Essay On Explorative Laparotomy

Introduction: Penetrating injuries of the abdomen are traditionally treated with exploratory laparotomy .The high non-therapeutic laparotomy rate and associated morbidity after mandatory laparotomy for abdominal stab wounds led to the current selective non-operative management strategy [1–3]. It is reported that 50–70% of abdominal stab injuries penetrate the peritoneum, but 20–40% of these penetrating wounds do not lead to significant organ injury [4]. Despite the growing use of diagnostic methods such as abdominal ultrasonography (US), computed tomography (CT), diagnostic peritoneal lavage (DPL), intravenous pyelography (IVP), and angiography, it is still difficult to evaluate the severity of penetrating abdominal stab wounds [5]. Patients with penetrating abdominal stab wounds are managed non-operatively in many centers, despite the fact that an explorative laparotomy may be an appropriate treatment strategy in selected patients. The criteria defining when an explorative laparotomy is appropriate state that hemodynamic instability and signs of peritonitis must be present. Hemodynamically stable patients without signs of
peritonitis may be carefully followed non-operatively [6, 7]. Although good results can be obtained with observation, there are inherent limitations to this approach. Observation requires that serial abdominal examinations be performed by an experienced surgeon able to detect subtle changes in physical findings (who may not be available at every time). Observation also requires hospital admission for several days, taxing the resources of overburdened institutions [8]. These reasons have prompted the search for a less invasive and more reliable method of evaluation. This is the basis of laparoscopy for abdominal trauma [9].
Patients and Methods: This study included 51 patients who were admitted to the emergency unit of Zagazig University hospitals during a period from April 2010 to October 2012. The patients were divided randomly into two groups: group I included patients who underwent exploratory laparotomy and group II included patients who underwent laparoscopic exploration. Preoperatively all patients were submitted to full history, careful general and abdominal examination, abdominal ultrasonography, laboratory tests and chest x-ray (for patients with stab wounds in the upper abdomen to exclude peumothorax). The following criteria were followed for patients’ selection: penetrating stab injuries in the abdomen with stable vital signs, no signs of peritonitis and ability to give informed consent for the study added to them intact sensations without evidence of raised intracranial pressure and absence of contraindication for pneumoperitoneum (i.e. cardiopulmonary disease).
Surgical Procedure: In preparing the patient for laparoscopic exploration, the usual rules of trauma care were followed, including adequate intravenous access, Foley catheterization, and stomach decompression with N/G tube. The procedure was conducted under general anesthesia and patients were prepped in the supine position from chin to thighs for a possible conversion to an open procedure. The operating table allowed Trendelenburg, reverse Trendelenburg positions, and side-to-side tilting of the table. The entrance site of the stab was sutured and covered with an occlusive dressing to allow for creation of pneumoperitoneum.
The first trocar for 10 mm laparoscope (30º) was inserted at the umbilicus. After the abdomen has been entered, the anterior abdominal wall at the site of the stab (that was depressed with a finger) was examined to detect peritoneal violation. If the peritoneum was intact the procedure was terminated. If there is violation of the peritoneum another two 5 mm trocars were inserted at the right and left paramedian sites at the level of the umbilicus for systemic examination of the abdomen using a traumatic bowel graspers. If no injury was identified, the procedure was terminated and the patient was put under observation. If injury was found, it was either managed laparoscopically or with exploratory
laparotomy.
Figure (1) shows the used algorithm for the laparoscopic management of abdominal stab wounds [adapted from Choi and Lim [10] Figure (1): algorithm for the laparoscopic management of abdominal stab wounds.