SciELO - Scientific Electronic Library Online

 
vol.50 número2Radiation dose to surgeons in theatreRepair of abdominal aortic aneurysms with aorto-uni-iliac stentgraft and femoro-femoral bypass índice de autoresíndice de assuntospesquisa de artigos
Home Pagelista alfabética de periódicos  

Serviços Personalizados

Artigo

Indicadores

Links relacionados

  • Em processo de indexaçãoCitado por Google
  • Em processo de indexaçãoSimilares em Google

Compartilhar


South African Journal of Surgery

versão On-line ISSN 2078-5151
versão impressa ISSN 0038-2361

S. Afr. j. surg. vol.50 no.2 Cape Town Mai. 2012

 

GENERAL SURGERY

 

Laparotomy for blunt abdominal trauma in a civilian trauma service

 

 

N. HowesI; T. WalkerI; N. L. AllortoII; G. V. OosthuizenIII; D. L. ClarkeIV

IM.B. Ch.B.; Department of General Surgery, Pietermaritzburg Metropolitan Complex, and Nelson R. Mandela School of Medicine, University of KwaZulu-Natal
IIF.C.S. (S.A.), M.Med.; Department of General Surgery, Pietermaritzburg Metropolitan Complex, and Nelson R. Mandela School of Medicine, University of KwaZulu-Natal
IIIF.C.S. (S.A.); Department of General Surgery, Pietermaritzburg Metropolitan Complex, and Nelson R. Mandela School of Medicine, University of KwaZulu-Natal
IVF.C.S. (S.A.), M.Med. Sci., M.B.A., M.Phil.; Department of General Surgery, Pietermaritzburg Metropolitan Complex, and Nelson R. Mandela School of Medicine, University of KwaZulu-Natal

 

 


ABSTRACT

This report looks at the group of patients who required a laparotomy for blunt torso trauma at a busy metropolitan trauma service in South Africa.
METHODS: A prospective trauma registry is maintained by the surgical services of the Pietermaritzburg metropolitan complex. This registry is interrogated retrospectively. All patients who required admission for blunt torso trauma over the period September 2006 - September 2007 were included for review. Proformas documenting mechanism of injury, age, vital signs, blood gas, delay in presentation, length of hospital stay, intensive care unit stay and operative details were completed.
RESULTS: A total of 926 patients were treated for blunt trauma by the Pietermaritzburg metropolitan services during the period under consideration. A cohort of 65 (8%) required a laparotomy for blunt trauma during this period. There were 17 females in this group. The mechanisms of injury were motor vehicle accident (MVA) (27), pedestrian vehicle accident (PVA) (21), assault (5), fall from a height (3), bicycle accident (6), quad bike accident (1) and tractor-related accident (2). The following isolated injuries were discovered at laparotomy: liver (9), spleen (5), diaphragm (1), duodenum (2), small bowel (8), mesentery (8), bladder (10), gallbladder (1), stomach (2), colon/rectum (2) and retrohepatic vena cava (1). The following combined injuries were discovered: liver and diaphragm (2), spleen and pancreas (1), spleen and liver (2), spleen, aorta and diaphragm (1), spleen and bladder (1) and small bowel and bladder (2). Eighteen patients in the series (26%) required relaparotomy. In 10 patients temporary abdominal containment was needed. The mortality rate was 26% (18 patients). There were 6 deaths from massive bleeding, all within 6 hours of operation, and 3 deaths from renal failure; the remaining 9 patients died of multiple organ failure. There were 8 negative laparotomies (7%). In the negative laparotomy group false-positive computed tomography (CT) scan findings were a problem in 3 cases, in 1 case hypotension and a fractured pelvis on admission prompted laparotomy, and in the other cases clinical findings prompted laparotomy. All patients who underwent negative laparotomy survived. There were 10 pelvic fractures, 5 lower limb fractures, 2 spinal injuries, 4 femur fractures and 2 upper limb fractures. CT scans were done in 25 patients. In 20 patients the systolic blood pressure on presentation was <90 mmHg and in 41 the pulse rate was >110 beats/min. In 16 patients there was a base excess of <-4 on presentation.
CONCLUSION: Laparotomy is needed in less than 10% of patients who sustain blunt abdominal trauma. Solid visceral injury requiring laparotomy presents with haemodynamic instability. Hollow visceral injury has a more insidious presentation and is associated with a delay in diagnosis. CT scan is the most widely used investigation in blunt abdominal trauma. It is both sensitive and specific for solid visceral injury, but its accuracy for the diagnosis of hollow visceral injury is less well defined. Clinical suspicion must be high, and hollow visceral injury needs to be actively excluded.


