Selective conservatism in trauma management: a South African contribution

AAST grade of liver injury is not the single most important consideration in decision making for liver trauma

BACKGROUND

The liver is one of the most injured organs in both blunt and penetrating trauma. The aim of this study was to identify whether the AAST liver injury grade is predictive of need for intervention, risk of complications and mortality in our patient population, and whether this differs between blunt and penetrating-trauma mechanisms.

METHODS

Retrospective review of all liver injuries from a single high-volume metropolitan trauma centre in South Africa from December 2012 to January 2022. Inclusion criteria were all adults who had sustained traumatic liver injury. Patients were excluded if they were under 15 years of age or had died prior to operation or assessment. Statistical analysis was undertaken using both univariate and multivariate models.

RESULTS

709 patients were included, of which 351 sustained penetrating and 358 blunt trauma. Only 24.3 % of blunt compared to 76.4 % of penetrating trauma patients underwent laparotomy (p< 0.001). In blunt trauma, increasing AAST grade correlated directly with rates of laparotomy with an odds ratio of 1.7 (p < 0.001). In penetrating trauma, there was no statistical significance between increasing AAST grade and the rate of laparotomy. The rate of bile leak was 4.5 % (32/709) and of rebleed was 0.7 % (5/709). Five patients underwent ERCP and endoscopic sphincterotomy for bile leak, and three required angio-embolization for rebleeding. Increasing AAST grades were significantly associated with the odds of bile leak in both blunt and penetrating trauma. There was a statistically significant increase in the odds of a rebleed with increasing AAST grade in penetrating trauma. Five patients rebled, of which three died. Seven patients developed hepatic necrosis. Seventy-six patients died (10 %). There were 34/358 (9 %) deaths in the blunt cohort and 42 /351 (11 %) deaths in the penetrating trauma cohort.

CONCLUSION

AAST grade in isolation is not a good predictor of the need for operation in hepatic trauma. Increasing AAST grade was not found to correlate with increased risk of mortality for both blunt and penetrating hepatic trauma. In both blunt and penetrating trauma, increasing AAST grade is significantly associated with increased bile leak. The need for ERCP and endoscopic sphincterotomy to manage bile leak in our setting is low. Similarly, the rate of rebleeding and of angioembolization was low.

Management of Hemorrhagic Shock: Physiology Approach, Timing and Strategies

Hemorrhagic shock (HS) management is based on a timely, rapid, definitive source control of bleeding/s and on blood loss replacement. Stopping the hemorrhage from progressing from any named and visible vessel is the main stem fundamental praxis of efficacy and effectiveness and an essential, obligatory, life-saving step. Blood loss replacement serves the purpose of preventing ischemia/reperfusion toxemia and optimizing tissue oxygenation and microcirculation dynamics. The "physiological classification of HS" dictates the timely management and suits the 'titrated hypotensive resuscitation' tactics and the 'damage control surgery' strategy. In any hypotensive but not yet critical shock, the body's response to a fluid load test determines the cut-off point between compensation and progression between the time for adopting conservative treatment and preparing for surgery or rushing to the theater for rapid bleeding source control. Up to 20% of the total blood volume is given to refill the unstressed venous return volume. In any critical level of shock where, ab initio, the patient manifests signs indicating critical physiology and impending cardiac arrest or cardiovascular accident, the balance between the life-saving reflexes stretched to the maximum and the insufficient distal perfusion (blood, oxygen, and substrates) remains in a liable and delicate equilibrium, susceptible to any minimal change or interfering variable. In a cardiac arrest by exsanguination, the core of the physiological issue remains the rapid restoration of a sufficient venous return, allowing the heart to pump it back into systemic circulation either by open massage via sternotomy or anterolateral thoracotomy or spontaneously after aorta clamping in the chest or in the abdomen at the epigastrium under extracorporeal resuscitation and induced hypothermia. This is the only way to prevent ischemic damage to the brain and the heart. This is accomplishable rapidly and efficiently only by a direct approach, which is a crush laparotomy if the bleeding is coming from an abdominal +/- lower limb site or rapid sternotomy/anterolateral thoracotomy if the bleeding is coming from a chest +/- upper limbs site. Without first stopping the bleeding and refilling the heart, any further exercise is doomed to failure. Direct source control via laparotomy/thoracotomy, with the concomitant or soon following venous refilling, are the two essential, initial life-saving steps.

Radiographic pneumoperitoneum following abdominal stab wound is not an absolute indication for mandatory laparotomy - A South African experience

INTRODUCTION

Pneumoperitoneum on chest radiograph (CXR) following abdominal stab wounds (SW) is generally considered as surrogate evidence of viscus perforation and an absolute indication for laparotomy. The exact yield of this radiographic finding is unknown.

MATERIALS AND METHODS

A retrospective study was conducted on all patients who presented with abdominal SW with no peritoneal signs but had pneumoperitoneum alone who underwent mandatory laparotomy from December 2012 to October 2020 at a major trauma centre in South Africa.

RESULTS

During the 8-year study period, 55 patients were included (91% male, mean age: 24 years). Laparotomy was positive in 67% (37/55). Of the 37 positive laparotomies, 28 (76%) were considered therapeutic and the remaining 9 (24%) were nontherapeutic. The negative laparotomy rate was 33%. A total of 52 organ injuries were identified at laparotomy in the 37 positive laparotomies. Twenty-five per cent (14/55) of patients experienced complications. The complication rate of the subgroup of 18 patients who had a negative laparotomy was 33% (6/18). Two per cent (1/55) of all 55 patients required intensive care admission. The mean length of hospital stay was 6 days. There were no mortalities in this cohort.

CONCLUSIONS

Pneumoperitoneum alone in patients with no peritoneal signs on initial assessment following abdominal SW cannot be considered an absolute indication for operative exploration. Up to one third of patients have no intra-abdominal injuries. This specific subgroup of patients can potentially be managed by a selective non-operative management approach.

Predicting the Outcome of Non-operative Management of Splenic Trauma in South Africa

INTRODUCTION

We aimed to expand on the global surgical discussion around splenic trauma in order to understand locally and clinically relevant factors for operative (OP) and non-operative management (NOM) of splenic trauma in a South African setting.

METHODS

A retrospective cohort study was performed using 2013-2017 data from the Pietermaritzburg Metropolitan Trauma Service. All adult patients (≥15 years) were included. Those managed with OP or NOM for splenic trauma were identified and analyzed descriptively. Multiple logistic regression analysis identified patients and clinical factors associated with management type.

