Definition and Overview
The exploration of penetrating wound of the abdomen refers to the medical procedure performed to evaluate penetrating injuries that affect all parts of the abdomen. Penetrating wounds, which are commonly caused by gunshots and stabbing, are handled differently from non-penetrating trauma (the impact does not break the skin) since their physical characteristics and mechanisms are not the same.
While superficial penetrating wounds of the abdomen can be adequately addressed with broad-spectrum antibiotics and conservative management, surgical intervention such as full exploratory laparotomy remains an essential part of the overall management of serious cases. Laparotomy is an abdominal exploration surgery that looks at the organs and structures in the abdomen including the bladder, kidneys and ureters, spleen, stomach, and intestines. This is performed if the patient exhibits unstable blood pressure (which can suggest inadequate blood flow to other organs), if conservative treatment fails to resolve symptoms such as the development of increasing level of pain, and if injury to the internal organs is suspected. The goals of the procedure are to control bleeding and contamination, identify and assess the injury’s severity, and reconstruct damaged organs, if needed.
Who Should Undergo and Expected Results
Patients who should undergo exploration of penetrating wound of the abdomen are those suffering from abdominal injuries that have pierced the skin resulting in a wound. In children, these injuries are often caused by falling onto sharp objects, playing with nails and sticks, and accidents involving kitchen utensils such as knives. In adults, the common causes of the injury are stabbing and gunshots due to criminal and terrorist incidents and unintended firearm accidents.
How is the Procedure Performed?
Penetrating wounds of the abdomen are managed based on the size of the wound, the severity of the injury, and the patient’s vital signs. Small, superficial wounds that do not result in excessive bleeding may not require treatment or may be managed using conservative therapies.
To evaluate the severity of the injury, doctors routinely ask for specific information including the type of object that caused the injury and the circumstances surrounding the event. The doctor also assesses the depth of penetration and inspects the object, if available. Imaging tests, such as x-rays and ultrasound, may be performed if the doctor suspects that an object is left behind in the puncture wound.
Meanwhile, in cases where there are clear signs of penetration into the abdominal cavity or the peritoneum, exploratory laparotomy is immediately performed. This is particularly crucial for:
- Patients with unstable blood pressure, heart rate, pulmonary artery occlusion pressure, and cardiac output
- Non-responsive patients
- Patients who suffer from multiple stab or gunshot wounds to multiple cavities
- Patients suspected of cardiac tamponade, a condition in which blood fills the space between the sac that encases the heart and the heart muscle
However, since many patients die from a triad of hypothermia, coagulopathy, and metabolic acidosis during surgical intervention to explore the penetrating wound of the abdomen, laparotomy is usually initially performed as a damage control surgery. This concept limits surgical procedures to contamination and haemorrhage control, minimising damage as it occurs, and accomplishing minimum repairs as quickly as possible. Patients are then transferred to the intensive care unit where they remain intubated and their electrolytes level and drain outputs closely monitored. They also continuously receive fluid and blood product resuscitation until they are taken back to the operating room within 24-48 hours for a definitive repair, which is then referred to as a “staged procedure”.
Staged laparotomy is performed under general anaesthesia. A scalpel is used to extend the wound. Instruments called retractors can be used to hold the incision open as the surgeon explore the abdominal cavity to assess the extent of damage. All solid organs and the entire bowel are assessed for evidence of inflammation, infection, and perforation. Any fluid surrounding the abdominal organs is also inspected. The injuries are then identified and surgical repair is performed. These may involve:
- Splenectomy or splenorrhaphy if the spleen is damaged
- Nephrectomy, if the kidney is injured
- Stapling procedure, if there is damage to the stomach extending into the lumen
- Partial or complete pancreatectomy, if the pancreas sustained severe injuries
Once laparotomy has been completed, the muscle of the abdominal wall and the overlying skin are sutured closed.
The death rate from penetrating abdominal wound can be as low as 0% to up to 100%, depending on the extent of the injury. If the injury does not affect the peritoneum (the transparent membrane that covers the abdominal organ), the patient has 0% mortality rate and minimal morbidity rate. However, if the injury damages multiple organs in the abdomen, the risk of patients dying from irreversible haemorrhagic shock and exsanguination can dramatically increase especially if they present with core temperature less than 35C and develop coagulopathy.
Possible Risks and Complications
Exploration of penetrating wound of the abdomen is a risky procedure particularly for severe cases. Its risks and possible complications include:
- Prolonged bleeding
- Abdominal compartment syndrome
- Deep vein thrombosis
- Pulmonary embolism
- Pressure ulcers
- Ventilator-associated pneumonia
- Catheter-related sepsis
- Wound infection
- Small bowel obstructions
Barone JE. Study Finds Risk Factors for Fistula and Sepsis After Damage-Control Laparotomy. Available athttp://www.medscape.com/viewarticle/810180. Accessed: September 6, 2013.
Bradley MJ, Dubose JJ, Scalea TM, Holcomb JB, Shrestha B, Okoye O, et al. Independent Predictors of Enteric Fistula and Abdominal Sepsis After Damage Control Laparotomy: Results From the Prospective AAST Open Abdomen Registry. JAMA Surg. 2013 Aug 21. [Medline].