Br. J. Surg. 1992, Vol. 79, June, 522-524
R . A. Brown, D. H. Bass, H. Rode, A. J. W. Millar and S. Cywes Department of Paediatric Surgery, lnstitute of Child Health and University of Cape Town, Red Cross Children's Hospital, Cape Town, South Africa Correspondence to: Dr R . A. Brown, Department of
Paediatric Surgery, Institute of Child Health, Red Cross Children's Hospital, 7700 Rondebosch, Cape Town, South Africa
Gastrointestinal tract perf oration in children due to blunt abdominal trauma Over a 14-year period 587 children under 13 years of age were admitted with blunt injury to the abdomen. Twenty-nine ( 4 - 9per cent) of these were found to have bowel rupture. Evidence of peritonitis was present at initial evaluation in 11 children (38 per cent). Radiological evidence of perforation (pneumoperitoneum) was present in only jive of 27 (19 per cent) with a further six of 27 ( 2 2 per cent) showing dilated loops of bowel or fluid levels. Thus 59 per cent of radiographs were not diagnostic. The mean time f r o m admission to laparotomy was 17 h. Proximal bowel perforation was common and perforation at multiple sites occurred in five patients; 59 per cent had a concomitant injury which resulted in two deaths (jirom head injury). Initial clinical and radiological evidence of bowel perforation can be misleading and reliance on such indicators may result in signiJicant diagnostic delay. Frequently repeated clinical examination is advocated; progression of abdominal signs should alert the clinician to proceed to laparotomy.
Blunt abdominal trauma in children causing liver and spleen injury can be successfully managed in most cases without surgery','. However, such trauma may also cause bowel rupture, either in isolation or together with other visceral injuries, and in these cases emergency surgery is indicated. Diagnosis of gastrointestinal tract perforation remains difficult and delay in diagnosis may result in increased morbidity rates. Dickinson et aL3 and Kovacs et aL4 stressed both the lack of special investigations which might help formulate management policy, and the importance of interpretation of abdominal signs by the attending surgeon.
Patients and methods During the period 1977-1990, 587 children with blunt abdominal trauma were admitted to the trauma unit at this hospital. In 197 children no specific injury was found, in 29 (4.9 per cent) there was gastrointestinal tract rupture, and in 361 a further 701 visceral injuries were documented'. In this paper the 29 children with gastrointestinal tract perforation are reviewed with special reference to the pattern of injury, value of radiology and factors which contributed towards diagnostic delay.
Results The mean age of the 29 children was 7 years 3 months (range 9 months to 12 years). The causes of injury are shown in Table 1. O n initial examination none of the patients was in hypovolaemic shock. Abdominal distension was present in 50 per cent, but clinical evidence of peritonitis as shown by generalized guarding with rebound tenderness was present in only 11 patients (38 per cent), and bowel sounds were recorded as normal in four of 26 (15 per cent). Analgesia was withheld if the abdominal examination was equivocal; once a decision to operate had been taken, intravenous morphine sulphate was commenced and continued after operation. Special investigations performed on admission included chest and abdominal radiography in 27 children and serum amylase measurement in 16. The results of these investigations are presented in Table2. Peritoneal lavage was not performed. A pneumoperitoneum was present in five children (19 per cent) although a further six (22 per cent) had radiographic features suggestive of intra-abdominal pathology, such as free fluid or dilated loops of bowel with air-fluid levels. Abdominal computed tomography (CT) was performed in only two cases to rule out
522
solid organ injury. In one of these a ruptured jejunum was identified by leakage of oral contrast; the other scan, despite indicating increased intra-abdominal fluid, showed no features of bowel perforation. The serum amylase level was significantly raised in five children (31 per cent). Associated injuries are listed in Table 3. The mean delay between admission and surgery was 17 (range 2-144) h. The indication for laparotomy was increasing
Table 1 Aetiology of blunt abdominal trauma causing hollow viscus perforation in 29 patients ~
Motor vehicle accident Pedestrian Passenger Assault Fall Struck by object (horse, swing, pillar) Crush
12
3 5 4 3 2
Table 2 Initial intlestiyations before operation Total number
Positive
28 27
4 (14) 5 (19)
16
5 (31)
~
Pyrexia (temperature > 37.5"C) Free air on chest or abdominal radiography Raised serum amylase (more than three times normal level) Values in parentheses are percentages
Table 3 Associated injuries in 17 of 29 patients Head injury Laceration of liver and/or spleen Fractured pelvis Fractured lower limb Pancreatitis Ruptured diaphragm
8 7* 7* 4 4* 2*
*Evidence of local force
E
l 323/92/060522-03
Q 1992 Butterworth-Heinemann
Ltd
Gastrointestinal tract perforation in children: R . A. Brown et al.
