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© Springer-Verlag New York Inc. 1997
Cost analysis of diagnostic laparoscopy vs laparotomy in the evaluation of penetrating abdominal trauma
J. M. Marks,1 D. F. Youngelman,2 T. Berk1
Department of Surgery, The Mount Sinai Medical Center, School of Medicine, Case Western Reserve University, One Mount Sinai Drive, Cleveland, OH 44106, USA 2 Department of Surgery, Harry S. Truman Memorial Veterans Hospital, 800 Hospital Drive, University of Missouri-Columbia, Columbia, MO 65201, USA Received: 11 March 1996/Accepted: 5 July 1996
Abstract Background: Diagnostic laparoscopy for the evaluation of injuries in patients with penetrating abdominal trauma has been shown to decrease the morbidity and mortality associated with mandatory laparotomy. The overall impact on patient care and hospital costs has not been thoroughly investigated. The goal of this study was to determine the economic impact of laparoscopy as a diagnostic tool in the management of patients following penetrating trauma to the abdomen or flank. Methods: Retrospective chart review of all hemodynamically stable patients with penetrating trauma to the abdomen or flank, but without other injuries requiring emergent intervention, admitted to a level I trauma center between January 1, 1992, and September 30, 1994. Those patients who underwent either laparoscopy (DL) or laparotomy (NL) or both (CONV) and who had no intraabdominal organ injuries requiring surgical therapeutic intervention were included in the study. Age, operative time, operative findings, length of hospitalization, Injury Severity Score (ISS), variable costs, and total costs were recorded for each patient. Results: Fourteen patients underwent negative/nontherapeutic laparoscopy (DL), 19 patients underwent negative/nontherapeutic laparotomy (NL), and four patients underwent both laparoscopy and laparotomy, a conversion procedure (CONV). There was no significant difference in age, operative times, or ISS between the DL and NL groups. Mean ISS of CONV patients was significantly greater than that of DL patients, 5.75 ± 1.97 vs 2.43 ± 0.63 (p < 0.05). Mean operative time for CONV patients was also significantly greater than both DL and NL patients, 106.5 ± 17.00 min vs 66.1 ± 6.55 and 47.3 ± 7.50 min, respectively (p < 0.05). The mean length of stay was significantly shorter in
the DL group as compared to the NL or CONV groups, 1.43 ± 0.20 vs 4.26 ± 0.31 and 5.0 ± 0.82 (p < 0.0001). The variable costs for the DL group were significantly lower than those incurred by patients in the NL and CONV groups, $2,917 ± 175 vs $3,384 ± 102 and $3,774 ± 286, (p < 0.05). Variable costs were not significantly different between the NL and CONV groups. Total costs were also significantly lower in the DL group when compared to NL and CONV, $5,427 ± 394 vs $7,026 ± 251 and $7,855 ± 750 (p < 0.005), but again, they were not statistically different between the NL and CONV groups. The overall total costs for laparoscopy, including the costs incurred by conversion patients, was significantly less than the total costs for laparotomy patients, $5,664 ± 394 vs $7,028.47 ± 250 (p < 0.005). This resulted in an overall savings of $1,059.44 per laparoscopy performed. The overall negative/nontherapeutic laparotomy rate during this study was 19.1%, which was significantly lower than the negative or nontherapeutic exploration rate during the time period prior to the use of laparoscopy (p < 0.01, z 2.550). Conclusion: Variable and total costs and length of stay were significantly lower in our population of patients who underwent DL as compared to NL. The rate of negative or nontherapeutic laparotomy was also significantly reduced when compared to the rate identified during the era prior to the use of laparoscopy. Laparoscopy resulted in an overall savings of $1,059 per laparoscopy performed when compared to laparotomy. Key words: Laparoscopy — Penetrating abdominal trauma — Cost effectiveness
Correspondence to: J. M. Marks Presented at the 5th World Congress of Endoscopic Surgery of the Society of American Gastrointestinal Endoscopic Surgeons (SAGES) Scientific Session, Philadelphia, Pennsylvania, USA, 15 March 1996
The use of diagnostic laparoscopy for the evaluation of penetrating abdominal trauma is gaining increasing acceptance. The high rates of negative and nontherapeutic laparotomy and their inherent complications are added incentive
