Minilaparoscopy for blunt abdominal trauma

A new technique of minilaparoscopy has been developed for use in patients with blunt abdominal trauma. Fifteen injured patients underwent laparoscopy using this new method. Six patients had normal findings, seven patients had evidence of minor injury, and two patients had what seemed to be major injuries. The patients with normal findings or minor injuries were treated nonoperatively and all did well. The two remaining patients underwent laparotomy where serious injuries were found and repaired accordingly. With this modified instrumentation, emergency laparoscopy is simple and rapid enough to become a practical tool in the management of blunt abdominal trauma.     

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.     

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 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 splenectomy in an adipose elderly patient with symptomatic non-Hodgkin lymphoma-related splenomegaly and traumatic central splenic hematoma

During recent years, laparoscopic splenectomy has shown to be a safe and effective surgical approach in patients with hematologic disorders requiring spleen removal. Especially in cases with splenomegaly, the laparoscopic approach results in a shorter hospital stay and faster recovery of the patients. Due to the increasing experience in laparoscopy, this approach also is emerging to be a therapeutic option in patients with blunt abdominal trauma with splenic rupture or hematoma. We report the case of an 80-year-old female patient who underwent laparoscopic splenectomy for symptomatic splenomegaly due to non-hodgkin Lymphoma in combination with stable traumatic splenic hematoma after blunt abdominal trauma.     

Laparoscopic decompression of abdominal compartment syndrome after blunt hepatic trauma

Abdominal compartment syndrome (ACS) can occur in a variety of surgical conditions, particularly those with major life-threatening hemorrhage, massive volume resuscitation, prolonged operation times, and coagulopathy. In severely traumatized patients, the incidence of ACS is reported to be as high as 14% to 15% after damage control laparotomies. Although favorable results have been achieved with nonsurgical management of adult blunt hepatic trauma, the failure rates still range from 0% to 19%. Exploratory laparotomy is considered the intervention of choice in patients with blunt hepatic trauma who fail nonsurgical treatment. Expedient abdominal decompression currently is the treatment of choice after ACS. Oliguria, tachypnea, and tachycardia developed in two blunt hepatic trauma patients with grade IV and V injuries while they were receiving nonsurgical treatment. The intra-abdominal pressures measured more than 35 and 25 cm H 2O, respectively. Two patients with grade II and III ACS received laparoscopic examination instead of laparotomy. Their ACS was decompressed effectively via laparoscopy without any adverse effects. Therefore, we suggest that laparoscopy can be used as a safe alternative for the decompression of ACS.     

Therapeutic laparoscopy for blunt abdominal trauma with bowel injuries

In the setting of abdominal trauma, laparoscopy is used mainly for diagnosis, and its role in definitive operative repair is still debated. We report the case of a 50-year-old woman who underwent diagnostic and therapeutic laparoscopy after being subjected to blunt abdominal trauma in a traffic accident. Multiple injuries to the small bowel and colon were repaired laparoscopically with a favorable outcome. Surgeons with experience in advanced laparoscopy and trauma care can use laparoscopy in the diagnosis and treatment of selected patients with blunt abdominal trauma.     

