Selective non-operative management for abdominal trauma in the deployed military setting: a review of evidence and considerations for large-scale combat operations (LSCO).

Abstract

In recent decades, there has been a recognition that selective non-operative management (SNOM) is both safe and feasible for selected patients following blunt and penetrating abdominal trauma. SNOM has been shown to reduce the rate of non-therapeutic laparotomy in the civilian context, even in the management of some patients with gunshot wounds (GSW). SNOM in the military context is both more controversial and challenging, given the different patterns of injury, resource constraints and extended evacuation chain. A review of the available literature was undertaken to help inform the development of best practices in military decision-making for deployed personnel. In anticipation of minimal military data regarding SNOM, attention was paid to translational evidence from the combined civilian-military literature. Within these limitations, SNOM may be appropriate in a highly selected subgroup of military patients in favourable circumstances. Suitable patients must be haemodynamically stable, without evidence of peritonitis, evisceration, bleeding or injury to hollow viscera and without associated significant head, spinal cord or other major extra-abdominal injuries. SNOM in the deployed setting may help to avoid the morbidity associated with non-therapeutic laparotomy and conserve limited resources. However, caution is advised when translating civilian data to the military setting, and future investigations should focus on military-specific injury patterns and resource limitations. Furthermore, the application of SNOM guidelines to the context of large-scale combat operations is more complex, and close monitoring of patient outcome data must be undertaken to evaluate the impact of SNOM in this context.