Page 16 - WJOLS - Laparoscopic Journal

WJOLS

A Review on the Role of Laparoscopy in Abdominal Trauma

The standard method of resuscitating trauma patient is
to follow ABCDE protocol (airway, breathing, circulation,
disability and exposure). Treating airway has number one
priority because if the patient can respond well, it indicates
almost near normal ventilation and oxygenation as well as
normal level of consciousness (GCS of 15/15). In
resuscitating these patients, the 1st hour from the time of
accident is uniquely important which is called golden hour,
due to the importance of managing the life-threatening injury
in that particular time, and within these critical minutes
airway management should be the first task of the
paramedics or physician. When life-threatening injuries, like
tension pneumothorax, massive hemothorax, injury to the
thoracic aorta and ruptured bronchopulmonary tree, have
Fig. 8: Three-port technique happened, the resuscitation has to be as fast as airway,
because some of them affects the airway, oxygenation and
exploration should be undertaken starting from right ventilation at the same time. Bleeding is always considered
hypochondrial region, assessing all solid organs, lower as a threatening signal towards death, that is why it is the
esophagus, stomach, duodenum and rest of small bowel by most stressful one to be managed, here is the arena where
running it from ileocecal valve to duodenojejunal junction, surgeon has to act quickly and properly as minutes will be
colon and rectum, mesentery as well as diaphragm as mostly counted rather than hours, and when the case is not
missed by the noninvasive radiological tools. hemodynamically stable, the option of laparoscopic approach
Violating the peritoneum in the penetrating wound injury does not exist and should not be attempted because it is
is an indication for laparoscopic exploration, and sometime time consuming and leads to many cardiorespiratory
local wound exploration is not informative due to the derangements in an already compromised victim.
tangential track of the injury, provided the peritonitis is Still as part of primary resuscitation, the last but not the
excluded because that declares a delayed presentation which least is neurological assessment as neurogenic shock should
needs aggressive surgical intervention and toileting. be kept in mind and not to be confused with the hypovolemic
A retrospective cohort study made for about 86 patients one, and examining (exposing) the patient in a warm
who sustained abdominal stab wound and were divided into environment to avoid hypothermia.
two groups, resulted in reducing nontherapeutic laparotomy The revolution in surgery nowadays is towards minimal
and avoiding its complications in most of the access approach, neither the less, this has also taken over
hemodynamically stable cases. 2 in traumatology for selected cases (stable patients whether
In some other studies, an extensive review is made on sustained blunt or penetrating injuries). Not only that, some
the effect of laparoscopy as a diagnostic and therapeutic trauma centers have made their own approach in handling
tool in the management of diaphragmatic ruptures, and theses cases with the use of video-assisted techniques.
4
considered the best line of management, even a rare case Previously there were literatures not supporting to the
of traumatic intrapericardial diaphragmatic injury and use of laparoscopy in trauma due to complications, including
herniation were managed successfully. missed intestinal injuries, trocar and needle-related enteral
Although it is out of debate that video-assisted laparoscopy and vascular injuries as well as gas embolism, but this has
and thoracoscopy should be conducted for stable patient, dramatically reduced as the new techniques and
some study has shown beneficial even for unstable cases, triangulations with ergonomics has respected. Some authors
1
provided it is utilized properly in experienced hand.
have reported gas embolism in cases of inferior vena cava
8
laceration, this was the lead point to the gasless technique.
DISCUSSION
Tension pneumothorax has also been reported in cases of
The American College of Surgeon, committee on trauma diaphragmatic injuries. 9
has standardized the management of patients sustaining Sometime inspite of using all the high quality
trauma whether blunt or penetrating after an accident investigations and imaging techniques, intra-abdominal
happened to the orthopedic surgeon Dr Jim Styner who injuries remain as a great challenge to be diagnosed, and
crashed his small plane into the rural area in 1976. After so that is why still laparotomy is performed as a standard
that a new program was developed in 1978 (the year of 1st line of treatment. Provided the patient is stable, this is the
ATLS course). field where laparoscopy has a great role. Although it is

World Journal of Laparoscopic Surgery, January-April 2011;4(1):13-17 15