Major Vessel Injury Research Articles

Major Vessel Injury

Major Vessel Injury

Open Laparoscopy Without Special Instruments or Sutures

An important advantage of open laparoscopy over closed techniques is the avoidance of placing a sharp trocar blindly into the peritoneal cavity. Although an open technique theoretically minimizes the risk of major retroperitoneal vessel injury and bowel injury, most laparoscopies are performed using a closed technique. In an effort to simplify open laparoscopy, a technique was developed that can be done without special equipment or sutures and nearly as quickly as a closed technique. To compare the effectiveness of this open laparoscopic technique to a closed technique, a prospective, observational, cohort study was carried out on 66 women undergoing laparoscopy for either infertility or pelvic pain. The open technique was performed on 35 consecutive patients and compared to a closed technique performed on 31 patients on a different service during the same period. Evaluation included total duration of the procedure, length of the incision, incidence of CO2 leakage and complications. The open technique took slightly longer, and the incision was slightly longer. CO2 leakage occurred in 5 of 35 of the open cases but in none of the 31 closed cases. Leakage was controlled effectively in every case by application of a towel clip to the skin incision. No complications occurred with either technique. This study suggested that an open technique that requires no special equipment or sutures may be a useful alternative approach for laparoscopy when insertion of a sharp trocar is undesirable.

Shotgun wounds of the limbs

Shotgun blasts may cause devastating injuries in civilian trauma practice. We have reviewed 23 consecutive patients with 28 deliberate shotgun wounds to limbs treated over a 4-year period. Wounds were categorized using the Red Cross wound classification. Twenty wounds were high-energy transfer grade 2 and 3 injuries: eight involved only the soft tissues (five category 2ST, three category 3ST), 10 wounds involved fractures (two category 2F, seven category 3F, one category 3VF), and three wounds involved major vessel injury (two category 3V, one category 3VF). Category 2ST and 3ST wounds were managed successfully with thorough wound excision of divitalized tissue, fasciotomy, and early wound closure. The more complex category 3F, 3V and 3VF wounds required a multidisciplinary approach to their management. Three lower limbs (category 3F, 3V, and 3VF wounds) with associated major nerve injury were amputated at the first operation; there were no cases of secondary amputation. Of the salvaged limbs, those with category 3F injury at or below the level of the elbow or knee had poor functional results.

Retrospective analysis of low-velocity gunshot wounds to the mandible

A retrospective study was conducted of 32 patients with mandibular fractures resulting from low-velocity gunshot injuries. Airway management was required in 25% of the patients, and 9% sustained major vessel injury. Patients were divided into two groups, depending on site of mandibular fracture: condyle, ramus, and coronoid ( n = 10), and angle, body, and symphysis ( n = 22). All patients in the condyle, ramus, coronoid group achieved clinical union without infection. Average postinjury maximal mandibular opening was restricted (28 mm), but the average follow-up period was relatively short (2 months). In the angle, body, symphysis group the infection rate was 27%, and in 18% of patients a continuity defect of the mandible developed. The average length of follow-up in this group was 5.4 months with a mean maximal mandibular opening of 36 mm.

Lumbar percutaneous discectomy

Since November 1988, 28 patients with lumbar L5 radiculopathy refractory to conservative care and with a radiologically verified central or mediolateral disc herniation at the level of L4/L5 had had a percutaneous discectomy. Radiological verification consisted of spinal CT +/- myelography, +/- myelo-CT, +/- MRI. A short-term follow-up analysis of at least 2 months taking the clinical and functional status as well as the professional reintegration into account revealed a 64.3% (18/28 patients) satisfactory outcome and a 32.1% (10/28 patients) failure rate. Of the latter 28.6% (8/28 patients) required further open surgery. One patient whose pain had only partially in regressed was shown at open operation to have a sequestered cranial prolapse as revealed by spinal CT after the percutaneous procedure. There were no major complications. One patient developed a sequestered extraforaminal herniation through the nucleotomy canal three weeks after the procedure. One patient bled for 2 minutes. There were no major vessel injuries. One patient reported local muscular pain, and enhanced nerve root pain after introduction of the trocar sleeve.

