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EFFICIENCY OF LAPAROSCOPY FOR PATIENTS IN CASE OF POLYTRAUMA WITH PREVAILING ABDOMINAL AND CHEST INJURIES

EFFICIENCY OF LAPAROSCOPY FOR PATIENTS IN CASE OF POLYTRAUMA WITH PREVAILING ABDOMINAL AND CHEST INJURIES
Андрей Плотников, хирург (11 городская клиническая больница)

Грубник Юрий, зав. отделением хирургии (11 городская клиническая больница), доктор медицинских наук

Одесский национальный медицинский университет, Украина

Участник конференции

В статье проанализированы результаты диагностики и лечения 822 пострадавших при политравме с превалирующим повреждением органов брюшной полости и грудной клетки. У 428 пациентов в лечебно-диагностическом алгоритме применялась лапароскопия. В 150 (35%) случаях не было выявлено существенных повреждений, и операция закончилась дренированием брюшной полости. В 162 (37.9%) случаях произведены лапароскопические операции и в 116 (27.1%) случаях произведена конверсия (лапаростомия). Послеоперационная летальность составила 5 (3%) случаев.

Ключевые слова: лапароскопия, операция, повреждение, политравма.

У статті проаналізовано результати діагностики і лікування 822 постраждалих при політравмі з переважаючим пошкодженням органів черевної порожнини і грудної клітини. У 428 пацієнтів в лікувально-діагностичному алгоритмі застосовувалася лапароскопія. У 150 (35%) випадках не було виявлено суттєвих пошкоджень, і операція закінчилася дренуванням  черевної порожнини. У 162 (37,9%) випадках зроблені лапароскопічні операції і в 116 (27.1%) випадках проведена конверсія (лапаростомія). Післяопераційна летальність склала 5 (3%) випадків.

Ключові слова: лапароскопія, операція, пошкодження, політравма.

The article analyzes the results of diagnosing and treatment of 822 patients with polytrauma with the prevailing abdominal and thorax injuries. In 428 cases laparoscopy has been used for the purposes of diagnosing and treatment.  In 150 (35%) cases, no significant injuries have been discovered, and the surgery ended with the abdominal drainage. In 162 (37.9%) cases, laparoscopic surgery and in 116 (27.1%) cases, the conversion (laparostomy) have been done. Operative mortality was 5 (3%) cases.

Keywords: laparoscopy, surgery, injury, polytrauma.

Introduction

Delivery of medical aid to the injured patients with the polytrauma with the prevailing abdominal and thorax injuries reserves high level of diagnostic errors, post-surgical complications, disability and mortality, which indicates the need of further improvement of diagnostic algorithms and surgical aid in this category of patients [Abacumov and co-authors, 2005; Yartsev and co-authors, 2008]. Minimally invasive operations have won wide application in the foreign and national surgery during the last years. They have been used even more frequently for the patients with emergency surgical diseases thanks to the practical implementation of modern technologies. Enhanced life quality of patients, reduced time of their stay in the hospital, as well as reduced time of their temporary disability and amount of complications make the important advantages of these surgeries.            

The aimof our investigation was to enhance health care efficiency for patients in case of polytrauma with the prevailing abdominal and thorax injury.

Methods and materials

We used to observe 822 injured patients with polytrauma with the prevailing pathology of abdominal and thorax injuries.  The age of patients varied from 17 to 70. The average age was 43.5±3.45. There were 487 men (59.25%) and 335 women (40.75%). 281 patients had associated somatic dysfunctions. In particular, 103 patients (12.5%) had coronary heart disease accompanied by diffuse and post-infarction cardiosclerosis; 62 patients (7.5%) had chronic bronchitis and pulmonary emphysema; 57 patients (6.9%) had diabetes mellitus; 38 patients (4.6%) had chronic pyelonephritis, and 21 patients (2.6%) – chronic cerebrovascular disorder.

A certain diagnosing algorithm was used, including laboratory tests, U/S of abdominal cavity organs, multiple-view X-ray imaging, observation catheter setting, CT, MRI, and laparoscopy.

Bleeding of parenchymal organs was stopped using our patented method of U-shaped hemostatic suturing on the mesh implant Rebound HDR with the Nitinol frame. The mesh was introduced to the abdominal cavity through the laparoscopic port, after which it uncrumbled in the abdominal cavity immediately thanks to the Nitinol frame. Then the mesh was put on the diaphragmatic surface of liver, and a similar mesh – on the visceral surface of liver. U-shaped sutures were put on liver through the meshes. As the mesh was in constant tension due to the Nitinol frame, the suture pressure was spread uniformly over the mesh surface, which prevented liver tissue from being cut with sutures. It ensured safe hemostasis. For better hemostasis we used fibrin glue TachoComb in combination with the framed mesh, which was applied to the section line and was put under the mesh to the section line In the latter case the mesh performed a plugging and fixation function.

For the purpose of diagnosing thorax injuries we use X-ray thorax imaging, computer tomography, and magnetic resonance imaging. In some cases pleural puncture was done.

