4. Indications for laparotomy
• Hemodynamic unstable
• Peritoneal irritation/diffuse abdominal pain >> S/S
• Fascia penetration
• Gunshot wound with transperitoneal path
Symptoms?
Yes No
Hemodynamic
stable
Yes OP OP
no OP ????
7. • Seems no emergent OP problem/active bleeding now
• On IV, check the CBC, prepare blood
• FAST / abdominal CT >internal bleeding/emergent OP indication
8.
9.
10.
11.
12.
13.
14.
15.
16.
17.
18.
19.
20. • Seems no emergent OP problem/active bleeding now
• On IV, check the CBC, prepare blood
• FAST / abdominal CT >internal bleeding/emergent OP indication
• Patient easy, CT report. Intend to let him MBD in AM8:00
• Duty VS consult GS CR…
21. • My question is …
Other examination?
How long in obs room?
Is there any evidence support the Tx?
Possibility of laparotomy in obs pts?
22.
23. Symptoms?
Yes No
Hemodynamic
stable
Yes OP OP
no OP NOM
NOM=
SELECTIVE NON OPERATIVE MANEGEMENT
24. Q1:
In stable stab wd pts,
rationale for early laparotomy?
25. Nancy(1969), New Orleans charity hospital
Unnecessary laparotomy Complication in
Unnecessary laparotomy
Early laparotomy 66% 24%
Clinical judgement 25% 0%
Friedmann(1968):70%negative laparotomy rate in mandatory laparotomy
Lee(1984): 7.8% negative laparotomy rate in selective management
initial presentation and examination accuracy: 88%
29. • Still in controversy
• If NOM was chosen, need other examination
Lowe, 1977, retrospective review of 362 pts with GSW
108 pts Tangential injury, NOM
254 pts Suspect penetrating visceral cavity
97.6% need surgical repair
Velmahos, 2001, retrospective 792 pts with NOM GSW
80 pts Delayed laparotomy, therapeutic rate:72%
712 pts NOM
Routine
laparotomy
47% false negative
31. • Negative fascia penetration: conservative TX
• Positive fascia penetration: mandatory op?
Fabian(1993): negative laparotomy rate 50%
• Still further investigation if fascia penetration
33. • ECHO: not enough data
• Angiography: not enough data
• DPL: high sen, spe, accuracy in old times
• CT:
Shanmuganathan(2004)
Sen:97%, spe:98%, accuracy:98% in penetrating stab wds
Velmahos(2005)
GSW: Sen 90.5, Spe: 96%
Radiology 2004:231:775-784
J trauma 2005:59:1155-1161
35. • MBD after 24hrs obs with minimal or no
abdominal tenderness
• Alzamel(2005)
Retrospective 650pts with NOM and delayed
laparotomy in 12hrs
• Velmehos(1997)
stable, tolerate food after 24hrs(1856pts)
36. TAKE HOME MESSAGE
NOM indication
Stab wound: rationale for NOM
Gun shot wound: still in debates
Examination: CT
OBS time:24hrs
Huang Guan-Lin M.D.
Kaohsiung CGMH urology department
38. ATLS textbook
• Easy miss diagnosis
Hollow viscus rupture
Solid organ bleeding
Bony pelvis bleeding
• Significant blood loss may present in
No dramatic change in appearance
No obvious change in peritoneal sign