Laparoscopy in penetrating abdominal trauma

Summary BACKGROUND: Penetrating abdominal trauma (PAT) poses a significant challenge to trauma surgeons. There is no doubt that persistent hemodynamic instability or signs of peritoneal irritation warrant immediate laparotomy. If the patient is hemodynamically stable and has equivocal abdominal examination findings, diagnosis may be obtained by laparoscopy. METHODS: The goal of this article is to evaluate the role of laparoscopy in the management of PAT. RESULTS: Patients with penetrating trauma to the thoracoabdominal and anterior abdominal wall are good candidates for laparoscopic evaluation. The peritoneal cavity and its contents, including the retroperitoneal space, can be thoroughly examined easily and safely. The main benefits of laparoscopy include the reduction of nontherapeutic laparotomies, identification of mostly intra-abdominal injury, and provision of potential therapy for some cases. Diagnostic laparoscopy has a high overall diagnostic accuracy, reduced morbidity, and shortened hospital stay and is also cost-effective. While laparoscopy has some limitations in the diagnosis of hollow viscus injury, it can detect and repair diaphragmatic injuries accurately and exclude the risk of nontherapeutic laparotomy due to a nonbleeding injury of the solid organs. CONCLUSIONS: The use of laparoscopy as a diagnostic or therapeutic method in patients with PAT is reserved only for hemodynamically stable patients and uncertain findings of peritonitis. Laparoscopy is an efficient and effective diagnostic tool when used by a well-trained surgeon. With experience, an increasing number of surgeons are using laparoscopy as an additional diagnostic tool for PAT in stable patients. With more experience and skills, laparoscopy may be used more therapeutically in selected patients. Minimally invasive surgery has already established itself as a useful tool in the management of PAT. The future seems to be promising for this field of surgery by innovative developments in computer technology and robotic systems.     

Mini-laparoscopy in blunt abdominal trauma

Summary Blunt abdominal trauma in multiorgan injured or comatose patients always presents a problem. The aim is to assess, in the shortest period of time, which organ injury requires priority and whether intra-abdominal bleeding or perforation exists. Abdominal lavage proved to be too sensitive. Not every positive case needs exploration. Approximately 15%–20% of the cases explored because of positive lavage did not show a significant bleeding site that would require surgical treatment. The authors developed a mini-laparoscope that can be used at the bedside, in the emergency room, or in the intensive care unit. The procedure can be performed with intravenous sedation and local anesthesia. In 150 cases, no hemoperitoneum was found in 53% of these cases. Except for 1 (see text for details), none of these patients needed further exploration. In 21%, severe hemoperitoneum was discovered; these patients were transferred to the operating room, and this was confirmed by surgery. In 26%, a small amount of blood was found in the gutters. These patients were observed in the intensive care unit and an unnecessary exploration was avoided. Laparoscopy gives a wider range of decision making by observing the abdominal cavity. It can be completed in 10–20 min at the bedside. No serious complications were encountered. This procedure should be taught and practiced in trauma centers. Partially based on a presentation to the International Congress on Surgical Endoscopy, Ultrasound, and Interventional Techniques, Berlin 1988     

Laparoscopy versus laparotomy in management of abdominal trauma

Background A majority of abdominal injuries (AIs) are associated with shock, hence most of the patients are hemodynamically unstable, which limits the use of video-assisted laparoscopy (VAL) in their management. The purpose of this study is to demonstrate the possibility of using VAL in management of stable and unstable patients with abdominal trauma. Methods In a period of six years 2,695 patients with AIs were evaluated. The subjects were evaluated retrospectively and divided into two groups. Group 1, consisting of 1,363 patients, had conventional routine investigations following which they underwent laparotomy for confirmatory diagnosis and definitive management. The second group, consisting of 1,332 patients, underwent diagnostic laparoscopy in addition to the conventional investigations in the first group; 411 patients of this group had therapeutic laparoscopy. Demographic information, incidence of organs injuries and operative findings, success rate of VAL and laparotomy repair, complications, associated injuries, and hospital mortality were evaluated. Results The age of 62.6% of our patients was 20–50 years, while 10.6% and 14.5% were less than 19 and greater than 50 years, respectively. Associated injuries were head, chest, musculoskeletal, and vertebral column. Most of the victims presented with shock; 50.7%, 24.7%, and 15.9% of the patients were in mild, moderate, and severe shock respectively, and 8.7% of the subjects had stable hemodynamic status. In the first group 47.1% of the laparotomies were absolutely indicated and 24.4% were negative. Of the patients who had laparotomy, 26.0% would have been managed confidently by VAL. In the second group following VAL 42.5% of the patients did not require surgical intervention. VAL surgery was performed in 30.8% of patients. Conversion to laparotomy was performed in 26.7% of the patients. Conclusions The VAL technique can be confidently used as a main tool to expedite evaluation and treatment of patients with abdominal trauma in cases of both stable and unstable hemodynamic status.     

