Abdominal Trauma, Penetrating

Last Updated: November 17, 2004

Synonyms and related keywords: gunshot wound, GSW, gut shot,
stab wound, missile injury,
celiotomy, diagnostic peritoneal lavage, DPL, diagnostic
laparoscopy, intra-abdominal injuries,
intraabdominal injuries, advanced trauma life support, ATLS

Author: Aleksander R Komar, MD, Fellow, Section of Trauma and Critical Care, SUNY Stony
Brook

Coauthor(s): Prem Patel, MD, FACS, FRCS, Director of Trauma, Department of Surgical

Services Brookdale Hospital Medical Center

History of the Procedure: The management of penetrating abdominal injuries has advanced
greatly in the past century. In the era preceding World War I, penetrating trauma was managed
expectantly. During World War II, studies showed that early celiotomy improved survival.
By the late 1950s, celiotomy was the rule for management of patients with penetrating
abdominal
trauma. In 1960, Shaftan suggested selective management of patients with abdominal stab
wounds after observing an increased rate of negative results from celiotomy.

The introduction of diagnostic peritoneal lavage (DPL) by Root in 1965, the CT scan in 1980,
and diagnostic laparoscopy in the 1990s has refined the diagnostic workup. Recently, some
authors have reported cases of patients with gunshot wounds (GSWs) managed selectively.

Problem: Penetrating abdominal injury implies that either a GSW or a stab wound
has violated the abdominal cavity.

Frequency:

In the United States: In 1998, homicide and legal intervention was the 13th most common cause
of death. According to data published by National Vital Statistics Reports for 2000, 30,708
persons died of firearm injuries in the United States. Of the firearm injury deaths in 1998, 61.9%
were white males, 21.5% were black males, 11.3% were white females, and 3% were black
females. The age-adjusted and age-specific death rates for firearm injuries generally were
highest for black males, followed by white males, black females, and white females.

Internationally: The number of firearm deaths in the United States far exceeds reported
numbers from all European countries. Among
European countries, Norway has the highest firearm death
rate, and it is approximately one fifth of that reported in the United States.

Pathophysiology: A GSW is caused by a missile propelled by combustion of powder.

It implies high-energy transfer and unpredictability of the extent of intra-abdominal injuries.
Not only is the missile track unpredictable, but also, secondary missiles such as bone fragments
or fragments of the bullet are capable of inflicting additional injuries. The missile velocity of
military firearms and hunting rifles is much higher than that of civilian handguns and therefore
has a much higher energy transfer. Shotgun injuries, especially at close range, frequently are

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associated with massive tissue damage and should be regarded as high-energy transfer
injuries.

Stab wounds are caused by a sharp object penetrating the abdominal wall. This type of injury
usually is more predictable with regard to injured organs, but a high index of suspicion must
be maintained to avoid overlooking occult injuries.

Clinical: History and vital signs at the scene are of importance, and the emergency medical
service (EMS) may be the only source of important medical information. Carefully question the
EMS team about the scene of the accident and vital signs upon initial presentation. A history
of hypotension given by EMS personnel frequently correlates with significant blood loss. Upon
arrival of patients at the emergency department, the advanced trauma life support (ATLS)
protocol should be followed.

Patients may present in extremis, and only immediate and organized surgical exploration with
adequate blood-product resuscitation may change a dismal prognosis. Actively bleeding
patients do not benefit from crystalloid
resuscitation, and exploration should not be delayed to routinely
infuse fluids. Patients presenting with hypotension already are in class III shock
(30-40% blood volume loss), and resuscitation with blood products should be considered.
Hemodynamically stable patients presenting with peritonitis should not be treated much
differently because irreversible shock soon may ensue.

For physical examination, completely undressing the patient for the primary survey and
examining the entire body surface for entry and exit wounds is important. Wounds that look
like entry and exit marks actually may be 2 separate entry wounds. Patients brought in as
presumed cases of blunt trauma may have penetrating injuries that have been overlooked
initially. Carefully record the pattern of the wounds. Patients with penetrating abdominal trauma
who present with abdominal pain, tenderness, and guarding should undergo exploration without
unnecessary delays.

GSWs are associated with a high incidence of intra-abdominal injuries. Although some patients
with GSWs to the abdomen can be watched, generally, celiotomy is recommended for a GSW
to the abdomen. Stab wounds are associated with a significantly lower incidence of
intra-abdominal injuries; therefore, selective management is indicated in hemodynamically
stable patients (see Image 1). The most common injuries found at the time of celiotomy for
penetrating trauma are in the small bowel (29%), liver (28%), colon (23%), and stomach (13%).

