Open diagnostic peritoneal lavage in blunt trauma victims.

Open diagnostic peritoneal lavage was 97.8 per cent accurate for diagnosis of intra-abdominal injury in 2,072 blunt trauma victims. The only significant injuries missed were in certain patients with a ruptured hemidiaphragm, renal trauma and extraperitoneal bladder rupture. However, these injuries were identified by other means. False-postive lavage results are generally a consequence of technical error and can be minimized by careful surgical technique. Hemoperitoneum must be explained for all patients to prevent needless morbidity and mortality. Only diagnostic tests of proved value in blunt abdominal trauma should be used and risk to the patient must be minimized. We currently rely upon diagnostic laparotomy to evaluate hemoperitoneum in patients with a weakly positive lavage result confirmed by a second infusion. With this policy, approximately one of every four to five laparotomies was for injuries not requiring surgical therapy; and, the over-all morbidity rate and mortality was 12 and 3.5 per cent, respectively, in this group. By using open diagnostic peritoneal lavage in essentially all blunt trauma victims, we have had no deaths from either unrecognized intra-abdominal injury or delayed treatment.     

A technique for open diagnostic peritoneal lavage.

Fifty consecutive long saphenous vein graft operations for limb salvage performed between 1958 and 1965 were observed by periodic arteriography. Of 50 grafts, 11 failed within two years, and at the time of the final review, two patients had defaulted. Extended observations of the remaining 37 grafts up to 15 years showed three main complications. First, graft degeneration affected seven grafts with earliest evidence of elongation, tortuosity, irregular dilation or aneurysmal formation at four years. It did not affect any graft after eight years. One graft required replacement because of degeneration. Second, proximal dilation was seen in six grafts, but it did not compromise patency or function and had a maximal incidence at four to six years. Third, the site of the distal anastomosis was narrowed in eight patients, but the narrowing was severe in four. This complication occurred at six to eight years and affected 25 per cent of the surviving patients. The narrowing was caused by thrombus formation within the area of anastomosis and was amenable to further arterial reconstruction.     

Acute cholecystitis complicating trauma.

Twelve patients developed acute cholecystitis complicating trauma. Acute acalculus cholecystitis was present in 11 patients. Nine patients died. A review of 20 reports comprising 98 patients shows 86.7% had acute acalculus cholelithiasis, and 61.1% had necrosis, gangrene, and/or perforation of the gallbladder. The overall mortality was 33.3% and only 16.1% of patients treated by cholecystectomy died. The etiology of acute cholecystitis complicating trauma is multifactorial. Gallstones are present infrequently whereas shock, increased bile pigment load, drugs, surgery, and (other) trauma are common precursors. Diagnosis is difficult and depends upon clinical suspicion and the physical examination. Immediate surgical intervention is required. Cholecystectomy is the procedure of choice. We recommend cholecystectomy at initial laparotomy whenever there is evidence of trauma to the gallbladder, or if the right or common hepatic artery is ligated for hepatic bleeding.