Laparoscopy for Abdominal Trauma Patient
Trauma is the leading cause of death between 1 and 44 years. In all age groups, it is surpassed only by cancer and atherosclerosis in mortality. The evaluation and treatment of abdominal injuries are critical components in the management of severely injured trauma patients. Because missed intra-abdominal injuries are a frequent cause of preventable trauma deaths, a high index of suspicion is warranted. Multiple factors, including the mechanism of injury, the body region injured, the patient’s hemodynamic and neurological status, associated injuries, and institutional resources influence the diagnostic approach and the outcome of abdominal injures.
Laparoscopy was first used for a trauma patient in 1956 by Lamy, who observed two cases of splenic injury. Since then, Gazzaniga noted that laparoscopy is useful for determining the need for laparotomy. In 1991, Berci reported that he had reduced the number of non-therapeutic laparotomies performed for hemoperitoneum by 25 percent through the use of laparoscopy in 150 patients with blunt abdominal trauma.
Data show that laparoscopy is a useful modality for evaluating and managing hemodynamically stable trauma patients with penetrating injuries. Increased use of laparoscopy in select patients with penetrating abdominal trauma will decrease the rate of negative and nontherapeutic laparotomies, thus lowering morbidity, decreasing the length of hospitalization, and provide for more efficient utilization of available resources. As technology and expertise among surgeons continue to improve, more standard therapeutic interventions may be done laparoscopically in the future. Mandatory surgical exploration for gunshot wounds to the abdomen has been a surgical dictum for the greater part of this century. Although non-operative management of blunt solid organ injuries and low-energy penetrating injuries such as stab wounds is well established, the same is not true for gunshot wounds. The vast majority of patients who sustain a gunshot injury to the abdomen require immediate laparotomy to control bleeding and contain contamination. Non-operative treatment of patients with a gunshot injury is gaining acceptance in only a highly selected subset of hemodynamically stable adult patients without peritonitis. Although the physical examination remains the cornerstone in the evaluation of patients with a gunshot injury, other techniques such as computed tomography, diagnostic peritoneal lavage, and diagnostic laparoscopy allow accurate diagnosis of intra-abdominal injury.
The ability to exclude internal organ injury non-operatively avoids the potential complications of unnecessary laparotomy. Clinical data to support selective non-operative management of certain gunshot injuries to the abdomen are accumulating, but the approach has risks and requires careful collaborative management by emergency physicians and surgeons experienced in the care of penetrating injury. Sosa reported 121 consecutive abdominal gunshot wounds managed with laparoscopy. Seventy-nine (65%) had negative laparoscopy, and these patients were managed without laparotomy. Another 7.2 percent avoided nontherapeutic laparotomy.
It is very important to determine the presence, location, and severity of intra-abdominal injury to decide the surgical intervention; and to thoroughly evaluate intra-abdominal organs for associated injuries in the trauma patient. For stab wounds, a serial physical examination is supplemented by local wound exploration, diagnostic peritoneal lavage (DPL), abdominal US, abdominal CT, magnetic resonance imaging (MRI), and in some cases, angiography to maximize the value of surgical intervention and to reduce negative and non-therapeutic laparotomy. Despite their many positive qualities, these diagnostic methods have some drawbacks. DPL is an invasive but sensitive procedure; it may result in non-therapeutic laparotomy with its attendant morbidity. The use of CT is limited to the hemodynamically stable patient. There has been increasing interest in the use of abdominal US because it is portable, noninvasive, rapid, and easily repeatable. However, it is less accurate for the diagnosis of diaphragmatic and hollow viscera. With experience in laparoscopic cholecystectomy and the advent of improved and readily accessible laparoscopic equipment and devices, laparoscopic surgery became widespread for intra-abdominal operations, setting the stage for renewed interest in its applications for the diagnosis of traumatic abdominal injuries and examination of their therapeutic potential.
