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.     

Diagnostic laparoscopy decreases the rate of unnecessary laparotomies and reduces hospital costs in trauma patients

BACKGROUND AND PURPOSE: The use of laparoscopy for the treatment of various surgical diseases has been well described, and recently, it has gained popularity in the evaluation of abdominal trauma patients. The value of diagnostic laparoscopy (DL) in avoiding unnecessary laparotomies and its effects on hospital costs was evaluated in a prospective clinical trial. PATIENTS AND METHODS: In a 48-month period, 99 hemodynamically stable abdominal trauma patients (28 blunt and 71 penetrating injuries) among 428 patients admitted with abdominal trauma in whom the decision for surgical exploration was made were accepted for the study and underwent DL prior to laparotomy. RESULTS: The DL was negative in 60.7% of the patients with blunt abdominal trauma (BAT) and in 62.0% of the patients with penetrating abdominal trauma (PAT). Laparoscopy-positive patients (Group 1) underwent immediate laparotomy, whereas on DL-negative patients (Group 2), no laparotomies were performed. Hospitalization times and hospital costs of the two groups were recorded and compared. The difference between the hospitalization times of Group 1 and Group 2 was statistically significant (P < 0.001). The use of DL reduced the rate of unnecessary laparotomies from 60.7% to 0 in BAT and from 78.9% to 16.9% in PAT. The mean hospitalization time was 2.75 +/- 1.20 days in patients with negative DL, whereas it was 7.4 +/- 2.20 days and 5.2 +/- 1.42 days in DL-positive patients undergoing a therapeutic and nontherapeutic laparotomy, respectively. When the hospital costs of the Group 1 patients were compared with those of Group 2 patients, there was a 4.07-fold increase in patients undergoing therapeutic laparotomy and a 1.78-fold increase in patients undergoing nontherapeutic laparotomy. CONCLUSION: Diagnostic laparoscopy might be used in selected patients to exclude significant intra-abdominal injuries.     

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.     

Therapeutic laparoscopy for abdominal trauma

Background: Instead of open laparotomy, laparoscopy can be used safely and effectively for the diagnosis and treatment of traumatic abdominal injuries. Methods: Between February 1998 and January 2002, 78 hemodynamically stable patients (49 males and 29 females) with suspicious abdominal injuries underwent diagnostic or therapeutic laparoscopy. The patients ranged in age from 15 to 79 years (median, 40.9 years). Of these patients, 52 were evaluated for blunt trauma and 26 had sustained a stab wound. Preoperative evaluation with enhanced abdominal computed tomography (CT) showed some significant injuries in all cases. All of the laparoscopic procedures were performed in the operating room with the patient under general anesthesia. Pneumoperitoneum was established using an open Hasson technique at the umbilicus, and a forward-viewing laparoscope (30°) was inserted. Two additional 5- or 10- and 12-mm trocars were placed in the right and left lateral quadrants for manipulation, retraction, aspiration–irrigation, coagulation, and the like. The abdominal cavity was systemically examined, the hemoperitoneum aspirated, and the lesion causing the bleeding or spillage located. Results: On the basis of the laparoscopic findings, diagnostic laparoscopy was enough for 13 patients, and therapeutic laparoscopy was performed in 65 patients (83%) for gastric wall repair [8], small bowel repair [15], small bowel resection–anastomosis [19], ligation of bleeders in the mesentery and omentum [8], sigmoid colon repair [4], Hartmann's procedure [5] cholecystectomy [2], distal pancreatectomy [2], and splenectomy [2]. Totally laparoscopic procedures were performed in 43 patients, laparoscopically assisted procedures in 20 patients, and hand-assisted laparoscopic surgery in 2 patients. No significant abdominal injuries were missed as a result of laparoscopy, and no conversion to exploratory laparotomy was noted. The mean operation time was 142 min, and the mean hospital stay was 9.8 days. There were three cases of postoperative complications (1 wound infection, 1 paralytic ileus, and 1 atelectasis), but no missed injuries and no mortality. Conclusions: The short-term results from this study suggest that laparoscopy is a safe, feasible, effective procedure for the evaluation and treatment of hemodynamically stable patients with abdominal trauma, and that it can reduce the number of nontherapeutic laparotomies performed.     

