Laparoscopy for blunt abdominal trauma: a challenging endeavor.

BACKGROUND AND AIMS: Laparoscopy in blunt abdominal trauma is challenging because of multiple associated injuries, higher trauma score values and higher morbidity and mortality, as compared with patients with penetrating abdominal trauma. The aim of this study was to investigate the role of laparoscopy in the management of blunt abdominal trauma patients and to highlight related challenges. MATERIAL AND METHODS: Over a 4-year period, patients managed laparoscopically for blunt abdominal trauma were retrospectively analyzed. Perioperative details, indications for laparoscopy and conversion, complications, and length of hospital stay were discussed. RESULTS: A total of 35 stable patients underwent laparoscopy. The mean Injury Severity Score was 12 (4-38). Therapeutic laparoscopy was performed in 15 (56%) and diagnostic in 12 (44%) patients. Eight (23%) patients were converted to therapeutic laparotomy. Intraoperative bleeding, complex injuries, visualization problem, and equipment failure necessitated conversion. Three (30%) patients with negative computed tomography scan had therapeutic laparoscopy for mesenteric injuries. There were no missed injuries. The mean length of hospital stay was 11 days in both groups. CONCLUSION: Laparoscopy for stable patients is feasible and safe. Multiple injuries make laparoscopy more difficult, and advanced laparoscopic skills are required. The conversion rate is high; however, the non-therapeutic laparotomies were completely eliminated in this study.

Trauma laparoscopy: A prospect of skills training (cohort study).

BACKGROUND: Diagnostic laparoscopy is well-accepted in management of penetrating abdominal trauma (PAT) with the rate of missed injuries below 1%. However, there is a reluctance to accept therapeutic laparoscopy in trauma society. The possible reason is a lack of laparoscopic skills by trauma surgeons. Moreover, no formal laparoscopy training program for trauma exists. The aim of this study was to interrogated our laparoscopy training particularly in trauma setting, and to investigate a possible relation between the seniority of surgeons performing the procedures and the complication rates. METHODS: All patients managed laparoscopically for PAT from January 2012 to December 2015 were analyzed. The seniority of operating surgeon was correlated with adverse outcomes, and with conversion. Surgeon-consultant (SC), assistant-consultant (AC), surgeon-senior-resident (SSR) and surgeon-junior-resident (SJC) groups were identified. Laparoscopic maneuvers used in this cohort were investigated and the set of essential laparoscopic skills was identified. The laparoscopic training program at our institution was described and discussed. RESULTS: Out of 283 patients with PAT approached with laparoscopy 33 (11.7%) were converted to laparotomy. Majority (49.6%) of laparoscopy was performed by senior resident. Consultant was an operating surgeon in 21.2% and an assistant in 8% of cases. Consultant was involved in cases with higher severity of injury and the complication rate was higher in the SC and AC groups. Essential laparoscopic skills were camera navigation, mobilization of intraabdominal organs, bowel run and intracorporeal suturing. During training, a senior resident was involved in 19% of operations for trauma. Trauma constituted 16% of all laparoscopy. CONCLUSION: Laparoscopy for trauma can be safely performed by residents under appropriate supervision. Laparoscopic skills should preferably be obtained during elective non-trauma procedures and transferred to trauma setting. Multimodal goal-directed, proctored training with regular assessments and feedback is effective and skills are transferable to trauma setting.

Multiple concurrent bilateral groin hernias in a single patient; a case report and a review of uncommon groin hernias: A possible source of persistent pain after successful repair.

