Journal of the New Zealand Medical Association, 12-December-2008, Vol 121 No 1287
Management of low-velocity, non-gunshot-wound penetrating abdominal injury: have we moved with the times?
Li Hsee, Ian Civil
Traditionally in the Australasian context, penetrating injuries to the abdomen have been surgically explored.1 If there was evidence that there was a breach of peritoneum, laparotomy was mandatory.
Over the past decade, the availability of various imaging modalities, such as Focused Abdominal Sonography for Trauma (FAST), improved CT imaging, and improvements in laparoscopic techniques have influenced overseas practice in managing this population of patients.
While high volume penetrating trauma centres have generally used observation liberally, low volume centres have tended to have an invasive approach. Over recent years, a negative FAST/Diagnostic Peritoneal Lavage (DPL) or lack of CT evidence of intra-abdominal injury has resulted in a non-operative approach in many trauma centres.2
In Auckland, New Zealand, where the case volume of penetrating abdominal wounds is small compared to other overseas trauma centres,3 and the working hours of the surgical residents are strictly controlled by safe working hour legislation, a more aggressive surgical approach has usually been undertaken.
Increased usage of imaging modalities such as CT and ultrasound scans and the acquisition of advanced laparoscopic skills4 in training has also occurred in New Zealand.
To determine whether the advances in surgical practice have affected our management of patients with penetrating abdominal injuries we undertook this retrospective study.
Patients were identified from the Auckland City Hospital trauma registry5 over a 10-year period (1996–2005). Patients with penetrating abdominal injury were identified using the relevant mechanism of injury and abdominal AIS codes.6 The anatomical description of the abdomen was defined from the level of fourth intercostal space to the groin.
Gun shot wounds were excluded. The medical files of these patients were retrospectively reviewed. Demographics including age, gender, ISS score, LOS, ICU admission days, location of injury, and initial vitals signs were recorded. All patients who had operative procedures had their operative notes, especially their intraoperative findings reviewed in detail.
The study population was subdivided into two groups for comparison purposes: the earlier group (1996–2000) and the later group (2001–2005). The number of patients who had observation only, laparoscopy only, laparoscopy converted to laparotomy, and laparotomy were recorded. In addition, the number patients who had negative laparotomy, and those who had therapeutic/non therapeutic surgery were noted. Statistical comparisons were performed using Fisher’s exact test.
There were 13,366 trauma patients admitted to Auckland City Hospital during this period. 123 patients were identified who had sustained non-gunshot wound injuries to the abdomen. This represented of 0.9% of total trauma admissions. The earlier and later group consists of 63 and 60 patients, respectively. The characteristics of the two groups are listed in Table 1. There were no statistically significant differences.
Table 1. Characteristics of the two injury groups
ISS=Injury Severity Score; ICU=Intensive Care Unit.
Treatment approaches are outlined in Table 2. Again, no statistical differences were recorded between the two cohorts.
Table 2. Treatment approaches
Table 3. Abdominal location of penetrating wound
Table 4. Associated injuries of study groups
At Auckland City Hospital, clinical guidelines govern the management of low-velocity, non-GSW penetrating abdominal injuries. The protocol is outlined below (Figure 1). This is consistent with the protocol outlined by Sugrue et al7 (A N Z J of Surgery. 2007:77:616).
Figure 1. Auckland City Hospital clinical protocol for management of haemodynamically stable penetrating lower chest or abdominal stab wounds
*Chest tube in situ for all chest injuries.
When a patient presented to the resuscitation room in the emergency department with cardiovascular instability, peritonitis or obvious evisceration of abdominal contents they are taken to the operating room for laparotomy. The group of patients that present with stable abdominal penetrating injuries are the group where investigation and management can be controversial.8
In our two cohorts of patients, basic demographic data are similar. All of the patients were discharged alive except for one patient in the second group who died of chemical poisoning as a part of his suicide attempt. They have similar ISS, pulse rate and systolic blood pressures on initial admission.
The types of injuries (intentional vs unintentional) and the anatomical locations of the penetrating wounds were also similar in the two groups. The length of hospital stay and ICU admission days tended to be shorter in the later group.
In the operative management of the two cohorts of patients, we have not identified any differences in terms of rate of laparoscopy and laparotomy. Despite the passage of time, increasing laparoscopic skills, and increasing non-operative management of trauma patients generally, laparotomy is still used frequently in the two cohorts of patients in our institution.
In the earlier and later groups 65% and 70% respectively of patients went straight to a laparotomy. Despite the increasing availability of laparoscopic instruments and expertise, we have not found a substantial increase in the utilisation of such procedures in these patients.
Three percent and 5% of patients had laparoscopy only to determine whether there was a breach of abdominal fascia. Eight and 12% of patients had laparoscopy converted to laparotomy in the early and late groups, respectively.
Despite the safety of laparoscopy in trauma,9,10 its use at the Auckland City Hospital has been limited. It has been suggested appropriate use of laparoscopy may avoid non-therapeutic laparotomy in up to 75% of patients rendering it cost-effective for the health organisation.11
In our two cohorts of patients, there were 17.3% and 20% of patients who had negative laparotomy and a further 23.9% and 30% who had a non-therapeutic laparotomy. These numbers are high compared to other trauma centres.12
We believe that this number of negative laparotomies and non therapeutic laparotomies can be reduced if laparoscopic procedures were being utilised more frequently.13 Although all consultant general surgeons have acquired expertise in advanced laparoscopic techniques, most of these acute operations are performed by duty surgical registrars.
Auckland City Hospital provides an active educational programme for trainees and consultants. Monthly trauma rounds and fora, and an annual trauma conference, have been run for more than 10 years. A Definitive Surgical Trauma Care (DSTC) course has also been run annually during the second 5-year period. However, the laparoscopic abilities of surgical registrars vary and acute cases are often dealt with out of hours.
The educational efforts maybe targeting a more senior group than those who actual treat the patients. The result may be more laparotomies rather than laparoscopies in the management of these patients.
The usage of CT scans to diagnose hollow viscous injuries has its limitations.14,15 These diagnoses often rely on a high index of suspicion, presence of free gas and/or fluids on the scan. Because of the potential of such injuries being missed, operative exploration is the gold standard. However, in selected cases such as a right upper quadrant stab wound, a CT scan prior to theatre for operative planning is often useful especially when liver injury is considered likely.
In stable posterior and flank wound patients, CT imaging may also be helpful in determining the extent of injuries.15 While the “selective conservatism”2,16 approach makes good sense in theoretical practice, this concept is clinically challenging in Australasia. This is due to the shorter surgical resident shifts, lack of clinical consistency in doing serial examinations, and the fear of potential missed serious injuries when the abdomen is unexplored.
In conclusion, our study has shown two remarkably similar cohorts of patients. Their surgical management has also been remained similar. Despite the availability of laparoscopic procedures and advanced imaging techniques, we have not seen a change of practice in our surgical unit.
Reasons for lack of change maybe the generally small numbers of such patients, lack of relevant skills amongst junior staff, failure of supervision, or failure of educational process within the hospital. Although overall outcomes were satisfactory, additional costs and patient morbidity may have been incurred.
Competing interests: None known.
Author information: Li Hsee, Trauma Fellow; Ian Civil, Director; Trauma Services, Auckland City Hospital, Auckland
Correspondence: Dr Li Hsee, Trauma Services, Auckland City Hospital, PO Box 92024, Auckland, New Zealand. Fax: +64 (0)9 3078931; email: firstname.lastname@example.org
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