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A stab wound is a penetrating wound made by anything sharp.

This includes knives, ice picks, screwdrivers, pens, scissors, arrows, or animal horns. Classically, stab wounds are low-velocity penetrating wounds that damage tissue the offending weapon passes through. Severity depends on the location of the stab wound, the manner of stabbing, the depth of penetration, and the type of weapon used. Regardless of the above, the victim almost always experiences pain and bleeding, with some very rare occasions they are unaware something has penetrated their bodies. The most common site of stab wounds is the abdominal area, more on the upper left region than right. Abdominal Stab Wounds In the 19th century, penetrating abdominal wounds were managed nonoperatively. The associated morbidity and mortality rates were greater than 70%. Experience gained during World War I, World War II, and the Korean Conflict led to an aggressive approach of operative management for all penetrating abdominal wounds. This approach resulted in an unacceptably high frequency of laparotomy with findings negative for trauma. In 1960, Shaftan developed an approach of selective conservatism for penetrating abdominal injury and revolutionized abdominal stab wound management.

The optimal method to determine the need for laparotomy has yet to be definitively established. Abdominal stab wound exploration forms part of a strategy developed by surgeons to allow a more selective approach. In asymptomatic patients with stab wounds to the anterior abdomen, methods are widely used to help determine the need for laparotomy: Abdominal stab wound exploration (Subsequent diagnostic peritoneal lavage [DPL], serial clinical evaluation, or both are used to further assess patients in whom an exploration cannot definitively exclude peritoneal penetration.) Serial clinical evaluation

The objective is to reduce the number of patients with trivial or no intraperitoneal injury who are subjected to laparotomy. However, a high degree of diagnostic accuracy must be maintained to limit the frequency of missed injury. A reduction in unnecessary hospitalization is also targeted. Abdominal stab wound exploration is a safe, rapid, and cost-effective tool in the management of asymptomatic patients who present with an anterior abdominal stab wound. This approach has no place in the treatment of patients who are unstable, who have peritonitis, or who have evisceration. Patients with peritonitis and those who are hemodynamically unstable should undergo mandatory laparotomy. More than 25% of anterior abdominal stab wounds do not penetrate the peritoneal cavity. Local wound exploration allows the safe discharge of these patients from the emergency department. Only half of the wounds that penetrate the peritoneum cause damage that requires surgical intervention. The organs most commonly injured with anterior abdominal stab wounds are the small bowel, the liver, and the colon. Missed hollow viscus injuries are associated with significant morbidity and mortality. Many modern physicians advocate abdominal stab wound exploration in asymptomatic patients who present with an anterior abdominal stab wound. An exploration with negative findings is reliable and highly sensitive. Abdominal stab wound exploration combined with further investigation, such as DPL or serial evaluation, achieves acceptable specificity rates. Minimizing the time taken to control ongoing intraperitoneal contamination is critical in penetrating stab wounds, and local exploration is a valuable first step in speeding up the decision-making process. When combined with DPL, abdominal stab wound exploration allows significant injuries that are not immediately apparent to be identified early.

INTRODUCTION

ANATOMY

An appreciation of the anatomy of the anterior abdominal wall at different levels is essential to understanding the procedure.

Osteology
Bone os coxae (TG63) pubis (TG64) Structure Description Notes one of three bones that paired; the os coxae forms the lateral part of the pelvis; it is form the pelvis formed by three fused bones: ischium, ilium & pubis; also known as the innominate bone (Latin, os = bone) an angulated bone the one of three bones that form the os coxae: ilium, ischium, forms the anterior part pubis; its body forms 1/5 of the acetabulum; its symphyseal of the pelvis surface unites with the pubis of the opposite side to form the pubic symphysis; the superior and inferior pubic rami participate in the formation of the obturator foramen pubic crest ridge on the superior border of the superior ramus process at the lateral end of pubic crest attachment of rectus abdominis & pyramidalis mm.

pubic tubercle pecten

attachment point of the medial end of the inguinal ligament

ridge on superior attachment point of the pectineal ligament surface of the superior pubic ramus fan-shaped bone that forms the lateral prominence of the pelvis one of three bones that form the os coxae: ilium, ischium, pubis

ilium (TG63) iliac crest

arching superior edge attachment for abdominal wall muscles of the ilium that forms the rim of the "fan" roughened area along the outer edge of the iliac crest spine at the anterior end of the iliac crest lateral attachment of the inguinal ligament

iliac tubercle anterior superior iliac spine

arcuate line ridge running from inferior boundary of the iliac fossa; marks the plane of anteroinferior to transition from abdominal cavity to pelvic cavity; part of the posterosuperior on the iliopectineal line (Note: this is obviously not the same

inner surface of the ilium

arcuate line as is found on the posterior aspect of the rectus sheath) (Latin, arcuate = bowed)

