Therapeutic and diagnostic role of laparoscopy in penetrating abdominal trauma

Transcription

1 Therapeutic and diagnostic role of laparoscopy in penetrating abdominal trauma Thesis Submitted for fulfillment of the Master degree (M.Sc.) in GENERAL SURGERY By MOHAMED OMAR ABD AL ALIM (M.B, B.Ch.) Under the supervision of PROF.DR.ABD EL MUOTY HESSIN ALI PROFESSOR OF GENERAL SURGERY FACULTY OF MEDICINE CAIRO UNIVERSITY PROF.DR.MUSTAFA ABD EL HAMID SOLIMAN PROFESSOR OF GENERAL SURGERY FACULTY OF MEDICINE CAIRO UNIVERSITY DR.MOHAMED ABD EL MONEIM AL MASRY LECTURE OF GENERAL SURGERY Faculty of medicine Cairo University 2012

2 Abstract Penetrating abdominal trauma traditionally has been considered an indication for a mandatory exploratory celiotomy. The high nontherapeutic laparotomy rate and associated significant morbidity after mandatory laparotomy for abdominal stab wounds led to the current widely used selective non -operative management strategy a selective approach would eliminate non-therapeutic laparotomies and provide prompt recognition and operative intervention when needed. But Delayed treatment of visceral injuries, is still undesirable. If a less invasive modality can provide reliable data about visceral injuries without high morbidity, then it would have an important role in penetrating abdominal trauma, hence the concept of laparoscopy for trauma. In this study conducted over 30 patients Laparoscopy have proven that it has the upper hand as a diagnostic tool over the CT scan and FAST as it identify intra-abdominal pathology in 56.6% of case while FAST 16.6% and CT scan 23.3%, also laparoscopy have succeeded in management of 12 out of 17 patient (70.6%) with intra-abdominal pathologies and prevention of non-therapeutic laparotomy in 13 out of 30 patients (43.4%). Key Words : penetrating abdominal trauma - diagnostic modalities - trauma diagnosed by laparoscopy.

3 ACKNOWLEDGMENT First and foremost, I feel always indebted to God, the kind and merciful I would like to express my deepest gratitude and sincerest thanks to PROF.DR. ABD EL MUOTY HESSIN ALI, Professor of General Surgery, Cairo University for giving me the chance to work under his supervision. Many thanks to PROF.DR.MUSTAFA ABD EL HAMID SOLIMAN, Professor of General Surgery, Faculty of Medicine, Cairo University as This thesis would not have been possible without the help, support and patience of DR. Mustafa not to mention his advice and unsurpassed knowledge, many thanks for his support, encouragement and valuable advices throughout this work. Words are not enough to express my great thanks and deep appreciation to DR. MOHAMED ABD EL MONEIM AL MASRY, lecturer of general surgery, Cairo University for his effort and support The good advice, support and friendship of Dr. Tarek Hegazy, lecturer of general surgery, Cairo University has been invaluable on both an academic and a personal level, for which I am extremely grateful A very special thanks to all my family and my colleagues for their support and encouragement throughout this work especially my colleague and friend Dr.Mohamed Atwa ii

4 Table of Contents Item Page List of Tables List of Figures iv v Introduction and Aim of work 1 REVIEW OF LITERATURE 6 Basic Abdominal Structures. 7 History of Penetrating Abdominal Trauma. 9 Types of Penetrating Abdominal Trauma. 12 Diagnostic Modalities in Penetrating Wounds With Internal organ injury. Therapy and Intervention In Penetrating Abdominal trauma 43 Laparoscope In Penetrating Abdominal Trauma. 52 Benefits of laparoscope over open surgery and other 55 diagnostic modalities. Patient and methods 62 Results 69 Discussion 84 Summary & Conclusion 93 References 96 Arabic Summary iii

