Surgical versus non-surgical management of abdominal injury
The authors of this review sought to identify every study where people with an abdominal injury were randomised to surgery or observation
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.
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]