Laparoscopy for triage of penetrating trauma: the decision to explore

Laparoscopy for Trauma and the Changes in its Use From 1990 to 2016: A Current Systematic Review and Meta-Analysis

BACKGROUND

The role of laparoscopy in the diagnosis and treatment of stable abdominal trauma patients is still a matter of serious debate and only incomplete data are available.

MATERIALS AND METHODS

We performed a systematic review and meta-analysis of the literature between January 1990 and August 2016.

RESULTS

Overall, 9817 laparoscopies were performed for abdominal trauma; only 26.2% of the cases were converted to a laparotomy. The incidence of therapeutic laparotomies showed a reduction from 69% to 47.5%, whereas the incidence of therapeutic laparoscopies increased from 7.2% to 22.7%.The overall perioperative mortality rate was significantly lower in the laparoscopy group [odds ratio (M-H, random); 95% confidence interval, 0.35 (0.26-0.48)]. The same group showed shorter length of hospital stay [odds ratio (M-H, random); 95% confidence interval, -3.48 (-8.91 to 1.96)].

CONCLUSIONS

This systematic review shows a significant decrease in the use of laparoscopy in trauma patients. Most likely the widespread use of imaging techniques allows a more accurate selection of patients for diagnostic laparoscopy. Infact, a reduction in incidence of nontherapeutic laparotomies is evident in these selected patients undergoing diagnostic laparoscopy. Moreover, the literature reported an increasing trend of therapeutic laparoscopy, demonstrating that it is safe and effective. The small number and poor quality of the studies identified, the retrospective observational nature of the studies (low level of evidence), the high risk of bias, and the high heterogeneity of some outcomes make the applicability of the results of this meta-analysis unclear.

Current technology: laparoscopic surgery in trauma

There has been a rapid increase in the use of laparoscopy in general surgery over recent years. However in the field of trauma its role has not been defined and its regular use remains limited to a select group of enthusiasts. We present a review of the current literature on laparoscopic surgery in trauma including therapeutic procedures and a brief synopsis of the alternative methods of investigation for abdominal injury, and our interpretation of the current role of laparoscopic surgery in trauma today.

Selective Nonoperative Management of Abdominal Stab Wounds

Stab wounds (SW) to the abdomen traditionally require urgent exploration when associated with shock, evisceration, or peritonitis. Hemodynamically stable patients without evisceration may benefit from serial exams even with peritonitis. We compared patients taken directly to the operating room with abdominal SWs (ED-OR) to those admitted for serial exams (ADMIT). We retrospectively reviewed hemodynamically stable patients presenting with any abdominal SW between January 2000 and December 2012. Exclusions included evidence of evisceration, systolic blood pressure ≤110 mm Hg, or blood transfusion. NON-THER was defined as abdominal exploration without identification of intra-abdominal injury requiring repair. Of 142 patients included, 104 were ED-OR and 38 were ADMIT. When ED-OR was compared with ADMIT, abdominal Abbreviated Injury Score was higher (2.4 vs 2.1; P = 0.01) and hospital length of stay was longer (4.8 vs 3.3 days; P = 0.04). Incidence of NON-THER was higher in ED-OR cohort (71% vs 13%; P ≤ 0.001). In a regression model, ED-OR was a predictor of NON-THER (adjusted odds ratio 16.6; P < 0.001). One patient from ED-OR expired after complications from NON-THER. There were no deaths in the ADMIT group. For those patients with abdominal SWs who present with systolic blood pressure ≥110 mm Hg, no blood product transfusion in the emergency department and lacking evisceration, admission for serial abdominal exams may be preferred regardless of abdominal exam.

The role of minimally invasive surgery in pediatric trauma: a collective review

Although minimally invasive surgery (MIS) has been utilized in selective trauma patients, there a relative paucity of literature on its role in both blunt and penetrating trauma in the pediatric population. Our purpose is to review the current literature on the role of MIS in abdominal and thoracic pediatric trauma. A review of the literature, indications, risks, and benefits of MIS in trauma will be presented. Relevant literature was obtained from use of the PubMed database.

