Diagnostic and therapeutic value of laparoscopy for small bowel blunt injuries: A case report

INTRODUCTION

Small bowel injuries after blunt abdominal trauma represent both a diagnostic and a therapeutic challenge. Early diagnosis and prompt treatment are necessary in order to avoid a dangerous diagnostic delay. Laparoscopy can represent a diagnostic and therapeutic tool in patients with uncertain clinical symptoms.

PRESENTATION OF THE CASE

We report the case of a 25-year-old man, haemodynamically stable, admitted for acute abdominal pain a few hours after a physical assault. Giving the persistence of the abdominal pain and the presence of free fluids at the computed tomography examination, an exploratory laparoscopy was performed.

DISCUSSION

At the laparoscopic exploration, an isolated small bowel perforation was found, 60 cm distal from the ligament of Treitz. The injury was repaired by laparoscopic suturing and the patient was discharged home at postoperative day 3 after an uneventful postoperative course.

CONCLUSIONS

Laparoscopy represents a valuable tool for patients with small bowel blunt injuries allowing a timely diagnosis and a prompt treatment.     

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.     

Laparoscopy in Pediatric Abdominal Trauma

Background:

The use and indications for laparoscopy have been increasing. As part of this trend, a new algorithm may emerge for pediatric trauma in which laparoscopic techniques are used in hemodynamically stable patients with suspected hollow viscus perforation.

Case Report:

We present a case in which laparoscopy was successfully used in a pediatric trauma patient as a diagnostic and therapeutic modality. A 4-year-old boy was a back-seat passenger in a head-on collision motor vehicle accident. He was restrained by a lap seat belt. He sustained a concussion, a large forehead laceration and a seat belt abdominal injury. On admission, he complained of abdominal pain. Physical examination revealed a soft, nondistended abdomen with moderate diffuse tenderness. He was hemodynamically stable. Computerized tomography of the abdomen revealed free fluid in the pelvis. No abnormalities were detected in the liver or spleen. Because of clinical deterioration and suspected intestinal perforation, diagnostic laparoscopy was utilized instead of proceeding directly to celiotomy. At laparoscopy a jejunal perforation was found and successfully repaired laparoscopically. Large hematomas were seen in the mesentery, as well as an unsuspected splenic laceration. No active bleeding was found. The patient recovered uneventfully and was discharged 5 days following the surgical procedure.

Conclusion:

This case illustrates the efficacy of using early laparoscopy in children with abdominal trauma when diagnosis is difficult and hollow viscus injury is suspected.     

Effect on Negative Laparoscopy Rate in Chronic Pelvic Pain Patients Using Patient Assisted Laparoscopy

Objective:

To determine the value of Patient Assisted Laparoscopy (PAL) in the diagnosis of pelvic pain.

Methods:

One hundred patients with pelvic pain were assessed by the procedure of Patient Assisted Laparoscopy to determine the cause of chronic pelvic pain.

Results:

Of the 100 patients with pelvic pain, 12 patients were not assessed due to technique failure, which included reaction to the carbon dioxide gas, inadequate visualization due to abdominal adhesions or failure to enter peritoneum. Of the remaining 88 patients, 61 had endometriosis; 16 had adhesions not associated with endometriosis; five had hernias; one had occult bowel cancer; one pseudo-stone from previous cholecystectomy; one had pain as a result of staples used at hysterectomy and one patient had chronic Crohn''s disease. Two patients had no demonstrated interabdominal cause for their symptoms.

Conclusion:

In contrast to the well published rate of 35% negative laparoscopy in those patients with pelvic pain when examined under general anesthetic, Patient Assisted Laparoscopy decreased the negative laparoscopy rate to less than 3%. This methodology was also of benefit in giving the patient a better understanding of the cause of her pain and the need for therapy.     

Laparoscopic Repair of a Posttraumatic Left-Sided Diaphragmatic Hernia Complicated by Strangulation and Colon Obstruction

Background:

Posttraumatic diaphragmatic hernias (PDH) are serious complications of blunt and penetrating abdominal or thoracic trauma. Traditional thoracic or abdominal operations are usually performed in these cases.

Methods:

We present 2 cases of posttraumatic left-sided diaphragmatic hernia complicated by strangulation and colon obstruction. Both cases were successfully treated with laparoscopy.

