This chapter will serve to offer a practical overall approach to penetrating abdominal trauma as organ specific, and selective nonoperative management is dealt with in other chapters. The attending clinician is faced with numerous challenges in view of the differing mechanism (stab or gunshot wounds) of injury and the confounding variables that may interfere in obtaining a comprehensive assessment of patients who have sustained penetrating trauma to the abdomen.

Possessing a sound knowledge of the anatomy of the abdomen is vital in appreciating the pathophysiology of trauma and directing subsequent management. The abdominal cavity is limited superiorly by the thoracic diaphragm and is continuous inferiorly at the pelvic brim with the pelvic cavity. Organs that are protected by the osteocartilaginous rib cage include the thoracic diaphragm, the esophagus, the stomach, the spleen, and the liver [1]. The upper border of the abdomen may therefore extend to the fifth intercostal space in a recumbent patient, and injuries to these abdominal viscera should always be considered in a thoracoabdominal trauma. Similarly, a gravid uterus or a distended bladder may extend beyond the pelvic brim into the abdominal cavity, while redundant sigmoid colon or loops of small bowel may be located in the pelvis especially post hysterectomy. Injury to retroperitoneal structures may present with minimal signs and be difficult to diagnose on clinical grounds alone.

The priority in managing a patient with penetrating abdominal trauma is to address the life-threatening issues as per Advanced Trauma Life Support (ATLS®) principles including airway with cervical spine immobilization, breathing, circulation with control of obvious bleeding, disability, and exposure [2]. Full exposure of the patient, especially the back, is mandatory to exclude other injuries including evidence of concomitant blunt force trauma. Laparotomy is mandatory in cases of refractory hypotension, evisceration, and peritonitis.

To aid the attending surgeon in fully assessing an “at risk” abdomen and confirming peritoneal breach and injury, numerous modalities have been incorporated into the management including local wound exploration, focused abdominal sonography for trauma (FAST), diagnostic peritoneal lavage (DPL), contrast-enhanced computed tomography (CECT), conventional angiography with embolization, and diagnostic laparoscopy. Laparotomy should be included in this list as, depending on how resource rich a facility is, this may be the most expedient manner of excluding or treating pathology. The surgeon needs to bear in mind that prolonged hypotension and delays in addressing intra-abdominal bleeding or pathology leads to an increased morbidity and mortality [3]. This must be weighed up against the potential sequelae of a negative or nontherapeutic laparotomy.

Local wound exploration is not recommended as it cannot reliably exclude a peritoneal breach or injury especially when thin spokes are utilized as weapons, in gunshot wounds, or when other variables, especially body habitus, preclude the surgeon from fully defining the tract. CECT scan is the investigation of choice in the equivocal abdomen. Despite its shortcomings of being unable to exclude hollow visceral, diaphragmatic, and pancreatic duct injuries, it is useful in the management of penetrating flank wounds and right upper quadrant and thoracoabdominal injuries. It defines visceral injuries thereby facilitating both conservative and surgical management [4]. DPL in penetrating abdominal trauma has largely been superseded by other less invasive tests [5]. The role of FAST in penetrating abdominal trauma is not as established as in blunt abdominal trauma though it still forms part of the initial assessment of most protocols [6].

Diagnostic laparoscopy is being increasingly used as a modality to exclude peritoneal breach and injuries and to address positive findings. There are obvious limitations including an inability to fully address the retroperitoneum, diaphragm, and subtle injuries [7]. The surgeon’s level of skill plays a significant part in being able to complete the entire procedure laparoscopically or having to convert to open. Presently the only advocated role is for the diagnosis and possible repair of a diaphragmatic injury following a left lower chest penetrating wound.

Investigations including full blood counts, urea and electrolytes, liver function tests, clotting profiles, serum amylase, cross matching of blood, arterial blood gas, and urine dipstick serve mainly as important adjuncts. X-rays of the long bones, C-spine and vertebral column, abdomen, pelvis, and thorax may aid the surgeon in his diagnosis (such as discovering free air under the diaphragm on an erect chest x-ray or pointing to an unstable pelvic fracture as being the source of bleeding). Obtaining these should never delay an unstable patient from receiving definitive surgical management. Radiology suites, as well as prolonged stays in casualties, are not conducive to the treatment of patients who have sustained significant trauma and serve to worsen the deadly triad of hypothermia, acidosis, and coagulation defects.

Nonoperative management was initially advocated by Shaftan in 1960 in a select group of patients with stab wounds [8]. This concept was extended to gunshot wounds, again in a select group, with Muckart et al. showing a 7 % negative laparotomy rate with no delayed laparotomies or morbidity [9]. These patients should be monitored in a high care facility with serial abdominal examinations. The nonoperative strategy should be aborted as soon as the patient’s clinical examination or investigations reveal any deterioration.