Importance of diagnostic laparoscopy in the assessment of the diaphragm after left thoracoabdominal stab wound: A prospective cohort study.

BACKGROUND: Stab wounds in the left thoracoabdominal region may cause diaphragmatic injury. The aim of the present study was to determine incidence of diaphragmatic injury and role of diagnostic laparoscopy in detection of injury in patients with left thoracoabdominal stab wound. METHODS: Total of 81 patients (75 male, 6 female; mean age 27.5±9.8 years; range 14 to 60 years) who presented with left thoracoabdominal stab wound between April 2009 and September 2014 were evaluated. Laparotomy was performed on patients who had hemodynamic instability, signs of peritonitis, or organ evisceration. Remaining patients were followed conservatively. After 48 hours, diagnostic laparoscopy was performed on patients without laparotomy indication to examine the left diaphragm for injury. Follow-up and treatment findings were prospectively evaluated. RESULTS: Thirteen patients underwent laparotomy while diagnostic laparoscopy was performed on remaining 68 patients. Left diaphragmatic injury was observed in 19 patients (23.5%) in the study group. Four injuries were diagnosed by laparotomy and 15 were diagnosed by laparoscopy. Presence of hemopneumothorax did not yield difference in incidence of diaphragmatic injury (p=0.131). No significant difference was detected in terms of diaphragmatic injury with respect to entry site of stab wound in the thoracoabdominal region (p=0.929). CONCLUSION: It is important to evaluate the diaphragm in left thoracoabdominal stab injuries, and diagnostic laparoscopy is still the safest and most feasible method.

Application of high resolution pQCT analysis for the assessment of a bone lesion: a technical note.

Peripheral quantitative computed tomography (pQCT) has found new fields of application in bone medicine, but none of them concerns the forensic practice. This study exposes the potential of pQCT applied to a penetrating lesion in a vertebral body. A pQCT scanner was used for the measurements (XCT Research SA+; Stratec Medizintechnik GmbH, Pforzheim, Germany). A more precise reconstruction of the path of the lesion within the trabecular bone was reached, with more details concerning the morphological characteristics of the lesion inside the vertebral body, and the elaboration of a 3D model was created, which allowed the operator to define the volume of the lack of tissues related to the lesion. The application of pQCT scan proved to be a potentially useful tool for the assessment of bone lesions, although further studies are needed in order to verify its applicability to forensic context.

The use of the anatomic 'zones' of the neck in the assessment of penetrating neck injury.

The traditional classification of neck injuries uses an anatomic description of Zones I through III. The objective of this article was to characterize the association between external wounds and the corresponding internal injuries after penetrating neck trauma to identify the clinical use of the anatomic zones of the neck. Patients who sustained penetrating neck trauma from December 2008 to March 2011 were analyzed. All patients underwent structured clinical examination documenting the external zone where the wound(s) were located. All internal injuries were then correlated with the external wounds. An internal injury was defined as "unexpected" if it was located outside the borders of the neck zone corresponding to the external wound. In total, 146 patients sustaining a penetrating neck injury were analyzed; 126 (86%) male. The mechanism of injury was stab wounds in 74 (51%) and gunshot wounds in 69 (47%). Mean age was 31 years (range, nine to 62 years). Thirty-seven (25%) patients sustained had a total of 50 internal injuries. There was a high incidence of noncorrelation between the location of the external injury and the internal structures that were damaged in patients with hard signs of vascular or aerodigestive injury. The use of the anatomic zones and their role in the workup of penetrating neck injury are questionable.

[Assessment of injuries to the neck and dentomandibular system complicated by the infectious process].

The objective of the present work was to consider problems pertaining to forensic medical examination of injuries to the neck and dentition system complicated by pyoinflammatory processes. Two clinical observations are reported to illustrate significant difficulties encountered by forensic medical experts during assessment of the severity of harm inflicted to human health in the cases requiring differential characteristic of injuries, evaluation of opportuneness and completeness of the provided medical aid, and the role of these factors in the development of fatal pyoseptic complications. Special emphasis is laid on the analysis of possibilities to attain these goals based on the "Medical criteria for the assessment of severity of harm inflicted to human health" (2008).

Review article: Emergency department assessment and management of stab wounds to the neck.

A stab wound to neck is an infrequent but highly important presentation to the ED in Australasia. Injuries to the two large neurovascular bundles that are vital to life might occur with associated injuries to midline aerodigestive structures. A literature review was undertaken to discuss the assessment and management of this injury in the emergency medicine setting.