Results:

We found that laparoscopy is a safe, successful, and gentle procedure not only for diagnosis but also for treatment of complicated PDH. Strangulation and colon obstruction were not contraindications to performing laparoscopic procedures. The postoperative course and long-term follow-up (range, 12 to 30 months) were uneventful and short. We expect the same good long-term results after laparoscopic repair as after open conventional surgery.

Conclusion:

We recommend the use a minimally invasive approach to treat posttraumatic diaphragmatic hernia complicated by strangulation and colon obstruction in hemodynamically stable patients.     

Outcomes after severe trauma at a northern Canadian regional trauma centre

Objective

To evaluate outcomes of trauma patients at a northern community trauma referral centre that does not meet several of the guidelines for a trauma centre.

Design

A retrospective study.

Setting

Sudbury General Hospital in northern Ontario.

Participants

All trauma patients admitted between 1991 and 1994 who had an Injury Severity Score (ISS) greater than 12.

Outcome measures

Actual survival to discharge was compared to survival predicted by TRISS analysis. Z, W and M scores were calculated by standard TRISS techniques.

Results

Of 526 patients with an ISS greater than 12, 416 (79%) were suitable for TRISS analysis. Of these 416 patients, 310 (74%) were men. The mean age was 39 years. Two hundred and sixty-one (63%) patients were admitted directly to the Sudbury General Hospital, whereas 155 (37%) were transferred from other hospitals. The leading causes of injury were motor vehicle–traffic accidents in 48%, motor vehicle–nontraffic in 21% and falls in 8%. Overall, there were more unexpected survivors than patients who died. The Z score for survivors was 4.95, and the W score was 5.66.

Conclusions

In the setting of a geographically isolated, medium-volume trauma centre where blunt injuries predominate, excellent trauma survival can be achieved without meeting all trauma centre guidelines for staffing and facilities. Relaxing stringent requirements for the availability of physicians may facilitate surgical recruitment and retention.     

Management of splenic injuries in a Canadian trauma centre

Objectives

To document the current practice pattern for the treatment of splenic injuries in one Canadian trauma centre and to identify factors that determined which method was employed.

Design

A cohort study.

Setting

A Canadian lead trauma centre.

Patients

A cohort of 100 patients with splenic injury treated at one trauma hospital over 5 years was identified from a prospective trauma database.

Main Outcome Measures

The success rate and failure rate for splenic salvage by splenectomy, splenorrhaphy or observation. Volume of blood transfused, injury severity score (ISS) and method of diagnosis.

Results

The median ISS for the cohort was 34 (36 for splenectomy, 38 for splenorrhaphy and 35 for observation). A blunt mechanism of injury was present in 96%. The diagnosis was made by computed tomography (CT) in 55%. Splenic salvage was accomplished in 51 patients; of these, 44 (86%) were in the observation group, and the success rate was 90% (within the range reported in the literature). Only seven patients underwent splenorrhaphy. CT was performed more frequently in the observation group than in the splenectomy group (82% v. 25%, p < 0.0001). The splenectomy group had more blood tranfused than the successful observation group (mean units 15 v. 3, p = 0.0001) and had a higher median ISS (36 v. 29, p = 0.02). Multivariate analysis revealed that the method of diagnosis (CT v. diagnostic peritoneal lavage) was the strongest factor associated with how the splenic injury was treated.

Conclusions

The finding in this report of an increase in observational treatment of splenic injuries represents a shift in practice from a previous Canadian report and is in keeping with recent published trends from the United States. Future studies are needed to assess whether any strong regional practice pattern variations in the management of blunt splenic injuries exists in other trauma centres across Canada.     

Minimally Invasive Surgery in Pediatric Trauma: One Institution's 20-Year Experience

Background:

Minimally invasive surgery (MIS) for trauma in pediatric cases remains controversial. Recent studies have shown the validity of using minimally invasive techniques to decrease the rate of negative and nontherapeutic laparotomy and thoracotomy. The purpose of this study was to evaluate the diagnostic accuracy and therapeutic options of MIS in pediatric trauma at a level I pediatric trauma center.

Methods:

We reviewed cases of patients aged 15 years and younger who had undergone laparoscopy or thoracoscopy for trauma in our institution over the past 20 years. Each case was evaluated for mechanism of injury, computed tomographic (CT) scan findings, operative management, and patient outcomes.

