Conservative Versus Delayed Laparoscopic Exploration for Blunt Abdominal Trauma

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1 Med. J. Cairo Univ., Vol. 80, No. 1, September: , Conservative Versus Delayed Laparoscopic Exploration for Blunt Abdominal Trauma TAMER M. NABIL, M.D.*; SALAH S. SOLIMAN, M.D.**; WAEL N. THABET, M.D.*** and RAMI M. MAKKAR, M.D. * * * The Departments of Surgery, Faculties of Medicine, Beni-Suef*, Fayoum** and Cairo Universities*** Abstract Introduction: The key issue in the choice of investigation is the cardiovascular stability of the patient. Diagnostic peritoneal lavage (DPL) is no longer the gold standard for determination of the need for laparotomy in blunt abdominal trauma not only because more specific and sensitive diagnostic procedures are available like delayed laparoscopic exploration (DLE), but also to avoid the unnecessary laparotomies even in cases of true positive DPL. The aim of this study is to compare conservative versus DLE for blunt abdominal trauma management as regards accuracy of diagnosis, decreasing incidence of complication, decreasing the need for unnecessary laparotomies and to shorten the hospital stay. Material and Methods: 28 hemodynamically stable patients with blunt abdominal trauma (BAT) were selected randomly and divided into two groups, there was no statistically significant difference in the mode of trauma between the two groups using the rank student t-test, also, no statistically significant difference in the age and the sex distribution between the two groups, as they passed the normality test. Group (A): Included 15 patients, managed by the classic conservative management with close monitoring by vital signs, urine output, laboratory tests and repeated imaging by abdominal US. Group (B): Included 13 patients managed by (DLE) at the third day of the trauma, patients had US, CT abdomen on admission and remain under observation till the third day. Follow-up for the patients from both groups after discharge to detect late complications after 3 months. Results: In 9 patients included in the study representing approximately 32% of all patients, there were injuries missed by U/S and detected by CT. And in 17 patients representing approximately 64%, U/S and CT detected the same injuries. Among the 13 patients that underwent delayed laparoscopic exploration (DLE) representing approximately 46% of all patients there were 5 missed injuries by CT that was discovered during (DLE) representing 38% of the 13 patients. Therapeutic laparoscopic intervention occurred in 3 patients representing approximately 23% of the 13 patients. Hospital stay for the Correspondence to: Dr. Tamer M. Nabil, The Department of Surgery, Faculty of Medicine, Beni-Suef University patients managed with (DLE) ranged between 4 to 10 days with an average of 5.69 days (±1.887). Hospital stay for the patients managed with conservative management ranged between 5 to 14 days with average of 8.93 days (±2.89). Follow-up information was available for all the patients over a period of 3 months after discharge, neither infective nor late hemorrhagic complications were observed. Conclusion: In the light of this study, (DLE) was found most significant for blunt abdominal trauma patients with CT scan showing haemoperitonium with no organ injuries, and to less extent in cases with splenic injuries, while in patients with hepatic injuries there was no significant data favoring (DLE) on conservative treatment. Key Words: Blunt abdominal trauma Delayed laparoscopic exploration Imaging. Introduction BLUNT abdominal injuries are present in about 25-30% of multiply injured patients and represent the most common type of abdominal injuries. Mortality rates of about 70% are cited in cases of concomitant injury of the abdomen, thorax and brain [1]. Table (1): Frequency and incidence of organ injury [2]. Organ injured Frequency % Spleen 57.2 Liver 46.6 Retroperitoneal hematoma 14.6 Colon 12.8 Small bowel 12.2 Kidney 9.5 Pancreas 6.0 Duodenum 5.4 Diaphragm 5.2 Urinary bladder 4.3 Stomach

2 576 Conservative Versus Delayed Laparoscopic Exploration Diagnostic laparoscopy: Although the benefits of laparoscopy are appealing in the trauma population, the complexity and potential hemodynamic instability associated with intra-abdominal injury usually preclude the use of this modality [3]. In approximately 20% of cases of unclear findings, and after other performed diagnostic procedures, laparoscopy provides definitive diagnosis. Making interpretation of the results very fast and reliable and, what is the most important, this method avoids additional trauma caused by conventional laparotomy [4]. Laparoscopic evaluation of the abdominal cavity has been established as sensitive and specific in the trauma setting (sensitivity, 92%; specificity, 100%) [5]. Whereas, inspection of the abdominal cavity and solid viscera is relatively easy to perform, complete examination of the intestine presents a greater challenge, with a 9% to 18% missed injury rate per patient [6]. Diagnosis in blunt trauma: Diaphragm rupture: Blunt injury tends to result in large tears that are more readily diagnosed by imaging modalities, and patients who are sufficiently stable to undergo imaging rather than immediate laparotomy can be considered for magnetic resonance imaging (MRI) for diagnosing this entity. Furthermore, because of the large size of these injuries, laparotomy is usually required