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.