belly knife trauma question

[europeman]

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question. w/low velocity trauma like stab to the belly, if they are stable withOUT peritontis and benign exams, what do you do if tractototmy reveals...

1) violation of anterior fascial layer only
2) violation of both fascial layers (or violation of linea alba)

Do you?
DPL?
CT?
OR? if so, lap or laparaotopy?
serial exam?

 

[idiot07]

I think in this case there are a lot of right answers and it's instituion dependent.

At our institution, We've been taught that you can't adequately assess the the deep fascia with local wound exploration, so if the anterior fascia is violated you're obligated to do more.

We tend to either scan (arguable if nescessary r/o vascular injury, solid organ injury, free air, also useful in flank injuries with trajectory toward colon) and observe these patients with serial exam, or go to the OR scope them, and if their is violation of the peritoneum convert to lapratomy.

This decision is dictated by hx (size of the knife etc), location of wound (more likely to do dx laprascopy for LUQ wound to r/o diaphragmatic injury), reliability of the patient (on drugs/drunk=unreliable exam=scope), surgeon preference, and the time of day (we have a 24 hr on/24 hr off type call schedule, and we worry about reliability of serial exams when changing care teams, so more likely to go straight to OR if near end of shift).

If there is violation of the peritoneum when you stick the laparoscope in, we almost always convert to open to run the bowel, as there is a relatively high incidence of missed injuries with the scope alone in the literature, and you lose your physical exam (if you wanted to just scope and observe).

The data clearly supports the use of serial exams if you feel you can reliably accomplish them, but sometimes it's more difficult than it seems, unless you have a good setup (I think LAC has a room where they stick all of these patients).

 

[dpmd]

LAC/USC indeed has a room where all these go, babysat by dedicated nursing staff and the intern whenever they aren't occupied elsewhere.

You question is exactly why I almost never do local exploration. Maybe my experience is different than the average, but I have rarely seen a patient where it shows no fascial violation and the patient gets to just go home. As long as there isn't anything sticking out of it, and the wound isn't so huge I can see to the bottom of it without doing anything more I clinically examine. If only local tenderness and good vitals I get a scan with the wound marked (most of the time they get po and IV contrast). If the track ends well above peritoneum they go home (typically ending in the muscle so a local wound exploration would have been positive). If it is close but no definite injury they get admitted with serial exams (could argue that the serial exams alone would be enough, but finding the first group is worth it to me). If it hit a solid organ they get non-op management, with the caveat that a spleen is a hard sell due to concern for diaphragm injury unless the trajectory is different than the usual-but then bowel injury would become a concern. If it is close to colon then it really depends on what is looks like around it, how the patient looks, and how adventurous the staff is. Have successfully watched these before, but it is not for the faint of heart. At my institution there is a lot of variability in staff preferences, but since most of these come in at night when the staff is at home even the ones that are OR-happy can be presented the story in such a way to have them agree with your management plan (though they might end up getting a nontherapeutic lap the next morning depending on the staff). I think your prior experiences shape your comfort level with not operating. Since I was a student at USC and most of my previous staff were more comfortable with not operating on everyone I have learned and applied that without any real disasters so it reinforces my strategy. Someone else who has seen major badness from delayed diagnosis would be understandably more hesitant.

 

[ESU_MD]

Nonop management in these injuries can be successful, even necessary in a busy system with plenty of workhorse manpower(residents)

In a smaller place, its a lot harder. Especially if you sit on something and your partner has to operate on it the next day.

Of course it goes without saying... In a hotel room with examiners i would not even think about suggesting nonop management for a penetrating belly wound and even doubt i would discuss laparoscopy. A top knife will go hey-diddle-diddle right down the middle with this scenario on the boards

 

[Rony]

I'm not sure I would agree about the differences among surgeons or institutions.

There are clear ATLS guidelines.

I would agree that what constitues a 'positive' wound exploration does vary. For instance, some institutions (e.g Temple) calls it positive when it violates the posterior fascia.

Simply put:

Anterior abdominal stab wound: local wound exploration OR laparoscopy; if positive for peritoneal penetration then laparatomy. Also, if peritoneal exam or hemodynamically stable then laparotomy.
Otherwise, CT scan.

Penetrating flank wound in a stable patient: CT scan with triple contrast OR serial exams.

