Selected Articles from the Journal Abdominal Surgery

This article originally appeared in the Winter 2009 / Spring 2010 issue of the Journal.

Abdominal Stab Wounds

Dr. Faris Dawood Al-Aswad
MBCHB, FICMS, FISS, ASGS, ASAS, FICS
Spacialist General Surgeon
NMC Specialty Hospital (Dubai – UAE)

AIM OF STUDY
The aim of the study is to study the reliability of selective conservative management of the penetrating stab wounds to the anterior abdomen depending exclusively on the clinical criteria, reducing the number of negative laparotomies, reducing period of hospital stay, morbidity and mortality, types of weapons that procedure penetrating stab wounds.

SUMMARY
This prospective study comprises of 96 patients with penetrating stab wounds to the anterior abdomen. These cases were collected over a period of 2 years and 3 months at Al-Yarmouk Teaching Hospital.

All cases were managed by selective conservative management policy depending exclusively on clinical criterion versus to the mandatory laparotomy for all penetrating stab wounds to the abdomen.

Peritoneal penetration was proved by digital exploration of the stab wound under local anesthesia, intra-abdominal structures evisceration (omentum, bowel), air under the diaphragm, or positive abdominal paracentesis.

Fifty-Two patients (54.16%) were operated upon immediately. The indications for operations were, acute abdomen, shock (vasomotor instability), omental or bowel evisceration, air under the diaphragm, uncontrolled bleeding from the stab wound and frank haematuria. No mortality was recorded.

Morbidity was recorded in 8 patients (8.3%). The mean hospital stay was 7.7 days. The negative laparotomies were 8.3%.

Forty-Four cases (45.84%) were managed conservatively, only 4 patients (41.16%) were needed delayed laparotomy and the indication for operation was peritonitis during period observation.

The remaining 40 patients were managed conservatively without mortality and little morbidity only 2 patients (2.08%) were developed stab wound infection. The mean hospital stay was 3.5 days.

If we depend on the mandatory exploration policy for all cases of penetrating stab wounds of the abdomen, the percentage of negative laparotomies will reach 50%.

INTRODUCTION
The anterior abdominal wall is defined as the area between xiphoid and pubic symphysis and both posterior axillary lines. This area consists from skin, subcutaneous tissue, the three muscles of the anterior abdominal wall (external oblique muscle, internal oblique muscle and transversus abdominis¹⁹). These muscle are separated in the flanks and fused in the ventral midline to overlap the rectus abdominis muscles and forming anterior and posterior rectus sheaths. Then the parietal peritoneum clothes the anterior and posterior abdominal walls, the under surface of the diaphragm, and the cavity of the pelvis¹⁹. This parietal peritoneum attaches to these anterior and posterior abdominal walls by extra-peritoneal areolar tissues which vary in thickness and density in different places. The parietal peritoneum is supplied segmentally by spinal nerves that innervate the overlying muscles. Thus the parietal peritoneum is sensitive while visceral peritoneum which surrounds the viscera has poor nerve supply. Thus the parietal peritoneum when irritated produces vague pain and poorly localized1.

Blood supply of the anterior abdominal wall comes from branches of musculophrenic artery and lumbar arteries which accompany the segmental nerves and run in the Neuro-Vascular plane between internal oblique muscle and transversus abdominis muscle.

The rectus muscle has its own blood supply from superior epigastric artery branch of internal thoracic artery and inferior epigastric artery branch of external iliac artery¹⁹.

The organs were injured in this study, small bowel 23 cases, colonic 8 cases, vascular 6 cases, stomach 4 cases, liver 3 cases, spleen 2 cases, gall bladder 1 case and urinary bladder 1 case.

MATERIALS AND METHODS
This is a prospective study over a period of 2 years and 3 months (November 1992 - November 1993), April 1994 - October 1994 and December 1994 - August 1995). During these periods 96 patients with penetrating stab wounds of the anterior abdomen were admitted to the surgical wards at Al-Yarmouk Teaching Hospital. Peritoneal penetration was proved by intra-abdominal structure evisceration (omentum or bowel), gas under the diaphragm, positive abdominal paracentesis and digital exploration of the stab wound under local anesthesia. After full assessment of the patient and available investigations and proper measures were done, the digital exploration of the stab wound must be performed.

