The accuracy of diagnostic laparoscopy in trauma patients: a prospective, controlled study

BACKGROUND: Numerous studies advocate the use of diagnostic laparoscopy (DL) for abdominal trauma, but none have documented its ability to diagnose specific injuries. This study tests the hypothesis that DL can accurately identify all significant intra-abdominal injuries in trauma patients. METHODS: Of trauma patients requiring laparotomy for presumed injuries, 47 underwent DL followed by laparotomy. Injuries noted at laparoscopy were compared with those found at laparotomy. RESULTS: Of these, 14 patients had no significant injuries necessitating operative intervention noted at laparoscopy and celiotomy. The remaining 33 patients harbored 93 significant injuries at laparotomy, of which only 57.0% were found by DL. DL possessed poor sensitivity (<50%) for injuries to hollow viscera. Despite DL's poor performance in finding specific injuries, it possessed excellent sensitivity (96.2%), and specificity (100%) for determining the need for therapeutic celiotomy. CONCLUSIONS: DL offers no clear advantage over diagnostic peritoneal lavage and computed tomography in blunt trauma. Its utility lies in assessment of the need for laparotomy in patients with penetrating wounds. Currently, DL cannot consistently identify all abdominal injuries, disqualifying it as a therapeutic tool in abdominal trauma.     

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.     

The value of laparoscopy in management of abdominal trauma

The role of laparoscopy (LS) in abdominal trauma is controversial. Concerns remain regarding missed injuries and safety. Our objective for this study was to determine the safety and better define the role of LS in abdominal trauma victims. We performed a retrospective review of all patients who sustained abdominal trauma and underwent LS in a level I trauma center. The main outcome measures were age, gender, mechanism of injury (MOI), indication for laparoscopy, presence of intra-abdominal injury (IA), therapeutic laparoscopy (TxLS), need for laparotomy, length of hospital stay (LOS), missed injuries, complications, and deaths. Forty-eight patients underwent LS (62 per cent male; average age, 28 years; MOI, 35 (85%) penetrating, 7 (15%) blunt; mean ISS, 8). At laparoscopy, 58 per cent of patients had no intra-abdominal injury. IA injury was treated with laparotomy in 14 (29%) and TxLS in 6 (13%). One patient had a negative laparotomy (2%). No injuries were missed. No patients required reoperation. There was one complication: a pneumothorax. There were no deaths. LS was most valuable in penetrating trauma, avoiding laparotomy in more than two-thirds of patients with suspected intra-abdominal injury. LS can serve as a useful adjunct for the evaluation of blunt trauma. In a level I trauma center with LS readily available, the procedure is associated with a low rate of complications and missed injury.     

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.     

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.     

The role of laparoscopy in the diagnosis and treatment of abdominal pain syndromes

Background: Diagnostic laparoscopy plays a significant role in the evaluation of acute and chronic abdominal pain in the era of therapeutic laparoscopic surgery. Methods: We referred to our personal series of laparoscopy for both acute and chronic abdominal pain. This is a retrospective review of data accumulated prospectively between 1979 and the present. Results: In our series, 387 consecutive patients underwent laparoscopy because of abdominal pain. In a group of 121 patients with acute abdominal pain, a definitive diagnosis was made in 119 cases (98%). Two patients needed laparotomy to confirm the diagnosis; both had a disease process that did not require laparotomy to treat. A definitive therapeutic laparoscopic procedure was performed in 53 cases 944%). In 45 patients (38%), a diagnosis was made that did not require therapeutic laparoscopy or laparotomy to treat. In the remaining 21 patients (17.5%), exploratory laparotomy was needed to treat the condition. In a chronic abdominal pain group of 265 patients, the etiology was established laparoscopically in 201 cases (76%). A definitive therapeutic laparoscopic procedure was performed in 128 patients (48%). There was a normal laparoscopic examination in 64 patients (24%). There was one false negative laparoscopy that required laparotomy to treat 1 month later. Conclusions: Laparoscopy is an accurate modality for the diagnosis of both acute and chronic abdominal pain syndromes. These data support the use of laparoscopy as the primary invasive intervention in patients with acute and chronic abdominal pain. Received: 24 March 1997/Accepted: 4 September 1997     

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.     