 

[DrCG20]

Of course it goes without saying... In a hotel room with examiners i would not even think about suggesting nonop management for a penetrating belly wound and even doubt i would discuss laparoscopy. A top knife will go hey-diddle-diddle right down the middle with this scenario on the boards

Completely agree here.

What can be done in a busy trauma center with 10 trauma per day and 24 med students/intern isn't real life for most of us.
A penetrating anterior abdomen wound in the oral exam = laparotomy.
Gotta play safe.

 

[europeman]

I just don't understand why you would serially examine ANYONE with violation of both facial layers if it's with a decent sized knife (as opposed to a really little one or a pick fork or something).

The reason is.... don't you have to fix the freaking hernia? How would you like to walk around with a 2cm facial defect in your luq? i wouldn't.

i guess you could close the anterior fascia at the bedside if you had good sedation (ketamine) in the trauma bay during/after your tractotomy... but doesn't seem ideal to me.

thoughts?

I just had an annoying night as trauma chief where the attending was a vascular surgeon covering for trauma that night... anyway, i called him for a positive tractotomy (luq, clearly violated both fascia layer), and it was 1am and wasn't in the mood for a scope, so we did a mini laparotomy and turns out her peritoneum wasn't violated. ran the bowel anyway, no injuries... closed the defect... blah blah.

THen an hour later, another patient comes in with a stab wound more central (linea alba, above umbo) CLEARLY with violation of fascia, but it was tangential and I couldn't see down w/trauma-bay tractotomy so I could only feel and coulnd't tell if peritoneum violoted (which, i know isn't the point of tractotomy), but clearly fascia totally violated. haha, my attending refused to take the patient, instead forced me to do serial exams. Anyway, his wound was just off midline, so his anterior fascia was violated, and then since the wound was tangential, the posterior violation was more midline (i.e. linea alba). anyway, i opted too close his anterior fascia right there in the trauma bay.

i just don't feel comfortable it was the best care you know?

brought it up with the trauma guys the next day (when my attending left), and it was interesting how different their thoughts were. One was like "why didn't you do DPL"? The other was like "It's fine, just do serial exams". Then i asked about the hernia... he was like "ahh, the anterior fascia closer is enough". Then another one was like "yo ushould have scoped him"

pretty ridiculous the differences of opinion for such a routine trauma.

thoughts?

 

[ESU_MD]

Tough cases. Nobody will ever fault you for operating on these patients.

Its interesting how judgement can change though in trauma. Maybe the guy had a full day of clinic or cases the next day? In trauma, you can always buy a few hours of "nonop management" until you sign out to the next guy. Let the day guys do the case.

I have never been real comfortable with watching these stabbings, would rather just do an exlap and forget about it. Its too much hassle, besides these patients would be the first to litigate for a missed injury. .... Unless they were mindingvtheir own business

 

[SLUser11]

I just don't understand why you would serially examine ANYONE with violation of both facial layers if it's with a decent sized knife ........so we did a mini laparotomy and turns out her peritoneum wasn't violated. ran the bowel anyway, no injuries... closed the defect... blah

I believe you answered your own question. The reason people are pushing the envelope on non-op management of low-velocity penetrating abdominal injuries is because of the high incidence of negative laparotomies.

The reason you're getting different answers from different attendings is that it's controversial. LD Britt is one of the leaders in non-op management, and he'll watch alot of these people, even if he's positive there's fascial compromise, as long as there's no peritonitis.

ESU's point can't be stressed enough, however. When it comes to an oral boards scenario, the safe answer is laparotomy for all stab wounds that violate the fascia.

As far as traumatic ventral hernias go, I think this depends on the size of the knife and size of the defect. There are plenty of people (not me) that still leave 12mm port sites alone as long as they're off the midline, and usually nothing bad happens.

Now, a stab wound to the thoraco-abdomen is something different. If there's fascial penetration there, the patient needs at least a diagnostic laparoscopy to rule out diaphragm injury.

 

[dpmd]

As far as traumatic ventral hernias go, I think this depends on the size of the knife and size of the defect. There are plenty of people (not me) that still leave 12mm port sites alone as long as they're off the midline, and usually nothing bad happens.

Also, just because you want to repair the defect does not mean you need to go to the OR immediately. If you serially examine and all is well you could even consider just fixing things instead of doing a full lap.

 

[opr8n]

question. w/low velocity trauma like stab to the belly, if they are stable withOUT peritontis and benign exams, what do you do if tractototmy reveals...

