LWE-local wound exploration that demonstrates a violation of peritoneum is an important positive finding , but not a conclusive evidence that a solid or hollow organ(bowel/mesentry)injury has taken place.where as negative or inadequate LWE doers not exclude these injuries.pts who are not candidates for immediate OR in absence of signs of hemodynamic instability,or peritoneal irritation or evisceration-all factors like time elapsed since injury, nature of weapon(lenght,width,shape wound site/region of injury,proximity of part below wound, musculature, obesity,mental status may be all taken into account or further tests may be needed to include or exclude injury but reliable SPE serial physical examinations is hall mark of the management in selective conservative management of penetrating abdominal trauma.

Penetrating Stab Wounds to the Abdomen: Use of Serial US and Contrast-enhanced CT in Stable Patients1 1. Jorge A. Soto, MD etalAugust 2001 Radiology, 220, 365-371. results suggest that the use of helical CT performed with oral, intravenous, and rectal contrast material and serial US, in combination, may help guide treatment for patients who have penetrating stab wounds to the abdomen but who do not have an indication for immediate laparotomy. The length of hospital stay for many of these patients may be decreased by using the imaging algorithm described herein. However, this algorithm should be proved in a larger patient population. These imaging techniques may also prove useful for evaluating patients in whom clinical examination is difficult, such as those with prior surgical interventions or incisional hernias and those with an altered level of consciousnes

ATTENTION_ the abstracts/summaries/conclusions of references quoted here are very useful for further reading on this subjects ,to promote or generate academic discussions,ans for ease to find relevant articles on this topic to help practitioners to choose the article for further reading and in noway are replacement for full articles which are copy- righted, and any one for further reading interest should go these journals so as not to get confused,we recommend full view of article,contact journal for that.the author declares having no business or financial interest

Practice Management Guidelines for Nonoperative Management of Penetrating Abdominal Trauma Eastern Association for the Surgery of Trauma: Practice Management Guideline Committee John J. Como, MD Faran Bokhari, MD William C. Chiu, MD Therese M. Duane, MD Michele R. Holevar, MD Margaret A. Tandoh, MD April 11, 2007Eastern Association for the Surgery of Trauma RECOMMENDATIONS: © Copyright 2007 – Eastern Association for the Surgery of Trauma a. Level 1 There is insufficient data to support a Level 1 recommendation on this topic b. Level 2 i. Patients who are hemodynamically unstable or who have diffuse abdominal tenderness after penetrating abdominal trauma should be taken emergently for laparotomy. ii. Patients with an unreliable clinical examination (i.e., severe head injury, spinal cord injury, severe intoxication, or need for sedation or intubation) should be explored or further investigation done to determine if there is intraperitoneal injury. iii. Others may be selected for initial observation. In these patients: 1. Triple-contrast (oral, intravenous, and rectal contrast) abdominopelvic computed tomography (CT) should be strongly considered as a diagnostic tool to facilitate initial management decisions as this test can accurately predict the need for laparotomy. 2. Serial examinations should be performed, as physical examination is reliable in detecting significant injuries after penetrating trauma to the abdomen. Patients requiring delayed laparotomy will develop abdominal signs. © Copyright 2007 – Eastern Association for the Surgery of Trauma 3. If signs of peritonitis develop, laparotomy should be performed. 4. If there is an unexplained drop in blood pressure or hematocrit, further investigation is warranted. c. Level 3 i. The vast majority of patients with penetrating abdominal trauma managed nonoperatively may be discharged after twenty-four hours of observation in the presence of a reliable abdominal examination and minimal to no abdominal tenderness. ii. Patients with penetrating injury to the right upper quadrant of the abdomen with injury to the right lung, right diaphragm, and liver may be safely observed in the presence of stable vital signs, reliable examination and minimal to no abdominal tenderness. iii. Angiography and investigation for and treatment of diaphragm injury may be necessary as adjuncts to initial nonoperative management of penetrating abdominal trauma. iv. Mandatory exploration for all penetrating renal trauma is not necessary. © Copyright 2007 – Eastern Association for the Surgery of Trauma IV. SCIENTIFIC FOUNDATIONS Indications for laparotomy: Patients who are hemodynamically unstable or who have diffuse abdominal tenderness after penetrating abdominal trauma should be taken emergently for laparotomy. Patients with an unreliable clinical examination (i.e., severe head injury, spinal cord injury, severe intoxication, or need for sedation or intubation) should be explored or further investigation done to determine if there is intraperitoneal injury. If signs of peritonitis develop, laparotomy should be performed. If there is an unexplained drop in blood pressure or hematocrit, further investigation is warranted. These recommendations are reasonably justifiable by available scientific evidence is strongly supported by expert opinion; therefore a Level 2 recommendation is appropriate. In general, patients fitting the above profile were excluded from nonoperative management and were not included in the studies evaluated by this committee. Physical examination: In patients selected for nonoperative management, serial examinations should be performed, as physical examination is reliable in detecting significant injuries after penetrating trauma to the abdomen. Patients requiring delayed laparotomy will develop abdominal signs. A number of Class II articles support this recommendation. Applicability: Prudent judgment should be exercised in deciding to apply nonoperative management of penetrating abdominal trauma in a particular institution, as the above recommendations are generally from large academic hospitals with in-house senior level clinicians with extensive experience in trauma, in which careful observation and close monitoring are possible. It may not be applicable to medical centers with fewer trauma resources. These patients need to be examined frequently, preferably by the same surgeon. Pain medications should be given with caution, if at all. If a patient should develop abdominal pain or hemodynamic instability, nonoperative management should be abandoned and the patient taken to surgery emergently.