Imaging assessment of penetrating craniocerebral and spinal trauma.

Craniocerebral and spinal penetrating trauma, which may be either missile (most typically gun-related) or non-missile (most typically knife-related), is becoming an increasingly common presentation to the urban general and specialized radiology service in the UK. These injuries carry significant morbidity and mortality with a number of criteria for prognosis identifiable on cross-sectional imaging. Potential complications can also be pre-empted by awareness of certain neuroradiological features. Not all of these injuries are criminal in origin, however, a significant proportion will be, requiring, on occasion, provision of both ante-mortem and post-mortem radiological opinion to the criminal investigative procedure. This review aims to highlight certain imaging features of penetrating craniocerebral and spinal trauma including important prognostic, therapeutic, and forensic considerations.

"Awake" laparoscopy for the evaluation of equivocal penetrating abdominal wounds.

BACKGROUND: Diagnostic laparoscopy is useful for the assessment of equivocal penetrating abdominal wounds, and has become the modality of choice for the evaluation of such wounds at our institution. We hypothesised that, in appropriate patients, diagnostic "awake" laparoscopy (AL) could be performed under local anaesthesia in the emergency department (ED), allowing for expedited discharge and potential cost savings. METHODS: Selected haemodynamically stable patients with penetrating abdominal injury underwent AL. Suitability for AL was at the discretion of the attending surgeon. Identification of peritoneal penetration by AL led to exploratory laparotomy in the operating room. Patients with no evidence of peritoneal penetration were discharged from the ED (ALneg). These patients were matched to a cohort of 24 patients who underwent diagnostic laparoscopy in the OR which was negative for peritoneal penetration (DLneg). Length of stay and hospital charges were compared. RESULTS: Over a 30-month period, 15 patients underwent AL without complication. No peritoneal penetration was found in 11 patients. The remaining four patients underwent exploratory laparotomy, of which two were positive for intra-abdominal injury. Mean time to discharge was 7h in the ALneg group versus 18 h in the DLneg group (p=0.0003). Cost savings on hospital charges averaged 2227 US dollars per patient in the ALneg group compared with the DLneg group. CONCLUSIONS: AL may be safely performed in the ED, allowing for expedited patient discharge. Cost savings are achieved by the avoidance of charges inherent to diagnostic laparoscopy performed in the operating room.

The contribution of laparoscopy in evaluation of penetrating abdominal wounds.

BACKGROUND: Penetrating abdominal wounds are traditionally explored by laparotomy. We investigated prospectively the role of laparoscopy within a defined protocol for management of penetrating abdominal wounds to determine its safety and advantages over traditional operative management. STUDY DESIGN: The study inclusion criteria were: stab and gun shot abdominal wounds, including junction zone injuries; stable vital signs; and absence of contraindications for laparoscopy. Diagnostic end points included detection of peritoneum or diaphragm violation, visceral injuries, and other indications for laparotomy. Systematic examination was undertaken using a multiport technique whenever the peritoneum or diaphragm had been violated. All repairs were done by open operation. RESULTS: A total of 40.6% of patients with penetrating trauma fulfilled study criteria (52 patients). Of these, 33% had no peritoneal penetration; 29% had no visceral injuries despite violation of peritoneum or diaphragm; 38% had visceral injuries, of which 40% (mainly liver and omentum) required no intervention. Twelve patients (23% of total) had open repairs. No missed injuries or death occurred in the study. Overall, 77% of penetrating injuries with stable vital signs avoided exploratory laparotomy. Compared with National Trauma Data Bank information for patients with the same Injury Severity Scores, hospitalization was reduced by more than 55% for the entire series. CONCLUSIONS: Laparoscopy for penetrating abdominal injuries in a defined set of conditions was safe and accurate, effectively eliminating nontherapeutic laparotomy and shortening hospitalization.

Selective clinical management of anterior abdominal stab wounds.

BACKGROUND: The optimal management of clinically stable patients with anterior abdominal stab wounds (AASWs) is debated. We implemented a protocol of serial clinical assessments to determine the need for laparotomy. The purpose of this study was to determine whether the approach is safe and effective. METHODS: Records of patients sustaining AASWs from 1999 to 2003 were reviewed. RESULTS: Seventy-seven patients sustained AASWs. Twenty-five were taken directly to the operating room because of hypotension (5), evisceration (7), or peritonitis (15). Seventeen patients had diagnostic peritoneal lavage (DPL) for associated thoracoabdominal wounds and 5 had local wound exploration (LWE) off protocol. The remaining 30 patients were managed with serial clinical assessments and were discharged uneventfully. CONCLUSION: Patients sustaining AASWs who present without hypotension, evisceration, or peritonitis may be managed safely under a protocol of serial clinical evaluations. This approach should be compared with LWE/DPL in a prospective, randomized multicenter trial.