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。     

The utility of focused abdominal ultrasound in blunt abdominal trauma: a reappraisal

BACKGROUND: Focused assessment with sonography for trauma (FAST) has become commonplace in the management of blunt abdominal trauma. However, newer computed tomography (CT) scanners have decreased imaging time for trauma patients and provide more detailed examination of abdominal contents. It was the aim of the current study to evaluate practice patterns of FAST and abdominal CT in blunt trauma victims. METHODS: This was a retrospective study of all blunt trauma patients (N = 299) who received at least 1 FAST examination in the emergency department by surgeons and were admitted. Patients were tracked for subsequent CT scanning, disposition from the emergency department, any operative findings, and survival. RESULTS: Twenty-one of 299 patients (7%) had a positive FAST. There were 7 deaths and 14 patients were taken directly to the operating room (OR) for control of abdominal bleeding. Thirty-one of 299 (10%) had equivocal FAST. There were 4 deaths and 8 patients were taken to the OR for control of abdominal bleeding. A total of 247 of the 299 patients had a negative FAST. CT scans were performed in 193: 15 showed a visceral injury. There were 13 deaths and 29 patients were taken to the OR (4 for bleeding). Patients with a positive FAST had a higher mortality than FAST-negative patients (P < .001) and greater likelihood for operation (P < .001). Those with equivocal FAST had a greater likelihood for operation than FAST-negative patients (P < .05). CONCLUSIONS: FAST examinations can identify patients at risk for hemorrhage and in whom operation may be needed and, therefore, can guide mobilization of hospital resources. FAST-negative patients can be managed expectantly, using more specific imaging techniques.     

腹腔镜在腹部外伤治疗中的应用

目的:分析应用腹腔镜经原创口诊断与治疗腹部外伤的临床价值。方法:2003年7月至2006年12月,对具有剖腹探查指征的14例腹部外伤患者使用腹腔镜经原创口诊断,并根据镜检结果决定镜下治疗或中转开腹手术。结果:14例腹部外伤患者均于镜下作出正确诊断,5例镜下手术,2例可免治疗性处理;7例中转开腹手术,其中5例于腹腔镜辅助下手术,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。     

腹腔镜检查在腹部肿瘤诊断中的应用

目的:探讨腹腔镜在腹部肿瘤诊断中的应用价值。方法:分为二组,实验组:诊断为腹部肿瘤,于剖腹术前行腹腔镜检查31例;对照组:经腹腔镜检查和活检术证实腹部肿瘤14例。结果:在实验组有4/31例(12.9%)、对照组有9/14例(64.82%)证实肿瘤在腹腔内广泛转移;全组腹腔镜检查诊断准确率为100%,避免不必要的剖腹探查13/45例(28.88%)。结论:腹腔镜检查对腹部肿瘤的诊断准确率高,有助于恶性肿瘤的准确分期,可避免许多不必要的剖腹探查,且并发症少,在腹部肿瘤的诊断中,是一个重要的辅助检查手段。     

腹腔镜手术在闭合性腹外伤中的应用

目的 探讨腹腔镜手术在闭合性腹外伤中的价值。方法 2003年12月～2006年7月腹腔镜诊治47例闭合性腹外伤。在全麻或硬膜外麻醉下,脐下做1 cm小切口,根据病人的具体情况选用气腹针或通过开放性通道建立人工气腹。未明确诊断者可适当置1～2个trocar配合探查;若明确诊断,根据病灶位置选择操作孔位置,一般2～3个。根据病变情况再做相应处理。结果 47例经腹腔镜手术明确诊断：肝破裂15例,脾破裂13例,小肠破裂9例,肠系膜损伤3例,胰腺损伤2例,腹膜后血肿2例,腹内多脏器损伤3例。腹腔镜下完成手术28例,17例中转开腹,2例诊断为腹膜后血肿无须处理。47例随访6个月无并发症发生。结论 腹腔镜下可明确诊断闭合性腹外伤,使患者得到及时、有效、合理的治疗。     

基层医院急诊腹腔镜在腹部外伤中的应用体会

目的:探讨急诊腹腔镜手术诊治腹部外伤的有效性。方法:2011年1月至2016年8月应用急诊腹腔镜诊治腹部创伤患者187例,并与同期186例传统剖腹探查病例进行对比,分析急诊腹腔镜在腹部创伤诊治中的及时性、诊断率、治疗率、非治疗性手术率等。结果:腔镜组187例均在腹腔镜下明确诊断或治疗,诊断率100%,139例(74.3%)在腹腔镜下完成治疗,16例(8.6%)未发现明显病灶无需处理,32例(17.1%)中转开腹。术后肠鸣音恢复时间平均(2.5±0.9)d,较剖腹组[(3.5±1.4)d]短(P0.05)。未发生腹腔镜相关并发症。结论:急诊腹腔镜诊治腹部损伤安全、可行,可及时做出正确诊断并予以治疗,提高抢救时效,加快康复。     

Delayed jejunal perforation following blunt abdominal trauma

Jejunal perforation is a known complication of abdominal trauma. We report two cases of jejunal perforation presenting nearly 2 months following blunt injury to the abdomen and discuss possible mechanisms for delayed small bowel perforation.     

