Laparoscopic Evaluation of Tangential Abdominal Gunshot Wounds
Jorge
L.
Sosa, MD; David Sims, MD; Larry Martin, MD; Robert Zeppa,
of laparoscopy in abdominal trauma has been proposed for several decades; however, it has not been widely used. With the advent of laparoscopic cholecystectomy, general surgeons are realizing the potential of this technique. This should result in an expanded role for laparoscopy, including the evaluation of abdominal trauma. We present a series in which laparoscopy was used in the evaluation of tangential gunshot wounds to the abdomen. \s=b\ The use
Laparoscopy enabled us to demonstrate whether the missile had violated the peritoneal cavity and to avoid laparotomy in cases without peritoneal penetration. (Arch Surg. 1992;127:109-110)
with Patients abdomen be
anterior or flank gunshot wounds to the in which the path of the missile appeared to tangential to the peritoneal cavity were chosen for laparoscopy. Patients in hemodynamically unstable con¬
dition or those with overt peritoneal signs were excluded. at the wound sites and missile path was not a contraindication to laparoscopy. Laparoscopy was performed in the operating room under full aseptic technique. General endotracheal anes¬ thesia was used in the majority of cases, with local anes¬ thesia used in selected cases. A supraumbilical skin inci¬ sion was chosen for a 10-mm camera port. Some patients underwent direct insufflation via a Verres needle with cannulation after adequate pneumoperitoneum was achieved; in others, an open Hasson technique and can¬ nula were used. The abdomen was inspected for blood or free fluid. Special attention was paid to the peritoneum at the wound sites to ensure no peritoneal violation. In patients with flank wounds, the colon was mobilized if necessary with the use of 5-mm ports introduced under direct vision. In this way, the retroperitoneum could be inspected as well as the posterior wall of the ascending or descending colon. Any peritoneal violation was an indi¬ cation for laparotomy.
However, abdominal tenderness
Accepted
for publication October 12, 1991. From the Department of Surgery (Drs Sosa, Sims, Martin, and Zeppa) and the Division of Trauma (Drs Martin and Zeppa), Jackson Memorial Hospital, University of Miami (Fla) School of Medicine. Reprint requests to the Division of Trauma Services, Department of Surgery, University of Miami School of Medicine, PO Box 016960 (D-40), Miami, FL 33101 (Dr Sosa).
MD
REPORT OF CASES Case 1.—A 21-year-old white woman was admitted with gunshot wounds to the abdomen and right thigh. An entrance was found in the right upper quadrant at about the midclavicular line, with the bullet palpable at the midaxillary line. The pa¬ tient was in hemodynamically stable condition and complained of pain at the wound site. No peritoneal signs were present. The path of the bullet appeared to be tangential to the peritoneal cavity. However, we could not be certain that the missile had not violated the peritoneum. Therefore, we chose to perform diag¬ nostic laparoscopy. It revealed an extraperitoneal hematoma from the bullet path. There was no intraperitoneal fluid or blood and no violation of the peritoneal cavity. The procedure was tol¬ erated well. The patient tolerated a regular diet 24 hours after the laparoscopy, but the leg wound required an extra day of hospitalization. She was discharged 48 hours after the procedure. Outpatient follow-up showed her to be doing well. Case 2. —A 17-year-old white boy sustained a gunshot wound to the left upper quadrant with an exit wound in the left flank at the posterior axillary line. He was in hemodynamically stable condition. Laparoscopy with mobilization of the descending co¬ lon revealed no peritoneal violation or colonie injury. The patient was discharged the next day with no dietary restrictions.
