Extremity compartment syndrome and fasciotomy: a literature review.

Trauma surgeons frequently encounter injured limbs at risk for compartment syndrome. This article reviews data regarding the pathophysiology of compartment syndrome, factors in measuring compartment pressures, thresholds for performing fasciotomies, and outcomes from the development of compartment syndromes and performing fasciotomies.

Ultrasound-guided central venous access.

HYPOTHESIS: Real-time ultrasound guidance should increase the success rate and lower the complication rate of central venous access in patients with relative contraindications to having the procedure performed. DESIGN: Prospective case series. SETTING: A community-based tertiary care hospital. PATIENTS: Fifty-two patients were studied. Relative risks to central venous catheter insertion included (1) thrombosis or stenosis of central veins, (2) inherent or acquired anticoagulation abnormalities, (3) inability to assume a supine position, (4) hypovolemia, (5) obesity or altered anatomy, and (6) severe respiratory compromise. INTERVENTIONS: Real-time ultrasound evaluation of the proposed vein to be cannulated, followed by real-time percutaneous central vein access. MAIN OUTCOME MEASURES: Successful cannulation of a central vein. RESULTS: All attempts at central vein cannulation were successful. No bleeding complications occurred. One pneumothorax occurred in an obese patient. CONCLUSIONS: Ultrasound-guided central venous access is a helpful technique to gain venous access in difficult cases. Surgeons who perform central venous access procedures should become acquainted with the techniques involved. The techniques should be incorporated into currently developing ultrasound instruction courses for surgeons.

Institutional learning curve of surgeon-performed trauma ultrasound.

BACKGROUND: Sonography has become the primary mode for the initial evaluation of abdominal injury in many trauma centers. However, the rate at which nonradiologists become proficient in this technique remains controversial. OBJECTIVE: To assess the learning curve for this technique in a single institution. DESIGN: Retrospective review of sonographic examinations for trauma performed by senior surgical residents during a 24-month period at an American College of Surgeons-verified level I trauma center. SETTING: University-affiliated private hospital. PATIENTS AND METHODS: Before the initiation of a program of surgeon-performed trauma ultrasound, senior surgical residents (postgraduate years 4 and 5) received 11.5 hours of hands-on and didactic instruction in the focused ultrasound examination for trauma. This examination then became a standard component of the evaluation of injured patients. Subsequent groups of senior residents received 8 hours of instruction at the onset of new academic years, 6 and 18 months, respectively, after the initial course. The sensitivity, specificity, accuracy, positive predictive value, and negative predictive value were then calculated for each 6-month period after the introduction of trauma sonography. RESULTS: During the 24-month study period, 902 sonographic examinations were performed. No statistically significant differences were noted in sensitivity, specificity, accuracy, positive predictive value, or negative predictive value for any 6-month period of study when compared with the other 6-month periods or with the values calculated for the entire study period. CONCLUSIONS: Senior surgical residents are capable of performing the focused ultrasound examination for trauma with a high level of skill after a concise introductory course. A learning curve was not apparent in our series. Criteria for being permitted to perform trauma sonography that include the requirement of a large number of examinations or extensive proctoring should be reassessed.

Sonographic examination of abdominal trauma by senior surgical residents.

The focused ultrasound examination is assuming an important role in the evaluation of abdominal trauma. We evaluated the ability of senior surgical residents to independently use this technique. We also evaluated the efficacy of a single sonographic examination instead of serial examinations. Senior surgical residents underwent sonography instruction by two attending surgeons certified in the technique. Once proficiency was attained, a single sonographic examination was performed on patients with abdominal trauma triaged to a Level I trauma center. Residents obtained additional diagnostic studies deemed appropriate. Ultrasound results were compared with other diagnostic studies and clinical course. Sonography was performed on 518 patients between January 10, 1995 and June 30, 1996. Mechanism of injury was blunt in 92 per cent of patients and penetrating in 8 per cent. There were 22 true positives, 12 false positives, 8 false negatives, and 476 true negatives. Five of the eight false negatives were secondary to limited hollow viscus injuries with minimal associated intraperitoneal fluid. Sensitivity, specificity, accuracy, positive predictive value, and negative predictive value were 73.3, 97.5, 96.1, 64.7, and 98.3 per cent, respectively. The use of computed tomography and diagnostic peritoneal lavage decreased from 25 to 18 per cent and 3.2 to 0.2 per cent, respectively, as diagnostic tools. We conclude that surgical residents can competently perform trauma ultrasound. A single sonographic examination is effective and reliable. Sonography has essentially replaced diagnostic peritoneal lavage in our institution.

