The use of laparoscopy in the diagnosis and treatment of blunt and penetrating abdominal injuries: 10-year experience at a level 1 trauma center

Predictive parameters for early detection of clinically relevant abdominal trauma in multiple-injury or polytraumatised patients: a retrospective analysis

Diagnosis of relevant organ injury after blunt abdominal injury (AI) in multiple-injury/polytraumatised patients is challenging. AI can be distinguished between injuries of parenchymatous organs (POI) of the upper abdomen (liver, spleen) and bowel and mesenteric injuries (BMI). Still, such injuries may be associated with delays in diagnosis and treatment. The present study aimed to verify laboratory parameters, imaging diagnostics, physical examination and related injuries to predict intraabdominal injuries. This retrospective, single-centre study includes data from multiple-injury/polytraumatised patients between 2005 and 2017. Two main groups were defined with relevant abdominal injury (AI+) and without abdominal injury (AI-). The AI+ group was divided into three subgroups: BMI+, BMI+/POI+, and POI+. Groups were compared in a univariate analysis for significant differences. Logistic regression analysis was used to determine predictors for AI+, BMI+ and POI+. 26.3% (271 of 1032) of the included patients had an abdominal injury. Subgroups were composed of 4.7% (49 of 1032) BMI+, 4.7% (48 of 1032) BMI+/POI+ and 16.8% (174 of 1032) POI+. Pathological abdominal signs had a sensitivity of 48.7% and a specificity of 92.4% for AI+. Transaminases were significantly higher in cases of AI+. Pathological computed tomography (CT) (free fluid, parenchymal damage, Bowel Injury Prediction Score (BIPS), CT Grade > 4) was summarised and had a sensitivity of 94.8%, a specificity of 98%, positive predictive value (PPV) of 94.5% and, negative predictive value (NPV) of 98.2% for AI+. The detected predictors for AI+ were pathological abdominal findings (odds ratio (OR) 3.93), pathological multi-slice computed tomography (MSCT) (OR 668.9), alanine (ALAT) ≥ 1.23 µmol/ls (OR 2.35) and associated long bone fractures (OR 3.82). Pathological abdominal signs, pathological MSCT and lactate (LAC) levels ≥ 1.94 mmol/l could be calculated as significant risk factors for BMI+. For POI+ pathological abdominal MSCT, ASAT ≥ 1.73 µmol/ls and concomitant thoracic injuries had significant relevance. The study presents reliable risk factors for abdominal injury and its sub-entities. The predictors can be explained by the anatomy of the trunk and existing studies. Elevated transaminases predicted abdominal injury (AI+) and, specifically, the POI+. The pathological MSCT was the most reliable predictive parameter. However, it was essential to include further relevant parameters.

Nationwide Trends in Utilization of Minimally Invasive Techniques for Blunt Abdominal Trauma

BACKGROUND

Despite increasing use of minimally invasive surgical (MIS) techniques for trauma, limited large-scale studies have evaluated trends, outcomes, and resource utilization at centers that utilize MIS modalities for blunt abdominal trauma.

METHODS

Operative adult admissions after blunt assault, falls, or vehicular collisions were tabulated from the 2016-2020 National Inpatient Sample. Patients who received diagnostic laparoscopy or other laparoscopic and robotic intervention were classified as MIS. Institutions with at least one MIS trauma operation in a year were defined as an MIS Performing Institution (MPI; rest: non-MPI). The primary endpoint was mortality, with secondary outcomes of reoperation, complication, postoperative length of stay (LOS), and hospitalization costs. Mixed regression models were used to determine the association of MPI status on the outcomes of interest.

RESULTS

Throughout the study period, the proportion of MIS operations and MPI significantly increased from 22.6 to 29.8% and 45.9 to 58.8%, respectively. Of an estimated 77,480 patients, 66.7% underwent care at MPI. After adjustment, MPI status was not associated with increased odds of mortality (adjusted odds ratio [AOR] 1.09, 95% confidence interval [CI] [.96,1.24]), reoperation (AOR 1.02, CI [.87,1.19]), or any of the tabulated complications. There was additionally no difference in adjusted LOS (β-.18, CI [-.85, +.49]) or costs (β+$1600, CI [-1600, +4800]), between MPI and non-MPI.

DISCUSSION

The use of MIS operations in blunt abdominal trauma has significantly increased, with performing centers experiencing no difference in mortality or resource utilization. Prospectively collected data on outcomes following MIS trauma surgery is necessary to elucidate appropriate applications.

Could trauma laparoscopy be the standard of care for hemodynamically stable patients? A retrospective analysis of 165 cases

BACKGROUND

Trauma laparoscopy may provide a less invasive alternative to laparotomy by providing accurate diagnosis and minimally invasive management of selected trauma patients. The risk of missing injuries during the laparoscopic evaluation still refrains surgeons from using this approach. Our aim was to evaluate feasibility and safety of trauma laparoscopy in selected patients.

METHODS

We performed a retrospective review of hemodynamically trauma patients who underwent laparoscopic management in a tertiary center in Brazil due to abdominal trauma. Patients were identified by searching through the institutional database. We collected demographic and clinical data, focusing on avoidance of exploratory laparotomy, and missed injury rate, morbidity, and length of stay. Categorical data were analyzed using Chi-square, while numerical comparisons were performed using Mann-Whitney and Kruskal-Wallis test.

