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Diagnosis

Published on February 2017 | Categories: Documents | Downloads: 7 | Comments: 0
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DIAGNOSIS
The diagnostic approach to penetrating wounds of the abdomen is slowly evolving based on newer technologies and minimally invasive surgical techniques. In 1960, Shaftan created controversy by suggesting that surgical judgment rather than mandatory celiotomy was the preferred approach to patients with penetrating trauma. 4 His initial efforts slowly gained support in the management of stab wounds. Stab wounds follow the rule of thirds: one-third do not penetrate the peritoneal cavity, one-third penetrate the peritoneal cavity but do not create injury, and one-third cause injury requiring operative repair. Recognizing that a mandatory policy of celiotomy resulted in negative or nontherapeutic celiotomy in two-thirds of patients, selective management is now a common practice. In 2001, Scalea et al. 5 reported a prospective series of hemodynamically stable patients with penetrating trauma studied by triple-contrast computed tomography (CT). There were 75 consecutive patients and 60% sustained gunshot or shotgun wounds. Nonoperative management was successful in 96% of patients with a negative CT scan. Despite this impressive series, most surgeons employ celiotomy for the treatment of gunshot wounds and accept a 15% negative or nontherapeutic celiotomy rate. In some institutions, both operative and selective management coexist, with surgical judgment prevailing in instances where the suspicion of intraperitoneal penetration or injury is low, that is, fl ank wounds and wounds confi ned to the liver. Indications for operation follow generally accepted algorithms (Figures 4 and 5). When criteria are met, most surgeons proceed with operative treatment. The emergence of experienced minimally invasive surgeons is beginning to modify indications for celiotomy after penetrating trauma, especially in wounds that potentially injure the hemidiaphragm or where abdominal penetration is in doubt. These enhanced skills have supported the evolution of laparoscopy from a primary diagnostic modality to both a diagnostic and therapeutic tool.6 Wounds to the diaphragm can be seen and repaired; wounds to other organ systems can be detected, characterized as to injury severity and, in many instances, repaired or controlled with hemostatics Small bowel wounds remain problematic. Injuries obvious to the laparoscopic surgeon are probably detectable by other simple or less invasive techniques, that is, physical examination, CT, and diagnostic peritoneal lavage (DPL). Occult injuries may be initially missed regardless of the diagnostic approach, but exclusion of peritoneal penetration is useful whether by local wound exploration or direct visualization via a laparoscope.

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