腹腔镜在腹部创伤诊治中的应用

外科急诊中常会遇到腹部创伤病人,其病因颇多（如暴力、车祸等）。这些病人同时可能伴有脑外伤或脊柱损伤。有时影像学检查、诊断性腹腔穿刺或腹腔灌洗等辅助检查结果往往同病人实际表现的症状与体征不一致,给诊治带来困难。如何明确腹部创伤病人是否真正需要开腹手术探查及治疗,一直是临床医师面临的棘手问题。Larson[1]等报道约20％左右的腹部钝性伤是不需要手术治疗的。对于那些税器刺伤病人,若仅凭借伤口深度而决定是否需行手术治疗,那将会有半数的病人施行了不必要的手术[2]。Hendson[3]等报道有20％～37％的锐器刺伤病人无需施…     

302例腹部穿透伤的诊治分析

我院于 2 0 0 0年至 2 0 0 4年共收治腹部穿透伤患者 30 2例 ,现报告如下。临床资料1 一般资料 :男性 2 30例 ,女性 72例。年龄 15～ 5 8岁。其中刀刺伤 10 7例 ,高处坠落刺伤 6 5例 ,车祸被锐器刺伤 6 2例 ,事故腹部伤 6 8例。负伤至入院时间为 15～ 6 8min。早期诊断 2 92例     

腹部穿透伤82例治疗分析

本院自1995年3月至2003年8月，共收住腹部穿透伤病人82例，根据临床治疗分析，剖腹探查并非腹部穿透伤的唯一治疗方法。现将腹部穿透伤治疗总结分析如下。     

腹腔穿透伤61例诊治体会

腹腔穿透伤无论战时或平时均较常见 ,我院自 1986年 3月至 2 0 0 0年 3月共收治腹腔穿透伤 61例 ,现报告如下。临床资料一、一般资料 :本组男 5 1例 ,女 10例 ,年龄 11～ 69岁 ,平均 2 4.2岁。受伤至手术时间 0 .5～ 2 0ｈ ,平均 1.6ｈ。致伤原因 :刀刺伤 3 7例 (60 .7% ) ,枪弹伤 10例 ,木棒戳伤 5例 ,车祸伤 3例 ,电锯伤 2例 ,铁锚刺伤 2例 ,爆炸伤 2例。二、特殊辅助检查 :诊断性腹腔穿刺 18例 ,阳性 10例 ;胸腹联合Ｘ线检查 16例 ,膈下游离气体阳性 11例 ;弯血管钳或手指探查伤道 2 5例 ,证明为穿透伤 18例。移动性浊音阳性 2 0例 ,大网…     

腹腔镜诊治腹部闭合伤42例体会

腹部闭合性损伤多为钝性暴力引起,其致伤因素和临床表现复杂多样,早期诊断是否存在脏器破裂或出血有时十分困难.大约1/3病例早期可无明显临床表现.尽管B超、X线、CT等检查已广泛应用,诊断准确率正逐步提高,但仍有20%的病例需要在手术中明确诊断.近年来腹腔镜手术的开展,为诊治腹部闭合伤提供了新的途径,腹腔镜探查术具有安全性和准确性高、并发症和死亡率低的特点.2001年10月至2004年12月,笔者用腹腔镜探查和治疗了42例闭合性腹部外伤患者,效果满意.现报告如下:     

腹腔镜探查在腹部外伤诊治中的应用

目的:探讨腹腔镜技术诊治腹部外伤的应用价值。方法:回顾分析32例腹部外伤患者行腹腔镜探查的临床资料。结果:32例均经腹腔镜探查明确诊断,无漏诊、误诊。26例(81.25%)在腹腔镜下完成手术处理,包括6例脾破裂修补术,3例脾切除术,4例肝破裂修补术,2例结肠破裂修补术,1例结肠造瘘术,4例小肠破裂修补术,2例胃破裂修补术,1例胰体损伤行损伤限制性病损清除引流术,2例肠系膜破裂缝合术,1例腹壁损伤腹膜缝合术。6例(18.75%)伤情较重的患者在腹腔镜指导下中转开腹,1例术后出血二次手术。患者均痊愈出院,无死亡病例。住院3~12 d,平均(7.2±2.88)d。结论:腹腔镜探查诊治腹部外伤具有创伤小、准确性高、并发症少、康复快、死亡率低的优点,较传统剖腹探查术具有显著优势,值得推广应用。     

胸腹结合部穿透伤诊治效果

胸腹结合部因局部解剖特点表现为:胸腔腹腔前后重叠,重要脏器集中,生理功能复杂,故该部位穿透伤既多发又复杂,伤后易误诊漏诊,治疗难度大。我院自1996年12月到2003年10月收治胸腹结合部穿透伤138例效果满意,现报告如下。1资料和方法1.1一般资料本组138例,男108例,女30例,年龄13~67岁,胸部伤:肋骨骨折18例,血、气胸、血气胸86例,肺挫伤、裂伤39例,心脏挫伤3例,左主支气管断裂1例,膈肌损伤83例,创伤性膈疝18例。腹部伤:肝破裂39例,脾破裂53例,肾裂伤13例,肾血管挫伤的大出血3例,大网膜血肿3例,胰腺损伤6例,胃肠破裂38例。1.2治疗方法胸腔闭式…     