Diagnostic laparoscopy in abdominal stab wounds: a prospective, randomized study.

BACKGROUND: The optimal strategy for identifying patients with abdominal stab wounds requiring surgical repair has not been defined. The potential benefits of diagnostic laparoscopy by incorporating it into the routine diagnostic workup of patients with anterior abdominal stab wounds was evaluated in a two-layer, randomized study. METHODS: From May 1997 through January 2002, stable patients without peritonitis but with demonstrated peritoneal violation were randomized (A) to exploratory laparotomy (AEL) (n = 23) or diagnostic laparoscopy (ADL) (n = 20). Simultaneously, patients with equivocal peritoneal violation on local wound exploration were randomized (B) to diagnostic laparoscopy (BDL) (n = 28) or expectant nonoperative management (BNOM) (n = 31). Hospital morbidity, length of stay, and costs were primary endpoints, with postdischarge disability being a secondary endpoint. RESULTS: In patients with peritoneal penetration (AEL vs. ADL), there were minimal differences in the therapeutic operation rate (8 of 23 [AEL] vs. 8 of 20 [ADL], p = 0.761), mortality (none), morbidity (3 of 23 vs. 2 of 20, p = 0.999), hospital stay (mean +/- SD) (5.7 +/- 2.5 vs. 5.1 +/- 4.0 days, p = 0.049), hospital costs (4.6 +/- 1.3 vs. 4.8 +/- 1.9 x 1,000 EUR, p = 0.576), and length of sick leave (34 +/- 12 vs. 29 +/- 11 days, p = 0.305). In patients with equivocal peritoneal penetration (BDL vs. BNOM), laparoscopy found more mostly minor organ injuries (7 of 28 [BDL] vs. 1 of 31 [BNOM], p = 0.022) with no significant difference in therapeutic operations (3 of 28 vs. 1 of 31, p = 0.337) or morbidity (3 of 28 vs. 0 of 31, p = 0.101), but was associated with increased length of stay (2.6 +/- 2.1 vs. 1.9 +/- 1.8 days, p = 0.022), hospital costs (4.2 +/- 1.3 vs. 1.5 +/- 1.1 x 1,000 EUR, p = 0.000), and sick leave requirements (18 of 23 vs. 8 of 28 of eligible patients, p = 0.001). CONCLUSION: In patients with demonstrated peritoneal violation, laparoscopy offers little benefit over exploratory laparotomy. In patients with equivocal peritoneal penetration on local wound exploration, laparoscopy detects more mostly minor organ injuries than expectant nonoperative management but is associated with increased hospital stay, costs, and sick leave requirements. Overall, diagnostic laparoscopy cannot be recommended as a routine diagnostic tool in anterolateral abdominal and thoracoabdominal stab wounds.

Occult diaphragmatic injuries caused by stab wounds.

BACKGROUND: Missed diaphragmatic perforation caused by penetrating trauma can lead to subsequent strangulation of a hollow viscus, which has prompted the use of invasive diagnostic procedures to exclude occult diaphragmatic injuries in asymptomatic, high-risk patients. The objective of this study was to determine the incidence of occult diaphragmatic injuries caused by stab wounds of the lower chest and upper abdomen, and to examine the natural history and consequences of missed diaphragmatic injuries. METHODS: On the basis of patient data from two previous randomized studies from our institution, a retrospective analysis was performed on 97 patients treated for anterior stab wounds located between the nipple line, the umbilical level, and the posterior axillary lines not having indications for immediate surgical exploration. The patients were divided into two groups on the basis of their initial randomized management (open or laparoscopic exploration vs. expectant observation). RESULTS: In the exploration group (n = 47), four diaphragmatic injuries (9%) were detected (three left-sided and one right-sided). Excluding patients with associated injuries requiring surgical repair, the incidence of occult diaphragmatic injuries was 3 of 43 (7%). In the observation group (n = 50), there were two patients (4%) with delayed presentation of missed left-sided diaphragmatic injury 2 and 23 months later, respectively. Both injuries resulted from stab wounds of the left flank and presented with herniation of the stomach or small bowel and colon. The overall incidence of occult diaphragmatic injuries in left-sided thoracoabdominal stab wounds was 4 of 24 (17%), and was much lower after stab wounds of left epigastrium (0%), right lower chest (0%), and right epigastrium (4%). CONCLUSION: In asymptomatic patients with anterior or flank stab wounds of the lower chest or upper abdominal area, the risk of an occult diaphragmatic injury is approximately 7% which, if undetected, is associated with a high risk of subsequent hollow viscus herniation. Exclusion of an occult diaphragmatic injury with invasive diagnostic methods, such as laparoscopy or thoracoscopy, should be considered at least in left-sided stab wounds of the lower chest.