Table 4 Site ofgasfrointestinalperforation and operative procedures in 29 patients Site Jejunum Ileum Stomach Duodenum Colon Multiple Surgical procedure Oversewing/simple closure Resection and anastomosis ~~
18 7 5 1
1 5
20 (69) 9 (31)
~
Values in parentheses are percentages
abdominal tenderness, with or without signs of peritonitis. Positive radiological findings provided further indication for laparotomy in 11 patients (41 per cent). Intravenous antibiotics (penicillin, aminoglycoside and metronidazole ) were given at induction of anaesthesia, and continued for a period of 5 days after operation. Intraoperative cephalosporin at a concentration of 2 mg ml-' in normal saline was used to irrigate the peritoneal cavity. The sites of injury and the procedures performed at laparotomy are presented in Table 4. The majority of ruptures occurred in the proximal bowel and were satisfactorily repaired by trimming of ragged borders and closure of the perforation. A further seven children with increasing abdominal tenderness were operated on for suspected peritonitis but were found to have no perforation at laparotomy. In only two of the seven patients was no pathology found; in the remaining five injuries included two retroperitoneal haematomas, two splenic lacerations, and one traumatic pancreatitis. Two patients (7 per cent) died, both from an associated head injury which was complicated in one case by respiratory distress syndrome and disseminated intravascular coagulation. Complications after operation occurred in ten children: intestinal obstruction requiring surgical intervention (three cases) and intra-abdominal infection (two cases) were the local sequelae; other problems included pneumonia, atelectasis and pleural effusion (three cases), transient renal failure (one case) and femoral vein thrombosis related to a fractured pelvis and femoral artery repair (one case). Patients were discharged a mean of 18 days after admission.
Discussion Of 587 children with a history of blunt abdominal trauma 29 (4.9 per cent) sustained a gastrointestinal tract perforation. This incidence was considerably lower than that of other visceral injuries, namely to the liver ( n = 224), spleen ( n = 96), and kidney ( n = 333)'. Management of paediatric trauma victims after resuscitation is initially conservative and surgical exploration is necessary only in a minority - less than 13 per cent in this series'. The increased and incorrect use of restraining car seat belts has been correlated with a greater incidence of bowel injury5, and child abuse must always be considered as a possible cause where the history and presenting features d o not tally. It has been stated that the fixed portions of the bowel (e.g. duodenojejunal flexure and ileocaecal area) are most at risk6, but in the present series this was not the case. The site of the bowel exposed to direct force was where the rupture occurred - in the proximal small bowel in more than two-thirds of cases. This may be due to the relatively thin and often protuberant abdominal wall of the child. Initial clinical examination may be misleading and only 50 per cent of patients were considered to have serious intra-abdominal pathology. Special investigations also do not play a pivotal role in confirming the diagnosis and proved unreliable, especially in the early stages. Abdominal radiographs are reported to show free air in under 50 per cent of
Br. J. Surg., Vol. 79, No. 6, June 1992
cases3.', and did so in only 19 per cent of patients in the present series, although other non-specific features such as dilated loops of bowel or free intraperitoneal fluid were present in a further 22 per cent. A left lateral decubitus view may show free intraperitoneal air' and specific radiological techniques may increase the yield, giving only three of 24 false-negative results in one series*. Abdominal CT with oral contrast medium may be a valuable investigation for excluding hollow viscus rupture. Donohue et aL9 reported 13 of 14 positive diagnoses on CT, but other authors have not matched this diagnostic accuracy, with a range varying from 47 to 65 per cent"*". Laboratory investigations have also proved unreliable in confirming the diagnosis. Significantly raised