K. M. Galvin1, A. Grigorian1, S. D. Schubl1, V. Gabriel1, A. Anavim2, A. Rudd2, J. L. Phillips2, J. Nahmias1 1University Of California – Irvine,Trauma And Critical Care Surgery,Orange, CA, USA 2University Of California – Irvine,Radiology,Orange, CA, USA
Introduction: The management of left thoracoabdominal stab wounds (LTASW) continues to be controversial. In hemodynamically stable patients without peritonitis, a delayed diagnostic laparoscopy to rule out diaphragmatic injury is commonly performed. We sought to determine the rate of finding no injuries on diagnostic laparoscopy in patients presenting after a LTASW with no signs of penetration to the muscle or deeper on computed tomography (CT) imaging as determined by an attending radiologist and trauma surgeon. Our secondary aim was to analyze the accuracy of identifying the depth of stab-wound penetration (i.e. muscle or deeper) by differently trained providers: radiology attending (RA) vs. radiology resident (RR) vs. trauma attending (TA) vs. general surgery resident (GSR).
Methods: A retrospective review of trauma patients from a single Level-I trauma center during a six year period was performed. CT images were independently reviewed by a RA, 2ndyear RR, TA, and 3rdyear GSR. A chi-square analysis was performed.
Results: Of 36 patients with LTASW that underwent CT imaging and later diagnostic laparoscopy, 11 (30.5%) had diaphragmatic injuries intraoperatively. Both the radiology and trauma attendings read that 2 (5.5%) patients had LTASW that did not penetrate muscle or deeper on imaging and no diaphragm injury was found intraoperatively (p=0.33). Both attendings were congruent in muscle or deeper penetration for 100% of the patients. The sensitivity and specificity in this limited sample was 100% and 92%, respectively, for the RA and TA. The negative predictive value of the attending read was 100%. The sensitivity and specificity for the RR was 100% and 88%, and for the GSR was 100% and 84%.
Conclusion: Currently, all patients with LTASW undergo a delayed diagnostic laparoscopy to rule out diaphragm injuries. Our small single center pilot study suggests that a subset of patients with LTASW and no signs of penetration to muscle or deeper on CT imaging may not require a delayed diagnostic laparoscopy. This could lead to a decrease in hospital length of stay, health care cost, and/or complications associated with surgery. A future multicenter or prospective study appears warranted.