A stab wound is a penetrating wound made by anything sharp. This includes knives, ice

picks, screwdrivers, pens, scissors, arrows, or animal horns. Classically, stab wounds

are low-velocity penetrating wounds that damage tissue the offending weapon passes

through. Severity depends on the location of the stab wound, the manner of stabbing,

the depth of penetration, and the type of weapon used. Regardless of the above, the

victim almost always experiences pain and bleeding, with some very rare occasions

they are unaware something has penetrated their bodies. The most common site of stab

wounds is the abdominal area, more on the upper left region than right.

Abdominal Stab Wounds

In the 19th century, penetrating abdominal wounds were managed non-

operatively. The associated morbidity and mortality rates were greater than 70%.

Experience gained during World War I, World War II, and the Korean Conflict led to an

aggressive approach of operative management for all penetrating abdominal wounds.

This approach resulted in an unacceptably high frequency of laparotomy with findings

negative for trauma. In 1960, Shaftan developed an approach of selective conservatism

for penetrating abdominal injury and revolutionized abdominal stab wound

management.

The optimal method to determine the need for laparotomy has yet to be

definitively established. Abdominal stab wound exploration forms part of a strategy

developed by surgeons to allow a more selective approach. In asymptomatic patients

with stab wounds to the anterior abdomen, methods are widely used to help determine

the need for laparotomy:

Abdominal stab wound exploration (Subsequent diagnostic peritoneal lavage

[DPL], serial clinical evaluation, or both are used to further assess patients in

whom an exploration cannot definitively exclude peritoneal penetration.)

Serial clinical evaluation

The objective is to reduce the number of patients with trivial or no intraperitoneal

injury who are subjected to laparotomy. However, a high degree of diagnostic accuracy

must be maintained to limit the frequency of missed injury. A reduction in unnecessary

hospitalization is also targeted.

Abdominal stab wound exploration is a safe, rapid, and cost-effective tool in the

management of asymptomatic patients who present with an anterior abdominal stab

wound. This approach has no place in the treatment of patients who are unstable, who

have peritonitis, or who have evisceration. Patients with peritonitis and those who are

hemodynamically unstable should undergo mandatory laparotomy.

More than 25% of anterior abdominal stab wounds do not penetrate the peritoneal

cavity. Local wound exploration allows the safe discharge of these patients from the

emergency department. Only half of the wounds that penetrate the peritoneum cause

damage that requires surgical intervention. The organs most commonly injured with

anterior abdominal stab wounds are the small bowel, the liver, and the colon. Missed

hollow viscus injuries are associated with significant morbidity and mortality.

Many modern physicians advocate abdominal stab wound exploration in

asymptomatic patients who present with an anterior abdominal stab wound. An

exploration with negative findings is reliable and highly sensitive. Abdominal stab wound

exploration combined with further investigation, such as DPL or serial evaluation,

achieves acceptable specificity rates. Minimizing the time taken to control ongoing

intraperitoneal contamination is critical in penetrating stab wounds, and local exploration

is a valuable first step in speeding up the decision-making process. When combined

with DPL, abdominal stab wound exploration allows significant injuries that are not

immediately apparent to be identified early.

INTRODUCTION

ANATOMY

An appreciation of the anatomy of the anterior abdominal wall at different levels is essential to understanding the procedure.

OsteologyBone Structure Description Notes

os coxae (TG6-3)

one of three bones that form the pelvis

paired; the os coxae forms the lateral part of the pelvis; it is formed by three fused bones: ischium, ilium & pubis; also known as the innominate bone (Latin, os = bone)

pubis (TG6-4)

an angulated bone the forms the anterior part of the pelvis

one of three bones that form the os coxae: ilium, ischium, pubis; its body forms 1/5 of the acetabulum; its symphyseal surface unites with the pubis of the opposite side to form the pubic symphysis; the superior and inferior pubic rami participate in the formation of the obturator foramen

pubic crest ridge on the superior border of the superior ramus

attachment of rectus abdominis & pyramidalis mm.

pubic tubercle

process at the lateral end of pubic crest

attachment point of the medial end of the inguinal ligament

pecten ridge on superior surface of the superior pubic ramus

attachment point of the pectineal ligament

ilium (TG6-3)

fan-shaped bone that forms the lateral prominence of the pelvis

one of three bones that form the os coxae: ilium, ischium, pubis

iliac crest arching superior edge of the ilium that forms the rim of the "fan"

attachment for abdominal wall muscles

iliac tubercle

roughened area along the outer edge of the iliac crest

anterior superior iliac spine

spine at the anterior end of the iliac crest

lateral attachment of the inguinal ligament

arcuate line ridge running from inferior boundary of the iliac fossa; marks the plane of

anteroinferior to posterosuperior on the inner surface of the ilium

transition from abdominal cavity to pelvic cavity; part of the iliopectineal line (Note: this is obviously not the same arcuate line as is found on the posterior aspect of the rectus sheath) (Latin, arcuate = bowed)