RESULTS

We evaluated 165 cases, of which 9.7% needed conversion to an exploratory laparotomy. One-hundred and twenty-one patients (73%) had at least one intrabdominal injury. Two missed injuries to retroperitoneal organs were identified (1.2%), of which only one was clinically relevant. Three patients died (1.8%), one of which was due to complications from an intestinal injury after conversion. No deaths were related to the laparoscopic approach.

CONCLUSION

In selected hemodynamically stable trauma patients, the laparoscopic approach is feasible and safe, and reduces the need for exploratory laparotomy and its associated complications.

Laparoscopy has better performance than laparotomy in the treatment of stable penetrating abdominal trauma: A retrospective cross-sectional study in a trauma referral hospital in Colombia

Background

Abdominal trauma is one of the leading causes of death. In Colombia, few studies have evaluated the results on related factors and outcomes when comparing laparotomy versus laparoscopy in the management of penetrating abdominal trauma. Therefore, the aim of this study was to investigate the feasibility and safety of laparoscopy in the treatment of stable penetrating abdominal trauma in a limited resources environment in a middle-income country.

Methods

Retrospective cross-sectional study was conducted in Bogota, Colombia from January 2018 to October 2020. Patients over 18 years old, hemodynamically stable with penetrating abdominal trauma without other body parts injuries, that underwent laparoscopy and/or laparotomy surgical exploration and treatment were included. Frequencies, percentages, correlations, and odds ratio were calculated.

Results

A total of 52 patients were analyzed (26 laparoscopy vs. 26 laparotomy). Stabbing injuries were more frequent in both groups (76.9%), as well as involvement of the anterior abdomen. None missed enterotomies were reported in the laparoscopy group. Surgical time and bleeding were significantly lower in the laparoscopic approach group (63 vs. 115 min and 65 vs. 992 cc, respectively). The time to oral intake and length of stay in the intensive care unit was significantly shorter in the laparoscopic management group (2 vs. 3 days and 1 vs. 4 days, respectively).

Conclusions

Surgical results found a safe scenario in a limited resources environment for the application of the laparoscopic technique to approach penetrating abdominal trauma in stable patients without missed injuries, low threshold of conversion to open approach, and additionally not presenting a higher percentage of complications compared with the laparotomy group in Colombia. Operative time, oral intake, and length of hospital stay were lower in the fully therapeutic laparoscopy group.

WSES guidelines on blunt and penetrating bowel injury: diagnosis, investigations, and treatment

The aim of this paper was to review the recent literature to create recommendations for the day-to-day diagnosis and surgical management of small bowel and colon injuries. Where knowledge gaps were identified, expert consensus was pursued during the 8th International Congress of the World Society of Emergency Surgery Annual (September 2021, Edinburgh). This process also aimed to guide future research.

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.

The Efficacy and Safety of Laparoscopy for Blunt Abdominal Trauma: A Systematic Review and Meta-Analysis

The efficacy and safety of laparoscopy for blunt trauma remain controversial. This systemic review and meta-analysis aimed to evaluate the usefulness of laparoscopy in blunt trauma. The PubMed, EMBASE, and Cochrane databases were searched up to 23 February 2021. Meta-analyses were performed using odds ratios (ORs), standardized mean differences (SMDs), and overall proportions. Overall, 19 studies with a total of 1520 patients were included. All patients were hemodynamically stable. In the laparoscopy group, meta-analysis showed lesser blood loss (SMD −0.28, 95% confidence interval (CI) −0.51 to −0.05, I² = 62%) and shorter hospital stay (SMD −0.67, 95% CI −0.90 to −0.43, I² = 47%) compared with the laparotomy group. Pooled prevalence of missed injury (0.003 (95% CI 0 to 0.023), I² = 0%), nontherapeutic laparotomy (0.004 (95% CI 0.001 to 0.026), I² = 0%), and mortality (0.021 (95% CI 0.010 to 0.043), I² = 0%) were very low in blunt trauma. In subgroup analysis, recently published studies (2011–present) showed lesser conversion rate (0.115 (95% CI 0.067 to 0.190) vs. 0.391 (95% CI 0.247 to 0.556), test for subgroup difference: p < 0.01). This meta-analysis suggests that laparoscopy is a safe and feasible option in hemodynamic stable patients with blunt abdominal trauma.

Diagnostic options for blunt abdominal trauma

PURPOSE

Physical examination, laboratory tests, ultrasound, conventional radiography, multislice computed tomography (MSCT), and diagnostic laparoscopy are used for diagnosing blunt abdominal trauma. In this article, we investigate and evaluate the usefulness and limitations of various diagnostic modalities on the basis of a comprehensive review of the literature.

METHODS

We searched commonly used databases in order to obtain information about the aforementioned diagnostic modalities. Relevant articles were included in the literature review. On the basis of the results of our comprehensive analysis of the literature and a current case, we offer a diagnostic algorithm.

