Abdominal stab wound exploration


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Abdominal stab wound exploration

  1. 1. In the 19th century, penetrating abdominal wounds were managed nonoperatively.The associated morbidity and mortality rates were greater than 70%.1 Experiencegained during World War I, World War II, and the Korean Conflict led to anaggressive approach of operative management for all penetrating abdominalwounds.2 This approach resulted in an unacceptably high frequency of laparotomywith findings negative for trauma. In 1960, Shaftan developed an approach ofselective conservatism for penetrating abdominal injury and revolutionizedabdominal stab wound management.3The optimal method to determine the need for laparotomy has yet to be definitivelyestablished. Abdominal stab wound exploration forms part of a strategy developedby surgeons to allow a more selective approach. In asymptomatic patients with stabwounds to the anterior abdomen, 2 methods are widely used to help determine theneed for laparotomy: • Abdominal stab wound exploration (Subsequent diagnostic peritoneal lavage [DPL], serial clinical evaluation, or both are used to further assess patients in whom an exploration cannot definitively exclude peritoneal penetration.) • Serial clinical evaluationThe objective is to reduce the number of patients with trivial or no intraperitonealinjury who are subjected to laparotomy. However, a high degree of diagnosticaccuracy must be maintained to limit the frequency of missed injury. A reduction inunnecessary hospitalization is also targeted.Investigators in this field are continuing to study other protocols and investigativetools. No protocol is currently universally accepted. Other modalities that have beenstudied include DPL alone, laparoscopy, CT, and ultrasonography. Thesestrategies of selection for laparotomy are explored in greater detail below.Abdominal stab wound exploration is a safe, rapid, and cost-effective tool in themanagement of asymptomatic patients who present with an anterior abdominalstab wound.4 This approach has no place in the treatment of patients who areunstable, who have peritonitis, or who have evisceration. Patients with peritonitisand those who are hemodynamically unstable should undergo mandatorylaparotomy.More than 25% of anterior abdominal stab wounds do not penetrate the peritonealcavity.5, 6 Local wound exploration allows the safe discharge of these patients fromthe emergency department. Only half of the wounds that penetrate the peritoneumcause damage that requires surgical intervention.1, 7 The organs most commonlyinjured with anterior abdominal stab wounds are the small bowel, the liver, and thecolon. Missed hollow viscus injuries are associated with significant morbidity andmortality.The authors advocate abdominal stab wound exploration in asymptomatic patients
  2. 2. who present with an anterior abdominal stab wound. An exploration with negativefindings is reliable and highly sensitive. Abdominal stab wound explorationcombined with further investigation, such as DPL or serial evaluation, achievesacceptable specificity rates. Minimizing the time taken to control ongoingintraperitoneal contamination is critical in penetrating stab wounds, and localexploration is a valuable first step in speeding up the decision-making process.When combined with DPL, abdominal stab wound exploration allows significantinjuries that are not immediately apparent to be identified early.Wound exploration can be performed successfully by surgeons or ED personnelwho are trained in the procedure. This strategy aids with patient flow through abusy emergency department.Flow chart illustrating the management options in patients with a stab woundto the anterior abdomen. Red arrows highlight an approach that favorsabdominal stab wound exploration.AnatomyAn appreciation of the anatomy of the anterior abdominal wall at different levels isessential to understanding the procedure. The differences are highlighted in red onthe diagrams below.Transverse section of the anterior abdominal wall above the arcuate line.Transverse section of the anterior abdominal wall below the arcuate line.Boundaries of the anterior abdomen: • Costal margins (superior)
  3. 3. • Inguinal ligaments (inferior) • Anterior axillary lines (lateral) • Boundaries of the anterior abdominal wall.INDICATIONSSection 3 of 15Abdominal stab wound exploration is indicated in a patient who presents with astab wound to the anterior abdomen, normal vital signs, no signs of peritonitis, andno evidence of evisceration.Stab wound to the anterior abdomen.Some authors advocate local exploration of wounds only anterior to the midaxillaryline. If the wound tracks anteriorly and the end point of the tract is not accuratelydetermined, the patient undergoes diagnostic peritoneal lavage (DPL). If the woundtracks posteriorly and is not obviously superficial, the patient is investigated as for apenetrating flank wound. This often involves a triple-contrast CT scan.8Special circumstances involve patients with additional injuries that require operativeintervention and cases in which the offending weapon or object is retained. • If the patient has additional injuries that require operative intervention, a
