Validity of Selective Management in Trans pelvic Gunshot Wounds

Abstract

The purpose of this study was to assess the validity of selective management in patients presenting with penetrating transpelvic gunshot wounds. In hemodynamically stable individuals who do not exhibit significant clinical warning signs, non-operative management may be a safe and viable approach. This method, known as selective management, emphasizes the identification of patients who do not necessitate immediate surgical intervention following such trauma. A retrospective analytical study was carried out at the Department of General Surgery, Misurata Teaching Hospital, over two years from February 17, 2011, to February 16, 2013. All patients admitted with transpelvic gunshot injuries were treated according to a predefined management protocol. Surgical exploration via laparotomy was reserved for cases showing clear clinical indicators, such as peritoneal signs, hemodynamic instability, gross hematuria, or rectal bleeding. Patients who did not exhibit these signs were managed conservatively and kept under close observation. The diagnostic accuracy of this selective approach was evaluated by calculating sensitivity, specificity, positive predictive value (PPV), negative predictive value (NPV), and overall accuracy. A total of 37 patients were included in the study and categorized into two groups. The first group consisted of 16 patients (43.2%) who underwent immediate laparotomy based on initial clinical assessment. In 15 of these cases, the procedure was deemed therapeutic. The clinical examination in this group demonstrated a sensitivity of 68.2%, a specificity of 92.3%, a PPV of 93.8%, and an NPV of 63.2%. The second group comprised 21 patients (56.8%) who were managed conservatively under the selective non-operative protocol. Among these, nine patients (24.3%) eventually required delayed surgery due to emerging clinical symptoms, although two of these laparotomies were non-therapeutic. The remaining twelve patients (32.4%) were successfully treated without surgery. For this group, the selective protocol achieved a sensitivity of 100%, specificity of 85.7%, PPV of 77.8%, and NPV of 100%. In conclusion, selective management appears to be a safe and effective strategy for reducing the incidence of unnecessary laparotomies in cases of transpelvic gunshot wounds. The cornerstone of this approach remains careful clinical examination, supplemented by appropriate diagnostic tools. As the adoption of selective non-operative protocols becomes more widespread, the rate of non-therapeutic surgical interventions continues to decline. Nevertheless, the success of this strategy depends heavily on accurate patient selection and strict adherence to the established management criteria.