RESULTS

A total of 86 studies were included in the review. Ecchymosis of the abdominal wall (seat belt sign) is a clinical sign that has a high predictive value. Laboratory values such as those for haematocrit, haemoglobin, base excess or deficit, and international normalised ratio (INR) are prognostic parameters that are useful in guiding therapy. Extended focused assessment with sonography for trauma (eFAST) has become a well established component of the trauma room algorithm but is of limited usefulness in the diagnosis of blunt abdominal trauma. Compared with all other diagnostic modalities, MSCT has the highest sensitivity and specificity. Diagnostic laparoscopy is an invasive technique that may also serve as a therapeutic tool and is particularly suited for haemodynamically stable patients with suspected hollow viscus injuries.

CONCLUSIONS

MSCT is the gold standard diagnostic modality for blunt abdominal trauma because of its high sensitivity and specificity in detecting relevant intra-abdominal injuries. In many cases, however, clinical, laboratory and imaging findings must be interpreted jointly for an adequate evaluation of a patient's injuries and for treatment planning since these data supplement and complement one another. Patients with blunt abdominal trauma should be admitted for clinical observation over a minimum period of 24 h since there is no investigation that can reliably rule out intra-abdominal injuries.

Management of multiple traumas in emergency medicine department: A review

One of the main causes of adults' disability during their working age is multiple trauma. The process of medical care of patients who are injured seriously is still a challenging job. The primary treatment of these patients in the emergency medicine departments is the most required choice after the wilderness first aid and also would be very required before definitive care in the hospital. The main aim of emergency medicine departments is quick recognition and treatment of injuries which pose severe threat to patients' life in appropriate order of priority. The procedure of primary evaluation in emergency medicine department with the help of medical routine examination and ultrasonography is based on the concept of focused assessment with sonography in trauma (FAST) for identifying spontaneous intraperitoneal hemorrhage. Emergency patients who suffer from massive hematothorax, serious lung and heart traumas, and penetrating traumas to the chest would undergo thoracotomy and patients who have few symptoms of perforated hollow viscous will undergo emergency laparotomy. Based on the trauma severity, emergency treatment could be the way to fast recovery of the structure of injured organ and its function. The subsequent goal, in the acute phase, will concentrate on preventing and stopping bleeding and secondary injuries like painful compartment syndrome or intra-abdominal infections (IAIs). However, the main aim of emergency medicine department in taking care of severely injured patients is the management of airway, protecting circulation and breathing, identification of neurologic problems, and whole body clinical examination with the help of healthcare providers.

Duodeno-pancreatic and extrahepatic biliary tree trauma: WSES-AAST guidelines

Duodeno-pancreatic and extrahepatic biliary tree injuries are rare in both adult and pediatric trauma patients, and due to their anatomical location, associated injuries are very common. Mortality is primarily related to associated injuries, but morbidity remains high even in isolated injuries. Optimal management of duodeno-bilio-pancreatic injuries is dictated primarily by hemodynamic stability, clinical presentation, and grade of injury. Endoscopic and percutaneous interventions have increased the ability to non-operatively manage these injuries. Late diagnosis and treatment are both associated to increased morbidity and mortality. Sequelae of late presentations of pancreatic injury and complications of severe pancreatic trauma are also increasingly addressed endoscopically and with interventional radiology procedures. However, for moderate and severe extrahepatic biliary and severe duodeno-pancreatic injuries, immediate operative intervention is preferred as associated injuries are frequent and commonly present with hemodynamic instability or peritonitis. The aim of this paper is to present the World Society of Emergency Surgery (WSES) and American Association for the Surgery of Trauma (AAST) duodenal, pancreatic, and extrahepatic biliary tree trauma management guidelines.

Outcome of trauma-related emergency laparotomies, in an era of far-reaching specialization

Background

Far reaching sub-specialization tends to become obligatory for surgeons in most Western countries. It is suggested that exposure of surgeons to emergency laparotomy after trauma is ever declining. Therefore, it can be questioned whether a generalist (i.e., general surgery) with additional differentiation such as the trauma surgeon, will still be needed and can remain sufficiently qualified. This study aimed to evaluate volume trends and outcomes of emergency laparotomies in trauma.

Methods

A retrospective cohort study was performed in the University Medical Center Utrecht between January 2008 and January 2018, in which all patients who underwent an emergency laparotomy for trauma were included. Collected data were demographics, trauma-related characteristics, and number of (planned and unplanned) laparotomies with their indications. Primary outcome was in-hospital mortality; secondary outcomes were complications, length of ICU, and overall hospital stay.

Results

A total of 268 index emergency laparotomies were evaluated. Total number of patients who presented with an abdominal AIS > 2 remained constant over the past 10 years, as did the percentage of patients that required an emergency laparotomy. Most were polytrauma patients with a mean ISS = 27.5 (SD ± 14.9). The most frequent indication for laparotomy was hemodynamic instability or ongoing blood loss (44%).Unplanned relaparotomies occurred in 21% of the patients, mostly due to relapse of bleeding. Other complications were anastomotic leakage (8.6%), intestinal leakage after bowel contusion (4%). In addition, an incisional hernia was found in 6.3%. Mortality rate was 16.7%, mostly due to neurologic origin (42%). Average length of stay was 16 days with an ICU stay of 5 days.

