European Course Trauma Care
GENERAL ASSESMENT OF THE MULTIPLY INJURED PATIENT

INTRODUCTION
The success of an integrated approach to care of the multiply injured patients rests on proper, efficacious management of time.
Trauma care in Europe must involve clusters of concerns from moment to moment rather than individual tracks portrayed by difficult-to-follow algorithms used in USA. For Donald D. Trunkey. "establishment of care priorities for a multiply injured patient will result of rapid patient overview, primary survey, secondary survey, and proper utilization of diagnostic and therapeutic techniques to resuscitation": this rational planification is followed in any European trauma room emergency, with some specific difference that will be exposed afterwards.

RAPID OVERVIEW
During the first second after admission of the injured patient in emergency room, a rapid overview is necessary at formation of initial impression: if possible, one single physician (surgeon or anesthesist) is in charge of this overview, and the other preselected medical personnel should stay very quiet: the focus is on the total patient.
Obvious visual includes means of ventilatory and cardiac activity, patient’s color, gross asymmetries, and presence or absence of body’s movement, and so that suggest whether the injured patient is stable, unstable or moribund.
This overview will determine subsequent organization of patient’s management, and will set the tone (vital or not) of the emergency: the examiner can proceed to the primary survey.

PRIMARY SURVEY

The American College of Surgeons has expanded the traditional ABC survey (Airway, Breathing, Circulation) to ABCDE (D= disability indicated by neurological status and E = exposure which refers to complete undress the patient for total evaluation), but this system is naturally used in all European countries.
If possible, primary survey must be performed by the same single individual who initially take care of the patient in emergency room: it requires no more than 2 - 5 minutes.

AIRWAY
Establishment or maintenance of airway patency is in first priority.
Clear phonation after attempting verbal contact with semi-conscious patient by asking aesy question (name, age....) establishes that the airway is patent: the need for additional ventilatory support will depend upon neurological stability, and quality of gas exchange.
On other hand, unconscious patient (or patient with massive maxillofacial trauma) will require ventilatory assistance from the start: because a cervical spine fracture can not be excluded, the neck must be protected during airway placement.
A sweep of surgeon’s finger around the oral cavity gives information about the bony integrity of the upper way, presence of obstructing retrofaringeal hematoma or foreign bodies, and possible avulsion of the tongue.
After 100% oxygenation (ambu-bag or mask) orotracheal intrubation (nasotracheal occasionally) is performed in no more than 60 seconds: in case of impossibility, a cricothiroidotomy must be expeditiously performed by surgeon and a n°5 or 6 cuffed tracheostomy tube will be inserted.

BREATHING
It is the second priority in primary survey following establishment of a secure airway: observation of respiratory rate, recruitment of accessory muscles, presence of flail chest, listening for sucking chest wounds.
Auscultation for detection of bowel sounds in the chest in case of diafragmatic dome rupture. Palpation for tracheal shift with sub cutaneous emphysem, pneumo or emopneumothorax. Sucking wounds of the chest are dressed occlusively, and the thorax is drained of air and blood by thoracostomy tubes: such drains must be inserted expeditiously, before chest X-ray, in case of acute respiratory distress.

CIRCULATION
It is the third priority, with three problems: control of external bleeding, efficiency of the cardiac pump, state of volemia.
External bleeding is generally controlled by paramedical rescues before admission in emergency room, but occasionally significant haemorrhage is observed on arrival: in that case, direct pressure can control bleeding and should be applied to wounds: rolled gauze or bandage are used; tourniquets should not be used except in case of uncontrolled haemorrhage from the stump of a traumatic amputation.
Differentiate a pump failure from volemia problems is usually easy: if diagnosis of clinical shock is sure, empty or collapsed neck veins suggest hypovolemia, but distended neck veins suggest a pump failure. In that phase of primary survey, several absolute emergencies must be recognized and treated.

