Laparoscopy in Pediatric Abdominal Trauma

Background:

The use and indications for laparoscopy have been increasing. As part of this trend, a new algorithm may emerge for pediatric trauma in which laparoscopic techniques are used in hemodynamically stable patients with suspected hollow viscus perforation.

Case Report:

We present a case in which laparoscopy was successfully used in a pediatric trauma patient as a diagnostic and therapeutic modality. A 4-year-old boy was a back-seat passenger in a head-on collision motor vehicle accident. He was restrained by a lap seat belt. He sustained a concussion, a large forehead laceration and a seat belt abdominal injury. On admission, he complained of abdominal pain. Physical examination revealed a soft, nondistended abdomen with moderate diffuse tenderness. He was hemodynamically stable. Computerized tomography of the abdomen revealed free fluid in the pelvis. No abnormalities were detected in the liver or spleen. Because of clinical deterioration and suspected intestinal perforation, diagnostic laparoscopy was utilized instead of proceeding directly to celiotomy. At laparoscopy a jejunal perforation was found and successfully repaired laparoscopically. Large hematomas were seen in the mesentery, as well as an unsuspected splenic laceration. No active bleeding was found. The patient recovered uneventfully and was discharged 5 days following the surgical procedure.

Conclusion:

This case illustrates the efficacy of using early laparoscopy in children with abdominal trauma when diagnosis is difficult and hollow viscus injury is suspected.     

腹腔镜在闭合性腹外伤中的应用

目的探讨腹腔镜技术在闭合性腹外伤病例中诊断、治疗的价值。方法对1999年8月至2004年12月期间26例闭合性腹外伤患者应用腹腔镜进行探查及治疗。结果26例中肝破裂3例,脾破裂6例,腹膜后血肿2例,肠系膜破裂3例,小肠破裂穿孔8例,结肠破裂穿孔1例,膀胱破裂1例,肠管挫伤2例。14例经腹腔镜顺利完成探查及治疗,另12例中转开腹手术。全部病例未发生术后并发症。结论腹腔镜技术在闭合性腹外伤患者的探查及治疗过程中是一种有临床应用价值的有效方法。     

Role of Laparoscopy in Penetrating Abdominal Trauma: A Systematic Review

Background

Debate remains regarding the optimum role of laparoscopy in the setting of trauma although it can offer advantages over traditional exploratory laparotomy. Laparoscopy can be a screening, diagnostic or therapeutic tool in trauma. The purpose of this review is to evaluate the role of laparoscopy in penetrating abdominal trauma

Methods

The PUBMED database was searched with the keywords “Laparoscopy AND Trauma”. Additional citation searching and searching of the grey literature was conducted. Relevant studies were chosen on the basis of the defined inclusion and exclusion criteria and quality was assessed where appropriate using the Downs and Black checklist

Results

In total, 51 studies were included in the analysis of which only 13 were prospective. In most studies, laparoscopy was used as a screening, diagnostic or therapeutic tool. In total, 2569 patients underwent diagnostic laparoscopy (DL) for penetrating abdominal trauma (PAT), 1129 (43.95 %) were positive for injury. 13.8 % of those with injury had a therapeutic laparoscopy. In total 33.8 % were converted to laparotomy, 16 % of which were non-therapeutic and 11.5 % of them were negative. 1497 patients were spared a non-therapeutic laparotomy. Overall, 72 patients suffered complications, there were 3 mortalities and 83 missed injuries. Sensitivity ranged from 66.7–100 %, specificity from 33.3–100 % and accuracy from 50–100 %. 23 of the 50 studies reported sensitivity, specificity and accuracy of 100 %, including the four most recent studies. In general the quality of the reported studies was poor. When used for cohort studies, the mean Downs and Black checklist score was 13.25 out of a possible total of 28.

