- Email: [email protected]
Laparoscopic treatment of duodenal injury caused by gunshot
Injury, Int. J. Care Injured 45 (2014) 916–917
Contents lists available at ScienceDirect
Injury journal homepage: www.elsevier.com/locate/injury
Case Report
Laparoscopic treatment of duodenal injury caused by gunshot Hagar Mizrahi *, Nissim Geron, Adeeb Nicola General Surgery Ward, The Baruch Padeh Medical Center, Poriya, Israel
A R T I C L E I N F O
A B S T R A C T
Article history: Accepted 10 January 2014
Duodenal injury in most cases, presents as a complex trauma of all adjacent organs which it is generally treated with a midline laparotomy though laparoscopic treatment in selected cases might be beneficial. We present a case of haemodynamically stable patient who suffered abdominal gunshot injury causing grade II trauma of the liver and penetrating wound of the first part of the duodenum and was treated laparoscopically. We believe that laparoscopic primary or assisted repair of injured duodenum is an appropriate surgical option in haemodynamically stable patients who sustain focal abdominal trauma. ß 2014 Elsevier Ltd. All rights reserved.
Keywords: Gunshot injury Laparoscopy for trauma Duodenum
Duodenal injury in most cases, presents as a complex trauma of all adjacent organs such as pancreas and bile system and as such, it is generally treated with a midline laparotomy. On the other hand, laparoscopic treatment in selected cases might be beneficial in terms of postoperative outcomes such as wound infection, postoperative pain management and length of stay which were proven to be better in other fields of surgery. We would like to present a case of abdominal gunshot injury which was treated laparoscopically.
II) with no active bleeding and a full thickness 2 cm penetrating wound of the first part of the duodenum. The bullet was seen at the lower edge of the duodenal wall (Fig. 2). No injury or haematoma of the pancreas were seen. The bullet was taken out and the wound was sutured with a 2/0 V-LocTM continuous suture, Covidien, and a 10 mm drain was placed nearby. The postoperative period was marked with fever and the patient was given an antibiotics. On the fifth day a computed tomography showed infiltration and small amount of fluid with no abscess or collection. The patient was discharged 12 days after surgery (mainly due to the patient’s social status).
Case description
Discussion
A 22-year-old male with no medical history, presented to the emergency room 2 h after gunshot injury to the right upper abdomen. Upon admission, the patient was haemodynamically stable. The physical examination showed gunshot wound to the right upper abdomen with no signs for peritonitis. Computed tomography demonstrated a bullet at the first part of the duodenum (Fig. 1) and a liver injury (Grade 2). A diagnostic laparoscopy was carried out. Pneumoperitoneum was established using a Veress needle in a closed technique above the umbilicus and a 30 degrees laparoscope was inserted through a 12 mm trocar. Two additional 5 mm trocars were placed in the right and left lateral quadrants for manipulation and an extra 5 mm trocar at the sub-xiphoid area was used to retract the stomach. The abdominal cavity was systemically examined as well as the lesser sac. A gunshot tract wound to the fifth segment of the liver (grade
Duodenal trauma is rare although it is more common in penetrating abdominal trauma. Treatment should be customized to the type and degree of injury. Several options are available including suture in one or two layers with or without omental or jejunal patch [1,2]. Additional decompression of the duodenum may be applied to help protect the suture line from dehiscence [1]. Recent studies have questioned the need for pyloric exclusion because of a demonstrated trend towards greater complication rate, pancreatic fistula rate, and increased length of hospital stay [3]. Laparoscopy in penetrating trauma for haemodynamically stable patients who are suspected to have intra-abdominal injury is a reasonable option which enables inspection of the peritoneal cavity and its organs. Traditionally, laparoscopy in trauma was used to evaluate peritoneal penetration and diaphragmatic laceration but recent years and gained experience had drove surgeons towards more active approach. Johnson et al. had published a retrospective study including 109 patients who undergone diagnostic laparoscopy for penetrating trauma, 26 of
Introduction
* Corresponding author. Tel.: +972 523469739; fax: +972 49590231. E-mail address: [email protected] (H. Mizrahi). 0020–1383/$ – see front matter ß 2014 Elsevier Ltd. All rights reserved. http://dx.doi.org/10.1016/j.injury.2014.01.013
[(Fig._1)TD$IG]
H. Mizrahi et al. / Injury, Int. J. Care Injured 45 (2014) 916–917
917
viscous injury, hepatorrhaphy, cholecystectomy, and repair of a fascial injury. One patient out of 89 procedures completed laparoscopically needed re-intervention due to missed common bile duct injury treated with endoscopic retrograde cholangiopancreatography with biliary stent placement [4]. Chol et al. had published a series of 78 haemodynamically stable patients, 26 of whom sustained a stab wound. In all cases treatment was achieved laparoscopically with no missed injuries or conversion to an open approach [5]. Other articles which published laparoscopic diagnosis and treatment of penetrating injuries in children had shown favourable results in terms postoperative recovery as well as complications [6,7].
