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PubMedDate not supplied

[Retrospective comparative study of 600 appendectomies carried out by laparotomy (Mac Burney) or laparoscopy. A plea for laparoscopy].

The authors report the results of a retrospective study comparing 305 appendectomies by laparotomy (performed in 1988-1989) with 295 appendectomies by laparoscopy (1990-1991). The appendectomy was performed by the "out" technic in 98% of cases of laparoscopy. The two populations are similar. There was no mortality. There was 1% of conversion, 1.4% of incidents and no major accident after laparoscopy. The post-operative course was smooth in 88.2% of cases after laparotomy and in 98% after laparoscopy. A treatment for pain was necessary in 98% of cases after laparotomy and only 45.4% after laparoscopy. The rates of parietal complications, intra-abdominal complications and reinterventions were respectively 10.8%, 1% and 2.4% after laparotomy and 0%, 2.4% and 2.4% after laparoscopy. The mean hospital stay was 7 days after laparotomy and 4 days after laparoscopy. In conclusion, laparoscopy appears superior to laparotomy for performance of an appendectomy: it allows better abdominal exploration, more simple and shorter post-operative course and suppresses parietal complications provided that it is performed by a surgeon with great experience of laparoscopy and respects classic principles of digestive surgery.

Acute Disease↗
PubMed1977

[Laparotomy in the therapy of Hodgkin's disease].

We have performed laparotomy and splenectomy for seventy patients with Hodgkin's disease. Among 43 stages I or II before exploration, primary laparotomy revealed ignored abdominal localizations in 16 cases (37,2%). Involvement of the spleen occurred in 13 of these 16 patients, lonely (5 cases), associated with positive nodes (4 cases) or associated with positive nodes and liver involvement (4 cases). Among 4 stages III before exploration, no regression was found. Among 9 patients with presumed stages I or II above the diaphragm and previously treated by radiotherapy, delayed laparotomy revealed abdominal relapse in 6 cases. At last, among 14 patients with obvious stages II or IV and previously treated by combination chemotherapy, laparotomy, caused by persistent evolutive signs, showed residual localizations under the diaphragm in 8 cases. According to these results, we preconise immediate laparotomy in almost all presumed stages I or II above the diaphragm. About third of these subjects have their staging advanced to stage III or IV and, according to us must be treated by combination chemotherapy while the remaining cases justify of radiotherapy. In obvious stages III and IV delayed laparotomy may be useful in some circumstances, after chemotherapy.

Cobalt Radioisotopes↗
PubMed1996

[Comprehensive staging laparotomy in stage I epithelial ovarian cancer].

OBJECTIVE: To evaluate the significance of comprehensive staging laparotomy in stage I epithelial ovarian cancer. METHODS: Forty-three patients with stage I epithelial ovarian cancer were divided into 3 groups and retrospectively analysed. Thirty two of these patients allotted to stage I ovarian cancer according to FIGO criteria were ascertained by comprehensive staging laparotomy (group A), 5 patients were upstaged following comprehensive staging laparotomy (group B) and 6 patients were staged without comprehensive laparotomy (group C). RESULTS: The mean operation time was 2 hours and 40 minutes, the mean volume of blood loss was 460 ml and no severe complications occurred during the comprehensive staging laparotomies. 13.5% (5/31) of patients were found to have retroperitoneal metastasis and then therefore were upstaged as stage III. Group A and B had better prognosis. During the 39.7 months followup period, tumor-free survival rates in group A and B were 97% (31/37) and 5/5 respectively. In group C, 2 patients recurrent and one died of the diseases, a tumor-free survival rates of 4/6. There was a significant difference in tumor-free survival rates between group A and C (P = 0.038). CONCLUSION: Comprehensive staging laparotomy should be considered as an important criterion in FIGO staging of epithelial ovarian cancer and a standard procedure in the treatment of stage I epithelial ovarian cancer.

Carcinoma, Endometrioid↗
PubMed1988

Second-look laparotomy in epithelial ovarian carcinoma. Prognostic factors associated with survival duration.

