Therapeutic Laparoscopy for Penetrating Anterior Abdominal Trauma; A safe Addition to the Diagnostic and Treatment Algorithm.

Salvatore Docimo, Jr., DO, MS, Alyssa Butt, BS, Vadim Meytes, Christopher Zambrano, Fausto Vinces, Michael Timoney, George Ferzli. Lutheran Medical Center

INTRODUCTION: The algorithm for the management of penetrating anterior abdominal injury (PAAI) is not clearly defined. The definitive diagnostic and therapeutic modality in penetrating anterior abdominal injury (PAAI) is exploratory laparotomy (EL), but it carries a morbidity and mortality up to 20% and 5%. Previous studies have shown that 30-50% of all stab wounds do not penetrate the peritoneum and the non-therapeutic laparotomy rate is as high as 70%. In an effort to reduce the morbidity associated with negative exploratory laparotomy, we retrospectively studied the use of laparoscopy as both a diagnostic tool, as well as a means of providing definitive therapy for PAAI in a Level I Trauma Center where the trauma surgeons have a high level of laparoscopic training. We also sought to determine if previous laparoscopic fellowship training and a low injury severity score (ISS) was associated with the use of laparoscopy in the treatment of PAAI.

METHODS AND PROCEDURES: We performed a retrospective review of trauma cases that underwent a DL at a Level I trauma center from 2008 to 2014. Inclusion criteria included all trauma patients who underwent diagnostic laparoscopy following PAAI. Exclusion criteria included: trauma patients above the below the age of 12, Glasgow Coma Scale (GSC) < 8, and hemodynamic instability. We divided our study group into patients who underwent: DL only, DL with conversion to EL (DL/EL), and DL with subsequent therapeutic laparoscopy (DL/TL). Endpoint outcomes were: missed injury, post-operative complications, length of stay (LOS), and avoidance of negative laparotomies.

RESULTS: Thirty patients with PAAI were included and underwent initial DL. Patients had an average: age of 30, BMI of 25.75, injury severity score (ISS) of 6.24 and, GCS of 15. FAST exam was performed in 18 (60%) patients with four (13.3%) having positive findings. No positive FAST exams were noted in DL group; 3 positive FAST exams were noted in the DL/TL group; and 1 positive FAST in the DL/EL group. The ISS of the DL, DL/TL, and DL/EL groups were 8.5, 11, and 12.28 (p=0.204; 95%CI). Nine (30%) cases required no intervention and remained DL. Fourteen (47%) cases underwent laparoscopic therapeutic intervention (hematoma evacuation, and visceral, mesentery, diaphgragm, or abdominal wall repair). Seven (23%) cases underwent conversion to EL. Average LOS for the DL, DL/TL, and DL/EL groups were 3.78, 2.5, and 6.28 days (p=0.044; 95%CI). Post-operative complications included one ileus in a DL case. No missed injuries in the DL or DL/TL groups were noted.

CONCLUSION:Therapeutic laparoscopy should be considered as an addition to the algorithm of management of PAAI. A trauma surgeon with advanced laparoscopic training may utilize laparoscopy, as both, a diagnostic and therapeutic modality for a subset of stable patients with PAAI. The difference in ISS for each group was not statistically significant and did not play a role in determining laparoscopic versus open therapies. In our study, laparoscopy in PAAI significantly decreased the incidence of negative laparotomy, avoided the complications associated with EL, and significantly decreased the hospital LOS.

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