Role of laparoscopy in penetrating abdominal trauma: a systematic review

BACKGROUND

Debate remains regarding the optimum role of laparoscopy in the setting of trauma although it can offer advantages over traditional exploratory laparotomy. Laparoscopy can be a screening, diagnostic or therapeutic tool in trauma. The purpose of this review is to evaluate the role of laparoscopy in penetrating abdominal trauma

METHODS

The PUBMED database was searched with the keywords "Laparoscopy AND Trauma". Additional citation searching and searching of the grey literature was conducted. Relevant studies were chosen on the basis of the defined inclusion and exclusion criteria and quality was assessed where appropriate using the Downs and Black checklist

RESULTS

In total, 51 studies were included in the analysis of which only 13 were prospective. In most studies, laparoscopy was used as a screening, diagnostic or therapeutic tool. In total, 2569 patients underwent diagnostic laparoscopy (DL) for penetrating abdominal trauma (PAT), 1129 (43.95 %) were positive for injury. 13.8 % of those with injury had a therapeutic laparoscopy. In total 33.8 % were converted to laparotomy, 16 % of which were non-therapeutic and 11.5 % of them were negative. 1497 patients were spared a non-therapeutic laparotomy. Overall, 72 patients suffered complications, there were 3 mortalities and 83 missed injuries. Sensitivity ranged from 66.7-100 %, specificity from 33.3-100 % and accuracy from 50-100 %. 23 of the 50 studies reported sensitivity, specificity and accuracy of 100 %, including the four most recent studies. In general the quality of the reported studies was poor. When used for cohort studies, the mean Downs and Black checklist score was 13.25 out of a possible total of 28.

CONCLUSIONS

In summary, laparoscopy in PAT may have an important role in a selected subgroup of patients, with surgeon expertise also an important factor. Laparoscopy has screening, diagnostic and therapeutic roles, particularly where diaphragm injury is suspected. It is extremely sensitive in determining need for laparotomy but detects hollow visceral injuries less reliably. It has potential as a therapeutic tool in centres with appropriate expertise. The development of specific guidelines or protocols may increase the value of laparoscopy in trauma but this would require more evidence of a higher quality.

Abdominal gunshot wounds: multi-detector-row CT findings compared with laparotomy: a prospective study

The purpose of this study was to access the accuracy of multi-detector-row computed tomography (MDCT) in diagnosing injuries in hemodynamically stable abdominal gunshot wound victims (AGWV). Triple-contrast MDCT was performed in hemodynamically stable AGWV during a 20-month prospective diagnostic accuracy study. Thirty-one patients (30 males, 1 female; mean age, 24.3 years) were evaluated by two radiologists for evidence of injury to solid and hollow organs, vascular structures, urinary bladder, diaphragm, fractures, and general findings (free fluid, pneumoperitoneum, and mesentery lesions). All of the patients underwent laparotomy, and prevalence, sensitivity, specificity, accuracy, and positive and negative predictive values were calculated. No statistically significant differences between radiologists were found. All of the solid and hollow organ lesions, vascular lesions, and general findings were detected. One of the four urinary bladder lesions was missed by MDCT, leading in this case to a sensitivity of 75%, specificity of 100%, positive predictive value of 100%, negative predictive value of 96.4%, and accuracy of 96.8% (p = 0.001). One of the eight diaphragm lesions was missed by MDCT, and its sensitivity was 87.5%, specificity was 100%, positive predictive value was 100%, negative predictive value was 95.8%, and accuracy was 96.8% (p < 0.001). Fractures were diagnosed in 74.4% of the patients (24 of 31). Fourteen (43.2%) patients demonstrated non-therapeutic laparotomy, in which minor lesions could have been managed conservatively. We concluded that MDCT is an accurate imaging method in evaluating selected AGWV, providing trusted information for emergency room physicians.

The role of laparoscopy in abdominal trauma - review of the literature

The necessity of urgent explorative laparotomy as a standard procedure in the treatment of abdominal penetrating wounds is controversial. Mandatory surgical intervention for penetrating abdominal trauma yields a high rate of negative laparotomies in the absence of visceral injuries. Laparoscopy is an alternative diagnostic procedure inspecting the peritoneum for signs of perforation and excluding significant intra-abdominal injuries. Following current guidelines, diagnostic laparoscopy should be used with caution only in selected cases due to the limited amount of reliable data confirming the effectiveness of such treatment. We present a review of the literature analysing the role of diagnostic laparoscopy in abdominal trauma.

