A 35-year-old woman is brought to the trauma bay after a stab wound to the left lower abdomen. She is conscious, blood pressure 108/70 mmHg, heart rate 96/min. Abdominal examination reveals a 2 cm laceration with minimal bleeding, no peritoneal signs, and no evisceration. FAST examination is negative for free fluid. Hemoglobin is 13.2 g/dL. She has no other injuries. What is the most appropriate management?

Explanation

## Penetrating Abdominal Trauma: Selective Non-Operative Management ### Clinical Context This patient has a **stable, penetrating abdominal wound** with **negative FAST** and **no peritoneal signs**. The key question is whether the fascial layer has been breached. ## Indications for Laparotomy in Penetrating Abdominal Trauma ```mermaid flowchart TD A[Penetrating abdominal wound]:::outcome --> B{Peritoneal signs or evisceration?}:::decision B -->|Yes| C[Laparotomy]:::urgent B -->|No| D{Hemodynamically stable?}:::decision D -->|No| E[Resuscitate + Laparotomy]:::urgent D -->|Yes| F[Local wound exploration]:::action F --> G{Fascia violated?}:::decision G -->|Yes| H[Laparotomy]:::action G -->|No| I[Observe, serial exams]:::action ``` ## Key Point: **Local wound exploration is the gold standard for determining fascial integrity in hemodynamically stable patients with penetrating abdominal wounds and no peritoneal signs.** If the anterior rectus fascia is intact, the patient can be managed non-operatively with observation [cite:ATLS 10th Edition]. ## High-Yield: - **Mandatory laparotomy indications:** - Peritoneal signs (rebound, guarding, rigidity) - Evisceration - Hemodynamic instability - Positive FAST - Fascial violation on local wound exploration - **Selective non-operative management (SNOM) criteria:** - Hemodynamically stable - No peritoneal signs - Fascial integrity confirmed - Reliable patient for follow-up - Serial abdominal exams q 2–4 hours × 24 hours ## Clinical Pearl: **Local wound exploration is performed under adequate anesthesia (local + IV sedation or general anesthesia) by extending the wound under direct visualization to assess the fascia.** Probing with a finger or instrument is insufficient; the entire wound tract must be visualized. ## Mnemonic: **"SNOM criteria" = Stable, No peritonitis, Objective fascial integrity, Monitored follow-up** ## Rationale for Correct Answer: This patient meets criteria for local wound exploration: 1. Hemodynamically stable (BP 108/70, HR 96) 2. No peritoneal signs 3. Negative FAST 4. Small laceration (2 cm) — likely superficial Local exploration will determine whether the fascia is violated. If intact, she can avoid unnecessary laparotomy. If violated, laparotomy is then performed.