CARDIAC ARREST
Patient with no palpable pulse or blood pressure is in cardiac arrest: cardiopulmonary resuscitation should be stopped for an interval sufficient to allow palpation of carotid or femoral pulses, then restarted:
thoracotomy in emergency room will provide best chance for survival in this patient in case of failure of usual external resuscitation and will perform four objectives:
- control great vessel and cardiac bleeding
- release cardiac tamponade
- optimize cardiac output
- redistribute the available blood to vital organs by cross - clamping the descending aorta.
However, if blunt trauma to the chest or abdomen is the cause of the cardiac arrest, the chance of salvage by thoracotomy is less than 5%.
Optimal results of emergency thoracotomy are naturally obtained if surgeon opens the chest with appropriate instruments, and if a full scale operating room is anytime held open for use without delay to provide definitive care: theses two conditions must be always combined in surgical emergency department to give best chance of survival to multiply injured patient.
The physician experience in thoracic trauma is another consideration in deciding whether to open the chest of a patient with cardiac arrest: after thoracotomy through the fourth or fifth left intercostal space, the pericardium is opened with preservation of phrenic nerves; first surgeon start cardiac compression with one hand while the other occludes the descending thoracic aorta and assisting surgeon begins treatment of accessible lesion to give to the patient the best chance of survival.

TENSION HEMO/PNEUMOTHORAX
Patient with respiratory distrss tracheal shift, distended neck veins, unilateral thoracic hyperresonance is suspected of tension hemo/pneumothorax.
Subsequent mediastinal shift with superior cava obstruction may lead to cardiac arrest unless immediate treatment: chest exsufflation by angiocatheter in the second intercostal space at the midclavicular line, prior chest X-ray , when patient is in distress with typical suffocating pneumothorax.
Definitive care always consists of insertion of chest tube through the fifth intercostal space at the mid to midaxillary line with X-ray control.
The tube is immediately connected to 20 cm H2O suction and in case of hemothorax, the volume of blood is controledat regular intervals: if blood output is massive (more than 500 ml) and continuous, autotrasfusion with cell-saver is begun.

PERICARDIAL TAMPONADE
Patient who have schock, distended neck veins, cool extremities and no pneumothorax is suspected of pericardial tamponade.
Pericardiocentesis is the first therapy: it consists in subxiphoid insertion of an spinal needle in direction of the left shoulder, with ECG control (inversion of QRS complex when epicardium is contacted) and blood suction: if blood is clotted, the pericardial sac should be opened through a subxiphoid incision or a left anterior thoracotomy; after pericardiotomy, in case of cardiac wounds, cardiorrhaphy is the greatest part of the resuscitation and should be performed earlier as possible in the emergeny room.
The pericardiocentesis needle can be left in place connetted with a tap: in this way the tap can be opened if the clinical sign of cardiac tamponade recur.
In case of cardiac arrest, internal massage is continued, and defibrillation is attempted.

MIOCARDIAL CONTUSION
It often occures after deceleration injuries or thoracic crush; miocardial contusion should set off rythm troubles in the first hours: therefore careful ECG monitoring is essential; Lidocaine is the best therapy in case of arrhytmias.

MIOCARDIAL INFARCTION
It may precede the traumatic event or result of coronary hypoperfusion after injury. The patient’s family interrogation is used in determining the possibility of antecedent cardiac disease.
Treatment of cardiogenic shock is the only way.

AIR EMBOLIZATION
It results of the of the fistulization of air into the pulmonary circulation after parenchymal disruption of the lung; blunt or penetrating chest injuries are common causes of air embolization after pulmonary laceration, diagnosis is performed in emergency behind:
- froth obtained after arterial stick: passage of large volumes of air has occurred and air in the coronary circulation may be one of the major causes of pump failure: early traetment consists of immediate thoracotomy on the side of the wound, and hilar clamping of the lung, but results are disappointing
- sudden cardiovascular collapse after endotracheal intubation: prevention may be possible by avoiding excessive positive pressure ventilation during resuscitation: the use of high frequency jet ventilation mey be value by reducing the severity of air embolism and by decreasing the size of the air leack. Later, diagnosis is suspected if focal neurologic signs occurre with no head injury, then confirmed by fundoscopic exam showing retinal artery air bubbles.

