LAPAROSCOPY IN TRAUMA - 11/09/11
Résumé |
Since 1990, laparoscopy has become the operative approach of choice for many abdominal problems. As surgeons have become more familiar with laparoscopic equipment and techniques, laparoscopy has received a wide range of applications, including complicated biliary tract disease, suspected appendicitis, gastroesophageal reflux, and diseases of the colon. Recent studies have evaluated the use of laparoscopy in the evaluation of patients with suspected abdominal injuries. This is a definite change in the approach to trauma, but whether it results in improved care needs to be closely evaluated.
Despite a few scattered attempts at intra-abdominal surgery in the early 1800s, it was the impetus of war that led to the modern management of abdominal trauma. At the onset of World War I, observation of penetrating wounds of the abdomen was the standard treatment. This time-honored approach was based on experience gained in armed conflicts that preceded the widespread use of anesthesia and antisepsis. The combination of weapons of enormous destructive potential and the appalling sanitary conditions associated with stationary trench warfare resulted in horrific mortality rates. By 1915, the second year of the war, it was appreciated that soldiers with abdominal wounds stood a better chance of survival with celiotomy, although their mortality risk was still about 60%.10 At the outset of World War II, 21 years after the end of World War I, abdominal exploration had become routine in the management of penetrating wounds of the abdomen. The mortality rate for abdominal wounds in World War II was about 24%.48 and was reduced even further during the Korean War and the war in Vietnam. At the end of the twentieth century, exploratory celiotomy remains the standard diagnostic and therapeutic approach for penetrating wounds of the abdomen.
With the increase in automotive travel following World War II, motor vehicle collisions became more frequent, resulting in a greater incidence of blunt injuries to intra-abdominal viscera. In the absence of a simple and reliable diagnostic test for intra-abdominal injuries, many blunt trauma victims were observed clinically and did not undergo surgery unless they developed hemorrhagic shock or peritonitis.7 The development of diagnostic peritoneal lavage (DPL) in the mid-1960s39 was a tremendous advance in the management of blunt trauma. It proved to be far superior to needle aspiration or clinical observation, and with refinements in techniques and interpretation DPL remains an indispensable diagnostic tool in the care of the injured patient.
The application of CT scans to trauma care enabled the surgeon to noninvasively visualize injuries to the solid viscera of the abdomen and the retroperitoneum.15 This technology has facilitated the evolution of nonoperative approaches to the management of selected patients with splenic and hepatic injuries, thereby avoiding many nontherapeutic celiotomies. Within the last decade, ultrasonography also has expanded the surgeon's diagnostic armamentarium for evaluation of patients with possible abdominal injuries.19, 20
In spite of a number of advances in diagnostic techniques, many patients who undergo celiotomy for trauma either have no injuries in the abdomen (negative exploration) or have injuries that require no specific treatment (nontherapeutic celiotomy). Although some of these operations may be unavoidable, they can nonetheless unnecessarily complicate a patient's recovery from injury. In a retrospective study, Weigelt and Kingman46 reported that 91 of 248 patients (37%) who underwent a negative laparotomy for trauma had a postoperative complication. The complication rate was more than twice as high in patients with associated injuries (55%) as in those with no other injuries (22%). The most frequent complication was atelectasis, which accounted for over half of all complications. Other causes of morbidity included pneumonia, phlebitis, urinary tract infections, and wound infections. Five patients developed small bowel obstruction as a delayed complication. In a more recent prospective study of morbidity following unnecessary laparotomies for trauma, Renz and Feliciano38 reported complication rates remarkably similar to those of the previous study. Complications occurred in 105 of 254 patients (41.3%) and were again more likely to occur in patients with associated injuries than in those without other injuries (61.3% versus 25.9%, respectively).
The incidence of unnecessary (negative and nontherapeutic) celiotomies for abdominal trauma varies with the mechanism of injury and the method of evaluation. Although DPL is extremely sensitive (>98%), it is rather nonspecific. Recently reported rates of negative and nontherapeutic celiotomy when using DPL in blunt trauma range from 5% to 37%, with more typical rates of 13% to 20%.12, 24, 25, 32 In general, the use of DPL in penetrating trauma is less satisfactory than in blunt trauma, and the use of DPL for stab wounds has resulted in unnecessary celiotomy rates of 20% to 37%.12, 25 These rates are not clearly an improvement over the use of physical examination alone in the evaluation of the need for celiotomy after injury, although the patient populations are probably not equivalent.34 DPL has been used only infrequently in the evaluation of patients with gunshot wounds to the abdomen. Henneman et al25 reported that 3 of 15 patients (20%) with tangential gunshot wounds had a false-positive peritoneal lavage. In contrast, Gruenberg et al21 reported no false-positive peritoneal lavages in 156 patients with gunshot wounds or shotgun wounds to the abdomen.
Whereas CT scan and ultrasonography reduce the unnecessary celiotomy rate for solid viscus injury following blunt trauma, they are rather insensitive to injuries of the hollow viscera and pancreas.20, 32, 43 Thus, complete reliance on these modalities may result in potentially serious or lethal delays in the treatment of these injuries. The ability of imaging studies to detect injuries of the intraperitoneal hollow viscera in penetrating abdominal trauma is quite limited because of the tendency of leaking bowel contents to spread rather than to form collections. Consequently, with the exception of stab wounds to the back and flanks,13, 23 CT and ultrasonography have very little to offer in the evaluation of patients with penetrating truncal trauma.
Laparoscopy was first described at the very beginning of the twentieth century and has been technically feasible for over 50 years.45 Early experiences with laparoscopy in the evaluation of patients with possible abdominal injuries were reported by Gazzaniga,18 Carnevale,6 Berci,1 and their co-workers. It was not until the development of the computer chip television camera, which allowed the laparoscopic image to be portrayed on a video monitor, that surgeons began to broaden the applications of laparoscopy. One of the first uses of the laparoscope to be “rediscovered” was evaluation of patients with suspected abdominal injuries.2, 4, 5, 14, 16, 27, 28, 33, 40, 41, 44
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| Address reprint requests to Galen V. Poole, MD, Department of Surgery, University of Mississippi Medical Center, 2500 North State Street, Jackson, MS 39216 |
Vol 76 - N° 3
P. 547-556 - juin 1996 Retour au numéro
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