The Role of Minimally Invasive Surgery in Pediatric Trauma

Laparoscopy in the Evaluation of Blunt Abdominal Injury in Level-I and II Pediatric Trauma Centers

Introduction

An American College of Surgeons (ACS) Level-I (L-I) pediatric trauma center demonstrated successful laparoscopy without conversion to laparotomy in ∼65% of trauma cases. Prior reports have demonstrated differences in outcomes based on ACS level of trauma center. We sought to compare laparoscopy use for blunt abdominal trauma at L-I compared to Level-II (L-II) centers.

Methods

The Pediatric Trauma Quality Improvement Program was queried (2014-2016) for patients ≤16 years old who underwent any abdominal surgery. Bivariate analyses comparing patients undergoing abdominal surgery at ACS L-I and L-II centers were performed.

Results

970 patients underwent abdominal surgery with 14% using laparoscopy. Level-I centers had an increased rate of laparoscopy (15.6% vs 9.7%, P = .019 ); however they had a lower mean Injury Severity Score (16.2 vs 18.5, P = .002) compared to L-II centers. Level-I and L-II centers had similar length of stay ventilator days, and SSIs (all P > .05).

Conclusion

While use of laparoscopy for pediatric trauma remains low, there was increased use at L-I compared to L-II centers with no difference in LOS or SSIs. Future studies are needed to elucidate which pediatric trauma patients benefit from laparoscopic surgery.

Diagnostic Laparoscopy for Abdominal Trauma in Infants and Children: How We Do It

Although once thought to be a point of contention, the use of minimally invasive surgery for the hemodynamically stable pediatric trauma patients has grown dramatically since its conception in the 1970s and becoming a widely acceptable option for select patient populations. An accumulation of literature over the decades has continued to support laparoscopy for both diagnostic and therapeutic purposes in the pediatric trauma patients as laparoscopy is likely to decrease morbidity, hospital cost, and negative laparotomy rates. In this review, we describe what we believe to be the critical aspects of diagnostic laparoscopy in the setting of pediatric trauma.

Role of Minimally Invasive Surgery in Management of Penetrating Abdominal Trauma in Children

INTRODUCTION

 Traditionally, exploratory laparotomy was used to treat penetrating abdominal trauma (PAT). At present, minimally invasive surgery (for diagnostic and therapeutic purposes) has developed and represents a rapidly evolving modality for dealing with PAT in stable children. In this article, we aim to present our experience, evaluate the effectiveness, and report the results of minimally invasive surgery (MIS) for PAT in stable pediatric patients.

MATERIALS AND METHODS

 This prospective study involved 117 hemodynamically stable pediatric cases of PAT (caused by gunshots, stab, and accidental stab), admitted, and managed according to the severity of injury. The information recorded for analysis included demographic data, the anatomical location of injury, the initial vital data and scoring systems, the organs affected, the procedures done, operative time, need for conversion to laparoscopic-assisted approach, length of hospital stay, complications, missed injury, and mortality rate.

RESULTS

 Among 117 pediatric patients with PAT, 15 cases were treated conservatively and 102 cases were managed by MIS. They were 70 males and 47 females with a mean age of 7.3 ± 0.6 years (range = 1-14 years). They included 48 cases of gunshot injury, 33 cases of abdominal stab, and 36 cases of accidental stab. Laparoscopy was diagnostic (DL) in 33.3% (n = 34) and therapeutic (TL) in 66.7% (n = 68) of cases. Of the 68 TL cases, we completely managed 59 cases (86.8%) by laparoscopy, while 9 cases (13.2%) were converted to limited laparotomy. The mean operative time was 17 ± 1 minutes (range = 12-25 minutes) for DL, 85 ± 9 minutes (range = 41-143 minutes) for complete TL cases, and 89 ± 3 minutes (range = 47-149 minutes) for laparoscopic-assisted procedures. For DL cases, the mean length of hospital stay was 2 ± 0.4 days, while for complete TL cases, it was 5.4 ± 0.83 days, and for laparoscopic-assisted cases, it was 5.8 ± 0.37 days. Postoperative complications occurred in eight cases (7.84%), with five cases (4.9%) required reintervention. No missed injury or mortality was recorded in the study. The patients were followed up for a median period of 52 months.

CONCLUSION

 For management of PAT in children, MIS has 100% accuracy in defining the injured organs with zero percent missed injuries.