Conclusion

This study shows a persistent number of patients requiring emergency laparotomy after (blunt) abdominal trauma over 10 years in a European trauma center. When performed by a dedicated trauma team, this results in acceptable mortality and complication rates in this severely injured population.

Laparoscopic Management of Pediatric Abdominal Trauma: A National Trauma Data Bank Experience

Purpose: To characterize injury patterns and institutional trends associated with the utilization of laparoscopy in the management of pediatric abdominal trauma. Methods: The National Trauma Data Bank (2010-2014) was queried for encounters involving patients ≤14 years who underwent an open or laparoscopic abdominal operation within 48 hours of emergency department arrival. Patient, injury, and hospital characteristics associated with each approach were identified. Multivariate logistic regression was used to evaluate the influence of patient and hospital characteristics on operative approach. Results: Laparoscopy comprised 7.8% (n = 355) of all abdominal trauma operations. Patients undergoing laparoscopy had lower injury severity scores and higher Glasgow Coma Scale scores on arrival compared with laparotomy subjects (P < .001). Laparoscopic patients also had a shorter length of hospital stay (5.0 versus 8.6 days, P < .001), but longer time to the operating room (9.2 versus 6.3 hours, P < .001) compared with their open counterparts. The proportion of cases managed laparoscopically increased from 6.2% in 2010 to 10.1% in 2014 (P = .013), with increase in utilization primarily driven by university hospitals (P = .026) and level I pediatric trauma centers (P = .043). Conversion to laparotomy was uncommon (18.6%), and mortality in the laparoscopic cohort was low (0.4%). Conclusions: Use of laparoscopy has increased in the pediatric abdominal trauma population, typically in a less injured cohort of patients. As familiarity with and availability of minimally invasive techniques increase, this trend will likely continue.

[Early clinical care strategy for severely injured patients with abdominal trauma]

BACKGROUND

The presence of abdominal injuries has a major impact on the mortality of severely injured patients. For injuries that require surgery, laparotomy is still the gold standard for early surgical care; however, there is increasing evidence that laparoscopy may be an alternative in the early clinical care of polytrauma patients.

OBJECTIVE

The present registry-based study analyzed the utilization and the outcome of laparoscopy in severely injured patients with abdominal trauma in Germany.

MATERIAL AND METHODS

A retrospective analysis of 12,447 patients retrieved from the TraumaRegister DGU^® (TR-DGU) was performed. The primary inclusion criteria were an injury severity score (ISS) ≥ 9 and an abbreviated injury scale (AIS) [abdomen] ≥ 1. The included patients were grouped according to early treatment management: (1) laparoscopy, (2) laparotomy and (3) non-operative management (NOM). Finally, group-specific patient characteristics and outcome were analyzed.

RESULTS

The majority of patients were treated by NOM (52.4%, n = 6069), followed by laparotomy (50,6%, n = 6295) and laparoscopy (0.7%, n = 83). The majority of laparoscopies were performed in patients with an AIS [abdomen] ≤ 3 (86.7%). The ISS of the laparoscopy group was significantly lower compared to that of the laparotomy and NOM groups (ISS 23.4 vs. 34.5 vs. 28.2, respectively, p ≤ 0.001). The standardized mortality rate (SMR), defined as the ratio between observed and expected mortality, was lowest in the patients receiving laparoscopy followed by laparotomy and NOM (SMR 0.688 vs. 0.931 vs. 0.932, respectively, p-value = 0.2128) without achieving statistical significance.

CONCLUSION

Despite being rarely employed the data indicate the effectiveness of laparoscopy for the early treatment of severely injured, hemodynamically stable patients with an AIS [abdomen] ≤ 3.

Epidemiology of Traumatic Esophageal Injury: An Analysis of the National Trauma Data Bank

Existing literature on traumatic injury of the esophagus (TIE) is limited. We aimed to describe the clinical characteristics and outcomes of TIE. We reviewed the National Trauma Data Bank for the years 2010–2015. We described the demographics, characteristics, and outcomes of adult (age ≥16 years) TIE patients and also compared those factors in blunt versus penetrating TIE. The association between TIE and mortality was analyzed using multivariable logistic regression. Thousand four hundred eleven adult TIE patients were identified (37 per 100,000 trauma patients, 95% confidence intervals (CI): 35, 39). TIE patients were younger (38 vs 52 years), more likely to be male (81% vs 62%), and more severely injured (Injury Severity Score ≥ 25: 45% vs 7%) than patients without TIE (all P < 0.001). TIE was observed 16 times more frequently with penetrating injuries (257 per 100,000, 95% CI: 240, 270) than with blunt injuries (16 per 100,000, 95% CI: 15, 18). Inhospital TIE mortality was 19 per cent. TIE patients had greater risk of mortality than other trauma patients, after adjusting for age, gender, and Injury Severity Score (odds ratio = 1.4, 95% CI: 1.1, 1.7). Mortality in blunt and penetrating TIE did not differ. Although extremely rare, TIE is independently associated with a marked increase in mortality, even after adjusting for other risk factors.

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.

