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Penetrating Abdominal Injury. Is Exploratory Laparotomy Still the Standard Treatment?. Dr Annie NK Chiu UCH JHSGR 21st Apr 2012. Outline. Definition of penetrating abdominal injury (PAI) Mechanism of penetrating injury Stab wound Gunshot wound Management Exploratory laparotomy - PowerPoint PPT Presentation
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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