Relaparoscopy for the detection and treatment of complications of laparoscopic cholecystectomy

BACKGROUND: Laparotomy remains the commonest intervention in patients with abdominal complications of laparoscopic surgery. Our own policy is to employ relaparoscopy to avoid diagnostic delay and unnecessary laparotomy. The results of using this policy in patients with suspected intra-abdominal complications following laparoscopic cholecystectomy are reviewed. METHODS: Data were collected from laparoscopic cholecystectomies carried out by five consultant surgeons in one center. Details of relaparoscopy for complications were analyzed. RESULTS: Thirteen patients underwent relaparoscopy within 7 days of laparoscopic cholecystectomy for intra-abdominal bleeding (2 patients) or abdominal pain (11 patients). The causes of pain were subhepatic haematoma (1), acute pancreatitis (1), small bowel injury (1), and minor bile leakage (6). In 2 patients no cause was identified. Twelve patients were managed laparoscopically and 1 patient required laparotomy. Median stay after relaparoscopy was 7 days (range 2 to 19). CONCLUSIONS: Exploratory laparotomy can be avoided by prompt relaparoscopy in the majority of patients with abdominal complications of laparoscopic cholecystectomy.     

Emergency laparoscopy for acute abdominal conditions: a prospective study

BACKGROUND: Currently, emergency laparoscopic surgery for acute abdominal conditions has become the favored surgical approach; therefore, we investigated the diagnostic accuracy and therapeutic efficacy of laparoscopy in acute abdominal pain in Saudi Arabian patients. PATIENTS AND METHODS: In this prospective study, 176 patients with acute abdominal pain (113 patients with pain localized to the right iliac region [group A] and 63 patients with generalized abdominal pain [group B] underwent emergency laparoscopy between January 2002 and December 2006. We evaluated the initial clinical diagnosis, the laparoscopic diagnosis, and the outcome in these two groups of patients. RESULTS: In group A, a definitive diagnosis was established at laparoscopy in 89% of patients, and it was therapeutic in 81.4% of the patients, and in 9 patients (8%) a conversion to laparotomy was necessary a to manage their condition. In group B, the diagnosis was accurate in 87% of patients, and it was therapeutic in 79.4% of the patients, and in 5 patients (8%) a conversion to laparotomy was necessary. There was no mortality. CONCLUSIONS: The emergency laparoscopy is a diagnostic and therapeutic option in the majority of acute abdominal pain conditions.     

Intra-abdominal free fluid without solid organ injury in blunt abdominal trauma: an indication for laparotomy

BACKGROUND: The optimal management of patients sustaining blunt abdominal trauma (BAT), in whom intra-abdominal free fluid but no solid organ injury is found on imaging, remains unclear. The purpose of this study was to determine the incidence and significance of this finding. METHODS: All patients presenting with suspected BAT to a provincial trauma center over a 30-month period were reviewed. A screening focused abdominal sonogram for trauma scan was obtained in every case. Stable patients with positive or indeterminate scans underwent computed tomographic scanning. Those with free fluid but without visible solid organ injury were studied. Radiologic interpretation, clinical management, and operative findings were analyzed. RESULTS: Twenty-eight of 1,367 patients (2%) met inclusion criteria. Twenty-one patients (75%) underwent exploratory laparotomy, which for 16 (76%) was therapeutic: bowel injuries were found in 10 patients, mesentery injuries in 6, and injuries to solid organs in 3. In five patients, laparotomy was nontherapeutic. Those with more than a trace of free fluid were significantly more likely to have a therapeutic procedure. Seven patients (25%) were observed, of whom two failed nonoperative management and underwent therapeutic laparotomies within 24 hours of admission for missed colon, splenic, and hepatic injuries. The presence of abdominal seat belt bruising or a Chance-type fracture in the study patients was associated with a 90% and 100% therapeutic laparotomy rate, respectively. Computed tomographic scan findings were variable and were not able to predict injury severity or need for surgery. CONCLUSION: The finding of more than trace amounts of free fluid in the absence of solid organ injury in BAT is often associated with clinically significant visceral injury. Early laparotomy is recommended for these patients.     

