Diagnostic laparoscopy decreases the rate of unnecessary laparotomies and reduces hospital costs in trauma patients

BACKGROUND AND PURPOSE: The use of laparoscopy for the treatment of various surgical diseases has been well described, and recently, it has gained popularity in the evaluation of abdominal trauma patients. The value of diagnostic laparoscopy (DL) in avoiding unnecessary laparotomies and its effects on hospital costs was evaluated in a prospective clinical trial. PATIENTS AND METHODS: In a 48-month period, 99 hemodynamically stable abdominal trauma patients (28 blunt and 71 penetrating injuries) among 428 patients admitted with abdominal trauma in whom the decision for surgical exploration was made were accepted for the study and underwent DL prior to laparotomy. RESULTS: The DL was negative in 60.7% of the patients with blunt abdominal trauma (BAT) and in 62.0% of the patients with penetrating abdominal trauma (PAT). Laparoscopy-positive patients (Group 1) underwent immediate laparotomy, whereas on DL-negative patients (Group 2), no laparotomies were performed. Hospitalization times and hospital costs of the two groups were recorded and compared. The difference between the hospitalization times of Group 1 and Group 2 was statistically significant (P < 0.001). The use of DL reduced the rate of unnecessary laparotomies from 60.7% to 0 in BAT and from 78.9% to 16.9% in PAT. The mean hospitalization time was 2.75 +/- 1.20 days in patients with negative DL, whereas it was 7.4 +/- 2.20 days and 5.2 +/- 1.42 days in DL-positive patients undergoing a therapeutic and nontherapeutic laparotomy, respectively. When the hospital costs of the Group 1 patients were compared with those of Group 2 patients, there was a 4.07-fold increase in patients undergoing therapeutic laparotomy and a 1.78-fold increase in patients undergoing nontherapeutic laparotomy. CONCLUSION: Diagnostic laparoscopy might be used in selected patients to exclude significant intra-abdominal injuries.     

Laparoscopy as diagnostic-therapeutic method in abdominal traumatism in the pediatric age

The management of blunt abdominal traumatism with a moderate amount of free peritoneal fluid and without solid organ injury as well as the one of minimal penetrating trauma is controversial. We present three cases of blunt abdominal trauma and two of penetrating trauma that underwent diagnostic laparoscopy in our department. We found a small bowel perforation in one of the cases of blunt trauma that was repaired by externalization of the jejuna loop by one of the ports. In the other two cases we found intestinal and mesenteric contusions and free fluid that were treated by peritoneal drainage. One of the cases of penetrating trauma presented omentum evisceration with no other injuries and the second presented a gastric perforation that needed reconversion to laparotomy. In our experience and according to literature, laparoscopy should be taken into account as a diagnostic procedure and sometimes also therapeutic in selected cases of both blunt and penetrating abdominal trauma in pediatric population.     

The accuracy of diagnostic laparoscopy in trauma patients: a prospective, controlled study

BACKGROUND: Numerous studies advocate the use of diagnostic laparoscopy (DL) for abdominal trauma, but none have documented its ability to diagnose specific injuries. This study tests the hypothesis that DL can accurately identify all significant intra-abdominal injuries in trauma patients. METHODS: Of trauma patients requiring laparotomy for presumed injuries, 47 underwent DL followed by laparotomy. Injuries noted at laparoscopy were compared with those found at laparotomy. RESULTS: Of these, 14 patients had no significant injuries necessitating operative intervention noted at laparoscopy and celiotomy. The remaining 33 patients harbored 93 significant injuries at laparotomy, of which only 57.0% were found by DL. DL possessed poor sensitivity (<50%) for injuries to hollow viscera. Despite DL's poor performance in finding specific injuries, it possessed excellent sensitivity (96.2%), and specificity (100%) for determining the need for therapeutic celiotomy. CONCLUSIONS: DL offers no clear advantage over diagnostic peritoneal lavage and computed tomography in blunt trauma. Its utility lies in assessment of the need for laparotomy in patients with penetrating wounds. Currently, DL cannot consistently identify all abdominal injuries, disqualifying it as a therapeutic tool in abdominal trauma.     

