Therapeutic laparoscopy in trauma

: To assess the therapeutic potential of emergent laparoscopy in the trauma setting, a retrospective review was performed in a busy urban trauma center. : Between December 1991 and October 1993, 133 hemodynamically stable patients with suspected abdominal injury were evaluated laparoscopically. All laparoscopic procedures were performed in the operating room under general anesthesia. Mechanism of injury was stab wound (58), gunshot wound (57), and blunt trauma (18). No significant injuries were found in 72 patients (54%), and these patients received no further treatment. On the basis of laparoscopic findings, 52 patients underwent formal exploratory laparotomy. Surgical exploration confirmed the presence of significant injuries in 44 of the 52 patients (85%). Therapeutic laparoscopy was performed in 6 patients (5%) for diaphragm repair (4), gastrotomy repair (1), and splenorrhaphy (1). Additionally, 10 patients underwent laparoscopy-guided blood salvage for autotransfusion during laparoscopic evaluation of blunt trauma. Three small-bowel enterotomies were repaired during minilaparotomy. : No significant injuries were missed as a result of our use of laparoscopy in trauma assessment. Complications—trocar enterotomy, trocar laceration of the interior epigastric artery, and transient hypotension—occurred in 3 patients secondary to the use of laparoscopy. : Trauma laparoscopy is a safe method for the evaluation of selected patients with abdominal trauma and can reduce the number of negative and nontherapeutic trauma laparotomies performed. Limited therapeutic intervention is possible in a small number of patients.     

Laparoscopy for Penetrating Thoracoabdominal Trauma: Pitfalls and Promises

Background:

How should the stable patient with penetrating abdominal or lower chest trauma be evaluated? Evolving trends have recently included the use of diagnostic laparoscopy. In September 1995 we instituted a protocol of diagnostic laparoscopy to identify those patients who could safely avoid surgical intervention.

Design:

Prospective case series.

Materials and Methods:

Hemodynamically stable patients with penetrating injuries to the anterior abdomen and lower chest were prospectively evaluated by diagnostic laparoscopy, performed in the operating room under general anesthesia, and considered negative if no peritoneal violation or an isolated nonbleeding liver injury had occurred. If peritoneal violation, major organ injury or hematoma was noted, conversion to open celiotomy was undertaken.

Results:

Seventy consecutive patients were evaluated over a two-year period. The average length of stay (LOS) following negative laparoscopy was 1.5 days, and for negative celiotomy 5.2 days. There were no missed intra-abdominal injuries following 30 negative laparoscopies, and 26 of 40 laparotomies were therapeutic. The technique also proved useful in evaluation of selected blunt and HIV+ trauma vic-tims with unclear clinical presentations. However, while laparoscopy was accurate in assessing the abdomen following penetrating lower chest injuries, significant thoracic injuries were missed in 2 out of 11 patients who required subsequent return to OR for thoracotomy.

Conclusions:

Laparoscopy has become a useful and accu-rate diagnostic tool in the evaluation of abdominal trauma. Nevertheless, laparoscopy still carries a 20% nontheraputic laparotomy rate. Additionally, significant intrathoracic injuries may be missed when laparoscopy is used as the pri-mary technique to evaluate penetrating lower thoracic trauma.     

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.     

The value of laparoscopy in management of abdominal trauma

The role of laparoscopy (LS) in abdominal trauma is controversial. Concerns remain regarding missed injuries and safety. Our objective for this study was to determine the safety and better define the role of LS in abdominal trauma victims. We performed a retrospective review of all patients who sustained abdominal trauma and underwent LS in a level I trauma center. The main outcome measures were age, gender, mechanism of injury (MOI), indication for laparoscopy, presence of intra-abdominal injury (IA), therapeutic laparoscopy (TxLS), need for laparotomy, length of hospital stay (LOS), missed injuries, complications, and deaths. Forty-eight patients underwent LS (62 per cent male; average age, 28 years; MOI, 35 (85%) penetrating, 7 (15%) blunt; mean ISS, 8). At laparoscopy, 58 per cent of patients had no intra-abdominal injury. IA injury was treated with laparotomy in 14 (29%) and TxLS in 6 (13%). One patient had a negative laparotomy (2%). No injuries were missed. No patients required reoperation. There was one complication: a pneumothorax. There were no deaths. LS was most valuable in penetrating trauma, avoiding laparotomy in more than two-thirds of patients with suspected intra-abdominal injury. LS can serve as a useful adjunct for the evaluation of blunt trauma. In a level I trauma center with LS readily available, the procedure is associated with a low rate of complications and missed injury.     

