Diagnosis and Treatment of Abdominal Injuries in Isolated and Combined Trauma (Clinical Study)

The dissertation is devoted to a clinical study of the diagnosis and treatment of abdominal injuries in isolated and combined trauma. Diagnostic and therapeutic algorithms have been developed and implemented in the work, covering traditional and endoscopic approaches, including video laparoscopic examination and operative treatment methods. The research is based on patentable scientific developments, including a video laparoscopy method for patients in shock, an original device for parenchymal organ hemostasis, and methods for laparoscopic bile duct drainage and diagnosis of abdominal organ injuries. A comparative analysis of treatment results across four groups of clinical observations has been conducted, yielding data on reduced intervention trauma, decreased numbers of diagnostic and therapeutic laparotomies, and lower postoperative complications and mortality with the application of minimally invasive endoscopic technologies. The relevance of the work is due to the rise in traumatic disease, high mortality from abdominal injuries, and the need to optimize surgical tactics using modern minimally invasive methods.

Relevance of the Topic

Over the past decade, a significant increase in "traumatic disease" has been observed worldwide, especially severe multiple and combined injuries. According to WHO data, one person dies from road traffic accidents every two minutes. Emergency surgery for injuries is considered not only a medical but also a social problem, affecting the destinies of millions of people who die or lose their ability to work. The relevance of the problem, as N.A. Efimenko and P.G. Bryusov (1999) believe, is due to the continuing rise in abdominal injuries, while a large number of complications (45.7–69.9%) and high mortality (16.2–69.5%), in the authors' opinion, are associated with the absence of a rational generally accepted surgical tactic. Mortality in injuries of several abdominal organs reaches 23.7% (E.K. Gumanenko, 1999), skeletal injuries in combined trauma — 26.2% (T.D. Nikitin, 1983), chest injuries — 29.3% (E.A. Nechaev, 1995).

Thus, over the past 5 years, mortality from road traffic accidents alone in Russia has increased by 65%, and the number of deceased, according to GIBDD, reaches 33,000–35,000 people per year (A.S. Ermolov, 2003). According to A.D. Pugachev et al. (1990), in 62.7% of the injured the trauma was extremely severe and became the cause of their death at the scene of the incident, another 5.4% died during transportation, and only 37.3% of patients received treatment. The injury as a result of a road traffic accident was the cause of death in 38.7%, catastrophe trauma — in 26.8%, railway accidents — in 11.2%, cold weapon injuries — in 17.6%, firearm injuries — in 2.4%.

According to the materials of the Military-Medical Academy of St. Petersburg (A.B. Singaevsky et al., 2002), in 73.5% of the injured one immediate cause of death was indicated, in 21.6% — two, in 4.9 — three. Acute massive blood loss led to a fatal outcome in 43.9%, and in 37.6% it was the only one, severe traumatic brain injury — in 25.1%, pneumonia (including aspiration) — in 27.6%. Sepsis became the immediate cause of death in 6.9% of cases.

According to the materials of the N.V. Sklifosovsky Research Institute of Emergency Medicine (A.S. Ermolov et al., 2003), among patients who died within 1 hour of admission to the intensive care unit, none were operated on; among those who died within 1 to 3 hours — only 22% were operated on, within 3 to 12 hours — 40%, within 12 to 24 hours — 54%. Diagnostic measures take about 1 hour. Therefore, with rare exceptions, operations to stop intra-abdominal hemorrhage were performed more than two hours after the injury.

Clinical symptoms of injury are the leading ones in establishing the diagnosis (S.Z. Gorshkov, V.S. Volkov, 1978; A.S. Ermolov, 1986). In the opinion of S.Z. Gorshkov (1974), B.A. Prokopova et al. (2002), physical symptoms of closed injuries of abdominal organs in severe combined trauma do not have reliable accuracy, therefore there is a need to obtain objective information using modern minimally invasive research methods (M.A. Aliyev et al., 2002; A.A. Bondarev et al., 2002; N.A. Efimenko et al., 2004; N.A. Baulin et al., 2004; B.R. Ishakov et al., 2004).

Although the first reports on the use of laparoscopy to detect injuries of internal abdominal organs appeared in the second half of the 1970s (A. Gazzaniga et al., 1976; N. Carnevale et al., 1977), the role of laparoscopy in examining trauma victims was not studied until the publication of A. Cuschieri's work in 1988. Further research by R. Ivatury (1992), D. Livingston (1992), J. Sacker (1992), J.C. Salvino (1992), Sosa (1992), T. Fabian (1993), R. Smith (1993) made it possible to judge the high diagnostic role of laparoscopy in abdominal injury.

