Occult diaphragm injuries at celiotomy for left chest stab wounds.

No dependable test exists for diagnosis of diaphragmatic injury in asymptomatic patients with thoraco-abdominal stab wounds. Forty-one consecutive patients with anterior stab wounds of the lower left chest were treated in a 30-month period. In the 21 patients seen during the first 15 months, operations were reserved for those with peritoneal signs or continuing blood loss. Ten of these 21 patients (48%) required celiotomy; 2 patients (10%) had isolated diaphragm injuries and there was one negative celiotomy. Of the eleven patients who were not explored, 2 (18%) returned within 18 months after injury with an incarcerated diaphragmatic hernia. During the subsequent 15 months, the next 20 patients were managed by routine celiotomy in a prospective study. The admission systolic blood pressure and incidence of pneumothorax, celiotomy, diaphragm injury, isolated diaphragm injury, and unnecessary celiotomy in these two groups were compared. Ten patients in the prospective group (50%) were found to have isolated diaphragm injuries (P less than 0.005) and 7 (35%) had negative celiotomies (P less than 0.02). The true incidence of occult diaphragm injuries may be underestimated. In the prospectively studied group, the policy of routine celiotomy for anterior stab wounds of the lower left chest resulted in recognition and repair of a fivefold greater number of isolated diaphragm injuries. In the absence of a reliable, noninvasive test to diagnose penetration of the diaphragm, celiotomy should be considered in light of the risks of late strangulation.     

Abdominal injuries associated with penetrating trauma in the lower chest

A 5 year experience of 248 patients with isolated penetrating lower chest injury was reviewed. Twenty-two (15 percent) of the stab wounds and 46 (46 percent) of the gunshot wounds caused associated intraabdominal injury. Among those taken to the operating room for laparotomy, physical examination proved misleading in 40 percent of the patients with stab wounds and 30 percent of those with gunshot wounds. The diagnostic accuracy of peritoneal lavage, used selectively, was 93 percent for the patients with stab wounds and 90 percent for those with gunshot wounds. The morbidity was high in patients with combined injuries, with major complications occurring in 27 percent of those with stab wounds and 43 percent of those with gunshot wounds. Two thirds or more of these complications were thoracic. There was one death (4 percent) among the patients with thoracoabdominal stab wounds and six (13 percent) among those with gunshot wounds.     

Delayed diagnosis of injuries to the diaphragm after penetrating wounds

During a 9-year period, 16 patients with a delay in diagnosis of an injury to the diaphragm after a penetrating wound were treated. The left hemidiaphragm was involved in 15 of 16 patients, and the delay in diagnosis from the time of arrival in the emergency center immediately after injury ranged from 16 hours to 14 years. In the patients in the Acute Group (delay of hours to days), three patients had diaphragmatic defects missed at the time of laparotomy, three patients had chest X-rays not immediately suggestive of diaphragmatic defects, two patients had false-negative lavages, and one patient treated elsewhere did not have a chest X-ray in the emergency room. In the patients in the Chronic Group (hernias presenting months to years after injury), four of seven patients had misreading of a recent chest X-ray or failure to have a chest X-ray performed during numerous return visits to the emergency center. Despite a variety of diagnostic maneuvers, these defects and hernias continue to be diagnosed after a delay. Careful review of early and late followup chest X-rays appears to be the easiest mechanism to avoid significant delays in diagnosis.     

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.     

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.     

Antibiotic prophylaxis in penetrating injuries of the chest.

Most prospective studies recommend antibiotic prophylaxis whilst a thoracostomy tube is in place or even longer. We conducted a randomised study of 188 patients with penetrating chest injuries requiring a chest drain. Of these patients, 95 received a single dose of ampicillin before insertion of the chest tube, the remaining 93 patients received additional antibiotic prophylaxis for as long as the drain was in place. The incidence of intrathoracic sepsis (pneumonia or empyema) was 3.1% and 3.2%, respectively. It is concluded that single-dose prophylaxis in penetrating chest trauma is as effective as prolonged prophylaxis. The importance of chest physiotherapy immediately after the drain insertion and of early removal of the drain is stressed. The role of various possible risk factors in the development of sepsis is discussed.     

