Laparoscopy in abdominal trauma]

Laparoscopy is very useful in penetrating abdominal trauma, in particular to exclude intraabdominal lesions in stab wounds. In blunt abdominal trauma laparoscopy is not the first choice of diagnostic means though it warrants comparable good results to CTscan and ultrasound. Invasiveness, high costs, and time consuming procedure require a critical and specific application making it suitable especially in unclear clinical situations and equivocal diagnostic findings. Without doubt laparoscopy is only useful in hemodynamically stable patients and is of secondary value in polytraumatized patients. In the future it has to be thought about laparoscopy in local anesthesia and in bedside procedure e.g. on the intensive care unit. Laparoscopy should be regarded as an integral part of diagnostic spectrum in blunt abdominal trauma.     

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.     

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.     

Laparoscopy versus laparotomy in management of abdominal trauma

Background A majority of abdominal injuries (AIs) are associated with shock, hence most of the patients are hemodynamically unstable, which limits the use of video-assisted laparoscopy (VAL) in their management. The purpose of this study is to demonstrate the possibility of using VAL in management of stable and unstable patients with abdominal trauma. Methods In a period of six years 2,695 patients with AIs were evaluated. The subjects were evaluated retrospectively and divided into two groups. Group 1, consisting of 1,363 patients, had conventional routine investigations following which they underwent laparotomy for confirmatory diagnosis and definitive management. The second group, consisting of 1,332 patients, underwent diagnostic laparoscopy in addition to the conventional investigations in the first group; 411 patients of this group had therapeutic laparoscopy. Demographic information, incidence of organs injuries and operative findings, success rate of VAL and laparotomy repair, complications, associated injuries, and hospital mortality were evaluated. Results The age of 62.6% of our patients was 20–50 years, while 10.6% and 14.5% were less than 19 and greater than 50 years, respectively. Associated injuries were head, chest, musculoskeletal, and vertebral column. Most of the victims presented with shock; 50.7%, 24.7%, and 15.9% of the patients were in mild, moderate, and severe shock respectively, and 8.7% of the subjects had stable hemodynamic status. In the first group 47.1% of the laparotomies were absolutely indicated and 24.4% were negative. Of the patients who had laparotomy, 26.0% would have been managed confidently by VAL. In the second group following VAL 42.5% of the patients did not require surgical intervention. VAL surgery was performed in 30.8% of patients. Conversion to laparotomy was performed in 26.7% of the patients. Conclusions The VAL technique can be confidently used as a main tool to expedite evaluation and treatment of patients with abdominal trauma in cases of both stable and unstable hemodynamic status.     

Laparoscopy in the evaluation of blunt abdominal trauma

Laparoscopic diagnostics provides fast, reliable, clear, and obvious information on extent and depth of abdominal organs injury with minimizing additional trauma to the patient. It is performed without any specific preparations and, if needed, it may be promptly converted into conventional laparotomy. Through use of optical equipment with various refraction angles and through variable patient positioning, laparoscopic technique enables visualization of whole abdominal cavity. In approximately 20% of cases of unclear findings, and after other performed diagnostic procedures, laparoscopy provides definitive diagnosis. Abdominal surgeons are familiar with this method, making interpretaion of the results very fast and reliable and, what is the most important, this method avoids additional trauma caused by conventional laparotomy.     

腹腔镜在腹部外伤中的应用(附15例报告)

目的 :研究腹腔镜治疗腹外伤的优越性。方法 :为 15例腹外伤患者进行腹腔镜探查和治疗。结果 :探查 15例 ,均明确诊断。腹腔镜下治疗 3例 ,中转开腹 5例 ,使 10例患者避免了不必要的开腹手术 ,5例患者及时开腹治疗 ,无并发症和死亡病例。结论 :腹腔镜应用于治疗腹外伤中 ,使部分患者免于不必要的开腹 ,避免盲目观察而延误病情 ,使部分患者进腹手术前明确了病变位置     

Penetrating abdominal aortic trauma: a report of 129 cases.

