The End of An Era

• Previous message: Tracheal Injury
• Next message: The End of An Era
• Messages sorted by: [ date ] [ thread ] [ subject ] [ author ]

Agree 100% Rick

Tim
South Africa

-----Original Message-----
From: trauma-list-bounces at trauma.org
[mailto:trauma-list-bounces at trauma.org]On Behalf Of docrickfry at aol.com
Sent: Friday, August 12, 2005 3:07 AM
To: trauma-list at trauma.org
Subject: Re: The End of An Era


Caesar--
I just read this paper yesterday--altho I can appreciate a role for laparoscopy in penetrating abd trauma, the cases where it can add something of value are few and far between.  In the numbers here are some facotrs quite hidden by your recitation of simple numbers--first, how many of these "saved laparotomies " occurred in GSW's vs stabs?  For stabs, these same numbers have been equally achievable over the past 20 years of literature without laparoscopy ever having been used, leading to the very relevant question of what it adds at all.  These acheivements can be done with the use of local wound exploration, simple overnite observation, and/or DPL (note that FAST cannot do this--positive or negative, FAST will not give any of the necessary answers, nor will CT).  Even for GSW's suspected to be tangential and never penetrating the peritoneum, DPL and/or observation and (horrors!) phys exam of abdomen does equally well at ruling out peritoneal penetration.  And--the appropriat
 e use of CT can also help in viewing a very reliable picture of the wound track, and even with penetration, can confirm simple liver penetration for RUQ wounds.
Now, you may ask, well, what's wrong with using laparoscopy instead?  This of course is the presumed basis of the study you offer, asked of course by a group  with a clear vested interest in the use of this modality as indicated by their failure to ever address this and the following points.  First and most obvious--it is quite arguable that laparoscopy saves anything at all when compared to laparotomy--think about it.  It requires a trip to the OR and putting the patient under general anesthsia, then making incisions in the abdomen, representing the major part of the risk and cost of a negative or nontherapeutic laparotomy anyway! The only difference being the sacrifice of the most basic of surgical principles--EXPOSURE! This in a nutshell has always been my biggest issue with the laparoscopists who so disingenuously portray this as "saving a laparotomy"--what baloney!
And secondly--interesting that no cost or charge data is included--it never is in these studies!  Because-again, showing how disingenuous the authors are--the laparoscopy  adds at least $3000 to the charges to the patient, and much added true cost as well--over and above a neg or nontherapeutic laparotomy, and CLEARLY above local trauma center wound exploration, serial physical exams (horrors!), DPL or CT (which have no OR fees, room charges or anesthesia and surgeon charges).
So--the way this data is presented blatantly ignores the basic issues that must be vetted in order to truly show laparoscopy to be SUPERIOR to standard modalities with proven values of over 20 years--that is, its value, if any at all, MUST be shown to outweigh its significantly added charges and costs, never mind the most basic issue of outweighing the clearly increased risks over trauma center and nonop approaches.
ERF
 
-----Original Message-----
From: Caesar Ursic <cursic at gmail.com>
To: Trauma & Critical Care mailing list <trauma-list at trauma.org>
Sent: Fri, 12 Aug 2005 09:22:36 +1000
Subject: The End of An Era


Ahmed N, Whelan J, Brownlee J, Chari V, Chung R.
The contribution of laparoscopy in evaluation of penetrating abdominal wounds.
J Am Coll Surg. 2005 Aug;201(2):213-6. 
(Department of Surgery, Huron Hospital, Cleveland Clinic Health
System, Cleveland, OH.)

BACKGROUND: Penetrating abdominal wounds are traditionally explored by
laparotomy. We investigated prospectively the role of laparoscopy
within a defined protocol for management of penetrating abdominal
wounds to determine its safety and advantages over traditional
operative management.
STUDY DESIGN: The study inclusion criteria were: stab and gun shot
abdominal wounds, including junction zone injuries; stable vital
signs; and absence of contraindications for laparoscopy. Diagnostic
end points included detection of peritoneum or diaphragm violation,
visceral injuries, and other indications for laparotomy. Systematic
examination was undertaken using a multiport technique whenever the
peritoneum or diaphragm had been violated. All repairs were done by
open operation.
RESULTS: A total of 40.6% of patients with penetrating trauma
fulfilled study criteria (52 patients). Of these, 33% had no
peritoneal penetration; 29% had no visceral injuries despite violation
of peritoneum or diaphragm; 38% had visceral injuries, of which 40%
(mainly liver and omentum) required no intervention. Twelve patients
(23% of total) had open repairs. No missed injuries or death occurred
in the study. Overall, 77% of penetrating injuries with stable vital
signs avoided exploratory laparotomy. Compared with National Trauma
Data Bank information for patients with the same Injury Severity
Scores, hospitalization was reduced by more than 55% for the entire
series.
CONCLUSIONS: Laparoscopy for penetrating abdominal injuries in a
defined set of conditions was safe and accurate, effectively
eliminating nontherapeutic laparotomy and shortening hospitalization.

Discuss.

CM Ursic
Sydney
--
trauma-list : TRAUMA.ORG
To change your settings or unsubscribe visit:
http://www.trauma.org/traumalist.html
--
trauma-list : TRAUMA.ORG
To change your settings or unsubscribe visit:
http://www.trauma.org/traumalist.html

• Previous message: Tracheal Injury
• Next message: The End of An Era
• Messages sorted by: [ date ] [ thread ] [ subject ] [ author ]