  4. 4. wound exploration may be performed in the operating room before the other procedure is commenced. • If the object has been retained and the surgeon strongly suspects that the peritoneum has not been breached, the object may be removed in the operating room and the wound locally explored. In such cases, the surgeon should be prepared to immediately convert to laparotomy, if necessary.CONTRAINDICATIONSSection 4 of 15Abdominal stab wound exploration is contraindicated if immediate laparotomy isindicated. The situations in which immediate laparotomy is indicated include thefollowing: • Unstable patient • Peritonitis • Evisceration (This remains controversial; see paragraph 3 in Selecting Candidates for Laparotomy section.) • Blood on rectal examination or blood in nasogastric tube aspirate suggests intra-abdominal injury (A low threshold for operative intervention is suggested.)Other contraindications to abdominal stab wound exploration include the following: • Lower chest wounds: Exploration of these wounds carries a high risk of iatrogenic pneumothorax. • Flank and back wounds: Some authors advocate exploration of these wounds if they are suspected to be superficial. However, this expectation may be unreliable, and the strong musculature makes the tract difficult to predict or to follow. Local wound exploration may result in further injury or a restart of hemorrhage that had stopped. • Patient refusal or uncooperative patient.Relative contraindications include the following: • Obesity • Multiple abdominal stab wounds
  5. 5. ANESTHESIASection 5 of 15 • Local anesthesia is used. • Use liberally, as patient comfort is essential. The procedure requires patient compliance and adequate anesthesia. Hemostasis is also important. • The authors’ suggested preparation is 1% lidocaine hydrochloride (10 mg/mL) with epinephrine 1:200,000 (5 mcg/mL). Other preparations can be used. • The maximum dose of lidocaine combined with epinephrine is 7 mg/kg, up to 500 mg. • Local exploration in uncooperative patients is best performed in the operating room under general anesthesia.For more information, see Local Anesthetic Agents, Infiltrative Administration.EQUIPMENTSection 6 of 15 • Adequate light source or operating lamp • Sterile gloves • Surgical masks • Surgical caps • Protective eyewear • Sterile gowns • Sterile drapes • Cleaning solution (10% povidone iodine [Betadine] or other suitable solution) • Lidocaine hydrochloride (1%) with epinephrine • Gauze swabs • Suture material (See Technique for suggestion of suture material.) • Wound dressing • Washout irrigant (1 L of 0.9% NaCl) • Scalpel • Blades, 2 • Retractors, 2 • Dissecting forceps (toothed and untoothed) • Needle holder • Scissors (curved dissecting and stitch scissors) • Hemostats, 5 • Diathermy may be used, if available. Diathermy assists with achieving
  6. 6. hemostasis.Equipment required for an abdominal stab wound exploration.POSITIONINGSection 7 of 15 • The patient is positioned supine. • Adequate exposure of the abdomen is essential. • Abdominal stab wound exploration can be effectively performed in the emergency departmentTECHNIQUESection 8 of 15 • Obtain informed consent for the procedure. • Gather and check equipment. • Position the patient supine and elevate the operating table or stretcher to an appropriate height. • Shave and prepare the area around the stab wound. The maintenance of a sterile field is essential. Sterile field. • Local wound exploration requires an operator and an assistant. Both the operator and assistant should scrub, as for any surgical procedure. • Liberally infiltrate local anesthetic with epinephrine around the wound, using standard surgical technique. Adequate hemostasis is necessary to facilitate direct visualization of the tract of the wound and to prevent further hemorrhage in wounds that penetrate the peritoneum. Also, the wound may need to be extended, which may result in further bleeding. For both these
  7. 7. reasons, lidocaine with epinephrine is preferred as the anesthetic agent. Achieving poor hemostasis has been associated with subsequent false- positive diagnostic peritoneal lavage (DPL) results and unnecessary laparotomy. Do not exceed the maximum dose of lidocaine. Anesthetize the wound.• Most stab wounds are small and need to be extended with a scalpel to allow visualization of the underlying fascia. To optimize subsequent wound healing and cosmetic result, midline wounds should be extended vertically and lateral wounds should be extended horizontally along natural skin lines. The required length of extension is determined by the depth of subcutaneous fat. Wounds heal from the sides rather than the ends; hence, lengthening the wound does not affect the repair process. Midline wound: Extend vertically. Lateral wound: Extend horizontally.• The assistant uses the retractors to visualize the depths of the wound. Diathermy is a useful aid in the maintenance of hemostasis. Visualize depths of the wound and maintain hemostasis.• Appreciation of the anatomy of the anterior abdominal wall at different levels is essential. The procedure cannot be safely completed if you do not know which layer you are exploring and what lies immediately beneath it. Transverse section of the anterior abdominal wall above the arcuate line. Transverse section of the anterior abdominal wall below the arcuate line.• Further explore the wound under direct vision, taking care to identify the fascial layers and the musculature. Breach of the anterior rectus fascia requires extension of the fascial defect. This can be achieved with a scalpel, with dissecting scissors, or with diathermy. This allows inspection of the underlying muscle and the posterior layer of the rectus sheath. There is no posterior layer of rectus sheath below the arcuate line, but the rectus fascial defect is still extended to allow inspection of the underlying muscle and transversalis fascia.