Negative laparoscopy or laparotomy was defined as an exploration without evidence of peritoneal penetration or intraabdominal organ injury. Materials and methods The charts were reviewed of all patients admitted (to the Mt. Charlton. which included a chief surgical resident and the surgical attending on call. 4. Marlow. Ninety-five percent of patients with gunshot wounds underwent laparotomy (77/81). Three of these patients were converted to laparotomy. a Foley catheter and orogastric or nasogastric tube were placed in each patient. One patient had a colon injury identified during laparoscopic evaluation. Overall.7% of gunshot victims (3/81). and September 30. z 2. All procedures were performed in the operating room under general anesthesia and all patients consented to possible conversion to laparotomy. All exploratory laparotomies were performed in standard fashion through a midline inci- sion under general anesthesia. STAB 48. Ohio. Cleveland. which confirmed the negative findings at laparoscopy. 11. All costs were adjusted for inflation to 1994 rates. Patients admitted with penetrating trauma to the abdomen or flank between January 1. prior to the use of laparoscopy. 14 patients underwent DL following a penetrating trauma to the abdomen or flank without an .1% (13/37) 19. which was significantly lower than the negative or nontherapeutic exploration rate during the time period prior to the use of laparoscopy (p < 0.01. and this was repaired primarily following conversion to formal laparotomy.8% (12/81) 48. positive diagnostic peritoneal lavage or positive wound exploration.10.01. An umbilical nondisposable trocar (Stortz. 7]. 7. NY. Nondisposable.8%. 1994 Gunshot/shotgun victims (n 81) Exploratory laparotomy Negative/nontherapeutic Therapeutic Diagnostic laparoscopy Negative/nontherapeutic Therapeutic Conversion (laparoscopy/laparotomy) Negative/nontherapeutic Therapeutic 8 69 3 0 1 0 Stab wound victims (n 50) 11 24 11 1 2 1 a Table 2. Hemodynamically stable patients (SBP > 90 mmHg. Results Between January 1.6% (20/47) 33. Additional 5-mm ports were placed under direct vision as necessary for manipulation of the bowel. Willoughby. 10-mm laparoscope was used initially in all patients. A 0°. Nontherapeutic laparoscopy or laparotomy was defined as an exploration identifying peritoneal penetration and/or intraabdominal organ injury which did not demand surgical therapeutic intervention. Melville. 1991.1%. 8. Four patients with gunshot wounds were evaluated by DL (Table 3).550) for the increasing use of this modality. MA) was placed by the Hasson technique and the abdomen was insufflated with CO2 to a pressure of 15 mmHg. Variable and total costs were determined for each patient by the hospital billing office. This retrospective study was undertaken to compare the costs incurred and the overall economic impact of laparoscopy as a diagnostic tool in the management of patients with penetrating trauma to the abdomen and flank. 1992.2% (20/71) 42. or z-test analysis. 17].2% of these patients (1/81). and CONV on 1. Sinai Medical Center. OH) were used routinely to decrease the risk of bowel injury and to lower the variable costs incurred by laparoscopy. noncrushing bowel clamps (Olympus. Statistical analysis was done by Students’ paired t-test. 1994. 24% underwent DL (12/50).5% (GSW 14. These patients were all evaluated by the trauma team.0%). 1989 and December 31. There were 81 patients with gunshot wounds and 50 patients with stab wounds (Table 1). 131 patients were admitted to the trauma service with penetrating injuries to the flank or abdomen.550) (Table 2). A 30° laparoscope was used as needed for evaluation of the diaphragm and upper abdominal organs. The combined negative or nontherapeutic laparotomy/laparoscopy rate was 27. 15. The overall economic impact of laparoscopy was calculated by averaging the additional expense incurred by the conversion group to the DL group (overall laparoscopy costs DL costs + [CONV costs − NL costs] / of DL + CONV patients). and 6% had CONV (3/50). Length of hospital stay has also been proven to be significantly shorter following laparoscopic evaluation as compared to formal laparotomy [4. and September 30. The second patient had equivocal findings at DL and the third had definitive evidence of peritoneal penetration without an identifiable intraabdominal injury.5% (9/78) 35. 1992. HR < 110) were candidates for diagnostic laparoscopy if they had (1) stab wounds to the abdomen or flank with presumptive peritoneal penetration based on omental evisceration. 