Prevention of adult respiratory distress syndrome with plasminogen activator in pigs

Death from traumatic shock has been associated with loss of blood externally or internally. However, many patients die after trauma, even though blood volume restoration is adequate. Death is often due to pulmonary failure (adult respiratory distress syndrome [ARDS]). Death and ARDS have been associated with disseminated intravascular coagulation (DIC) and microclots in the lungs. Dissolution of the microclots after trauma can be achieved by activation of endogenous plasmin. Nine pigs were anesthetized for 48 h. Trauma was administered by 60 standard blows to each thigh resulting in a bruise of muscle but no skin, bone, or major vessel injury. Nutrition and respiration were maintained at normal levels. All nine pigs died with severe lung pathology and low PaO2. Ten other traumatized pigs were treated with a plasminogen activator iv 4 h after trauma. Five of these were treated with tissue plasminogen activator (tPA) and five with urokinase. All treated pigs survived 48 h and maintained a normal PaO2. Autopsy showed minimal lung pathology.

A Reassessment of the Role of Arteriography in Penetrating Proximity Extremity Trauma

Penetrating proximity extremity trauma (PPET) was prospectively studied to clarify the role of routine arteriographic evaluation (AG). Over a 24-month period, 135 patients were identified with 152 injuries from PPET. All patients underwent AG and were randomized to either immediate or delayed timing. There were 27 arteriographic abnormalities from these 152 wounds, of which 16 (10.5%) were in major arteries. One acute arteriovenous fistula underwent immediate surgery. The remaining 15 major vessel injuries were nonoperatively observed, including seven cases of segmental arterial narrowing, six intimal flaps, and two small pseudoaneurysms (one of which enlarged and underwent surgical repair after 10 weeks of followup). Nine of the remaining 14 lesions resolved; two improved and three remained clinically unchanged over a mean followup interval of 2.7 months. Shotgun trauma was the mechanism which carried the greatest risk of significant vascular injury. Although "soft" clinical signs were significantly more predictive of vascular injury following PPET than proximity alone (p less than 0.0005), 50% of all injuries to major arteries did not manifest soft signs. No extremity morbidity resulted from delayed AG or from vascular injury management. We conclude from our study population: 1) the natural history of clinically occult arterial injuries was predominantly benign; 2) AG could be safely delayed up to 24 hours; 3) "soft" signs were not clinically useful predictors of vascular injury; and 4) with the exception of shotgun wounds, AG did not appear to be a cost effective screening modality, since detection of a single vascular injury requiring surgery cost $66,420.00.

Management of the major coagulopathy with onset during laparotomy.

An experience with 31 patients who developed major bleeding diatheses during laparotomy was reviewed. Management of the initial 14 patients was by standard hematologic replacement, completion of all facets of operation, and then closure of the peritoneal cavity, usually with suction drainage; only one patient survived. The subsequent 17 patients had laparotomy terminated as rapidly as possible to avoid additional bleeding. Major vessel injuries were repaired; ends of resected bowel were ligated; and holes in other gastrointestinal segments and the bladder were closed by purse-string sutures. One patient had a ureter ligated. Laparotomy pads (4-17) were then packed within the abdomen to effect tamponade, and the abdomen was closed under tension without drains or stomata. Following correction of the coagulopathy, the abdomen was re-explored at 15 to 69 hours in the 12 survivors. Definitive surgery then was completed: bowel resection and reanastomosis; ureter reimplantation; drains for bile, pancreatic juice, and urine; and stomata for bowel or urine diversion or decompression. Eleven of 17 patients, deemed to have a lethal coagulopathy, survived. This technique of initial abortion of laparotomy, establishment of intra-abdominal pack tamponade, and then completion of the surgical procedure once coagulation has returned to an acceptable level has proven to be lifesaving in previously non-salvageable situations.

Causes of death after blunt chest injury.

During the 10 years from 1968 a total of 1119 patients with chest and associated injuries were admitted to the Royal Newcastle Hospital (RNH); 530 of these needed ICU treatment and fifty-nine died. Common causes of death included irreparable associated injuries to brain and exsanguination due to major vessel injury. However, the commonest cause encountered was refractory respiratory failure due to pulmonary sepsis. This condition was associated with hypovolaemic shock, intra-abdominal injuries, failure of conservative treatment and injuries in the older age groups.

