Management guidelines for penetrating abdominal trauma

Walter L. Biffl and Ernest E. Moore

Department of Surgery, Denver Health Medical
Center/University of Colorado, Denver, Colorado, USA
Correspondence to Walter L. Biffl, MD, Department of
Surgery, Denver Health Medical Center, 777 Bannock
Street, MC 0206, Denver, CO 80204-4507, USA
Tel: +1 303 436 5842; fax: +1 303 436 3123;
e-mail: walter.biffl@dhha.org
Current Opinion in Critical Care 2010,
16:609617

Purpose of review
Patients with penetrating abdominal trauma are at risk of harboring life-threatening
injuries. Many patients are in need of emergent operative intervention. However,
there are clearly patients who can be safely managed nonoperatively. This review
evaluates the literature to identify management guidelines for patients with penetrating
abdominal trauma.
Recent findings
Accumulating evidence supports nonoperative management of patients with stab
wounds to the thoracoabdominal region, the back, flank, and anterior abdomen.
Furthermore, select patients with gunshot wounds can be safely managed
nonoperatively.
Summary
Shock, evisceration, and peritonitis warrant immediate laparotomy following penetrating
abdominal trauma. Thoracoabdominal stab wounds should be further evaluated
with chest X-ray, ultrasonography, and laparoscopy or thoracoscopy. Wounds to the
back and flank should be imaged with CT scanning. Anterior abdominal stab wound
victims can be followed with serial clinical assessments. The majority of patients
with gunshot wounds are best served by laparotomy; however, select patients may be
managed expectantly.
Keywords
abdominal trauma, guideline, nonoperative management, penetrating trauma,
thoracoabdominal trauma
Curr Opin Crit Care 16:609617
2010 Wolters Kluwer Health | Lippincott Williams & Wilkins
1070-5295

Introduction
The optimal management of patients with penetrating
abdominal injuries has been debated for decades, since
mandatory laparotomy (LAP) gave way to the concept of
selective conservatism [1]. There is little disagreement
that hemodynamic compromise, peritonitis, impalement, or evisceration mandate prompt LAP. But there
is considerable divergence of opinion regarding the
approach to a hemodynamically stable, asymptomatic
patient. Furthermore, the concept of selective nonoperative management has recently been applied to gunshot
wounds (GSWs). The current review will focus on
the selective nonoperative management of penetrating
abdominal trauma.

over, there are significant consequences of unnecessary

LAP in terms of complication rates, length of stay (LOS),
and costs. Renz and Feliciano [2] performed the first
prospective study of patients undergoing unnecessary
LAP after trauma. They concluded the following: the
mean LOS following an unnecessary LAP for trauma was
8 days; 41% of patients had a complication resulting from
the LAP; the mean LOS among patients experiencing a
complication was 9 days, compared with 5 days in those
without a complication; compared with patients without
associated injuries, patients with associated injuries had
higher complication rates (61 vs. 26%) and LOS (11 vs. 5
days); and mean LOS following completely negative
LAP was still 4.7 days. Retrospective studies have
reported similar outcomes, leading to the conclusion that
unnecessary LAP should be avoided [3].

Mandatory laparotomy and its consequences

Mandatory LAP was considered the standard of care for
abdominal stab wounds until 1960 and for GSWs until
much more recently. Whereas LAP may be considered
the most conservative, safest approach to identify and
treat all injuries in a timely manner, it is unnecessary in as
many as 70% of abdominal stab wound cases [1]. More1070-5295 2010 Wolters Kluwer Health | Lippincott Williams & Wilkins

Selective nonoperative management

In developing management strategies for penetrating
abdominal trauma, it is helpful to divide the abdomen
into regions: the anterior abdomen (from xiphoid to
pubis, between the anterior axillary lines); the flank
and back (posterior to the anterior axillary lines); and
DOI:10.1097/MCC.0b013e32833f52d2

