Laparoscopy in the diagnosis and repair of diaphragmatic injuries in left-sided penetrating thoracoabdominal trauma

Role of laparoscopic surgery in managing hemodynamically stable abdominal trauma patients: a single level I trauma center, propensity score matching study

BACKGROUND

The role of laparoscopy in the treatment and diagnosis of penetrating thoraco-abdominal injury has been established. However, there is no clear consensus on the role of laparoscopy in blunt injury due to numerous reasons, such as concerns of missed injury and technical problems in treating various abdominal organs. This study aimed to determine the feasibility of laparoscopy and evaluate its safety in managing blunt and penetrating abdominal trauma.

METHODS

The medical records and Korean Trauma Data Base (KTDB) of patients who underwent abdominal surgery from January 2018 to December 2022 at a single level I center were collected. Patients were classified into a laparoscopy group and a laparotomy group. The laparoscopy groups were matched 1:1 with the laparotomy group by using propensity score matching (PSM). Patient demographics, injured organ and its grade, operative procedure, and postoperative outcomes were evaluated and compared between the two groups.

RESULTS

After propensity score matching, 128 patients were included. There was no significant imbalance in demographics between the two groups except sex. Injured organ and its grade showed no significant differences between the two groups except for the incidence of omentum. Small bowel and mesenteric repair were performed most often in both groups. Splenectomy, pancreatic surgery, duodenectomy, and liver resection were performed exclusively in the laparotomy group. Severe postoperative complication rate (3% vs. 20%: p = 0.004), length of stay in ICU (3.3 ± 3.2 days vs. 4.6 ± 3.7; p = 0.046), and operation time (93.9 ± 47.7 min vs. 112.8 ± 57.7; p = 0.046) were significantly lower in the laparoscopy group. The conversion rate was about 16%. There was no missed injury.

CONCLUSIONS

In hemodynamically stable abdominal trauma patients who sustained penetrating or blunt injury, laparoscopy is feasible and safe as a diagnostic and therapeutic modality in selected cohort of abdominal trauma.

Diaphragmatic Injuries in Patients with Penetrating Thoracoabdominal Injuries without Shock or Acute Abdomen at Admission

Introduction

Penetrating thoracoabdominal injuries (PTAIs) are associated with diaphragmatic injuries and subsequent complications. This study aimed to describe the prevalence of diaphragmatic injuries in patients with PTAI without signs of shock or acute abdomen at admission.

Methods

A cross-sectional, single-centered study was conducted in Bogotá, Colombia. The study included all patients with PTAI who underwent surgical exploration and were admitted without signs of shock or acute abdomen, between January 2019 and August 2021. Indications for surgical exploration included presence of left thoracoabdominal wound, hemo- or pneumothorax in presurgical imaging, abdominal pain, hypotension, or anemia.

Results

A total of 284 patients were included in the final analysis. The median age was 29 years (interquartile range: 22-33), with 269 (94.7%) patients being males. Out of these, 268 (94.3%) patients experienced stabbing as the mechanism of injury. The prevalence of diaphragmatic injuries diagnosed during surgical exploration was 15.1% (43 patients). There were 183 patients with left-sided PTAI and 115 patients with right-sided PTAI. The prevalence of the right diaphragmatic injury was 25.2% (29 patients), while for left diaphragmatic injury, it was 8.1% (15 patients). Only one patient presented with bilateral diaphragmatic injury.

Conclusions

The prevalence of diaphragmatic injuries in patients with PTAI, without signs of shock or acute abdomen upon admission, was 15.1%. However, the prevalence was 25.2% in the right PTAI and 8.1% in the left PTAI. These findings suggest that surgical exploration of the diaphragm in cases of PTAI should be performed regardless of the side of the wound.

Laparoscopic repair of a traumatic diaphragmatic rupture

INTRODUCTION AND IMPORTANCE

Traumatic diaphragmatic ruptures following blast injury or penetrating trauma rarely present themselves with chronic symptoms warranting elective surgery.

CASE PRESENTATION

We present the case of a 49-year-old man who survived a grenade explosion and experienced chronic chest pain. Considering the previous trauma, computed tomography imaging was performed and showed a left-sided traumatic diaphragmatic rupture ventral to the spleen, resulting in herniation of the transverse colon and omentum in the thoracic cavity. Metal shrapnel was located between the stomach and spleen, the suspected cause of the diaphragmatic hernia. The patient was eligible for minimal invasive laparoscopic surgery.