Muscles
Muscle Origin external lower 8 abdomin ribs al oblique( N249,T G5-04) Inserti Innervatio Action on n linea alba, pubic crest & tubercl e, anterior superio r iliac spine & anterior half of iliac crest flexes and laterally bends the trunk intercostal nerves 711, subcostal, iliohypogas tric and ilioinguinal nerves Artery musculophr enic a., superior epigastric a., intercostal aa. 7-11, subcostal a., lumbar aa., superficial circumflex iliac a., deep circumflex iliac a., superficial epigastric a., inferior epigastric a., superficial external pudendal a. musculophr enic a., superior epigastric a., intercostal aa. 7-11, subcostal a., lumbar aa., superficial circumflex iliac a., deep circumflex iliac a., superficial epigastric a., inferior epigastric a., superficial external pudendal a. musculophr enic a., superior epigastric a., intercostal aa. 7-11, Notes the inguinal ligament is a specialization of the external abdominal oblique aponeurosis; the external spermatic fascia is the external abdominal oblique muscle's contribution to the coverings of the testis and spermatic cord Image

internal abdomin al oblique( N250,T G5-04)

thoraco lumbar fascia, anterior 2/3 of the iliac crest, lateral 2/3 of the inguina l ligamen t

lower 3 or 4 ribs, linea alba, pubic crest and pecten

flexes and laterally bends the trunk

intercostal nerves 711, subcostal, iliohypogas tric and ilioinguinal nerves

anterior fibers of internal abdominal oblique course up and medially, perpendicular to the fibers of external abdominal oblique; the cremaster muscle and fascia is the internal abdominal oblique muscle's contribution to the coverings of the testis and spermatic cord transversus abdominis muscle does not contribute to the coverings of the spermatic cord and testis;

transver sus abdomin is(N251, TG5-05)

lower 6 ribs, thoraco lumbar fascia, anterior 3/4 of

linea alba, pubic crest and pecten

flexes and laterally bends trunk

intercostal nerves 711, subcostal, iliohypogas tric and ilioinguinal

Joints and Ligaments Joint linea alba(N249,N251,N252A,N252 B,TG5-05, TG5-06) Description connects xiphoid with pubic symphysis & crest Significance formed by intermingling of aponeuroses of external abdominal oblique, internal abdominal oblique, & transversus abdominis (Latin, linea alba = white line) the inguinal ligament is a specialization of the inferior border of the external abdominal oblique aponeurosis; it is the site of origin for a part of the internal abdominal oblique muscle and for a part of the transversus abdominis muscle; also known as: Poupart's ligament the lacunar ligament is a flattened portion of the aponeurosis of the external abdominal oblique m. that projects posteriorly from the pubic tubercle; it forms the medial border of the femoral ring and the floor of the inguinal canal at the superficial inguinal ring (Latin, lacuna = a lake or pit)

inguinal the ligament that ligament(N250,N251, TG5-04) connects the anterior superior iliac spine with the pubic tubercle

lacunar ligament(N251,N262, TG508D,TG5-09D)

an extension of the medial end of inguinal ligament which connects the pubic tubercle with the pecten of the pubis

pectineal ligament(N251,N262, TG508D,TG5-09D)

a thickening of the pectineal ligament looks fascia on the pecten like an extension of the lacunar of the pubis ligament along the surface of the pectineal line; also known as Cooper's ligament (note: Cooper's ligaments are also found in the breast)

pubic symphysis (TG6-04)

symphysis

midline joint uniting the pubic bodies (Greek, symphysis = a growing together) also known as: conjoint tendon (Latin, falx = sickle)

falx inguinalis

the inferomedial attachment of internal abdominal oblique and transversus abdominis

Nerves Nerve intercostal n. (N254,N257,TG502) Source ventral primary rami of spinal nerves T1-T11 Branches lateral & anterior cutaneous brs. Motor intercostal muscles; abdominal wall muscles (via T7T11); muscles of the forearm and hand (via T1) Sensory Notes

skin of the chest intercostal n.travels below the and abdomen posterior intercostal a. in the anterolaterally; costal groove skin of the medial side of the upper limb (via T1-T2)

subcostal n. (N254,N257,TG502) iliohypogastric n. (N257,N266,TG502, TG5-38)

ventral primary ramus of T12 lumbar plexus (ventral primary ramus of spinal nerve L1) lumbar plexus

lateral cutaneous br., anterior cutaneous br. lateral and anterior cutaneous brs.