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610 Trauma

the thoracoabdomen (from the nipple line to the costal

margin). The approach of each of these regions varies.
Thoracoabdomen

Injuries in the thoracoabdominal region may create injuries in both the chest and the abdomen, including the
diaphragm. Whereas blunt diaphragmatic injuries may be
relatively easy to diagnose, penetrating injuries are typically occult. The presence of a small knife wound in the
diaphragm can elude detection by the most sensitive
imaging modalities. A prospective series from the Maryland Shock-Trauma Center included 50 patients with CT
findings suggesting a potential diaphragm injury [4]. The
authors considered the CT findings to be specific in just
40% of patients; such findings included contiguous organ
injury on either side of the diaphragm, and herniation of
abdominal fat through a defect in the diaphragm. Nonspecific findings included a wound tract extending up to
the diaphragm, thickening of the diaphragm from blood
or edema, and apparent defect in the diaphragm without
herniation or adjacent hematoma. Seventeen (34%)
patients had surgical evaluation of the diaphragm
LAP in 12 and thoracoscopy in 5 and diaphragmatic
injury was confirmed in only 12 (71%) of that subgroup.
Of note, two patients with specific findings had no
diaphragmatic injury.
Diagnostic peritoneal lavage (DPL) has been employed
to help detect diaphragmatic wounds. Moore and
Marx [5] proposed a red blood cell (RBC) threshold of

5000/mm3, as this level was not likely to be ascribed to

the procedure and thus implied at least a diphragmatic
defect. More recently, direct assessment of the diaphragm with thoracoscopy or laparoscopy has been
suggested. Uribe and colleagues [6] performed routine
thoracoscopy and found diaphragmatic injuries in 32% of
patients with penetrating thoracoabdominal injuries. On
subsequent LAP they found that 89% of the patients with
diaphragmatic injuries had intra-abdominal injuries that
required surgical repair. In the 1990s, a number of investigators attempted to clarify the role of laparoscopy.
Murray and colleagues [7] prospectively studied 110
patients with penetrating injuries to the left lower chest,
and found occult diaphragmatic injuries in 26 (24%) of
them. Friese and colleagues [8] confirmed these results,
also finding diaphragmatic injuries in 24% (8 of 34) of
patients with penetrating thoracoabdominal injuries.
They further evaluated the accuracy of laparoscopy by
following it with LAP, and found just one missed injury.
A reasonable management strategy for stable patients
with penetrating thoracoabdominal trauma is outlined
in Fig. 1. An upright chest X-ray and Focused Abdominal
Sonographic Examination for Trauma (FAST) are performed. If both are normal, DPL is performed with a
RBC threshold of 5000/mm3. A () DPL mandates LAP
or laparoscopy. If there is a hemothorax or pneumothorax
with (-) FAST, thoracoscopy is performed. Since the
patient already requires tube thoracostomy, this adds
little additional morbidity. If there is a diaphragm injury

Figure 1 Management of stable patients with penetrating thoracoabdominal trauma

Penetrating
thoracoabdominal
trauma

Upright CXR
FAST

CXR ()
FAST ()

CXR (+)
FAST ()

CXR ()
FAST (+)

CXR (+)
FAST (+)

DPL

Thoracoscopy

Laparoscopy/
laparotomy

Tube thoracostomy
Laparoscopy/
laparotomy

Normal

>5000 RBC/ml
>500 WBC/ml
Enteric contents

(+) Diaphragm
injury

Discharge if no
other indications
for admission

Laparoscopy/
laparotomy

Laparoscopy/
laparotomy

CXR (), hemothorax or pneumothorax; DPL, diagnostic peritoneal lavage; FAST (), hemoperitoneum.

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Management of penetrating abdominal trauma Biffl and Moore 611

Table 1 Classification and management recommendations for

CT scan findings following penetrating flank/back injuries
Risk

CT findings

Intervention

Low

No penetration
Penetration into subcutaneous
tissue
Penetration into muscle
Retroperitoneal hematoma,
not near critical structure
Contrast extravasation from colon
Major extravasation from kidney
Hematoma adjacent to major
retroperitoneal vessel
Free air in retroperitoneum, not
attributed to wounding object
Evidence of injury above and
below diaphragm
Free fluid in peritoneal cavity

Discharge from ED

Moderate
High

Serial clinical
assessments
Laparotomy

Adapted from Himmelman et al. [9].

as expected in 24% of patients [7,8] LAP or laparoscopy is performed to exclude injury below the diaphragm [6]. If there is a () FAST, LAP or laparoscopy
is necessary.
Back/flank

Penetrating trauma to the back or flank is associated with

a lower likelihood of significant injury. However, these
injuries can pose a special problem because of the difficulty in clinically evaluating the retroperitoneal organs
with physical exam and FAST. In a stable patient, CT
scanning is reliable for excluding significant injury [9,10].
Stable patients may be managed according to CT scan
findings (Table 1). Recently, the necessity of rectal
contrast has been questioned [11]. With improved sensitivity of multidetector-row CT (MDCT), it is generally
possible to follow the wound tract and get an accurate
assessment. Ultimately, the surgeon must exercise good
clinical judgment in determining the most appropriate
course of action.
Anterior abdomen

