The treatment of penetrating trauma to the flank remains somewhat controversial, although there is a tendency toward more conservative management. Some patients present with signs and symptoms that mandate immediate exploratory celiotomy.

Although in the past, celiotomy was more liberally utilized, it should be reserved for those patients who present with these conditions:

• Hemorrhagic shock

• Peritonitis

• Evisceration

• Transabdominal missile path

• Intraperitoneal free air

At the time of surgery, all intraperitoneal and retroperitoneal organ structures should be evaluated according to standard operative procedures.

Although some surgeons still advocate mandatory exploratory laparotomy in an effort to detect all injuries early, most surgeons now advocate selective management with early CT scanning, which allows many injuries to be managed by close observation. Using this conservative approach, celiotomy rates have been decreasing from 100 percent to approximately 30 percent with the incidence of positive laparotomy rising from 15 percent to approximately 80 percent, without increases in untoward outcome.5 Using this approach, the risks associated with the "negative laparotomy" (early: hemorrhage and infection; and late: complications small bowel obstruction) as well as added expense are avoided. Many recent reviews support this selective management approach.

Exploratory laparotomy is most commonly performed for flank gunshot wounds. Many flank stab wounds can be safely managed conservatively. In the case of high-velocity gunshot wounds, blast effect must be considered. Depending on the exact location and type of injury, consideration of the blast effect may lead to exploratory laparotomy if there is concern as to the bowel, bladder, or vascular integrity; or laparoscopy may be used to determine the extent of intraperitoneal injury. An experienced surgeon should perform laparoscopy, as bowel injuries may be difficult to detect.

With CT, the exact depth of a stab wound can often be determined. Decision algorithms based upon low-risk patients' flank stab wounds (penetration superficial to the deep fascia) or high-risk (penetration beyond the deep fascia) have been developed and appear to be clinically justified. 6 Hemodynamically stable patients with stab wounds to the flank can be risk-stratified based upon these contrast-enhanced computer tomography findings. Low-risk patients may be discharged immediately from the Emergency Department. High-risk patients require surgical consultation and should be admitted to the hospital, but in many cases a discharge decision can be made within 24 h.

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