Practice management guidelines for selective nonoperative management of penetrating abdominal trauma

BACKGROUND

: Although there is no debate that patients with peritonitis or hemodynamic instability should undergo urgent laparotomy after penetrating injury to the abdomen, it is also clear that certain stable patients without peritonitis may be managed without operation. The practice of deciding which patients may not need surgery after penetrating abdominal wounds has been termed selective management. This practice has been readily accepted during the past few decades with regard to abdominal stab wounds; however, controversy persists regarding gunshot wounds. Because of this, the Eastern Association for the Surgery of Trauma Practice Management Guidelines Committee set out to develop guidelines to analyze which patients may be managed safely without laparotomy after penetrating abdominal trauma. A secondary goal of this committee was to find which diagnostic adjuncts are useful in the determination of the need for surgical exploration.

METHODS

: A search of the National Library of Medicine and the National Institutes of Health MEDLINE database was performed using PubMed (www.pubmed.gov).

RESULTS

: The search retrieved English language articles concerning selective management of penetrating abdominal trauma and related topics from the years 1960 to 2007. These articles were then used to construct this set of practice management guidelines.

CONCLUSIONS

: Although the rate of nontherapeutic laparotomies after penetrating wounds to the abdomen should be minimized, this should never be at the expense of a delay in the diagnosis and treatment of injury. With this in mind, a routine laparotomy is not indicated in hemodynamically stable patients with abdominal stab wounds without signs of peritonitis or diffuse abdominal tenderness. Likewise, it is also not routinely indicated in stable patients with abdominal gunshot wounds if the wounds are tangential and there are no peritoneal signs. Abdominopelvic computed tomography should be considered in patients selected for initial nonoperative management to facilitate initial management decisions. The majority of patients with penetrating abdominal trauma managed nonoperatively may be discharged after 24 hours of observation in the presence of a reliable abdominal examination and minimal to no abdominal tenderness. Diagnostic laparoscopy may be considered as a tool to evaluate diaphragmatic lacerations and peritoneal penetration in an effort to avoid unnecessary laparotomy.

The utility of diagnostic laparoscopy in the evaluation of anterior abdominal stab wounds

BACKGROUND

To assess if diagnostic laparoscopy (DL) is superior to nonoperative modes (serial abdominal examination with/without computed axial tomography [CAT] and diagnostic peritoneal lavage) in determining the need for therapeutic laparotomy (TL) after anterior abdominal stab wound (ASW).

METHODS

Retrospective review of ASW patients. Patients were divided into group A (DL/exploratory laparotomy) to identify peritoneal violation (PV) and group B (initial nonoperative modes).

RESULTS

Seventy-three patients met inclusion criteria. In group A (n = 38), 29 patients (76%) had PV by DL and underwent exploratory laparotomy. Only 10 (35%) underwent TL (sensitivity for PV = 100%; specificity and positive predictive value of PV in determining need for TL = 29% and 33%, respectively). In group B (n = 35), 7 patients (20%) underwent TL, yielding an improved specificity (96%) and positive predictive value (88%).

CONCLUSIONS

We find no role for DL in the evaluation of ASW patients solely to determine PV.

Minimally invasive surgery

The field of Minimally Invasive Surgery or Minimally Access Surgery (MAS) as it is commonly known has grown remarkably over the past two decades. MAS has a steep learning curve and unexpected complications with MAS are not infrequent unless approached with great caution. However it leads to a shorter hospital stay, less analgesic use, rapid return to school and a better cosmetic outcome. MAS in children started in India a decade ago, and has a great impact on the way we manage pediatric surgical problems today. This article is a brief description of most of the procedures that are being done with the help of MAS. In addition to these, new techniques, procedures and innovations are always ongoing in this fast developing field. MAS is being practiced in limited centers in our country with expanding experience and indications. Its use in children as the first option for early appendicitis, intraabdominal testis, gall stone disease and a few other conditions is now proven beyond doubt. There are other indications and areas of application of MAS which are continuously evolving and needs institutional audit and validation at every step before moving to the next phase.

Colon and rectal injuries

PURPOSE

This study was designed to develop treatment algorithms for colon, rectal, and anal injuries based on the review of relevant literature.

METHODS

Information was obtained through a MEDLINE ( www.nobi.nih.gov/entrez/query.fcgi ) search, and additional references were obtained through cross-referencing key articles cited in these papers.

RESULTS

A total of 203 articles were considered relevant.

CONCLUSIONS

The management of penetrating and blunt colon, rectal, and anal injuries has evolved during the past 150 years. Since the World War II mandate to divert penetrating colon injuries, primary repair or resection and anastomosis have found an increasing role in patients with nondestructive injuries. A critical review of recent literature better defines the role of primary repair and fecal diversion for these injuries and allows for better algorithms for the management of these injuries.

