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Anterior Abdominal Stab Wounds
(AASW’s)
Jose Baez PGY-4
KCHC
June 3 2010
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Case Presentation
• CC: Pain to epigastrium
• HPI: 47 year-old female who presented to KCHC on
4/10/10 after sustaining a stab wound to the
epigastrium
• PMHx: asthma
• PSHx: C-section
• Meds: albuterol inhaler
• NKDA
• Shx: etoh, drug use, + tobacco
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Case Presentation
• Physical Exam:
– V/S: 102/70, HR: 92, RR: 22, T: 97.7
– GCS: 15
– CHEST: clear bilaterally
– ABD: 1.5 cm SW to epigastric region, + local
tenderness, no bleeding or hematoma. No
omental or intestinal evisceration
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Case Presentation
• Labs/Diagnostic Modalities
– Vbg: 7.33/42/39/70/21/-3.1
– Lactate 3.6, 1.2
– CBC: 19/14/44/370
– LFT’s-wnl, amylase/lipase-wnl
– UCG: negative
– Utox: cocaine
– Etoh: 40
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Case Presentation
• Upright CXR: negative for free air, no acute
cardiopulmonary disease
• FAST: negative
• Local wound exploration (LWE): + Fascial Defect
• Management:
– Admitted to SICU for serial abd exams and serial labs
– Serial exams indicated persistent/worsening local
peritonitis, rising leukocytosis ( 19 to 22), no hemodynamic
instability (stable hct)
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Operative Intervention
• Procedure: Exploratory laparotomy with repair of
CBD injury
• Findings: pelvic adhesions, Grade I liver lac
(segment 2) anterior surface, bile staining in area
of portal triad and pylorus, 1-2mm CBD serosal
injury
• Drains: JP x 1
• Methylene blue given via NGT-no dye seen in
upper GI tract
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Hospital Course
• POD# 1: Extubated
• POD#2: Tolerated clears, JP output
30cc SSF
• POD#3:Regular diet
• POD#5: Discharged with JP
• LFT’s- wnl throughout hospital stay
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AASW’s
• Abdomen is a diagnostic black box
• In ED: need to identify if the fascia/peritoneum
has been violated
– Positive: need further eval for intrabdominal organ
injury ~ with 50% need for laparotomy
• Anterior abdomen (boundaries): from costal
margins to inguinal ligaments and bilateral ant
axillary lines
• 1/3 of AASWs violate the peritoneal cavity; 1/3 of
these cause injury requiring operative repair.
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AASWs (Diagnositic Modalities)
• OR for laparotomy
– Hemodynamic instability
– Peritonitis
– Omental or intestinal evisceration
– Peritoneal or fascial penetration
• Non-operative approach
– In pts with none of the above mentioned findings
– Serial exams, LWE, DPL, DL, CT, US
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Serial exams
• Serial exams with observation
– According to a prospective study where 651 pts
with AASWs where followed: laparotomy vs
observation rate (53% vs 47%)
– Of the 47% only 2.9% required subsequent
surgery, therefore it’s a safe modality
– Problems: need for experienced and frequent
evals of pt; possibility of delayed dx of injury
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Local wound exploration
• LWE
– Need to ID violation of peritoneal cavity
– If negative: no risk for intrabdominal injury
therefore discharge from ED
– If positive: OR for exploration
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Diagnostic Peritoneal Lavage (DPL)
• Why? It quickly determines presence of
intraperitoneal injury/need for exploration
• Reduces number of negative laparotomies
without increasing morbidity/mortality
related to delays
• Useful if unable to perform serial exams
• Accuracy 89-95%
• Sensitivity varies depending on criteria for a
postive test
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DPL
• KCHC criteria
– RBC > 20k/mm3
– WBC > 500/mm3
– Bile or particulate matter
on aspirate
• Absolute CI
– Need for laparotomy
• Relative CI
– Prior abd surgeries,
obesity, ascites
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Diagnostic Laparoscopy (DL)
• Why? Detect peritoneal violation
• Proved to be most useful to rule out
diaphragmatic injuries
• Associated with high rate of negative
laparotomies (~20%)
• Cost-effectiveness is unclear ( OR costs, length
of stay)
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Computerized Tomography (CT)
• Poor sensitivity for AASWs due to inability to
detect hollow viscus injury
• Better for evaluation of back and retroperitoneal
injuries
• CT enema is highly sensitive for evaluating the
retroperitoneum
• CT scan offers no advantage over serial exams or
DPL for AASWs
• Adjunct to identify the wound tract, solid organs
and retroperitoneum
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Ultrasonography
• Identify free intraperitoneal fluid
• More defined role in blunt trauma with a
sensitivity of 85-99% and specificity of 97%
• Not as reliable for penetrating with a
sensitivity of 45% and specificity of 94%
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Biffl, WL. www.downstatesurgery.org
Kaups KL, et al. Management of Patients With
Anterior Abdominal Stab Wounds: A Western Trauma
Association Multicenter Trial. J of Trauma: Injury, Infection, and
Critical Care. Volume 66(5), May 2009, pp 1294-1301
• Multicenter prospective study, 2 years, 11
institutions, 359 pts
• Purpose to compare different management
strategies of asx AASW’s patients to treat and
identify injuries in a safe and cost-effective manner
• Inclusion: Age > 16, AASW
• Exclusion: back, flank, thoracoabdominal stab wound
• Indications for Imed Laparatomy: hypotension,
peritonitis, evisceration
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Results/Discussion
• 81/359 pts had indication for immediate
laparotomy of which 84% where therapeutic
• Used LWE, DPL and CT to facilitate ED
discharge vs laparotomy
– ED d/c : 23,21,16% respectively
– Negative laparotomies based on abnormal
findings : 57, 24, 31% respectively
– 26/359 were selected for SCA of which 12%
underwent laparotomy (33% neg lap)
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Results
• If immediate indication for laparotomy:
laparotomy is highly therapeutic 84%
• If other modalities are abnormal, there is a
high yield of negative laparotomies
• Propose LWE as best method for facilitating
ED discharge
• Bottom line: high yield of negative
laparotomies with modalities, if no indication
for immediate laparotomy, recommend SCA’s
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2
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References
1. .Hasaniya N, Demetriades D, Stephens A, et al. Early morbidity and mortality of nontherapeutic operations for penetrating trauma. Am Surg, 1994, 60 (10), 744-7
2. Nance FC, Wennar MH, Johnson LW, et al. Surgical judgment in the management of
penetrating wounds of the abdomen: experience with 2212 patients. Ann Surg,
1974, 179 (5), 639-46
3. Demetriades D and Rabinowitz B, Indications for operation in abdominal stab
wounds. A prospective study of 651 patients. Ann Surg, 1987, 205 (2), 129-32
4. Biffl, WL. Kaups KL, et al. Management of Patients With Anterior Abdominal Stab
Wounds: A Western Trauma Association Multicenter Trial. J of Trauma: Injury,
Infection, and Critical Care. Volume 66(5), May 2009, pp 1294-1301
5. Aaron Winnick, MD and Patricia A. O’Neill, MD. Trauma, Surgical Critical Care and
Surgical Emergencies