図５が釘（クギ：△）の刺入部で，図３で先端は明らかに腹腔内に到達している（△）が，周囲に遊離ガス，腹水，血腫や腸間膜濃度上昇などを認めない．図３の高濃度の▲はア−チファクトである．釘打ち銃によるクギ刺創だからかなりの高エネルギーを推測し，腹腔内臓器損傷の可能性は極めて高いと思われ手術したが，大網を貫通しているだけで出血やその他の損傷を認めなかった．クギが小腸に刺入したまま内容物の漏出を防いでいる可能性は否定できず，開腹手術の適応はある．

参考症例 １（包丁刺創・腹腔内臓器損傷なし）：53歳男性で，自殺目的で包丁を刺した症例であるが，約15cm腹腔内に刺入している（図A，B，C ）．手術で腹腔内に1500mlの出血を認めたが腹壁の上腹壁動脈からの活動性出血で，腹腔内臓器に損傷を認めなかった．小腸は浮遊性臓器だから刃物の先端が当たっても，押されて移動するだけで，必ずしも穿孔を起こさないことが意外に多いということである．刺されたままの，あるいは残存した刃物は腸管内容物の漏出を，または大血管からの出血を最小限に抑えている可能性があり，決して救急室で抜去してはいけない．

参考症例 ２（包丁刺創・腹腔内臓器損傷なし）：45歳女性．果物ナイフで左上腹部を刺した．ナイフの刃の部分は図の↑が皮膚のレベルで，そこから先端は腹腔内に刺さっていたが，試験開腹で出血も臓器損傷も認めなかった症例である．

文献考察：不必要手術の術後合併症は結構多い．
１）J Trauma. 1995 Mar;38(3):350-6.
Unnecessary laparotomies for trauma: a prospective study of morbidity.
Renz BM, Feliciano DV.

OBJECTIVE: Despite advances in diagnostic techniques, unnecessary laparotomies (no repairs/no drains) are still performed in trauma centers. The true risks of such procedures are unclear. Our hypothesis was that the overall incidences of complications after an unnecessary laparotomy for trauma that have been reported in the literature were significant underestimates because of flaws in study design. To test our hypothesis, a prospective study to record all perioperative complications in patients undergoing an unnecessary laparotomy for trauma was performed. DESIGN: Prospective case series. MEASUREMENTS AND MAIN RESULTS: The main outcome measures were perioperative complications. An unnecessary laparotomy was performed in 254 patients who sustained trauma. The mechanism of injury was a penetrating wound in 98% of the patients. Complications occurred in 41.3% of the patients (n = 105) and included atelectasis (15.7%), postoperative hypertension that required medical treatment (11.0%), pleural effusion (9.8%), pneumothorax (5.1%), prolonged ileus (4.3%), pneumonia (3.9%), surgical wound infection (3.2%), small bowel obstruction (2.4%), urinary infection (1.9%), and others. Complication rates for patients who did (n = 111) and did not (n = 143) have an associated injury were 61.3% and 25.9%, respectively (p = 0.0001). Complications occurred in 19.7% of 81 patients who did not have an associated injury and who did not have intraperitoneal or retroperitoneal penetration. The mortality rate for the entire series was 0.8% and was unrelated to the unnecessary laparotomies. CONCLUSIONS: Unnecessary laparotomies for trauma result in a significant morbidity when complications are recorded prospectively. Current efforts to reduce the incidence of these unnecessary procedures without increasing that of missed injuries are obviously worthwhile.　PMID: 7897713

２）J Trauma. 1995 Jan;38(1):54-8.
Complications of negative laparotomy for truncal stab wounds.
Leppaniemi A, Salo J, Haapiainen R.

In a retrospective study of 459 patients undergoing mandatory explorative laparotomy for truncal stab wounds, 172 (37%) negative laparotomies were identified, divided in two groups: group I (n = 147) without, and group II (n = 25) with associated extra-abdominal injuries or surgical procedures other than laparotomy. One patient (0.6%) died of associated mediastinal vascular injuries. The overall postoperative morbidity rate was 21%, 17% in group I, and 44% in group II (p
3)修復を必要としない手術（nontherapeutic laparotomy＝negative laparotomy）の重大合併症は12％．
Am Surg. 2003 Jul;69(7):562-5.
Nontherapeutic laparotomies revisited.
Haan J, Kole K, Brunetti A, Kramer M, Scalea TM.

A wide variability exists in the reported incidents of complications following nontherapeutic laparotomy for trauma. We undertook this study to examine the decision-making leading to and complication rates related to the use of nontherapeutic laparotomy in an era of nonoperative management. We conducted a retrospective chart review of all nontherapeutic laparotomies as defined by the operating surgeon performed between May 1998 and May 2001. A total of 50 patients (6%) underwent nontherapeutic laparotomies predominantly for penetrating injury. The most frequent preoperative reason for nontherapeutic laparotomy was the question of hollow viscous or diaphragmatic injury on preoperative studies. Peritoneal signs on examination and peritoneal penetration on wound exploration were also frequent indications for surgery. Significant complication rates were low at approximately 12 per cent. Total length of stay was 7.3 days and 5 days if patients with significant other associative injuries were excluded. Overall morality was 4 per cent and unrelated to the nontherapeutic laparotomy in all cases. Overall incidence of nontherapeutic laparotomy has decreased with the use of abdominal helical CT and triple-contrast CT to evaluate penetrating injuries. Despite these advances diaphragmatic and hollow viscous injuries remain a concern. Although overall serious complication rates were low the use of nontherapeutic laparotomy adds significantly to length of stay and complications.PMID: 12889616