serum amylase levels occurred in only five (31 per cent) of the 16 patients for whom they were measured; a normal level does not exclude bowel perforation4. Peritoneal lavage has been advocated as a reliable method of confirming intestinal perforation, with an accuracy of over 90 per cent in the blunt trauma victim quoted by McLellan et a1.I'. However, routine peritoneal lavage is not practised at this institution as the presence of intraperitoneal blood per se is not an indication for surgery, its accuracy is not sufficient (especially in the early stages) and subsequent clinical evaluation becomes more difficult. It may be of particular benefit when tenderness cannot be adequately evaluated, e.g. in the unconscious patient. Laparoscopy may also offer advantages for the early diagnosis of bowel rupture. Repeated clinical examination, preferably by the same surgeon at intervals of 2-4 h, provides the most reliable indicator of significant intra-abdominal pathology; progressive deterioration should alert the clinician to underlying bowel perforation. Surgery consists of a full laparotomy and inspection of the total extent of the gastrointestinal tract to exclude the multiple sites of perforation seen in 17 per cent of children in this series. Simple debridement and oversewing is performed if possible, but resection and anastomosis may be necessary for more extensive injuries. Associated injuries are the major cause of morbidity and even death in blunt trauma victimsI3; 59 per cent in the present series had associated injuries. Of significance was the damage done by the force to adjacent sites (fractured pelvis, lacerated liver or spleen and ruptured diaphragm). Two patients died, both with an associated head injury. No deaths were specifically attributable to diagnostic delay - on average 17 h - although a threshold of 12 h has been suggested as significant to decrease the rate of complications6. Intestinal rupture secondary to blunt abdominal trauma is less common in children than in adults". Routine special investigations d o not offer the 'fast route' to early diagnosis of gastrointestinal tract perforation. Rather, repeated clinical evaluation of the abdomen, preferably by the same surgeon, remains the most reliable way of reaching an early diagnosis.
References 1.
2.
3. 4. 5. 6. 7.
8.
Cywes S, Bass DH, Rode H , Millar AJW. Blunt abdominal trauma in children. Pediatr Surg Ini 1990; 5 : 350-4. Oldham KT, Guice KS, Ryckman F, Kaufman RA, Martin LW, Noseworthy J . Blunt liver injury in childhood: evolution of therapy and current perspective. Surgery 1986; 100: 542-9. Dickinson SJ, Shaw A, Santulli TV. Rupture of the gastrointestinal tract in children by blunt trauma. Surg Gynrrol Obstet 1970; 131: 655-7. Kovacs G Z , Davies MRQ, Saunders W, Fonseca J, Gose C. Hollow viscus rupture due to blunt trauma. Surg Gynecol Ohsret 1986; 163: 552-4. Winton TL, Girotti MJ, Manley PN, Sterns EE. Delayed intestinal perforation after non-penetrating abdominal trauma. Can J Surg 1985; 28: 437-9. Evans JP. Traumatic rupture of the ileum. Br J Surg 1973; 60: 119-21. Roh JJ, Thompson JS, Harned RK, Hodgson PE. Value of pneumoperitoneum in the diagnosis of visceral perforation. Am J Surg 1983; 146: 830-3. Zahran M, Eklof 0, Thomasson B. Blunt abdominal trauma
523
Gastrointestinal tract perforation in children: R . A. Brown e t al.
9. 10.
11.
and hollow viscus injury in children: the diagnostic value of plain radiography. Pedrutr Rudiol 1984; 14: 304-9. Donohue JH, Federle M P , Grifiths BG, Trunkey DD. Computed tomography in the diagnosis of blunt intestinal and mesenteric injuries. J Trauma 1987; 27: 11-17. Fischer RP, Miller-Crotchett P, Reed RL. Gastrointestinal disruption: the hazard of non-operative management in adults with blunt abdominal injury. J Truumu 1988; 28: 1445-9. Bulas DI, Taylor GA, Eichelberger MR. The value of CT in
12. 13.
detecting bowel perforation in children after blunt abdominal trauma. Am J Radio/ 1989; 153: 561-4. McLellan BA, Hanna SS, Montoya DR et a/. Analysis of peritoneal lavage parameters in blunt abdominal trauma. J Trauma 1985; 25: 393-9. Robbs JV, Moore SW, Pillay SP. Blunt abdominal trauma with jejunal injury: a review. J Trauma 1980; 20: 308-1 I .