RESULTS

There were 127 patients with splenic injury. Median age was 29 [19-35] years with 42 (33%) women and 85 (67%) men. Blunt injuries occurred in the majority (81, 64%). Organ Injury Scale (OIS) grades included I (25, 20%), II (43, 34%), III (36, 28%), IV (15, 11%), and V (8, 6%). Nine patients expired. On univariate analysis, increasing OIS was associated with OP management, need for intensive care unit (ICU) admission, and hospital and ICU duration of stay, but not mortality. In patients with a delayed compared to early presentation, ICU utilization (62% vs. 36%, p = 0.008) and mortality (14% vs. 4%, p = 0.03) were increased. After adjusting for age, sex, presence of shock, and splenic OIS, penetrating trauma (adjusted odds ratio, 5.7; 95%CI, 1.7-9.8) and admission lactate concentration (adjusted odds ratio, 1.4; 95%CI 1.1-1.9) were significantly associated with OP compared to NOM (p = 0.002; area under the curve 0.81).

CONCLUSIONS

We have identified injury mechanism and admission lactate as factors predictive of OP in South African patients with splenic trauma. Timely presentation to definitive care affects both ICU duration of stay and mortality outcomes. Future global surgical efforts may focus on expanding non-operative management protocols and improving pre-hospital care in patients with splenic trauma.

Role of conservative management in low energy transfer penetrating shotgun abdominal injuries

Background and aims

Penetrating abdominal trauma can be caused by a variety of weapons which require different management protocols. After a long era of mandatory laparotomy for abdominal gunshot wounds, the concept of selective laparotomy and conservative management in the form of serial observations has been introduced in some centers. This study aims to assess the feasibility and safety of conservative management and close observation of victims of low energy transfer shotgun penetrating abdominal injury.

Methods

A prospective cohort study of hemodynamically stable patients who had sustained low energy transfer shotgun injuries to the abdomen who presented to the surgical emergency department of Cairo University Hospitals from May 2016 to January 2019. They were subjected to a conservative management and follow-up protocol.

Results

A total of 250 patients (167 males and 83 females) were included. The conservative management protocol was successful in 217/250 patients (86.8%), unsuccessful in 22 patients (8.8%) where abdominal exploration was done either open or laparoscopically. Delayed diagnosis of bowel injury occurred in one patient (0.4%). There was one death (0.4%) and abdominal exploration was negative in 10 (4%) patients.

Conclusion

We recommend this conservative protocol for the victims of low energy transfer penetrating shotgun injuries which may save many patients from the morbidities of unnecessary laparotomy. We accept that the injury pattern may not be sufficiently common in many countries to allow comfort with this non-operative approach.

Selective Nonoperative Management of Abdominal Stab Wounds with Isolated Omental Evisceration is Safe: A South African Experience

BACKGROUND AND AIMS

Selective nonoperative management of abdominal stab wound is well established, but its application in the setting of isolated omental evisceration remains controversial. The aim of the study is to establish the role of selective nonoperative management in the setting of isolated omental evisceration.

MATERIALS AND METHODS

A retrospective study was conducted over an 8-year period from January 2010 to December 2017 at a major trauma center in South Africa to determine the outcome of selective nonoperative management.

RESULTS

A total of 405 consecutive cases were reviewed (91% male, mean age: 27 years), of which 224 (55%) cases required immediate laparotomy. The remaining 181 cases were observed clinically, of which 20 (11%) cases eventually required a delayed laparotomy. The mean time from injury to decision for laparotomy was <3 h in 92% (224/244), 3-6 h in 6% (14/244), 6-12 h 2% (4/244), and 12-18 h in 1% (2/244). There was no significant difference between the immediate laparotomy and the delayed laparotomy group in terms of length of stay, morbidity, or mortality. Ninety-eight percent (238/244) of laparotomies were positive and 96% of the positive laparotomies (229/238) were considered therapeutic.

CONCLUSION

Selective nonoperative management for abdominal stab wound in the setting of isolated omental evisceration is safe and does not result in increased morbidity or mortality. Clinical assessment remains valid and accurate in determining the need for laparotomy but must be performed by experienced surgeons in a controlled environment.

Diagnostic laparoscopy or selective non-operative management for stable patients with penetrating abdominal trauma: What to choose?

Background

Selective non-operative management (NOM) and diagnostic laparoscopy (DL) are well-accepted approaches in the management of stable patients with penetrating abdominal trauma (PAT). The aim of this pilot study was to investigate the advantages and disadvantages of early DL in stable asymptomatic or minimally symptomatic patients with PAT as opposed to NOM, a standard of care in this scenario. The secondary aim was to suggest possible indications for DL.

Methods

Patients managed with DL or NOM over a 12-month period were included in this study. The age, gender, mechanism and location of injuries, trauma scores, haemodynamic and metabolic parameters, intraoperative findings and length of hospital stay (LOS) were recorded and correlated with outcomes.

Results

Thirty-six patients were in the NOM group and 35 in the DL group. Stab wounds were more common. The most common location of injury was the anterior abdominal wall in the NOM group and the lower chest in the DL group. Computed tomography (CT) scan was performed more often in the NOM group (75% vs. 17.1%). The injury severity score (ISS), New ISS and PAT Index were higher in the DL group. Nearly 23 (66%) patients in the DL group had a penetration of the peritoneum, but no significant abdominal injuries. LOS in the NOM group was 2 days versus 3.1 days in the DL group. There were no missed injuries, complications or mortality.

Conclusion

NOM is a preferred modality for minimally symptomatic stable patients. However, there is a risk of missed injuries and delayed treatment. DL accurately visualizes injuries, decreases unnecessary CT scans and avoids nontherapeutic laparotomies.

Routine cervical spine immobilisation is unnecessary in patients with isolated cerebral gunshot wounds: A South African experience

OBJECTIVE

Routine immobilisation of the cervical spine in trauma has been a long established practice. Very little is known in regard to its appropriateness in the specific setting of isolated traumatic brain injury secondary to gunshot wounds (GSWs).

METHODS

A retrospective study was conducted over a 5 year period (January 2010 to December 2014) at the Pietermaritzburg Metropolitan Trauma Service, Pietermaritzburg, South Africa in order to determine the actual incidence of concomitant cervical spine injury (CSI) in the setting of isolated cerebral GSWs.

