C{- 2. '1'/

Demetrios Demetriades, MD, PhD; George Velmahos, MD, PhD; Edward Comwell III, MD; Thomas V. Reme, MD;Sheldon Caber, MD; paramdeep s. Bhasin, MD; Howard Belzberg, MD; Juan Asensio, MD

patients (59.9%) met the criteria for operation and un-derwent a laparotomy. The incidence of nontherapetiticoperations was 2.2%, and that of negative operations was8.6%.One hundred six patients (34.3%) were selectedCor observation. Fourteen oC the initiany observed pa-tients underwent a.1ate operation, but it was therapeuticin only 5. OYeran, 92 patients (29.8%) were success-fully managed nonoperatively .The Oyeran sensitivity ofthe initial physical examination was 97.1%. The es ti-mated bullet trajectory was not reliable in identifying theneed Cor operation because oC 224 patients with likely peri-toneal penetration only 169 (75.4%) had signiCicant in-

juries requiring surgical repair.

Obiective: To investiga te the Tole of selective non-operative management of gunshot wounds to theabdomen.

Deslgn: A prospective, protocol-guidedstudyinclud-ing all gunshot wounds oí fue anterior abdomen.

Conclusion: In fue appropriate environment, many ci-vilian abdominal gunshot wounds can be managed non-operatively.

Palienls and Melhods: The patients were assessed andmanaged according to a written protocolo Patie~ts with he-modynamic instability or peritonitis orassociated spinalcord or head injury orrequiring a general anesthetic foran extra-abdominal injury weremanaged by laparotomy.Therest of fue patients were~elected foi"initial nonoper-" "" "ative management withserial phy~ical,,~minations.

" "Resulls: During a 16-month period, 309 patients withgunshot wounds of the anterior abdqmen were treated.Eighteen patients in extremis (5.8%) underwent an emer-gency department-performed thoracotomy. Another 185 Arch Surg 1997;132:178-183

HE POLlCY of selective non-operative management forstab wounds to the ante-rior abdomen has been ac-cepted by most trauma cen-

terso (The anterior abdomen was definedas the afea between the xiphoid and cos-tal margins superiorly, the pubic symphy-sis and the inguinalligaments inferiorly,and the midaxillary lines posteriorly.)However, gunshot wounds (GSWs) of theabdomen are treated much more aggres-sively, with routine surgical explorationbeing the acceptable standard of careo Ear-lier reports from South Africa suggestedthat selective conservative management forabdominal GSWs was a safe practice, butthis concept has faced majar skepticismin the United States. This study investi-gates the safety and efficiency of nonop-erative management in carefully selectedpatients with abdominal GSWs.

life and underwent an emergency depart-ment-perfonned thoracotomywith no sur-vivors.Another 185 patients (59.9%) hadsignsofperitónitis, hemod~amic insta-bility, other majar extra-abdominal inju-ries requiring operation, or spinal cord orhead trauma and, therefore, underwent anurgent laparotomy. The remaining 106 pa-tients (34.3%) were selected for nonop-erative management; they had minimal orno peritoneal signs, were hemod~ami-cally stabilized with minimal fluid trans-fusions, and did not require an urgent op-eration for other extra-abdominal injuries.

The bullet tract was assessed as likelyto have penetrated the peritoneum in 224patients (72.5%), unlikely in 68 patients(22.0%), and "cannot comment" in fue re-maining 17 patients (5.5%). The inci-dence of intra-abdominal injuries in fuesegroups is shown in 'rab.. 1 .OYerall, only75.4% of patients with likely peritoneal pen-etration had significant injuries requiringtreatment. This figure was 2.9% for pa-tients with unlikely peritoneal penetra-tion. Fiftypatients (excluding thosewho un-delWent emergency department-performedthoracotomies) had likely peritoneal pen-etration and their initial systolic blood

From the Division 01 TraumaCLINICAL EV ALUATION

Eighteen (5.8%) of the 309 patients wereadmitted in extremis or with no signs of

ARCH SURGNOL 132, FEB 1997178

PATIENTS AND METHODS

P~TIENTS

A prospective protocol-guided study was performed at theLos Angeles County and University of Southem Califor-nia Medical Center, Los Angeles, one of the largest level 1trauma centers in the country (6900 trauma admissions in1995), with a dedicated Division of Trauma and CriticalCare with 7 full-time trauma faculty. The faculty are in-house on a 24-hour basis, lead all trauma team activa-tions, and supervise all operations.