Visceral Injuries in Patients with Blunt and Penetrating Abdominal Trauma Presenting to a Tertiary Care Facility in Karachi, Pakistan

Introduction

Abdominal injuries are responsible for 10% of the mortalities due to trauma. Delays in early diagnosis or misdiagnoses are two major reasons for the mortality and morbidity associated with abdominal trauma. The objectives of this study were to determine the frequency of visceral injuries in patients with abdominal trauma and compare the frequency of visceral injuries in patients with blunt and penetrating abdominal trauma.

Methods

We conducted a cross-sectional study from May 2016 to May 2018 of patients presenting to the emergency department (ED) at Jinnah Postgraduate Medical Center in Karachi, Pakistan. Patients were 12 to 65 years old and presented within 24 hours of abdominal trauma. We recorded the type of abdominal visceral injuries, such as liver, spleen, intestine, stomach, mesentery, and pancreas.

Results

The mean patient age was 31 ±13 years. Penetrating trauma was found in most patients (n=72, 51%). Liver injuries were found in 37 patients (26.4%), spleen injuries in 29 patient (20.7%), stomach injuries in eight patients (5.7%), intestine injuries in 67 patients (47.9%), mesentery injuries in 21 patients (15%), and pancreas injuries in nine patients (6.4%). The type of abdominal trauma was found significantly associated with liver injury (p-value 0.021), and intestine injury (p-value <0.001).

Conclusion

Penetrating trauma (51.4%) was more common than blunt trauma (48.5%), and intestines are the most commonly affected by penetrating and blunt trauma injuries (70.1% and 47.8%, respectively). The liver is the most commonly affected (42.85%) in blunt trauma injuries, followed by the spleen (28.5%). The appropriate authorities should consider this information when instituting public health and safety initiatives.

Laparoscopy for Trauma and the Changes in its Use From 1990 to 2016: A Current Systematic Review and Meta-Analysis

BACKGROUND

The role of laparoscopy in the diagnosis and treatment of stable abdominal trauma patients is still a matter of serious debate and only incomplete data are available.

MATERIALS AND METHODS

We performed a systematic review and meta-analysis of the literature between January 1990 and August 2016.

RESULTS

Overall, 9817 laparoscopies were performed for abdominal trauma; only 26.2% of the cases were converted to a laparotomy. The incidence of therapeutic laparotomies showed a reduction from 69% to 47.5%, whereas the incidence of therapeutic laparoscopies increased from 7.2% to 22.7%.The overall perioperative mortality rate was significantly lower in the laparoscopy group [odds ratio (M-H, random); 95% confidence interval, 0.35 (0.26-0.48)]. The same group showed shorter length of hospital stay [odds ratio (M-H, random); 95% confidence interval, -3.48 (-8.91 to 1.96)].

CONCLUSIONS

This systematic review shows a significant decrease in the use of laparoscopy in trauma patients. Most likely the widespread use of imaging techniques allows a more accurate selection of patients for diagnostic laparoscopy. Infact, a reduction in incidence of nontherapeutic laparotomies is evident in these selected patients undergoing diagnostic laparoscopy. Moreover, the literature reported an increasing trend of therapeutic laparoscopy, demonstrating that it is safe and effective. The small number and poor quality of the studies identified, the retrospective observational nature of the studies (low level of evidence), the high risk of bias, and the high heterogeneity of some outcomes make the applicability of the results of this meta-analysis unclear.

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.

Outcomes of selective surgery in patients with suspected small bowel injury from blunt trauma

Purpose

The role of initial conservative therapy with selective surgery for patients with suspected blunt bowel injury by radiologic evaluation is less clear. The aim of the study is to assess the outcomes of patients who received initial conservative therapy with selective delayed surgery, compared to emergency surgery.

Methods

During this 8-year study, a total of 77 patients who were hemodynamically stable were enrolled, in which computed tomography verified suspected bowel injury from blunt trauma (mesenteric hematoma, mesenteric fat infiltration, bowel wall thickening, and free fluid without solid organ injury) was managed with either initial conservative therapy with selective delayed surgery (group A; n = 42) or emergency surgery (group B; n = 35). The clinical outcomes including the rate of negative or nontherapeutic exploration and postoperative complications, between the groups were compared.

Results

The enrolled patients had a mean age of 41 years including 51 men and 26 women. No difference in the clinical characteristics was found between the groups. In group A, 18 patients underwent delayed surgery and 24 recovered without surgery. Among patients who underwent surgery, 3 (17%) underwent negative or nontherapeutic explorations. In group B, 13 (37%) underwent negative or nontherapeutic explorations. Postoperative complications occurred in 21 patients and there was no difference between the groups.

Conclusion

Initial conservative therapy with selective delayed surgery did not increased severe postoperative complications and had a low rate of negative or nontherapeutic surgical explorations in hemodynamically stable patients with suspected blunt bowel injury.

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.

The use of laparoscopy in managing penetrating thoracoabdominal injuries in Africa: 83 cases reviewed

Background

The use of laparoscopy in managing haemodynamically stable patients with penetrating thoracoabdominal injuries in developed countries is wildly practiced, but in Africa, the use of laparoscopy is still in its infancy stage. We reviewed a single centre experience in using laparoscopy in Africa for management of patients with both isolated diaphragmatic injuries as well as diaphragmatic injuries associated with intra-abdominal injuries requiring intervention.