In the opinion of M.V. Gridnev et al. (1992), Yu.S. Pridybaylov et al. (2004), N.V. Lebedev et al. (2004), the fate of a victim with closed abdominal trauma and damage to internal organs depends on a timely and correctly determined operation. Therefore, the authors believe that one should not strive to establish an exact diagnosis, but rather, during observation of the victim, quickly determine whether he needs operative treatment or not. In doubtful cases, it is necessary to perform a diagnostic laparotomy as early as possible, rather than waiting for the development of diffuse peritonitis or an expressed picture of internal hemorrhage.

All these questions can be answered by video laparoscopy, which in one-third of victims logically transitions into an endoscopic operation (B.S. Briskin, 1999; N.A. Baulin et al., 1999; A.S. Balalykin et al., 2000; K.N. Nikolaev, 2002; M. Ishitani, 1989, etc.). A.S. Ermolov (1986), A.A. Buianov et al. (2006), V.V. Boyartsev et al. (2006), G.V. Pakhomova et al. (2006) emphasize that in polytrauma, the risk of even complicated laparoscopy is insignificant compared to the information it provides. The authors believe that the method should be applied precisely when the diagnosis is unclear.

Laparoscopy contributes to establishing the true nature of the injury, determining the timing of surgical intervention (G.L. Aleksandrovich et al., 1987; M.M. Murzanov et al., 1998; A.N. Lyzikova et al., 2004; S.A. Kasumyan et al., 2004; A.E. Borisov et al., 2006; A.A. Gulyaev et al., 2006). The value of the method increases in examining victims with combined trauma, when the situation does not allow changing body position (J. Sackier, 1992; G. Berci, 1993).

Deserves attention is the method of diagnostic and therapeutic laparoscopy, which is more commonly used for various injuries of abdominal organs. As many surgeons believe (S.I. Emelyanov et al., 1995; M.I. Perelman and S.R. Dobrovolsky, 2000), the question of its use in penetrating abdominal wounds requires further study.

Penetrating stab and firearm wounds of the abdominal cavity in peacetime constitute 20–40% of the total number of abdominal injuries. Mortality remains high, ranging from 9 to 27.6% (A.A. Grinberg, 2001). According to A.A. Grinberg (1999), A.R. Melikyan and G.Z. Balayan (2004), I.F. Sufiyarov et al. (2006), active surgical tactics involving emergency laparotomy with revision of abdominal organs lead to a large number (20–40%) of unjustified operations, when the surgeon does not find injuries in the abdomen. In another 5–9% of cases, only incidental injuries of hollow, parenchymal organs, and the omentum are detected.

A.I. Korabelnikov (1988) shared his experience of laparoscopy in the diagnosis of stab wounds of the abdomen in 186 patients; a penetrating character of the wounds was noted in 163 of them, injury of internal organs was verified in 52.1%, including the small and large intestine, liver, stomach, omentum, spleen, and diaphragm. Internal organs were not damaged in 47.9% of patients. The author does not provide an analysis of surgical tactics, although it is obvious that in some cases the operation was undertaken in vain.

E.G. Abdullaev et al. (2003), based on the experience of 252 laparoscopies, showed that in 73.1% of victims with knife wounds of the abdomen, operative intervention was not required. In 28.8% of cases, the wounds turned out to be non-penetrating into the abdominal cavity; in 63.5%, signs of damage to hollow and parenchymal organs were not detected. Retroperitoneal hematomas were noted in 4.3% of victims.

It can be expected that the introduction of diagnostic and treatment algorithms, modern surgical technologies will significantly reduce the traumafulness of operations and contribute to reducing the frequency of complications and mortality (V.I. Egorov et al., 1995; E.I. Sigal et al., 1995; I.S. Funloe et al., 1995; V.D. Fedorov et al., 1998, etc.).

Thus, the development of algorithms of diagnostic and therapeutic actions in isolated and combined abdominal trauma, minimally invasive diagnostic video laparoscopic and therapeutic endoscopic interventions on abdominal organs appears to be a relevant problem at present and requires further research in this direction.

Goal of the Work

The goal of this study is to improve the results of diagnosis and surgical treatment of victims with isolated and combined abdominal trauma through the development and clinical use of diagnostic and therapeutic algorithms, the development of a diagnostic and treatment program for penetrating stab wounds of the abdomen, and the use of all possibilities of endoscopic technologies.