Paper accepted 4 December 1991
S urgicaI workshop Br. J. Surg. 1992, Vol. 79, June, 524
Use of a suprapubic catheter for laparoscopic cholangiography E. C. Coveney and J. P. O'Sullivan Department of Surgery, Wexford General Hospital, Wexford, Ireland Correspondence to: Mr E. C . Coveney
The advent of laparoscopic cholecystectomy has presented the surgeon with new technical challenges. Although this operation is now well established, the role of laparoscopic cholangiography is still not clearly defined. Opinion is divided as to whether cholangiography should be performed routinely or reserved selectively for patients with clinical or biochemical evidence of common bile duct stones'-4. While peroperative visualization is superior to standard cholecystectomy, the high incidence of bile duct anomalies and inadequate dissection of the common duct ensures that the potential for bile duct injury remains. Cholangiography minimizes this risk by clarifying any uncertainties regarding anatomy and indicating whether iatrogenic injury has occurred. Unsuspected common bile duct stones occur in up to 10 per cent of standard cholecystectomies. Routine cholangiography would identify these cases, allowing stone removal after operation via endoscopic sphincterotomy or abandonment of the procedure in favour ofopen exploration. Various methods of laparoscopic cholangiography have been d e ~ c r i b e d ~which - ~ involve the use of catheters introduced and manipulated into the cystic duct using grasping forceps, or the use of custom-made and expensive cholangiocatheters.
Surgical technique In an effort to overcome protracted, difficult and sometimes futile attempts to cannulate the opened cystic duct using forceps-held catheters, this unit has begun to use a suprapubic catheter (Bonnano; Becton-Dickinson, Rutherford, New Jersey, USA) during cholangiography for cystic duct cannulation. The catheter ( I 8 Fr trocar, 14 Fr cannula) is introduced under direct camera vision by a separate puncture in the right hypochondrium. The trocar is > 2 0 c m long, making the cystic duct easily accessible from virtually any position in
524
Figure 1
Catheter measures 20 cm and curves on removal of trocar
a patient of any size (Figure I ). The catheter tip curves naturally as the trocar is removed, facilitating positioning in the duct. The tip of the catheter is manipulated under camera vision, using the trocar from outside the abdomen, to the opening fashioned in the cystic duct. The trocar is gently retracted as the tip is advanced into the cystic duct ( a distance of 3 cm to include all lateral drainage holes). With the cannula in position, the trocar holds the catheter rigidly in position intra-abdominally until it can be safely fixed within the duct by ligature clips. The trocar can then be removed and operative cholangiography performed through the catheter. This technique is safe, simple and uses inexpensive and readily available equipment. It may shorten the procedure of peroperative cholangiography during laparoscopic cholecystectomy by obviating the need for manipulation of catheters using grasping forceps.
References 1.
2. 3. 4.
5. 6.
Berci G , Sackier J M , Paz-Partlow M. Routine or selected cholangiography during laparoscopic cholecystectomy ? Am J Surg 1991; 161: 355-60. McEntee G , Grace PA, Boucher-Hayes D . Laparoscopic cholecystectomy and the common bile duct. Br J Surg 1991; 78: 385-6. Sackier JM, Berci G , Phillips E, Carroll B, Shapiro S, Paz-Partlow M. The role of cholangiography in laparoscopic cholecystectomy. Arch Sury 1991; 126: 1021-5. Bagnato VJ, McGee GE, Hatten LE, Varner JE, Culpepper JP. Justification for routine cholangiography during laparoscopic cholecystectomy. Surg Lapurosc Endosr 1991 ; 1: 89-93. Nathanson LK, Shimi S, Cuschieri A. Laparoscopic cholecystectomy: the Dundee technique. Br J Surg 1991; 78: 155-9. Schirmer BD, Edge SB, Dix J e fa / . Laparoscopic cholecystectomy. Treatment of choice for symptomatic cholelithiasis. Ann Surg 1991; 123: 665-16.