RESULTS

During the 5 year study period, 102 patients were included. Ninety-two per cent (94/102) were male and the mean age was 29 years. Ninety-eight per cent of the injuries were secondary to low velocity GSWs. Twenty-seven (26%) patients had cervical collar placed by the Emergency Medical Service. The remaining 75 patients had their cervical collar placed in the resuscitation room. Fifty-five (54%) patients had a Glasgow Coma Scale (GCS) of 15 and underwent plain radiography, all of which were normal. Clearance of cervical spine based on normal radiography combined with clinical assessment was achieved in all 55 (100%) patients. The remaining 47 patients whose GCS was <15 all underwent a computed tomography (CT) scan of their cervical spine and brain. All 47 CT scans of the cervical spine were normal and there was no detectable bone or soft tissue injury noted.

CONCLUSION

Patients who sustain an isolated low velocity cerebral GSW are highly unlikely to have concomitant CSI. Routine cervical spine immobilisation is unnecessary, and efforts should be directed at management strategies aiming to prevent secondary brain injury. Further studies are required to address the issue in the setting of high velocity GSWs.

Developing a simplified clinical prediction score for mortality in patients with cerebral gunshot wounds: The Maritzburg Score

Introduction Cerebral gunshot wounds are highly lethal and literature on the clinical scores for mortality prediction is limited. Materials and methods A retrospective study was undertaken over a 5-year period at the Pietermaritzburg Metropolitan Trauma Service in South Africa. A simplified clinical prediction score was developed based on clinical and/or physiological variables readily available in the resuscitation room. Results A total of 102 patients were included; 92% (94/102) were male and the mean age was 29 years; 22% (22/102) died during the admission. The presence of visible brain matter (odds ratio 12.4, P = 0.003) and motor score less than 5 (odds ratio 89.6, P  < 0.001) allows the prediction success of 92% (sensitivity 73% and specificity 98%). The area under the receiver operating characteristic curve was 94% (95% confidence interval 88-100%, P  < 0.001). Conclusions The presence of visible brain matter, together with a motor score of less than 5, allows accurate identification of non-survivors of cerebral gunshot wounds. Further study is required to validate this score.

The correlation between ATLS and junior doctors' anatomical knowledge of central venous catheter insertion at a major trauma centre in South Africa

OBJECTIVE

To review the ability of junior doctors (JDs) in identifying the correct anatomical site for central venous catheterization (CVC) and whether prior Advanced Trauma Life Support (ATLS) training influences this.

DESIGN

We performed a prospective, observational study using a structured survey and asked a group of JDs (postgraduate year 1 [PGY1] or year 2 [PGY2]) to indicate on a photograph the exact site for CVC insertion via the internal jugular (IJV) and the subclavian (SCV) approach. This study was conducted in a large metropolitan university hospital in South Africa.

RESULTS

A total of 139 JDs were included. Forty-four per cent (61/139) were males and the mean age was 25 years. There were 90 PGY1s (65%) and 49 PGY2s (35%). Overall, 32% (45/139) were able to identify the correct insertion site for the IJV approach and 60% (84/139) for the SCV approach. Of the 90 PGY1s, 34% (31/90) correctly identified the insertion site for the IJV approach and 59% (53/90) for the SCV approach. Of the 49 PGY2s, 29% (14/49) correctly identified the insertion site for the IJV approach and 63% (31/49) for the SCV approach. No significant difference between PGY1 and 2 were identified. Those with ATLS provider training were significantly more likely to identify the correct site for the IJV approaches [OR=4.3, p=0.001]. This was marginally statistically significant (i.e. p>0.05 but <0.1) for the SCV approach.

CONCLUSIONS

The majority of JDs do not have sufficient anatomical knowledge to identify the correct insertion site CVCs. Those who had undergone ATLS training were more likely to be able to identify the correct insertion site.

Selective non-operative management of abdominal stab wounds is a safe and cost effective strategy: A South African experience

INTRODUCTION Selective non-operative management (SNOM) of abdominal stab wounds is well established in South Africa. SNOM reduces the morbidity associated with negative laparotomies while being safe. Despite steady advances in technology (including laparoscopy, computed tomography [CT] and point-of-care sonography), our approach has remained clinically driven. Assessments of financial implications are limited in the literature. The aim of this study was to review isolated penetrating abdominal trauma and analyse associated incurred expenses. METHODS Patients data across the Pietermaritzburg Metropolitan Trauma Service (PMTS) are captured prospectively into the regional electronic trauma registry. A bottom-up microcosting technique produced estimated average costs for our defined clinical protocols. RESULTS Between January 2012 and April 2015, 501 patients were treated for an isolated abdominal stab wound. Over one third (38%) were managed successfully with SNOM, 5% underwent a negative laparotomy and over half (57%) required a therapeutic laparotomy. Over five years, the PMTS can expect to spend a minimum of ZAR 20,479,800 (GBP 1,246,840) for isolated penetrating abdominal stab wounds alone. CONCLUSIONS Provided a stringent policy is followed, in carefully selected patients, SNOM is effective in detecting those who require further intervention. It minimises the risks associated with unnecessary surgical interventions. SNOM will continue to be clinically driven and promulgated in our environment.

Civilian cerebral gunshot wounds in rural South African patients are associated with significantly higher mortality rates than in urban patients

INTRODUCTION

This study focuses on a specific and often dramatic injury, namely gunshot wounds (GSW) of the head in order to determine whether there is a discrepancy in outcome between patients who sustain their injury in a rural setting and those who sustain it in an urban setting.

MATERIALS AND METHODS

This study involves a retrospective review of our prospectively maintained regional electronic trauma registry. All patients who sustained a cerebral GSW from January 2010 to December 2014 were reviewed.

RESULTS

During the 5-year study period, a total of 102 patients sustained an isolated cerebral GSW. Ninety-two per cent (94/102) were male and the mean age was 29 years. Ninety-four per cent (94/102) of injuries were related to interpersonal violence. Of the 102 patients in the study, 54% (55/102) were urban and were transported directly to our trauma centre. The remaining 46% (47/102) were rural and were transported to a rural district hospital prior to being referred to our trauma centre. The time of injury was available in 60% (61/102) of patients. The mean time from injury to arrival for all patients was 11 h (SD 7). The mean time from injury to arrival was significantly shorter for urban versus rural, 6 h (SD 5) and 15 h (SD 5), respectively (p < 0.001). The median admission GCS score was significantly lower in rural compared to urban patients (p = 0.022). The need for neurosurgery, need for ICU admission or length of hospital stay was not significantly different between rural and urban patients. Rural patients have a fourfold higher mortality compared with urban patients (36 vs 9%, p = 0.001). Amongst survivors, there was no significant difference in median length of hospital stay or mean discharge GCS.

CONCLUSIONS

Cerebral GSWs are highly lethal injuries associated with significant mortality. Rural patients have a significantly longer transfer time, lower GCS on arrival and higher mortality than urban patients. Efforts should be directed at improving the pre-hospital EMS system in order to reduce delay to definitive care so that patient outcome can be optimised.