Relevant Anatomy: The anatomical borders of the abdomen are as follows:

 Superior - Level of the nipples

 Inferior - Level of the anus
 Flanks - Area between ipsilateral anterior and posterior axillary lines
 Thoracoabdominal - Area between level of the nipples and 12th ribs
 Back - Area posterior to the posterior axillary lines, below the tip of the scapula
 Retroperitoneal organs - Duodenum, pancreas, kidneys, ureters, urinary bladder,
ascending and descending colon, major abdominal vessels, rectum

Contraindications: Patients without recordable cardiac activity upon presentation should not
be further resuscitated.

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Lab Studies:

 CBC (all patients): Findings may indicate hemorrhage. Acute bleeding frequently does
not reflect the hemoglobin level until fluid resuscitation is in progress.
 Chemistry (all patients): This is useful for establishing a baseline. Findings may indicate
underlying renal insufficiency or diabetes mellitus.
 Prothrombin/partial thromboplastin time (all patients): Findings may indicate
coagulopathy.
 Arterial blood gas determination (ABG) (all patients): This evaluation helps provide
extremely important information about the hemodynamic status of the patient. Patients
with profound metabolic acidosis may require immediate exploration.
 Type and crossmatch blood: Prepare 6 units of blood, which allows for immediate
replacement in patients who arrive in a state of profound shock.
 Urine dipstick test for blood (all patients): This is a quick test to help evaluate for potential
genitourinary injuries.
 Drug and alcohol abuse-7 test: Patients with penetrating trauma frequently are
intoxicated with many different substances.
 Urine test: Perform a pregnancy test.

Imaging Studies:

 Chest radiographs (CXR) are part of a routine workup in all patients with penetrating
abdominal trauma. In patients with a GSW, findings can reveal hemothorax or
pneumothorax secondary to penetration of the missile into the chest. In patients with
thoracoabdominal stab wounds, x-ray films can indicate violation of the thoracic cavity
by the stab wound. Air under the diaphragm indicates peritoneal penetration. The cardiac
silhouette needs to be evaluated to help rule out penetrating cardiac trauma.
 Abdominal radiographs are indicated in all patients with a GSW because findings help
predict the pattern of the injury based on the location of the missile.
 CT scan of the abdomen with triple contrast (ie, oral, intravenous, rectal) is indicated in
stable patients with stab wounds to the flank and back. Extravasation of the contrast,
hematoma , violation of the peritoneum, and free
fluid in the abdomen are indications for exploration.
CT scan is more sensitive for the pneumoperitoneum than plain radiographs. Abdominal
CT scan with oral, intravenous, and sometimes rectal contrast provides the most
information about solid organs and retroperitoneal structures. CT scan has low diagnostic
sensitivity for helping detect small bowel, diaphragmatic, and pancreatic injuries. It can be
used in the workup of hematuria because it is relatively specific for helping detect renal
injuries.
 Ultrasound, ie, a rapid screening sonogram, has a function similar to that of DPL,
enabling triage of patients rather then providing definitive diagnosis. Four views are used
in trauma, with visualization of the right upper quadrant, left upper quadrant, pelvis, and
pericardium. Ultrasound is up to 95% sensitive for helping detect intra-abdominal
hemorrhage but is not sensitive for helping detect hollow organ injuries. It has a limited
role in penetrating trauma.
 Intravenous pyelogram may be indicated. One shot may be indicated for patients with
hematuria who may need nephrectomy. Its purpose is to help evaluate contralateral
kidney function.

Diagnostic Procedures:

 Nasogastric intubation is needed for all patients to decompress the stomach before
endotracheal intubation. Nasogastric intubation can help detect gastric injury by the
presence of blood in the nasogastric tube (NGT).