muscles of skin of the the subcostal n. is equivalent the anterolateral to a posterior intercostal n. abdominal abdominal wall found at higher thoracic levels wall muscles of the lower abdominal wall skin of the iliohypogastric n. receives a lower contribution from T12 in abdominal wall, approximately 50% of cases upper hip and upper thigh

ilioinguinal n. (N257,N266,TG5-

anterior muscles of skin of the cutaneous br. the lower lower

ilioinguinal n. courses through the inguinal canal and

02, TG5-38)

(ventral primary ramus of spinal nerve L1)

(also known abdominal abdominal wall superficial inguinal ring as: anterior wall and anterior labial/scrotal scrotum/labium n.) majus

genitofemoral(TG5- lumbar genital & 02) plexus femoral brs. (ventral primary rami of L1-L2)

cremaster m.

skin of anterior scrotum/labia majora & upper medial thigh

lies on psoas major in abdomen; genital br. passes through deep inguinal ring & inguinal canal; brushing thigh elicits elevation of testis via cremasteric reflex

Arteries Artery epigastric, inferior(N25,N253,TG505,TG5-07) Source Branches Supply to Notes inferior epigastric a. anastomoses with the superior epigastric a. within the rectus abdominis m. superficial epigastric a. is one of three superficial arteries that arise from the femoral a. (see also: superficial circumflex iliac a. and superficial external pudendal a.) superior epigastric a. is the direct continuation of the internal thoracic a.; it anastomoses with the inferior epigastric a. within the rectus

external iliac a. cremasteric a. lower rectus abdominis m., pyramidalis m., lower abdominal wall femoral a. cutaneous brs. superficial fascia and skin of the lower abdominal wall

epigastric, superficial(N249, TG502)

epigastric, internal superior(N191, TG4-08, T thoracic a. G5-05)

no named branches

upper rectus abdominis m., upper abdominal wall

abdominis m. intercostal, posterior (TG4-39) highest intercostal (upper 2 intercostal spaces), descending thoracic aorta (3rd-11th intercostal spaces) descending thoracic aorta posterior br., spinal br., anterior br., collateral br., lateral cutaneous br. intercostal muscles, spinal cord and vertebral column, deep back muscles, skin and superficial fascia overlying the intercostal spaces vertebrae, spinal cord; muscles, skin & fascia of the upper abdominal wall posterior intercostal aa. supply the lateral and posterior portions of the intercostal space; anterior intercostal aa. supply the anterior portions of the intercostal spaces subcostal a. is equivalent to a posterior intercostal a., but is named subcostal because it courses inferior to the 12th rib

subcostal (TG4-39)

spinal br., collateral br., lateral cutaneous br.

Topographic Anatomy Structure/Space arcuate line (TG5-05, TG5-07) Description/Boundaries anatomical feature on the inner surface of the abdominal wall; a fascial line in the transverse plane approximately 1/2 of the distance from the umbilicus to the pubic symphysis an area on the anterior abdominal wall between the midclavicular lines, superior to the transpyloric line Significance arcuate line is the point at which the posterior lamina of the rectus sheath ends and transversalis fascia lines the inner surface of the rectus abdominis m. (Latin, arcuate = bowed) one of 9 regions of the abdomen

epigastric region (TG5-01)

hypochondriac region (TG5-01)

an area on the anterior right and left hypochondriac abdominal wall lateral to regions comprise 2 of 9 the midclavicular line, regions of the abdomen superior to the transpyloric line

hypogastric region (TG5-01)

an area on the anterior abdominal wall between the midclavicular lines, inferior to the intertubercular line anterior abdominal wall lateral to midclavicular line, inferior to intertubercular line an imaginary line drawn in the horizontal plane at the upper margin of the iliac crests an imaginary line drawn in the horizontal plane at the upper margin of the iliac tubercles

one of 9 regions of the abdomen; also known as: pubic region

inguinal region (TG5-01)

right and left inguinal regions comprise 2 of 9 regions of the abdomen; also known as: iliac region intercristal line locates the level of the L4 vertebra; a useful landmark in spinal tap procedure intertubercular line locates the level of the L5 vertebra; used with midinguinal and transpyloric lines to divide the abdominal wall into 9 regions linea alba is formed by the combined abdominal muscle aponeuroses; it is used for midline abdominal incisions to avoid major nerves or vessels (Latin, linea alba = white line) right and left lumbar regions comprise 2 of 9 regions of the abdomen; also known as: lateral region

intercristal line

intertubercular line (TG5-01)

linea anatomical feature on the alba(N249,N251,N252A,N252B,TG5- midline of the anterior 05, TG5-06) abdominal wall; an aponeurotic band that extends from the xiphoid process to the pubic symphysis; lumbar region an area on the anterior abdominal wall lateral to the midclavicular line, inferior to transpyloric line, superior to intertubercular line a point on the anterior abdominal wall which is 1/3 of the distance along a line from the right anterior superior iliac spine to the umbilicus