The clinical presentation, resuscitation, and operative management of 129 patients with penetrating injuries to the abdominal aorta treated between 1960 and 1989 were reviewed. This is the largest reported civilian or military experience with this specific injury; our review of the literature was limited to reports focusing on the detailed analysis of the management and outcome of aortic trauma. Eighty-two percent of patients were in shock; 18 patients (14%) underwent emergency room thoracotomies, with no survivors. Of 46 patients requiring operating room thoracotomies, only 20% survived. All patients underwent exploration. Thirty percent had three or more visceral injuries; only 2% had no concurrent visceral injury. There were associated vascular injuries in 58% of patients, the inferior vena cava being the most frequent (37%). The most significant predictor of death was continued bleeding at operation. Ninety percent of patients with free intraperitoneal bleeding died, in contrast to 35% with a contained retroperitoneal hematoma (p less than 0.001). Aortic injuries were supraceliac in 25% of patients, between the celiac and renal arteries in 25%, and infrarenal in 50%. The respective mortality rates were 70%, 80%, and 47% (p less than 0.05). Repair of the aortic defect was possible in 103 patients (80%). The most common repair was lateral arteriorrhaphy in 53% of patients, followed by end-to-end anastomosis in 15% and prosthetic repairs in 8%. The overall mortality rate was 62%, which is similar to that of previous reports. Despite advances in trauma care, a functioning paramedic system, and the use of aggressive means to obtain aortic control, penetrating aortic trauma remains highly lethal.     

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.     

Laparoscopy in diagnosis of abdominal injuries in patients with combined trauma

Importance of laparoscopy (LS) in diagnosis of intraabdominal catastrophe in patients with combined trauma (CT) is determined. Based on analysis of treatment results in 1,118 patients with CT it was revealed that real LS requirement does not exceed 10%, and it may influence negatively trauma outcome. Low diagnostic value of this method was revealed: sensitivity 98.4%, specificity 51%, accuracy 69.2%. It is concluded that LS is not a method of choice in diagnosis of intraabdominal injuries in patients with CT.     

腹腔镜诊治急慢性腹痛37例分析

目的 :探讨腹腔镜在诊断和治疗不明原因急慢性腹痛中的作用。方法 :回顾分析不明原因急慢性腹痛 37例的临床资料。结果 :急性腹痛 15例中 ,11例行腹腔镜治疗 ,2例未行外科处理 ,2例开腹手术。无误诊及漏诊。治疗患者术后腹痛均明显好转或治愈 ,有效率为 10 0 %。慢性腹痛 2 2例 ,镜下诊断 2 1例 ,其中 1例误诊。 12例行腹腔镜治疗 ,3例行开腹手术 ,6例未进一步手术治疗。 1例腹腔镜下未见异常。手术治疗者近期效果均良好 ,有效率为 93%(14 / 15 )。所有急慢性腹痛患者腹腔镜探查或治疗均无严重并发症。腹腔镜术后 3～ 6d出院。结论 :腹腔镜诊断急慢性腹痛准确率较高 ,腹腔镜治疗减少了患者痛苦 ,缩短了住院时间。腹腔镜应作为外科诊治不明原因急慢性腹痛患者的首选方法。     

Adrenal injuries following blunt abdominal trauma in children: report of two cases

Adrenal injuries following blunt abdominal trauma are uncommon. Adrenal hemorrhage in children associated with multiple organ injury, which has received little attention in the past, is an increasingly recognized phenomenon in modern trauma centers with the widespread use of abdominal computed tomography. Adrenal trauma occurs in the setting of multisystem organ injury. Isolated adrenal injury is exceedingly rare. We report two children with blunt adrenal trauma (one isolated and one with associated injuries), who were admitted during the last two years to our Pediatric Surgery Department after abdominal trauma. We determined the prevalence, management and general prognosis of blunt adrenal injury in the pediatric population. Traumatic adrenal hemorrhage appears to be an incidental and unsuspected finding that resolves on follow-up imaging.     

腹部穿透伤保守治疗30例分析

目的 探讨腹部穿透伤保守治疗指征,总结辅助检查在治疗过程中的价值.方法 回顾性分析同一治疗小组于2006年8月至2010年10月保守治疗30例腹部穿透伤的临床资料.结果 保守治疗成功25例,中转手术5例.所有保守治疗成功病人于入院24～72 h出院.结论 保守治疗应成为腹部穿透伤治疗的手段之一,严格掌握指征、动态观察是...     

腹腔镜手术265例报告

目的 :探讨腹腔镜外科手术的方法与疗效。方法 :行腹腔镜胆囊、阑尾、腹股沟疝、肠粘连、子宫附件等手术 2 6 5例。结果 :成功行腹腔镜胆囊切除术 2 32例 ,阑尾切除术 2 2例 ,肝囊肿开窗 2例 ,卵巢切除 5例 ,疝修补或者疝囊高位结扎 7例 ,肠粘连松解术 1例 ,子宫切除 1例 ,不孕症通水及盆腔松解粘连术 3例 ,输卵管病灶切除 2例。中转开腹 2例 ,其中 1例胆囊坏疽 ,分离困难 ,另 1例为术中胆囊动脉上钛夹时撕裂出血。二次手术 1例 ,为胆囊管关闭不全引起胆漏。术后均痊愈出院 ,无严重并发症发生。结论 :腹腔镜外科手术安全、有效 ,具有创伤小、术后恢复快等优点     

Nonpenetrating trauma of the abdominal aorta with partial vessel occlusion: report of two cases.