17]. Included in this study were all patients who underwent diagnostic nontherapeutic laparoscopy (DL) or negative or nontherapeutic laparotomy (NL).9% (40/118) Group II 1992–1994 (laparotomy only) 11. Laparoscopy was not considered in patients who required other emergent procedures such as exploration for peripheral vascular injury or those who were not hemodynamically stable. Fifteen patients underwent diagnostic laparoscopy following stab wounds to the flank or abdomen. which was comparable to the negative or nontherapeutic laparotomy rate of 33. All four were negative and one was converted to laparotomy. All quadrants were carefully inspected and the small bowel and colon were examined completely. Conversion patients (CONV) were those patients who underwent both laparoscopy and laparotomy. as determined by z-test) for a similar time period between March 1. 1992. 1994. Both of these last two patients underwent open laparotomy which confirmed the laparoscopic findings. Seventy percent of patients with stab wounds underwent laparotomy (35/50). and September 30. DL was performed on 3. Laparoscopy has been shown to be useful in excluding or confirming peritoneal penetration and therefore in preventing unnecessary laparotomy [2–5. One patient underwent a therapeutic laparoscopy with repair of a diaphragmatic defect. Morbidity and mortality rates have also been shown to be significantly lower in patients undergoing laparoscopy as compared to celiotomy [2.1%a (22/115) Group III 1992–1994 (laparoscopy or laparotomy) 14. or (2) tangential gunshot wounds without obvious peritoneal penetration. The overall negative/nontherapeutic laparotomy rate was 19.273 Table 1.5% (36/131) Group I vs group II (p < 0. z 2.9% (p > 0.0% (24/50) 27. a level I trauma center) with penetrating trauma to the abdomen or flank between January 1. Comparison of the negative/nontherapeutic exploration rates for patients with penetrating trauma to the abdomen or flank Group I 1989–1991 (laparotomy only) Gunshot/shotgun victims Stab wound victims Total 28. After induction of general anesthesia.
5 ± 17. and over 70% were discharged by the 1 postoperative day. Mean operative time for CONV patients was also significantly greater than both DL and NL patients. Patients could be safely evaluated and discharged home without admission to the hospital.005). The variable costs for the DL group were significantly lower than those incurred by patients in the NL and CONV groups. Four patients. and September 30. The total costs calculated in this study. There were 11 patients with stab wounds and three patients with tangential gunshot wounds. The overall total costs for laparoscopy. hospitalization or increased costs. None of the stab wound victims had evidence of peritonitis. Variable costs reflect the number and nature of procedures undergone by each patient and include the cost of supplies and labor specific to each patient’s care. Salvino et al. 94. The use of the operating room affords the surgeon greater flexibility. $5. intraoperative. Alternatives to DL in the evaluation and management of hemodynamically stable patients with penetrating abdominal trauma include observation with selective laparotomy or mandatory laparotomy.1 ± 6.00 min vs 66.05). to perform DL in the operating room setting.855 ± 750 (p < 0.05). In the ongoing evaluation of the use of DL in trauma patients. 1992. Seventy-three percent (10/14) of patients undergoing DL were discharged within 1 day of surgery. Postoperative expenditures in the NL group. most protocols require taking the patient to the operating room.31 days and 5.26 ± 0. were almost three times greater than those incurred by patients in the laparoscopy group. We had no morbidity related to the laparoscopic procedures and demonstrated a significantly decreased length of stay.63 (p < 0.97 vs 2. best represent the cost as perceived by a third-party payer.059.917 ± 175 vs $3.47 ± 250 (p < 0.20 days. have shown the safety and efficacy of emergency department laparoscopic evaluation . The one patient with a shotgun wound underwent a laparotomy following a CT scan which revealed a single intraabdominal pellet. and it is our recommendation. 8. Nine of 11 patients with stab wounds had preoperative evidence of peritoneal penetration with either an omental evisceration or a positive wound exploration.427 ± 394 vs $7.274 Table 3.00 ± 0. There was no significant difference in age. Nine of 11 patients with stab wounds had either an omental evisceration or positive wound exploration. One patient required hospitalization for 3 days because of an associated chest injury.026 ± 251 and $7. This pellet was located in the omentum and no therapeutic intervention was necessary. Total costs were also significantly lower in the DL group when compared to NL and CONV. This resulted in an overall savings of $1. There were no intraoperative or postoperative complications that prolonged. Pa- . 