In the evaluation and management of abdominal injury, current diagnostic methods have a defined sensitivity, specificity, and accuracy, but none of these represents a gold standard. Thus, abdominal exploration by laparotomy should not be discarded as a worthy diagnostic and therapeutic procedure for patients with equivocal and unreliable findings. It is associated with complication rates as high as 40 percent including a 10 to 40 percent negative laparotomy rate, a 20 percent morbidity rate, a 0 to 5 percent mortality rate, and a 3 percent long-term risk of bowel obstruction secondary to adhesions.
Laparoscopy has been reported infrequently as a therapeutic tool in selected trauma patients. Examples of therapeutic laparoscopy include repair of diaphragmatic lacerations with sutures, staples, or prosthetic mesh; suturing of gastrointestinal perforations; hemostasis of low- grade liver and splenic lacerations; resection of small bowel and colon; cholecystectomy; splenectomy; and distal pancreatectomy. Autotransfusion of collected blood from the hemoperitoneum is another potential application. Fabian in a large study of 182 trauma patients, reported one suture repair of diaphragmatic injury. Successful laparoscopic repair of the small bowel, colon, and rectal injuries, and laparoscopic repair of a small gastric stab wound using hernia stapler have been reported recently. For the repair of solid visceral injuries, there are three methods that merit investigation: The totally laparoscopic procedure, the laparoscopically assisted procedure, hand-assisted laparoscopic surgery (HALS). The argon beam coagulator, fibrin glue, topical hemostatic agent, and absorbable mesh may be beneficial for hepatic and splenic lacerations. Laparoscopic repair of bowel injuries can be performed using suture or staples.
Primary suture repair of a small bowel injury would be amenable by a totally laparoscopic procedure. Using a porcine model, Pietrafitta and Soperet described a technique for an intraperitoneal functional end-to-end anastomosis of the small intestine. Milsom and Bohm modified these techniques and reported that their technique for intracorporeal intestinal anastomosis has been proven safe in dozens of animal and human procedures, but that it had some drawbacks. It requires a long operating time and needs two or three 30 mm Endo- GIAs and a skin incision for specimen retrieval. Recently, animal research has assessed the potential for hand-assisted laparoscopic exploration to detect traumatic injuries. Asbun reported that hand-assisted laparoscopic exploration is more accurate than laparoscopic exploration alone in detecting injuries (63 vs. 38%), but that it still resulted in an unacceptable rate of missed injuries.
Hand-assisted laparoscopic surgery allows for the application of minimally invasive surgical techniques to complex intra-abdominal operations, particularly when specimen removal is required. The rationale for this approach is that the hand offers the surgeon some advantage in terms of tactile feedback, exposure, retraction, and orientation, enabling the surgeon to perform with greater safety and efficiency. Most trauma surgeons consider omental herniation through an anterior abdominal stab wound an indication for laparotomy because frequently there are significant intra-abdominal injuries. As an alternative to laparotomy, the herniated omentum was evaluated and managed, with laparoscopy performed through the abdominal stab wound or accessory trocar. If there are no significant injuries, the wound can be managed without further treatment. Depending on the surgeon’s preference, therapeutic laparoscopy can be continued.
The complications of laparoscopy for trauma include not only the usual complications of anesthesia and laparoscopy but also some that are unique to the trauma patient. Fabian independently reported the development of tension pneumothorax in patients with diaphragmatic injury from positive-pressure pneumoperitoneum. If suspected, induction of pneumoperitoneum is stopped, and an immediate needle thoracocentesis is performed, followed by a tube thoracostomy if needed. However, routine prophylactic tube thoracostomy is not indicated. The risks of gas embolism in patients with intra-abdominal venous injuries, especially liver lacerations, are another problem. Among 133 laparoscopic examinations of trauma, Smith did encounter this complication in two patients with injuries of the inferior vena cava tamponaded by a clot.