It is recognized that of all anterior abdominal stab wounds

(AASWs), only 5075% enter the peritoneal cavity, and
of those, only 5075% cause an injury requiring operative
repair. Thus, only a minority of stable, asymptomatic
patients would be expected to require operative intervention [12]. In 1960, Shaftan [1] first challenged the
dictum of mandatory LAP for AASWs, introducing a
policy of selective conservatism, that is, management
based primarily on clinical evaluation. This approach was
promulgated by the groups at Kings County Medical
Center [1] and Charity Hospital [13]. But concerns about
delays to intervention led to techniques aimed at determining whether the peritoneum had been entered,
including sinography [14] and local wound exploration
(LWE) [12,15]. Although sinography proved less useful
[16], LWE allowed many patients to be safely discharged
from the emergency department (ED) if the peritoneal

cavity was not violated [12]. On the other hand, it was

realized that the decision for LAP should be based not just
on peritoneal penetration, but on the presence of a significant intraperitoneal injury. This led to the adoption of
DPL to look for evidence of significant intra-abdominal
injury in the setting of a positive () LWE (i.e. penetration into the peritoneal cavity) [12,15,17]. Through the
1990s, technology-based approaches were introduced,
including laparosocopy [18,19], CT scanning [20], and
ultrasonography [21]. The debate has continued to focus
on the balance between invasiveness, resource utilization,
and timely repair of significant injuries [2224].
Multicenter study of anterior abdominal stab wound
management

A recent study advocating serial clinical assessments

(SCAs) [25] prompted discussion of this issue among
members of the Western Trauma Association (WTA)
Multicenter Trials Group. It was agreed that there was
no uniformity in this area, and that an organized outcomes
analysis was warranted. A prospective study was performed
to determine whether any particular management strategy
stood out as being either superior or inferior, compared
with other strategies, in the evaluation and management of
asymptomatic patients with AASWs [26].
Over a 2-year period (20062007), 11 participating
institutions prospectively collected data on patients with
AASWs. Each institution/surgeon followed its own established protocol or clinical judgment. There was no aspect
of the management of the patient that was dictated by the
study. Criteria for inclusion in the study were age at least
16 years and an AASW. The anterior abdomen was
defined as that area bordered by the costal margin superiorly, the groin creases inferiorly, and the anterior axillary
lines laterally. Patients with back, flank, or presumed
thoracoabdominal wounds were excluded, as diagnostic
evaluations of these wounds might include CT, DPL,
or laparoscopy. Extra-abdominal injuries were not exclusionary, nor was intoxication.
In general, the WTA investigators agreed that patients
with hypotension (systolic blood pressure <90 mmHg) or
other evidence of hemodynamic instability (shock),
omental or intestinal evisceration, or peritonitis on
physical exam should have prompt LAP. The remaining
asymptomatic patients were then managed per institutional protocol or surgeons judgment, with tests performed ad lib. For the most part, tests were carried out
within a relatively short (<2 h) time frame. The FAST
was performed in select patients in the standard fashion
[21]. A () FAST was defined as any evidence of hemoperitoneum. The LWE was performed in the ED, by
the technique previously described [12]. In brief, local
anesthetic was infiltrated into the wound area, and an
incision was made that allowed adequate evaluation of

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612 Trauma

the wound tract to its distal extent. A () LWE was

defined variably as violation of either the anterior or
posterior fascia; a negative () LWE was one that
revealed intact fascia and proved that the peritoneal
cavity had not been violated. The DPL technique
involved an infraumbilical incision and passage of a
catheter into the peritoneal cavity [27]. If the initial
aspirate contained more than 10 ml gross blood, bile,
succus entericus, or food, it was considered grossly
positive and the patient went for LAP. If not, 1 l of
warm normal saline was instilled and recovered by gravity
siphonage, and the lavage effluent sent for biochemical
analysis. Criteria for () DPL varied slightly among
different centers, but the majority considered more than
100 000 RBCs/mm3, more than 500 white blood cells
(WBCs)/mm3, or elevated amylase/alkaline phosphatase/bilirubin in the lavage effluent to represent a ()
DPL [28]. There was no defined protocol for CT scanning, but most centers employed MDCT scanners. The
protocol for SCAs included clinical assessments, including physical examination and measurement of a complete
blood count (CBC), every 8 h [25]. A change in hemodynamic status, the development of peritonitis, evidence
of ongoing blood loss, or leukocytosis was further investigated by CT scan, DPL, or LAP. Absent any of these
findings, patients were discharged after tolerating feeding. All patients were given follow-up appointments at
the time of discharge. The necessity of each LAP was
determined by the operating surgeon to be either nontherapeutic (NONTHER) or therapeutic (THER). The
principal management strategy (i.e. the one on which
decisions were made to discharge, operate, or admit) was
determined from the data sheets, and patients were
grouped accordingly for certain analyses.
Over the 2-year study period a total of 359 patients were
enrolled from 11 centers. Three hundred and eighteen
(89%) were men and 41 women. The mean age was
33.40.3 years. There were two or more wounds in
121 (34%) patients.
Immediate laparotomy

Immediate LAP was performed in 81 (23%) patients.

