Diagnostic Laparoscopy for Trauma: How Not to Miss Injuries.

INTRODUCTION: Diagnostic laparoscopy (DL) is a well-accepted approach for penetrating abdominal trauma (PAT). However, the steps of procedure and the systematic laparoscopic examination are not clearly defined in the literature. The aim of this study was to clarify the definition of DL in trauma surgery by auditing DL performed for PAT at our institution, and to describe the strategies on how to avoid missed injuries. METHODS: The data of patients managed with laparoscopy for PAT from January 2012 to December 2015 were retrospectively analyzed. The details of operative technique and strategies on how to avoid missed injuries were discussed. RESULTS: Out of 250 patients managed with laparoscopy for PAT, 113 (45%) patients underwent DL. Stab wounds sustained 94 (83%) patients. The penetration of the peritoneal cavity or retroperitoneum was documented in 67 (59%) of patients. Organ evisceration was present in 21 (19%) patients. Multiple injuries were present in 22% of cases. The chest was the most common associated injury. Two (1.8%) iatrogenic injuries were recorded. The conversion rate was 1.7% (2/115). The mean length of hospital stay was 4 days. There were no missed injuries. In the therapeutic laparoscopy (TL) group, DL was performed as the initial part and identified all injuries. There were no missed injuries in the TL group. The predetermined sequential steps of DL and the standard systematic examination of intraabdominal organs were described. CONCLUSIONS: DL is a feasible and safe procedure. It accurately identifies intraabdominal injuries. The selected use of preoperative imaging, adherence to the predetermined steps of procedure and the standard systematic laparoscopic examination will minimize the rate of missed injuries.

Characteristics of computed tomography in hemodynamically unstable blunt trauma patients: Experience at a tertiary care center.

Emergent exploratory laparotomy is recommended for hemodynamically unstable blunt trauma patients suspected of having hemoperitoneum. However, given the unreliability of ultrasonography and rapid scan speed of computed tomography (CT), CT might help clinicians provide accurate information even in hemodynamically unstable trauma patients. This observational study aimed to describe the bleeding site and hospital course of severe blunt trauma patients with hemoperitoneum diagnosed by CT scan.We enrolled all consecutive adult blunt trauma patients (≥18 years old) who underwent whole-body CT before operation between February 2012 and October 2016. Patients with hemoperitoneum on CT images were included and categorized into hemodynamically stable and unstable (persistent hypotension despite fluid resuscitation) groups.Among 1723 severe blunt trauma patients, 136 patients with hemoperitoneum were included. Of these, 98 (72.1%) patients had documented intraperitoneal injury, and the liver (60.2%) was most frequently damaged site, followed by spleen (23.5%) and mesentery (23.5%). The rate of intraperitoneal organ injury did not differ between hemodynamically stable (n = 107) and unstable (n = 29) groups (69.2% vs 82.8%, P = .15), while the documented active internal bleeding was high in the unstable group (29.9% vs 69.0%, P < .001). In the unstable group, 14 (48.3%) patients underwent emergent operation, while 3 patients underwent embolization, and the others were treated in a conservative manner.Even in hemodynamically unstable hemoperitoneum patients, 17.2% had no documented intraperitoneal injury and over half of the patients were treated without emergent operation.

Hemoperitoneo y síndrome compartimental abdominal por catéter venoso femoral intraperitoneal / Hemoperitoneum and abdominal compartment syndrome due to intraperitoneal femoral venous catheter

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18F-FDG PET/CT, cytoreductive surgery and intraperitoneal chemohyperthermia for the therapeutic management in peritoneal carcinomatosis: a pilot study / 18F-FDG PET/TC, cirugía citorreductora y quimiohipertermia intraperitoneal para el tratamiento terapéutico de la carcinomatosis peritoneal: estudio piloto