Results:

There were 23 patients in the study (16 boys and 7 girls). Twenty-one had undergone diagnostic laparoscopy and 2 had had diagnostic thoracoscopy. In 16, there were positive findings in diagnostic laparoscopy. Laparoscopic therapeutic interventions were performed in 6 patients; the remaining 10 required conversion to laparotomy. Both patients who underwent diagnostic thoracoscopy had positive findings. One had a thoracoscopic repair, and the other underwent conversion to thoracotomy. There were 5 negative diagnostic laparoscopies. There was no mortality among the 23 patients.

Conclusions:

The use of laparoscopy and thoracoscopy in pediatric trauma helps to reduce unnecessary laparotomy and thoracotomy. Some injuries can be repaired by a minimally invasive approach. When conversion is necessary, the use of these techniques can guide the placement and size of surgical incisions. The goal is to shift the paradigm in favor of using MIS in the treatment of pediatric trauma as the first-choice modality in stable patients.     

Laparoscopic Orchidopexy: The Treatment of Choice for the Impalpable Undescended Testis

Objective:

Management of the impalpable testis often represents a significant diagnostic and therapeutic challenge for the radiologist and surgeon. The aim of this work is to present the superior value of laparoscopy as a single tool for the diagnosis and treatment of the impalpable testis.

Methods and Procedures:

Thirty-three patients with 43 impalpable testes are included in this study. For each patient, magnetic resonance imaging (MRI) then laparoscopy were performed. Either the testis or blindending cord structures are searched for. The testis was either brought down to the scrotum or removed depending on the condition of each patient.

Results:

MRI detected 16 out of 43 impalpable testes (37.2%). Laparoscopy, on the other hand, detected 18 intra-abdominal testes, 7 inguinal and 16 blindending cord structures either above or below the internal inguinal ring. Blindending cord structures suggested a vanished testis. Orchidopexy was done for 23 cases, orchidectomy in 18 cases and laparoscopy only in 2 cases.

Conclusion:

Laparoscopy seems to offer a safe and reliable diagnostic and therapeutic option to patients with impalpable testes. Intra-abdominal dissection allows more testes to be brought down to the scrotum. The procedure is best viewed as laparoscopy-assisted, as Orchidopexy has to be done in a conventional manner.     

Adrenal gunshot wound: Laparoscopic approach. Report of a case

INTRODUCTION

Although there is no debate that patients with peritonitis or hemodynamic instability should undergo urgent laparotomy after penetrating abdominal injury, it is also clear that certain stable patients may be managed without operation. Controversy persists regarding use of laparoscopy.

PRESENTATION OF CASE

We report a case of gunshot wounds with bullet in left adrenal gland and perirenal subcapsular hematoma. The patients had no signs of peritonitis but in the observation period we noted a significative blood loss, so we performed an exploratory laparoscopy.

DISCUSSION

We found the bullet in adrenal parenchyma. The postoperative period was regular and the patient was discharged without any local or general complication.

CONCLUSION

Although the data are still controversial, the importance of the laparoscopic approach is rapidly increasing also in case of penetrating trauma of the abdomen. This technique assumes both a diagnostic and therapeutic role by reducing the number of negative laparotomies.     

Laparoscopy and Complicated Meckel Diverticulum in Children

Background and Objectives:

Meckel diverticulum can present with a variety of complications but is often found incidentally during other surgical procedures. The role of laparoscopy in the management of Meckel diverticulum is established. We reviewed our experience with complicated cases of Meckel diverticulum in children managed with laparoscopy.

Methods:

A 15-year retrospective chart review revealed 14 cases of complicated Meckel diverticulum managed with laparoscopy. Incidentally found Meckel diverticulum and cases done by laparotomy were excluded. Ages varied from 2 years to 16 years old. There were 10 males and four females. Eight cases had small bowel obstruction; of those, three had extensive intestinal gangrene. Four cases had significant rectal bleeding, three had acute diverticulitis, and two had intussusception caused by the diverticulum.

Results:

Eleven cases were treated with laparoscopic Meckel diverticulectomy and three with laparoscopic-assisted bowel resection because of extensive gangrene of the intestine. Two of the three cases with significant intestinal gangrene returned several weeks later with small bowel obstruction secondary to adhesions. They were successfully managed with laparoscopic lysis of adhesions. There were no other complications.

