Laparoscopy (to detect occult diaphragm injury) versus clinical and radiological follow up to detect diaphragm injury and herniation, in patients with asymptomatic left thoracoabdominal stab wounds : A prospective randomized controlled study

Master Thesis


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University of Cape Town

Background: The need to exclude occult diaphragmatic injury in left thoracoabdominal (TA) stab wounds continues to be controversial. Current trauma guidelines recommend either routine diagnostic thoracoscopy or laparoscopy and repair of an injury if found. Objective: To determine if asymptomatic patients with left sided (TA) stab wounds can be safely treated with careful clinical and chest X-ray follow up to ascertain healing of occult injuries. Methods: A parallel-group, prospective, randomized control study was conducted at the Trauma Centre at the Groote Schuur Hospital from 01 September 2009 through to 01 November 2014. All patients with asymptomatic left TA stab wounds included in the trial were randomized into two groups. Group A underwent diagnostic laparoscopy to exclude a diaphragm injury, and Group B underwent clinical and radiological follow up. Results: Twenty-seven patients were randomized to Group A (n=27) and thirty-one to Group B (n=31). All patients were young males with a median age of 26 years (range from 18 to 48). The incidence of occult diaphragm injury in group A was 29%. Occult injuries found at laparoscopy were all repaired. All patients in group 2 had normal chest X-rays and no symptoms at their last visit. The mean follow up time was 24 months (range of 0 to 58). There was no morbidity nor mortality associated with the conservative management of occult diaphragmatic injuries. The mean hospital stay for the patients in Group A was 5 days (SD 1.3), compared to a mean hospital stay of 2.9 days (SD, 1.5) p < 0.001, in Group B. Conclusions : Clinical and radiological follow up is feasible and appears to be safe in patients with occult diaphragm injuries after left TA stab wounds.