BackgroundTraditionally, laparotomy/thoracotomy is the standard approach for thoracoabdominal injuries. However, it has a non-therapeutic rate of 12–40% and 40% morbidity. Laparoscopy, as a diagnostic and therapeutic modality, has evolved to be integral to general and subspecialty surgeons in the management of patients. However, its use in the field of trauma surgery has been limited. We present a case of traumatic diaphragmatic injury from a low velocity penetrating wound successfully repaired through laparoscopic approach.Case presentationA 20 year old male, presented with a traumatic diaphragmatic injury secondary to a low velocity penetrating injury. A computed tomographic scan revealed a tear on the left diaphragm with the superior pole of the spleen and omentum eviscerating through. He subsequently underwent diagnostic laparoscopy and primary repair of the diaphragmatic injury. His recovery was uneventful and he was discharged on the third postoperative day.ConclusionA review of current literature and our case suggest that the use of laparoscopy for the management of penetrating thoracoabdominal injuries is continually evolving and has shown to be a promising approach compared to traditional laparotomy in carefully selected patients. Laparoscopic repair of penetrating traumatic diaphragmatic injuries is a safe and expedient option for hemodynamically stable patients.
Management of blunt splenic injury (BSI) has evolved with a focus on nonoperative management (NOM) and spleen preservation. Factors predictive of failure of NOM are yet ill defined. We report our experience of outcomes of NOM of BSI and evaluate factors that predict failure. This is a retrospective study from a prospective trauma registry of a university-affiliated major trauma center over a 4 ½-year period. All the patients admitted with BSI from January 2004 to May 2009 were included in this study. Demographic, clinical, operative, and outcome data were studied. Forty-five patients (51.1%) with a mean age of 38 years (range, 16–77 years) were admitted for NOM. The majority of patients was male (88.9%). Mean Injury Severity Score (ISS) was 25.2 ± 12.7 and the majority of the patients (42.2%) had Grade II BSI. Three patients (6.7%) underwent splenic artery angioembolization. Three patients (6.7%) failed NOM and required splenectomy. The overall splenic salvage rate was 93.3%. The median hospital stay was 7 days (range, 2–66 days) and there was no mortality. Lower hemoglobin on admission (15.9 versus 10.1 g/dL, P = 0.006), hematocrit <30.0% on admission (P = 0.04), higher ISS (39.3 versus 24.2, P = 0.04) and Grade V injury (P = 0.003) predicted failure of NOM. NOM for BSI is safe, feasible, and it increases splenic salvage. Splenic artery angioembolization is a useful adjunct. Low hemoglobin, hematocrit <30%, high ISS, and grade V splenic injury predicts failure of NOM. Grade V splenic injury should be considered for routine angioembolization if NOM is contemplated.
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