Comparison of routine laparotomy and selective management in the treatment of stab wounds penetrating the peritoneum

Purpose: Generally, laparotomy has been the routine practice to diagnose and treat patients with stab wounds that penetrate the peritoneum. Due to high rate of negative laparotomies however, the last two decades gave rise to the selective management of the abdominal trauma among clinicians who work in trauma centers. Although less intrusive than laparotomy, selective management is still a controversial method, because when and under what circumstances operation shall be required are not yet settled questions. With this retrospective study, we aimed to compare the two methods and find out whether unnecessary laparotomies can be prevented with the selective management of abdominal trauma. We also investigated the emergency laparotomy indications in this group. Materials and Methods: Patients admitted to the emergency department and had undergone routine laparotomy upon diagnosis of penetrating abdominal stab wounds between January 1995 and December 2000, were compared to patients who were subjected to the selective approach upon same diagnosis between January 2001-January 2004. The comparison of the two groups was based on the following factors: age, gender, duration of hospitalisation, physical examination of findings, diagnostic tests, organ injured, surgical technique, and the incidence of unnecessary laparotomy. The morbidity and mortality rates of both approaches were also evaluated. Results: A total of 74 patients were enrolled in the study. Thirty three patients underwent routine laparotomy, whereas 41 patients were managed with selective approach. While the number of negative laparotomies was 30% (10 out of 33) in the laparotomy group, it was only 14% (6 out of 41) in the selective group. Seventeen out of 41 patients in the selective group underwent emergency laparotomy. The remaining 24 were managed conservatively. The emergency laparotomies were regarded as negative in 3 patients and nontherapeutic in 2 (p<0.05). Four patients ended up with delayed laparotomies and all were regarded as therapeutic. In the selective approach group, our findings indicated that 3 patients with peritoneal irritation, one with the evisceration of omentum from the wound, and one with DPL positively underwent unnecessary laparotomies. Conclusion: By selective management of patients with penetrating abdominal stab wounds, the number of unnecessary laparotomies can be diminished. Among selective management patients, whether peritoneal irritation findings, the positive DPL, and evisceration of omentum from the wound still require laparotomy shall be scrutinized. Further prospective tests are needed in patients with stable hemodynamics to determine whether the conservative technique should be opted for.