Complications of nonoperative management of high-grade blunt hepatic injuries

BACKGROUND: Nonoperative management of blunt hepatic injuries is highly successful. Complications associated with high-grade injuries, however, have not been well characterized. The purpose of the present study was therefore to define hepatic-related complications and associated treatment modalities in patients undergoing nonoperative management of high-grade blunt hepatic injuries. METHODS: Three hundred thirty-seven patients from two regional Level I trauma centers with grade 3 to 5 blunt hepatic injuries during a 40-month period were reviewed. Complications and treatment of hepatic-related complications in patients not requiring laparotomy in the first 24 hours were identified. RESULTS: Of 337 patients with a grade 3 to 5 injury, 230 (68%) were managed nonoperatively. There were 37 hepatic-related complications in 25 patients (11%); 63% (5 of 8) of patients with grade 5 injuries developed complications, 21% (19 of 92) of patients with grade 4 injuries, but only 1% (1 of 130) of patients with grade 3 injuries. Complications included bleeding in 13 patients managed by angioembolization (n = 12) and laparotomy (n = 1), liver abscesses in 2 patients managed with computed tomography-guided drainage (n = 2) and subsequent laparotomy (n = 1). In one patient with bleeding, hepatic necrosis followed surgical ligation of the right hepatic artery and required delayed hepatic lobectomy. Sixteen biliary complications were managed with endoscopic retrograde cholangiopancreatography and stenting (n = 7), drainage (n = 5), and laparoscopy (n = 4). Three patients had suspected abdominal sepsis and underwent a negative laparotomy, whereas an additional three patients underwent laparotomy for abdominal compartment syndrome. CONCLUSION: Nonoperative management of high-grade liver injuries can be safely accomplished. Mortality is low; however, complications in grade 4 and 5 injuries should be anticipated and may require a combination of operative and nonoperative management strategies.     

Therapeutic laparoscopy in trauma

: To assess the therapeutic potential of emergent laparoscopy in the trauma setting, a retrospective review was performed in a busy urban trauma center. : Between December 1991 and October 1993, 133 hemodynamically stable patients with suspected abdominal injury were evaluated laparoscopically. All laparoscopic procedures were performed in the operating room under general anesthesia. Mechanism of injury was stab wound (58), gunshot wound (57), and blunt trauma (18). No significant injuries were found in 72 patients (54%), and these patients received no further treatment. On the basis of laparoscopic findings, 52 patients underwent formal exploratory laparotomy. Surgical exploration confirmed the presence of significant injuries in 44 of the 52 patients (85%). Therapeutic laparoscopy was performed in 6 patients (5%) for diaphragm repair (4), gastrotomy repair (1), and splenorrhaphy (1). Additionally, 10 patients underwent laparoscopy-guided blood salvage for autotransfusion during laparoscopic evaluation of blunt trauma. Three small-bowel enterotomies were repaired during minilaparotomy. : No significant injuries were missed as a result of our use of laparoscopy in trauma assessment. Complications—trocar enterotomy, trocar laceration of the interior epigastric artery, and transient hypotension—occurred in 3 patients secondary to the use of laparoscopy. : Trauma laparoscopy is a safe method for the evaluation of selected patients with abdominal trauma and can reduce the number of negative and nontherapeutic trauma laparotomies performed. Limited therapeutic intervention is possible in a small number of patients.     

The role of laparoscopy in penetrating abdominal trauma.

BACKGROUND: Minimally invasive surgery has become increasingly utilized in the trauma setting. When properly applied, it offers several advantages, including reduced morbidity, lower rates of negative laparotomy, and shortened length of hospital stay. The purpose of this study was to evaluate the role of laparoscopy in the management of trauma patients with penetrating abdominal injuries. METHODS: We conducted a 3-year retrospective chart review of 4541 trauma patients admitted to our urban Level II trauma center. Penetrating abdominal injuries accounted for 209 of these admissions. Patients were divided into 3 treatment groups based on the characteristics of their abdominal injuries. Management was either observation, immediate laparotomy, or screening laparoscopy. RESULTS: Thirty-three patients were observed in the Emergency Department based on their initial physical examination and radiologic studies. After Emergency Department evaluation, 154 patients underwent immediate laparotomy. In this group, 119 therapeutic laparotomies, 11 nontherapeutic laparotomies, and 24 negative laparotomies were performed. A review of the negative laparotomies revealed that possibly 8 of 10 gun shot wounds and all 14 stab wounds could have been done laparoscopically. Twenty-two patients underwent laparoscopic evaluation, 9 of which were converted to open procedures. CONCLUSION: Minimally invasive surgical techniques are particularly helpful as a screening tool for anterior abdominal wall wounds and lower chest injuries to rule out peritoneal penetration. Increased use of laparoscopy in select patients with penetrating abdominal trauma will decrease the rate of negative and nontherapeutic laparotomies, thus lowering morbidity and decreasing length of hospitalization. As technology and expertise among surgeons continues to improve, more therapeutic intervention may be done laparoscopically in the future.     