Laparoscopy in abdominal trauma. Preliminary report in 37 cases

The role of diagnostic laparoscopy (DL) and therapeutic laparoscopy (TL) in abdominal trauma is not clear. Even after diagnostic punction lavage (DPL), ultrasonography (US), and CT scan (CT), in some cases is difficult to decide between laparotomy and observation. In 37 cases of abdominal trauma, a laparoscopic evaluation was done; 28 abdominal blunt trauma (22 associated with multiple trauma), and 9 abdominal wounds (8 stab wounds). In blunt abdominal trauma, DL was done for haemoperitoneum (26 cases), after DPL, US or CT. In three cases, with equivocal diagnosis, an extra abdominal operation in general anaesthesia was necessary. In abdominal wounds a DL was done for suspicion of penetration. All the patients were haemodynamic stable, TS > or = 12. A laparotomy was necessary in 12 cases (32.43%), a LT was possible in 5 cases (13.51%). In the rest of cases, a DL with or without lavage-drenage enough.     

A prospective analysis of diagnostic laparoscopy in trauma.

OBJECTIVE: This study was performed to assess current and potential future application for laparoscopy (DL) in the diagnosis of penetrating and blunt injuries. Efficacy, safety, and cost analyses were performed. SUMMARY BACKGROUND DATA: Diagnostic peritoneal lavage (DPL) and computed tomography (CT) have been the mainstays in recent years for diagnosis of equivocal nontherapeutic laparotomy, whereas CT is not helpful for the vast majority of penetrating wounds. DL may be a useful adjunct to fill in these gaps. METHODS: Hemodynamically stable patients with equivocal evidence of intraabdominal injury were prospectively entered into the protocol. DL was performed under general anesthesia; patients with wounds penetrating the peritoneum or blunt injury with significant organ injury underwent laparotomy. RESULTS: Over 19 months, 182 patients (55% stab, 36% GSW, 9% blunt) were studied. No peritoneal penetration was found at DL in 55% of penetrating wounds with 66% of the remainder having therapeutic laparotomy, 17% nontherapeutic laparotomy, and 17% negative laparotomy. Therapeutic laparotomy was performed in 53% of blunt injuries after DL. Tension pneumothorax occurred in one patient and one had an iatrogenic small bowel injury. Charges for DL were $3,325 per patient compared with $3,320 for a similar group undergoing negative laparotomy before this protocol. CONCLUSIONS: DL is a safe modality for trauma. With current technology, DL is most efficacious for evaluation of equivocal penetrating wounds. Significant cost savings would be gained by performance under local anesthesia. Development of miniaturized optics, bowel clamps, retractors, and stapling devices will reduce overall costs and permit some therapeutic applications for laparoscopy in trauma management.     

Laparoscopy in the evaluation of penetrating thoracoabdominal trauma

The evaluation of penetrating thoracoabdominal trauma for the presence of a diaphragmatic injury presents a diagnostic challenge to the trauma surgeon. The use of diagnostic laparoscopy (DL) in this setting was reviewed at a level-one trauma institution. Eighty patients (71 males, 9 females) with penetrating injuries to the thoracoabdominal region underwent DL to rule out injury to the diaphragm. Fifty-eight patients (72.5%) had a negative study and were spared a celiotomy. In the remaining 22 patients (27.5%), injury to the diaphragm was identified. This subset of patients underwent a mandatory celiotomy to rule out an associated intra-abdominal injury. Seventeen out of 22 (77.2%) patients had a positive exploration requiring surgical intervention, representing an associated intra-abdominal injury rate of 21.2 per cent. Intra-abdominal injuries requiring repair included small bowel, colon, spleen, liver, and stomach, in descending order. There were no missed injuries or deaths. One patient with a left diaphragmatic injury secondary to a stab wound developed a subdiaphragmatic abscess. Respiratory insufficiency secondary to atelectasis was the most common complication. Diagnostic laparoscopy is an essential and safe modality for the evaluation of diaphragmatic injuries in penetrating thoracoabdominal trauma.     

