Laparoscopy has occupied a central place in general and emergency surgery in recent years. The best example of this is its proven superiority over open surgery for performing cholecystectomies. Laparoscopic Trainer.
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Today, several procedures whose first indication is laparoscopy are well established. However, laparoscopy for diagnostic and therapeutic purposes in trauma is a rediscovery. There are many references to the efficiency of diagnostic laparoscopy (DL), in addition to a long history of use, covering approximately 20 years.
In recent years, it uses with increasing frequency in polytraumatized patients. Laparoscopic surgery has allowed great achievements in the evaluation and treatment of these patients, fulfilling three fundamental objectives:
- Make a diagnosis in a short time
- Perform the appropriate surgical treatment
- Achieve a cure with low morbidity
The excellent results in the treatment of common emergencies. Such as appendicitis and cholecystitis, have fueled a push to apply the technology to the treatment of other more complicated abdominal catastrophes. Initial studies suggest that this application is not only feasible, but also provides benefits like other more conventional applications.
Laparoscopy In Abdominal Trauma
It is evident that, in a polytraumatized patient with hemodynamic instability, the initial surgical conduct is mandatory. However, in those patients in whom internal injuries suspects but who maintain hemodynamic stability. The judicious and rational use of diagnostic investigation techniques is necessary to establish the need for surgical intervention.
In this way, changing the doctrine of a mandatory laparotomy to a more selective approach, it decides which patient deserves an operation. The development of a balance between avoiding delay in management. And, at the same time, reducing the number of non-therapeutic laparotomies has resulted in the introduction of several diagnostic modalities. That uses as tools to complement the physical examination.
Diagnostic Peritoneal Lavage
Initially, diagnostic peritoneal lavage (DPL), and later computed tomography (CT) of the abdomen. And Focuses Assessment with Sonography for Trauma (FAST) demonstrates benefit in reducing negative laparotomies. Each having a well-established diagnostic value for various traumas.
With the introduction of video and the explosion in instrument technology, laparoscopy has gained popularity among trauma surgeons. Its use, not only as a diagnostic tool, but also as a therapeutic one, is continuously growing in the treatment of patients with abdominal trauma. The indications and usefulness of laparoscopy vary depending on the mechanism of trauma.
Risks Of the Use of Laparoscopy in Trauma
The probability of producing tension pneumothorax, or pneumopericardium, in the presence of diaphragmatic wounds is a fear present in performing laparoscopy in trauma. During their internship in laparoscopic technique, many of them have not received practical training with Laparoscopic Trainer.
Theoretically it is so; however, in practice this situation represents an unusual complication. Given the suspicion of diaphragmatic injury, the prophylactic placement of a chest tube decreases the possibility of this complication.
On the other hand, some authors comment that this practice is not usually necessary for the prevention of tension pneumothorax, firstly, because its incidence is very low and, secondly, because the positive pressure of mechanical ventilation is theoretically superior to the pressure of the pneumoperitoneum induced by the insufflator.
Also, in case of diaphragmatic and pericardial injuries, such drainage does not protect against pneumopericardium. Animal studies publishes showing that a 5-cm wound to the diaphragm, in combination with an induced intra-abdominal pressure of 15 mm Hg, can produce a tension pneumothorax.
Some authors comment that performing laparoscopy with pressures of 5 mm Hg would reduce the probability of producing this phenomenon. Unfortunately, there are no studies that show that an adequate exploration of the abdominal cavity is possible with a pneumoperitoneum of only 5 mm Hg.
Complication In the Use of Laparoscopy
The most feared complication in the use of laparoscopy in trauma is, without a doubt, the lack of recognition of injuries; that is, unnoticed injuries. An important factor is the experience of the surgeon, as well as the technical ability, and availability of the equipment and material necessary for the correct performance of the procedure. It does not forget that when in doubt it is always convenient to convert to a laparotomy.
Another potential complication is the impossibility of reproducing each of the surgical steps performed using the conventional approach, within which we have an adequate review of the abdominal cavity and evacuation of blood remains that could condition intra-abdominal collections and infection.
Use Of Laparoscopy in Trauma
Over the years, advances in video quality and minimally invasive surgical instrument technology have been remarkable. As in other fields of surgery, these advances have stimulated an increase in the use of laparoscopy in trauma and emergency surgery. In trauma patient care, the laparoscope evolved from an identification, then a diagnostic, and more recently a therapeutic instrument. In the same way, its application in visceral emergencies continues to expand.
Although it is tempting to think that the use of the laparoscope limits only by the availability of the equipment and skill of the surgeon, the basic concepts that govern emergency surgeries applies in every situation. It is important to evaluate each patient individually and confirm that the clinical presentation allows the use of the laparoscope.
Once it decides to proceed, the surgeon must anticipate the type of injury you may face and have a treatment plan. The operation must continue in an organized and detailed manner. It is imperative to recognize early when the situation exceeds the limits of the laparoscope, and convert to laparotomy, understanding that this is not failure but part of the spectrum of treatment.
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