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

The Role of Diagnostic Laparoscopy in the Evaluation of Abdominal Trauma Patients: A Trauma Quality Improvement Program Study

PURPOSE

We aimed to identify factors related to delayed intervention in abdominal trauma patients who underwent diagnostic laparoscopy using a nationwide databank.

METHODS

From 2017 to 2019, abdominal trauma patients who underwent diagnostic laparoscopy were retrospectively evaluated using the Trauma Quality Improvement Program. Patients who underwent delayed interventions after a primary diagnostic laparoscopy were compared with those who did not. Factors associated with poor outcomes that are usually correlated with overlooked injuries and delayed interventions were also analyzed.

RESULTS

Of the 5221 studied patients, 4682 (89.7%) underwent inspection without any intervention. Only 48 (0.9%) patients underwent delayed interventions after primary laparoscopy. Compared with patients receiving immediate interventions during primary diagnostic laparoscopy, patients receiving delayed interventions were more likely to have small intestine injuries (58.3% vs. 28.3%, p < 0.001). Among patients with hollow viscus injuries, a significantly higher probability of overlooked injuries that required delayed intervention was observed in patients with small intestine injuries (small intestine injury: 16.8%; gastric injury: 2.5%; large intestine injury: 5.2%). However, delayed small intestine repair did not significantly affect the risk of surgical site infection (SSI) (p = 0.249), acute kidney injury (AKI) (p = 0.998), or hospital length of stay (LOS) (p = 0.053). In contrast, significantly positive relationships between delayed large intestine repair and poor outcomes were observed (SSI, odds ratio = 19.544, p = 0.021; AKI, odds ratio = 27.368, p < 0.001; LOS, β = 13.541, p < 0.001).

CONCLUSIONS

Most examinations and interventions (near 90%) were successful during primary laparoscopy for abdominal trauma patients. Small intestine injuries were easily overlooked. Delayed small intestine repair-related poor outcomes were not observed.

The role of laparoscopy in closed abdominal injury

Objective

To investigate the effect of laparoscopy on the diagnosis and treatment of closed abdominal injury.

Methods

A total of 26 patients with closed abdominal injury admitted to our hospital from January 2016 to January 2019 were searched. All patients were treated by laparoscopy. All patient reports were made with the informed consent of the patients.

Results

All patients were diagnosed clearly during operation. Among them, there were 3 cases of gastric perforation, 2 cases of liver rupture, 13 cases of spleen rupture, 3 cases of small intestine rupture, 1 case of liver round ligament laceration, 2 cases of small mesenteric vascular laceration, 1 case of colon liver mesenteric laceration, and 1 case of retroperitoneal hematoma. Of the 26 patients in this group, 23 (88.5%) completed laparoscopically or laparoscopically assisted; 5 cases (19.3%) only performed laparoscopic exploration without special treatment, and 3 cases (11.5%) switched to laparotomy. The blood loss was 50-2000 ml (mean 500 ml), and the operative time was 60-180min (mean 128min). The length of hospital stay was 3-21 d (mean 9 d). There were no complications or deaths related to laparoscopy in the whole group. Conclusion Laparoscopic technique has the advantages of less trauma, high diagnosis rate and fast recovery. It can also be used for surgical treatment in the diagnosis and treatment of closed abdominal injury, so as to achieve the purpose of comprehensive diagnosis and treatment. The limitations of laparoscopy should also be noted.

An interesting case of laparoscopic management of traumatic diaphragmatic rupture in an acute setting

Traumatic rupture of the diaphragm is an uncommon injury, often diagnosed late as it is associated with concurrent abdominal and thoracic visceral injuries which are the main cause of morbidity and mortality. Diaphragmatic rupture has been reported in 1-7 % of the patients following major blunt thoracoabdominal trauma and 10-15 % of the patients following penetrating trauma. In an emergency scenario, open approach remains the mainstay of management; however the laparoscopic approach has been steadily gaining acceptance. We report the case of a 35 year old male who was diagnosed with diaphragmatic rupture following blunt trauma to the chest and abdomen. The patient underwent emergency laparoscopic reduction of contents with anatomical repair of the ruptured diaphragm.

