ORIGINAL ARTICLE

Laparoscopy in Blunt and Penetrating Abdominal Trauma Mogeli Sh. Khubutiya, Prof Dr Med, Peter A. Yartsev, Prof Dr Med, Andrey A. Guliaev, Prof Dr Med, Vladislav D. Levitsky, MD, PhD, and Margarita A. Tlibekova, MD

Abstract: The objective of our study was to assess the abilities and limitations of laparoscopy and evaluate its role in examination and treatment of patients with abdominal trauma. A total of 628 patients with blunt and penetrating abdominal trauma were included in this retrospective 12-year survey (2000 to 2011). All patients in the study underwent either laparotomy (280 patients) or urgent laparoscopy (348 patients). There was no difference in the demographic data and trauma severity between the 2 groups. Conversion to open surgery was performed in 130 cases (37.3%). Diagnostic laparoscopy without therapeutic manipulations was used in 160 patients (46%) and therapeutic laparoscopy was carried out in 58 patients (16.7%). Quicker recovery time, less pain, shorter hospital stay, and lower complication rate were observed in patients after laparoscopic surgery compared with patients after open surgery. No missed abdominal organs injuries were revealed after laparoscopic examination of abdominal cavity. Key Words: laparoscopy, abdominal trauma, injury, wound, hemoperitoneum

(Surg Laparosc Endosc Percutan Tech 2013;23:507–512)

T

rauma is a most crucial issue in contemporary medicine. Nowadays the disability and mortality rates remain extremely high in polytrauma patients.1 Different studies show abdominal injuries in 1.5% up to 36.5% of traumatic injuries getting progressively frequent and severe.2,3 More to the point, high rate of diagnostic mistakes, postoperative complications, and mortality have been observed in treatment of abdominal trauma patients.3–6 Thus, there is an obvious need to improve management of this patient population.6,7 The improvement of medical care for abdominal trauma patients is particularly important because the overwhelming majority of them (77% to 98%) are young adults.4,5 Several studies have demonstrated that laparoscopy as a diagnostic and treatment tool can be beneficial in such patients.8–10 However, nowadays the role of laparoscopy in management of trauma patients is controversial. Although contraindications for using laparoscopy in the injured are developed, indications are not defined. The aim of our study was to assess the abilities and limitations of Received for publication February 19, 2013; accepted March 18, 2013. From the Department of Urgent Surgical Gastroenterology, Sklifosovsky Clinical and Research Institute for Emergency Medicine, Healthcare Department for the City of Moscow, Moscow, Russia. The authors declare no conflicts of interest. Reprints: Margarita A. Tlibekova, MD, Department of Urgent Surgical Gastroenterology, Sklifosovsky Clinical and Research Institute for Emergency Medicine, Healthcare Department for the City of Moscow, 3 B. Sukharevskaya Square, Moscow 129090, Russia (e-mail: [email protected]). Copyright r 2013 by Lippincott Williams & Wilkins

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laparoscopy and to evaluate its role in the management of abdominal trauma patients.

MATERIALS AND METHODS Patients This retrospective 12-year study (2000 to 2011) was conducted in the Sklifosovsky Clinical and Research Institute for Emergency Medicine. A total of 628 patients with blunt and penetrating abdominal trauma were included in the study. Laparoscopy was used as a diagnostic and therapeutic tool for abdominal trauma patients in our institute since 2006. Two hundred eighty patients (group A) were treated before the adoption of laparoscopy, and 348 patients (group B) were treated after. There was no difference in the demographic data and trauma severity between the 2 groups. All patients who required immediate laparotomy (such as hemodynamically unstable patients, patients with peritonitis, or patients with ongoing bleeding, when expected rate of bleeding exceeded 500 mL/h) were excluded from the study. Patients who successfully underwent conservative treatment were excluded from the study as well. Since 2006, selection of patients for laparoscopy was based on the following inclusion criteria: In blunt trauma: 1. Moderate ongoing bleeding, with increase of intraperitoneal fluid volume >200 mL/h but 3) wounds of anterior abdominal wall without clinical and instrumental evidences of abdominal organ injury. 2. Penetrating thoracoabdominal trauma. 3. Impossibility to inspect a wound canal along its length (eg, stab wounds in lumbar or gluteal regions). Failure of nonoperative management (NOM) was an indication for laparoscopy either in blunt or in penetrating abdominal trauma.

