Laparoscopy vs. Laparotomy for the Management of Abdominal Trauma: A Systematic Review and Meta-Analysis

Acute care nurses' experience in providing evidence-based care for patients with laparotomy wounds: A scoping review

To systematically search and synthesise available literature on barriers and enablers to evidence-based care for patients with laparotomy wounds reported by acute care nurses. Specifically, we focused on wound assessment, infection control techniques, wound products used, escalation of care, dressing application, documentation and holistic care. The Preferred Reporting Items for Systematic review and Meta-Analyses extension for Scoping Reviews Checklist and explanation documents directed the review. The methodology framework created by Arksey and O'Malley, updated by Levac et al., and the Joanna Briggs Institute were utilised to assist the scoping review process. Data synthesis was guided by the Theoretical Domains Framework. Six qualitative and mixed methods studies were selected for the review. Most reported barriers and enablers were mapped to knowledge, skills, beliefs about consequences, environmental context and resources and beliefs about capability domains. The main barriers were limited access to and utilisation of wound assessment tools and clinical practice guidelines for wound management and suboptimal time management skills. Inconsistent management of laparotomy wounds was related to ward culture and nurses' lack of knowledge and skills in surgical wound assessment and aseptic technique during wound encounters. The reported enablers were knowledge of multi-factorial risk factors for surgical wound recovery, valuing education and reflective practice and believing that protocols should be utilised alongside comprehensive wound assessments. Holistic wound care included patient education on the role of mobilisation and nutrition in wound healing. Acute care nurses do not routinely incorporate comprehensive, evidence-based care recommendations for laparotomy wound management. Further research on evidence-based care behaviours in managing laparotomy wounds is required. The results indicate a need for standardising the practice of laparotomy wound management while acknowledging the current challenges faced in the ward environment.

Cesena guidelines: WSES consensus statement on laparoscopic-first approach to general surgery emergencies and abdominal trauma

BACKGROUND

Laparoscopy is widely adopted across nearly all surgical subspecialties in the elective setting. Initially finding indication in minor abdominal emergencies, it has gradually become the standard approach in the majority of elective general surgery procedures. Despite many technological advances and increasing acceptance, the laparoscopic approach remains underutilized in emergency general surgery and in abdominal trauma. Emergency laparotomy continues to carry a high morbidity and mortality. In recent years, there has been a growing interest from emergency and trauma surgeons in adopting minimally invasive surgery approaches in the acute surgical setting. The present position paper, supported by the World Society of Emergency Surgery (WSES), aims to provide a review of the literature to reach a consensus on the indications and benefits of a laparoscopic-first approach in patients requiring emergency abdominal surgery for general surgery emergencies or abdominal trauma.

METHODS

This position paper was developed according to the WSES methodology. A steering committee performed the literature review and drafted the position paper. An international panel of 54 experts then critically revised the manuscript and discussed it in detail, to develop a consensus on a position statement.

RESULTS

A total of 323 studies (systematic review and meta-analysis, randomized clinical trial, retrospective comparative cohort studies, case series) have been selected from an initial pool of 7409 studies. Evidence demonstrates several benefits of the laparoscopic approach in stable patients undergoing emergency abdominal surgery for general surgical emergencies or abdominal trauma. The selection of a stable patient seems to be of paramount importance for a safe adoption of a laparoscopic approach. In hemodynamically stable patients, the laparoscopic approach was found to be safe, feasible and effective as a therapeutic tool or helpful to identify further management steps and needs, resulting in improved outcomes, regardless of conversion. Appropriate patient selection, surgeon experience and rigorous minimally invasive surgical training, remain crucial factors to increase the adoption of laparoscopy in emergency general surgery and abdominal trauma.

CONCLUSIONS

The WSES expert panel suggests laparoscopy as the first approach for stable patients undergoing emergency abdominal surgery for general surgery emergencies and abdominal trauma.

Concordance of CT imaging and surgical lesions in penetrating abdominal trauma

OBJECTIVE

The management of penetrating abdominal wounds has greatly benefited from the development of computed tomography (CT), particularly in stable patients. In this setting, the scanner is the reference examination. Our study aims to evaluate the performance of preoperative CT in the assessment of penetrating abdominal lesions.

MATERIAL AND METHODS

Between January 1, 2015 and January 1, 2022, 81 patients were hospitalized following penetrating abdominal trauma at the Army Training Hospitals of Sainte-Anne and Laveran. Fifty-one stable patients who had an abdominopelvic CT scan and thereafter underwent abdominal surgery (laparotomy or laparoscopy) were included. Radiological and surgical data were collected from the electronic record and compared by a descriptive analysis (calculation of the sensitivity, specificity, positive and negative predictive value of the CT for the detection of lesions of the various organs) and by a correlation of the CT findings with surgical findings using Kripendorff's alpha coefficient.