15. It has been our practice.005).774 ± 286. 16]. Several patients were discharged home immediately following DL without further observation.05). although not necessarily using general anesthesia [2. including the physicians’ fees. 3. $5. The physicians’ fees for each patient were added to both the variable and total costs.0001).50 min. The mean length of stay was significantly shorter in the DL group as compared to the NL and CONV groups. 106. Comparison of preoperative and intraoperative findings in laparotomy and laparoscopy patients Laparotomy Number of patients (n) Gunshot/shotgun Stab wound Preoperative indications Positive wound exploration Positive DPL Positive CT scan Evisceration Suspicion Intraoperative findings: No peritoneal violation Peritoneal violation without intraabdominal organ injury Intraabdominal organ injury not requiring intervention Intraabdominal organ injury requiring intervention 19 8 11 7 0 1 2 9 8 5 6 0 Laparoscopya 18 4 14 13 0 0 1 4 13 4 0 1 a Includes conversion patients undergoing both laparoscopy and laparotomy identifiable intraabdominal injury requiring therapeutic intervention or conversion to laparotomy between January 1.43 ± 0. including the costs incurred by conversion patients. there were no missed injuries in the three groups. the greatest proportion of costs in both the DL and NL groups was intraoperative. A detailed analysis comparing the average costs incurred by laparoscopy and laparotomy is provided in Table 5.44 per laparoscopy performed (Table 6). and one patient with a shotgun wound in the NL group. 1. but again were not statistically different between the NL and CONV groups. both in the analysis of variable and of total costs.7% of NL patients (18/19) remained hospitalized for 3 days or more. 13]. 2. respectively (p < 0.028. Discussion The goal of our review was to assess the overall economic impact of diagnostic laparoscopy in the management of stable patients with penetrating abdominal trauma. reflecting the increased cost of prolonged hospitalization. 11. operative times. described previously. 1994 (Table 3).75 ± 1.664 ± 394 vs $7. however. The three patients with gunshot wounds were without signs of peritonitis prior to DL and no intraabdominal injuries were discovered during laparoscopic evaluation. This would support the use of DL in the emergency department with local anesethesia and intravenous sedation [1.82 days. Three of the gunshot wound patients had signs of peritoneal irritation preoperatively. Variable costs were not significantly different between the NL and CONV groups. and postoperative expenditures. $2. were significantly less than the total costs for laparotomy patients. underwent both laparoscopy and laparotomy and are included in the CONV group. vs 4. Mean ISS of CONV patients was significantly greater than DL patients. There were 11 patients with stab wounds. 5. In comparison.384 ± 102 and $3.55 and 47. (p < 0. 5.43 ± 0. None of these patients had intraabdominal injuries identified at DL. seven patients with gunshot wounds. Also. Nineteen patients who underwent negative or nontherapeutic laparotomy (NL) were identified during the same time period (Table 3).3 ± 7. When the costs were divided into preoperative. respectively (p < 0. or ISS between the DL and NL groups (Table 4).
275 Table 4.50c 2919 ± 175e 5427 ± 394f p < 0. or local wound exploration in the evaluation of patients with penetrating abdominal trauma . reported a decrease in their nontherapeutic laparotomy rate from 11% to 8. Lastly. Laparoscopy proved to be not only safe. but it helped avoid an unnecessary laparotomy and the increased costs incurred by an extended hospitalization. There is no dispute regarding the efficacy and safety of DL in selected trauma patients.75 ± 1.43 ± 0. In addition.05 vs conversion p < 0. This would not only lower the variable costs incurred by each patient but also lower the relative proportion of intraoperative costs associated with diagnostic or therapeutic laparoscopy.9% to 19. with the use of laparoscopy. preferentially in an operating room setting. . visualization has been limited by a lack of brightness and a smaller field of vision. Both of these outcomes should significantly decrease the cost of caring for these patients. These procedures should all be carried out. hospitals can reduce the costs of treating patients without affecting the standards of patient care. by experienced laparoscopic surgeons. 