Another approach to evaluate abdominal stab wounds is local wound exploration (LWE). This technique helps determine if the fascia was penetrated and peritoneum violated. There have been trials that show that sensitivity and specificity of LWE for peritoneal violation are 100 percent.⁴ Even with cooperative patients, LWE is rarely feasible in the emergency department setting as it requires a sterile field, equipment, appropriate lighting, staffing, and anticipation that the incision may need to be extended.

Exploratory laparotomy remains the gold-standard for diagnostic evaluation. This surgical approach evaluates certain injuries that can only be excluded by direct observation, such as diaphragmatic injury.^1,3 There are risks with this invasive approach such as infection, iatrogenic injury, abdominal pain, and sequalae of abdominal surgery. The use of exploratory laparoscopy is a less invasive alternative to laparotomy.

Therapeutic Approach

The role of treatment for abdominal stab wounds has changed from an early, definitive laparotomy to damage-controlled resuscitation and non-operative management. Exploratory laparotomy or laparoscopy is recommended in patients with hemodynamic instability, signs of peritoneal irritation, hematemesis, or blood per rectum after an anterior stab wound.² In those who are stable, one can utilize the various diagnostic evaluations mentioned earlier.¹⁵ Operating on stab wound victims based on clinical status and diagnostic tools leads to a decrease in nontherapeutic laparotomies, complication rates, and hospital length of stay.^16,17

Serial clinical exam is a possible management approach that can be utilized to avoid laparotomy. Re-examination should include an abdominal, neurological, and vascular exam.¹⁸ This approach depends on consistent, trained evaluation but can be logistically challenging.

As the liver is the largest solid organ in the abdomen, it is the most frequently injured and its extensive vascular supply makes injuries to this organ challenging to manage.¹⁷ Due to this, mortality of operative liver injuries remains high. One adjunct therapy that can help with liver injury is angiographic embolization (AE).⁵ Like the liver, the spleen’s size makes it a major target and cause of morbidity and mortality in stab wound injuries. Splenectomy is the treatment in patients with hemorrhagic shock and splenic trauma. In hemodynamically stable patients, splenic salvage can be pursued with serial imaging and AE.^2,5

Vascular injuries from penetrating abdominal trauma are uncommon, however they can be lethal. These injuries demand rapid control of bleeding and resuscitation. Vascular injuries can be accompanied by hematomas or active hemorrhage. Management will be dictated based on the type of bleed, stability of the patient, and location of injury. AE can also be a diagnostic and therapeutic adjunct for these patients.^3,5