Paper accepted 10 January 1992
0007-1 323/92/060524-01
('
1992 Butterworth-Hememann
itd
R . A. Brown, D. H. Bass, H. Rode, A. J. W. Millar and S. Cywes Department of Paediatric Surgery, lnstitute of Child Health and University of Cape Town, Red Cross Children's Hospital, Cape Town, South Africa Correspondence to: Dr R . A. Brown, Department of
Paediatric Surgery, Institute of Child Health, Red Cross Children's Hospital, 7700 Rondebosch, Cape Town, South Africa
Gastrointestinal tract perf oration in children due to blunt abdominal trauma Over a 14-year period 587 children under 13 years of age were admitted with blunt injury to the abdomen. Twenty-nine ( 4 - 9per cent) of these were found to have bowel rupture. Evidence of peritonitis was present at initial evaluation in 11 children (38 per cent). Radiological evidence of perforation (pneumoperitoneum) was present in only jive of 27 (19 per cent) with a further six of 27 ( 2 2 per cent) showing dilated loops of bowel or fluid levels. Thus 59 per cent of radiographs were not diagnostic. The mean time f r o m admission to laparotomy was 17 h. Proximal bowel perforation was common and perforation at multiple sites occurred in five patients; 59 per cent had a concomitant injury which resulted in two deaths (jirom head injury). Initial clinical and radiological evidence of bowel perforation can be misleading and reliance on such indicators may result in signiJicant diagnostic delay. Frequently repeated clinical examination is advocated; progression of abdominal signs should alert the clinician to proceed to laparotomy.
Blunt abdominal trauma in children causing liver and spleen injury can be successfully managed in most cases without surgery','. However, such trauma may also cause bowel rupture, either in isolation or together with other visceral injuries, and in these cases emergency surgery is indicated. Diagnosis of gastrointestinal tract perforation remains difficult and delay in diagnosis may result in increased morbidity rates. Dickinson et aL3 and Kovacs et aL4 stressed both the lack of special investigations which might help formulate management policy, and the importance of interpretation of abdominal signs by the attending surgeon.
Patients and methods During the period 1977-1990, 587 children with blunt abdominal trauma were admitted to the trauma unit at this hospital. In 197 children no specific injury was found, in 29 (4.9 per cent) there was gastrointestinal tract rupture, and in 361 a further 701 visceral injuries were documented'. In this paper the 29 children with gastrointestinal tract perforation are reviewed with special reference to the pattern of injury, value of radiology and factors which contributed towards diagnostic delay.
Results The mean age of the 29 children was 7 years 3 months (range 9 months to 12 years). The causes of injury are shown in Table 1. O n initial examination none of the patients was in hypovolaemic shock. Abdominal distension was present in 50 per cent, but clinical evidence of peritonitis as shown by generalized guarding with rebound tenderness was present in only 11 patients (38 per cent), and bowel sounds were recorded as normal in four of 26 (15 per cent). Analgesia was withheld if the abdominal examination was equivocal; once a decision to operate had been taken, intravenous morphine sulphate was commenced and continued after operation. Special investigations performed on admission included chest and abdominal radiography in 27 children and serum amylase measurement in 16. The results of these investigations are presented in Table2. Peritoneal lavage was not performed. A pneumoperitoneum was present in five children (19 per cent) although a further six (22 per cent) had radiographic features suggestive of intra-abdominal pathology, such as free fluid or dilated loops of bowel with air-fluid levels. Abdominal computed tomography (CT) was performed in only two cases to rule out
522
solid organ injury. In one of these a ruptured jejunum was identified by leakage of oral contrast; the other scan, despite indicating increased intra-abdominal fluid, showed no features of bowel perforation. The serum amylase level was significantly raised in five children (31 per cent). Associated injuries are listed in Table 3. The mean delay between admission and surgery was 17 (range 2-144) h. The indication for laparotomy was increasing
Table 1 Aetiology of blunt abdominal trauma causing hollow viscus perforation in 29 patients ~
Motor vehicle accident Pedestrian Passenger Assault Fall Struck by object (horse, swing, pillar) Crush
12
3 5 4 3 2
Table 2 Initial intlestiyations before operation Total number
Positive
28 27
4 (14) 5 (19)
16
5 (31)
~
Pyrexia (temperature > 37.5"C) Free air on chest or abdominal radiography Raised serum amylase (more than three times normal level) Values in parentheses are percentages
Table 3 Associated injuries in 17 of 29 patients Head injury Laceration of liver and/or spleen Fractured pelvis Fractured lower limb Pancreatitis Ruptured diaphragm
8 7* 7* 4 4* 2*
*Evidence of local force
E
l 323/92/060522-03
Q 1992 Butterworth-Heinemann
Ltd
Gastrointestinal tract perforation in children: R . A. Brown et al.
