الفهرس 
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Abstract
Summary
Penetrating abdominal trauma (PAT) is commonly seen in emergency departments and poses a significant challenge to trauma surgeons. The most important decision that must be obtained during the management of these traumas is which patient must be operated on.
In the past few decades, there has been a major shift from operative to selective non-operative management of penetrating abdominal trauma.
Although there is no doubt that continued haemodynamic instability or signs of peritoneal irritation warrant immediate laparotomy, if the patient is haemodynamically stable and has no urgent indications for laparotomy, the course of action can be controversial, involving the decision on whether to perform a laparotomy or undertake conservative management.
In the past, we routinely did an exploratory laparotomy in any patients with penetrating wounds of the abdomen, even who had no obvious clinical indications for exploratory laparotomy (normal vital signs, no bowel evisceration, no peritoneal signs and no evidence of gastrointestinal bleeding). Which resulted in a relative high rate of unnecessary laparotomy.
Although the modern management of PAT has decreased non-therapeutic laparotomy by using selective non-operative management protocols, immediate recognition of intra-abdominal injury still poses a significant clinical challenge, particularly in patients who have minimal
or no symptoms and have no obvious indications for emergent laparotomy. The most important questions are which diagnostic procedures will be used, which patient requires laparotomy, and when to operate the patient.
The ultimate goal of ”selective conservatism” is to minimize the incidence of negative exploration of the abdomen without increasing morbidity from missed or delayed recognition of serious injuries.
The of objective of our study was to evaluate the role of selective conservatism in management of penetrating abdominal trauma, as regard the rate of unnecessary laparotomy, missed or delayed injuries, complications and hospital stay.
from our study we conclude this management protocol for patient with penetrating abdominal trauma;
Immediate laparotomy for patients with:
1- Haemodynamic instability (systolic blood pressure <90mmHg and positive FAST).
2- Peritonitis or significant tenderness remote from the wound site.
3- Bowel evisceration.
4- Proctorrhagia.
5- Haematemesis.
6- Retained stabbing implement.
DPL for Patients with no signs that mandate immediate exploration:
If positive: laparotomy will be done.
If negative: the patient is observed for 48 hour and Pelviabdominal CT will be done for selected cases (patients with haematuria, penetrating wound to the back and flank).
- If the patient develop peritonitis or haemodynamic instability or has CT criteria indicate exploration: the patient underwent delayed laparotomy.
- If the patients are well the following day: they start a normal diet, and are discharged once diet was tolerated and have completed the observation period.
Penetrating Abdominal Trauma
Unstable or Peritonitis
Stable with no peritonitis
Immediate Laparotomy
DPL
Positive
Laparotomy
Negative
Serial physical examination
And Pelviabdominal CT in selected cases
Develop peritonitis or haemodynamic instability or positive CT
No
Yes
Laparotomy
Discharge
Diagnostic peritoneal lavage may be investigated as a screening tool for peritoneal penetration to minimize the unnecessary hospital admissions and improve immediate identification of hollow viscus injury. Also, laparoscopy will have a major impact in the management algorithm of penetrating abdominal trauma.
Selective management of penetrating abdominal trauma based on this protocol is safe, applicable method and reduces significantly the rate of unnecessary laparotomy and hospital stay, but with adequate coverage.