Operation For Trauma Research Articles

Early placement of a non-invasive, pressure-regulated, fascial reapproximation device improves reduction of the fascial gap in open abdomens: a retrospective cohort study

BackgroundSince current fascial traction methods involve invasive procedures, they are generally employed late in the management of the open abdomen (OA). This study aimed to evaluate early versus late placement...

Simultaneously operation for combined head and abdominal blunt trauma: A case report

An 82-year-old woman fell down the stairs and was brought to our hospital. When she came to our hospital, she had a left acute epidural hematoma, brain contusion, and splenic injury. During plain computed tomography (CT) imaging, hypotension and deteriorated level of consciousness was observed, and simultaneous head and abdominal surgery was performed to control intracranial hematoma growth and hemorrhagic shock. The head was positioned in right rotation and the trunk in supine position, and craniotomy and splenectomy were performed simultaneously. Simultaneous head and abdominal surgery is a very effective treatment strategy for multiple trauma because it does not require repositioning of the patient.

Indications for the Appropriate Use of Damage Control Surgery and Damage Control Interventions in Civilian Trauma Patients

In patients undergoing emergent operation for trauma, surgeons must decide whether to perform a definitive or damage control (DC) procedure. DC surgery (abbreviated initial surgery followed by planned reoperation after a period of resuscitation in the intensive care unit) has been suggested to most benefit patients more likely to succumb from the “vicious cycle” of hypothermia, acidosis, and coagulopathy and/or postoperative abdominal compartment syndrome (ACS) than the failure to complete organ repairs. However, there currently exists no unbiased evidence to support that DC surgery benefits injured patients. Further, the procedure is associated with substantial morbidity, long lengths of intensive care unit and hospital stay, increased healthcare resource utilization, and possibly a reduced quality of life among survivors. Therefore, it is important to ensure that DC laparotomy is only utilized in situations where the expected procedural benefits are expected to outweigh the expected procedural harms. In this manuscript, we review the comparative effectiveness and safety of DC surgery when used for different procedural indications. We also review recent studies suggesting variation in use of DC surgery between trauma centers and the potential harms associated with overuse of the procedure. We also review published consensus indications for the appropriate use of DC surgery and specific abdominal, pelvic, and vascular DC interventions in civilian trauma patients. We conclude by providing recommendations as to how the above list of published appropriateness indications may be used to guide medical and surgical education, quality improvement, and surgical practice.

Laparoscopy Compared With Laparotomy for the Management of Pediatric Blunt Abdominal Trauma

BackgroundThere is minimal evidence evaluating the risks and benefits of laparoscopy use in hemodynamically stable children with suspected abdominal injuries. The objective of this study was to evaluate postoperative outcomes in a large cohort of hemodynamically stable pediatric patients with blunt abdominal injury. MethodsUsing the 2015-2016 National Trauma Data Bank, all patients aged <18 y with injury severity score (ISS) ≤25, Glasgow coma scale ≥13, and normal blood pressure who underwent an abdominal operation for blunt abdominal trauma were included. Patients were grouped into three treatment groups: laparotomy, laparoscopy, and laparoscopy converted to laparotomy. Treatment effect estimation with inverse probability weighting was used to determine the association between treatment group and outcomes of interest. ResultsOf 720 patients, 504 underwent laparotomy, 132 underwent laparoscopy, and 84 underwent laparoscopy converted to laparotomy. The median age was 10 (IQR: 7-15) y, and the median ISS was 9 (IQR: 5-14). Mean hospital length of stay was 2.1 d shorter (95% confidence interval [CI]: 0.9-3.2 d) and mean intensive care unit length of stay was 1.1 d shorter (95% CI: 0.6-1.5 d) for the laparoscopy group compared with the laparotomy group. The laparoscopy group had a 2.0% lower mean probability of surgical site infection than the laparotomy group (95% CI: 1.0%-3.0%). ConclusionsIn this cohort of hemodynamically stable pediatric patients with blunt abdominal injury, laparoscopy may have improved outcomes over laparotomy.