Upon detecting a considerable blood volume in the pleural cavity, thoracoscopy was done. During the thoracoscopy we discovered the source of bleeding after the aspiration of blood and blood clots, followed by coagulation of bleeding vessels.

Thoracoscopy was done in 48 cases as follows: the patient lies in the lateral position on the healthy side on a roll placed between the 4th and 5th rib, which ensures maximum spreading of ribs from the intervention side and providesgood visualization of pleural cavity, all sections of diaphragm and mediastinum. Based on the data [Om and co-authors, 2005], it has 100% sensitivity, 97% specificity, and 98% accuracy. To introduce thoracoscope we used a point in the fifth or sixth intercoastal space at the midaxillary line. After introducing thoracoscope we also did two or three additional thorax sections, when necessary, and set ports for introduction of manipulators and instruments.

Results:

We analyzed the results of diagnosing and treatment of 822 patients with polytrauma with the abdominal and thorax injuries.  No major injuries were discovered in 190 patients during the examination, which allowed to treat them without surgery. In 204 cases major abdominal and thorax injuries were discovered during the examination, which served an indication for emergency laparotomy. In 428 cases laparoscopic diagnosing was done to ascertain the diagnosis. In 150 out of 428 video laparoscopies no major abdominal injuries were discovered, and the intervention ended with the abdominal drainage. In 162 cases laparoscopic surgeries were done. During laparoscopic surgeries we widely used electrocoagulation in different modifications for the purpose of bleeding control. Besides, to stop bleeding and achieve safe hemostasis we developed and implemented in practice a method of fixation of polypropylene and other kinds of meshes on an elastic Nitinol frame to the rupture line of parenchymal organs (patent dated December 26, 2011, No.66396). 

In some cases TachoComb was put under the mesh to the rupture line for the purpose of safe hemostasis.

In 41 cases, in the case of live injury degree III according to OIS (Organ Injury Scaling) with the subcapsular hematoma of over 25-50% of liver surface with the continued bleeding, the method of Nitinol frame-based mesh implant application was used. Hemostasis applied according to our methodology (application of a polyproplene mesh on an elastic Nitinol frame) turned out to be very effective in the cases of subcapsular hematomas with the continued bleeding and in the case of intrahepatic hematomas. No recurring bleeding was observed in any of 34 cases. Abdominal cavity was subject to mandatory drain in the dextral hypochondrium with PVC drainage.

For the purpose of mitigating the risk of irreversible shock occurrence and replenishing circulating blood volume for patients with the apparent medium and heavy blood loss, we have widely used autohemotransfusions using Cell Saver 5 for 43 patients. 

Cell Saver 5 allowed extending the list of indications for laparoscopy and laparoscopic surgeries even in case of hemoperitoneum of up to 1,500 ml, and limiting the scope of contraindications for laparoscopic interventions considerably, paying more attention to the state of hemodynamics and cardiovascular disorder. Based on our data we believe that the contraindications to laparoscopy in the case of abdominal injuries include terminal state of patients, multiple injuries of hollow organs, general purulent peritonitis, massive intra-abdominal bleeding (over 1,500 ml of blood), diaphragm injury, and certain combinations of injuries characterized by the crush injury of internal abdominal organs. Therefore, the use of laparoscopic technologies for abdominal injuries is appropriate. Wide diagnostic and treatment opportunities of the method determine not only its expediency, but also the need of a reasonable activr surgical tactic. According to our data, laparoscopic surgeries allow to exclude unnecessary laparotomies, to perform a complete surgery in over a half of patients (62%) who need endovideolaparoscopic interventions.

As it does not seem to be possible to compare 162 patients who underwent laparoscopic surgery and 320 patients who underwent laparotomy due to a different severety level of the general state of patients and different severity of their injuries, we took a group of 50 patients who underwent treatment before the introduction of laparoscopic surgeries and had the injuries of the degree not exceeding I-III according to OIS, which corresponds to the degree of abdominal and thorax injuries of the patients who underwent laparoscopic surgery, in order to evaluate efficiency of laparoscopic surgeries in case of polytrauma with the prevailing abdominal and thorax injuries. For the purpose of evaluating efficiency of laparoscopic surgeries we performed a comparative analysis of the duration of laparoscopic surgeries and similar surgeries in the control group of patients who underwent laparotomy.  These data are shown in Table 1.  Table 1 shows that the duration of video-laparoscopic intervention in most case was shorter, because opening and closing of laparotomic access takes more time.

Table 1.

 Comparison chart of the duration of operative treatment of patients who underwent laparoscopy and laparotomy in the case of abdominal injury

 

Kinds of surgery

                Time of surgery

Patients with laparoscopy

Patients with laparotomy

Surgeries in the case of liver injury degree 1-3 according to OIS

 70.63±2.54

60±2.64

Surgeries in the case of spleen injury degree 1-2 according to OIS

51.38±1.88

73.25±3.75

Surgeries in the case of stomach injury

62±2.2

59.25±2.58

Surgeries in the case of small intestinal wound

52.88±1.82

48.63±1.82

Surgeries in the case of urinary bladder wound

46.88±0.65

65.38±1.28

Surgeries in the case of mesentery wound

53.38±1.91

55.25±1.26

Total patients

162

50

 

p<0.05

The biggest differences between the video-laparoscopic and traditional laparotomic intervention are observed during the post-surgical period. Treatment duration in the intensive care unit after the video-laparoscopic surgery was 0.84±0.4 days; for patients who underwent laparotomic surgery it made 1.20±0.4 days (р>0,05), and for patients who underwent curative laparotomy it made 2.60±0.7 days. We should also consider the extended period of stay in the intensive care unit to 3.08±0.7 days in case conversion is needed.