The study included all patients with a bullet entry orexit in the anterior abdomen. Patients with obviously su-perficial wounds were not included in the study.

During a 16-month period (March 1994 to June 1995),309 patients with GSWs of the anterior abdomen weretreated. Most patients (290 [93.9%]) were male; their meanagewas 24.7years (range, 7-77years); and their ethnic pro-filewas as follows: Hispanic, 235 (76%); black, 45 (14.7%);white, 15 (4.9%); andAsian, 14 (4.6%). Two hundred thir-leen patients (69%) had a single GSW, 44 (14.2%) had 2GSWs, and 52 (16.8%) had 3 or more GSWs. The meantime from injury to admission, which could be docu-mented in 235 patients...was 49 minutes.

all patients, chest and abdominal X-lar films were takenunless severe hemodynamic instability dictatedinimedi-ate transportation to an operating room. -';;¿

Patients with hemodypamic instability caused by bleed':ing, peritonitis (rigidity, rebound tendemess, significantten-demess away from fue bullet wound), associated spinal cord,or severe head injury, or those who required an extra-abdominal operation, were selected for emergent lapa-rotomy. A second-generation cephalosporin therapy wasstarted in fue emergency department and continued for 2,:!-hours. .

Patients with minimal or equivocal abdominal signswereselected for nonoperative management, irrespectÍveof fue site of entry or exit of fue bullet, and irrespective ofalcohol or other drug use. Similarly, patients-with mild hy-potensiori or tachycardia who responded rapidly to smallvolumes of intravenous resuscitation were observed if theabdomen was softand not tender, and no blood transfu-sions were required in isolated abdominal trauma. Thesepatients were admitted to fue Surgical Admitting Unir, whichis also fue base station of the trauma team on callo In thisafea, monitoring of blood pressure, pulse rate, serial he-matocrit indexes, and oxygen saturation is routinely per-formed on all patients.

Patients selected for observatioÍl underweni chest andabdominal radiography and urinalysis. Intravenous py-elography or abdominal contrast computed tomographicscan or both were obtained, according to fue áttending traumasurgeon's preference. Laparoscopy was performed on pa-tients withleft thoracoabdominal injury and a soft abdo-men. No prophyIactic aJ;1tibiotics or analgesic drugs were ad-ministered. The observation included frequent clinicalassesstn~~ by ~e ~~t~g surgeons andrecording. ofbl~pressure,pulse rate, 1emperature,0x;ygensaturauon, and

or an 'ti'ri"""Iailíed lioclbledro of thehtJIlaiocri(~mdexorc"'!-~ "-", PC-C"",...,.,O'.,",~, "other eVidenceo(o~going blOód J9ss:W¡j5pr~ent.. ~n qpera-

to. th.e generalnusslon and subsequently discharged after24 10 48 hoursunless associated injuries required further iIipatient care."'

,

viMETHODS

All study patients were assessed and rnanaged accordingto a written protocolo The protocol included epidemiologi-cal data, the time from injury to adniission, the number ofbullets, and bullet entryand exit siteS.. The probabilityofperitoneal penetrationon the basisof esumated bulletttact,(penetration most likely, ulilikely, or cannot comment) was

..,," '" , "O;a subJecnve assessment maiJeby,:t4~cQi~ftr~q~~resld~nt(postgraduate year 4 or 5). Theab4ominal exalI!cÍllation was

-c '"classified as obvious peritonitis or mild tenderness aroundthe bullet tract with no peritoneal signs. Anyextra-abdominal injuries were recorded anddescrib:ed.Theini-tialand subsequent hematocrit indexes were recorded. fu

:

iI!