Laparoscopic management of penetrating liver trauma: a safe intervention for hemostasis

We describe the case of a 48-year-old woman who underwent emergent diagnostic and therapeutic laparoscopy after sustaining two self-inflicted abdominal stab wounds. After evacuation of approximately 1.5 L hemoperitoneum, a through-and-through liver injury with active bleeding was locally packed with hemostatic agents (Surgicel and Avitene) to achieve successful hemostasis. The patient also underwent systematic exploration of the abdominal cavity, which was free of associated injury. She had an uneventful recovery. This case adds to the growing evidence supporting the role of therapeutic laparoscopy in the safe management of carefully selected stable patients with penetrating abdominal trauma.     

Gall bladder injuries as part of the spectrum of civilian abdominal trauma in South Africa

BACKGROUND: Trauma to the gall bladder is rare, but when missed or improperly managed it may be associated with significant morbidity. The aim of the present study was to review the management and outcomes of gall bladder trauma in a trauma centre. METHODS: Forty-three patients with gall bladder injury due to abdominal trauma were reviewed over a 3-year period. Surgical management, associated injuries, morbidity and mortality rates were determined. RESULTS: Among 1242 patients undergoing laparotomy for acute trauma, 43 patients (3.46%) with gall bladder injuries were identified. Forty patients sustained penetrating injuries (37 with gunshot wounds and three with stab wounds), and three patients suffered from blunt trauma. All patients with gall bladder injury underwent abdominal exploration because of associated intra-abdominal injuries. Thirty-six patients were treated with cholecystectomy, four patients underwent primary suture repair of the gall bladder perforation, while three patients with gall bladder injury were treated without any surgical intervention at laparotomy. No complications could be attributed to the gall bladder trauma or surgery. CONCLUSION: Cholecystectomy is the preferred procedure of choice for gall bladder injuries and is associated with no morbidity.     

Management of penetrating and blunt diaphragmatic injury

The past 5 years' experience with diaphragmatic injuries at the University of Texas Health Science Center in San Antonio was reviewed to refine the clinical signs and appropriate treatment. During this period 102 patients were treated. Ninety-three patients incurred penetrating trauma to the diaphragm and nine patients suffered blunt trauma. Chest X-rays were normal in 40 patients, a hemo- and/or pneumothorax was present in 57, herniated abdominal viscera in four, and free air in one. Peritoneal lavage was positive in six of seven patients with blunt diaphragmatic injury, but was falsely negative in two of five patients (20%) with penetrating diaphragmatic injury. Eighty-nine patients (87%) experienced 137 associated injuries (excluding hemo- and/or pneumothorax). Nine patients (8.8%) had an isolated diaphragmatic injury. Four patients (4%) had a diaphragmatic injury associated with only a hemo- and/or pneumothorax. All patients, except for three with injuries recognized late, were operated upon immediately. Two patients had a missed diaphragmatic injury at initial laparotomy. There was one death in the series from a consumption coagulopathy. It was concluded that injuries to the diaphragm should be suspected in all patients with severe blunt torso trauma or with penetrating injuries near the diaphragm. Because of the nonspecificity of X-rays and the 20% false negative rate for peritoneal lavage, we believe that missed injuries and morbidity can be minimized by immediate laparotomy for all patients with abdominal and low thoracic penetrating injuries. Care must be taken not to overlook associated injuries.     

Computed tomographic scan can be used for surgical decision making in zone II penetrating neck injuries

BACKGROUND: Controversy surrounds the evaluation of zone II penetrating neck injuries. Current literature supports mandatory exploration or selective management. Computed tomographic (CT) scanning provides high-resolution images that are used for trauma in other body regions. The purpose of this study is to prospectively evaluate the utility of CT scanning in the evaluation of zone II penetrating neck injuries. METHODS: From July 1998 to November 1999, 14 stable patients were studied who sustained zone II penetrating neck injuries. All patients had a physical examination, infusion CT scan of the neck, and an operative exploration. Before surgery, the trauma surgeon evaluated the CT scan and interpreted it as demonstrating either "high" or "low" probability for significant injury. Surgical findings were compared with the surgeon's preoperative interpretation of the CT scan. RESULTS: Three of 14 patients had five significant injuries. All these patients had high probability of injury CT scans, with four of the five injuries specifically diagnosed by CT scan. Sensitivity, specificity, positive predictive value, and negative predictive value were 100%, 91%, 75%, and 100% (p < 0.02), respectively. CONCLUSION: This small prospective study demonstrates that zone II penetrating neck injuries can be accurately evaluated by CT scan. In addition, the CT scan can be used for surgical decision making. This will eliminate the need for mandatory exploration and limit the role of angiography, esophagography, and endoscopy in zone II penetrating neck injuries.     