for exploration and repair [7]. Evaluation of free fluid: Stable patients after blunt abdominal trauma who are evaluated by CT scan may be found to have free intraperitoneal fluid without evidence of solid organ injury. This fluid may represent enteric contents, urine, or blood. Bleeding sources include mesenteric or bowel injury, omental lacerations, or an undiagnosed solid organ injury. There is conflicting data regarding the need for laparotomy in this subset of patients. Laparoscopy can be used to obtain a sample of fluid for analysis as well as examination of the peritoneum for occult injury. In this regard, laparoscopy can guide the need for laparotomy. This represents an advantage of laparoscopy over Diagnostic peritoneal lavage (DPL), which is highly sensitive and may contribute to a non therapeutic laparotomy [3]. Therapeutic laparoscopy: Although the use of diagnostic laparoscopy in selected stable trauma patients has become widely accepted, therapeutic laparoscopy remains controversial. These techniques typically require advanced laparoscopic training. Definitive repair of injury: Laparoscopic repair of diaphragm injuries represents the most commonly reported therapeutic use. Increasing numbers of case reports regarding the use of laparoscopy for therapy of limited gastrointestinal injuries, pancreatic resection, and bladder repair [8]. The use of therapeutic laparoscopy for hepatic trauma is limited, but it has been used for application of fibrin glue to provide hemostasis to bleeding liver injuries, also Laparoscopy should be considered as an alternative to percutaneous radiological drainage and ERCP in stable patients with blunt liver trauma and haemobilious ascites as it may be superior by providing more extensive lavage, while avoiding the morbidity of a laparotomy [9]. Some surgeons advocate interval washout of peritoneal blood after major liver or spleen injury to decrease ileus, peritoneal symptoms, inflammatory response, and/or control bile leakage from a liver injury. In this delayed setting, the laparoscope may be used for irrigation and evacuation of blood and bile from the peritoneal cavity, as well as the placement of closed suction drainage [10]. Patients requiring surgery for splenic injury are hemodynamically unstable and/or actively bleeding, which prohibits the use of laparoscopy because of time and visualization constraints [11]. Current standard of care indicates nonoperative therapy for splenic injury in hemodynamically stable patients. There are, however, selected patients who may be unable or unwilling to comply with the prolonged period of limited activity required for nonoperative management. Elective laparoscopic splenectomy may be a viable option in these patients [12]. Current contraindications: Speed: Laparoscopy is contraindicated in any patient in whom speed to definitive control of a source of bleeding or contamination is imperative.

3 Tamer M. Nabil, et al. 577 Efficiency: As the goal of laparoscopy is to provide shorter recovery time, it holds no advantage over laparotomy in patients who may be expected to have multiple system intra-abdominal injuries [3]. Head injury: Elevated ICP results from reduced venous return as well as increased partial pressure of carbon dioxide (CO 2) from absorption of CO 2 pneumoperitoneum [13]. Based on existing data, head injury must be considered a contraindication to laparoscopy with pneumoperitoneum. Head-injured patients should undergo laparotomy if abdominal exploration is deemed necessary. Lung injury: In patients with severely decreased pulmonary compliance, requiring high positive end expiratory pressure, pneumoperitoneum is likely to reduce functional residual capacity. Acute lung injury should be considered contraindication to laparoscopy [3]. Complications: General complications of laparoscopy are similar to those of open surgery, including wound infection, hernia formation, and adhesions. When assessing complication rates in prospective trials in trauma complications are rare, with an overall rate of approximately 1% [14]. Tension pneumothorax/pneumopericardium: In patients with potential diaphragmatic injury, the insufflation of the abdominal cavity may result in induction of tension pneumothorax [15]. Overall, this is the most common complication of laparoscopy for trauma and if unsuspected and not rapidly treated, it may result in patient death. Similar pathophysiology can occur with an opening into the pericardium [15]. Missed injury: The incidence of missed injury in laparoscopy for trauma is extremely variable, ranging from 41% to 77%. Part of this wide variation may be explained by the fact that trauma surgeons typically perform fewer laparoscopic procedures [16]. Laparoscopic evaluation is sensitive in defining the presence of an injury but is very poor at specifying the injury; hence, multiple bowel injuries may be present with only one specifically identified [16]. Given the unacceptably high rate of missed bowel injury, it is most conservative to convert to laparotomy if laparoscopic examination is equivocal. Moreover, retroperitoneal exploration is limited with the laparoscope. If findings indicative of retroperitoneal injury are noted, conversion to laparotomy with retroperitoneal exploration should be undertaken [17]. Gas embolism: Gas embolism has not been reported in the trauma literature but remains a theoretical concern, particularly in patients who may have