The area sterilized with (Povidone Iodine), sterile draping were used, sterile gloves and instruments were prepared for these purposes. Local infiltration of the area surrounding the wound with Xylocaine 1% or 2% without adrenaline. Exploration of the wound was done under direct vision with good light, securing haemostasis, layer by layer, we follow the tract of the wound, if difficult to see the end of the tract, extension of the wound must be done. It is not difficult to follow the tract and seeing the peritoneum violation. After that the wound closed in layers. Small stab wounds were not explored, 10 patients had small wounds. If the stab wound wasn't penetrate the peritoneum proved by digital exploration, the wound must be sutured and was considered as superficial wound and the patient must be discharged from causality unit and treated as out patient.

Eighteen patients with superficial stab wounds to the anterior abdomen who received medical care 1-3 hours after injury.Digital exploration of the wounds were showed superficial wounds. They were discharged from casualty unit and they were treated as out patients. No complications and no readmission were recorded.

MANAGEMENT
The total number of patients in our study were (96) patients (87 males and 9 females). They were admitted to the surgical units at Al-Yarmouk Teaching Hospital.

Those patients treated by the policy of service of selective conservative management of penetrating stab wounds to the anterior abdomen depending exclusively on clinical criteria.

Every patient had intravenous line, blood was drawn for P.C.V. Blood Urea, S.Electrolytes, blood sugar and blood grouping and cross matching if needed. GUE for microscopic haematuria, the x-ray of the abdomen or lower chest at erect position for detection gas under the diaphragm. Nasogatric tube or Foley's catheter were inserted if indicated.

Digital exploration of the stab wound under local anesthesia must be performed to prove the peritoneal penetration unless there were intra abdominal structures evisceration (omentum or bowel), gas under the diaphragm detected by x-ray of the abdomen, positive abdominal paracentesis, small wounds or immediate decision for laparotomy was established during the initial evaluation of the condition. After the patient was evaluated on clinical grounds,we placed the patient in one of these categories for analysis purposes:

Category A: (Immediate Laparotomy): Those patients group consist of patients thought to have significant injury by criteria upon initial evaluation. This category includes 52 patients (54.2%)

The indication for laparotomy:

1. Acute abdomen (peritoneal irritation) 25 patients had signs of acute abdomen: Guarding or rigidity rebound tenderness or absent bowel sounds.
2. Intra-abdominal structures evisceration (omentum or bowel). 16 patients (12 patients had omental evisceration and 4 patients had small bowel evisceration)
3. Shock or vasomotor instability: 5 patients
4. Gas under the diaphragm: 4 patients (3 of them had signs of acute abdomen and 1 patient had signs of vasomotor instability).
5. Uncontrolled bleeding from the wound: 1 patient.
6. GIT bleeding: no patient.
7. Frank haematuria: 1 patient

Category B: (Observation): This includes 44 patients(45.8%).These patients did not have signs of peritoneal irritation or minimal signs of (mild localized tenderness around stab wound) and vasomotor stability, they were admitted and managed under observation category which this subdivided into two groups:

B1. (No Laparotomy): This group comprises 40 patients. Those patients were thought to have no indication for surgery upon initial clinical examination and eventually they were discharged from the hospital within 3-5 days without exploration.

B2. (Delayed laparotomy): Group includes 4 patients. Those patients were not thought to have indications for Laparotomy upon initial clinical evaluation but then developed signs which need surgical exploration during observation.

Category B (Observation category) comprise of 44 patients (45.8%). Six patients had small stab wounds and digital exploration of the wounds was not done.

Thirty eight (38 patients) had peritoneal penetration was proved by digital exploration of the wound under local anesthesia.

All patients in this category had intravenous line, blood was drawn for P.V.C, blood grouping and cross matching if need blood, blood urea, S.electrolytes, B.sugar, GUE for micro or macroscopic heamaturia, X-ray of the abdomen were taken. Naso gastric or Foleys catheter were inserted when needed.

Those patients had no signs of peritoneal irritation (guarding or rigidity, rebound tenderness, absent bowel sounds) or minimal tenderness around the stab wound and vasomotor stability (BP=110/70 and pulse rate=90/minute or below).

