The fallacy of a roadmap computed tomography after an abdominal gunshot wound: A road that leads to nowhere

The 2019 Western Trauma Association guidelines recommend an abdominopelvic computed tomography (CTAP) in patients with a question of abdominal penetration after a gunshot wound. However, it is common practice to obtain a CTAP to provide a roadmap for an operation or to potentially alter management even in patients with classic indications for a laparotomy. The hypothesis for this study was that a CTAP for preoperative planning has no value in patients with an abdominal gunshot wound.

This was a retrospective study from 2017 to 2022 of patients with an abdominal gunshot wound who had a preoperative CTAP. Data collection included clinical characteristics and CTAP and operative findings. Admission hypotension, abdominal pain and/or peritonitis, evisceration, and a transabdominal trajectory were considered clear indications for laparotomy. Computed tomography and operative findings were compared to determine concordance and if computed tomography altered management.

There were 149 patients included in the study, of which 72.5% had a clear indication for laparotomy. The CTAP findings were concordant with operative findings in 57.0% of patients, while additional injuries were found at laparotomy in 36.2% of patients. Based on CTAP, a negative diagnostic angiogram was performed in three patients (2.0%). Three patients (2.0%) underwent a trial of nonoperative management based on CTAP findings. All underwent laparotomy after a clinical change. Six patients (4.0%) had a nontherapeutic operation; all patients had findings suspicious for either a hollow viscous injury or a vascular injury on preoperative imaging.

While a CTAP scan may help to define an intra-abdominal trajectory when the trajectory is unclear, it does not alter management in those with indications for operation. In addition, CTAP missed injuries in a third of patients and contributed to all six nontherapeutic laparotomies. A preoperative CTAP has minimal value in patients who have indications for an operation.

Diagnostic Test/Criteria; Level IV.