breach the peritoneum, the wound is explored, haemostasis assured, debrided and closed.
- If the peritoneum is breached, the protocol is to convert to laparotomy for full exploration to exclude viscus injury. (laparoscopy is not considered sensitive enough to rule out viscus injury in the setting of penetrating abdominal injury).
Another approach which I prefer is conservative management and serial examination of the stable patient with penetrating abdominal injury as described in the review article below (click on the blue link to access):
Wohlgemut JM and Jansen Jan O (2013) The principles of non-operative management of penetrating abdominal injury. Trauma 15(4), 289-300
Another good article is a prospective study published in the Annals of Surgery (see link below):
Demetriades D and Rabinowitz B (1987) Indications for operation in abdominal stab wounds. Annals of Surgery 205, 129-132
In my personal experience, the only difficult part in the conservative management pathway is that it is sometimes difficult to differentiate between peritonism and abdominal wall tenderness due to the injury. This is why one will always have some patients that will fail the conservative management pathway, and have a subsequent negative laparotomy. This can be minimized by the use of long acting local anaesthesia in and around the wound, which will lessen the pain from the wound but would not mask peritonism.
Merwe Harslief is a surgeon with special interests in laparoscopic and trauma surgery. He trained in South Africa and has worked in the UK and Australia where he now practices.