腹部创伤的诊断与治疗

腹部创伤患者救治中如何降低漏诊率和阴性探查率仍然是临床难题.本文基于血流动力学和致伤机制提出诊断与治疗流程,进一步阐述该流程中涉及的体格检查、创伤重点超声评估（FAST）、CT检查和诊断性腹腔灌洗（DPL）等腹部创伤伤情评估技术,钝性伤和穿透伤手术指征等紧急救治策略,以及腹腔镜下和剖腹时的探查技术.     

Evaluation of ultrasound,lavage, and computed tomography in blunt abdominal trauma

Summary We have analysed the data of 136 patients with multiple injuries treated between 1983 and 1988 in order to assess the sensitivity, specificity, and accuracy of ultrasound, lavage and computed tomography (CT) for the preoperative diagnosis of blunt abdominal trauma. CT was carried out in doubtful cases (n=29) if ultrasound and lavage had not provided sufficient information. Fifty-eight patients were primarily excluded from the study because neither clinical examination nor ultrasound gave any sign of an intra-abdominal lesion. In 25 cases, sonography could be compared with lavage, CT, and the intraoperative situs. Ultrasound showed reliable results in respect to accuracy (100%), sensitivity (84%), and specificity (98%). Computed tomography confirmed all sonographic diagnoses in 29 patients but did not provide further information. Peritoneal lavage gave correct information in all patients operated upon. Our 5-years' experience suggests that ultrasound is a reliable, quick, cheap, and repeatable technique of great value in patients with blunt abdominal traumata.Presented at the International Congress on Surgical Endoscopy, Ultrasound, and Interventional Techniques, Berlin 1988     

腹腔镜在腹部闭合性损伤中的应用

目的探讨腹腔镜在腹部闭合性损伤中的应用. 方法 2000年7月～2003年12月我院对21例血流动力学稳定的腹部闭合性损伤急诊行腹腔镜探查及治疗. 结果 21例均在腹腔镜下明确诊断.开腹肝修补术4例,腹腔镜肝修补术2例,开腹脾切除术5例,手助腹腔镜脾切除术3例,腹腔镜辅助下小切口小肠修补术2例,小肠部分切除术4例,腹腔镜大网膜血管缝扎止血1例. 结论腹腔镜诊治腹部闭合性外伤准确、安全、有效.     

Traumatic mesenteric cyst after blunt abdominal trauma

Mesenteric cysts are rare abdominal tumors of unclear histologic origin, usually asymptomatic. Post-traumatic mesenteric cyst usually results as a consequence of a mesenteric lymphangitic rupture or a hematoma followed by absorption and cystic degeneration. The preoperative histological and radiological diagnosis is difficult. We present the case of a 45-year-old male patient with sizable, palpable abdominal tumor, the gradual swelling of which the patient himself combined with the blunt abdominal trauma he acquired from an opponent's knee in a football game 5 months ago.     

腹腔镜联合微波治疗闭合性肝外伤的临床体会

目的:探讨腹腔镜联合微波治疗闭合性肝外伤的可行性及效果.方法:前瞻性随机对照将47例闭合性肝外伤患者分为腹腔镜联合微波组(A组,n =25)与开腹手术组(B组,n=22);对比两组手术情况、术后恢复情况及术后并发症.结果:A组术中出血量明显减少,术后无严重并发症发生,患者康复时间明显缩短.结论:相对传统开腹手术,腹腔镜微波治疗闭合性肝外伤具有患者创伤小、康复快、并发症少及住院时间短等优点,可作为治疗闭合性肝外伤的另一选择.     

腹腔镜诊断和治疗腹部闭合性损伤120例报告

目的:探讨应用腹腔镜诊断和治疗腹部闭合性损伤的临床效果。方法:120例腹部闭合性损伤患者在腹腔镜下诊断和治疗。结果:120例均于腹腔镜下明确诊断并治疗。其中48例出血停止,56例腹腔镜下止血成功,16例腹腔镜下行脾脏切除术。90例避免了剖腹手术,占75%。结论:腹腔镜可用于腹部闭合性损伤的诊断和治疗,且较腹腔穿刺、腹腔灌洗及剖腹探查简便易行。     

Rupture of the normal renal pelvis after blunt abdominal trauma

Blunt abdominal trauma with isolated rupture of the normal renal pelvis is an extremely rare clinical entity. The correct preoperative diagnosis may be difficult and challenging because of the insidious onset, lack of blood loss, and frequently, lack of urinary symptoms. Intraoperative inspection of the collecting system is the most accurate method to fully define an extent of injury. The object of the case report is to present the case of a 15-year-old male with isolated pelvic rupture of a normal kidney because of strong punch in the abdomen during the handball match.