Nonoperative management of solid organ injuries. Past, present, and future

All patients with injuries to the solid organs of the abdomen and who are hemodynamically stable should be considered candidates for nonoperative management after their injuries have been staged by abdominal CT scanning, but because the CT stage of the injury does not always predict which patients require laparotomy, these patients must remain under the care of experienced trauma surgeons who can not only recognize the presence of an associated hollow viscus injury in need of repair but also will be readily available to operate if the nonoperative approach fails. Until continued bleeding can be safely ruled out, a period of close monitoring in an ICU-like setting seems warranted. Although delayed bleeding from the liver seems extremely rare, delayed rupture of the spleen and continued hemorrhage into the retroperitoneum from an injured kidney are not unusual, so patients with splenic and renal injuries should be considered candidates for repeat imaging procedures before discharge. Others likely to benefit from a second look at their injuries include patients with subcapsular hematomas, patients with recognized extravasation on the initial scan, and athletes anxious to return to contact sports. Experience from major trauma centers suggests that the incidence of missed intestinal injuries is low in adults and children managed nonoperatively, but surgeons must be diligent in monitoring for increasing abdominal pain, abdominal distention, vomiting, and signs of inflammation, which may be delayed manifestations of intestinal disruption. Patients with vascular injuries (grade V injuries to the spleen, liver, or kidney) may be candidates for radiologic procedures, such as angioembolization or stenting, but some of these patients are best served by immediate laparotomy. Selected patients with penetrating injuries may also be candidates for the nonoperative approach, but further research in this area is needed before this approach can be widely embraced. As we approach the year 2000, the nonoperative approach to hepatic, splenic, and renal injuries will continue to have a major role in the treatment of trauma patients. Currently, the morbidity and mortality rates of nonoperative management are acceptably low, but surgeons still must monitor their results carefully as they apply these methods more liberally among injured patients.     

Current indications and results of VATS in the evaluation and management of hemodynamically stable thoracic injuries

Objective: Thoracic injuries are among the most severe forms of trauma and also a leading cause of morbidity and mortality. Video Assisted Thoracic Surgery (VATS) has recently provided an alternative method to simultaneously diagnose and manage patients sustaining chest injuries. We analyze our experience with VATS in the setting of thoracic trauma detailing indications for exploration, procedures performed and results of surgery. Methods: A 6-year single institution review of patients undergoing VATS due to injuries sustained from both blunt and penetrating chest trauma at a Level I trauma center and university teaching hospital. Comparisons were made between groups of blunt and penetrating trauma as to Injury Severity Score (ISS), presence of extra-thoracic injuries, initial thoracostomy drainage and length of postoperative stay. Results: VATS was successfully performed in 19 consecutive patients without conversion to thoracotomy. Indications for exploration included acute hemorrhage, retained hemothorax, suspected diaphragmatic injuries (DI), suspected cardiac injury, intra-thoracic foreign body, persistent airleak and chronic empyema. Procedures performed consisted of evacuation of retained hemothorax, hemostasis of intra-thoracic bleeders, repair of DI, wedge lung resections and decortication. Mean postoperative length of stay was 5.86 days. There were no morbidities. One patient with severe intra-abdominal injuries expired on the first postoperative day. Conclusion: In hemodynamically stable patients with thoracic injuries, VATS provides an accurate assessment of intra-thoracic organ injury and can be utilized to definitively and effectively manage injuries sustained as a result of blunt or penetrating thoracic trauma. VATS should be used with caution in patients sustaining severe and life threatening intra-abdominal injuries.     

