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.     

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.     

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 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.     

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.     

Cost analysis of diagnostic laparoscopy vs laparotomy in the evaluation of penetrating abdominal trauma

Background: Diagnostic laparoscopy for the evaluation of injuries in patients with penetrating abdominal trauma has been shown to decrease the morbidity and mortality associated with mandatory laparotomy. The overall impact on patient care and hospital costs has not been thoroughly investigated. The goal of this study was to determine the economic impact of laparoscopy as a diagnostic tool in the management of patients following penetrating trauma to the abdomen or flank. Methods: Retrospective chart review of all hemodynamically stable patients with penetrating trauma to the abdomen or flank, but without other injuries requiring emergent intervention, admitted to a level I trauma center between January 1, 1992, and September 30, 1994. Those patients who underwent either laparoscopy (DL) or laparotomy (NL) or both (CONV) and who had no intraabdominal organ injuries requiring surgical therapeutic intervention were included in the study. Age, operative time, operative findings, length of hospitalization, Injury Severity Score (ISS), variable costs, and total costs were recorded for each patient. Results: Fourteen patients underwent negative/nontherapeutic laparoscopy (DL), 19 patients underwent negative/nontherapeutic laparotomy (NL), and four patients underwent both laparoscopy and laparotomy, a conversion procedure (CONV). There was no significant difference in age, operative times, or ISS between the DL and NL groups. Mean ISS of CONV patients was significantly greater than that of DL patients, 5.75 ± 1.97 vs 2.43 ± 0.63 (p < 0.05). Mean operative time for CONV patients was also significantly greater than both DL and NL patients, 106.5 ± 17.00 min vs 66.1 ± 6.55 and 47.3 ± 7.50 min, respectively (p < 0.05). The mean length of stay was significantly shorter in the DL group as compared to the NL or CONV groups, 1.43 ± 0.20 vs 4.26 ± 0.31 and 5.0 ± 0.82 (p < 0.0001). The variable costs for the DL group were significantly lower than those incurred by patients in the NL and CONV groups, $2,917 ± 175 vs $3,384 ± 102 and $3,774 ± 286, (p < 0.05). Variable costs were not significantly different between the NL and CONV groups. Total costs were also significantly lower in the DL group when compared to NL and CONV, $5,427 ± 394 vs $7,026 ± 251 and $7,855 ± 750 (p < 0.005), but again, they were not statistically different between the NL and CONV groups. The overall total costs for laparoscopy, including the costs incurred by conversion patients, was significantly less than the total costs for laparotomy patients, $5,664 ± 394 vs $7,028.47 ± 250 (p < 0.005). This resulted in an overall savings of $1,059.44 per laparoscopy performed. The overall negative/nontherapeutic laparotomy rate during this study was 19.1%, which was significantly lower than the negative or nontherapeutic exploration rate during the time period prior to the use of laparoscopy (p < 0.01, z = 2.550). Conclusion: Variable and total costs and length of stay were significantly lower in our population of patients who underwent DL as compared to NL. The rate of negative or nontherapeutic laparotomy was also significantly reduced when compared to the rate identified during the era prior to the use of laparoscopy. Laparoscopy resulted in an overall savings of $1,059 per laparoscopy performed when compared to laparotomy. Received: 11 March 1996/Accepted: 5 July 1996     

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     

Laparoscopy in the evaluation of the intrathoracic abdomen after penetrating injury.

Penetrating trauma to the intrathoracic abdomen is a difficult clinical problem, especially with reference to the detection of diaphragmatic injuries. A retrospective analysis of 657 laparotomies for penetrating abdominal trauma at our institution revealed 78 laparotomies with negative results. The majority (44.8%) were for wounds in the lower chest and upper abdomen. The role of laparoscopy in evaluating these difficult areas was studied in 40 (34 stab wounds and 6 gunshot injuries) patients. Fifteen stab wounds and five gunshot wounds were nonpenetrating. Laparoscopy revealed eight clinically unsuspected diaphragmatic lacerations in seven patients. Twenty patients had hemoperitoneum. Five patients with omental bleeding and abdominal wall bleeding and four with nonbleeding liver lacerations underwent nontherapeutic laparotomies. One patient with a nonbleeding liver laceration was observed successfully without laparotomy. Ten of the 20 patients with hemoperitoneum had therapeutic laparotomies. The incidence of diaphragmatic lesions discovered by laparoscopy in this series was comparable with that reported after a mandatory laparotomy for thoracoabdominal wounds. It is concluded that laparoscopy is an excellent modality for the evaluation of the intrathoracic abdomen and the diaphragm.     

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.     

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.     

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.     

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.     

The role of laparoscopy in penetrating abdominal stab wounds

The role of diagnostic laparoscopy (DL) in abdominal stab wounds (ASWs) is not clearly defined. We hypothesized that peritoneal penetration (PP) during DL was a valid indication to convert to an exploratory laparotomy (EL). Retrospective review of hemodynamically stable ASWs requiring operation. A total of 161 patients with ASWs were identified, with 36 of 92 patients (39.1%) undergoing DL converted to EL. All 36 patients had PP; 20 of 36 (55.6%) ELs were therapeutic (TL). The number of nontherapeutic laparotomies (NTLs) prevented was 56 (60.9%). Five of 92 patients had PP on DL but did not undergo EL. Twenty-four of 69 patients who underwent initial EL had an NTL (34.8%). If this group had undergone an initial DL, and PP was used to determine need for EL, the number of NTLs would have been reduced to 10 (14.5%), a 58.3% reduction. Evidence of PP during DL is a reasonable indicator to determine the need for EL and reduce the number of NTLs.     