Sixty-eight (84%) of the immediate LAPs were THER.
The indications for LAP, and a breakdown of the therapeutic necessity, are shown in Table 2. Of note, FAST
was normal in 11 of these patients, and 7 (64%) had
THER LAP. On the contrary, of 22 patients with ()
FAST, 2 (9%) had NONTHER LAP. The (LOS) was 4.3
days after NONTHER LAP and 5.1 days after THER
LAP (P ns). Seventeen (21%) of the immediate LAP
patients had complications, including two (2%) deaths.
Management of stable, asymptomatic patients

At the time of initial evaluation in the ED, 278 (77%)

patients did not have an indication for immediate LAP.

Table 2 Immediate laparotomy (LAP) (indications and therapeutic efficacy)

Indication

Nontherapeutic

Shock
Evisceration
Peritonitis
Other

3
5
5
0

(13%)
(14%)
(29%)
(0%)

Therapeutic
21
31
12
4

Other: hemorrhage from wound (2), extensive wounds (1), impaled

knife (1). Adapted from Biffl et al. [26].

Ultrasound (FAST) was performed in 134 (48%) patients.

Twelve patients had () FAST and two had equivocal
studies. Five patients four of those with () and one
with equivocal FAST were taken directly for LAP
based on FAST result, in the absence of shock, evisceration, or peritonitis (Table 3). Three of them had THER
LAP (hollow viscus, diaphragm, and solid organ) and two
(40%) had NONTHER LAP. The second patient with
equivocal FAST had () LWE and grossly positive DPL
and went to the operating room, but had a NONTHER
LAP. Of the other eight patients with () FAST, three
had a THER LAP. Thus, in all, six (50%) of the patients
with () FAST but no indications for immediate LAP
had a NONTHER LAP. The FAST was interpreted as
normal in 120 patients; of them, 23 (19%) had THER
LAP. Including patients who had indications for immediate LAP, and with the endpoint of needing THER LAP,
23% of FAST exams were false (). The sensitivity
(SENS) of FAST was 21%, specificity (SPEC) 94%,
positive predictive value (PPV) 50%, and negative predictive value (NPV) 81% (Table 4). No patient was
discharged from the ED based on FAST alone.
CT scanning was employed as the primary decisionmaking tool in 138 (50%) patients. Twenty-nine (21%)
of the 138 patients were discharged from the ED based
on normal CT findings. A LAP was performed because
of CT findings in 46 (33%) patients. Of these, 11 (24%)
were NONTHER and 35 were THER (Table 3). Eight
Table 3 Summary of outcomes associated with primary management strategies
Strategy N
CT
LWE
DPL
SCA
FAST

ED D/C

OR

138 29 (21%) 46 (33%)

132 31 (23%) 23 (17%)
45
7 (16%) 13 (29%)
26
3 (12%) 3 (12%)
5
0
5 (100%)

NONTHER THER LAP/NEG

LAP
TEST
11 (24%)
13 (57%)
4 (31%)
1(33%)
2 (40%)

8/108 (7%)
0 (0%)
2/32 (6%)
n/a
23/120 (19%)

CT, computed tomography; DPL, diagnostic peritoneal lavage; ED D/C,

number of patients discharged from emergency department based on
results; FAST, focused sonographic assessment for trauma; LWE, local
wound exploration; N, number of patients managed primarily by strategy;
NONTHER LAP, nontherapeutic laparotomy; OR, number of patients
taken to the operating room based on results; SCA, serial clinical
assessments; THER LAP/NEG TEST, patients ultimately requiring therapeutic laparotomy who initially had a normal test result. Adapted from
Biffl et al. [26].

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Management of penetrating abdominal trauma Biffl and Moore 613

Table 4 Summary of sensitivity, specificity, positive predictive

value, and negative predictive value of tests for therapeutic
laparotomy

had a NONTHER LAP. There were no complications

among these patients.

TEST

CT
FAST
LWE
DPL
SCA

145
132
125
45
26

Nine patients underwent laparoscopy. Seven were NONTHER. Both cases requiring therapeutic interventions
were converted to open.

