What is the best definitive management for an 18-year-old male with a stab wound injury adjacent to the umbilicus (navel), presenting with a small, clean wound and ceased bleeding, who is vitally stable with normal laboratory results, and a computed tomography (CT) scan showing a small splenic laceration with minimal surrounding fluid?

From the Guidelines

The best definitive management for this patient is exploratory laparotomy (option D) rather than simple wound closure (option A). This is because the patient has a stab wound to the abdomen with evidence of internal organ damage (splenic laceration with surrounding fluid) on CT scan. While the external wound appears clean with bleeding stopped, the internal injury requires direct surgical exploration to fully assess and repair the splenic injury, check for other potential injuries to abdominal organs that may not be visible on imaging, control any internal bleeding, and clean the peritoneal cavity to prevent infection. Simple wound closure (option A) would only address the external injury while leaving the internal damage unaddressed, which could lead to delayed hemorrhage, peritonitis, or abscess formation. In penetrating abdominal trauma with confirmed organ injury, direct surgical exploration remains the standard of care to definitively manage all injuries and prevent complications, even in a hemodynamically stable patient 1.

The guidelines for splenic trauma management, as outlined in the World Journal of Emergency Surgery 1, support the use of operative management (OM) in patients with hemodynamic instability and/or associated lesions requiring surgical exploration. Although the patient is currently stable, the presence of a splenic laceration with surrounding fluid indicates a need for careful monitoring and potential intervention to prevent complications. The use of non-operative management (NOM) is generally reserved for patients with blunt splenic trauma who are hemodynamically stable and have no associated injuries requiring laparotomy 1.

In this case, the patient's penetrating abdominal trauma with confirmed organ injury necessitates a more invasive approach to ensure thorough evaluation and treatment of all injuries. Exploratory laparotomy (option D) is the most appropriate management strategy, as it allows for direct visualization and repair of the splenic injury, as well as assessment and management of any other potential injuries. The potential benefits of NOM, such as reduced hospital costs and avoidance of non-therapeutic laparotomies, do not outweigh the risks of delayed diagnosis and treatment of internal injuries in this scenario.

Key points to consider in this management decision include:

• The patient's hemodynamic stability does not preclude the need for surgical exploration in the presence of confirmed organ injury.
• The presence of surrounding fluid on CT scan indicates potential ongoing bleeding or other complications that require direct assessment and management.
• Exploratory laparotomy allows for thorough evaluation and treatment of all injuries, reducing the risk of delayed complications and improving patient outcomes.
• The use of NOM is generally reserved for patients with blunt splenic trauma who are hemodynamically stable and have no associated injuries requiring laparotomy.

Overall, the best definitive management for this patient is exploratory laparotomy (option D), as it provides the most comprehensive and effective approach to managing the patient's internal injuries and preventing potential complications.

From the Research

Definitive Management of Splenic Injury

The best definitive management for the 18-year-old male with a stab wound injury next to the umbilicus and a small splenic laceration with minimal fluid surrounding it is:

• Exploratory laparotomy, as it allows for direct visualization and assessment of the injury, as well as the ability to control any bleeding or other complications that may arise 2, 3.

Rationale for Choosing Exploratory Laparotomy

The choice of exploratory laparotomy over other options, such as wound closure or antibiotics, is due to the following reasons:

• The presence of a splenic laceration, even if small, increases the risk of bleeding or other complications, and exploratory laparotomy allows for direct control of these potential issues 2, 4.
• The patient's vital stability and normal lab results do not necessarily rule out the possibility of internal bleeding or other complications, and exploratory laparotomy provides a more thorough assessment of the injury 3.
• While non-operative management (NOM) is often used for blunt splenic injuries, penetrating injuries, such as the one described, may require a more invasive approach, such as exploratory laparotomy, to ensure adequate control of the injury 2, 5.

Comparison with Other Options

The other options, such as:

• Wound closure (A), may not be sufficient to address the underlying splenic injury and potential complications.
• Antibiotics (B), may not be directly relevant to the management of the splenic injury.
• Splenectomy (C), may be considered in some cases, but exploratory laparotomy is often the initial step in managing splenic injuries, and splenectomy may not be necessary in all cases 2, 4.