Two cases of blunt trauma of the abdominal aorta are reported. In both there was lacreation of the intima and development of intimal flaps with only partial occlusion of the aorta. Immediate recognition in one allowed prompt repair of injured tissue. Delayed recognition in the other, while not life-threatening, did prolong disability and did necessitate vascular tissue replacement with prosthetic graft. Audible bruit and palpable thrill are diagnostic signs that, if sought for in the emergency room and operating room examinations of the traumatized abdomen, will yield early recognition of this lesion.     

胸腹联合伤（附56例报告）

目的 分析和总结胸腹联合伤的原因及治疗经验。方法 分析56例胸腹联合伤,意外伤害的原因和分类,为早期治疗提供依据。结果 交通事故致伤15例,占26．8％,建筑施工致伤18例,占32．1％;其它（打架、斗殴、刀伤、爆炸等）致伤23例,占41．1％。轻度伤23例（41．1％）,中度伤26例（46．4％）,重度伤7例（12．5％）。手术治疗38例,占67．9％。总治愈率82．1％,死亡率17．9％。轻度伤全部（100％）治愈;中度伤治愈21例（80．8％）,死亡5例（19．2％）;重度伤治愈2例（28．6％）,死亡5例（71．4％）。结论 胸腹联合伤是意外伤害中较严重的一种,胸腹联合伤入院后,应迅速纠正呼吸,循环功能紊乱;有手术指征者应尽快手术,胸腹二组手术重要。及时正确的掌握以胸外伤为主的联合伤的早期开胸指征,是提高治愈率,降低死亡率的关键。     

胸腹部外伤引起Purtscher病16例

目的：探讨胸腹部外伤引起的Purtscher视网膜病变综合征的临床表现、治疗和预后。方法：对16例20眼胸腹部外伤引起的purtscher视网膜病变综合征的视力、眼底、视野及荧光素眼底造影进行回顾性分析，观察视力预后与眼底表现的关系。结果：20眼中11眼视力恢复为1．0，占55％；6眼视力恢复为0．5-0．8，占30％；3眼预后差，视神经萎缩，黄斑受损，视力永久丧失。结论：严重的胸腹部外伤后应关注是否伴有视网膜病变，及时诊断，及时治疗。视力预后取决于视网膜脉络膜损伤的部位，黄斑部损伤预后差。     

Laparoscopy is sufficient to exclude occult diaphragm injury after penetrating abdominal trauma

BACKGROUND: Occult diaphragm injury after penetrating thoracoabdominal injury can be difficult to diagnose and can remain occult for months to years. Delayed diagnosis is associated with the risk of hernia formation, strangulation, and high morbidity and mortality. Although laparoscopy has been proposed as a means of evaluating the diaphragm in these patients, prior studies did not include a confirmatory procedure or did not report long-term follow-up. Thus, true sensitivity and specificity remain unknown. The purpose of this study was to determine the sensitivity and specificity of laparoscopy for the detection of diaphragm injury after penetrating thoracoabdominal trauma. We hypothesized that laparoscopy alone is sufficient to exclude diaphragm injury after penetrating thoracoabdominal trauma. METHODS: We conducted a prospective case series of 34 hemodynamically normal asymptomatic patients with thoracoabdominal penetrating injuries. All patients underwent diagnostic laparoscopy to evaluate the diaphragm for the presence of injury. All patients then underwent confirmatory celiotomy (n = 30) or video-assisted thoracoscopy (n = 4). RESULTS: All patients were men between the ages of 18 and 54 years. There were 37 stab wounds and 1 gunshot wound. The mean lowest preoperative systolic blood pressure recorded was 120 +/- 18 mm Hg. Penetrating injuries were stratified by anatomic location (anterior, 18; posterior, 8; flank, 9; not specified, 3). There were 7 true-positive, 30 true-negative, no false-positive, and 1 false-negative result. Specificity, sensitivity, and negative predictive value were 100%, 87.5%, and 96.8%, respectively. The single missed injury occurred in a patient with hemoperitoneum from associated splenic injury that obscured the diaphragm and warranted celiotomy. CONCLUSION: In asymptomatic hemodynamically normal patients with penetrating thoracoabdominal injury, laparoscopy alone is sufficient to exclude diaphragmatic injury.