Mandatory exploration is the standard method for managing patients wit
h gunshot wounds to the abdomen and hack. This policy is associated wi
th a high incidence of unnecessary laparotomies and significant morbid
ity. Reports from our center have shown that a policy of selective man
agement, based on clinical findings, is safe in such patients. Patient
s with bullet trajectories that carry a high likelihood for intraabdom
inal organ injury may constitute a subgroup at particular risk. The ne
ed for routine or selective exploration in similar patients must be as
sessed. Therefore we decided to analyze patients with transpelvic guns
hot wounds. The objective of the study was to examine if a policy of s
elective management of patients with transpelvic gunshot wounds is saf
e. This prospective study was conducted at an academic level I trauma
center. We admitted 37 patients with transpelvic gunshot wounds over a
12-month period. All patients were managed according to a protocol th
at dictated laparotomy in the presence of significant clinical finding
s (peritoneal signs, hemodynamic instability, gross hematuria, rectal
bleeding) and observation in the absence of the above. Additional diag
nostic workup was performed only in appropriate cases rather than rout
inely. Nineteen (51.3%) patients were immediately operated on the basi
s of clinical findings. Sixteen of these laparotomies were therapeutic
. Eighteen (48.6%) patients were initially observed, Subsequently, thr
ee of them underwent exploration for development of abdominal tenderne
ss. All three laparotomies were nontherapeutic. The remaining 15 (40.5
%) patients were successfully managed nonoperatively. There were no de
lays in diagnosis or missed injuries, Clinical examination had a sensi
tivity of 100% and specificity of 71.4% in detecting the need for lapa
rotomy. A policy of selective management is thus safe, even for patien
ts who suffer gunshot wounds with a high likelihood for intraabdominal
organ injury, Clinical examination, supported by additional studies i
n appropriate cases, is the main method of selecting patients for oper
ation or nonoperative treatment.