The Role of Laparoscopy in Blunt Abdominal Trauma

Department of Surgery, Helsinki University Central Hospital, Finland.
Annals of Medicine (Impact Factor: 3.89). 01/1997; 28(6):483-9. DOI: 10.3109/07853899608999112
Source: PubMed


In a collective analysis of 11 reports with a total of 355 blunt abdominal trauma patients, the sensitivity and specificity of diagnostic laparoscopy in predicting the eventual need for therapeutic laparotomy were 94% and 98%, respectively, with an overall accuracy of 97%. Although fairly accurate and safe (morbidity rate about 1.2%), the invasiveness, cost and time-consuming nature of diagnostic laparoscopy limit its routine use in trauma patients. It could, however, be useful in selecting patients with minor or nonbleeding injuries for nonoperative management after positive peritoneal lavage or computed tomography, and in excluding occult bowel and diaphragmatic injuries in patients with equivocal findings, thereby reducing the number of unnecessary laparotomies. With the improvement of laparoscopic techniques and instrumentation, more injuries can probably be managed laparoscopically with all the benefits observed with the shift from open to laparoscopic procedures in other patient populations, and it is likely that laparoscopy will find its place as an integral part of evaluating and treating patients with blunt abdominal trauma. At present, however, laparoscopy cannot be recommended as a routine tool for evaluating patients with blunt abdominal trauma, except in controlled clinical trials.

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    ABSTRACT: Mortalität und Morbidität des stumpfen Bauchtraumas hängen direkt von der rechtzeitigen, korrekten Diagnosestellung ab. Da in der überwiegend Zahl der Fälle Begleitverletzungen vorliegen und die Patienten häufig nicht (mehr) kommunikations- bzw. kooperationsfähig sind, ist die klinische Diagnostik unzuverlässig. Bezüglich der weiteren, bildgebenden Diagnostik wurde das praktische Vorgehen in den letzten Jahren vereinfacht und weitgehend vereinheitlicht: Initial erfolgt die Ultraschalldiagnostik des Abdomens. Bei Patienten, die aufgrund eines Blutverlusts in das Abdomen kreislaufinstabil geworden sind, kann diese Ursache immer sonographisch entdeckt und damit gleichzeitig die Indikation zur Notfalllaparotomie gestellt werden. Bei kreislaufstabilen Patienten wird zur weiteren Feindiagnostik des Abdomens bei nicht ganz eindeutigem Ultraschallbefund die computertomographische Untersuchung (CT) des Abdomens angeschlossen. Vom Nachweis direkter oder indirekter Zeichen einer Läsion hängt das weitere Vorgehen ab und kann u. a. die Angiographie (Leber, Milz, Niere, Mesenterialwurzel, V. cava), die endoskopisch-retrograde Cholangio-Pankreateographie (ERCP) (Leber, Gallenwege Pankreas) bzw. die Punktion von freier intraabdominaler Flüssigkeit umfassen, wodurch Verletzungen von Hohlorganen diagnostiziert werden können. Die heute recht zuverlässige computertomographische Diagnostik des stumpfen Bauchtraumas stellt darüberhinaus eine wesentliche Voraussetzung für die heute immer deutlichere Tendenz zur konservativen Behandlung von Parenchymläsionen beim stumpfen Bauchtrauma dar. Da die Möglichkeit der Ultraschalldiagnostik heute praktisch in jedem Versorgungskrankenhaus gegeben ist und die sonographische Diagnostik fester Bestandteil der chirurgischen Ausbildung ist, sind konkurriende Verfahren wie die diagnostische Peritoneallavage praktisch bedeutungslos geworden. Auch die diagnostische Laparoskopie hat – im Ggs. zum Perforationstrauma – keinen aktuellen Stellenwert. Lethality and morbidity of blunt abdominal trauma are directly dependent on the immediately valid diagnostic work-up. Since blunt abdominal trauma usually occurs in the setting of multisystem injury and patients are no longer cooperative, clinical methods of diagnosis are unreliable. In regard to the imaging procedures, the practical approach has been simplified and standardized in the last few years. Initially, ultrasonography of the abdomen is performed. If the patient is hemodynamically unstable because of intra-abdominal loss of blood, this can be reliably detected by ultrasound and emergency laparotomy is indicated. If patients are hemodynamically stable, more sophisticated assesment of the abdomen can be achieved by computed tomography. The next step depends on direct or indirect signs of an intra-abdominal lesion. Angiography may be indicated in injuries to the liver, spleen, kidney, mesenteric root or caval vein. If lesions to the liver, biliary or pancreas are detected, ERCP may be required. Lacerations of hollow organs are identified by fine-needle aspiration of free intra-abdominal fluid. Findings on computed tomography are usually reliable enough to support a more conservative approach in the treatment of parenchymal lesions in blunt abdominal trauma. Since the facilities to perform ultrasound are provided in all emergency units and knowledge of ultrasonography is an essential part of surgical training, competitive diagnostic procedures like peritoneal lavage have completely lost their former important clinical role. Similarly, diagnostic laparoscopy is – in contrast to abdominal perforations – no longer of importance.
    Der Chirurg 11/1999; 70(11):1246-1254. DOI:10.1007/s001040050776 · 0.57 Impact Factor
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    ABSTRACT: Laparoscopy is a nearly century-old technique that has experienced a resurgence of interest from surgeons since the development of technology that has broadened its applications. Although laparoscopy has been used to evaluate patients with possible abdominal trauma, its use for this purpose is limited by the availability of other diagnostic procedures that may be more suitable for particular circumstances and are more accurate for certain injuries. Laparoscopy is contraindicated in patients who are hypovolemic or hemodynamically unstable and should not be performed in patients with clear indications for celiotomy. It may not be appropriate for patients with cardiac dysfunction, nor for those with significant head injuries who are at risk for intracranial hypertension. Its best applications may be in stable patients with stab wounds or those with tangential gunshot wounds of the abdomen. The likelihood of missing hollow visceral injuries depends upon the indications for conversion to celiotomy. If peritoneal violation or the presence of a small amount of blood in the peritoneal cavity is used as an indication for celiotomy, then the missed injury rate will be low but the unnecessary celiotomy rate will be diminished only slightly compared with a policy of mandatory celiotomy. Excessive enthusiasm for laparoscopy in trauma might result in its use when other diagnostic measures or simple observation are more appropriate. The desire to perform a procedure can be compelling, especially in circumstances in which the general surgeon would not operate upon a patient but simply provide postoperative care after other surgeons have operated. The use of laparoscopy for these purposes can only be condemned, as it increases the costs and risks of care without improving the outcome. The role of laparoscopy in trauma is evolving, and further research into its diagnostic role and therapeutic applications is clearly needed.
    Surgical Clinics of North America 07/1996; 76(3):547-56. DOI:10.1016/S0039-6109(05)70461-8 · 1.88 Impact Factor
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