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  Foley catheter insertion (all patients) can help indicate injury to the urogenital system by
the presence of blood. Catheter insertion also enables monitoring of the fluid
resuscitation and helps prevent bladder injuries before DPL and celiotomy.
 DPL, abdominal ultrasound, or emergent laparotomy can be used as diagnostic
modalities for unstable patients in whom intra-abdominal injury is suggested, with
reported sensitivity, specificity, and accuracy of 95-100%. For stable patients, DPL
retains its value, being superior to CT scan of the abdomen for helping detect hollow
organ injuries. Two commonly accepted methods of DPL are open DPL and closed DPL.

o The open method involves exposure of the peritoneum through a small

infraumbilical midline incision and insertion of the lavage catheter into the
peritoneal cavity under direct vision. This step is followed by aspiration, and
if aspirate is grossly negative for blood, 1 liter of warm peritoneal dialysate
(or isotonic sodium chloride solution) is infused into the peritoneum. Fluid then is
retrieved by gravity siphonage and evaluated for the presence of
RBCs (>10,000/mm3); WBCs (>500/mm3); bile; fibers; particles; and lavage fluid
from the Foley catheter, NGT, or chest tube.
o The closed technique involves blind insertion of the catheter into the peritoneum
over the guide wire through a small skin puncture.
o Both methods seem to be equally safe for the patient, with an average
complication rate of less than 1%. The open technique, currently recommended
by the American College of Surgeons Committee on Trauma, requires more time
for completion. The closed technique seems to have a higher procedural
complication rate, with difficulties in advancing the guide wire or inadequate fluid
return. Importantly, remember that diagnostic evaluation should never delay
celiotomy in any patient with a clear indication for operation, such as suspected
intra-abdominal hemorrhage or peritonitis.

 Tube thoracostomy is indicated in thoracoabdominal injuries.

o Of all chest injuries, 85% do not require thoracotomy, and the patient can be
treated with relatively simple measures such as airway control and tube
thoracostomy. Positive intrathoracic pressure interferes with venous return to
the heart and adequate ventilation.
o Because sequelae of the thoracic injury interfere with air exchange, treatment
must take high priority, just after securing the airway, obtaining intravenous
access, and beginning fluid resuscitation.
o In hemodynamically stable patients, the presence of a pneumothorax injury
should be confirmed with radiographic findings. On CXR findings, loss of 20%
of lung dimension corresponds to 50% loss of lung volume.

 Resist the temptation to treat small pneumothorax with observation alone because
delayed increase may occur and become life threatening at the least desirable moment,
eg, during intubation or transport to another area.

o Release of a major hemothorax or pneumothorax in a patient with chest trauma

is essential to establishing adequate ventilation, and treatment cannot await
performing CXR.
o The presence of subcutaneous emphysema, absent breath sounds, or acute
respiratory distress warrants chest tube thoracostomy without any delay. After
placement of the chest tube, CXR helps evaluate decompression and retains its
great diagnostic value.

 Hemothorax and tension pneumothorax require a large-bore 38-40F chest tube placed

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 in the midaxial line in the fifth or sixth intercostal space. A 20-cc syringe with 1% lidocaine
can be used not only to provide local anesthesia, but also to help locate the upper edge
of the rib in patients who are obese.

o A 2- to 3-cm incision should be made one interspace below the targeted level
rib to avoid injury to the intercostal neurovascular bundle, located just below the
lower edge of the rib. Upon opening, the pleural space should be inspected by
sweeping a finger around to ensure proper location and to free potential
adhesions.
o Insert the chest tube, and advance it in a posterior and superior direction. Then,
the chest tube should be connected to the suction/collection system under 20 cm
of water negative pressure, preferably through the autotransfusion device.
o CXR should follow chest tube placement immediately. If the pleural space still
contains blood, insert another chest tube.

 Rigid sigmoidoscopy is indicated in all patients presenting with injuries below the iliac
crests or with blood found after rectal examination. This procedure may help identify
rectal injuries that otherwise may be missed.

Medical therapy: Initial resuscitation of patients with penetrating abdominal injuries depends
on the condition of the patient upon arrival.

Insert multiple large-bore catheters into the upper extremities, or, if necessary, obtain central
venous access. Because intra-abdominal venous injury is a possibility, lower extremity venous
access is not recommended.

Perform blood replacement during resuscitation with type-specific blood. Having 2 units of
O Rh-negative blood available immediately in the emergency department is a good practice.

Start efforts to limit hypothermia as soon as the patient arrives. Ensure that prewarmed fluids,
high-flow blood warmers, and prewarmed blankets to cover the patient all are present.

Most patients with penetrating abdominal injuries benefit from intravenous antibiotics
given perioperatively.