5 List of Tables Item Page Table (1): Glasgow coma scale ( Baskett 1991) 20 Table (2): Priorities for the trauma team during the resuscitation (Dirscoll, ) Table (3): Classification of hypovolemic shock according to blood 23 loss.(baskett.1991) Table (4): sex distribution of patient 70 Table (5): age distribution in 30 patients 71 Table (6): Type of penetrating abdominal wounds in 30 patients 72 Table (7): Abdominal regions suffered from stab wound 73 Table (8): chest x-ray findings in 30 patients 75 Table (9): Ultrasonograrphic findings in 30 patients (30 pt) 76 Table (10): CT findings in 30 patients 77 Table (11): Laparoscopic Findings in 30 patients 78 Table (12): Mode of management in 30 patients 79 Table (13): Abdominal Organ Injuries in Patients with Penetrating 80 dabdominal Wounds Managed with laparoscopic or open laparotomy (17 pt) Table (14) frequency of organs injured in penetrating abdominal trauma 81 diagnosed by laparoscopy(17 pt) Table (15): organ injured managed by laparoscopic surgery 82 Table (16): comparison between CT, FAST, and Laparoscopy as diagnostic 83 tool Table (17): post-operative stay 83 iv

6 List of figures Item Page Figure 1: picture of stab abdomen (Michelle, 2009) 14 Figure 2: picture of shot gun (Michelle, 2009) 16 Figure 3: X-ray chest showing air under the diaphragm (peter et la 1988 ) 35 Figure 4: Plain x-ray abdomen showing ground glass appearance due to 35 presence of fluid or pus in the peritoneal cavity (peter et la 1988 ) Figure 5: fast us (Markus et al., 2008) 37 Figure 6: (a) Large liver laceration (b) Linear laceration in pancreatic body 40 (c) Gastric contrast material extravasation in the lesser sac. Figure 7: Laparoscopic view of peritoneal damage by stab injury (Selman et 60 al., 2011). Figure 8: Patient s position on the operating table for a trauma laparotomy 65 or laparoscopy.( Selman et al.,2010) Figure 9: Trocar positions for laparoscopy in trauma case (Selman et al., ) Figure 10: sex distribution of patient 70 Figure 11: age distribution in 30 patients 71 Figure 12: Type of penetrating abdominal wounds in 30 patients 72 ) Figure 13: Abdominal regions suffered from stab wound 74 Figure 14: chest x-ray findings in 30 patients 75 Figure 15: Ultrasonograrphic findings in 30 patients 76 Figure 16: CT findings in 30 patients 77 Figure 17: Laparoscopic Findings in 30 patients 78 Figure 18: Mode of management of the 30 patients 79 Figure 19: Frequency of organs injured in penetrating abdominal trauma diagnosed by laparoscopy (17 pt) 81 v

7 INTRODUCTION & AIM OF THE WORK

8 Introduction & Aim of the work Introduction In the 19 th century, penetrating abdominal wounds were managed nonoperatively. The associated morbidity and mortality rates were greater than 70%. Experience gained during World War I, World War II, and the Korean Conflict led to an aggressive approach of operative management for all penetrating abdominal wounds. This approach resulted in an unacceptably high frequency of laparotomy with findings negative for trauma (Cayton et al., 1996). Penetrating abdominal injuries present a major challenge, especially when the lower chest and the upper abdomen are involved where there is a high risk of 25%-50% of diaphragmatic and other intra-abdominal organ injuries (Friese et al., 2005). The management of penetrating abdominal stab wounds has been the subject of continued reappraisal and controversy. Traditionally, the concern for delayed diagnosis of intra-abdominal injuries has led many trauma centers to advocate mandatory abdominal exploration whenever a stab wound was proven or suspected to have penetrated into the abdominal cavity.this liberal approach resulted in a reluctant acceptance of a 50% incidence of non-therapeutic laparotomies in an attempt to prevent delayed diagnosis of intra-abdominal injuries. (Krausz et al., 2006). 2

9 Introduction & Aim of the work All strategies for the management of abdominal trauma underline the need for an interdisciplinary approach to diagnosis and therapy.this requires focused and intelligent use of efficient diagnostic procedures and tools such as Routine investigations such as diagnostic peritoneal lavage, X-ray, ultrasonography, computer tomography, and play a vital role in triage of patients with abdominal trauma (Demetriades et al., 2003). Minimally invasive surgical techniques have become increasingly utilized in all areas of surgery. Current use of laparoscopy in the evaluation and management of trauma patients has been a natural extension of this trend. Several studies have analyzed various aspects of its application to the trauma patient. Although utilized for both blunt and penetrating injuries, laparoscopy has gained the most widespread acceptance as a useful tool in the management of patients with penetrating abdominal injuries. Its ability to accurately determine anterior peritoneal penetration from stab and gunshot wounds has been proven. Others have expanded its role beyond simply a screening tool for injury, to its current use in some centers as a diagnostic and therapeutic modality. (Erik et al., 2004). Diagnostic laparoscopy in trauma patients has been first described by Gazzaniga in 1976.Despite this long history of sporadic use, indications for its use in trauma casualties main controversial. This technique has primarily been used to detect peritoneal penetration in tangential wounds of the abdominal wall and for evaluation of the diaphragm in patients with lower 3

