Should Laparotomy Be Mandator or Selective in Gunshot Wounds of the Abdomen?

Lowe, Robert J.; Saletta, John D.; Read, Don R.; Radhakrishnan, Jayant; Moss, Gerald S.

doi:10.1097/00005373-197712000-00003

Cited by 66 publications

(24 citation statements)

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“…3,7,10 The first argument is based on an alleged incidence of intraabdominal organ injury, after an abdominal gunshot wound, of 90% or greater. Although this may be true for military missiles, abdominal gunshot wounds from civilian violence are associated with a lower incidence of clinically significant intraabdominal organ injuries, ranging in many studies from 30% to 74%.…”

Section: Discussionmentioning

confidence: 99%

Selective Nonoperative Management in 1,856 Patients With Abdominal Gunshot Wounds: Should Routine Laparotomy Still Be the Standard of Care?

Velmahos¹,

Δημητριάδης²,

Toutouzas³

et al. 2001

Annals of Surgery

224

186

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ObjectiveTo evaluate the safety of a policy of selective nonoperative management (SNOM) in patients with abdominal gunshot wounds. Summary Background DataSelective nonoperative management is practiced extensively in stab wounds and blunt abdominal trauma, but routine laparotomy is still the standard of care in abdominal gunshot wounds. MethodsThe authors reviewed the medical records of 1,856 patients with abdominal gunshot wounds (1,405 anterior, 451 posterior) admitted during an 8-year period in a busy academic level 1 trauma center and managed by SNOM. According to this policy, patients who did not have peritonitis, were hemodynamically stable, and had a reliable clinical examination were observed. ResultsInitially, 792 (42%) patients (34% of patients with anterior and 68% with posterior abdominal gunshot wounds) were selected for nonoperative management. During observation 80 (4%) patients developed symptoms and required a delayed laparotomy, which revealed organ injuries requiring repair in 57. Five (0.3%) patients suffered complications potentially related to the delay in laparotomy, which were managed successfully. Seven hundred twelve (38%) patients were successfully managed without an operation. The rate of unnecessary laparotomy was 14% among operated patients (or 9% among all patients). If patients were managed by routine laparotomy, the unnecessary laparotomy rate would have been 47% (39% for anterior and 74% for posterior abdominal gunshot wounds). Compared with patients with unnecessary laparotomy, patients managed without surgery had significantly shorter hospital stays and lower hospital charges. By maintaining a policy of SNOM instead of routine laparotomy, a total of 3,560 hospital days and $9,555,752 in hospital charges were saved over the period of the study. ConclusionSelective nonoperative management is a safe method for managing patients with abdominal gunshot wounds in a level 1 trauma center with an in-house trauma team. It reduces significantly the rate of unnecessary laparotomy and hospital charges.During the past two decades selective nonoperative management (SNOM) has been used with increasing frequency for abdominal trauma. Many injuries previously managed exclusively by surgery are now being observed closely in the absence of peritonitis or hemodynamic instability. SNOM is considered the standard of care for blunt injuries and stab wounds and has decreased the rate of unnecessary laparotomy, shortened the length of hospital stay, and produced significant cost savings.1,2 However, abdominal gunshot wounds have been excluded from this advancement.

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Section: Discussionmentioning

confidence: 99%

Selective Nonoperative Management in 1,856 Patients With Abdominal Gunshot Wounds: Should Routine Laparotomy Still Be the Standard of Care?

Velmahos¹,

Δημητριάδης²,

Toutouzas³

et al. 2001

Annals of Surgery

224

186

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“… 2,3 In cases of gunshot wounds of the abdomen, most of the trauma centres recommend a mandatory laparotomy, irrespective of the clinical signs. Lowe et al 5 and Sawidson et al 6 advocated a policy of mandatory laparotomy for all gunshot wounds suspected of penetrating the peritoneum. Shaftan 2 was one of the earliest to emphasize the role of selective policy of exploration in gunshot wound injuries.…”

Section: Discussionmentioning

confidence: 99%

Non‐operative Management of Gunshot Injury of Liver Causing Bilhaemia

Bose

Mazumdar

Singh

2000

Aust. N.Z. J. Surg.

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“…Es existieren klinische Studien [38], wonach mehr als 40% der Patienten, die initial bei der klinischen Untersuchung keine Symptome zeigten, trotzdem eine intraabdominelle Verletzung erlitten hatten. In eigenen Studien wird die Inzidenz intraabdomineller Verletzungen nach einer Schussverletzung mit bis zu 98% beziffert.…”

Section: Nichtoperatives Management Von Penetrierenden Verletzungen Dunclassified

Das penetrierende Trauma des K�rperstamms

Bowley

Boffard

2001

Der Unfallchirurg

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Trauma has been described as a "disease of bleeding" [45]. Recognition of acute blood loss after injury, and restoration of homeostasis is the cornerstone of the initial care of the badly injured patient. Hypovolaemia remains the most common cause of death among those killed in action during military conflicts [46] and, in the civilian arena, increasing numbers of patients are being encountered with penetrating injuries, even in societies where blunt injury have previously been the norm. Increased use of higher calibre weapons or with altered ammunition means some patients will present with exsanguinations and critical physiological instability. Successful outcomes after the treatment of patients with penetrating trauma depend on the integration of many agencies, from prehospital care, initial reception, assessment and resuscitation through the operating room, intensive care and post-injury rehabilitation. Recognition of the importance of time and adherence to sound trauma management principles with conservative management when appropriate should see further improvements in our treatment of this important group of patients. Reducing the incidence of these injuries is the responsibility of us all and must be the focus of all governmental initiatives.

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Should Laparotomy Be Mandator or Selective in Gunshot Wounds of the Abdomen?

Cited by 66 publications

References 0 publications

Selective Nonoperative Management in 1,856 Patients With Abdominal Gunshot Wounds: Should Routine Laparotomy Still Be the Standard of Care?

Selective Nonoperative Management in 1,856 Patients With Abdominal Gunshot Wounds: Should Routine Laparotomy Still Be the Standard of Care?

Non‐operative Management of Gunshot Injury of Liver Causing Bilhaemia

Das penetrierende Trauma des K�rperstamms

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