Article

A Review on the Role of Laparoscopy in Abdominal Trauma

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Abstract

Background: The trauma victims are considered the top critical patients and require a rapid decision in the management. As the main fear is bleeding, so most of them ended having laparotomy, although almost 40% ended having a less invasive management like using laparoscopy. Materials and methods: The use of laparoscopy as a diagnostic (with the facility to be used as a therapeutic) option at the same setting can be considered a very good tool provided the patient is hemodynamically stable. Classically, standard three ports (extraport can be added according to therapeutic technique) are used. Most of the intestinal, mesenteric and diaphragmatic injuries can be detected and repaired successfully as well as some parenchymal injuries, provided not bleeding actively and, if necessary, using some tissue adhesives. Results: The laparoscopic technique as a diagnostic as well as therapeutic tool (in some cases) can be used safely and with fewer complications as it reduces the significant number of negative laparotomies. Conclusion: An access to the abdominal cavity laparoscopically can achieve good results in hemodynamically stable patients and avoids the morbidities related to laparotomy, decreases hospital stay and considered as a cost-effective tool.

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The purpose of the present study was to evaluate the use of laparoscopy for the diagnosis and treatment for hemodynamically stable patients with abdominal stab wounds. We conducted a retrospective cohort study to compare the outcomes of 86 hemodynamically stable patients with suspected intra-abdominal injuries from abdominal stab wounds who underwent either exploratory laparotomy or diagnostic laparoscopy. Thirty-eight patients (group A) were treated before the adoption of laparoscopy as a diagnostic and therapeutic tool for abdominal stabbing injuries at our hospital, and 48 patients (group B) were treated after. Demographic information, injury severity, operative findings, rates of nontherapeutic interventions, operation time, length of hospital stay, and morbidity of the two groups were evaluated. There was no difference in the demographics and injury severity between the two groups. Laparoscopy decreased the nontherapeutic laparotomy rate from 57.9% in group A to 0% in group B (P < 0.001). The accuracy of diagnostic laparoscopy was 100% in group B. Patients in group B had a significantly shorter hospital stay (5.0 days versus 9.9 days; P < 0.001) and shorter operation time (90.7 min vs. 118.7 min; P = 0.019) than group A. For patients in group B with significant intra-abdominal injuries, therapeutic laparoscopy was successfully performed in 16 of 17 patients (94.1%), treating a total of 22 intra-abdominal injuries. Laparoscopy is feasible and safe for the diagnosis and treatment of hemodynamically stable patients with abdominal stab wounds. It can reduce the nontherapeutic laparotomy rate and shorten the length of hospital stay.
Conference Paper
PURPOSE: To assess the therapeutic potential of emergent laparoscopy in the trauma setting, a retrospective review was performed in a busy urban trauma center. PATIENTS AND METHODS: Between December 1991 and October 1993, 133 hemodynamically stable patients with suspected abdominal injury were evaluated laparoscopically. All laparoscopic procedures were performed in the operating room under general anesthesia, Mechanism of injury was stab wound (58), gunshot wound (57), and blunt trauma (18), No significant injuries were found in 72 patients (54%), and these patients received no further treatment. On the basis of laparoscopic findings, 52 patients underwent formal exploratory laparotomy. Surgical exploration confirmed the presence of significant injuries in 44 of the 52 patients (85%), Therapeutic laparoscopy was performed in 6 patients (5%) for diaphragm repair (4), gastrotomy repair (1), and splenorrhaphy (1). Additionally, 10 patients underwent laparoscopy-guided blood salvage for autotransfusion during laparoscopic evaluation of blunt trauma, Three small-bowel enterotomies were repaired during minilaparotomy. RESULTS: NO significant injuries were missed as a result of our use of laparoscopy in trauma assessment, Complications-trocar enterotomy, trocar laceration of the inferior epigastric artery, and transient hypotension-occurred in 3 patients secondary to the use of laparoscopy. CONCLUSIONS: Trauma laparoscopy is a safe method for the evaluation of selected patients with abdominal trauma and can reduce the number of negative and nontherapeutic trauma laparotomies performed. Limited therapeutic intervention is possible in a small number of patients.
Background: Considerable skepticism still exists about the role of diagnostic laparoscopy in the evaluation of penetrating abdominal trauma, The reported experience with therapeutic laparoscopy has been limited, Methods: Retrospective analysis of a collective experience from three large urban trauma centers with 510 patients (316 stab wounds, 194 gunshot wounds) who were hemodynamically stable and had no urgent indications for celiotomy, Results: Laparotomy was avoided in 277 of the 510 patients (54.3%) either because of nonpenetration or insignificant findings on laparoscopy, All were discharged uneventfully after a mean hospital stay of 1.7 days, Twenty-six had successful therapeutic procedures on laparoscopy (diaphragmatic repair in 16 patients, cholecystectomy in 1 patient, hepatic repair in 6 patients, and closure of gastrotomy in 3 patients) with uneventful recovery, In the remaining 203 patients, laparotomy was therapeutic in 155, Fifty-two patients had nontherapeutic celiotomy for exclusion of bowel injuries or as mandatory laparotomy for penetrating gunshot wounds (19.7%), The overall incidence of nontherapeutic laparotomy was 10.2%, Complications from laparoscopy were minimal (10 of 510) and minor, Conclusions: Laparoscopy has an important diagnostic role in stable patients with penetrating abdominal trauma, In carefully selected patients, therapeutic laparoscopy is practical, feasible, and offers all the advantages of minimally invasive surgery.