McBurney's point (TG5-15)

McBurney's point is the approximate location of the vermiform appendix; point of tenderness in appendicitis

midaxillary line (TG4-01)

an imaginary vertical line used as a surface landmark passing through the for descriptive purposes middle of the axilla

midclavicular line (TG4-01)

an imaginary vertical line used as a surface landmark passing through the for descriptive purposes midshaft of the clavicle an imaginary vertical line passing through the midpoint of inguinal ligament a region on the anterior abdominal wall defined by the midline and the transumbilical line a region on the anterior abdominal wall defined by the midline and the transumbilical line a region on the anterior abdominal wall defined by the midline and the transumbilical line a region on the anterior abdominal wall defined by the midline and the transumbilical line an anatomical feature of the anterior abdominal wall; the lateral edge of the rectus abdominis m. an imaginary horizontal line 1/2 of the distance between the jugular notch and the pubic crest used with the transpyloric and intertubercular lines to divide the abdomen into 9 regions one of 4 abdominal quadrants

midinguinal line (TG5-01)

quadrant, inferior left (TG5-01)

quadrant, inferior right (TG5-01)

one of 4 abdominal quadrants

quadrant, superior left (TG5-01)

one of 4 abdominal quadrants

quadrant, superior right (TG5-01)

one of 4 abdominal quadrants

semilunar line (TG5-01)

semilunar line is formed by the fused aponeuroses of the abdominal wall mm. at the lateral margin of the rectus sheath transpyloric line is used with the midinguinal and intertubercular lines to divide the abdominal wall into 9 regions; the fundus of the gall bladder lies at the intersection of the transpyloric line with the right 9th costal cartilage; the pylorus of the stomach is located at this plane; a horizontal plane through the transpyloric line locates the

transpyloric line (TG5-01)

level of the L1 vertebra transumbilical line (TG5-01) an imaginary horizontal line through the umbilicus anatomical features in the anterior abdominal wall; folds in the anterior abdominal wall (usually 3) transumbilical line is used with the midline to divide abdomen into 4 quadrants transverse lines are creases that overlie the tendinous intersections in the rectus abdominis m.

transverse lines

umbilical region

a region on the anterior one of 9 regions of the abdominal wall between abdomen the midclavicular lines, inferior to the transpyloric line, superior to the intertubercular line remnant of the attachment of the umbilical cord to the anterior abdominal wall umbilicus marks the approximate level of the L3/L4 intervertebral disc in non-obese individuals (Latin, umbilicus = navel)

umbilicus (TG5-01)

superficial (external) inguinal ring(N387,N249,N259,N260,TG508A, TG5-09A)

slitlike opening between exit from the inguinal canal the diagonal fibers of the aponeurosis of the external oblique, superolateral to the pubic tubercle site of an outpouching of opening into the inguinal the transversalis fascia canal approx. 1.25 cm superior to the middle of the inguinal ligament and lateral to the inferior epigastric a. Anterior - aponeurosis of the ext. oblique;Posterior transversalis fascia; Roof - fibers of the int. oblique and transverse pathway for the spermatic cord in males and round ligament of the uterus in females

deep (internal) inguinal ring(TG508C, TG5-09C)

inguinal canal(N387,N249,N259,N260,TG508A, TG5-09A)

abdominis; Floor superior surface of the inguinal ligament

Viscera/Fascia Organ Location extends laterally from the spinous processes and forms a thin covering for the deep muscles in the thoracic region and a strong, thick covering for muscles in the lumbar region Description Notes

thoracolumbar aponeurosis (fascia) (N174, TG1-13)

(Greek, aponeurosis = forms the a broad, flat nerve; aponeurotic due to the origin of resemblance between latissimus dorsi nerves & tendons)

conjoint tendon (TG5-08D,TG5-09D)

attached to the most also called the falx pubic crest and inferior, medial Inguinalis pecten pubis tendinous fibers of the internal oblique join with the aponeurotic fibers of the deeper transverse abdominis passes through continuous superficial with tail of inguinal ring, epididymis inguinal canal & deep ring to reach posteroinferior surface of bladder where it joins with duct of seminal (Latin, ductus = to lead + deferens = to carry away)

ductus deferens (TG5-08D,TG5-09D)

vesicle to form ejaculatory duct fascia, cremasteric (TG5-08B, TG5-09B) intermediate covering of spermatic cord derived from internal abdominal oblique muscle(Greek, fascia = a band + cremaster = a suspender) derived from aponeurosis of external abdominal oblique muscle(Greek fascia = a band) derived from transversalis fascia thickened laterally as iliotibial tract/band; connected to femur by lateral & medial intermuscular septa attaches to pubic tubercle attaches to pubic crest Scarpa's fascia attaches to it below inguinal ligament

fascia, external spermatic(TG508B, TG5-09B)

outermost covering of spermatic cord

fascia, internal spermatic(TG508C, TG5-09C) fascia lata (N249, TG3-02)

innermost covering of spermatic cord deep fascia forming tubular investment of the thigh

crus, lateral (TG5-08C,TG5-09C)

lateral border of superficial inguinal ring medial border of superficial inguinal ring

