*Hady Razak Hady1, Patrycja Pawluszewicz1, Lech Trochimowicz1, Pawel Wojciak1, Mikolaj Czerniawski1, Inna Diemieszczyk1, Monika Laskowska1, Jacek Dadan1, Krystyna Lapuc-Seweryn2, Przemyslaw Zuratynski3, Klaudiusz Nadolny4, Jerzy Robert Ladny1, 4
The role of laparoscopy in diagnosis and treatment of parenchymal organs injuries after abdominal trauma in own material
Rola laparoskopii w diagnostyce i leczeniu uszkodzeń narządów miąższowych po urazach jamy brzusznej w materiale własnym
1Ist Department of General and Endocrine Surgery, University Clinical Hospital in Bialystok, Poland
2University Clinical Hospital in Bialystok, Poland
3Emergency Medicine Workshop, Department of Emergency Medicine, Faculty of Health Sciences with Subfaculty of Nursing and Institute of Maritime and Tropical Medicine, Medical University of Gdansk, Poland
4Department of Emergency and Disaster Medicine, Medical University of Bialystok, Poland
Streszczenie
Wstęp. W ostatnich latach obserwuje się wyraźny wzrost występowania urazów wielonarządowych będących wynikiem wypadków komunikacyjnych, wypadków w rolnictwie i przemyśle, a także przestępstw z użyciem ostrych narzędzi. Wśród urazów wielonarządowych znaczną część stanowią urazy jamy brzusznej i narządów miąższowych.
Cel pracy. Celem pracy było przedstawienie materiału własnego w leczeniu chirurgicznym uszkodzeń narządów miąższowych po urazach tępych i ostrych jamy brzusznej ze szczególnym uwzględnieniem laparoskopii.
Materiał i metody. W pracy przedstawiono 326 chorych hospitalizowanych w I Klinice Chirurgii Ogólnej i Endokrynologicznej w latach 2000-2015 z powodu urazów narządów miąższowych jamy brzusznej.
Wyniki. Wśród badanej populacji najczęstszą przyczyną urazów jamy brzusznej były wypadki komunikacyjne. Większości urazów narządów miąższowych towarzyszyły obrażenia innych narządów, tylko 23,5% stanowiły urazy izolowane. Najczęściej obserwowano uszkodzenie wątroby, śledziony lub obu narządów jednocześnie. Pacjentów diagnozowano oraz wdrożono leczenie. U 88 chorych zastosowano laparoskopię jako metodę diagnostyczno-leczniczą.
Wnioski. Urazy jamy brzusznej stanowią istotny problem diagnostyczno-leczniczy obecnych czasów. Szybka i właściwa diagnostyka oraz wdrożenie odpowiedniego leczenia mają znaczący wpływ na przeżycie i powrót do zdrowia pacjentów. Coraz częściej wykorzystujemy laparoskopię jako metodę nie tylko diagnostyczną, ale również leczniczą.
Summary
Introduction. Nowadays a significantly growing occurrence of multi-organ traumas is observed, which are in general caused most often by traffic accidents, agriculture accidents as well as a result of crime. Abdomen and parenchymal organs’ traumas are very common and significant comorbidity in such cases.
Aim. The aim of the study was to preasent own material comprising cases of the surgical treatment of parenchymal organ damage after blunt and acute abdominal trauma with special emphasis on laparoscopy.
Material and methods. This study comprises 326 cases of parenchymal organ injuries, hospitalized and treated in 1st Department of General and Endocrine Surgery in years 2000 to 2015.
Results. Among examined population of patients, traumas of abdomen were most commonly caused by traffic accidents. The majority of parenchymal organs’ injuries coexisted with other traumas, only 23.5% of them were isolated. All patients were diagnosed and treated. Laparoscopy was used as a method of diagnosis and treatment in 88 cases.
Conclusions. Abdominal traumas are important diagnostic and therapeutic challenge of the last years. Immediate and proper diagnosis and treatment significantly influences the survival and recovery rates for patients. There’s also noticeable raise in use of laparoscopy as a diagnostic and therapeutic method.
Introduction
Abdominal injuries are an important medical challenge in the field of general surgery and emergency medicine. Injuries are the third most common cause of death in Poland after cardiovascular diseases and neoplasms and the first most common cause of death in young people under 40 years old (1). In Poland, there are approximately 3,5 million injuries per year and post-traumatic mortality is 78/100.000 that is approximately 30.000 people per year (2). One of the most common causes of injuries, apart from assaults and falls from heights, are traffic accidents. Annually there are approximately 40.000 injuries and 3.000 deaths in about 25.000 accidents (3). Worldwide, around 1,25 million people die each year due to traffic accidents (4). Statistics of Polish Police show that in the last decade the number of accidents and deaths caused by them decreased almost by half, but still remains very high (3).
Multi-organ traumas are associated with life threat, require urgent and proper diagnosis and treatment by a multidisciplinary team. Despite the development of emergency medicine, imaging diagnostic techniques and surgical procedures, as well as establishing a new standards for treatment of multiple organ injuries, their mortality rate is still high and varies form 15-30%.