Papel da laparoscopia no trauma abdominal penetrante

OBJETIVO: O papel da laparoscopia na redução da taxa de laparotomias não-terapêuticas e da morbidade em pacientes vítimas de trauma abdominal penetrante tem sido amplamente discutido durante os últimos anos. O objetivo do presente estudo é relatar a experiência inicial de um hospital universitário no manejo laparoscópico de pacientes com trauma abdominal penetrante. MÉTODO: Durante um período de três anos, a laparoscopia foi realizada em 37 pacientes vítimas de trauma abdominal penetrante, hemodinamicamente estáveis. Os prontuários médicos foram revisados e os parâmetros analisados foram as indicações do procedimento, lesões associadas, necessidade de conversão, tempo de permanência hospitalar e complicações. RESULTADOS: Houve 18 (48,6%) casos de laparoscopias diagnósticas (LD) positivas e 19 (51,4%) negativas. Dos pacientes com LD positiva, oito (44,4%) foram submetidos à laparotomia exploradora com finalidade terapêutica ou para melhor delineamento da lesão. Houve 10 (55,6%) LD positivas nas quais não foi realizada conversão para cirurgia aberta. Quatro pacientes apresentaram lesões reparáveis laparoscopicamente, sendo realizado hepatorrafia (n=2) e frenorrafia (n=2). Os outros seis pacientes apresentavam lesões isoladas sem sangramento ativo, e a laparotomia não-terapêutica foi evitada. Os pacientes receberam dieta no primeiro dia de pós-operatório e o tempo médio de hospitalização foi de 3,8 dias. CONCLUSÕES: Nossa experiência inicial confirma que a laparoscopia é um bom método de avaliação e tratamento no trauma penetrante. A morbidade relacionada à laparotomias desnecessárias pode ser minimizada quando o procedimento é bem indicado, e o tratamento pode ser realizado com sucesso em casos selecionados.

The Role of Laparoscopy in Penetrating Abdominal Stab Wounds

The role of diagnostic laparoscopy (DL) in abdominal stab wounds (ASWs) is not clearly defined. We hypothesized that peritoneal penetration (PP) during DL was a valid indication to convert to an exploratory laparotomy (EL). Retrospective review of hemodynamically stable ASWs requiring operation. A total of 161 patients with ASWs were identified, with 36 of 92 patients (39.1%) undergoing DL converted to EL. All 36 patients had PP; 20 of 36 (55.6%) ELs were therapeutic (TL). The number of nontherapeutic laparotomies (NTLs) prevented was 56 (60.9%). Five of 92 patients had PP on DL but did not undergo EL. Twenty-four of 69 patients who underwent initial EL had an NTL (34.8%). If this group had undergone an initial DL, and PP was used to determine need for EL, the number of NTLs would have been reduced to 10 (14.5%), a 58.3% reduction. Evidence of PP during DL is a reasonable indicator to determine the need for EL and reduce the number of NTLs.

[Abdominal wound injuries: diagnosis and treatment. Report of 79 cases]

INTRODUCTION

- Traditionally, penetrating abdominal wounds justify routine laparotomy. However, this policy can be adapted to mechanism of injury (stab or firearm) and accuracy of imaging procedures if they eliminate visceral injury thus allowing close follow up.

PATIENTS AND METHODS

Retrospective study of 79 patients (May 1995-May 2002) with a penetrating abdominal wound: (47 (59%) stab wounds and 32 (41 %) firearm wounds). Correlation between imaging and surgical findings, treatment, post-operative course were studied.

RESULTS

Sixty-eight patients were operated on from the outset, and 11 underwent close follow-up. Of the 11 patients who had follow-up, (9 after stab wound and 2 after firearm wound), two had to be operated (1 in each group). Correlation between imaging and surgical findings was good in 34 (72%) patients after stab wound and in 21 (80%) after firearm wound; the mean number of visceral injuries was 1 and 3 respectively. Six patients (8%) died (mortality: 2% and 16% respectively), 12 (15%) had postoperative complications.

CONCLUSION

Penetrating abdominal stab wounds can be treated by close follow-up if imaging excludes visceral injury. Firearm wounds still justify routine laparotomy due to both multiplicity of visceral injuries and bad prognosis.

