Routine laparotomy is no longer the gold standard for treating hemodynamically stable patients with penetrating abdominal injuries since Shaftan defined non-operative treatment in patients with penetrating abdominal injuries [1, 7]. Aside from this shift in care, new challenges have arisen regarding how to select which of these stable patients require a laparotomy as a secondary way of examination. The evaluation of the peritoneal violation is one of the most crucial ways to decide whether a laparotomy is necessary [8]. There are a lot of algorithms for management of the hemodynamically stable patient with penetrating anterior abdominal wall injuries [9]. While some rely on serial clinical examinations, others use investigations such as local wound exploration and diagnostic laparoscopy in identifying patients with penetrating wounds and deciding their further management [10]. In stable patients with penetrating wounds, LWE has been used to rule out anterior fascia penetration; if this test is negative, patients may be safely released from the emergency room [11]. The prevalence of needless laparotomies, however, is significant when the results of this invasive procedure are positive, according to earlier research [11–13]. As a practical matter, several guidelines no longer propose a LWE technique for treating penetrating abdominal injuries and instead recommend a contrast-enhanced abdomen CT as a non-invasive diagnostic tool [1].
Regarding the accuracy of abdominal CT scans for identifying intra-abdominal injuries and peritoneal violations, various findings from earlier research have been reported. In a research by Biffl et al., 138 patients had CT scans performed as the main decision-making tool. While 46 (33%) of the patients had laparotomies as a result of the CT findings, 29 (21%) of the patients were released without complications due to normal CT scan results. Of these, 35 (76%) underwent therapeutic laparotomies and 11 patients (24%) underwent non-therapeutic laparotomies. The authors determined the sensitivity, specificity, positive predictive value (PPV), and negative predictive value (NPV) of CT scans necessitating therapeutic laparotomies; the corresponding values were 77, 73, 47, and 91% [8, 14]. Interestingly, these values were shown to be higher in a study by Berardoni et al. to assess the diagnostic accuracy of the CT scans involving 98 patients with abdominal stab wounds. The CT scans' sensitivity, specificity, PPV, NPV, and accuracy in identifying the requirement for surgical intervention were, respectively, 93, 93, 70, 99, and 93% [15].
There are few investigations on CT tractography in the literature, one of those studies reported by Bruckner et al. on seven patients who underwent CT tractographies and had abdominal gunshot wounds that were thought to be tangential [16]. The CT tractographies' findings for every case of peritoneal violation were all normal. There were no issues when all patients were admitted to the hospital for observation. The authors claim that their stringent patient selection criteria, which only permitted stable patients who had suffered tangential gunshot injuries, were to blame for the lack of encouraging outcomes [16]. Bansal et al. reported in another study on 41 hemodynamically stable patients with posterior torso stab wounds who underwent CT tractography that this modality detected abnormalities of the thoracic, intraperitoneal, or retroperitoneal cavities in 11 individuals (26.8%). Therapeutic intervention was necessary for each of these patients. The 30 individuals who remained were admitted to the hospital for observation and had no issues; their CT tractography results were normal. In order to manage patients with posterior torso stab wounds, the authors concluded that CT tractography was a safe and effective diagnostic technique [17].
In our policy to avoid unnecessary anesthesia for those patients and avoid unnecessary hospital stay for follow up, contrast CT scan is done for every anterior abdominal wall injury patient with stable condition. With a lot of equivocal CT reports there is a grey zone which needs to be considered and studied well. Especially with the limited resources which encourage us to be very cost effective for every admission and every surgical intervention. In the current study, we used a CT tractography based approach to stratify patients whose contrast CT scan is equivocal regarding peritoneal penetration or not and decide their subsequent management. Serial clinical examination and observation were determined to be the gold standard of diagnosis in the previous investigations. Our study's strength differs from that of the earlier research because it was discovered that CT scan alone was less accurate than CT scan combined with CT tractography. The accuracy, PPV, NPV, sensitivity, and specificity of our findings were all 100% supporting the results of Uzunosmanoğlu, H., et al. [8]. In the study CT tractography identified the role of laparotomy accurately in 100% of the patients, and none of the patients without peritoneal penetration needed surgical intervention in their follow-up.
Limitations
There are a few important limitations to this study. First off, whereas many other studies used CTs with triple contrast (oral, rectal, and intravenous), the CTs used in this study only used oral and intravenous contrast. This limitation, however, is unimportant because there were no rectum or descending colon injuries when examining specific diagnosis of injuries. Rectal contrast would not have led to any new diagnosis, even if it had been applied. Second, since there is a dearth of knowledge about the clinical outcomes of laparotomies. The number of non-therapeutic laparotomies performed with this approach may be incomprehensible to the readers.