Methods All patients in our study underwent either urgent laparoscopy or laparotomy. Noninvasive investigations, such as laboratory investigations, serial abdominal US examinations, x-ray in multiple views, and computed tomography had been performed before the decision about necessity of an operation was made. Sensitivity, specificity, positive predictable value (PPV), and negative predictable value (NPV) were

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length from all sides. Atraumatic grasping forceps with large capturing area were used to reduce the risk of intestinal damage. A small intestine loop was pinched across the whole diameter, but the tips of the forceps should not have exceeded the intestinal wall to avoid the intestinal mesentery traumatization. After the examination of an intestine loop on one side, the same loop was rotated round the mesentery axis and examined on the opposite side. This manipulation required using a laparoscope with the viewing angle of 30 to 45 degrees. Further, the ascending colon and the anterior wall of the transverse colon were examined; the posterior wall of the transverse colon became available for examination after traction of the epiploon (atraumatic grasping forceps were used). The left flexure of the colon was the most difficult part for inspection because of its connection with the inferior edge of the spleen; hence, colon tractions in this region might cause damage to the spleen. It should be mentioned that even in open surgery an inspection of the left flexure of the colon is quite challenging. Colon examination was completed by inspection of the descending colon and the sigmoid intestine.

calculated using the formulas: Sensitivity ¼ Number of true positives/ðNumber of true positives þ Number of false negativesÞ Specificity ¼ Number of true negatives/ ðNumber of true negatives þ Number of false negativesÞ PPV ¼ Number of true positives/

ðNumber of true positives þ Number of false positivesÞ NPV ¼ Number of true negatives/

ðNumber of true negatives þ Number of false negativesÞ

The Laparoscopic Technique of Abdominal Cavity Inspection Laparoscopic inspection of abdomen started with an examination of a parietal peritoneum wound (in penetrating abdominal trauma) and adjacent viscera. It was followed by complete consecutive laparoscopic examinations of liver, spleen, stomach, small intestine, and colon. The presence, location, and volume of a retroperitoneal hematoma were evaluated. Special attention was paid to the presence of the fixed large blood clots which indicated the source of bleeding. Liver examination started from the diaphragmatic surface of the liver, after that its front edge was lifted by a retractor and the bottom surface was inspected. Spleen examination was performed in a patient in the Fowler position rotated on the right side. In this position the diaphragmatic surface of the spleen was available for good visualization without an additional traction. Stomach was inspected from its cardia to duodenum. Careful examination of the duodenal area was essential. Hematoma, emphysema, or bile coloration in this area were considered as the evidence of duodenum injury and constituted the indications to conversion. If examination of the posterior gastric wall was required, the omental bursa was cut open. When integrity of the gastric wall or duodenum was questioned, the patient underwent an intraoperative esophagogastroduodenoscopy. Small intestine examination started from the ileocecum because the ileum can be identified easier than the ligament of Treitz. An inspection of the ileocecum was conducted with a patient in the Trendelenburg position rotated on the left side. Usually such a position allowed identifying the cecum and the proximal part of the ileum. Small intestine loops were consecutively extended between 2 atraumatic forceps and examined on the whole

Statistical Analysis Statistical analyses were performed using Statistica 6.0-StatSoft. Data are presented as mean ± SD or ratio. Mann-Whitney U test was used when appropriate. P-value 0.05

35.8 ± 3.5

36.5 ± 2.3

> 0.05

> 0.05

152 41 9.8 ± 0.5

136 38 6.4 ± 0.2

< 0.05

All data are expressed as ratio or mean ± SD. The P-values correspond to comparison between the 2 groups of patients.

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Laparoscopy in Abdominal Trauma

TABLE 2. Conversions to Open Surgery

Laparoscopic Findings

No. Patients

Conversions to the Total No. of Patients Underwent Laparoscopy (%)

74

21.3

41 15

11.8 4.3

Impossibility to detect the source of intraabdominal bleeding and achieve hemostasis Hollow organ injuries Impossibility to exclude colon injuries in its retroperitoneal part

Laparoscopy Results

Secondly, the incisions in laparoscopy were smaller than in laparotomy. As a result, the necessity in the usage of opioid drugs for severe pain was considerably reduced (0.8 ± 0.3 d after laparoscopy vs. 1.7 ± 0.4 d after exploratory laparotomy, P < 0.0001). Thirdly, paralytic ileus was observed for 2.1 ± 0.3 days after laparoscopic intervention versus 3.1 ± 0.4 days after exploratory laparotomy (P < 0.0001). Further, postoperative course of antibiotic therapy and intravenous fluid management were reduced in patients who underwent laparoscopy. Thus, antibiotic therapy was used in the patients after laparoscopy for 7.1 ± 1.0 days versus 8.6 ± 0.7 days in patients after exploratory laparotomy (P = 0.02). Patients after laparoscopy needed 3.5 ± 0.9 days of intravenous fluid management in contrast with 5.3 ± 0.6 days for those after exploratory laparotomy (P = 0.10). The lowest rate of postoperative complications was observed in patients after laparoscopy (2.5%), whereas after exploratory laparotomy it was 18.4%. The highest complication rate was seen after therapeutic laparotomy (32.2%), whereas after conversion it was 22.4%. The length of hospital stay after laparoscopy in patients with abdominal trauma without additional injuries was 3.5 ± 0.5 days, whereas after exploratory laparotomy it was 13.3 ± 1.1 days (P = 0.12).