Article
To assess the therapeutic potential of emergent laparoscopy in the trauma setting, a retrospective review was performed in a busy urban trauma center. Between December 1991 and October 1993, 133 hemodynamically stable patients with suspected abdominal injury were evaluated laparoscopically. All laparoscopic procedures were performed in the operating room under general anesthesia. Mechanism of injury was stab wound (58), gunshot wound (57), and blunt trauma (18). No significant injuries were found in 72 patients (54%), and these patients received no further treatment. On the basis of laparoscopic findings, 52 patients underwent formal exploratory laparotomy. Surgical exploration confirmed the presence of significant injuries in 44 of the 52 patients (85%). Therapeutic laparoscopy was performed in 6 patients (5%) for diaphragm repair (4), gastrotomy repair (1), and splenorrhaphy (1). Additionally, 10 patients underwent laparoscopy-guided blood salvage for autotransfusion during laparoscopic evaluation of blunt trauma. Three small-bowel enterotomies were repaired during minilaparotomy. No significant injuries were missed as a result of our use of laparoscopy in trauma assessment. Complications--trocar enterotomy, trocar laceration of the inferior epigastric artery, and transient hypotension--occurred in 3 patients secondary to the use of laparoscopy. Trauma laparoscopy is a safe method for the evaluation of selected patients with abdominal trauma and can reduce the number of negative and nontherapeutic trauma laparotomies performed. Limited therapeutic intervention is possible in a small number of patients.
Article
This study was performed to assess current and potential future application for laparoscopy (DL) in the diagnosis of penetrating and blunt injuries. Efficacy, safety, and cost analyses were performed. Diagnostic peritoneal lavage (DPL) and computed tomography (CT) have been the mainstays in recent years for diagnosis of equivocal nontherapeutic laparotomy, whereas CT is not helpful for the vast majority of penetrating wounds. DL may be a useful adjunct to fill in these gaps. Hemodynamically stable patients with equivocal evidence of intraabdominal injury were prospectively entered into the protocol. DL was performed under general anesthesia; patients with wounds penetrating the peritoneum or blunt injury with significant organ injury underwent laparotomy. Over 19 months, 182 patients (55% stab, 36% GSW, 9% blunt) were studied. No peritoneal penetration was found at DL in 55% of penetrating wounds with 66% of the remainder having therapeutic laparotomy, 17% nontherapeutic laparotomy, and 17% negative laparotomy. Therapeutic laparotomy was performed in 53% of blunt injuries after DL. Tension pneumothorax occurred in one patient and one had an iatrogenic small bowel injury. Charges for DL were $3,325 per patient compared with $3,320 for a similar group undergoing negative laparotomy before this protocol. DL is a safe modality for trauma. With current technology, DL is most efficacious for evaluation of equivocal penetrating wounds. Significant cost savings would be gained by performance under local anesthesia. Development of miniaturized optics, bowel clamps, retractors, and stapling devices will reduce overall costs and permit some therapeutic applications for laparoscopy in trauma management.
Article
Instead of open laparotomy, laparoscopy can be used safely and effectively for the diagnosis and treatment of traumatic abdominal injuries. Between February 1998 and January 2002, 78 hemodynamically stable patients (49 males and 29 females) with suspicious abdominal injuries underwent diagnostic or therapeutic laparoscopy. The patients ranged in age from 15 to 79 years (median, 40.9 years). Of these patients, 52 were evaluated for blunt trauma and 26 had sustained a stab wound. Preoperative evaluation with enhanced abdominal computed tomography (CT) showed some significant injuries in all cases. All of the laparoscopic procedures were performed in the operating room with the patient under general anesthesia. Pneumoperitoneum was established using an open Hasson technique at the umbilicus, and a forward-viewing laparoscope (30 degrees) was inserted. Two additional 5- or 10- and 12-mm trocars were placed in the right and left lateral quadrants for manipulation, retraction, aspiration-irrigation, coagulation, and the like. The abdominal cavity was systemically examined, the hemoperitoneum aspirated, and the lesion causing the bleeding or spillage located. On the basis of the laparoscopic findings, diagnostic laparoscopy was enough for 13 patients, and therapeutic laparoscopy was performed in 65 patients (83%) for gastric wall repair [8], small bowel repair [15], small bowel resection-anastomosis [19], ligation of bleeders in the mesentery and omentum [8], sigmoid colon repair [4], Hartmann's procedure [5] cholecystectomy [2], distal pancreatectomy [2], and splenectomy [2]. Totally laparoscopic procedures were performed in 43 patients, laparoscopically assisted procedures in 20 patients, and hand-assisted laparoscopic surgery in 2 patients. No significant abdominal injuries were missed as a result of laparoscopy, and no conversion to exploratory laparotomy was noted. The mean operation time was 142 min, and the mean hospital stay was 9.8 days. There were three cases of postoperative complications (1 wound infection, 1 paralytic ileus, and 1 atelectasis), but no missed injuries and no mortality. The short-term results from this study suggest that laparoscopy is a safe, feasible, effective procedure for the evaluation and treatment of hemodynamically stable patients with abdominal trauma, and that it can reduce the number of nontherapeutic laparotomies performed.