Aim. Peritoneal carcinomatosis is a common evolution of neoplasms and the terminal stage of disease. A new therapeutic technique, based on the total surgical removal of peritoneal lesions (peritonectomy procedure - PP) combined with the intraperitoneal chemohyperthermia (IPCH), has been developed. Proper patient selection is mandatory for optimizing the results of treatment. The aim of this study was to investigate the role of [(18)F]fluoro-2-deoxy-d-glucose Positron Emission Tomography/Computed Tomography (18F-FDG PET/CT) in patients with peritoneal carcinosis selected to undergo PP and IPCH. Furthermore, we aimed to identify characteristic patterns of abdominal18F-FDG uptake and to correlate these patterns with available anatomic findings after surgery. Methods. Patients with either histologically confirmed peritoneal carcinosis or suspected upon clinical follow-up and/or imaging findings were prospectively submitted to pre-surgery 18F-FDG PET/CT scan. Only those patients without evidence of extra-peritoneal metastases at PET/CT scan were treated with PP and IPCH. Results. 11 patients with peritoneal carcinomatosis (5 colorectal, 4 ovarian, 1 pancreatic) and 1 unknown primitive cancer, were eligible for the study. In all cases PET/CT scan showed multiple peritoneal implants. In 6 out of 11 cases (54%) metastases were evidenced by 18F-FDG PET/CT: 2 cases with liver metastases; 1 case with bone metastases; 3 patients with lymph-node lesions. Two distinct imaging patterns, with focal or diffuse increased 18F-FDG uptake, were recognized. Conclusions. PP + IPCH of patients selected by 18F-FDG PET/CT seems to be safe and feasible. PET/CT scan appears as a reliable tool for the detection, characterization of peritoneal implants with potential impact in the therapeutic management of these patients (AU)

Objetivo. La carcinomatosis peritoneal es una evolución común de las neoplasias y constituye el estadio terminal de la enfermedad. Se ha desarrollado una nueva técnica, basada en la extirpación quirúrgica de las lesiones peritoneales (procedimiento de peritonectomía - PP), combinada con quimiohipertermia intraperitoneal (IPCH). La adecuada selección de los pacientes es primordial, a fin de optimizar los resultados del tratamiento. El objetivo de este estudio fue investigar el papel de la tomografía de emisión de positrones con [(18)F]fluoro-2-deoxy-d-glucosa/tomografía computarizada (18F-FDG PET/TC) en pacientes con carcinomatosis peritoneal, seleccionados para someterse a PP e IPCH. Además, tratamos de identificar los patrones característicos de la captación abdominal de 18F-FDG y correlacionar dichos patrones con los hallazgos anatómicos disponibles tras la cirugía. Métodos. Se realizaron exámenes 18F-FDG PET/TC de manera prospectiva, y previamente a la cirugía, a los pacientes con carcinomatosis peritoneal histológicamente confirmada, o sospechada mediante seguimiento clínico y/o hallazgos de imagen. Solo puede tratarse con PP y IPCH a aquellos pacientes que no reflejen evidencia de metástasis extraperitoneales en los exámenes PET/TC. Resultados. Se seleccionó para el estudio a 11 pacientes con carcinomatosis peritoneal (5 colorrectales, 4 ováricas, una pancreática) y un cáncer primitivo desconocido. En todos los casos, el examen PET/TC reflejó múltiples implantes peritoneales. En 6 de los 11 casos (54%) las metástasis fueron evidenciadas mediante 18F-FDG PET/TC: 2 casos con metástasis hepáticas, un caso con metástasis óseas, y 3 pacientes con lesiones ganglionares. Se reconocieron 2 patrones de imagen distintos, con aumento de captación focal o difusa de 18F-FDG. Conclusiones. La combinación PP + IPCH de los pacientes seleccionados mediante 18F-FDG PET/TC parece ser una técnica segura y factible. La PET/TC se revela como una herramienta fiable para la detección y caracterización de los implantes peritoneales, con un impacto potencial sobre el tratamiento terapéutico de dichos pacientes (AU)

An unusual cause of abdominal distension: intraperitoneal bladder perforation secondary to intermittent self-catheterisation.

