Delayed celiotomy or laparoscopy as part of the nonoperative management of blunt hepatic trauma

Abstract

Background: Nonoperative management (NOM) is considered standard treatment for 80% of blunt hepatic trauma (BHT). NOM is associated with some events that may require delayed operation (DO), usually considered a criterion of failure of NOM.

Methods: A retrospective case note review was performed on 257 consecutive patients with BHT, with a median age of 32.7 years, admitted from 1994 to 2005. We considered the 186 patients (72%) who had an initial indication of NOM, and focused on the 28 patients who were secondarily operated (DO), mainly on the 22 patients operated on for liver-related indications. Celioscopy was used in five cases.

Results: The severity grade of these 22 patients was: zero grade I, seven grade II, ten grade III, four grade IV, one grade V. The timing of DO varied from day 0 to day 11. Ten patients were operated on for a peritoneal inflammatory syndrome. Death occurred in three patients at days 2, 10, and 125. One was attributed to underestimation of hepatic necrosis, another to a nondiagnosed peritoneal inflammatory syndrome; 27, 3% of the patients had liver-related complications.

Conclusions: Our data suggest that BHT treated by NOM must be frequently reevaluated and that DO is an actual part of the so-called nonoperative treatment. The use of laparoscopic washing has to be proposed as soon as day 3 or 5 in patients with large hemoperitoneum and any sign of inflammatory response (fever, leukocytosis, discomfort, tachycardia).