This article that reports on 70 consecutive patients is one of only a few studies of advanced ovarian cancer that have attempted to define predictive factors associated with survival duration after second-look laparotomy. As in many other investigations, several factors have been analyzed for predicting second-look outcome. The prognostic variables analyzed in this study included age, stage, histologic grade, residual disease status after initial surgery, and type (cisplatin versus no cisplatin) and number of cycles of chemotherapy. Only stage (P = 0.002) and optimal disease (less than 2 cm residual tumor size) after initial surgery (P less than 0.001) were significantly associated with the absence of disease at second-look laparotomy, and both were significant predictors of second-look outcome in a multivariate logistic regression model. Their impact on actuarial survival after second-look laparotomy diminished, however. Actuarial survival after second-look laparotomy was associated with residual tumor size at second-look surgery (P = 0.02). According to second-look findings, the 3-year actuarial survival rates and standard errors were as follows: no pathologic evidence of disease, 80.7% +/- 13.4% 3-year survival; microscopic disease plus less than or equal to 2 cm residual disease, 49.1% +/- 13.1% survival; and gross residual disease (i.e., greater than 2 cm maximum tumor diameter), 29.5% +/- 11.4% survival. We also examined the effect of extensive tumor resection at second-look laparotomy on survival for patients with greater than 2 cm gross residual disease. Optimum resection (less than 2 cm residual tumor mass) resulted in significantly greater survival than suboptimum resection (P less than 0.001). This strongly suggests that there is a survival advantage associated with optimum resection at second-look laparotomy.

Actuarial Analysis↗
PubMed2003

Risk factors for conversion to laparotomy during gynecologic laparoscopy.

STUDY OBJECTIVE: To identify risk factors and short-term outcomes associated with conversion from laparoscopic surgery to laparotomy. DESIGN: Case control study (Canadian Task Force classification II-2). SETTING: Large urban, academic medical center. SUBJECTS: All 2530 gynecologic laparoscopies, including those converted to laparotomy. INTERVENTION: Laparoscopic surgery. MEASUREMENTS AND MAIN RESULTS: Statistical analysis was performed to compare risk factors in converted versus non-converted cases. Multiple logistic regression analysis was performed using variables found to be significant on univariate analysis. Of 2530 laparoscopies identified, 159 (6.3%) were converted to laparotomy; 323 were selected by random number assignment from the remaining cases for the control group. The following factors were significantly associated with unintended laparotomy (OR; 95% CI): surgeon inexperience (2.43; 1.38, 4.17), level of laparoscopic complexity (3.19; 1.20, 5.10), body mass index greater than 30 kg/m(2) (2.45; 1.40, 4.41), suspicion of malignancy (17.45; 7.32, 43.57), history of laparotomy (1.34; 1.02, 1.78), presence of adhesions (2.30; 1.37, 3.76), and intraoperative technical difficulty (17.86; 7.32, 43.57). When stratified by level of complexity, experience in laparoscopy does not appear to confer protection during level 1 laparoscopic procedures (0.42; 0.12, 1.37) but does significantly reduce the frequency of conversion during level 2 procedures (0.39; 0.72, 0.93). Age, parity, bowel injury, vascular injury, and history of pelvic inflammatory disease and endometriosis did not increase the risk of conversion. Compared with controls, patients who were converted experienced significantly greater blood loss (p < 0.001), longer operating room time (p < 0.001), and longer hospital stay (p < 0.001). CONCLUSION: All women undergoing laparoscopy should be counseled that unintended laparotomy is a known risk and has additional morbidity over laparoscopy alone. Less-experienced surgeons attempting complicated procedures significantly increase the risk of conversion.

Academic Medical Centers↗
PubMed1994

Risk of Anterior Abdominal Wall Adhesions Increases with Number and Type of Previous Laparotomy

