Laparoscopy in Penetrating Abdominal Trauma

The Role of Minimally Invasive Surgeries in Trauma

This article delves into the role of minimally invasive surgeries in trauma, specifically laparoscopy and video-assisted thoracic surgery (VATS). It discusses the benefits of laparoscopy over traditional laparotomy, including its accuracy in detecting peritoneal violation and intraperitoneal injuries caused by penetrating trauma. The article also explores the use of laparoscopy as an adjunct to nonoperative management of abdominal injuries and in cases of blunt trauma with unclear abdominal injuries. Furthermore, it highlights the benefits of VATS in diagnosing and treating thoracic injuries, such as traumatic diaphragmatic injuries, retained hematomas, and persistent pneumothorax.

Laparoscopic treatment for colonic injuries following penetrating trauma: A feasible option in a surgical department of Sub-Saharan Africa

Introduction

The management of abdominal penetrating trauma remains complex. Between the risk of negative laparotomy and missed visceral injury, laparoscopy is a good alternative. We report 2 cases of abdominal penetrating trauma with colonic injury diagnosed and treated with laparoscopic approach.

Observations

The first patient was 15 years old, with no medical history and received at 3 h of a penetrating trauma by stabbing. Hemodynamic status was normal. An exploratory laparoscopy was performed. It objectified a penetration of the peritoneum on the left flank with an injury of the anti-mesenteric edge of the descending colon that was sutured. The second patient was 20 years old, with no history, who had a penetrating trauma of the left iliac fossa by stabbing. Arterial pressure was normal. He was received 6 h after the trauma. An exploratory laparoscopy objectified an injury of 2 cm located at the sigmoid colon which was sutured with a good evolution.

Conclusion

Laparoscopy in abdominal wounds is a good option in selected patients. It has a diagnostic and therapeutic importance in colonic injuries. The limits are represented by the possibility of unrecognized visceral lesions that can lead to additional morbidity.

Characteristics of Laparoscopic Surgery for Trauma Patients and Risks of Conversion to Open Laparotomy

BACKGROUND

The discussion is ongoing about appropriate indications for laparoscopic surgery in trauma patients. As timing and risks of conversion to laparotomy remain unclear, we aimed to elucidate characteristics of and risks for conversion following laparoscopic surgery, using a nationwide database.

METHODS

A retrospective observational study was conducted, using Japanese Trauma Data Bank (2004-2018). We included adult trauma patients who underwent laparoscopic surgery as an initial surgical intervention. Conversion to laparotomy was defined as laparotomy at the initial surgery. Patient demographics, mechanism and severity of injury, injured organs, timing of surgery, and clinical outcomes were compared between patients with and without conversion. Risks for conversion were analyzed focusing on indications for laparoscopic surgery, after adjusting patient and institution characteristics.

RESULTS

Among 444 patients eligible for the study, 31 required conversions to laparotomy. The number of laparoscopic surgeries gradually increased over the study period (0.5-4.5% of trauma laparotomy), without changes in conversion rates (5-10%). Patients who underwent conversion had more severe abdominal injuries compared with those who did not (AIS 3 vs 2). While length of hospital stay and in-hospital mortality were comparable, abdominal complications were higher among patients with conversion (12.9 vs. 2.9%), particularly when laparoscopy was performed for peritonitis (OR, 22.08 [5.11-95.39]). A generalized estimating equation model adjusted patient background and identified hemoperitoneum and peritoneal penetration as risks for conversion (OR, 24.07 [7.35-78.75] and 8.26 [1.20- 56.75], respectively).

CONCLUSIONS

Trauma laparoscopy for hemoperitoneum and peritoneal penetration were associated with higher incidence of conversion to open laparotomy.

A characterization of trauma laparotomies in a scandinavian setting: an observational study

BACKGROUND

Despite treatment advances, trauma laparotomy continuous to be associated with significant morbidity and mortality. Most of the literature originates from high volume centers, whereas patient characteristics and outcomes in a Scandinavian setting is not well described. The objective of this study is to characterize treatments and outcomes of patients undergoing trauma laparotomy in a Scandinavian setting and compare this to international reports.

METHODS

A retrospective study was performed in the Copenhagen University Hospital, Rigshospitalet (CUHR). All patients undergoing a trauma laparotomy within the first 24 h of admission between January 1st 2019 and December 31st 2020 were included. Collected data included demographics, trauma mechanism, injuries, procedures performed and outcomes.

RESULTS

A total of 1713 trauma patients were admitted to CUHR of which 98 patients underwent trauma laparotomy. Penetrating trauma accounted for 16.6% of the trauma population and 66.3% of trauma laparotomies. Median time to surgery after arrival at the trauma center (TC) was 12 min for surgeries performed in the Emergency Department (ED) and 103 min for surgeries performed in the operating room (OR). A total of 14.3% of the procedures were performed in the ED. A damage control strategy (DCS) approach was chosen in 18.4% of cases. Our rate of negative laparotomies was 17.3%. We found a mortality rate of 8.2%. The total median length of stay was 6.1 days.