Use of laparoscopy in evaluation and treatment of penetrating and blunt abdominal injuries

Use of laparoscopy in penetrating trauma has been well established; however, its application in blunt trauma is evolving. The authors hypothesized that laparoscopy is safe and feasible as a diagnostic and therapeutic modality in both the patients with penetrating and blunt trauma. Trauma registry data and medical records of consecutive patients who underwent laparoscopy for abdominal trauma were reviewed. Over a 4-year period, 43 patients (18 blunt trauma / 25 penetrating trauma) underwent a diagnostic laparoscopy. Conversion to laparotomy occurred in 9 (50%) blunt trauma and 9 (36%) penetrating trauma patients. Diagnostic laparoscopy was negative in 33% of blunt trauma and 52% of penetrating trauma patients. Sensitivity/specificity of laparoscopy in patients with blunt and penetrating trauma was 92%/100% and 90%/100%, respectively. Overall, laparotomy was avoided in 25 (58%) patients. Use of laparoscopy in selected patients with blunt and penetrating abdominal trauma is safe, minimizes nontherapeutic laparotomies, and allows for minimal invasive management of selected intra-abdominal injuries.     

Use of computed tomography in anterior abdominal stab wounds: results of a prospective study

HYPOTHESIS: Computed tomography (CT) can be used to evaluate patients with anterior abdominal stab wounds (AASWs). DESIGN: Prospective observational study. SETTING: Academic level I trauma center. PATIENTS AND METHODS: All of the patients sustaining AASWs, excluding those with hemodynamic instability, peritonitis, or omental evisceration, were admitted for serial abdominal examinations with or without CT depending on attending preference. Patients with associated left thoracoabdominal stab wounds underwent diagnostic laparoscopy. MAIN OUTCOME MEASURES: Change in patient management as a direct result of the CT scan findings, as well as sensitivity, specificity, positive predictive value, and negative predictive value of CT scanning calculated against clinical outcome (the need for laparotomy, uneventful discharge without laparotomy, or return to the hospital for adverse events). RESULTS: One hundred fifty-six consecutive patients with AASWs were included over 24 months. Computed tomography was performed for 67 patients (CT group) whereas 89 patients were admitted for serial examination only (no-CT group). Nineteen of the 67 patients in the CT group had positive CT results, leading to laparotomy in 10 patients. Of the 48 patients with negative CT results, 3 underwent diagnostic laparoscopy for an associated thoracoabdominal stab wound and 2 eventually underwent laparotomy for clinical deterioration with negative results. Excluding patients with associated thoracoabdominal stab wounds, the negative predictive value of CT was 100%. CONCLUSIONS: In patients with AASWs, CT can be used to identify visceral injuries. It is a promising tool that may identify patients who can be discharged after a shorter period of observation. Further evaluation of its use in patients with AASWs is warranted.     

腹腔镜在腹部外伤中的应用体会

目的:分析腹腔镜诊断与治疗腹部外伤的临床价值。方法:2002年7月~2006年7月,我院对具有剖腹探查指征的68例腹部外伤患者使用腹腔镜诊断,并根据镜检结果决定镜下治疗或中转开腹手术。结果:51例腹部外伤于镜下作出正确诊断,19例于镜下手术,18例可免治疗性处理;31例中转开腹手术,其中9例为腹腔镜辅助开腹或手助腹腔镜手术,术后并发症5例,全组均治愈出院。结论:腹腔镜诊治腹部外伤具有创伤小、安全可靠、诊断率高,并有效降低阴性剖腹探查率等优点,适用于大部分腹部外伤的病例。     

Selective conservatism in abdominal stab wounds: the efficacy of serial physical examination

An analysis of 186 consecutive patients with anterior abdominal stab wounds in a 2-year period was carried out to assess the efficacy of serial physical examination as the determining factor for the need for laparotomy. Of 106 patients managed by clinical evaluation, the incidence of negative laparotomy was 0.9% and three patients (2.7%) had an "unnecessary" celiotomy. There were no missed injuries or delayed detection of intraperitoneal visceral trauma. The incidence of negative laparotomy among patients subjected to wound exploration +/- peritoneal lavage (n = 41) was 2.4%, and 39 patients had mandatory laparotomy for evisceration, with a negative celiotomy rate of 20.5%. Our experience supports serial physical examination as a highly effective method of "selective conservatism" of anterior abdominal stab wounds. Mandatory laparotomy for evisceration needs further clarification.     

