Indications for computed tomography in children with blunt abdominal trauma

This investigation was undertaken to identify clinical variables, alone or in combination, that could be used to assign children to high- and low-risk categories for intra-abdominal injury following blunt trauma. Six hundred consecutive children who were examined with computed tomography (CT) following blunt trauma were enrolled. Complete data sets were available on 375 children. Stepwise logistic regression was used to identify predictor variables for the presence of abdominal injury. There were 174 children with abdominal injury detected by CT. Of these, 95 were classified as having significant injury. Indicators associated with significantly higher risk of abdominal injury included the following: more than three clinical indications given (odds likelihood ratio [OLR] = 4.60, 95% confidence interval [95% Cl] = 2.29, 9.21, p less than 0.001); gross hematuria (OLR = 5.80, 95% Cl = 2.51, 13.4, p less than 0.001); lap belt injury (OLR = 12.2, 95% Cl = 2.22, 66.8, p less than 0.01); assault or abuse as the mechanism of injury (OLR = 5.08, 95% Cl = 1.07, 24.2, p less than 0.05); abdominal tenderness (OLR = 2.73, 95% Cl = 1.296, 5.82, p less than 0.01); and Trauma Score less than or equal to 12 (OLR = 2.27, 95% Cl = 1.006, 5.13, p less than 0.01). No child with asymptomatic hematuria (n = 56), regardless of grade or neurologic impairment in the absence of abdominal findings (n = 15), had an abnormal CT examination. These data are useful as an adjunct to clinical judgment in triage when the availability of CT equipment is limited or there are competing extra-abdominal injuries.     

腹腔镜手术在闭合性腹外伤中的应用

目的 探讨腹腔镜手术在闭合性腹外伤中的价值。方法 2003年12月～2006年7月腹腔镜诊治47例闭合性腹外伤。在全麻或硬膜外麻醉下,脐下做1 cm小切口,根据病人的具体情况选用气腹针或通过开放性通道建立人工气腹。未明确诊断者可适当置1～2个trocar配合探查;若明确诊断,根据病灶位置选择操作孔位置,一般2～3个。根据病变情况再做相应处理。结果 47例经腹腔镜手术明确诊断：肝破裂15例,脾破裂13例,小肠破裂9例,肠系膜损伤3例,胰腺损伤2例,腹膜后血肿2例,腹内多脏器损伤3例。腹腔镜下完成手术28例,17例中转开腹,2例诊断为腹膜后血肿无须处理。47例随访6个月无并发症发生。结论 腹腔镜下可明确诊断闭合性腹外伤,使患者得到及时、有效、合理的治疗。     

Indications for the Bankart operation

This is a clinical and radiological follow-up on 61 patients operated upon between 1973 and 1983 according to the Bankart technique. In 84 per cent of all cases primary dislocation had taken place before the age of thirty. On an average 11 recurrent dislocations occurred before the operative procedure was performed. The radiological follow-up comprised X-rays in a.p. position with internal rotation of 60 degrees, in tangent plane according to Hermodsson as well as in dorsal tangent plane. In the modified score of Caroit and Cyprien 34 operations had excellent, 25 good, 2 moderate and 2 poor results (recurrent postoperative dislocation and deep infection). Neglecting those cases with severe deformation of the glenoid one can state that the Bankart technique offers fair results in the treatment of recurrent dislocation of the shoulder.     

Indications for operation in abdominal stab wounds. A prospective study of 651 patients.

This prospective study comprises 651 patients with knife wounds of the anterior abdomen. Three hundred and forty-five patients (53%) had symptoms of an acute abdomen on admission and were operated on immediately. The remaining 306 patients (47%) were managed conservatively with serial clinical examinations. This group included 26 patients with omental or intestinal evisceration, 18 patients with air under the diaphragm, 12 patients with blood found on abdominal paracentesis, and 18 patients with shock on admission. Only 11 patients (3.6%) needed subsequent operation, and there was no mortality. The overall incidence of unnecessary laparotomies was 5% (completely negative, 3%). Of the 467 patients with proven peritoneal penetration, 27.6% had no significant intra-abdominal injury. It is concluded that many abdominal stab wounds can safely be managed without operation. The decision to operate or observe can be made exclusively on clinical criteria. Peritoneal penetration, air under the diaphragm, evisceration of omentum or bowel, blood found on abdominal paracentesis, and shock on admission are not absolute indications for surgery. Alcohol consumption by the patient does not interfere with the clinical assessment.     