CONCLUSION

The overall rates, findings, and outcomes of trauma laparotomies in this Danish cohort is comparable to reports from similar Western European trauma systems.

Laparoscopic Versus Laparotomy Surgical Interventions for Trauma Patients with Single Upper Left Quadrant Penetrating Injuries: Analysis of the American College of Surgeons Trauma Quality Improvement Program Dataset

BACKGROUND

We aim to identify patient cohorts where laparoscopy can be safely utilized with comparable or better outcomes to laparotomy among patients with single penetrating LUQ injuries with a hypothesis that compared to laparotomy, laparoscopy may be associated with equal or improved outcomes of low injury severity patients.

METHODS

Retrospective review of the ACS-TQP-Participant Use File 2016-2019 dataset. Patients with single LUQ penetrating injuries were included. Primary outcome was risk-adjusted in-hospital mortality. Secondary outcomes included: risk-adjusted complication rates, hospital length-of-stay (H-LOS), and ICU-LOS. Descriptive statistics and multivariable regression with reliability adjustments to account for variations in practice were performed.

RESULTS

Of 4149 patients analyzed, 3571 (86.1%) underwent laparotomy, 489 (11.8%) underwent laparoscopy, and 89 (2.1%) underwent laparoscopy-to-laparotomy conversion. Adjusted mortality rates were not significantly different among all study cohorts (P > .05). Compared to laparoscopy, adjusted odds of complications were 4.3-fold higher for all patients who underwent laparotomy and 4-fold higher for laparoscopy-to-laparotomy (LtL) patients (P < .05). Diaphragmatic injuries were associated with significantly increased odds of undergoing LtL, whereas sustaining a colonic injury, gastric injury, hepatic injury, or requiring PRBC transfusions were associated with significantly increased odds of undergoing laparotomy (P < .05). H-LOS (days) was significantly longer for patients who underwent laparotomy compared to laparoscopy (3.9 ± 4.0 vs. 10.8 ± 13.4, P < .0001).

CONCLUSIONS

Laparoscopy may be considered a viable alternative to laparotomy for hemodynamically stable adult patients with single penetrating LUQ injuries of low injury burden validating our hypothesis. Laparoscopy may be less safe for patients with associated diaphragmatic, colonic, or hepatic injuries.

Diagnostic and Therapeutic Laparoscopy for Abdominal Trauma: A Single Surgeon’s Experience at a Level I Trauma Center

PurposeLaparoscopy has various advantages over laparotomy in terms of postoperative recovery. The number of surgeons using laparoscopy as a diagnostic and therapeutic tool in abdominal trauma patients is increasing, whereas open conversion is becoming less common. This report summarizes a single surgeon’s experience of laparoscopy at a level I trauma center and evaluates the feasibility of laparoscopy as a diagnostic and therapeutic tool for abdominal trauma patients. MethodsIn total, 30 abdominal trauma patients underwent laparoscopy by a single surgeon from October 2014 to May 2020. The purpose of laparoscopy was categorized as diagnostic or therapeutic. Patients were classified into three groups by type of surgery: total laparoscopic surgery (TLS), laparoscopy-assisted surgery (LAS), or open conversion (OC). Univariate analysis was performed to determine the advantages and disadvantages. ResultsThe mechanism of injury was blunt in 19 (63.3%) and penetrating in 11 patients (36.7%). Eleven (36.7%) and 19 patients (63.3%) underwent diagnostic and therapeutic laparoscopy, respectively. The hospital stay was shorter for patients who underwent diagnostic laparoscopy than for those who underwent therapeutic laparoscopy (5.0 days vs. 13.0 days), but no other surgical outcomes differed between the groups. TLS, LAS, and OC were performed in 12 (52.2%), eight (34.8%), and three patients (13.0%), respectively. There was no significant difference in morbidity and mortality among the three groups. ConclusionsLaparoscopic surgery for selected cases of abdominal trauma may be feasible and safe as a diagnostic and therapeutic tool in hemodynamically stable patients due to the low OC rate and the absence of fatal morbidity and mortality.

Impact of laparoscopy on the perioperative outcome of penetrating abdominal trauma management during the post revolution period

BACKGROUND

Penetrating abdominal trauma (PAT) poses a significant challenge to trauma surgeons. Laparotomy is still the most popular procedure for managing PAT but has high morbidity and mortality rates. Presently, laparoscopy aims to provide equal or superior visualization compared to open approaches but with less morbidity, postoperative discomfort, and recovery time. The aim of this research is to assess the impact of laparoscopy on the management of PAT.

