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February 1997

Selective Nonoperative Management of Gunshot Wounds of the Anterior Abdomen

Arch Surg. 1997;132(2):178-183. doi:10.1001/archsurg.1997.01430260076017

Objective:  To investigate the role of selective nonoperative management of gunshot wounds to the abdomen.

Design:  A prospective, protocol-guided study including all gunshot wounds of the anterior abdomen.

Patients and Methods:  The patients were assessed and managed according to a written protocol. Patients with hemodynamic instability or peritonitis or associated spinal cord or head injury or requiring a general anesthetic for an extra-abdominal injury were managed by laparotomy. The rest 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 department—performed thoracotomy. Another 185 patients (59.9%) met the criteria for operation and underwent a laparotomy. The incidence of nontherapeutic operations was 2.2%, and that of negative operations was 8.6%. One 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 successfully managed nonoperatively. The overall sensitivity of the initial physical 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 injuries requiring surgical repair.

Conclusion:  In the appropriate environment, many civilian abdominal gunshot wounds can be managed nonoperatively.Arch Surg 1997;132:178-183