This potential problem of laparoscopy has stimulated interest in ‘‘gasless’’ laparoscopy based on an expansion of the peritoneal cavity by mechanical retractors. In addition to averting the risks of tension pneumothorax and gas embolism, it facilitates the use of conventional instruments such as hemostats, needles, sutures, and electrocautery, resulting in significant cost savings. The major disadvantage of gasless laparoscopy, however, is the excessive cost of the powered mechanical arm and the poor exposure in the lateral gutters. Less expensive apparatus to lift the abdominal wall is expected. The transperitoneal absorption of carbon dioxide may cause metabolic and hemodynamic changes such as acidosis, cardiac suppression, atelectasis, subcutaneous emphysema, and increased intracranial pressure, resulting in more profound consequences for the trauma patient. Joseph demonstrated that carbon dioxide (CO2) pneumoperitoneum causes significantly increased intracranial pressure in a porcine model of head injury.
The results of this study led them to recommend the avoidance of CO2 pneumoperitoneum for the evaluation of patients with head injuries. Undoubtedly, gasless laparoscopy could replace CO2 pneumoperitoneum in these cases. Missed intra-abdominal injuries are among the most frequent causes of potentially preventable trauma deaths. The evaluation and management of abdominal trauma is dependant on multiple factors, including mechanism of injury, location of the injury, hemodynamic status of the patient, neurological status of the patient, associated injuries, and institutional resources. Therefore careful selection, a high index of suspicion, and a low threshold for laparotomy will provide the patient with the benefits of minimally invasive surgery and reducing the rates and morbidity of unnecessary laparotomy.
Complications
Complications may occur during access, trocar insertion, or the diagnostic manipulation of viscera. These complications include cardiac arrhythmias, hemodynamic instability due to decreased venous return, bleeding, bile leak, perforation of a hollow viscus, laceration of a solid organ, vascular injury, gas embolism, and subcutaneous or extraperitoneal dissection of the insufflation gas. If proper sterilization of instrument is not done then wound infection or leakage of ascites may occur postoperatively. Failure to accurately diagnose the extent of intra-abdominal pathology is another potential complication for which a patient may have to go for other surgery.
Conclusion
Diagnostic laparoscopy is one of the very important methods of investigation for patients in whom the diagnosis or extent of the disease is unclear or the abdominal findings are equivocal. It can be performed safely in an inpatient or outpatient setting, potentially expediting diagnosis and treatment.
Trauma is the leading cause of death between 1 and 44 years. In all age groups, it is surpassed only by cancer and atherosclerosis in mortality. The evaluation and treatment of abdominal injuries are critical components in the management of severely injured trauma patients. Because missed intra-abdominal injuries are a frequent cause of preventable trauma deaths, a high index of suspicion is warranted. Multiple factors, including the mechanism of injury, the body region injured, the patient’s hemodynamic and neurological status, associated injuries, and institutional resources influence the diagnostic approach and the outcome of abdominal injures.
Laparoscopy was first used for a trauma patient in 1956 by Lamy, who observed two cases of splenic injury. Since then, Gazzaniga noted that laparoscopy is useful for determining the need for laparotomy. In 1991, Berci reported that he had reduced the number of non-therapeutic laparotomies performed for hemoperitoneum by 25 percent through the use of laparoscopy in 150 patients with blunt abdominal trauma.
Data show that laparoscopy is a useful modality for evaluating and managing hemodynamically stable trauma patients with penetrating injuries. Increased use of laparoscopy in select patients with penetrating abdominal trauma will decrease the rate of negative and nontherapeutic laparotomies, thus lowering morbidity, decreasing the length of hospitalization, and provide for more efficient utilization of available resources. As technology and expertise among surgeons continue to improve, more standard therapeutic interventions may be done laparoscopically in the future. Mandatory surgical exploration for gunshot wounds to the abdomen has been a surgical dictum for the greater part of this century. Although non-operative management of blunt solid organ injuries and low-energy penetrating injuries such as stab wounds is well established, the same is not true for gunshot wounds. The vast majority of patients who sustain a gunshot injury to the abdomen require immediate laparotomy to control bleeding and contain contamination. Non-operative treatment of patients with a gunshot injury is gaining acceptance in only a highly selected subset of hemodynamically stable adult patients without peritonitis. Although the physical examination remains the cornerstone in the evaluation of patients with a gunshot injury, other techniques such as computed tomography, diagnostic peritoneal lavage, and diagnostic laparoscopy allow accurate diagnosis of intra-abdominal injury.