HYPOVOLEMIA AND SHOCK
three levels of ypovolemia determine three degrees of shock:
Mild shock (10 - 20% volume loss) cold skin, feeling of cold and thirsty, tachycardia and sweating are essential signs
Moderate shock (20 to 40% volume loss):maintenance of cerebral and cardiac perfusion is achieved at the expense of other organs: kidney is affected early, and urine output level controlled by urinary catheter is the best method to guide normalisation of the volemia by fluid therapy
Severe shock (more than 40% volume loss) go to deficit of cerebral and cardiac perfusion: afitation that may progress to coma and arrhytmias or miocardic ischemia (ECG) are clinical symptoms.
Access to the circulation should provide diagnostic information, restore volume, and anticipate further losses:
In first, access via and angiocatheter inserted into foream vein: a simple of blood is sent for type, cross-match an d complete blood count and other classical exams (electrolytes, glucose, urea, amylase...). Two large bore venous line are reccomended in every trauma patient.
The choice of fluid should be limited to isotonic solution, such as Ringer’s lactate or acetate, and blood, only in case of absolute necessity: usually, two litres of balanced salt solution are infused immediately: during this first infusion, central venous pressure, urine output, level of consciousness and amelioration of peripheral perfusion give the best indication of the satisfactory resuscitation: maintenance of adequate sistemic blood pressure and urine output are the essential purposes. Decision about eventual blood transfusion is difficult whith respect to HIV, HBV and HCV: in case of severe external hemorrage, autotrasfusion via cell-saver is the best way: in absolute emergency, blood transfusion should be performed if hemoglobina level is less than 7g/dl (9 g/dl in case of antecedent cardiac disease).

DISABILITY
Level of consciousness, and rapid neurological evaluation give the degree of patient’s disability in early assessment. The AVPU method is used in USA:
A = Alert
V = respond to Verbal stimuli
P = respond to Painful stimuli
U = Unresponsive
In France the same consideration are done and noted at the admission of the patient in emergency room: the Glascow’s score (EMV) (3 to 15) is generally used:
E = opening eyes to stimuli (1 - 4)
M = Moving to stimuli (1 - 6)
V = Verbal response (1 - 5)

EXPOSURE
All the patient’s clothing must be removed for complete assessment (use of shears to cut garments is authorized)

SECONDARY SURVEY

It requires 5 to 10 minutes and proceeds literally "from head to toe":
Placement of nasogastric tube and Foley urinary drain accompanies usually this sequence:
Head examination with observation and palpation of the scalp, rcord of pupillari size and ocular abnormalities, inspection of auditory canals and tympanic membrans (blood or cerebrospinal fluid egrees commonly associated with cranial base fracture), detection of ecchymosis in the periorbital soft tissue.
Maxillofacial trauma patients are suspected to have cervical spine injury until proven otherwise by X-ray: the head must be steadied by contention system (sandbags, tape, minerva).
Neck examination (inspection and palpation to search penetrating wounds, subcutaneous crepitances, tracheal deviation, abnormalities in neck vein appearance.
Chest examination is completed: palpation of clavicles and all ribs, auscultation of breath sounds and heart tones, anterior - posterior sternal compression for detection of the site of fractured segment, placement of ECG monitoring.
Abdominal examination is capital to discern whether a surgical condition exists: penetrating wound of abdomen requires absolute surgical exploration; in case of blunt trauma, X-ray, sonography and CT scan are used; a nasogastric tube should be inserted for inspection and evaquation of gastric fluid.
Rectal examination seeks to detect presence of blood, urethral or prostatic lesion, rectal injury, lax sphinter tone, and pelvic fractures.
Insert of Foley urinary catheter, at the only condition there is noblood from the urethral meatus. Extremities inspection and palpation for assessment of circulation, major soft tissue injuries, hematomas, and fractures.
Neurological examination for assessment of hemispheric functions, brain system function, spinal cord motor activity, sensation and reflex.

Resuscitation is well underway after 5 to 10 minutes of primary and secondary survey: patient stability will define the time that can safely be taken for further problem definition

DIAGNOSTIC STUDIES

HISTORY AND CONSULTATION
Rapid history by rescues is always informational: details of difficult extrication, possible spinal injury, cardiac and breath activities in the field, changes during transport, presence of friends or relatives are essential information.
Occasionally, patient himself asks to question prior to decline from severe shock; friends and relatives are asked after second survey: this early consultation in trauma care is an elementary rule to know circumstances of the trauma, and general status of the patient (treatment, way of life, age...).

LABORATORY DETERMINATIONS
Rapid report of blood counts, arterial blood gas, urinanalisys, and status of blood type and cross-match.
Electrolytes, toxics, hepatic enzymes are determined in the same time, but absolute emergency decisions are often taken without results.
Hematocrit and hemoglobina level are the essential exams used to guide resuscitation when schock is present.