Nonoperative management of abdominal gunshot wounds

Mandatory surgical exploration for gunshot wounds to the abdomen has been a surgical dictum for the greater part of this past century. Although nonoperative management of blunt solid organ injuries and low-energy penetrating injuries such as stab wounds is well established, the same is not true for gunshot wounds. The vast majority of patients who sustain a gunshot injury to the abdomen require immediate laparotomy to control bleeding and contain contamination. Nonoperative treatment of patients with a gunshot injury is gaining acceptance in only a highly selected subset of hemodynamically stable adult patients without peritonitis. Although the physical examination remains the cornerstone in the evaluation of patients with gunshot injury, other techniques such as computed tomography, diagnostic peritoneal lavage, and laparoscopy allow accurate determination of intra-abdominal injury. The ability to exclude internal organ injury nonoperatively avoids the potential complications of unnecessary laparotomy. Clinical data to support selective nonoperative management of certain gunshot injuries to the abdomen are accumulating, but the approach has risks and requires careful collaborative management by emergency physicians and surgeons experienced in the care of penetrating injury.

Diagnostic Laparoscopy in Abdominal Stab Wounds: A Prospective, Randomized Study

BACKGROUND

The optimal strategy for identifying patients with abdominal stab wounds requiring surgical repair has not been defined. The potential benefits of diagnostic laparoscopy by incorporating it into the routine diagnostic workup of patients with anterior abdominal stab wounds was evaluated in a two-layer, randomized study.

METHODS

From May 1997 through January 2002, stable patients without peritonitis but with demonstrated peritoneal violation were randomized (A) to exploratory laparotomy (AEL) (n = 23) or diagnostic laparoscopy (ADL) (n = 20). Simultaneously, patients with equivocal peritoneal violation on local wound exploration were randomized (B) to diagnostic laparoscopy (BDL) (n = 28) or expectant nonoperative management (BNOM) (n = 31). Hospital morbidity, length of stay, and costs were primary endpoints, with postdischarge disability being a secondary endpoint.

RESULTS

In patients with peritoneal penetration (AEL vs. ADL), there were minimal differences in the therapeutic operation rate (8 of 23 [AEL] vs. 8 of 20 [ADL], p = 0.761), mortality (none), morbidity (3 of 23 vs. 2 of 20, p = 0.999), hospital stay (mean +/- SD) (5.7 +/- 2.5 vs. 5.1 +/- 4.0 days, p = 0.049), hospital costs (4.6 +/- 1.3 vs. 4.8 +/- 1.9 x 1,000 EUR, p = 0.576), and length of sick leave (34 +/- 12 vs. 29 +/- 11 days, p = 0.305). In patients with equivocal peritoneal penetration (BDL vs. BNOM), laparoscopy found more mostly minor organ injuries (7 of 28 [BDL] vs. 1 of 31 [BNOM], p = 0.022) with no significant difference in therapeutic operations (3 of 28 vs. 1 of 31, p = 0.337) or morbidity (3 of 28 vs. 0 of 31, p = 0.101), but was associated with increased length of stay (2.6 +/- 2.1 vs. 1.9 +/- 1.8 days, p = 0.022), hospital costs (4.2 +/- 1.3 vs. 1.5 +/- 1.1 x 1,000 EUR, p = 0.000), and sick leave requirements (18 of 23 vs. 8 of 28 of eligible patients, p = 0.001).

CONCLUSION

In patients with demonstrated peritoneal violation, laparoscopy offers little benefit over exploratory laparotomy. In patients with equivocal peritoneal penetration on local wound exploration, laparoscopy detects more mostly minor organ injuries than expectant nonoperative management but is associated with increased hospital stay, costs, and sick leave requirements. Overall, diagnostic laparoscopy cannot be recommended as a routine diagnostic tool in anterolateral abdominal and thoracoabdominal stab wounds.

Diagnostic laparoscopy for the acute abdomen and trauma

BACKGROUND

We set out to investigate the potential benefits of routine diagnostic laparoscopy (DL) in cases of acute abdomen.

METHODS

A prospective study of 120 DL in acute abdominal cases was performed in comparison with 310 similar acute abdominal cases treated without DL. The diagnostic accuracy, hospital stay, therapeutic delay, and convalescence time were then evaluated.