腹腔镜在腹部外伤诊治中的应用价值分析

目的探讨腹腔镜探查术在急诊腹部外伤诊治中的应用价值。方法回顾性分析我科自2005年8月至2010年10月收治的62例经腹腔镜探查的腹部外伤患者的临床资料。结果62例腹部外伤患者均于镜下作出诊断,诊断准确率100％。46例于镜下完成探查手术（其中探查阴性10例及腹膜后血肿2例未作特殊处理）,16例中转开腹手术。手术时间40～180min,平均100min,住院时间3—24d,平均9d。所有患者均治愈,无肠漏、腹腔内大出血、腹腔脓肿等严重并发症。结论腹腔镜探查术应用于急诊腹部外伤具有创伤小、诊断准确率高、恢复快以及诊断和治疗兼顾等优点,可有效地降低阴性剖腹探查率,提高治愈率,值得基层医院广泛推广。     

腹腔镜技术在腹部创伤中的应用

目的分析腹腔镜诊断与治疗腹部创伤中的临床价值。方法 2004年8月至2008年8月,本院对35例腹部创伤患者使用腹腔镜诊断,并根据镜检结果镜下治疗或中转开腹手术。结果 34例腹部创伤于镜下作出正确诊断,1例开腹后正确诊断;12例免治疗性处理,19例镜下手术（包含2例手助镜下手术）,4例中转开腹手术,术后均治愈出院。结论腹腔镜诊治腹部创伤具有创伤小、安全可靠、诊断率高,并有效降低阴性剖腹探查率等优点,适用于大部分轻-中症腹部创伤的病例。     

腹腔镜在腹部创伤中的诊治体会

目的探讨腹腔镜在腹部创伤中的临床疗效。方法回顾性分析2008年8月至2011年8月55例腹部创伤患者实施腹腔镜诊断和治疗的临床资料。结果腹腔镜手术成功35例,中转开腹手术12例,无需手术处理8例,4例术后有并发症,全组均治愈出院。结论腹腔镜在腹部创伤中的应用具有独特优点,在明确诊断的同时,又可以兼顾治疗,创伤小,术后恢复快。     

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.     

Impact of laparoscopy on the perioperative outcomes of penetrating abdominal trauma

BackgroundPenetrating abdominal trauma (PAT) poses a significant challenge to trauma surgeons. Laparotomy is still the most popular procedure for managing PAT but has high morbidity and mortality rates. Presently, laparoscopy aims to provide equal or superior visualization compared to open approaches but with less morbidity, postoperative discomfort, and recovery time. The aim of this research is to assess the impact of laparoscopy on the management of PAT.MethodsThis was a retrospective observational study carried out at the Emergency Hospital of Mansoura University/Egypt and at King Faisal Medical Complex, Taif/KSA from September 2014 to September 2018. All hemodynamically stable patients with PAT who were managed by laparoscopy were included in this study. Data extracted for analysis included demographic information, criteria of abdominal stabs, type of management, and perioperative outcome.ResultsForty patients were recruited in this research and the male-to-female ratio was 5.6:1. The mean age of the patients was 31.4 ± 12.318 years. During the laparoscopic procedure, no peritoneal penetration was observed in 4 patients (negative laparoscopy), while peritoneal penetration was observed in the remaining 36 patients. No visceral injuries were noted in 2 patients of the 36 patients with peritoneal penetration, while the remaining 34 patients had intra-abdominal injuries.ConclusionLaparoscopy performed on hemodynamically stable trauma patients was found to be safe and technically feasible. It also reduced negative and non-therapeutic laparotomies and offered paramount therapeutic and diagnostic advantages for traumatic diaphragmatic injuries.     

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     

"Awake" laparoscopy for the evaluation of equivocal penetrating abdominal wounds

BACKGROUND: Diagnostic laparoscopy is useful for the assessment of equivocal penetrating abdominal wounds, and has become the modality of choice for the evaluation of such wounds at our institution. We hypothesised that, in appropriate patients, diagnostic "awake" laparoscopy (AL) could be performed under local anaesthesia in the emergency department (ED), allowing for expedited discharge and potential cost savings. METHODS: Selected haemodynamically stable patients with penetrating abdominal injury underwent AL. Suitability for AL was at the discretion of the attending surgeon. Identification of peritoneal penetration by AL led to exploratory laparotomy in the operating room. Patients with no evidence of peritoneal penetration were discharged from the ED (ALneg). These patients were matched to a cohort of 24 patients who underwent diagnostic laparoscopy in the OR which was negative for peritoneal penetration (DLneg). Length of stay and hospital charges were compared. RESULTS: Over a 30-month period, 15 patients underwent AL without complication. No peritoneal penetration was found in 11 patients. The remaining four patients underwent exploratory laparotomy, of which two were positive for intra-abdominal injury. Mean time to discharge was 7h in the ALneg group versus 18 h in the DLneg group (p=0.0003). Cost savings on hospital charges averaged 2227 US dollars per patient in the ALneg group compared with the DLneg group. CONCLUSIONS: AL may be safely performed in the ED, allowing for expedited patient discharge. Cost savings are achieved by the avoidance of charges inherent to diagnostic laparoscopy performed in the operating room.     

