- Email: [email protected]
Sinography of abdominal stab wounds
Sinography of Abdominal Stab Wounds C. TRIMBLE, M.D., Denver, Colorado M. POMERANTZ, lM.D., Denver, Colorado B. EISEMAN, M.D., Denver, Colorado
Abdominal stab wounds traditionally demand prompt surgical exploration on the suspicion that they penetrate the peritoneal cavity and perforate a vessel or viscus [.Z]. The slight risk of exploration is outweighed by the danger of overlooking visceral injury. The fact remains that the results of 36 to 50 per cent of such explorations are negative [Z-6], resulting in a significant attendant economic loss. To minimize the incidence of such needless laparotomies, there are those who observe patients with abdominal stab wounds and perform laparotomy only when clinical appraisal so warrants [2]. In 1965, Cornell, Ebert, and Zuidema [7] suggested that radiographic evidence of perforation of the abdominal wall by sinography might aid in determining the indication for laparotomy. This paper reports our initial experience with this technic. Technic After steriIe skin preparation and draping, the wound is infiltrated with 5 to 10 cc. of local anesthetic. A No. 12-18 French rubber catheter is placed in the stab wound with its tip immediately underlying the skin. Care is taken not to probe or direet the catheter into the wound tract. A purse-string suture of heavy silk is secured in the wound around the catheter. A minimum of 50 cc. of meglumine diatrizoate (Renografina 60 per cent) is manually injected from a 50 cc. syringe into the catheter, using sufficient force to cause an everting bulge of the skin. Thereafter, the catheter is clamped and anteroposterior, lateral, and oblique roentgenograms of the abdomen are promptly taken. We add no dye to the radiopaque medium.
From the Department Denver, Colorado.
426
of
Surgery,
Denver
General
Hospital.
Indications Any patient with a stab wound of the trunk which may potentially penetrate the peritoneum is a candidate for sinography. It is particularly helpful in avoiding unnecessary exploration when multiple trauma adds to the operative risk. It is not indicated in patients who have protruding viscus, peritonitis, or shock, and who therefore obviously require laparotomy. As with any laboratory adjunct, clinical indications override other considerations. interpretation
of Roentgenograms
In the absence of peritoneal penetration, the contrast medium diffuses along extraperitoneal soft tissue planes. (Fig. 1.) When there is violation of the peritoneal cavity, intra-abdominal structures characteristically are outlined by contrast inedium. (Fig. 2 and 3.) Occasionally, intrathoracic structures may be outlined if the chest has been entered. (Fig. 4 and 5.) For adequate interpretation, multiple views are necessary and when studies are inconclusive, a repeat injection may be helpful. Multiple stab wounds should be examined, but it is best that each tract be individually injected and then x-rayed to eliminate superimposition of contrast media, which may confuse interpretation. Ready absorption of the contrast medium usually occurs from the peritoneal lining or soft tissues, and the renal collecting systems may be visualized on delayed films. Clinical Material and Results Since July 1, 1967, sinography has been routinely employed for abdominal stab wounds at the Denver General Hospital. The results The
American
Journal
of Surgery
Sinography
of Abdominal
Stab Wounds
1
Fig. 1. Negative sinogram. The contrast medium is in the soft tissues wall. Further oblique films localized this extraperitoneally. Fig. 2. Penetrating stab wound of left upper quadrant spleen and loops of bowel.
with contrast
3 Fig. 3.
Positive
sinogram
False-negative Fig. 4. men; contrast medium
Vol. 117, March 1969
of the abdominal
medium
outlining
the
4 with contrast
medium
diffused throughout
sinogram. A wound at the leftcostal margin outlines only intrathoracic pleural surfaces.
the entire entered
abdominal
cavity.
the chest as well as the abdo-
427
Trimble,
Pomerantz,
and Eiseman
hundred needless laparotomies per year. The economic impact in terms of cost to the patient and the hospital is obvious. Patients with negative results on sinography whose conditions remained clinically stable were discharged in forty-eight to seventy-two hours, whereas after laparotomy giving negative results, hospitalization is for four to six days. Had a clinical observation period not been utilized, regardless of a sinogram giving negative results, four patients with penetrating wounds would have been discharged and their injuries missed.
Comments
Stab wound at the xiphoid process Fig. 5. contrast medium demonstrating penetration the pericardial sac and not into the abdominal ity.
with into cav-
of thirty examinations performed as of September 1, 1967 are summarized as follows: I.
II.