(Latin, crus = leg)

crus, medial (TG5-08C,TG5-09C)

(Latin, crus = leg)

rectus tough, sheath(N249,N251,N252A,N252B,TG5- aponeurotic, 05, TG5-06, TG5-06) tendinous sheath of the rectus abdominis muscle round ligament of uterus(N397, TG509A, TG5-09C,TG5-09D) attaches to continuous inner aspect of with ovarian

(Latin, rectus = straight)

a.k.a. ligamentum teres uteri; remnant of

labia majora, ligament traverses superficial inguinal ring, inguinal canal & deep inguinal ring to reach lateral surface of uterus below uterine tube scrotal ligament (TG6-31A) band of connective tissue that attaches the inferior end of the testis to the inner aspect of the scrotal sac sac of haircovered skin containing the testis scrotal ligament is the remnant of the gubernaculum testis

gubernaculum(Latin, teres = round)

scrotum (TG6-31A)

in the scrotum the fatty and membranous layers of the superficial fascia (as seen in the lower abdominal wall) are fused to form the tunica dartos scroti spermatic cord comprises the: ductus deferens, testicular a., pampiniform plexus, deferential a. & v. and genital br. of the genitofemoral n.; coverings of the cord are

spermatic cord (N387, TG5-08A, TG508C, TG5-08D,TG5-10C)

bundle of vessels, nerves and lymphatics ensheathed in tissue layers derived from the abdominal wall; it begins at the deep inguinal ring, passes through the inguinal canal and the

superficial ring to reach the testis in the scrotum

the: internal spermatic fascia (from the transversalis fascia), cremasteric muscle and fascia (from the internal abdominal oblique), external spermatic fascia (from the external abdominal oblique aponeurosis) testis is the male gonad; its exocrine product is sperm which drain to the head of the epididymis via efferent ductules; its endocrine product is testosterone; the testis migrates into the scrotum shortly before birth; it is tethered to the scrotum inferiorly by the scrotal ligament (a remnant of the gubernaculum)

testis (TG6-32B)

an endocrine and exocrine gland contained within the scrotum

tunica dartos scroti (TG6-32B)

a subcutaneous layer of smooth muscle located in the scrotum

fatty and (Greek, dartos = membranous leather) layers of the superficial fascia (as seen in the lower abdominal wall) are fused in the scrotum to form the tunica dartos scroti tunica vaginalis (Latin, vagina = testis has two sheath) layers: visceral and parietal; the visceral layer lies on the anterolateral surface of the testis and epididymis; the parietal layer lines the inner surface of the scrotal sac covers the deep right and left sides surface of the continuous deep to transverse the linea alba abdominis and its aponeurosis hernias can occur here

tunica vaginalis testis (TG6-32B)

a peritoneal sac located anterolateral to the testis

fascia, lines majority transversalis(N251,N252,N259, TG5-07) of abdominal wall

fascia, weak(N251,N252,N259, TG5-07) located in the inguinal triangle Lymphatics Structure superficial inguinal nodes(TG6Location in the superficial fascia parallel Afferents from Efferents to Regions drained

Notes

lymphatic external lower superficial inguinal vessels from iliac nodes; abdominal nodes are 12-20 in the superficial deep wall; external number; they

34)

to the inguinal ligament and along the terminal part of the greater saphenous v.

lower limb, inguinal superficial nodes abdominal wall, perineum

genitalia; superficial parts of the lower limb

become inflamed during infections of the lower limb; they may become inflamed during infections of the external genitalia

Clinical Terms Term appendicitis Definition inflammation (and usually infection) of the appendix, a finger-like projection of the first portion of the colon, that often causes right, lower quadrant abdominal pain, fever and loss of appetite acute or chronic inflammation of the gallbladder; may necessitate a cholecystectomy or gall bladder removal, which is now usually performed laparoscopically. History may reveal pain, fever with chills and nausea with vomiting. McBurney's point lies 1/3rd superiomedially along the line between the right anterior superior iliac spine and the umbilicus; this point marks the usual location of the appendix within the right iliac fossa; McBurney's incision is an oblique incision over this point inferomedially directed, splitting the fibers of the external oblique aponeurosis; fibers of internal abdominal oblique and transversus abdominis muscles are then split to gain access to the appendix incisions made through the fibrous tissue of the linea alba superior and/or inferior to the umbilicus; linea alba usually only transmits small vessels and nerves, therefore these incisions are relatively harmless and bloodless; however, in some patients these incisions may be problematic as they may cut through vascularized fat; also, as it is poorly vascularized, incisions of the linea alba may result in necrosis if the incisions are not brought together well; lower median incisions are often used in female patients to access the female pelvic viscera; median incisions are generally used for exploratory procedures incision through the anterior layer of the rectus sheath which is laterally retracted, and then through the posterior layer and peritoneum to enter the peritoneal cavity provides access to the gallbladder and biliary tract on the right side and the spleen on the left; made parallel to the costal margin but at least 2.5 cm inferior to avoid the 7th and 8th thoracic spinal nerves

