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.     

Diagnostic laparoscopy for penetrating injuries in the thoracoabdominal region

Background The role of laparoscopy in diagnosis of penetrating abdominal injuries is still controversial. In the present investigation diagnostic laparoscopy was studied in penetrating injuries of the thoracoabdominal region.Methods Between March 1998 and June 2003, 43 patients with penetrating thoracoabdominal injuries underwent diagnostic laparoscopy at the Rambam Medical Center. There were 41 males and two females; the average age was 30 years (range, 16–54 years). Thirty-one patients had a lower chest injury, eight patients had an upper abdomen and flank injury, and four patients had combined chest and abdomen injuries. In 11 patients intraperitoneal penetration was diagnosed. In 10 patients the procedure was converted to open laparotomy, and one patient with a small laceration of the right diaphragm opposite the liver was observed without laparotomy.Results The average operating time for the laparoscopy was 25 min (10–45 min), and 85 min (40–175 min) for laparotomy. Patients who underwent laparoscopy were discharged after an average of 1.6 (1–3) days, while those who underwent laparotomy were discharged after an average of 7.6 (2–15) days.Conclusions Laparoscopy is a useful diagnostic tool in penetrating injuries of the chest, thoracoabdominal region, and flank. This procedure is particularly reliable in diaphragmatic tears. Laparoscopy should be considered the procedure of choice for the evaluation of penetrating injuries of the lower chest and upper abdomen for diagnosis of peritoneal penetration.     

Laparoscopy in the evaluation of penetrating thoracoabdominal trauma

The evaluation of penetrating thoracoabdominal trauma for the presence of a diaphragmatic injury presents a diagnostic challenge to the trauma surgeon. The use of diagnostic laparoscopy (DL) in this setting was reviewed at a level-one trauma institution. Eighty patients (71 males, 9 females) with penetrating injuries to the thoracoabdominal region underwent DL to rule out injury to the diaphragm. Fifty-eight patients (72.5%) had a negative study and were spared a celiotomy. In the remaining 22 patients (27.5%), injury to the diaphragm was identified. This subset of patients underwent a mandatory celiotomy to rule out an associated intra-abdominal injury. Seventeen out of 22 (77.2%) patients had a positive exploration requiring surgical intervention, representing an associated intra-abdominal injury rate of 21.2 per cent. Intra-abdominal injuries requiring repair included small bowel, colon, spleen, liver, and stomach, in descending order. There were no missed injuries or deaths. One patient with a left diaphragmatic injury secondary to a stab wound developed a subdiaphragmatic abscess. Respiratory insufficiency secondary to atelectasis was the most common complication. Diagnostic laparoscopy is an essential and safe modality for the evaluation of diaphragmatic injuries in penetrating thoracoabdominal trauma.     

Laparoscopic repair of traumatic diaphragmatic injuries

Background: The purpose of this study was to evaluate the feasibility and limitations of laparoscopic repair of traumatic diaphragmatic injuries. Methods: Laparoscopic repair of an acute traumatic diaphragmatic laceration or chronic traumatic diaphragmatic hernia was attempted in 17 patients between January 1997 and January 2001. The patients in the study included 13 men and 4 women with a mean age of 33.2 years (range, 15–63 years). Nine patients had a blunt injury, and eight patients had a penetrating injury. Laparoscopic repair was attempted for eight patients during their hospitalization for the traumatic injury (mean, 2.3 days; range, 0–6 days) and for ten patients with a chronic diaphragmatic hernia (mean, 89 months; range, 5–420 months). The chronic diaphragmatic hernias-presented with abdominal pain (9/9), or vomiting (3/9). Results: Thirteen traumatic diaphragmatic injuries were repaired laparoscopically, and four (2 acute and 2 chronic) required conversion. Among the laparoscopically repaired diaphragmatic injuries, three defects (chronic) were repaired using expanded polytetrafluoroethylene (ePTFE), and nine were repaired primarily. The mean length of the diaphragmatic defects was 4.6 cm (range, 1.5–12 cm). The mean operative time was 134.7 min (range, 55–200 min). The mean estimated blood loss was 108.5 ml (range, 30–500 ml), and the postoperative length of stay was 4.4 days (range, 1–12 days). There were no intraoperative complications, but three patients developed pulmonary complications (atelectasis/pneumonia). Follow-up evaluation was available for 11 patients. There were no documented recurrences after a mean follow-up period of 7.9 months (range, 1 week to 24 months). Conversion resulted from a reluctance or inability to perform laparoscopic suture of transverse diaphragmatic lacerations longer than 10 cm anterior to the esophageal hiatus and adjacent to the pericardium (n = 2) or communicating with the esophageal hiatus (n = 2). One patient also required spleneotomy for an unrecognized splenic laceration that had occurred at the time of the original trauma. The four patients undergoing laparotomy had a mean postoperative discharge date of 8.7 days (range, 6–14 days). Conclusions: Laparoscopy is an alternative approach to repairing acute traumatic diaphragmatic lacerations and chronic traumatic diaphragmatic hernias. Large traumatic diaphragmatic injuries adjacent to or including the esophageal hiatus are best approached via laparotomy.     

