Francisco de Salles Collet e Silva

The article “A place for everything…and everything in its place?” 1 was a case presented and discussed at an online Virtual International Case Conference. This meeting takes place once a month and is overseen online by the Panamerican Trauma Society, the AAST International Relations Committee, the University of Miami, and the International Trauma System Development Program at Virginia Commonwealth University.

RESUMO Introdução: O benefício da laparoscopia no trauma abdominal contuso (TAC) permanece em debate. Este estudo analisou pacientes com TAC tratados por laparoscopia em um serviço terciário de referência em trauma no Brasil. Métodos: Foi realizado um estudo clínico retrospectivo com pacientes hemodinamicamente estáveis vítimas de TAC tratados por laparoscopia ao longo de um período de 12 anos. As laparoscopias foram classificadas como diagnósticas (LD) ou terapêuticas (LT). Resultados: Durante o período de 12 anos, 85 pacientes com TAC foram tratados por via laparoscópica. A idade mediana foi de 30 anos, com predomínio do sexo masculino (80%) e pacientes classificados como ASA I (72%). A colisão veicular foi o mecanismo de trauma mais frequente (46%). As principais indicações para laparoscopia foram a presença de líquido livre sem lesão parenquimatosa na tomografia computadorizada (TC) (59%) e dor abdominal/sinais de irritação peritoneal (11,5%). A taxa de conversão foi de 26%, e esses pacientes foram incluídos no grupo controle (n=22). Entre as laparoscopias concluídas (n=63), 36% (n=31) foram diagnósticas e 38% (n=32) terapêuticas. O sinal do cinto de segurança esteve presente em 12% dos pacientes da série total. Os procedimentos terapêuticos mais frequentes foram suturas da bexiga, cólon e diafragma. Houve correspondência entre os achados tomográficos e intraoperatórios, sem identificação de lesões despercebidas. O tempo cirúrgico foi maior no grupo de conversão (p<0,05). Conclusão: A laparoscopia pode ser segura e eficaz no manejo de pacientes vítimas de trauma abdominal contuso, desde que previamente selecionados e hemodinamicamente estáveis. O sucesso dessa abordagem depende do tripé: seleção adequada dos pacientes, cirurgiões treinados e disponibilidade integral de materiais e exames complementares.

Background: The benefit of laparoscopy in blunt abdominal trauma (BAT) remains debated. This study analyzed patients with BAT treated by laparoscopy in a tertiary reference trauma service in Brazil. Methods: A retrospective clinical study of hemodynamically stable patients with BAT treated by laparoscopy over a 12-year period was conducted. Laparoscopies were classified as diagnostic (DL) or therapeutic (TL). Results: Over a 12-year period, 85 patients with BAT were treated laparoscopically. The median age was 30 years, and most patients were male (80%) and had an ASA of I (72%). Collision was the most frequent mechanism (46%). The main indications for laparoscopy were the presence of free fluid without parenchymal lesions on CT (59%) and abdominal pain/signs of peritoneal irritation (11.5%). The conversion rate was 26%, and these patients were included in the control group (n=22). Among the laparoscopies (n=63), 36% (n=31) were DL, and 38% (n=32) were TL. The seat belt sign was present in 12% of the patients in the total series. The most frequent therapeutic procedure is suturing of the bladder, colon, and diaphragm. There was correspondence between the CT and intraoperative findings, and there were no unnoticed injuries. The surgical time was longer in the CG (p<0.05). Conclusion: Laparoscopy can be safe and effective for the management of patients who are victims of blunt abdominal trauma, selected preoperatively and hemodynamically stable. Success in this type of approach depends on a tripod: adequate selection of patients, trained surgeons and full-time availability of materials and subsidiary tests.

Background Trauma laparoscopy may provide a less invasive alternative to laparotomy by providing accurate diagnosis and minimally invasive management of selected trauma patients. The risk of missing injuries during the laparoscopic evaluation still refrains surgeons from using this approach. Our aim was to evaluate feasibility and safety of trauma laparoscopy in selected patients. Methods We performed a retrospective review of hemodynamically trauma patients who underwent laparoscopic management in a tertiary center in Brazil due to abdominal trauma. Patients were identified by searching through the institutional database. We collected demographic and clinical data, focusing on avoidance of exploratory laparotomy, and missed injury rate, morbidity, and length of stay. Categorical data were analyzed using Chi-square, while numerical comparisons were performed using Mann–Whitney and Kruskal–Wallis test. Results We evaluated 165 cases, of which 9.7% needed conversion to an exploratory laparotomy. One-hundred and twenty-one patients (73%) had at least one intrabdominal injury. Two missed injuries to retroperitoneal organs were identified (1.2%), of which only one was clinically relevant. Three patients died (1.8%), one of which was due to complications from an intestinal injury after conversion. No deaths were related to the laparoscopic approach. Conclusion In selected hemodynamically stable trauma patients, the laparoscopic approach is feasible and safe, and reduces the need for exploratory laparotomy and its associated complications.

