Surgery versus observation for people with abdominal injury

Injury to the abdomen is common and can be blunt from road traffic crashes or falls, or penetrating from gun shots or stabbing. These injuries are usually associated with injury to the abdominal organs such as the liver, spleen, kidneys, intestine and its covering, and big blood vessels. Massive bleeding or leakage of abdominal content into the abdominal cavity can occur, which may threaten a person's life. Examination of the patient by the doctor (physical examination), though the most accurate method of assessing people, is insufficient to determine the extent of damage. On the other hand, a person should not have a surgical procedure unless it is necessary. There are reports that injuries can be missed even when surgery is carried out.

Observing a patient with the hope that the person's injury heals naturally and intervening surgically if the need arises is known as selective non-operative management (SNOM) or observation. An observation protocol is used when the person has no sign of internal bleeding or abdominal infection (peritonitis). Surgery is resorted to if, during observation, signs of bleeding or infection are observed.

The authors of this review sought to identify every study where people with an abdominal injury were randomised to surgery or observation. The authors searched a variety of medical databases but only identified 2 studies, involving 51 and 63 people respectively, both of which took place in Finland and were conducted by the same researchers. Both studies included people with penetrating abdominal injuries, from having been stabbed. The review authors considered both studies to be at moderate risk of bias, since only part of the randomisation process was described and the study protocols were not available to enable full assessment of overall quality.

In one study (1992-1994) people received either an observation protocol or mandatory surgery. None of the people in the study died, and there was no difference in the number of people with medical complications between the study groups. One of the harms mentioned by the study authors was that surgery was performed on some people who did not actually need it. Unnecessary surgery can subject people to potential complications.

In the other study (1997-2002) people received an observation protocol or diagnostic laparoscopy (minimal surgery). No one died in either group, and there were no differences between the groups in the number of surgeries needed. There were no unnecessary surgeries in either group.

Based on the findings of these two small studies, there is no evidence to support the use of surgical management over an observation protocol for people with abdominal trauma showing no signs of bleeding or infection.

The authors recommend that future randomised controlled studies clearly report the type of injury, number of damaged organs, extent of damage of internal organs, and complications in the people included.

Authors' conclusions: 

Based on the findings of 2 studies involving a total of 114 people, there is no evidence to support the use of surgery over an observation protocol for people with penetrating abdominal trauma who have no signs of peritonitis and are stable.

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Background: 

Injury to the abdomen can be blunt or penetrating. Abdominal injury can damage internal organs such as the liver, spleen, kidneys, intestine, and large blood vessels. There are controversies about the best approach to manage abdominal injuries.

Objectives: 

To assess the effects of surgical and non-surgical interventions in the management of abdominal trauma in a haemodynamically stable and non-peritonitic abdomen.

Search strategy: 

We searched the Cochrane Injuries Group's Specialised Register, The Cochrane Library, Ovid MEDLINE(R), Ovid MEDLINE(R) In-Process & Other Non-Indexed Citations, Ovid MEDLINE(R) Daily and Ovid OLDMEDLINE(R), EMBASE Classic+EMBASE (Ovid), ISI WOS (SCI-EXPANDED, SSCI, CPCI-S & CPSI-SSH), CINAHL Plus (EBSCO), and clinical trials registers, and screened reference lists. We ran the most recent search on 17 September 2015.

Selection criteria: 

Randomised controlled trials of surgical interventions and non-surgical interventions involving people with abdominal injury who were haemodynamically stable with no signs of peritonitis. The abdominal injury could be blunt or penetrating.

Data collection and analysis: 

Two review authors independently applied the selection criteria. Data were extracted by two authors using a standard data extraction form, and are reported narratively.

Main results: 

Two studies are included, which involved a total of 114 people with penetrating abdominal injuries. Both studies are at moderate risk of bias because the randomisation methods are not fully described, and the original study protocols are no longer available. The studies were undertaken in Finland between 1992 and 2002, by the same two researchers.

In one study, 51 people were randomised to surgery or an observation protocol. None of the participants in the study died. Seven people had complications: 5 (18.5%) in the surgical group and 2 (8.3%) in the observation group; the difference was not statistically significant (P = 0.42; Fischer's exact). Among the 27 people who had surgery, 6 (22.2%) surgeries were negative laparotomies, and 15 (55.6%) were non-therapeutic.

In the other study, 63 people were randomised to diagnostic laparoscopy (surgery) or an observation protocol. There were no deaths and no unnecessary surgeries in either group. Four people did not receive the intervention they were assigned. There was no difference in therapeutic operations between the two groups: 3 of 28 in the diagnostic laparoscopy group versus 1 of 31 in the observation protocol group (P = 0.337).

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