  8. 8. Explore under direct vision.• The goal of exploration is to determine the end point of the tract. This is not always easy, especially in more lateral wounds. The fascial planes are more difficult to identify laterally. Following the tract through muscle can be challenging. If the posterior rectus fascia or transversalis fascia is adequately visualized and is intact, the patient does not have an intra- abdominal injury. After adequate wound care, the patient can be discharged from the emergency department. Nonpenetrating wound: External oblique muscle intact in base of wound.• If the posterior rectus fascia or the transversalis fascia is penetrated, the local wound exploration findings are positive. The frequency of peritoneal injury is high in patients with positive findings. Assessing the integrity of the parietal peritoneum itself is technically difficult, and exploring at this level risks converting a nonpenetrating wound into a wound that breaches the peritoneum. If breach of the peritoneum cannot be confidently excluded, the patient requires further assessment and investigation. Penetrating midline wound.
  9. 9. Penetrating lateral wound. (The exploration of this wound clearly determined that the stomach had been penetrated. Therefore, the patient did not require diagnostic peritoneal lavage [DPL], as laparotomy was already indicated. During laparotomy, a hole in the stomach and 2 holes in the small bowel were repaired. The patient had an uneventful postoperative course and was discharged from the hospital 3 days later.) • Patients who require further investigation usually undergo DPL. The wound should be temporarily packed with dry gauze and a sterile dressing until the lavage is completed. This packing helps prevent further hemorrhage into the peritoneum from the wound. A DPL with positive findings further delineates patients who are more likely to have an intra-abdominal injury that requires surgical intervention. The stomach and bladder must be decompressed before DPL. • The wound is then thoroughly irrigated with saline and closed in layers. Hemostasis and sound surgical technique prevent subsequent wound complications. The sheath is closed with strong absorbable suture (PDS 0 or Vicryl 0). Muscle need only be repaired if the defect is large. If muscle repair is necessary, interrupted absorbable sutures (Vicryl 2-0) are used. In individuals who are obese, the subcutaneous fat can be approximated with absorbable sutures. The wound edges rarely require debridement before skin closure. The skin is closed with skin clips, interrupted nonabsorbable sutures, or continuous subcuticular sutures. Some authors have advocated suturing the surgical extension wound but leaving the stab wound to heal by secondary intention to minimize the risk of infection. Unless the wound is markedly contaminated, this is unnecessary. Suture wound in layers. (This patient sustained a nonpenetrating stab wound to the abdomen. After the wound was repaired, the patient was discharged from the emergency department, and routine follow-up wound care was arranged with the local clinic.) • Patients with an exploration with negative findings may be discharged home. Antibiotics are not required. Routine surgical wound care is provided.PEARLSSection 9 of 15The critical concept is to determine the end point of the tract under direct vision. • Ensure good lighting. • Ensure hemostasis and adequate anesthesia. • Extend the wound to allow good visualization.