Follow-up revealed no problems. Case 3. —A 21-year-old black man sustained a gunshot wound
to the abdomen. The entrance site was at the left midclavicular line 6 cm below the costal margin with the bullet palpable 2 cm medial to the left posterior axillary line. The patient was in he¬ modynamically stable condition and the abdomen was soft but tender at the wound area. An intravenous pyelogram was obtained, the results of which were normal. The patient continued to complain of pain in the wound area. It was unclear if the bullet path had violated the peritoneum so laparoscopy was performed. Direct visualization of the entrance site revealed no peritoneal violation. The descending colon was mobilized, and no injury was identified. The retroperitoneum was directly inspected and a minimal hematoma was found lat¬ eral to the kidney. No further intervention was deemed neces¬ sary. The patient was discharged the next day with no dietary restrictions. Follow-up showed him to be doing well. Case 4.—A 62-year-old morbidly obese white man sustained a shotgun injury to the right lower quadrant. He was in hemo¬ dynamically stable condition, complaining of pain at the wound site. Lateral abdominal roentgenography showed that the shot¬ gun pellets appeared to be embedded in the anterior abdominal wall. Since we could not be sure that some pellets had not vio¬ lated the peritoneal cavity, we opted for laparoscopy. This revealed free blood in the right paracolic gutter and two defects in the peritoneum. Laparotomy revealed an enterotomy, which was primarily repaired. A free pellet in the peritoneal cavity and
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one embedded in a sigmoid epiploic appendage were found. The patient did well and was discharged 1 week later. Case 5. —A 25-year-old black man sustained a gunshot wound
abdomen. He was in hemodynamically stable condition with minimal wound discomfort. Examination revealed an entrance site in the midepigastrium, with the bullet palpable above the left iliac crest at the midaxillary line. Laparoscopy with mobilization of the sigmoid colon revealed no peritoneal viola¬ tion or colonie injury. The patient was discharged the next day with no dietary restrictions. At follow-up 1 week later he was doing well. Case 6.—A 25-year-old white man sustained a gunshot wound to the right upper quadrant. The entrance wound was at the midclavicular line just above the costal margin; the exit was at the posterior axillary line below the costal margins. The patient was in hemodynamically stable condition and denied having abdominal pain. The abdomen was soft. Diagnostic laparoscopy revealed an entrance wound into the peritoneum with a nonbleeding through-and-through wound in the liver and a small pool of blood in the right paracolic gutter. Exploratory laparot¬ omy demonstrated no other injuries. The patient was discharged 4 days later. to the
RESULTS
performed diagnostic laparoscopy in eight patients for tangential gunshot wounds to the abdomen. Missiles violated the peritoneum in two patients, one of whom had a small-bowel injury and the other a liver lac¬ eration. In the six patients with negative laparoscopy findings, there were no missed injuries and no morbidity We have
associated with the laparoscopy. The procedure was well tolerated when local anesthesia and sedation were used.
COMMENT Since its inception in 1901 by Kelling and its subsequent clinical introduction in 1910 by Kelling and Jacobaeus, laparoscopy has not been widely practiced by general surgeons. This has been true despite excellent reports on its efficacy and safety by surgeons such as Ruddock. ' With the advent of laparoscopie cholecystectomy and the wide interest this has generated, general surgeons are becom¬ ing increasingly familiar with laparoscopy. This should result in a wider application of the procedure in general surgery. The use of laparoscopy in the evaluation of ab¬ dominal trauma has been advocated by several authors2"7; however, it has failed to gain widespread acceptance. In cases of penetrating abdominal trauma specifically, lap¬ aroscopy has been shown to be effective in evaluating stab wounds,2·3-5 but it has not been recommended for gunshot wounds,3-5 and some authors have considered gunshot wounds a relative contraindication.6 We use laparoscopy as an adjunct in the evaluation of patients with gunshot wounds to the abdomen in an ef¬ fort to decrease the rate of negative laparotomies and their
accompanying morbidity. Negative laparotomies are associated with a morbidity as high as 20%.8 They also require a prolonged hospital stay and put the patient at long-term risk for small-bowel obstruction. In cases of tangential gunshot wounds to the abdomen,
it is often difficult to assess if the missile violated the peri¬ toneal cavity. Patients often complain of pain related to
soft-tissue wounding, thus making the evaluation of peritoneal signs difficult. This leads to exploration, the results of which are also often negative. Observation of these patients can be problematic, requiring multiple ex¬ aminations at regular intervals, which can be difficult in a busy trauma center. Late diagnosis of significant ab¬ dominal injury can lead to increased morbidity and mor¬ tality. Diagnostic laparoscopy can be very useful in these patients. As experience is gained with this procedure we may also be able to eliminate nontherapeutic laparotomies, such as in case 6 in which a nonbleeding liver laceration was the only injury. This has certainly been possible in blunt abdominal trauma.3-5 Technically, this procedure is ideally suited for anterior abdominal injuries. Flank wounds can be satisfactorily evaluated, and with mobili¬ zation the retroperitoneal surface of the colon can be carefully inspected. More posterior injuries and retroperi¬ toneal structures are not easily examined. We used intra¬ venous pyelography in patients with flank injuries to as¬ sist in the evaluation of possible renal or ureteral injury. Although general anesthesia was used in most of our patients, laparoscopy can certainly be done with local an¬ esthesia, thus decreasing the morbidity. Some of our pa¬ tients required mobilization of the colon, which would not likely be tolerable without a general anesthetic. The anes¬ thetic technique should be tailored to the case. While we did not analyze cost, there is no doubt that diagnostic laparoscopy would be significantly less expen¬ sive in patients not needing laparotomy and should not add greatly to the expense in those patients requiring subsequent exploration. Diagnostic laparoscopy in the evaluation of tangential gunshot wounds to the abdomen is an effective tech¬ nique. It should result in the elimination of negative lap¬ arotomies and lead to a decrease in morbidity and signif¬ icant cost
savings.