Diagnostic and therapeutic laparoscopy for penetrating abdominal trauma: a multicenter experience.

BACKGROUND: Considerable skepticism still exists about the role of diagnostic laparoscopy in the evaluation of penetrating abdominal trauma. The reported experience with therapeutic laparoscopy has been limited. METHODS: Retrospective analysis of a collective experience from three large urban trauma centers with 510 patients (316 stab wounds, 194 gunshot wounds) who were hemodynamically stable and had no urgent indications for celiotomy. RESULTS: Laparotomy was avoided in 277 of the 510 patients (54.3%) either because of nonpenetration or insignificant findings on laparoscopy. All were discharged uneventfully after a mean hospital stay of 1.7 days. Twenty-six had successful therapeutic procedures on laparoscopy (diaphragmatic repair in 16 patients, cholecystectomy in 1 patient, hepatic repair in 6 patients, and closure of gastrotomy in 3 patients) with uneventful recovery. In the remaining 203 patients, laparotomy was therapeutic in 155. Fifty-two patients had nontherapeutic celiotomy for exclusion of bowel injuries or as mandatory laparotomy for penetrating gunshot wounds (19.7%). The overall incidence of nontherapeutic laparotomy was 10.2%. Complications from laparoscopy were minimal (10 of 510) and minor. CONCLUSIONS: Laparoscopy has an important diagnostic role in stable patients with penetrating abdominal trauma. In carefully selected patients, therapeutic laparoscopy is practical, feasible, and offers all the advantages of minimally invasive surgery.

Videothoracoscopy an effective method for evaluating and managing thoracic trauma patients.

BACKGROUND: The objective of this study was to assess the diagnostic and therapeutic effectiveness of videothoracoscopy in thoracic trauma patients. METHODS: The design was a retrospective review. The setting was a major trauma center at an urban county hospital. Forty-one hemodynamically stable patients sustaining thoracic trauma were reviewed (34 penetrating and 7 blunt injuries). In the acute setting (< 24 h), videothoracoscopy was used for continued bleeding(6) and suspected diaphragmatic injury(17). Thoracoscopy was used in delayed settings (> 24 h) for treatment of thoracic trauma complications(18) including clotted hemothorax(14), persistent air leak(1), widened mediastinum(1), and suspected diaphragmatic injury(2). RESULTS: The average Injury Severity Score (ISS) of these patients was 18.9 +/- 10.0. Three of 6 patients (50%) with continued bleeding were successfully treated thoracoscopically. Nine of 10 (90%) diaphragmatic injuries were confirmed by thoracoscopy, and 7 of these 9 patients (77%) were repaired thoracoscopically. Thirteen of 14 patients (93%) with clotted hemothoraces and one with a persistent air leak were treated successfully using thoracoscopy. An aortic injury was ruled out in one patient. CONCLUSIONS: Videothoracoscopy is a safe, accurate, minimally invasive, and potentially cost-effective method for the diagnosis and therapeutic management of thoracic trauma patients.

Therapeutic laparoscopy in trauma.