1) violation of anterior fascial layer only
2) violation of both fascial layers (or violation of linea alba)

Do you?
DPL?
CT?
OR? if so, lap or laparaotopy?
serial exam?

if it is only ant layer, wash wound out, leave open d/c home
no fast, no CT, no operation, no admnission

if it violates the post sheath (or there is no post sheath), then everyone gets FAST (institution specific), then CT, then overnight admission ... all of this is without peritonitis ... these patient sdo not need the OR, not even a scope
If they had tenderness from what i would expect, i would explore them laparoscopically

 

[opr8n]

. LD Britt is one of the leaders in non-op management, and he'll watch alot of these people, even if he's positive there's fascial compromise, as long as there's no peritonitis.
.

yes

ive spent time with LD and agree with his line of reasoning, his opinion is also very well articulated on sesap 13 audio companion on this matter

 

[tussy]

Here's a real case from a few weeks ago - stab wound with tiny knife, clinically local wound exploration looked like it was outside the fascia, no clinical findings, soft belly, etc. Did CT which showed penetration of fascia. Took patient to the OR and put in a scope - could see a small amount of bile and blood in lesser sac. Laparotomy - penetrating wound to duodenum and head of pancreas.

My approach (small community hospital). In a stable patient - do CT, if posterior fascia is violated put in a laparoscope, laparotomy as necessary.

 

[SLUser11]

Here's a real case from a few weeks ago - stab wound with tiny knife, clinically local wound exploration looked like it was outside the fascia, no clinical findings, soft belly, etc. Did CT which showed penetration of fascia. Took patient to the OR and put in a scope - could see a small amount of bile and blood in lesser sac. Laparotomy - penetrating wound to duodenum and head of pancreas.

My approach (small community hospital). In a stable patient - do CT, if posterior fascia is violated put in a laparoscope, laparotomy as necessary.

People stab each other in canada? I always think of it as being way safer than the states...

 

[tussy]

People stab each other in canada? I always think of it as being way safer than the states...

He stabbed himself in the abdomen accidently. It is safer.

 

[europeman]

I believe you answered your own question. The reason people are pushing the envelope on non-op management of low-velocity penetrating abdominal injuries is because of the high incidence of negative laparotomies.

The reason you're getting different answers from different attendings is that it's controversial. LD Britt is one of the leaders in non-op management, and he'll watch alot of these people, even if he's positive there's fascial compromise, as long as there's no peritonitis.

ESU's point can't be stressed enough, however. When it comes to an oral boards scenario, the safe answer is laparotomy for all stab wounds that violate the fascia.

As far as traumatic ventral hernias go, I think this depends on the size of the knife and size of the defect. There are plenty of people (not me) that still leave 12mm port sites alone as long as they're off the midline, and usually nothing bad happens.

Now, a stab wound to the thoraco-abdomen is something different. If there's fascial penetration there, the patient needs at least a diagnostic laparoscopy to rule out diaphragm injury.

i've always heard this dogma, which, makes sense... but is there any evidence you even have to fix a small diaphragmatic injury? especially if it's from something very small like a small knife or something? is bowel really gonna herniate through a 1cm linear defect? do they grow or something?

 

[Buzz Me]

i've always heard this dogma, which, makes sense... but is there any evidence you even have to fix a small diaphragmatic injury? especially if it's from something very small like a small knife or something? is bowel really gonna herniate through a 1cm linear defect? do they grow or something?

A missed diaphragmatic injury isn't as big a deal on the right side (where the liver will "pack" it off), but on the left the injury may enlarge over time until you get herniation of the stomach, spleen, colon, etc.

 

[Winged Scapula]

A missed diaphragmatic injury isn't as big a deal on the right side (where the liver will "pack" it off), but on the left the injury may enlarge over time until you get herniation of the stomach, spleen, colon, etc.

Yep.

 

[aashiq]

question. w/low velocity trauma like stab to the belly, if they are stable withOUT peritontis and benign exams, what do you do if tractototmy reveals...

1) violation of anterior fascial layer only
2) violation of both fascial layers (or violation of linea alba)

Do you?
DPL?
CT?
OR? if so, lap or laparaotopy?
serial exam?

That's a question I was once faced with. There was violation of anterior fascial layer only and I got away by doing nothing.
I think serial examinations is the key and any deterioration in patient's status mandates immediate laparoscopy.
In my institution DPL is no longer practised and CT wont be sensitive enough to detect hollow viscus injury early.