Carotid arterial trauma: assessment with the Glasgow Coma Scale (GCS) as a guide to surgical management.

Management of carotid arterial injuries associated with focal neurological deficit or altered state of consciousness (SCON) remains unresolved. Experience with these injuries in one particular hospital was reviewed and the Glasgow Coma Scale (GCS) utilized to assist with clinical stratification of these patients. A literature review was also conducted to better define indications for repair or ligation of carotid injuries. From 1978 to 1990, 34 patients with carotid arterial injuries were reviewed with reference to the GCS, focal deficit, hypotension, anatomic site and mechanism of injury. The literature from 1952 to 1993 was surveyed for carotid artery injuries (1316 patients). Outcome of treatment with or without repair was compared with pre-operative neurologic status. Thirty-four patients with injuries of the common (24) or internal (10) carotid arteries were managed with repair (68%), ligation (24%) or observation (9%). The SCON was normal in 18 patients; 16 patients (88%) underwent repair and all remained normal. All patients with GCS 9-14 regained a normal SCON after surgical repair, while 10 patients with GCS < 8 had repair (5), ligation (3), and non-operative management (2); five returned to normal, four died and one remained comatose. However, outcomes correlated poorly with management. Of 1316 patients cited in the surgical literature, patients with no deficit and patients with pre-operative deficits did significantly better after repair as compared with ligation (P<0.001). In comatose patients, management did not affect outcome. It is concluded that carotid arterial injuries should be repaired in patients with normal neurologic evaluation, focal pre-operative neurologic deficits and in patients with GCS > 9. Comatose patients with GCS < 8 do poorly regardless of management. The GCS provides an objective for stratification of patients with altered SCON who benefit from repair of carotid arterial injuries.

Cost analysis of diagnostic laparoscopy vs laparotomy in the evaluation of penetrating abdominal trauma.

BACKGROUND: Diagnostic laparoscopy for the evaluation of injuries in patients with penetrating abdominal trauma has been shown to decrease the morbidity and mortality associated with mandatory laparotomy. The overall impact on patient care and hospital costs has not been thoroughly investigated. The goal of this study was to determine the economic impact of laparoscopy as a diagnostic tool in the management of patients following penetrating trauma to the abdomen or flank. METHODS: Retrospective chart review of all hemodynamically stable patients with penetrating trauma to the abdomen or flank, but without other injuries requiring emergent intervention, admitted to a level I trauma center between January 1, 1992, and September 30, 1994. Those patients who underwent either laparoscopy (DL) or laparotomy (NL) or both (CONV) and who had no intraabdominal organ injuries requiring surgical therapeutic intervention were included in the study. Age, operative time, operative findings, length of hospitalization, Injury Severity Score (ISS), variable costs, and total costs were recorded for each patient. RESULTS: Fourteen patients underwent negative/nontherapeutic laparoscopy (DL), 19 patients underwent negative/nontherapeutic laparotomy (NL), and four patients underwent both laparoscopy and laparotomy, a conversion procedure (CONV). There was no significant difference in age, operative times, or ISS between the DL and NL groups. Mean ISS of CONV patients was significantly greater than that of DL patients, 5.75 +/- 1.97 vs 2.43 +/- 0.63 (p < 0.05). Mean operative time for CONV patients was also significantly greater than both DL and NL patients, 106.5 +/- 17.00 min vs 66.1 +/- 6.55 and 47. 3 +/- 7.50 min, respectively (p < 0.05). The mean length of stay was significantly shorter in the DL group as compared to the NL or CONV groups, 1.43 +/- 0.20 vs 4.26 +/- 0.31 and 5.0 +/- 0.82 (p < 0.0001). The variable costs for the DL group were significantly lower than those incurred by patients in the NL and CONV groups, $2,917 +/- 175 vs $3,384 +/- 102 and $3,774 +/- 286, (p < 0.05). Variable costs were not significantly different between the NL and CONV groups. Total costs were also significantly lower in the DL group when compared to NL and CONV, $5,427 +/- 394 vs $7,026 +/- 251 and $7,855 +/- 750 (p < 0.005), but again, they were not statistically different between the NL and CONV groups. The overall total costs for laparoscopy, including the costs incurred by conversion patients, was significantly less than the total costs for laparotomy patients, $5,664 +/- 394 vs $7,028.47 +/- 250 (p < 0.005). This resulted in an overall savings of $1,059.44 per laparoscopy performed. The overall negative/nontherapeutic laparotomy rate during this study was 19.1%, which was significantly lower than the negative or nontherapeutic exploration rate during the time period prior to the use of laparoscopy (p < 0.01, z = 2.550). CONCLUSION: Variable and total costs and length of stay were significantly lower in our population of patients who underwent DL as compared to NL. The rate of negative or nontherapeutic laparotomy was also significantly reduced when compared to the rate identified during the era prior to the use of laparoscopy. Laparoscopy resulted in an overall savings of $1,059 per laparoscopy performed when compared to laparotomy.

