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Laparoscopy in Abdominal Trauma

Laparoscopy in Abdominal Trauma. By Hesham Amer General Surgery Cairo University. Abdominal Injuries.

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Laparoscopy in Abdominal Trauma

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  1. Laparoscopy in Abdominal Trauma By Hesham Amer General Surgery Cairo University.

  2. Abdominal Injuries • They are broadly divided into blunt & penetrating injuries ; this has a direct implication on the diagnostic workup & therapy.However the initial assessment & resuscitation if needed are the same. • Wartime abdominal injuries are mainly penetrating. • Civilian injuries are mainly blunt.

  3. Abdominal Injuries • Causes of blunt abdominal trauma are: *Motor vehicle crashes 75% (pedestrians & passengers). * Falls ( vertical deceleration). * Motorcycle & bicycle crashes. * Assaults.

  4. Abdominal Injuries. • Causes of penetrating abdominal trauma: * Stab wounds. * Gunshot wound ( GSW). * Shotgun wounds. * Impalement injuries.

  5. Peculiarties of Abdominal Injuries. • They are usually associated with other injuries(25% isolated abdominal injuries).The association of CNS, Chest & limb injuries may obscure injury of abdominal contents & their symptoms. • Intra-abdominal injuries carry a high morbidity & mortality because they are often not detected (anatomical considerations), or severity is underestimated especially in blunt trauma there maybe few or no external signs. • Always have a high index of suspicion of abdominal injury when the history suggests severe trauma .

  6. Peculiarties of Abdominal injuries. • Clinical re-evaluation in blunt abdominal trauma is mandatory ; why? Because: *Muscle guarding resulting from intraperitoneal injury can be due to abdominal wall injuries (cause of non therapeutic laparotomy in the haemodynamically stable patient). *Signs of peritoneal irritation after rupture of a hollow viscus can be slow to develop as in cases of small intestinal injury. • 20% of polytrauma pat. require abdominal operations.

  7. Peculiarties of Abdominal Injuries. • The abdomen encompasses a large area of the body from the diaphragm ( level of the nipples) superiorly to the infragluteal fold inferiorly. This is specially relevant to penetrating injuries that can transgress the chest or thighs to involve intra abdominal organs.

  8. Potential Benefits of Laparoscopy in Trauma Management. • Diagnostic: 1) In multi- trauma : Is there an abdominal injury? 2) Presence of haemorrhage. 3) Source of Hge. 4) Has the injury penetrated the peritoneum? 5) Solid or hollow viscus injury? 6) Diaphragmatic injuries. • Therapeutic.

  9. Limitations of Laparoscopy in Trauma Management. 1) Haemodynamic instability ( absolute contraindication). 2) Need of general anaesthesia. 3) Retroperitoneal injuries. 4) Intestinal manipulations. 5) Subject to availability of: $ technology. Team (anaesthesia, technicians &surgeons). Contestant imaging or technique( DPL).

  10. Diagnostic issues in Trauma. • In multitrauma : is there an abdominal injury? * In haemodynamic instability no role for laparoscopy. * In haemodynamic stability; To exclude hge---- FAST & CT more cost effective. To exclude intraperitoneal organ spillage ---- DPL is more cost effective than laparoscopy ( local anaesthesia). NB: in gluteal & chest stabs laparoscopy is cost effective.

  11. Diagnostic issues in Trauma. • In multitrauma : is there an abdominal injury? * In haemodynamic instability no role for laparoscopy. * In haemodynamic stability; To exclude hge---- FAST & CT more cost effective. To exclude intraperitoneal organ spillage ---- DPL is more cost effective than laparoscopy ( local anaesthesia). NB: in gluteal & chest stabs laparoscopy is cost effective.

  12. Diagnostic issues in Trauma. 2) Presence of hge: * In haemodynamic instability no role for laparoscopy , FAST is the best. * In haemodynamic stability; To exclude hge---- FAST & CT more cost effective.

  13. Diagnostic issues in Trauma. 3) Source of hge: * In haemodynamic instability no role for laparoscopy , FAST is the best. * In haemodynamic stability with penetrating low velocity injuries; laparoscopy is the best ; it could detect anterior abdominal wall bleeding that may prevent an unnecessory laparotomy.

  14. Diagnostic issues in Trauma. 4) Is It penetrating?: * In haemodynamic instability( high velocity weapons) no role for laparoscopy --- Immediate laparotomy after ressuscitation. * In haemodynamic stability with penetrating low velocity injuries; laparoscopy is the best ; it could also detect tangential firearm injuries. * In haemodynamically stable posterior stabs ----- CT with contrast is the most cost effective.

  15. Diagnostic issues in Trauma. 5a) Solid viscus injury: * In haemodynamic instability no role for laparoscopy --- FAST may suggest Immediate laparotomy after ressuscitation is better. * In haemodynamic stability with penetrating low velocity injuries; laparoscopy is more cost effective than CT for detection of associated hollow viscus injuries. * In haemodynamically stability with blunt trauma--- CT is more cost effective.

  16. Diagnostic issues in Trauma. 5b) Hollow viscus injury: * In haemodynamic instability no role for laparoscopy --- Immediate laparotomy after ressuscitation is best. * In haemodynamic stability with intraperitoneal injuries due to blunt trauma ----CT (pneumoperitoneum) but with penetrating low velocity injuries; laparoscopy is more cost effective than CT . * In haemodynamically stability extraperitoneal injury with blunt or penetrating trauma--- CT is more cost effective.

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