Prevalence, management and outcome of traumatic diaphragm injuries managed by the Pietermaritzburg Metropolitan Trauma Service

INTRODUCTION This audit of traumatic diaphram injury (TDI) from a busy South African trauma service reviews the spectrum of disease and highlights current approaches to these injuries. METHODS The Pietermaritzburg Metropolitan Trauma Service (PMTS) has maintained an Electronic Surgical Registry (ESR) and a Hybrid Electronic Medical Record (HEMR) system since January 1st 2012. RESULTS A total of 105 TDIs were identified and repaired during the study period. The mean patient age was 30 years (range 15-68 years - SD 9.7). The majority (92.4%) of patients were male (97/105). Penetrating trauma was the leading mechanism of injury (94%). 75 patients sustained a TDI from a stab wound, and the remaining 24 injuries resulted from gunshot wounds. Multiple associated injuries and high morbidity was seen with right diaphragm injury, blunt trauma, gunshot wounds and chronic diaphragmatic hernias. CONCLUSIONS TDI is a fairly uncommon injury with a local incidence of 1.6%. It presents in a spectrum from the obvious to the occult. Multiple associated injuries and high morbidity occur following blunt trauma or gunshot wounds, right diaphragm injury and chronic diaphragmatic hernias. Diagnostic laparoscopy offers a diagnostic and therapeutic tool to prevent progression of occult TDI to chronic diaphragmatic hernias.

Traumatic diaphragmatic injuries: a retrospective review of a 12-year experience at a tertiary trauma centre

INTRODUCTION

Traumatic diaphragmatic injuries (TDIs) are clinically challenging. We aimed to review TDIs treated at a tertiary trauma centre over a 12-year period.

METHODS

This was a single-centre retrospective review of adult patients with TDIs treated between 1 January 2003 and 31 December 2014. Primary outcomes were mortality rates and Injury Severity Scores (ISS) associated with each TDI subtype. Secondary outcomes included proportions of TDIs diagnosed radiologically, operatively or during autopsy. We compared the TDI subtypes with respect to mechanism of injury, mortality rates and median ISS. Data was analysed using descriptive statistics.

RESULTS

Among 46 patients studied, the TDI subtypes noted were acute diaphragmatic herniation (n = 14, 30.4%), tears (n = 22, 47.8%) and contusions (n = 10, 21.7%). Patients with these TDI subtypes had a mortality rate of 35.7%-100%, while the ISS ranges for survivors and deaths were 22.0-34.0 (interquartile range [IQR] 6.5-23.0) and 53.5-66.0 (IQR 16.0-28.5), respectively. TDIs were identified via chest radiography (n = 2/33, 6.1%) and computed tomography (n = 6/13, 46.2%). All survivors (n = 21) and deaths (n = 25) underwent open surgery or autopsy, respectively, which confirmed TDIs. Blunt traumas and penetrating traumas were more frequently associated with acute herniation/contusions and tears, respectively. There were statistically significant differences among the TDI subtypes in their mechanism of injury, mortality rate and median ISS of survivors.

CONCLUSION

TDIs showed varying injury patterns with blunt versus penetrating mechanisms of injury, and were associated with significant mortality rates. Preoperative imaging had limited diagnostic use.

Feasibility of selective non-operative management for penetrating abdominal trauma in France

INTRODUCTION

In France, non-operative management (NOM) is not the widely accepted treatment for penetrating wounds. The aim of our study was to evaluate the feasibility of NOM for the treatment of penetrating abdominal traumas at 3 hospitals in the Southeast of France.

METHODOLOGY

Our study was multicentric and retroprospective from January, 2010 to September, 2013. Patients presenting with a penetrating abdominal stab wound (SW) or gunshot wound (GSW) were included in the study. Those with signs of acute abdomen or hemodynamic instability had immediate surgery. Patients who were hemodynamically stable had a CT scan with contrast. If no intra-abdominal injury requiring surgery was evident, patients were observed. Criteria evaluated were failed NOM and its morbidity, rate of non-therapeutic procedures (NTP) and their morbidity, length of hospital stay and cost analysis.

RESULTS

One hundred patients were included in the study. One patient died at admission. Twenty-seven were selected for NOM (20 SW and 7 GSW). Morbidity rate was 18%. Failure rate was 7.4% (2 patients) and there were no mortality. Seventy-two patients required operation of which 22 were NTP. In this sub-group, the morbidity rate was 9%. There were no mortality. Median length of hospital stay was 4 days for the NOM group and 5.5 days for group requiring surgery. Cost analysis showed an economic advantage to NOM.

CONCLUSION

Implementation of NOM of penetrating trauma is feasible and safe in France. Indications may be extended even for some GSW. Clinical criteria are clearly defined but CT scan criteria should be better described to improve patient selection. NOM reduced costs and length of hospital stay.

Laparoscopy for Occult Left-sided Diaphragm Injury Following Penetrating Thoracoabdominal Trauma is Both Diagnostic and Therapeutic

INTRODUCTION

The diagnosis of occult traumatic diaphragm injury (TDI) has posed a dilemma to trauma surgeons. No imaging modality can accurately and conclusively identify small defects in the integrity of the diaphragm following penetrating trauma. Diagnostic laparoscopy (DL) offers a minimally invasive method of evaluating the integrity of the diaphragm.

METHODS

An Electronic Surgical Registry (ESR) and a Hybrid Electronic Medical Record (HEMR) system have been maintained within the Pietermaritzburg Metropolitan Trauma Service since January 1, 2012. The study was conducted between 2 hospitals located in Pietermaritzburg, KwaZulu Natal, South Africa, namely, Greys (tertiary) and Edendale (regional). Patient data were entered into the registries at the end of patient care (discharge, interhospital transfer, or death). The registries were interrogated to retrieve all cases of DL performed for left-sided penetrating thoracoabdominal trauma.

RESULTS

A total of 96 patients underwent semielective DL following penetrating left-sided thoracoabdominal trauma. This included 94 stab wounds and 2 gunshot wounds. The mean patient age was 29 years (range, 15 to 68 y, SD=8.8). The majority (59/96) of patients were male. Twenty-two (23% incidence) cases of TDI were identified at DL. Eighteen (82%) were repaired laparoscopically, and the remaining 4 required conversion to laparotomy and open repair.

CONCLUSIONS

TDI presents in a spectrum from the obvious to the occult. Our results validate the utilization of DL as a minimally invasive intervention for both the diagnosis and repair of TDI in selected patients presenting with penetrating left-sided thoracoabdominal trauma.