10 Introduction & Aim of the work thoracic wounds. More extensive laparoscopic examination of the stomach, colon and small bowel and repair of diaphragmatic and hollow viscus injuries is performed only by a few trauma surgeons skilled in advanced laparoscopic techniques. The main concern even in the hands of the experienced surgeon in advanced laparoscopic techniques is that small lacerations of the bowel may be overlooked. (Zantut et al., 1997). The goal of laparoscopic surgery is to provide equal or superior visualization compared with open procedures but with less patient morbidity, post operative discomfort and recovery time. This goal has clearly been met with a number of laparoscopic procedures including cholecystectomy, gastroesophageal reflux procedures and diagnostic laparoscopy. Although the benefits of laparoscopy are appealing in the trauma population the complexity and potential hemodynamic instability associated with intraabdominal injury usually preclude the use of this modality. Carefully selected trauma patients may benefit from this emerging technology. (Claudia et al., 2004). 4

11 Introduction & Aim of the work Aim of the work: To evaluate the role of laparoscopy as diagnostic tool and its impaction on definitive treatment whether laparoscopic or by focused laparotomy in penetrating abdominal trauma. 5

12 REVIEW OF LITERATURE

13 Review of Literature BASIC ABDOMINAL STRUCTURES The abdominal cavity, which extends from the diaphragm down to the pelvis, is divided into three anatomical areas : thoracic abdomen, retroperitoneal abdomen and true abdomen.due to the height of the diaphragm during exhalation, al injures below the level of the nipple line should be suspected to be an abdominal injury until proven otherwise (Gomez et al., 1989). The abdomen is divided into regions that are defined by lines on the surface of the abdominal wall. Usually nine regions are the delineated two vertical and two horizontal lines. The vertical line on each side correspond to the midclavicular line when extends downwards it reaches the midingunial point, which is midway between symphsis and the anterior superior iliac spine. The lower transverse line is drawn between the tubercles of the iliac crests (intertuberculer plane) and the upper transverse line is the transpyloric plane, midway between the jugular notch and the top of the pubic symphysis.(some clinicians use the subcostal plane which is a little lower level with the lowerst part of the costal margin ).Using these four lines, three cental regions are defined from above downwards : epigastric umbilical and suprapubic. Similarly there are three lateral regions on each side hypochondrial, lumber, and iliac (Sinnatamby et al., 1999). 7

14 Review of Literature So the abdomen is divided into 4 quadrants and 9 regions below the diaphragm and above the pelvic inlet. These help define areas when locating specific abdominal organ. Trauma to the upper abdomen usually involves the right upper quadrant and left upper quadrant as well as the 6 regions located above the intertubercular plane. Sign, symptoms and imaging may involve the entire abdomen, pelvis and even the chest region (Bontrager et al., 2004). Organs and structures located in the upper abdomen that are protected by the ribs are considered to be in the thoracic abdomen, structures in the thoracic abdomen include the liver, spleen diaphragm and stomach. (Fieldees, 1995). The peritoneum is the membrane lining the abdominal cavity structures located behind this membrane are in the retroperitoneal abdomen and include the kidney, uterus, Pancreas and duodenum (Blaisidell et al., 1993). The remainder of the abdominal structures including the small intestine and large intestine and the bladder are located in the true abdomen.in females the uterus, fallopian tubes and ovaries are also included with in this area. (Fieldees, 1995). 8