Abdominal injuries are approximately 2% of all traumas and are also more frequent among men (5). Young people under 40 years old constitute 75% of total number of abdominal injury cases and 50% of them are isolated abdominal traumas. Other abdominal injuries accompany traumas of other parts of the body, including head, neck, chest and limbs (5). Among victims with multiple injuries, more than 20% have abdominal trauma and more than 50% patients who died at the scene of accident had confirmed damage of the abdominal organs.
The utmost cause of death as a result of multi-organ injury is a hemorrhagic shock with its complications. Blunt and penetrating traumas can be distinguished among all abdominal injuries. Blunt injuries are usually a result of traffic accidents, falls from height, assaults, while penetrating injuries often result from the crime with sharp tools or are effects of accidents in agriculture (6). As a result of injuries of abdominal organs, hemorrhage or intestinal perforation usually occur. Not only parenchymal organs such as liver or spleen, which injuries are mostly accompanied by extensive bleeding into peritoneal cavity, but also gastrointestinal tract can be damaged.
Immediate and accurate diagnosis followed by implementation of appropriate treatment increase the chances of survival and enforces the recovery of the injured patient. In case of abdominal trauma, apart from physical examination, there are two major imaging diagnostic techniques: ultrasonography (USG) in FAST protocol confirms presence of blood/fluid in peritoneal cavity and computer tomography (CT), which allows additionally to visualize air, fluid and extravasing contrast agent inside the abdomen. Diagnostic puncture and lavage of peritoneal cavity can also be taken under consideration. Due to increasing popularity and availability of laparoscopy, it is also possible to apply this method in diagnostics of abdominal parenchymal organs’ trauma, especially in inconclusive cases. The limitation is only the availability of equipment and efficiency of the surgical team in laparoscopic techniques.
Laparoscopy allows not only diagnostic, but also treatment of bleeding or damage to abdominal organs (7, 8). Despite advances in imaging techniques, diagnosis of abdominal injuries remains difficult, especially in patients with multiple injuries, unconscious and with craniocerebral injuries. At the appropriate time, unrecognized and thus incorrectly treated abdominal injuries may lead to early posttraumatic death (9) along with cranial and cerebral injuries.
Aim
The aim of the study was to present own material comprising cases of the surgical treatment of parenchymal organ damage after blunt and acute abdominal trauma with special emphasis on laparoscopy.
Material and methods
During 15 years between 2000 and 2015, 326 patients with abdominal trauma were hospitalized in the Trauma Center and the 1st Department of General and Endocrine Surgery of the University Hospital in Bialystok. Among patients hospitalized due to abdominal trauma, 128 (39.3%) were women and 198 (60.7%) men aged between 16 and 83 years old. The average age was 42.5 years old (fig. 1).
Fig. 1. Gender of patients hospitalized due to abdominal traumas
The mechanism of injury resulting in damage of parenchymal organs was analyzed. Also performed diagnostic methods were presented along with precise description of the type of damage to parenchymal organs, as well as the coexisting pathologies, applied treatment and its results.
Results
Among 211 (64.7%) patients with parenchymal organs’ injuries suffered a trauma as a result of traffic accidents. 64 (19.6%) patients were hospitalized due to penetrating abdominal trauma. A fall from height was the cause of injury in 26 (8%) patients. 25 (7.7%) patients were hospitalized after an assault (fig. 2 and tab. 1).
Fig. 2. Abdominal traumas mechanism
Tab. 1. Mechanism of abdominal injuries
| Mechanism of abdominal injuries | Number of patients |
| n | % |
| Traffic injuries | 211 | 64.7 |
| Sharp tools wounds | 64 | 19.6 |
| Fall from height | 26 | 8 |
| Assault | 25 | 7.7 |
Among 326 patients, only 77 (23.5%) had isolated abdominal trauma. In remaining 249 (76.5%) patients, a multi-organ trauma was diagnosed. Table 2 presents the types of damage associated with abdominal injuries.
Tab. 2. Co-traumas of parenchymal organs of the abdomen injuries
| Co-traumas of parenchymal organs of the abdomen injuries | Number of patients |
| n | % |
| Craniocerebral trauma | 85 | 26.1 |
Fracture:
limbs
pelvis
spine |
145
26
21 |
44.5
8.0
6.4 |
| Thoracic injury | 70 | 21.5 |
In the diagnostics of abdominal parenchymal organs’ trauma, in addition to physical examination, imaging methods such as X-ray, ultrasound and computer tomography as well as diagnostic laparoscopy and laparotomy were used (tab. 3). Among 88 patients undergoing diagnostic laparoscopy, in 37 (42%) cases, conversion to laparotomy was necessary. The remaining 51 (58%) patients underwent laparoscopy as a diagnostic and therapeutic procedure. In 37 (11.3%) patients diagnostic and therapeutic laparotomy was performed without previous imaging diagnostics.
Tab. 3. Diagnostic procedures in abdominal injuries
| Parenchymal organs injuries – diagnostics procedures | Number of patients |
| n | % |
| Abdominal USG | 254 | 77.9 |
| CT | 209 | 64.1 |
| Abdominal + thorax RTG | 250 | 79.7 |
| Peritoneal cavity puncture | 21 | 6.4 |
| Diagnostics laparoscopy | 88 | 27.0 |
| Conversion to laparotomy | 37 | 42.0 |
| Diagnostics-treatment laparotomy | 37 | 11.3 |
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