Laparoscopy in blunt abdominal trauma

Summary BACKGROUND: The decision in favor of surgery or nonoperative conservative treatment in abdominal trauma requires a precise diagnosis that is not always possible with imaging techniques. As there is particular danger that an injury to the diaphragm or intestines be overlooked, the indications for exploratory laparotomy should be generous. Owing to this circumstance, however, up to 41% of exploratory laparotomies turn out to be nontherapeutic and could be, or could have been, avoided with laparoscopy. METHODS: A diagnostic laparoscopy with therapeutic option in blunt abdominal trauma should only be attempted in stable patients. Usually three trocars are used and the exploration of the abdomen is systematic, beginning with the right upper quadrant and continuing clockwise. Small lacerations of the intestines and mesentery can be detected and sutured endoscopically, as well as injuries to the diaphragm. Injuries to parenchymal organs are not a primary indication for laparoscopy, but they can be sealed with tissue adhesive and collagen tamponade to prevent further bleeding. RESULTS: Routine use of laparoscopy can achieve a sensitivity of 90–100% in abdominal trauma. This can reduce the number of unnecessary laparotomies and the related morbidity. CONCLUSIONS: Laparoscopy can be performed safely and effectively in stable patients with abdominal trauma. The most important advantages are reduction of morbidity, shortening of hospitalization and cost-effectiveness. In the future, new developments in laparoscopy equipment and the introduction of computer technology and robotic devices can be expected to have a decisive influence on the treatment of trauma patients.     

Laparoscopy in Abdominal Trauma

Background:   

The decision in favor of surgery or nonoperative conservative treatment in blunt and penetrating abdominal trauma requires a precise diagnosis that is not always possible with imaging techniques, whereby there is great danger that an injury to the diaphragm or intestines may be overlooked. To avoid such oversights, indications for exploratory laparotomy have traditionally been generous, to the extent that up to 41% of exploratory laparotomies turn out to be nontherapeutic and could be, or could have been, avoided with laparoscopy.     

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.     

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.     

Nontherapeutic laparotomies revisited

A wide variability exists in the reported incidents of complications following nontherapeutic laparotomy for trauma. We undertook this study to examine the decision-making leading to and complication rates related to the use of nontherapeutic laparotomy in an era of nonoperative management. We conducted a retrospective chart review of all nontherapeutic laparotomies as defined by the operating surgeon performed between May 1998 and May 2001. A total of 50 patients (6%) underwent nontherapeutic laparotomies predominantly for penetrating injury. The most frequent preoperative reason for nontherapeutic laparotomy was the question of hollow viscous or diaphragmatic injury on preoperative studies. Peritoneal signs on examination and peritoneal penetration on wound exploration were also frequent indications for surgery. Significant complication rates were low at approximately 12 per cent. Total length of stay was 7.3 days and 5 days if patients with significant other associative injuries were excluded. Overall morality was 4 per cent and unrelated to the nontherapeutic laparotomy in all cases. Overall incidence of nontherapeutic laparotomy has decreased with the use of abdominal helical CT and triple-contrast CT to evaluate penetrating injuries. Despite these advances diaphragmatic and hollow viscous injuries remain a concern. Although overall serious complication rates were low the use of nontherapeutic laparotomy adds significantly to length of stay and complications.     

Small bowel perforation caused by compound pelvic fracture found in diagnostic laparoscopy

Small bowel perforations in blunt abdominal trauma (BAT), especially in multiply injured patients, are difficult to diagnose in the first hours after the accident, either clinically or by imagistic studies. A less encountered diagnostic modality is diagnostic laparoscopy (DL), selectively indicated. We present the case of a patient with BAT and complex pelvic fracture, hemodynamically stable, with TS= 15, who clinically had abdominal tenderness and on ultrasound (US) and CT scan, had free intra-abdominal fluid (FIAF), without any injuries of a solid viscus, which led us to suspect a hollow viscus injury. We proceeded with a DL, imposed by the equivocal diagnosis, taking advantage of the general anesthesia needed for the femoral and pelvic fracture immobilization. We identified an ileal perforation and decided to convert to open surgery, and we found a second perforation. Segmentary ileal resection was performed. Orthopedically, in emergency, the femoral fracture and the posterior arch of the pelvis were immobilized, but due to the septic risk, the anterior arch was immobilized 10 days later. DL is a valuable tool in BAT with FIAF on US and CT scan with suspicion of hollow viscus perforation in the hemodynamically stable patients, in order to decide between laparotomy and observation. In equivocal diagnosis cases, DL avoids unnecessary or delayed laparotomy. Whenever possible and indicated, orthopedic lesions will be dealt with in emergency ("early total care"), in order to reduce the recovery and hospitalization period.     

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.