he abdomen is a commonly injured body region and frequently requires the care of a surgeon for definitive management.  A penetrating abdominal injury is caused due to the mechanical force of a foreign object breaching the skin in the abdominal area and inflicting damage to the structures in its path and resulting in an open wound.¹

The vital nature of the organs contained within the abdomen makes evaluation and management a priority. Penetrating abdominal injuries are associated with significant morbidity and mortality rates due to injury to vascular structures and vital organs.² The evaluation of penetrating abdominal trauma requires an approach different from that for blunt mechanisms. Because of the high rate of intra-abdominal injury, patients sustaining anterior abdominal gunshot wounds are often taken immediately to the operating room for laparotomy.

Intraperitoneal spectrum of injuries is unpredictable as initial primary assault maybe further complicated by secondary injuries arising from either bone or bullet fragments. Concealed injuries further contribute to morbidity and mortality of victims.³ Presentation of the injuries varies depending on the type of penetrating object or ballistic kinetic energy involved, viscera involved, and number of wounds. ⁴ Present study was aimed to study clinical presentations, patterns, management modalities and its outcome in patients of penetrating injuries to abdomen

Present study was a prospective observational study, done in General surgery department in tertiary care centre in India between October 2020 to September 2022. In this study 107 patients were studied who were admitted to trauma care centre and general surgery ward with history of penetrating injuries to abdomen.

Inclusion criteria: Patients admitted to trauma care centre and general surgery ward with history of penetrating trauma to abdomen

Exclusion criteria: Patients not consenting to participate in the study

Study was explained to patients in local language & written consent was taken for participation & study. All patients with abdominal trauma underwent history taking, thorough clinical examination, relevant laboratory & radiological investigations (X-Ray, ultrasonography or CT scans). After initial assessment & resuscitation of the patients, thorough assessments for injuries were carried out.  The decision for surgical procedure was depended on the extent of penetrating injuries, hemodynamic stability and radiologic findings. The postoperative progress of patients was closely monitored.

Data was collected and compiled using Microsoft Excel,  analysed using SPSS 23.0 version. Statistical analysis was done using descriptive statistics.

107 patients were included in present study. Majority were from 21-30 (33.9%) years age group, were male (96.5%) and had h/o stab injury by sharp objects 98 (91.6%). At the time of presentation majority patients were hemodynamically stable (51.4 %), had peritonitis (77.6%)  and only 12 (11.2%) patients had evisceration at the time of presentation.

Table 1: General characteristics

Common associated injuries were head injury (9.3%), chest injuries (3.7%) & injury to extremities (3.7%).

 Table 2: Associated injuries

In this study among  penetrating injuries to abdomen, organs involved were small bowel (50.5 %), large bowel (21.5 %), liver (14 %), mesentery (13.1 %), stomach (4.7 %), spleen (2.8 %), duodenum (1.9 %), pancreas (1.9 %) & kidney (0.9 %).

 Table 3: Organ involved

In this study, common surgical procedures done in patients with penetrating injuries to abdomen were primary closure (28 %), ileostomy (21.5 %), resection anastomosis (11.2 %), colostomy (11.2 %), mesentery repair (11.2 %) & packing (7.5 %).

 Table 4: Surgical Procedure done

In this study 95.3% patients underwent therapeutic laparotomy and negative laparotomy was 4.7%.

Table 5: Role of laparotomy in operated patients

In this study common post-op complications were Wound infection (15 %), Wound dehiscence (6.5 %), Pneumonia (6.5 %), Sepsis (4.8 %), Renal failure & Shock (2.8 %) & Anastomotic leak (0.9 %).

Table 6: Post operative complications

According to this study 98 patients were discharged and 9 patients died (mortality was 8,4%)

Table 7: Outcome

In this study 5 patients died out of 18 patients with associated injuries and 4 patients out of 89 patients with isolated penetrating trauma to abdomen.