All these patients were admitted to the surgical units Al-Yarmouk Teaching Hospital and were put under close observation chart for 48 hours (one hourly chart for first six hours including pulse rate, blood pressure, temperature and abdominal signs). Then two hourly observation chart for second six hours and then four hourly chart for twelve hours.

At the second day we put the patient at six hourly observation chart and blood was drawn for P.C.V, X-ray of the abdomen at erect position must be done.

Forty patients (41.6%) of the category B did not develop any signs of peritonitis (guarding, rigidity, rebound tenderness or absent bowel sounds) or vasomotor instability during observation. They were discharged form the hospital within 3-5 days. No mortality was recorded and 2 patients had stab wounds infections (2.08%)(B1 group). Four patients (4.16%) of the category B developed signs of peritonitis during observation and underwent delayed laparotomy. No mortality and morbidity were recorded at this group (B2).

We concentrate a detailed management of those four patients who were underwent delayed laparotomy. The first was attended 48 hours post trauma to the casualty unit. The patient was 19 yrs old male, had small wound at right flank (right upper quadrant) about 0.5cm diameter with crustation above the wound. The penetrating wound produced by metallic sharp rod.

Pulse rate 110/minute, temperature 38C° B.P=110/70. The abdomen was distended, rigidity mainly at right side of the abdomen, rebound tenderness positive with absent bowel sounds. P.C.V 36%, blood urea 40mg/100ml, random blood sugar 100mg/100ml.

X-ray of the abdomen and lower chest at erect position was showing gas under the diaphragm. Explorative laparotomy was performed through right paramedian incision. The operative findings were a small perforation of ascending colon, and distended loops of small bowel. It was sutured in two purse string sutures. The patient passed motion 24 hours post-operatively and discharged from the hospital within 5 days with clean wound.

The second patient had penetrating wound by metallic sharp rod at left lower quadrant just below and to the left from umbilicus, about 0.5cm diameter. The patient was 20 years old and received medical care at the casualty unit 36 hours post trauma. On examination, pulse rate 110/minute, temperature=38C°,B.P-120/70.The abdomen was distended, lower abdominal rigidity and absent bowel sounds. X-ray of the abdomen was showing multiple fluid levels at center of the abdomen. Exploratory laparotomy was performed by lower median incision and operative finding, small perforation was sutured at the ileum and distended loops of small bowel. The perforation was sutured in two layers. The patient was passed motion 24 hrs post-operatively and discharged at fifth postoperative day with clean wound.

The third patient was 30yrs old ,who had penetrating wound at left lower quadrant of abdomen by screw driver. He attended to the casualty unit 3hrs post trauma. Pulse rate 84/mt, B.P=130/80, temperature 37C°, P.C.V=40%.

Other laparotomy investigations were normal values. Plane X-ray of abdomen at erect position showing no air under diaphragm. The abdomen soft, no any localized or generalized abdominal signs. The patient was admitted to the surgical unit and was put under close observation chart. After 24 hrs observation pulse rate start to increase 80/mt to 110/mt, BP=130/80, temperature reached at 37.8C, The abdomen not distended but there was positive rebound tenderness at lower abdomen. X-ray of abdomen still had nothing of relevant, bowel sounds still positive. Explorative laparotomy was done 36hrs post-trauma and operative findings only small perforation of sigmoid colon, no soiling around the perforation, small haematoma of the mesocolon. This perforation was sutured in two layers.The patient passed motion 48hrs post-operatively and discharged on 6th post-operative day with clean wound.

The patient was 30yrs old who got penetrating stab wound to the left upper quadrant of the abdomen produced by knife, about 5cm length. On examination of the patient, pulse rate80/mt, BP=120/80, temperature=37C°. The abdomen was soft, only there was mild tenderness around the stab wound. Radiological and laboratory investigations were showing nothing of the relevant. Digital exploration of the wound under local anesthesia was performed and peritoneal penetration was proved.

The patient was admitted to the surgical unit under close observation. After 14hours there was increasing pulse rate, reached at 110 – 120/mt, B.P 120/80, temp-37.8C° upper abdominal guarding positive rebound tenderness, with positive bowel sounds, exploratory laparotomy was done sixteen hours post-trauma and only found jejunal perforation with jejunal mesenteric haematoma, it was sutured in two layers. The patient passed motion at third post operative day and discharged at seventh post operative day without any morbidity.

