Laparoscopic splenectomy after trauma: Who, when and how. A systematic review

To the point: Utility of laparoscopy for operative management of stabbing abdominal trauma

BACKGROUND

Algorithms for managing penetrating abdominal trauma are conflicting or vague regarding the role of laparoscopy. We hypothesized that laparoscopy is underutilized among hemodynamically stable patients with abdominal stab wounds.

METHODS

Trauma Quality Improvement Program data (2016-2019) were used to identify stable (SBP ≥110 and GCS ≥13) patients ≥16yrs with stab wounds and an abdominal procedure within 24hr of admission. Patients with a non-abdominal AIS ≥3 or missing outcome information were excluded. Patients were analyzed based on index procedure approach: open, therapeutic laparoscopy (LAP), or LAP-conversion to open (LCO). Center, clinical characteristics and outcomes were compared according to surgical approach and abdominal AIS using non-parametric analysis.

RESULTS

5984 patients met inclusion criteria with 7 ​% and 8 ​% receiving therapeutic LAP and LCO, respectively. The conversion rate for patients initially treated with LAP was 54 ​%. Compared to conversion or open, therapeutic LAP patients had better outcomes including shorter ICU and hospital stays and less infection complications, but were younger and less injured. Assessing by abdominal AIS eliminated ISS differences, meanwhile LAP patients still had shorter hospital stays. At time of admission, 45 ​% of open patients met criteria for initial LAP opportunity as indicated by comparable clinical presentation as therapeutic laparoscopy patients.

CONCLUSIONS

In hemodynamically stable patients, laparoscopy remains infrequently utilized despite its increasing inclusion in current guidelines. Additional opportunity exists for therapeutic laparoscopy in trauma, which appears to be a viable alternative to open surgery for select injuries from abdominal stab wounds.

LEVEL OF EVIDENCE

Prognostic and Epidemiological; Level IV.

[Blunt abdominal trauma in children and adolescents: treatment concepts in the acute phase]

Fatal accidents due to blunt force trauma are the leading cause of death in children and adolescents [1]. Abdominal trauma is the third most common cause of death after traumatic brain injury and thoracic injuries [2]. Abdominal injury is seen in approximately 2-5% of children involved in accidents [3]. Blunt abdominal injuries are common sequelae of traffic accidents (for example as seat belt injury), falls, and sports accidents. Penetrating abdominal injuries are rare in central Europe. Spleen, liver, and kidney lacerations are the most common injuries after blunt abdominal trauma [4]. In most situations, nonoperative management (NOM) has become the gold standard with the surgeon leading the multidisciplinary treatment [5].

The role of laparoscopic splenectomy in traumatic splenic injury: a narrative review

INTRODUCTION

Splenic injuries are one of the commonest occurrences in abdominal trauma. Nonoperative management (NOM) is the treatment of choice in hemodynamically stable patients with low grade injuries in the absence of vascular injury on CT; however, in some cases, NOM can fail and surgery is required. Traditionally, splenectomy is performed via laparotomy but, recently, the use of laparoscopy is rapidly increasing because the numerous advantages it offers for selected trauma patients.

EVIDENCE ACQUISITION

A systematic review of the literature was performed through Medline for papers on the laparoscopic splenectomy (LS) in trauma patients, published from January 2006 to July 2022. The inclusion criteria were the study population consisted of hemodynamically stable adult patients treated with LS, as primary treatment or in case of complication or failure of NOM. The data extracted included gender, patient age, type of trauma, ISS, indication for LS and if LS was performed primary or secondary to NOM. The considered outcomes were operative time, length of stay, morbidity and mortality.

EVIDENCE SYNTHESIS

Eight papers were considered suitable for the study and all the articles were retrospective studies and only one of them was multicentered. A total of 202 patients were included in the study and all of these suffered splenic trauma and all patients were hemodynamically stable or responding to fluid resuscitation. Trauma mechanism was blunt in 92.9% of cases and penetrating in 7%. Twenty-one patients underwent LS after failure of angioembolization. Operative time of LS was reported in 6 papers and the mean was 130.7 mins. Length of stay was reported in 7 papers and the mean was 8.12 days. Overall morbidity was 7.7% and the postoperative mortality was cited in 6 articles with an overall percentage of 2.5%.

CONCLUSIONS

Laparoscopy should be considered a valid alternative to open surgery, in hemodynamically stable patients and when performed by an experienced surgeon, such as the minimally invasive trauma surgeon.

Guidelines for the performance of minimally invasive splenectomy

BACKGROUND

Minimally invasive splenectomy (MIS) is increasingly favored for the treatment of benign and malignant diseases of the spleen over open access approaches. While many studies cite the superiority of MIS in terms of decreased morbidity and length of stay over a traditional open approach, the comparative effectiveness of specific technical and peri-operative approaches to MIS is unclear.

OBJECTIVE

To develop evidence-based guidelines that support clinicians, patients, and others in decisions on the peri-operative performance of MIS.

METHODS

A guidelines committee panel of the Society of American Gastrointestinal and Endoscopic Surgeons (SAGES) including methodologists used the Grading of Recommendations Assessment, Development and Evaluation approach to grade the certainty of evidence and formulate recommendations.

RESULTS

Informed by a systematic review of the evidence, the panel agreed on eight recommendations for the peri-operative performance of MIS for adults and children in elective situations addressing six key questions.

CONCLUSIONS

Conditional recommendations were made in favor of lateral positioning for non-hematologic disease, intra-operative platelet administration for patients with idiopathic thrombocytopenic purpura instead of preoperative administration, and the use of mechanical devices to control the splenic hilum. Further, a conditional recommendation was made against routine intra-operative drain placement.

Laparoscopic surgery for splenic injuries in the era of non-operative management: current status and future perspectives

The spleen is one of the organs most commonly injured by blunt abdominal trauma. It plays an important role in immune response to infections, especially those sustained by encapsulated bacteria. Nonoperative management (NOM), comprising clinical and radiological observation with or without angioembolization, is the treatment of choice for traumatic splenic injury in patients who are hemodynamically stable. However, this strategy carries a risk of failure, especially for high-grade injuries. No clear predictors of failure have been identified, but minimally invasive surgery for splenic injury is gaining popularity. Laparoscopic surgery has been proposed as an alternative to open surgery for hemodynamically stable patients who require surgery, such as after failed NOM. We reviewed research articles on laparoscopic surgery for hemodynamically stable patients with splenic trauma to explore the current knowledge about this topic. After presenting an overview of the treatments for splenic trauma and the immunological function of the spleen, we try to identify the future indications for laparoscopic surgery in the era of NOM.