Selective nonoperative management of gunshot wounds of the anterior abdomen

Objective: To investigate the role of selective non-operative management of gunshot wounds to the abdomen. Design: A prospective, protocol-guided study including all gunshot wounds of the anterior abdomen. Patients and Methods: The patients were assessed and managed according to a written protocol. Patients with hemodynamic instability or peritonitis or associated spinal cord or head injury or requiring a general anesthetic for an extra- abdominal injury were managed by laparotomy. The rest of the patients were selected for initial nonoperative management with serial physical examinations. Results: During a 16-month period, 309 patients with gunshot wounds of the anterior abdomen were treated. Eighteen patients in extremis (5.8%) underwent an emergency department-performed thoracotomy. Another 185 patients (59.9%) met the criteria for operation and underwent a laparotomy. The incidence of nontherapeutic operations was 2.2%, and that of negative operations was 8.6%. One hundred six patients (34.3%) were selected for observation. Fourteen of the initially observed patients underwent a late operation, but it was therapeutic in only 5. Overall, 92 patients (29.8%) were successfully managed nonoperatively. The overall sensitivity of the initial physical examination was 97.1%. The estimated bullet trajectory was not reliable in identifying the need for operation because of 224 patients with likely peritoneal penetration only 169 (75.4%) had significant injuries requiring surgical repair. Conclusion: In the appropriate environment, many civilian abdominal gunshot wounds can be managed non-operatively.