 

[HNANAL]

question. w/low velocity trauma like stab to the belly, if they are stable withOUT peritontis and benign exams, what do you do if tractototmy reveals...

1) violation of anterior fascial layer only
2) violation of both fascial layers (or violation of linea alba)

Do you?
DPL?
CT?
OR? if so, lap or laparaotopy?
serial exam?

you treat it like any penetrating injury and in this case
Need to do CT scan and you must FAST the belly.
If above is negative, belly exam for 12-18 hours. If negative, po trial then dc home.

in case someone thinks I make this stuff up.
http://www.ncbi.nlm.nih.gov/pubmed/21529801
http://www.ncbi.nlm.nih.gov/pubmed/19913226
http://www.ncbi.nlm.nih.gov/pubmed/20220426
http://www.ncbi.nlm.nih.gov/pubmed/18069579
http://www.ncbi.nlm.nih.gov/pubmed/16998371
http://www.ncbi.nlm.nih.gov/pubmed/20009679
http://www.ncbi.nlm.nih.gov/pubmed/20852416

many many more

 

[europeman]

was talking to my attending about this who told me where he trained (NYU) he always gave them PO right up front. The thought was that if something isn't wrong, you'll be much more comfortable in 16-24 hours if they still look good after having already tolerating a meal or two.

and if they do have an injury, the PO will help it manifest quicker. it's not like it's gonna hurt them any more than if they were npo

anesthesia just has to get over it 😉 it's a rapid sequence no matter anyhow...

 

[dpmd]

I feed the stab wounds I am watching for the same rationale as your attending. Plus, doesn't your belly hurt when you are hungry?

Besides the ones that go straight to the OR always seem to have eaten the world's largest meal (especially if there is a gastric injury-a recent one had fricking noodles all over the place that were very distracting as we were trying to stop his retroperitoneal exsanguination)

 

[SLUser11]

Plus, doesn't your belly hurt when you are hungry?

I know you're being partially facetious, but making someone NPO for 12-18 hours while you do serial exams obviously won't cause excruciating "hunger pains." I'm afraid a med student will read your post and take you seriously.

I would love, however, to see that defense during an M and M presentation, though...."the patient had some tachycardia, diffuse abdominal tenderness...we figured they were hunger pains so we fed her...."

 

[Buzz Me]

The first thing I always tell consulting teams (usually Medicine) when requesting a stat surgical consult is, "why isn't the patient NPO?"

They always want us to rush the patient off to the OR stat...but never make the patient NPO. Can't miss a meal! The horror!

 

[dpmd]

I know you're being partially facetious, but making someone NPO for 12-18 hours while you do serial exams obviously won't cause excruciating "hunger pains." I'm afraid a med student will read your post and take you seriously.

I would love, however, to see that defense during an M and M presentation, though...."the patient had some tachycardia, diffuse abdominal tenderness...we figured they were hunger pains so we fed her...."

I was being facetious about the hunger thing. I do feed them though, then when enough time has passed and they are fine it is that much quicker that they can be discharged (rather than waiting for the order to get written, possibly disappear from the piece of crap computer system, finally get noticed by the nurse, patient eventually gets some food tolerates it and can go home)

 

[HNANAL]

and then you find the pt needs surgery, but threw up and aspirate and die 👍

 

[thedrjojo]

we just had this the other day, a positive local wound exploration (anterior fascia) prompted us to take to the OR only because she OD'd on Ambien as well so we felt we couldn't rely on her exam/complaints. Turned out to be a non-therapeutic ex-lap, and now she has a whopping ileus, renal failure and when i left saturday post call she had just went into afib and was being transferred to step down from the floor... sigh

 

[SLUser11]

we just had this the other day, a positive local wound exploration (anterior fascia) prompted us to take to the OR only because she OD'd on Ambien as well so we felt we couldn't rely on her exam/complaints. Turned out to be a non-therapeutic ex-lap, and now she has a whopping ileus, renal failure and when i left saturday post call she had just went into afib and was being transferred to step down from the floor... sigh

That's an excellent case because it brings up the fact that there is a real, palpable morbidity to these "negative laparotomies." That was one of the main reasons that a push toward non-operative management occurred.

Even in the young, otherwise healthy patient, there is risk for hernia, SSI, DVT, etc.....or the worst of all complications: the whiny patient in your trauma clinic wanting more Percocets.

 

[45408]

Thank God we don't have to go to trauma clinic here.