Reliability of physical examination in penetrating chest injuries

The decision to insert an intercostal drain in chest injury must occasionally be made without a chest radiograph. A prospective analysis of the reliability of physical examination in penetrating pleural injuries was undertaken. A total of 51 consecutive patients were examined before obtaining a chest radiograph. The presumptive diagnosis and decision to institute intercostal drainage were compared with the radiological diagnosis and the actual decision in each patient. A policy of selective drainage of large pleural collections was employed. The series consisted mainly of stab injuries in young men. Physical examination accurately diagnosed 13 of the 14 large pneumo- or haemothoraces. This reliability combined with the selective drainage policy showed that physical examination accurately predicted the need for tube thoracostomy with a sensitivity of 96 per cent and a specificity of 93 per cent. This study suggests that experienced clinicians should not hesitate to institute immediate lifesaving intercostal drainage when needed, before a chest radiograph is obtained.     

Thoracoscopy as an aid to the diagnosis of diaphragmatic injury in penetrating wounds of the left lower chest: a preliminary report

In an attempt to evaluate the place of thoracoscopy, the investigation was performed on 11 patients with penetrating wounds of the left lower chest, who had no definite clinical or radiological indication for operation. In 6 patients the diaphragm was seen clearly, and in 2 of these an unsuspected diaphragmatic injury was found. Both injuries were later confirmed at operation. The other 4 patients had intact diaphragms and were successfully treated conservatively.It is suggested that thoracoscopy is a useful aid in the diagnosis of left-sided, diaphragmatic injury and that the best results are obtained if it is performed within 24 hours of injury.     

Occult diaphragmatic injury from stab wounds to the lower chest and abdomen

Ninety-five patients with stab wounds to the lower chest and abdomen underwent routine abdominal exploration. Eighteen of these patients had diaphragmatic injury and in five patients it was the only injury found. Isolated diaphragmatic injury in asymptomatic patients cannot be reliably delineated by either serial physical examination or peritoneal lavage. Delayed recognition of incarcerated diaphragmatic hernia after stab wounds to the lower left chest and upper abdomen has an associated mortality rate of 36%. The anatomic area of concern can be defined as stab wounds that penetrate the left side of the chest below the fourth intercostal space anteriorly, the sixth intercostal space laterally, and the tip of the scapula posteriorly. Exploratory laparotomy is necessary in these patients until a reliable nonoperative method is established that can exclude injuries to the diaphragm.     

Renal salvage in penetrating kidney injuries: a prospective analysis

BACKGROUND: Routine exploration of penetrating kidney injuries is not advised because of the fear of a higher nephrectomy rate. This study was conducted to assess the efficacy of renal salvage in patients who underwent routine exploration of the injured kidney and to document complications related to the procedure. METHODS: This was a prospective study over a 2-year period. RESULTS: Fifty patients (46 male and 4 female patients), median age 29 years (range, 16-69 years), were included. Mechanisms of injury were gunshot wound in 43 patients (86%) and stab wounds in 7 patients (14%). Mean Revised Trauma Score was 10.5. All patients underwent laparotomy. Three injuries were bilateral, for a total of 53 renal units. There were three deaths on the operating table (two nephrectomies and one bilateral repair). Management of the remaining 49 renal units was as follows: simple drainage in 13 (26.5%), renal repair in 17 (35%), partial nephrectomy in 6 (12%), and nephrectomy in 13 (26.5%). There were two minor complications directly related to the renal salvage: transient hypertension in one patient and a urine leak, which settled on conservative management. CONCLUSION: An overall renal salvage rate of 73.5% for penetrating trauma was achieved with routine exploration of the injured kidney.     