RESULTS

DL established the indications for intervention in 96% of cases, yielded a diagnosis in 90%, and changed the treatment in 14%. The sensitivity achieved was 99.3%, specificity was 83.3%, and accuracy was 88.6%. There were two false positives, one false negative, and three results insufficient to make a diagnosis. Morbidity was one (0.8%), and mortality was one (0.8%). Seventy-nine patients (66%) were managed by laparoscopy and 24 by open interventions. The hospital stay in DL groups was shorter (median, 5 days vs 6 days in controls, p<0.0003), as was the effective treatment time (median, 5 days vs 6 days, p<0.0012). The convalescence time was also shorter in DL groups (median, 14 days vs 14 days, p<0.04). Therapeutic delay occurred in 16% of the control group cases, doubling the morbidity rate, increasing mortality by 50%, and prolonging hospital stay (median, 9 days vs 6 days, p>0.3 (NS).

CONCLUSIONS

DL in the acute abdomen is a safe and accurate procedure that enables laparoscopic interventions and helps avoid nontherapeutic surgery. DL and appropriate treatment reduces hospital stay, therapeutic delay, and convalescence time.

Avaliação diagnóstica da laparoscopia associada à análise do líquido intraperitoneal nas lesões intra-abdominais provocadas por arma de ar comprimido: estudo experimental em cães

Avaliação de eficácia da laparoscopia, associada à análise bacteriológica do líquido intraperitoneal pela coloração de Gram., no diagnóstico de lesões intra-abdominais provocadas em cães com arma de ar comprimido. A alta incidência de óbitos como resultado de ferimentos por arma de fogo tem contribuído para implantação de novas técnicas diagnósticas. O uso crescente de laparoscopia diagnóstica em urgências torna necessário aprimorar qualidade e fidedignidade dos resultados obtidos. Este experimento avalia acurácia, sensibilidade e especificidade da laparoscopia, incluindo 20 cães submetidos a trauma abdominal, com disparo do tipo encostado, e cinco cães como grupo de controle. Na laparoscopia, foram feitos inventário sistemático da cavidade abdominal, conferido por laparotomia, e coleta de líquido intraperitoneal para análise bacteriológica. A laparoscopia apresentou acurácia de 88,29%, sensibilidade de 88,29% e especificidade de 100%. O valor preditivo positivo da coloração de Gram foi 100%. Concluiu-se que a laparoscopia é eficaz no diagnóstico de lesões intra-abdominais provocadas por arma de ar comprimido, em cães hemodinamicamente estáveis. Mas, algumas lesões, evidenciadas na laparotomia, passaram despercebidas na laparoscopia. Realização concomitante de análise bacteriológica pela coloração de Gram pode aumentar a eficácia e diminuir a possibilidade de erros no diagnóstico de lesões. Laparoscopia associada à análise bacteriológica possibilita melhores resultados com mínimo dano ao paciente

Bedside laparoscopy

The improved technical sophistication of laparoscopy offers an attractive highly accurate diagnostic modality at the bedside for critically ill patients who are confined to the ICU and intensive monitoring unit and who are in need of timely abdominal evaluation. If the surgeon understands the physiologic effects of peritoneal insufflation and considers them during the procedure, the patient tolerates the procedure well. It is important to limit insufflation pressures and laparoscopy time. The author also recommends using the open Hasson technique. Its primary use is diagnostic in penetrating and blunt trauma and in the obscure abdomen. It has been successfully employed therapeutically for acalculous cholecystitis, abscess drainage, and correction of placement of gastrostomy tubes and peritoneal dialysis catheters. It helps avoid risky transport trips and negative or nontherapeutic laparotomy with its known associated risks.

The efficacy of serial physical examination in penetrating abdominal trauma

Over a 10-year period we reviewed the records of 370 consecutive patients with potentially penetrating abdominal wounds (48 gunshot and 322 stab wounds). Selective non-operative management for abdominal stab wounds was introduced, guided by serial physical examination. In our study the terms therapeutic and non-therapeutic laparotomies were used, the latter comprising negative as well as insignificant findings. Initially diagnostic peritoneal lavage and local wound exploration were used, but these methods were later abandoned. Mortality was 10.2% and morbidity 25% in the group of gunshot wounds and 1.2% and 8.6% in the group of stab wounds. During this period the rate of laparotomies for stab wounds decreased from 55% to 30%, while the rate of non-therapeutic laparotomies decreased from 24% to 0% in the last year. Delayed laparotomy did not cause death or increase morbidity. Our results support the concept of selective non-operative management of abdominal stab wounds using repeated physical examination. Peritoneal perforation and haemoperitoneum should not be an indication for routine laparotomy.

