図４の↑が皮膚欠損を示し1の刺創部である．図５〜図７の△は刺創路の皮下血腫で，図８〜図１２の▲は腹腔内の血腫で，腹膜を貫通する刺創であることがわかる．しかし，出血量は少量で，消化管穿孔を示唆する遊離ガス，腸管壁肥厚，腸間膜の濃度上昇や腹水を認めず，腹腔内臓器損傷の可能性は低い．図３と図４の白矢印は石灰化した膵周囲リンパ節であろう．腹部所見でも腹膜刺激症状を認めないので手術は不要と判断し，4日間の観察で順調に経過し無事退院した．

参考症例（Plain CT，腹膜貫通創・negative laparotomy）：53歳男性．知人に右上腹部をナイフで刺された．腹部膨満はなく，刺創周辺以外は軟で圧痛もない．刺創検索で腹膜を貫通していることが確認された．

刺創路に沿って皮下に血腫（△）を，さらに腹腔内にも血腫（▲）を認め，CTで腹腔内に達する刺創であることがわかる．上記症例同様，消化管穿孔所見はなく，出血量は少量で，腹膜刺激症状を認めないので経過観察可能と思われる．しかし，腹膜貫通所見だけで試験開腹が施行されたが，既に自然止血した大網の小損傷を認めるだけで，negative laparotomy（修復すべき外傷を認めない）となった．

文献考察：腹部刺創例に診断的腹腔鏡検査の有用性は低い．
J Trauma. 2003 Oct;55(4):636-45.
Diagnostic laparoscopy in abdominal stab wounds: a prospective, randomized study.
Leppaniemi A, Haapiainen R.

BACKGROUND: The optimal strategy for identifying patients with abdominal stab wounds requiring surgical repair has not been defined. The potential benefits of diagnostic laparoscopy by incorporating it into the routine diagnostic workup of patients with anterior abdominal stab wounds was evaluated in a two-layer, randomized study. METHODS: From May 1997 through January 2002, stable patients without peritonitis but with demonstrated peritoneal violation were randomized (A) to exploratory laparotomy (AEL) (n = 23) or diagnostic laparoscopy (ADL) (n = 20). Simultaneously, patients with equivocal peritoneal violation on local wound exploration were randomized (B) to diagnostic laparoscopy (BDL) (n = 28) or expectant nonoperative management (BNOM) (n = 31). Hospital morbidity, length of stay, and costs were primary endpoints, with postdischarge disability being a secondary endpoint. RESULTS: In patients with peritoneal penetration (AEL vs. ADL), there were minimal differences in the therapeutic operation rate (8 of 23 [AEL] vs. 8 of 20 [ADL], p = 0.761), mortality (none), morbidity (3 of 23 vs. 2 of 20, p = 0.999), hospital stay (mean +/- SD) (5.7 +/- 2.5 vs. 5.1 +/- 4.0 days, p = 0.049), hospital costs (4.6 +/- 1.3 vs. 4.8 +/- 1.9 x 1,000 EUR, p = 0.576), and length of sick leave (34 +/- 12 vs. 29 +/- 11 days, p = 0.305). In patients with equivocal peritoneal penetration (BDL vs. BNOM), laparoscopy found more mostly minor organ injuries (7 of 28 [BDL] vs. 1 of 31 [BNOM], p = 0.022) with no significant difference in therapeutic operations (3 of 28 vs. 1 of 31, p = 0.337) or morbidity (3 of 28 vs. 0 of 31, p = 0.101), but was associated with increased length of stay (2.6 +/- 2.1 vs. 1.9 +/- 1.8 days, p = 0.022), hospital costs (4.2 +/- 1.3 vs. 1.5 +/- 1.1 x 1,000 EUR, p = 0.000), and sick leave requirements (18 of 23 vs. 8 of 28 of eligible patients, p = 0.001). CONCLUSION: In patients with demonstrated peritoneal violation, laparoscopy offers little benefit over exploratory laparotomy. In patients with equivocal peritoneal penetration on local wound exploration, laparoscopy detects more mostly minor organ injuries than expectant nonoperative management but is associated with increased hospital stay, costs, and sick leave requirements. Overall, diagnostic laparoscopy cannot be recommended as a routine diagnostic tool in anterolateral abdominal and thoracoabdominal stab wounds.PMID: 14566116