Joints and Ligaments

Joint Description Significance

linea alba(N249,N251,N252A,N252B,TG5-05, TG5-06)

connects xiphoid with pubic symphysis & crest

formed by intermingling of aponeuroses of external abdominal oblique, internal abdominal oblique, & transversus abdominis (Latin, linea alba = white line)

inguinal ligament(N250,N251, TG5-04)

the ligament that connects the anterior superior iliac spine with the pubic tubercle

the inguinal ligament is a specialization of the inferior border of the external abdominal oblique aponeurosis; it is the site of origin for a part of the internal abdominal oblique muscle and for a part of the transversus abdominis muscle; also known as: Poupart's ligament

lacunar ligament(N251,N262, TG5-08D,TG5-09D)

an extension of the medial end of inguinal ligament which connects the pubic tubercle with the pecten of the pubis

the lacunar ligament is a flattened portion of the aponeurosis of the external abdominal oblique m. that projects posteriorly from the pubic tubercle; it forms the medial border of the femoral ring and the floor of the inguinal canal at the

Muscles

Muscle OriginInserti

onAction

Innervation

Artery NotesImag

e

external abdominal oblique(N249,TG5-04)

lower 8 ribs

linea alba, pubic crest & tubercle, anterior superior iliac spine & anterior half of iliac crest

flexes and laterally bends the trunk

intercostal nerves 7-11, subcostal, iliohypogastric and ilioinguinal nerves

musculophrenic a., superior epigastric a., intercostal aa. 7-11, subcostal a., lumbar aa., superficial circumflex iliac a., deep circumflex iliac a., superficial epigastric a., inferior epigastric a., superficial external pudendal a.

the inguinal ligament is a specialization of the external abdominal oblique aponeurosis; the external spermatic fascia is the external abdominal oblique muscle's contribution to the coverings of the testis and spermatic cord

internal abdominal oblique(N250,TG5-04)

thoracolumbar fascia, anterior 2/3 of the iliac crest, lateral 2/3 of the inguinal ligament

lower 3 or 4 ribs, linea alba, pubic crest and pecten

flexes and laterally bends the trunk

intercostal nerves 7-11, subcostal, iliohypogastric and ilioinguinal nerves

musculophrenic a., superior epigastric a., intercostal aa. 7-11, subcostal a., lumbar aa., superficial circumflex iliac a., deep circumflex iliac a., superficial epigastric a., inferior epigastric a., superficial external pudendal a.

anterior fibers of internal abdominal oblique course up and medially, perpendicular to the fibers of external abdominal oblique; the cremaster muscle and fascia is the internal abdominal oblique muscle's contribution to the coverings of the testis and spermatic cord

transversus abdominis(N251,TG5-05)

lower 6 ribs, thoracolumbar fascia, anterior

linea alba, pubic crest and pecten

flexes and laterally bends trunk

intercostal nerves 7-11, subcostal, iliohypogastric and

musculophrenic a., superior epigastric a., intercostal

transversus abdominis muscle does not contribute to the coverings of the spermatic cord

superficial inguinal ring (Latin, lacuna = a lake or pit)

pectineal ligament(N251,N262, TG5-08D,TG5-09D)

a thickening of fascia on the pecten of the pubis

the pectineal ligament looks like an extension of the lacunar ligament along the surface of the pectineal line; also known as Cooper's ligament (note: Cooper's ligaments are also found in the breast)

pubic symphysis (TG6-04) symphysis midline joint uniting the pubic bodies (Greek, symphysis = a growing together)

falx inguinalis the inferomedial attachment of internal abdominal oblique and transversus abdominis

also known as: conjoint tendon (Latin, falx = sickle)

Nerves

Nerve Source Branches Motor Sensory Notes

intercostal n. (N254,N257,TG5-02)

ventral primary rami of spinal nerves T1-T11

lateral & anterior cutaneous brs.

intercostal muscles; abdominal wall muscles (via T7-T11); muscles of the forearm and hand (via T1)

skin of the chest and abdomen anterolaterally; skin of the medial side of the upper limb (via T1-T2)

intercostal n.travels below the posterior intercostal a. in the costal groove

subcostal n. (N254,N257,TG5-

ventral primary

lateral cutaneous

muscles of the

skin of the anterolateral

the subcostal n. is equivalent to a posterior intercostal n.