35
29
25
11
2

PTP

SENS

SPEC

PPV

NPV

(24%)
(22%)
(20%)
(24%)
(8%)

77%
21%
100%
82%
100%

73%
94%
54%
88%
96%

47%
50%
35%
69%
67%

91%
81%
100%
94%
100%

CT, computed tomography; DPL, diagnostic peritoneal lavage; FAST,

focused sonographic assessment for trauma; LWE, local wound exploration; N, total number of patients having the test who did not have
indications for immediate laparotomy; NPV, negative predictive value;
PPV, positive predictive value; PTP, pretest probability number
(percentage) of patients having that test who ultimately had a therapeutic
laparotomy; SCA, serial clinical assessments; SENS, sensitivity; SPEC,
specificity. Adapted from Biffl et al. [26].

patients with normal CT scans ultimately underwent a

THER LAP. The SENS, SPEC, PPV, and NPV of CT
were 77, 73, 47, and 91%, respectively (Table 4).
LWE was performed in 132 (47%) patients. In seven (5%)
patients, it was unsuccessful in determining the depth of
penetration. Seventy-one patients had () LWE and
23 of them were taken directly to the operating room
based on this finding; 13 (57%) had NONTHER LAPs
(Table 3). Fifty-four patients had () LWE. Of these, 31
(57%; 23% of the total LWE group) were discharged from
the ED. The other 23 with () LWE were admitted for
observation and were all ultimately discharged uneventfully. The SENS was 100%, SPEC 54%, PPV 35%, and
NPV 100% (Table 4).
DPL was performed in 45 (16%) patients (Table 3). Eight
were grossly positive and the patients went to the operating room six had THER LAP and two had NONTHER LAP. Three patients had () DPL based on more
than 100 000 RBCs/mm3, and all had THER LAP. Three
had more than 500 WBCs/mm3, and two of them had
NONTHER LAP. Two patients had elevated amylase,
alkaline phosphatase, and/or bilirubin levels, and both
had THER LAPs with hollow viscus injuries. In total, out
of 13 patients who had abnormal DPL results, 4 had
NONTHER LAP. Three patients with normal DPL
results underwent LAP because they developed peritonitis; two of them had THER LAP for hollow viscus
injuries. To sum up, in this group with a pretest probability of THER LAP of 24%, the SENS and SPEC of
DPL were 82 and 88%, respectively; the PPV and NPV
were 69 and 94%, respectively (Table 4).
Twenty-six (9%) patients were managed primarily on the
basis of SCAs (Table 3). Three (12%) of them were
discharged from the ED after a period of observation.
Three were taken to the operating room for the development of peritonitis, at 5, 6, and 8 h after presentation.
Two of them had hollow viscus injuries, and the other one

Laparotomy findings and outcomes

A total of 174 (48%) of the 359 patients had LAP. One

hundred and twenty-nine (36%) of the overall group had a
THER LAP. Of all the LAPs, 45 (26%) were NONTHER. Most patients (77%) who did not have LAP and
were admitted for observation stayed 1 day or less.
Prolonged stays were generally attributed to psychiatric
or social issues, or to the need for chest tube management. The mean LOS of patients undergoing LAP was
4.7 days; the LOS following a THER LAP was 5.1 days,
and 3.6 days following NONTHER LAP. There was a
morbidity rate of 20% following THER LAP, and 4%
following NONTHER LAP. The LOS associated with
complications after LAP was 7.8 days, compared with
4.1 days without complications.
What do we conclude from the Western Trauma
Association multicenter study?

Shaftans [1] concept of selective conservatism was

based on the observation that only one-half of stab
wounds that penetrated the peritoneal cavity caused an
injury that required operative repair. Over the years a
variety of strategies have been employed in an attempt to
diagnose and treat significant injuries in a timely manner,
but to avoid unnecessary LAP. In the WTA series, only
36% of AASW victims required LAP, reinforcing the fact
that most patients can be managed without intervention.
Further, 26% of the LAPs were NONTHER, suggesting
there is still room for improvement [26].
There is uniform agreement that immediate LAP is
indicated for certain indications. Shock is one clear
indication for emergent abdominal exploration. Indeed,
in the WTA series, 88% of patients presenting with shock
had THER LAPs. Evisceration is also an accepted indication for immediate LAP. In the WTA study, intestinal
evisceration was associated with THER LAP in 100% of
cases. However, there has been some debate regarding
omental evisceration. The Denver group challenged the
concept of routine LAP for patients with omental evisceration many years ago, based on their experience that
29% of such patients had no significant intra-abdominal
injuries [12]. On the other hand, recent series have
argued the opposite but based on similar incidences
(6580%) of significant intra-abdominal injury [29,30].
In the WTA series, 16 (76%) of 21 patients with isolated
omental evisceration had THER LAPs. These numbers
are remarkably consistent and do not settle the argument.
However, it is the feeling of the authors that since the