The management of colonic trauma in the damage control era

INTRODUCTION The purpose of this study was to audit our current management of colonic trauma, and to review our experience of colonic trauma in patients who underwent initial damage control (DC) surgery. METHODS All patients treated for colonic trauma between January 2012 and December 2014 by the Pietermaritzburg Metropolitan Trauma Service were included in the study. Data reviewed included mechanism of injury, method of management (primary repair [PR], primary diversion [PD] or DC) and outcome (complications and mortality rate). Results A total of 128 patients sustained a colonic injury during the study period. Ninety-seven per cent of the injuries were due to penetrating trauma. Of these cases, 56% comprised stab wounds (SWs) and 44% were gunshot wounds (GSWs). Management was by PR in 99, PD in 20 and DC surgery in 9 cases. Among the 69 SW victims, 57 underwent PR, 9 had PD and 3 required a DC procedure. Of the 55 GSW cases, 40 were managed with PR, 9 with PD and 6 with DC surgery. In the PR group, there were 16 colonic complications (5 cases of breakdown and 11 of wound sepsis). Overall, nine patients (7%) died. CONCLUSIONS PR of colonic trauma is safe and should be used for the majority of such injuries. Persistent acidosis, however, should be considered a contraindication. In unstable patients with complex injuries, the optimal approach is to perform DC surgery. In this situation, formal diversion is contraindicated, and the injury should be controlled and dropped back into the abdomen at the primary operation. At the repeat operation, if the physiological insult has been reversed, then formal repair of the colonic injury is acceptable.

Selective conservatism in the management of thoracic trauma remains appropriate in the 21st century

INTRODUCTION

Selective conservatism for thoracic trauma is well established but the emergence of new technologies may cause management strategies to continue to evolve.

METHODS

A retrospective study was conducted on thoracic trauma patients managed in a single institution in South Africa over a 4-year period to determine the appropriateness of our current policy of selective conservatism.

RESULTS

A total of 1,239 patients were included in the study; 112 required an emergency thoracotomy, 125 were admitted for observation and 1,002 required a tube thoracostomy (TT). Ninety-one per cent of the patients were male and the median age was 24 years. Seventy-five per cent of the cases were penetrating trauma and the remaining were blunt trauma. The indications for TT were pneumothorax (PTX) (n=382, 38%), haemothorax (HTX) (n=300, 30%) and haemopneumothorax (HPTX) (n=320, 32%). A total of 13% (127/1,002) of all chest x-rays (CXR) following tube removal demonstrated residual pathologies that precluded immediate discharge: 32 (8%) in Group A (PTX), 44 (15%) in Group B (HTX) and 51 (16%) in Group C (HPTX). All 32 patients in Group A were simply observed and did not require further intervention. In Group B, 17 patients required repeat TTs and 27 required video assisted thoracoscopic surgery (VATS) for clearance of residual HTX. Twenty-nine patients in Group C required repeat TTs and twenty-two required VATS.

CONCLUSIONS

The vast majority of patients with thoracic trauma can be managed conservatively with TT alone. Residual pathology appeared to be lowest in patients with a PTX, which seldom requires treatment, while only a minority of patients required repeat TTs or VATS for a retained HTX. Selective conservatism is still appropriate in the current era in a developing world setting.

Selective non-operative management of stab wounds to the posterior abdomen is safe: the Pietermaritzburg experience

INTRODUCTION

The selective non-operative management (SNOM) of stab injuries of the anterior abdomen is well established, but its application to the posterior abdomen remains controversial.

MATERIALS AND METHODS

A retrospective review of 1013 patients was undertaken at a major trauma service in South Africa over a five-year period.

RESULTS

Ninety per cent of patients were males, and the mean age was 25 years. The mean time from injury to presentation was 4h and 73% of all injuries were inflicted by knives. A total of 9% (93) of patients required a laparotomy [Group A] and 82% (833) were successfully observed without the need for operative intervention [Group B]. CT imaging was performed on 52 patients (5%) who had haematuria [Group C], 25 (3%) who had neurological deficits [Group D], and 10 (1%) with retained weapon injuries [Group E]. The accuracy of physical examination for identifying the presence of organ injury was 88%. All observed patients who required laparotomy declared themselves within 24h. There were no mortalities as direct result of our current management protocol.

CONCLUSIONS

Selective management based on active clinical observation and serial physical examination is safe, and when coupled with the judicious use of advanced imaging, is a prudent and reliable approach in a resource constrained environment.

The spectrum of injuries resulting from posterior abdominal stab wounds: a South African experience

INTRODUCTION

The spectrum of injury associated with anterior abdominal stab wounds (SWs) is well established. The literature on the spectrum of organ injury associated with SWs to the posterior abdomen, however, is limited.

METHODS

We reviewed our experience of 105 consecutive patients who had established indications for laparotomy managed over a 4-year period in a high volume trauma service in South Africa.

RESULTS

Of the 105 patients, 97 (92%) were male and the overall mean age was 24 years. Fifty-seven patients (54%) had immediate indications for laparotomy. The remaining 48 patients (46%) initially underwent active clinical observation and the indications for laparotomy became apparent during the observation period. Of the 105 laparotomies performed, 94 (90%) were positive and 11 (10%) were negative. Of the 94 positive laparotomies, 92 were therapeutic and 2 were non-therapeutic. A total of 176 organ injuries were identified: 50 (53%) of the 94 patients sustained a single organ injury while the remaining 44 (47%) sustained multiple organ injuries. The most commonly injured organs were the colon (n=63), spleen (n=21) and kidney (n=19).

CONCLUSIONS

The pattern of intra-abdominal injuries secondary to SWs to the posterior abdomen is different to that seen with the anterior abdomen. Colonic injury is most commonly encountered, followed by injuries to the spleen and kidney. Clinicians must remain vigilant because of the potential for occult injuries.

Correlation between ATLS training and junior doctors' anatomical knowledge of intercostal chest drain insertion

OBJECTIVE

To review the ability of junior doctors (JDs) in identifying the correct anatomical site for intercostal chest drain insertion and whether prior Advanced Trauma Life Support (ATLS) training influences this.

DESIGN

We performed a prospective, observational study using a structured survey and asked a group of JDs (postgraduate year 1 [PGY1] or year 2 [PGY2]) to indicate on a photograph the exact preferred site for intercostal chest drain insertion.

SETTING

This study was conducted in a large metropolitan university hospital in South Africa.