Laparoscopy was used in 348 patients with abdominal trauma. Conversion to open surgery was performed in 130 (37.3%) patients (Table 2). Urgent diagnostic laparoscopy without therapeutic manipulations was used in 160 patients (46%) (Table 3). Therapeutic laparoscopy was performed in 58 patients (16.7%) (Table 4). Moderate ongoing bleeding was revealed in two thirds of them. In patients with ongoing bleeding from liver wounds and lacerations (grade II), hemostasis was achieved by bipolar and monopolar coagulation, argon plasma coagulation, usage of Surgicel hemostatic plugs, and suturing of wounds. Spleen injuries were found in 21 patients. Usage of hemostatic plugs allowed achieving hemostasis in 6 patients, whereas laparoscopic splenectomy was performed in 10 patients with bleeding from spleen tears and in 5 patients with expanding spleen hematoma. Laparoscopic suturing of wounds was performed in patients with bladder wall lacerations (grade III), intestine, stomach, and sigmoid colon injuries, and diaphragmatic wounds (grade II). Cholecystectomy was carried out in patients with gallbladder injuries. Sensitivity of laparoscopy in our study was as high as 100%; specificity of laparoscopy was 92%. PPV amounted at 94% and NPV was 100%.

DISCUSSION The Treatment Outcomes

The purpose of our study was to assess the abilities and limitations of laparoscopy and to evaluate its role in the management of abdominal trauma patients. Nowadays treatment of hemodynamically unstable patients with abdominal trauma is developed, whereas diagnostic and treatment algorithm of hemodynamically stable patients remains a source of controversy.6,7,11 Emergency exploratory laparotomy is one of the options in management of

Laparoscopy as a diagnostic and therapeutic tool demonstrated clear benefits in patients with abdominal trauma. Firstly, the patients who underwent laparoscopy showed reduction of bed rest time compared with those who underwent exploratory laparotomy (1.4 ± 0.2 d after laparoscopy vs. 2.4 ± 0.5 d after laparotomy, P < 0.0001). TABLE 3. Indications to Diagnostic Laparoscopy

Clinical and Instrumental Findings Multiple (>3) wounds of the anterior abdominal wall with an absence of clinical and instrumental evidences of abdominal organ injuries Increase of hemoperitoneum in serial ultrasound examinations Impossibility to exclude hollow organ injuries in patients with blunt abdominal trauma Thoracoabdominal wounds Impossibility to inspect a wound canal along its length

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No. Patients

Diagnostic Laparoscopy to the Total No. of Patients Underwent Laparoscopy (%)

79

22.7

28

8

22

6

20 11

5.8 3.2

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TABLE 4. Therapeutic Laparoscopy

Organ Injuries

No. Patients

Therapeutic Laparoscopy to the Total No. of Patients Underwent Laparoscopy (%)

16

4.7

12 9

3.5 2.6

5 5 3 3 2

1.4 1.4 0.9 0.9 0.6

2 1

0.6 0.3

Spleen injuries with active bleeding from the tears (grade II) Diaphragmatic wounds and lacerations Ongoing bleeding from liver wounds and lacerations (grade II) Spleen hematoma (grade III) Stomach injury Bladder wall lacerations (grade III) Intestine injury Concomitant injury (diaphragm and stomach injury, diaphragm and liver injury) Gallbladder injury Sigmoid colon injury

such patients, but no injuries were found in 15% to 40% of the cases.12,13 Another practice is to perform primary and secondary survey, computed tomography, US examination, observation, and conservative treatment.14,15 However, some authors reported about high rate of unsuccessful NOM,15–17 which was related either to limitations of noninvasive diagnostic tests17–19 or to features of the patients’ clinical conditions (eg, agitation after alcohol consumption, usage of recreational drugs, etc.).20,21 High rate of exploratory laparotomies12,13 on one hand and drawbacks of noninvasive tests on the other hand coursed the needs to find a new approach in the management of abdominal trauma patients. We believe that laparoscopy can be an option in treatment of such patients and has many potential advantages. Firstly, diagnostic laparoscopy can be used safely in patients with equivocal results of noninvasive tests.8–10 In our study it was the patients with thoracoabdominal injuries, patients with increase of hemoperitoneum volume, and patients with suspicion of hollow organ injuries. Among the patients with thoracoabdominal injuries, diagnostic laparoscopy allowed detection of hollow organ injuries in 11.2%, and parenchymal organ injuries with ongoing bleeding in 44.4% of the cases. Impossibility to exclude additional source of bleeding in patients with retroperitoneal hematoma was considered as an indication to laparoscopy in 28 (8%) cases. Bleeding rate was

Laparoscopy in blunt and penetrating abdominal trauma.

The objective of our study was to assess the abilities and limitations of laparoscopy and evaluate its role in examination and treatment of patients w...
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