ABSTRACT
Objective. To report our experience with thoracoscopic pericardial window (TPw) for occult penetrating cardiac injury. Patients and methods. during the study period (1 January - 31 december 2000); a small group of haemodynamically stable patients with anterior leftsided praecordial wounds were selected for TPw. All patients underwent general anaesthesia with doublelumen intubation and collapse of the left lung. A rigid laparoscope was inserted through a 2 cm incision in the 5th intercostal space in the anterior axillary line. Another 3 cm incision was made in the fourth intercostal space over the cardiac silhouette. Conventional instruments were used to grasp and open the pericardium. Any myocardial injury identified was an indication to proceed to sternotomy. in the absence of a myocardial injury and bleeding; the procedure was terminated and considered therapeutic. Results. seventy-one patients with suspected penetrating cardiac injuries were seen. TPw was successfully completed in 13 patients. All were men; with a mean age of 29.8 (range 19 - 38) years. Ten and 3 patients sustained stab and gunshot wounds; respectively. The mean revised trauma score was 7.84. Ultrasound was performed in 12 patients; the results were equivocal for 2 patients; and positive for an effusion in 4 patients. Haemopericardium was found in 3 patients; 2 of whom proceeded to sternotomy. No cardiac injury was found in 1; a left ventricular contusion was identified in the second; and the third patient had no further procedure after good video-thoracoscopic visualisation of the anterior myocardium revealed no injury. in another patient; pericardial bruising was evident without any haemopericardium. The mean operative time was 13.4 (range 10 - 15) minutes; with a mean hospital stay of 5.4 (range 3 - 8) days. There were no complications. The use of a double-lumen endotracheal tube increased the cost of TPw by 23when compared with subxiphoid pericardial window (sPw). Conclusion. TPw is a feasible; although in our setting not cost-effective; diagnostic option for occult penetrating cardiac injuries
Subject(s)
Heart Diseases , Thoracic Surgery , Wounds and InjuriesABSTRACT
Major injuries of the pancreas are uncommon; but may result in considerable morbidity and mortality because of the magnitude of associated vascular and duodenal injuries or underestimation of the extent of the pancreatic injury. Prognosis is influenced by the cause and complexity of the pancreatic injury; the amount of blood lost; duration of shock; speed of resuscitation and quality and nature of surgical intervention. Early mortality usually results from uncontrolled or massive bleeding due to associated vascular and adjacent organ injuries. Late mortality is a consequence of infection or multiple organ failure. Neglect of major pancreatic duct injury may lead to life-threatening complications including pseudocysts; fistulas; pancreatitis; sepsis and secondary haemorrhage. Careful operative assessment to determine the extent of gland damage and the likelihood of duct injury is usually sufficient to allow planning of further management. This strategy provides a simple approach to the management of pancreatic injuries regardless of the cause. Four situations are defined by the extent and site of injury: (i) minor lacerations; stabs or gunshot wounds of the superior or inferior border of the body or tail of the pancreas (i.e. remote from the main pancreatic duct); without visible duct involvement; are best managed by external drainage; (ii) major lacerations or gunshot or stab wounds in the body or tail with visible duct involvement or transection of more than half the width of the pancreas are treated by distal pancreatectomy; (iii) stab wounds; gunshot wounds and contusions of the head of the pancreas without devitalisation of pancreatic tissue are managed by external drainage; provided that any associated duodenal injury is amenable to simple repair; and (iv) non-reconstructable injuries with disruption of the ampullary-biliary-pancreatic union or major devitalising injuries of the pancreatic head and duodenum in stable patients are best treated by pancreatoduodenectomy. Internal drainage or complex defunctioning procedures are not useful in the emergency management of pancreatic injuries; and can be avoided without increasing morbidity. Unstable patients may require initial damage control before later definitive surgery. Successful treatment of complex injuries of the head of the pancreas depends largely on initial correct assessment and appropriate treatment. The management of these severe proximal pancreatic injuries remains one of the most difficult challenges in abdominal trauma surgery; and optimal results are most likely to be obtained by an experienced multidisciplinary team
Subject(s)
Pancreatic Diseases/surgeryABSTRACT
Major injuries of the pancreas are uncommon; but may result in considerable morbidity and mortality because of the magnitude of associated vascular and duodenal injuries or underestimation of the extent of the pancreatic injury. Prognosis is influenced by the cause and complexity of the pancreatic injury; the amount of blood lost; duration of shock; speed of resuscitation and quality and nature of surgical intervention. Early mortality usually results from uncontrolled or massive bleeding due to associated vascular and adjacent organ injuries. Late mortality is a consequence of infection or multiple organ failure. Neglect of major pancreatic duct injury may lead to life-threatening complications including pseudocysts; fistulas; pancreatitis; sepsis and secondary haemorrhage. Careful operative assessment to determine the extent of gland damage and the likelihood of duct injury is usually sufficient to allow planning of further management. This strategy provides a simple approach to the management of pancreatic injuries regardless of the cause. Four situations are defined by the extent and site of injury: (i) minor lacerations; stabs or gunshot wounds of the superior or inferior border of the body or tail of the pancreas (i.e. remote from the main pancreatic duct); without visible duct involvement; are best managed by external drainage; (ii) major lacerations or gunshot or stab wounds in the body or tail with visible duct involvement or transection of more than half the width of the pancreas are treated by distal pancreatectomy; (iii) stab wounds; gunshot wounds and contusions of the head of the pancreas without devitalisation of pancreatic tissue are managed by external drainage; provided that any associated duodenal injury is amenable to simple repair; and (iv) non-reconstructable injuries with disruption of the ampullary-biliary-pancreatic union or major devitalising injuries of the pancreatic head and duodenum in stable patients are best treated by pancreatoduodenectomy. Internal drainage or complex defunctioning procedures are not useful in the emergency management of pancreatic injuries; and can be avoided without increasing morbidity. Unstable patients may require initial damage control before later definitive surgery. Successful treatment of complex injuries of the head of the pancreas depends largely on initial correct assessment and appropriate treatment. The management of these severe proximal pancreatic injuries remains one of the most difficult challenges in abdominal trauma surgery; and optimal results are most likely to be obtained by an experienced multidisciplinary team