undiagnosed and unexpected venous and cardiac injuries. If physiologic changes suggest gas embolism, laparoscopy must be aborted with immediate evacuation of pneumoperitoneum [18]. Cost analysis: Similar cost was found between diagnostic laparoscopy and negative laparotomy [19]. Diagnostic laparoscopy was found to have a 42% reduction in operative time and a 33% decrease in hospital charges [20]. The aim of this study is to compare conservative versus delayed laparoscopic exploration (DLE) for blunt abdominal trauma management as regards accuracy of diagnosis, decreasing incidence of complication, decreasing the need for unnecessary laparotomies and to shorten the hospital stay. Material and Methods This prospective study included 375 patients with history of blunt abdominal trauma admitted to Casualty and Emergency Unit, Kasr El-Aini Hospital, Cairo University, during the period from 2/2009 to 2/2010, 28 patients of them were vitally stable following initial resuscitation, 13 patients underwent delayed laparoscopic exploration, while the other 15 patients had conservative treatment. 28 hemodynamically stable patients with (BAT) were selected randomly and divided into two groups, there was no statistically significant difference in the mode of trauma between the two groups using the rank student t-test, also, no statistically significant difference in the age and the sex distribution between the two groups, as they passed the normality test. Group (A): Included 15 patients, managed by the classic conservative management with close monitoring by vital signs, urine output, laboratory tests and repeated imaging by abdominal US.

4 578 Conservative Versus Delayed Laparoscopic Exploration Group (B): Included 13 patients managed by (DLE) at the third day of the trauma, patients had US, CT abdomen on admission and remain under observation till the third day. Follow-up for the patients from both groups after discharge to detect late complications after 3 months. Inclusion criteria for the patients to be included in the study: Patients with history of blunt trauma to the abdomen, either isolated or as a part of multiple trauma. Abdominal examination for all patients was highly suspicious of an intra-abdominal injury. Age, sex and mechanism of injury had no rule in patient selection. Exclusion criteria for other trauma patients not included in the study: Patients with history of penetrating trauma to the abdomen. Patients with history of blunt trauma to the abdomen those remain vitally unstable after initial resuscitation. All patients of the study underwent immediate initial resuscitation and primary assessment, followed by thorough history taking and general and local examination and routine laboratory (CBC, liver function, kidney function, serum sodium and potassium, prothrombin time and concentration and urine analysis). Ultrasound and computed tomography: After resuscitation of the blunt trauma victims and stabilization of the vital signs by the trauma surgeons team, abdominal ultrasonography and computed tomography scans were performed for all cases who were vitally stable all through while clinically were found to be suspicious of having an intrabdominal injury. Conservative treatment included close followup the patient with continuous monitoring of the vital signs, urine output, daily laboratory tests (CBC, liver function, kidney function). The followup of the solid organs trauma was done by ultrasonography to determine resolution of the trauma and the success of conservative treatment. Follow-up information was collected from all patients after a period of 3 months after discharge, to detect infective, late hemorrhagic or adhesive complications. Results The patient included were 23 males (82% of total) 10 males in (DLE) representing approximately 77% and 13 males in conservative group representing approximately (87%), and 5 females (18% of total) 3 females in (DLE) and 2 in conservative group. Males Females Fig. (1): Sex distribution of patients included in the study. Their age ranged from (6 years to 45 years) with a mean age of 28.5 years (±10.4). The most frequent cause of abdominal trauma was motor vehicle accident, accounting for approximately 78% of all cases. (47% drivers, 13% passenger and 40% pedestrians). This was followed by falls from a height accounting for approximately 11% of all cases and direct kicks or blows to the abdomen accounting for approximately 7% of all cases. Among the 28 patients included in the study 12 patients representing approximately 43%, had multiple trauma, while 16 patients representing approximately 57% had isolated abdominal injury. The most associated injuries were extremity fractures occurring in 5 patients representing 17%, followed by thoracic trauma occurring in 4 patients representing 14%, then fracture pelvis occurring in 3 patients representing 11 %. Other associated injuries were: Urological injuries in 2 patients (7%) and craniocerebral injuries in 1 patient (3%), all of them were managed conservatively. Clinical evaluation of the 28 patients included in the study revealed that all patients were vitally stable following immediate resuscitation. All patients in the study underwent U/S and CT. In 9 patients included in the study representing approximately 32% of all patients, there were injuries missed by U/S and detected by CT. And in 17 patients representing approximately 64%, U/S and CT detected the same injuries.