Role of ultrasonography in penetrating abdominal trauma: a prospective clinical study

BACKGROUND: Focused Assessment with Sonography for Trauma (FAST) is rapidly establishing its place in the evaluation of blunt abdominal trauma. However, no prospective study specifically evaluates its role in penetrating abdominal trauma. METHODS: Data were collected prospectively in 75 consecutive stable patients with penetrating trauma to the abdomen, flank, or back, from December 1998 to June 1999. Those with an obvious need for emergent laparotomy were excluded. FAST was performed as the initial diagnostic study on all patients. Wound location, type of weapon, and findings of diagnostic peritoneal lavage, triple-contrast computed tomographic scan, or laparotomy were recorded. The presence of peritoneal blood was noted. Data were analyzed using the chi(2) test. RESULTS: Of the 75 patients, there were 32 stab and 43 gunshot wounds. There were 66 male patients and 9 female patients; the mean age was 30 years; 41 had proven abdominal injury and 34 had no injury; and 21 patients had a positive FAST. Nineteen had peritoneal blood and injuries requiring repair at the time of laparotomy. There were two false-positive studies. Fifty-four patients had a negative FAST. In 32 patients, this was a true-negative study. Thirteen patients had a false-negative FAST and had peritoneal blood and significant injury on further evaluation. Nine patients had a negative FAST and no peritoneal blood but still had abdominal injuries requiring operative repair, including liver (four), small bowel (four), diaphragm (three), colon (three), and stomach (one). The overall sensitivity of FAST was 46% and the specificity was 94%. The positive predictive value was 90%, and the negative predictive value was 60%. CONCLUSION: FAST can be a useful initial diagnostic study after penetrating abdominal trauma. A positive FAST is a strong predictor of injury, and patients should proceed directly to laparotomy. If negative, additional diagnostic studies should be performed to rule out occult injury.     

Emergency laparoscopy for abdominal stab wounds

Background: Management strategies for abdominal stab wounds (ASW) in initially asymptomatic patients range from mandatory explorative laparotomy (EL) to conservative approaches with observation alone. Emergency diagnostic laparoscopy (DL) may play a potential role between these two extremes—hence lowering the rate of unnecessary laparotomies and keeping the rate of missed injuries to a minimum. Patients and Methods: At our institution mandatory EL was carried out in every patient with ASW until 1992. In a retrospective study the charts of 43 patients with ASW were reviewed in terms of initial diagnostic procedures, intraabdominal injuries, and course and length of hospital stay. Between 5/1993 and 4/1995 DL was performed in a prospective study in 15 patients with suspected peritoneal penetration (PP) after ASW according to a standardized diagnostic and therapeutic algorithm. Results: In 17 patients (40%) EL showed no PP; 15 (35%) had significant intraabdominal injuries, while 11 patients with PP didn't have lacerations of intraabdominal organs, resulting in an overall rate of nontherapeutic laparotomy of 65%. Mortality was 6% (n= 3), average hospital stay 8 days. Primary DL could exclude PP in 10 out of 15 patients (66%). The remaining five patients (33%) showed PP: In two patients with ASW to the right upper quadrant, intraabdominal injuries could be excluded by DL, and in one patient a low-grade liver injury was treated laparoscopically, thus avoiding laparotomy in a total of 87% (n= 13). In two patients with PP laparoscopy was converted to laparotomy: no pathological finding in one case, splenectomy for spleen laceration in the second patient, resulting in a rate of nontherapeutic laparotomies of 7%. All patients in this series had an uneventful course; average hospital stay was 2.4 days. Conclusions: DL offers an important diagnostic tool in excluding peritoneal penetration in ASW, hence lowering the rate of unnecessary laparotomies. Given experience and skills, laparoscopy may be used therapeutically in selected cases of ASW. Received: 24 February 1997/Accepted: 10 August 1997     

