The disadvantage of selective management rests in its more complex algorithm than that associated with surgical exploration. Patients suitable for nonoperative treatment must be identified and separated from those requiring emergent neck exploration, the appropriate diagnostic evaluations and their limitations must be determined and patients must be carefully observed for evidence of injuries missed on initial evaluation. Potential diagnostic strategies range from physical examination alone to the exhaustive use of diagnostic studies, such as angiography, endoscopy and CT scanning. Much as a standard and explicit operative approach to neck exploration is employed, so too should be the approach to selective nonoperative management. Indications for mandatory exploration must be defined, indications for the use of individual diagnostic modalities should be defined and adhered to, and the indications for observation without investigations should be determined and applied.
Most centres employing selective nonoperative management do so under explicit guidelines.
Finally, an approach including selective nonoperative management must ensure that death and major morbidity that may have been avoided by earlier operation are absolutely nonexistent. The infrequency of major life-threatening injury in patients without indication for immediate exploration limits the interpretation of these small numbers. Irish and colleagues have not statistically proven the safety of selective management in the low-volume setting. A single missed injury, leading to major morbidity or death would greatly alter the conclusions derived from this study. In summary, Irish and colleagues have demonstrated that selective management, in their hands, is safe and relatively more efficient than surgical exploration for penetrating neck injuries.