Surgical therapy:

Damage control

Ninety percent of preventable deaths in trauma patients are related to shock from inadequate
recognition of intra-abdominal hemorrhage caused by solid viscous injury. Those incurring severe
multisystem trauma are particularly susceptible to the development of a fatal coagulopathic state
secondary to hypothermia, acidosis, dilution, and consumption. Transfusion of 2 or more blood
volumes of saline and packed RBCs decreases the level of coagulation factors to 15%. Due to
large transfusion requirements and delay in coagulation profile results, coagulation factors should
be replaced empirically.

Metabolic acidosis affects both the circulatory system and coagulation, decreasing cardiac output
and triggering diffuse intravascular coagulation. The chances of salvaging a patient with a pH
lower than 7.0 at admission are close to zero. Despite rewarming devices and IV fluids for the
patient, heat loss in the operating room is difficult, if not impossible, to avoid.

Damage control involves rapid celiotomy to control major injuries, followed by temporary closure

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of the abdomen and another exploration after the patient is rewarmed and stabilized. With the
use of this technique, approximately 40% of critically injured patients can be saved.

Place the patient on the operating table, preferably on the rewarming device. The abdomen and
chest are prepared from the thighs to the neck, and the patient is draped. After informing the
anesthesiologist, enter the abdomen from a midline incision. This critical moment can be
associated with significant blood loss, and rapid blood infusion should be ready. Upon entering
the abdominal cavity, perform 4-quadrant packing with laparotomy pads. Manual compression
of the subdiaphragmatic aorta may be instituted if packing alone does not control the
hemorrhage. At this moment, the operation is
stopped and blood/fluid resuscitation is performed.

After consultation with the anesthesiologist, proceed with subsequent unpacking of the
4 quadrants and identification of injuries. Vascular injuries are controlled with clamping and
ligation, bowel injuries are stapled across, and no attempt at any primary repair is made. Liver
and retroperitoneal injuries are controlled with packing alone.

When damage control has been completed, the abdomen is closed rapidly with either towel clips
or running suture. The patient then is transported to the recovery room and actively rewarmed
and resuscitated. Reoperate within 24-48 hours, and perform definitive repair of the injured
organs.

Closure of the abdomen

Patients who have undergone massive fluid resuscitation by the time life-threatening injuries are
controlled may develop significant bowel edema, precluding primary closure of the abdomen.
Also, patients who have undergone damage control who require another exploration in 24-48
hours may require temporary closure of the abdomen. Several means of closure are suggested,
from packing and approximating the skin with towel clips to suturing an intravenous fluid bag to
the fascia. In the authors' experience, temporary closure with Gore-Tex mesh sutured to the skin
with running 1.0 Prolene provides atraumatic coverage of the bowel and reduces postoperative
adhesions and fluid losses.

Preoperative details:

Place the patient supine with both arms extended.

A wide exposure of the chest, abdomen, and both lower extremities is necessary in case
thoracotomy or vascular control in the extremity is necessary.

Before making the abdominal incision, the chest and thighs are covered with sterile drapes
to limit heat losses.

Warming devices should be placed over the patient's upper extremities and head, and all fluids
should be administered through the warmers.

Cell Saver is extremely useful on many occasions. The authors use it routinely on all trauma
patients.

Intraoperative details:

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Hollow organ injuries

Stomach

Examine the stomach carefully, both the anterior and posterior walls. Examination of the
posterior wall of the stomach requires entering the lesser sac by opening the gastrocolic
ligament. Excision of the xiphoid process may improve exposure of gastroesophageal junction
left lateral segment of the liver may facilitate exposure.

Most penetrating injuries to the stomach can be primarily repaired. A quick and safe way to
achieve this is by firing a TA 30-55 stapler across the defect, approximated with Judd-Allis
clamps. Resect extensive injuries in the pylorus, and restore continuity of the gastrointestinal
tract with gastrojejunostomy. Gastroesophageal junction injuries should be repaired and covered
by fundic wrap, similarly to Toupet fundoplication.

Duodenum

The duodenum is exposed by mobilizing the hepatic flexure of the colon and by performing the
Kocher maneuver (ie, incising posterior peritoneum along lateral duodenal border).
The duodenum shares its blood supply with the head of the pancreas and receives the common
bile duct (CBD) and pancreatic duct. Duodenal injuries can be divided into 5 grades, as follows:

 Grade 1 (intramural hematoma with a <50% circumference): Hematomas can be observed.