CLINICAL DISCUSSION

During surgery, a left diaphragmatic rupture and metal shrapnel on the right side of the rupture were found. The hernia was reduced and the metal shrapnel was removed, aiding in fully repositioning of the omentum and transversed colon. After which the left lower lung lobe was able to fully inflate. The rupture was closed using single V-lock sutures and strips of the Phasix mesh to reinforce the diaphragm repair with single ethibond sutures. No surgical or post-operative complications were observed and the patient did not experience any of his previous complaints.

CONCLUSION

In this case, laparoscopic repair of diaphragmatic rupture after penetrating trauma can be considered as an effective surgical approach.

Diagnostic utility of multidetector CT scan in penetrating diaphragmatic injuries: A systematic review and meta-analysis

Penetrating diaphragmatic injuries pose diagnostic and management challenges. Computed tomography (CT) scans are valuable for stable patients, but concern exists for missed injuries and complications in nonoperatively managed cases. The objective of this study was to explore the diagnostic utility of multidetector CT scan (MDCT) in identifying diaphragmatic injuries resulting from penetrating trauma. A systematic review and meta-analysis were conducted, following established guidelines, by searching PubMed, Scopus, Web of Science, and Embase databases up to July 6, 2023. Eligible studies reporting MDCT's diagnostic accuracy in detecting penetrating diaphragmatic injuries were included. Relevant data elements were extracted and analyzed using STATA software. The study included 9 articles comprising 294 patients with confirmed penetrating diaphragmatic injuries through surgical procedures. MDCT's diagnostic performance revealed a pooled sensitivity of 74% (95% CI: 56%-87%) and a pooled specificity of 92% (95% CI: 79%-97%) (Fig. two), with significant heterogeneity in both sensitivity and specificity across the studies. The Fagan plot demonstrated that higher pre-test probabilities correlated with higher positive post-test probabilities for penetrating diaphragmatic injury diagnosis using MDCT, but even with negative results, there remained a small chance of having the injury, especially in cases with higher pre-test probabilities. This study highlights MDCT's effectiveness in detecting diaphragmatic injury from penetrating trauma, with moderate to high diagnostic accuracy. However, larger sample sizes, multicenter collaborations, and prospective designs are needed to address observed heterogeneity, enhancing understanding and consistency in MDCT's diagnostic capabilities in this context.

Could trauma laparoscopy be the standard of care for hemodynamically stable patients? A retrospective analysis of 165 cases

BACKGROUND

Trauma laparoscopy may provide a less invasive alternative to laparotomy by providing accurate diagnosis and minimally invasive management of selected trauma patients. The risk of missing injuries during the laparoscopic evaluation still refrains surgeons from using this approach. Our aim was to evaluate feasibility and safety of trauma laparoscopy in selected patients.

METHODS

We performed a retrospective review of hemodynamically trauma patients who underwent laparoscopic management in a tertiary center in Brazil due to abdominal trauma. Patients were identified by searching through the institutional database. We collected demographic and clinical data, focusing on avoidance of exploratory laparotomy, and missed injury rate, morbidity, and length of stay. Categorical data were analyzed using Chi-square, while numerical comparisons were performed using Mann-Whitney and Kruskal-Wallis test.

RESULTS

We evaluated 165 cases, of which 9.7% needed conversion to an exploratory laparotomy. One-hundred and twenty-one patients (73%) had at least one intrabdominal injury. Two missed injuries to retroperitoneal organs were identified (1.2%), of which only one was clinically relevant. Three patients died (1.8%), one of which was due to complications from an intestinal injury after conversion. No deaths were related to the laparoscopic approach.

CONCLUSION

In selected hemodynamically stable trauma patients, the laparoscopic approach is feasible and safe, and reduces the need for exploratory laparotomy and its associated complications.

Current trends in the diagnosis and management of traumatic diaphragmatic injuries: A systematic review and a diagnostic accuracy meta-analysis of blunt trauma

BACKGROUND

Traumatic diaphragmatic injuries (TDI) are wounds or ruptures of the diaphragm due to thoraco-abdominal trauma. Nowadays, CT-scan is considered the gold standard for TDI diagnosis. The aim of this study was to assess the current diagnostic accuracy of CT-scan in the diagnosis of TDI and describe the management of this type of injury.