Positive sinograms showing peritoneal penetration : 8 A. Penetration confirmed by operation: 7 B. Penetration not confirmed by operation: l* Negative sinograms showing no peritoneal penetration : 22 A. No operation with early discharge: 14 B. Operation performed on clinical grounds: 8 1. Confirmation of nonpenetration: 4 occurred 2. Actual penetration (false-negative) : 4
Had operation been routinely performed in the thirty patients with abdominal stab wounds on admission, 60 per cent would have undergone needless exploration for nonpenetrating injuries. In the Denver General Hospital this could amount to approximately one *Exploration in this patient was delayed by other more urgent concurrent cases; no clinical indications for exploration were present, and the patient was discharged after an uneventful hospital course. 428
Sinography has been hailed with optimism as a diagnostic aid in abdominal stab wounds [s-5,8]. The reported experience suggests an incidence of false-negative examinations of less than 0.5 per cent. The four false-negatives in our initial thirty cases provide a significantly higher incidence. This preliminary experience illustrates potential areas of diagnostic inaccuracy. One patient had a diagnostic peritoneal lavage with 1,000 cc. of normal saline solution preceding sinography. Radiopaque medium within the peritoneal cavity in such a patient is so diluted that interpretation of roentgenograms is inaccurate. Another false-negative result occurred in a patient with multiple abdominal stab wounds, only one of which demonstrated penetration by sinography. The other wound appeared not to have penetrated. At exploration, however, both wounds had penetrated the peritoneum. Interpretation is obviously difficult in the presence of multiple sinograms through several stab wounds. A third-false negative result occurred when an insufficient amount of contrast medium was injected into an oblique tract. The defensive state of the musculature at the time of injury may subsequently produce a linearly displaced pathway through the abdominal wall during relaxation. Considerable injection forces may be required for contrast medium to flow into the peritoneum via this irregular tract. The last-false negative response occurred when the knife entered at the costal margin and passed through the chest, costophrenic angle, diaphragm, and then into the abdomen. Contrast medium followed the path of least The American
Journal of Surgery
Sinography
resistance and only outlined intrathoracic planes. Even when a knife wound penetrates the peritoneum, it may do little harm. Approximately 20 per cent of penetrating wounds cause no injury to the viscus, and an equally large percentage may produce only self-limited superficial injury to the liver, omentum, or bowel serosa [ 61. Sinography will not eliminate this group from unnecessary operation.
Summary 1. Sinograms have been performed on thirty patients after stab wounds of the abdomen. In eighteen patients no radiographic evidence of peritoneal penetration was found. Fourteen of these patients avoided having an otherwise needless operation. In four, however, clinical judgment dictated laparotomy, which proved to be unnecessary. 2. Four false-negative results occurred because of the following reasons: (1) use after peritoneal lavage ; (2) complexity in the presence of multiple wounds ; (3) inadequate volume and pressure of injection ; (4) unreliability when the wound tract transits pleura. 3. If the technic of sinography is exact, nonoperative treatment of a patient in whom sinography gives negative results is justified if there are no clinical indications for operation.
Vol. 117, March 1969
of Abdominal
Stab Wounds
References 1.
2.
3.
MAYNARD,A. L., and OROPEZA,G. Mandatory operation for penetrating wounds of the abdomen. Am. J. Surg., 115:30’7, 1968. MASON, J. H. The expectant management of abdominal stab wounds. J. Trauma, 4:210, 1964. CORNELL,W. P., EBERT, P. A., GREENFIELD, L. J., and ZUIDEMA,G. D. A new non-operative technique for the diagnosis of penetrating injuries to the abdomen. J. Trauma, 7 ~307, 1967.
4.
5.
6.
7.
STEICHEN,F. M., PEARLMAN,D. M., DARGAN, E. L., PROMMAS, D. C., and WEIL, P. H. Wounds of the abdomen: radiographic diagnosis of intraperitoneal penetration. Ann. Surg., 77:82, 1967. TOBIAS, S., DECLEMENT, F. A., and CLEVELAND, J. C. Management of abdominal stab techniques for wounds : roentgenographic diagnosis of peritoneal penetration. Arch. Surg., 95:27, 1967. Five year review of abdominal stab wounds at Denver General Hospital. Unpublished data. August 1967. CORNELL,W. P., EBERT, P. A., and ZUIDEMA, G. D. X-ray diagnosis of penetrating wounds of the abdomen. J. S. Res., 5:142, 1965.
8.