 Grade 2 (hematoma >50% and laceration <50% in circumference): Hematoma should be
drained by longitudinal serosal incision; lacerations should be primarily closed in a
transverse fashion.
 Grade 3 (laceration >50% in circumference (any segment) and transection of the first, third,
or fourth portion of the duodenum): Lacerations should be primarily closed in 2 layers,
and transection should be anastomosed in an end-to-end fashion. In large defects,
a loop of the jejunum can be used to close the defect in a Roux-en-Y fashion.
 Grade 4 (laceration >75% in circumference of second portion, transection of ampulla or
intrapancreatic CBD): If the CBD and ampulla are intact, the defect is closed with a
jejunal loop brought up in a Roux-en-Y fashion. If the ampulla or CBD is injured, the
patient requires pancreaticoduodenectomy. If the patient is not stable, damage control
should be instituted and final resection should be performed 24 hours later.
 Grade 5 (duodenal devascularization or combined duodenal-pancreatic injury): These injuries
are associated with high mortality and morbidity rates. After hemostasis is obtained and
duodenal injuries are repaired, the patient should undergo duodenal diverticularization
(antrectomy and gastrojejunostomy) or pyloric exclusion (firing a TA 55 stapler across the
pylorus and gastrojejunostomy) to divert chyme away from the duodenum. Extensive
peripancreatic drainage is mandatory.

Small bowel

Examine the entire small bowel for signs of injury. Most stab wounds and GSWs that do not
destroy more than 50% of the bowel circumference can be repaired in a transverse fashion.
Perform resection with primary anastomosis if a bowel wall defect of larger than 50% of the
circumference is present, if devascularizing injuries are present, or if multiple defects of the
short fragment of the bowel are present. This is accomplished quickly by firing a gastrointestinal
anastomotic (GIA) stapler inside the lumen of the approximated bowel loops and then firing a
TA 55 stapler across the bowel lumen (Images 2-4).

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Colon

Mobilization of the retroperitoneal portion of the colon is necessary for intraoperative evaluation
of this organ. The right colon is evaluated by incising the avascular line of Toldt and reflecting
the colon medially. Hepatic and splenic flexures must be divided, and the greater omentum
should be separated in suspicious areas. As a general rule, injuries to the colon should be
primarily repaired, assuming that the patient is not hypotensive. Fecal contamination is not a
contraindication to the primary repair.

A hemodynamically unstable patient should undergo damage control rather than a definitive
procedure. Defects of smaller than 50% of the colonic diameter can be closed in a transverse
fashion, approximating the tissue with Babcock clamps and firing a TA 30-55 stapler across the
defect. Larger defects or devitalized fragments of the colon require resection.
Ileocolic anastomosis probably is safer than colocolic anastomosis; therefore, extended resection
may be preferred in case of multiple injuries to the colon.

Rectum

Injuries to the rectum below the peritoneal reflection are an exception to the rule of primary repair.
These injuries are treated by presacral drainage and diversion of the fecal stream.

Solid organ injuries

Liver

The liver is the most commonly injured organ secondary to penetrating trauma and the second
most commonly injured organ (after the spleen) after blunt trauma. Several maneuvers can be
used to control liver injuries, as follows:

 Bimanual compression of the injury temporarily stops bleeding and allows the time
necessary for blood resuscitation.
 Portal triad occlusion (Pringle maneuver) decreases blood loss and helps to select
patients who would benefit from left or right hepatic artery ligation.
 Intrahepatic omental packing is superior to gauze packing for controlling bleeding and
obliterating space resulting from parenchymal debridement.
 More extensive liver injuries may require a rapid and extensive finger-fracture technique
for vascular control.
 Wide mobilization of hepatic attachments with medial rotation of the liver exposes
the suprahepatic and infrahepatic vena cava.
 Placement of an atriocaval shunt may be used to control retrohepatic vascular injuries.
 Perihepatic packing and planned reexploration can be a life-saving procedure for patients
with coagulopathy, acidosis, or hypothermia.
 Continuous arterial bleeding after packing can be managed with selective hepatic
embolization.
 Absorbable mesh wrap is another option in major liver injuries.
 All liver injuries should be drained, and closed suction drains have the lowest septic
complication rate.

Portal triad injuries, although rare, are associated with extremely high mortality rates,
approaching 70% for isolated portal vein injuries. The portal vein should be repaired, if possible;
ligation is the second alternative, with an expected mortality rate of 20%. Careful volume
resuscitation should follow portal vein ligation to avoid hypotension related to fluid sequestration

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in the splanchnic bed. Simple ligation of the hepatic artery, preferably proximally to the
gastroduodenal artery, is recommended for most major hepatic artery injuries. Shock-related and
transfusion-related coagulopathy occurring in the immediate postoperative period are responsible
for 80% of the deaths in patients with liver injury. Control of the hemorrhage remains a critical
component of the successful management of liver injuries.