METHODS

A systematic review was conducted according to the 2009 Preferred Reporting Items for Systematic Reviews and Meta-analyses (PRISMA) guidelines. Two independent reviewers searched the literature in a systematic fashion using online databases, including Medline, Scopus, Embase, and Google Scholar. Human studies investigating the diagnosis and the following management of TDI were included. Pooled estimates of sensitivity, specificity, and positive/negative likelihood (with corresponding 95% confidence intervals) were analyzed based on the bivariate model for blunt TDI. The Newcastle-Ottawa scale for cohort studies was used for the quality assessment of selected articles. The PROSPERO registration number was as follows: CRD42022301282.

RESULTS

Fifteen studies published between 2001 and 2019 were included. All included studies reported a contrast-enhanced computed tomography as the preferred method to obtain diagnostic imaging. Left-sided TDI was the type of injury most frequently found. False negative TDI at CT-scan were more frequent than false positive TDI (11.13 ± 23.24 vs. 2.66 ± 6.65). Six studies on blunt TDI were included in the meta-analysis, showing a high sensitivity [0.80 (95%CI 0.65-0.90)] and specificity [0.98 (95%CI 0.89-1.00)] of the CT-scan in detecting TDI. Overall, 7 articles reported laparotomy as the method of choice to repair TDI. Only 3 studies reported a laparoscopic and/or thoracoscopic approach to TDI repair.

CONCLUSION

CT-scan has a good sensitivity and specificity for blunt TDI diagnosis. However, TDI diagnosis and management are often delayed. The use of water-soluble contrast in CT-scan should be considered when the diagnosis of TDI is not defined after the first scan, and clinical suspicion is still high. In this context, a highly trained trauma team is essential for trauma management and correct imaging interpretation.

Laparoscopic Versus Laparotomy Surgical Interventions for Trauma Patients With Single Upper Left Quadrant Penetrating Injuries: Analysis of the American College of Surgeons Trauma Quality Improvement Program Dataset

BACKGROUND

We aim to identify patient cohorts where laparoscopy can be safely utilized with comparable or better outcomes to laparotomy among patients with single penetrating LUQ injuries with a hypothesis that compared to laparotomy, laparoscopy may be associated with equal or improved outcomes of low injury severity patients.

METHODS

Retrospective review of the ACS-TQP-Participant Use File 2016-2019 dataset. Patients with single LUQ penetrating injuries were included. Primary outcome was risk-adjusted in-hospital mortality. Secondary outcomes included: risk-adjusted complication rates, hospital length-of-stay (H-LOS), and ICU-LOS. Descriptive statistics and multivariable regression with reliability adjustments to account for variations in practice were performed.

RESULTS

Of 4149 patients analyzed, 3571 (86.1%) underwent laparotomy, 489 (11.8%) underwent laparoscopy, and 89 (2.1%) underwent laparoscopy-to-laparotomy conversion. Adjusted mortality rates were not significantly different among all study cohorts (P > .05). Compared to laparoscopy, adjusted odds of complications were 4.3-fold higher for all patients who underwent laparotomy and 4-fold higher for laparoscopy-to-laparotomy (LtL) patients (P < .05). Diaphragmatic injuries were associated with significantly increased odds of undergoing LtL, whereas sustaining a colonic injury, gastric injury, hepatic injury, or requiring PRBC transfusions were associated with significantly increased odds of undergoing laparotomy (P < .05). H-LOS (days) was significantly longer for patients who underwent laparotomy compared to laparoscopy (3.9 ± 4.0 vs. 10.8 ± 13.4, P < .0001).

CONCLUSIONS

Laparoscopy may be considered a viable alternative to laparotomy for hemodynamically stable adult patients with single penetrating LUQ injuries of low injury burden validating our hypothesis. Laparoscopy may be less safe for patients with associated diaphragmatic, colonic, or hepatic injuries.

Diagnosing penetrating diaphragmatic injuries: CT scan is valuable but not reliable

BACKGROUND

The diagnosis of penetrating isolated diaphragmatic injuries can be challenging because they are usually asymptomatic. Diagnosis by chest X-ray (CXR) is unreliable, while CT scan is reported to be more valuable. This study evaluated the diagnostic ability of CXR and CT in patients with proven DI.