Table 4 Site ofgasfrointestinalperforation and operative procedures in 29 patients Site Jejunum Ileum Stomach Duodenum Colon Multiple Surgical procedure Oversewing/simple closure Resection and anastomosis ~~
18 7 5 1
1 5
20 (69) 9 (31)
~
Values in parentheses are percentages
abdominal tenderness, with or without signs of peritonitis. Positive radiological findings provided further indication for laparotomy in 11 patients (41 per cent). Intravenous antibiotics (penicillin, aminoglycoside and metronidazole ) were given at induction of anaesthesia, and continued for a period of 5 days after operation. Intraoperative cephalosporin at a concentration of 2 mg ml-' in normal saline was used to irrigate the peritoneal cavity. The sites of injury and the procedures performed at laparotomy are presented in Table 4. The majority of ruptures occurred in the proximal bowel and were satisfactorily repaired by trimming of ragged borders and closure of the perforation. A further seven children with increasing abdominal tenderness were operated on for suspected peritonitis but were found to have no perforation at laparotomy. In only two of the seven patients was no pathology found; in the remaining five injuries included two retroperitoneal haematomas, two splenic lacerations, and one traumatic pancreatitis. Two patients (7 per cent) died, both from an associated head injury which was complicated in one case by respiratory distress syndrome and disseminated intravascular coagulation. Complications after operation occurred in ten children: intestinal obstruction requiring surgical intervention (three cases) and intra-abdominal infection (two cases) were the local sequelae; other problems included pneumonia, atelectasis and pleural effusion (three cases), transient renal failure (one case) and femoral vein thrombosis related to a fractured pelvis and femoral artery repair (one case). Patients were discharged a mean of 18 days after admission.
Discussion Of 587 children with a history of blunt abdominal trauma 29 (4.9 per cent) sustained a gastrointestinal tract perforation. This incidence was considerably lower than that of other visceral injuries, namely to the liver ( n = 224), spleen ( n = 96), and kidney ( n = 333)'. Management of paediatric trauma victims after resuscitation is initially conservative and surgical exploration is necessary only in a minority - less than 13 per cent in this series'. The increased and incorrect use of restraining car seat belts has been correlated with a greater incidence of bowel injury5, and child abuse must always be considered as a possible cause where the history and presenting features d o not tally. It has been stated that the fixed portions of the bowel (e.g. duodenojejunal flexure and ileocaecal area) are most at risk6, but in the present series this was not the case. The site of the bowel exposed to direct force was where the rupture occurred - in the proximal small bowel in more than two-thirds of cases. This may be due to the relatively thin and often protuberant abdominal wall of the child. Initial clinical examination may be misleading and only 50 per cent of patients were considered to have serious intra-abdominal pathology. Special investigations also do not play a pivotal role in confirming the diagnosis and proved unreliable, especially in the early stages. Abdominal radiographs are reported to show free air in under 50 per cent of
Br. J. Surg., Vol. 79, No. 6, June 1992
cases3.', and did so in only 19 per cent of patients in the present series, although other non-specific features such as dilated loops of bowel or free intraperitoneal fluid were present in a further 22 per cent. A left lateral decubitus view may show free intraperitoneal air' and specific radiological techniques may increase the yield, giving only three of 24 false-negative results in one series*. Abdominal CT with oral contrast medium may be a valuable investigation for excluding hollow viscus rupture. Donohue et aL9 reported 13 of 14 positive diagnoses on CT, but other authors have not matched this diagnostic accuracy, with a range varying from 47 to 65 per cent"*". Laboratory investigations have also proved unreliable in confirming the diagnosis. Significantly raised