:

patients with trauma,only150 (2~%)had#egativeteStresults for alcohol or other drug use:27(7l:1%)of therounderwent a laparotomy..(whichwas 1herapeutic in24[88%]), and theremaimng11patierÍtswere observedand none of themhad a notable intia-abdominal iI;ljuryrequiring treatlrient.Overall,14 patients (31;1 %) in thiSgroup of patients with a score ofl~ss than 13 on theGlasgow ComaScalebut no head injuryhad np notableintra-abdominal trauma.

pressurewas 90 mmHgor lower. Tbirt}'-nine (78%) ofthesepatients required a laparotomy, which was therapeutic in34 (87.2%).The remairiing patients were observed; in 1of mero, peritoneal signs were later noted and he under-went a laparotomy that was therapeutic.

The initial Glasgow Coma Scale score was less than13 withouthead trauma in 38 patients, most likely re-sultingfrom shock or alcohol and other drug use. m anunpublished prospective study for ourcenter of the519

Figure 1. Uver and kidney injury: failed observarían.

'ff

\)';

Figure 2. Kidney' injury: successfulnonoperative management. Figure 3. Splenic inju¡y: successful nonoperative management.

ASSOCIA TED JNjURIES

Oyerall, 144 patients (46.6%) had extra-abdominalinjuries (extremities, 28.8% chest, 15.2%; neck, 6.5%;and head, 4.2%). Forty-eight (33.3%) of these patientswere selected for observation; in 2 observed patients(4.2%), laparotomies were delayed because ofincreas-

Cc C

ing abdominal pain, but findingsfro~ boili operatioI1Swere normal.

abnormal intravenous pyelograph~c findings were suc-cessfully treated nonoperatively.

Laparoscopic evaluation was peformed in 5 pa-tients; abnormal findings were noted in 3 patients whohad laparotomies performed, 1 of which was nonthera-peutic (nonbleeding superficialliv~r,.laceration).

MANAGEMENT

Eighteen patients in extremis or with no si&I:tS of life un-derwent an emergency department-performed lhora-cotorny; none of them survived. Another 185 patients(59.9%) underwent an emergency celiotomy because ofsigns of peritonitis orhemodynamicinstability or .bothorbecause of associated severe head or spinal cord injury.The operation was therapeutic in 165 patients (89.2%),gave normal findings in 16 (8.5%) and was nonthera-peutic in 4 (2.2%) (Figure 4). Four of the patientswith normallaparotomy findings had spinal injury orrequired another extra-abdominal operation and, byprotocol, were automatically selected for laparotomy.

The overall mortality was 12.1% (37 deaths).Ex-cluding the deaths in fue group 'of 18 patients who un-derwent an emergency department-performed thora-cotomy, the mortality for those undergoing laparotomy

INVESTIGATIONS

Besides the standard chest and abdominal x-lar films infairly stable patients, a computed tomographic scan wasperformed on 19 patients(6.1%). The computed tomo-graphic scans showed abnormal findings in 7 patients anddemonstrated solid organ injuries (liver, spleen, kid-ney) in 6 patients and spinal injury in 1 patient. Five pa-tients with solid organ injuries were selected for ob~er-vation (Figure 1 throughFigure 3): 1 of them requiredsubsequent operation for ongoing bleeding from fue liverand fue remaining4 patients had an uneventful recovery.

"One-shot" intravenous pyelograms were per-formed in 43 patients (13.9%), and theyshowed abnor-mal findings (renal injury) in 10. Two of fue patients with

ARCH SURGNOL 132, FEB 1997ISO

tient, fue diagnosis was established on admission by meansof computed tomography, which showed a liver and rightkidney injury (Figure 1) ,and fue patient was ~electedfor

ccobservation because ofhemodynamic stability~ri~,~,~§!~,abdomen. During the observationperiod,the~bdoni~~became distended and fue hematoCrltiridexdroppéd.The

, ,CC.c' , ..., .'""'0"patient underwent transfusiori.'(jf6 U ó(blood and,~iíi'violation of the protocol, was ob~~~edfdf48hours be~;fore he was operated on. Hehad postoperativeabdomi21nal compartment syndrome, aCuterespiTaiÓry(:1iS-tt~ ~:1drome, and candidiasis, andherequiiéd,prolohgedhospitalization until final dischargefroiiiili~ hóspita).i'¡,i