METHODS

This was a retrospective observational study carried out at the Emergency Hospital of Mansoura University/Egypt and at King Faisal Medical Complex, Taif/KSA from September 2014 to September 2018. All hemodynamically stable patients with PAT who were managed by laparoscopy were included in this study. Data extracted for analysis included demographic information, criteria of abdominal stabs, type of management, and perioperative outcome.

RESULTS

Forty patients were recruited in this research and the male-to-female ratio was 5.6:1. The mean age of the patients was 31.4 ± 12.318 years. During the laparoscopic procedure, no peritoneal penetration was observed in 4 patients (negative laparoscopy), while peritoneal penetration was observed in the remaining 36 patients. No visceral injuries were noted in 2 patients of the 36 patients with peritoneal penetration, while the remaining 34 patients had intra-abdominal injuries.

CONCLUSION

Laparoscopy performed on hemodynamically stable trauma patients was found to be safe and technically feasible. It also reduced negative and non-therapeutic laparotomies and offered paramount therapeutic and diagnostic advantages for traumatic diaphragmatic injuries.

Time to surgery: Is it truly crucial in initially stable patients with penetrating injury?

BACKGROUND

Treatment recommendations for patients with penetrating abdominal injury are well established. Trauma victims with clear indications for surgery, should undergo immediate operative intervention without any delay or additional imaging. However, the optimal time for surgery remains unclear. There are some significant advantages in preoperative abdominal CT, including gathering essential information regarding a few difficult to reach anatomical areas, avoiding unnecessary explorations associated with increased morbidity and assessing the existence of extra-abdominal injuries that may have non-expectable impact on initial therapeutic plan. The aim of this study was to determine the impact of "time-to-surgery" on final medical outcomes in patients with penetrating abdominal trauma with normal blood pressure on admission.

METHODS

A retrospective cohort study using the Israeli National Trauma Registry was conducted from 2000- 2018. This study included trauma patients with penetrating injuries and a systolic blood pressure of 90mmHg or above on admission. All patients included in the study were divided into three groups according to the time that lapsed from their admission to surgery: half an hour, an hour, and two hours. We assessed the outcome for each patient, including length of hospital stay, need for intensive care and mortality. Statistical analysis was performed using the Chi-square test, ANOVA test. A p-value of less than 0.05 was considered statistically significant.

RESULTS

The study included 1,136 penetrating trauma patients. Among these, 78.0% (886) had sustained low-energy penetrating injury (SWPI) and 22.0% (250) had sustained high-energy penetrating injury (FAPI). Males accounted for 93.5% (1,062) of the patients. Mean age was 30.4. About 29% (327) of all the patients underwent surgery within 30 minutes from admission, 42% (475) within 30-60 min, and 29% (334) patients were operated within one to two hours. Patients who underwent surgery within 30 minutes, had worse ISS and GCS scores and were, therefore, more likely to have worse clinical outcomes. No other differences in outcomes were found in patients who were operated upon within 2 hours.

CONCLUSIONS

Time to surgery within two hours from admission has no impact on final outcomes in trauma patients with penetrating injury and normal blood pressure on admission.

Laparoscopic Management of Blunt and Penetrating Abdominal Trauma: A Single-Center Experience and Review of the Literature

Introduction: Trauma is a leading cause of death in young patients. The prevalence of blunt and penetrating trauma varies widely across the globe. Similarly, the global experience with laparoscopy in trauma patients also varies. There is a growing body of evidence to suggest that laparoscopy is feasible in trauma patients. We sought to contribute to these data by reporting our experience with laparoscopic management of blunt and penetrating trauma in a Belgian center. Materials and Methods: We retrospectively collected data on all trauma patients admitted to the Saint-Pierre University Hospital in Brussels, Belgium, over the 4-year period from January 2014 to December 2017. Hospital records for patients subjected to exploratory laparoscopy were retrospectively reviewed, and a descriptive analysis was reported. Results: There were 26 patients at a mean age of 40 years treated with laparoscopic exploration for injuries from blunt trauma (7), stab wounds (14), and gunshot injuries (5). The median interval between the arrival at the emergency unit and diagnostic laparoscopy was 175 minutes (range: 27-1440), and the median duration of operation was 119 minutes (range: 8-300). In all patients who underwent laparoscopy for trauma, there were 27% overall morbidity, no mortality, 11% reoperation rate, 7.4% conversions, and 19% incidence of negative laparoscopy. The median intensive care unit stay was 3 days (range: 0-41), and median total hospital stay was 7 days (range: 2-78). Conclusions: Laparoscopy is a safe, feasible, and effective tool in the surgical armamentarium to treat hemodynamically stable patients with blunt and penetrating abdominal trauma. It allows complete and thorough evaluation of intra-abdominal viscera, reduces the incidence of nontherapeutic operations, and allows therapeutic intervention to repair a variety of injuries. However, it requires appropriate surgeon training and experience with advanced laparoscopic techniques to ensure good outcomes.