Management of liver trauma

BACKGROUND AND METHODS

Management of blunt or penetrating injuries to the liver remains a significant challenge. This review discusses the mechanisms of liver injury, grading system for severity, available diagnostic modalities and current management options. It is based on a Medline literature search and the authors' clinical experience.

RESULTS

Unstable patients require immediate laparotomy, but selected patients who are haemo- dynamically stable may be managed without operation. The preferred operative techniques include resectional debridement, hepatotomy with direct suture ligation and perihepatic packing; anatomical resection, hepatic artery ligation and various bypass techniques have a limited, more defined role for selected injuries. Major complications include haemorrhage, sepsis and bile leak.

CONCLUSION

Enhanced resuscitation, anaesthesia and intensive care have contributed to a significant reduction in mortality rates from liver trauma. Optimum results are obtained with a specialist team that includes an experienced liver surgeon, anaesthetist, endoscopist and interventional hepatobiliary radiologist with expertise in managing postoperative complications.

Analysis of laparoscopy in trauma

BACKGROUND

The optimum roles for laparoscopy in trauma have yet to be established. To date, reviews of laparoscopy in trauma have been primarily descriptive rather than analytic. This article analyzes the results of laparoscopy in trauma.

STUDY DESIGN

Outcome analysis was done by reviewing 37 studies with more than 1,900 trauma patients, and laparoscopy was analyzed as a screening, diagnostic, or therapeutic tool. Laparoscopy was regarded as a screening tool if it was used to detect or exclude a positive finding (eg, hemoperitoneum, organ injury, gastrointestinal spillage, peritoneal penetration) that required operative exploration or repair. Laparoscopy was regarded as a diagnostic tool when it was used to identify all injuries, rather than as a screening tool to identify the first indication for a laparotomy. It was regarded as a diagnostic tool only in studies that mandated a laparotomy (gold standard) after laparoscopy to confirm the diagnostic accuracy of laparoscopic findings. Costs and charges for using laparoscopy in trauma were analyzed when feasible.

RESULTS

As a screening tool, laparoscopy missed 1% of injuries and helped prevent 63% of patients from having a trauma laparotomy. When used as a diagnostic tool, laparoscopy had a 41% to 77% missed injury rate per patient. Overall, laparoscopy carried a 1% procedure-related complication rate. Cost-effectiveness has not been uniformly proved in studies comparing laparoscopy and laparotomy.

CONCLUSIONS

Laparoscopy has been applied safely and effectively as a screening tool in stable patients with acute trauma. Because of the large number of missed injuries when used as a diagnostic tool, its value in this context is limited. Laparoscopy has been reported infrequently as a therapeutic tool in selected patients, and its use in this context requires further study.

Determining anatomic injury with computed tomography in selected torso gunshot wounds

BACKGROUND

Changes in the management of torso gunshot wounds (TGSWs) have evolved in recent years as a result of differences between military and civilian injuries and increasing interest in avoiding nontherapeutic invasive procedures. The objective of this study was to establish the utility and accuracy of computed tomography (CT) in the evaluation of selected patients with TGSWs.

METHODS

Retrospective review for a 6-year period of patients who sustained TGSWs and underwent CT solely for the purpose of trajectory determination. Patients had complete physical examinations and plain radiographic evaluations by a dedicated group of in-house trauma surgeons. When trajectory was indeterminate after evaluation, CT was performed. In some cases, CT was used when trajectory was determined to be intracavitary but organ injury was believed to be unlikely or amenable to nonoperative management.

RESULTS

Fifty TGSW patients underwent 52 computed tomographic scans. Abdominal/pelvic CT was performed in 37 patients, and thoracic CT was performed in 15 patients. All patients were stable and none sustained complications attributable to CT or delay in therapy. Twenty of 37 abdominal/pelvic computed tomographic scans excluded transabdominal or pelvic trajectory. Seventeen of 37 scans proved transabdominal or pelvic trajectory; nine laparotomies were performed, and eight patients were observed. Nine of 15 thoracic computed tomographic scans excluded transmediastinal trajectory. Six of 15 scans suggested vascular proximity and prompted further workup, which was positive in two cases.

CONCLUSION

CT of selected TGSW patients is safe and may reduce the incidence of invasive diagnostic procedures. A prospective evaluation of CT for TGSW patients is warranted.