Role of laparoscopy in blunt perforations of the small bowel

Background: The purpose of this study was to determine whether laparoscopy could improve our ability to diagnose and treat perforations of the small bowel. Methods: From 1985 to 2001, among 250 patients admitted for a blunt abdominal trauma, 195 surgical explorations were performed, comprising 42 laparoscopies. On admission, 108 patients underwent an abdominal ultrasonography (US) and 104 a computed tomography (CT). Thirty-nine patients had a blunt small bowel trauma (BSBT) that was explored and/or treated by laparoscopy (n = 15) or celiotomy (n = 24). We compared the patients who underwent emergency surgery (23) and those who were operated on after a mean delay of 51 h. Results: On admission, for detecting free intraperitoneal fluid with a BSBT, the sensitivity of CT was 93.3% and specificity was 13.6%. Regarding the 23 patients who underwent emergency surgery, 8/20 had positive US and 10/15 had positive CT, whereas the 15 celiotomies and 8 laparoscopies indicated BSBT. Regarding the 16 patients who underwent delayed surgery, 9 patients underwent a celiotomy and 7 a laparoscopy; all BSBTs were diagnosed. In searching for BSBT, the sensitivity and specificity of laparoscopy were both 100%, whereas the sensitivity of CT was 83.3% and specificity was 22.2%. Twenty of 23 patients undergoing emergency surgery had bowel suture repair compared to 3/16 after delayed surgery. In contrast, a resection was necessary in 10/12 patients treated after a delay compared to 2/17 operated in emergency. Five BSBTs were sutured by laparoscopy, whereas 10 required conversion. Laparoscopy avoided celiotomy in 15 cases. There were no deaths and no enterostomy. Conclusion: In hemodynamically stable patients with blunt abdominal trauma, laparoscopy safely and effectively identifies small bowel injuries. Early recognition of these injuries and timely surgical treatment offer the best prognosis.     

腹腔镜早期探查术在腹部钝性外伤继发肠损伤中的应用价值

目的探讨腹腔镜早期探查术应用于腹部钝性外伤继发肠损伤中的临床效果,提高其治疗效果。方法回顾性分析在本院住院治疗的腹部钝性外伤继发肠损伤早期实施腹腔镜探查术患者40例的临床资料,并与同期早期（受伤后开始手术不超过6小时）手术患者38例进行比较。结果两组患者一般资料、肠管损伤部位及程度比较,差异无统计学意义（P〉0.05）;两组患者死亡率均较低,差异无统计学意义（P〉0．05）,但是观察组患者住院时间、ICU监护时间、机械通气时间及并发症发生率均低于对照组,差异存在统计学意义（P〈0．05）。结论腹腔镜探查术是集诊断和治疗为一体的现代化外科微创技术,在技术和设备许可的情况下,正确把握适应征,可以使腹部钝性外伤继发肠损伤患者获得最佳的诊治效果。     

基层医院急诊腹腔镜在腹部外伤中的应用体会

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

Laparoscopy offers diagnosis and treatment in abdominal stab injuries

PURPOSE: To assess the role of laparoscopy in the diagnosis and treatment of abdominal stab injuries (ASI). METHODS: Patients who underwent laparoscopic procedures due to ASI were included in the study. Hemodynamic instability, injuries to the posterior trunk, concomitant severe cranial injuries, and prior abdominal operations were considered as contraindication for laparoscopy. RESULTS: From January 1997 to March 2006, 88 patients underwent laparoscopic management of ASI. In 45 patients (51.1%), there was no intra-abdominal pathology requiring surgical intervention (nontherapeutic laparoscopy) and 5 patients in this group had no peritoneal penetration (negative laparoscopy). In another 25 patients (28.4%), laparoscopic treatment was performed (therapeutic laparoscopy), including bleeding control in liver, colonic, gastric, and diaphragmatic repairs and intra-abdominal bleeding control. Laparotomy was avoided in a total of 70 (79.5%) patients. In 18 patients (20.5%), laparoscopy was converted to laparotomy. There was no mortality, and except one missed small bowel injury nor perioperative morbidity in patients undergoing laparoscopy. In the laparotomy group, major complications were seen in 7 patients. CONCLUSIONS: Laparoscopy is safe and efficient in the management of ASI and should be more frequently considered as a therapeutic tool.     

Laparoscopy as diagnostic-therapeutic method in abdominal traumatism in the pediatric age

The management of blunt abdominal traumatism with a moderate amount of free peritoneal fluid and without solid organ injury as well as the one of minimal penetrating trauma is controversial. We present three cases of blunt abdominal trauma and two of penetrating trauma that underwent diagnostic laparoscopy in our department. We found a small bowel perforation in one of the cases of blunt trauma that was repaired by externalization of the jejuna loop by one of the ports. In the other two cases we found intestinal and mesenteric contusions and free fluid that were treated by peritoneal drainage. One of the cases of penetrating trauma presented omentum evisceration with no other injuries and the second presented a gastric perforation that needed reconversion to laparotomy. In our experience and according to literature, laparoscopy should be taken into account as a diagnostic procedure and sometimes also therapeutic in selected cases of both blunt and penetrating abdominal trauma in pediatric population.     