02) ramus of T12

br., anterior cutaneous br.

abdominal wall

abdominal wall found at higher thoracic levels

iliohypogastric n.(N257,N266,TG5-02, TG5-38)

lumbar plexus (ventral primary ramus of spinal nerve L1)

lateral and anterior cutaneous brs.

muscles of the lower abdominal wall

skin of the lower abdominal wall, upper hip and upper thigh

iliohypogastric n. receives a contribution from T12 in approximately 50% of cases

ilioinguinal n.(N257,N266,TG5-02, TG5-38)

lumbar plexus (ventral primary ramus of spinal nerve L1)

anterior cutaneous br. (also known as: anterior labial/scrotal n.)

muscles of the lower abdominal wall

skin of the lower abdominal wall and anterior scrotum/labium majus

ilioinguinal n. courses through the inguinal canal and superficial inguinal ring

genitofemoral(TG5-02)

lumbar plexus (ventral primary rami of L1-L2)

genital & femoral brs.

cremaster m.

skin of anterior scrotum/labia majora & upper medial thigh

lies on psoas major in abdomen; genital br. passes through deep inguinal ring & inguinal canal; brushing thigh elicits elevation of testis via cremasteric reflex

Arteries

Artery Source Branches Supply to Notes

epigastric, inferior(N25,N253,TG5-05,TG5-07)

external iliac a. cremasteric a. lower rectus abdominis m., pyramidalis m., lower abdominal wall

inferior epigastric a. anastomoses with the superior epigastric a. within the rectus abdominis m.

epigastric, superficial(N249, TG5-02)

femoral a. cutaneous brs. superficial fascia and skin of the lower abdominal wall

superficial epigastric a. is one of three superficial arteries that arise

from the femoral a. (see also: superficial circumflex iliac a. and superficial external pudendal a.)

epigastric, superior(N191, TG4-08, TG5-05)

internal thoracic a.

no named branches

upper rectus abdominis m., upper abdominal wall

superior epigastric a. is the direct continuation of the internal thoracic a.; it anastomoses with the inferior epigastric a. within the rectus abdominis m.

intercostal, posterior (TG4-39)

highest intercostal (upper 2 intercostal spaces), descending thoracic aorta (3rd-11th intercostal spaces)

posterior br., spinal br., anterior br., collateral br., lateral cutaneous br.

intercostal muscles, spinal cord and vertebral column, deep back muscles, skin and superficial fascia overlying the intercostal spaces

posterior intercostal aa. supply the lateral and posterior portions of the intercostal space; anterior intercostal aa. supply the anterior portions of the intercostal spaces

subcostal (TG4-39) descending thoracic aorta

spinal br., collateral br., lateral cutaneous br.

vertebrae, spinal cord; muscles, skin & fascia of the upper abdominal wall

subcostal a. is equivalent to a posterior intercostal a., but is named subcostal because it courses inferior to the 12th rib

Topographic Anatomy

Structure/Space Description/Boundaries Significance

arcuate line (TG5-05, TG5-07) anatomical feature on the inner surface of the

arcuate line is the point at which the posterior lamina

abdominal wall; a fascial line in the transverse plane approximately 1/2 of the distance from the umbilicus to the pubic symphysis

of the rectus sheath ends and transversalis fascia lines the inner surface of the rectus abdominis m. (Latin, arcuate = bowed)

epigastric region (TG5-01) an area on the anterior abdominal wall between the midclavicular lines, superior to the transpyloric line

one of 9 regions of the abdomen

hypochondriac region (TG5-01) an area on the anterior abdominal wall lateral to the midclavicular line, superior to the transpyloric line

right and left hypochondriac regions comprise 2 of 9 regions of the abdomen

hypogastric region (TG5-01) an area on the anterior abdominal wall between the midclavicular lines, inferior to the intertubercular line

one of 9 regions of the abdomen; also known as: pubic region

inguinal region (TG5-01) anterior abdominal wall lateral to midclavicular line, inferior to intertubercular line

right and left inguinal regions comprise 2 of 9 regions of the abdomen; also known as: iliac region

intercristal line an imaginary line drawn in the horizontal plane at the upper margin of the iliac crests

intercristal line locates the level of the L4 vertebra; a useful landmark in spinal tap procedure

intertubercular line (TG5-01) an imaginary line drawn in the horizontal plane at the upper margin of the iliac tubercles

intertubercular line locates the level of the L5 vertebra; used with midinguinal and transpyloric lines to divide the abdominal wall into 9 regions

linea alba(N249,N251,N252A,N252B,TG5-05, TG5-06)

anatomical feature on the midline of the anterior abdominal wall; an aponeurotic band that extends from the xiphoid process to the pubic

linea alba is formed by the combined abdominal muscle aponeuroses; it is used for midline abdominal incisions to avoid major nerves or vessels (Latin,

symphysis; linea alba = white line)

lumbar region an area on the anterior abdominal wall lateral to the midclavicular line, inferior to transpyloric line, superior to intertubercular line

right and left lumbar regions comprise 2 of 9 regions of the abdomen; also known as: lateral region

McBurney's point (TG5-15) a point on the anterior abdominal wall which is 1/3 of the distance along a line from the right anterior superior iliac spine to the umbilicus

