DISCUSSION:
Violence and bodily injury can result due to many factors and causes. We
are in a world of
Stab wounds are most commonly homicidal, followed by suicidal and
accidental. (1) Alcohol intoxication makes the clinical evaluation of
such patients more difficult. (2) Literature shows the incidence of
stabbing to be higher in young men, most to the thoracic spine (61%)
and least to the lumbar spine (7%). (3)
Direct central back stabbings rarely produce serious injuries to the
spinal cord and the retroperitoneal structures due to the presence of
muscles and vertebras, with the spinous and transverse processes
deflecting the blows laterally. There is a lot of debate regarding the
management of stab wounds to the back and flank. Mainly as they can pose
a special problem due to the difficulty in clinically evaluating the
retroperitoneal organs with physical exam and FAST. In a clinically
stable patient, non-operative management can be tried with the use of
triple contrast CT scan as a tool to ensure no serious injury is
present. (4)
Digital exploration of the wound under local anesthesia can be done for
assessment of peritoneal breach but is not useful for evaluation of
intra-abdominal injuries. The local wound exploration must be
technically adequate, sufficient exposure of the wound is required to
follow the tract of the stab. (5) Some trauma centers advocate mandatory
laparotomy for all penetrating stab wounds to the abdomen. (6)
However, in case of intestinal eviscerations the treatment includes
prompt resuscitation, exclusion of other injuries, with an early and
careful laparotomy allowing uneventful recovery a possibility. Immediate
laparotomy is necessary in patients with hemodynamic instability,
presence of peritonitis, evisceration, or impalement injuries. (7) The
policy of mandatory laparotomy leads to many negative laparotomies, up
to 53%. (8)
Mandatory laparotomy was considered the standard of care for abdominal
stab wounds and gunshot wounds till the 1960s. The dictum of mandatory
laparotomy for anterior abdomen wall stab wounds was challenged and a
policy of “selective conservatism” was used, in which management was
based primarily on clinical evaluation. (9) Also since there are
significant consequences of unnecessary laparotomy in terms of
morbidity, hospital stay, and costs and even mortality.
There were many tests aimed at determining whether the peritoneum had
been entered, including sinography (10) and local wound exploration.
(11)