1994 Negative or nontherapeutic laparoscopy Patients (n) Gunshot/shotgun victims (n) Stab wound victims (n) Mean age (years) Injury Severity Score Length of stay (days) Operative time (minutes) Variable costs (dollars) Total costs (dollars) a b Negative or nontherapeutic laparotomy Laparoscopy and laparotomy (conversion) 4 1 3 of mean) 38.00 3774 ± 286 7855 ± 750 14 3 11 19 8 11 (Calculation of means ± standard error 31. and September 30. the costs incurred by this procedure are commonly the next issue to be carefully evaluated.0 ± 0. we were able to significantly reduce our negative or nonthera- peutic laparotomy rate from 33.21 ± 0. or supervised.01 vs conversion d p < 0.5 ± 2. In addition.82 106. Once it has been determined that a given procedure is safe and effective.1 ± 6. Comparison of patients having undergone negative or nontherapeutic laparoscopy and/or laparotomy between January 1.41 2.059 savings per laparoscopy performed. With the currently available 5-mm or 4-mm laparoscopes. In our series.26 ± 0. and there should be no hesitation to convert to an open procedure if the patient becomes unstable or if complete laparoscopic evaluation is not possible. Also.001 vs laparotomy and conversion tients may be easily repositioned and rotated on a standard operating room table to facilitate the complete evaluation of the abdomen. In conclusion. 2].65 5. The use of disposable instrumentation increases a hospital’s variable costs.1%.0001 vs laparotomy and conversion c p < 0. all patients should consent to exploratory laparotomy.66 4.5 ± 17. The overall economic impact of laparoscopy resulted in a $1. This study has demonstrated how decreased length of stay following DL leads to decreased total hospital costs. With newer technology and improvement in optics. computed tomography. It is vital that patients undergo a complete laparoscopic evaluation of the entire abdomen. The surgeon will be able to proceed directly to a laparotomy or to proceed with therapeutic laparoscopy.43 ± 0.23 3.5% since initiating DL rather than diagnostic peritoneal lavage. By eliminating the use of many disposable laparoscopic instruments. time will not be wasted transporting them to a different area of the hospital. by avoiding an unnecessary laparotomy and the increased costs incurred by this procedure. The ready availability of both 0° and 30° laparoscopes is also valuable. however.3 ± 7. Carey et al. they were able to decrease the morbidity rate to 3% and the mean hospital stay to 1. Some of the reported studies in emergency department laparoscopy have also documented the use of smallersize laparoscopes [1.05 vs laparotomy and conversion f p < 0.5 ± 6. 10.2 ± 2. Diagnostic laparoscopy is a cost-effective procedure for the evaluation of hemodynamically stable patients.97 5.31 66. in those patients who will require conversion to laparotomy due to inadequate laparoscopic evaluation or because of the need for therapeutic intervention.4 days.1 days . 1992. Investigators at the University of Miami found that their 12. In addition. The ability to decrease or even eliminate negative or nontherapeutic laparotomy could impact the overall morbidity and mortality of the trauma population [6. and we suspect that these costs will further decrease as the variable costs associated with laparoscopy decrease. these procedures should be carried out by experienced laparoscopic surgeons who have familiarity with advanced laparoscopic techniques. hospital costs and length of stay were significantly lower in our population of patients when comparing negative or nontherapeutic laparoscopy with laparotomy in the evaluation of penetrating abdominal trauma. there were no missed injuries or complications.55d 3384 ± 102 7026 ± 251 30.4% negative laparotomy rate following mandatory laparotomy was associated with a 22% morbidity rate in these patients and a mean hospital stay of 5. 12]. By using diagnostic laparoscopy in a similar group of patients. where a surgeon’s resources are greatest. laparoscopy can provide further cost savings. the use of these smaller scopes may become more commonplace.05 vs conversion e p < 0.63a 1. The use of gasless laparoscopy and conventional instruments has also been shown to be safe and cost effective .20b 47.