  10. 10. • Use retractors and a trained assistant. • Use a hemostat or other instrument as a guard to cut onto when exploring the depths of the wound. This assists with accuracy of dissection and prevents extending the wound at a deeper level than anticipated. • The exploration usually takes 10-15 minutes. Meticulous dissection ultimately saves time. • The exploration of an abdominal wound in patients who are markedly obese can be particularly challenging. In these patients, consider performing the procedure in the operating room with the patient under general anesthesia. • Do not probe the wound with a finger or blunt object, as this can cause further hemorrhage, give a false impression of the tract, distort the anatomy of the wound, and introduce infection into the depths of the wound. • Diathermy simplifies the exploration because it helps maintain hemostasis. • When doubt exists, prudence involves further investigation, observation, or consideration for exploratory laparotomy.COMPLICATIONSComplications of abdominal stab wound exploration are rare (rate is approximately1%). Complications include local wound infection and bleeding.Published papers report no false-negative exploration findings.5, 9SELECTING CANDIDATES FOR LAPAROTOMYNo debate exists about the management of patients who are hemodynamicallycompromised or who exhibit peritonitis upon abdominal examination. Thesepatients are immediately transferred to the operating room and undergolaparotomy.The optimal management for an asymptomatic patient with an anterior abdominalstab wound remains controversial. Routine laparotomy was once advocated but isno longer accepted practice. The universally accepted practice is now selectivemanagement of asymptomatic patients with stab wounds. However, the methodsused to select those who will benefit from laparotomy are controversial.No consensus has been reached regarding the treatment of patients withevisceration of omentum or an abdominal organ. Many still opt for operativeintervention in this group and cite a high incidence of organ injury as the reason fortheir standpoint.10, 11 Demetriades and others have shown that these patients can
  11. 11. also be successfully managed nonoperatively, provided that they are stable andthat the findings of their abdominal examination remain benign.12, 13Methods that aid practitioners in the selection of patients whose injuries are likely towarrant laparotomy are an area of ongoing study. Each method has its merits andshortfalls, and combinations of techniques are not uncommon.The 2 most commonly used selective approaches are abdominal stab woundexploration (combined with DPL) and serial clinical evaluation. Results from theavailable studies show comparable patient outcomes.Modern approaches have succeeded in limiting the mortality due to anteriorabdominal stab wounds to as low as 0-3.6%.1, 14 Selective approaches haveachieved unnecessary laparotomy rates of less than 10%.1, 4, 6, 9, 12, 14 In abdominalstab wounds, the morbidity rate of a laparotomy with negative findings is in therange of 1.5-8%.14, 15, 16 Regrettably, a limited number of injuries are still missed.Abdominal stab wound explorationAbdominal stab wound exploration allows for safe and immediate discharge ofapproximately 25% of patients with an abdominal stab wound. When performed bytrained operators, this procedure is 100% sensitive.9 If one considers patients whomandate laparotomy and those who have an exploration with negative findings,local wound exploration can guide an early, clear, and safe decision in more thanhalf of patients who present with an anterior stab wound.9 Unfortunately,positive local wound exploration findings carry a poor specificity for significant intra-abdominal injury. If all patients with positive abdominal exploration findings were toundergo laparotomy, more than 40% would do so unnecessarily.1, 9 Patients withpositive local exploration findings, therefore, undergo DPL to further select thosewho are likely to have an intra-abdominal injury that requires surgical intervention.This strategy successfully reduces the number of nontherapeutic laparotomies.17Diagnostic peritoneal lavageDPL was initially developed as a tool to help assess for intra-abdominal injury inpatients who had sustained blunt trauma. Its value in penetrating trauma isaccepted, but its application is less clear. No consensus exists concerning whatconstitutes a positive result, and protocols vary from one institution to the next. Pre-lavage aspiration of 20 mL of blood is generally accepted as a positive result. Thelavage fluid is assessed for red blood cells, white blood cells, bile, feces, andvegetable matter.Some authors have also assessed various enzymes, including alkalinephosphatase (ALP) and amylase, with limited clinical value. Some authors haveused a red blood cell count of greater than 100,000/μL and a white blood cell count