To solve this problem, the following tasks were set:

1. To develop algorithms of diagnostic and therapeutic actions in isolated and combined abdominal trauma.

2. To develop algorithms of diagnostic and therapeutic actions in penetrating stab wounds of the abdomen.

3. To determine the causes and frequency of diagnostic laparotomies in patients with isolated and combined abdominal trauma, in penetrating stab wounds of the abdomen, and to establish the severity and negative consequences of such interventions.

4. To determine indications for the use of prolonged video laparoscopy in selecting the tactic of surgical treatment in patients with isolated and combined abdominal trauma, in penetrating stab wounds of the abdomen.

5. To study the results of endoscopic operations in patients with isolated and combined abdominal trauma, in penetrating stab wounds of the abdomen, and to give recommendations for their use.

6. To develop an algorithm for the diagnosis and treatment of intra-abdominal hemorrhages in patients with isolated and combined abdominal trauma.

7. To determine indications for conversion in endoscopic operations in patients with isolated and combined abdominal trauma, in penetrating stab wounds of the abdomen.

8. To conduct a comparative analysis of the results of diagnosis and treatment of victims with isolated and combined abdominal trauma, in penetrating stab wounds of the abdomen, by traditional methods and using endoscopic technologies.

Scientific Novelty of the Research

The dissertation represents a clinical study based on patentable scientific developments.

- The necessity of applying endoscopic technologies in the diagnosis and treatment of injuries of abdominal organs in isolated and combined abdominal trauma, in penetrating stab wounds of the abdomen, has been proven.

- Algorithms of diagnostic and therapeutic actions for victims in isolated and combined abdominal trauma, in penetrating stab wounds of the abdomen, have been developed.

- An algorithm for the diagnosis and treatment of intra-abdominal hemorrhages in patients with isolated and combined abdominal trauma has been developed.

- A "Method for Performing Video Laparoscopy in Patients with Combined Trauma in a State of Shock of Various Degrees of Severity" has been proposed (Russian Federation Patent No. 2212847, 2003).

- An "Device for Hemostasis of Parenchymal Organs" has been developed (Russian Federation Patent for Utility Model No. 30072, 2003), which made it possible to improve the treatment results of patients with isolated and combined liver and spleen injuries.

- In case of liver and biliary tract injury, a method of laparoscopic external drainage of extrahepatic bile ducts has been used (Russian Federation Patent for Invention No. 2218949, 2003).

- In case of injury of abdominal organs, a "Method for Diagnosing Injury of an Abdominal Organ" has been developed (Notification of Application Filing and Registration No. 2005130121. Moscow. Rospatent. 2005).

- The diagnostic and therapeutic capabilities of prolonged video laparoscopy in injuries of parenchymal and hollow organs of the abdominal cavity in isolated and combined abdominal trauma, in penetrating stab wounds of the abdomen, have been determined.

- Indications for endoscopic and open operations in isolated and combined abdominal trauma, in penetrating stab wounds of the abdomen, have been established and systematized. Indications for conversion have been developed.

- In patients with isolated and combined abdominal trauma, changes in systemic hemodynamics and peripheral blood circulation parameters after open and endoscopic operations have been studied.

- A comparative evaluation of the diagnosis and treatment of victims with isolated and combined abdominal trauma, in penetrating stab wounds of the abdomen, by traditional methods and using endoscopic technologies has been carried out.

Practical Significance of the Work

Based on the analysis of the results of diagnosis and surgical treatment of victims with isolated and combined abdominal trauma, in penetrating stab wounds of the abdomen, in four groups of clinical observations — by open and endoscopic methods, the following provisions have been developed and implemented into clinical practice:

- Diagnostic and therapeutic algorithms in isolated and combined abdominal trauma, in penetrating stab wounds of the abdomen.

- An algorithm for the diagnosis and treatment of intra-abdominal hemorrhages in patients with isolated and combined abdominal trauma.

- A new method of video laparoscopy in patients with combined abdominal trauma in a state of shock of various degrees of severity.

- An original device for hemostasis in case of parenchymal organ injury.

- A method of external drainage of the biliary passages during endoscopic surgery.

- In case of injury of abdominal organs, a "Method for Diagnosing Injury of an Abdominal Organ."

- Indications for the use of prolonged laparoscopy in isolated and combined abdominal trauma, in penetrating stab wounds of the abdomen, have been determined.

- The therapeutic capabilities of endoscopic technologies in emergency surgery of isolated and combined abdominal injuries, in penetrating stab wounds of the abdomen, have been used.

- Indications for conversion in isolated and combined abdominal trauma, in penetrating stab wounds of the abdomen, have been developed.

The main provisions submitted for defense:

The scientific and practical solution of the problem of diagnosis and treatment of injuries of abdominal organs in isolated and combined abdominal trauma is submitted for defense.

