The number of recorded knife injuries resulting in hospital admission in England has increased by 30% over the period of 1997–2005.1
Penetrating chest injuries contribute significantly to the trauma workload of a busy emergency department in the UK.2
Stab injuries to the thoracoabdominal region (or the intrathoracic abdomen) pose specific and well-documented problems.3
Injuries in this region can affect both the thoracic and upper-abdominal organs and make assessment and management particularly challenging. Haemodynamically unstable patients may require thoracotomy, laparotomy or both approaches to deal with underlying injuries. Patients with haemodynamic instability, peritonitis or intestinal evisceration require immediate surgery. Non-operative treatment of right-upper-quadrant thoracoabdominal knife injuries has become increasingly common in recent years.4
The rationale behind the change in management, which would previously warrant laparotomy, is that a significant percentage of injuries do not require surgical treatment and patients can be spared the morbidity of a non-therapeutic laparotomy. The key to non-operative management is patient selection.5
Relative contraindications to the non-operative management include free abdominal gas on plain radiography; omental protrusion via the stab wound; patients who need surgery for other injuries, for example, head injuries; and patients who cannot be closely observed. Patients without these contraindications, who are not shocked and who have minimal abdominal signs are suitable for non-operative management. With this approach, it is important to identify patients who may have suffered occult injuries and require further diagnostic evaluation or operative treatment. Patients treated non-operatively require regular clinical evaluation, preferably by the same team of experienced clinicians.
Another aspect of conservative treatment that must not be forgotten is that after the acute event, some patients may require laparoscopy to assess for diaphragmatic injury which may require laparoscopic or open surgical repair. Missed diaphragmatic injuries and subsequent hernia development are a major cause of late morbidity in thoracoabdominal stab wounds.3
This is particularly important in left-sided diaphragmatic injuries that will lack the buttressing effect of the liver.
Traumatic injuries to the gallbladder are rare. This is partly due to the anatomical protection that is provided by the liver, lower-right thoracic cage, surrounding omentum and intestines. Road-traffic accidents appear to be the commonest cause of gallbladder injuries in Westernised countries,6
especially in countries with low gun crime. Penetrating injuries from gunshot wounds are more reported in countries such as South Africa which has a high rate of gun violence. In one study of 1242 patients undergoing laparotomy for acute trauma in South Africa, there were 43 injuries (3.5%) to the gall bladder (37 from gunshot wounds, three knife wounds and three from blunt abdominal trauma).7
In this study, associated injuries of the liver, pancreas, biliary tree, major intra-abdominal vascular structures (such as inferior vena cava, portal vein or aorta), right kidney, transverse colon, duodenum and stomach were commonly associated with penetrating injuries, especially gunshot wounds. Often it is the severity of the associated injuries that govern subsequent outcome.8
Early diagnosis and treatment is crucial to avoid unnecessary morbidity and mortality.9 10
Patients with gallbladder injury may present with a variety of features. Shock and haemoperitoneum can occur hours after injury from transection of the cystic artery or associated liver or other injuries. Later presentation may occur with right-upper-quadrant pain and biliary peritonitis. Isolated, penetrating gallbladder injuries may produce minimal symptoms initially. A rarer presentation is of blood within the gallbladder causing blockage of the cystic duct and features of acute cholecystitis ensue.11
A high index of suspicion and appropriate selection of imaging studies may lead to early identification.
Management of gallbladder injury is often with open laparotomy. In the case of apparently isolated gallbladder injury, the surgeon should carefully examine for trauma to other nearby organs. The optimum surgical treatment for a gallbladder injury is cholecystectomy.7 8
Suture repair (cholecystorraphy) of penetrating injuries has been described, but there are risks associated with this procedure, such as repair breakdown and subsequent bile leakage. In addition, even absorbable sutures placed in the gallbladder wall carry the risk of forming a nidus for subsequent stone formation. Cholecystectomy eliminates these risks, and the procedure has a fairly low rate of morbidity. The placement of a closed suction drain in the gallbladder fossa is recommended after cholecystectomy to monitor and treat potential postoperative bile leaks. Cholecystostomy (closure of a perforation over a drain, such as a Foley catheter, and leaving the gallbladder in situ) is another potential treatment for gallbladder injury.6
However, this should be seen as only a damage-control option and should only be used in patients who are desperately ill and have other injuries which would mean that taking extra time to perform a cholecystectomy would be potentially dangerous.
Laparoscopic cholecystectomy has been described as the treatment for an isolated gallbladder perforation due to abdominal stab wound.12
However, the laparoscopic approach has some limitations and is generally not recommended in the situation of gallbladder trauma where other concomitant injuries need to be excluded. Although the laparoscope can give a good superficial view of the peritoneal cavity and provide excellent diaphragmatic views, inspection of the duodenum, pancreas and porta hepatitis is not sufficient in the hands of most general surgeons without advanced laparoscopic experience.
- Clinical assessment of the patient with stab injuries may be clouded by other injuries or drug and alcohol intoxication.
- Absolute indications for laparotomy include haemodynamic instability and diffuse abdominal peritonitis (in particular, deep tenderness away from the site of injury).
- Selected patients with penetrating thoracoabdominal trauma can be treated conservatively, without surgery.
- Although penetrating injuries to the right-upper-quadrant/liver may be treated non-operatively, continued vigilance and observation is required so that associated injuries to the gallbladder, biliary tree, stomach, duodenum or transverse colon are not missed.