[(Fig._2)TD$IG]
Summary
Fig. 1. CT image of the bullet at the duodenum.
The patient described above was haemodynamically stable on arrival and physical examination revealed entry wound and tender abdomen. He had a computed tomography before surgery which enabled evaluation of the trauma before surgery. The surgery was performed by an experienced laparoscopic surgeon. All these factors permitted minimally invasive surgery and avoidance of laparotomy and its consequences. To the best of our knowledge, this is the first case of duodenal injury treated with laparoscopy. We believe that laparoscopic primary or assisted repair of injured bowel is an appropriate surgical option in haemodynamically stable patients who sustain focal abdominal trauma. References
Fig. 2. Picture taken during surgery with the bullet held by a laparoscopic grasper.
whom suffered gunshot injury. Laparoscopy was negative in 67.9% patients and nontherapeutic in 11.9% patients. Eleven (10.1%) patients underwent a total of 13 therapeutic laparoscopic procedures including repair of a diaphragmatic injury, hollow
[1] Peitzman AB, Schwab CW, Yealy DM, Rhodes M, Fabian TC. The trauma manual trauma and acute care surgery. 4th ed. LLW; 2012. p. 374–6. [2] Degiannis E, Boffard K. Duodenal injuries. Br J Surg 2000;87(November (11)):1473–9. [3] Seamon MJ, Pieri PG, Fisher CA, Gaughan J, Santora TA, Pathak AS, et al. A tenyear retrospective review: does pyloric exclusion improve clinical outcome after penetrating duodenal and combined pancreaticoduodenal injuries? J Trauma 2007;62(April (4)):829–33. [4] Johnson JJ, Garwe T, Raines AR, Thurman JB, Carter S, Bender JS, et al. The use of laparoscopy in the diagnosis and treatment of blunt and penetrating abdominal injuries: 10-year experience at a level 1 trauma center. Am J Surg 2013;205(March (3)):317–20. [5] Chol YB, Lim KS. Therapeutic laparoscopy for abdominal trauma. Surg Endosc 2003;17(March (3)):421–7. [6] Streck CJ, Lobe TE, Pietsch JB, Lovvorn 3rd HN. Laparoscopic repair of traumatic bowel injury in children. J Pediatr Surg 2006;41(November (11)):1864–9. [7] Marwan A, Harmon CM, Georgeson KE, Smith GF, Muensterer OJ. Use of laparoscopy in the management of pediatric abdominal trauma. J Trauma 2010;69(October (4)):761–4.
Contents lists available at ScienceDirect
Injury journal homepage: www.elsevier.com/locate/injury
Case Report
Laparoscopic treatment of duodenal injury caused by gunshot Hagar Mizrahi *, Nissim Geron, Adeeb Nicola General Surgery Ward, The Baruch Padeh Medical Center, Poriya, Israel
A R T I C L E I N F O
A B S T R A C T
Article history: Accepted 10 January 2014
Duodenal injury in most cases, presents as a complex trauma of all adjacent organs which it is generally treated with a midline laparotomy though laparoscopic treatment in selected cases might be beneficial. We present a case of haemodynamically stable patient who suffered abdominal gunshot injury causing grade II trauma of the liver and penetrating wound of the first part of the duodenum and was treated laparoscopically. We believe that laparoscopic primary or assisted repair of injured duodenum is an appropriate surgical option in haemodynamically stable patients who sustain focal abdominal trauma. ß 2014 Elsevier Ltd. All rights reserved.
Keywords: Gunshot injury Laparoscopy for trauma Duodenum
Duodenal injury in most cases, presents as a complex trauma of all adjacent organs such as pancreas and bile system and as such, it is generally treated with a midline laparotomy. On the other hand, laparoscopic treatment in selected cases might be beneficial in terms of postoperative outcomes such as wound infection, postoperative pain management and length of stay which were proven to be better in other fields of surgery. We would like to present a case of abdominal gunshot injury which was treated laparoscopically.
II) with no active bleeding and a full thickness 2 cm penetrating wound of the first part of the duodenum. The bullet was seen at the lower edge of the duodenal wall (Fig. 2). No injury or haematoma of the pancreas were seen. The bullet was taken out and the wound was sutured with a 2/0 V-LocTM continuous suture, Covidien, and a 10 mm drain was placed nearby. The postoperative period was marked with fever and the patient was given an antibiotics. On the fifth day a computed tomography showed infiltration and small amount of fluid with no abscess or collection. The patient was discharged 12 days after surgery (mainly due to the patient’s social status).
