الفهرس 
1- IntroductionOnly 14 pages are availabe for public view
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Abstract
Abdominal trauma affects 10% to 15% of injured patients. Although significant intra-abdominal injury is relatively infrequent, the consequences of missed or delayed diagnosis can be significant. Therefore, accurate and timely diagnosis of injuries is essential. The initial history and physical examination are of paramount importance information regarding the mechanism of injury and state of the patient before arriving in the emergency department.
Mechanisms of injuries may be penetrating or blunt. The most common cause of mortality in abdominal trauma is secondary to delayed resuscitation or excessive hemorrhage with inadequate volume resuscitation or Intra-abdominal organ injury and rupture or perforation precipitates gastrointestinal content spillage into the peritoneal cavity, frequently leading to peritonitis and delayed mortality from severe sepsis.
Despite the high prevalence of patients with abdominal trauma. Physical examination not be accurate because patients may have altered mental status or distracting injuries. Diagnostic peritoneal lavage was introduced as a diagnostic modality to identify hemoperitoneum but it is invasive method and its role has been almost entirely eliminated because there has been increased reliance on abdominal computed tomography. Focused Assessment with Sonography in trauma and has also been added to the diagnostic algorithm for patients with abdominal trauma.
In hemodynamically stable victims of blunt trauma, Computed Tomography (CT) with intravenous contrast has become the gold standard for the diagnostic evaluation of the abdomen, with greater than 95% specificity for detecting injury to the solid organs (liver, spleen, and kidney). Injury to the intestine, pancreas, mesentery, and diaphragm are more difficult to diagnose with CT. Even in the current era of multidetector scanners, up to 21% of patients with bowel or mesenteric injuries may initially have negative studies. In hemodynamically unstable victims, diagnostic laparoscopy has proven to be a useful modality in these situations.
The burden of major trauma, predominantly blunt in nature, continues to rise in the most of the countries. More often the young are affected with lifelong debilitating consequences. Minimally invasive technique, such as laparoscope procedures, have become standard for the treatment of many surgical conditions, being able to minimize the impact of the surgery, to reduce postoperative pain, time to recover and to improve cosmetic outcomes.
In laparoscopic the relative morbidity and mortality, complication rates, and missed injury rates are low and comparable with open approaches. Additionally, a wide variety of intra-abdominal pathology can be addressed laparoscopically including injuries to the bowel, diaphragm, liver, spleen, and pancreas.
The recent guidelines developed by the Eastern Association for the Surgery of Trauma Practice Management Guidelines Committee recommend selective non-operative management in penetrating abdominal trauma and that routine laparotomy is not indicated in hemodynamically stable patients with abdominal stab wounds without signs of peritonitis or diffuse abdominal pain and in patients suffering tangential gunshot wounds without peritonitis.
Our study was randomized prospective study. It include 30 patients with abdominal trauma of any type whether blunt or penetrating, RTA or falling from height, stab or gunshot. In order to study the sensitivity and specificity in diagnosis and evaluation of abdominal trauma by the use of ultrasonography, CT and abdominal laparoscopy and comparing accuracy of diagnosis of them with the final diagnosis.
Our study was randomized prospective study. It include 30 patients with mean age was (30.2±10.08) years old and mean BMI was (26.36±3.12). 96.7% of them were males and 3.3% of them were females. The mean systolic blood pressure (108.33±15.11) mmHg, mean diastolic blood pressure (69±9.23) mmHg, mean heart rate (101.87±18.87) beats/minute and mean hemoglobin was (9.34±1.39) g/dl. These patients were exposed to abdominal trauma 33.3% of them were RTA, 43.3% were gunshot, 20% were stab wound and 3.3% were explosion.
The intraoperative bleeding occurs in one patient (3.3%). Female patient presented after lower abdominal stab wound (BP 90/50 -HB 8 –HR 120) after resuscitation diagnostic laparoscopy find uncontrolled bleeding from uterine tear. Conversion to laparotomy and control bleeding.
In our study Post-operative complications occur in 9 patients 5 patients (16.6%) post laparotomy and 4 patients (13.3%) post laparoscopy. we notice that patients undergo laparotomy delayed in return to daily activity (2-12 days) and to work (4-28 days) due to time of operation, length of incision and occurrence of complication and depend on age, BMI, power of healing and intraoperative technique.
In our experience, the use of laparoscopy as a diagnostic and therapeutic tool lead to avoidance of an open surgery in more than 66.6% (20/30) of patients. Negative and non-therapeutic laparoscopies were performed in 4 patients and therapeutic laparoscopy was performed in 10 patients: 6 patients hand assisted splenectomy, 3 patients need repair of liver tears, 3 patients need diaphragmatic tear repair, 6 patients need primary repair for bowel and 2 patients need stomach repair. However, conversion to laparotomy was needed in 10 cases more than 30%. Multiple organ injuries (16%), colostomy for descending and sigmoid colonic tears (10%), resection anastomosis for multiple small bowel injuries (3.3%), repair for uterine injuries (3.3%).
The keys to successfully diagnosing and treating significant intra-abdominal injuries laparoscopically include a systemic exploration to avoid missed injuries using appropriate changes in position of the patient, careful planning of port placement.
Minimally invasive surgery has become a useful tool in the management of trauma. Laparoscopy can detect and repair injuries to the hollow viscus and diaphragm and exclude the risks of non-therapeutic laparotomy. Further advantages are reduced morbidity, shortened hospital stay, and lower cost. In the future, there may be exciting advancements for this field of surgery through innovative developments.