5 Tamer M. Nabil, et al. 579 Table (2): Summary of the 28 patients included in this study. The first 13 patients underwent (DLE). Sex Age Mode of trauma FAST scan CT scan Hospital stay No. 1 M 38 MCA Hepatic hematoma+collection Seg. 5 hematoma+collection 4 days No. 2 F 15 MCA Splenic tear+collection G : III splenic tear+collection 6 days No. 3 M 30 MCA Moderate collection Seg. 6 tear+collection 5 days No. 4 F 27 MCA Mild collection Mild collection 4 days No. 5 M 21 Fall from a height Splenic tear+collection G: III splenic tear+collection 10 days No. 6 M 45 Kick to abdomen Mild perisplenic collection G: II splenic tear+collection 5 days No. 7 M 16 MCA Mild perisplenic collection G: II splenic tear+collection 6 days No. 8 M 38 Motorcycle accident Mild collection Seg. 5 tear+collection 4 days No. 9 M 17 Fall from a height Hepatic hematoma+collection Seg. 4,8 hematoma+collection 4 days No. 10 M 26 MCA Mild collection Seg. 6,7 hematoma+collection 4 days No. 11 M 40 MCA Subcapsular splenic hematoma Subcapsular splenic hematoma 7 days No. 12 F 22 MCA Moderate collection Moderate collection 4 days No. 13 M 30 MCA Moderate collection Moderate collection 5 days No. 14 M 38 MCA Perisplenic collection G: II splenic tear+collection 10 days No. 15 M 28 MCA Hepatic hematoma+collection Seg. 5 hematoma+collection 12 days No. 16 M 25 MCA Mild collection Mild collection 5 days No. 17 M 45 MCA Hepatic hematoma+collection Seg. 4 hematoma+collection 14 dys No. 18 M 26 MCA Mild collection Seg. 6,7 tear+collection 10 days No. 19 M 22 MCA Splenic tear+collection G: III splenic tear+collection 10 days No. 20 M 34 MCA Mild collection Seg. 7 hematoma+collection 9 days No. 21 M 40 Motorcycle accident Mild collection Seg. 6 hematoma+collection 6 days No. 22 M 19 Motorcycle accident Mild collection Mild collection 7 days No. 23 M 30 MCA Mild collection Moderate collection 8 days No. 24 F 26 MCA Splenic tear+collection Multiple splenic tears+collection 10 days No. 25 M 33 MCA Mild collection Seg. 7 tear+collection 7 days No. 26 F 7 Fall from a height Splenic tear+collection Shattered lower splenic pole+ 14 days collection No. 27 M 38 MCA Mild collection Mild collection 7 days No. 28 M 6 Blow to abdomen Mild collection Mild collection 7 days MVA Falls Kicks, blows Fracture extremity Thoracic trauma Fracture pelvis Urologic trauma Craniocerebral injuries Fig. (2): Mechanism of blunt trauma in patients included in the study. Fig. (3): Associated injuries in 12 patients included in the study.