We report a strikingly unusual case of traumatic intraperitoneal perforation of an augmented bladder from clean intermittent self-catheterisation (CISC), which presented a unique diagnostic challenge. This case describes a 48-year-old T1 level paraplegic, who had undergone clamshell ileocystoplasty for detrusor overactivity, presenting with abdominal distension, vomiting and diarrhoea. Initial investigations were suggestive of disseminated peritoneal malignancy with ascitic fluid collections, but the ascitic fluid was found to be intraperitoneal urine from a perforation of the urinary bladder. This was associated with an inflammatory response in the surrounding structures causing an appearance of colonic thickening and omental disease. Although the diagnostic process was complex due to this patient's medical history, the treatment plan initiated was non-operative, with insertion of an indwelling urinary catheter and radiologically guided drainage of pelvic and abdominal collections. Overdistension perforations of augmented urinary bladders have been reported, but few have described perforation from CISC.

Liver allografts from donors with peritoneal contamination: report of two cases.

Organs from deceased donors with traumatic abdominal injury, peritoneal contamination and open abdomen are usually discarded due to risks of transmission of severe infections to the recipient. There are no specific recommendations regarding organ utilization from these donors, but they might be an unexplored source able to attenuate organ shortage. Herein, the first successful report of a case involving liver transplantation using a liver allograft procured from a deceased donor with an open abdomen is outlined. This donor was a young trauma patient in which peritoneal contamination had occurred following a gunshot wound. Also included in this the report is liver transplant from a donor, who also was a trauma victim with an enteric perforation. The decision-making process to accept liver allografts from donors with a greater risk of peritoneal infection involved the absence of uncontrolled sepsis or visible contamination of the cavity. Appropriate donor-recipient matching and adequate anti-infectious management might have contributed to a favorable outcome, which suggest that these donors can be used as alternatives to reduce organ shortage.

Photodynamic therapy using nanoparticle loaded with indocyanine green for experimental peritoneal dissemination of gastric cancer.

Although there have been multiple advances in the development of novel anticancer agents and operative procedures, prognosis of patients with advanced gastric cancer remains poor, especially in patients with peritoneal metastasis. In this study, we established nanoparticles loaded with indocyanine green (ICG) derivatives: ICG loaded lactosomes (ICGm) and investigated the diagnostic and therapeutic value of photodynamic therapy (PDT) using ICGm for experimental peritoneal dissemination of gastric cancer. Experimental peritoneal disseminated xenografts of human gastric cancer were established in nude mice. Three weeks after intraperitoneal injection of the cancer cells, either ICGm (ICGm-treated mice) or ICG solution (ICG-treated mice) was injected through the tail vein. Forty-eight hours after injection of the photosensitizer, in vivo and ex vivo imaging was carried out. For PDT, 48 h after injection of the photosensitizer, other mice were irradiated through the abdominal wall, and the body weight and survival rate were monitored. In vivo imaging revealed that peritoneal tumors were visualized through the abdominal wall in ICGm-treated mice, whereas only non-specific fluorescence was observed in ICG-treated mice. The PDT reduced the total weight of the disseminated nodules and significantly improved weight loss and survival rate in ICGm-treated mice. In conclusion, ICGm can be used as a novel diagnostic and therapeutic nanodevice in peritoneal dissemination of gastric cancer.

Asymptomatic intra-peritoneal rupture of hydatid cyst of the liver: case report.

BACKGROUND: Intra-peritoneal rupture of hydatid cyst is a rare complication and there is no consensus about its treatment. CASE PRESENTATION: The reported case concerns a 25 years old female patient who had been complaining for four months from a moderate pain in the right upper quadrant. No clinical or biological signs of sepsis or allergic reactions were witnessed. Ultrasound and CT examinations showed a multilocular hepatic cyst in addition to multiple unilocular cysts in the abdomen. The suspected diagnosis was hepatic and peritoneal HC and a surgical treatment was scheduled four weeks later. Surgical exploration showed a large ruptured HC on the left lobe of the liver, with daughter cysts in the peritoneal cavity. Left lobectomy of the liver with complete ablation of all daughter cysts and a wide peritoneal lavage were performed. For the three months following the surgery, Albendazole had been given to the patient. No recurrence occurred after four years of follow-up. CONCLUSION: Intra-peritoneal rupture of liver HC could be asymptomatic. This case showed that in some cases, occurrence of complications is not systematic. This suggests that urgent surgical treatment is not always mandatory in the absence of alarming signs. Well-conducted medical treatment would reduce the risk of occurrence of secondary peritoneal hydatidosis.