Methods

A retrospective analysis of prospectively collected data of patients presenting with penetrating thoracoabdominal injuries was done. All patients offered laparoscopic exploration and repair from January 2012 to December 2015 at Dr. George Mukhari Academic Hospital were analysed. Means (±SD) were presented for continuous variables, and frequencies (%) were presented for categorical variables. All analyses were performed using SAS version 9.3 (SAS Institute, Cary, NC).

Results

A total of 83 stable patients with penetrating thoracoabdominal injuries managed with laparoscopy met the inclusion criteria and were included in the study. The Injury Severity Score ranged from 8 to 24, with a median of 18. The incidence of diaphragmatic injuries was 54%. Majority (46.8%) of patients had Grade 3 (2–10 cm defect) diaphragmatic injury. Associated intra-abdominal injuries requiring intervention were encountered in 28 (62%) patients. At least 93.3% of the patients were treated exclusively with laparoscopy. The morbidity was encountered in 7 (16%) patients; the most common cause was a clotted haemothorax Clavien-Dindo III-b, but only 1 patient required a decortication. There was one non-procedure-related mortality.

Conclusions

A success rate of 93% in using laparoscopy exclusively was documented, with an overall 82% uneventful outcome. The positive outcomes found in this study when laparoscopy was used in stable patients with thoracoabdominal injuries support similar work done in other trauma centres. However, in addition, this study seem to suggest that the presence of peritonitis in stable patient is not a contra-indication to laparoscopy and thoracoscopy may be useful especially in right side diaphragmatic injury where the liver can preclude adequate visualization of the entire diaphragm and to thoroughly clean the chest cavity and prevent future complication such as residual clotted haemothorax.

Clinical relevance: The presence of peritonitis in stable patients with penetrating thoracoabdominal injury is not a contra-indication to laparoscopy provided the operating surgeon has adequate laparoscopic skills.

Duodenal trauma

Duodenal trauma represents a unique challenge to the surgeon due to its relative rarity, anatomic location, and often the difficulty in diagnosing and managing these injuries. Despite these challenges, significant advances have been made over the previous century, and mortality has fallen to as low as 17%. The CT scan is the primary modality for diagnosis in the blunt trauma patient, and thorough surgical exploration at laparotomy is the mainstay for penetrating injuries. Management is guided by the grade of injury, with low-grade hematomas managed by observation, intermediate grade injuries by primary repair, and high-grade injuries with a damage control surgery approach. While pyloric exclusion remains the most common technique to augment primary repair in intermediate and higher grade injuries, the utility of this procedure has come into question in current literature, and an overall ‘less-is-more’ surgical approach has been advocated in recent publications. Complications following duodenal trauma are common and include fistulae, duodenal obstruction, and infectious complications. However, the overall morbidity and mortality have improved with these injuries. Future investigation is needed to determine the optimal management approach for these challenging patients.

Laparoscopy in Blunt Abdominal Trauma: for Whom? When?and Why?

The management of blunt abdominal trauma has evolved over time. While laparotomy is the standard of care in hemodynamically unstable patients, stable patients are usually treated by non-operative management (NOM), incorporating adjuncts such as interventional radiology. However, although NOM has shown good results in solid organ injuries, other lesions, namely those involving the hollow viscus, diaphragm, and mesentery, do not qualify for this approach and need surgical exploration. Laparoscopy can substantially reduce additional surgical aggression. It has both diagnostic and therapeutic potential and, when negative, may reduce the number of unnecessary laparotomies. Although some studies have shown promising results on the use of laparoscopy in blunt abdominal trauma, randomized controlled studies are lacking. Laparoscopy requires adequate training and experience as well as sufficient staffing and equipment.

CT scan and Diagnostic Peritoneal Lavage: towards a better diagnosis in the area of nonoperative management of blunt abdominal trauma

BACKGROUND

The diagnosis of small bowel and mesenteric injuries (BBMI) after blunt abdominal trauma remains difficult, which results in delayed treatment and increased mortality and morbidity. Diagnostic peritoneal lavage (DPL) in patients with 1 or 2 abnormal CT findings that are suggestive of BBMI was proposed, but the rate of unnecessary surgical exploration remains high.

PATIENTS AND METHODS

Blunt abdominal trauma patients with 1 or 2 CT findings predictive of BBMI from 2001 to 2014 underwent a DPL with calculation of a cell count ratio (CCR) dividing the ratio of white blood cells (WBCs) to red blood cells (RBCs) (WBC/RBC ratio) in the lavage fluid by the WBC/RBC ratio in peripheral blood. Surgical exploration of the abdomen was performed immediately in cases with a CCR≥1. CT findings, DPL and surgery results, and global outcome were analyzed.