Adhesions to the anterior abdominal wall after previous midline vertical laparotomy were found in 68% of patients undergoing laparoscopy (Childers et al: Gynecol Oncol 50:221, 1993). We reviewed the prevalence of anterior wall adhesions in patients with previous laparotomy incisions who underwent laparoscopy (>95% of patients) or laparotomy. The prevalence of omental and/or bowel adhesions to the anterior abdominal wall in proximity to the umbilicus were tallied and analyzed by incision site (midline vertical or suprapubic transverse) and number of previous laparotomies (one or more than one). The following table illustrates the number of patients in each category with anterior abdominal wall adhesions. While the prevalence of adhesions is increased with more than one previous laparotomy this did not reach statistical significance (Chi-square test). A midline vertical laparotomy does significantly increase the risk for anterior wall adhesions compared to a transverse incision (p<0.05). However, it should be noted that 28% of patients with a previous suprapubic transverse incision (Pfannenstiel or Maylard) had omental and/or bowel adhesions. In this series, one patient with two previous transverse incisions had an incidental enterotomy. We currently employ the technique of LUQ trocar placement in patients with previous midline and suprapubic transverse incisions.

Journal Article↗
PubMed1989

Prognostic indicators of laparotomy findings in clinical stage I-II supradiaphragmatic Hodgkin's disease.

Between July 1968 and July 1986, 915 patients with clinical stage (CS) I and II Hodgkin's disease limited to sites above the diaphragm underwent laparotomy and splenectomy at Stanford University. Fifteen percent were CS I, of whom 76% had cervical/supraclavicular disease, 13% axillary disease, and 9% mediastinal presentations. CS I patients were more likely to be male, were significantly older, and were significantly less likely to have nodular sclerosis (NS) histology than CS II patients. Twenty percent of CS I patients and 30% of CS II patients were pathologically upstaged. No CS I patients were upstaged to pathological stage (PS) IV. Univariate and multivariate analyses of presenting clinical characteristics were performed to predict staging laparotomy findings. CS I women, CS I patients with mediastinal-only disease, and CS I men with either lymphocyte predominance or interfollicular histologies were at low risk for having disease below the diaphragm (5%) or requiring chemotherapy (0%). CS II women who were less than 27 years old and had only two or three sites of disease were also at low risk for upstaging (9%) or requiring chemotherapy (2%). Mixed cellularity histology and male gender were associated with increased risk for subdiaphragmatic disease and require laparotomy; the presence of systemic symptoms was not correlated with laparotomy findings. These results confirm the importance of performing staging laparotomy for the majority of patients who present with supradiaphragmatic Hodgkin's disease if treatment programs are based on the presence and extent of subdiaphragmatic disease. Selected subgroups are at low risk for subdiaphragmatic disease and might be spared laparotomy if they are treated with mantle, paraaortic, and splenic irradiation.

Adolescent↗
PubMed1992

[Laparotomy in HIV-infected patients. Indications, results apropos of 104 operated patients].

From May 1st 1983 to March 1st 1991, 126 laparotomies were performed on 104 patients infected by human immunodeficiency virus (HIV). We report the operative indications, macroscopic findings, anatomopathologic and microbiological results, and hospital mortality in this population. In 12.5% of cases, infection by HIV was established after operation. Sixty-eight percent of patients presented criteria for AIDS. The population was divided into 4 groups of indications: Group I: 30 patients had an emergency exploratory laparotomy. Laparotomy provided a diagnosis in 80% of cases, with a hospital mortality in 66%. Group II: 45 patients had an emergency laparotomy with a preoperative diagnosis. Hospital mortality was 24.4%. Group III: 29 patients had a non-urgent laparotomy with no mortality. Group IV: 14 patients were reoperated (22 laparotomies). For the entire population, hospital mortality was 9.3% for seropositive patients and 38.8% for AIDS patients.

Acquired Immunodeficiency Syndrome↗
PubMedDate not supplied

Effect of type of anesthesia and lower-abdominal laparotomy in mice on the cytokine response to acute stress.