Two stage Whipple operation for high grade pancreas trauma- A single center experience

Two stage Whipple operation for high grade pancreas trauma- A single center experience

Thoracic Epidural Anesthesia and Analgesia (TEA) in Patients with Rib Fractures

BackgroundWe analyzed the results of surgical reduction and fixation of ribs under thoracic epidural anesthesia and analgesia (TEA) in patients who had no more than 3 consecutive rib fractures with severe displacement to examine the clinical usefulness of this method.Materials and MethodsFrom May 2008 to March 2010, 35 patients underwent surgical reduction and fixation of ribs under TEA. We reviewed the indications for this technique, number of fixed ribs, combined surgical procedures for thoracic trauma, intraoperative cardiopulmonary events, postoperative complications, reestablishment of enteral nutrition, and ambulation.ResultsThe indications of TEA were malunion or nonunion of fractured ribs in 29 (82.9%; first operation) and incompletely ribs under previous general anesthesia in 6 (17.1%; second operation). The average number of fixed ribs per patient was 1.7 (range: 1~3). As a combined operation for thoracic trauma, 17 patients (48.6%) underwent removal of intrathoracic hematomas, and we performed repair of lung parenchyma (2), wedge resection of lung (1) for accompanying lung injury and pericardiostomy (1) for delayed hemopericardium. No patient had any intraoperative cardiopulmonary event nor did any need to switch to general anesthesia. We experienced 3 postoperative complications (8.6%): 2 extrapleural hematomas that spontaneously resolved without treatment and 1 wound infection treated with secondary closure of the wound. All patients reestablished oral feeding immediately after awakening and resumed walking ambulation the day after operation.ConclusionThoracic epidural anesthesia and analgesia (TEA) may positively affect cardiopulmonary function in the perioperative period. Moreover, this technique leads to an earlier return of gastrointestinal function and early ambulation without severe postoperative complications, resulting in a shortened hospital stay and lowered costs.

Nonoperative management of blunt renal injury: a need for further study

Background Blunt renal injury in children is usually managed without an operation. However, there are no published guidelines for nonoperative management. Therefore, we conducted a retrospective review to examine the natural history of these injuries and to identify potential recommendations for management. Methods A retrospective analysis of our most recent 12-year experience with blunt renal injury was performed. Results One hundred eleven trauma patients were identified as having a renal injury. Mean age was 10.8 ± 4.4 years with a weight of 43.1 ± 20.8 kg and 65% of the patients were males. In patients with an isolated renal injury (n = 65), the mean length of bed rest was 3.8 ± 1.9 days, resulting in a mean length of hospitalization of 3.8 ± 3.1 days. There were no transfusions, and the only operation for renal trauma was a nephrectomy in a patient with existing end-stage obstructive nephropathy of that kidney. There were 15 patients discharged with persistent hematuria, none of which had long-term sequelae. Conclusion Our data suggest the risk of significant injury from blunt renal trauma is low, and clearance of hematuria is not likely an important parameter such that bed rest with serial blood and urine monitoring may not be justified. There is clearly a role for the prospective application of a more liberal management protocol.

One Hundred Consecutive Splenectomies for Trauma: Is Histologic Evaluation Really Necessary?

Splenectomy remains the most commonly performed abdominal operation for trauma. Although the vast majority of these patients (pts) are young and healthy, histologic evaluation is still routinely performed. We propose that routine histologic sampling of an injured yet otherwise grossly normal spleen is unnecessary. A retrospective review of 100 consecutive pathologic specimens of pts undergoing splenectomy for trauma at a Level I trauma center was performed during a 25-month period. Data are reported as mean +/- SD. Average age was 34.4 +/- 15.1 years. There were 78 men and 22 women. Average injury severity score was 28.3 +/- 12.9. The most common mechanisms of injury were motor vehicle collisions (56%) and motorcycle collisions (15%). Average length of stay was 17.4 +/- 19 days. Microscopic pathologic findings returned as benign with no evidence for neoplasia in 99 of 100 specimens. Mean specimen weight was 184.6 +/- 188.7 g. Only one spleen, which appeared grossly abnormal and weighed 1,800 g, had abnormal histology demonstrating extramedullary hematopoiesis. This pt died before further workup. Our review suggests that the routine microscopic evaluation of spleens removed after traumatic injury, as is currently the standard of care at our institution, is unnecessary. Such examination should only be performed in cases of marked splenomegaly or in spleens that appear grossly abnormal.

