Laparoscopy in trauma: An overview of complications and related topics

The Effect of Intermittent Pneumatic Compression on Hemodynamics and Regional Cerebral Oxygen Saturation in Laparoscopic Bariatric Surgery with Mild Hypercapnia in the Steep Reverse Trendelenburg Position

Obesity negatively affects hemodynamics and cerebral physiology. We investigated the effect of the utilization of an intermittent pneumatic compression (IPC) device on hemodynamics and cerebral physiology in patients undergoing laparoscopic bariatric surgery under general anesthesia with lung-protective ventilation. Sixty-four patients (body mass index > 30 kg/m2) were randomly assigned to groups that received an IPC device (IPC group, n = 32) and did not (control group, n = 32). The mean arterial pressure (MAP), heart rate (HR), need for vasopressors, cerebral oxygen saturation (rSO2), and cerebral desaturation events were recorded. The incidence of intraoperative hypotension was not significantly different between groups (p = 0.153). Changes in MAP and HR over time were similar between groups (p = 0.196 and p = 0.705, respectively). The incidence of intraoperative cerebral desaturation was not significantly different between groups (p = 0.488). Changes in rSO2 over time were similar between the two groups (p = 0.190) during pneumoperitoneum. Applying IPC to patients with obesity in the steep reverse Trendelenburg position may not improve hemodynamic parameters, vasopressor requirements, or rSO2 values during pneumoperitoneum under lung-protective ventilation. During laparoscopic bariatric surgery, IPC alone has limitations in improving hemodynamics and cerebral physiology.

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.

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.

Minimally Invasive Surgery for Genitourinary Trauma: A Nationwide Outcomes-Based Analysis

INTRODUCTION

Bladder and ureteral injuries are uncommon in trauma patients but are associated with increased morbidity and mortality. Patients presenting with such injuries may undergo either open surgical repair or laparoscopic repair. We aimed to compare outcomes of open surgical approach and laparoscopy in trauma patients with isolated bladder and ureteral injury. We hypothesized that laparoscopy is associated with improved outcomes.

METHODS

We performed a 2017 review of American College of Surgeons Trauma Quality Improvement Program and identified trauma patients with bladder and ureteral injury who underwent open surgical repair or laparoscopy. A 1:1 propensity score matching was performed adjusting for demographics, emergency department vitals (systolic blood pressure, heart rate, Glasgow Coma Scale), mechanism of injury, Injury Severity Score, each body region Abbreviated Injury Scale score, and transfusion units. Outcomes were rates of in-hospital major complications and mortality.

RESULTS

Of the 1,004,440 trauma patients, 384 patients (open: 192 and laparoscopy: 192) were matched and included. The mean age was 36 ± 15 y, Injury Severity Score was 27 [27-48], 77% were males, and 56% of patients had a blunt mechanism of injury, and 44% had penetrating injuries. Overall mortality was 7.3%. On univariate analysis, mortality was lower in the open group as compared to the laparoscopy group (10.4% versus 4.2%, P = 0.019) and survivor-only hospital length of stay was longer in the open group (8 [8-9] versus 7 [5-11], P = 0.008). There was no difference in overall major complications (23% versus 21%, P = 0.621). On multivariate analysis, open surgical repair was independently associated with lower odds of mortality (adjusted odds ratio: 0.405, 95% confidence interval: [0.17-0.95], P-value = 0.038) CONCLUSIONS: In our analysis open surgical repair of bladder and ureteral injuries was associated with lower mortality with other outcomes being similar when compared to laparoscopy. Laparoscopic surgical repair may not have an advantage over the open surgical repair for bladder and ureteral injuries. Further prospective studies are needed to delineate the ideal surgical approach for these injuries.

The impact of robotic surgery on a tertiary care colorectal surgery program, an assessment of costs and short term outcomes: A Canadian perspective

BACKGROUND

Robotic surgery for colorectal pathology has gained interest as it can overcome technical challenges and limitations of traditional laparoscopic surgery. A lack of training and costs have been cited as reasons for limiting its use in Canada. The objective of this paper was to assess the impact of robotic surgery on outcomes and costs in a Canadian setting.

METHODS

This is a retrospective study of consecutive patients undergoing left sided colorectal surgery ("Pre-Robotic Phase" n = 145 vs. "Post Robotic Phase" n = 150) and a single tertiary care centre in Ontario, Canada. Utilization and success of minimally invasive surgery (MIS), length of stay, complications and hospital costs were compared. Univariate and Multivariate analysis was used for these comparisons.

RESULTS

Characteristics, diagnosis and type of resection were similar between groups. Robotic Implementation resulted in higher rates of successful MIS (i.e. attempt at MIS without conversion) (85% vs. 47%, P < 0.001), shorter mean length of stay (4.7 days vs. 8.4 days, P < 0.001), and similar mean operative times (3.9 h vs. 3.9 h, P = 0.93). Emergency Department visits were fewer in the Robotic Phase (24% vs. 34%, P = 0.04), with no difference in readmission, anastomotic leak or unplanned reoperation. After robotic implementation, the mean total hospital costs decreased, but this was not statistically significant (-$1453, 95% CI -$3974 to +$1068, P = 0.25). Regression analysis, adjusting for age, gender, obesity, ASA and procedure showed similar findings (Robotic Phase -$657, 95% CI -$3038 to +$1724, vs Pre Robotic Phase [Reference], P = 0.59).