Vascular surgery for penetrating injury of the neck<Superscript>*</Superscript>

BACKGROUND: Vascular injuries due to penetrating neck trauma are rare, but potentially lethal injuries. METHODS: 17 patients were treated for vascular injuries after penetrating neck trauma by specialised vascular surgeons between 1.1.1998 and 31.12.2010. All patients underwent surgical exploration and vascular surgical treatment for bleeding. RESULTS: Trauma mechanism was stab wound in 9 patients, metal fragments in 3 and various items in 5 patients. 4 patients had attempted suicide, and 3 patients were injured in a fight or murder attempt. The injuries were to zone II according to Monson in 14 patients, zone I in 2 patients, and zones I and II in 1 patient. In 8 patients arterial injuries and in 9 patients venous lesions were treated. Mortality was 11.8% (2/17 patients). CONCLUSIONS: Penetrating trauma to the neck is a serious and potentially lethal injury. CTA is recommended in the literature in diagnostic exploration of hemodynamically stable patients. Emergency surgery by an experienced vascular surgeon can help to determine the extent of trauma and its treatment. In arterial trauma to the carotid arteries a complete intraoperative exposure with external and internal inspection of the vessel including the intimal layer is recommended. The role of endovascular treatment for vascular injury due to penetrating neck trauma needs further evaluation.     

Impact of increased use of laparoscopy on negative laparotomy rates after penetrating trauma

BACKGROUND: Our institution was one of the first to report the use of laparoscopy in the management of penetrating abdominal trauma (PAT) in 1977. Despite early interest, laparoscopy was rarely used. Changes in 1995 resulted in an increase in interest and use of laparoscopy. We present our recent experience with laparoscopy. METHODS: Our trauma registry and operative log were used to identify patients with blunt and penetrating injuries to the abdomen, back, and flank who underwent laparotomy or laparoscopy during the past 5 years. Patient demographics, operative findings, complications, and length of stay were reviewed. The number of laparoscopic explorations, therapeutic, nontherapeutic, and negative laparotomies were trended. RESULTS: There were 429 abdominal explorations for trauma. The rate of laparoscopy after penetrating injury increased from 8.7% to 16%, and after stab wounds from 19.4% to 27%. There was an associated decrease in the negative laparotomy rate. Laparoscopy prevented unnecessary laparotomy in 25 patients with PAT. Four patients with diaphragm injuries underwent repair laparoscopically. CONCLUSION: An aggressive laparoscopic program can improve patient management after PAT.     

Prospective evaluation of screening multislice helical computed tomographic angiography in the initial evaluation of penetrating neck injuries

BACKGROUND: The optimal management strategy for patients sustaining penetrating neck injury without an urgent indication for operative exploration remains controversial. The objective of this study was to prospectively assess multislice helical computed tomography angiography (MCTA) as a stand alone screening modality for the initial evaluation of hemodynamically stable patients with penetrating neck injuries. Our hypothesis was that MCTA is a sensitive diagnostic screening test that could noninvasively evaluate the vascular and aerodigestive structures of the neck. METHODS: After Institutional Review Board approval, all penetrating neck injuries assessed during a 16-month period were prospectively evaluated at a Level I trauma center. Patients without an indication for urgent neck exploration underwent MCTA screening. MCTA accuracy was tested against an aggregate gold standard of final diagnosis encompassing all imaging, surgical procedures and clinical follow-up obtained. RESULTS: In all, 106 injuries penetrated the platysma; 15 required urgent exploration and 91 underwent MCTA (34 gunshot wounds/57 stab wounds). Nineteen external wounds were in zone 1, 39 were in zone 2, 10 in zone 3, and 23 traversed multiple zones. MCTA was nondiagnostic in 2.2% secondary to artifact from retained missile fragments. Follow-up was achieved in 84.5% of patients for a mean of 33.3 days (range: 2-150). MCTA achieved 100% sensitivity and 93.5% specificity in detecting all vascular and aerodigestive injuries sustained. MCTA correctly identified two tracheal and two carotid artery injuries requiring operative or endovascular repair in asymptomatic patients. No injuries requiring intervention were missed by MCTA. CONCLUSION: In the initial evaluation of stable penetrating neck injuries, MCTA appears to be a sensitive and safe screening modality. Further investigation is warranted.     

Laparoscopy as diagnostic-therapeutic method in abdominal traumatism in the pediatric age

The management of blunt abdominal traumatism with a moderate amount of free peritoneal fluid and without solid organ injury as well as the one of minimal penetrating trauma is controversial. We present three cases of blunt abdominal trauma and two of penetrating trauma that underwent diagnostic laparoscopy in our department. We found a small bowel perforation in one of the cases of blunt trauma that was repaired by externalization of the jejuna loop by one of the ports. In the other two cases we found intestinal and mesenteric contusions and free fluid that were treated by peritoneal drainage. One of the cases of penetrating trauma presented omentum evisceration with no other injuries and the second presented a gastric perforation that needed reconversion to laparotomy. In our experience and according to literature, laparoscopy should be taken into account as a diagnostic procedure and sometimes also therapeutic in selected cases of both blunt and penetrating abdominal trauma in pediatric population.     