Early Management of Gunshot Injuries to the Face in Civilian Practice

Gunshot injuries to the face in civilian practice are rarely reported. Potential complications in the Emergency Department can have catastrophic consequences, and inappropriate operative management of the facial soft and skeletal tissues are related to outcome. A structured diagnostic and management approach is used in our Trauma Unit to deal with gunshot wounds to the face. A retrospective study of 55 patients who sustained gunshot injury to the face was conducted over a 6(1/2)-year period. Demographic details, mechanism of injury, and mode of presentation and management were recorded. Mortality and morbidity data were collated. There were 51 male and 4 female patients. All injuries were caused by low-velocity gunshots, except for one that was a shotgun injury. Overall, 28 of the 55 patients (50%) underwent orotracheal intubation on scene or in the resuscitation room, and 2 had cricothyroidotomy. In addition to the maxillofacial trauma, associated injuries were common. Forty patients underwent operation for maxillofacial trauma, 34 on the day of admission and the remaining 6 within 5 days of injury. Multiple operations over a 2-week period were necessary for 18 of the 40 patients. Complications directly related to the gunshot injury to the face were very limited. Mortality was related to associated injuries. Gunshot injury to the face in civilian violence is a "benign" condition as long as the Patient's airway is kept patent and hemorrhage is controlled. Early operative intervention for repair of the soft and skeletal facial structures leads to satisfactory results. Mortality directly related to the facial trauma is uncommon.

Acute Treatment of Penetrating Popliteal Artery Trauma: The Importance of Soft Tissue Injury

During a 20-year period from 1973 to 1992, 109 patients underwent early operation for acute popliteal artery trauma. Clinical variables were analyzed for their association with amputation. Gunshot wounds accounted for the majority of injuries (73%), followed by shotgun wounds (18%), stab wounds (6%), iatrogenic injuries (2%), and lacerations (1%). Fasciotomies were performed selectively in 41% of patients. Seven patients (6%) lost the injured extremity despite arterial repair. The mean time from injury to arterial repair was not significantly different for patients with or without subsequent amputation (8.6 +/- 3.6 and 9.7 +/- 7.4 hours, respectively; p = 0.69). Delay in diagnosis longer than 6 or 12 hours after the injury did not increase the risk of amputation. Other factors not associated with limb loss were preoperative ischemic neurologic deficit or compartmental hypertension, concomitant fracture, and popliteal vein injury. Severe soft tissue injury (p < 0.0001) or postoperative wound sepsis (p < 0.0001) substantially increased the risk of amputation. Delayed fasciotomies were uncommon (4%) but were associated with a significantly increased risk of amputation (p < 0.0001). Vein grafting for arterial repair (p = 0.0017) and shotgun injuries (p < 0.0001) were associated with amputation to the extent that they were related to severe soft tissue injury. The degree of soft tissue trauma and subsequent infection of devitalized tissue limits the success of popliteal arterial repair. Changes in the mechanism of trauma, liberal use of four-compartment fasciotomies, and aggressive management of soft tissue injury resulted in a significant decline in the amputation rate from 21% (4/19) in the first 5 years to 0% (0/39) in the last 5 years of the study.

TWO CASES OF NECROTIZING FASCIITIS

Necrotizing fasciitis is a repidly progressive, often fatal soft tissue infection involving the overlying skin because of thrombosis of nutrient vessels which occurs secondarily. Early diagnosis and radical debridement are essential. Two cases of necrotizing fasciitis are reported. case 1 was a 60-year-old man with diabetes mellitus. He was admitted to the hospital for diabetic gangrene of the bottom. after admission his symptom rapidly progressed and necrotizing fasciitis occurred. Radica debridement was performed. Case 2 was a 45-year-old man. After emergency operation for an abdominal trauma, necrotizing fasciitis occurred from the middle wound to the waist. Radical debridement was carried out, but the fascial necrosis extended to the parietal peritoneum, and the patient died. This paper also presents some notes on accumulated 28 cases from the Japanese literature.

