Management and Complications of Gunshot Wounds to the Abdomen
Gunshot wounds to the abdomen require immediate surgical exploration in most cases, with selective non-operative management reserved only for hemodynamically stable patients in specialized trauma centers with continuous monitoring capabilities. 1
Initial Assessment and Management
Hemodynamic Status Evaluation
- Unstable patients: Immediate surgical exploration is mandatory
- Stable patients: Further assessment may be considered in specialized centers
Assessment Algorithm
Primary survey: Assess hemodynamic status using ACS/ATLS classification 1
- Class I-II: Potential candidate for selective management
- Class III-IV: Immediate surgical exploration
Local wound exploration (LWE) to confirm peritoneal violation 1, 2
- If no peritoneal violation: Patient may be discharged if no other injuries
- If peritoneal violation present: Proceed to next step
CT scan evaluation in stable patients with peritoneal violation 1
- Sensitivity of approximately 80% for detecting intestinal injuries
- Particularly useful for evaluating retroperitoneal organs or colon in flank/posterior wounds
- Warning: A negative CT should not be the sole determinant for discharge 2
Operative Management
Indications for Immediate Laparotomy
- Hemodynamic instability
- Peritoneal signs
- Evisceration
- Free air on imaging
- Rectal bleeding or gross hematuria
- Bullet trajectory through multiple anatomical compartments
Intraoperative Considerations
- Classify injury as destructive or non-destructive
- Evaluate risk factors: fecal contamination, shock, associated injuries 2
- Primary repair is preferred for most injuries with lower energy transfer 2
Selective Non-Operative Management (SNOM)
SNOM may be considered only in specialized centers with the following conditions 1, 2:
- Hemodynamically stable patient
- Cooperative patient capable of reliable serial examinations
- Absence of peritoneal signs
- Availability of continuous monitoring and immediate surgical capability
- Experienced trauma surgeons available for consistent evaluations
SNOM Requirements
- Minimum 48 hours of serial clinical examinations by consistent specialists
- Continuous vital sign monitoring
- Serial inflammatory marker testing 2
- Immediate surgical exploration if:
Potential Complications
Early Complications
- Hemorrhagic shock (leading cause of early mortality)
- Hollow viscus perforation with peritonitis
- Solid organ injury with bleeding
- Vascular injury with exsanguination
- Missed injuries (particularly retroperitoneal)
Late Complications
- Intra-abdominal abscess
- Anastomotic leakage
- Wound infection
- Enterocutaneous fistula
- Adhesive bowel obstruction
- Abdominal compartment syndrome
Special Considerations
Transpelvic Gunshot Wounds
- Higher likelihood of intraabdominal organ injury
- Clinical examination has shown 100% sensitivity and 71.4% specificity in detecting need for laparotomy 3
- Selective management can be safe even with high likelihood of intraabdominal injury 3
Right Upper Quadrant Wounds
- May be selectively managed in highly specialized centers
- Requires stable vital signs and minimal abdominal tenderness 4
- Continuous availability of surgical team and operating room
Pitfalls and Caveats
- Missed injuries: The most dangerous complication of selective management
- Delayed diagnosis: Can lead to increased morbidity and mortality
- Over-reliance on imaging: Clinical examination remains the cornerstone of decision-making
- Inadequate monitoring: SNOM requires continuous and consistent evaluation
- Inappropriate patient selection: Not all patients are candidates for SNOM
While selective non-operative management has shown promising results in carefully selected patients 3, 5, 4, the traditional approach of mandatory exploration remains the safest option for most patients with abdominal gunshot wounds, particularly in centers without extensive experience in trauma management.