Impact of increased use of laparoscopy on negative laparotomy rates after penetrating trauma

BACKGROUND: Our institution was one of the first to report the use of laparoscopy in the management of penetrating abdominal trauma (PAT) in 1977. Despite early interest, laparoscopy was rarely used. Changes in 1995 resulted in an increase in interest and use of laparoscopy. We present our recent experience with laparoscopy. METHODS: Our trauma registry and operative log were used to identify patients with blunt and penetrating injuries to the abdomen, back, and flank who underwent laparotomy or laparoscopy during the past 5 years. Patient demographics, operative findings, complications, and length of stay were reviewed. The number of laparoscopic explorations, therapeutic, nontherapeutic, and negative laparotomies were trended. RESULTS: There were 429 abdominal explorations for trauma. The rate of laparoscopy after penetrating injury increased from 8.7% to 16%, and after stab wounds from 19.4% to 27%. There was an associated decrease in the negative laparotomy rate. Laparoscopy prevented unnecessary laparotomy in 25 patients with PAT. Four patients with diaphragm injuries underwent repair laparoscopically. CONCLUSION: An aggressive laparoscopic program can improve patient management after PAT.     

The importance of laparoscopy in blunt abdominal trauma

The importance of laparoscopy in the management of blunt abdominal trauma should be evaluated. Therefore we retrospectively analysed all patients with blunt abdominal trauma treated in the Department of Surgery at the Carl-Thiem-Hospital Cottbus between 1998 and 2000. Within this period a total number of 53 patients with blunt abdominal trauma underwent operative treatment, 20 (37.7 %) of them had primary laparoscopy. Of the 11 cases where laparoscopic operation could be completed without conversion to exploratory laparotomy, 8 patients had intra-abdominal injuries and underwent sufficient laparoscopic treatment. The percentage of so called "negative" exploratory laparotomies within this study was 13.2 %. Our analysis suggests that laparoscopy should become firmly established in the diagnostic management and, if indicated, in the treatment of blunt abdominal trauma as well.     

Laparoscopic evaluation of penetrating thoracoabdominal traumatic injuries

Background

General surgeons’ recent familiarity with advanced laparoscopic techniques have rendered laparoscopy feasible safely in the trauma setting. Traditionally high rates of nontherapeutic laparotomies also contribute to this increased interest. This study was undertaken to determine the predictive value and accuracy of diagnostic laparoscopy (DL) in evaluation of penetrating thoracoabdominal trauma.

Methods

Entry criteria included thoracoabdominal gunshot (GSW) or stab wounds (SW) in otherwise hemodynamically stable patients. A high index of suspicion for either hemoperitoneum, peritonitis, or diaphragmatic injury was required for inclusion. All patients underwent DL in the operating room followed by standard laparotomy. The findings of the two evaluations were compared.

Results

Twenty-four patients were included in the study. Twenty males and 4 females with an average age of 34 years made up the group. Violation of the peritoneal cavity was present in 21 cases and absent in 3. No intraabdominal injuries were found during laparotomy in the latter three cases without peritoneal violation. The specificity and positive predictive value were 100% for lesions of the diaphragm, liver, spleen, pancreas, kidney, and hollow viscus. The sensitivity was highest for liver and spleen injuries (88%), followed by diaphragmatic injuries (83%), pancreas and kidney injuries (50%), and lowest for injuries of hollow viscus (25%). The negative predictive value was 95, 99, 91, and 57%, respectively, for these organs.

Conclusions

DL could have avoided unnecessary laparotomy in 38% of cases in this study. There were no complications related to laparoscopy. The greatest value of DL in penetrating thoracoabdominal injuries is in the evaluation of peritoneal violation, diaphragmatic, and upper abdominal solid-organ injuries. It is not ideal for predicting hollow viscus injuries.     