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.     

A multi faceted quality improvement programme results in improved outcomes for the selective non-operative management of penetrating abdominal trauma in a developing world trauma centre

Introduction

The selective non-operative management (SNOM) of penetrating abdominal trauma (PAT) is well established in our environment. As a quality-improvement initiative, we aimed to re-evaluate patient outcomes with PAT. This follows the application of new imaging and diagnostic modalities using protocolised management algorithms.

Methodology

A prospectively maintained digital registry was retrospectively interrogated and all patients with PAT treated by our service from January 2012 to March 2013 were included in this study.

Results

A total of 325 patients sustained PAT during the fourteen-month study period. This included 238 SWs, 80 GSWs and 7 impalement injuries. 11 patients had eviscerated bowel, and 12 had eviscerated omentum. A total of 123 patients (38%) were selected for a trial of SNOM. This included 103 SWs, 15 GSWs and 5 impalement injuries. Emergency laparotomy was performed on 182 patients (115 SWs, 65 GSWs and 2 impalement injuries) and 21 patients with left sided thoraco-abdominal SWs underwent definitive diagnostic laparoscopy (DL). SNOM was successful in 122 cases (99%) and unsuccessful in one case (1%). In the laparotomy group 161 (88%) patients underwent a therapeutic procedure, in 12 cases (7%) the laparotomy was non-therapeutic and in 9 cases (5%) the laparotomy was negative. In the laparoscopy group (24), two patients required conversion for colonic injuries and one for equipment failure. Seven (33.3%) laparoscopies were therapeutic with the identification and intra-corporeal repair of seven left hemi-diaphragm injuries.

Conclusion

We have improved our results with the SNOM of PAT and have also managed to safely and successfully extend the role of SNOM to abdominal GSWs. We have selectively adopted newer modalities such as laparoscopy to assess stable patients with left thoraco-abdominal SWs and abdominal CT scan for the SNOM of abdominal GSWs.     

上腹部手术后胆管结石的腹腔镜手术治疗

目的 :探讨上腹部手术后胆管结石腹腔镜手术治疗的方法、可行性、安全性和有效性。方法 :14例有上腹部手术史胆管结石患者采用 4孔法进行腹腔镜手术联合术中、术后胆道镜检查 ,取石治疗。结果 :腹腔镜手术成功率 93% ,无 1例发生胆漏、切口感染、大出血等并发症 ,术后 1年复查无 1例结石复发。结论 :上腹部手术后胆管结石患者行腹腔镜手术治疗可行、安全且有效。     

Laparoscopy and thoracoscopy in penetrating thoracoabdominal injuries

Summary BACKGROUND: Cavitary endoscopy, to incorporate laproscopy and thoracoscopy, has a great potential in the management of trauma both for diagnosis and treatment and has the potential to expand its horizons, fostered by innovations in imaging, computerization, virtual reality, and artificial intelligence. METHODS: Indications for cavitary endoscopy were developed with consideration of the relevant literature and the authors own experience. The surgical technique for penetrating injuries, which depends on the particular indication, is described. RESULTS: Cavitary endoscopy is a safe and efficient means of determining the depth of penetrating injuries and can make up for the diagnostic deficits of imaging techniques. Therapeutic measures such as diaphragmatic sutures can also be applied safely. CONCLUSIONS: The trauma surgeon should utilize it ably and efficiently for the benefit of the patient but without increasing iatrogenic complications.     

The hand-held ultrasound examination for penetrating abdominal trauma

BACKGROUND: An evaluation of hand-held ultrasonography (US) in the assessment of penetrating torso trauma has not yet been reported. METHODS: A 2.4 kg hand-held ultrasound device was used to examine penetrating trauma victims in an exam designated as the Hand-Held Focused Assessment with Sonography for Trauma (HHFAST). Results were compared with other US examinations including formal FAST (FFAST), computed tomography, diagnostic peritoneal lavage, operative and autopsy findings, and serial examination. Performance considered both the detection of fluid and injuries requiring intervention. RESULTS: The HHFAST was excellent for detecting free intraperitoneal fluid, which had 100% specificity for peritoneal penetration, but was only moderately sensitive for injuries requiring therapy. CONCLUSIONS: Hand-held sonography can quickly detect intraperitoneal fluid, which has good test performance in determining the presence of an intra-abdominal injury. Negative FAST examinations after penetrating trauma should be followed up with another diagnostic modality.