Traumatic hollow viscus and mesenteric injury: role of CT and potential diagnostic-therapeutic algorithm

Despite its rarity, traumatic hollow viscus and mesenteric injury (HVMI) have high mortality and complication rates. There is no consensus regarding its best management. Our aim is to evaluate contrast enhanced CT (ceCT) in the screening of HVMI and its capability to assess the need for surgery. All trauma patients admitted to an urban Level 1 trauma center between 2010 and 2018 were retrospectively evaluated. Patients with ceCT scan prior to laparotomy were included. Patients requiring surgical repair of HVMI and a ceCT scan consistent with HVMI were considered true positives. Six ceCT scan criteria for HVMI were used; at least one criterion was considered positive for HVMI. Sensitivity (Sn), specificity (Sp), predictive values (PV), likelihood ratios (LR) and accuracy (Ac) of ceCT of single ceCT criteria and of the association of ceCT criteria were calculated using intraoperative findings as gold standard. Therapeutic time (TT), death probability (DP), and observed mortality (OM) were described. 114 of 4369 patients were selected for ceCT accuracy analysis; 47 were considered true positives. Sn of ceCT for HVMI was 97.9%, Sp 63.6%, PPV 66.2%, NPV 97.6%, + LR 2.69, −LR 0.03, Ac 78%; no single criterion stood out. The association of four or more criteria improved ceCT Sp to 98.5%, PPV to 95.6%, + LR to 30.5. Median TT was 2 h (IQR: 1–3 h). OM was 7.8%—not significantly higher than overall OM. CeCT in trauma has become a reliable screening test for HVMI and a valid exam to select HVMI patients for surgical exploration.

[Penetrating abdominal trauma]

The management of patients with penetrating abdominal trauma has significantly changed in recent years. While exploratory laparotomy was the gold standard in Germany in all patients up to the 1970s, selective nonoperative management (SNOM) is increasingly being discussed in hemodynamically stable patients without pathological findings in computed tomography (CT) scan or extended focussed assessment with sonography for trauma (eFAST). A standard algorithm taking a balance between invasiveness, patient safety and the use of resources into account has still to be implemented in Germany. The presented algorithm includes an immediate laparotomy in hemodynamically unstable patients as damage control surgery followed by a second look procedure after 48 h. Hemodynamically stable patients should primarily undergo diagnostic laparoscopy and be treated by early total care surgery, depending on the clinical and diagnostic imaging findings. Patients without clinical symptoms or pathological findings in imaging studies should be treated according to SNOM with close clinical controls.

[Value of laparoscopy in blunt and penetrating abdominal trauma-a systematic review]

BACKGROUND

The range of indications for laparoscopic procedures has been continuously widened in recent years. At the same time, however, the diagnostic and therapeutic role of laparoscopy in the management of blunt and penetrating abdominal trauma remains controversial.

METHODS

A systematic literature search was carried out in PubMed from 2008 to 2019 on the use of laparoscopy in blunt and penetrating abdominal trauma. Studies were analyzed in terms of relevant operative and perioperative event rates (rate of missed injuries, conversion rate, postoperative complication rate). On the basis of this analysis, an algorithm for the use of laparoscopy in abdominal trauma was developed for clinical practice.

RESULTS

A total of 15 full texts with 5869 patients were found. With a rate of 1.4%, laparoscopically missed injuries were very rare for both penetrating and blunt abdominal trauma. Of all trauma laparoscopies 29.3% were converted to open surgery (laparotomy). Among the non-converted laparoscopies 60.5% were therapeutic. Complications occurred after trauma laparoscopy in 8.6% of cases.

CONCLUSION

By means of systematic laparoscopic exploration, missed injuries in abdominal trauma are extremely rare, so that concerns in this respect no longer seem justified. A large proportion of intra-abdominal injuries can be treated using laparoscopy or laparoscopically assisted procedures.

Are we doing too many non-therapeutic laparotomies in trauma? An analysis of the National Trauma Data Bank

BACKGROUND

Exploratory laparotomy (EL) has been the definitive diagnostic and therapeutic modality for operative abdominal trauma in the US. Recently, many trauma centers have started using diagnostic laparoscopy (DL) in stable trauma patients in an effort to reduce the incidence of non-therapeutic laparotomy (NL). We aim to evaluate the incidence of NL in the trauma population in the US and compare the outcomes between DL and NL.

