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2012 JOURNAL OF UNIVERSAL SURGERY

Vol. 1 No. 1:2 doi: 10.3823/801

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Features of the Cases Injured by Stab Wounds

Omer Engin1, Fuat Ipekci1, Bulent Calik2, Ahmet Deniz Ucar3, Volkan Tekin3
1 Tepecik Training and Research Hospital, Surgery Department, Izmir,Turkey 2 Buca Seyfi Demirsoy State Hospital, Surgery Department, Izmir, Turkey 3 Izmir Bozyaka Training and Research Hospital, Surgery Department, Izmir, Turkey * Correspondence: omerengin@hotmail.com

Abstract
Background: Criminal attacks involving stab wounds can be seen all over the
world. Stab wounds and related organ injuries are somehow different than other kinds of injuries. Specification of our series was done and recent classical knowledge is presented.

Methods and Findings: Stab wound injuries admitted to our hospital with penetration to the abdominal and/or thoracic cavities were examined retrospectively. Age, sex distribution, abdominal penetration, injured organs and their characteristics, morbidity and mortality rates were investigated.:Majority of the cases in our series was constituted by male gender.And ages older than andropause was minimal. Almost all the cases had abdominally penetrated wounds, negative laparotomy ratio was 25,5%. Average number of injured organs in positive laparotomy section was 1,16 and if an organ was injured, associated organ injury probability was found to be variable. For example, associated organ injury rate was 40% in liver injury but the percentage rises up to 80% in colonic injuries.

Conclusions: Increasing the security measures may help to reduce stab wound
injury events in urban places where criminal attacks are seen more frequently. Preventing the injured and accused people from facing each other during recovery in the same ward and re-involving in criminal events by psychological approach may affect personal behaviour positively. Abdominal penetration does not necessarily cause intra-abdominal organ injury. Surgeon must make an effort to reduce the number of negative laparotomy. If the patient needs emergency operation, surgeon should perform the appropriate surgical intervention without delay. Exploration of the abdomen should include inspection of all the intra-abdominal organs and if an organ injury is detected, meticulous inspection must be done while exploring the neighboring anatomical structures.

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Key words: stab wound; abdominal injury; thoracic trauma; abdominal trauma;
colon perforation; liver injury; splenic injury; hemorrhagic; mortality

Introduction
Stab wound injuries are seen as life threatening events worldwide which need urgent intervention. Some places are more likely to witness this kind of assault. People living in a particular city know these places where stab wounds, gunshot Copyright iMedPub

wounds and violent events are more frequently seen. Stab wound injured patients are brought to the hospital by ambulances or private vehicles. Sometimes two or more victims may be put together in a private vehicle (automobile) in order to bring them to the hospital. In the case of ambulance transportation, depending on the patient situation, correct hospi-

iMedPub Journals

2012 JOURNAL OF UNIVERSAL SURGERY

Vol. 1 No. 1:2 doi: 10.3823/801

Our Site: http://www.imedpub.com/

tal choice is made by the central control unit of emergency care centre taking into account the intensive care unit and operation room condition. If the patient is being brought in a private vehicle, destination is always the nearest hospital as a rule. This choice of transportation may change in accordance with the educational level of that population.

Table 1. Organ injuries and negative laparotomy ratios.

Methods
Stab wound injury admissions between 2008 and 2010 which were operated under general anesthesia were investigated retrospectively. Cases with abdominal or thoracic penetration were included in the study. Demographic characteristics, wound site and peculiarity, injured organs, treatment protocols, mortality, morbidity were examined retrospectively.

Results
91 cases of stab wound injuries were operated under general anesthesia. Male/female ratio was 80/11. Average male age was 33,85 (17-62) and average female age was 36 (20-60). Mean age was 34,1 in our series. Suicidal stab injury was seen in 3 cases but all the remaining cases had been attacked by someone as a criminal assault. Abdominal penetration was seen in 81 cases, thoracic penetration number was 1 and both cavity penetration number was 9 in 91 cases. Evisceration was a matter in 7 cases. There were 13 patients with tube insertion (thoracostomy) in which 9 of the cases had thoracic stab wound injuries and 4 diaphragmatic ruptures due to abdominal stab wound injury through the diaphragm. Single organ injury number was 31 (34%), multi-organ injury number was 37 (40,5%) negative laparotomy number was found to be 23 (25,5%) (Table 1). Single organ injury probability numbers were as follows; liver: 9; small bowel: 5; spleen: 4; colon: 2; kidney: 2 and other organs followed with different frequencies. Total number of the injured organs detected in 91 cases was as follows; small bowel: 17; liver: 15; colon: 15; spleen: 7; stomach: 6; diaphragm: 4; duodenum: 2; pancreas: 1; heart: 1 and others: 11 (Table 2). One patient has got early intestinal obstruction due to obstructive bands and went to relaparotomy. Ileostomy maturation procedure has been done in one case of enterocu-

