Controversial aspects of diagnosis and management of blunt abdominal trauma

Controversial factors from the literature in the diagnosis and management of blunt abdominal trauma have been discussed in relation to experiences with 278 patients during the past sixteen years. There should be little controversy over the need for a team approach in the management of these patients. The frequency of multiple intra-abdominal injuries requires broad experience with all abdominal surgery or close cooperation between general surgeon and urologist. A transperitoneal approach through a midline incision seems preferable to more limited procedures. The frequency of extraabdominal injury further encourages close consultation with the orthopedist, thoracic surgeon, and neurosurgeon. Special diagnostic procedures do not replace repeated clinical evaluation in diagnostic accuracy. Realization that roentgenograms are of very limited value except in injuries of the genitourinary tract may decrease controversy regarding their routine use. The value of the white blood cell count as an aid to diagnosis of visceral injury is lessened in the light of the frequent leukocytosis which occurs with injuries to the extremities and head in the absence of abdominal injury. Needle paracentesis is of value only when performed carefully and when negative aspirations are not considered of diagnostic significance. Controversies regarding the management of injuries to specific organs have been discussed. Pancreatic fistulas continue to occur after external drainage procedures; further evaluation of internal drainage with the initial operation is encouraged. Liver resection should present no controversy if it is performed when necessary to accomplish adequate debridement. Double catheter drainage after repair of injury to the bladder seems less important than assurance that the drainage tube remains open. Much of the controversy regarding management of abdominal injuries may arise from combining statistically those patients with blunt and open injuries or failure to appreciate the importance of multiple injury.