Operative Versus Selective Non‐operative Management in Adult Penetrating Abdominal Trauma With Bowel or Omental Evisceration: A Systematic Review and Meta‐Analysis

ABSTRACT Background Penetrating abdominal trauma with bowel or omental evisceration has traditionally mandated exploratory laparotomy due to perceived high risk of intra‐abdominal injury. Selective nonoperative management (SNOM) has gained acceptance in stable patients, but evidence specific to evisceration remains limited and controversial. Objective To compare outcomes of operative management versus SNOM in adults with penetrating abdominal trauma and documented evisceration. Methods Systematic review conducted per PRISMA 2020 guidelines. Databases searched were as follows: PubMed, Scopus, Wits Summon, and Google Scholar (1980–2025). Inclusion were as follows: adults ≥ 18 years, penetrating (stab/gunshot) trauma, documented bowel/omental evisceration, operative versus SNOM comparison, and outcomes (mortality, missed injuries, delayed therapeutic laparotomy, complications, and length of stay). Risk of bias via Newcastle–Ottawa Scale; evidence certainty via GRADE. Random‐effects meta‐analysis performed where feasible PROSPERO registration number: (CRD420261345559). Results From 292 records, 152 remained after deduplication; 47 full texts assessed; 20 studies included in qualitative synthesis; and 13 in meta‐analysis. SNOM significantly reduced nontherapeutic laparotomy (pooled OR 0.61, 95% CI 0.46–0.80; I 2 = 26%; and p < 0.001) without increased mortality or morbidity. Subgroup analysis showed SNOM particularly safe in isolated omental evisceration (failure < 15%), with higher therapeutic rates in bowel/organ cases. Evidence certainty was moderate (downgraded for observational design and heterogeneity). Conclusions In hemodynamically stable patients with penetrating abdominal trauma and evisceration, SNOM appears safe and preferable in selected cases reducing unnecessary laparotomies without compromising outcomes. Prospective trials are needed to refine indications.