Endorectal pull-through operation for massive rectal trauma in children

Endorectal pull-through operation for massive rectal trauma in children

Transfusion requirements in conservative nonoperative management of blunt splenic and hepatic injuries during childhood

Nonoperative management of splenic and hepatic injuries in children is safe, and the majority of those with isolated injuries do not require blood transfusion. Thirty-seven children were treated for blunt splenic or hepatic trauma from November 1983 to September 1989. There was one death in a patient with a lethal head injury. No operations were performed on those with isolated splenic or hepatic injuries. Three of those with multiple injuries underwent delayed laparotomy. Two had perirenal and retroperitoneal hematomas without active bleeding, and one had a bowel obstruction secondary to an intramural jejunal hematoma. There were no late complications related to the splenic or hepatic injuries. Eight children (22%) required surgery for other injuries. Twelve children were not transfused, including the majority (8/11) of those with isolated splenic or hepatic injury. The hematocrit of four of these children fell to below 28% and this anemia was well-tolerated. Two children with bleeding disorders (factor VIII [antihemophilic factor] and factor XII [Hageman factor] deficiency) did not require packed red blood cells transfusion. Two clinically distinct groups of children received blood transfusions: (1) eight patients with multiple injuries were transfused during initial resuscitation when unstable or during early operation for other system trauma (mean, 62.0 mL blood/kg body weight); and (2) three hemodynamically stable patients with isolated injuries and 14 stable patients with multiple injuries were transfused empirically after initial resuscitation solely because of decreasing blood counts. They received an average of 16.5 and 21.1 mL blood/kg body weight, respectively.(ABSTRACT TRUNCATED AT 250 WORDS)

Nonoperative management versus early operation for blunt splenic trauma in adults

Nonoperative management versus early operation for blunt splenic trauma in adults

Emergency Operation for Abdominal Trauma

Emergency Operation for Abdominal Trauma

A test to help diagnosis of rupture in the injured duodenum

INTRODUCTION THE duodenum is uncommonly injured in blunt abdominal trauma. Ten per cent of patients undergoing operation for blunt abdominal trauma have intestinal injuries (Cox, unpublished results). Ten per cent of these intestinal injuries are duodenal (Hawkins and Mullen, 1974). The evaluation of duodenal trauma is most difftcult because of its retroperitoneal position. The diagnosis is missed in as many as 10 -20 per cent of cases, and in those cases the mortality may be as high as 77 per cent (Kelly et al., 1978; King and Provan, 1974). The preoperative evaluation of this injury is often unrewarding. The following cases of duodenal injury are presented to show the difficulty in diagnosis as well as to suggest a method for the intraoperative delineation of the injury.

Delayed flank approach to isolated renal trauma in children

Seven cases of delayed operation for renal trauma are presented. The only kidney lost would have been lost with early operation. No undue friability of the renal tissue was found. The flank approach in delayed procedures for renal trauma has certain advantages over the transabdominal approach.

Renal injuries caused by external blunt trauma: Moderate approach to serious injuries

The records of 65 patients with renal injuries caused by external force were reviewed. Careful clinical observation and serial radiologic examinations permitted the separation of patients into two groups, major and minor renal injuries; the former were usually treated surgically and the latter, conservatively. Purposeful delayed operation for serious renal trauma caused by blunt external force possesses many of the advantages of immediate surgical intervention, but does not require preliminary pedicle control or emergency arteriography. Immediate surgical repair, delayed purposeful secondary operation, and conservatism all may be employed to advantage depending on individual circumstances.

Traumatic hepatic sequestra

The deleterious effects of retained devitalized hepatic tissue after an operation for liver trauma are well recognized. These include sepsis, delayed hemorrhage, and uncontrolled biliary fistula. Insufficient attention has been directed to the diagnosis, localization, and operative removal of hepatic sequestra. In this series of five patients with intractable sepsis, all recovered dramatically after complete excision of residual devascularized tissues. These sequestra were identified by utilizing one or more diagnostic methods, including hepatic scanography, sinograms, and cholangiography. The combination of anteroposterior and lateral scanograms proved to be particularly helpful in localizing the sequestrum and in guiding the placement of the incision for its removal. A more aggressive approach to removal of devitalized tissue in the treatment of major hepatic injuries, including segmental and lobar resection, should obviate these complications.