Croce MA. Minard G. Simon RJ.80 118.67 950. Henderson VJ.80 780.73 27.00 333.00 21. Sims D.53 15. Rush BF (1992) The role of laparoscopy in abdominal trauma.42 13.026. Sanders G. Pianim N. Detailed analysis of average costs incurred by laparoscopy and laparotomy Laparoscopy Variable Daily room and care IV therapy Emergency services Blood bank Chemistry lab Histology lab Hematology lab Electrocardiology lab Pharmacy Recovery room Operating room Central supply Respiratory care Anesthesia Microbiology lab Radiology Surgeon’s fee Anesthesiologist’s fee Total $244. J Trauma 34: 506–515 Smith RS. Esposito TJ. Marks JM (1995) Laparoscopic examination of the bowel in trauma patients.13 112.67 246.33 143. 14.92 94. Martin L (1995) Negative laparotomy in abdominal gunshot wounds: potential impact of laparoscopy.67 24. Morgenstern L (1983) Emergency minilaparoscopy in abdominal trauma. Stewart RM.17 66. Klein SR (1994) Triage by laparoscopy in patients with penetrating abdominal trauma. 11.00 18. Bongard F (1993) Medical economic consequences of gang-related shootings. Hirvela ER. Stahl WM (1993) A critical evaluation of laparoscopy in penetrating abdominal trauma.427.50 110. Koo R. Fry WR. Fry WR. Fernando HC.25 634. Carey JE.53 394. Michel SL. 15.37 ± 102 7. Brams DM.07 13.25 51.384.00 Variable $843.384.53 54.028. 16. Klein S. Surg Gynecol Obstet 148: 23–26 Ponsky JL.919. Sheldon GF (1979) Morbidity of a negative finding at laparotomy in abdominal trauma.60 92.00 Total $843.005 Acknowledgment. Arch Surg 127: 109–110 Sosa JL.93 900.75 28.93 323. Baker M. We wish to thank Leslie Brown and Jane Dostal for their excellent assistance in the preparation of this manuscript.07 c p < 0. Organ CH Jr.07 51.00 76.276 Table 5. Laparotomy 7. Aszodi A.57 ± 394c overall DL costs (DL costs + [CONV costs-NL costs])/DL + CONV patients (n) b p 0.07 1. Surg Laparosc Endosc 5: 415–418 Petersen SR.83 1.33 36.73 16.67 6. Morabito DJ.27 2. 3.42 142.42 5.20 900. Davis I.58 1. Baringer DC.53 7.00 46.00 308. Am Surg 61: 92–95 4. Sims D. Ramey R. Comparison of overall costs incurred by laparoscopy during the study period vs the costs of negative or nontherapeutic laparotomy Laparoscopya Variable costs (dollars) Total costs (dollars) a 6.77 $5. Ann Surg 217: 557–565 5. Martin L.47 $3.08 950. Ginzburg E. Am J Surg 161: 332–335 3. Br J Surg 81: 384–385 Henderson VJ. Ponsly JL (1995) Laparoscopic repair of a diaphragmatic laceration. 13. 12. (1995) Therapeutic laparoscopy in trauma. Berci G. 9. Wahlstrom E.80 435.47 ± 251 8.67 26.33 120. Organ CH Jr. Stein M (1995) Laparoscopy and thoracoscopy in evaluation of abdominal trauma.77 $2. Morabito DJ. J Trauma 33: 471–475 Marks Jm. J Trauma 38: 194–197 .83 124.17 2.00 40. Dunkelman D.33 171. Peunte I. Kudsk KA (1993) A prospective analysis of diagnostic laparoscopy in trauma. Machiedo GW.122. Leighton T.07 59.47 $7.00 13. Chen J. Gastrointest Endosc 143(2): 146–148 Ryan M. 17.67 9. References 1. Peskin GW (1993) Gasless laparoscopy and conventional instruments. Am Surg 59: 365–370 Ivatury RR.67 57. Marshall WJ. Sackier JM. Koehler RH. Tsoi EKM.713.028.00 308.42 0. 10. Pritchard FE.07 4. Koehler RH. Alle KM. Berci G.00 Table 6. Fabian TC. Am J Surg 146: 261–265 2.50 253.33 869. Paz-Parlow M (1991) Emergency laparoscopy. Smith RS (1993) Negative trauma celiotomy.60 57. Blackwood J.00 Laparotomy Total $2.93 713. Gamelli RL (1993) The role of diagnostic laparoscopy in the management of trauma patients: a preliminary assessment. Am J Surg 170: 632–636 Sosa JL.00 333.43 ± 174b 5.08 0. 3. Tortella BJ. Zeppa R (1992) Laparoscopic evaluation of tangential abdominal gunshot wounds.40 6. Sleeman D. Dries DJ.33 435.13 296.07 255. Morris RC.664. Miller R. Arch Surg 128: 1102–1107 Smith RS. Am Surg 59: 831– 833 Salvino CK.13 174. J Trauma 34: 822–828 Livingston DH.25 3.47 150.
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