RESULTS

Thirty-seven were included in the study (27 males, median age of 30 years (range, 17-69 years)). Exploratory laparotomy was performed in 24 patients (65%). Sixteen patients (67%) had BBMI: 7 hollow organ perforations or tears (29%), including 4 bowel resection with primary anastomosis and 3 single sutures, and 9 patients had mesenteric injuries. CT findings associated with BBMI and hollow organ perforation were large peritoneal effusion (p=0.02) and small bowel wall abnormalities (p=0.002). No postoperative complications were observed. Sensitivity and specificity of DPL for the diagnosis of bowel injuries were respectively 100% (CI 95% [59-100]) and 43% (CI 95% [25-63]). The sensitivity remained 100% (CI 95% [59-100]) when the ratio was ≥4 (n=10 patients), and the specificity reached 90% (CI 95% [73-98]).

CONCLUSION

DPL is sensitive for the diagnosis of BBMI in stable trauma patients with 1 or 2 unexplained CT abnormalities, but specificity is low with a high rate of nontherapeutic laparotomy in case of CCR≥1. Indications for exploratory laparotomy could be restricted to patients with a CCR≥4 to improve the specificity of diagnosis management.

The Use of Laparoscopy in the Management of Trauma Patients: Brief review

Laparoscopy is one of the most effective intervention modalities, resulting in improved outcomes for major surgeries. In the past decade, the laparoscopic approach in trauma patients has shown better diagnostic outcomes than traditional laparotomies. Furthermore, this approach is cost-effective, significantly reduces the length of hospital stay and contributes to reduced complication rates. However, the use of laparoscopies in trauma cases is generally restricted to patients with normal haemodynamic parameters and is contraindicated for individuals with head injuries. With advances in knowledge and improved training, laparoscopies can also be used in the treatment of other conditions, such as diaphragmatic injuries and organ lacerations. This article briefly reviews the extent of laparoscopy use and its significance in the management of trauma patients.

Minimally invasive is maximally effective: Diagnostic and therapeutic laparoscopy for penetrating abdominal injuries

BACKGROUND

Laparoscopic techniques have evolved, allowing increased capabilities within most subspecialties of general surgery, but have failed to gain traction managing injured patients. We hypothesized that laparoscopy is effective in the diagnosis and treatment of penetrating abdominal injuries.

METHODS

We retrospectively reviewed patients undergoing abdominal exploration following penetrating trauma at our Level 1 trauma center during a 6-year period from January 1, 2008, to December 31, 2013. Demographic and resuscitation data were obtained from our trauma registry. Charts were reviewed for operative details, hospital course, and complications. Hospital length of stay (LOS) and complications were primary end points. Patients were classified as having nontherapeutic diagnostic laparoscopy (DL), nontherapeutic diagnostic celiotomy (DC), therapeutic laparoscopy (TL), or therapeutic celiotomy (TC). TL patients were case-matched 2:1 with TC patients having similar intra-abdominal injuries.

RESULTS

A total of 518 patients, including 281 patients (55%) with stab wounds and 237 patients (45%) with gunshot wounds, were identified. Celiotomy was performed in 380 patients (73%), laparoscopy in 138 (27%), with 44 (32%) converted to celiotomy. Nontherapeutic explorations were compared including 70 DLs and 46 DCs with similar injury severity. LOS was shorter in DLs compared with DCs (1 day vs. 4 days, p < 0.001). There were no missed injuries. Therapeutic explorations were compared by matching all TL patients 2:1 to TC patients with similar type and severity of injuries. Twenty-four patients underwent TL compared with 48 TC patients in the case matched group. LOS was shorter in the TL group than in the TC group (4 days vs. 2 days, p < 0.001). Wound infections were more common with open exploration (10.4% vs. 0%, p = 0.002), and more patients developed ileus or small bowel obstruction after open exploration (9.4% vs. 1.1%, p = 0.018).

CONCLUSION

Laparoscopy is safe and accurate in penetrating abdominal injuries. The use of laparoscopy resulted in shorter hospitalization, fewer postoperative wound infection and ileus complications, as well as no missed injuries.

LEVEL OF EVIDENCE

Therapeutic study, level IV.

The Role of Laparoscopy in Penetrating Abdominal Trauma: Our Initial Experience

BACKGROUND

Diagnostic and therapeutic laparoscopy is a known approach in managing patients with penetrating abdominal trauma (PAT). However, multiple controversies exist on indications, contraindications, and its appropriateness. The aim of this study was to evaluate the appropriateness of diagnostic and therapeutic laparoscopy in patients with PAT at Dr George Mukhari Academic Hospital, Pretoria, South Africa.

MATERIALS AND METHODS

This was a retrospective, observational study. All patients with PAT managed by diagnostic and therapeutic laparoscopy during 2012-2013 were included. Recorded indications and contraindications, the mechanism of injury, the anatomical location of injury, intraoperative findings, reasons for conversion, and adverse outcomes (complications, reoperations and mortality) were analyzed in every case.

RESULTS

One hundred fourteen patients were included. Stab injuries were sustained by 81 (71%) patients, and 33 (29%) patients sustained gunshot wounds (GSW) to the abdomen. The conversion rate was 7%. The operation was completed laparoscopically in 106 patients: 79 with stab wounds (74.5%) and 27 with GSW (25.5%). Laparoscopy was diagnostic for 44 patients (41.5%) and therapeutic for 62 patients (58.5%). In total, 13 patients (12%) required re-intervention, and 2 patients died (1.9%). The complications were not specific to the laparoscopic approach. No missed injuries were reported in the study.