McBurney's point is the approximate location of the vermiform appendix; point of tenderness in appendicitis

midaxillary line (TG4-01) an imaginary vertical line passing through the middle of the axilla

used as a surface landmark for descriptive purposes

midclavicular line (TG4-01) an imaginary vertical line passing through the midshaft of the clavicle

used as a surface landmark for descriptive purposes

midinguinal line (TG5-01) an imaginary vertical line passing through the midpoint of inguinal ligament

used with the transpyloric and intertubercular lines to divide the abdomen into 9 regions

quadrant, inferior left (TG5-01) a region on the anterior abdominal wall defined by the midline and the transumbilical line

one of 4 abdominal quadrants

quadrant, inferior right (TG5-01) a region on the anterior abdominal wall defined by the midline and the transumbilical line

one of 4 abdominal quadrants

quadrant, superior left (TG5-01) a region on the anterior abdominal wall defined by the midline and the transumbilical line

one of 4 abdominal quadrants

quadrant, superior right (TG5-01) a region on the anterior abdominal wall defined by the midline and the transumbilical line

one of 4 abdominal quadrants

semilunar line (TG5-01) an anatomical feature of the anterior abdominal wall; the lateral edge of the rectus abdominis m.

semilunar line is formed by the fused aponeuroses of the abdominal wall mm. at the lateral margin of the rectus sheath

transpyloric line (TG5-01) an imaginary horizontal line 1/2 of the distance between the jugular notch and the pubic crest

transpyloric line is used with the midinguinal and intertubercular lines to divide the abdominal wall into 9 regions; the fundus of the gall bladder lies at the intersection of the transpyloric line with the right 9th costal cartilage; the pylorus of the stomach is located at this plane; a horizontal plane through the transpyloric line locates the level of the L1 vertebra

transumbilical line (TG5-01) an imaginary horizontal line through the umbilicus

transumbilical line is used with the midline to divide abdomen into 4 quadrants

transverse lines anatomical features in the anterior abdominal wall; folds in the anterior abdominal wall (usually 3)

transverse lines are creases that overlie the tendinous intersections in the rectus abdominis m.

umbilical region a region on the anterior abdominal wall between the midclavicular lines, inferior to the transpyloric line, superior to the intertubercular line

one of 9 regions of the abdomen

umbilicus (TG5-01) remnant of the attachment of the umbilical cord to the anterior abdominal wall

umbilicus marks the approximate level of the L3/L4 intervertebral disc in non-obese individuals (Latin, umbilicus = navel)

superficial (external) inguinal ring(N387,N249,N259,N260,TG5-08A, TG5-09A)

slitlike opening between the diagonal fibers of the aponeurosis of the

exit from the inguinal canal

external oblique, superolateral to the pubic tubercle

deep (internal) inguinal ring(TG5-08C, TG5-09C)

site of an outpouching of the transversalis fascia approx. 1.25 cm superior to the middle of the inguinal ligament and lateral to the inferior epigastric a.

opening into the inguinal canal

inguinal canal(N387,N249,N259,N260,TG5-08A, TG5-09A)

Anterior - aponeurosis of the ext. oblique;Posterior - transversalis fascia; Roof - fibers of the int. oblique and transverse abdominis; Floor - superior surface of the inguinal ligament

pathway for the spermatic cord in males and round ligament of the uterus in females

Viscera/Fascia

Organ Location Description Notes

thoracolumbar aponeurosis (fascia) (N174, TG1-13)

extends laterally from the spinous processes and forms a thin covering for the deep muscles in the thoracic region and a strong, thick covering for muscles in the lumbar region

forms the aponeurotic origin of latissimus dorsi

(Greek, aponeurosis = a broad, flat nerve; due to the resemblance between nerves & tendons)

conjoint tendon (TG5-08D,TG5-09D) attached to pubic crest and pecten pubis

the most inferior, medial tendinous

also called the falx Inguinalis

fibers of the internal oblique join with the aponeurotic fibers of the deeper transverse abdominis

ductus deferens (TG5-08D,TG5-09D) passes through superficial inguinal ring, inguinal canal & deep ring to reach posteroinferior surface of bladder where it joins with duct of seminal vesicle to form ejaculatory duct

continuous with tail of epididymis

(Latin, ductus = to lead + deferens = to carry away)

fascia, cremasteric (TG5-08B, TG5-09B) intermediate covering of spermatic cord

derived from internal abdominal oblique muscle(Greek, fascia = a band + cremaster = a suspender)

fascia, external spermatic(TG5-08B, TG5-09B)

outermost covering of spermatic cord

derived from aponeurosis of external abdominal oblique muscle(Greek fascia = a band)

fascia, internal spermatic(TG5-08C, TG5-09C)

