The management of penetrating abdominal trauma parallels the evolution of diagnostic modalities. In the 19th century, expectant (observation) management was the approach of choice worldwide. In 1880, Paule Reclese, a French surgeon, advocated supportive care only for penetrating abdominal injuries. Sir William McCormick, chief Army Surgeon during this same period, coined the McCormick aphorism regarding the management of gunshot wounds to the abdomen that stated “if a man undergoes surgery after being shot he dies and lives if left in peace.” Even with a mortality rate that was exceedingly high, such dogma was the standard of care during this era for any penetrating abdominal trauma. This management approach was, unfortunately, applied when President James A. Garfield sustained a gunshot wound to the abdomen. The observational management, called the “Garfield Death Watch,” by the President's medical team resulted in the demise of President Garfield. There were very few voices that challenged this surgical dogma of nonoperative management, with Dr Marion Simms, a prominent Southern surgeon who became president of the American Medical Association, being the most vocal.1 With predictably overwhelming morbidity/mortality associated with these injuries, it became apparent that a more aggressive, interventional approach was needed for penetrating injuries to the abdomen, and, as a result, mandatory exploration, or celiotomy, became the prevailing management option of choice and essentially the standard of care.
Shafton and Nance's landmark articles, which emphasized surgical judgment in the management of penetrating wounds of the abdomen, changed the approach to penetrating abdominal injuries from mandatory celiotomy to a more selective management.2,3 Enhanced diagnostic imaging has greatly assisted in making the nonoperative/selective management a more reliable and acceptable treatment option in penetrating abdominal trauma.
Initial Trauma Management
Before focusing on the specific anatomical region where there is an obvious traumatic injury, an initial assessment of the entire patient is imperative. The concept of initial assessment includes the following components: (1) rapid primary survey, (2) resuscitation, (3) detailed secondary survey (evaluation), and (4) reevaluation. Such an assessment is the cornerstone of the Advanced Trauma Life Support (ATLS) program.4 Integrated into primary and secondary surveys are specific adjuncts. Such adjuncts include the application of electrocardiographic monitoring and the utilization of other monitoring modalities such as arterial blood gas determination, pulse oximetry, the measurement of ventilatory rate and blood pressure, insertion of urinary and/or gastric catheters, and incorporating necessary x-rays and other diagnostic studies, when applicable, such as focused abdominal sonography for trauma (FAST) examination, other diagnostic studies (plain radiography of the spine/chest/pelvis and computed tomography [CT]), and diagnostic peritoneal lavage (DPL). Determining the right diagnostic study depends on the mechanism of injury and the hemodynamic status of the patient.
The focus of the primary survey is to both identify and expeditiously address immediate life-threatening injuries. Only after the primary survey is completed (including the initiation of resuscitation) and hemodynamic stability is addressed, ...