Bilateral arterial injury in the lower limbs associated with open pelvic fractures: a case report

The complications of pelvic fracture include blood loss, urinary tract injury, nerve injury and orthopaedic disability. Bleeding is quoted as the cause of death in 65 per cent of patients dying with a fractured pelvis (Rothenberger et al., 1978a). In a fifth of these patients disruption of the iliac or femoral vessels is the major source of bleeding. However, the incidence of major vessel injury in pelvic fractures is only 1 per cent. Arterial injury in both lower limbs is reported here, in association with an open fracture of the pelvis.

Major vessel injury during laparoscopy: Anatomy of two cases

Major vessel injury during laparoscopy: Anatomy of two cases

Open Pelvic Fracture

Twenty-two of 604 patients (4%) with pelvic fracture (PF) had open fractures. Eight per cent of all pedestrian and motorcycle accidents resulted in open PF, compared to 0.8% of all vehicular accidents. With one exception, all patients sustained multiple injuries. The mortality rate for an open PF was 50%, in marked contrast to 10.5% for a closed PF. Of more importance, the pelvic fracture was the primary cause of death in 73% of those dying with an open PF and in 30% of those dying with a closed PF. The higher mortality is due to an increased risk of infection and to massive hemorrhage because of a high risk of concomitant major vessel injury, as well as increased diffuse retroperitoneal hemorrhage, in these open fractures. Therapy directed to restoring blood volume, identifying and repairing major vessel injury, and attempting to decrease the diffuse retroperitoneal hemorrhage is essential. If drainage is necessary, it should be accomplished with a closed system. Immediate colostomy and use of antibiotics should decrease the infectious complications.

Gunshot wounds of the abdomen

• During a five-year period from July 1968 through June 1973, 277 abdominal gunshot wounds (GSWs) occurred, the overall fatality of which was 10%. Abdominal exploration was done in all patients. No intra-abdominal injury was found in 40 patients (14%) and no death occurred in this group. There were 28 fatalities (12%) in 237 patients (86%) who had intra-abdominal injuries. Morbidity and mortality were related not only to the number of organs injured, but also to specific organs injured. The leading cause of early death was hypovolemia due to major vessel injuries. Septicemia was the most common cause of death if the patient survived the first 24 hours of hospitalization. Penetrating abdominal stab wounds and gunshot wounds must be considered separately, and mandatory routine abdominal exploration for all penetrating gunshot wounds is advised. In stab wounds to the abdomen, conservative management may be preferable. ( Arch Surg 111:862-865, 1976)

Gunshot Wounds of the Abdomen

During a five-year period from July 1968 throuhgh June 1973, 277 abdominal gunshot wounds (GSWs) occurred, the overall fatality of which was 10%. Abdominal exploration was done in all patients. No intra-abdominal injury was found in 40 patients (14%) and no death occurred in this group. There were 28 fatalities (12%) in 237 patients (86%) who had intra-abdominal injuries. Morbidity and mortality were related not only to the number of organs injured, but also to specific organs injured. The leading cause of early death was hypovolemia due to major vessel injuries. Septicemia was the most common cause of death if the patient survived the first 24 hours of hospitalization. Penetrating abdominal stab wounds and gunshot wounds must be considered separately, and mandatory routine abdominal exploration for all penetrating gunshot wounds is advised. In stab wounds to the abdomen, conservative management may be preferable.

Prospective evaluation of hemostatic techniques for liver injuries.

The methods of hemostasis used for liver injuries were evaluated prospectively in 637 patients treated at Detroit General Hospital during a 5-year period. Variables evaluated included severity of injury, presence or absence of bleeding, and methods of hemostasis, The liver injury was either not bleeding or was controlled by temporary pack compression during laparotomy in 325 patients: none of these patients, including the 284 in whom no hemostatic procedure was used, rebled postoperatively. Active bleeding at laparotomy was directly related to the severity of liver injury, and required some hemostatic procedure in 312 patients. The methods of hemostasis were liver sutures (244 patients), nonanatomic resection (30 patients), anatomic resection (21 patients), hepatic artery ligation (nine patients), hepatotomy with intraparenchymal vascular control (five patients), and temporary internal pack with later re-operation (three patients). Rebleeding occurred in eight of the 243 patients who survived (seven after liver sutures and one after nonanatomic resection) and four required re-operation for control of bleeding. Sixty-nine patients with active bleeding died. Death on the table in 38 patients was related primarily to uncontrolled bleeding from liver and major vessel injury. Postoperative rebleeding from the liver occurred in 14 of 31 patients who died after surgery: following initial control by liver sutures (seven patients); anatomic resection (four patients); and hepatic artery ligation (three patients). There was no apparent relationship between any hemostatic procedure and the subsequent appearance of the hepatic ischemia or parahepatic abscess. Based on this experience, the merits and detriments of individual hemostatic procedures are presented.