ROUTINE EXAMS IN EMERGENCY ROOM

X-rays
X-rays must be ordered selectively in emergency room:
Chest X-ray and cervical spine films are essential before transporting an unstable patient in operatory room or in CT scan.
Abdominal plain films are usefull to detect abnormal air presence in peritoneal cavity, to localize exactly nasogastric tube when disruption of diafragmatic dome is suspected, and to appreciate occasionally course and location of bullets.
Plain films of total spine should be done if spinal cord injury is suspected: all seven cervical vertebrae should be read as free from abnormalities prior to moving a such patient: CT scanning will provide more complete information in case of doubt.
Skull X-rays are usefull to search fractures when head injury is present without focal neurologic deficit: CT scanning is always required when neurological abnormality, or manifest injury of the head are noted at the admission.
Necessity of routine pelvic and long bone X-rays after blunt trauma is an obviousness.
The precise number and sequence of the other X-rays to be obtained should be determined by the secondary survey and the patient’s stability.

ULTRASOUND
Ultrasonography in the initial diagnosis of patients with abdominal trauma is systematic in the majority of the European emergency centres:
The advantages the ultrasounds relative to paracentesis and peritoneal lavage are that it is non invasive, rapid (several minutes), and finally providing a correct view of abdominal anatomy.
The ability to perform the test with moving ultrasonograph in emergency room during the first resuscitation is the greatest advantage relative to CT scan.
Disadvantages of ultrasonography are its mediocre sensitivity for subtle initial injuries or those not resulting in intraperitoneal fluid, when meterorism or emphysema mix up the image, and its dependence on experienced radiologist both for performance and interpretation.
However, sensitivity rate for intraperitoneal fluid approaches 90%. Detection of a splenic rupture or an severe trauma to the liver are possible, but pancreatic injury is usually masked by gastric contents.
Gross retroperitoneal blood collections are early detected after injury of vertebral column or pelvic bones.

PERITONEAL LAVAGE
The use of peritoneal lavage has considerably diminished in European emergency centres where the ultrasonography and Ct scanning are easily available.
The test in 97% accurate in the absence of retroperitoneal hemorrage or bladder’s rupture: it consists of incising on the midline of the abdomen under the umbilicus and inserting a lavage catheter into the peritoneal cavity: a half liter of isotonic salt solution is instilled while the patient’s flanks are gently agitated: then the bottle is set on the floor to siphon out the lavage fluid: the presence of blood, bile or intestinal contents is easily detected by examination and cell count. The best use of lavage is in unstable patient without time for CT scan, after inconclusive ultrasonography.

SPECIAL IMAGING PROCEDURES

COMPUTED TOMOGRAPHY SCANNING
CT scan is very important in the care sequence of multiply injuried patients.
Proximity of the scan from the emergency room is determining: ideally, it should be in the emergency department as near as possible to the trauma room, at the same floor.
Time is an other concern in decision to include a scan in the assessment : combined scanning of head, chest and abdomen requires 30 to 60 minutes under optimal circumstances, and the desire for extensive imaging must not eclipse the clinical impression that operative intervention must be performed without delay.
No scan should be performed until primary and secondary surveys are complete, resuscitation lines and appropriate monitors are in place, and a cleary articulated set of care priorities is defined. Obviously, surveillance of the patient during the scan is very important: in CHLS (Lyon, France), any injured patient undergoing CT scan is accompained by one anesthesiologist (or disponible surgeon) and one nurse specialized on anesthesiology: if the patient’s status is declining during the scan, examination is quickly terminated; senior surgeon and anesthesiologist are always present in the ospital at the start of any scan for trauma: 24 hour availability of two surgeons, one anesthesiologist, and one radiologist authorizes an complete management of any multiply injuried patient.
The diagnostic capabilities of CT scan are remarkable for any body region, but surgeon must be careful of to repair injuries and not images!
-Serious head injury is best diagnosed by scanning: if patient is in hemodynamically stability, combination of high-resolution scanners and the injection ofd intravenous contrast provides assistance in detection of subdural hematomas, epidural hematomas, hemorragic contusion, intracerebral hematomas, subarachnoids hemorrhages, intraventricular hemorrhages, brain swellings and traumatic hydrocephalus.
Extremely speed in evaluation of such lesions is obvious: irreversible neurological damage may occur rapidly in case of epidural hematoma, increasing in severe mortality if treatment is delayed.
- Assessment of maxillofacial trauma by CT scan in conjunction with plan films is necessary in case of orbital disruption, Le Fort fractures, fronto-ethmoidal fractures and facial gunshot wounds.
- CT scan of the neck is useful for evaluation of soft tissue injuries, and pharingeal, laryngeal or tracheal lesions: direct laringoscopy should be performed in case of doubt.
- Assessment of spinal trauma is considerably aided by CT scanning with three dimensional reformation of images which will describe precisely vertebral fractures and eventual spinal cord injuries.
- Chest evaluation by CT scan is used to search mediastinal injuries (in combination with esophageal contrast study), to recognize pneumothorax and hemothorax which might not be evident on initial plain chest X-ray, to detect a diafragmatic rupture; if minor thoracic aortic injury is noted, an aortography is immediately indicated.
- Abdominal CT scan has improved the ability to define problems preoperatively: it is the best complement of emergency utrasonography: non invasive. It shows all the organs including the retroperitoneal structures; however, it takes a longer time than ultrasound to elucidate intra abdominal injuries in the preoperative period: hemodynamical stability of the patient is determining to take decision of abdominal CT scan

