Selective nonoperative management of gunshot wounds of the anterior abdomen

D. Demetriades, G. Velmahos, E. Cornwell 3rd, T. V. Berne, S. Cober, P. S. Bhasin, H. Belzberg and J. Asensio
Department of Surgery, School of Medicine, University of Southern California, Los Angeles, USA.

OBJECTIVE: To investigate the role of selective nonoperative management of gunshot wounds to the abdomen. DESIGN: A prospective, protocol-guided study including all gunshot wounds of the anterior abdomen. PATIENTS AND METHODS: The patients were assessed and managed according to a written protocol. Patients with hemodynamic instability or peritonitis or associated spinal cord or head injury or requiring a general anesthetic for an extra-abdominal injury were managed by laparotomy. The test of the patients were selected for initial nonoperative management with serial physical examinations. RESULTS: During a 16-month period, 309 patients with gunshot wounds of the anterior abdomen were treated. Eighteen patients in extremis (5.8%) underwent an emergency department-performed thoracotomy. Another 185 patients (59.9%) met the criteria for operation and underwent a laparotomy. The incidence of nontherapeutic operations was 2.2%, and that of negative operations was 8.6%. One hundred six patients (34.3%) were selected for observation. Fourteen of the initially observed patients underwent a late operation, but it was therapeutic in only 5. Overall, 92 patients (29.8%) were successfully managed nonoperatively. The overall sensitivity of the initial physical examination was 97.1%. The estimated bullet trajectory was not reliable in identifying the need for operation because of 224 patients with likely peritoneal penetration only 169 (75.4%) had significant injuries requiring surgical repair. CONCLUSION: In the appropriate environment, many civilian abdominal gunshot wounds can be managed non-operatively.