serum amylase levels occurred in only five (31 per cent) of the 16 patients for whom they were measured; a normal level does not exclude bowel perforation4. Peritoneal lavage has been advocated as a reliable method of confirming intestinal perforation, with an accuracy of over 90 per cent in the blunt trauma victim quoted by McLellan et a1.I'. However, routine peritoneal lavage is not practised at this institution as the presence of intraperitoneal blood per se is not an indication for surgery, its accuracy is not sufficient (especially in the early stages) and subsequent clinical evaluation becomes more difficult. It may be of particular benefit when tenderness cannot be adequately evaluated, e.g. in the unconscious patient. Laparoscopy may also offer advantages for the early diagnosis of bowel rupture. Repeated clinical examination, preferably by the same surgeon at intervals of 2-4 h, provides the most reliable indicator of significant intra-abdominal pathology; progressive deterioration should alert the clinician to underlying bowel perforation. Surgery consists of a full laparotomy and inspection of the total extent of the gastrointestinal tract to exclude the multiple sites of perforation seen in 17 per cent of children in this series. Simple debridement and oversewing is performed if possible, but resection and anastomosis may be necessary for more extensive injuries. Associated injuries are the major cause of morbidity and even death in blunt trauma victimsI3; 59 per cent in the present series had associated injuries. Of significance was the damage done by the force to adjacent sites (fractured pelvis, lacerated liver or spleen and ruptured diaphragm). Two patients died, both with an associated head injury. No deaths were specifically attributable to diagnostic delay - on average 17 h - although a threshold of 12 h has been suggested as significant to decrease the rate of complications6. Intestinal rupture secondary to blunt abdominal trauma is less common in children than in adults". Routine special investigations d o not offer the 'fast route' to early diagnosis of gastrointestinal tract perforation. Rather, repeated clinical evaluation of the abdomen, preferably by the same surgeon, remains the most reliable way of reaching an early diagnosis.
References 1.
2.
3. 4. 5. 6. 7.
8.
Cywes S, Bass DH, Rode H , Millar AJW. Blunt abdominal trauma in children. Pediatr Surg Ini 1990; 5 : 350-4. Oldham KT, Guice KS, Ryckman F, Kaufman RA, Martin LW, Noseworthy J . Blunt liver injury in childhood: evolution of therapy and current perspective. Surgery 1986; 100: 542-9. Dickinson SJ, Shaw A, Santulli TV. Rupture of the gastrointestinal tract in children by blunt trauma. Surg Gynrrol Obstet 1970; 131: 655-7. Kovacs G Z , Davies MRQ, Saunders W, Fonseca J, Gose C. Hollow viscus rupture due to blunt trauma. Surg Gynecol Ohsret 1986; 163: 552-4. Winton TL, Girotti MJ, Manley PN, Sterns EE. Delayed intestinal perforation after non-penetrating abdominal trauma. Can J Surg 1985; 28: 437-9. Evans JP. Traumatic rupture of the ileum. Br J Surg 1973; 60: 119-21. Roh JJ, Thompson JS, Harned RK, Hodgson PE. Value of pneumoperitoneum in the diagnosis of visceral perforation. Am J Surg 1983; 146: 830-3. Zahran M, Eklof 0, Thomasson B. Blunt abdominal trauma
523
Gastrointestinal tract perforation in children: R . A. Brown e t al.
9. 10.
11.
and hollow viscus injury in children: the diagnostic value of plain radiography. Pedrutr Rudiol 1984; 14: 304-9. Donohue JH, Federle M P , Grifiths BG, Trunkey DD. Computed tomography in the diagnosis of blunt intestinal and mesenteric injuries. J Trauma 1987; 27: 11-17. Fischer RP, Miller-Crotchett P, Reed RL. Gastrointestinal disruption: the hazard of non-operative management in adults with blunt abdominal injury. J Truumu 1988; 28: 1445-9. Bulas DI, Taylor GA, Eichelberger MR. The value of CT in
12. 13.
detecting bowel perforation in children after blunt abdominal trauma. Am J Radio/ 1989; 153: 561-4. McLellan BA, Hanna SS, Montoya DR et a/. Analysis of peritoneal lavage parameters in blunt abdominal trauma. J Trauma 1985; 25: 393-9. Robbs JV, Moore SW, Pillay SP. Blunt abdominal trauma with jejunal injury: a review. J Trauma 1980; 20: 308-1 I .