 

“Full text available only in PDF format”

 

REFERENCES

1. Mohamed AA, Mahran KM, Zaazou MM. Blunt abdominal trauma requiring laparotomy in polytraumatized patients. Saudi Med J 2010;31(1):43-48.         [ Links ]

2. Crookes BA, Shackford SR, Gratton J, Khaleel M, Ratliff J, Osler T. 'Never be wrong': the morbidity of negative and delayed laparotomies after blunt trauma. J Trauma 2010:69(6):1386-1391        [ Links ]

3. Stuhlfaut JW, Anderson SW, Soto JA. Blunt abdominal trauma: current imaging techniques and CT findings in patients with solid organ, bowel, and mesenteric injury. Semin Ultrasound CT MR 2007:28(2):115-129.         [ Links ]

4. Brofman N, Atri M, Hanson JM, Grinblat L, Chughtai T, Brenneman F. Evaluation of bowel and mesenteric blunt trauma with multidetector CT. Radiographics 2006:26(4):1119-1131.         [ Links ]

5. Stuhlfaut JW, Anderson SW, Soto JA. Blunt abdominal trauma: current imaging techniques and CT findings in patients with solid organ, bowel, and mesenteric injury. Semin Ultrasound CT MR 2007:28(2):115-129.         [ Links ]

6. Brofman N, Atri M, Hanson JM, Grinblat L, Chughtai T, Brenneman F. Evaluation of bowel and mesenteric blunt trauma with multidetector CT. Radiographics 2006:26(4):1119-1131.         [ Links ]

7. Brody JM, Leighton DB, Murphy BL, et al. CT of blunt trauma bowel and mesenteric injury: typical findings and pitfalls in diagnosis. Radiographics 2000:20(6):1525-1536; discussion 1536-1537.         [ Links ]

8. Yegiyants S, Abou-Lahoud G, Taylor E. The management of blunt abdominal trauma patients with computed tomography scan findings of free peritoneal fluid and no evidence of solid organ injury. Am Surg 2006:72(10):943-946.         [ Links ]

9. Livingston DH, Lavery RF, Passannante MR, et al. Free fluid on abdominal computed tomography without solid organ injury after blunt abdominal injury does not mandate celiotomy. Am J Surg 2001;182(1):6-9.         [ Links ]

10. Holmes JF, London KL, Brant WE, Kuppermann N. Isolated intraperitoneal fluid on abdominal computed tomography in children with blunt trauma. Acad Emerg Med 2000;7(4):335-341.         [ Links ]

11. Rodriguez C, Barone JE, Wilbanks TO, Rha CK, Miller K. Isolated free fluid on computed tomographic scan in blunt abdominal trauma: a systematic review of incidence and management. J Trauma 2002:53(1):79-85.         [ Links ]

12. Chol YB, Lim KS. Therapeutic laparoscopy for abdominal trauma. Surg Endosc 2003:17(3):421-427.         [ Links ]

13. Smith RS, Fry WR, Morabito DJ, Koehler RH, Organ CH Jr. Therapeutic laparoscopy in trauma. Am J Surg 1995:170(6):632-636.         [ Links ]

14. Krige JE, Nicol AJ. Treating major liver injuries. S Afr J Surg 2006:44(4):128-130.         [ Links ]

15. Nicol AJ, Hommes M, Primrose R, Navsaria PH, Krige JE. Packing for control of hemorrhage in major liver trauma. World J Surg 2007:31(3):569-574.         [ Links ]

16. Nicol AJ, Navsaria PH, Krige JE. Damage control surgery. S Afr J Surg 2010:48(1):4-5.         [ Links ]

17. Malinoski DJ, Patel MS, Yakar DO, et al. A diagnostic delay of 5 hours increases the risk of death after blunt hollow viscus injury. J Trauma 2010:69(1):84-87.         [ Links ]

18. Fakhry SM, Brownstein M, Watts DD, Baker CC, Oller D. Relatively short diagnostic delays (<8 hours) produce morbidity and mortality in blunt small bowel injury: an analysis of time to operative intervention in 198 patients from a multicenter experience. J Trauma 2000:48(3):408-414: discussion 414-415.         [ Links ]

19. Subramanian V, Raju RS, Vyas FL, Joseph P, Sitaram V. Delayed jejunal perforation following blunt abdominal trauma. Ann R Coll Surg Engl 2010:92(2):W23-24.         [ Links ]

20. Oztürk H, Onen A, Otçu S, et al. Diagnostic delay increases morbidity in children with gastrointestinal perforation from blunt abdominal trauma. Surg Today 2003:33(3):178-82.         [ Links ]

21. Sule AZ, Kidmas AT, Awani K, Uba F, Misauno M. Gastrointestinal perforation following blunt abdominal trauma. East Afr Med J 2007:84(9):429-433.         [ Links ]

22. Schenk WG 3rd, Lonchyna V, Moylan JA. Perforation of the jejunum from blunt abdominal trauma.. J Trauma 1983:23(1):54-56.         [ Links ]

23. Munshi IA, DiRocco JD, Khachi G. Isolated jejunal perforation after blunt thoracoabdominal trauma. J Emerg Med 2006:30(4):393-395.         [ Links ]

Creative Commons License Todo o conteúdo deste periódico, exceto onde está identificado, está licenciado sob uma Licença Creative Commons