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。     

Laparoscopic splenectomy for blunt trauma: a safe operation following embolization

Background  Embolization of the injured spleen from blunt trauma reduces the risk of continued or delayed hemorrhage in patients being treated with nonoperative management (NOM). Splenectomy is required in some patients following embolization due to continued bleeding or infarction with abscess formation. Laparoscopic splenectomy for blunt trauma can be done safely in patients following embolization. Methods  A retrospective chart review was conducted on patients undergoing splenectomy following embolization due to blunt trauma at two level I trauma centers. Minimally invasive techniques were compared to laparotomy for operative time, operative blood loss, and postoperative length of stay. Results  Eleven of 46 patients required splenectomy following embolization, eight for continued bleeding and three for abscess formation. Four of these patients had their spleens removed laparoscopically, three for continued bleeding and one for abscess formation. Patients undergoing laparoscopic splenectomy for continued bleeding had slightly longer operative times, more blood loss but shorter postoperative stay than those undergoing laparotomy. (96 versus 76 min, 500 versus 300 cc, and 4.0 versus 7.0 days, respectively). Laparoscopic removal of the abscessed spleen took 270 min compared to 55 and 90 min for the open procedures but the postoperative hospital stay was only 6 days compared to 10 and 13 days. There were no serious complications in any patients. Conclusion  Laparoscopic removal of the spleen following embolization for blunt trauma is safe and should be considered in patients that have persistent bleeding or are at risk for delayed bleeding, as well as patients in whom complications of infarction and abscess formation develop.     

Laparoscopic cholecystectomy in penetrating trauma.

Laparoscopy in trauma is useful in diagnosing but limited in treatment. We report the case of a patient with a stab wound in the right upper quadrant and gallbladder perforation who underwent diagnostic and laparoscopic treatment. The therapeutic opportunities in abdominal trauma are scant for laparoscopic surgery; the isolated gallbladder injury is one of them, it being possible to apply the usefulness of this less invasive technique in this case.     

Laparoscopic cholecystectomy: a safe approach for management of acute cholecystitis.

BACKGROUND AND OBJECTIVES: Laparoscopic cholecystectomy (LC) is increasingly being used as an appropriate early treatment in patients with cholecystitis. This study evaluated the safety, effectiveness, and complications of LC in all cases of acute cholecystitis. METHODS: A retrospective study involved the patients who underwent LC for acute cholecystitis within 72 hours of admission. The preoperative diagnosis was based on clinical, laboratory, and echographic examinations, while the final diagnosis was confirmed by histopathological examination of the excised gallbladder. RESULTS: We identified 184 patients with acute cholecystitis. Intraoperative cholangiography (IOC) was not performed. Preoperative endoscopic retrograde cholangiopancreatography (ERCP) was performed in 62 patients (33.7%), and postoperative ERCP in 13 patients (7.1%). Conversion to open cholecystectomy was necessary in 19 patients (10.3%); 16 patients for severe inflammation and adhesions and 3 patients because of uncontrolled bleeding. The mean operative time was 68 minutes. No deaths occurred. The overall complication rate was 6% with 3 postoperative bile leakages and 2 nonbilious subhepatic collections. The mean postoperative hospital stay was 2.8 days. CONCLUSIONS: LC is a safe, effective procedure for the early management of patients with acute cholecystitis. LC can be safely performed without routine IOC when ERCP is performed preoperatively on the basis of specific indications. Meticulous dissection and good exposure of Calot's triangle may prevent bile duct injuries.     

Laparoscopic splenectomy is an effective and safe intervention for hypersplenism secondary to liver cirrhosis

Background  

Laparoscopic splenectomy has become the standard procedure for the normal to moderately enlarged spleens. We performed this study to investigate the safety, feasibility, and effectiveness of laparoscopic splenectomy for hypersplenism secondary to liver cirrhosis.     

Fibrin glue and hemostasis in liver trauma: a case report

We have used fibrin glue to control non-arterial hemorrhage from major liver lacerations in two patients with excellent results. It is an ideal biologic hemostatic agent. Fibrin glue uses none of the body's intrinsic clotting factors and can be prepared from commonly available products in minutes.     

Selective management of penetrating neck trauma

Of 110 patients with penetrating injuries of the neck, 58 were selectively observed and 52 underwent prompt surgical exploration according to defined criteria. In the group initially selected for observation, none required subsequent surgical intervention, and there was no mortality. Among those patients operated upon primarily, the negative exploration rate was 17 percent, and two patients died, both as a result of their injuries (mortality rate, 4%). We conclude that selective management of patients with penetrating neck injuries, when guided by repeated and careful examinations, is appropriate, does not increase the risk to patients, and avoids unnecessary surgical procedures.     