Conclusions

In summary, laparoscopy in PAT may have an important role in a selected subgroup of patients, with surgeon expertise also an important factor. Laparoscopy has screening, diagnostic and therapeutic roles, particularly where diaphragm injury is suspected. It is extremely sensitive in determining need for laparotomy but detects hollow visceral injuries less reliably. It has potential as a therapeutic tool in centres with appropriate expertise. The development of specific guidelines or protocols may increase the value of laparoscopy in trauma but this would require more evidence of a higher quality.     

腹腔镜在腹部外伤并胃肠道损伤中的诊治作用分析

目的探讨腹腔镜在腹部外伤并胃肠道损伤中的诊治作用。方法对我院2005年1月至2010年6月期间60例行腹腔镜手术治疗的腹部外伤并胃肠道损伤患者的临床资料,以及腹腔镜手术入路及术中处理情况进行回顾性分析。结果 60例患者均经腹腔镜手术证实为胃肠道损伤,根据损伤的具体情况,行完全腹腔镜手术20例、腹腔镜下辅助手术40例,其中行胃肠穿孔修补术45例,肠段切除术15例。所有患者均顺利完成手术,无术后胃肠道瘘和腹腔出血情况,有2例患者术后出现切口感染,经换药后治愈。结论腹腔镜在腹部外伤并胃肠道损伤方面的诊断价值确切,治疗效果满意,避免了不必要的剖腹手术,且创伤小,是一种安全、合理的手术方式。     

Laparoscopy in Non-Trauma Abdominal Emergencies

The role for laparoscopy has evolved throughout the years and more evidence has become available to support its use in abdominal emergencies. Although the literature has expanded and more randomized controlled trials are available, skepticism persists concerning the use of laparoscopy in emergency situations. We attempt to provide the readers with a concise review and highlight the most relevant issues and available evidence in seven different non-trauma abdominal emergencies.     

An Unusual Case of Blunt Abdominal Trauma: A Bleeding and Ruptured GallBladder Managed by Laparoscopy

An isolated gall-bladder injury after blunt abdominal trauma is rare. Intraluminal bleeding with a perforation and an intra-abdominal haemorrhage is even rarer. Early diagnosis is difficult, even with a CT-scan or an US-scan available. Clinical suspicion, serial clinical examination and repeated imaging, can prevent mortality and morbidity. We present a case where laparoscopy was used to diagnose and treat an isolated gall-bladder lesion after blunt abdominal trauma.     

腹腔镜技术在外科急腹症中的应用

目的探讨腹腔镜技术在外科急腹症中的应用价值。方法2002年3月～2007年3月,行306例急诊腹腔镜手术探查与相应治疗。术前诊断急性阑尾炎105例,腹痛原因待查34例,急性胆囊炎、胆囊结石64例,消化道穿孔51例,胆总管结石、急性胆管炎5例,肠梗阻33例,有明确外伤史9例,重症急性胰腺炎5例。结果本组306例全部术中明确诊断,腹腔镜手术成功275例,其中阑尾切除术123例,胆囊切除术57例,消化道穿孔修补术48例,22例肠梗阻中行肠粘连松解13例、小肠复位联合斜疝修补4例、腹腔镜辅助下乙状结肠癌根治直肠前吻合4例、小切口小肠肠段切除端端吻合术1例,胆总管切开取石T管引流术3例,右叶肝破裂修补术2例,脾破裂止血3例,重症急性胰腺炎清创冲洗引流术5例,腹腔镜探查12例（肠系膜挫裂伤2例,腹壁刀刺伤伴大网膜挫伤1例,原发性腹膜炎8例,过敏性紫癜腹型1例）;余31例腹腔镜完成困难而中转开腹。306例随访1～18个月,无术中、术后并发症。结论急诊腹腔镜探查术不仅可以对病因不明的急腹症做出准确诊断,且可同时行腹腔镜手术治疗。即使腹腔镜下不能完成的手术,也可以指导及时开腹,以及采取较为合适的手术切口。     