METHODS

Using ICD-9 codes, the National Trauma Data Bank (2010-2015) was queried for patients undergoing any abdominal surgical intervention. Patients were divided into two groups: diagnostic laparoscopy (DL) and exploratory laparotomy (EL). Hemodynamically unstable patients on arrival and patients with abbreviated injury score (AIS) > 3 were excluded. Patients in EL group without any codes for gastrointestinal, diaphragmatic, hepatic, splenic, vascular, or urological procedures were considered to have undergone NL. After excluding patients who were converted to open from the DL group, multivariate regression models were used to analyze the outcomes of DL vs NL group with respect to mortality, length of stay, and complications.

RESULTS

A total of 3197 patients underwent NL vs 1323 patients who underwent DL. Compared to DL group, the NL group were older (mean age: 35 vs. 31, P < 0.01). Rate of penetrating injury was 77% vs 86% for patients in NL vs DL. On multivariate analysis, NL was associated with increased mortality (OR 4.5, 95% CI 2.1-9.7), higher rate of complications (OR 2.2, 95% CI 1.4-3.3), and a longer hospital stay (OR 2.7, 95% CI 2.1-3.5). NL was also associated with higher rates of pneumonia, VTE, ARDS, and cardiac arrest.

CONCLUSION

With increasing experience in minimally invasive surgery, DL should be a part of the armamentarium of trauma surgeons. This study supports that in well-selected trauma patients DL has favorable outcomes compared to NL. These findings warrant further investigation.

"Pop in a scope": attempt to decrease the rate of unnecessary nontherapeutic laparotomies in hemodynamically stable patients with thoracoabdominal penetrating injuries

BACKGROUND

Management of patients with thoracoabdominal penetrating injuries is challenging. Thoracoabdominal penetrating trauma may harbor hollow viscus injuries in both thoracic and abdominal cavities and occult diaphragmatic lesions. While radiological tests show poor diagnostic performance in these situations, evaluation by laparoscopy is highly sensitive and specific. Furthermore, minimally invasive surgery may avoid unnecessary laparotomies, despite concerns regarding complication and missed injury rates. The objective of the present study is to evaluate the diagnostic and therapeutic performance of laparoscopy in stable patients with thoracoabdominal penetrating injuries.

METHODS

Retrospective analysis of hemodynamically stable patients with thoracoabdominal penetrating wounds was managed by laparoscopy. We collected data regarding the profile of the patients, the presence of diaphragmatic injury, perioperative complications, and the conversion rate. Preoperative imaging tests were compared to laparoscopy in terms of diagnostic accuracy.

RESULTS

Thirty-one patients were included, and 26 (84%) were victims of a stab wound. Mean age was 32 years. Ninety-three percent were male. Diaphragmatic lesions were present in 18 patients (58%), and 13 (42%) had associated injuries. There were no missed injuries and no conversions. Radiography and computerized tomography yielded an accuracy of 52% and 75%, respectively.

CONCLUSION

Laparoscopy is a safe diagnostic and therapeutic procedure in stable patients with thoracoabdominal penetrating wound, with low complication rate, and may avoid unnecessary laparotomies. The poor diagnostic performance of preoperative imaging exams supports routine laparoscopic evaluation of the diaphragm to exclude injuries in these patients.

Laparoscopic management of retroperitoneal injuries from penetrating abdominal trauma in haemodynamically stable patients

Background:

Laparoscopy is increasingly utilised in the trauma setting. However, its safety and reliability in evaluating and managing retroperitoneal injuries are not known.

Aim:

The aim of this study was to analyse our experience with laparoscopic management of retroperitoneal injuries due to penetrating abdominal trauma (PAT) and to investigate its feasibility, safety and accuracy in haemodynamically stable patients.

Methods:

Over a 4-year period, patients approached laparoscopically with retroperitoneal injuries were analysed. Mechanism, location and severity of injuries were recorded. Surgical procedures, conversion rate and reasons for conversion and outcomes were described.

Results:

Of the 284 patients with PAT, 56 patients had involvement of retroperitoneum. Stab wounds accounted 62.5% of patients. The mean Injury Severity Score was 7.4 (4–20). Among retroperitoneal injuries, the colon (27%) was the most commonly involved hollow viscera followed by duodenum (5%). The kidney (5%) and the pancreas (4%) were the injured solid organs. The conversion rate was 19.6% and was mainly due to active bleeding (73%). Significantly more patients with gunshot wound were converted to laparotomy (38% vs. 9%). Therapeutic laparoscopy was performed in 36% of patients. There were no recorded missed injuries or mortality. Five (9%) patients developed the Clavien-Dindo Grade 3 complications, three were managed with reoperation, one with drainage/debridement and one with endovascular technique.

Conclusion:

Laparoscopic management of retroperitoneal injuries is safe and feasible in haemodynamically stable patients with PAT. However, a high conversion rate indicates difficulties in managing these injuries. The requirements are the dexterity in laparoscopy and readiness to convert in the event of bleeding.