ichelle da Silva1, Pradeep H. Navsaria1 Contact Information, Sorin Edu1 and Andrew J. Nicol1 world jr of surgery 2009 (1) Trauma Center, Groote Schuur Hospital and Faculty of Health Sciences, University of Cape Town, Anzio Road, Observatory, Cape Town, 7925, South Africa Published online: 21 November 2008 Abstract Background Abdominal stab wounds with evisceration remain an indication for emergency laparotomy. The purpose of this study was validate a policy of mandatory laparotomy for organ evisceration and a policy of selective nonoperative management with serial physical abdominal examination for omentum evisceration. Conclusions Evisceration should continue to prompt operative intervention. An exception can be made to a select few patients with omentum evisceration with benign abdominal findings.

CLINICAL MANAGEMENT OF PENETRATING TRAUMA Karim Brohi, M.D.;Penetrating Abdominal Trauma Patients who present with penetrating abdominal trauma and who are in shock, have generalised peritonitis, or evisceration of abdominal contents should have an immediate laparotomy. In some patients, there are multiple stab wounds or gunshot wounds with unknown trajectories. In these cases, when the patient is in shock, ultrasound or diagnostic peritoneal lavage may be helpful in identifying the abdomen as a site of major haemorrhage. In the haemodynamically normal patient, options for investigation include physical exam and haemodynamic observation, diagnostic peritoneal lavage (DPL) and computed tomography (CT). Decisions on further investigation will vary depending on the available resources, the presence of other injuries and the conscious level of the patient. CT may exclude peritoneal penetration and allow patients to be discharged immediately. However when there is peritoneal penetration, the diagnosis of hollow organ injury is currently less reliable by CT, and further investigation or observation is required. Diagnostic peritoneal lavage is a very sensitive but non-specific test for abdominal penetration. However the non-therapeutic rate for DPL is high, as many abnormal findings are accounted for by omental & mesenteric injuries, or solid organ injury that requires no intervention. Clinical observation has a high sensitivity and specificity for the management of penetrating abdominal trauma. However it is labour and resource intensive and may not be appropriate for all institutions. Additionally, it relies on the patient being awake, alert & cooperative, with no spinal cord injury or other ‘distracting’ injury. Caution should always be exercised when dealing with thoracoabdominal or pelvic trauma, flank and back wounds, as the diaphragm and retroperitoneal structures are difficult to assess and injuries are easily missed.