Intra-abdominal insufflation as a diagnostic modality for penetrating anterior abdominal wall trauma in a busy urban center; a retrospective case-series

Vadim Meytes, DO, Michael Amaturo, DO, Elizabeth E Price, Filippo Romanelli, Michael Timoney, MD. NYU Lutheran Medical Center

The algorithm for evaluating patients with anterior abdominal stab wounds has been a topic of discussion for many years.  It has constantly been evolving in order to be able to manage these patients quickly, accurately, and inexpensively.  Over the years, the algorithm has involved less invasive approaches in order to reduce length of hospital stay and cost. Currently, penetrating anterior abdominal wall trauma is managed by CT scans, local wound exploration, FAST exams, or serial abdominal exams followed by either diagnostic laparoscopy or exploratory laparotomy and close observation. Here we aim to propose a new algorithm for the management of these patients utilizing Veress needle abdominal insufflation to evaluate for posterior abdominal sheath violation in order to avoid further invasive nontherapeutic management.

Eight patients admitted to our Level 1 trauma center with penetrating anterior abdominal wall injuries were evaluated using either local wound exploration or CT scan followed by diagnostic laparoscopy for any intra-abdominal pathology. These cases were then retrospectively evaluated for the efficacy of Veress needle insufflation as a diagnostic modality. Positive insufflation test was viewed as the inability to reach or maintain a target intra-abdominal pressure of 15 mm Hg or if the surgeon could visibly see or hear CO2 escaping from the stab wound.

Eight patients from December 2013 to June 2014 presented after sustaining penetrating anterior abdominal stab wounds. Five patients underwent local wound exploration which revealed violation of the anterior abdominal fascia. The other three patients had CT scans with suspicious findings. All eight patients went to the operating theater for diagnostic laparoscopy. Upon intra-abdominal insufflation using a Veress needle to a target pressure of 15 mm Hg, all patients with posterior abdominal sheath violations (5) had CO2 escape from their wound. All patients without a violation did not have CO2 escape. Our results showed a sensitivity/specificity of 100% and positive predictive value/negative predictive value of 100%.

Utilizing our technique of intra-abdominal insufflation combined with monitoring for CO2 escape, we were able to successfully rule out posterior abdominal sheath injuries. We propose this as a novel diagnostic modality in the decision making for the need of a formal exploration of penetrating anterior abdominal wall injuries. With further research, our technique can be used safely, accurately and in a timely manner for the injured trauma patient.  Our technique would allow for a decreased number of nontherapeutic diagnostic laparoscopies, less risk of complications, and decreased overall cost.

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