  12. 12. of greater than 500/μL as the threshold. At these relatively high values, theincidence of missed injury increases and, consequently, even patients withnegative lavage findings are further assessed and observed.4, 6, 14 These cell countcutoff values are the same as those used for blunt trauma. When applied, thesevalues achieve an accuracy rate of 90-91%.4, 18Isolated injuries to hollow organs often cause little bleeding. These injuries arecommonly associated with lavage red blood cell counts of less than 100,000/μL oreven of less than 10,000/μL. However, red cell counts of less than 1,000/μL arealmost never associated with significant intra-abdominal injury.4, 9, 19The white blood cell count threshold is not without problems, either. An elevatedcount raises suspicion of a hollow visceral injury. The intraperitoneal contents donot reliably produce a white cell response to injury until approximately 3 hours afterthe injury occurs. Hence, the timing of the lavage becomes important. Lavagesperformed soon after injury may reflect relatively low white cell counts despitesignificant injury. If significant delay occurs before the lavage is performed, even asimple breach of the peritoneum may produce a significantly raised white blood cellcount.4No threshold for DPL achieves 100% accuracy. The clinician must determine therelative weight of missed injury (false-negative findings) versus that of unnecessarylaparotomy (false-positive findings). Up to 60% of visceral injuries involve the smallbowel or colon.1, 20 Injuries to these organs are still the leading cause of morbidityand mortality in patients with abdominal stab wounds.9 Surgeons are aware that therisk of morbidity and mortality of missed hollow visceral injury far outweighs that ofunnecessary laparotomy; therefore, many have elected to lower their threshold foroperative intervention. DPL is increasingly considered a quantitative assay thatmerely serves to provide further information to assist in decision-making and shouldno longer be used blindly with absolute cutoff values.DPL may be unhelpful in patients with retroperitoneal injury. A lower thresholdincreases the sensitivity of the investigation but results in an increase inunnecessary surgery.21 Demetriades achieved successful nonoperativemanagement of patients with solid viscus injury with a protocol combining serialobservation and CT scan.22 DPL is not organ-specific. Oreskovich and Carricoquote a complication rate for DPL of less than 1%.9Serial clinical evaluationSerial clinical evaluation is a method used by many surgeons as a selectiveapproach to abdominal stab wound management. Approximately 30% of patientswith a significant abdominal injury have initial benign abdominal examinationfindings.1 Furthermore, up to 10% of injuries are initially overlooked, even in the
  13. 13. more advanced trauma centers.23 These statistics clearly demonstrate the value ofserial evaluation.The length of hospital stay in patients whose injuries are managed conservativelyvaries among institutions. One study showed that no significant injuries werediscovered in any patients who were asymptomatic after 12 hours of observation.24Most protocols, however, recommend evaluation of the patient over 24-72 hours.12,25, 26 The delay in laparotomy inherent in such an approach has not been associatedwith adverse outcome.12 This is, possibly, because most severe injuries are obviousearly. Degree of contamination is likely more important than the delay in surgery,provided the delay is not excessive. However, few would argue with the principlethat the time taken to control contamination should be minimized. Martin et al founda 6-fold increase in complications in patients with colonic injury who were notoperated on within 12 hours.27Unfortunately, studies have also shown that 14-28% of patients without an injurythat penetrates the peritoneum have misleading positive abdominal examinationfindings.6, 14, 15Other methods of selectionOther methods of selection have been advocated, but few claim advantage overthe 2 selective approaches discussed above.Some authors advocate DPL alone without prior local wound exploration asparticularly useful in patients who are difficult to assess clinically because of drugsor alcohol or who are to be anesthetized for another procedure. A studysuccessfully used a red blood cell lavage count of less than 1,000/μL as a criterionfor immediate discharge from the emergency department.19 The authors claim thatDPL is a simple procedure with few complications and that the complications, whenthey occur, are usually immediately evident. This view is certainly not shared by all.Sinography ("stabogram") and blind probing of wounds are unreliable procedures.1,28Few authors advocate the use of laparoscopy in the management of anteriorabdominal stab wounds. It may be useful as an adjunct in special circumstances.Laparoscopy is reliable when used to determine breach of the peritoneum or toassess potential diaphragm injuries in patients with wounds to the left upperquadrant or lower chest. It is unreliable in the assessment of hollow visceralinjuries. A protocol of stab wound exploration followed by emergency departmentawake laparoscopy for equivocal cases has been studied, but it resulted in 31.3%of selected patients being exposed to the risks of unnecessary surgery.29 At thisstage, laparoscopy lacks sufficient therapeutic value to be used routinely inabdominal stab wounds.30
