微创即高效：穿透性腹部损伤的诊断与治疗性腹腔镜检查
Minimally invasive is maximally effective: Diagnostic and therapeutic laparoscopy for penetrating abdominal injuries.
作者信息
Chestovich Paul J, Browder Timothy D, Morrissey Shawna L, Fraser Douglas R, Ingalls Nichole K, Fildes John J
机构信息
From Department of Surgery (T.D.B), Stanford University, Stanford, California; and Division of Trauma and Critical Care (P.J.C., S.L.M., D.R.F., N.K.I., J.J.F.), University of Nevada School of Medicine, Las Vegas, Nevada.
出版信息
J Trauma Acute Care Surg. 2015 Jun;78(6):1076-83; discussion 1083-5. doi: 10.1097/TA.0000000000000655.
BACKGROUND
Laparoscopic techniques have evolved, allowing increased capabilities within most subspecialties of general surgery, but have failed to gain traction managing injured patients. We hypothesized that laparoscopy is effective in the diagnosis and treatment of penetrating abdominal injuries.
METHODS
We retrospectively reviewed patients undergoing abdominal exploration following penetrating trauma at our Level 1 trauma center during a 6-year period from January 1, 2008, to December 31, 2013. Demographic and resuscitation data were obtained from our trauma registry. Charts were reviewed for operative details, hospital course, and complications. Hospital length of stay (LOS) and complications were primary end points. Patients were classified as having nontherapeutic diagnostic laparoscopy (DL), nontherapeutic diagnostic celiotomy (DC), therapeutic laparoscopy (TL), or therapeutic celiotomy (TC). TL patients were case-matched 2:1 with TC patients having similar intra-abdominal injuries.
RESULTS
A total of 518 patients, including 281 patients (55%) with stab wounds and 237 patients (45%) with gunshot wounds, were identified. Celiotomy was performed in 380 patients (73%), laparoscopy in 138 (27%), with 44 (32%) converted to celiotomy. Nontherapeutic explorations were compared including 70 DLs and 46 DCs with similar injury severity. LOS was shorter in DLs compared with DCs (1 day vs. 4 days, p < 0.001). There were no missed injuries. Therapeutic explorations were compared by matching all TL patients 2:1 to TC patients with similar type and severity of injuries. Twenty-four patients underwent TL compared with 48 TC patients in the case matched group. LOS was shorter in the TL group than in the TC group (4 days vs. 2 days, p < 0.001). Wound infections were more common with open exploration (10.4% vs. 0%, p = 0.002), and more patients developed ileus or small bowel obstruction after open exploration (9.4% vs. 1.1%, p = 0.018).
CONCLUSION
Laparoscopy is safe and accurate in penetrating abdominal injuries. The use of laparoscopy resulted in shorter hospitalization, fewer postoperative wound infection and ileus complications, as well as no missed injuries.
LEVEL OF EVIDENCE
Therapeutic study, level IV.
背景
腹腔镜技术不断发展，使普通外科的大多数亚专业领域的能力有所提高，但在处理受伤患者方面却未能得到广泛应用。我们推测腹腔镜检查在穿透性腹部损伤的诊断和治疗中是有效的。
方法
我们回顾性分析了2008年1月1日至2013年12月31日期间在我们的一级创伤中心接受穿透性创伤后腹部探查的患者。人口统计学和复苏数据来自我们的创伤登记处。查阅病历以获取手术细节、住院过程和并发症。住院时间（LOS）和并发症是主要终点。患者被分类为进行非治疗性诊断性腹腔镜检查（DL）、非治疗性诊断性剖腹术（DC）、治疗性腹腔镜检查（TL）或治疗性剖腹术（TC）。TL患者与腹腔内损伤相似的TC患者按2:1进行病例匹配。
结果
共确定了518例患者，其中281例（55%）为刺伤，237例（45%）为枪伤。380例患者（73%）进行了剖腹术，138例（27%）进行了腹腔镜检查，其中44例（32%）转为剖腹术。比较了非治疗性探查，包括70例DL和46例DC，损伤严重程度相似。DL组的住院时间比DC组短（1天对4天，p<0.001）。没有漏诊损伤。通过将所有TL患者与损伤类型和严重程度相似的TC患者按2:1进行匹配来比较治疗性探查。病例匹配组中有24例患者接受了TL，48例患者接受了TC。TL组的住院时间比TC组短（4天对2天，p<0.001）。开放性探查后伤口感染更常见（10.4%对0%，p=），更多患者在开放性探查后出现肠梗阻或小肠梗阻（9.4%对1.1%，p=0.018）。
结论
腹腔镜检查在穿透性腹部损伤中是安全准确的。使用腹腔镜检查可缩短住院时间，减少术后伤口感染和肠梗阻并发症，且无漏诊损伤。
证据级别
治疗性研究，四级。
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