J. L. Sosa

1,000 Consecutive Ultrasounds for Blunt Abdominal Trauma

Diagnostic peritoneal lavage (DPL) and computed tomography (CT) are the primary diagnostic modalities used in the evaluation of patients with suspected blunt abdominal trauma (BAT). DPL is fast and accurate but is associated with complications. CT is also accurate, yet requires stability and transportability of the patients. Ultrasound (US) has been suggested as an aid in evaluating BAT. We evaluated US in the initial assessment of BAT in 1000 patients. Patients were eligible for the study if they met specified trauma criteria and had suspected BAT. We then followed the outcome of the patients and their further work-up. US showed a sensitivity of 88%, a specificity of 99%, and an accuracy of 97% for detecting intraabdominal injuries. We conclude that emergency ultrasound may be used as the initial diagnostic modality for suspected blunt abdominal trauma.

Open Versus laparoscopic appendectomy : a prospective randomized comparison

ObjectiveThe authors compare open and laparoscopic appendectomy in a randomized fashion with regard to length of operation, complications, hospital stay, and recovery time. MethodsAdult patients (older than 14 years of age) with the diagnosis of acute appendicitis were randomized to either open or laparoscopic appendectomy over a 9-month period. All patients received preoperative antibiotics. The operative time was calculated as beginning with the incision and ending when the wound was fully closed. Patients that were converted from laparoscopic to open appendectomy were considered a separate group. Return to normal activity and work were determined by questioning during postoperative clinic, telephone, or mailed questionnaire. ResultsThere was a total of 169 patients randomized, 88 to the open and 81 to the laparoscopic group. The groups were similar demographically. Of the 81 laparoscopic patients, 13 (16%) were converted to open. In the open group, 70 patients (79.5%) had acute appendicitis and 21 (23.9%) had perforative appendicitis. In the laparoscopic group, 62 patients (76.5%) had acute appendicitis and 10 (12.3%) had perforative appendicitis. There was no statistical difference in the return to activity or work between the laparoscopic and open groups. The operative time was significantly longer in the laparoscopic group (102.2 minutes vs. 81.7 minutes, p < 0.01). The hospital stay of 2.2 days in the laparoscopic group and 4.3 days in the open group was statistically different (p = 0.007). There was no difference in the hospital stay for those with acute appendicitis (1.89 days vs. 2.61 days, p = 0.067) compared with those with a normal appendix but with pelvic inflammatory disease (1.1 days vs. 2.3 days, p = 0.11). There was a significant difference in patients with perforative appendicitis (1.5 days vs. 9.5 days, p < 0.01). The hospital cost for patients having laparoscopic appendectomy was

Can ultrasound replace diagnostic peritoneal lavage in the assessment of blunt trauma

6077 and for an open appendectomy

Management Of Lower Extremity Arterial Trauma

7227 (p = 0.164). There were no increased complications associated with the laparoscopic technique. ConclusionLaparoscopic appendectomy is comparable to open appendectomy with regard to complications, hospital stay, cost, return to activity, and return to work. There was a greater operative time involved with the laparoscopic technique. Laparoscopic appendectomy does not offer any significant benefit over the open approach for the routine patient with appendicitis.

Laparoscopic-assisted colostomy closure after Hartmann's procedure.

Diagnostic peritoneal lavage (DPL) and computed tomography (CT) are the primary diagnostic modalities in the evaluation of patients with suspected blunt abdominal trauma (BAT). Diagnostic peritoneal lavage is fast and accurate but associated with complications. Computed tomography is also accurate, yet requires that patients be stable and transportable. A prospective study was designed to determine the utility of emergency ultrasound (US) studies in the initial assessment of BAT. Two hundred acutely injured patients with suspected BAT were evaluated with US. Patients were eligible for the study if they met trauma criteria and had suspected BAT. Subsequently, without knowledge of the US results, DPL or CT was performed. Ultrasound showed a sensitivity of 83%, a specificity of 100%, and an accuracy of 97% in detecting intra-abdominal injuries. Six injuries were missed but only one was felt to be significant. If US had been used in all 200 patients, 199 would have had appropriate care. We conclude US is reliable in the detection of free intraperitoneal fluid and may be used in place of DPL or CT.

Laparoscopy in 121 consecutive patients with abdominal gunshot wounds

Extremity vascular trauma is common in most urban trauma centers and controversy remains about the optimal management of arterial injuries. We examined the records of 188 patients who had lower extremity arterial trauma from September 1987 to April 1992 to help clarify these issues. There were 142 (75.5%) gunshot wounds, 18 (9.6%) stab wounds, 5 (2.7%) shotgun wounds, and 23 (12.2%) patients with blunt trauma. There were 43 (22.9%) associated venous injuries. There were 10 repair failures in the acute postoperative period. There were no repair failures for the iliac artery. Three failures involved the superficial femoral artery (SFA), six were popliteal, and one tibial. Vein and polytetrafluoroethylene (PTFE) grafts were used to repair the SFA with equal success. Repair of the popliteal artery with PTFE failed in four of five cases, while vein grafts failed in only 2 of 19 cases (p < 0.01). Graft failure was associated with blunt trauma in 8 of 23 patients (35%), and always resulted in amputation. Penetrating injuries accounted for only 2 of 165 (1.2%) failures and were successfully redone with no amputations. Venous injury was present in all SFA failures. Popliteal vein injury was present in two PTFE and two vein grafts that failed. There were no infections of vein or PTFE grafts. In conclusion, PTFE and vein have equal graft patency for the repair of the iliac and femoral arteries. However, the patency of PTFE was significantly worse in the popliteal location. Vein grafts should be used for repair of this vessel. Graft failure and amputation were more common with popliteal and tibial injuries from blunt mechanisms.(ABSTRACT TRUNCATED AT 250 WORDS)