The ability to exclude internal organ injury non-operatively avoids the potential complications of unnecessary laparotomy. Clinical data to support selective non-operative management of certain gunshot injuries to the abdomen are accumulating, but the approach has risks and requires careful collaborative management by emergency physicians and surgeons experienced in the care of penetrating injury. Sosa reported 121 consecutive abdominal gunshot wounds managed with laparoscopy. Seventy-nine (65%) had negative laparoscopy, and these patients were managed without laparotomy. Another 7.2 percent avoided nontherapeutic laparotomy.
It is very important to determine the presence, location, and severity of intra-abdominal injury to decide the surgical intervention; and to thoroughly evaluate intra-abdominal organs for associated injuries in the trauma patient. For stab wounds, a serial physical examination is supplemented by local wound exploration, diagnostic peritoneal lavage (DPL), abdominal US, abdominal CT, magnetic resonance imaging (MRI), and in some cases, angiography to maximize the value of surgical intervention and to reduce negative and non-therapeutic laparotomy. Despite their many positive qualities, these diagnostic methods have some drawbacks. DPL is an invasive but sensitive procedure; it may result in non-therapeutic laparotomy with its attendant morbidity. The use of CT is limited to the hemodynamically stable patient. There has been increasing interest in the use of abdominal US because it is portable, noninvasive, rapid, and easily repeatable. However, it is less accurate for the diagnosis of diaphragmatic and hollow viscera. With experience in laparoscopic cholecystectomy and the advent of improved and readily accessible laparoscopic equipment and devices, laparoscopic surgery became widespread for intra-abdominal operations, setting the stage for renewed interest in its applications for the diagnosis of traumatic abdominal injuries and examination of their therapeutic potential.
In the evaluation and management of abdominal injury, current diagnostic methods have a defined sensitivity, specificity, and accuracy, but none of these represents a gold standard. Thus, abdominal exploration by laparotomy should not be discarded as a worthy diagnostic and therapeutic procedure for patients with equivocal and unreliable findings. It is associated with complication rates as high as 40 percent including a 10 to 40 percent negative laparotomy rate, a 20 percent morbidity rate, a 0 to 5 percent mortality rate, and a 3 percent long-term risk of bowel obstruction secondary to adhesions.
Laparoscopy has been reported infrequently as a therapeutic tool in selected trauma patients. Examples of therapeutic laparoscopy include repair of diaphragmatic lacerations with sutures, staples, or prosthetic mesh; suturing of gastrointestinal perforations; hemostasis of low- grade liver and splenic lacerations; resection of small bowel and colon; cholecystectomy; splenectomy; and distal pancreatectomy. Autotransfusion of collected blood from the hemoperitoneum is another potential application. Fabian in a large study of 182 trauma patients, reported one suture repair of diaphragmatic injury. Successful laparoscopic repair of the small bowel, colon, and rectal injuries, and laparoscopic repair of a small gastric stab wound using hernia stapler have been reported recently. For the repair of solid visceral injuries, there are three methods that merit investigation: The totally laparoscopic procedure, the laparoscopically assisted procedure, hand-assisted laparoscopic surgery (HALS). The argon beam coagulator, fibrin glue, topical hemostatic agent, and absorbable mesh may be beneficial for hepatic and splenic lacerations. Laparoscopic repair of bowel injuries can be performed using suture or staples.
Primary suture repair of a small bowel injury would be amenable by a totally laparoscopic procedure. Using a porcine model, Pietrafitta and Soperet described a technique for an intraperitoneal functional end-to-end anastomosis of the small intestine. Milsom and Bohm modified these techniques and reported that their technique for intracorporeal intestinal anastomosis has been proven safe in dozens of animal and human procedures, but that it had some drawbacks. It requires a long operating time and needs two or three 30 mm Endo- GIAs and a skin incision for specimen retrieval. Recently, animal research has assessed the potential for hand-assisted laparoscopic exploration to detect traumatic injuries. Asbun reported that hand-assisted laparoscopic exploration is more accurate than laparoscopic exploration alone in detecting injuries (63 vs. 38%), but that it still resulted in an unacceptable rate of missed injuries.