Current status of laparoscopic surgery usage in Türkiye: A middle-income country

Objectives

This study aimed to determine the usage status of laparoscopic procedures in general surgical practice in Türkiye, which is a sample of middle-income countries.

Material and Methods

The questionnaire was sent to general surgeons, gastrointestinal surgeons, and surgical oncologists who have completed their residency training and are actively working in university, public or private hospitals. Demographic data, laparoscopy training and the period of education, the rate of laparoscopy use, the type and volume of laparoscopic surgical procedures, their views on the advantages and disadvantages of laparoscopic surgery, and the reasons for preferring laparoscopy were determined with a 30-item questionnaire.

Results

Two hundred and forty-four questionnaires from 55 different cities of Türkiye were evaluated. The responders were mainly males, younger surgeons (F/M= 11.1/88.9 % and 30-39 y/o), and graduated from the university hospital residence program (56.6%). Laparoscopic training was frequently taken during residency (77.5%) in the younger age group, while the elderly participants mostly received additional training after specialization (91.7%). Laparoscopic surgery was mostly not available in public hospitals for advanced procedures (p <0.0001) but was available for cholecystectomy and appendectomy operations (p= NS). However, participants working in university hospitals mostly stated that the laparoscopic approach was the first choice for advanced procedures.

Conclusion

The results of this study showed that the surgeons working in MICs spent strong effort to use laparoscopy in daily practice, especially in university and high-volume hospitals. However, inappropriate education, cost of laparoscopic equipment, healthcare policies, and some cultural and social barriers might have negatively impacted the widespread use of laparoscopic surgery and its usage in daily practice in MICs such as Türkiye.

Laparoscopic repair and total gastrectomy for delayed traumatic diaphragmatic hernia complicated by intrathoracic gastric perforation with tension empyema: a case report

Background

Blunt traumatic diaphragmatic hernia (TDH) is a complication of blunt diaphragmatic injury. If missed, it could lead to critical presentations, such as incarceration or strangulation of the herniated intra-abdominal organs, and thus, early surgical repair is required. Methods of the operative approach against delayed TDH remain unclear. Even with the spread of the minimally invasive approach, laparotomy has been predominantly selected for cases with hemodynamic or gastrointestinal complaints. Literature on the use of laparoscopy for repair of such cases is limited, and no study has been conducted for those with intrathoracic gastric perforation.

Case presentation

A 55-year-old male patient with a history of multiple traumas presented with shock, followed by left hypochondrium pain and vomiting. The patient was admitted to the emergency department of our institution and diagnosed with delayed TDH complicated by intrathoracic gastric perforation, and tension empyema. Emergency surgery using laparoscopic approach was performed, despite unstable hemodynamics, considering orientation, exposure, and operativity compared with laparotomy. Repair of the diaphragm plus total gastrectomy was successfully performed by minimally invasive management. The patient made an uneventful recovery without recurrence after 8 months.

Conclusion

Unstable hemodynamic conditions and intrathoracic gastric perforation could not be contraindications to laparoscopic repair in treating delayed TDH.

[Advantages of laparoscopic technologies for blunt abdominal trauma: a systematic review and meta-analysis]

OBJECTIVE

To analyze the effectiveness of laparotomy and laparoscopy in the treatment of patients with blunt abdominal trauma.

MATERIAL AND METHODS

Literature searching was conducted in accordance with the recommendations «Preferred Reporting Items for Systematic Reviews and Meta-Analyses» between January 2015 and August 2021. We used the electronic databases PubMed, Cochrane Library, Scopus, eLibrary.

RESULTS

Laparoscopy reduces hospital-stay, postoperative morbidity and mortality in hemodynamically stable patients with blunt abdominal trauma compared to laparotomy.

CONCLUSION

Further systematic reviews and meta-analyses of randomized controlled trials are required to obtain high quality data.