The indications for abdominal scanning in traumatized patients are:
# equivocal abdominal examination in a stable patient
# presence of head or spinal cord injury associates with suspicious abdominal trauma
# hematuria
# pelvic fractures with hemorrage necessiting the rulig out of associated abdominal injuries
# presence of associated injuries requiring surgery with general anestesia precluding clinical observation of the abdomen.
The diagnostic power of CT scan is greatest in assessment of splenic, epatic and renal injuries as well as pelvic and retroperitoneal hematomas.
Anytime, duodeno-pancreatic injuries may not be apparent for for first hour until sufficient reaction or blood extravasion has occurred, or traumatic acute pancreatitis has begun: second CT scanning should be performed in such event.
In case of penetrating flank or back wound, CT scanning is useful in demonstrating eventual peritoneal involvement. But laparotomy remains mandatory when diagnosis is doubtful.
- Pelvic and acetabular CT scanning correlated with plains films aids in orthopaedic planning of hip or pelvic bone surgery: contrast intro the bladder and the rectum provides additional simultaneous organ visualization: major pelvic fractures should have abdominal and pelvic CT scan to sequence care of abdominal and extra abdominal injuries properly.

CONTRAST STUDIES
Contrast studies permit assessment of vascular tree, gastrointestinal tract, and urinary tract, and are frequently combined with CT scan Indication for angiography are:
- Severe neck injuries
- chest injuries with mediastinal widening, first rib fracture or deviation of the trachea.
- abdominal injuries with non visualizing kidney at intravenous pyelography
- pelvic fracture with massive hemorrage
- penetrating injuries in proximity to major vessels
- dislocation of the knee
- fracture with abolized pulses.
The best indication for intravenous pyelography (IVP) are:
massive hematuria after blunt trauma
confirmation of the presence of two promptly visualizing kidneys: two film in five minutes provide generally adequate information: non visualizing kidneys require examination by arteriography or angioscan.
Gastrointestinal tract contrast studies are performed with gastrografin: penetrating neck or mediastinal wounds, and severe blunt chest injuries require an esophageal contrast for early diagnosis of devastating esophageal wounds.
Gastroduodenal contrast is used for searching traumatic disruption of left diafragmatic dome with gastric hernia.
Rectal contrast studies are helpful after penetrating rectal trauma, in case of inconclusive sigmoidoscopy.

CYSTOGRAMS AND URETHROGRAMS
The bladder and urethra are visualized by cystogram and urethrogra: any bleeding from the urethral meatus will require assessment by urethrogram prior to Foley catheter insert. Patients with disrupted urethras require cystostimy or cystocath for urinary drainage.
Cystogram is essential in case of severe pelvic fracture with hematuria, or after blunt full - bladder hypogastric trauma.