Impact of increased use of laparoscopy on negative laparotomy rates after penetrating trauma

BACKGROUND: Our institution was one of the first to report the use of laparoscopy in the management of penetrating abdominal trauma (PAT) in 1977. Despite early interest, laparoscopy was rarely used. Changes in 1995 resulted in an increase in interest and use of laparoscopy. We present our recent experience with laparoscopy. METHODS: Our trauma registry and operative log were used to identify patients with blunt and penetrating injuries to the abdomen, back, and flank who underwent laparotomy or laparoscopy during the past 5 years. Patient demographics, operative findings, complications, and length of stay were reviewed. The number of laparoscopic explorations, therapeutic, nontherapeutic, and negative laparotomies were trended. RESULTS: There were 429 abdominal explorations for trauma. The rate of laparoscopy after penetrating injury increased from 8.7% to 16%, and after stab wounds from 19.4% to 27%. There was an associated decrease in the negative laparotomy rate. Laparoscopy prevented unnecessary laparotomy in 25 patients with PAT. Four patients with diaphragm injuries underwent repair laparoscopically. CONCLUSION: An aggressive laparoscopic program can improve patient management after PAT.     

Laparoscopy in the diagnosis of blunt and penetrating injuries to the abdomen.

Laparoscopy was evaluated in thirty-seven patients from a group of 132 consecutive patients who were treated for blunt or penetrating injury to the abdomen. A total of twenty-three patients underwent laparoscopy and laparotomy. The findings at laparotomy correlated with laparoscopy. Fourteen patients underwent laparoscopy only, and there were no proved false-negative results. Of the 132 patients considered for laparotomy, 118 underwent abdominal exploration. Laparotomy was considered unnecessary in twenty-five of the 118 patients (21 per cent) and in retrospect, laparoscopy could have identified in each patient the presence of a minor injury or no injury at all. Laparoscopy is a useful method for evaluating blunt and penetrating injuries to the abdomen in selected patients.     

The value of laparoscopy in management of abdominal trauma

The role of laparoscopy (LS) in abdominal trauma is controversial. Concerns remain regarding missed injuries and safety. Our objective for this study was to determine the safety and better define the role of LS in abdominal trauma victims. We performed a retrospective review of all patients who sustained abdominal trauma and underwent LS in a level I trauma center. The main outcome measures were age, gender, mechanism of injury (MOI), indication for laparoscopy, presence of intra-abdominal injury (IA), therapeutic laparoscopy (TxLS), need for laparotomy, length of hospital stay (LOS), missed injuries, complications, and deaths. Forty-eight patients underwent LS (62 per cent male; average age, 28 years; MOI, 35 (85%) penetrating, 7 (15%) blunt; mean ISS, 8). At laparoscopy, 58 per cent of patients had no intra-abdominal injury. IA injury was treated with laparotomy in 14 (29%) and TxLS in 6 (13%). One patient had a negative laparotomy (2%). No injuries were missed. No patients required reoperation. There was one complication: a pneumothorax. There were no deaths. LS was most valuable in penetrating trauma, avoiding laparotomy in more than two-thirds of patients with suspected intra-abdominal injury. LS can serve as a useful adjunct for the evaluation of blunt trauma. In a level I trauma center with LS readily available, the procedure is associated with a low rate of complications and missed injury.     

The importance of laparoscopy in blunt abdominal trauma

The importance of laparoscopy in the management of blunt abdominal trauma should be evaluated. Therefore we retrospectively analysed all patients with blunt abdominal trauma treated in the Department of Surgery at the Carl-Thiem-Hospital Cottbus between 1998 and 2000. Within this period a total number of 53 patients with blunt abdominal trauma underwent operative treatment, 20 (37.7 %) of them had primary laparoscopy. Of the 11 cases where laparoscopic operation could be completed without conversion to exploratory laparotomy, 8 patients had intra-abdominal injuries and underwent sufficient laparoscopic treatment. The percentage of so called "negative" exploratory laparotomies within this study was 13.2 %. Our analysis suggests that laparoscopy should become firmly established in the diagnostic management and, if indicated, in the treatment of blunt abdominal trauma as well.     

