Nonoperative management of blunt abdominal trauma: have we gone too far?
BACKGROUND
The paradigm shift in the management of blunt abdominal trauma has been to become less invasive with both diagnostic tools and management. Avoidance of a laparotomy with its short-term and long-term risks is of obvious benefit to the patient.


METHODS
Review of the pertinent literature.


RESULTS
Most blunt hepatic and splenic injuries are managed nonoperatively. Management of blunt splenic injury with observation and organ preservation will avoid the lifelong risk of overwhelming postsplenectomy infection. However, what are the risks? Does nonoperative management simply delay laparotomy? The answer is no. The pendulum has swung too far toward observation. Most patients with blunt hepatic injury, irrespective of the grade, are hemodynamically stable and can be observed. On the other hand, high-grade injury (IV and V) often necessitates operation or management of complications by interventional radiology or gastroenterology procedures. When hepatic injury necessitates laparotomy because of hemodynamic instability, the operation is technically challenging, with a significant risk of death. As shown by large studies, the risk of failure of nonoperative management of blunt splenic injury includes preventable deaths. Factors in such deaths include inappropriate clinical decision-making, false-negative diagnostic studies, and initial misreading of computed tomography scans.


CONCLUSIONS
Safe nonoperative management requires adherence to cardinal surgical principles, examination and re-examination of the patient, and fastidious clinical judgment.
Peitzman
Andrew B
AB
Department of Surgery, University of Pittsburgh Medical Center, Pittsburgh, Pennsylvania 15213, USA. peitzmanab@upmc.edu
Ferrada
Paula
P
Puyana
Juan Carlos
JC
D000368:Aged; D006801:Humans; D008099:Liver / Q000293:injuries*; D008875:Middle Aged; D013154:Spleen / Q000293:injuries*; D016896:Treatment Outcome; D014949:Wounds, Nonpenetrating / Q000628:therapy*