[Detection of wooden rod in pleural and peritoneal cavities during forensic autopsy].

INTRODUCTION: A rare event of fatal sexual assault by the insertion of a wooden rod through the anus to the upper chest is reported. Examination of the body at the scene did not raise any suspicion of assault while the subsequent autopsy revealed findings that changed the assessment of the cause of death and the circumstances. CASE HISTORY: The body of a 57 years old man with a history of psychiatric illness was found in his room. At autopsy a round wooden rod which was inserted through the anus was found in the peritoneal and pleural cavities. In addition, signs of manual pressure were detected on the neck and trunk, and on the head and extremities signs of blunt trauma were observed. DISCUSSION: In patients affected by mental disorders it is difficult to distinguish between self-inflicted anal injuries and injuries sustained during an attack. Detection of damage to other areas of the body (such as the neck) assist in determining the nature of the assault. SUMMARY: This case demonstrates the need for a full autopsy in every case of death under unclear circumstances, especially when a limited examination of the body can't determine the type of death (natural, accident, suicide or homicide).

[Interrelation of nuclear envelope with cell organelles in peritoneal cells during ontogenesist and in experimental pathology].

Visceral and parietal peritoneum was studied by electron microscopy in albino mice both in the process of ontogenesis and after its injury induced by the the intraperitoneal injection of 0.5% novocaine solution. It was shown that during the early stages of intrauterine development (Day 13) most of the mesotheliocytes and mesenchymal cells contained predominantly free ribosomes (polysomes) in their cytoplasm while other organelles were rare and were located near the nuclear envelope. Subsequently, the number of membranous organelles increased while that of polysomes decreased. One day after the injury of the mesothelium, undifferentiated mesotheliocytes containing numerous polysomes in their cytoplasm appeared at the margin of wound surface. In these cells the protrusion 9f membranes of nuclear envelope and their association with the membranous organelles (endoplasmic reticulum, Golgi complex, mitochondria) were detected. The observed interrelations between the nuclear envelope and the membranous cytoplasmic organelles is considered to be a possible way of their formation in the undifferentiated cells. Rare occurrence of this phenomenon in adults animals under the pathological condition and its absence during the physiological regeneration is considered as a manifestation of the law of histogenetic recapitulation.

Prophylactic preperitoneal mesh placement in open bariatric surgery: a guard against incisional hernia development.

BACKGROUND: Incisional hernia is one of the most common late complications of open bariatric surgery. The aim of this study was to assess the safety and efficacy of preperitoneal prosthetic enforcement of midline incisions during open bariatric surgery in preventing incisional hernia development. METHODS: This study randomized 64 morbidly obese patients admitted to undergo open bariatric surgery into two equal groups (I and II). A prophylactic sheet of polypropylene mesh was fixed in the preperitoneal space during wound closure in group I while in group II the wound was closed conventionally. RESULTS: This study included 51 females and 13 males ranged in age from 19 to 60 years. No significant difference was observed in mean age, mean preoperative body weight, mean body mass index, mean hospital stay, and mean follow-up period of either group. Three open procedures were done: vertical banded gastroplasty, Roux-en-Y gastric bypass, and vertical sleeve gastrectomy. No significant difference in mean operative time in either group for each operation was noted. Early postoperative wound complications were similar in either group. Incisional hernia incidence was significantly higher in group II, nine cases (28.1%), than in group I, one case (3.1%). CONCLUSIONS: Using prophylactic preperitoneal Prolene mesh during wound closure in open bariatric surgery is safe and effective in preventing incisional hernia development.

Inhibition of surgical trauma-enhanced peritoneal dissemination of tumor cells by human catalase derivatives in mice.

