Anterior stab selected for observation, scoped for breach, repaired for colon injury — the full selective pathway in one patient

Tasks

1. Laparotomy now, or select? State the guideline and the randomised price of getting this wrong.^[18][19]
2. You select observation — detail the protocol, the failure clock and the consent numbers.^[20][17]
3. At 14 hours he develops localised then generalised peritonitis. CT now shows extraluminal gas. State your operative plan including laparoscopy versus laparotomy, bowel handling and diaphragm check.^[24][26]
4. At operation the sigmoid colon has a 2 cm laceration with moderate faecal contamination and the patient remains stable without shock or major bleeding. Repair or divert — defend with trial and multicentre numbers.^[27][28][30]
5. State your antibiotic plan and duration with the trial behind it.^[34][33]

Model management

1. Select, do not open by routine. EAST: no routine laparotomy for stable stab wounds without peritonitis or diffuse tenderness.^[18] The RCT behind selection: 19% morbidity after mandatory laparotomy versus 8% observed, 17% delayed operations, two days versus five in hospital.^[19] A negative FAST changes nothing here — high specificity but low sensitivity for visceral injury.^[5]
2. Admit for serial examination with CT already done, for a full day. Modern practice observes 83% after near-universal CT with 2% failure; failures declare peritonitis at 10 and 20 hours.^[20] Consent quotes the wider selected experience: 1,505 observed stab patients across 20 studies with zero selection mortality.^[17] Multiple wounds would not change the plan — no extra injury or laparotomy signal.^[16]
3. Operate now — peritonitis ends selection. Diagnostic laparoscopy is reasonable for the breach question in a stable patient but peritonitis with extraluminal gas needs laparotomy with systematic bowel examination; laparoscopy's examined yield is avoiding laparotomy in 54.3% of stable penetrations, not replacing laparotomy for peritonitis.^[24] Inspect the diaphragm whenever the trajectory allows — a fifth of thoracoabdominal penetrations carry injury and CT misses them.^[26][31]
4. Primary repair. Five RCTs: equal mortality with fewer total complications at OR 0.28 for repair over diversion.^[27] The 297-patient AAST resection study: two-thirds anastomosed, complications 24% with no difference between strategies, and the repair-versus-diversion choice itself not a risk factor — contamination, transfusion burden and single-agent prophylaxis were.^[28] EAST low-risk lane (no shock, major bleeding, severe contamination or delay) recommends repair or resection-and-anastomosis over routine stoma across 705 randomised patients.^[30]
5. Twenty-four hours of intravenous antibiotics, then stop. The 300-patient cefoxitin trial randomised 24 hours against five days with no influence of duration on infection.^[34] Regimen choice follows local protocol within the RCT-compared landscape — no placebo trial exists to compare against.^[33]