Paper accepted 4 December 1991
S urgicaI workshop Br. J. Surg. 1992, Vol. 79, June, 524
Use of a suprapubic catheter for laparoscopic cholangiography E. C. Coveney and J. P. O'Sullivan Department of Surgery, Wexford General Hospital, Wexford, Ireland Correspondence to: Mr E. C . Coveney
The advent of laparoscopic cholecystectomy has presented the surgeon with new technical challenges. Although this operation is now well established, the role of laparoscopic cholangiography is still not clearly defined. Opinion is divided as to whether cholangiography should be performed routinely or reserved selectively for patients with clinical or biochemical evidence of common bile duct stones'-4. While peroperative visualization is superior to standard cholecystectomy, the high incidence of bile duct anomalies and inadequate dissection of the common duct ensures that the potential for bile duct injury remains. Cholangiography minimizes this risk by clarifying any uncertainties regarding anatomy and indicating whether iatrogenic injury has occurred. Unsuspected common bile duct stones occur in up to 10 per cent of standard cholecystectomies. Routine cholangiography would identify these cases, allowing stone removal after operation via endoscopic sphincterotomy or abandonment of the procedure in favour ofopen exploration. Various methods of laparoscopic cholangiography have been d e ~ c r i b e d ~which - ~ involve the use of catheters introduced and manipulated into the cystic duct using grasping forceps, or the use of custom-made and expensive cholangiocatheters.
Surgical technique In an effort to overcome protracted, difficult and sometimes futile attempts to cannulate the opened cystic duct using forceps-held catheters, this unit has begun to use a suprapubic catheter (Bonnano; Becton-Dickinson, Rutherford, New Jersey, USA) during cholangiography for cystic duct cannulation. The catheter ( I 8 Fr trocar, 14 Fr cannula) is introduced under direct camera vision by a separate puncture in the right hypochondrium. The trocar is > 2 0 c m long, making the cystic duct easily accessible from virtually any position in
524
Figure 1
Catheter measures 20 cm and curves on removal of trocar
a patient of any size (Figure I ). The catheter tip curves naturally as the trocar is removed, facilitating positioning in the duct. The tip of the catheter is manipulated under camera vision, using the trocar from outside the abdomen, to the opening fashioned in the cystic duct. The trocar is gently retracted as the tip is advanced into the cystic duct ( a distance of 3 cm to include all lateral drainage holes). With the cannula in position, the trocar holds the catheter rigidly in position intra-abdominally until it can be safely fixed within the duct by ligature clips. The trocar can then be removed and operative cholangiography performed through the catheter. This technique is safe, simple and uses inexpensive and readily available equipment. It may shorten the procedure of peroperative cholangiography during laparoscopic cholecystectomy by obviating the need for manipulation of catheters using grasping forceps.
References 1.
2. 3. 4.
5. 6.
Berci G , Sackier J M , Paz-Partlow M. Routine or selected cholangiography during laparoscopic cholecystectomy ? Am J Surg 1991; 161: 355-60. McEntee G , Grace PA, Boucher-Hayes D . Laparoscopic cholecystectomy and the common bile duct. Br J Surg 1991; 78: 385-6. Sackier JM, Berci G , Phillips E, Carroll B, Shapiro S, Paz-Partlow M. The role of cholangiography in laparoscopic cholecystectomy. Arch Sury 1991; 126: 1021-5. Bagnato VJ, McGee GE, Hatten LE, Varner JE, Culpepper JP. Justification for routine cholangiography during laparoscopic cholecystectomy. Surg Lapurosc Endosr 1991 ; 1: 89-93. Nathanson LK, Shimi S, Cuschieri A. Laparoscopic cholecystectomy: the Dundee technique. Br J Surg 1991; 78: 155-9. Schirmer BD, Edge SB, Dix J e fa / . Laparoscopic cholecystectomy. Treatment of choice for symptomatic cholelithiasis. Ann Surg 1991; 123: 665-16.
Paper accepted 10 January 1992
0007-1 323/92/060524-01
('
1992 Butterworth-Hememann
itd