The most commonly wouiÍded iritta:.-ábdomiriárór::;gan in the group of 217 patientS whouhde~erttC1~p~-,rotomywas fue smallbowel (81 [37.3%]). The incidericesof other organ injuries were as follows: cólon, 59 (27.3%);-liver, 59 (27.2%); kidney, 34 (15.7%);diaphragm;33'(15.2%); vessels, 31 (14.3%); stomach, 27 (12.4%); sple~n,15 (6.9%); and bladder, 14 {6.5%). Overall, the!3 non-therapeutic operations iricluded 6 liver injuries, 2 kidneyinjuries, 1 splenic injury, 1 extraperitoneal bladder perfo-ration, and 3 mesenteric or mesocolic hematom:as.

The hospital stay in fue group of patients with thera-peutic laparotomies was 12.5 days, and fue complicationlate was 39.3%. OYerall, 199 early and late operations wereperformed.Thefindirigsfrom23 (11.6%) ofthem werenor-mal and 6(3%) were nontherapeutic. The mean hospitalstay iri fue group of patients with normal surgical findingsor nontherapeutic operations was 6.4 days; fue complica-tion rate was 27.6% (8 patients), and the mean hospitalcharges were $18123. In at least 5 (21.7%) of the pa-tients, fue complications were probably direcdy related t?fue anesthesia or laparotomy (Iab.. 3). The m~n hos;"".piral stay iri fue successfully observed group w~ 3.3 days,and the mean hospital charges were $8595. '

was 10.3% (19 deaths). Seven of fuese deaths were frommassive hemorrhage and occurred in fue operating room.The remaining 12 deaths were from irreversible shockand bleeding (6 patients) or multiorgan failure (6 pa-tients) and occurred inthe surgical intensive care unit.There was no death in fue group of 106 patients who wereselected for initialobservation.

Of fue 100 patients (34.3%) who were selected fornonoperative management, 11 patients had an admis-sion systolic pressure of 90 mm Hg or lower, 11 patientshad Glasgow Coma Scale scores of less than 13 but nohead injury, 48 patients had extra-abdominal GSWs, and33 patients had 2 or more GSWs. In 44 (41.5%) patientsof this group, the bullet tract was assessed as most likelyto have penetrated the peritoneum.

Fourteen patients in the initial1y observed group of106 required subsequent operation because of increas-ing tendemess (13 patients) or evidence of continuedbleeding(l patient). Nine of the laparotomies gave nor-mal findings or were nontherapeutic and 5 were thera-peutic. Details of the 5 therapeutic operations are givenin Tabl. 2. The sensitivity of the initial physical exami-nation was 97.1 %. The diagnosis was delayed in4 of thepatients by 6 to 13..5 hours. A114 patients had colon in-juries that were managed by primary repair. In 1 of fuesepatients, a psoas abscess developed and was success-ful1y managed by percutaneous aspiration. In a fifth pa-

L_~~~~~~~

Ves No! !

llaparolorny I O~~~~~~-\ r Late Signs 01

\ Perilonitis or Bleeding

Ves No -1 Discharge.:t48 h I

Selective nonoperative management of abdominal~nif~injuries has become an acceptable practice in ~Y ~1,!~centers. The selection of patients for operatiqn~!,o9s.ér~~ation is. base1.almost exclusively on cli~ic~l~~~m.!~::,tion. ThIS pohcy has been shown to besaf~~~~¿~!f~,~:;ti ve in re~ucing thenumber of nontpe.'~~p,~:~;~iclaparotomIes.1-3 However, the role ofcnop,9P~!~.t:!.ye~anagement in abdominal GS.Ws is highly,~~~!rq~~~-sIal and mandatory operatIon has~~~~ln~d:.theacceptedstandardof care 4-7 'fc' ,

.,,;1;.'.11 ,-;:!:::'!;.."'"

laparascopy lar LeftThoracoabdominal WQunds

CT Scan?

Intravenous Pyelogram?

Contrast Enema?

Figure 4. AIgoríthm for the management of gunshot wounds (G5Ws).CT índícates computed tomographíc.