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 management of penetrating injuries of the back. A prospective study of 230 patients.

This is a prospective study of 230 patients with penetrating injuries of the back. The decision to operate or observe was taken exclusively on the abdominal physical findings. One hundred ninety-five patients (85%) did not require operation, 30 (13%) underwent a therapeutic laparotomy, four (1.7%) an unnecessary operation, and one patient (0.4%) had a completely negative laparotomy. The diagnosis and management was delayed in five (2.2%) patients with no serious consequences. Mortality rates were not recorded in this series. The initial physical examination was accurate in 95.2% of the patients. We suggest that penetrating injuries of the back should be assessed in the same way as anterior abdominal injuries. Physical abdominal examination is reliable in detecting significant intra-abdominal injuries.     

Selective nonoperative management of penetrating abdominal solid organ injuries

OBJECTIVE: To assess the feasibility and safety of selective nonoperative management in penetrating abdominal solid organ injuries. BACKGROUND: Nonoperative management of blunt abdominal solid organ injuries has become the standard of care. However, routine surgical exploration remains the standard practice for all penetrating solid organ injuries. The present study examines the role of nonoperative management in selected patients with penetrating injuries to abdominal solid organs. PATIENTS AND METHODS: Prospective, protocol-driven study, which included all penetrating abdominal solid organ (liver, spleen, kidney) injuries admitted to a level I trauma center, over a 20-month period. Patients with hemodynamic instability, peritonitis, or an unevaluable abdomen underwent an immediate laparotomy. Patients who were hemodynamically stable and had no signs of peritonitis were selected for further CT scan evaluation. In the absence of CT scan findings suggestive of hollow viscus injury, the patients were observed with serial clinical examinations, hemoglobin levels, and white cell counts. Patients with left thoracoabdominal injuries underwent elective laparoscopy to rule out diaphragmatic injury. Outcome parameters included survival, complications, need for delayed laparotomy in observed patients, and length of hospital stay. RESULTS: During the study period, there were 152 patients with 185 penetrating solid organ injuries. Gunshot wounds accounted for 70.4% and stab wounds for 29.6% of injuries. Ninety-one patients (59.9%) met the criteria for immediate operation. The remaining 61 (40.1%) patients were selected for CT scan evaluation. Forty-three patients (28.3% of all patients) with 47 solid organ injuries who had no CT scan findings suspicious of hollow viscus injury were selected for clinical observation and additional laparoscopy in 2. Four patients with a "blush" on CT scan underwent angiographic embolization of the liver. Overall, 41 patients (27.0%), including 18 cases with grade III to V injuries, were successfully managed without a laparotomy and without any abdominal complication. Overall, 28.4% of all liver, 14.9% of kidney, and 3.5% of splenic injuries were successfully managed nonoperatively. Patients with isolated solid organ injuries treated nonoperatively had a significantly shorter hospital stay than patients treated operatively, even though the former group had more severe injuries. In 3 patients with failed nonoperative management and delayed laparotomy, there were no complications. CONCLUSIONS: In the appropriate environment, selective nonoperative management of penetrating abdominal solid organ injuries has a high success rate and a low complication rate.     

Laparoscopic ultrasound enhances diagnostic laparoscopy in the staging of intra-abdominal neoplasms

Routine laparoscopy and laparoscopic ultrasound (LUS) for staging intra-abdominal malignancies remains controversial. Thus, we undertook a prospective study to assess the value of preoperative laparoscopy with LUS for patients with intra-abdominal tumors judged resectable by preoperative studies. Laparoscopy was successfully performed in 76 of 77 patients, and 60 underwent LUS. Of 33 patients with presumed pancreatic cancer, laparoscopic findings changed the operative management of 11 patients, and LUS altered the management of an additional 6 patients. Laparotomy was avoided in 9 patients (27%). Among 14 patients with hepatobiliary tumors, laparotomy was avoided in 9 patients in whom laparoscopy and/or LUS revealed either benign or advanced disease. Operative management was altered in 4 of 18 patients with gastric or esophageal cancer by laparoscopic findings. LUS did not add to the management of these patients. Of 12 patients with presumed intra-abdominal lymphoma, 9 were diagnosed with lymphoma and 3 with benign disease, without laparotomy in all but 1 case. Laparoscopy and LUS are valuable tools for evaluating the resectability of pancreatic and hepatobiliary tumors. Laparoscopy, and to a lesser degree LUS, greatly facilitates diagnosing patients with intra-abdominal lymphomas and spares an occasional patient with esophagogastric carcinoma from undergoing laparotomy.     