A prospective analysis of diagnostic laparoscopy in trauma.

OBJECTIVE: This study was performed to assess current and potential future application for laparoscopy (DL) in the diagnosis of penetrating and blunt injuries. Efficacy, safety, and cost analyses were performed. SUMMARY BACKGROUND DATA: Diagnostic peritoneal lavage (DPL) and computed tomography (CT) have been the mainstays in recent years for diagnosis of equivocal nontherapeutic laparotomy, whereas CT is not helpful for the vast majority of penetrating wounds. DL may be a useful adjunct to fill in these gaps. METHODS: Hemodynamically stable patients with equivocal evidence of intraabdominal injury were prospectively entered into the protocol. DL was performed under general anesthesia; patients with wounds penetrating the peritoneum or blunt injury with significant organ injury underwent laparotomy. RESULTS: Over 19 months, 182 patients (55% stab, 36% GSW, 9% blunt) were studied. No peritoneal penetration was found at DL in 55% of penetrating wounds with 66% of the remainder having therapeutic laparotomy, 17% nontherapeutic laparotomy, and 17% negative laparotomy. Therapeutic laparotomy was performed in 53% of blunt injuries after DL. Tension pneumothorax occurred in one patient and one had an iatrogenic small bowel injury. Charges for DL were $3,325 per patient compared with $3,320 for a similar group undergoing negative laparotomy before this protocol. CONCLUSIONS: DL is a safe modality for trauma. With current technology, DL is most efficacious for evaluation of equivocal penetrating wounds. Significant cost savings would be gained by performance under local anesthesia. Development of miniaturized optics, bowel clamps, retractors, and stapling devices will reduce overall costs and permit some therapeutic applications for laparoscopy in trauma management.     

Diagnostic laparotomy for abdominal trauma. A university hospital experience

Following the experience of World War II, exploratory laparotomy in all patients with penetrating abdominal trauma was deemed mandatory until 1960 when Shaftan reported his experience with selective laparotomy. In 1973, Nance et al. reported on selective observation of abdominal stab wounds. There seems to be little controversy over mandatory laparotomy for abdominal gunshot wounds. Blunt trauma is generally managed expectantly with the adjunctive use of peritoneal lavage, CT scanning, and serial examinations of the abdomen. Despite the selective approach and the use of adjunctive diagnostic methods, exploratory laparotomy continues to be the most accurate method used to diagnose the presence of intra-abdominal injury. In order to examine our experience with diagnostic laparotomy for trauma, both blunt and penetrating, a retrospective study of 494 consecutive patients undergoing exploratory laparotomy over the past 4 years was undertaken. Abdominal stab wounds were explored under local anesthesia, and, if found to penetrate the posterior fascia, laparotomy was accomplished. All patients with abdominal gunshot wounds underwent exploration. Exploratory laparotomy in patients with blunt abdominal trauma was mandated by clinical signs, positive peritoneal lavage, or positive CT scan. All patients with unexplained shock and/or signs of peritoneal irritation underwent urgent laparotomy. In this series of 494 patients, 99 or 20 per cent of the entire group had a negative exploration (30% for stab wounds, 16% for gunshot wounds, and 19% for blunt abdominal trauma). The morbidity for the negative laparotomy group was limited to five patients with postoperative atelectasis. There were no anesthesia complications, iatrogenic intraoperative injuries, or wound infections. There were five deaths but none were laparotomy-related.(ABSTRACT TRUNCATED AT 250 WORDS)     

Correlation of abdominal trauma index and injury severity score with abdominal septic complications in penetrating and blunt trauma.