Laparoscopic repair of traumatic diaphragmatic injuries

BACKGROUND: Laparoscopy has been proposed as a diagnostic and potentially therapeutic modality for penetrating diaphragmatic lacerations. The purpose of this study was to assess the technical feasibility and strength of various laparoscopic repairs of diaphragmatic injuries. METHODS: Swine underwent either open suture repair or laparoscopic repair by staple, suture, or patch technique of a 2-cm laceration to both the right and the left muscular or tendinous diaphragmatic leaflets. Six weeks after operation, diaphragms were harvested for either histologic analysis or bursting strength measurements. RESULTS: All methods of repair proved technically feasible. There was no significant difference in bursting strength measurements between treatment groups. Bursting was due to tissue failure either at or adjacent to the repair site. Histologic analysis confirmed healing of all specimens with the laparoscopic patch technique inciting less inflammation and greater fibroblastic proliferation than the other techniques. CONCLUSIONS: Laparoscopic repair of diaphragmatic lacerations can be accomplished using any of the currently available techniques. Laparoscopic stapling, suturing, or patch techniques all result in complete healing with a strong and durable repair. When selecting a particular technique, familiarity of the surgeon should be used as a guideline.     

Laparoscopic repair of two unusual traumatic colorectal injuries

Although the role of laparoscopy in the repair of iatrogenic colonic perforations in prepared bowel is well established, the use of laparoscopy as a therapeutic tool in the management of patients with traumatic intraabdominal injuries remains unclear. We report two cases of traumatic colorectal injuries that were managed successfully by therapeutic laparoscopy. Both patients sustained traumatic perforations to the large bowel as a result of unusual accidents in the home. Laparoscopic repair of the perforations with interrupted sutures and peritoneal lavage were performed with good results in both cases. We believe that the laparoscopic repair of traumatic colonic injuries is feasible in selected patients and offers a number of accepted advantages over formal laparotomy.     

Electrodiagnostic evaluation of traumatic nerve injuries

This article reviews the techniques of motor and sensory nerve conduction studies and needle electromyography methods, which are particularly useful for localizing nerve injuries in upper extremity and hand trauma. Included are details of methods for detecting and quantifying the degree of axon loss and for using this information to make treatment decisions and predict outcomes. The epidemiology and classification of traumatic peripheral nerve injuries, the effects of these injuries on nerve and muscle, and the means by which electrodiagnosis is used to help classify the injury are described. An overview of recovery mechanisms also is presented.     

Diagnostic laparoscopy for the evaluation of occult diaphragmatic injury following penetrating thoracoabdominal trauma