CORNELL,W. P. and EBERT, P. A. Penetrating wounds of the abdominal wall: a new die nostic technique. Am. J. Roentgenol., 96: 414, 1966.
429
Abdominal stab wounds traditionally demand prompt surgical exploration on the suspicion that they penetrate the peritoneal cavity and perforate a vessel or viscus [.Z]. The slight risk of exploration is outweighed by the danger of overlooking visceral injury. The fact remains that the results of 36 to 50 per cent of such explorations are negative [Z-6], resulting in a significant attendant economic loss. To minimize the incidence of such needless laparotomies, there are those who observe patients with abdominal stab wounds and perform laparotomy only when clinical appraisal so warrants [2]. In 1965, Cornell, Ebert, and Zuidema [7] suggested that radiographic evidence of perforation of the abdominal wall by sinography might aid in determining the indication for laparotomy. This paper reports our initial experience with this technic. Technic After steriIe skin preparation and draping, the wound is infiltrated with 5 to 10 cc. of local anesthetic. A No. 12-18 French rubber catheter is placed in the stab wound with its tip immediately underlying the skin. Care is taken not to probe or direet the catheter into the wound tract. A purse-string suture of heavy silk is secured in the wound around the catheter. A minimum of 50 cc. of meglumine diatrizoate (Renografina 60 per cent) is manually injected from a 50 cc. syringe into the catheter, using sufficient force to cause an everting bulge of the skin. Thereafter, the catheter is clamped and anteroposterior, lateral, and oblique roentgenograms of the abdomen are promptly taken. We add no dye to the radiopaque medium.
From the Department Denver, Colorado.
426
of
Surgery,
Denver
General
Hospital.
Indications Any patient with a stab wound of the trunk which may potentially penetrate the peritoneum is a candidate for sinography. It is particularly helpful in avoiding unnecessary exploration when multiple trauma adds to the operative risk. It is not indicated in patients who have protruding viscus, peritonitis, or shock, and who therefore obviously require laparotomy. As with any laboratory adjunct, clinical indications override other considerations. interpretation
of Roentgenograms
In the absence of peritoneal penetration, the contrast medium diffuses along extraperitoneal soft tissue planes. (Fig. 1.) When there is violation of the peritoneal cavity, intra-abdominal structures characteristically are outlined by contrast inedium. (Fig. 2 and 3.) Occasionally, intrathoracic structures may be outlined if the chest has been entered. (Fig. 4 and 5.) For adequate interpretation, multiple views are necessary and when studies are inconclusive, a repeat injection may be helpful. Multiple stab wounds should be examined, but it is best that each tract be individually injected and then x-rayed to eliminate superimposition of contrast media, which may confuse interpretation. Ready absorption of the contrast medium usually occurs from the peritoneal lining or soft tissues, and the renal collecting systems may be visualized on delayed films. Clinical Material and Results Since July 1, 1967, sinography has been routinely employed for abdominal stab wounds at the Denver General Hospital. The results The
American
Journal
of Surgery
Sinography
of Abdominal
Stab Wounds
1
Fig. 1. Negative sinogram. The contrast medium is in the soft tissues wall. Further oblique films localized this extraperitoneally. Fig. 2. Penetrating stab wound of left upper quadrant spleen and loops of bowel.
with contrast
3 Fig. 3.
Positive
sinogram
False-negative Fig. 4. men; contrast medium
Vol. 117, March 1969
of the abdominal
medium
outlining
the
4 with contrast
medium
diffused throughout
sinogram. A wound at the leftcostal margin outlines only intrathoracic pleural surfaces.
the entire entered
abdominal
cavity.
the chest as well as the abdo-
427
Trimble,
Pomerantz,
and Eiseman
hundred needless laparotomies per year. The economic impact in terms of cost to the patient and the hospital is obvious. Patients with negative results on sinography whose conditions remained clinically stable were discharged in forty-eight to seventy-two hours, whereas after laparotomy giving negative results, hospitalization is for four to six days. Had a clinical observation period not been utilized, regardless of a sinogram giving negative results, four patients with penetrating wounds would have been discharged and their injuries missed.
Comments
Stab wound at the xiphoid process Fig. 5. contrast medium demonstrating penetration the pericardial sac and not into the abdominal ity.
with into cav-
of thirty examinations performed as of September 1, 1967 are summarized as follows: I.
II.