RESULTS
Ninety-six patients comprise this study. The age ranges from 14 years to 55 years. The mean age is 27.125 years. Eighty-seven (90.25%) were male, and nine (9.375) were females. The results will be seen in tables 1 -10.

DISCUSSION
Some trauma centers advocate mandatory laparotomy for any potentially penetrating stab wounds to the abdomen^15,25. Many authors have found an incidence ranging from 14.35% of patients with normal initial physical examination associated with significant intra-abdominal injury. In contrast 15.18% of patients with peritoneal signs had no intra-abdominal injuries^12,15,17.

However in many study 8 patients (8.3%) were had peritoneal signs upon initial examination and they were operated upon immediately (category A) and they were not had any visceral or vascular injuries.

Four of them had signs of acute abdomen and other four patients had omental evisceration.

Four patients had normal initial physical examination and later they were developed signs of peritonitis and delayed laparotomies were performed.

The policy of mandatory laprotomy leads to many negative laparotomies. In some series up to 53%^10,15,16. Although some authors reported no mortality in the negative laparotomy but others could not achieve this results.

Mayards found 6.3% mortality rate¹⁵, Lowe found 1.6% mortality rate¹⁴. A negative laparotomy performed as an emergency without any patient preparation, poor anesthetics facilities; untrained anesthetists pose a significant risk. Most patients have full stomach and are prone to aspiration during induction of anesthesia. Nance¹⁸ reported 4 iatrogenic splenic injuries, 3 small bowel injuries, colonic in series 250 negative laparotomies.

In this study no mortality was recorded and 2 cases with negative laparotomies were developed complications, Morbidity 2.08%, One surgical wound infection, and one chest infection.

The number of surgical intervention in our study was 56 laparotomies (58.3%), 52 patients were immediately operated on and 4 patients had delayed laparotomy.

The same results were reported by D.Demetriades and Robinowiz (56.6%)⁷.

If we followed the mandatory laparotomy in our study the negative laparotomies will reach 50%.

Digital exploration of the wound under local anesthesia was used for proving of penetrating of peritoneum not for evaluation of intra-abdominal injuries²⁶.

Eighteen patients had superficial wounds and suturing of wounds were performed.Discharged from the casualty unit and treated as outpatients.

Ten patients in category A, the wounds were digitally explored and 38 patients in category B.

The other proving for peritoneal penetration included.

Sixteen patients intra-abdominal structure evisceration, 5 air under the diaphragm, 6 positive abdominal paracentesis, 9 small stab wounds and 12 immediate decision for surgery was taken and proving of peritoneal penetration in 11 patients during operation and 1 with frank haematuria was showing extra-peritoneal injury to the urinary bladder.

Stab gram was not used in my study for the following reasons

1. Limited facilities in our hospital including the availability of radio-opaque dyes and x-ray films.
2. Some patients are sensitive to the dye²⁰.
3. The dye produces severe pain at site of injection and might mask20 the physical findings.
4. False positive reached 14% reported by Aragon³.

We did not use peritoneal lavage in our study. The causes^22,23:

1. We are depending exclusively on clinical criteria for evaluation of intra-abdominal injuries.
2. Lavage was time consuming, costly some surgeons consider it and explorative laparotomy.
3. May produce iatrogenic injuries²³.
4. Missing of solitary bowel lesions²³.

Major vascular injuries usually exhibit vasomotor instability and this will serve as indication for exploration. Isolated small bowel injuries or colonic injuries which often do not bleed significantly where these lesions that must be detected by careful physical examination and may be missed by peritoneal lavage. Abdominal paracentesis was used in my study as adjunctive or accessory diagnostic aid to the clinical findings to prove peritoneal violation. It was used in 6 cases, 5 patients were presented with shock or vasomotor instability 3 of them had liver injuries, 1 splenic injury and one patient with jujenal mesentric haematoma and bleeding vessels. The sixth one had uncontrolled bleeding from the wound, abdominal paracentesis was showing positive result and explorative laparotomy was performed ,no injury re veiled except bleeding from left inferior epigastric vessels.

