Laparoscopy and loop colostomy : a new approach to extra-peritoneal rectal injuries

Includes bibliographical references.Distal rectal washout and presacral drainage appear to have little or no influence on the morbidity and mortality in patients with low-energy trauma to the rectum. The ever-increasing popularity and obvious advantages of minimal access surgery have prompted surgeons to apply its use to a variety of surgical diseases, including trauma-related conditions. This study retrospectively reviews and examines the safety and efficacy of laparoscopy and the formation of a diverting sigmoid loop colostomy through an abdominal wall trephine, in a limited number of carefully selected patients with isolated extra-peritoneal rectal injuries. The patient is thus spared a major laparotomy wound. The value of distal rectal washout and presacral drainage in such injuries is also examined

Negative pressure wound therapy management of the "open abdomen" following trauma: a prospective study and systematic review

INTRODUCTION: The use of Negative Pressure Wound Therapy (NPWT) for temporary abdominal closure of open abdomen (OA) wounds is widely accepted. Published outcomes vary according to the specific nature and the aetiology that resulted in an OA. The aim of this study was to evaluate the effectiveness of a new NPWT system specifically used OA resulting from abdominal trauma. METHODS: A prospective study on trauma patients requiring temporary abdominal closure (TAC) with grade 1or 2 OA was carried out. All patients were treated with NPWT (RENASYS AB Smith & Nephew) to achieve TAC. The primary outcome measure was time taken to achieve fascial closure and secondary outcomes were complications and mortality. RESULTS: A total of 20 patients were included. Thirteen patients (65%) achieved fascial closure following a median treatment period of 3 days. Four patients (20%) died of causes unrelated to NPWT. Complications included fistula formation in one patient (5%) with spontaneous resolution during NPWT), bowel necrosis in a single patient (5%) and three cases of infection (15%). No fistulae were present at the end of NPWT. CONCLUSION: This new NPWT kit is safe and effective and results in a high rate of fascial closure and low complication rates in the severely injured trauma patient

Non-operative management of abdominal stab wounds- an analysis of 186 patients

Background: The modern management of abdominal stab wounds remains controversial and subject to continued reappraisal. In the present study we reviewed patients with abdominal stab wounds to examine and validate a policy of selective non-operative management with serial physical abdominal examination in a busy urban trauma centre with a high incidence of penetrating trauma. Methods: Over a 12-month period (2005), the records of all patients with abdominal stab wounds were reviewed. Patients with abdominal stab wounds presenting with peritonitis, haemodynamic instability, organ evisceration and high spinal cord injury underwent emergency laparotomy. No local wound exploration, diagnostic peritoneal lavage or ultrasound was used. Haematuria in patients without an indication for emergency surgery was investigated with a contrasted computed tomography (CT) scan. Patients selected for non-operative management were admitted for serial clinical abdominal examination for 24 hours. Patients in whom abdominal findings were negative were given a test feed. If food was tolerated, they were discharged with an abdominal injury form. Results: One hundred and eighty-six patients with abdominal stab wounds were admitted. There were 171 (91.9%) males, with a mean age of 29.5 years. Seventy-four patients (39.8%) underwent emergency laparotomy. There were 5 negative laparotomies (6.8%). The remaining 112 patients (60.2%) were assigned for abdominal observation. One hundred (89.3%) of these patients were successfully managed non-operatively. The remaining 12 patients underwent delayed laparotomy, which was negative in 2 cases (16.7%). Non-operative management was successful in 53.8% of patients overall. The overall sensitivity and specificity of serial abdominal examination was 87.3% and 93.5%, respectively. Conclusion: Serial physical examination alone for asymptomatic or mildly symptomatic patients with abdominal stab wounds enables a significant reduction in unnecessary laparotomies