cholecystitis

McBurney's point/incision

median incision

paramedian incision

subcostal incision

Pfannenstiel (suprapubic) incision transpyloric plane paresthesia periumbilical emesis anorexia auscultation abdominal guarding rebound tenderness

incision made at the pubic hairline; horizontal with a slight downward convexity; used for most gynecological and obstetrical operations (e.g., for cesarean section and removal of a tubal pregnancy) at the midpoint between the suprasternal notch and the pubic symphysis, at the level of the first lumbar vertebra an abnormal spontaneous sensation such as burning, pricking, and numbness around or near the umbilicus act of vomiting uncontrolled loss of appetite for food the act of listening for sounds within the body, chiefly for ascertaining the condition of the lungs, heart, pleura, abdomen and other organs and for the detection of pregnancy spasm of the anterolateral abdominal muscles and a muscular rigidity usually in response to intraperitoneal inflammation or irritation when pressure is applied to an area of the abdominal wall and then suddenly removed, extreme localized pain is felt by the patient usually in response to intraperitoneal inflammation or irritation an acute inflammation of the lining of the stomach and intestines that can be initiated by food poisoning due to viral or bacterial infection resulting in nausea (+/- emesis), pain, and diarrhea (+/- blood) inflammation of the peritoneum an obstetrical procedure in which an infant, instead of being born vaginally, is surgically removed from the uterus; requires both an incision into the abdominal wall and the wall of the uterus; done in ancient civilizations to save babies after the death of a full-term pregnant mother, hence, the name Caesarian, since it is believed that Caesar was born by this procedure

gastroenteritis peritonitis

Caesarian/Cesarian section

PATHOPHYSIOLOGY

Assessment and Diagnostics

In abdominal stab wounds, the liver, stomach, and intestines are commonly affected. Nurses and doctors in the ER need to thoroughly assess the patient for signs of hemorrhage and hypovolemic shock (blood may be pooling inside the peritoneum especially when the object used to stab has not been removed) a drop in blood pressure, cold, clammy, and paling extremities, diminishing peripheral pulses, tachycardia, tachypnea, diaphoresis, and confusion as well as gastric and intestinal leakage into the peritoneal space. The latter will have to be continually monitored to prevent infection later on. Assess for liver trauma because bile from the liver can leak into the peritoneal cavity causing bile peritonitis. Some cases present peritonitis upon

abdominal examination secondary to stab wounds. The patient may be experiencing fever and signs of inflammation, diffuse tenderness, and abdominal pain. CT-scanning, ultrasonography, abdominal X-ray, peritoneal lavage and DPL can be done to determine the extent of the injury. Laparotomy is indicated for peritoneal penetration, evisceration, and massive bleeding. Liver function tests may reveal increased liver enzyme activity, but may also indicate previously undetected liver disease. Hematology reports may show elevated ESR and WBC count. The former suggests active inflammation while the latter does a possible ruptured spleen. Increased neutrophil count means an active infection. Urinalysis may reveal RBCs from a possible bladder trauma. Arterial blood gas analysis can reveal abnormalities such as metabolic acidosis. Prothrombin time, international normalized ratio, and activated partial thromboplastin time screen for coagulopathy. Serum amylase and lipase levels, when persistently elevated, may indicate injury to the pancreas or bowel.

Indications : Abdominal stab wound exploration is indicated in a patient who presents with a stab wound tothe anterior abdomen, normal vital signs, no signs of peritonitis, and no evidence of evisceration

Stab wound to the anterior abdomen.

Some authors advocate local exploration of wounds only anterior to the midaxillary line. If the wound tracks anteriorly and the end point of the tract is not accurately determined, the patient undergoes diagnostic peritoneal lavage (DPL). If the wound tracks posteriorly and is not obviously superficial, the patient is investigated as for a penetrating flank wound. This often involves a triple-contrast CT scan. Special circumstances involve patients with additional injuries that require operative intervention and cases in which the offending weapon or object is retained. If the patient has additional injuries that require operative intervention, a wound exploration may be performed in the operating room before the other procedure is commenced. If the object has been retained and the surgeon strongly suspects that the peritoneum has not been breached, the object may be removed in the operating room and the wound locally explored. In such cases, the surgeon should be prepared to immediately convert to laparotomy, if necessary.

