An audit of failed non-operative management of abdominal stab wounds.
Selective non-operative management based on clinical assessment has been shown to be a generally safe approach in the management of penetrating stab wounds of the torso. However there will be a subset of patients who fail selective non-operative management. This audit focuses on the failures.


METHODS
The metropolitan surgical service in Pietermaritzburg covers 3 hospitals. At the weekly metropolitan morbidity and mortality meeting all trauma patients are reviewed. All cases of failed selective non-operative management of penetrating abdominal stab wounds are discussed. Failed non-operative management is usually defined as any patient who ultimately requires surgical exploration. We do not subscribe to this as we feel as long as the need for surgical intervention is recognised within a short period of time (<12h) there is little additional morbidity. Recognition of the need for surgical intervention after 12h would be regarded by us as failed non-operative management as we feel the risk of delay associated morbidity begins to increase significantly after this time.


RESULTS
A total of 340 patients with a penetrating anterior abdominal stab wound were managed over the 2 year period under review. A total of 192 (56%) of these patients were subjected to mandatory laparotomy. Of these mandatory laparotomies 98% were positive. The remaining 148 (44%) patients were observed. Of the 148 observed patients a total of 30 (20%) subsequently underwent surgery. A total of 13 patients were only taken to surgery after 12h of observation. In this group of 13 patients the average delay between admission and recognition of injury was 40 h. There were six gastric injuries, one pyloric and pancreatic injury, two gallbladder injuries, one liver, one colon and two small bowel injuries. There were no deaths. 9 patients recovered with no additional morbidity. In the remainder, morbidity included, relaparotomy (1), open abdomen (1), renal failure (1) and prolonged stay in ICU (3).


CONCLUSIONS
Clinical assessment accurately predicts the need for mandatory laparotomy following a stab wound to the torso. In patients who do not meet the indications for mandatory laparotomy and who are subjected to non-operative management 20% will come to surgery. A subgroup may only be recognised as requiring surgery after more than 12h. These patients are at risk of delay associated morbidity. There are particular anatomical sites and structures which are prone to error.
Clarke
D L
DL
Pietermaritzburg Metropolitan Complex, Department of General Surgery, University of Kwa-Zulu Natal, Nelson R Mandela School of Medicine, South Africa. damianclar@gmail.com
Allorto
N L
NL
Thomson
S R
SR
D000007:Abdominal Injuries / Q000175:diagnosis / Q000453:epidemiology / Q000601:surgery*; D057210:Delayed Diagnosis / Q000009:adverse effects; D003964:Diaphragm / Q000293:injuries; D006801:Humans; D007813:Laparotomy; D008485:Medical Audit; D013019:South Africa; D013503:Surgery Department, Hospital; D013898:Thoracic Injuries / Q000175:diagnosis / Q000453:epidemiology / Q000628:therapy; D013997:Time Factors; D014193:Trauma Centers; D017211:Treatment Failure; D019037:Urban Health Services; D014951:Wounds, Stab / Q000175:diagnosis / Q000453:epidemiology / Q000601:surgery*