innermost covering of spermatic cord

derived from transversalis fascia

fascia lata (N249, TG3-02) deep fascia forming tubular investment of the thigh

thickened laterally as iliotibial tract/band; connected to femur by

Scarpa's fascia attaches to it below inguinal ligament

lateral & medial intermuscular septa

crus, lateral (TG5-08C,TG5-09C) lateral border of superficial inguinal ring

attaches to pubic tubercle

(Latin, crus = leg)

crus, medial (TG5-08C,TG5-09C) medial border of superficial inguinal ring

attaches to pubic crest

(Latin, crus = leg)

rectus sheath(N249,N251,N252A,N252B,TG5-05, TG5-06, TG5-06)

tough, aponeurotic, tendinous sheath of the rectus abdominis muscle

(Latin, rectus = straight)

round ligament of uterus(N397, TG5-09A, TG5-09C,TG5-09D)

attaches to inner aspect of labia majora, traverses superficial inguinal ring, inguinal canal & deep inguinal ring to reach lateral surface of uterus below uterine tube

continuous with ovarian ligament

a.k.a. ligamentum teres uteri; remnant of gubernaculum(Latin, teres = round)

scrotal ligament (TG6-31A) band of connective tissue that attaches the inferior end of the testis to the inner aspect of the scrotal sac

scrotal ligament is the remnant of the gubernaculum testis

scrotum (TG6-31A) sac of hair-covered skin containing the testis

in the scrotum the fatty and membranous layers of the

superficial fascia (as seen in the lower abdominal wall) are fused to form the tunica dartos scroti

spermatic cord (N387, TG5-08A, TG5-08C, TG5-08D,TG5-10C)

bundle of vessels, nerves and lymphatics ensheathed in tissue layers derived from the abdominal wall; it begins at the deep inguinal ring, passes through the inguinal canal and the superficial ring to reach the testis in the scrotum

spermatic cord comprises the: ductus deferens, testicular a., pampiniform plexus, deferential a. & v. and genital br. of the genitofemoral n.; coverings of the cord are the: internal spermatic fascia (from the transversalis fascia), cremasteric muscle and fascia (from the internal abdominal oblique), external spermatic fascia (from the external abdominal oblique aponeurosis)

testis (TG6-32B) an endocrine and exocrine gland contained

testis is the male gonad; its exocrine product is

within the scrotum

sperm which drain to the head of the epididymis via efferent ductules; its endocrine product is testosterone; the testis migrates into the scrotum shortly before birth; it is tethered to the scrotum inferiorly by the scrotal ligament (a remnant of the gubernaculum)

tunica dartos scroti (TG6-32B) a subcutaneous layer of smooth muscle located in the scrotum

fatty and membranous layers of the superficial fascia (as seen in the lower abdominal wall) are fused in the scrotum to form the tunica dartos scroti

(Greek, dartos = leather)

tunica vaginalis testis (TG6-32B) a peritoneal sac located anterolateral to the testis

tunica vaginalis testis has two layers: visceral and parietal; the visceral layer lies on the anterolateral surface of the testis and epididymis; the

(Latin, vagina = sheath)

parietal layer lines the inner surface of the scrotal sac

fascia, transversalis(N251,N252,N259, TG5-07)

lines majority of abdominal wall

covers the deep surface of the transverse abdominis and its aponeurosis

right and left sides continuous deep to the linea alba

fascia, weak(N251,N252,N259, TG5-07) located in the inguinal triangle

hernias can occur here

Lymphatics

Structure LocationAfferents

fromEfferents

toRegions drained

Notes

superficial inguinal nodes(TG6-34)

in the superficial fascia parallel to the inguinal ligament and along the terminal part of the greater saphenous v.

lymphatic vessels from the superficial lower limb, superficial abdominal wall, perineum

external iliac nodes; deep inguinal nodes

lower abdominal wall; external genitalia; superficial parts of the lower limb

superficial inguinal nodes are 12-20 in number; they become inflamed during infections of the lower limb; they may become inflamed during infections of the external genitalia

Clinical Terms

Term Definition

appendicitis inflammation (and usually infection) of the appendix, a finger-like projection of the first portion of the colon, that often causes right, lower quadrant abdominal pain, fever and loss of appetite

cholecystitis acute or chronic inflammation of the gallbladder; may necessitate a cholecystectomy or gall bladder removal, which is now usually performed laparoscopically. History may reveal pain, fever with chills and nausea with vomiting.

