Introduction

Penetrating thoracoabdominal injuries raise a critical surgical question: which cavity should be explored first, the chest or the abdomen? In unstable patients, an incorrect initial approach may delay control of the dominant life-threatening injury.

Aim

The aims of this study were to describe the clinical characteristics of patients with penetrating thoracoabdominal injuries, analyze the sequence of operative interventions, and evaluate the appropriateness of initial cavity selection.

Material and methods

We performed a retrospective cohort study of adult patients with penetrating thoracoabdominal injuries who underwent emergency surgical treatment at Kyiv City Clinical Hospital No. 17 between January 2000 and December 2023. For the purpose of this analysis, patients were stratified according to the initial operative approach into chest-first and abdomen-first groups. The primary outcome was the appropriateness of initial cavity selection, defined as control of the dominant life-threatening injury through the initially selected surgical access without an urgent need to proceed to the opposite cavity.

Results

The study population consisted of 111 patients with penetrating thoracoabdominal injuries requiring emergency surgical intervention. The mechanisms of injury were stab wounds in 99 (89.2%) patients, gunshot wounds in 7 (6.3%) patients, and penetrating injuries involving impacted foreign bodies in 5 (4.5%) patients. According to the initial operative approach, 69 patients were assigned to the chest-first group and 42 patients to the abdomen-first group. A single-cavity operation was sufficient in 74 patients, whereas 37 patients required sequential or repeated access to another cavity. Thoracotomy alone was performed in 40 patients, laparotomy alone in 34 patients, and combined or repeated procedures in 37 patients. The mean estimated blood loss was 836 ml. Emergency department thoracotomy was performed in 18 (16.2%) patients. Incorrect initial cavity selection occurred in 6 patients (5.4% of the total cohort; 16.2% of patients requiring combined or repeated access). The mortality rate was 0.9%, with 1 death among 111 patients.

Conclusions

Penetrating thoracoabdominal injuries should not be managed according to a universal “chest-first” or “abdomen-first” rule. The initial operative approach should be guided by hemodynamic status, suspected source of bleeding, imaging findings, chest tube output, and mechanism of injury. Although most patients in this cohort were successfully managed through the initially selected cavity, surgeons should remain prepared for rapid conversion to the opposite cavity when the initial assessment proves incorrect.