Liver trauma in children

A review of our experience with urban children who sustained blunt abdominal trauma revealed that liver trauma occurred in one-third of all children. The cause of trauma, predominantly blunt in nature, led to a multitude of associated injuries which not only caused visceral and skeletal injury endangering the patient, but, more apparent even though less significant injuries delayed diagnosis and therapy of the underlying severe liver injury. Awareness of the possibility of liver injury in children with blunt abdominal trauma, prompt operative intervention with adequate vascular control prior to the attempted repair of liver or associated major vessel injuries should significantly increase the salvage of these pediatric trauma victims.

Traumatic Ruptured Bronchus and Injury of Major Thoracic Vessels

Traumatic Ruptured Bronchus and Injury of Major Thoracic Vessels

Modern Methods of Managing Traumatic Rupture and Amputation of the Bronchus

(1) Blunt trauma as a result of traffic accidents is by far the most common cause of traumatic laceration or rupture of the human bronchus. (2) Failure to make the correct early diagnosis of bronchial rupture or amputation See Images in the PDF File has been insufficiently emphasized in the past. Such failure invariably results in a high mortality rate in those cases where the injury goes undiagnosed and untreated. (3) A new classification for bronchial lacerations and injuries is presented and the appropriate treatment for such injuries is described. Five case reports illustrating the types of injury encountered and the proper application of appropriate surgical treatment are presented. (4) Thoracotomy with primary repair of the bronchial laceration or suture anastomosis of the severed bronchus is unquestionably the treatment of choice. Since associated major vessel injury is uncommon, elective pneumonectomy even as late as 15 years after traumatic amputation of the bronchus is almost invariably unnecessary in the management of this injury.

Management of injuries to the inferior vena cava

1. 1. Forty-two instances of injury to the inferior vena cava were found at laparotomy during the past ten years at Parkland Memorial Hospital. Of this group twenty-five survived, yielding a mortality of 40.5 per cent. 2. 2. Three principal factors determining survival were associated major vessel injury, the level of inferior vena cava injury and whether or not the vessel was actively bleeding at laparotomy. The latter seems to be the most important factor. 3. 3. All retroperitoneal hematomas should be explored. In 75 per cent of these cases, there was an additional reason to explore the retroperitoneal area. 4. 4. Suture repair by the technics outlined was the preferred method of treatment. Ligation was occasionally necessary if the injury was below the renal veins and primary repair could not be accomplished. 5. 5. It is essential to have a set of major vascular instruments immediately available when treating intra-abdominal trauma.

An angiosarcoma associated with an Œdematous limb: A case report

Laparoscopic gynecologic surgery has been widely used with a range of benefits. However, there are complications that are related to the abdominal entry process. Serious complications are gastrointestinal tract and major blood vessel injuries. This review introduces the recent available literature to prevent and eliminate the laparoscopic entry complications. The open entry technique is associated with a significant reduction of failed entry, compared to the closed entry technique; however there is no difference in the incidence of visceral or vascular injury. Laparoscopic entry by the left upper abdomen (i.e., Palmer's point) or the middle upper abdomen (i.e., the Lee-Huang point) could be considered in patients with suspected periumbilical adhesions or a history of umbilical hernia, or after three failed attempts of insufflation at the umbilicus. The Lee-Huang point has its own benefit for the operative laparoscopy in large pelvic pathologies and gynecology malignancy cases. The angle of Veress needle insertion varies from 45° in nonobese women to 90° in extraordinarily obese women. The high intra-peritoneal pressure entries, which range from 20 mmHg to 25 mmHg, minimize the risk of vascular injury. Therefore, this will not adversely affect the cardiopulmonary function in healthy women. The Veress intraperitoneal pressure (<10 mmHg) is a reliable indicator of correct intraperitoneal placement of the Veress needle. The elevation of anterior abdominal wall for placement of a Veress needle increases the risks of failed entry and shows no advantage in regard to vascular or visceral complications. Surgeons should continue to increase their knowledge of anatomy, their training, and their experience to decrease laparoscopic complications.