CT-guided tractography is a safe and complementary diagnostic tool in the management of penetrating abdominal trauma

BACKGROUND/OBJECTIVE

Despite extensive published research, the surgical approach to penetrating abdominal trauma patients is still under debate. Computed tomography-guided tractography (CTT) is an imaging modality in which water soluble iodinated contrast medium is administered into the site of the injury in the CT unit. The aim of this study was to determine the diagnostic accuracy of the CTT.

METHODS

A retrospective evaluation was made of patients admitted to the Emergency Department with penetrating abdominal trauma and who underwent CTT. Contrast enhanced abdominal CT and CTT reports, surgical findings and clinical results were examined.

RESULTS

Evaluation was made of a total of 101 patients comprising 89 males (88.1%) and 12 females (11.9%). CTT was determined to have 92.8% sensitivity, 93.6% specificity, 97% positive predictive value, and 85.5% negative predictive value. In 27 patients (26.7%) where the CTT indicated passage through the peritoneum, no parenchymal organ injury was present. Only one patient (2.9%) without peritoneal penetration on CTT had organ injury at exploration. No procedure-related morbidities developed.

CONCLUSION

CTT is a safe imaging modality for the evaluation of hemodynamically stable patients. Compared to other imaging modalities, there is clearer demonstration of whether or not the peritoneum is intact. However penetration on CTT does not exactly correlate with organ injury.

Laparoscopy for blunt abdominal trauma: a challenging endeavor

BACKGROUND AND AIMS

Laparoscopy in blunt abdominal trauma is challenging because of multiple associated injuries, higher trauma score values and higher morbidity and mortality, as compared with patients with penetrating abdominal trauma. The aim of this study was to investigate the role of laparoscopy in the management of blunt abdominal trauma patients and to highlight related challenges.

MATERIAL AND METHODS

Over a 4-year period, patients managed laparoscopically for blunt abdominal trauma were retrospectively analyzed. Perioperative details, indications for laparoscopy and conversion, complications, and length of hospital stay were discussed.

RESULTS

A total of 35 stable patients underwent laparoscopy. The mean Injury Severity Score was 12 (4-38). Therapeutic laparoscopy was performed in 15 (56%) and diagnostic in 12 (44%) patients. Eight (23%) patients were converted to therapeutic laparotomy. Intraoperative bleeding, complex injuries, visualization problem, and equipment failure necessitated conversion. Three (30%) patients with negative computed tomography scan had therapeutic laparoscopy for mesenteric injuries. There were no missed injuries. The mean length of hospital stay was 11 days in both groups.

CONCLUSION

Laparoscopy for stable patients is feasible and safe. Multiple injuries make laparoscopy more difficult, and advanced laparoscopic skills are required. The conversion rate is high; however, the non-therapeutic laparotomies were completely eliminated in this study.

Value of diagnostic and therapeutic laparoscopy for patients with blunt abdominal trauma: A 10-year medical center experience

Laparoscopy has been used for the diagnosis and treatment for hemodynamically stable patients with penetrating abdominal trauma. This study evaluated whether diagnostic and therapeutic laparoscopy can be used as effectively in select patients with blunt abdominal trauma. All hemodynamically stable patients undergoing operations for blunt abdominal trauma over a 10-year period (2006–2015) at a tertiary medical center were included. Patients undergoing laparotomy were categorized as group A. Patients who underwent laparoscopy were categorized as group B. The clinical outcomes of the 2 groups were compared. There were 139 patients in group A and 126 patients in group B. Group A patients were more severely injured (mean injury severity score of 23.3 vs. 18.9, P < .001) and had a higher frequency of traumatic brain injuries (25.2% vs. 14.3%, P = .039). The sensitivity and specificity of diagnostic laparoscopy for patients in group B was 99.1% and 100.0%, respectively. No non-therapeutic laparotomies were performed in group B, and the success rate of therapeutic laparoscopy was 92.0% (103/112) for patients with significant intra-abdominal injuries. Patients in the 2 groups had similar perioperative and postoperative outcomes in terms of operation times, blood loss, blood transfusion requirements, mortality, and complications (all, P > .05). Laparoscopy is a feasible and safe tool for the diagnosis and treatment of hemodynamically stable patients with blunt abdominal trauma who require surgery.

Hollow viscus injuries: predictors of outcome and role of diagnostic delay

INTRODUCTION

Hollow viscus injuries (HVIs) are uncommon but potentially catastrophic conditions with high mortality and morbidity rates. The aim of this study was to analyze our 16-year experience with patients undergoing surgery for blunt or penetrating bowel trauma to identify prognostic factors with particular attention to the influence of diagnostic delay on outcome.

METHODS

From our multicenter trauma registry, we selected 169 consecutive patients with an HVI, enrolled from 2000 to 2016. Preoperative, intraoperative, and postoperative data were analyzed to assess determinants of mortality, morbidity, and length of stay by univariate and multivariate analysis models.