INTERPRETATION

Implementation of a robotic colorectal surgery program in a Canadian tertiary care centre showed improved clinical outcomes, without a significant increase in the cost of care. Although this study is from a single institution, we have demonstrated that robotic colorectal surgery is feasible and can be cost effective in the right setting.

Controversies in Surgery: Trauma

As care of the injured patient continues to evolve, new surgical technologies and new resuscitative therapies can change the algorithms that drive trauma care. In particular, the advent of resuscitative endovascular balloon occlusion of the aorta has changed the way trauma surgeons treat patients in extremis. The science of resuscitation continues to evolve, leading to controversy about the optimal administration of fluid and blood products. Laparoscopy has given additional tools to the trauma surgeon to potentially avoid exploratory laparotomy, and rib fracture fixation can be beneficial in the proper patient.

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.

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.

Multiple isolated small bowel perforations following blunt abdominal trauma

INTRODUCTION

Small bowel injury is uncommon after blunt abdominal trauma. Repeated clinical assessment is important, especially when investigative imaging is negative.

CASE PRESENTATION

39-year-old male presented to the emergency department following a blunt abdominal trauma. No initial hemodynamic abnormalities were found. Abdominal CT scan was negative for small bowel perforation. Repeated clinical assessment revealed increasing abdominal pain with tachycardia, and an emergent laparotomy was undertaken. Four grade II and one grade I small bowel perforations were found, all repaired with interrupted sutures. Patient was discharged home on day 7.

DISCUSSION/CONCLUSION

The diagnosis of small bowel injury is difficult and a low threshold of suspicion is crucial to reduce morbidity and mortality. Hemodynamic instability or abdominal tenderness after blunt abdominal trauma are indications for immediate surgical exploration, despite negative imaging findings. Serial clinical assessment is the main decision tool to perform an abdominal exploration.

Use of laparoscopic colectomy increasing in trauma: comparison of laparoscopic vs. open colectomy

Laparoscopy accounts for > 70% of general surgical cases. Given the increased use of laparoscopy in emergent colorectal disease, we hypothesized that there would be an increased use of laparoscopic colectomy (LC) in trauma patients. In addition, we hypothesized increased length of stay (LOS) and mortality in trauma patients undergoing open colectomy (OC) vs. LC. This was a retrospective analysis using the National Trauma Data Bank (2008-2015). We included adult patients undergoing LC or OC. A multivariable logistic regression model was used for determining risk of LOS and mortality. We identified 19,788 (96.8%) patients undergoing OC and 644 (3.2%) who underwent LC. There was a 21-fold increased number of patients that underwent LC over the study period (p < 0.05), with approximately 119 per 10,000 trauma patients undergoing LC. The most common operation was a laparoscopic right hemicolectomy (27.5%). LC patients had a lower median injury severity score (ISS) (16 vs. 17, p < 0.001). There was no difference in LOS (p = 0.14) or mortality (p = 0.44) between the two groups. This remained true in patients with isolated colorectal injury. The use of LC has increased 21-fold from 2008 to 2015, with laparoscopic right hemicolectomy being the most common procedure performed. There was no difference in LOS, in-hospital complications, or mortality between the two groups. We suggest that LC should be considered in stable adult trauma patients undergoing colectomy. However, future prospective research is needed to help determine which trauma patients may benefit from LC.

Delayed hydronephrosis due to retroperitoneal hematoma after a seatbelt injury: A case report

RATIONALE

Hydronephrosis caused by retroperitoneal hematoma after a seatbelt injury is a unique clinical entity.

PATIENT CONCERNS

A 21-year-old man, who had been wearing a seatbelt, was brought to our hospital after a motor vehicle collision, complaining of abdominal pain. Computed tomography (CT) revealed retroperitoneal hematoma in the upper pelvic region. Since he was hemodynamically stable throughout admission, he was managed conservatively. Seventeen days after initial discharge, the patient revisited our emergency department due to right back pain.

DIAGNOSES

CT scans indicated retroperitoneal hematoma growth resulting in hydronephrosis of the right kidney.

INTERVENTIONS

Laparoscopic drainage of the retroperitoneal hematoma was successfully performed.

OUTCOMES

His symptoms resolved after the surgery. Follow-up CT scans three months later demonstrated complete resolution of the hydronephrosis and retroperitoneal hematoma.

LESSONS

Our case highlights a patient with delayed hydronephrosis because of retroperitoneal hematoma expansion after a seatbelt injury.

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.

Transperitoneal laparoscopic nephrectomy in acute Grade 4 renal trauma with literature review and a note on some unusual complications

Most renal traumas are successfully managed conservatively. Grade 4 and 5 trauma, however, can require nephrectomy which is almost always by laparotomy and laparoscopic nephrectomy (LN) is still considered contraindicated in acute trauma setting. We report successful transperitoneal LN in an acute grade 4 renal trauma with retroperitoneal haematoma, extensive parenchymal devascularisation and urinary extravasation though retroperitoneoscopic nephrectomy in trauma has been reported recently. However, we believe transperitoneal approach is more logical and replicates all the principles of open renal trauma surgery more accurately. A review of LN in renal trauma and some unusual problems to be anticipated during laparoscopic procedures in acute trauma setting is presented.