BACKGROUND AND OBJECTIVE: Recent emphasis has been placed on the accuracy of systemic cytokine levels as an index to the severity of acute surgical stress. In this investigation, a murine animal model was developed to determine the effect of the type of anesthesia on the cytokine response to a standard surgical stress. METHODS: The initial phase was designed to assess the severity of the acute stress response to a standard surgical stimulus by measuring the release of proinflammtory cytokines in 30 Balb C mice subjected to halothane anesthesia and exploratory laparotomy. The severity of the operative stress was assessed by serum levels of epinephrine and C-reactive protein at 0, 1, 2, 4, and 6 hours and compared with systemic levels of interleukin-1, interleukin-6, and tumor necrosis factor-alpha. In the next phase, in order to assess the stress response associated with the induction of anesthesia without surgery. IL-6 was measured in 10 mice undergoing halothane anesthesia or combined halothane-spinal anesthesia. In the final series of experiments, designed to assess the effect of anesthetic type on the stress response induced by the standard surgical stress, 40 mice underwent halothane anesthesia with laparotomy or combined halothane-spinal anesthesia with laparotomy. RESULTS: Following exploratory laparotomy, serum epinephrine was significantly elevated at 2 hours (P < .05 vs time 0), while C-reactive protein became elevated at 6 hours (P < .05). Serum interleukin-6 rose rapidly, reaching a peak at hour 2 (P < .001) and then declining through hour 6, but interleukin-1 and tumor necrosis factor, were elevated in only a few animals undergoing laparotomy. Neither halothane nor combined halothane/spinal anesthesia had any effect on the interleukin-6 stress response in the absence of surgical stress. Similarly, the degree of operative stress after exploratory laparotomy was not affected by the type of anesthesia. CONCLUSIONS: Serum interleukin-6 was the best marker for acute surgical stress, which could not be induced by anesthetic interventions alone. The combination of halothane with spinal anesthesia was not able to attenuate the degree of stress as compared with halothane anesthesia alone in animals undergoing abdominal surgery.

Abdomen↗
PubMed1999

Laparoscopic colectomy: indications for conversion to laparotomy.

HYPOTHESIS: Although experience with laparoscopic colectomy continues to accumulate, criteria for patient selection for the procedure have yet to be developed. We propose that review of indications for conversion to laparotomy during laparoscopic colectomy should define some of the current technical limitations of the procedure. This information may facilitate development of selection criteria for laparoscopic colon and rectal surgery. DESIGN: Single-institution retrospective medical records review. SETTING: Tertiary referral center. PATIENTS: Two hundred patients who underwent laparoscopic colon surgery, in 47 (23.5%) of whom the procedure was converted to laparotomy. INTERVENTIONS: A registry of 200 patients who have undergone laparoscopic colon surgery was analyzed. Medical records of 47 patients whose procedure was converted were reviewed to assess indications for conversion and identify factors contributing to the need for conversion. RESULTS: Between July 1, 1991, and September 30, 1998, 200 laparoscopic colon procedures were performed: 78 ascending colectomies, 74 descending or sigmoid colectomies, 14 diverting stomas, and 34 "other procedures." The 200 patients were divided into 4 cohorts of 50 consecutive patients to analyze changes with time. The conversion rate was statistically greater in the first quarter (18 patients [36.0%]) than in subsequent quarters (16.0%; P <.05). The rate of conversion to laparotomy for segmental resection of the ascending and descending colon (31/153 [20.3%]) has been equivalent and less than the conversion rate for other procedures (16/33 [48.5%]; P <.05). The distribution of patients by operative indication has been fairly constant. The indication for operation has not influenced the need for conversion. The indications for conversion were technical problems in 15 patients (hypercarbia, unclear anatomy, and stapler misfire), laparoscopic complications in 9 patients (bleeding, cystotomy, and enterotomy), and problems that exceeded the limits of laparoscopic dissection in 23 patients (phlegmon, adhesions, obesity, and adjacent organ involvement by cancer). CONCLUSIONS: Our conversion rate has decreased during our experience, and currently the need for conversion to laparotomy is most frequently caused by situations such as excessive tumor bulk, adhesions, and diverticular phlegmon that exceed the technical limitations of laparoscopic dissection. Colorectal reanastomosis following a Hartmann resection and procedures involving resection of the distal rectum are unlikely to be successfully completed. Although obesity accentuates the technical limitations of laparoscopic dissection, it is an infrequent cause for conversion to laparotomy.

Colectomy↗
PubMed2001

Avoidance of abdominal compartment syndrome in damage-control laparotomy after trauma.

