El rol de la cirugía mínimament invasiva y el manejo conservador en las heridas penetrantes de abdomen, saber cuándo menos es más
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2019
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Las heridas penetrantes en abdomen antes de 1960 eran manejadas con laparotomía independientemente de la clínica del paciente. Utilizando estos criterios, un 50% de las heridas por arma blanca y 20% de las heridas por arma de fuego a nivel del abdomen no presentaban hallazgos que requirieran de una intervención quirúrgica a la hora de realizar la laparotomía. Posteriormente grandes cirujanos como Shaftan, Biffl, Moore, Leppaniemi, Navsaria, Demetriades, Innaba, Velmahos entre otros, describieron métodos diagnósticos para poder identificar cuales pacientes realmente requerían de una intervención quirúrgica. El paso inicial para poder desarrollar un manejo conservador es definir cuales pacientes no son candidatos a este tipo de terapéutica, en este caso se debe conocer que el paciente inestable, con datos de peritonismo, eviscerado, empalado o con limitación para un examen físico apropiado, no son candidatos a un manejo conservador y deben ser sometidos a un procedimiento quirúrgico inmediato. Una vez descartadas las condiciones anteriores, es posible utilizar las herramientas diagnósticas complementarias. El uso del lavado peritoneal diagnostico, el ultrasonido, la tomografía, la exploración local de la herida y el examen físico seriado permitieron una disminución importante en el número de laparotomías no terapéuticas, logrando una disminución en la morbilidad y la mortalidad de los pacientes, la estancia hospitalaria y los costos. A pesar de tener la disponibilidad de estos estudios diagnósticos, se ha comprobado que el examen físico seriado es el que tiene mayor sensibilidad y especificidad a la hora de tomar la decisión sobre cuales pacientes deben de ser sometidos a una intervención quirúrgica. La laparoscopía, la cual ha demostrado ser una excelente alternativa y en muchos casos el “gold standard” de la cirugía electiva; recientemente se ha utilizado en pacientes víctimas de traumas abdominales penetrantes. La...
Inglés: Before 1960’s, all abdominal penetrating wounds were managed with laparotomy, without considering the patient’s status. Using this criteria, 50% of stab wounds and 20% of gun shot wounds had non therapeutic laparotomies. Later on, surgeons like Shaftan, Biffl, Moore, Leppaniemi, Navsaria, Demetriades, Innaba, Valmahos, described diagnostic methods that allowed the identification of which patients really required a surgical intervention. The first step for developing a conservatory management is defining with patients are not candidates for this type of therapy. Surgeons should identify unstable patients, evisceration, peritonism, impalement or limitation in the physical exam due to altered mental status; and these patients should be taken to the operating room immediately. Once the surgeon excludes the after mentioned status, he could use the complementary diagnostic tools. The diagnostic peritoneal lavage, ultrasound, computed tomography, local wound exploration and serial physical exams have allowed a lower percentage of non therapeutic laparotomies a lower incidence of morbidity, mortality, hospital length of stay and costs. Serial physical exam is the diagnostic method that has proven to be the one with higher sensibility and specificity for detecting intraabdominal pathology that requires a surgical intervention. Laparoscopy has demonstrated to be an excellent alternative and in most cases a “gold standard” for most of the elective abdominal surgeries Recently laparoscopy has been utilized for patients with abdominal penetrating wounds and has demonstrated a decrease in morbidity and hospital stay. Surgeons fear that conservatory and minimally invasive surgeries could increase the number of missed injuries. Recent studies in high trauma volume centers have not been able to demonstrate an increase in morbidity due to delayed laparotomies in patient which were initially treated with...
Inglés: Before 1960’s, all abdominal penetrating wounds were managed with laparotomy, without considering the patient’s status. Using this criteria, 50% of stab wounds and 20% of gun shot wounds had non therapeutic laparotomies. Later on, surgeons like Shaftan, Biffl, Moore, Leppaniemi, Navsaria, Demetriades, Innaba, Valmahos, described diagnostic methods that allowed the identification of which patients really required a surgical intervention. The first step for developing a conservatory management is defining with patients are not candidates for this type of therapy. Surgeons should identify unstable patients, evisceration, peritonism, impalement or limitation in the physical exam due to altered mental status; and these patients should be taken to the operating room immediately. Once the surgeon excludes the after mentioned status, he could use the complementary diagnostic tools. The diagnostic peritoneal lavage, ultrasound, computed tomography, local wound exploration and serial physical exams have allowed a lower percentage of non therapeutic laparotomies a lower incidence of morbidity, mortality, hospital length of stay and costs. Serial physical exam is the diagnostic method that has proven to be the one with higher sensibility and specificity for detecting intraabdominal pathology that requires a surgical intervention. Laparoscopy has demonstrated to be an excellent alternative and in most cases a “gold standard” for most of the elective abdominal surgeries Recently laparoscopy has been utilized for patients with abdominal penetrating wounds and has demonstrated a decrease in morbidity and hospital stay. Surgeons fear that conservatory and minimally invasive surgeries could increase the number of missed injuries. Recent studies in high trauma volume centers have not been able to demonstrate an increase in morbidity due to delayed laparotomies in patient which were initially treated with...
Descripción
Tesis (especialista en cirugía general)--Universidad de Costa Rica. Sistema de Estudios de Posgrado. Programa de Estudios de Posgrado, 2019
Palabras clave
ABDOMEN - CIRUGIA, CIRUGIA - TECNICAS, HERIDAS PENETRANTES