SELECTIVE NONOPERATIVE MANAGEMENT OF GUNSHOT WOUNDS OF THE ANTERIOR ABDOMEN

Objective: To investigate the role of selective nonoperative managemen t of gunshot wounds to the abdomen. Design: A prospective, protocol-gu ided study including all gunshot wounds of the anterior abdomen. Patie nts and Methods: The patients were assessed and managed according to a written protocol. Patients with hemodynamic instability or peritoniti s or associated spinal cord or head injury or requiring a general anes thetic for an extra-abdominal injury were managed by laparotomy. The r est 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 departmen t-performed thoracotomy. Another 185 patients (59.9%) met the criteria for operation and underwent a laparotomy. The incidence of nontherape utic operations was 2.2%, and that of negative operations was 8.6%. On e 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 successf ully managed nonoperatively. The overall sensitivity of the initial ph ysical 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 i njuries requiring surgical repair. Conclusion: In the appropriate envi ronment, many civilian abdominal gunshot wounds can be managed nonoper atively.