RESULTS

A total of 152 JDs participated in the study. Among them, 63 (41%) were men, and the mean age was 24 years. There were 90 (59%) PGY1 doctors and 62 (41%) PGY2 doctors. Overall, 28% (42/152) of all JDs correctly identified the site that was located within the accepted safe triangle. A significantly higher proportion of PGY2 doctors selected the correct site when compared with PGY1 doctors (39% vs 20%, p = 0.026). Those who had prior ATLS provider training were 6.8 times more likely to be able to identify the correct site (RR = 6.8, 95% CI: 3.7-12.5).

CONCLUSIONS

Most of the JDs do not have sufficient anatomical knowledge to identify the safe insertion site for intercostal chest drain. Those who had undergone ATLS training were more likely to be able to identify the safe insertion site.

Understanding the burden and outcome of trauma care drives a new trauma systems model

BACKGROUND

The Pietermaritzburg Metropolitan Trauma Service (PMTS) attempts to provide care for a whole city and hence is referred to as a service rather than a center. As part of a multifaceted quality improvement program, the PMTS has developed and implemented a robust electronic surgical registry (ESR). This review of the first year's data from the ESR forms part of a situational analysis to assess the burden of trauma managed by the service and the quality of care delivered within the constraints of the available resources.

METHODS

Formal ethical approval was obtained prior to design and development of this study, and appropriate commercial software was sourced. The exercise of data capture was integrated into the process of service delivery and was accomplished at the endpoint of patient care. 12 months after implementation of the registry, the data were extracted and audited.

RESULTS

A total of 2,733 patients were admitted over the 12 month study period. The average patient age was 28.3 years. There were 2,255 (82.5 %) male patients and 478 (17.5 %) female patients. The average monthly admission rate was 228 patients, with a peak of 354 admissions over the December period. The mean injury severity score (ISS) was 12 [interquartile range (IQR) 6.7-23.2]. A quarter (24.8 %) of all new emergency admissions had an ISS > 15. The average duration of stay for patients was 5.12 days (IQR 2.3-13.2 days). Some 2,432 (92.1 %) patients survived, and 208 (7.9 %) died. A total of 333 (13 %) patients required admission to either the intensive care unit (ICU) or the high dependency unit. From the city mortuary data a further 362 deaths were identified. These included 290 deaths that occurred on scene and 72 that occurred within Pietermaritzburg hospitals other than Greys and Edendale. The total trauma-related mortality for the entire city in 2012 was 570 (51 % on-scene deaths and 49 % in-hospital deaths). Blunt trauma accounted for 62 % of deaths.

CONCLUSIONS

The PMTS treats a significant volume and spectrum of trauma. Despite significant resource limitations, we have managed to implement a functional and sustainable trauma service across multiple hospitals. We believe the major resource deficits limiting our service could be ameliorated by the development of an additional trauma facility, adequately equipped with dedicated trauma operating slates and trauma ICU beds. The adoption of our current model of trauma care came out of a need to work within our resource constraints, and it differs from the traditional model. Within the aforementioned limits, our data suggest that this model of delivering care is feasible, practical, and successful. Considering the universal burden of trauma and the all-too-common imbalance between resource demand and supply among many health-care institutions, it is our hope that this report will contribute to the ongoing academic debate around the topic of optimal systems of providing global trauma care.

What is the yield of routine chest radiography following tube thoracostomy for trauma?

INTRODUCTION

Routine chest radiography (CXR) following tube thoracostomy (TT) is a standard practice in most trauma centres worldwide. Evidence supporting this routine practice is lacking and the actual yield is unknown.

MATERIALS AND METHODS

We performed a retrospective review of 1042 patients over a 4-year period who had a routine post-insertion CXR performed in accordance with current ATLS® recommendations.

RESULTS

A total 1042 TTs were performed on 1004 patients. Ninety-one per cent of patients (913/1004) were males, and the median age for all patients was 24 years. Seventy-five per cent of all injuries (756/1004) were from penetrating trauma, and the remaining 25% (248/1004) were from blunt. The initial pathologies requiring TT were: haemopneumothorax: 34% (339/1042), haemothroax: 31% (314/1042), simple pneumothorax: 25% (256/1042), tension pneumothorax: 8% (77/1042) and open pneumothorax: 5% (54/1042). One hundred and three patients had TTs performed on clinical grounds alone without a pre-insertion CXR [Group A]. One hundred and ninety-one patients had a pre-insertion CXR but had persistent clinical concerns following insertion [Group B]. Seven hundred and ten patients had pre-insertion CXR but no clinical concerns following insertion [Group C]. Overall, 15% (152/1004) [9 from Group A, 111 from Group B and 32 from Group C] of all patients had their clinical management influenced as a direct result of the post-insertion CXR.

CONCLUSIONS

Despite the widely accepted practice of routine CXR following tube thoracostomy, the yield is relatively low. In many cases, good clinical examination post tube insertion will provide warnings as to whether problems are likely to result. However, in the more rural setting, and in resource challenged environments, there is a relatively high yield from the CXR, which alters management. Further prospective studies are needed to establish or refute the role of the existing ATLS® guidelines in these specific environments.

The selective conservative management of penetrating thoracic trauma is still appropriate in the current era

INTRODUCTION

Traumatic pleural collections secondary to penetrating chest trauma are generally managed by intercostal chest drainage (ICD), but these protocols were developed a few decades ago when stabs (SWs) predominated over gunshot wounds (GSWs). This study reviews the outcome of a selective conservative approach to penetrating thoracic trauma to establish if it is still appropriate in the current era.

MATERIALS AND METHODS

We reviewed 827 patients over a four-year period with penetrating unilateral non-cardiac wounds of the chest in order to review the efficacy of our policy and to define the differences in the spectrum of injury between SWs and GSWs.

RESULTS

Ninety-two per cent (764/827) were males, and the median age was 24 years. Seventy-six per cent (625/827) sustained SWs and twenty-four per cent (202/827) GSWs. Chest pathologies were: pneumothorax (PTX): 362 (44%), haemothorax (HTX): 150 (18%) and haemopneumothorax (HPTX): 315 (38%). Ninety-six per cent of patients were managed non-operatively. Four per cent (36/827) were subjected to a thoracotomy [31 SWs and 5 GSWs]. No difference was observed in terms of the need for operative intervention: 5% vs. 3% [p=0.202]. PTX was seen exclusively in SWs: 58% vs. 0% and there were significantly more HPTXs seen in the GSWs: HPTX: 24% vs. 81% [p<0.001]. The median days of ICD in situ were significantly longer in GSWs compared to SWs for all pathologies. For HTX: 4.5 (interquartile range [IQR]: 3-6) vs. 3.5 (IQR: 0-5) days, p=0.001 and HPTX: 4 (IQR: 3-5) vs. 3.0 (IQR: 3-4) days, p<0.001. There were seven (15%) complications. A total of five (13%) patients died and all deaths were confined to the operative group.