HYPOTHESIS: Abdominal compartment syndrome (ACS) is a morbid complication of damage-control laparotomy. Moreover, the technique of abdominal closure influences the frequency of ACS. DESIGN: Retrospective cohort study. SETTING: Urban level I trauma center. PATIENTS: We studied 52 patients with trauma who required damage-control laparotomy during the 5 years ending December 31, 1999, and who survived longer than 48 hours. MAIN OUTCOME MEASURES: Abdominal compartment syndrome, acute respiratory distress syndrome (ARDS), and multiple organ failure (MOF). RESULTS: Mean (+/- SD) age was 33 +/- 2 years; 38 (73%) were male. Mechanism of injury was blunt in 29 patients (56%), and mean (+/- SD) Injury Severity Score was 28 +/- 2. Development of ARDS and/or MOF was seen in 23 patients (44%); ARDS and MOF increased mortality from 12% (3/26) to 42% (11/26). Abdominal compartment syndrome was a common complication (17/52), and was associated with an increase in ARDS and/or MOF (12 patients [71%] vs 11 patients [31%] without ACS; P =.02, chi(2) test) and death (6 [35%] vs 8 patients [23%] without ACS). Primary fascial closure (n = 10) at the initial laparotomy was associated with ACS in 8 (80%) (P =.001, chi(2) test) and ARDS and/or MOF in 9 (90%) (P =.01, chi(2) test); skin closure (n = 25), with ACS in 6 (24%) and ARDS/MOF in 9 (36%); and Bogotá bag closure (n = 17), with ACS in 3 (18%) and ARDS/MOF in 8 (47%). CONCLUSIONS: Damage-control laparotomy is associated with frequent complications. In particular, ACS is a serious complication that increases ARDS and/or MOF and mortality. Avoiding primary fascial closure at the initial laparotomy can minimize the risk for ACS.

Abdomen↗
PubMed1998

Consolidative 32P after second-look laparotomy for ovarian carcinoma.

We report our experience with consolidative 32P after second-look laparotomy. Forty-three patients received consolidative 32P after platinum-based chemotherapy and a negative (39 patients, 91%) or positive (4 patients) second-look laparotomy. Thirty-one patients (72%) initially had stage III (30 patients) or stage IV (1 patient) disease; 28 patients (65%) had grade 3 tumors. Patients had follow-up from 3.5 to 14.9 years (median, 7.7 years); no patient was lost to follow-up. The 5-year rates of control of disease within the abdomen (local control) for the overall group and the subset of patients with stage II-IV disease and a negative second-look laparotomy were 65% and 69%, respectively. The corresponding 5-year survival rates were 78 and 81%, respectively. Multivariate analyses revealed that tumor found at second-look laparotomy significantly influenced the likelihood of local control and cause-specific survival. Acute side effects included cellulitis (1 patient) and ileus (3 patients). Two patients (5%) experienced severe late complications; both experienced small bowel obstruction that necessitated surgical intervention. Consolidative 32P appears to reduce the risk of recurrence and improve survival after negative second-look laparotomy. The risk of significant complications is low.

Antineoplastic Agents↗
PubMed1988

Staging laparotomy in Hodgkin's disease: a community hospital experience.

Between 1977 and 1984, 50 patients with Hodgkin's disease underwent a staging laparotomy performed by nine surgeons in a community hospital. Adequate procedures were performed in 80% of cases compared to staging laparotomies done between 1969 and 1976 when only 40% were properly performed. Abdominal lymphangiogram had a false-negative rate of 0 but a false positive rate of 70%. Clinical stage III disease was significantly downstaged at laparotomy (65% of cases). Postoperative complication rate was 4% and there were no operative deaths. A subset of patients not requiring laparotomy have been identified. Because the quality of staging laparotomy and lymphangiography was variable, we encourage all centres treating patients with Hodgkin's disease to review their own experience with these techniques before making individual patient treatment decisions.

Alberta↗
PubMed1999

Second look for ovarian cancer: laparoscopy or Laparotomy? A prospective comparative study.