- Directions for improving the treatment results of victims in isolated and combined abdominal trauma, as well as in penetrating stab wounds of the abdomen, have been determined through the creation and application of diagnostic and therapeutic algorithms of surgical tactics.

- A patentable method of performing diagnostic and therapeutic video laparoscopy in victims in a state of shock of various degrees of severity has been implemented.

- A patentable method of endoscopic hemostasis from parenchymal organs using an original compression-balloon method has been used.

- In case of liver and biliary tract injury, a patentable method of laparoscopic external drainage of extrahepatic bile ducts has been implemented.

- In case of abdominal organ injury, a patentable "Method for Diagnosing Injury of an Abdominal Organ" has been developed.

- An algorithm for diagnosis and treatment in isolated and combined abdominal trauma has been applied.

- An algorithm for diagnosis and treatment in penetrating stab wounds of the abdomen has been developed.

- An algorithm for the diagnosis and treatment of intra-abdominal hemorrhages in patients with isolated and combined abdominal trauma has been used.

- The application of endoscopic technologies in the diagnosis and treatment of isolated and combined abdominal trauma has made it possible to significantly reduce the number of diagnostic and therapeutic laparotomies and improve the treatment results of patients.

- Based on a comparative analysis of the clinical application of open and endoscopic technologies in victims with isolated and combined abdominal trauma, with penetrating stab wounds of the abdomen, it has been established that minimally invasive endoscopic interventions are significantly less traumatic, promote early activation of patients, reduce postoperative complications and mortality, and shorten the duration of hospital stay.

Presentation of the Work

The main provisions and results of the scientific research were reported and discussed at: the International Congress "Endoscopic Surgery" (Moscow, 1995); the Scientific-Practical Conference dedicated to the 10th anniversary of BSMP No. 2 (Rostov-on-Don, 1997); the All-Russian Scientific Conference dedicated to the 130th anniversary of the birth of N.I. Napalkov (Rostov-on-Don, 1998); congresses of the Association of Endoscopic Surgery of the Russian Federation (Moscow, 1998–2006); meetings of the Rostov Regional Scientific Society of Surgeons (Rostov-on-Don, 1996–2006); the Scientific-Practical Conference "Minimally Invasive Technologies in Emergency Surgery" (Rostov-on-Don, 2002); the Plenum of the Board of the Russian Association of Endoscopic Surgery and the Interregional Conference of Surgeons "Mini-Invasive Technologies in Emergency Surgery" (Krasnodar-Anapa, 2002); a meeting of the surgery section of the Coordination Council in the Southern Federal District for postgraduate and additional professional education (Kislovodsk, 2003); the International Surgical Congress "Actual Problems of Modern Surgery" (Moscow, 2003); the Scientific-Practical Conference "Modern Aspects of Surgery" (Rostov-on-Don, 2004); the Regional Scientific-Practical Conference "Implementation of Endoscopic Surgery in the Practice of District Hospitals" (Rostov-on-Don, 2004); the 2nd Scientific-Practical Conference "Actual Problems of Surgery" (Rostov-on-Don, 2004); the 4th Conference of Gastroenterologists of the Southern Federal District (Kislovodsk, 2005); the First Congress of Moscow Surgeons "Emergency and Specialized Surgical Care" (Moscow, 2005); the All-Russian Conference with the participation of CIS countries dedicated to the 60th anniversary of the Victory of Soviet Medicine in the Great Patriotic War of 1941–1945 (Moscow, 2005); the International Surgical Congress "New Technologies in Surgery" (Rostov-on-Don, 2005); the International Surgical Congress "New Technologies in Surgery" (Moscow, 2005).

Publications:

49 printed works have been published on the topic of the dissertation.

Implementation of the Results of the Work into Practice

The main results of the work have been implemented into clinical practice at the departments of surgical diseases No. 1, 2, 4 of Rostov State Medical University, surgical departments of BSMP No. 1 and BSMP No. 2 (Rostov-on-Don), surgical departments of OKB No. 1, 2 (Rostov-on-Don).

Dissertation materials published in print and methodological recommendations are used in reading lectures and conducting practical classes for students and physicians of the advanced training faculty of Rostov State Medical University.

Volume and Structure of the Dissertation

The dissertation is presented on 195 pages of typed text and was prepared on an IBM-compatible computer Pentium-IV-3.0/512/120, and consists of an introduction, an analytical literature review, original research, conclusion, conclusions, practical recommendations, and a bibliography (329 sources, including 268 domestic and 61 foreign authors). The work is illustrated with 26 figures and 50 tables.