METHODS

Single center retrospective study (2009-2019), including all patients with penetrating diaphragmatic injuries (pDI) documented at laparotomy or laparoscopy with preoperative CXR and/or CT evaluation. Imaging findings included hemo/pneumothorax, hemoperitoneum, pneumoperitoneum, elevated diaphragm, definitive DI, diaphragmatic hernia, and associated abdominal injuries.

RESULTS

230 patients were included, 62 (27%) of which had isolated pDI, while 168 (73%) had associated abdominal or chest trauma. Of the 221 patients with proven DI and preoperative CXR, the CXR showed hemo/pneumothorax in 99 (45%), elevated diaphragm in 51 (23%), and diaphragmatic hernia in 4 (1.8%). In 86 (39%) patients, the CXR was normal. In 126 patients with pDI and preoperative CT, imaging showed hemo/pneumothorax in 95 (75%), hemoperitoneum in 66 (52%), pneumoperitoneum in 35 (28%), definitive DI in 56 (44%), suspected DI in 26 (21%), and no abnormality in 3 (2%). Of the 57 patients with isolated pDI the CXR showed a hemo/pneumothorax in 24 (42%), elevated diaphragm in 14 (25%) and was normal in 24 (42%).

CONCLUSIONS

Radiologic diagnosis of DI is unreliable. CT scan is much more sensitive than CXR. Laparoscopic evaluation should be considered liberally, irrespective of radiological findings.

Open versus laparoscopic repair of traumatic diaphragmatic injury: A nationwide propensity-matched analysis

INTRODUCTION

Minimally invasive surgical techniques have become routinely applied in the evaluation and treatment of patients with isolated traumatic diaphragmatic injuries (TDI). However, there remains a paucity of data that compares the laparoscopic repair to the open repair approach. The aim of our study is to examine patient outcomes between TDI patients managed laparoscopically versus those managed using open repair.

METHODS

Adult (age ≥18 years) trauma patients presenting with TDI that required surgical repair were identified in the Trauma Quality Improvement Program database 2017. Patients were excluded if they underwent any other surgical procedure of the abdomen or chest. Patients were then stratified into 2 groups based on the surgical approach: laparoscopic repair of the diaphragm versus open repair. Propensity-score matching in a 1:2 ratio was performed. Primary outcome measures were in-hospital major complications and length of stay (LOS). Secondary outcome measure was in-hospital mortality.

RESULTS

A total of 177 adult trauma patients who had a laparoscopic repair of their isolated diaphragmatic injury were matched to 354 patients who had an open repair. Mean age was 35 ± 16 years, 78% were male, and mean BMI was 27 ± 7 kg/m². 67 percent of the patients had penetrating injuries, and the median ISS was 17 [9-21]. CT imaging was done in 67% of the patients, with 71% presenting with left-sided injury and 21% having visceral herniation. Conversion from laparoscopic to open was reported in 7.3% of the cases. Patients with a laparoscopic repair had significantly lower rates of major complications (5.6 versus 14.4%; P<0.001), shorter hospital LOS (6 [3-9] versus 9 [5-13] days; P<0.001) and ICU LOS (3 [2-7] versus 5 [2-10] days; P<0.001). No difference was found in rates of in-hospital mortality (0.6 versuss 2.0%; P = 0.129) between the 2 groups.

CONCLUSION

Laparoscopic repair of traumatic diaphragmatic injury was associated with decreased morbidity and a shorter hospital course, with a low conversion rate to open repair. Future studies remain necessary to further explore the long-term outcomes of patients with such injury.

LEVEL OF EVIDENCE

Level III STUDY TYPE: Therapeutic.

When laparoscopic repair is feasible for diaphragmatic hernia in adults? A retrospective study and literature review

BACKGROUND

Diaphragmatic hernia (DH), congenital or traumatic, is uncommon but sometimes can lead to a serious surgical emergency. There are no clinical guidelines or approved recommendations for the management of this condition, and most data are from retrospective, single-institution series. The aim is to analyze the management of the DH at our institution and review the indications for laparoscopic repair.

METHODS

A retrospective serie of patients diagnosed of DH with surgical treatment at our institution between 2009 and 2019. Literature review was carried out to establish the current indications of laparoscopic repair in each type of DH.

