Sorting out the Problem of a Needle in a Haystack – Using Technology Curtail Delays

Dear Editor, While a good surgeon knows when to operate, a great surgeon would know when not to operate. However, this balancing act between negative laparotomy and missed abdominal injury is more challenging for a trauma surgeon as many cases of isolated mesenteric injury following blunt trauma may remain subclinical at presentation.[1] I am writing this letter to share about a case of blunt trauma abdomen (BTA) following a fall from stairs. The patient presented after 1 day with only complaint of mild pain abdomen. Clinically, he had normal blood pressure with tachycardia and mild tenderness in the right lumbar region which was relieved with analgesics. Contrast-enhanced computed tomography scan of the abdomen revealed hemoperitoneum with mesenteric hematoma and no solid organ injury. Blood investigations including hemogram, liver, and kidney function tests were normal. To avoid operative delay, exploratory laparotomy is often immediately performed for the least suspicion of intestinal and mesenteric injury. However, it has been observed that for all hemodynamically stable patients, the rate of nontherapeutic laparotomy is as high as 44% and up to 31% for suspected bowel and mesenteric injuries, respectively.[2] Having said that, even less severe posttraumatic mesenteric injury is a potentially life-threatening condition that may progressively compromise the blood supply to the bowel and produce gangrene while patients may continue to have normal bowel function for a period ranging from 2 weeks to 3 months resulting in delayed presentation.[3] Because of tachycardia and resolving but persistent localized guarding in the right lumbar region, we decided to perform diagnostic laparoscopy in this patient. Intraoperatively, there was minimal hemoperitoneum with no intraperitoneal fecal contamination. The small intestine was adhered to the anterior abdominal wall with inter-bowel adhesions and omentum covering the perforated site [Figure 1]. As adhesiolysis was carried out, a segment of gangrenous bowel of length 20 cm containing the perforation with mesenteric hematoma was identified. This gangrenous segment was delivered outside through a small vertical infraumbilical incision and resected [Figure 2]. An extracorporeal side-to-side ileo-ileal anastomosis was done using a stapler. The patient was allowed to have oral intake on postoperative day (POD) 3 and was discharged on POD 4 with no subsequent postoperative complications.Figure 1: Laparoscopic view of small bowel adhered to the anterior abdominal wall with perforation, indicated by a black arrowFigure 2: Specimen showing resected segment of small bowel with gangrenous changesEmergency laparoscopy (EL) in BTA is a quick, effective, reasonable and minimally invasive diagnostic and treatment option.[4] It offers direct intraperitoneal visualization, low risk of contamination, reduced intraoperative blood loss, less postoperative pain, early recovery, reduced wound-related complications, better cosmetic results and opportunity for conversion to open approach, if necessary. In this patient, bowel perforation and gangrene were a complication of mesenteric hematoma, which itself is a rare occurrence in blunt abdominal trauma.[5] By sharing this experience, I would like to underscore the role of EL in BTA in solving a difficult preoperative dilemma. In hemodynamically stable patients with absent or less obvious clinicoradiological findings, it can be a screening tool to diagnose or rule out an intra-abdominal catastrophe. However, in a polytrauma case with suspected intracranial injury or acute respiratory distress syndrome, one should use it cautiously due to the associated risk of increasing the intracranial pressure or further compromising the lung compliance in respective conditions. To conclude, performing EL in hemodynamically stable BTA cases perfectly aligns with the idea of Primum nonnocere and allows one to achieve more by doing less. Financial support and sponsorship Nil. Conflicts of interest There are no conflicts of interest.