Guidelines for the management of haemodynamically stable patients with stab wounds to the anterior abdomen

Dr Sugrue and co-workers1 have described practice guidelines to improve the delivery of care for above-mentioned group of trauma patients. With the help of a multidisciplinary working party, evidence-based guidelines were developed; all data were graded by level of evidence as outlined by the Australian National Health and Medical Research Council. Apart from the clear and wellaccepted indications for urgent laparotomy in patients with abdominal stab wounds, the guidelines focus on the management of the stable patient without any urgent indication for laparotomy. The presented concept in this subgroup of patients indicates local wound exploration if the patient is thin and compliant, otherwise a laparoscopy should be carried out. It is further stated that abdominal computed tomography (CT) scan is not indicated. The concept of selective non-operative management in these patients does not have a role in the presented guidelines. In principal, I would like to state that it is very important to have clinical practice guidelines in place, even more as Australian trauma centres are confronted with a very low volume of penetrating trauma. However, I would like to comment on a few points in regards to the presented concept. (1) Local wound exploration (LWE) is discussed very controversial, as stated by Dr Bautz in his report on the same injuries in South Africa.2 The incidence of missed penetrations was so high that LWE was banned by most centres as diagnostic procedure. The recently released guidelines for non-operative management of penetrating abdominal trauma by the Eastern Association for Surgery of Trauma (EAST) do not see LWE as part of the protocol anymore.3 Here the literature review started from 1991 onwards, whereas most of the cited references in support of LWE in the article by Sugrue and co-workers were published in the 1980s. (2) In contrast to what is stated in the article by Surgue and coworkers, I think it is well documented in the literature that CT scanning plays an important role in the selective non-operative management of penetrating abdominal injuries. Just as an example, Shanmuganathan and co-workers presented a prospective series of 200 patients with penetrating torso injuries.4 The initial evaluation with triple-contrast CT in stable patients showed a sensitivity of 97%, a specificity of 98 and 98% accuracy for peritoneal evaluation. Two patients with a negative CT developed clinical signs during observation and underwent therapeutic laparotomy. (3) The role of laparoscopy as diagnostic tool in abdominal stab wound is also not very clear, especially if a concept of serial physical examination combined with triple-contrast CT scanning is available. Interestingly, the EAST guidelines do not see a routine role for laparoscopy in the group of patients that is suitable for selective non-operative management. Laparoscopy seems to have a limited role in the diagnosis and eventual repair of diaphragmatic injuries in thoracoabdominal stab wounds, similar as outlined by Dr Bautz in his report. Based on these arguments, including the EAST guidelines, I think there is a very strong role for selective non-operative management of stable patients with abdominal stab wounds, including triple-contrast CT scanning and serial abdominal examination. Local wound exploration should not be carried out routinely anymore and the role of laparoscopy should be limited to suspected diaphragmatic injuries in this group of patients.