Ditmars M L, Bongard F
Department of Surgery, Harbor/UCLA Medical Center, Torrance, California.
J Laparoendosc Surg. 1996 Oct;6(5):285-91. doi: 10.1089/lps.1996.6.285.
The role of diagnostic laparoscopy in penetrating trauma continues to evolve. We reviewed our experience to determine the effect of laparoscopy on therapeutic laparotomy rates, length of hospital stay, and hospital charges. Laparoscopy was performed on 106 hemodynamically stable patients with penetrating abdominal injuries (66 had gunshot wounds, 40 had stab wounds). All patients with laparoscopically identified peritoneal penetration underwent open laparotomy. At laparoscopy, 41 (39%) had positive findings, whereas 65 (61%) had none. Two patients with retroperitoneal hematomas and one with ecchymosis of the peritoneum were not explored. Thus 68 (64%) did not require laparotomy. Among the 38 who underwent laparotomy, 29 (76%) had positive findings and 9 (24%) had a negative laparotomy. Nineteen patients (50%) had a therapeutic laparotomy. This compares with a therapeutic laparotomy rate of 18% had all 106 patients undergone mandatory laparotomy. Data for length of stay and hospital charges were analyzed. Due to the extended stay associated with tube thoracostomy (n = 21), a subgroup excluding patients with chest tubes was also analyzed. In this subgroup, there was a significant difference in hospital stay between those who had only a laparoscopy and those who underwent a negative laparotomy (2.6 +/- 1.7 vs. 4.7 +/- 1.6, p < 0.01). The average nonsurgical charge for patients who had a negative laparotomy was more than double that for those who had laparoscopy only ($8275 +/- 4692 vs. $3762 +/- 3786, p < 0.01). We conclude that the use of diagnostic laparoscopy to identify peritoneal penetration resulted in an improved therapeutic laparotomy rate as well as significant reduction in hospital stay and hospital charges.
诊断性腹腔镜检查在穿透性创伤中的作用仍在不断演变。我们回顾了我们的经验，以确定腹腔镜检查对治疗性剖腹手术率、住院时间和住院费用的影响。对106例血流动力学稳定的腹部穿透伤患者进行了腹腔镜检查（66例为枪伤，40例为刺伤）。所有经腹腔镜检查发现有腹膜穿透的患者均接受了剖腹手术。在腹腔镜检查中，41例（39%）有阳性发现，而65例（61%）没有。2例腹膜后血肿患者和1例腹膜瘀斑患者未进行探查。因此，68例（64%）患者不需要进行剖腹手术。在接受剖腹手术的38例患者中，29例（76%）有阳性发现，9例（24%）剖腹手术结果为阴性。19例患者（50%）接受了治疗性剖腹手术。相比之下，如果对所有106例患者都进行强制性剖腹手术，治疗性剖腹手术率为18%。对住院时间和住院费用数据进行了分析。由于与胸腔闭式引流相关的住院时间延长（n = 21），还对一个排除有胸管患者的亚组进行了分析。在这个亚组中，仅接受腹腔镜检查的患者与剖腹手术结果为阴性的患者之间的住院时间存在显著差异（2.6±1.7天对4.7±1.6天，p < 0.01）。剖腹手术结果为阴性的患者的平均非手术费用比仅接受腹腔镜检查的患者高出一倍多（8275±4692美元对3762±3786美元，p < 0.01）。我们得出结论，使用诊断性腹腔镜检查来确定腹膜穿透可提高治疗性剖腹手术率，并显著缩短住院时间和降低住院费用。