Case description
Discussion
A 22-year-old male with no medical history, presented to the emergency room 2 h after gunshot injury to the right upper abdomen. Upon admission, the patient was haemodynamically stable. The physical examination showed gunshot wound to the right upper abdomen with no signs for peritonitis. Computed tomography demonstrated a bullet at the first part of the duodenum (Fig. 1) and a liver injury (Grade 2). A diagnostic laparoscopy was carried out. Pneumoperitoneum was established using a Veress needle in a closed technique above the umbilicus and a 30 degrees laparoscope was inserted through a 12 mm trocar. Two additional 5 mm trocars were placed in the right and left lateral quadrants for manipulation and an extra 5 mm trocar at the sub-xiphoid area was used to retract the stomach. The abdominal cavity was systemically examined as well as the lesser sac. A gunshot tract wound to the fifth segment of the liver (grade
Duodenal trauma is rare although it is more common in penetrating abdominal trauma. Treatment should be customized to the type and degree of injury. Several options are available including suture in one or two layers with or without omental or jejunal patch [1,2]. Additional decompression of the duodenum may be applied to help protect the suture line from dehiscence [1]. Recent studies have questioned the need for pyloric exclusion because of a demonstrated trend towards greater complication rate, pancreatic fistula rate, and increased length of hospital stay [3]. Laparoscopy in penetrating trauma for haemodynamically stable patients who are suspected to have intra-abdominal injury is a reasonable option which enables inspection of the peritoneal cavity and its organs. Traditionally, laparoscopy in trauma was used to evaluate peritoneal penetration and diaphragmatic laceration but recent years and gained experience had drove surgeons towards more active approach. Johnson et al. had published a retrospective study including 109 patients who undergone diagnostic laparoscopy for penetrating trauma, 26 of
Introduction
* Corresponding author. Tel.: +972 523469739; fax: +972 49590231. E-mail address: [email protected] (H. Mizrahi). 0020–1383/$ – see front matter ß 2014 Elsevier Ltd. All rights reserved. http://dx.doi.org/10.1016/j.injury.2014.01.013
[(Fig._1)TD$IG]
H. Mizrahi et al. / Injury, Int. J. Care Injured 45 (2014) 916–917
917
viscous injury, hepatorrhaphy, cholecystectomy, and repair of a fascial injury. One patient out of 89 procedures completed laparoscopically needed re-intervention due to missed common bile duct injury treated with endoscopic retrograde cholangiopancreatography with biliary stent placement [4]. Chol et al. had published a series of 78 haemodynamically stable patients, 26 of whom sustained a stab wound. In all cases treatment was achieved laparoscopically with no missed injuries or conversion to an open approach [5]. Other articles which published laparoscopic diagnosis and treatment of penetrating injuries in children had shown favourable results in terms postoperative recovery as well as complications [6,7].
[(Fig._2)TD$IG]
Summary
Fig. 1. CT image of the bullet at the duodenum.
The patient described above was haemodynamically stable on arrival and physical examination revealed entry wound and tender abdomen. He had a computed tomography before surgery which enabled evaluation of the trauma before surgery. The surgery was performed by an experienced laparoscopic surgeon. All these factors permitted minimally invasive surgery and avoidance of laparotomy and its consequences. To the best of our knowledge, this is the first case of duodenal injury treated with laparoscopy. We believe that laparoscopic primary or assisted repair of injured bowel is an appropriate surgical option in haemodynamically stable patients who sustain focal abdominal trauma. References
Fig. 2. Picture taken during surgery with the bullet held by a laparoscopic grasper.
whom suffered gunshot injury. Laparoscopy was negative in 67.9% patients and nontherapeutic in 11.9% patients. Eleven (10.1%) patients underwent a total of 13 therapeutic laparoscopic procedures including repair of a diaphragmatic injury, hollow
[1] Peitzman AB, Schwab CW, Yealy DM, Rhodes M, Fabian TC. The trauma manual trauma and acute care surgery. 4th ed. LLW; 2012. p. 374–6. [2] Degiannis E, Boffard K. Duodenal injuries. Br J Surg 2000;87(November (11)):1473–9. [3] Seamon MJ, Pieri PG, Fisher CA, Gaughan J, Santora TA, Pathak AS, et al. A tenyear retrospective review: does pyloric exclusion improve clinical outcome after penetrating duodenal and combined pancreaticoduodenal injuries? J Trauma 2007;62(April (4)):829–33. [4] Johnson JJ, Garwe T, Raines AR, Thurman JB, Carter S, Bender JS, et al. The use of laparoscopy in the diagnosis and treatment of blunt and penetrating abdominal injuries: 10-year experience at a level 1 trauma center. Am J Surg 2013;205(March (3)):317–20. [5] Chol YB, Lim KS. Therapeutic laparoscopy for abdominal trauma. Surg Endosc 2003;17(March (3)):421–7. [6] Streck CJ, Lobe TE, Pietsch JB, Lovvorn 3rd HN. Laparoscopic repair of traumatic bowel injury in children. J Pediatr Surg 2006;41(November (11)):1864–9. [7] Marwan A, Harmon CM, Georgeson KE, Smith GF, Muensterer OJ. Use of laparoscopy in the management of pediatric abdominal trauma. J Trauma 2010;69(October (4)):761–4.