6 580 Conservative Versus Delayed Laparoscopic Exploration 20 injury (3.5%), 1 patient with diaphragmatic tear (3.5%) and non-expanding retroperitoneal hematoma in 1 patient (3.5%). 15 Table (3): Frequency of organ injured in patients included in the study. 10 Organ injured No. of patients % of total Liver Spleen 9 32 Urinary bladder CT & U/S same U/S miss injuries diaphragm Retroperitoneal hematoma Fig. (4): Accuracy of U/S compared to CT in detecting injuries. Among the 13 patients that underwent delayed laparoscopic exploration (DLE) representing approximately 46% of all patients there were 5 missed injuries by CT that was discovered during (DLE) representing 38% of the 13 patients, they were (diaphragmatic tear, urinary bladder tear, pelvic non-expanding retroperitoneal hematoma, liver tear, large falciform hematoma). While in the other 8 patients whom underwent (DLE) representing approximately 62% of the 13 patients, there were no missed injuries detected by (DLE). The most frequent intrabdominal injuries based on (DLE) and C.T findings were the hepatic injuries in 11 patients (39%), followed by splenic injuries in 9 patients (32%), 1 patient with urinary bladder Therapeutic laparoscopic intervention occurred in 3 patients representing approximately 23% of the 13 patients (splenic tear management, repair of a urinary bladder tear, evacuation of a splenic subcapsular hematoma). In 1 therapeutic laparoscopic intervention representing approximately 7% of the 13 patients, a later laparotomy was needed as evacuation of splenic subcapsular hematoma followed by recollection of the hematoma after 3 days. Conversion to laparotomy occurred in 1 patient representing approximately 7% of the 13 patients, as (DLE) revealed grade IV splenic injury and diaphragmatic tear, splenectomy and tear repair was done. Management of the patients who underwent (DLE) showed the following results. Table (4): (DLE) based management of 13 patient in the study. DLE results No. of patients Missed injuries by CT Therapeutic laparoscopy Need for laparotomy % of total Grade: II-III Hepatic hematoma Grade: II-III Hepatic laceration Splenic subcapsular hematoma Grade: II-II Splenic laceration Grade: IV Splenic laceration hilar vessel laceration Diaphragmatic tear Urinary bladder tear Non-expanding retroperitoneal zone 3 hematoma Haemopertonium (no definite injuries)

7 Tamer M. Nabil, et al. 581 All the 13 patients underwent (DLE), insertion of intraperitoneal drain was done after aspiration of any collected blood. Management of the patients who underwent conservative management showed the following results. Table (5): Conservative based management of 15 patients in the study. CT results No. of patients Missed injuries by U/S Need for laparotomy % of total Grade: II-III Hepatic hematoma Hepatic laceration Grade: II-III Splenic laceration Haemoperitonium (no definite injuies) Hospital stay for the patients managed with (DLE) ranged between 4 to 10 days with an average of 5.69 days (±1.887): Hepatic injuries patients: Ranged between 5 to 7 days with average 4.8 days (±1.33). Splenic injuries patients: Ranged between 5 to 10 with average 6.8 days (±1.92). Urinary bladder injuries: 8 days hospital stay. Haemoperitonium with no definite injuries: 4 (±2.34) days hospital stay. Table (6): Average hospital stay by days for patients underwent (DLE). (DLE) results No. of patients Average hospital stay Standard deviation All cases Hepatic injuries Splenic injuries Urinary bladder injuries 1 8 Haemoperitonium with no definite injuries Hospital stay for the patients managed with conservative management ranged between 5 to 14 days with average of 8.93 days (±2.89): Hepatic injuries: Range between 6 to 14 days with average 9.6 days (±3.01). Splenic injuries: Range between 10 to 14 days with average 11 days (±2.2). Haemoperitonium with no definite injuries: Range between 5 to 8 days with average 6.4 days (± 1.34). Table (7): Average hospital stay by days for patients underwent conservative management. Conservative results No. of patients Average hospital stay Standard deviation All cases Hepatic injuries Splenic injuries Haemoperitonium with no definite injuries Table (8): Comparison of mean hospital stay for patient treated with DEL versus patients treated with conservative treatment. DLE Mean±SD Conservative treatment Mean±SD p value All cases 5.69± ± S. Hepatic & splenic injuries Significance 5.8± ± Highly S. Hepatic injuries 4.8± Non S. Splenic injuries 6.8± ± S. Urinary bladder injuries Haemoperitonim with no definite injuries 8± l Highly S. 4± ± S. Follow-up information was available for all the patients over a period of 3 months after discharge neither infective nor late hemorrhagic complications were observed.

8 582 Conservative Versus Delayed Laparoscopic Exploration Fig. (5): CT scan of Grade IV intrahepatic hematoma with no haemoperitonium. Fig. (8): Large hepatic laceration reaching gall bladder fossa. Fig. (6): CT scan of Grade IV hepatic laceration of the right lobe. Fig. (9): Repair of the bladder tear laparoscopically. Fig. (7): CT scan of Grade III splenic upper pole laceration with perisplenic blood collection and a small left lobe hepatic hematoma. Discussion Several advances in diagnostic modalities challenge the traditional dogmatic approach to abdominal trauma. As competence with laparoscopy continues to evolve, It shows promise for evaluation of certain types of patients with abdominal trauma [21]. Fig. (10): Splenic tear sealed by large hematoma. In this prospective study all the 28 patients included were vitally stable and underwent both US and CT scan following an initial primary resuscitation, 13 patients of them underwent (DLE) representing 46% of all patients, the remaining 15 patients representing approximately 54% had conservative management.