RESUMO Introdução: o presente estudo tem como objetivo avaliar as medidas que permitiram a implementação de cirurgias laparoscópicas de urgência em hospital de ensino médico ao longo de 15 anos. Método: foi realizado estudo clínico retrospectivo de pacientes submetidos a Apendicectomia aberta ou Laparoscópica no período de 15 anos (2004 a 2018). Os dados clínicos foram confrontados com as ações implementadas: 1) Treinamento dos médicos residentes em cirurgia minimamente invasiva (2007); 2) Uso do endoclip para tratamento do coto apendicular (2008); 3) Disponibilidade do set de laparoscopia em tempo integral para o Pronto Socorro (2010); e, 4) Terceirização do serviço de manutenção do set e materiais de vídeo e uso do endoclip Hem-o-lok® para tratamento do coto apendicular (2013). Resultados: foram realizadas 1.168 cirurgias, das quais 691 abertas (59%), 465 laparoscopias (40%) e 12 convertidas (1%). O treinamento da equipe levou à realização de 11% de laparoscopia (2007) e o uso do endoclip para tratamento do coto apendicular para 16% (2008). Com a disponibilização do set de vídeo em tempo integral para o Pronto Socorro a partir de 2011, houve aumento de laparoscopias para 26% (2012). A padronização do endoclip Hem-o-lok® no tratamento do coto apendicular aumentou para 85% e a partir de 2016 foi realizado em todos os casos, sem complicação relacionada ao seu uso, mesmo em apendicites complicadas. Conclusão: o emprego da laparoscopia no serviço de urgência envolve além do treinamento da equipe cirúrgica, investimento tecnológico contínuo e uso de técnicas que sejam factíveis, viáveis e seguras.

Background: the barriers to implement emergency laparoscopy in public teaching hospitals involve issues such as resident learning curves and resource costs and availability. This study was designed to describe the issues facing the implementation of laparoscopic approach for acute appendicitis over 15 years in a single academic center in Brazil. Materials and Methods: retrospective study of patients undergoing emergency appendectomy from 2004 to 2018. Clinical data were compared to four major actions implemented in the emergency surgical service: minimally invasive surgery training for residents (2007), laparoscopic stump closure using metal clips (2008), 24/7 availability of laparoscopic instruments for emergency surgeries (2010), and third-party contract for maintenance of the laparoscopic instruments and implementation of polymeric clips for stump closure (2013). We evaluated the increase in laparoscopic appendectomy after the implementation of those major changes. Results: we identified 1168 appendectomies during the study period, of which 691 (59%), 465 (40%), and 12 (1%) were open, laparoscopic, and converted, respectively. The implementation of the major changes since 2004 resulted in an increase of laparoscopic appendectomies from 11% in 2007 to 80% in 2016. These actions were decisive in the widespread use of laparoscopy for acute appendicitis (p<0.001). The standardization of the hem-o-lok clip in the treatment of the appendiceal stump made the procedure more feasible, reducing the surgical time using laparoscopic access and increasing the team’s adherence, so that this became the route of choice in about 85% of cases in the period from 2014 to 2018, 80% performed by 3rd year resident physicians. No intraoperative complications were noted related to laparoscopic access, even in more complicated appendicitis. There was no mortality reported, no reoperations or readmissions to hospital during a 30-day postoperative period. Conclusion: the development of a feasible, reproducible, and safe technical standardization, associated with continuous cost optimization, are the cornerstones for a consistent and viable change in the current practice for appendectomies in middle and lower-income countries.

Selective management of penetrating neck injuries has been considered the standard of care with minimal risks to patient safety. In a previous non-randomized prospective study conducted at our center, selective management proved to be safe and reduced unnecessary exploratory cervicotomies. In the present study, the role of clinical examination and selective diagnostic tests were assessed by reviewing demographic and clinical data. A comparison of results between two groups (mandatory surgical exploration versus selective surgical exploration) was made to check the safety of selective management in terms of the rates of morbidity and mortality. A retrospective analysis at the Emergency Department of the Hospital das Clínicas of the University of Sao Paulo was performed by a chart review of our trauma registry, identifying 161 penetrating neck trauma victims. Of the 161 patients, 81.6 % were stabbed and 18.4 % had gunshot injuries. Stratifying the wound entry points by neck zones, we observed that zone I was penetrated in 32.8 %, zone II in 44.1 % and zone III in 23.1 % of all the cases. Thirty one patients (19.2 %) had immediate surgical exploration, which had a mean length of stay of 6 days, a complication rate of 12.9 % and a mortality rate of 9.4 %. Of the 130 who underwent selective surgical exploration 34 (26.1 %) required operative procedures after careful physical examination and diagnostic testing based on clinical indications. The mean length of stay for the selective surgical exploration group was 2 days with a complication rate of 17.6 % with no mortality, and virtually all of them were related to associated injuries in distant body segment. No statistical significance was found comparing mortality and complication rates between the two groups. Selective approach avoided 59 % of unnecessary exploratory cervicotomies. Careful evaluation of asymptomatic and stable patients with minor signs of injury can safely avoid unnecessary neck explorations with low rates of morbidity. This should be the standard management of such patients.