* The diagnosis of liver and kidney injury was made on admission by means of computed tomographic scan. Despite a dropping hematocrit index and in

violarían of the protocol, the patient underwent transfusion of 6 U 01 bloodbefore laparotomy.

ARCH SURGNOL 132, FEB 1997181

Peritonitis

Hemodynamic Instabilily

Severe Head Injury

Spinal Cord Injury

Need lor General Anesthesialor Other Reasons

*Probab/y not directly related to the anesthesia or laparotomy.

Figure 5. Management of 309 patients with abdominal gunshot wounds(GSWs). Asterisk indicates that 4 patients had an associated spinal cordinju/y or required general anesthesia for extra-abdominal injuries.

Valentine eta18 strongly suggested that laparotomyshould be perfonned "regardless of physical examina-tion or estimated trajectory." Similarly, Sawidson et a19stated that "exploratory laparotomy should be per-forrned in all GSWs of the abdomen when even theslightest question óf penetrationexists." Two reasonsarecited for this aggressive approach. The first reason isthe high incidence of intra-abdóminal injuries, which inmany series has been reported to be ashigh as 98%.5Henderson et al: in a retrospective series of 250patients with abdominal GSWs, reported a positiveexploration rateóf 85%. Liebenberg a.nd Maasch,5 in astudy of 105 patients, reported positive laparotomyfindings in 103 patients (98%) and concludedthat vir-tually all patients with abdominal GSWs require lapa-rotomy.Moore eta17 reported intra-abdominal injuriesin 235 (96%) of245 cases with GSWs.However, thesestudies do not distinguish between a normal finding onlaparotomy and a therapeutic laparotomy. Manypatients with minor solid organ injuries do not benefitfrom a surgical procedure.

Several other series1O-14 have reported intra-a~o~~l injuries in only 70% to 80% These figures sug-~~tthat befweeri 20% and 30%of abdominal GSWs mar

~

quiTe surgical repair. Similar data were reported in pre-vious prospective studies from South Africa.14,15

The second reason in suppon of mandatory lapa;.rotomy is fue unreliability of fue initial physical examina-tion findings in evaluating fue abdomen. Moore et al7 re-ported that 26 (17%) of 156 patients with intraperitonealtrauma had unimpressive physical signs on admission.

Lowe et aro found that 41.5% ofp~tients with noclinical signs on admission had intra-abdominal inju-ries, Similarly, Thal et ap6 suggested alow accuracy forclinical examination. Itis difficult, however, to draw con-clusions on the reliability ofphysical examination re-sults from retrospective~reviews.It is also.possible thatsurgeons practicing mandatory laparotomy for all ab-dominal GSWs did not perfonn a careful clinical exami-nation if the findings were used to make therapeutic de-cisions. Most traur:na surgeons currently accept theconcept of selectiye nonoperative managemeniforknifeinjuries of the abdomen,based on physical examinationfindings. It seems paradoxicalto believe that physical ex-amination results are reliable in knife injuries butunre-liable in GSWs. In theory, physical examination in GSWsshould have a higher sensitivity than in knife wounds be,-cause of the greaternumber of intra-abdominallesionsassociated with GSWs. In a previous prospective studyof 146 patients, Demetriades et al14 reported a: false-negative result of 4 .8% and a false-positive result of 3.4%.The first large reports suggesting that carefulIy selectedpatients with abdominal GSWs cansafely be managednonoperatively carne from 2 different centers in SouthAfrica. Muckan et ap5 reponed a series of 111 patients,22 (20%) ofwhom were successfulIy managed nonop-eratively. In a prospective studyof 146 patients by De-metriades et al,14 41 patients (28%) were observed and 7of them required subsequent operation without anyserious consequences. The remaining 34.(23.3%) of thepatients were successfully observed. This c~ncept was ca~-tiously accepted by very few American centers and onlyfor GSWs involving the right upper abdominal qUád-Tanto Chmielewskietap7 described l2suchpatients (6.5%of all ;¡bdominal GSWs) who were managed nonopera-tively. Renz and Feliciano18 reponed 13 right thoracoab-dominal injuries managed nonóperatively. In OUT pre-sent large series of 309 patients, 92 (29.8%) weresuccessfully managed nonoperatively. '