9 Tamer M. Nabil, et al. 583 The aim of performing (DLE) was to confirm accuracy of C.T scan, performing some therapeutic intervention like drainage of free or intraparenchymal blood, repair of tears laparoscopically and to shorten the hospital stay. In the 13 patients underwent (DLE) some or all these aims were successfully achieved. The CT scanner is strictly off-limits to unstable trauma patients. However, in the patient that is cardiovascularly stable following resuscitation, CT is the investigation of choice in many institutions. Sensitivity to detect injuries between 92% and 97.6% and specificity as high as 98.7% has been reported in patients subjected to emergency CT. Small bowel, pancreatic and mesenteric injuries may not be detected [22]. Among the 13 patients that underwent delayed laparoscopic exploration (DLE) representing approximately 46% of all patients there were 5 missed injuries by CT that was discovered during (DLE) representing approximately 38% of the 13 patients, they were (diaphragmatic tear, urinary bladder tear, pelvic non-expanding retroperitoneal hematoma, liver tear, large falciform hematoma). Therapeutic laparoscopic interventions were done in 3 patients of the (DLE) group (surgical application on splenic tear, repair of a urinary bladder tear, evacuation of a splenic subcapsular hematoma). After evacuation of the splenic subcapsular hematoma, a later laparotomy was needed due to recollection of the hematoma after 3 days, for which open splenectomy was done. Conversion to laparotomy occurred in 1 patient, as (DLE) revealed grade IV splenic injury and diaphragmatic tear while CT did not show the extent of the splenic injury and diaphragmatic tear was missed by CT, splenectomy and tear repair was done. As Regarding the hospital stay, in this study, the patients managed by (DLE) had shorter hospital stay in relation to those managed conservatively, as the patients results revealed that the overall hospital stay for (DLE) was significantly shorter, with an average of 5.69± days. In this study, The group that benefit the most from shortening the hospital stay was the patients with haemoperitonium with no definite injuries, followed by patients with splenic injuries, while differences in hospital stay in patients with hepatic injuries were not significant. Follow-up information was available for all the patients over a period of 3 months after discharge. Neither infective nor late hemorrhagic complications were observed. Conclusion: The key determinant for the choice of the appropriate investigation or management of solid organ injuries following blunt abdominal trauma is the hemodynamic stability of the patient. Solid organ injuries graded from I-III in hemodynamically stable patients are expected to benefit from conservative management, thus minimizing the morbidity and mortality associated with nontherapeutic laparotomies in multiply injured patients. Delayed laparoscopic exploration can be used for hemodynamically stable blunt abdominal trauma patients as an accurate diagnostic and sometimes therapeutic tool. In the light of this study, (DLE) was found most significant for blunt abdominal trauma patients with CT scan showing haemoperitonium with no organ injuries, and to less extent in cases with splenic injuries, while in patients with hepatic injuries there was no significant data favoring (DLE) on conservative treatment. CT-based grades of liver and splenic injuries made it possible to predict the outcome of conservative management. Abdominal ultrasonography has proved to be of little value in deciding the possibility of conservative treatment due to inability to detect the grade of solid organ injury. References 1- MININO A.M., HERON M.P., MURPHY S.L., et al.: Deaths: Final data for Natl. Vital Stat. Rep., , FISHER R.P., MILLER P. and REED R.L., et al.: The hazard of nonoperative management in adults with blunt abdominal injury. J. Trauma, 28: , NICOLAU A.E.: Is laparoscopy still needed in blunt abdominal trauma? Chirurgia (Bucur), 106 (1): 59-66, GREGORI P.D., BAJEC D.D., RADENKOVI D.V., et al.: Laparoscopy in the evaluation of blunt abdominal trauma. Acta. Chir. Iugosl, 57 (4): 33-8, KABAN G.K., NOVITSKY Y.W., PERUGINI R.A., et al.: Use of laparoscopy in evaluation and treatment of penetrating and blunt abdominal injuries. Surg. Innov, 15 (1): 26-31, BECKER H.P., WILLMS A. and SCHWAB R.: Laparoscopy for abdominal trauma. Chirurg, 77 (11): , RUBIKAS R.: Diaphragmatic injuries. Eur. J. Cardiothorac. Surg., 20 p. 53, 2001.

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