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614 Trauma

patient has, at the very least, a symptomatic hernia, it

should be repaired, and given the relatively high likelihood of finding a significant intra-abdominal injury, it is
best done in the operating room rather than in the ED.
Peritonitis is a relatively subjective finding, and thus it is
not surprising that this finding, in the absence of shock or
evisceration, led to NONTHER LAP in 29% of patients.
Of note, only 50% of patients with local peritonitis on
presentation had a THER LAP, compared with 81% of
those with diffuse peritonitis. It is difficult to justify
delaying intervention in a patient with peritonitis, but
an experienced clinician should attempt to differentiate
true peritoneal signs from physical findings related to
the wound.
Once the hemodynamically unstable and symptomatic
patients are selected out, the number requiring THER
LAP decreases considerably. In the WTA series, THER
LAP was required in only 61 (22%) of 278 patients who
did not initially have shock, evisceration, or peritonitis.
Thus, the goal is to identify these patients in a timely
manner while minimizing costs and potentially morbid
interventions. To that end, a variety of strategies are
employed by trauma surgeons.
There is no question that the introduction of FAST in
the mid-1990s dramatically changed the management of
blunt trauma patients [21]. However, its utility in
patients with penetrating abdominal wounds is less clear
[31]. In the WTA study, FAST was performed in 134
(48%) of the patients, but the primary management
decision was based on FAST in only 5 (4%) of them.
Thus, whereas many trauma surgeons apparently
employ the test, it is recognized that the simple presence
of hemoperitoneum does not necessarily correlate with a
significant injury requiring operative intervention. In
fact, 10 (28%) of 36 patients with abnormal FAST in
the WTA series had a NONTHER LAP or did not
require LAP. The major value of the test is probably
in identifying patients who have hemoperitoneum, so
that they may be observed. On the other hand, the
absence of hemoperitoneum does not equate with the
absence of injury. In this series, 23% of patients with a
normal FAST ultimately had a THER LAP. Thus, we
agree with Udobi and colleagues [31] that patients
should not be discharged from the ED based solely on
a normal FAST. And although ultrasonography has been
advocated for identifying fascial defects after penetrating trauma [32], it is probably not reliable enough to
determine a patients suitability for ED discharge.
With advancing imaging technology and whole-body
techniques, CT scanning is being used more and more
broadly in trauma, supplanting plain radiography and
arteriography for many applications [4,33,34]. In the
WTA series, CT was performed more frequently than

any other test. Proof of extraperitoneal trajectory allows

safe ED discharge, and this occurred in 21% of the
patients who had the test. On the other hand, a ()
CT scan that is, one showing intra-abdominal abnormalities can be misleading. Forty-six (33%) asymptomatic patients who had CT scans were taken to the
operating room based on CT findings, and 24% of the
resultant LAPs were NONTHER. Further, of 35 patients
with a THER LAP, 18 had only solid organ injuries or
fascial defects, which in many cases are amenable to
nonoperative management. Like FAST, CT scan reveals
evidence of injuries, for example, free intraperitoneal
fluid, that are of questionable clinical significance. Consequently, we do not advocate it as the sole determinant
of the need for LAP.
A LWE was performed in 132 (47%) patients in the WTA
study. The primary value of LWE is in its ability to
determine whether or not the stabbing object violated the
peritoneal cavity. In this series, 54 patients had a ()
LWE, but only 31 (57%) of them were discharged from
the ED, suggesting that it has even greater potential to
facilitate ED discharge. Conversely, it is clear from the
data that a () LWE should not be used as an indication
for LAP: 57% of the LAPs performed for this indication
were NONTHER. It is important to recognize that LWE
must be technically adequate to be used in this regard. A
simple probing of the stab wound is not reliable to rule
out peritoneal violation [35]. The procedure requires
adequate exposure of the wound to follow the tract of
the stabbing object [12]. Further, there was some variation in defining a () LWE in the WTA series. Some
surgeons considered violation of anterior fascia to constitute a () LWE. This definition ignores the muscle
and/or posterior fascia, and does not correlate with violation of the peritoneal cavity. A stricter definition of ()
LWE that is, violation of the posterior fascia and
peritoneum would likely increase the number of
patients eligible for ED discharge. The surgeon must
keep in mind that LWE may be compromised in very
obese patients or those with a tangential wound tracking
through muscle layers. On the basis of the WTA results
that LWE has a SENS and NPV of 100%, we advocate
LWE to rule out peritoneal penetration and allow ED
discharge; we suggest that those asymptomatic patients
with () LWE be admitted for SCAs (Fig. 2).
DPL has been used to identify significant peritoneal
injuries following AASWs for at least 30 years
[12,15,17]. Whereas DPL is a good test, it has some
noteworthy limitations. It is an invasive procedure with
a risk of iatrogenic injury, and therefore a () result
requires a period of observation. In addition, DPL can
be associated with a relatively high number of NONTHER LAPs, such as when there is moderate bleeding
from the wound, omentum, or liver [23,36]. The RBC