The greatestconcem with nonoper~tive manage-ment is that bollow viscusperforationsmay be Ínissedto re-

ARCH SURGNOL 132, FEB 1997181

~~~

rotomy. Consequently, the current protocol at ourtrauma center is as shown in Figure 5.

In conclusion, in theappropriate clínical setting, ab-dominal GSWs shouldbe managed just like knife wo~nds.A selective, nonoperative management based largelyonthe findíngs from serial clínical examinations is safe andelimínates many unnecesSaryoperations.

Reprints: Demetrios Demetriades, MD, PhD, Department01 Surgery, University 01 South California School 01 Medi-cine, HCC, 1510 San Pablo St, Los Angeles, CA 90033.

during the initial clinical examination. However, thesubsequent examination should be able to identiry thesepatients. In OUT study, the sensitivity of fue initial ex-amination was 97.1%. The diagnosis was delayed in 4patients (by 6 to 13.5 hours) (Table 2), but with noserious consequences. It has be en shown in manystudies1.14.19 that delay by a few hours does not increasemorbidity and mortality.

The estimated bullet trajectory has limited value inpredicting the need for laparotomy. Surprisingly, 24.6%of all patients with most likely peritoneal penetration didnot have an injury that required surgical repair. Con-trary, only 2.9% of patients with unlikely peI:itoneal pen-etration needed a therapeutic operation. Low-velocity bul-lets have an unpredictable trajectory because they marfollow fascial planes of lower resistance.

Diagnostic laparoscopy has been successfully usedin the evaluation of abdominal GSWs. Peritoneal pen-etration or hemoperitoneum are considered as indica-tions for a laparotomy.13,20 This approach is obviously bet-ter than mandatory operation, but it still requires generalanesthesia. Also, peritoneal penetration or free blood isnot necessarily associated with significant injury requir-ing surgicalrepair. We are currently using laparoscopyas a standard investigative tool for evaluation of the dia-phragm in patients with left thoracoabdominal GSWs andwithout evidence of peritonitis or significant intra-abdominal bleeding.

It has been suggested that alcohol or other illicit druguse mar interfere with fue abdominal examination. How-ever ,other studies1.3 have shown that physical examina-tion findings in these patients are reliable. In OUT popu-lation with trauma, prevalence of alcohol and other drugabuseis high. In OUT recently completed prospective, un-published study, 178 (76.4%) of 233 patients with pen-etrating traúma weie under the influence of alcohol orother illicit drugs or both. We evaluated these patientsexactly like fue Test of fue victims.

We believe that the policy of mandatory operationfor all abdominal GSWs should bereexamined. It has beenshown that unnecessary operations for trauma are asso-ciated with a high incidence of complications and pro-longed hospital stay.21-24 In a recent editorial, Nance andNance25 suggested that

...the time has come to challenge a philosophy that acceptsan unnecessary laparotomy in at least 20% of subjects. Selec-tive nonoperative mailagement should be used for GSWs as itis already being used in patients with blunt trauma or stabwounds.

The present study has demonstrated that a significantnumber of patients can safely be managed nonopera-tively. Had we followed a policy of mandatory opera-tion in this series of 291 patients (excluding those with18 emergency department-performed thoracotomies), 121patients (41.6%) would ha ve had án unnecessaryoperation. Had we operated on all victims with likelyperitoneal penetration or peritonitis, 57 patients(19.6%) would have had an unnecessary operation.Byfollowing a policy of selective nonoperative manage-ment based on clinical examination results, only 29(10%) of these patients had an unnecessary lapá-

