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Re: Guidelines for the management of haemodynamically stable patients with stab wounds to the anterior abdomen

Dr Nau raises some very important points relating to our article ‘Guidelines for the Management of Haemodynamically Stable Patients with Stab Wounds to the Anterior Abdomen’.1 First, we agree with Dr Nau that it is important to have practice guidelines for key conditions not just in trauma but throughout surgery and medicine. We must recognize, however, that there are challenges with guidelines, relating in part to keeping them up to date with published work, and second, ensuring that quality of articles referenced is maintained. We recognize local wound exploration can be challenging, and when we included it, it was on the basis of the article by Leppaniemi and co-workers, in which 19% of 109 patients with anterior abdominal stabs had intact fascia and were spared further abdominal investigation.2 Bautz in his editorial quiet rightly points out it can be a tricky procedure and should not be done in obese patients and those with multiple anterior abdominal stab wounds.3 Our library searching methods did not manage to locate the publication from Unfallchirurg in 2003.4 The Eastern Association Surgery Trauma (EAST) guidelines were published in April 2007 and were not available when we submitted our article in early 2006.5 These guidelines relate to both gunshot and stab wounds. It is very encouraging to see them update the original version from 1998, which were one of the first guidelines produced by EAST.6 Increasingly, computed tomography (CT) is coming of age, and yes, we agree there may be a role for CT, but unfortunately articles like those by Shanmuganathan and co-workers relate to different types of mechanism of injury.7 Interestingly, the CT scanner used in their series was an ‘earlier’ model, but the radiologist reporting on the scans is probably one of the worlds most experienced. Triple-contrast scanning would rarely be indicated in an anterior abdominal stab wound. The issue of serial physical examination and laparoscopy will relate to institutional resources. Continuity of care can be challenging to achieve with shortened hours and a missed injury may have serious consequences. Laparoscopy affords a rapid mode of investigation. We would like to thanks Dr Nau for his thoughtful and important comments. We hope that all institutions in Australia and New Zealand will adopt a guideline that is tried, tested and reviewed for their hospital.