PURPOSE: To assess the therapeutic potential of emergent laparoscopy in the trauma setting, a retrospective review was performed in a busy urban trauma center. PATIENTS AND METHODS: Between December 1991 and October 1993, 133 hemodynamically stable patients with suspected abdominal injury were evaluated laparoscopically. All laparoscopic procedures were performed in the operating room under general anesthesia. Mechanism of injury was stab wound (58), gunshot wound (57), and blunt trauma (18). No significant injuries were found in 72 patients (54%), and these patients received no further treatment. On the basis of laparoscopic findings, 52 patients underwent formal exploratory laparotomy. Surgical exploration confirmed the presence of significant injuries in 44 of the 52 patients (85%). Therapeutic laparoscopy was performed in 6 patients (5%) for diaphragm repair (4), gastrotomy repair (1), and splenorrhaphy (1). Additionally, 10 patients underwent laparoscopy-guided blood salvage for autotransfusion during laparoscopic evaluation of blunt trauma. Three small-bowel enterotomies were repaired during minilaparotomy. RESULTS: No significant injuries were missed as a result of our use of laparoscopy in trauma assessment. Complications--trocar enterotomy, trocar laceration of the inferior epigastric artery, and transient hypotension--occurred in 3 patients secondary to the use of laparoscopy. CONCLUSIONS: Trauma laparoscopy is a safe method for the evaluation of selected patients with abdominal trauma and can reduce the number of negative and nontherapeutic trauma laparotomies performed. Limited therapeutic intervention is possible in a small number of patients.

Isopneumic laparoscopy in general surgery and trauma: an update.

The purpose of this study was to assess the capability of a retractor system that permits laparoscopic surgery without carbon dioxide pneumoperitoneum and to determine if the system facilitates the use of traditional surgical instruments during minimally invasive surgery. This study was performed at a university-affiliated county hospital (Alameda County Medical Center, Highland General Hospital campus) in Oakland, California. The study design was prospective evaluation with data collection. Eighty-eight isopneumic laparoscopic procedures were performed between July 1992 and October 1993. A planar abdominal wall distention system consisting of an intra-abdominal fan retractor and an electrically powered mechanical arm was used to provide exposure. Conventional surgical instruments as well as laparoscopic instruments were used in each case. Laparoscopy without pneumoperitoneum was used in the evaluation of 43 patients with abdominal trauma (gunshot wound, 18; stab wound, 19; blunt trauma, 6). The need for formal abdominal exploration was obviated in 35 of 43 (81%) cases. Repair of three enterotomies, four diaphragmatic lacerations, and one gastric perforation was performed with conventional instruments. Isopneumic laparoscopic techniques were also used for cholecystectomy (n = 36), diagnosis laparoscopy (n = 4), appendectomy (n = 3), sigmoidopexy (n = 1), and closure of a perforated duodenal ulcer (n = 1). Abdominal exposure approximating that obtained by pneumoperitoneum was obtained in 37 of 45 cases. One major (trocar tip enterotomy) and two minor complications (superficial wound infection) occurred in this group of patients. The ability to use traditional surgical instruments was advantageous in several cases. Laparoscopic surgical procedures can be performed without pneumoperitoneum in the majority of cases. The ability to use conventional surgical instruments is an advantage of this technique. Further improvements in abdominal wall distention systems and modifications of existing surgical instruments are required to further expand the role of isopneumic laparoscopy.

Ultrasonographic examination of wound tracts.

OBJECTIVE: To determine if ultrasonography is useful in evaluating penetrating injuries of the trunk to assess whether violation of the peritoneum or pleura has occurred. METHODS: The study group was 29 patients who suffered gunshot (n = 17), stab (n = 10), or shotgun (n = 2) wounds. The abdomen was at risk in 21 injuries, the thorax in eight. The results of physical examination and plain x-rays suggested the pleura and or peritoneum might be intact in all patients. Using a 7-MHz transducer, wound tract(s) were images, looking for the presence of soft-tissue air and/or echolucent areas consistent with soft-tissue blood. Injuries were deemed extraperitoneal or extrapleural if (1) the entire tract was visualized; (2) it appeared superficial to the deepest fascial structure in that area; and (3) in shotgun injuries, all visible pellets on x-ray films were identified by ultrasound in the abdominal wall. RESULTS: Evidence of penetration occurred in four abdominal wounds and one thoracic wound. These were confirmed by operation in the abdominal cases and by subsequent chest x-ray examination in the one thoracic wound. The diagnosis of nonpenetration was confirmed in all the remainder by serial benign abdominal examination (n = 15), chest x-ray examination (n = 8), and laparoscopy (n = 1). Positive and negative predictive accuracy were thus 100% in this pilot series. CONCLUSIONS: Ultrasonographic exploration of penetrating truncal injuries is feasible and accurate. Ultrasonographic wound exploration may serve as a noninvasive and safe replacement for diagnostic laparoscopy, conventional local wound exploration, peritoneal lavage, and 6-hour chest x-rays (repeated chest x-rays taken 6 hours after initial chest x-ray examination). If used as part of the initial physical examination, cost-effectiveness can also be realized.