CONCLUSIONS

SWs continue to predominate over GSWs. PTXs were more commonly associated with SWs, whilst HPTX are more commonly associated with GSWs. A policy of selective conservatism is still applicable to the management of traumatic pleural collections.

Penetrating cardiac injuries and the evolving management algorithm in the current era

BACKGROUND

Penetrating cardiac injuries carry a significant mortality, especially if operative intervention is delayed because of diagnostic difficulties.

METHODS AND MATERIALS

We reviewed our experience of 134 consecutive cases over a 6 year period. For the initial 5 years, the diagnosis was based on clinical grounds only. During the final year of study, focused ultrasound focused abdominal sonar for trauma (FAST) and subxiphoid pericardial window were introduced.

RESULTS

Ninety-six per cent (128/134) were males and the overall mean age was 27 y. Eighty-four per cent (112/134) sustained isolated cardiac injury and the remaining sixteen per cent (22/134) had concurrent injuries elsewhere. A total of 10 FAST's were performed and the sensitivity was 20%. Fifteen subxiphoid pericardial window were performed (8 had diagnostic uncertainty, 2 with double jeopardy, and 5 with delayed tamponade) and had a sensitivity of 100%. The survival rate for the 109 patients from the pre-adjunct period was 83% and 88% for the 25 patients in the post-adjunct period, which was not statistically significant (P value = 0.765). There was no significant difference in the complication rate, mean intensive care unit stay, or mean total hospital stay.

CONCLUSIONS

Penetrating cardiac injuries are highly lethal. A high index of suspicion, coupled with early operative intervention remains the key in securing the survival of these patients.

Selective non operative management of gunshot wounds to the abdomen: a collective review

BACKGROUND

Over the past four decades there has been a shift from operative to selective conservatism in trauma. Selective nonoperative management (SNOM) of stab wounds to the abdomen is widely accepted in trauma centres. However, selective conservatism with gunshot wounds to the abdomen is controversial. This collective review assesses the evidence of SNOM of gunshot wounds to the abdomen.

METHODS

A Medline search between 1 January 1960 and 31 July 2013 was conducted identifying studies that investigated SNOM of gunshot wounds to the abdomen. Case reports, review articles and editorials were excluded. All other studies that investigated SNOM of gunshot wounds to the abdomen and its outcomes were included.

RESULTS

A total of 37 studies were included of which 22 were prospective, 14 were retrospective and 1 case series. A total of 21330 patients with gunshot wounds to the abdomen were included, of which 6468 (30.3%) were managed nonoperatively. Successful SNOM was possible in 5510 (85.18%) patients and 958 (14.8%) failed SNOM and underwent delayed laparotomies. SNOM reduces rates of non-therapeutic laparotomies and the associated morbidity. Special aspects reviewed include the prehospital and nursing involvement in this modality of care.

CONCLUSIONS

Current evidence supports SNOM of gunshot wounds to the abdomen. It is associated with a decreased rate of non therapeutic laparotomy. Careful patient selection and specially designed protocols should be established and adhered to.

Current management of penetrating torso trauma: nontherapeutic is not good enough anymore

A highly organized approach to the evaluation and treatment of penetrating torso injuries based on regional anatomy provides rapid diagnostic and therapeutic consistency. It also minimizes delays in diagnosis, missed injuries and nontherapeutic laparotomies. This review discusses an optimal sequence of structured rapid assessments that allow the clinician to rapidly proceed to gold standard therapies with a minimal risk of associated morbidity.

Abdominal trauma in durban, South Africa: factors influencing outcome

Abdominal injury as a result of both blunt and penetrating trauma has an appreciable mortality rate from hemorrhage and sepsis. In this article, we present our experience with the management of abdominal trauma in Durban and investigate factors that influence outcome. We performed a prospective study of patients with abdominal trauma in one surgical ward at King Edward VIII Hospital in Durban over a period of 7 years, from 1998 through 2004. Demographic details, cause of injury, delay before surgery, clinical presentation, findings at surgery, management and outcome were documented. There were 488 patients with abdominal trauma with a mean age of 29.2 ± 10.7 years. There were 440 penetrating injuries (240 firearm wounds; 200 stab wounds) and 48 blunt injuries. The mean delay before surgery was 11.7 ± 16.4 hours, and 55 patients (11%) presented in shock. Four hundred and forty patients underwent laparotomy, and 48 were managed nonoperatively. The Injury Severity Score was 11.1 ± 6.7, and the New Injury Severity Score was 17.1 ± 11.1. One hundred and thirty-seven patients (28%) were admitted to the intensive care unit (ICU), with a mean ICU stay of 3.6 ± 5.5 days. One hundred and thirty-two patients developed complications (28%), and 52 (11%) died. Shock, acidosis, increased transfusion requirements, number of organs injured, and injury severity were all associated with higher mortality. Delay before surgery had no influence on outcome. Hospital stay was 9.2 ± 10.8 days. The majority of abdominal injuries in our environment are due to firearms. Physiological instability, mechanism of injury, severity of injury, and the number of organs injured influence outcome.

A multi faceted quality improvement programme results in improved outcomes for the selective non-operative management of penetrating abdominal trauma in a developing world trauma centre

INTRODUCTION

The selective non-operative management (SNOM) of penetrating abdominal trauma (PAT) is well established in our environment. As a quality-improvement initiative, we aimed to re-evaluate patient outcomes with PAT. This follows the application of new imaging and diagnostic modalities using protocolised management algorithms.

METHODOLOGY

A prospectively maintained digital registry was retrospectively interrogated and all patients with PAT treated by our service from January 2012 to March 2013 were included in this study.

RESULTS

A total of 325 patients sustained PAT during the fourteen-month study period. This included 238 SWs, 80 GSWs and 7 impalement injuries. 11 patients had eviscerated bowel, and 12 had eviscerated omentum. A total of 123 patients (38%) were selected for a trial of SNOM. This included 103 SWs, 15 GSWs and 5 impalement injuries. Emergency laparotomy was performed on 182 patients (115 SWs, 65 GSWs and 2 impalement injuries) and 21 patients with left sided thoraco-abdominal SWs underwent definitive diagnostic laparoscopy (DL). SNOM was successful in 122 cases (99%) and unsuccessful in one case (1%). In the laparotomy group 161 (88%) patients underwent a therapeutic procedure, in 12 cases (7%) the laparotomy was non-therapeutic and in 9 cases (5%) the laparotomy was negative. In the laparoscopy group (24), two patients required conversion for colonic injuries and one for equipment failure. Seven (33.3%) laparoscopies were therapeutic with the identification and intra-corporeal repair of seven left hemi-diaphragm injuries.

