A 26-yrs-old woman sustains a tangential gunshot

Discussion in 'MRCS Forum' started by Lona., Oct 26, 2007.

  1. Lona.

    Lona. Guest

    A 26-yrs-old woman sustains a tangential gunshot wound to the lower abdomen. She is awake and normotensive. She has rebound tenderness on physical examination. Which approach is contraindicated?
    a- Perform a diagnostic laparoscopy
    b- Perform a laparoscopy
    c- Type and cross-match four units of PRBCs
    d- Perform a rectal examination
    e- Place a Foley catheter
  2. Lona.

    Lona. Guest

    Answer: a- Perform a diagnostic laparoscopy. (Berci, Am J Surg 161:332-335, 1991) The indications for diagnostic laparoscopic exploration are increasing rapidly as the tools and techniques for such intervention improve. In the stable trauma patient with a tangential gunshot wound or with a stab wound to the lower chest wall or abdomen, laparoscopy may show no actual peritoneal penetration and might make a laparotomy unnecessary. If the peritoneum or diaphragm is injured, subsequent laparotomy and exploration are generally indicated to exclude other possible injuries and to facilitate repair of the diaphragm. All unstable patients or those with signs of peritoneal irritation (e.g. rebound tenderness) should undergo prompt celiotomy. Laparoscopic staging of malignancies allows improved preoperative assessment of the respectability of intraabdominal malignancies. The procedure has proved particularly useful in cases of pancreatic carcinoma. Laparoscopic evaluations may expedite differentiation of competing etiologies of right lower quadrant pain; this would allow appendectomy for pelvic inflammatory disease and preempt celiotomy. In critically ill patients, the development of low flow or embolic ischemic insults to the bowel can be fatal if not recognized and treated early. Many such patients are already being ventilated in intensive care units; in this setting, bedside laparoscopy can ascertain the need for early exploration for bowel revascularization or resection.

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