CONCLUSIONS

Diagnostic and therapeutic laparoscopy in patients with PAT is an appropriate management in hemodynamically stable patients or those responsive to initial resuscitation. The location of injuries is not a limiting factor, although it affects placement of ports. The conversion is not a complication but rather the correct way of completing the operation in an appropriate situation. It should be considered in patients with extensive intraabdominal bleeding suggesting the possibility of major vessel injury, a significant deterioration of the patient, and the complexity of injuries requiring a prolonged laparoscopic procedure.

[Diagnosis and treatment of abdominal trauma]

Abdominal trauma represents the leading cause of haemorrhagic shock in the severely injured patient and is associated with high mortality and morbidity rates. The trauma surgeon has a central role in the multidisciplinary team addressing the specific diagnostic and therapeutic needs of patients with abdominal trauma. The management of blunt and penetrating abdominal trauma has undergone substantial changes in recent decades. Major innovations have been established in the field of diagnostic imaging and of nonoperative interventions such as angioembolization and endoscopic procedures. Another key development is the introduction of the damage control concept for the care of patients with abdominal trauma. The present manuscript comprises a review of the current management of abdominal trauma with an emphasis on diagnostic and therapeutic innovations.

Laparoscopic treatment of duodenal injury caused by gunshot

Duodenal injury in most cases, presents as a complex trauma of all adjacent organs which it is generally treated with a midline laparotomy though laparoscopic treatment in selected cases might be beneficial. We present a case of haemodynamically stable patient who suffered abdominal gunshot injury causing grade II trauma of the liver and penetrating wound of the first part of the duodenum and was treated laparoscopically. We believe that laparoscopic primary or assisted repair of injured duodenum is an appropriate surgical option in haemodynamically stable patients who sustain focal abdominal trauma.

Through the 10-mm Looking Glass: Advances in Minimally Invasive Surgery in Trauma

BACKGROUND

Minimally invasive surgery is increasingly being used in trauma surgery as both a diagnostic and a therapeutic tool. However, significant debate regarding the accuracy, safety, and indications for minimally invasive surgery in trauma continues to impede widespread acceptance of these techniques among trauma surgeons.

METHOD

Herein, we report a contemporary review of the current role of both laparoscopy and thoracoscopy in modern trauma surgery. Literature search was performed using PubMed database and the following keywords: "Trauma," "Minimally Invasive Surgery," "Laparoscopy," and "Thoracoscopy."

RESULTS

Current recommendations advocate for the use of laparoscopy as a diagnostic tool in penetrating trauma for the diagnosis of diaphragm injuries and peritoneal violation. A significant body of research demonstrates that laparoscopy in select hemodynamically normal patients can significantly decrease nontherapeutic laparotomy rates and hospital costs and is highly sensitive and specific with very low missed injury rates, including small bowel injuries. Laparoscopic repairs to a wide breadth of abdominal and thoracic injuries have been reported with impressive results. Adherence to a standardized laparoscopic examination system and routine use of laparoscopy in elective or acute care practice strongly influence positive results with minimally invasive surgery in trauma. Video-assisted thoracoscopic surgery is most commonly used for evaluation of diaphragm, evacuation of retained hemothorax, and management of ongoing bleeding post-trauma.

CONCLUSION

Minimally invasive surgery does offer several advantages compared to traditional open surgery and should be considered as an additional tool in the trauma surgeon's armamentarium in the care of select injured patients.

Isolated abdominal trauma: diagnosis and clinical management considerations

PURPOSE OF REVIEW

The scope of the present study is to review the topics of initial assessment, diagnosis and clinical management of an isolated abdominal trauma.

RECENT FINDINGS

Progress in the management of trauma patients increasing survival includes a multidisciplinary approach involving multiple specialties at presentation. If immediate surgical intervention is needed, 'damage control' is the best option; if not, it has been proven that conservative management is superior to operative, in terms of survival for the majority of intraabdominal injury. 'Open abdomen' should be performed in major abdominal traumas when indicated. Early enteral feeding is beneficial, even in the presence of 'open abdomen'.

SUMMARY

Abdominal trauma is a complex injury; the multidisciplinary approach has made nonoperative management feasible and effective. When surgical intervention is needed, it should be performed in an orderly fashion, within the context of the overall management.

Laparoscopy in the acute abdomen

Laparoscopy has become a routine procedure in the management of acute abdominal disease and can be considered both an excellent therapeutic and additional diagnostic tool in selected cases. However, a high level of expertise in laparoscopic and emergency surgery is required. Hemodynamic instability, huge abdominal distension, fecal peritonitis and perforated cancer are relative contraindications for the laparoscopic approach. In recent years, abdominal emergencies have increasingly been managed successfully by laparoscopy. In acute appendicitis, acute cholecystitis and perforated peptic ulcer, randomized controlled trials have proven that the laparoscopic approach is as safe and as effective as open surgery, with fewer complications and a quicker postoperative recovery. Other indications such as blunt and penetrating trauma to the abdomen, small bowel occlusion and perforated diverticular disease are under debate, indicating that more randomized controlled trials comparing laparoscopic and open surgery are still necessary.