"Pop in a scope": attempt to decrease the rate of unnecessary nontherapeutic laparotomies in hemodynamically stable patients with thoracoabdominal penetrating injuries.

BACKGROUND: Management of patients with thoracoabdominal penetrating injuries is challenging. Thoracoabdominal penetrating trauma may harbor hollow viscus injuries in both thoracic and abdominal cavities and occult diaphragmatic lesions. While radiological tests show poor diagnostic performance in these situations, evaluation by laparoscopy is highly sensitive and specific. Furthermore, minimally invasive surgery may avoid unnecessary laparotomies, despite concerns regarding complication and missed injury rates. The objective of the present study is to evaluate the diagnostic and therapeutic performance of laparoscopy in stable patients with thoracoabdominal penetrating injuries. METHODS: Retrospective analysis of hemodynamically stable patients with thoracoabdominal penetrating wounds was managed by laparoscopy. We collected data regarding the profile of the patients, the presence of diaphragmatic injury, perioperative complications, and the conversion rate. Preoperative imaging tests were compared to laparoscopy in terms of diagnostic accuracy. RESULTS: Thirty-one patients were included, and 26 (84%) were victims of a stab wound. Mean age was 32 years. Ninety-three percent were male. Diaphragmatic lesions were present in 18 patients (58%), and 13 (42%) had associated injuries. There were no missed injuries and no conversions. Radiography and computerized tomography yielded an accuracy of 52% and 75%, respectively. CONCLUSION: Laparoscopy is a safe diagnostic and therapeutic procedure in stable patients with thoracoabdominal penetrating wound, with low complication rate, and may avoid unnecessary laparotomies. The poor diagnostic performance of preoperative imaging exams supports routine laparoscopic evaluation of the diaphragm to exclude injuries in these patients.

Prevention of Fascial Dehiscence with Onlay Prophylactic Mesh in Emergency Laparotomy: A Randomized Clinical Trial.

BACKGROUND: Fascial dehiscence (FD) occurs in up to 14.9% of high-risk patients undergoing emergency laparotomy. Although prophylactic mesh can prevent FD, its use in emergency operations remains controversial. STUDY DESIGN: A prospective randomized clinical trial was conducted at the Hospital das Clínicas from Faculdade de Medicina da Universidade de São Paulo in Brazil. It was performed among high-risk patients, defined according to Rotterdam risk model, undergoing midline emergency laparotomy. The patients were randomized into the suture group (SG), with slowly absorbable running sutures placed with a 36-mm-long needle at a suture-to-wound length ratio of 4:1, and the prophylactic mesh group (PMG), with fascial closure as in the SG but reinforced with onlay polypropylene mesh. The primary end point was incidence of FD at 30 days post operation. RESULTS: We analyzed 115 patients; 52 and 63 were allocated to the SG and PMG, respectively. In all, 77.4% of the cases were for colorectal resection. FD occurred in 7 (13.5%) patients in the SG and none in the PMG (p = 0.003). There was no difference between the groups in number of patients with surgical site occurrence (SSO) or SSO requiring procedural intervention. However, some specific SSOs had higher incidences in the mesh group: surgical site infection (20.6% versus 7.7%; p = 0.05), seroma (19.0% versus 5.8%; p = 0.03), and nonhealing incisional wound (23.8% versus 5.8%; p = 0.008). Of SSOs in the PMG and SG, 92.3% and 73.3%, respectively, resolved spontaneously or with bedside interventions. CONCLUSIONS: Prophylactic onlay mesh reinforcement in emergency laparotomy is safe and prevents FD. Surgical site infection, seroma, and nonhealing incisional wound were more common in the mesh group, but associated with low morbidity within 30 days post operation.