CONTRAINDICATION: Abdominal stab wound exploration is contraindicated if immediate laparotomy is

indicated. The situations in which immediate laparotomy is indicated include the following: Unstable patient Peritonitis Evisceration (This remains controversial; see paragraph 3 in Selecting Candidates for Laparotomy section.) Blood on rectal examination or blood in nasogastric tube aspirate suggests intraabdominal injury (A low threshold for operative intervention is suggested.)

Other contraindications to abdominal stab wound exploration include the following: Lower chest wounds: Exploration of these wounds carries a high risk of iatrogenic pneumothorax. Flank and back wounds: Some authors advocate exploration of these wounds if they are suspected to be superficial. However, this expectation may be unreliable, and the strong musculature makes the tract difficult to predict or to follow. Local wound exploration may result in further injury or a restart of hemorrhage that had stopped. Patient refusal or uncooperative patient.

Relative contraindications include the following:


Obesity Multiple abdominal stab wounds

ANESTHESIA: Local anesthesia is used. Use liberally, as patient comfort is essential. The procedure requires patient compliance and adequate anesthesia. Hemostasis is also important. The authors suggested preparation is 1% lidocaine hydrochloride (10 mg/mL) with epinephrine 1:200,000 (5 mcg/mL). Other preparations can be used. The maximum dose of lidocaine combined with epinephrine is 7 mg/kg, up to 500 mg. Local exploration in uncooperative patients is best performed in the operating room under general anesthesia. EQUIPTMENT:

Adequate light source or operating lamp Sterile gloves Surgical masks

Surgical caps Protective eyewear Sterile gowns Sterile drapes Cleaning solution (10% povidone iodine [Betadine] or other suitable solution) Lidocaine hydrochloride (1%) with epinephrine Gauze swabs Suture material (See Technique for suggestion of suture material.) Wound dressing Washout irrigant (1 L of 0.9% NaCl) Scalpel Blades, 2 Retractors, 2 Dissecting forceps (toothed and untoothed) Needle holder Scissors (curved dissecting and stitch scissors) Hemostats, 5 Diathermy may be used, if available. Diathermy assists with achieving hemostasis.

Equipment required for an abdominal stab wound exploration.

POSITIONING: Adequate exposure of the abdomen is essential. The patient is positioned supine.

Abdominal stab wound exploration can be effectively performed in the emergency department. TECHNIQUE: Obtain informed consent for the procedure. Gather and check equipment. Position the patient supine and elevate the operating table or stretcher to an appropriate height. Shave and prepare the area around the stab wound. The maintenance of a sterile field is essential.

Local wound exploration requires an operator and an assistant. Both the operator and assistant should scrub, as for any surgical procedure. Liberally infiltrate local anesthetic with epinephrine around the wound, using standard surgical technique. Adequate hemostasis is necessary to facilitate direct visualization of the tract of the wound and to prevent further hemorrhage in wounds that penetrate the peritoneum. Also, the wound may need to be extended, which may result in further bleeding. For both these reasons, lidocaine with epinephrine is preferred as the anesthetic agent. Achieving poor hemostasis has been associated with subsequent false-positive diagnostic peritoneal lavage (DPL) results and unnecessary laparotomy. Do not exceed the maximum dose of lidocaine. Most stab wounds are small and need to be extended with a scalpel to allow visualization of the underlying fascia. To optimize subsequent wound healing and cosmetic result, midline wounds should be extended vertically and lateral wounds should be extended horizontally along natural skin lines. The required length of extension is determined by the depth of subcutaneous fat. Wounds heal from the sides rather than the ends; hence, lengthening the wound does not affect the repair process. The assistant uses the retractors to visualize the depths of the wound. Diathermy is a useful aid in the maintenance of hemostasis. Appreciation of the anatomy of the anterior abdominal wall at different levels is essential. The procedure cannot be safely completed if you do not know which layer you are exploring and what lies immediately beneath it.

Further explore the wound under direct vision, taking care to identify the fascial layers and the musculature. Breach of the anterior rectus fascia requires extension of the fascial defect. This can be achieved with a scalpel, with dissecting scissors, or with diathermy. This allows inspection of the underlying muscle and the posterior layer of the rectus sheath. There is no posterior layer of rectus sheath below the arcuate line, but the rectus fascial defect is still extended to allow inspection of the underlying muscle and transversalis fascia. The goal of exploration is to determine the end point of the tract. This is not always easy, especially in more lateral wounds. The fascial planes are more difficult to identify laterally. Following the tract through muscle can be challenging. If the posterior rectus fascia or transversalis fascia is adequately visualized and is intact, the patient does not have an intra-abdominal injury. After adequate wound care, the patient can be discharged from the emergency department.