taneous fistula after primary suturing of the ileum in the first operation. Small bowel resection was performed in one case. Primary suturing was the sole process in the remaining cases of organ perforation. Bile leakage developed in a case of primary suturing in a liver injury and spontaneously regressed after medical therapy. Associated organ injury rate was variable for each organ in our series. For example associated organ injury percentage was 40% in liver injuries, whereas, it was 70,5% for small intestine, 80% in colon and 43% in splenic injuries. Ten patients needed blood transfusion. Average blood transfusion amount was 3,7 (1-6) units per case. Three cases died (3/91; 3%).

Table 2. Number of the injured organs.

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Vol. 1 No. 1:2 doi: 10.3823/801

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Discussion

Penetrating injury can be seen after different kinds of events including stab wounds, gunshot wounds, industrial accidents, falls from height, traffic accidents etc. The name of the organ(s) wounded and characteristics of injury is subject to change in every particular case. Demographic property of every single case can also have definitive peculiarity as well. Home accidents are frequently seen in female population, whereas, industrial accidents are more common in males (1,2). Male domination is evident in our series and age distribution rises with the adolescent ages and shows an accumulation as a peak at mature ages then drops down especially just at the beginning of andropause (Table 3). Medical literature reveals similar results about crime-gender and crime-age distribution. Criminal activities rise in adolescence, peak in early adulthood, and then decline thereafter. Age and gender dispersions of both victims and suspects always show the same manner which means that both of these two populations are more likely to come eye to eye in intentional events (3,4). The most frequent age of onset of symptoms related to andropause was 51-60 years. Number of stab wound injured people after andropause in our series was minimal (Table 3). Andropause seems to be a gift for a person which prevents him from involving in a criminal scenario as both victim and offender. Testosterone appears to be the responsible agent for crime and stab wound injuries (5). Stab wound injuries admitted to the emergency care unit may involve only one body cavity like only thoracic or only abdominal cavity. Multiple cavities may also be involved

which we call thoracoabdominal injury. These two cavities were examined in our study because surgeons are supposed to perform successful intervention of both those cavities. Patients operated under general anesthesia in the operating room conditions were included and cases in which only tube insertion (thoracostomy) under local anesthesia performed were excluded from the study. In addition to the stab wound site, direction of the tool in the body is also important. Left upper quadrant intrusion continuing to the right and inferomedial as an oblique manner can result in pancreatic head and duodenum injuries. If this kind of entrance continues upwards, diaphragmatic rupture would not be unlikely. Long tools used in a crime have a chance to proceed in the body more than expected and may result multiple organ injury in contrast to a relatively short one. On the other hand, if the victim is slim, a short knife can create disastrous and multiple organ injuries unexpectedly. The force applied on to the tool is also important. Forceful intrusion of a relatively short knife can result a retroperitoneal injury. 3D dimension of the knife is important as well. A thin knife may cause minimal injury at the adjacent organs, whereas, thick ones may be more harmful. A thick knife may cause damage to the neighbouring organs such as duodenum, pancreas and liver together at a single onslaught for example. Patients weight, tool dimensions, trace of injury in the body are guide parameters and surgeon should keep them in mind during the exploration. Surgeon should explore meticulously all the organs one by one including the ones located in the lesser omental sac; otherwise, overlooked injuries on the unexplored organs may increase morbidity and mortality. Wound site exploration is important to decide whether or not abdominal penetration took place. Making sure the peritoneal integrity is not disrupted is crucial. Evisceration from the wound site is the proof of abdominal penetration. Evisceration percentage was 7,7% in our series. In the literature this number is given as 17,4% in some other studies. Abdominal penetration does not cause organ injury itself. All negative laparotomy cases had abdominal penetration, furthermore two cases with evisceration revealed negative laparotomy (6). Tube thoracostomy can be applied in hemopneumothorax. Stab wounds around the surrounding tissues of thoracic cavity (thoracic wall, diaphragm) may result in hemopneumothorax. Hemopneumothorax may be seen after thoracic wall injury in a direct manner or diaphragmatic rupture resulting as consequence of an abdominal tracing stab wound injury. Tube thoracostomy procedure was applied in 4 (4,04%) cases where hemopneumothorax was due to thoracic injury which was caused by abdominal injury trespassing diaphragm. There are some case series of abdominal stab wounds with 14% diaphragmatic injury in the literature. Meticulous diaphragm exploration should be done. This kind of diaphragmatic rup-

Table 3. Age distribution of the male cases.