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 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.     

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。     

腹腔镜诊断和治疗腹部闭合性损伤120例报告

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

Laparoscopy in a case of pediatric blunt abdominal trauma

The use of laparoscopy in the assessment and treatment of blunt abdominal trauma has been reported for both adults and children. With increasing surgical experience and improvements in equipment, an expanding range of therapeutic interventions is available. The management of a 7-year-old boy who sustained blunt abdominal trauma during a fall from a bicycle is described. He was hemodynamically stable, but his abdomen remained tender, with guarding in the right upper quadrant. Serial ultrasound scans showed a thick-walled gallbladder and increasing intraabdominal fluid. Laparoscopy was used both as a diagnostic tool, and then as a therapeutic method. Diagnostic laparoscopy showed a ruptured gallbladder treated by laparoscopic cholecystectomy. A 3-cm grade 1 liver laceration also was identified, which required no intervention. Free bile was aspirated and the peritoneal cavity thoroughly lavaged. The child made a rapid postoperative recovery. The ultimate aim in the management of blunt trauma is to avoid unnecessary laparotomy while preventing undue delay in the detection of significant intraabdominal pathology. Computed tomography scanning, ultrasound scanning, and diagnostic peritoneal lavage all have strengths for detecting different injury types, but they also have a low specificity in determining the need for laparotomy. The advantages and limitations of laparoscopy in hemodynamically stable children who have sustained injuries from blunt trauma are discussed. The authors recommend laparoscopy in experienced hands as an additional tool for the optimal management of selected trauma cases.     

Emergency laparoscopy.

Unnecessary abdominal explorations in severely injured patients can be reduced by employing emergent or urgent laparoscopy in blunt abdominal trauma and the obscured, acute abdominal cases. In 150 blunt abdominal trauma cases, a mini-laparoscopy was used in the emergency room or the intensive care unit without major complications. In 56%, the findings were negative. In 19%, the laparoscopic findings were corroborated by surgery. In 25%, a minimal to moderate hemoperitoneum was found and the laparoscopic impression dictated close observation. Unnecessary exploration was avoided except in one case. In the elderly high-risk patient with a poor history, abdominal examination can be noninformative. Laparoscopy can detect acute appendicitis or organ perforation. In the young female, appendicitis can be differentiated from pelvic inflammatory disease. Laparoscopy is more accurate and gives a larger latitude for decision-making than lavage. It can also be useful in the obscured problematic abdominal case.     

Role of laparoscopy in the staging of malignant disease

Although diagnostic laparoscopy has been used by surgeons and gastroenterologists since the early 1900s, today's surgical oncologists have been relatively slow to embrace this technology. Together with the fervor and benefits afforded by laparoscopic therapeutic interventions in the management of patients with benign disease and the diagnostic usefulness in blunt trauma and abdominal pain, awareness has been rekindled regarding the advantages of laparoscopy for the staging of abdominal malignancy. As surgeons begin to realize that extirpative procedures are doomed to failure in curing patients with diffuse abdominal metastases disclosed on laparoscopic assessment, palliative measures, such as stent placement, ablative procedures, balloon dilatation, intraluminal high-dose radiation, and laser techniques will be used commonly by surgical endoscopists and gastroenterologists. Similarly, it is hoped that the use of systemic chemotherapy will achieve better specificity in cell destruction in patients identified laparoscopically to have uncontained disease in the abdominal cavity. The sensitivity of sonography combined with laparoscopy has been shown to approach that of celiotomy in the evaluation of solid organs, thereby avoiding unnecessary laparotomy and its associated morbidities. Using sonography as a complement to laparoscopy will extend the usefulness of both techniques. The application of laparoscopy and the advent of miniaturized laparoscopic instrumentation (Fig. 7), both diagnostic and therapeutic, in the management of patients with abdominal malignancy will be limited only by the creativity and expertise of physicians and instrument makers.