腹部外傷に対する腹腔鏡下手術

Diagnostic and therapeutic laparoscopy for abdominal trauma

　要旨：外傷に対する腹腔鏡の導入については，いまだに議論が多い．循環動態の安定した症例が適応となる．欧州内視鏡外科学会のガイドラインは外傷に対する腹腔鏡検査の有用性は認めながらも，さらなるデータが必要との見解である．気腹が頭蓋内圧を亢進させ，気胸を増幅するので注意が必要である．鋭的外傷における腹腔鏡検査はunnecessary laparotomyを減少させるとの報告が多いが，刺傷においてはルーチンの検査としては推奨できないとの指摘もある．鈍的外傷では限局した消化管損傷の修復に腹腔鏡下手術は有用と報告され，小児例でも安全に行えるとされる．しかし，見逃し例も報告されており，疑わしい症例においては，躊躇することなく開腹術へ変更することが重要である．

　The role of laparoscopy in diagnosis and treatment of abdominal injuries is still controversial. Laparoscopy for abdominal trauma is adopted, if patients are stable hemodynamically. According to the evidence-based guidelines of the European Association for Endoscopic Surgery, diagnostic laparoscopy may be useful if no diagnosis can be found by conventional diagnostics, and more clinical data are needed on the use of laparoscopy after blunt or penetrating trauma of the abdomen. Since pneumoperitoneum during laparoscopy has been known to result in a rise in intracranial pressure and exacerbation in pneumothorax, surgeons need attention on the use of pneumoperitoneum in the head and thorax injured patients. Much has been written about the efficacy of diagnostic laparoscopy for penetrating abdominal trauma. However, a prospective randomized study stated that diagnostic laparoscopy cannot be recommended as a routine diagnostic tool in anterolateral abdominal and thoracoabdominal stab wounds. Several reports have described that laparoscopic primary or assisted repair of isolated injured bowel is an appropriate surgical option, and diagnostic and therapeutic laparoscopy in pediatric trauma is a safe method. However, the conversion to the open laparotomy should not be hesitated in the complicated cases, because high rates of missed injuries were reported in the acute settings of abdominal trauma.