UROGENITAL TRAUMA

Transpelvic gunshot wounds: routine laparotomy or selective management?
Velmahos GC, Demetriades D, Cornwell EE 3rd
World J Surg. 1998; 22: 1034-8.

• Mandatory exploration is the standard method for managing patients with gunshot wounds to the abdomen and back. This policy is associated with a high incidence of unnecessary laparotomies and significant morbidity. Reports from our center have shown that a policy of selective management, based on clinical findings, is safe in such patients. Patients with bullet trajectories that carry a high likelihood for intraabdominal organ injury may constitute a subgroup at particular risk. The need for routine or selective exploration in similar patients must be assessed. Therefore we decided to analyze patients with transpelvic gunshot wounds. The objective of the study was to examine if a policy of selective management of patients with transpelvic gunshot wounds is safe. 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 that dictated laparotomy in the presence of significant clinical findings (peritoneal signs, hemodynamic instability, gross hematuria, rectal bleeding) and observation in the absence of the above. Additional diagnostic workup was performed only in appropriate cases rather than routinely. Nineteen (51.3%) patients were immediately operated on the basis of clinical findings. Sixteen of these laparotomies were therapeutic. Eighteen (48.6%) patients were initially observed. Subsequently, three of them underwent exploration for development of abdominal tenderness. All three laparotomies were nontherapeutic. The remaining 15 (40.5%) patients were successfully managed nonoperatively. There were no delays in diagnosis or missed injuries. Clinical examination had a sensitivity of 100% and specificity of 71.4% in detecting the need for laparotomy. A policy of selective management is thus safe, even for patients who suffer gunshot wounds with a high likelihood for intraabdominal organ injury. Clinical examination, supported by additional studies in appropriate cases, is the main method of selecting patients for operation or nonoperative treatment.
  
  
• Editorial Comment
  While the first paper deals with selective management of gunshot wounds to the back and abdomen, this paper centers on gunshot wounds to the pelvis. It is a much smaller study of only 37 patients, and as in the 2001 study cited previously, patients only had laparotomy if they had peritoneal signs, hemodynamic instability, gross hematuria or rectal bleeding. 51% got immediate operation and 49% were observed. 3/18 (17%) of those observed required exploration for peritoneal signs, but all 3 were nontherapeutic! So, once again this group turns what we know about trauma on its head. If you pick the correct physical exam signs to trigger surgery, you can avoid unnecessary laparotomy in about half of patients with gunshot to the pelvis. I must repeat, I think this is amazing. I think data such as this can give us the strength to “sin boldly” in our own world of genitourinary trauma, and determine which of our signs and symptoms predict who will not need operating.

Dr. Richard A. Santucci
Assistant Professor of Urology
Wayne State University
Detroit, Michigan, USA