Indications for operation in elbow dislocation

This paper briefly presents the anatomy of the elbow joint, its pathophysiology, the various types of dislocation of the elbow joint and concomitant injuries, the appropriate diagnostic procedures and the indications for surgery and the operative technique applied for correction of dislocation. The only urgent indications for operative treatment are elbow joint dislocation with concomitant bone injuries, persistent instability or luxation position, open injuries and vessel and/or nerve injuries. For purely ligamentous lesions combined with relative loss of stability an operative procedure does not seem necessary. The operative technique applied for the treatment of habitual or recurrent dislocation is also described.     

Indications for intubation in blunt chest trauma

The value of endotracheal intubation and internal stabilization in severe chest injuries is well known. Recent reports have proposed that many such patients can be managed without intubation. To determine which patients need intubation we reviewed 140 patients with three or more rib fractures who presented to our hospitals from 1 January 1979 through 31 December 1983: 119 nonintubated patients (Group A); 13 patients intubated on admission (Group B); five patients intubated after hospital day 1 (Group C); and three patients intubated questionably on admission (Group D). The purpose of this report was to identify the factors which indicated severe pulmonary injury necessitating intubation. The need for intubation was correlated with five risk factors: 1) initial respiratory rate of over 25 min; 2) pulse greater than 100 min; 3) systolic blood pressure less than 100 mm Hg; 4) poor initial arterial blood gas; 5) the presence of other injuries. There was no correlation between severity of pulmonary injury and number of fractures, bilateral and/or segmental fractures, flail chest, contusion of lung, or age of patient. There was a greater percentage of complications and deaths in intubated patients (Groups B, C, and D). Group C patients all had poor initial blood gases and were erroneously not intubated early, even though 60% of them had three or more risk factors, as did Group B patients. Only 4% of patients who did not need intubation (Group A) had three or more risk factors. Group D patients were intubated without apparent indication. They had good initial blood gas levels and only one risk factor.(ABSTRACT TRUNCATED AT 250 WORDS)     

Indications for laparoscopy in emergency abdominal surgery

An analysis of 107 urgent laparoscopies enabled the authors to establish exact and full indications for using this method in hospital of general surgery. Proposals to improve the examination methods and to make them simpler are given. An original method of intraoperative laparoscopy is described. The authors give recommendations for using expedient laparoscopy in departments of urgent surgery as a sufficiently effective and accessible method of diagnosis and in certain cases as a method of treatment of emergent conditions.     

Temporary abdominal wall closure in trauma patients: Indications,technique, and results

From 1988 to 1992 more than 5300 patients were admitted to a level I trauma center, with 36 of these patients requiring Silastic abdominal closure. Patients ages ranged from 13 to 75 years with a mean Injury Severity Score (ISS) of 30 (range 13–50). Nineteen patients (53%) suffered penetrating injuries, and 17 (47%) were victims of blunt trauma. Silastic closure was performed at admission laparotomy in 15 patients (42%) due to inability to close the fascia primarily. Twenty-one patients (58%) underwent Silastic closure at reexploration for inability to close primarily (12 patients), elevated intraabdominal pressure with deteriorating renal function (6 patients), and wound sepsis with fascial necrosis (3 patients). Twenty-six patients (72%) survived and 10 patients (28%) expired. The causes of death were multiple organ failure (9 patients) and exsanguination (1 patient). Of the 26 survivors, 8 patients (31%) underwent fascial closure at initial hospitalization, and 18 patients (69%) required split-thickness skin grafting to visceral granulation tissue. Of theses 18 patients, 13 (72%) have already undergone ventral herniorrhaphy at subsequent admission. No patient developed a complication attributable to the technique.