Prediction of injury caused by penetrating wounds to the abdomen, flank, and back

Controversy about the appropriate evaluation of penetrating abdominal, flank, and back injuries prompted this retrospective review of 311 patients at an urban level 1 trauma center over 5 years. Seventy-five (24%) patients sustained gunshot wounds to the abdomen. All patients with gunshot wounds underwent exploratory laparotomy; results of 67 laparotomies (89%) were positive. Of 236 patients sustaining stab wounds (140 abdominal wounds, 51 flank wounds, 26 back wounds, and 19 wounds to multiple sites), 147 were treated according to a selective protocol, based on results of physical examination, wound exploration, peritoneal lavage, and ancillary diagnostic studies. No injuries were found at celiotomy in three (2%) of these 147 patients. One false-negative result of evaluation of a flank wound occurred. Significant injuries were found in 13 patients (68%) with stab wounds to multiple sites, 61 patients (44%) with abdominal stab wounds, 15 patients (29%) with flank stab wounds, and four patients (15%) with back stab wounds. Mandatory exploration of gunshot wounds is justified. Physical findings of intra-abdominal injury or positive results of peritoneal lavage identify stab wound victims likely to benefit from surgical exploration. A policy of mandatory observation or routine celiotomy for treatment of stab wounds is not justified.     

The utility of diagnostic laparoscopy in the evaluation of anterior abdominal stab wounds

Background

To assess if diagnostic laparoscopy (DL) is superior to nonoperative modes (serial abdominal examination with/without computed axial tomography [CAT] and diagnostic peritoneal lavage) in determining the need for therapeutic laparotomy (TL) after anterior abdominal stab wound (ASW).

Methods

Retrospective review of ASW patients. Patients were divided into group A (DL/exploratory laparotomy) to identify peritoneal violation (PV) and group B (initial nonoperative modes).

Results

Seventy-three patients met inclusion criteria. In group A (n = 38), 29 patients (76%) had PV by DL and underwent exploratory laparotomy. Only 10 (35%) underwent TL (sensitivity for PV = 100%; specificity and positive predictive value of PV in determining need for TL = 29% and 33%, respectively). In group B (n = 35), 7 patients (20%) underwent TL, yielding an improved specificity (96%) and positive predictive value (88%).

Conclusions

We find no role for DL in the evaluation of ASW patients solely to determine PV.     

Role of laparoscopy in blunt perforations of the small bowel

Background: The purpose of this study was to determine whether laparoscopy could improve our ability to diagnose and treat perforations of the small bowel. Methods: From 1985 to 2001, among 250 patients admitted for a blunt abdominal trauma, 195 surgical explorations were performed, comprising 42 laparoscopies. On admission, 108 patients underwent an abdominal ultrasonography (US) and 104 a computed tomography (CT). Thirty-nine patients had a blunt small bowel trauma (BSBT) that was explored and/or treated by laparoscopy (n = 15) or celiotomy (n = 24). We compared the patients who underwent emergency surgery (23) and those who were operated on after a mean delay of 51 h. Results: On admission, for detecting free intraperitoneal fluid with a BSBT, the sensitivity of CT was 93.3% and specificity was 13.6%. Regarding the 23 patients who underwent emergency surgery, 8/20 had positive US and 10/15 had positive CT, whereas the 15 celiotomies and 8 laparoscopies indicated BSBT. Regarding the 16 patients who underwent delayed surgery, 9 patients underwent a celiotomy and 7 a laparoscopy; all BSBTs were diagnosed. In searching for BSBT, the sensitivity and specificity of laparoscopy were both 100%, whereas the sensitivity of CT was 83.3% and specificity was 22.2%. Twenty of 23 patients undergoing emergency surgery had bowel suture repair compared to 3/16 after delayed surgery. In contrast, a resection was necessary in 10/12 patients treated after a delay compared to 2/17 operated in emergency. Five BSBTs were sutured by laparoscopy, whereas 10 required conversion. Laparoscopy avoided celiotomy in 15 cases. There were no deaths and no enterostomy. Conclusion: In hemodynamically stable patients with blunt abdominal trauma, laparoscopy safely and effectively identifies small bowel injuries. Early recognition of these injuries and timely surgical treatment offer the best prognosis.