RESULTS

Surgery was carried out in 15 patients with DH, 5 congenital and 10 traumatic hernias. Traumatic hernias were classified as acute (n = 2) and chronic (n = 8). 53.4% of all cases (8 patients) required urgent surgery using an abdominal approach (5 open and 3 laparoscopic) and elective surgery was performed in 46.6% of all cases (7 patients) with an abdominal approach (3 open and 4 laparoscopic) and 2 patients with a combined approach. Primary repair was performed in 4 patients (26.6%), closure and mesh reinforcement in 9 cases (60%) and only mesh placement in 2 patients (13.4%). Postoperative morbidity and mortality were 20% and 0%, respectively. No recurrences were detected.

CONCLUSIONS

DH may pose different scenarios which require urgent or elective surgical treatment. Laparoscopic approach may be a first option in elective surgery; and in emergency setting taking into account hemodynamic stability and associated injuries.

Leukocytes are not Reliable in Predicting Possible Diaphragmatic Injury in Patients with Penetrating Left Thoracoabdominal Stab Wounds

BACKGROUND

The diaphragm is injured in approximately one-third of penetrating left thoracoabdominal stab wounds. Diagnostic laparoscopy or thoracoscopy is performed to reveal the diaphragmatic injury. This study investigated whether leukocytes, leukocyte subgroups, platelets, the neutrophil-to-lymphocyte ratio (NLR), and the thrombocyte-to-lymphocyte ratio (PLR) can be used to detect diaphragm injury without the need for diagnostic laparoscopy.

METHODS

Patients hospitalized between January 2010 and January 2020 due to penetrating left thoracoabdominal stab wounds were examined. Laparotomy was performed in patients who had indications for laparotomy, such as hemodynamic instability and peritonitis. Diagnostic laparoscopy was performed to reveal possible diaphragmatic injury in patients who did not require laparotomy after 48h of follow-up. Leukocytes, leukocyte subgroups, platelets, NLR, and PLR were measured both at admission and during follow-up, and the results were compared between patients with and without diaphragm injury during diagnostic laparoscopy.

RESULTS

The study included 108 patients with penetrating left thoracoabdominal stab wounds that did not require laparotomy after 48h of follow-up. Of these, 102 patients were male (94.44%), and the average age was 27.68 years (range 15-66 years). Diaphragm injury was detected in 31 patients (28.70%) in diagnostic laparoscopy, and the diaphragm was intact in 77 patients (71.30%). In the comparison of patients with and without diaphragmatic injury, no statistically significant difference was found in terms of age, gender, platelets, leukocyte values, NLR, and PLR both at admission and during follow-up.

CONCLUSIONS

Leukocytes, leukocyte subsets, platelets, NLR, and PLR were insufficient in the detection of asymptomatic diaphragmatic injuries caused by penetrating left thoracoabdominal stab wounds.

[Value of laparoscopy in blunt and penetrating abdominal trauma-a systematic review]

BACKGROUND

The range of indications for laparoscopic procedures has been continuously widened in recent years. At the same time, however, the diagnostic and therapeutic role of laparoscopy in the management of blunt and penetrating abdominal trauma remains controversial.

METHODS

A systematic literature search was carried out in PubMed from 2008 to 2019 on the use of laparoscopy in blunt and penetrating abdominal trauma. Studies were analyzed in terms of relevant operative and perioperative event rates (rate of missed injuries, conversion rate, postoperative complication rate). On the basis of this analysis, an algorithm for the use of laparoscopy in abdominal trauma was developed for clinical practice.

RESULTS

A total of 15 full texts with 5869 patients were found. With a rate of 1.4%, laparoscopically missed injuries were very rare for both penetrating and blunt abdominal trauma. Of all trauma laparoscopies 29.3% were converted to open surgery (laparotomy). Among the non-converted laparoscopies 60.5% were therapeutic. Complications occurred after trauma laparoscopy in 8.6% of cases.

CONCLUSION

By means of systematic laparoscopic exploration, missed injuries in abdominal trauma are extremely rare, so that concerns in this respect no longer seem justified. A large proportion of intra-abdominal injuries can be treated using laparoscopy or laparoscopically assisted procedures.

Investigating the effects of drainage by hemovac drain on shoulder pain after female laparoscopic surgery and comparison with deep breathing technique: a randomized clinical trial study

BACKGROUND

The incidence of shoulder pain following laparoscopic surgery has been reported to be high. This study was designed to investigate the effect of Hemovac drain on postoperative pain of women after laparoscopic surgery, dose of postoperative drug, duration of hospitalization as well as comparison with deep breathing technique.

