A heuristic approach and heretic view on the technical issues and pitfalls in the management of penetrating abdominal injuries

There is a general decline in penetrating abdominal trauma throughout the western world. As a result of that, there is a significant loss of expertise in dealing with this type of injury particularly when the patient presents to theatre with physiological instability. A significant percentage of these patients will not be operated by a trauma surgeon but, by the "occasional trauma surgeon", who is usually trained as a general surgeon. Most general surgeons have a general knowledge of operating penetrating trauma, knowledge originating from their training years and possibly enhanced by reading operative surgery textbooks. Unfortunately, the details included in most of these books are not extensive enough to provide them with enough armamentaria to tackle the difficult case. In this scenario, their operative dexterity and knowledge cannot be compared to that of their trauma surgeon colleagues, something that is taken for granted in the trauma textbooks. Techniques that are considered basic and easy by the trauma surgeons can be unfamiliar and difficult to general surgeons. Knowing the danger points and pitfalls that will be encountered in penetrating trauma to the abdomen, will help the occasional trauma surgeons to avoid intraoperative errors and improve patient care. This manuscript provides a heuristic approach from surgeons working in a high volume penetrating trauma centers in South African. Some of the statements could be considered heretic by the "accepted" trauma literature. We believe that this heuristic ("rule of thumb" approach, that originating from "try and error" experience) can help surgical trainees or less experienced in penetrating trauma surgeons to improve their surgical decision making and technique, resulting in better patient outcome.