OBJECTIVE: The objective of this study was to evaluate, for patients with ovarian cancer, the feasibility, reliability, and complications of a laparoscopic second look and to compare them with those of a second look by laparotomy. METHODS: Twenty patients treated by initial surgery and adjuvant chemotherapy for ovarian carcinoma underwent a laparoscopic second look, immediately followed by a comparative laparotomy. All were in complete remission after chemotherapy. Both operations were performed according to a predefined checklist, identical for both surgical techniques and for each patient: after liberation of adhesions, an exhaustive intraperitoneal inspection was performed, with systematic peritoneal cytology and biopsies. Each patient therefore was her own control for the two techniques. RESULTS: The positive predictive value of laparoscopy for the diagnosis of residual disease was 100% (6 of 6 cases), while the negative predictive value was 86% (2 false-negative cases out of 14). Because of the presence of postoperative adhesions, the rate of complete intraperitoneal investigation was 95% for laparotomy versus 41% for laparoscopy. The complication rate of laparoscopy requiring laparotomy was 5.3%. CONCLUSIONS: After treatment of ovarian cancer, a laparoscopic second look appears to be less reliable than one performed by laparotomy. The presence of severe postoperative adhesions is the main obstacle to an exhaustive, reliable, and safe laparoscopic second look.

Adult↗
PubMed2000

Hysterectomy for obese women with endometrial cancer: laparoscopy or laparotomy?

OBJECTIVE: The aim of this study was to investigate the feasibility and safety of laparoscopic management of obese women with early stage endometrial cancer and to compare the surgical outcome, cost, hospital stay, recall of postoperative pain control, time to return to full activity and to work, and overall satisfaction among these women and those managed by laparotomy. METHODS: We conducted a prospective study over 2 years applying laparoscopic surgery to all women with clinical stage I endometrial cancer and body mass indices (BMIs) between 28.0 and 60.0 who can tolerate such surgery. As a control, we used women with clinical stage I endometrial cancer and similar BMIs who underwent laparotomy in the previous 2 years. Both groups were compared in their characteristics, surgical outcome, cost, and hospital stay, and interviewed regarding time to recovery, recall of postoperative pain control, and overall satisfaction with their management. RESULTS: Forty of 42 obese women who presented with clinical stage I endometrial cancer during the study period were offered laparoscopic surgery. The procedure was converted to laparotomy in 3 (7.5%) patients. Laparoscopic surgery was thus successful in 88.1% of all obese women. There was no significant difference between women who underwent laparoscopy and those who underwent laparotomy in patient characteristics, proportion of women who underwent lymphadenectomy, complications, total cost, patients' recall of postoperative pain, and patients' satisfaction with management. Women who underwent laparoscopy had a significantly longer operative time, more pelvic lymph nodes removed, a smaller drop in postoperative hematocrit, less pain medication, and a shorter hospital stay (194.8 versus 137.7 min, P <0.001; 11.3 versus 5.3, P < 0.001; 3.9 versus 5.4, P = 0.029; 32.3 versus 124.1 mg, P < 0.001; and 2.5 versus 5.6 days, P < 0.001, respectively). There was a trend toward earlier resumption of full activity and return to work among women who underwent laparoscopy (23.2 versus 45.0 days, P = 0.073, and 35.3 versus 67.0 days, P = 0.055, respectively). CONCLUSIONS: Most obese women with early stage endometrial cancer can be safely managed through laparoscopy with excellent surgical outcome, shorter hospitalization, and less postoperative pain than those managed through laparotomy.

Adult↗
PubMed1997

Enhancing effect of thoraco-laparotomy on liver metastasis and the role played by active oxygens in its mechanism.

The enhancing effect on liver metastasis produced by the excessive surgical stress of thoraco-laparotomy (TL), and its regulation with a radical scavenger, were studied in 10-week-old Donryu rats. The rats were divided into three groups: those given thoraco-laparotomy for 1 h (the TL group); those given laparotomy alone for 1 h (the L group); those given a short laparotomy (the C group). The effects of treatment with 5 mg/kg of EPC-K1 was assessed in the TL group. A rat hepatocellular carcinoma cell line AH 60C (5 x 10(5) cells) was administered into the portal vein under general anesthesia. The number of metastatic liver nodules was counted 3 weeks later, and the lipid peroxide (LPO) levels of the liver and serum were measured by the TBA method on postoperative days (PODs) 1, 2, and 3. The number of metastatic liver nodules was 40.6 +/- 29.7, 15.0 +/- 15.8, and 13.7 +/- 9.4 in the TL, L, and C groups, respectively. When EPC-K1 was administered to the TL group, the LPO level on POD 1 decreased from 49.8 +/- 25.8 to 18.9 +/- 7.9 nM/g, and the number of metastatic liver nodules decreased from 27.2 +/- 30.0 to 8.9 +/- 12.7 in parallel. The findings of this study suggested that the excessive surgical stress produced by thoraco-laparotomy enhanced liver metastasis in parallel with an increase in LPO levels; however, the radical scavenger EPC-K1 could aid in reversing this effect.