  14. 14. Ultrasonography, on its own, is inadequate as an investigation of anteriorabdominal stab wounds and rarely aids in the management of these cases.31Focused abdominal sonography for trauma (FAST) scan has proved to be areliable method of investigation in blunt abdominal trauma, especially when thescan is repeated.32 This type of scan is less helpful in the assessment of patientswith penetrating injury.31, 33 Low sensitivity and low negative predictive value limit itsaccuracy as an investigation. Positive FAST scan findings are useful predictors ofsignificant intraperitoneal injury and, when performed early, can decrease the timeto operation.33 To confidently exclude significant intraperitoneal injury in patientswith negative FAST scan findings, additional investigations are required.33A small study of 35 patients has suggested a role for fascial ultrasonography todetect fascial penetration in anterior abdominal stab wounds.34 As an investigation,fascial ultrasonography had a specificity and positive predictive value of 100%.Positive fascial ultrasonographic findings rule out the need for an abdominal stabwound exploration. Unfortunately, even in more experienced hands, fascialultrasonography had a sensitivity of only 73%. The resultant drawback, therefore, isthat negative fascial ultrasonographic findings do not adequately exclude an intra-abdominal injury, which requires further investigation or observation. Furtherassessment of the use of fascial ultrasonography may be justified.Despite the instrumental role of CT scan in the assessment of penetrating flank andback wounds, it has traditionally been of little help with anterior abdominal wounds.The technology has not adequately revealed hollow visceral and diaphragminjuries.35 Interestingly, the presence of free intraperitoneal air has poor specificityfor intra-abdominal organ injury. Air can track through a defect in the abdominalwall and enter the peritoneal cavity. As part of a prospective study of 651 patientswith abdominal stab wounds, 18 patients with free air under the diaphragm on plainradiograph were managed conservatively by method of serial examination. Only 2of these patients went on to laparotomy, and no adverse outcomes were reportedin the other 16 patients.12With improved technology, CT scan may be becoming a more useful study forpenetrating abdominal wounds. More recent studies find fewer missed hollowvisceral injuries than was previously reported.22, 36 Serial clinical evaluation, whencombined with CT scan, has been shown to be an effective strategy in the selectivemanagement of abdominal stab wounds.22, 36 This approach is only suitable for well-staffed major centers with sufficient experience in abdominal stab woundmanagement.Further developmentsFurther trials (or, perhaps, technology) may provide the next development inanterior abdominal stab wound management. No meaningful change has occurredin decades in the suggested management of this important and growing group of
  15. 15. patients. No single investigation is likely to provide all the information necessary toaccurately determine which patients are likely to have injuries that require surgicalintervention. The combination of physical examination and other investigations hasallowed a reduction in unnecessary intervention.37A multidisciplinary working party recently developed evidence-based guidelines forthe management of haemodynamically stable patients with stab wounds to theanterior abdomen. They conducted a systematic review of the available literatureand recommended the use of abdominal stab wound exploration.38For now, abdominal stab wound exploration remains a valid and effective tool thatallows safe and early discharge of a significant number of patients. It is alsovaluable as a first step in a process that limits the time to decision-making in themanagement of asymptomatic patients with anterior abdominal stab wounds.FURTHER READINGCayton CG, Nassoura ZE. Abdomen. In: Ivatury RR, Cayton CG, editors. Textbookof Penetrating Trauma. 1st ed. Baltimore, Md: Williams & Wilkins, 1996:281-299.Kirby R, Viswanathan S, Jiang R. Diagnostic and Therapeutic techniques. In:Sherry E, Trieu L, Templeton J, editors. Trauma. 1st ed. New York: OxfordUniversity Press, 2003. p.715-716.Back and flank woundsCoppa GF. Back and Flank. In: Ivatury RR, Cayton CG, eds. Textbook ofPenetrating Trauma. 1st ed. Baltimore, Md: Williams & Wilkins, 1996:300-308.Diagnostic peritoneal lavageMarx J. Diagnostic Peritoneal Lavage. In: Ivatury RR, Cayton CG, editors.Textbook of Penetrating Trauma. 1st ed. Baltimore, Md: Williams & Wilkins,1996:335-343.Wilson RF, Walt AJ. General Considerations in Abdominal Trauma. In: Wilson RF,Walt AJ. Management of Trauma: Pitfalls and Practice. 2nd ed. Baltimore, Md:Williams & Wilkins; 1996:411-431/20.
  16. 16. Media type: IllustrationMedia file 4: Boundaries of the anterior abdominal wall. View Full Size ImageMedia type: Illustration
  17. 17. Media file 5: Stab wound to the anterior abdomen. View Full Size ImageMedia type: PhotoMedia file 6: Equipment required for an abdominal stab wound exploration. View Full Size ImageMedia type: Photo
  18. 18. Non-penetrating wound. External oblique muscle intact in base of wound
  19. 19. Penetrating midline woundPenetrating lateral wound to the stomach requiring exploration