References 1. Ruddock JC. Peritoneoscopy. Surg Gynecol Obstet. 1937;65:623-638. 2. Gazzaniga AB, Stanton WW, Bartlett RH. Laparoscopy in
the diagnosis of blunt and penetrating injuries to the abdomen. Am J Surg. 1976;131:315-318. 3. Berci G, Dunkelman D, Michel S, Sanders G, Wahistrom E, Morgenstern L. Emergency minilaparoscopy in abdominal trauma. Am J Surg. 1983;146:261-265. 4. Nagy AG, James D. Diagnostic laparoscopy. Am J Surg.
1989;157:490-493. 5. Berci G, Sackier JM, Pas MP. Emergency laparoscopy. Am J Surg. 1991;161:332-335. 6. Robinson HB, Smith GW. Applications for laparoscopy in general surgery. Surg Gynecol Obstet. 1976;143:829-833. 7. Gomel V. Laparoscopy in general surgery. Am J Surg. 1976;131:319-322. 8. Lowe RF, Boyd DR, Folk FA, Baker RJ. The negative laparotomy for abdominal trauma. J Trauma. 1972;12:853-860.
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Jorge
L.
Sosa, MD; David Sims, MD; Larry Martin, MD; Robert Zeppa,
of laparoscopy in abdominal trauma has been proposed for several decades; however, it has not been widely used. With the advent of laparoscopic cholecystectomy, general surgeons are realizing the potential of this technique. This should result in an expanded role for laparoscopy, including the evaluation of abdominal trauma. We present a series in which laparoscopy was used in the evaluation of tangential gunshot wounds to the abdomen. \s=b\ The use
Laparoscopy enabled us to demonstrate whether the missile had violated the peritoneal cavity and to avoid laparotomy in cases without peritoneal penetration. (Arch Surg. 1992;127:109-110)
with Patients abdomen be
anterior or flank gunshot wounds to the in which the path of the missile appeared to tangential to the peritoneal cavity were chosen for laparoscopy. Patients in hemodynamically unstable con¬
dition or those with overt peritoneal signs were excluded. at the wound sites and missile path was not a contraindication to laparoscopy. Laparoscopy was performed in the operating room under full aseptic technique. General endotracheal anes¬ thesia was used in the majority of cases, with local anes¬ thesia used in selected cases. A supraumbilical skin inci¬ sion was chosen for a 10-mm camera port. Some patients underwent direct insufflation via a Verres needle with cannulation after adequate pneumoperitoneum was achieved; in others, an open Hasson technique and can¬ nula were used. The abdomen was inspected for blood or free fluid. Special attention was paid to the peritoneum at the wound sites to ensure no peritoneal violation. In patients with flank wounds, the colon was mobilized if necessary with the use of 5-mm ports introduced under direct vision. In this way, the retroperitoneum could be inspected as well as the posterior wall of the ascending or descending colon. Any peritoneal violation was an indi¬ cation for laparotomy.
However, abdominal tenderness
Accepted
for publication October 12, 1991. From the Department of Surgery (Drs Sosa, Sims, Martin, and Zeppa) and the Division of Trauma (Drs Martin and Zeppa), Jackson Memorial Hospital, University of Miami (Fla) School of Medicine. Reprint requests to the Division of Trauma Services, Department of Surgery, University of Miami School of Medicine, PO Box 016960 (D-40), Miami, FL 33101 (Dr Sosa).