CONCLUSION

We have improved our results with the SNOM of PAT and have also managed to safely and successfully extend the role of SNOM to abdominal GSWs. We have selectively adopted newer modalities such as laparoscopy to assess stable patients with left thoraco-abdominal SWs and abdominal CT scan for the SNOM of abdominal GSWs.

Comparison of conservative management and laparotomy in the management of stable patients with abdominal stab wound

INTRODUCTION

The management of the hemodynamically stable patients with penetrating abdominal stab wounds is a problematic issue among trauma surgeons.

METHODS

In a retrospective study, we analyzed stable patients with anterior abdominal stab wound from August 2009 to 2010. The patients who were hemodynamically unstable or had developed peritonitis were excluded. In our center, the patients are treated through conservative or operative management depending on the protocol of management of the stable penetrating abdominal stab wound in our center. We compared the effectiveness, mean duration of hospital admission, and the time of starting diet in 2 groups.

RESULTS

There were 99 cases including 47 patients in the conservative group and 52 in the laparotomy group. The laparotomy was negative in 73% and positive in 27% of the patients. In the conservative group, all the patients remained asymptomatic and stable except for 6 patients who needed subsequent laparotomy. The maximum period between admission and delayed laparotomy in these 6 patients was 17 hours. The mean length of hospital stay and the time of starting diet were 70.4 vs 43 hours and 42.3 vs 30.6 hours in the operative group and conservative group, respectively. P < .05 was considered significant.

CONCLUSION

Our study showed that conservative management of asymptomatic and stable patients with anterior abdominal stab wound with physical examination can decrease the rate of normal laparotomy and the length of hospitalization and help to start diet earlier. This study made this hypothesis that after 17 hours of observation, diet can be started for the stable asymptomatic patients.

An audit of failed non-operative management of abdominal stab wounds

Selective non-operative management based on clinical assessment has been shown to be a generally safe approach in the management of penetrating stab wounds of the torso. However there will be a subset of patients who fail selective non-operative management. This audit focuses on the failures.

METHODS

The metropolitan surgical service in Pietermaritzburg covers 3 hospitals. At the weekly metropolitan morbidity and mortality meeting all trauma patients are reviewed. All cases of failed selective non-operative management of penetrating abdominal stab wounds are discussed. Failed non-operative management is usually defined as any patient who ultimately requires surgical exploration. We do not subscribe to this as we feel as long as the need for surgical intervention is recognised within a short period of time (<12h) there is little additional morbidity. Recognition of the need for surgical intervention after 12h would be regarded by us as failed non-operative management as we feel the risk of delay associated morbidity begins to increase significantly after this time.

RESULTS

A total of 340 patients with a penetrating anterior abdominal stab wound were managed over the 2 year period under review. A total of 192 (56%) of these patients were subjected to mandatory laparotomy. Of these mandatory laparotomies 98% were positive. The remaining 148 (44%) patients were observed. Of the 148 observed patients a total of 30 (20%) subsequently underwent surgery. A total of 13 patients were only taken to surgery after 12h of observation. In this group of 13 patients the average delay between admission and recognition of injury was 40 h. There were six gastric injuries, one pyloric and pancreatic injury, two gallbladder injuries, one liver, one colon and two small bowel injuries. There were no deaths. 9 patients recovered with no additional morbidity. In the remainder, morbidity included, relaparotomy (1), open abdomen (1), renal failure (1) and prolonged stay in ICU (3).

CONCLUSION

Clinical assessment accurately predicts the need for mandatory laparotomy following a stab wound to the torso. In patients who do not meet the indications for mandatory laparotomy and who are subjected to non-operative management 20% will come to surgery. A subgroup may only be recognised as requiring surgery after more than 12h. These patients are at risk of delay associated morbidity. There are particular anatomical sites and structures which are prone to error.

The spectrum of diaphragmatic injury in a busy metropolitan surgical service

INTRODUCTION

The diaphragm may be injured by penetrating or blunt trauma. Diaphragmatic breach without visceral injury or herniation may be difficult to detect due to a paucity of clinical signs and herniation may be misdiagnosed following the erroneous interpretation of chest radiology. If not recognized there is a considerable risk of late morbidity and mortality. This prospective study reviews our experience with diaphragmatic injury in a busy general surgical service with a large trauma component.

METHODOLOGY

A trauma database is maintained by the general surgical service of the Pietermaritzburg metropolitan complex. All patients who sustained a diaphragmatic injury between September 2006 and September 2007 were included in this study.

RESULTS

A total of 54 patients with diaphragmatic injury were treated in the period under review. There were three broad groups, namely those with simple breach of the diaphragm (37), acute diaphragmatic hernias (11) and chronic diaphragmatic hernias (6). Thirty-seven patients had a diaphragmatic breach confirmed at either laparotomy or laparoscopy. The mechanisms of injury were stab (24), gunshot wound (10), blunt trauma (2), and shotgun (1). There were seven (19%) deaths. In 19 asymptomatic patients laparoscopy was performed because of the presence of a stab wound to the left thoraco-abdominal region. Five (38%) of these patients were shown to have a diaphragmatic breach at laparoscopy. Eleven patients presented with an acute diaphragmatic hernia. The mechanisms of injury were stab (5), blunt trauma (5), and gunshot (1). The hernia contents were stomach (10), colon (1), and spleen (2). The operative approach was a laparotomy in 10 patients and a thoraco-laparotomy in one. Six patients presented with a chronic diaphragmatic hernia of longer than six months duration. The mechanisms of injury were stab (4), blunt trauma (1) and gunshot wound (1). The average delay from injury to presentation was 3.5 years. The contents were colon (3) and stomach (3). All were managed by laparotomy.

CONCLUSION

If there is an established indication for laparotomy diaphragmatic breach is usually recognized and dealt with appropriately although failure to follow standard principles may result in the injury being overlooked. Isolated diaphragmatic injury without associated visceral damage cannot be diagnosed clinically or radiologically. Direct video-endoscopic inspection confirms or excludes the diagnosis and has a high pick up rate. Diaphragmatic herniation can present acutely after trauma or at a time remote from the original injury. Acute diaphragmatic injury may be confused with other pathologies and there is a risk of inappropriate intervention. Most diaphragmatic hernias can be repaired via laparotomy.