Comparison of post-surgical complications in the control groups of patients is given in Table 2. Having united these data, we received a reliable (p<0.05) difference of the advantage of laparoscopic surgeries compared to laparotomic surgeries. Comparison data are given in Table 3.

Table 2.

Post-surgical complications of patients who underwent laparoscopic surgeries and laparotomy in the control group

Types of complications

Patients who underwent laparoscopic surgeries

n=162

Patients who underwent laparotomy n=50

Bile leak

3

2

Pneumonia

5

6

Eventration

-

2

Post-operative wound infection

-

5

Trocar wound infection

4

 

Cystitis

3

1

Total

15

16

p>0.05

Table 3.

Efficiency of laparoscopyic surgeries compared to traditional surgeries

Group of patients

Number of patients

Average number of bed-days

Post-
surgical complications

Mortality rate

 

Patients who underwent laparoscopic surgeries

162

5.64±0.4

15(9%)

5(3%)

Patients who underwent laparotomy

  50

8.25±0.39

16(32%)

4(8%)

 

p<0.05

Conclusions and prospects of further developments

1. It has been ascertained reliably (p<0.05) that the average bed-day after laparoscopic surgeries is less than that after laparotomic surgeries, and makes 5.64±0.4 vs. 8.25±0.39. The average bed-day in the intensive care unit during the post-surgical period after laparoscopic surgeries also decreased to 0.84±0.4 days. Laparoscopic surgeries entail less post-surgical complications (9%) than laparotomic surgeries (32%). The mortality rate after laparoscopic surgeries decreased to 3%, while mortality in case of laparotomic intervention made 9%.

2. Our methods of laparoscopic bleeding control in case of injury of parenchymal organs using a polypropylene mesh allow to extend the list of indications for laparoscopic surgeries and increase their efficiency considerably.

3. The application of Cell Saver 5 allows to extend the list of indications for laparoscopic surgeries for patients with stable hemodynamics in case of concomitant abdominal injury, abdominal bleeding, allows to improve the patient's state of health considerably, to reduce the time of surgery, and to decrease the risk of post-surgical complications and mortality. In some cases donor blood transfusion may be avoided, which allows to prevent transfusion complications and possible infection with the deseases transmitted through blood transfusion.

We plan to continue development of the treatment and diagnosing algorithm and practical implementation of our methods of laparoscopic surgeries for the patients in case of polytrauma with the prevailing abdominal and thorax injuries.

 

References:

  1. M.M. Abakumov. Abdominal injuries in case of polytrauma / M.M. Abakumov, N. V. Lebedev, V.I. Malyarchuk.  M.: Medicine, 2005. - 178 p.
  2. Video laparoscopy in diagnosing and treatment of patients with closed abdominal injury / A.A. Gulyayev, G.V. Pakhomova, P.A. Yartsev, V.T. Samsonov, M.V. Radygina // Collection of abstracts "9th Moscow International Congress of Endoscopic Surgery". Moscow, April 6-8, 2005. - P. 104-106.
  3. A.V. Kapshitar. Specifics of diagnostic laparoscopic interventions in patients with closed intensinal injury / A. V. Kapshitar // Clinical surgery. - 2012. - No.10. - P. 57-59.
  4. I.A. Miziyev, Z.M. Baziyev, A.B. Tutukov, V.M. Dygov. Experience of thoracoscopic surgeries in Kabardino-Balkaria // The 2nd congress of surgeons of the Southern Federal Okrug: materials of the congress. Pyatigorsk, 2009. P. 179-180.
  5. A.D. Timoshin, A.L. Shestakov, A.V. Yurasov. Minimally invasive interventions in the abdominal surgery. M.: Triada-X, 2003. 216 p.
  6. Methods for improving treatment results for the patients with multisystem and concomitant injuries / V.N. Chernov, A.A. Pushkov, I.I. Taranov, V.T. Yuskov // Medical aid delivery in case of concomitant injury: Collection of research works. Vol. 108. - M., 2007. - P. 67-71.
  7. Yu.L. Shevchenko. Sparing surgery. M.: Geotar-Media, 2005. 320 p.
  8. V.G. Stenko. Treatment of patients with the heavy concomitant injury / V.G. Stenko // First Medical Aid. - 2004. - Vol. 5. - No.3. - P. 195-196.
  9. Assessment of nonoperative management of blunt spleen and liver trauma / P. S. Om [el al.] // Am. Surg. – 2005. – Vol. 71. – P. 379-386.
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