Hand-assisted laparoscopic surgery allows for the application of minimally invasive surgical techniques to complex intra-abdominal operations, particularly when specimen removal is required. The rationale for this approach is that the hand offers the surgeon some advantage in terms of tactile feedback, exposure, retraction, and orientation, enabling the surgeon to perform with greater safety and efficiency. Most trauma surgeons consider omental herniation through an anterior abdominal stab wound an indication for laparotomy because frequently there are significant intra-abdominal injuries. As an alternative to laparotomy, the herniated omentum was evaluated and managed, with laparoscopy performed through the abdominal stab wound or accessory trocar. If there are no significant injuries, the wound can be managed without further treatment. Depending on the surgeon’s preference, therapeutic laparoscopy can be continued.
The complications of laparoscopy for trauma include not only the usual complications of anesthesia and laparoscopy but also some that are unique to the trauma patient. Fabian independently reported the development of tension pneumothorax in patients with diaphragmatic injury from positive-pressure pneumoperitoneum. If suspected, induction of pneumoperitoneum is stopped, and an immediate needle thoracocentesis is performed, followed by a tube thoracostomy if needed. However, routine prophylactic tube thoracostomy is not indicated. The risks of gas embolism in patients with intra-abdominal venous injuries, especially liver lacerations, are another problem. Among 133 laparoscopic examinations of trauma, Smith did encounter this complication in two patients with injuries of the inferior vena cava tamponaded by a clot.
This potential problem of laparoscopy has stimulated interest in ‘‘gasless’’ laparoscopy based on an expansion of the peritoneal cavity by mechanical retractors. In addition to averting the risks of tension pneumothorax and gas embolism, it facilitates the use of conventional instruments such as hemostats, needles, sutures, and electrocautery, resulting in significant cost savings. The major disadvantage of gasless laparoscopy, however, is the excessive cost of the powered mechanical arm and the poor exposure in the lateral gutters. Less expensive apparatus to lift the abdominal wall is expected. The transperitoneal absorption of carbon dioxide may cause metabolic and hemodynamic changes such as acidosis, cardiac suppression, atelectasis, subcutaneous emphysema, and increased intracranial pressure, resulting in more profound consequences for the trauma patient. Joseph demonstrated that carbon dioxide (CO2) pneumoperitoneum causes significantly increased intracranial pressure in a porcine model of head injury.
The results of this study led them to recommend the avoidance of CO2 pneumoperitoneum for the evaluation of patients with head injuries. Undoubtedly, gasless laparoscopy could replace CO2 pneumoperitoneum in these cases. Missed intra-abdominal injuries are among the most frequent causes of potentially preventable trauma deaths. The evaluation and management of abdominal trauma is dependant on multiple factors, including mechanism of injury, location of the injury, hemodynamic status of the patient, neurological status of the patient, associated injuries, and institutional resources. Therefore careful selection, a high index of suspicion, and a low threshold for laparotomy will provide the patient with the benefits of minimally invasive surgery and reducing the rates and morbidity of unnecessary laparotomy.
Complications
Complications may occur during access, trocar insertion, or the diagnostic manipulation of viscera. These complications include cardiac arrhythmias, hemodynamic instability due to decreased venous return, bleeding, bile leak, perforation of a hollow viscus, laceration of a solid organ, vascular injury, gas embolism, and subcutaneous or extraperitoneal dissection of the insufflation gas. If proper sterilization of instrument is not done then wound infection or leakage of ascites may occur postoperatively. Failure to accurately diagnose the extent of intra-abdominal pathology is another potential complication for which a patient may have to go for other surgery.
Conclusion
Diagnostic laparoscopy is one of the very important methods of investigation for patients in whom the diagnosis or extent of the disease is unclear or the abdominal findings are equivocal. It can be performed safely in an inpatient or outpatient setting, potentially expediting diagnosis and treatment.