McBurney's point/incision

McBurney's point lies 1/3rd superiomedially along the line between the right anterior superior iliac spine and the umbilicus; this point marks the usual location of the appendix within the right iliac fossa; McBurney's incision is an oblique incision over this point inferomedially directed, splitting the fibers of the external oblique aponeurosis; fibers of internal abdominal oblique and transversus abdominis muscles are then split to gain access to the appendix

median incision incisions made through the fibrous tissue of the linea alba superior and/or inferior to the umbilicus; linea alba usually only transmits small vessels and nerves, therefore these incisions are relatively harmless and bloodless; however, in some patients these incisions may be problematic as they may cut through vascularized fat; also, as it is poorly vascularized, incisions of the linea alba may result in necrosis if the incisions are not brought together well; lower median incisions are often used in female patients to access the female pelvic viscera; median incisions are generally used for exploratory procedures

paramedian incision incision through the anterior layer of the rectus sheath which is laterally retracted, and then through the posterior layer and peritoneum to enter the peritoneal cavity

subcostal incision provides access to the gallbladder and biliary tract on the right side and the spleen on the left; made parallel to the costal margin but at least 2.5 cm inferior to avoid the 7th and 8th thoracic spinal nerves

Pfannenstiel (suprapubic) incision

incision made at the pubic hairline; horizontal with a slight downward convexity; used for most gynecological and obstetrical operations (e.g., for cesarean section and removal of a tubal pregnancy)

transpyloric plane at the midpoint between the suprasternal notch and the pubic symphysis, at the level of the first lumbar vertebra

paresthesiaan abnormal spontaneous sensation such as burning, pricking, and numbness

periumbilical around or near the umbilicus

emesis act of vomiting

anorexia uncontrolled loss of appetite for food

auscultationthe act of listening for sounds within the body, chiefly for ascertaining the condition of the lungs, heart, pleura, abdomen and other organs and for the detection of pregnancy

abdominal guardingspasm of the anterolateral abdominal muscles and a muscular rigidity usually in response to intraperitoneal inflammation or irritation

rebound tenderness when pressure is applied to an area of the abdominal wall and then

suddenly removed, extreme localized pain is felt by the patient usually in response to intraperitoneal inflammation or irritation

gastroenteritisan acute inflammation of the lining of the stomach and intestines that can be initiated by food poisoning due to viral or bacterial infection resulting in nausea (+/- emesis), pain, and diarrhea (+/- blood)

peritonitis inflammation of the peritoneum

Caesarian/Cesarian section

an obstetrical procedure in which an infant, instead of being born vaginally, is surgically removed from the uterus; requires both an incision into the abdominal wall and the wall of the uterus; done in ancient civilizations to save babies after the death of a full-term pregnant mother, hence, the name Caesarian, since it is believed that Caesar was born by this procedure

PATHOPHYSIOLOGY

Assessment and

Diagnostics

In abdominal stab wounds, the liver, stomach, and intestines are commonly affected.

Nurses and doctors in the ER need to thoroughly assess the patient for signs of

hemorrhage and hypovolemic shock (blood may be pooling inside the peritoneum

especially when the object used to stab has not been removed) – a drop in blood

pressure, cold, clammy, and paling extremities, diminishing peripheral pulses,

tachycardia, tachypnea, diaphoresis, and confusion – as well as gastric and intestinal

leakage into the peritoneal space. The latter will have to be continually monitored to

prevent infection later on. Assess for liver trauma because bile from the liver can leak

into the peritoneal cavity causing bile peritonitis. Some cases present peritonitis upon

abdominal examination secondary to stab wounds. The patient may be experiencing

fever and signs of inflammation, diffuse tenderness, and abdominal pain.

CT-scanning, ultrasonography, abdominal X-ray, peritoneal lavage and DPL can

be done to determine the extent of the injury. Laparotomy is indicated for peritoneal

penetration, evisceration, and massive bleeding. Liver function tests may reveal

increased liver enzyme activity, but may also indicate previously undetected liver

disease. Hematology reports may show elevated ESR and WBC count. The former

suggests active inflammation while the latter does a possible ruptured spleen. Increased

neutrophil count means an active infection. Urinalysis may reveal RBC’s from a possible

bladder trauma. Arterial blood gas analysis can reveal abnormalities such as metabolic

acidosis. Prothrombin time, international normalized ratio, and activated partial

thromboplastin time screen for coagulopathy. Serum amylase and lipase levels, when

persistently elevated, may indicate injury to the pancreas or bowel.

Indications :

Abdominal stab wound exploration is indicated in a patient who presents with a stab wound tothe anterior abdomen, normal vital signs, no signs of peritonitis, and no evidence of evisceration

Stab wound to the anterior abdomen.

Some authors advocate local exploration of wounds only anterior to the midaxillary line. If the wound tracks anteriorly and the end point of the tract is not accurately determined, the patient undergoes diagnostic peritoneal lavage (DPL). If the wound tracks posteriorly and is not obviously superficial, the patient is investigated as for a penetrating flank wound. This often involves a triple-contrast CT scan.

Special circumstances involve patients with additional injuries that require operative intervention and cases in which the offending weapon or object is retained.

If the patient has additional injuries that require operative intervention, a wound exploration may be performed in the operating room before the other procedure is commenced.