Video-assisted Thoracoscopic pericardial window for penetrating cardiac trauma

Objective: To report our experience with thoracoscopic pericardial window (TPW) for occult penetrating cardiac injury. Patients and methods: During the study period (1 January - 31 December 2000), a small group of haemodynamically stable patients with anterior leftsided praecordial wounds were selected for TPW. All patients underwent general anaesthesia with doublelumen intubation and collapse of the left lung. A rigid laparoscope was inserted through a 2 cm incision in the 5th intercostal space in the anterior axillary line. Another 3 cm incision was made in the fourth intercostal space over the cardiac silhouette. Conventional instruments were used to grasp and open the pericardium. Any myocardial injury identified was an indication to proceed to sternotomy. In the absence of a myocardial injury and bleeding, the procedure was terminated and considered therapeutic. Results: Seventy-one patients with suspected penetrating cardiac injuries were seen. TPW was successfully completed in 13 patients. All were men, with a mean age of 29.8 (range 19 - 38) years. Ten and 3 patients sustained stab and gunshot wounds, respectively. The mean revised trauma score was 7.84. Ultrasound was performed in 12 patients; the results were equivocal for 2 patients, and positive for an effusion in 4 patients. Haemopericardium was found in 3 patients, 2 of whom proceeded to sternotomy. No cardiac injury was found in 1, a left ventricular contusion was identified in the second, and the third patient had no further procedure after good video-thoracoscopic visualisation of the anterior myocardium revealed no injury. In another patient, pericardial bruising was evident without any haemopericardium. The mean operative time was 13.4 (range 10 - 15) minutes, with a mean hospital stay of 5.4 (range 3 - 8) days. There were no complications. The use of a double-lumen endotracheal tube increased the cost of TPW by 23% when compared with subxiphoid pericardial window (SPW). Conclusion: TPW is a feasible, although in our setting not cost-effective, diagnostic option for occult penetrating cardiac injuries

Is case triaging a useful tool for emergency surgeries? A review of 106 trauma surgery cases at a level 1 trauma center in South Africa

The optimal timing for emergency surgical interventions and implementation of protocols for trauma surgery is insufficient in the literature. The Groote Schuur emergency surgery triage (GSEST) system, based on Cape Triaging Score (CTS), is followed at Groote Schuur Hospital (GSH) for triaging emergency surgical cases including trauma cases. The study aimed to look at the effect of delay in surgery after scheduling based on the GSEST system has an impact on outcome in terms of postoperative complications and death

Predicting mortality in damage control surgery for major abdominal trauma

Damage control surgery (DCS) has become well established in the past decade as the surgical strategy to be employed in the unstable trauma patient. The aim of this study was to determine which factors played a predictive role in determining mortality in patients undergoing a damage control laparotomy. Materials and methods. A retrospective review of all patients undergoing a laparotomy and DCS in a level 1 trauma centre over a 3-year period was performed. Twenty-nine potentially predictive variables for mortality were analysed. Results. Of a total of 1 274 patients undergoing a laparotomy for trauma, 74 (6%) required a damage control procedure. The mean age was 28 years (range 14 - 53 years). The mechanism of injury was gunshot wounds in 57 cases (77%), blunt trauma in 14 (19%) and stabs in 3 (4%). Twenty patients died, giving an overall mortality rate of 27%. Factors significantly associated with increased mortality were increasing age (p=0.001), low base excess (p=0.002), pH (p<0.001), core temperature (p=0.002), and high blood transfusion requirement over 24 hours (p=0.002). Conclusion. The overall survival of patients after damage control procedures for abdominal trauma is excellent (73%). The main factors that are useful in deciding when to initiate DCS are age, base excess, pH and the core temperature

The firearm pandemic: time to act and flatten the curve

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Penetrating renal injuries: an observational study of non-operative management and the impact of opening Gerota’s fascia

Background Non-operative management has become increasingly popular in the treatment of renal trauma. While data are robust in blunt mechanisms, the role of non-operative management in penetrating trauma is less clear. Additionally, there is a paucity of data comparing gunshot and stab wounds. Methods A retrospective review of patients admitted to a high-volume level 1 trauma center (Groote Schuur Hospital, Cape Town) with penetrating abdominal trauma was performed. Patients with renal injuries were identified and compared based on mechanism [gunshot (GSW) vs. stab] and management strategy (operative vs. non-operative). Primary outcomes of interest were mortality and failure of non-operative management. Secondary outcomes of interest were nephrectomy rates, Clavien-Dindo complication rate, hospital length of stay, and overall morbidity rate. Results A total of 150 patients with renal injuries were identified (82 GSW, 68 stab). Overall, 55.2% of patients required emergent/urgent laparotomy. GSWs were more likely to cause grade V injury and concurrent intra-abdominal injuries (p > 0.05). The success rate of non-operative management was 91.6% (89.9% GSW, 92.8% stab, p = 0.64). The absence of hematuria on point of care testing demonstrated a negative predictive value of 98.4% (95% CI 96.8–99.2%). All but 1 patient who failed non-operative management had associated intra-abdominal injuries requiring surgical intervention. Opening of Gerota’s fascia resulted in nephrectomy in 55.6% of cases. There were no statistically significant risk factors for failure of non-operative management identified on univariate logistic regression. Conclusions NOM of penetrating renal injuries can be safely and effectively instituted in both gunshot and stab wounds with a very low number of patients progressing to laparotomy. Most patients fail NOM for associated injuries. During laparotomy, the opening of Gerota’s fascia may lead to increased risk of nephrectomy. Ongoing study with larger populations is required to develop effective predictive models of patients who will fail NOM