Written by Seth Walsh-Blackmore
In abdominal stab wound patients without criteria for immediate operative intervention, 24 hours of observation was sufficient to identify a failure of conservative management.
Why does this matter?
A negative laparotomy has morbidity and cost without benefit, which has driven selective non-operative management (SNOM) for penetrating abdominal trauma. Trauma beds have a high cost and staff burden, so when are we confident patients will not benefit from further monitoring?
When is one cut enough?
This was a single Level 1 trauma center prospective cohort of 256 patients presenting with abdominal stab wounds. The 5th intercostal space to the perineum, flank, and back defined the abdominal area. Those with significant penetrating injuries to other regions requiring operative or endovascular intervention were excluded. One hundred seventy-six patients met SNOM criteria. They lacked indication for immediate laparotomy (unstable hemodynamics, evisceration, diffuse peritonitis), and initial CT did not find a hollow viscus or operative solid organ injury. Patients were observed in a dedicated area, receiving serial exams and labs.
Three (2%) failed SNOM and received a laparotomy. Two were taken for peritonitis at 10 and 20 hours after an equivocal initial CT scan and had positive laparotomies. A third was taken to the OR at 32 hours for worsening leukocytosis with known liver laceration on CT, but laparotomy was negative. Median observation was 60 (48-96) hours. Twenty-four (11%) were discharged before 24 hours.
This was an experienced academic trauma center which had investigated SNOM for over a decade. A key to their success with SNOM was appropriately identifying who needed the OR initially. There were two negative laparotomies of the 73 performed based on the initial exam and CT. Serial exams identified the SNOM patients that needed OR, so this strategy required the staff to perform exams frequently and confidently. Assuming this, was 24 hours enough? The study reinforced that operative injuries with this mechanism revealed themselves quickly when adequately monitored and examined. A matter of uncertainty was the 11% discharged before 24 hours, given the lack of follow-up. If 24 hours seemed aggressive, consider that no patient with a negative initial CT failed SNOM. Perhaps discharge of those patients at 24 hours and extended observation for those with an equivocal CT or other concern is the right balance.
Author’s proposed algorithm for isolated abdominal stab wounds :
Prospective Evaluation of the Selective Nonoperative Management of Abdominal Stab Wounds: When is it Safe to Discharge? J Trauma Acute Care Surg. 2022 Jul 5. doi: 10.1097/TA.0000000000003733. Epub ahead of print.
Demetriades D, Hadjizacharia P, Constantinou C, Brown C, Inaba K, Rhee P, Salim A. Selective nonoperative management of penetrating abdominal solid organ injuries. Ann Surg. 2006 Oct;244(4):620-8. doi: 10.1097/01.sla.0000237743.22633.01. PMID: 16998371; PMCID: PMC1856549.