MD
REPORT OF CASES Case 1.—A 21-year-old white woman was admitted with gunshot wounds to the abdomen and right thigh. An entrance was found in the right upper quadrant at about the midclavicular line, with the bullet palpable at the midaxillary line. The pa¬ tient was in hemodynamically stable condition and complained of pain at the wound site. No peritoneal signs were present. The path of the bullet appeared to be tangential to the peritoneal cavity. However, we could not be certain that the missile had not violated the peritoneum. Therefore, we chose to perform diag¬ nostic laparoscopy. It revealed an extraperitoneal hematoma from the bullet path. There was no intraperitoneal fluid or blood and no violation of the peritoneal cavity. The procedure was tol¬ erated well. The patient tolerated a regular diet 24 hours after the laparoscopy, but the leg wound required an extra day of hospitalization. She was discharged 48 hours after the procedure. Outpatient follow-up showed her to be doing well. Case 2. —A 17-year-old white boy sustained a gunshot wound to the left upper quadrant with an exit wound in the left flank at the posterior axillary line. He was in hemodynamically stable condition. Laparoscopy with mobilization of the descending co¬ lon revealed no peritoneal violation or colonie injury. The patient was discharged the next day with no dietary restrictions.
Follow-up revealed no problems. Case 3. —A 21-year-old black man sustained a gunshot wound
to the abdomen. The entrance site was at the left midclavicular line 6 cm below the costal margin with the bullet palpable 2 cm medial to the left posterior axillary line. The patient was in he¬ modynamically stable condition and the abdomen was soft but tender at the wound area. An intravenous pyelogram was obtained, the results of which were normal. The patient continued to complain of pain in the wound area. It was unclear if the bullet path had violated the peritoneum so laparoscopy was performed. Direct visualization of the entrance site revealed no peritoneal violation. The descending colon was mobilized, and no injury was identified. The retroperitoneum was directly inspected and a minimal hematoma was found lat¬ eral to the kidney. No further intervention was deemed neces¬ sary. The patient was discharged the next day with no dietary restrictions. Follow-up showed him to be doing well. Case 4.—A 62-year-old morbidly obese white man sustained a shotgun injury to the right lower quadrant. He was in hemo¬ dynamically stable condition, complaining of pain at the wound site. Lateral abdominal roentgenography showed that the shot¬ gun pellets appeared to be embedded in the anterior abdominal wall. Since we could not be sure that some pellets had not vio¬ lated the peritoneal cavity, we opted for laparoscopy. This revealed free blood in the right paracolic gutter and two defects in the peritoneum. Laparotomy revealed an enterotomy, which was primarily repaired. A free pellet in the peritoneal cavity and
Downloaded From: http://archsurg.jamanetwork.com/ by a New York University User on 05/21/2015
one embedded in a sigmoid epiploic appendage were found. The patient did well and was discharged 1 week later. Case 5. —A 25-year-old black man sustained a gunshot wound
abdomen. He was in hemodynamically stable condition with minimal wound discomfort. Examination revealed an entrance site in the midepigastrium, with the bullet palpable above the left iliac crest at the midaxillary line. Laparoscopy with mobilization of the sigmoid colon revealed no peritoneal viola¬ tion or colonie injury. The patient was discharged the next day with no dietary restrictions. At follow-up 1 week later he was doing well. Case 6.—A 25-year-old white man sustained a gunshot wound to the right upper quadrant. The entrance wound was at the midclavicular line just above the costal margin; the exit was at the posterior axillary line below the costal margins. The patient was in hemodynamically stable condition and denied having abdominal pain. The abdomen was soft. Diagnostic laparoscopy revealed an entrance wound into the peritoneum with a nonbleeding through-and-through wound in the liver and a small pool of blood in the right paracolic gutter. Exploratory laparot¬ omy demonstrated no other injuries. The patient was discharged 4 days later. to the
RESULTS
performed diagnostic laparoscopy in eight patients for tangential gunshot wounds to the abdomen. Missiles violated the peritoneum in two patients, one of whom had a small-bowel injury and the other a liver lac¬ eration. In the six patients with negative laparoscopy findings, there were no missed injuries and no morbidity We have
associated with the laparoscopy. The procedure was well tolerated when local anesthesia and sedation were used.