Spleen

Massive bleeding from the left upper quadrant probably is caused by splenic injury. Hilar
vascular injury, extensive fragmentation, total avulsion, or associated severe injuries are
indications for splenectomy. Palpate the tail of the pancreas, and obtain vascular control of the
splenic vessels. In case of a life-threatening emergency, the spleen is delivered into the wound
in a blunt fashion, the left upper quadrant is tightly repacked, and a clamp is applied across the
splenic hilum.

Diaphragm

In thoracoabdominal penetrating injuries, this organ frequently is injured. All defects should be
repaired because later enlargement of the defect may cause diaphragmatic herniation.
A practical way of repairing diaphragmatic injuries involves use of long Judd-Allis clamps and
long needle holders. The surgeon places interrupted Prolene 2.0 sutures on the diaphragm, and
the assistant grasps the needle with a second needle holder.

For vascular injuries, see Abdominal Vascular Injuries.

Postoperative details: Postoperative management depends on intraoperative findings.

The most challenging patients who have undergone damage control need to be stabilized before
definitive surgery. Obtain a CXR and ABG determination immediately in the recovery room.
Blood replacement therapy should be performed according to massive transfusion protocols,
with 6 units of platelets and 2 units of fresh frozen plasma given for every 5 units of packed
RBCs. Patients require active rewarming and close electrolyte monitoring. Closely record the
output of all drains and tubes. Patients with evidence of ongoing bleeding do not benefit from
expectant management and, at times, may be candidates for angiographic embolization.

Follow-up care: For excellent patient education resources, visit eMedicine's Wounds Center.
Also, see eMedicine's patient education article Puncture Wound.

Early complications include coagulopathy, ongoing bleeding, and abdominal compartment

syndrome.

Intermediate complications include sepsis, acute respiratory distress syndrome, pneumonia,

intra-abdominal collection, wound infection, and enterocutaneous fistula.

Late complications include small bowel obstruction and incisional hernias.

Stab wounds

Thirty percent of patients presenting with stab wound to the abdomen have injuries requiring
operative repair. The risk of missing significant intra-abdominal
injuries must be weighed against the significant rate of complications
following exploration of an abdominal stab wound and not finding additional injuries.
In a prospective study of morbidity published by Feliciano in 1995, complications occurred during

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41% of unnecessary celiotomies. The most common
complications were pulmonary in nature (>30%), wound
infection (3.2%), and small bowel obstruction (2.4%).

Gunshot wounds

Approximately 80% of GSWs cause significant injury. Patients in critical condition requiring
damage control surgery have a mortality rate of 60%. The mortality
rate associated with colonic injuries is 2-12%. Morbidity is related to
infectious complications.

Approximately 30% of all patients requiring celiotomy for trauma have hepatic injuries.
Minor injuries (grade I and II) constitute the majority of cases and require simple repairs with
minimal expected mortality, usually caused by
associated injuries. Twenty percent of patients have complex injuries
(grade III to V), associated with mortality rates as high as 30%. The overall mortality rate for liver
injuries approaches 10%.

Portal triad injuries, although rare, are associated with extremely high mortality rates,
approaching 70% for isolated portal vein injuries. The portal vein should
be repaired if possible; ligation is the second alternative, with an expected
mortality rate of 20%.

Laparoscopy

The role of the diagnostic laparoscopy in patients with equivocal physical examination findings
currently is limited to confirmation of peritoneal penetration. If violation of the
peritoneum is confirmed, patients undergo celiotomy. With
increasing laparoscopic skills and advances of the technology, a certain number of negative
explorations, particularly for stab wounds, could be avoided by diagnosing
and repairing bowel injuries laparoscopically. However, randomized
studies are necessary to prove that laparoscopic small bowel examination is sensitive
for injuries.

CT scan for the evaluation of unstable patients

With the advantage of spiral CT scan, the time necessary for performing the scan is reduced to 5
minutes and the amount of information available gained from
this test is enormous. Spiral CT may replace CXR, abdominal
radiograph, DPL, and focused trauma sonogram altogether, providing more information in less
time than any of these other tests.

Abdominal Trauma, Penetrating excerpt

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