Laparoscopic Approach to Repair Traumatic Diaphragmatic Injuries: A National Trauma Databank Comparison

Wissam Raad, MD, MRCS, J. Alexander Palesty, MD, FACS

Saint Mary’s Hospital, The Stanley J. Dudrick Department of Surgery, Yale Affiliate

INTRODUCTION – Traumatic diaphragmatic Injury (TDI) usually occurs secondary to multiple trauma. Prompt diagnosis and repair of those injuries is important. Multiple approaches to repairing the diaphragmatic hernia have been described in the literature. The goal of this study is to compare the laparoscopic versus other non-laparoscopic approaches to TDI repair.

METHODS AND PROCEDURES – Retrospective review of all trauma patients undergoing laparoscopic or open abdominal diaphragmatic hernia repair from the National Trauma Databank for the admission years 2009 and 2010. Patient demographics, number of hours to procedure, type of trauma center, and mechanism of injury were observed. Hemodynamic characteristics were evaluated by Injury Severity Score ISS, systolic blood pressure, pulse, respiratory rate, percent oxygen saturation, and Glasgow Coma Scale in the emergency department. Resource utilization was evaluated by examining the number of patients transferred to the Intensive Care Unit (ICU), patients transferred to the operating room (OR transfers), hospital length of stay (LOS), intensive care unit LOS, number of ventilator days, and hospital disposition comparison. Outcomes were measured by reviewing the mortality rate and major complication rates in both approaches. Levene’s test and Student’s t-test were used for statistical analysis.
RESULTS – There were 138 cases of TDI repair included through in the study period (27 laparoscopic and 111 labeled open or other repairs). The male to female ration was 1.7:1 in the laparoscopic approach group, and 3:1 in the open approach (P-value = 0.028). The average age was 42 and 43 respectively (P-value= 0.005) and the number of hours to procedure was 110 and 84 respectively (P value = 0.612). Level I trauma centers performed 7(25.9%) laparoscopic repairs, and 49 (44.1%) utilizing a non-laparoscopic approach (P-value=0.000), while Level II trauma centers performed 12 (44.4%) and 27 (24.3%) respectively (P-value=0.004). On the other hand, community centers performed 17(63%) laparoscopicaly, and 44(39.6%) non-laparoscopic repairs (P-value=0.029), while university trauma centers performed 9 (33.3%) and 58 (52.3%) (P-value=0.001), and non-teaching trauma centers performed 1 (3.7%) and 9 (8.1%) repairs respectively (P-value=0.432). The remaining data is summarized in the tables below.

CONCLUSION(S) – The male to female ratio for patients undergoing laparoscopic repair is lower indicating a trend to utilize laparoscopy more frequently on females. Patients undergoing laparoscopic repair are younger. Level II trauma centers and community trauma centers are performing more laparoscopic repairs compared to level I and University centers respectively. Patients undergoing laparoscopic repairs have a lower GCS and ISS and their average length of stay is 1 day longer. There was a higher incidence pulmonary embolism in the laparoscopy group. This brief retrospective study would indicate that the laparoscopic approach is a relatively safe and viable technique. However, prospective studies are needed to appropriately evaluate the safety of this approach in the trauma population.

Session: Podium Presentation

Program Number: S096

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