Non-operative management of penetrating liver injuries: a prospective study

This is a report of a study of 63 cases of penetrating liver injuries. Forty-two patients (67 per cent) who presented with signs of an acute abdomen were operated on. The liver was routinely sutured and drained. There was no incidence of postoperative intra-abdominal sepsis or haematobilia. In the remaining 21 patients (33 per cent) liver involvement was suggested by the fact that the wound was over the liver region, and penetrated the peritoneum, and abdominal paracentesis for blood was positive or the patient was shocked or pale. The patients in this group had a soft abdomen and they were treated conservatively with observation and blood transfusions if necessary. No complications were recorded in this group. It is concluded that many civilian penetrating injuries of the liver may be managed non-surgically. If an operative approach is selected suturing of the liver with drainage is the recommended procedure.     

The contribution of laparoscopy in evaluation of penetrating abdominal wounds

BACKGROUND: Penetrating abdominal wounds are traditionally explored by laparotomy. We investigated prospectively the role of laparoscopy within a defined protocol for management of penetrating abdominal wounds to determine its safety and advantages over traditional operative management. STUDY DESIGN: The study inclusion criteria were: stab and gun shot abdominal wounds, including junction zone injuries; stable vital signs; and absence of contraindications for laparoscopy. Diagnostic end points included detection of peritoneum or diaphragm violation, visceral injuries, and other indications for laparotomy. Systematic examination was undertaken using a multiport technique whenever the peritoneum or diaphragm had been violated. All repairs were done by open operation. RESULTS: A total of 40.6% of patients with penetrating trauma fulfilled study criteria (52 patients). Of these, 33% had no peritoneal penetration; 29% had no visceral injuries despite violation of peritoneum or diaphragm; 38% had visceral injuries, of which 40% (mainly liver and omentum) required no intervention. Twelve patients (23% of total) had open repairs. No missed injuries or death occurred in the study. Overall, 77% of penetrating injuries with stable vital signs avoided exploratory laparotomy. Compared with National Trauma Data Bank information for patients with the same Injury Severity Scores, hospitalization was reduced by more than 55% for the entire series. CONCLUSIONS: Laparoscopy for penetrating abdominal injuries in a defined set of conditions was safe and accurate, effectively eliminating nontherapeutic laparotomy and shortening hospitalization.     

Comprehensive clinical x-ray-radionuclide study of lung function in penetrating chest injuries

Results of the complex clinico-x-ray-radionuclide research of 52 patients with penetrating injuries of the chest have shown that the morphological and functional state of the injured lung can be assessed by findings of rheography, spirography, scanning and scintigraphy, roentgenography and roentgenoscopy.     

Laparoscopic evaluation of penetrating thoracoabdominal traumatic injuries

Background

General surgeons’ recent familiarity with advanced laparoscopic techniques have rendered laparoscopy feasible safely in the trauma setting. Traditionally high rates of nontherapeutic laparotomies also contribute to this increased interest. This study was undertaken to determine the predictive value and accuracy of diagnostic laparoscopy (DL) in evaluation of penetrating thoracoabdominal trauma.

Methods

Entry criteria included thoracoabdominal gunshot (GSW) or stab wounds (SW) in otherwise hemodynamically stable patients. A high index of suspicion for either hemoperitoneum, peritonitis, or diaphragmatic injury was required for inclusion. All patients underwent DL in the operating room followed by standard laparotomy. The findings of the two evaluations were compared.

Results

Twenty-four patients were included in the study. Twenty males and 4 females with an average age of 34 years made up the group. Violation of the peritoneal cavity was present in 21 cases and absent in 3. No intraabdominal injuries were found during laparotomy in the latter three cases without peritoneal violation. The specificity and positive predictive value were 100% for lesions of the diaphragm, liver, spleen, pancreas, kidney, and hollow viscus. The sensitivity was highest for liver and spleen injuries (88%), followed by diaphragmatic injuries (83%), pancreas and kidney injuries (50%), and lowest for injuries of hollow viscus (25%). The negative predictive value was 95, 99, 91, and 57%, respectively, for these organs.

Conclusions

DL could have avoided unnecessary laparotomy in 38% of cases in this study. There were no complications related to laparoscopy. The greatest value of DL in penetrating thoracoabdominal injuries is in the evaluation of peritoneal violation, diaphragmatic, and upper abdominal solid-organ injuries. It is not ideal for predicting hollow viscus injuries.