Conclusions:

Laparoscopy is safe and effective in the management of complicated Meckel diverticulum in children. Most cases can be managed with simple diverticulectomy. Laparoscopy is useful when the diagnosis is uncertain. When extensive gangrene is present, laparoscopy can help to mobilize the intestine and evaluate the degree of damage, irrigate and cleanse the peritoneal cavity, and minimize the incision necessary to accomplish the bowel resection.     

Pneumoperitoneum in a patient with pneumothorax and blunt neck trauma

INTRODUCTION

Blunt trauma as a cause of pneumoperitoneum is less frequent and its occurrence without a ruptured viscus is rarely seen.

PRESENTATION OF CASE

We report a case of blunt neck trauma in which a motorcycle rider hit a fixed object causing severe laryngotracheal injury. The patient developed pneumothorax bilaterally and had pneumoperitoneum despite no injury to the internal viscus. Bilateral chest tube drainage and abdominal exploratory laparotomy was performed.

CONCLUSION

Free air in the abdomen after blunt traumatic neck injury is very rare. If pneumoperitoneum is suspected in the presence of pneumothorax, exploratory laparotomy should be performed to rule out intraabdominal injury. As, there is no consensus for this plan yet, further prospective studies are warrant. Conservative management for pneumoperitoneum in the absence of viscus perforation is still a safe option in carefully selected cases.     

Intestinal Injury Secondary to an Umbilical Piercing

Background:

Body piercing has become increasingly popular throughout the world and may cause unanticipated complications during surgery.

Methods:

We describe the case of a 35-y-old woman with hepatocellular carcinoma who underwent a diagnostic laparoscopy for metastatic disease evaluation.

Results:

An early intestinal injury occurred upon abdominal entry and introduction of pneumoperitoneum. The injury was secondary to a single adhesion between the abdominal wall and small bowel caused by a previous umbilical piercing.

Conclusions:

Umbilical piercing can lead to unanticipated intraoperative complications even if it is removed prior to surgery. Surgeons performing laparoscopy should be aware of potential pitfalls associated with these art forms.     

The management of trauma victims with head injury: a study by the national confidential enquiry into patient outcome and death

Introduction

In 2006 the National Confidential Enquiry into Patient Outcome and Death undertook a large prospective study of trauma care, which revealed several findings pertaining to the management of head injuries in a sample of 493 patients.

Methods

Case note data were collected for all trauma patients admitted to all hospitals accepting emergencies in England, Wales, Northern Ireland and the Channel Islands over a three-month period. Severely injured patients with an injury severity score (ISS) of ≥16 were included in the study. The case notes for these patients were peer reviewed by a multidisciplinary group of clinicians, who rated the overall level of care the patient received.

Results

Of the 795 patients who met the inclusion criteria for the study, 493 were admitted with a head injury. Room for improvement in the level of care was found in a substantial number of patients (265/493). Good practice was found to be highest in high volume centres. The overall head injury management was found to be satisfactory in 84% of cases (319/381).

Conclusions

This study has shown that care for trauma patients with head injury is frequently rated as less than good and suggests potential long-term remedies for the problem, including a reconfiguration of trauma services and better provision of neurocritical care facilities.     

A cross-sectional study of knife injuries at a London major trauma centre

INTRODUCTION

No national recording systems for knife injuries exist in the UK. Understanding the true size and nature of the problem of knife injuries is the first stage in reducing the burden of this injury. The aim of this study was to survey every knife injury seen in a single inner city emergency department (ED) over a one-year period.

METHODS

A cross-sectional observational study was performed of all patients attending with a knife injury to the ED of a London major trauma centre in 2011. Demographic characteristics, patterns of injury, morbidity and mortality data were collected.

RESULTS

A total of 938 knife injuries were identified from 127,191 attendances (0.77% of all visits) with a case fatality rate of 0.53%. A quarter (24%) of the major trauma team’s caseload was for knife injuries. Overall, 44% of injuries were selfreported as assaults, 49% as accidents and 8% as deliberate self-harm. The highest age specific incident rate occurred in the 16–24 year age category (263/100,000). Multiple injuries were seen in 19% of cases, of which only 81% were recorded as assaults. The mean length of stay for those admitted to hospital was 3.04 days. Intrathoracic injury was seen in 26% of cases of chest trauma and 24% of abdominal injuries had a second additional chest injury.