COMMENT Since its inception in 1901 by Kelling and its subsequent clinical introduction in 1910 by Kelling and Jacobaeus, laparoscopy has not been widely practiced by general surgeons. This has been true despite excellent reports on its efficacy and safety by surgeons such as Ruddock. ' With the advent of laparoscopie cholecystectomy and the wide interest this has generated, general surgeons are becom¬ ing increasingly familiar with laparoscopy. This should result in a wider application of the procedure in general surgery. The use of laparoscopy in the evaluation of ab¬ dominal trauma has been advocated by several authors2"7; however, it has failed to gain widespread acceptance. In cases of penetrating abdominal trauma specifically, lap¬ aroscopy has been shown to be effective in evaluating stab wounds,2·3-5 but it has not been recommended for gunshot wounds,3-5 and some authors have considered gunshot wounds a relative contraindication.6 We use laparoscopy as an adjunct in the evaluation of patients with gunshot wounds to the abdomen in an ef¬ fort to decrease the rate of negative laparotomies and their
accompanying morbidity. Negative laparotomies are associated with a morbidity as high as 20%.8 They also require a prolonged hospital stay and put the patient at long-term risk for small-bowel obstruction. In cases of tangential gunshot wounds to the abdomen,
it is often difficult to assess if the missile violated the peri¬ toneal cavity. Patients often complain of pain related to
soft-tissue wounding, thus making the evaluation of peritoneal signs difficult. This leads to exploration, the results of which are also often negative. Observation of these patients can be problematic, requiring multiple ex¬ aminations at regular intervals, which can be difficult in a busy trauma center. Late diagnosis of significant ab¬ dominal injury can lead to increased morbidity and mor¬ tality. Diagnostic laparoscopy can be very useful in these patients. As experience is gained with this procedure we may also be able to eliminate nontherapeutic laparotomies, such as in case 6 in which a nonbleeding liver laceration was the only injury. This has certainly been possible in blunt abdominal trauma.3-5 Technically, this procedure is ideally suited for anterior abdominal injuries. Flank wounds can be satisfactorily evaluated, and with mobili¬ zation the retroperitoneal surface of the colon can be carefully inspected. More posterior injuries and retroperi¬ toneal structures are not easily examined. We used intra¬ venous pyelography in patients with flank injuries to as¬ sist in the evaluation of possible renal or ureteral injury. Although general anesthesia was used in most of our patients, laparoscopy can certainly be done with local an¬ esthesia, thus decreasing the morbidity. Some of our pa¬ tients required mobilization of the colon, which would not likely be tolerable without a general anesthetic. The anes¬ thetic technique should be tailored to the case. While we did not analyze cost, there is no doubt that diagnostic laparoscopy would be significantly less expen¬ sive in patients not needing laparotomy and should not add greatly to the expense in those patients requiring subsequent exploration. Diagnostic laparoscopy in the evaluation of tangential gunshot wounds to the abdomen is an effective tech¬ nique. It should result in the elimination of negative lap¬ arotomies and lead to a decrease in morbidity and signif¬ icant cost
savings.
References 1. Ruddock JC. Peritoneoscopy. Surg Gynecol Obstet. 1937;65:623-638. 2. Gazzaniga AB, Stanton WW, Bartlett RH. Laparoscopy in
the diagnosis of blunt and penetrating injuries to the abdomen. Am J Surg. 1976;131:315-318. 3. Berci G, Dunkelman D, Michel S, Sanders G, Wahistrom E, Morgenstern L. Emergency minilaparoscopy in abdominal trauma. Am J Surg. 1983;146:261-265. 4. Nagy AG, James D. Diagnostic laparoscopy. Am J Surg.
1989;157:490-493. 5. Berci G, Sackier JM, Pas MP. Emergency laparoscopy. Am J Surg. 1991;161:332-335. 6. Robinson HB, Smith GW. Applications for laparoscopy in general surgery. Surg Gynecol Obstet. 1976;143:829-833. 7. Gomel V. Laparoscopy in general surgery. Am J Surg. 1976;131:319-322. 8. Lowe RF, Boyd DR, Folk FA, Baker RJ. The negative laparotomy for abdominal trauma. J Trauma. 1972;12:853-860.
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