Negative Laparotomy in Abdominal Gunshot Wounds: Potential Impact of Laparoscopy

PURPOSE: The aim of the study was to review our experience with colostomy closure after Hartmanns procedure and the possible impact of laparoscopic colostomy closure. METHODS: A retrospective review of hospital stay after colostomy closure by laparotomy in the last four years was conducted. A chart review of patients undergoing laparoscopic colostomy closure after Hartmanns procedure since the introduction of operative laparoscopy at our institution was also done. RESULTS: One hundred twenty patients had colostomy closure carried out by the trauma service at the University of Miami/Jackson Memorial Hospital. In thirty-seven patients, colostomy closure was associated with other surgical procedures such as ventral herniorrhaphy, delayed closure of the open abdomen, ureteroneocystostomy, and so forth, or they underwent loop colostomy closure. These patients were excluded from further review. Sixty-five patients underwent reversal of Hartmanns procedure by laparotomy. They had an average hospital stay of 9.5 days (range, 6 to 34 days). This group of patients had colostomy closure prior to the introduction of operative laparoscopy in our institution. With increased laparoscopy experience, laparoscopically assisted Hartmanns reversal has been attempted in 18 patients and completed in 14 patients. The average hospital stay in the laparoscopically completed group was 6.3 days (range, 4 to 10 days). This group had a 0 percent mortality and a 14.3 percent morbidity. This compares favorably to recently reported series of colostomy closure by laparotomy. CONCLUSION: Laparoscopically assisted Hartmanns reversal results in comparable morbidity, but may be associated with shorter hospital stay when compared with laparotomy.

Laparoscopic Evaluation of Tangential Abdominal Gunshot Wounds

OBJECTIVE The purpose of this study was to evaluate the sensitivity, specificity, and predictive value of diagnostic laparoscopy (DL) in a large group of stable patients with abdominal gunshot wounds (ABGSWs). DESIGN This study was a prospective case series developed by management protocol. MATERIALS AND METHODS In a 2 1/2-year period, DL was performed in 121 consecutive patients who were hemodynamically stable with ABGSWs and met protocol criteria. This represented 18% of all patients with ABGSWs seen in this period at the Ryder Trauma Center. The evaluation was conducted to determine peritoneal violation, the presence of intra-abdominal blood, and the need for exploration. MEASUREMENTS AND MAIN RESULTS There were 42 (35%) positive and 79 (65%) negative DLs. In patients with positive DL, 39 (92.8%) had exploratory laparotomy. In this group, 32 (82%) had therapeutic laparotomy, 6 (15.4%) had nontherapeutic laparotomy, and 1 (2.5%) had a negative laparotomy. In this patient, DL was felt to be inadequate by the attending surgeon, although no penetration or intraperitoneal blood were present, and a negative laparotomy was done. This represents a failure rate of 0.8%. There were 3 (7.2%) positive DLs, in whom laparotomy was not performed. These patients had isolated nonbleeding liver injuries, and nontherapeutic laparotomy was successfully avoided. The negative DL group was divided into 47 patients (60%) with isolated ABGSWs, and 32 patients (40%) with associated injuries, mostly orthopedic and thoracic. There were no false-negative DLs and no delayed laparotomies in these 121 patients. There was no mortality in this study group. The sensitivity for peritoneal penetration was 100%, and the specificity was 98.7%. The positive predictive value was 97.6%, and the negative predictive value was 100%. In deciding on need for laparotomy (i.e., injury requiring repair), DL had a positive predictive value of 82%; more importantly, the negative predictive value was 100%. CONCLUSIONS In stable patients with ABGSWs and questionable intra-abdominal injury, DL can be safely used. It is highly sensitive and specific. It can effectively reduce the incidence of negative and nontherapeutic laparotomies, and the overall morbidity and hospital stay in this group of patients.

Laparoscopic Assisted Colorectal Surgery

OBJECTIVE To evaluate the morbidity and hospital stay resultant from negative exploratory laparotomy (NL) for abdominal gunshot wounds (ABGSWs) and the potential impact the use of diagnostic laparoscopy (DL) could have on these variables. DESIGN A retrospective study was conducted. MATERIALS AND METHODS The charts of all patients with ABGSWs over a 4-year period were reviewed. Data was collected on injuries, rate of NL, morbidity and hospital stay. This was compared to a subsequent group of patients with ABGSWs managed with a DL protocol. MEASUREMENTS AND MAIN RESULTS Over a 4-year period, 817 patients had exploratory laparotomy (EL) for ABGSWs. The NL rate was 12.4% (101 of 817); 69 of these patients had no associated injury or other procedures. They had a 22% morbidity and an average hospital stay of 5.1 days. Subsequently, 85 patients with ABGSWs underwent DL. This group was similar to the EL group and would have undergone EL prior to the introduction of DL at our institution. In this group, 34 patients had no associated injury or other procedures. They had a 3% morbidity, and their average hospital stay was 1.4 days. The morbidity and hospital stay were statistically significantly reduced (p < 0.01) in patients with negative DL versus NL. CONCLUSIONS These data demonstrate that NL is associated with a high morbidity and long hospital stay. The use of DL can reduce the rate of NL, and result in lower morbidity and shorter hospital stay in patients with ABGSWs.