The Abdominal Trauma Index (ATI) was designed to stratify patients with penetrating injuries, and has been used to classify patients with blunt trauma. The Injury Severity Score (ISS) was originally designed to stratify victims of blunt trauma, and it has also been used for victims of penetrating trauma. We attempted to validate the use of ISS and ATI for both penetrating and blunt trauma. A total of 592 penetrating and 334 blunt trauma patients who underwent laparotomy over a 5-year period were evaluated. The overall rate of abdominal sepsis was 7.5% for blunt trauma and 7.6% for penetrating trauma. Mortality (excluding deaths within 48 hours) was 7% for blunt trauma and 1% for penetrating trauma. In the penetrating injury population, an ATI value greater than 15 and an ATI value greater than 25 were significantly associated with abdominal septic complications (ASCs) (p less than 0.001, both comparisons). An ISS greater than or equal to 16 was also associated with ASCs (p less than 0.001). The ASC rate for gunshots was higher than that for stab wounds (11% vs. 2%; p less than 0.001). In the blunt group, an ATI value greater than 15 and an ATI value greater than 25 were associated with ASCs (p less than 0.01 and p less than 0.001, respectively). The association of ASCs and ISS was linear with increasing ISS in patients with blunt abdominal trauma.(ABSTRACT TRUNCATED AT 250 WORDS)     

Laparoscopy in abdominal trauma. Preliminary report in 37 cases

The role of diagnostic laparoscopy (DL) and therapeutic laparoscopy (TL) in abdominal trauma is not clear. Even after diagnostic punction lavage (DPL), ultrasonography (US), and CT scan (CT), in some cases is difficult to decide between laparotomy and observation. In 37 cases of abdominal trauma, a laparoscopic evaluation was done; 28 abdominal blunt trauma (22 associated with multiple trauma), and 9 abdominal wounds (8 stab wounds). In blunt abdominal trauma, DL was done for haemoperitoneum (26 cases), after DPL, US or CT. In three cases, with equivocal diagnosis, an extra abdominal operation in general anaesthesia was necessary. In abdominal wounds a DL was done for suspicion of penetration. All the patients were haemodynamic stable, TS > or = 12. A laparotomy was necessary in 12 cases (32.43%), a LT was possible in 5 cases (13.51%). In the rest of cases, a DL with or without lavage-drenage enough.     

Role of Laparoscopy in Penetrating Abdominal Trauma: A Systematic Review

Background

Debate remains regarding the optimum role of laparoscopy in the setting of trauma although it can offer advantages over traditional exploratory laparotomy. Laparoscopy can be a screening, diagnostic or therapeutic tool in trauma. The purpose of this review is to evaluate the role of laparoscopy in penetrating abdominal trauma

Methods

The PUBMED database was searched with the keywords “Laparoscopy AND Trauma”. Additional citation searching and searching of the grey literature was conducted. Relevant studies were chosen on the basis of the defined inclusion and exclusion criteria and quality was assessed where appropriate using the Downs and Black checklist

Results

In total, 51 studies were included in the analysis of which only 13 were prospective. In most studies, laparoscopy was used as a screening, diagnostic or therapeutic tool. In total, 2569 patients underwent diagnostic laparoscopy (DL) for penetrating abdominal trauma (PAT), 1129 (43.95 %) were positive for injury. 13.8 % of those with injury had a therapeutic laparoscopy. In total 33.8 % were converted to laparotomy, 16 % of which were non-therapeutic and 11.5 % of them were negative. 1497 patients were spared a non-therapeutic laparotomy. Overall, 72 patients suffered complications, there were 3 mortalities and 83 missed injuries. Sensitivity ranged from 66.7–100 %, specificity from 33.3–100 % and accuracy from 50–100 %. 23 of the 50 studies reported sensitivity, specificity and accuracy of 100 %, including the four most recent studies. In general the quality of the reported studies was poor. When used for cohort studies, the mean Downs and Black checklist score was 13.25 out of a possible total of 28.

Conclusions

In summary, laparoscopy in PAT may have an important role in a selected subgroup of patients, with surgeon expertise also an important factor. Laparoscopy has screening, diagnostic and therapeutic roles, particularly where diaphragm injury is suspected. It is extremely sensitive in determining need for laparotomy but detects hollow visceral injuries less reliably. It has potential as a therapeutic tool in centres with appropriate expertise. The development of specific guidelines or protocols may increase the value of laparoscopy in trauma but this would require more evidence of a higher quality.     

