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% 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

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) 20022008 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

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/mm 3, 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

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 LWEDPLFASTCT scanLaparoscopy Sensitivity (%)7187-10046-8594-9750-100 Specificity (%)7752-8948-9595-9874-90 NPV (%)7978-10060-9895-9998-100 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 Laparotomy Stable haemodynamic and No peritonitis CT scan Hollow organ injurySolid organ injury Embolization Negative Observation If haemodynamic instability or peritonitis Left thoracoabdominal injury NoYes Laparoscopy

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