CONCLUSIONS

Violent intentional injuries are a significant contributory factor to the workload of the major trauma team at this centre. This paper contributes to a more comprehensive understanding of the nature of these injuries seen in the ED.     

Systematic review of blunt abdominal trauma as a cause of acute appendicitis

INTRODUCTION

Acute appendicitis commonly presents as an acute abdomen. Cases of acute appendicitis caused by blunt abdominal trauma are rare. We present a systematic review of appendicitis following blunt abdominal trauma. The aim of this review was to collate and report the clinical presentations and experience of such cases.

SUBJECTS AND METHODS

A literature review was performed using PubMed, Embase and Medline and the keywords ‘appendicitis’, ‘abdominal’ and ‘trauma’.

RESULTS

The initial search returned 381 papers, of which 17 articles were included. We found 28 cases of acute appendicitis secondary to blunt abdominal trauma reported in the literature between 1991 and 2009. Mechanisms of injury included road-traffic accidents, falls, assaults and accidents. Presenting symptoms invariably included abdominal pain, but also nausea, vomiting and anorexia. Only 12 patients had computed tomography scans and 10 patients had ultrasonography. All reported treatment was surgical and positive for appendicitis.

CONCLUSIONS

Although rare, the diagnosis of acute appendicitis must be considered following direct abdominal trauma especially if the patient complains of abdominal right lower quadrant pain, nausea and anorexia. Haemodynamically stable patients who present shortly after blunt abdominal trauma with right lower quadrant pain and tenderness should undergo urgent imaging with a plan to proceed to appendicectomy if the imaging suggested an inflammatory process within the right iliac fossa.     

Recent changes in the management of blunt splenic injury: effect on splenic trauma patients and hospital implications

INTRODUCTION

Management of blunt splenic injury has been controversial with an increasing trend towards splenic conservation. A retrospective study was performed to identify the effect of this changed policy on splenic trauma patients and its implications.

PATIENTS AND METHODS

Data regarding patient demography, mode of splenic injury, CT grading, blood transfusion requirement, operative findings hospital stay and follow-up were collected. Statistical analysis of the data was performed using non-parametric Mann–Whitney tests

RESULTS

Over an 8-year period, only 21 patients were admitted with blunt splenic injury. Ten patients were managed operatively and 11 non-operatively. Non-operative management failed in one patient due to continued bleeding. Using Buntain''s CT grading, the majority of grades I and II splenic injuries were managed non-operatively and grades III and IV were managed operatively (P = 0.008). Blood transfusion requirement was significantly higher among the operative group (P = 0.004) but the non-operative group had a significantly longer hospital stay (P = 0.029). Among those managed non-operatively (median age, 24.5 years), a number of patients were followed up with CT scans with significant radiation exposure and unknown long-term consequences.

CONCLUSIONS

Non-operative management of blunt splenic trauma in adults can be performed with an acceptable outcome. Although CT is classed as the ‘gold standard’, initial imaging for detection and evaluation of blunt splenic injury, ultrasound can play a major role in follow-up imaging and potentially avoids major radiation exposure.     

Laparoscopic repair of chronic traumatic diaphragmatic hernia using biologic mesh with cholecystectomy for intrathoracic gallbladder

Background and Objectives:

Diaphragmatic rupture is a serious complication of both blunt and penetrating abdominal trauma. In the acute setting, delay in diagnosis can lead to severe cardiovascular and respiratory compromise. Chronic cases can present years later with a plethora of clinical symptoms. Laparoscopic techniques are being increasingly utilized in the diagnosis and treatment of traumatic diaphragmatic hernias.

Method:

We describe a case of a 70-year-old female who presented with signs and symptoms of a small bowel obstruction. She was ultimately found to have an obstruction secondary to a chronic traumatic diaphragmatic hernia with an intrathoracic gallbladder and incarcerated small intestine. A cholecystectomy and diaphragmatic hernia repair were both performed laparoscopically. This case report presents an atypical cause of bowel obstruction and reviews the current literature on laparoscopic management of traumatic diaphragmatic hernias.

Results and Conclusion:

Laparoscopy is increasingly used in the diagnosis and treatment of traumatic diaphragmatic hernias with good results.