Surgical trauma, which is inevitably associated with the surgical removal of cancer, has been reported to accelerate tumor metastasis. The close association of reactive oxygen species with the trauma and tumor metastasis supports the possibility of using antioxidants for the inhibition of metastasis. To inhibit surgical trauma-enhanced peritoneal dissemination, human catalase (hCAT) derivatives, i.e., hCAT-nona-arginine peptide (hCAT-R9) and hCAT-albumin-binding peptide (hCAT-ABP), were designed to increase the retention time of the antioxidant enzyme in the abdominal cavity after intraperitoneal administration. Both (125)I-labeled derivatives showed significantly prolonged retention in the cavity compared to (125)I-hCAT. Cauterization of the cecum of mice with a hot iron, an experimental model of surgical trauma, induced abdominal adhesions. In addition, cauterization followed by colon26 tumor cell inoculation increased lipid peroxidation in the cecum and mRNA expression of molecules associated with tissue repair/adhesion and inflammation in the peritoneum. hCAT derivatives significantly suppressed the increased mRNA expression. The cauterization also increased the number of tumor cells in the abdominal organs, and the number was significantly reduced by hCAT-R9 or hCAT-ABP. These results indicate that hCAT-R9 and hCAT-ABP, both of which have a long retention time in the peritoneal cavity, can be effective at inhibiting surgery-induced peritoneal metastasis.

Malfunción valvular de derivación ventriculoperitoneal en una paciente embarazada a término / No disponible

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Civilian extraperitoneal rectal gunshot wounds: surgical management made simpler.

BACKGROUND: Rectal injuries are associated with significant morbidity and mortality. Controversy persists regarding routine presacral drainage, distal rectal washout (DRW), and primary repair of extraperitoneal rectal injuries. This retrospective review was performed to determine the outcome of rectal injuries in an urban trauma center with a high incidence of penetrating trauma where a non-aggressive surgical approach to these injuries is practiced. METHODS: The records of all patients with a full-thickness penetrating rectal injury admitted to the Trauma Center at Groote Schuur Hospital over a 4-year period were reviewed. These were reviewed for demographics, injury mechanism and perioperative management, anatomical site of the rectal injury, associated intra-abdominal injuries and their management. Infectious complications and mortality were noted. Intraperitoneal rectal injuries were primarily repaired, with or without fecal diversion. Extraperitoneal rectal injuries were generally left untouched and a diverting colostomy was done. Presacral drainage and DRW were not routinely performed. RESULTS: Ninety-two patients with 118 rectal injuries [intraperitoneal (7), extraperitoneal (59), combined (26)] were identified. Only two extraperitoneal rectal injuries were repaired. None had presacral drainage. Eighty-six sigmoid loop colostomies were done. Two (2.2%) fistula, one rectocutaneous, and one rectovesical, were recorded. There were nine (9.9%) infectious complications: surgical site infection (4), buttock abscess (1), buttock necrosis (1), pubic ramus osteitis (1), septic arthritis (2). No perirectal sepsis occurred. CONCLUSIONS: Extraperitoneal rectal injuries due to low-velocity trauma can be safely managed by fecal diversion alone.

Management of peritonitis in cattle.

Peritonitis commonly is included in a list of differential diagnoses in food animal practice. Understanding the physiology of the ruminant peritoneal cavity and its response to injury is important to institute an adequate therapeutic plan. Ancillary procedures are used often and are necessary to confirm the diagnosis and should be well-organized.

FAST (focused assessment with sonography in trauma) accurate for cardiac and intraperitoneal injury in penetrating anterior chest trauma.

OBJECTIVE: To evaluate the FAST (focused assessment with sonography in trauma) examination for determining traumatic pericardial effusion and intraperitoneal fluid indicative of injury in patients with penetrating anterior chest trauma. METHODS: An observational prospective study was conducted over a 30-month period at an urban level I trauma center. FAST was performed in the emergency department by emergency physicians and trauma surgeons. FAST results were recorded before review of patient outcome as determined by 1 or more of the following: thoracotomy, laparotomy, pericardial window, cardiologic echocardiography, diagnostic peritoneal lavage, computed tomography, and serial examinations. RESULTS: FAST was undertaken in 32 patients with penetrating anterior chest trauma: 20 (65%) had stab wounds, and 12 (35%) had gunshot wounds. Sensitivity of FAST for cardiac injury (n = 8) in patients with pericardial effusion was 100% (95% confidence interval, 63.1%-100%); specificity was 100% (95% confidence interval, 85.8%-100%). The presence of pericardial effusion determined by FAST correlated with the need for thoracotomy in 7 (87.5%) of 8 patients (95% confidence interval, 47.3%-99.7%). One patient with a pericardial blood clot on cardiologic echocardiography was treated nonsurgically. FAST had 100% sensitivity for intraperitoneal injury (95% confidence interval, 63.1%-100%) in 8 patients with views indicating intraperitoneal fluid but without pericardial effusion, again with no false-positive results, giving a specificity of 100% (95% confidence interval, 85.8%-100%). This prompted necessary laparotomy in all 8. CONCLUSIONS: In this series of patients with penetrating anterior chest trauma, the FAST examination was sensitive and specific in the determination of both traumatic pericardial effusion and intraperitoneal fluid indicative of injury, thus effectively guiding emergent surgical decision making.

