Srinivas H Reddy, MD, Melvin E Stone, MD, Jacquelyn Shaw, BS, Sheldon Teperman, MD, Harry M Delany, MD. Jacobi Medical Center – Albert Einstein College of Medicine.
Background:
The role of laparoscopy in trauma has long been a subject of debate. One of the earliest published reports of using this modality was for confirmation of peritoneal violation in abdominal trauma by Nino Carnevale back in 1977 from our institution, Jacobi Medical Center – Albert Einstein College of Medicine. With the evolving specialized training in advanced laparoscopy and the constantly improving instruments, scopes and monitors, has the role of laparoscopy changed in our management the trauma patient? The aim of this study was to review and evaluate outcomes of minimally invasive surgery in patients with trauma admitted to our hospital. We are also attempting to more clearly define updated criteria for laparoscopic intervention in patients with blunt or penetrating injury to abdominal viscera.
Methods:
This is a retrospective review of prospectively collected data of injured hemodynamically stable patients who underwent minimally invasive surgery for blunt or penetrating torso trauma in a level I trauma center in New York City from 2006 to 2011. Data was collected from an updated trauma registry, operative logs and electronic medical records. Variables obtained included patient demographics, mechanism of injury, injury severity score (ISS), location of injury, operative procedures and findings, blood loss, complications, length of stay, postoperative outcomes.
Results:
Of the 359 patients needing emergent abdominal exploration for trauma, 56 (16%) underwent laparoscopic exploration. Diagnostic laparoscopy was initiated primarily in stab wound injuries (77%), but was also employed for gunshot wounds (16%) and blunt trauma (7%). Injury Severity Score (ISS) was significantly less for procedures initiated with diagnostic laparoscopy compared to exploratory laparotomy (ISS=8 vs. 13, p=0.001). Laparoscopy was useful in avoiding open laparotomies in 45% of patients when no significant injury was found, leading to a significant difference in negative exploration rates compared to open procedures (21% vs. 54%, p=0.0004). On the basis of laparoscopic findings, 43% of patients underwent conversion to exploratory laparotomy; 79% of these patients required repair of significant injuries. Therapeutic laparoscopy was performed in 12% of patients: diaphragm repair (n=1), gastric repair (n=2), colon repair (n=1), appendectomy (n=1), cholecystectomy (n=1) and coagulation of liver laceration (n=1). Outcomes were improved when laparoscopy was utilized: repeat operations declined by 10%, length of stay decreased up to four-fold (p=0.038), discharge dispositions requiring services fell by 16%, and mortality rates declined by 6.3%.
Conclusion:
Trauma laparoscopy is a safe and effective method for evaluation of the hemodynamically stable patient with suspected abdominal visceral injury and can reduce the number of negative and nontherapeutic trauma laparotomies as well as postoperative hospital days, and discharge care requirements. Laparoscopy was also helpful in diagnosing diaphragmatic and bowel injuries that were not seen on CT scan. Criteria for the selective use of laparoscopy in trauma need to be better defined and should include lower ISS and stab wound mechanism of injury. Moreover, in the current era where surgeons undergo more training in minimally invasive surgery than ever before, with significantly more laparoscopic operative experience, and the technologically improved equipment readily available, laparoscopy can be a very useful diagnostic, as well as a therapeutic modality in treating appropriately selected trauma patients.
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