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Sun Nov 23 18:54:49 GMT 2008

Dr. McSwain is a respected senior trauma surgeon, but who lives in the past.    Costs and utilization of instrumentation and devices is encouraged by our administration, for the insurance companies and carriers, including Kaiser Permanente pay for these almost full.    We merely look for signs of peritoneal penetration, as you did with DPL.   We look for blood and at the liver and LUQ.   We do not fully run the bowel.   We look at the diaphragm and at the upper part of the stomach at the hepato-gastric peritoneum to look for blood in the lesser sac.   Contusion or transection of the pancreas and duodenum has been previously ruled out by the CT scan and our radiologist.      We can bill more for the laparoscopy than we could for the DPL or FAST.    For round large and heavy patients we are able to use the laparoscope for penetrating injury where we believe there is a tangential injury, only to the fat and not entering the peritoneum.     

Mohammed

> Subject: Re: Trauma Screening Laparoscopy> Date: Sun, 23 Nov 2008 11:42:01 -0600> From: nmcswai at tulane.edu> To: trauma-list at trauma.org> > How do you explore the pancreas and 4th portion of the duodenum? And how long does it take you to run the entire small bowel? I find that both are time consuming and the patient does better with no operative procedure if they have a negative physical examination> > Other question what is the time and cost comparison and complications of DPL and FAST in your institution vs laprascopic assessment of the abdominal cavity> > Typed by the thumbs of> Norman on his BlackBerry > > Norman McSwain, MD> Tulane Univ Surgery> 504 988-5111> > ----- Original Message -----> From: trauma-list-bounces at trauma.org <trauma-list-bounces at trauma.org>> To: trauma-list at trauma.org <trauma-list at trauma.org>> Sent: Sun Nov 23 11:03:56 2008> Subject: Trauma Screening Laparoscopy> > > In Private Practice, we increasingly are using minimal invastive approaches. With blunt and penetrating injury to the abdomen, a negative laparoscopy gives us confidence. It is replacing DPL (of course) and FAST as the preferred screening test in abdominal trauma> > Mohammed > > > Subject: RE: Laparoscopy in trauma> Date: Sat, 22 Nov 2008 18:02:25 -0600> From: nmcswai at tulane.edu> To: trauma-list at trauma.org> > Tim> > Yes it *can* be an indication but *should* it? A hole in the diaphragm> is just like a hole in the peritoneum from any other direction. This is> violation of the peritoneum, it is not sign of repairable injury. I have> not read those studies for a while, but using identification of> "repairable injury" as a positive outcome and no "repairable injury" as> a negative outcome, I do not believe that they showed any different> outcome than did Nance or Shafton. This would make the general> anesthesia and the insertion of the laparoscopy an unnecessary> operation.> > And Yes, I know that many of today's surgeons (or at least this is true> of the younger surgeons in the US), can (will) no longer do effective> abdominal examinations, and they VOMIT, but that does not make the> principle incorrect> > Use the indications that Nance described. 1) si> gnificant blood loss => uncontrolled hemorrhage, 2) acute abdomen = hole in the GI tract go to> the OR for a laparotomy. Otherwise after 24 hours of observation with> *serial physical examinations*, if neither #1 or #2 have developed then> discharge home without any operation> > Norman> > Norman McSwain Jr, MD FACS> Trauma Director Charity Hospital> Professor of Surgery> Tulane University School of Medicine> 504 988 5111> > > -----Original Message-----> From: trauma-list-bounces at trauma.org> [mailto:trauma-list-bounces at trauma.org] On Behalf Of Dr Timothy> Hardcastle> Sent: Saturday, November 22, 2008 12:12 PM> To: Trauma &amp; Critical Care mailing list> Subject: RE: Laparoscopy in trauma> > > > There is very little if any use for the laparoscopy in the primary> > assessment and management of either blunt or penetrating trauma of the> > abdomen.> >VATS is different. It can be used for the management of hemorrhage in> > most chest injuries. It can be used to identify diaphragm> atic> > perforation ( and the potential need for a laparotomy). And it is> > cheaper in complications, time and money than a thoracotomy> >> > The chest and abdomen are two different cavities, two different types> of> > problems tow different kinds of complications and two different> > outcomes. Do not try to compare these in the same thought process> >> > Norman> >> > Norman McSwain Jr, MD FACS> > Trauma Director Charity Hospital> > Professor of Surgery> > Tulane University School of Medicine> > 504 988 5111> Norm> > Maybe one place for lap-scope is where VATS not available and there is> lower left chest stab (not GSW) looking for occult diaphragm injury. At> least three large series supporting this.> > Tim> Dr T C Hardcastle> M.B., Ch.B. (Stell); M. Med. (Chir) (Stell); FCS (SA)> Principal Specialist Trauma Surgeon /> Honorary Lecturer UKZN Dept Surgery> Deputy Director - IALCH Trauma Service> > --> trauma-list : TRAUMA.ORG> To change your settings or unsubscribe visit:> h> http://www.trauma.org/index.php/community/list/url/http:list.ftech.net/pipermail/trauma-list/2008-November/ttp://www.trauma.org/index.php?/community/> --> trauma-list : TRAUMA.ORG> To change your settings or unsubscribe visit:> hhttp://www.trauma.org/index.php/community/list/url/http:list.ftech.net/pipermail/trauma-list/2008-November/ttp://www.trauma.org/index.php?/community/> _________________________________________________________________> Access your email online and on the go with Windows Live Hotmail.> http://windowslive.com/Explore/Hotmail?ocid=TXT_TAGLM_WL_hotmail_acq_access_112008> --> trauma-list : TRAUMA.ORG> To change your settings or unsubscribe visit:> hhttp://www.trauma.org/index.php/community/list/url/http:list.ftech.net/pipermail/trauma-list/2008-November/ttp://www.trauma.org/index.php?/community/> --> trauma-list : TRAUMA.ORG> To change your settings or unsubscribe visit:> hhttp://www.trauma.org/index.php/community/list/url/http:list.ftech.net/pipermail/trauma-list/2008-November/ttp://www.trauma.org/index.php?/community/
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