If the object has been retained and the surgeon strongly suspects that the peritoneum has not been breached, the object may be removed in the operating room and the wound locally explored. In such cases, the surgeon should be prepared to immediately convert to laparotomy, if necessary.

CONTRAINDICATION:

Abdominal stab wound exploration is contraindicated if immediate laparotomy is indicated. The situations in which immediate laparotomy is indicated include the following:

Unstable patient Peritonitis Evisceration (This remains controversial; see paragraph 3 in Selecting

Candidates for Laparotomy section.) Blood on rectal examination or blood in nasogastric tube aspirate suggests intra-

abdominal injury (A low threshold for operative intervention is suggested.)

Other contraindications to abdominal stab wound exploration include the following:

Lower chest wounds: Exploration of these wounds carries a high risk of iatrogenic pneumothorax.

Flank and back wounds: Some authors advocate exploration of these wounds if they are suspected to be superficial. However, this expectation may be unreliable, and the strong musculature makes the tract difficult to predict or to follow. Local wound exploration may result in further injury or a restart of hemorrhage that had stopped.

Patient refusal or uncooperative patient.

Relative contraindications include the following:

Obesity Multiple abdominal stab wounds

ANESTHESIA:

Local anesthesia is used.

Use liberally, as patient comfort is essential. The procedure requires patient compliance and adequate anesthesia. Hemostasis is also important.

The authors’ suggested preparation is 1% lidocaine hydrochloride (10 mg/mL) with epinephrine 1:200,000 (5 mcg/mL). Other preparations can be used.

The maximum dose of lidocaine combined with epinephrine is 7 mg/kg, up to 500 mg.

Local exploration in uncooperative patients is best performed in the operating room under general anesthesia.EQUIPTMENT:

Adequate light source or operating lamp Sterile gloves Surgical masks Surgical caps Protective eyewear Sterile gowns Sterile drapes Cleaning solution (10% povidone iodine [Betadine] or other suitable solution) Lidocaine hydrochloride (1%) with epinephrine Gauze swabs Suture material (See Technique for suggestion of suture material.) Wound dressing Washout irrigant (1 L of 0.9% NaCl) Scalpel Blades, 2 Retractors, 2 Dissecting forceps (toothed and untoothed) Needle holder Scissors (curved dissecting and stitch scissors) Hemostats, 5 Diathermy may be used, if available. Diathermy assists with achieving

hemostasis.

Equipment required for an abdominal stab wound exploration.

POSITIONING:

Adequate exposure of the abdomen is essential.The patient is positioned supine.Abdominal stab wound exploration can be effectively performed in the emergency department.

TECHNIQUE:

Obtain informed consent for the procedure. Gather and check equipment. Position the patient supine and elevate the operating table or stretcher to an

appropriate height. Shave and prepare the area around the stab wound. The maintenance of a sterile

field is essential.

Local wound exploration requires an operator and an assistant. Both the operator and assistant should scrub, as for any surgical procedure.

Liberally infiltrate local anesthetic with epinephrine around the wound, using standard surgical technique. Adequate hemostasis is necessary to facilitate direct visualization of the tract of the wound and to prevent further hemorrhage in wounds that penetrate the

peritoneum. Also, the wound may need to be extended, which may result in further bleeding. For both these reasons, lidocaine with epinephrine is preferred as the anesthetic agent. Achieving poor hemostasis has been associated with subsequent false-positive diagnostic peritoneal lavage (DPL) results and unnecessary laparotomy. Do not exceed the maximum dose of lidocaine.

Most stab wounds are small and need to be extended with a scalpel to allow visualization of the underlying fascia. To optimize subsequent wound healing and cosmetic result, midline wounds should be extended vertically and lateral wounds should be extended horizontally along natural skin lines. The required length of extension is determined by the depth of subcutaneous fat. Wounds heal from the sides rather than the ends; hence, lengthening the wound does not affect the repair process.

The assistant uses the retractors to visualize the depths of the wound. Diathermy is a useful aid in the maintenance of hemostasis.

Appreciation of the anatomy of the anterior abdominal wall at different levels is essential. The procedure cannot be safely completed if you do not know which layer you are exploring and what lies immediately beneath it.

Further explore the wound under direct vision, taking care to identify the fascial layers and the musculature. Breach of the anterior rectus fascia requires extension of the

fascial defect. This can be achieved with a scalpel, with dissecting scissors, or with diathermy. This allows inspection of the underlying muscle and the posterior layer of the rectus sheath. There is no posterior layer of rectus sheath below the arcuate line, but the rectus fascial defect is still extended to allow inspection of the underlying muscle and transversalis fascia.