Animals↗
PubMed1998

Transpelvic gunshot wounds: routine laparotomy or selective management?

Mandatory exploration is the standard method for managing patients with gunshot wounds to the abdomen and back. This policy is associated with a high incidence of unnecessary laparotomies and significant morbidity. Reports from our center have shown that a policy of selective management, based on clinical findings, is safe in such patients. Patients with bullet trajectories that carry a high likelihood for intraabdominal organ injury may constitute a subgroup at particular risk. The need for routine or selective exploration in similar patients must be assessed. Therefore we decided to analyze patients with transpelvic gunshot wounds. The objective of the study was to examine if a policy of selective management of patients with transpelvic gunshot wounds is safe. This prospective study was conducted at an academic level I trauma center. We admitted 37 patients with transpelvic gunshot wounds over a 12-month period. All patients were managed according to a protocol that dictated laparotomy in the presence of significant clinical findings (peritoneal signs, hemodynamic instability, gross hematuria, rectal bleeding) and observation in the absence of the above. Additional diagnostic workup was performed only in appropriate cases rather than routinely. Nineteen (51.3%) patients were immediately operated on the basis of clinical findings. Sixteen of these laparotomies were therapeutic. Eighteen (48.6%) patients were initially observed. Subsequently, three of them underwent exploration for development of abdominal tenderness. All three laparotomies were nontherapeutic. The remaining 15 (40.5%) patients were successfully managed nonoperatively. There were no delays in diagnosis or missed injuries. Clinical examination had a sensitivity of 100% and specificity of 71.4% in detecting the need for laparotomy. A policy of selective management is thus safe, even for patients who suffer gunshot wounds with a high likelihood for intraabdominal organ injury. Clinical examination, supported by additional studies in appropriate cases, is the main method of selecting patients for operation or nonoperative treatment.

Abdominal Injuries↗
PubMed2005

Risk factors for conversion to laparotomy during laparoscopic management of an ectopic pregnancy.

OBJECTIVE: To identify risk factors for conversion to laparotomy during laparoscopic management of ectopic pregnancy. METHODS: A retrospective chart review of patients who underwent laparoscopy for treatment of ectopic pregnancy, during a 32-month period (6/1999-2/2002), at the University of Miami Jackson Memorial Hospital. We identified 229 patients; 201 had a successful laparoscopy (non-converted group) and 28 who were converted to laparotomy (converted group). Variables analyzed between the two groups were demographic data, patient-related risk factors available to the surgeon prior to the surgery (previous laparotomy, previous laparoscopy, history of PID, history of endometriosis, diameter of ectopic pregnancy as measured by ultrasound, amount of free fluid on ultrasound, BMI), and surgeons' experience. RESULTS: Out of the 229 laparoscopies, 28 were converted to laparotomy (12.2%). The rate of conversion was significantly higher for less experienced compared to experienced surgeon (OR = 6.1, 95% CI = 2.35-15.88). Significantly more women had a BMI > 30 kg/m2 in the converted group compared to the non-converted group (42% vs. 14%; OR = 4.28, 95% CI = 1.7-10.75) and the converted group had significantly higher rate of large free fluid reported on ultrasound compared to the non-converted group (21.42% vs. 7.46%; OR = 3.38, 95% CI = 1.04-10.61). CONCLUSION: Less experienced surgeon, BMI > 30 kg/m2, and large amount of free fluid on ultrasound increase the risk of conversion to laparotomy during laparoscopic management of ectopic pregnancy.

Adult↗