Table 8: Type of injury and mortality

The classic signs of peritonitis including diffuse tenderness, guarding and rebound tenderness make exploratory laparotomy mandatory regardless of cause of injury. But many patients may not have all these findings and relying on physical examination alone can be misleading. Plain X-ray films, local wound exploration, diagnostic peritoneal lavage, FAST/eFAST, CT and laparoscopy have become useful adjuncts in the management of trauma patients with suspected abdominal injuries.^5,6,7

A laparotomy is performed to explore the abdomen and to repair injuries that are identified. It is important that the exploration of the abdomen be performed systematically to avoid missing injuries that may be subtle. As described in the setting of damage control, this approach may require abbreviation in the setting of deteriorating physiologic condition.^8,9,10

In this study Primary closure for bowel perforation done in 28% patients and resection anastomosis was done in 11.2 % patients, Ileostomy in 21.5% patients with bowel injury, colostomy done in 11.2%, Mesentery repair done in 11.2%, Packing of liver done in 7.5%, drainage of peritoneum and haemostasis done in 6.5% patients with penetrating trauma to abdomen. In   a study done by Chatragadda Ramya et al.,¹¹ 41.7% patients underwent primary closure / resection anastomosis for bowel injury in 41.7% patients, Stoma done in 15 patients, packing of liver done in 6.3% patients, Splenectomy done in 21% patients. In a study done by Samir Toppo et al.,¹² 32.5% patients underwent Primary closure / resection anastomosis, 17.6% patients underwent stoma procedures, liver repair or packing done in 11.7% patients, Mesentery repair done in 11.7% patients, Drainage of peritoneum and haemostasis done in 8.8% patients and 2.9% patients underwent splenectomy.

In this study 95.3% patients with exploratory laparotomy underwent Therapeutic laparotomy where as 4.7% laparotomy procedures were negative laparotomy. In a study done by Naveen P et al.,¹³ 85% patients underwent therapeutic laparotomy and negative laparotomy was 15%. In a study done by B. Raj Siddharth n et al.,¹⁰ 75% patients with exploratory laparotomy underwent Therapeutic laparotomy and negative laparotomy was 25%. In a study done by Chatragadda Ramya et al.,¹¹ 80.2% patients underwent therapeutic laparotomy and 19.8% patients underwent negative laparotomy.

In this study 15% patients had wound infection, 6.5% patients had wound dehiscence, 6.55 patients developed Pneumonia, 4.8% patients developed sepsis, 2.8% patients developed renal failure and shock and anastomotic leak in 0.9% patients. In a study done by B. Raj Siddharth n et al.,¹⁰ wound infection was developed by 9.4% patients, wound dehiscence in 14.1%, Pneumonia in 11% and Anastomotic leak in 1.7% patients. In a study done by Chatragadda Ramya et al.,¹¹ wound infection was seen in 30% patients, wound dehiscence in 14.1%, pneumonia in 40% patients and sepsis in 15% patients. In a study done by Samir Toppo et al.,¹² wound infection and wound dehiscence seen in 26.7% patients and sepsis in 6.7% patients 

In this study 7.5% patients died due to complications. 4patients died due to shock, 3 patients died due to sepsis, 1 patient died due to pneumonia. In a study done by Naveen P et al.,¹³ mortality rate was 11.5%. In a study done by Chatragadda Ramya et al.,¹¹ mortality rate was 5%. In a study done by Samir Toppo et al.,¹³ mortality rate was 3.35%.

The evaluation of penetrating abdominal trauma requires an approach different from that for blunt mechanisms. Because of the high rate of intra-abdominal injury, patients sustaining anterior abdominal gunshot wounds are often taken immediately to the operating room for laparotomy.

Penetrating wounds involving the upper abdomen may also require evaluation of the chest for mediastinal, pleural, or pulmonary injuries. Determining the trajectory of the missile while preparing for surgery may guide exploration. Penetrating wounds should be identified with radiopaque markers, and plain radiographs should be obtained to determine their location and relation to missile position. The number of missiles and skin wounds should add up to an even number, or a more intense search for injuries is required.

Most common clinical presentation was peritonitis followed by haemodynamic instability and evisceration. Small bowel is most common site of injury followed by large bowel and liver. Primary closure of bowel perforation is the most common procedure done. Most common complication was wound infection / surgical site infection followed by wound dehiscence and pneumonia. Mortality was higher is patients with associated head or chest injuries.In patients of penetrating trauma to abdomen, early diagnosis and early surgical management leads to better outcome. The results are favourable when there I is good teamwork backed by good critical care set-up.

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