BACKGROUND: Occult diaphragmatic injury following penetrating thoracoabdominal trauma can be difficult to diagnose. Radiographic findings are often non-specific or absent. Undetected injuries may remain clinically silent, only to present later with life-threatening complications associated with diaphragmatic herniation. Diagnostic laparoscopy allows for the evaluation of trauma patients lacking clinical indications for a formal laparotomy. The purpose of this study was to evaluate the incidence of occult diaphragmatic injury and investigate the role of laparoscopy in patients with penetrating thoracoabdominal trauma who lack indications for exploratory laparotomy except the potential for a diaphragmatic injury. METHODS: Haemodynamically stable patients with penetrating thoracoabdominal trauma without indications for laparotomy (haemodynamic instability, evisceration, or peritonitis on exam) and evaluated with diagnostic laparoscopy to determine the presence of a diaphragmatic injury were retrospectively reviewed. Thoracoabdominal wounds were defined as wounds bounded by the nipple line over the anterior and posterior chest superiorly and the costal margin inferiorly. RESULTS: One hundred and eight patients were evaluated for penetrating thoracoabdominal injuries (80 stabs and 28 gunshots) over the study period. 22 (20%) diaphragmatic injuries were identified. These were associated with injuries to the spleen (5), stomach (3) and liver (2). There was a greater incidence of haemopneumothorax (HPTX) in patients with diaphragmatic injury (32%) compared to those without injury (20%). 29% of patients with a HPTX had a diaphragmatic injury. However, 18% of patients with a normal chest radiograph were also found to have a diaphragmatic injury. CONCLUSIONS: The incidence of diaphragmatic injury associated with penetrating thoracoabdominal trauma is high. Clinical and radiographic findings can be unreliable for detecting occult diaphragmatic injury. Diagnostic laparoscopy provides a vital tool for detecting occult diaphragmatic injury among patients who have no other indications for formal laparotomy.     

Transdiaphragmatic pleural lavage in penetrating thoracoabdominal trauma

BACKGROUND: The purpose of this study was to determine the incidence of thoracic sepsis following a systematic thoracic cavity washout through the injured diaphragm in patients with penetrating thoracoabdominal trauma. METHODS: Prospectively collected data on all patients presenting with penetrating thoracoabdominal trauma between July 1999 and July 2002 were analysed. Patients with peritoneal biliary-gastroenteric (BGE) contamination and a diaphragmatic laceration were managed by laparotomy and transdiaphragmatic thoracic lavage. RESULTS: A total of 217 patients had penetrating thoracoabdominal injuries, of whom 110 had BGE contamination of the peritoneal cavity with spillage into the pleural cavity. The mean Injury Severity Score was 38.1. Gunshot and stab wounds occurred in 79 (71.8 per cent) and 31 (28.2 per cent) respectively. Contamination was from the stomach (55.4 per cent), large bowel (37.3 per cent), small bowel (29.1 per cent), gallbladder and bile ducts (9.1 per cent) and pancreas (6.4 per cent). Thoracic complications occurred in six patients (5.5 per cent): empyema in two, Escherichia coli-related pneumonia in three and pleuritis in one. There were no deaths. CONCLUSION: A thoracic washout through the injured diaphragm in patients with penetrating thoracoabdominal trauma and BGE contamination was associated with a low rate of intrathoracic septic complications.     

Triple-contrast computed tomography in the evaluation of penetrating posterior abdominal injuries

Routine exploration of stable patients who have penetrating injuries of the posterior abdomen results in a high rate of unnecessary operation. Prolonged observation, while safe, is expensive and potentially morbid in the event that a retroperitoneal injury has occurred and treatment is delayed. To evaluate these injuries, we have developed and employed a protocol for computed tomographic (CT) scanning of the abdomen employing oral, intravenous, and rectal administration of contrast material to visualize the retroperitoneal contents. Between Jan 1, 1985, and Dec 1, 1986, 40 patients were studied in this manner. In each case, the path of penetration could be determined exactly by tracing the course of air and hematoma through the tissues. All retroperitoneal organs could be evaluated well enough to exclude injuries requiring intervention. The majority of patients showed subcutaneous penetrations only. All six significant intra-abdominal injuries were diagnosed correctly and confirmed at laparotomy. All 34 patients deemed by CT not to have significant injury were observed for 72 hours, and all were discharged uneventfully. Triple-contrast CT appears to be of great value in the triage of penetrating posterior abdominal trauma into operative and nonoperative groups.     

Topognostic and prognostic evaluation of traumatic facial nerve injuries

If and when to intervene during the course of a traumatic facial palsy depends on the immediacy of the palsy, signs and symptoms of an associated temporal bone fracture, function of the various facial branches, and the results of electrical stimulation. Some facial nerve tests will be more valuable than others in a given case. The following is a philosophy of management that has proven useful to the author in the management of facial palsies of traumatic causes.     

