Guth A A, Pachter H L
Bellevue Hospital Center Trauma and Shock Unit, Department of Surgery, New York City, USA.
JSLS. 1998 Apr-Jun;2(2):123-7.
How should the stable patient with penetrating abdominal or lower chest trauma be evaluated? Evolving trends have recently included the use of diagnostic laparoscopy. In September 1995 we instituted a protocol of diagnostic laparoscopy to identify those patients who could safely avoid surgical intervention.
Prospective case series.
Hemodynamically stable patients with penetrating injuries to the anterior abdomen and lower chest were prospectively evaluated by diagnostic laparoscopy, performed in the operating room under general anesthesia, and considered negative if no peritoneal violation or an isolated nonbleeding liver injury had occurred. If peritoneal violation, major organ injury or hematoma was noted, conversion to open celiotomy was undertaken.
Seventy consecutive patients were evaluated over a two-year period. The average length of stay (LOS) following negative laparoscopy was 1.5 days, and for negative celiotomy 5.2 days. There were no missed intra-abdominal injuries following 30 negative laparoscopies, and 26 of 40 laparotomies were therapeutic. The technique also proved useful in evaluation of selected blunt and HIV+ trauma victims with unclear clinical presentations. However, while laparoscopy was accurate in assessing the abdomen following penetrating lower chest injuries, significant thoracic injuries were missed in 2 out of 11 patients who required subsequent return to OR for thoracotomy.
Laparoscopy has become a useful and accurate diagnostic tool in the evaluation of abdominal trauma. Nevertheless, laparoscopy still carries a 20% nontherapeutic laparotomy rate. Additionally, significant intrathoracic injuries may be missed when laparoscopy is used as the primary technique to evaluate penetrating lower thoracic trauma.
对于腹部或下胸部穿透伤的稳定患者应如何进行评估？最近，不断发展的趋势包括使用诊断性腹腔镜检查。1995年9月，我们制定了一项诊断性腹腔镜检查方案，以确定那些可以安全避免手术干预的患者。
前瞻性病例系列研究。
对前腹部和下胸部穿透伤且血流动力学稳定的患者进行前瞻性评估，在全身麻醉下于手术室进行诊断性腹腔镜检查，若未发生腹膜侵犯或仅存在孤立的非出血性肝损伤，则视为阴性。若发现腹膜侵犯、主要器官损伤或血肿，则改行开腹手术。
在两年时间里，连续对70例患者进行了评估。腹腔镜检查阴性后的平均住院时间（LOS）为1.5天，开腹手术阴性后的平均住院时间为5.2天。30例腹腔镜检查阴性的患者未遗漏任何腹内损伤，40例开腹手术中有26例具有治疗意义。该技术在评估某些临床表现不明确的钝性伤和HIV阳性创伤患者时也被证明是有用的。然而，虽然腹腔镜检查在评估下胸部穿透伤后的腹部情况时较为准确，但在11例需要随后返回手术室进行开胸手术的患者中，有2例遗漏了严重的胸部损伤。
腹腔镜检查已成为评估腹部创伤的一种有用且准确的诊断工具。尽管如此，腹腔镜检查仍有20%的非治疗性开腹手术率。此外，当将腹腔镜检查作为评估下胸部穿透伤的主要技术时，可能会遗漏严重的胸内损伤。
