August 1997

Invited Commentary

Author Affiliations

Denver Health Medical Center Denver, Colo

Arch Surg. 1997;132(8):913. doi:10.1001/archsurg.1997.01430320115019

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Diagnostic peritoneal lavage revolutionized the management of patients with blunt abdominal trauma and abdominal stab wounds. Missed injuries and unnecessary laparotomies have become rare. Surgeons have often presumed that all gunshot wounds that penetrate the peritoneal cavity require laparotomy; while not absolutely correct, it is not a bad policy. The difficulty has been to determine whether a bullet has penetrated the peritoneum. This is particularly true for posterior and flank gunshot wounds, where the bullet does not exit, and for through-and-through gunshot wounds that seem to be tangent to the peritoneum. Clinical judgment has been reasonably accurate in identifying patients at risk; radiopaque markers at the entrance and exit sites with anterior or posterior and lateral x-ray films will aid in estimating the trajectory of the missile. Nevertheless, bullets, particularly the low-velocity variety, can be deflected by skin or fascia and actually travel in a curved path, skirting around the

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