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Management of penetrating abdominal trauma Biffl and Moore 615

Figure 2 Proposed clinical pathway for management of patients

with anterior abdominal stab wounds

Anterior abdominal
stab wound

OR

YES

Shock
Peritonitis
Evisceration
NO

D/C

Negative

Local wound exploration*

FAST**
Positive/equivocal

23-Hour observation:
serial physical exam,
CBC q8 hrs

OR

YES

Peritonitis
Hemodynamic instability
NO

CT, DPL
or OR

YES

Significant drop in hemoglobin (>3 g/dl)

Leukocytosis
NO

Feed
D/C

Consider CT scan if patient is morbidly obese or wound tract is long

and tangential;  Decision to D/C patient, or to operate should not be
made on FAST alone. However, if FAST identifies hemoperitoneum,
patient should be admitted for observation and serial clinical assessments. The clinician must determine when it is safe for discharge. OR,
operating room; D/C, discharge; CBC, complete blood count; CT,
computed tomography scan; DPL, diagnostic peritoneal lavage.

threshold has been debated over the years [17,23,36].

The generally accepted threshold for positivity
(>100 000 RBCs/mm3) was selected based on balancing
missed injuries with NONTHER LAPs. Lowering the
threshold to 50 000, 10 000 or 1000 RBCs/mm3 increases
the number of NONTHER LAPs with diminishing
returns on finding occult injuries. In fact, in the
WTA series, if a threshold of more than 10 000 RBCs/
mm3 were used, there would have been two NONTHER LAPs to balance the one additional timely
THER LAP. If the threshold were lowered further to
more than 1000 RBCs/mm3, one other THER LAP
would have been performed more promptly, but there
would have been 11 additional NONTHER LAPs. So
whereas not all the WTA investigators initially agreed
on the threshold, the data support and the majority
now accept more than 100 000 RBCs/mm3 as the
threshold for a () DPL.

Difficulties in interpreting the DPL WBC count have also

been widely discussed and to date there is no threshold
that offers 100% accuracy [3739]. In the WTA series, a
high lavage WBC count (>500 WBCs/mm3) led to two
NONTHER LAPs, and two patients with hollow viscus
injuries had a subthreshold lavage WBC count. Recognizing the problem of equivocal DPL results, measurement of
amylase and alkaline phosphatase have been suggested to
improve the sensitivity of DPL [28,40,41]. These results,
like the WBC count, are somewhat dependent on the
timing of DPL; furthermore, the enzymes may not reliably
diagnose colon injury [38,40,41]. Unfortunately, in the
WTA series, enzyme levels were no better than WBC
counts at identifying bowel injuries. In sum, the WTA data
suggest that there are still shortcomings in the utility of
DPL: 31% of LAPs prompted by () DPLs were NONTHER, and 6% of patients with normal DPL later needed
THER LAP. The SENS (82%), SPEC (88%), PPV (69%),
and NPV (94%) are similar to those reported by Henneman
and colleagues [23] in 1990 for abdominal stab wounds
(72, 91, 74, and 90%, respectively). Although there is still a
role for DPL in trauma care today, it may not be in the
setting of AASWs [42]. On the basis of the results of the
WTA study, it may be reasonable to conclude that as
experience with DPL decreases and thus potential
morbidity increases it may be best to take it out of
the decision-making arm for these patients.
Serial clinical assessments were used as the primary
management strategy in only 26 patients in the WTA
study. The major theoretical shortcomings of this strategy
are an over-reliance on subjective findings and a potential
for delayed intervention and consequent morbidity.
Whereas peritonitis has been found to lead to a number
of NONTHER LAPs [25], we contend that it is still a
reliable indicator of the need for intervention, particularly
if the clinical finding is corroborated by an experienced
examiner. Ultimately, if the finding of peritonitis is being
documented, the most conservative approach is to
explore the abdomen. Regarding the safety issue, as
noted in previous studies, admission for SCAs appears
to be a well tolerated strategy [22,24,25]. And whereas the
number in this series was relatively small, it represents an
extension of a previous series by one investigator
(W.L.B.), in which 30 patients were managed safely
without a single delayed LAP [25]. In the WTA series,
there were three patients managed with this strategy who
went to the operating room in a delayed fashion (they all
developed peritonitis within 8 h of presentation). Two of
the three had THER LAP. The LOS in these patients
was 1.5 days longer than other patients undergoing THER LAP, raising the possibility that there may have
been a consequence of the delayed intervention. However, the numbers are too small to draw any conclusions,
and there could have been other factors involved that
were not evident. Although delayed intervention is