Nonpenetrating wound: External oblique muscle intact in base of wound.

If the posterior rectus fascia or the transversalis fascia is penetrated, the local wound exploration findings are positive. The frequency of peritoneal injury is high in patients with positive findings. Assessing the integrity of the parietal peritoneum itself is technically difficult, and exploring at this level risks converting a nonpenetrating wound into a wound that breaches the peritoneum. If breach of the peritoneum cannot be confidently excluded, the patient requires further assessment and investigation.

Penetrating

midline

wound.

Penetrating lateral wound. (The exploration of this wound clearly determined that the stomach had been penetrated. Therefore, the patient did not require diagnostic peritoneal lavage [DPL], as laparotomy was already indicated. During laparotomy, a hole in the stomach and 2 holes in the small bowel were repaired. The patient had

an

uneventful

postoperative

course

and

was

discharged

from

the

hospital

days

later.

Patients who require further investigation usually undergo DPL. The wound should be temporarily packed with dry gauze and a sterile dressing until the lavage is completed. This packing helps prevent further hemorrhage into the peritoneum from the wound. A DPL with positive findings further delineates patients who are more likely to have an intra-abdominal injury that requires surgical intervention. The stomach and bladder must be decompressed before DPL. The wound is then thoroughly irrigated with saline and closed in layers. Hemostasis and sound surgical technique prevent subsequent wound complications. The sheath is closed with strong absorbable suture (PDS 0 or Vicryl 0). Muscle need only be repaired if the defect is large. If muscle repair is necessary, interrupted absorbable sutures (Vicryl 2-0) are used. In individuals who are obese, the subcutaneous fat can be approximated with absorbable sutures. The wound edges rarely require debridement before skin closure. The skin is closed with skin clips, interrupted nonabsorbable sutures, or continuous subcuticular sutures. Some authors have advocated suturing the surgical extension wound but leaving the stab wound to heal by secondary intention to minimize the risk of infection. Unless the wound is markedly contaminated, this is unnecessary. Patients with an exploration with negative findings may be discharged home. Antibiotics are not required. Routine surgical wound care is provided.

Nursing Diagnosis Acute pain related to abdominal wound Deficient fluid volume related to active loss of blood Impaired tissue integrity related to penetrating abdominal wound Risk for infection related to introduction of a foreign body into the abdomen Nursing Intervention Assist patient onto ER bed. Insert two large-bore intravenous (I.V.) lines to infuse 0.9% sodium chloride or lactated Ringer's solution, according to facility protocol. Control the patient's pain without sedating him, so you can continue to assess his injuries and ask him questions. Generally, I.V. analgesics such as morphine can adequately manage pain without sedation.

Insert an indwelling urinary catheter, unless you suspect a urinary tract injury. An indwelling urinary catheter is inserted to minimize urine leakage into the abdomen or supporting tissues. If a urethral injury is suspected, consider catheterizing the bladder through a suprapubic approach. Frequently observe for and quantify the degree of hematuria with an indwelling urinary catheter. The initial urine obtained may have been in the bladder prior to the traumatic event. If hematuria is noted, this may be because of the placement of the urinary catheter. Measure and discard the initial urine specimen and test the subsequent urine specimen for the presence of blood. Suspected injury to the urethra (i.e., gross blood) is a contraindication to catheterization through the urethra. Draw blood specimens stat for baseline lab values. Insert a gastric tube to decompress the patient's stomach, prevent aspiration, and minimize leakage of gastric contents and contamination of the abdominal cavity. This also gives you access to gastric contents to test for blood. Administer tetanus prophylaxis and antibiotics as ordered. Cover open abdominal wounds with a sterile dressing. If evisceration of abdominal contents has occurred, place a sterile, moist dressing over the injury. Stabilize impaled objects Administer antibiotics, as prescribed. Leakage of gastric and bowel contents will result in peritonitis and possibly sepsis. Administer analgesics, as prescribed. Prepare the patient for operative intervention, hospital admission, or transfer, as indicated. Evaluation and Ongoing Assessment Refer to Initial Assessment, for a description of the ongoing evaluation of the patient's airway, breathing, circulation, and disability. Additional evaluations include: Monitoring cardiovascular status for changes suggestive of hypovolemic shock Reassessing the abdomen frequently and thoroughly to detect subtle changes Monitoring urinary elimination for changes suggestive of hypovolemic shock

STAB WOUND

Submitted to: Mr. Lester Palacios R.N. Clinical Instructor UPHSL-Bian Submitted by: Mary Anne E. Elepao

BSN 4 F, Group 22