Duplex scanning replaces arteriography and operative exploration in the diagnosis of potential cervical vascular injury.

BACKGROUND: The pursuit of a diagnosis is more aggressive in suspected cervical vascular injury than in extremity vascular proximity injury, since the complications of missing the neck injury may result in irreversible neurologic damage. Most institutions use arteriography and operative exploration, but these modalities identify only 10% of cervical vascular traumas. While duplex scanning is the screening test of choice for carotid occlusive disease, few published reports have described experience with this modality in cervical vascular trauma. PATIENTS AND METHODS: To determine if duplex scanning can replace arteriography or operative exploration as the initial screening modality in the assessment of potential cervical vascular trauma, we performed a prospective evaluation in two parts. First, we used duplex scanning and cervical arteriography, concomitantly, to rule out injury in 15 patients. We then used duplex scanning alone in 85 patients, reserving arteriography for cases in which the scan revealed an arterial injury. RESULTS: Duplex scans and arteriography and operation diagnosed cervical vascular trauma equally well. Eight injuries were identified in all areas of the cervical arterial tree. No duplex scans have been falsely negative or falsely positive. Use of duplex scans instead of arteriography saved $1,252 per case. CONCLUSIONS: Duplex scanning detects cervical vascular injuries as effectively as arteriography or operation, and is faster and less expensive. This approach expands the utility of diagnostic ultrasound in the evaluation of trauma patients. It has become the procedure of choice for diagnosing cervical vascular trauma at our institution.

Successful laparoscopic splenorrhaphy using absorbable mesh for grade III splenic injury: report of a case.

We report herein on successfully performing a laparoscopic mesh splenorrhaphy in addition to blood salvage on a patient with a grade III splenic injury from blunt abdominal trauma. Given the lower success rates for nonoperative observation in grade III splenic trauma, we believe laparoscopic evaluation of splenic injury may offer an improved assessment over computed tomography (CT) scanning by localizing and quantitating the source of blood loss while at the same time enabling the surgeon to perform laparoscopically assisted blood salvage, autotransfusion, and laparoscopic repair. These advantages in diagnosis and therapy warrant further investigation into the role of laparoscopy in the evaluation and treatment of splenic trauma in selected stable patients.

Laparoscopic surgery without pneumoperitoneum. A preliminary report.

Laparoscopic surgery using pneumoperitoneum to create an operating field is known to have cardiopulmonary side effects. Conventional laparoscopic techniques require operating in a sealed environment. In July 1992, we initiated an investigation of the use of an electric-powered abdominal-wall lifter to expose an operating field. In our preliminary study, we have successfully completed 16 of 20 cases (80%) using this method of exposure. One trocar-related small-bowel injury was recognized immediately and repaired uneventfully. Two patients with dense adhesions made laparoscopic cholecystectomy impossible. One case of laparoscopic cholecystectomy was completed by conversion to pneumoperitoneum. Conventional instruments can be used through small incisions. Digital examination of abdominal contents can be achieved through the periumbilical incision or through other small incisions with the guidance of this retractor; this is superior to pneumoperitoneum since the surgeon can use more than just visual examination of intraabdominal pathology in laparoscopic surgery.

Gasless laparoscopy using a planar lifting technique.

In clinical use, the mechanical lifting technique has demonstrated the ability to displace the abdominal wall and create a useful cavity for visualization and surgical manipulation. By forming a planar ceiling, as opposed to the domed ceiling of conventional pneumoperitoneum, the abdominal organs are brought into closer proximity of the surgeon. Instrument length may be shortened, imparting greater surgical control. Without the necessity for gas sealing, entry portals are simplified. Conventional instruments (right angle clamps) may be introduced through the fan retractor insertion sites or by way of separate stab incisions. The planar lifting technique has the potential for simplifying laparoscopy and restoring instrument control to the operating surgeon.

Cardiac injuries: analysis of an unselected series of 251 cases.