RESULTS

Overall mortality and morbidity rates were 15.9% and 36.1%, respectively. The mean length of hospital stay was 23±7 days. Morbidity was independently related to an increase of white blood cells (P=0.01), and to delay of treatment >6 hours (P=0.033), while Injury Severity Score (ISS) (P=0.01), presence of shock (P=0.01), and a low diastolic arterial pressure registered at emergency room admission (P=0.02) significantly affected postoperative mortality.

CONCLUSION

There is evidence that patients with clinical signs of shock, low diastolic pressure at admission, and high ISS are at increased risk of postoperative mortality. Leukocytosis and delayed treatment (>6 hours) were independent predictors of postoperative morbidity. More effort should be made to increase the preoperative detection rate of HVI and reduce the delay of treatment.

Trauma laparoscopy: when to start and when to convert?

BACKGROUND

The use of laparoscopy for stable patients with abdominal trauma is increasing and its accuracy is nearly 100%. However, indications for laparoscopy and for conversion differ among centers. The aim of this study was to investigate indications for trauma laparoscopy and for conversion to laparotomy.

METHODS

All trauma patients managed with laparoscopy over a 4-year period were retrospectively analyzed. Indications for laparoscopy, morbidity, and reasons for conversion were investigated and predictors of morbidity and conversion were sought. The management algorithm of trauma patients was reviewed and updated.

RESULTS

Laparoscopy was used in 318 stable trauma patients. Thirty-five patients presented with blunt and 283 with penetrating abdominal injuries. The conversion rate was 11.7% for penetrating and 22.9% for blunt abdominal trauma patients. The most common reason for conversion was continuous intraabdominal bleeding that could not be controlled quickly. It was followed by multiple complex injuries, hemodynamic instability, and intraoperative visualization problems. Diagnostic laparoscopy was performed in 45%, and therapeutic laparoscopy in 55% of cases. There were no missed injuries. Complications occurred in 21.2% in the converted group and in 9.6% in the laparoscopic group. Among initial systolic blood pressure, pulse, hemoglobin, lactate, and base deficit levels, only lower pH was associated with conversion.

CONCLUSION

The management of all stable trauma patients with laparoscopy appears to be a safe approach. The use of sound laparoscopic equipment by a well-coordinated trauma team with adequate expertise in laparoscopy, adherence to the algorithm, and strict compliance with predetermined procedural steps are fundamental to success. Continuous intraoperative bleeding, complexity of injuries, deterioration of the patient, poor visibility, and equipment failure are indications for conversion.

Laparoscopic Versus Open Surgery for Abdominal Trauma: A Case-Matched Study

BACKGROUND

The use of laparoscopic surgery in abdominal emergencies, such as in trauma, has had a slow acceptance. The advantages described with this approach include less postoperative pain, faster recovery, quicker return to everyday activities, and fewer wound complications. The aim of this retrospective study was to compare outcomes following laparoscopic versus open surgery for abdominal trauma (either blunt or penetrating).

MATERIALS AND METHODS

Nineteen patients with abdominal trauma who underwent laparoscopic surgery from January 2013 to May 2016 were compared with 19 patients undergoing open surgery during the same time period. Patients were matched (1:1) for age, gender, body-mass index, American Society of Anesthesiologists score, hemodynamic stability, and injury mechanism. Intra- and postoperative variables were compared between groups.

RESULTS

Laparoscopic group displayed a significantly shorter operative time (93.3 versus 134.2 minutes; P < .009), lower estimated blood loss (100 versus 600 mL; P < .019), faster return to normal diet (1.6 versus 2.4 days; P < .039), and shorter hospital length of stay (LOS) (3.8 versus. 5.6 days; P < .042). There were no statistical significant differences in 30-day mortality between both groups.

CONCLUSIONS

Laparoscopic surgery for abdominal trauma, either blunt or penetrating, is safe and technically feasible in hemodynamically stable patients. We found in our study that laparoscopic surgery was associated with shorter operative time, lower estimated blood loss, faster return to normal diet, and shorter hospital LOS.

Diagnostic accuracy of triple-contrast multi-detector computed tomography for detection of penetrating gastrointestinal injury: a prospective study

PURPOSE

Neither the performance of CT in diagnosing penetrating gastrointestinal injury nor its ability to discriminate patients requiring either observation or surgery has been determined.

MATERIALS AND METHODS

This was a prospective, single-institutional observational study of patients with penetrating injury to the torso who underwent CT. Based on CT signs, reviewers determined the presence of a gastrointestinal injury and the need for surgery or observation. The primary outcome measures were operative findings and clinical follow-up. CT results were compared with the primary outcome measures.