Unreliability of standard quantitative criteria in diagnostic peritoneal lavage performed for suspected penetrating abdominal stab wounds

Thirty-five patients with abdominal stab wounds in whom clinical examination was equivocal on 2 separate occasions underwent diagnostic peritoneal lavage (DPL) prior to laparotomy. The red and white blood cell counts (cells/mm3) of the lavage effluent were compared with the operative findings. There were 26 positive and 9 unnecessary laparotomies, the latter consisting of 4 negative and 5 non-therapeutic operations. Use of the standard quantitative criteria for red cells in DPL failed to identify significant injury in eight patients (31%), while the standard white cell count missed six injuries (23%). Their combined use resulted in three missed injuries (12%). Two false-positive results occurred using the red cell count alone and four using the white cell count alone, producing a combined false-positive result in four patients (11%). Reducing the cell threshold level to exclude missed injuries would increase dramatically the rate of unnecessary laparotomies. Although the standard quantitative criteria for DPL are superior to clinical assessment in patients with equivocal findings, their use in penetrating trauma does not achieve the same diagnostic accuracy as in blunt abdominal trauma.     

Laparoscopy for Penetrating Thoracoabdominal Trauma: Pitfalls and Promises

Background:

How should the stable patient with penetrating abdominal or lower chest trauma be evaluated? Evolving trends have recently included the use of diagnostic laparoscopy. In September 1995 we instituted a protocol of diagnostic laparoscopy to identify those patients who could safely avoid surgical intervention.

Design:

Prospective case series.

Materials and Methods:

Hemodynamically stable patients with penetrating injuries to the anterior abdomen and lower chest were prospectively evaluated by diagnostic laparoscopy, performed in the operating room under general anesthesia, and considered negative if no peritoneal violation or an isolated nonbleeding liver injury had occurred. If peritoneal violation, major organ injury or hematoma was noted, conversion to open celiotomy was undertaken.

Results:

Seventy consecutive patients were evaluated over a two-year period. The average length of stay (LOS) following negative laparoscopy was 1.5 days, and for negative celiotomy 5.2 days. There were no missed intra-abdominal injuries following 30 negative laparoscopies, and 26 of 40 laparotomies were therapeutic. The technique also proved useful in evaluation of selected blunt and HIV+ trauma vic-tims with unclear clinical presentations. However, while laparoscopy was accurate in assessing the abdomen following penetrating lower chest injuries, significant thoracic injuries were missed in 2 out of 11 patients who required subsequent return to OR for thoracotomy.

Conclusions:

Laparoscopy has become a useful and accu-rate diagnostic tool in the evaluation of abdominal trauma. Nevertheless, laparoscopy still carries a 20% nontheraputic laparotomy rate. Additionally, significant intrathoracic injuries may be missed when laparoscopy is used as the pri-mary technique to evaluate penetrating lower thoracic trauma.     

Evaluation of video-assisted thoracoscopic surgery in the diagnosis of diaphragmatic injuries

: Injury to the diaphragm from penetrating or blunt thoracoabdominal trauma is notoriously difficult to diagnose. Chest radiography, computed tomography scan, contrast studies, diagnostic peritoneal lavage, and laparoscopy are inadequate; thus, celiotomy is commonly performed in patients with suspected diaphragmatic injury. We compared the diagnostic accuracy of video-assisted thoracoscopic surgery (VATS) with that of exploratory celiotomy in the evaluation of diaphragmatic and thoracoabdominal injury. : Hemodynamically stable patients admitted to a level I trauma center with blunt or penetrating injury to the lower chest or abdomen underwent VATS and subsequent celiotomy under the same general anesthetic. Intraoperative thoracoscopic findings were blinded to the abdominal surgeons. : Twenty-six patients were enrolled in the study over a 12-month period. Diaphragmatic injuries were identified in 8 patients (31%). Videothoracoscopy identified all eight injuries in these patients. Six of the 8 patients (75%) with diaphragmatic injuries sustained associated injury to intrathoracic or intra-abdominal organs. There was no mortality and no procedure-related morbidity. There were no missed injuries in patients who underwent VATS. : Video-assisted thoracoscopy is a safe, expeditious, and accurate method of evaluating the diaphragm in injured patients, and is comparable in diagnostic accuracy to exploratory celiotomy.     

