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
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
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.
This research is supported by the Department for International Development’s Evidence Building and Synthesis Research Programme which is led by Liverpool School of Tropical Medicine.
Oyo-Ita, A.; Chinnock, P.; Ikpeme, I.A. Surgical versus non-surgical management of abdominal injury. Cochrane Database of Systematic Reviews (2015) Issue 11, Art. No.: CD007383. [DOI: 10.1002/14651858.CD007383.pub3]
Surgical versus non-surgical management of abdominal injury