In my study 12 cases were presented with omental evisceration an absolute indication for laparotomy. Four patients were not had any significant injuries. Some authors apply the policy of selective conservative of some cases of omental evisceration. But Cathy A4 .Burnweit and his colleagues were found 75% of patients with omental evisceration associated with major intra-abdominal injuries. Demtriads treat6 24 with omental evisceration 2 bowel evisceration with no mortality or morbidity.

Although those 4 patients with omental evisceration have not any significant injuries, omental eviceration remains an absolute indications for laparotomy. Some authors used conservative management to omental evisceration^6,7,21.

Free air under the diaphragm as was demonstrated by erect abdominal x-ray considered an indication for laparotomy. 5 patients were recorded with air under the diaphragm in this study.

The cases with pneumoperitneum were demonstrated at table No.8. Some authors treated conservatively for many cases with air under the diaphragm, they thought that the air enter the abdomen either through the stab wound or penetrating the right hemidaphragm as reported by D.Demetriades⁷ and Robin Owtz who were treated 5 patients with air under the diaphragm conservatively , with no morbidity or mortality. In our study all cases with air under the diaphragm had significant injuries which cannot treat them conservatively , as shown at table No.8.

Six cases presented with signs of shock (vasomotor instability), one of them had air under the diaphragm operated immediately and found splenic injury and penetration left dome of the diaphragm. The remaining patients were abdominal paracentesis done and free flowing aspirated blood , immediate laparotomy were performed and injuries were 3 cases liver injuries, 1 splenic injury, 1 jujenal mesentric haematoma and bleeding from jujenal vessels. Conservative management in these cases not tried. Some authors report conservative management to some liver injuries with successful results⁷.

Although 2 liver injuries were superficial laceration but physical evaluation was showing vasomotor instability, one liver injury was deep and need urgent laparotomy. Splenic injuries were showing clear signs of intra-abdominal bleeding and both treated by splenectomy. Jujenal haematoma and bleeding from jujenal vessels need immediate laparotomy. Discussion about liver injuries and positive paracentesis ,an abdominal paracentesis that is positive for blood is considered an indication for surgery^3,24.

Demetriades⁶ believe this alone should not be absolute indication for exploration. 12 patients were treated conservatively without complications. Free blood in the peritoneal cavity in the absence of hallow viscus perforation often does not give signs of acute abdomen. Such patients can safely be managed conservatively. The free blood may originate from the abdominal wall wound or superficial liver laceration it has been shown that many liver injuries are treated with only laparotomy because they do not bleed at operation.

Levin¹³ et al reported that 14% of 535 liver injuries had only laparotomy without any specific treatment.

Fischer⁹ et al reported a figure 21.3%. Demetriades6 et al a recent prospective study from his centre. One third of the patients with penetrating liver injuries were treated conservatively with no morbidity or mortality. One patient was sustained stab wound to the suprapubic region at right lower quadrant with frank haematuriala operated upon immediately and showing extra peritoneal injury to the urinary bladder. One patient had uncontrolled bleeding from the wound, abdominal paracentesis was positive. Laparotomy was done ,no injury was revealed except bleeding from left inferior epigastric vessels. Three patients were presented with stab wounds to the abdomen with alcohol consumption .They were operated immediately 2 of them had small bowel injury and one with liver injury.

Alcohol intoxication is generally considered as making clinical evaluation difficult or impossible^2,10,15. In many series alcohol intoxicated patients were assessed and treated in the same way as the rest^6,7.

If mandatory laparotomy was performed to all stab wounds to the anterior abdomen, the incidence of negative laparotomies will reach (50%).While this study used clinical examination as the sole criteria for exploration, the incidence of negative laparotomies were reduced to (8.3%).The reliability of initial clinical abdominal assessment was shown at table 11.

CONCLUSION
It is concluded that many penetrating stab wounds to the anterior abdomen can be safely managed without operation, the decision to operate or observe can be made exclusively on clinical criteria.Versus to mandatory exploration of all the penetrating abdominal stab wounds.