Resolution of Chronic Shoulder Pain after Repair of a Posttraumatic Diaphragmatic Hernia: A 22-Year Delay in Diagnosis and Treatment

Diagnosing traumatic diaphragmatic rupture (TDR) due to penetrating rib fractures is challenging because the lesions are often too small to be detected and may present years after injury. Patients with delays in diagnosis of TDR rarely present with orthopaedic-related complaints of pain. We report the case of a 52-year-old female who presented with chronic left shoulder pain following a motor vehicle accident (MVA). In addition to left-side lower rib fractures, she also sustained a left-sided splenic laceration, pneumothorax, and two-part upper humerus fracture. Fracture treatment was percutaneous pinning; the other injuries were treated nonoperatively. Her shoulder pain could not be attributed to shoulder or neck pathology. Twenty years after the MVA, she began experiencing episodes of left-sided abdominal pain and nausea. A CT scan obtained two years later revealed a diaphragm hernia, which was repaired laparoscopically. Unique aspects of this case include (1) presentation to an orthopaedic surgeon with a chief complaint of chronic shoulder pain; (2) at 22 years, this is the fourth longest case of a delay in diagnosis of TDR; and (3) the unique symptom of ipsilateral referred shoulder pain, which immediately improved after hernia repair.

Laparoscopic Splenectomy for Trauma

Background and Objectives:

The use of laparoscopy in the trauma setting is gaining momentum, with more therapeutic procedures being performed. We evaluated the use of laparoscopic splenectomy among trauma patients with data from the National Trauma Database. We compared outcomes for trauma patients undergoing laparoscopic (LS) versus open splenectomy (OS).

Methods:

From the National Trauma Database (2007 to 2015), we identified all patients who underwent a total splenectomy. Patients who had other abdominal operations were excluded. All patients were categorized into 1 of 2 groups: LS or OS. Outcomes of in-hospital mortality, postoperative length of stay, and incidence of major complications between the 2 groups were compared. Bivariate parametric and nonparametric analyses were performed. Patients were then matched on baseline demographic and injury characteristics by using propensity score matching techniques, and we compared differences by using regression analysis.

Results:

A total of 25,408 patients underwent OS and 113 patients underwent LS (0.44%). Patients were significantly different at baseline, with the LS group being less severely injured. Bivariate analysis revealed no difference in length of stay (9 vs 8 days, P = .62), incidence of major complications (10% vs 15%, P = .24), or mortality (6% vs 11%, P = .23). LS was performed in 29.2% of patients beyond 24 hours from presentation compared with 9.5% in the OS (P < .001). Adjusted multivariate analysis showed no overall difference in outcomes.

Conclusion:

LS for trauma is increasingly being used at many centers throughout the United States. The procedure is safe, with outcomes similar to those of OS in selected trauma patients.

Laparoscopic Repair of Diaphragmatic Rupture: A Case Report with Radiological and Surgical Correlation

The leading cause of diaphragmatic rupture is penetrating abdominal trauma, including gunshot- and stab-related wounds; however, diaphragmatic rupture can also result from blunt trauma to the abdomen. The diagnosis can be difficult to make as the physical examination may be unremarkable, and imaging, that is, a conventional chest X-ray and/or CT imaging, may initially fail to reveal the injury. Failure to recognize diaphragmatic rupture can result in a delayed presentation, sometimes years later, with a potential catastrophic outcome. Therefore, prompt and swift diagnosis is critical to avoid this potential harmful scenario. Traditionally, repair is performed through a laparotomy or a thoracotomy incision. Owing to the many advances made in minimally invasive surgery, not only has laparoscopy become the modality of choice to diagnose diaphragmatic rupture due to its high degree of sensitivity and specificity, but it can provide simultaneous therapeutic intervention as well. We report a case of laparoscopic repair of a diaphragmatic rupture in a 22-year-old female who sustained blunt abdominal trauma during a motor vehicle accident.

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.