RESULTS

The cohort was largely male (n=45; 88%), with injuries by knife wound in 62.7% of cases (n=32) and gunshot in 35.3% (n=18) of cases. The median age was 36years (25-47). The median index of severity score (ISS) was 17 (10-26). Excellent agreement between predicted and actual findings was obtained for solid organs (α=0.801) with high sensitivity and specificity (81.8% and 96.6%, respectively). The largest discrepancies were observed for the hollow organs (α=26.2%, sensitivity of 53.3% and specificity of 76.2%) and the diaphragm (α=67.3%, sensitivity 75%, specificity 92.3%). Surgical exploration was non-therapeutic for five patients (9.8%). The failure rate for non-operative treatment was 10% (n=1).

CONCLUSION

CT detection of solid organ lesions in patients with penetrating abdominal wounds is excellent. However, the detection of hollow organ and diaphragmatic wounds remains a challenge with a risk of over- and underdiagnosis. Laparoscopic exploration should be able to fill in the gaps in the CT findings.

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.

Introduction of Laparoscopy in an Urban High-Volume Sub-Saharan Trauma Centre

INTRODUCTION

Trauma is a major disease burden in low and middle-income countries like South Africa. Abdominal trauma is one of the leading reasons for emergency surgery. The standard of care for these patients is a laparotomy. In selected trauma patients, laparoscopy has both diagnostic and therapeutic usage. The trauma burden and the number of cases seen in a busy trauma unit make laparoscopy challenging.

AIM

We wanted to describe our journey with laparoscopy in the management of abdominal trauma in a busy urban trauma unit in Johannesburg, South Africa.

METHODS

We reviewed all trauma patients who underwent diagnostic laparoscopy (DL) or therapeutic laparoscopy (TL) between 01 January 2017 and 31 October 2020 for blunt and penetrating abdominal trauma. The demographic data, indications for laparoscopy, injuries identified, procedures performed, intraoperative laparoscopic complications, conversion to laparotomy, morbidity, and mortality were evaluated.

RESULTS

A total of 54 patients who had laparoscopy were included in the study. The median age was 29 years (IQR 25-25). Most injuries were penetrating 85.2% (n = 46/54) and 14.8% blunt trauma. Most patients were males, 94.4% (n = 51/54). Indications for laparoscopy included diaphragm evaluation (40.7%), pneumoperitoneum for evaluation of potential bowel injury (16.7%), free fluid with no evidence of solid organ injury (12.9%) and colostomy (5.5%). There were 8 (14.8%) cases converted to laparotomy. There were no missed injuries or mortality in the study group.

CONCLUSION

Laparoscopy in selected trauma patients is safe even in a busy trauma unit. It is associated with less morbidity and shortened hospital length of stay.

Diagnostic methods and surgical treatment of patients with thoracoabdominal traumas (review of the literature)

Thoracoabdominal traumatism is a topical problem of modern medicine due to its wide prevalence, severe course and unfavorable outcome. This article presents an overview of the epidemiology, diagnosis, and surgical treatment of patients with thoracoabdominal injuries. It showed that the current incidence of thoracoabdominal injuries reaches 13.7-16.4% of all chest and abdominal injuries. Lethality in thoracoabdominal injuries ranges from 3.13% to 20%. In most cases these are patients of working age, with an average age of 27.5-34.8 years, men comprising 71.2%. Nowadays, the number of patients with thoracoabdominal injuries tends to increase in Uzbekistan and other economically developing countries of the world because of increasing transportation, construction and crime. Video-thoracoscopy and video-laparoscopy are among the widespread methods of diagnosis and treatment of thoracoabdominal traumas. According to many authors, the specificity of video-laparoscopy and video-thoracoscopy is 100%, and the sensitivity is 87.5-99.3%.

Potential Spectrum of Accompanied Penetrating Abdominal Intraperitoneal Injuries with Bowel Evisceration: Surprises Awaiting the Trauma Surgeon in Resource Limited Settings

Penetrating abdominal injuries involves violation of the peritoneal cavity and injuries to solid organs and other intraperitoneal viscera such as major blood vessels and hollow organs. Typically such injuries arise from gunshot wounds or stab wounds. With increase in crime rates and motor traffic accidents in urban areas, the trauma surgeon in civilian urban centers faces spectrum of injuries similar to his colleague in war torn areas. Potential spectrum of penetrating abdominal injuries is wide and accurate diagnosis in resource limited centers is challenging. Majority of injuries are concealed and diagnosed intraoperatively and dealt with relatively junior trauma surgeons in emergency settings in remote limited settings. Computed tomography (CT) scans and Magnetic Resonance Imaging (MRI) facilities are scarce in resource limited settings. Haemodynamic states of penetrating abdominal injuries patients presenting in emergency departments necessitate urgent surgical exploration and management with minimal room for full radiological work-up. Evisceration of bowels with unstable haemodynamic states mandate laparotomy due to wide spectrum of accompanied intraperitoneal injuries. Four cases of penetrating abdominal injuries are presented with modes of assault ranging from gunshot injuries to stab wounds with broken bottles to highlight the intra-abdominal spectrum of injuries, challenges in diagnosis and emergency managements done in a resource limited setting.

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.