Thoracic computed tomography is an effective screening modality in patients with penetrating injuries to the chest

BackgroundThe precise role of thoracic CT in penetrating chest trauma remains to be defined. We hypothesized that thoracic CT effectively screens hemodynamically normal patients with penetrating thoracic trauma to surgery vs. expectant management (NOM).MethodsA ten-year review of all penetrating torso cases was retrospectively analyzed from our urban University-based trauma center. We included hemodynamically normal patients (systolic blood pressure ≥90) with penetrating chest injuries that underwent screening thoracic CT. Hemodynamically unstable patients and diaphragmatic injuries were excluded. The sensitivity, specificity, positive predictive value and negative predictive value were calculated.ResultsA total of 212 patients (mean injury severity score = 24, Abbreviated Injury Score for Chest = 3.9) met inclusion criteria. Of these, 84.3% underwent NOM, 9.1% necessitated abdominal exploration, 6.6% underwent exploration for retained hemothorax/empyema, 6.6% underwent immediate thoracic exploration for significant injuries on chest CT, and 1.0% underwent delayed thoracic exploration for missed injuries. Thoracic CT had a sensitivity of 82%, specificity of 99%, positive predictive value of 90%, a negative predictive value of 99%, and an accuracy of 99% in predicting surgery vs. NOM.ConclusionsThoracic CT has a negative predictive value of 99% in triaging hemodynamically normal patients with penetrating chest trauma. Screening thoracic CT successfully excludes surgery in patients with non-significant radiologic findings.     

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目的 探讨腹部创伤再手术的原因和预防。方法 回顾分析14年间43例腹部创伤早期再手术病人的资料。结果 再手术病例占同期1126例创伤剖腹术病人的3.8%。钝性伤31例，穿透性伤12例。再手术原因主要为首次手术漏诊（13例）、处置失误（12例）、并发症（15例）、阴性再手术（3例）。43例病人共行再手术50例次，其中2例经受4次手术。病死率为11.6%(5/43），主要死因为再手术后消耗性凝血病或（和）严重感染并发症诱发多器官功能障碍综合征（MODS）。结论 剖腹术时坚持全面探查，正确掌握手术操作技术和重视腹部创伤的充分引流，是减少再手术的关键。     

Diagnostic modalities in abdominal trauma. Peritoneal lavage, ultrasonography, computed tomography scanning, and arteriography

Numerous algorithms encompassing the diagnostic studies described above have been published in recent years. For practical purposes, diagnostic peritoneal lavage and CT scanning are the diagnostic studies most commonly used in patients without obvious indications for celiotomy after blunt or penetrating abdominal trauma. Diagnostic peritoneal lavage is invasive, rapidly performed, cheap, and accurate and has a primary role in documenting intra-abdominal bleeding or contamination in hypotensive patients with blunt trauma or selected stable patients with penetrating stab wounds. It misses small and large injuries to the diaphragm and cannot rule out injury to retroperitoneal structures. Computed tomography is noninvasive, time consuming to perform, expensive, and accurate and has a primary role in defining the location and magnitude of intra-abdominal injuries in stable patients with blunt trauma or with penetrating trauma to the flank or back. In many hospitals, it misses gastrointestinal perforations or ruptures. Both studies may be needed in the same stable patient, and both should be available and used in a complementary fashion in the modern trauma center.     

腹腔镜技术在诊治腹部穿透伤中的应用评价

目的:本研究通过分析我院应用腹腔镜技术诊断和治疗腹部穿透伤病人的具体资料,探讨腹腔镜技术在诊治腹部穿透伤中的应用价值。方法:2007年1月至2010年12月,我院收治的腹部穿透伤142例病人中,39例采用非手术治疗,86例采用腹腔镜探查手术,17例采用开腹探查手术。结果:在86例采用腹腔镜探查手术的病例中,51例在腹腔镜下完成止血、修补等治疗;19例因出血迅猛、腹腔污染严重及病变难以处理而中转开腹手术;16例探查阴性。结论:腹腔镜技术在腹部穿透伤的处理中兼具诊断和治疗的作用,避免了一些不必要的开腹手术,从而取代了很多开腹手术;有创伤小,恢复快等优势,有一定的应用价值。