15 History of penetrating abdominal trauma

16 Review of Literature Penetrating abdominal trauma (PAT) is commonly seen in emergency departmentsand poses a significant challenge to trauma surgeons. The most important decisionthat must be obtained during the management of these traumas is which patient must be operated on. Mandatorylaparotomies for all patients with PAT have resulted in nontherapeutic (negative or insignificant findings) operations in 11% to 40% of the patients. Complications of nontherapeutic laparotomy may be severe and when it is performed for PAT, mortality and complication rates vary from 0% to 5% and 5% to 22%, respectively.( van Haarst et al, 1999). Although there is no doubt that continued hemodynamic instability or signs of peritoneal irritation warrant immediate laparotomy, if the patient is hemodynamically stable and has no urgent indications for laparotomy, the course of action can be controversial, involving the decision on whether to perform a laparotomy or undertake conservative management. After the questioning of routine laparotomy by Shaftan. (Shaftan et al., 1960). The management trend has moved from mandatory exploration to selective approach. Although the modern management of PAT has decreased nontherapeutic laparotomy by using selective nonoperative management protocols, immediate recognition of intra-abdominal injury still poses a significant clinical challenge, particularly in patients who have minimal or no symptoms and have no obvious indications for emergent surgery. The most important questions are which diagnostic procedures will be used, which patient requires laparotomy, and when to operate the patient. Presently, the major challenge is to decide on adequate diagnostic 10

17 Review of Literature modalities. Although several diagnostic methods including noninvasive (serial physical examination and clinical status, ultrasound, computerized tomography scan, endoscopy, echocardiography, and magnetic resonance imaging) and invasive methods (diagnostic peritoneal lavage, angiography, intravenous pyelogram, local wound exploration) are available for evaluation of the patients, unfortunately, a single evaluation test can never provide adequate diagnosis in all situations and all mechanisms of injury. These methods have a defined sensitivity,specificity, and accuracy, but none of them represents a gold standard for the evaluation of these injuries, particularly for patients with equivocal and unreliable findings. Furthermore, the methods for management of these patients should be diagnostic, timesaving, and appropriate for treatment, and less complicated. (Bostrom et al., 2000). Laparoscopy was first used in 1902 by Kelling to explore the abdominal cavity, but it was totally neglected by surgeons until quite recently. The breakthrough for surgical laparoscopy came after the first successful cholecystectomies performed by Mühe and Mouret. Since then, improvement of technical and optical equipment has led surgeons to familiarize themselves with this method and to apply it to an ever-widening spectrum of indications. The modern concept of diagnostic laparoscopy for trauma began in the early 60s, but the use of laparoscopy has only just recently increased. To evaluate the presence of peritoneal penetration and severity of intra-abdominal injuries and to reduce nontherapeutic laparotomies, as well as to provide definitive therapy in some instances, are the purposes of the laparoscopic approach (Simon et al., 2002). 11

18 TYPES OF PENETRATING ABDOMINAL TRAUMA

19 Review of Literature Penetrating trauma may be from gunshots (including shotguns) and stabbings, which may be homicidal, suicidal or accidental; or due to industrial, road traffic and domestic accidents. MECHANISM OF INJURY Knife Wounds Stab wounds are more common than bullet wounds and are generally less lethal, unless they enter the retroperitoneal space to injure the great vessels or pancreas. For many years, a laparotomy was deemed mandatory following any form of penetrating abdominal trauma. However recently, trauma centers have been using a more selective approach, particularly in management of stab wounds and even gunshot injuries. (Saadia et al., 2000) This is partly due to the increased frequency of and therefore experience with penetrating trauma. It is also related to the greater accessibility and quality of imaging techniques. (Sabiston, 1997) It has been found that 66% of stabbings enter the peritoneal cavity but less than 50% result in a visceral injury necessitating operative repair. (Zinner et al., 1997) Therefore adoption of a policy of expectant observation can be utilized. That is, observe the patient carefully and regularly for signs of internal 13

20 Review of Literature haemorrhage or peritonitis, and if present, laparotomy should be performed immediately. (Leppaniemi et al.,1999). Penetrating flank wounds are associated with injury to the colon, duodenum, kidney and major vascular structures. Therefore life threatening injuries may exist despite haemodynamic stability and negative diagnostic peritoneal lavage. In this situation most surgeons have a low threshold for early abdominal exploration, particularly if the injury is thought to encroach on significant retroperitoneal structures as indicated by radiological imaging. (Zinner et al., 1997). Figure (1): picture of stab abdomen (Michelle, 2009) 14