Determining the need for laparotomy in penetrating torso trauma: A prospective study using triple-contrast enhanced abdominopelvic computed tomography

Background: The nontherapeutic laparotomy rate in penetrating abdominal tra uma remains high and the morbidity rate in these cases is approximately 40% . Selective management, rather than mandatory laparotomy, has become a popu lar approach in both stab wounds and gunshot wounds. The advent of spiral t echnology has stimulated a reassessment of the role of computed tomography (CT) in many aspects of trauma care. We prospectively investigated the curr ent utility of triple-contrast CT as a diagnostic tool to facilitate initia l therapeutic management decisions in penetrating torso trauma. Methods: We studied hemodynamically stable patients with penetrating injury to the torso (abdomen, pelvis, flank, back, or lower chest) without defini te indication for laparotomy, admitted to our trauma center during the 1-ye ar period from 7/99 through 6/00. Patients under, went triple-contrast enha nced spiral CT as the initial study. A positive CT scan was defined as any evidence of peritoneal violation (free air or fluid, contrast leak, or visc eral injury). Patients with positive CT, except those with isolated solid v iscus injury, underwent laparotomy. Patients with negative CT were observed . Results: There were 75 consecutive patients studied: mean age 30 years (ran ge 15-85 years); 67 (89%) male; 41 (55%) gunshot wound, 32 (43%) stab wound , 2 (3%) shotgun wound; mean admission systolic blood pressure 141 mm Hg (r ange 95-194 mm Hg); 26 (35%) had positive CT and 49 (65%) had negative CT. In patients with positive CT, 18 (69%) had laparotomy: 15 therapeutic, 2 no ntherapeutic, and I negative. Five patients had isolated hepatic injury and 2 had hepatic and diaphragm injury on CT and all were successfully managed without laparotomy. Of these seven patients, three had angioembolization a nd two had thoracoscopic diaphragm repair. In patients with negative CT, 47 /49 (96%) had successful nonoperative management and 1 had negative laparot omy. The single CT-missed peritoneal violation had a left diaphragm injury at laparotomy. CT accurately predicted whether laparotomy was needed in 71/ 75 (95%) patients. Conclusion: in penetrating torso trauma, triple-contrast abdominopelvic CT can accurately predict need for laparotomy, exclude peritoneal violation, a nd facilitate nonoperative management of hepatic injury. Adjunctive angiogr aphy and investigation for diaphragm injury may be prudent.