RESUMO
BACKGROUND: The high missed occult small bowel injuries (SBI) associated with laparoscopy in trauma (LIT) is a major reason why some surgeons still preclude LIT today. No standardized laparoscopic examination for evaluation of the peritoneal cavity is described for trauma. The objective of this article is to verify if a systematic standardized laparoscopic approach could correctly identify SBI in the peritoneal cavity for penetrating abdominal trauma (PAT). METHODS: Victims with PAT were evaluated in a prospective, nonrandomized study. A total of 75 hemodynamically stable patients with suspected abdominal injuries were operated by LIT and converted to laparotomy if criteria were met: SBI and lesions to blind spot zones--retroperitoneal hematoma, injuries to segments VI or VII of the liver, or injuries to the posterior area of the spleen. Inclusion criteria were equivocal evidence of abdominal injuries or peritoneal penetration; systolic blood pressure >90 mm Hg and <3 L of IV fluids in the first hour of admission; Glasgow Coma Scale score >12; and age >12 years. Exclusion criteria were back injuries; pregnancy; previous laparotomy; and chronic cardiorespiratory disease. RESULTS: Sixty patients were males and there were 38 stab wounds and 37 gunshot wounds. No SBI was missed, but a pancreatic lesion was undiagnosed due to a retroperitoneal hematoma. Twenty patients (26.6%) were converted. Unnecessary laparotomies were avoided in 73.33%. Therapeutic LIT was possible in 22.7%. Accuracy was 98.66% with 97.61% sensitivity and 100% specificity. CONCLUSIONS: Standard systematic laparoscopic exploration was 100% effective to detect SBI in the peritoneal cavity. Conversion from LIT to laparotomy should be done if injuries to blind spot zones are found which are poorly evaluated by LIT. Therapeutic LIT is feasible in PAT.
Assuntos
Traumatismos Abdominais/diagnóstico , Intestino Delgado/lesões , Laparoscopia , Vísceras/lesões , Ferimentos por Arma de Fogo/diagnóstico , Ferimentos Perfurantes/diagnóstico , Traumatismos Abdominais/cirurgia , Adolescente , Adulto , Algoritmos , Árvores de Decisões , Feminino , Humanos , Laparotomia , Masculino , Pessoa de Meia-Idade , Valor Preditivo dos Testes , Espaço Retroperitoneal , Ferimentos por Arma de Fogo/cirurgia , Ferimentos Perfurantes/cirurgia , Adulto JovemRESUMO
Para avaliar os efeitos do pneumoperitônio da laparoscopia na perfusão esplâncnica, foram realizadas medidas hemodinâmicas sistêmicas (PAM, FC, SaO2, PAP, PCP,PVC, DC), e loco-regionais (fluxo portal e tonometria gástrica), em 21 cães submetidos a insuflação abdominal por hélio ou CO2; bem como um grupo controle. Verificou-se que existem alterações significativas sistêmicas e loco-regionais, com pneumoperitônio de 30 mmHg, com elevação do PCO2-gap e queda do fluxo portal maiores no grupo CO2 do que no hélio. No entanto, no grupo insuflado com 15 mmHg com hélio, não ocorreram alterações por efeito mecânico do pneumoperitônio; mas no outro grupo, a absorção de CO2 promoveu elevação significativa da PCO2-gap./ Evaluation of the laparocopic pneumoperitoneum effect with carbon dioxide or Helium over the splanchnic perfusion: experimental study in dogs [thesis]. Faculdade de Medicina, Universidade de São Paulo; 2004. In order to establish the effects of the laparoscopic pneumoperitoneum at the splanchnic perfusion, sistemic hemodinamic measures (MAP, HR, SaO2, PAP, CWP, CVP, CO) as well as local-regional measures (portal flux and gastric tonometry) were performed in 21 dogs submitted to abdominal insufflation with Helium, CO2 and a Control group. Measurements showed that there were significant sistemic and locoregional alterations with 30 mmHg pneumoperitoneum with PCO2-gap elevation and portal flux decrease portal more significant in the CO2 group...