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616 Trauma

potentially deadly in the setting of blunt small bowel

injury [43], this does not seem to translate to penetrating
trauma victims [44,45].
Laparoscopy did not prove useful in the WTA series. Of
nine procedures performed, seven were NONTHER.
The two patients requiring THER procedures had open
LAP. As noted above, the authors do not feel the presence of peritoneal violation is an independent criterion
for LAP; thus, there is not a major role for laparoscopy in
the setting of AASWs.
There are a number of limitations of the WTA study.
First, management was not controlled prospectively. The
investigators agreed in principle on indications for
immediate LAP, but further management was based
entirely on individual/institutional protocols and clinical
judgment. On the contrary, it offered a real-life view of
current trends in the treatment of AASWs in trauma
centers in the USA. Another limitation was that adjudication of the therapeutic necessity of LAPs was the responsibility of the attending surgeon who entered the case.
Clearly, this introduced the potential for bias and should
be addressed in future investigations in this area. However, if the percentage of THER LAPs has been overstated, it further suggests that diagnostic tests in asymptomatic patients lead to NONTHER LAPs. Another
shortcoming is the lack of follow-up. Although there were
no reports of patients being readmitted after discharge for
treatment of a missed injury in this series, it is conceivable that patients were seen elsewhere. The fact that not
everyone had a LAP might be considered a limitation.
The SENS, SPEC, PPV, and NPV data were all calculated based on a THER LAP as the outcome. However,
we once again submit that the mere presence of an injury
is not necessarily the major issue. Many injuries may be
safely managed nonoperatively, and this study is about
identifying those who need LAP, not those who do not.
In summary, then, the prospective multicenter WTA
study reinforced that shock, evisceration, and peritonitis
mandate immediate LAP following AASWs. Patients
without these findings are at much lower risk. The series
demonstrated that performing tests to help identify significant intraperitoneal injury in the low-risk group was
associated with a substantial number of NONTHER
LAPs, as well as increased resource utilization. No study
proved superior they all led to similar numbers of
NONTHER LAPs, with their attendant complications
and prolonged LOS. Conversely, there is no evidence
that a strategy of SCAs is any less well tolerated than any
other strategy. Thus, we proposed the clinical pathway
outlined in Fig. 2. In order to limit the number of hospital
admissions, LWE should be performed in the ED to
definitively determine the depth of penetration. Absence
of peritoneal penetration suggests the patient may be

safely discharged. In the presence of morbid obesity or a

long tangential knife tract, CT scanning may be used as
an alternative to LWE. On the contrary, peritoneal
penetration, absent evidence of ongoing hemorrhage or
hollow visceral injury, should not be considered an
indication for LAP. Rather, patients with evidence of
peritoneal penetration are admitted for SCAs. It is
important that a skilled examiner perform the serial
abdominal examinations. There is currently a prospective
multicenter trial to document the safety and cost-effectiveness of this approach.

Gunshot wounds
Mandatory LAP has long been considered the standard of
care for management of abdominal GSWs, given that over
90% of patients with peritoneal penetration have an
injury requiring operative management [46]. In recent
years, however, a number of reports have identified a
subset of patients who may be candidates for nonoperative management [4749,50]. Stable, asymptomatic
patients are candidates for CT scanning. Those who have
clear evidence of extracavitary trajectory can be discharged from the ED. Patients with isolated solid organ
injuries may be candidates for nonoperative management. However, the setting must be appropriate, as
the patients condition could change abruptly. As much
of the literature has come primarily from two centers, this
approach should be undertaken with caution.

References and recommended reading

Papers of particular interest, published within the annual period of review, have
been highlighted as:

of special interest
 of outstanding interest
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