INTRODUCTION: The wide use of laparoscopy for groin hernia repair has unveiled "hidden hernias" silently residing in this area. During the open repair of the presenting hernia, the surgeon was often unaware of these occult hernias. These patients postoperatively may present with unexplained chronic groin or pelvic pain. PRESENTATION OF CASE: Rare groin hernias are defined according to their anatomical position. Challenges in the diagnosis and management of occult rare groin hernias are discussed. These problems are illustrated by a unique case report of multiple (six) coexisting groin hernias, whereof five were occult and two were rare. DISCUSSION: Rare groin hernias are uncommon because they are difficult to diagnose clinically and are not routinely looked for. They are often occult and may coexist with other inguinal hernias, thus posing a diagnostic and treatment challenge to the surgeon, especially if there is persistent groin pain after "successful" repair. MRI is the most accurate preoperative and postoperative diagnostic tool, if there is a clinical suspicion that the patient might have an occult hernia. CONCLUSION: Preperitoneal endoscopic approach is the recommended method in confirming the diagnosis and management of occult groin hernias. A sound knowledge of groin anatomy and a thorough preperitoneal inspection of all possible sites for rare groin hernias are needed to diagnose and repair all defects. The preperitoneal mesh repair with adequate overlap of all hernia orifices is the recommended treatment of choice.

Haemangiopericytoma/solitary fibrous tumour of the greater omentum.

We report a rare case of haemangiopericytoma/solitary _brous tumour of the greater omentum in a 41-year-old woman. It presented as a large mobile abdominal mass measuring 30 × 24 × 8 cm. A computed tomography scan con_rmed the presence of a large vascular tumour, and biochemical tumour markers were non-contributory. The tumour was removed through a conventional laparotomy incision with the aid of a Ligasure dissector. There were no macroscopic metastases, and histologically it was benign. The size of >5 cm, however, suggests that it may have been malignant. In the absence of visible metastases and in view of the favourable histological features, it was decided to follow up the patient very closely and give further treatment if necessary.

Vascular malformation of the jejunum associated with nodal non-Hodgkin's malignant lymphoma.

We report a case of multiple minute angioectasia of the jejunum presenting with fatal gastrointestinal bleeding. Repeated endoscopies, mesenteric angiography and scintigraphy failed to locate the bleeding site. Multiple minute angioectasia was suspected on intraoperative enteroscopy; however, surgical resection failed to permanently control gastrointestinal haemorrhage. The final histology report confirmed the presence of multiple minute angioectasia of the jejunum. In this case study, we review current diagnostic and therapeutic modalities, and discuss the association between gastrointestinal angioectasia and malignant lymphoma.

Blunt diaphragmatic rupture: four year's experience.

BACKGROUND: Blunt diaphragmatic rupture (DR) is a rare condition usually masked by multiple associated injuries, which are the main cause of morbidity and mortality. The overall incidence of diaphragmatic injury is 0.8-5.8% in blunt trauma--2.5-5% in blunt abdominal trauma and 1.5% in blunt thoracic trauma. A correct diagnosis remains difficult and is usually made late. METHODS: Over four years 12 patients with blunt DR were treated in our hospital. Their charts and X-rays were analyzed. All the surgeons involved were interviewed. Diagnostic and treatment modalities were analyzed and discussed. RESULTS: Acute diaphragmatic rupture (ADR) was diagnosed in nine patients within seven days. Three patients presented with bowel obstruction and post-traumatic diaphragmatic hernia was diagnosed intraoperatively. Nine patients had rupture of the left hemidiaphragm, two had rupture of the right hemidiaphragm, and one had bilateral DR. Diagnosis of DR was made in all patients in the ADR group before surgery. The correct diagnosis was made within 12 h by junior medical officers in 66.6% of cases. Two patients were diagnosed on a second chest X-ray in response to progressive respiratory distress. The diaphragmatic defect was repaired in all patients via laparotomy; only one patient required additional thoracotomy. Mortality was 25%. CONCLUSIONS: Single or serial plain chest radiographs with a high index of suspicion are diagnostic in most cases of DR. Respiratory distress should be treated with intubation as intercostal drainage (ICD) may not improve the situation and is associated with a high risk of iatrogenic injuries. Surgical repair is mandatory and laparotomy should be the preferred approach in unstable patients. To avoid missed injury thorough inspection of both hemidiaphragms should be done routinely on every trauma patient undergoing laparotomy. It is widely recommended to use non-absorbable suturing for diaphragm repair but slowly absorbable material seems reliable also.