African Journal of Paediatric Surgery

CASE REPORT
Year
: 2014  |  Volume : 11  |  Issue : 2  |  Page : 189--190

Paediatric penetrating thoraco-abdominal injury: Role of minimallly invasive surgery


Jack Donati-Bourne, Mohammad I. Bader, Dakshesh Parikh, Ingo Jester 
 Department of Paediatric Surgery, Birmingham Children's Hospital NHS Foundation Trust, Birmingham, United Kingdom

Correspondence Address:
Ingo Jester
Department of Paediatric Surgery, Birmingham Children«SQ»s Hospital NHS Foundation Trust, Birmingham
United Kingdom

Abstract

We report two cases of penetrating thoraco-abdominal injuries who presented to our trauma centre. One with stab to lower left chest and the other one had pallet injury to right upper abdomen. The clinical presentation, radiological investigations and operative intervention are reviewed.



How to cite this article:
Donati-Bourne J, Bader MI, Parikh D, Jester I. Paediatric penetrating thoraco-abdominal injury: Role of minimallly invasive surgery.Afr J Paediatr Surg 2014;11:189-190


How to cite this URL:
Donati-Bourne J, Bader MI, Parikh D, Jester I. Paediatric penetrating thoraco-abdominal injury: Role of minimallly invasive surgery. Afr J Paediatr Surg [serial online] 2014 [cited 2020 Oct 29 ];11:189-190
Available from: https://www.afrjpaedsurg.org/text.asp?2014/11/2/189/132835


Full Text

 Introduction



The conventional surgical management for penetrating wounds to the trunk, for much of the 20 th century, was deemed to be routine exploratory laparotomy. Surgical management of penetrating trauma has recently been challenged by the sophisticated radiological imaging, minimally invasive techniques and adult experiences. We present two such cases managed with minimally invasive surgery.

 Case Reports



The present case is about a 15-year-old patient who presented with a left lower lateral chest wall stab injury. Clinically, he had tender abdomen. A computed tomography (CT) scan showed localized air at the penetration site but no pneumothorax. Initial diagnostic laparoscopy revealed the tract via pleural cavity through diaphragm into the stomach. Laparoscopically, both the diaphragm and stomach injuries were repaired [Figure 1], [Figure 2] and [Figure 3]. No drains were kept post-operatively. He was discharged after being monitored for evidence of infection and development of pneumothorax.{Figure 1}{Figure 2}{Figure 3}

An 8-year-old child was shot just below the angle of scapula. Initial X-ray revealed the pellet was situated near the cardiophrenic angle very close to heart. A CT scan localise the pellet on the lateral aspect next to the right lobe of liver and within the peritoneal cavity. Therefore, instead of thoracoscopy, laparoscopy was performed but no injury was found. On table X-ray confirmed the pallet to be above the diaphragm which was retrieved through a small diaphragmatic incision. The diaphragm was repaired with no drains. She recovered well and discharged with no complications.

 Discussion



Penetrating trauma accounts for up to 20% of all paediatric trauma admissions. [1] It is often difficult to evaluate the extent of intraabdominal injuries even with sophisticated radiological investigations. Exploratory laparotomy is considered as a gold standard, but it is associated with significant morbidity and mortality. [2] Minimally invasive approach is a safe option is hemodynamically stable patients. [3],[4] Laparoscopy was first used for trauma in 1956. [3] It is viable alternative in patients following penetrating thoraco-abdominal trauma where the nature of intraabdominal injuries is unclear. In our first case, a large tract could be found on laparoscopy through diaphragm into the stomach. In addition to its diagnostic advantage it also offers the therapeutic benefit of repair of the injuries identified. [3],[4] It is very useful for early diagnosis of hollow viscus injury and occult diaphragmatic injuries. This decreases the morbidity due to late diagnosis in these cases. [4],[5]

Gunshot wound can be very misleading for external body surface. Laparoscopy can identify any peritoneal breach. Sometimes, it is not possible to locate the path of trajectory but an on table radiography is useful adjuvant in those cases in locating pallets.

The major drawback to laparoscopy is the possibility of missing injuries to the solid organs, small bowel, mesentery, ureters and bladder. One report suggests that diagnostic laparoscopy can miss significant injuries in up to 19% of the patients. [6],[7]

 Conclusion



Minimal invasive surgery can play a significant role in the management of penetrating injuries in children. On table imaging can be useful adjuvant for localising foreign body that might have migrated. Negative laparoscopy can avoid an unnecessary exploratory laparotomy. Conversely a positive finding may allow either a therapeutic intervention or direct appropriate open surgery.

References

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