Page 20 - World Journal of Laparoscopic Surgery

Ebrahim Mansoor, RK Mishra
SPECIFIC-ORGAN TRAUMA 4,14 are often only candidates for open surgery. In very
experienced hands and in a highly controlled environ-
The advancements in stapler technology and energy
devices, (as well as the enhanced knowledge of sutur- ment, it appears intuitively possible to conduct damage
ing and knotting techniques), have enabled the minimal control laparoscopy especially when surgical staplers
access surgeon to intervene efficiently and safely for and a wide array of energy devices are at the disposal of
specific-organ trauma. There is little minimal access the surgeon.
techniques cannot accomplish equivocally or better than Pediatric Considerations 16
open surgery. Some examples are shown below (Table 2).
There is a relative paucity of literature for the use of MAS
Table 2: Suturing and knotting techniques
in the pediatric trauma patient. Diagnostic laparoscopy
Injured organ Possible intervention has been shown to be feasible and safe. Interventional
Diaphragm Suture repair ± mesh application work is possible in the hands of a surgeon au fait with
Liver Suture; application of hemostatic agent
Gallbladder Cholecystectomy pediatric minimal access surgical techniques and with
Stomach Repair or resection and anastomosis the availability of appropriately sized instruments.
Pancreas Drain placement; distal pancreatectomy
Spleen Splenectomy Pregnancy 14
Small bowel/ Repair/resect and anastomosis/stoma
colon/rectum Surgery in the gravid patient is hazardous in emergent
Ureter Anastomosis over stent open surgery and often results in maternal and child mor-
Mesenteric bleed Suture, clip, or hemostasis with energy device bidity or mortality. This is especially more pronounced
Bladder Repair with MAS especially in light of trocar injuries and the
Abdominal wall Repair effects of pneumoperitoneum. Extrapolating from the
defect nontrauma setting, MAS may be possible in the first
and second trimester. Intense maternal counseling is
Copious peritoneal lavage with warmed saline advocated. More studies are recommended prior to firm
and intraperitoneal drain placement is indicated for recommendations on MAS for the pregnant patient with

peritoneal soiling. At the conclusion of the operation, all abdominal trauma.
10 mm port sites must be repaired.
CONCLUSION 4,8,12-15
CONTROVERSIES AND SPECIAL
CIRCUMSTANCES Minimal access surgery represents a viable, safe, and
cost-effective alternative in the adult and pediatric
Laparotomy versus Laparoscopy 4,8,12,13,15 trauma patient for selected injuries. Lack of training and
Laparoscopy has been shown to be equally efficacious as experience in minimal access techniques is the main
laparotomy in selected circumstances as indicated above. impediment to widespread use. Trauma centers and
The missed injury rate is negligible with good technique. other surgical facilities dealing with trauma patients
Conversion to open surgery must not be deemed to be a are encouraged to incorporate minimal access tech-
failure of the laparoscopic modality. However, the conver- niques in their training programs. Results obtained
sion rate is minimized in experienced hands. Length of with laparoscopic examination and therapy utilizing
stay and costs are comparatively reduced with laparos- MAS techniques are commensurate with the skill and
copy. The concern that carbon dioxide pneumoperitoneum experience of the operator. Preliminary data suggest that
promotes septicemia in the setting of bowel content spill- laparoscopy should be further popularized for abdomi-
age or peritonitis appears to be unwarranted. nal trauma; however, randomized controlled studies
are required to truly validate the role of MAS for the
Second-Look Laparoscopy trauma setting.

This has not been clearly validated in the trauma lit-
erature. Technically, it is viable and must be done on REFERENCES
demand. Previous port sites or the drain site can be used 1. Kaban GK, Novitsky YW, Perugini RA, Haveran L, Czerniach D,
for a “second-look.” Kelly JJ, Litwin DE. Use of laparoscopy in evaluation and
treatment of penetrating and blunt abdominal injuries. Surg
Damage Control Laparoscopy Innov 2008 Mar;15(1):26-31.
2. Bombil I, Maraj A, Lunda WS. Laparoscopy at Sebokeng
Damage control laparoscopy has not been adequately Hospital with emphasis on trauma. Global J Med Res 2014;
described in the trauma literature. Patients in extremis 14(4).
124