The role of laparoscopy in blunt abdominal trauma.

Department of Surgery, Helsinki University Central Hospital, Finland.
Annals of Medicine (Impact Factor: 4.73). 01/1997; 28(6):483-9. DOI: 10.3109/07853899608999112
Source: PubMed

ABSTRACT 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: In acute abdominal syndromes when a surgical exploration is required by the presence of peritoneal symptoms, laparoscopy allows to recognize the lesions and to perform simultaneously the appropriate treatment in most cases. When the surgical indication is doubtful, mainly in case of acute appendicitis, sonography or scanography may confirm the diagnosis. In case of persisting doubt, diagnostic laparoscopy is justified and laparoscopic appendicectomy seems to be the best method when another pathology is not detected by laparoscopy. In abdominal wounds, laparoscopy is useful to confirm their intraperitoneal penetration, mainly in gunshot wounds, and to recognize a diaphragmatic wound which is often isolated and unknown. Laparoscopy often fails to detect all abdominal injuries. In blunt abdominal traumas, laparoscopy is not recommended at the first step. In conclusion, laparoscopy with diagnostic intent only is rarely indicated in abdominal emergencies and its use is not worth being extended. Diagnostic value of laparoscopy is closely linked to its therapeutic interest. Laparoscopy with both diagnostic and therapeutic intent has to be developed in most abdominal emergencies.
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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 70(11):1246-1254. · 0.52 Impact Factor