Selective nonoperative management of penetrating abdominal solid organ injuries

OBJECTIVE: To assess the feasibility and safety of selective nonoperative management in penetrating abdominal solid organ injuries. BACKGROUND: Nonoperative management of blunt abdominal solid organ injuries has become the standard of care. However, routine surgical exploration remains the standard practice for all penetrating solid organ injuries. The present study examines the role of nonoperative management in selected patients with penetrating injuries to abdominal solid organs. PATIENTS AND METHODS: Prospective, protocol-driven study, which included all penetrating abdominal solid organ (liver, spleen, kidney) injuries admitted to a level I trauma center, over a 20-month period. Patients with hemodynamic instability, peritonitis, or an unevaluable abdomen underwent an immediate laparotomy. Patients who were hemodynamically stable and had no signs of peritonitis were selected for further CT scan evaluation. In the absence of CT scan findings suggestive of hollow viscus injury, the patients were observed with serial clinical examinations, hemoglobin levels, and white cell counts. Patients with left thoracoabdominal injuries underwent elective laparoscopy to rule out diaphragmatic injury. Outcome parameters included survival, complications, need for delayed laparotomy in observed patients, and length of hospital stay. RESULTS: During the study period, there were 152 patients with 185 penetrating solid organ injuries. Gunshot wounds accounted for 70.4% and stab wounds for 29.6% of injuries. Ninety-one patients (59.9%) met the criteria for immediate operation. The remaining 61 (40.1%) patients were selected for CT scan evaluation. Forty-three patients (28.3% of all patients) with 47 solid organ injuries who had no CT scan findings suspicious of hollow viscus injury were selected for clinical observation and additional laparoscopy in 2. Four patients with a "blush" on CT scan underwent angiographic embolization of the liver. Overall, 41 patients (27.0%), including 18 cases with grade III to V injuries, were successfully managed without a laparotomy and without any abdominal complication. Overall, 28.4% of all liver, 14.9% of kidney, and 3.5% of splenic injuries were successfully managed nonoperatively. Patients with isolated solid organ injuries treated nonoperatively had a significantly shorter hospital stay than patients treated operatively, even though the former group had more severe injuries. In 3 patients with failed nonoperative management and delayed laparotomy, there were no complications. CONCLUSIONS: In the appropriate environment, selective nonoperative management of penetrating abdominal solid organ injuries has a high success rate and a low complication rate.     

Laparoscopic management of penetrating liver trauma: a safe intervention for hemostasis

We describe the case of a 48-year-old woman who underwent emergent diagnostic and therapeutic laparoscopy after sustaining two self-inflicted abdominal stab wounds. After evacuation of approximately 1.5 L hemoperitoneum, a through-and-through liver injury with active bleeding was locally packed with hemostatic agents (Surgicel and Avitene) to achieve successful hemostasis. The patient also underwent systematic exploration of the abdominal cavity, which was free of associated injury. She had an uneventful recovery. This case adds to the growing evidence supporting the role of therapeutic laparoscopy in the safe management of carefully selected stable patients with penetrating abdominal trauma.     

腹部创伤的诊断与治疗

腹部创伤患者救治中如何降低漏诊率和阴性探查率仍然是临床难题.本文基于血流动力学和致伤机制提出诊断与治疗流程,进一步阐述该流程中涉及的体格检查、创伤重点超声评估（FAST）、CT检查和诊断性腹腔灌洗（DPL）等腹部创伤伤情评估技术,钝性伤和穿透伤手术指征等紧急救治策略,以及腹腔镜下和剖腹时的探查技术.     

Therapeutic laparoscopy for blunt abdominal trauma with bowel injuries

In the setting of abdominal trauma, laparoscopy is used mainly for diagnosis, and its role in definitive operative repair is still debated. We report the case of a 50-year-old woman who underwent diagnostic and therapeutic laparoscopy after being subjected to blunt abdominal trauma in a traffic accident. Multiple injuries to the small bowel and colon were repaired laparoscopically with a favorable outcome. Surgeons with experience in advanced laparoscopy and trauma care can use laparoscopy in the diagnosis and treatment of selected patients with blunt abdominal trauma.