Penetrating torso trauma: triple-contrast helical CT in peritoneal violation and organ injury--a prospective study in 200 patients.

PURPOSE: To assess the accuracy of computed tomography (CT) in demonstrating the presence or absence of peritoneal violation and type of intraperitoneal organ injury, if any, in hemodynamically stable patients with penetrating torso trauma but without definite peritoneal signs or radiographic evidence of free intraperitoneal air. MATERIALS AND METHODS: During a 29-month period, helical CT with oral, rectal, and intravenous contrast material (triple-contrast) was performed in 200 hemodynamically stable patients, including 169 men (age range, 15-85 years; mean age, 31 years) and 31 women (age range, 17-45 years; mean age, 28 years) with penetrating torso trauma. The study group included 86 patients with gunshot wounds, 111 with stab wounds, and three impaled by sharp objects. CT scans were evaluated prospectively by three trauma radiologists for evidence of peritoneal violation to determine injury to intra- or retroperitoneal solid organs, bowel, mesentery, vascular structures, diaphragm, and urinary tract. Sensitivity, specificity, and accuracy of CT in the diagnosis of peritoneal violation were determined. RESULTS: CT findings aided diagnosis of peritoneal violation in 34% of patients (68 of 200) and were negative for peritoneal violation in 66% of patients (132 of 200). Two patients with negative CT findings failed to improve with observation and underwent therapeutic laparotomy. CT had 97% sensitivity (66 of 68 findings), 98% specificity (130 of 132 findings), and 98% accuracy (196 of 200 findings) for peritoneal violation. CT aided diagnosis of 28 hepatic, 34 bowel or mesenteric, seven splenic, and six renal injuries. Laparotomy based on CT findings in 38 patients was considered therapeutic in 87% (33 of 38) and nontherapeutic in 8% (three of 38) and had negative results in 5% (two of 38). CONCLUSION: Triple-contrast helical CT accurately demonstrates peritoneal violation and visceral injury in patients with penetrating torso wounds.

[Effect of peritoneal lavage with povine-iodine on prevention of postoperative sepsis after exposure of peritoneal cavity to sea water in rat].

OBJECTIVE: To observe the effects of peritoneal lavage with povine-iodine on prevention of sepsis after exposure of peritoneal cavity to sea water in rat. METHODS: Eighty-four SD rats were randomly divided into two groups, and the peritoneal cavity was exposed to sea water. Rats in group A were not treated (group A, n=42), and the peritoneal cavity was lavage with povine-iodine in group B (n=42). Plasma levels of endotoxin and tumor necrosis factor (TNF) were measured preimmersion, and 0, 12, 24 hours after seawater immersion (n=6), and positive incidence of blood bacterial culture was performed (n=18 in each group) in groups A and B. RESULTS: 1. Plasma levels of endotoxin and TNF in group A and B were increased significantly after exposure of peritoneal cavity to sea water (compared with baseline values, all P<0.05). Plasma levels of endotoxin and TNF in group B became lower than those in group A from 12 hours after seawater immersion (P<0.05 or P<0.01). 2. Positive incidence of bacterial culture in group B was 16.7 % (3/18) and it was lower than that in group A (77.8 % (14/18), P<0.01). CONCLUSION: Povine-iodine lavage in the peritoneal cavity can reduce levels of plasma endotoxin and TNF, and lower positive incidence of bacterial culture in rats after exposure of peritoneal cavity to sea water, thereby preventing the development of postoperative sepremia.