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Resumen Entre 1988 y 1992 fucron admitidos 5.300 pacientes a un centro de trauma de Nivel I, de los cuales 36 requirieron cierre abdominal con silastic. Las edades oscilaron entre 13 y 75 años y el ISS fue de 30 (rango 13–50). Diecinueve pacientes (53%) sufrieron lesiones penetrantes y 17 (47%) trauma cerrado. El cierre con silastic fue realizado en la laparotomía de admisión en 15 casos (42%) debido a la imposibilidad de cerrar la fascia en forma primaria. En 21 pacientes (58%) se realizó cierre con silastic en reexploración por imposibilidad de hacer cierre primario (12 pacientes), por presión intraabdominal elevada con deterioro de la función renal (6 pacientes) y por sepsis de la herida con necrosis de la fascia (3 pacientes). Veintiséis pacientes (72%) sobrevivieron y 10 pacientes (28%) murieron. Las causas de muerte fueron falla orgánica múltiple (9 pacientes) y exanguinación (1 paciente). De los 26 sobrevivientes, 8 (31%) recibieron cierre de la fascia en la hospitalización inicial, en tanto que 18 (69%) requirieron injerto de piel sobre el tejido de granulación visceral. Trece de estos 18 pacientes (72%) han sido ya sometidos a herniorrafia ventral en subsiguientes admisiones hospitalarias. Ningún paciente ha desarrollado complicaciones atribuibles a esta técnica.

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Résumé Entre 1988 et 1992, plus de 5300 patients ont été admis dans un Trauma Center de niveau 1, 36 parmi eux nécessitant une fermeture abdominale avec du silastique. Ces patients étaient âgés de 13 à 75 ans et l'Injury Severity Score moyen était de 30 (extrêmes 13–50). Dixneuf patients (53%) avaient des lésions pénétrantes alors que 17 (47%) avaient des lésions fermées. La fermeture avec une plaque de silastique a été effectuées. La laparotomie initiale chez 15 (47%) des patients en raison de l'impossibilité de fermer l'aponévrose. Vingt et un patients (58%) ont eu ce type de fermeture lors d'une laparotomie ultérieure en raison soit d'impossibilité de fermeture (12 patients), soit d'une hyperpression abdominale associée à une défaillance rénale croissante (6 patients), soit du fait d'un sepsis de la paroi avec une nécrose pariétale (3 patients). Vingt six patients (72%) ont survécu et 10 patients (28%) sont décédés. La cause décès a été une défaillance polyviscérale chez 9 patients et un cas d'exsanguination. Parmi les 26 survivants, 8 (31%) ont eu une fermeture pendant leur hospitalisation initiale alors que 18 patients (69%) ont nécessité des greffes de peau minces sur un tissu de granulation. Treize de ces 18 patients ont déjà eu une cure de leur éventration à une séance opératoire ultérieure. Aucune complication n'a pu être rattachée à cette technique.

     

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.     

Emergency laparotomy for abdominal trauma

We have retrospectively reviewed our experience of 153 consecutive patients who underwent emergency laparotomy for suspected intraabdominal injury over a 10-year period.

The commonest cause of injury was road traffic accidents (61 per cent), and the commonest indication for operation was signs of peritoneal irritation (35 per cent). Peritoneal lavage was performed in 62 patients (41 per cent). The liver was the organ most frequently injured (52 patients, 34 per cent) and 52 per cent of these patients died. Splenic injuries occurred in 46 patients (30 per cent). The negative laparotomy rate was 16 per cent. Forty-five patients died (29 per cent) and five of these had negative laparotomies. The Injury Severity Score (ISS) of all patients who died was > 16.     

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.     

Indications for radiographic assessment in suspected renal trauma

We recommend that the criteria for radiographic assessment of suspected renal trauma be: (1) penetrating trauma to the flank or abdomen, regardless of the degree of hematuria; (2) blunt trauma and gross hematuria; or (3) blunt trauma associated with microhematuria and blood pressure below 90 mm Hg before or after emergency room admission. In hemodynamically stable patients in whom renal injury alone is suspected, we recommend intravenous urography, which will adequately stage 60 to 85 per cent of renal injuries. Computed tomography should be performed if the urography results are equivocal or as the primary study when multiple injuries are suspected. Arteriography can be reserved for patients with suspected renovascular injuries in whom CT scans are inconclusive.     

Indications for operative management of abdominal aortic aneurysms

The increasing incidence of abdominal aortic aneurysms, along with the more frequent use of screening techniques, has resulted in greater numbers of patients with small abdominal aortic aneurysms. The questions of frequency of surveillance and timing of intervention are the two most controversial issues faced by surgeons dealing with this condition. Most management decisions are based on the size of the aneurysm but other factors must also be considered. This review makes recommendations on the management of small abdominal aortic aneurysms according to the current available evidence.