1. Oemetriades O, Rabinowitz B. Indications lor operation in abdominal stab wounds:a prospective study 01 651 patients. Ann Surg. 1987;205:129-132.

2. Oemetriades O, Rabinowitz B, Solianos C. et al. The management 01 penetrat-ing injuries 01 the back: a prospective study 01 230 patients. Ann Burg. 1988;207:72-74.

3. Shorr RM, Gottlieb MM, Webb K, Ishiguro LI. Berne TV. Selective manage-ment 01 abdominal stab wounds: importance 01 the physical examination. ArchSurg.1988;123:1141-1145.

4. Henderson VJ, Organ CH, Smith RS. Negative trauma celiotomy. Am Surg.1993;59:365-370.

5. liebenberg NO, Maasch AJ. Penetrating abdominal wounds: a prospective trial ofconservative treatment based on physical signs. S Afr Med J. 1988;74:231-233.

6. Moore EE, Marx JA. Penetrating abdominal wounds: rationale for exploratorylaparotomy. JAMA. 1985;253:2705-2708.

7. Moore EE, Moore JB, Van-Ouzer-Moore S, Thompson JS. Mandatory lapa-rotomy for gunshot wounds penetrating the abdomen. Am J Surg. 1980;140:847-851.

8. Valentine J, Blocker S, Chang J. Gunshot injuries in children. J Trauma. 1984;24:952-956.

9. Sawidson 1, Miller E, litwin MS. Gunshot wounds of the abdomen. Arch Burg.1976;111 :862-865.

10. lowe RJ, Saletta JO, Read OR, Radhakrishnan J, Moss GS. Should lapa-rotomy be mandatory or selectiva in gunshot wounds 01 the abdomen. J Trauma.1977;17:903-907.

11. Nance F, Wennar M, Johnson l, Ingram J, Cohn l. Surgical judgement inthemanagement of penetrating wounds 01 the abdomen. Ann Surg. 1974;179:639-646.

12. Sosa Jl, Arrilaga A, Puente 1, Sheeman O, Ginzburg E. Martin l. Laparoscopy.in 121 consecutiva patients with abdominal gunshot wounds. J Trauma. 1995;39:501-506.

13. Renz BM, Feliciano OV. Unnecessary laparotomies lor trauma: a prospectivestudy 01 morbidily. J Trauma. 1995;38:350-356.

14. Oemetriades O, Charalambides O, lakhoo M, Pantanowitz o. Gunshot woundsof the abdomen: roja of selectiva conservative management. 8r J Burg. 1991;78:220-222.

15. Muckart DI, Abdóol AT, King B. Selectiva conservative management of ab-dominal gunshot wounds: a prospective study. 8r J Surg. 1990;77:652-655.

16. Thal ER. May AA, Beesinger O. Peritoneallavage. Arch Surg. 1980;115:430-433.17. Chmielewski GW, Nicholas JM, Oulchavsky SA, OiebellN. Nonoperative man-

agement 01 gunshot wounds 01 the abdomen. Am Surg. 1995;8:665-668.18. Renz BM, Feliciano OV. Gunshot wounds to the rlght thoracoabdomen: a pro-

spective study of nonoperative management. J Trauma. 1994;37:737-744.19. Huizinga W, Baker l, Ntshali Z. Selectiva management of abdominal and tho-

racic stab wounds with established peritoneal penetration. Am J Burg. 1987;153:564-568.

20. Sosa Jl, Sims O, Martin l, Zeppa R. laparoscopic evaluation of tangentialabdominal gunshot wounds. Arch Surg. 1992;127:109-110.

21. Oemetriades O, Vandenbossche P. Ritz M et al. Non-therapeu1ic operation forpenetrating trauma: early morbidily and mortalily. 8r J Surg. 1993;80:860-861.

22. Hasaniga N, Oemetriades O, Stephens A, Oubrowskiz R. Berne T. Early mor-bidily and mortalily 01 non-therapeutic op~rations for penetrating trauma. AmSurg. 1994;60:744-747.

23. Renz BM, Feliciano OV. The length 01 hospital stay after an unnecessary lapa-rotomy fortrauma: a prospective study. J Trauma. 1996;40:187-190.

24. Renz BM. Feliciano OV. Unnecessary laparotomies for trauma: a prospectivestudy of morbidily. J Trauma. 1995;38:350-356.

25. Nance Ml, Nance FC. It is time we told the emperor about his clothes. J Trauma.1996;40:185-186.

ARCH SURGNOL 132, FEB 1997183