The goal of exploration is to determine the end point of the tract. This is not always easy, especially in more lateral wounds. The fascial planes are more difficult to identify laterally. Following the tract through muscle can be challenging. If the posterior rectus fascia or transversalis fascia is adequately visualized and is intact, the patient does not have an intra-abdominal injury. After adequate wound care, the patient can be discharged from the emergency department.

Nonpenetrating wound: External oblique muscle intact in base of wound.

If the posterior rectus fascia or the transversalis fascia is penetrated, the local wound exploration findings are positive. The frequency of peritoneal injury is high in patients with positive findings. Assessing the integrity of the parietal peritoneum itself is technically difficult, and exploring at this level risks converting a nonpenetrating wound into a wound that breaches the peritoneum. If breach of the peritoneum cannot be confidently excluded, the patient requires further assessment and investigation.

Penetrating midline wound.

Penetrating lateral wound. (The exploration of this wound clearly determined that the stomach had been penetrated. Therefore, the patient did not require diagnostic peritoneal lavage [DPL], as laparotomy was already indicated. During laparotomy, a hole in the stomach and 2 holes in the small bowel were repaired. The patient had an uneventful postoperative course and was discharged from the hospital 3 days later.

Patients who require further investigation usually undergo DPL. The wound should be temporarily packed with dry gauze and a sterile dressing until the lavage is completed. This packing helps prevent further hemorrhage into the peritoneum from the wound. A DPL with positive findings further delineates patients who are more likely to have an intra-abdominal injury that requires surgical intervention. The stomach and bladder must be decompressed before DPL.The wound is then thoroughly irrigated with saline and closed in layers. Hemostasis and sound surgical technique prevent subsequent wound complications. The sheath is closed with strong absorbable suture (PDS 0 or Vicryl 0). Muscle need only be repaired if the defect is large. If muscle repair is necessary, interrupted absorbable sutures (Vicryl 2-0) are used. In individuals who are obese, the subcutaneous fat can be approximated with absorbable sutures. The wound edges rarely require debridement before skin closure. The skin is closed with skin clips, interrupted nonabsorbable sutures, or continuous subcuticular sutures. Some authors have advocated suturing the surgical extension wound but leaving the stab wound to heal by secondary intention to minimize the risk of infection. Unless the wound is markedly contaminated, this is unnecessary.

Patients with an exploration with negative findings may be discharged home. Antibiotics

are not required. Routine surgical wound care is provided.

Nursing Diagnosis

Acute pain related to abdominal wound

Deficient fluid volume related to active loss of blood

Impaired tissue integrity related to penetrating abdominal wound

Risk for infection related to introduction of a foreign body into the abdomen

Nursing Intervention

Assist patient onto ER bed.

Insert two large-bore intravenous (I.V.) lines to infuse 0.9% sodium chloride or

lactated Ringer's solution, according to facility protocol.

Control the patient's pain without sedating him, so you can continue to assess his

injuries and ask him questions. Generally, I.V. analgesics such as morphine can

adequately manage pain without sedation.

Insert an indwelling urinary catheter, unless you suspect a urinary tract injury. An

indwelling urinary catheter is inserted to minimize urine leakage into the abdomen

or supporting tissues. If a urethral injury is suspected, consider catheterizing the

bladder through a suprapubic approach. Frequently observe for and quantify the

degree of hematuria with an indwelling urinary catheter. The initial urine obtained

may have been in the bladder prior to the traumatic event. If hematuria is noted,

this may be because of the placement of the urinary catheter. Measure and discard

the initial urine specimen and test the subsequent urine specimen for the presence

of blood. Suspected injury to the urethra (i.e., gross blood) is a contraindication to

catheterization through the urethra.

Draw blood specimens stat for baseline lab values.

Insert a gastric tube to decompress the patient's stomach, prevent aspiration, and

minimize leakage of gastric contents and contamination of the abdominal cavity.

This also gives you access to gastric contents to test for blood.

Administer tetanus prophylaxis and antibiotics as ordered.

Cover open abdominal wounds with a sterile dressing. If evisceration of abdominal

contents has occurred, place a sterile, moist dressing over the injury.

Stabilize impaled objects

Administer antibiotics, as prescribed. Leakage of gastric and bowel contents will

result in peritonitis and possibly sepsis.

Administer analgesics, as prescribed.

Prepare the patient for operative intervention, hospital admission, or transfer, as

indicated.

Evaluation and Ongoing Assessment

Refer to Initial Assessment, for a description of the ongoing evaluation of the patient's

airway, breathing, circulation, and disability. Additional evaluations include:

Monitoring cardiovascular status for changes suggestive of hypovolemic shock

Reassessing the abdomen frequently and thoroughly to detect subtle changes

Monitoring urinary elimination for changes suggestive of hypovolemic shock

STAB WOUND

Submitted to:Mr. Lester Palacios R.N.

Clinical InstructorUPHSL-Biñan

Submitted by: Mary Anne E. ElepañoBSN 4 – F, Group 22