Retrospective analysis was performed on the medical records of 251 patients treated for cardiac injuries at Highland General Hospital trauma facility in Alameda County, California, to identify factors that contribute to patient survival and predict death. Thirty-six patients (14%) had blunt injuries, 153 patients (61%) had gunshot wounds (GSW), and 62 patients (25%) had stab wounds. The overall survival rate was 18.7%, GSW survival was 6.5%, stab wound survival was 37.1%, and blunt injury survival was 40%. Patients who arrived with some vital signs had 62.2% survival and patients who arrived with absent vital signs had < 1% survival. Stepwise multiple logistic regression analysis revealed that for patients with absent vital signs the only significant predictor of outcome was GSW as the mechanism of injury and for patients with vital signs the ISS and the presence of combined right and left heart injuries were significant independent predictors of outcome. We conclude that the routine and aggressive use of emergency room thoracotomy for patients with penetrating cardiac injury must be re-examined.

Preliminary report on videothoracoscopy in the evaluation and treatment of thoracic injury.

A prospective trial of videothoracoscopy was conducted at an urban trauma center between February 1992 and February 1993 to determine the efficiency of this less invasive method of evaluation and treatment. Twenty-four consecutive patients with chest trauma (penetrating, n = 22; blunt, n = 2) were examined thoracoscopically for clotted hemothorax that otherwise would have been treated with thoracotomy (n = 9), suspected diaphragmatic injury (n = 10), and continued bleeding (n = 5). To ensure maximal exposure, general anesthesia with a double-lumen endotracheal tube was used in each patient. Clotted hemothorax was successfully evacuated in eight of nine patients (89%). Diaphragmatic laceration was suspected in 10 patients (2 abnormal chest radiographs, 8 proximity penetrating wounds) and confirmed thoracoscopically in 5. In four patients, diaphragmatic lacerations were successfully repaired with thoracoscopic techniques. Five patients underwent thoracoscopy for continued hemorrhage (greater than 1,500 mL per 24 hours) after tube thoracostomy. Intercostal artery injury was confirmed in all patients, and diathermy provided hemostasis in three patients without thoracotomy. No complications occurred. These data suggest the following: (1) Videothoracoscopy is an accurate, safe, and minimally invasive method for the assessment of diaphragmatic injuries, control of continued chest wall bleeding, and early evacuation of clotted hemothorax. (2) This technique should be used more frequently in patients with thoracic trauma. (3) Technical advances may expand the therapeutic role of thoracoscopy.

The success of duplex ultrasonographic scanning in diagnosis of extremity vascular proximity trauma.

OBJECTIVE: To determine if duplex ultrasonographic scanning is diagnostically equivalent to arteriography and/or operative exploration in the diagnosis of extremity vascular proximity trauma. DESIGN: A prospective evaluation comparing duplex scanning with arteriography or operative exploration in 50 patients. Subsequently, duplex scanning was used alone for 175 extremity vascular proximity injuries, with other diagnostic methods used when injury was indicated on the duplex scan. SETTING: A busy urban trauma center. PATIENTS: Consecutive sample of 200 patients with 225 extremity injuries. SELECTION CRITERIA: Vascular proximity injury or diminished strength of the extremity pulse. MAIN OUTCOME MEASURES: The presence or absence of vascular proximity injury confirmed on angiography and/or operative exploration. RESULTS: Duplex scanning had 100% sensitivity and 100% specificity compared with arteriography and/or operative exploration in the first 50 cases. In the remaining 175 cases of extremity trauma, vascular injuries were diagnosed with duplex scanning alone. Duplex scanning detected 18 injuries, 17 of which were confirmed by correlation with arteriograms and/or operative exploration. One false-positive result--spasm of the superficial femoral artery--was found on arteriography. Seven unsuspected venous injuries were also diagnosed. CONCLUSIONS: Duplex scanning is a noninvasive, safe, effective method for the initial evaluation of potential extremity vascular proximity injury. It has replaced arteriography in the initial diagnosis of extremity vascular proximity trauma by our trauma service.

Gasless laparoscopy and conventional instruments. The next phase of minimally invasive surgery.