基层医院腹腔镜技术在急腹症中的应用

2002年1月～2011年3月我科应用腹腔镜对232例急腹症进行探查、手术,227例完成腹腔镜诊断和治疗,2例因胆囊三角冰冻样改变、3例因阑尾周围脓肿中转开腹手术。232例随访3～12个月,平均3.5月,其中随访>6个月89例:1例阑尾切除术后6个月左侧戳孔发生网膜内疝再次手术11 d后痊愈;1例阑尾切除术后12个月右下腹再发疼痛2次,考虑网膜粘连,给予消炎治疗后未再发;6例十二指肠球部穿孔有轻度嗳气、返酸等消化道症状;其余病人均无并发症发生。我们认为腹腔镜诊断和治疗急腹症安全、有效,其微创优势得到充分发挥,也适于女性右下腹急症明确诊断,尤其适合外伤性和病理性急腹症的早诊断、早治疗。严格选择适应证、合理中转手术是急腹症腹腔镜一体化诊疗能否顺利完成的关键。     

Actual Diagnostic Strategies in Blunt Abdominal Trauma

An accurate assessment of patients with potential blunt abdominal trauma should include a safe and reliable method of determining the need for operative intervention because the mortality and morbidity of these injuries are directly dependent on the immediately valid diagnostic work-up. Since peritoneal signs are often subtle, overshadowed by pain from associated injury or masked by head trauma and intoxicants, clinical methods of diagnostics are often unreliable. Since the frequently injured liver and spleen are nowadays more frequently managed nonoperatively, an acute assessment not only of the presence of injury, but also of the nature and extent of the injuries to the intraabdominal organs, raises an increasing demand of both sensitive and specific diagnostic modalities. This article discusses the use of different diagnostic modalities including peritoneal lavage, computed tomography scanning, ultrasound and laparoscopy in the diagnosis and immediate management of blunt abdominal trauma patients, and formulates a trauma protocol for managing these patients. Received: June 21, 2001; revision accepted: February 15, 2002     

Adrenal Injury Following Blunt Abdominal Trauma

Background  

Adrenal injury secondary to abdominal trauma is quite rare because the adrenal gland is located deep in the retroperitoneum and is well cushioned by surrounding soft tissues. This report presents our experiences of managing patients with adrenal injury following abdominal blunt trauma.     

Laparoscopy for Penetrating Thoracoabdominal Trauma: Pitfalls and Promises

Background:

How should the stable patient with penetrating abdominal or lower chest trauma be evaluated? Evolving trends have recently included the use of diagnostic laparoscopy. In September 1995 we instituted a protocol of diagnostic laparoscopy to identify those patients who could safely avoid surgical intervention.

Design:

Prospective case series.

Materials and Methods:

Hemodynamically stable patients with penetrating injuries to the anterior abdomen and lower chest were prospectively evaluated by diagnostic laparoscopy, performed in the operating room under general anesthesia, and considered negative if no peritoneal violation or an isolated nonbleeding liver injury had occurred. If peritoneal violation, major organ injury or hematoma was noted, conversion to open celiotomy was undertaken.

Results:

Seventy consecutive patients were evaluated over a two-year period. The average length of stay (LOS) following negative laparoscopy was 1.5 days, and for negative celiotomy 5.2 days. There were no missed intra-abdominal injuries following 30 negative laparoscopies, and 26 of 40 laparotomies were therapeutic. The technique also proved useful in evaluation of selected blunt and HIV+ trauma vic-tims with unclear clinical presentations. However, while laparoscopy was accurate in assessing the abdomen following penetrating lower chest injuries, significant thoracic injuries were missed in 2 out of 11 patients who required subsequent return to OR for thoracotomy.

Conclusions:

Laparoscopy has become a useful and accu-rate diagnostic tool in the evaluation of abdominal trauma. Nevertheless, laparoscopy still carries a 20% nontheraputic laparotomy rate. Additionally, significant intrathoracic injuries may be missed when laparoscopy is used as the pri-mary technique to evaluate penetrating lower thoracic trauma.