Surgeon choice in management of pediatric abdominal trauma

BACKGROUND

No guidelines exist for management of hemodynamically stable children with suspected hollow viscus injury. We sought to determine factors contributing to surgeon management of these patients.

METHODS

Surgeon members of the Eastern Association for the Surgery of Trauma and American Pediatric Surgical Association completed a survey on 3 blunt abdominal injury scenarios: (1) isolated, (2) with multisystem injury, and (3) with traumatic brain injury (TBI), and a penetrating injury scenario. Multivariable logistic regression was used to determine factors associated with initial management of observation vs. operation for blunt injury and observation vs. local wound exploration versus laparoscopy for penetrating injury.

RESULTS

Of 394 surgeons (response rate 22.3%), 50.3% were pediatric surgeons. For scenarios 1-3, 32.2%, 49.3%, and 60.7% of surgeons chose operation over observation, respectively. Compared to isolated blunt injury, surgeons were more likely to choose operation for patients with multisystem injury (aOR 2.20, 95%CI: 1.78-2.72) or TBI (aOR 3.60, 95%CI: 2.79-4.66). Pediatric surgeons were less likely to choose operation (aOR 0.32, 95%CI: 0.22-0.44). For penetrating injury, 39.1%, 29.5%, and 31.5% of surgeons chose observation, local wound exploration, and laparoscopy, respectively.

CONCLUSIONS

Large variation exists in management of hemodynamically stable children with suspected hollow viscus injury. Although patient injury characteristics account for some variation, surgeon factors such as type of surgeon also play a role. Evidence-based practice guidelines should be developed to standardize care.

TYPE OF STUDY

Cross-Sectional Survey.

LEVEL OF EVIDENCE

N/A.

Laparoscopy Compared With Laparotomy for the Management of Pediatric Blunt Abdominal Trauma

BACKGROUND

There is minimal evidence evaluating the risks and benefits of laparoscopy use in hemodynamically stable children with suspected abdominal injuries. The objective of this study was to evaluate postoperative outcomes in a large cohort of hemodynamically stable pediatric patients with blunt abdominal injury.

METHODS

Using the 2015-2016 National Trauma Data Bank, all patients aged <18 y with injury severity score (ISS) ≤25, Glasgow coma scale ≥13, and normal blood pressure who underwent an abdominal operation for blunt abdominal trauma were included. Patients were grouped into three treatment groups: laparotomy, laparoscopy, and laparoscopy converted to laparotomy. Treatment effect estimation with inverse probability weighting was used to determine the association between treatment group and outcomes of interest.

RESULTS

Of 720 patients, 504 underwent laparotomy, 132 underwent laparoscopy, and 84 underwent laparoscopy converted to laparotomy. The median age was 10 (IQR: 7-15) y, and the median ISS was 9 (IQR: 5-14). Mean hospital length of stay was 2.1 d shorter (95% confidence interval [CI]: 0.9-3.2 d) and mean intensive care unit length of stay was 1.1 d shorter (95% CI: 0.6-1.5 d) for the laparoscopy group compared with the laparotomy group. The laparoscopy group had a 2.0% lower mean probability of surgical site infection than the laparotomy group (95% CI: 1.0%-3.0%).

CONCLUSIONS

In this cohort of hemodynamically stable pediatric patients with blunt abdominal injury, laparoscopy may have improved outcomes over laparotomy.

Therapeutic laparoscopy for pediatric abdominal trauma

BACKGROUND

For the surgical treatment of traumatic hollow viscus injuries, laparoscopy offers a potentially less morbid approach to open exploration among appropriately selected patients. This study aimed to evaluate utilization trends and efficacy of laparoscopy in the management of pediatric abdominal trauma.

STUDY DESIGN

To gain both study granularity and power, our institutional trauma registry (2005-2017) and the National Trauma Data Bank (NTDB; 2010-2015) identified patients ≤18 years who required celiotomy for abdominal trauma. Injury mechanisms, patient characteristics, and hospital courses were compared between open and laparoscopic approaches. Unadjusted and adjusted statistical analyses were performed.