REFERENCES

1. A.J. Hardings Rains and Charles V.Mann. Baily & Loves: Short practice of Surgery 20th Edition 1990 page 1003.

2. A.M. De lacy M. Pera. J.C. Garcia. Valdecasas, L.Grando J.Fuster, E Cugot, M.A. Lopez Boado, J. Visa, C. Pera : Management of penetrating abdominal stab wounds Br. J. Surg. 1988 : 75: 231-33.

3. Aragon G.E, Eiseman B. Abdominal stab wounds : Evaluation of sinography: J. Trauma 1976 : 16 : 792.

4. Cathy A. Burnweith MD, Erwin R Tha\ MD : Significance of omental evisceration in abdominal stab wounds. Am. J.Surg. 1986 :16: 676.

5. Cornell W.P, Ebert P.A, Greenfield L.J. A new non-operative technique for the diagnosis of penetrating injuries to the abdomen. J. Trauma 1967 : 7 : 307-14. J. Trauma 1967 :7:307-14.

6. D.Demetriades MD PhD., B. Rabinotiz FRCS. Indications for operation in abdominal stab wounds. Aprospective study of 651 patients. Ann. Surg. : 1987, 205 : 129 – 30.

7. D.Demetriades, B. Robinwtiz : Selective conservative management of penetrating abdominal wounds, a prospective study. Br. J.Surg. :1984 : 71: 92–94.

8. Donalson L.A., Findlay I.C, Smith A.. A retrospective review of 89 stab wounds to the abdomenand chest. British Journal Surgery. 1981 : 68:793-96.

9. Fischer D, O Farrell K., Perry J. The value of peritoneal drains in the treatment of the liver injuries. J. Trauma 1987. 18. 393. 398.

10. Forde K., Ganepola G., Is mandatory exploration for penetrating abdominal truma extinct. The morbidity and mortality of negative exploration in large municipal hospital. Journal Truma, 1974: 14: 764-766.

11. Galbraith T.A., Oreskovich M.R., Helmbach D.M et al. Role of peritoneal lavage in the management of stab wounds of the abdomen. Am. J.Surg. 1980:140:60-71.

12. Hapson W. B., Sherman R.T., Sanders J.W. : Stab wounds of the abdomen a 5 years review of 279 cases. American Surgery. 1966: 32: 213-218.

13. Levin A.Gaser P., Nance F.: Surgical restraint in the management of hepatic injury: a review of Charity Hospital experience: Trauma 1987: 18: 399-404.

14. Lowe R.J, Boyd, D.R., Folk, F.A., Baker R. : The negative laprotomy for abdominal trauma J.Trauma 1972: 12: 853.

15. Mayard A.Oropeza G. Mandatory operation for penetrating wounds of abdomen. American Journal Surgery, 1968: 115:307-312.

16. McNabney W. K., McCause A. Management of stab wounds of the abdomen. American Journal Surgery 1968: 115: 307.

17. Moss L.K., Schmidt F.E., Creech O.: Analysis of 550 stab wounds of the abdomen. Ann. Surg. 1962: 28: 483-489.

18. Nance F.C, Wennar M.H, Johnson L.W. : Surgical judgment in the management of penetrating wounds of the abdomen experience with 2212 patients. Ann. Surg. 1974: 197: 639.

19. R.J.Last: Anatomy, Regional and applied: Seventh Edition 1984 page 256, 269.

20. Shwartz, Shires, Spensor. Principle of surgery: Copy 1988: page 249.

21. Shaftan G.W.: Discussion of Cornell W.P et al: Trauma. 1967 : 7 : 307.

22. Thompson J.S., Moore E.E.: Peritoneal lavage in the evaluation of penetrating abdominal trauma. Surg. Gyncol. Obstet. 1981: 153: 861-863.

23. W. Chapman Lee M.D, Joseph F. UDDO, Francis C., Nance: Surgical Judgment in the management of abdominal stab wounds utilizing clinical criteria from 10 years experience. Ann. Surg. 1984 : 199: 549.

24. Wilder J.R., Kudchadkar A.. Stab wounds of the abdomen observe or explore. JAMA. 1980: 243: 2503.

25. Wilson H., Sherman R.T.. Civilian penetrating wounds of the abdomen, factors in mortality and differences from military wounds in 494 cases. Annals Surgery, 1961 : 153: 639-644.