OBJECTIVE: To assess the capability of a retractor system that permits laparoscopic surgery without pneumoperitoneum and to determine if the system facilitates the use of conventional surgical instruments during minimally invasive surgery. DESIGN: Prospective evaluation and data collection with review. SETTING: University-affiliated county hospital. PATIENTS: Twenty-nine male and 29 female subjects evaluated prospectively via 27 trauma-related and 31 elective procedures. METHODS: Fifty-eight laparoscopic procedures were performed between July 1992 and February 1993 with a system consisting of an intra-abdominal fan retractor and an electrically powered mechanical arm using conventional surgical and laparoscopic instruments. RESULTS: Gasless laparoscopy was used in the evaluation of 27 patients with abdominal trauma (11 gunshot wounds, 11 stab wounds, and five blunt injuries). The need for celiotomy was obviated in 20 (74%) of 27 cases. Three enterotomies, two diaphragmatic lacerations, and one gastric perforation were repaired with conventional instruments. Gasless laparoscopic techniques were also used in cholecystectomy (n = 26), diagnostic laparoscopy (n = 3), and appendectomy (n = 2). Exposure similar to that obtained by pneumoperitoneum was obtained in 30 (97%) of 31 cases. One major (trocar tip enterotomy) and two superficial wound infections occurred in this group. The ability to use conventional surgical instruments was advantageous in several cases. CONCLUSIONS: Comparable exposure was achieved in this cohort of patients with gasless laparoscopy. The use of conventional surgical instruments provides an advantage with this technique. Further improvements in abdominal wall lift systems and modification of existing surgical instruments may expand the role of gasless laparoscopy.

Recidivism in an urban trauma center.

The incidence of recurrent injury requiring evaluation and treatment at an urban trauma center was assessed by examination of data from the registry of an urban trauma unit. A subgroup of 342 recidivists sustained 711 traumatic injuries. This represented 6.4% of trauma service activations or consultations. The rates of recurrence in random groups of 100 patients with trauma and 50 patients with traumatic deaths were 5% and 12%, respectively. These rates of recurrent injury are lower than those of several previous reports. Comparison of patients with recurrent episodes of trauma with patients who experience a single episode of trauma revealed significant differences in age, sex distribution, mechanism of injury, and fatal outcomes. Recidivists averaged only 7.9 months between episodes of injury. In patients with recurrent trauma with fatal outcomes, the mean interval between initial injury and death was 18.8 months. Early identification of patients at high risk for recurrence may provide an opportunity for behavior modification.

Extrathoracic carotid reconstruction: the subclavian-carotid artery bypass.

Although the predominant location of symptomatic carotid artery occlusive disease is the carotid bifurcation, proximal common carotid artery lesions cause similar symptoms. Common carotid artery lesions occur as isolated disease or in tandem with carotid bulb disease. Restoration of carotid artery inflow from subclavian based extraanatomic bypasses should provide adequate reconstruction of these lesions. To evaluate subclavian-carotid artery bypass, a retrospective review of all patients undergoing this procedure from Jan. 1, 1977, to Feb. 20, 1989, was performed. Twenty patients (14 men, 6 women) with a mean age of 60 years were treated. Fifteen patients (75%) were admitted with transient ischemic attacks. Five (25%) had nonfocal symptoms (e.g., dizziness, syncope). Arteriographic evaluation demonstrated severe proximal occlusive disease of the common carotid artery in all cases. Reconstruction bypasses were performed to the carotid bulb (45%), internal carotid artery (30%), and external carotid artery (25%). Four patients underwent endarterectomy of the internal carotid artery in conjunction with subclavian-carotid artery bypass. Bypass conduits included saphenous vein (75%) and prosthetic grafts (25%). Asymptomatic phrenic nerve neuropraxia was identified by postoperative chest radiography in four cases, with no resultant respiratory disease. No perioperative strokes occurred. One postoperative death (5%) resulted from a myocardial infarction. Long-term results were available for 18 patients (90%), with a mean follow-up of 50 months (range, 1 to 122 months). Four patients have died of causes unrelated to carotid vascular disease. Serial duplex scans have documented graft patency in all 18 patients. A single patient returned with focal neurologic symptoms as a result of a posterior circulation infarct.(ABSTRACT TRUNCATED AT 250 WORDS)