The management of penetrating pelvic trauma

Eighty-nine patients with penetrating pelvic trauma were treated during a three-year period. Sixty-three of 72 patients who had mandatory exploration had findings at operation. The negative laparotomy rate was higher for patients with posterior penetrations (40%). Diagnostic peritoneal lavage, sigmoidoscopy, and intravenous pyelography were useful adjunctive tests to confirm the lack of need for exploration in patients with negative physical findings. This protocol of tests was particularly useful for patients with posterior sites of injury. Patients with injury to multiple organ systems had a higher rate of infectious complications (48%) than those with single system injury (11% complication rate). Primary repair of colon, urologic and vascular injuries was safe even in patients with injury to multiple organ systems.     

Surgical management of severe liver trauma: a role for liver transplantation

Severe devascularizing liver injuries continue to carry a high mortality. Rapid operative intervention to achieve hemostasis and debride devitalized tissue remains essential to salvaging these patients. For those with unsalvageable liver injuries liver transplantation can be employed. Careful support of the patient in the anhepatic state, reversal of coagulopathy, and use of venous bypass intraoperatively permit successful transplantation.     

Non-operative management of penetrating liver injuries: a prospective study

This is a report of a study of 63 cases of penetrating liver injuries. Forty-two patients (67 per cent) who presented with signs of an acute abdomen were operated on. The liver was routinely sutured and drained. There was no incidence of postoperative intra-abdominal sepsis or haematobilia. In the remaining 21 patients (33 per cent) liver involvement was suggested by the fact that the wound was over the liver region, and penetrated the peritoneum, and abdominal paracentesis for blood was positive or the patient was shocked or pale. The patients in this group had a soft abdomen and they were treated conservatively with observation and blood transfusions if necessary. No complications were recorded in this group. It is concluded that many civilian penetrating injuries of the liver may be managed non-surgically. If an operative approach is selected suturing of the liver with drainage is the recommended procedure.     

Airway management for victims of penetrating trauma: analysis of 50,000 cases

Background

Current recommendations for victims of penetrating trauma include prompt transportation to a trauma center. It remains unclear whether field intubation allows for improvements in mortality rate.

Methods

A retrospective review of the National Trauma Data Bank of adult victims of penetrating trauma was performed. Standard demographic data, method, and location of airway management were examined. Mortality rate was used as the primary outcome measure.

Results

There were 56,094 victims of penetrating trauma identified. A total of 1,925 patients required a prehospital airway. The mortality rate for patients who underwent airway management at the scene was 69.2%, compared with a rate of 35.9% for patients in whom airway management was deferred. The mortality rate for patients undergoing surgical airway management at the scene was only 23.9%.

Conclusions

Victims of penetrating trauma who require any airway management have a high mortality rate. The cause of this difference awaits further prospective investigation.     

Laparoscopic treatment of biliary peritonitis following nonoperative management of blunt liver trauma

Introduction  

Nonoperative management (NOM) of hemodynamically stable patients with blunt hepatic injuries is considered the current standard of care. However, it is associated with several in-hospital complications. In selected cases laparoscopy could be proposed as diagnostic and therapeutic means.     

Laparoscopic repair of small bowel injury in penetrating abdominal trauma

A role for laparoscopy in the management of selected trauma patients is now possible. We report a case of a patient with a stab wound and a bowel perforation who underwent diagnostic and laparoscopic treatment.     

Surgical management of penetrating pelvic trauma: a case report and literature review

High-velocity penetrating pelvic injury is one of the most difficult challenges to trauma surgeons. The injury sites frequently include soft tissue, pelvis, genitourinary tract, vascular structures and intraabdominal viscera. We present an unusual case of a male patient suffering a collision at night with a deformed steel bar penetrating into his right groin. Careful planning of the surgical approach is important before extracting the foreign body. The possibility of multiorgan damage to intrapelvic structures such as colon, urinary bladder, vessels and nerves, frequently necessitates a multidisciplinary involvement and systematic approach. Besides, limited incision as well as modification should be considered, and debridement and perioperative antibiotics can be used to reduce the risk of serious wound infection.     

Laparoscopic temporary packing for hemostasis

Control of bleeding from the renal parenchyma remains one of the challenges of laparoscopic partial nephrectomy. If adjuvant measures fail, packing of the surgical bed may achieve hemostasis. We report a novel series of temporary laparoscopic packing of the surgical bed with minimally invasive kidney surgery. Technique and potential complications are also discussed.     

Pitfalls in the management of penetrating chest trauma

A prospective study designed specifically to analyze errors in management and iatrogenic complications was conducted on 234 consecutive patients with penetrating chest trauma. Eleven percent of penetrating pleural injuries were incorrectly diagnosed on initial physical and radiologic examination, but this led to wrong management decisions in only 4 percent. Decisions regarding intercostal tube drainage were particularly inaccurate when emergency intubation was required prior to chest radiography. Atypical clinical features of penetrating cardiac injuries caused delay in diagnosis and thoracotomy in 3 of 14 patients. Only two of four mediastinal vascular injuries were recognized on initial examination. Transdiaphragmatic injuries were initially missed in 5 of 14 patients. This resulted in management errors and delay in these patients. Awareness of atypical presentations and circumstances in which misjudgments and wrong decisions are prone to occur should help to avoid pitfalls and reduce mortality from penetrating chest trauma.