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Vol. 1 No. 1:2 doi: 10.3823/801

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ture must be kept in mind because respiratory failure, incarceration of the internal organs at early phase and late term organ herniation problems may be seen (7,8). Negative laparotomy rate was 25,5% in our series which is comparable with the literature but considerably high in our opinion. There are studies claiming selective non-operative management for stab wounds to the anterior abdomen can reduce this ratio (9,10). Laparotomy is performed after decision of operation. All organs must be examined during laparotomy. Single organ injury rate was 34% and multiple organ injury rate was 37% in our series. These two numbers are nearly equal. Positive laparotomy cases were 68 and number of organs injured was 79. Rate of some organs injured with associated organ injury ratio differs from some others. For example, associated organ injury rate for liver was 40% however this rate was 80% in colonic injury. We noticed organ damage as a rule in all our cases of diaphragmatic rupture due to abdominal cavity trespassing stab wound injury. Table 4 demonstrates the damaged organs and associated organ injury rates.

If no necrotic tissue was found or early surgical intervention was performed or no future stricture was expected after suturing, we preferred primer suturing in small intestine and colonic injuries. If intestinal wall was not alive or multiple lacerations were close to each other and suturing of them would probably result in stricture in the future, we preferred resection. Tendency to primary anastomosis instead of fecal diversion in colonic injury is increasing in the literature knowledge. Ileostomy conversion was done in one of the cases with small intestinal injury primary sutured in the first intervention (14,15)

Table 5. The damaged and mostly injured neighboring organs.

Injured organ Liver Small Intestine Colon Diaphragm Spleen Pancreas Stomach Duodenum Kidney The most common associated organ injury Kidney Colon Small Intestine Liver Diaphragm Small Intestine Liver, Diaphragm, Colon Liver Liver

Table 4. Damaged organ and associated organ injury rates. Associate organ injury rates are in the vertical column and each organ is seen in the horizontal column. For example if duodenal injury is seen first, ratio of the associated organ injury is 100%. These associated organs are liver, pancreas etc.

Solid organ injury may be treated either operatively or nonoperatively. Non-operative follow up studies show good results. Conservative treatment modalities are increasingly taking more place . Non-operative follow up necessitates stable patient, CT and USG, intensive care unit, operating room and blood bank availability. If surgeon decides on operation, surgical restoration can be done according to severity of injury (16,17,18). As a result, increasing the security measures may help to reduce stab wound injury events in urban places where criminal attacks are seen more frequently. Preventing the injured and accused people from facing each other and re-involving in the criminal events by psychological approach may affect personal behavior positively. Defining the abdominal penetration at the time of hospital admission is important. Abdominal penetration does not necessarily result in intra-abdominal organ injury. Surgeon must make an effort to reduce negative laparotomy number. If the patient needs emergency operation, surgeon should perform the appropriate surgical intervention without delay.

Table 5 demonstrates the damaged and mostly injured neighboring organs. Any given associated organ injury in a particular damaged organ may be similar in different series but these organs are always in close anatomic positions. That is to say, in a case of organ injury detection, neighboring organs must also be examined.(11,12,13).

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2012 JOURNAL OF UNIVERSAL SURGERY

Vol. 1 No. 1:2 doi: 10.3823/801

Our Site: http://www.imedpub.com/

References
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10. Clarke SCE, Stearns AT, Payne C, McKay AJ. (2008) The impact of published recommendation on the management of penetrating abdominal injury. British Journal of Surgery.95:515-521 11. Govender M, Madiba TE. (2010) Current management of large bowel injuries and factors influencing outcome. Injury. 41(1): 58-63 12-Armenakas NA, Duckett CP, McAninch JW. (1999) Indications for nonoperative management of renal stab wounds. The Journal of Urology. 161(3):768-771 13. Sikhondze WL, Madiba TE, Naidoo NM, Muckart DJJ. (2007) Predictors of outcome in patients requiring surgery for liver trauma. Injury. 38(1):65-70. 14. Butt MU, Zacharias N, Velmahos GC. (2009) Penetrating abdominal injuries: management controversies. Skandinavian Journal of Trauma, Resuscitation and Emergency Medicine. 17:19. 15. Sitnikov V, Yakubu A, Sarkisyan V, Turbin M. (2009) The role of videoassisted laparoscopy in management of patients with small bowel injuries in abdominal trauma. Surg Endosc. 23:125-129 16. -Zargar M, Laal M. (2010) Liver trauma: Operative and non-operative management. International Journal of Collaborative Research on Internal Medicine&Public Health. 2(4): 96-107. 17. Mikocka-Walus A, Beevor HC, Gabbe B, Gruen RL, Winnett J, Cameron P. (2010) Management of spleen injuries: the current profile. ANZ Journal of Surgery; 80(3): 157-161 18. Brooks A, Simpson JAD. (2009) Blunt and penetrating abdominal trauma. Surgery. 27(6): 266-271

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