RESULTS

Of one hundred and seventy-one patients (72 gunshot wounds, 99 stab wounds; age range, 18-57 years; median age, 28 years) with penetrating torso trauma who underwent CT, 45 % were followed by an operation and 55 % by clinical follow up. Thirty-five patients had a gastrointestinal injury at surgery. The sensitivity, specificity, and accuracy of CT for diagnosing a gastrointestinal injury for all patients were each 91 %, and for predicting the need for surgery, they were 94 %, 93 %, 93 %, respectively. Among the 3 % of patients who failed observation, 1 % had a gastrointestinal injury.

CONCLUSION

CT is a useful technique to diagnose gastrointestinal injury following penetrating torso injury. CT can help discriminate patients requiring observation or surgery.

KEY POINTS

• The most sensitive sign is wound tract extending up to gastrointestinal wall. • The most accurate sign is gastrointestinal wall thickening. • Triple-contrast CT is a useful technique to diagnose gastrointestinal injury. • Triple-contrast CT helps to discriminate patients requiring observation and surgery.

Epidemiology and outcome of penetrating injuries in a Western European urban region

PURPOSE

Severe life-threatening injuries in Western Europe are mostly caused by blunt trauma. However, penetrating trauma might be more common in urban regions, but their characteristics have not been fully elucidated.

METHODS

Retrospective analysis of data from patients admitted to our urban university level I trauma center between 2008 and 2013 with suspicion of severe multiple injuries. Collection of data was performed prospectively using a PC-supported online documentation program including epidemiological, clinical and outcome parameters.

RESULTS

Out of 2095 trauma room patients admitted over the 6-year time period 194 (9.3 %) suffered from penetrating trauma. The mean Injury Severity Score (ISS) was 12.3 ± 14.1 points. In 62.4 % (n = 121) the penetrating injuries were caused by interpersonal violence or attempted suicide, 98 of these by stabbing and 23 by firearms. We observed a widespread injury pattern where mainly head, thorax and abdomen were afflicted. Subgroup analysis for self-inflicted injuries showed higher ISS (19.8 ± 21.8 points) than for blunt trauma (15.5 ± 14.6 points). In 82.5 % of all penetrating trauma a surgical treatment was performed, 43.8 % of the patients received intensive care unit treatment with mean duration of 7.4 ± 9.3 days. Immediate emergency surgical treatment had to be performed in 8.0 vs. 2.3 % in blunt trauma (p < 0.001). Infectious complications of the penetrating wounds were observed in 7.8 %.

CONCLUSIONS

Specific characteristics of penetrating trauma in urban regions can be identified. Compared to nationwide data, penetrating trauma was more frequent in our collective (9.3 vs. 5.0 %), which may be due to higher crime rates in urban areas. Especially, self-inflicted penetrating trauma often results in most severe injuries.

Role of exploratory laparoscopy in haemodynamically stable patient with a penetrating abdominal trauma

A young lady presented to the hospital following a penetrating abdominal trauma. She was haemodynamically stable during the initial assessment. Despite fruitless finding from blood test, plain radiograph and computed tomographic scanning, a bowel contusion was found during an explorative laparoscopy. Here, we highlight the need for laparoscopy as a diagnostic and therapeutic tool in haemodynamically stable patient with a penetrating abdominal trauma.

Surgical outcomes of a civil war in a neighbouring country

OBJECTIVES

The civil war in Syria began on 15 March 2011, and many of the injured were treated in the neighbouring country of Turkey. This study reports the surgical outcomes of this war, in a tertiary centre in Turkey.

METHODS

159 patients with civilian war injuries in Syria who were admitted to the General Surgery Department in the Research and Training Hospital of the Medical School of Mustafa Kemal University, Hatay, Turkey, between 2011 and 2012 were analysed regarding the age, sex, injury type, history of previous surgery for the injury, types of abdominal injuries (solid or luminal organ), the status of isolated abdominal injuries or multiple injuries, mortality, length of hospital stay and injury severity scoring.

RESULTS

The median age of the patients was 30.05 (18-66 years) years. Most of the injuries were gunshot wounds (99 of 116 patients, 85.3%). Primary and previously operated patients were transferred to our clinic in a median time of 6.28±4.44 h and 58.11±44.08 h, respectively. Most of the patients had intestinal injuries; although a limited number of patients with colorectal injuries were treated with primary repair, stoma was the major surgical option due to the gross peritoneal contamination secondary to prolonged transport time. Two women and 21 men died. The major cause of death was multiorgan failure secondary to sepsis (18 patients).

CONCLUSIONS

In the case of civil war in the bordering countries, it is recommended that precautions are taken, such as transformation of nearby civilian hospitals into military ones and employment of experienced trauma surgeons in these hospitals to provide effective medical care. Damage control procedures can avoid fatalities especially before the lethal triad of physiological demise occurs. Rapid transport of the wounded to the nearest medical centre is the key point in countries neighbouring a civil war.