Symptomatic hepatothorax presenting 25 years after penetrating thoracoabdominal injury

Hepatic herniation through the diaphragm is a rare finding. It generally occurs due to a congenital diaphragmatic abnormality or blunt trauma resulting in a diaphragmatic defect. Making the diagnosis is difficult, as there are few definitive clinical signs and chest radiograph (CXR) findings may be non-specific. To our knowledge, only a single case report exists of penetrating right diaphragm injury leading to hepatic herniation.A 42-year-old man presented to the emergency department of a regional hospital with hyperglycaemia and exertional dyspnoea. He was diagnosed with diabetes mellitus type 2. He gave a history of smoking for 15 pack-years, was negative for retroviral disease and had no history of pulmonary tuberculosis. He had no significant surgical history but reported being stabbed with a knife in 1995. The point of entry was below the level of the nipple in the right anterior axillary line. At the time, he was treated with an intercostal drain and discharged home.CXR showed a right-sided chest mass. We considered a differential diagnosis of pulmonary consolidation, diaphragm eventration or hepatothorax. Computerized tomography of the chest and abdomen demonstrated apparent intrathoracic extension of the right liver lobe and partial attenuation of the superior vena cava and right atrium due to a mass effect. The upper border of the liver abutted the aortic arch. Surgical treatment options were discussed. The patient declined surgery and will be followed up as an outpatient.     

Management of penetrating laryngotracheal injuries

Background. Penetrating Iaryngotracheal injuries are uncommon; however, these injuries are associated with significant morbidity and mortality. In an attempt to define the management of penetrating laryngotracheal injuries, we reviewed our experience with these injuries. Methods. We retrospectively analyzed the records of all patients admitted to a Level I trauma center who required operative management for penetrating laryngotracheal injuries. During the period of this study all patients with penetrating neck injuries were managed according to a protocol of selective exploration. Results. Of fifty-seven patients with penetrating laryngotracheal injury 32 patients sustained gunshot wounds and 25 had stab wounds. The injuries were to the larynx in 24 (42%) and trachea in 33 (58%). Forty-six (81%) had isolated airway injuries and 11 (19%) had combined airway and digestive-tract injuries. Emergent airway management in 32 (56%) patients included: tracheostomy (15), endotracheal intubation (14), and cricothyroidotomy (3). Respiratory distress and subcutaneous crepitus were the commonest clinical findings. Diagnostic evaluation included: Iaryngoscopy/tracheoscopy (17), esophagoscopy (12), contrast esophagography (9), angiography (8), and bronchoscopy (3). Repair of laryngotracheal and esophageal injury was performed in the majority of patients. Selected patients with milder Iaryngotracheal injury did not have tracheostomy performed, with no increase in morbidity or mortality. There were 2 (3.5%) early deaths from associated major vascular injury. Conclusion. Mortality can be minimized by aggressive airway control. Endotracheal intubation can be accomplished safely in selected patients with penetrating laryngotracheal injuries. Digestive-tract injuries can often clinically occult and contribute significantly to morbidity and mortality; therefore, early evaluation of the esophagus is vital. Simple repair of Iaryngotracheal and digestive-tract injuries can be performed safely with good results. In patients with minor injuries, tracheostomy does not appear to be mandatory. © 1995 Jons Wiley & Sons, Inc.     

Management of penetrating neck injuries

In 44 patients neck wounds penetrating the platysma were evaluated over a 5-year period. Twenty-one patients were admitted and observed; 22 patients were explored immediately. One was dead upon arrival in the emergency room. The decision to explore was based upon initial clinical evaluation using criteria of unstable vital signs, bleeding, hematoma, subcutaneous emphysema, respiratory distress, or neurologic deficits. Of the 21 patients selected for observation, none had complications or required later surgery. There was a negative exploration rate of 23%. Had all patients been explored, the negative exploration rate would have been 60%. We conclude that selective exploration, based upon careful clinical evaluation, is both safe and reasonable in cases of penetrating neck trauma.