RESULTS

Overall, data were similar among 393 institutional and 11,399 NTDB patients undergoing laparoscopic (n = 88, 22%; n = 1663, 16%) or open (n = 305, 78%; n = 9736, 85%) surgery for abdominal trauma. In both registries, laparoscopy was more commonly employed in younger (institutional p = 0.026; NTDB p < 0.001) female (p = 0.019; p < 0.001) patients having lower injury severity (p < 0.001) and blunt injuries (p = 0.031; p < 0.001). Laparoscopy was associated with fewer complications overall when adjusting for demographics and injury severity [institutional OR 0.25 (0.08-0.75), p = 0.013; NTDB OR 0.69 (0.55-0.88), p = 0.002]. An increase in utilization of MIS for pediatric abdominal trauma was detected over time (NTDB: r = 0.88, p = 0.02).

CONCLUSION

For the management of pediatric abdominal trauma, laparoscopy was employed typically in younger, more stable, and female patients sustaining blunt injuries. Appropriately selected patients have similar or better outcomes to patients treated with laparotomy, with no increase in adverse events or missed injuries. Increased utilization of laparoscopy to manage abdominal trauma in children suggests greater acceptance of this approach.

LEVEL OF EVIDENCE

Level III.

Predictors and Outcomes of Laparoscopy in Pediatric Trauma Patients: A Retrospective Cohort Study

Introduction: Laparoscopy has been shown to offer a safe alternative to laparotomy in hemodynamically stable pediatric trauma patients. Our purpose was to identify factors predictive of this approach and examine surgical outcomes. Methods: This is a retrospective cohort study using the ACS Pediatric Trauma Quality Improvement Program to examine pediatric patients who underwent exploration for blunt or penetrating abdominal trauma in 2014 and 2015. Patients with contraindications to laparoscopy were excluded. Multivariable modeling identified predictors of a laparoscopic approach. Secondary analysis assessed differences in outcomes and resource utilization between laparoscopy and laparotomy groups. Results: A total of 160 patients met inclusion criteria. Patients undergoing surgery in the northeastern (odds ratio [OR]: 2.25, 95% confidence interval [CI]: 1.26-4.03, P = .006) and western (OR: 2.03, 95% CI: 1.06-3.88, P = .032) U.S. regions had over two times greater odds of undergoing laparoscopy as those treated in the south. Patients injured by a firearm were significantly less likely to undergo laparoscopy than those suffering blunt injury (OR: 0.27, 95% CI: 0.13-0.55, P < .001). After adjustment, patients explored laparoscopically in comparison with those through laparotomy had decreased average length of stay (LOS) (mean difference [MD]: 2.55 days, 95% CI: 1.19-3.90, P < .001) and number of intensive care unit (ICU) days (MD: 1.13 days, 95% CI: 0.28-1.98, P = .01). Conclusion: Trauma laparoscopy may decrease LOS and ICU days in select pediatric patients requiring abdominal exploration; however, laparoscopy is not uniformly practiced in the United States. Targeted education and protocols for initial use of laparoscopy should be incorporated into hospitals treating this group to minimize morbidity and resource utilization.

Characterization of Patients with Minimally Invasive Surgery Converted in a Pediatric Hospital

Introduction: Minimally invasive surgery (MIS) in pediatric surgery is now the standard of care for various surgical conditions. We have seen an increase in MIS with some of the procedures requiring intraoperative conversion to open surgery. Materials and Methods: This is a single-institution retrospective study of patients who underwent MIS between 2009 and 2017 requiring conversion to open surgery. Preoperative characteristics, cause of conversion, and postoperative factors were recorded. Results: A total of 154 patients had converted to MIS, 89.6% underwent laparoscopic procedures. Mean age was 8.5 years, 53.9% were male. Primary cause leading to surgery was not oncologic (89.6%), dirty contaminated wound was found in 49.35%, inflammatory response markers were altered, and 38.9% of our patients were American Society of Anesthesiologists physical status classification 3. Principal causes of conversion were failure in progression (53.25%) and loss of anatomic reference (24.5%). A total of 44.16% of the patients required postoperative pediatric intensive care unit admission, 29.2% required reintervention, and mortality rate was 0.65%. We detailed data regarding thoracoscopic, appendectomy, and laparoscopic procedures. Conclusion: Conversion to MIS is a decision the surgeon must make in different scenarios. This study allowed us to characterize our population regarding converted MIS procedures. Male gender, age group, altered inflammatory markers, not oncologic pathology, and dirty wound were frequently found, but we cannot establish any of them as risk factors. Main cause for conversion to open surgery was failure in the progression of the procedure in our study according to reported literature. We intend to develop further studies to determine 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.