Laparoscopy for triage of penetrating trauma: the decision to explore.

The role of diagnostic laparoscopy in penetrating trauma continues to evolve. We reviewed our experience to determine the effect of laparoscopy on therapeutic laparotomy rates, length of hospital stay, and hospital charges. Laparoscopy was performed on 106 hemodynamically stable patients with penetrating abdominal injuries (66 had gunshot wounds, 40 had stab wounds). All patients with laparoscopically identified peritoneal penetration underwent open laparotomy. At laparoscopy, 41 (39%) had positive findings, whereas 65 (61%) had none. Two patients with retroperitoneal hematomas and one with ecchymosis of the peritoneum were not explored. Thus 68 (64%) did not require laparotomy. Among the 38 who underwent laparotomy, 29 (76%) had positive findings and 9 (24%) had a negative laparotomy. Nineteen patients (50%) had a therapeutic laparotomy. This compares with a therapeutic laparotomy rate of 18% had all 106 patients undergone mandatory laparotomy. Data for length of stay and hospital charges were analyzed. Due to the extended stay associated with tube thoracostomy (n = 21), a subgroup excluding patients with chest tubes was also analyzed. In this subgroup, there was a significant difference in hospital stay between those who had only a laparoscopy and those who underwent a negative laparotomy (2.6 +/- 1.7 vs. 4.7 +/- 1.6, p < 0.01). The average nonsurgical charge for patients who had a negative laparotomy was more than double that for those who had laparoscopy only ($8275 +/- 4692 vs. $3762 +/- 3786, p < 0.01). We conclude that the use of diagnostic laparoscopy to identify peritoneal penetration resulted in an improved therapeutic laparotomy rate as well as significant reduction in hospital stay and hospital charges.

A prospective analysis of diagnostic laparoscopy in trauma.

OBJECTIVE: This study was performed to assess current and potential future application for laparoscopy (DL) in the diagnosis of penetrating and blunt injuries. Efficacy, safety, and cost analyses were performed. SUMMARY BACKGROUND DATA: Diagnostic peritoneal lavage (DPL) and computed tomography (CT) have been the mainstays in recent years for diagnosis of equivocal nontherapeutic laparotomy, whereas CT is not helpful for the vast majority of penetrating wounds. DL may be a useful adjunct to fill in these gaps. METHODS: Hemodynamically stable patients with equivocal evidence of intraabdominal injury were prospectively entered into the protocol. DL was performed under general anesthesia; patients with wounds penetrating the peritoneum or blunt injury with significant organ injury underwent laparotomy. RESULTS: Over 19 months, 182 patients (55% stab, 36% GSW, 9% blunt) were studied. No peritoneal penetration was found at DL in 55% of penetrating wounds with 66% of the remainder having therapeutic laparotomy, 17% nontherapeutic laparotomy, and 17% negative laparotomy. Therapeutic laparotomy was performed in 53% of blunt injuries after DL. Tension pneumothorax occurred in one patient and one had an iatrogenic small bowel injury. Charges for DL were $3,325 per patient compared with $3,320 for a similar group undergoing negative laparotomy before this protocol. CONCLUSIONS: DL is a safe modality for trauma. With current technology, DL is most efficacious for evaluation of equivocal penetrating wounds. Significant cost savings would be gained by performance under local anesthesia. Development of miniaturized optics, bowel clamps, retractors, and stapling devices will reduce overall costs and permit some therapeutic applications for laparoscopy in trauma management.