EXPLORATION LAPAROSCOPY
Emergency laparoscopic examination is controversial: theoric risk would be air embolization in case of large venous injuries.
In practice, laparoscopy should be only performed under general anesthesia in a stable patient with no sospicion of massive internal hemorrage: it could detect wounds of the small bowel or the colon, initial moderate splenic hemorrage, mild injury of the liver, and retroperitoneal hematoma: however, complete treatment of such lesions will require in many cases complementary laparotomy.
On the other hand, in case of doubt, complete laparoscopic overview of the abdominal cavity may avoid useless laparotomy.
The surgeon would remember that the laparoscopic complete exploration of posterior wall of colon or stomach remains very hard to realize in emergency athmosphere.

GENERAL APPROACH TO THE MULTIPLY INJURED PATIENT

PROPHYLAXIS AGAINST INFECTION
Perioperative antibiotics are useful in the management of open fractures, dirty soft tissue wounds, small bowel or colon injuries, and exposures of tendon and joint cartilage. The value of prophylactive anitibiotherapy in chest trauma is controversial.
The treatment is generally given for a total of 48 - 96 hours
Prophylaxis against tetanus must be considered for all open wounds.

ASSIGNMENT OF PRIORITIES
The preservation of life in severe multiple injury requires clear recognition of management priorities: In the first hours after trauma, the goal is not to treat individual injuries as they present, but to determine and manage those that threaten the patient’s life: airway obstrucion, severe external hemorrage, chest injuries causing cardiorespiratory distress, head injuries with severe increase in intracranial pressure, and cervical spine injuries are immediate threas to life and must be treated without delay:
- The airway management takes always the highest priority
- Bleeding from solid intra - abdominal organs or retroperitoneal structures, stable craniocerebral injuriesighest prior, burns, and extensive soft tissue wounds may be threatening life, but their treatment can be delayed for a few minutes if intensive resuscitation is necessary.
- Any patients would have complication or loss of function if diagnosis or treatmentis delayed more than a few hours: peripheral vascular tendon and nerves injuries, eye injuries, and partial amputations of limbs are some examples.
- Closed fractures, dislocation and small soft tissue wounds are the only for which treatment can be delayed for several hours.
A team approach is appropriate in the multiply injured patient and may include simultaneous treatment of an epicranial hematoma by neurosurgeon, while general surgeon performs splenectomy. In the patient with severe abdominal injuries and non extensive mediastinal injury, exploration of the abdomen with repair of injuries is indicated first: angiography after laparotomy is obviously necessary.
If the patient has severe abdominal trauma associated to major vascular injuries in the extremities, there must be controlled prior to, or, at least, simultaneously with abdominal exploration; if the patient remains unstable during resuscitation, exploration laparotomy should be carried out before definitive treatment of the peripheral vascular injuries.
Anyway, multiply injured patient is not dismantable!

SURGICAL PREPARATION AND EXPOSURE
The trauma patient must be prepared and drapled widely so that the surgeon can get access to any body cavity and can properly place drains and chest tubes. The entiere torse should be prepared with antiseptic paint and draped so that the surgeon can work in a sterile field from the neck to the legs. In absolute emergency, immediate laparotomy or thoracotomy should be performed without skin preparation.
For rapid access and complete exposure of the abdomen, the midline incision is the best: only rarely transverse or oblique incision will be appropriate in trauma emergency: laparotomy could be extended up to the strenum or into the right or left chest if necessary. Laparoscopy or mini - laparotomy (upper, around or just above the ombilicus) can be performed when presence of abdominal lesion is questionable: the incision should be extended if intra - abdominal injury is encountred.
Generally, supine position of the patient is preferred for any injured patient, excepted if lesion are precisely know prior to start surgery and could be treated in specific position (posterolateral thoracotomy for exampleto control of severe bleeding wound of the lung). After neurosurgical, thoracic, and abdominal injuries have been treated, maxillofacial and orthopaedic trauma are treated, in that order, and during the initial anesthetic if possible, but exceptions to this general priorization many naturally occur.

CONCLUSION
Assessment of the multiply injured patient begins with a rapid overview consisting in a short moment of complete visual inspection: this will reveal whether the patient is stable or not, and will set the order of the resuscitation. Primary survey follows with the goal of basic physiological support: at the end of the first survey, viability is again evaluatede, after which the secondary survey begins: priority is given to greater definition of cervical spine, chest, head and abdominal injuries. Special imaging procedures, such CT scan, must be interrupted in the declining patient who might benefit immediatly from burr holes, thoracotomy or laparotomy. Use of laparoscopy remains controversial.