Positive sinograms showing peritoneal penetration : 8 A. Penetration confirmed by operation: 7 B. Penetration not confirmed by operation: l* Negative sinograms showing no peritoneal penetration : 22 A. No operation with early discharge: 14 B. Operation performed on clinical grounds: 8 1. Confirmation of nonpenetration: 4 occurred 2. Actual penetration (false-negative) : 4
Had operation been routinely performed in the thirty patients with abdominal stab wounds on admission, 60 per cent would have undergone needless exploration for nonpenetrating injuries. In the Denver General Hospital this could amount to approximately one *Exploration in this patient was delayed by other more urgent concurrent cases; no clinical indications for exploration were present, and the patient was discharged after an uneventful hospital course. 428
Sinography has been hailed with optimism as a diagnostic aid in abdominal stab wounds [s-5,8]. The reported experience suggests an incidence of false-negative examinations of less than 0.5 per cent. The four false-negatives in our initial thirty cases provide a significantly higher incidence. This preliminary experience illustrates potential areas of diagnostic inaccuracy. One patient had a diagnostic peritoneal lavage with 1,000 cc. of normal saline solution preceding sinography. Radiopaque medium within the peritoneal cavity in such a patient is so diluted that interpretation of roentgenograms is inaccurate. Another false-negative result occurred in a patient with multiple abdominal stab wounds, only one of which demonstrated penetration by sinography. The other wound appeared not to have penetrated. At exploration, however, both wounds had penetrated the peritoneum. Interpretation is obviously difficult in the presence of multiple sinograms through several stab wounds. A third-false negative result occurred when an insufficient amount of contrast medium was injected into an oblique tract. The defensive state of the musculature at the time of injury may subsequently produce a linearly displaced pathway through the abdominal wall during relaxation. Considerable injection forces may be required for contrast medium to flow into the peritoneum via this irregular tract. The last-false negative response occurred when the knife entered at the costal margin and passed through the chest, costophrenic angle, diaphragm, and then into the abdomen. Contrast medium followed the path of least The American
Journal of Surgery
Sinography
resistance and only outlined intrathoracic planes. Even when a knife wound penetrates the peritoneum, it may do little harm. Approximately 20 per cent of penetrating wounds cause no injury to the viscus, and an equally large percentage may produce only self-limited superficial injury to the liver, omentum, or bowel serosa [ 61. Sinography will not eliminate this group from unnecessary operation.
Summary 1. Sinograms have been performed on thirty patients after stab wounds of the abdomen. In eighteen patients no radiographic evidence of peritoneal penetration was found. Fourteen of these patients avoided having an otherwise needless operation. In four, however, clinical judgment dictated laparotomy, which proved to be unnecessary. 2. Four false-negative results occurred because of the following reasons: (1) use after peritoneal lavage ; (2) complexity in the presence of multiple wounds ; (3) inadequate volume and pressure of injection ; (4) unreliability when the wound tract transits pleura. 3. If the technic of sinography is exact, nonoperative treatment of a patient in whom sinography gives negative results is justified if there are no clinical indications for operation.
Vol. 117, March 1969
of Abdominal
Stab Wounds
References 1.
2.
3.
MAYNARD,A. L., and OROPEZA,G. Mandatory operation for penetrating wounds of the abdomen. Am. J. Surg., 115:30’7, 1968. MASON, J. H. The expectant management of abdominal stab wounds. J. Trauma, 4:210, 1964. CORNELL,W. P., EBERT, P. A., GREENFIELD, L. J., and ZUIDEMA,G. D. A new non-operative technique for the diagnosis of penetrating injuries to the abdomen. J. Trauma, 7 ~307, 1967.
4.
5.
6.
7.
STEICHEN,F. M., PEARLMAN,D. M., DARGAN, E. L., PROMMAS, D. C., and WEIL, P. H. Wounds of the abdomen: radiographic diagnosis of intraperitoneal penetration. Ann. Surg., 77:82, 1967. TOBIAS, S., DECLEMENT, F. A., and CLEVELAND, J. C. Management of abdominal stab techniques for wounds : roentgenographic diagnosis of peritoneal penetration. Arch. Surg., 95:27, 1967. Five year review of abdominal stab wounds at Denver General Hospital. Unpublished data. August 1967. CORNELL,W. P., EBERT, P. A., and ZUIDEMA, G. D. X-ray diagnosis of penetrating wounds of the abdomen. J. S. Res., 5:142, 1965.
8.
CORNELL,W. P. and EBERT, P. A. Penetrating wounds of the abdominal wall: a new die nostic technique. Am. J. Roentgenol., 96: 414, 1966.
429