Assessment of risk for intra-abdominal adhesions at laparoscopy for urological tumors

PURPOSE: Abdominal wall adhesions at laparoscopy may predispose patients to access related injuries and increase the complexity of the procedure. We have observed concern from referring physicians regarding the safety of laparoscopy in patients who previously underwent surgery because of the risk of abdominal adhesions. To assess the risk of adhesions at laparoscopy a retrospective cohort study was performed. MATERIALS AND METHODS: All patients who underwent a transperitoneal urological laparoscopic procedure in a 6-year period at our institution were included in this study. A chart review was performed to obtain demographic/surgical data and identify preoperative risk factors for adhesions, such as previous abdominal or pelvic surgery, radiation and/or intra-abdominal inflammatory disease. Operative videotapes were reviewed to determine the presence and location of adhesions. Standard statistical analyses were performed. RESULTS: During the study period 127 patients underwent transperitoneal laparoscopy and videotapes on 82 (65%) were available for review. A total of 44 patients (54%) were identified with preoperative risk factors for adhesions (group 1), while 38 (46%) had no risk factors (group 2). The relative risk of adhesions was 1.34 (95% CI 0.89 to 2.01, p = 0.18) when risk factors were identified. There were no differences in the groups in patient age, operative time, access technique, conversion to open surgery or complications. Estimated blood loss was significantly higher in group 2, likely due to the preponderance of cytoreductive laparoscopic nephrectomy in this group. CONCLUSIONS: There was no difference in the risk of intra-abdominal adhesions in patients with and without identifiable preoperative risk factors. Preoperative risk factors for adhesions should not contraindicate the transperitoneal laparoscopic approach for urological oncology procedures.     

腹腔镜技术在诊治腹部穿透伤中的应用评价

目的:本研究通过分析我院应用腹腔镜技术诊断和治疗腹部穿透伤病人的具体资料,探讨腹腔镜技术在诊治腹部穿透伤中的应用价值。方法:2007年1月至2010年12月,我院收治的腹部穿透伤142例病人中,39例采用非手术治疗,86例采用腹腔镜探查手术,17例采用开腹探查手术。结果:在86例采用腹腔镜探查手术的病例中,51例在腹腔镜下完成止血、修补等治疗;19例因出血迅猛、腹腔污染严重及病变难以处理而中转开腹手术;16例探查阴性。结论:腹腔镜技术在腹部穿透伤的处理中兼具诊断和治疗的作用,避免了一些不必要的开腹手术,从而取代了很多开腹手术;有创伤小,恢复快等优势,有一定的应用价值。     

A new approach to extraperitoneal rectal injuries: laparoscopy and diverting loop sigmoid colostomy

BACKGROUND: Current management of extraperitoneal rectal injuries involves a laparotomy and diversion of the fecal stream. In this study, we review our experience with laparoscopy and diverting loop sigmoid colostomy without laparotomy in the management of these injuries. METHODS: All patients admitted to the trauma unit at Groote Schuur Hospital between January 1995 and May 2000 with a rectal injury were evaluated. The presence of a rectal injury was confirmed by rectal examination and proctosigmoidoscopy. Intraperitoneal injuries were excluded by laparoscopy. Only patients who did not have intraperitoneal injuries were included in the study. The patients were then managed with a diverting loop sigmoid colostomy created through an abdominal wall trephine without laparotomy. RESULTS: Ten patients were included in the study. In eight patients, laparoscopy excluded intraperitoneal injuries. All 10 patients had a diverting loop sigmoid colostomy fashioned. There were no complications related to either the rectal injury or colostomy. Nine stomas have since been closed. CONCLUSION: In patients with isolated extraperitoneal rectal injuries, laparoscopic exclusion of intraperitoneal injuries, followed by a diverting loop sigmoid colostomy, is a feasible option.