METHODS

In this clinical trial, one hundred and fourteen female patients treated by laparoscopy were randomly assigned to three groups of 38 patients. In our study group, the Hemovac drain was implemented from the secondary trocar site with a closed system. In the deep breathing group, the patient was asked to breathe slowly and deeply three time per hour at full vigilance after surgery. In the non-drain group, laparoscopic surgery was done routinely. The severity of abdominal and shoulder pain was measured with a visual scale of pain at 3, 6, 12, and 24 h after surgery.

RESULTS

There were no significant differences in age, type of surgery, duration of hospitalization, postoperative nausea and vomiting between the groups after surgery. The severity of shoulder pain was significant between groups 3, 6, 12, and 24 h after surgery (p < 0.001). Consumption of diclofenac after operation was higher in the control group (p < 0.001). The pain level of laparoscopic surgery was not different between the three groups within the first 24 h after surgery (p = 0.841).

CONCLUSIONS

The use of Hemovac drain in female laparoscopic surgery is beneficial for reducing the subsequent shoulder pain. Further studies are recommended to investigate the effects of deep breathing as a non-pharmacological and safe method in other laparoscopic areas.

Evaluation and management of abdominal stab wounds: A Western Trauma Association critical decisions algorithm

This is a recommended management algorithm from the Western Trauma Association addressing the management of adult patients with abdominal stab wounds. Because there is a paucity of published prospective randomized clinical trials that have generated Class I data, these recommendations are based primarily on published observational studies and expert opinion of Western Trauma Association members. The algorithm and accompanying comments represent a safe and sensible approach that can be followed at most trauma centers. We recognize that there will be patient, personnel, institutional, and situational factors that may warrant or require deviation from the recommended algorithm. We encourage institutions to use this as a guideline to develop their own local protocols.

[Conventional and minimally invasive surgery in diagnosis and treatment of thoracoabdominal wounds]

AIM

To develop the algorithm of optimal combination of conventional and minimally invasive procedures for surgical diagnosis and treatment of thoracoabdominal wounds (TAW).

MATERIAL AND METHODS

The most common borders of TAW were analyzed in 81 bodies of victims. Typical borders of costodiaphragmatic pleural sinus were assessed in 90 male cadavers. There were 81 victims with TAW who were divided into two groups. The first group included 40 patients who underwent newly developed methods of treatment. Group II consisted of 41 patients who were treated earlier.

RESULTS

The algorithm of invasive diagnosis of diaphragm wounds and the method of sequential determination of indications for conventional or endoscopic procedures were developed and applied in the first group. Minimally invasive operations alone or in combination with open surgery were applied in 80% of patients in group I and in 53.66% of patients in group II. Thirty-eight (97.5%) and 35 (85.37%) patients convalesced in groups I and II, respectively.

CONCLUSION

Thoracotomy was required in 34.29% of cases for TAW correction, laparotomy - in 71.43% of cases. Minimally invasive operations were sufficient in other cases.

"Pop in a scope": attempt to decrease the rate of unnecessary nontherapeutic laparotomies in hemodynamically stable patients with thoracoabdominal penetrating injuries

BACKGROUND

Management of patients with thoracoabdominal penetrating injuries is challenging. Thoracoabdominal penetrating trauma may harbor hollow viscus injuries in both thoracic and abdominal cavities and occult diaphragmatic lesions. While radiological tests show poor diagnostic performance in these situations, evaluation by laparoscopy is highly sensitive and specific. Furthermore, minimally invasive surgery may avoid unnecessary laparotomies, despite concerns regarding complication and missed injury rates. The objective of the present study is to evaluate the diagnostic and therapeutic performance of laparoscopy in stable patients with thoracoabdominal penetrating injuries.

METHODS

Retrospective analysis of hemodynamically stable patients with thoracoabdominal penetrating wounds was managed by laparoscopy. We collected data regarding the profile of the patients, the presence of diaphragmatic injury, perioperative complications, and the conversion rate. Preoperative imaging tests were compared to laparoscopy in terms of diagnostic accuracy.

RESULTS

Thirty-one patients were included, and 26 (84%) were victims of a stab wound. Mean age was 32 years. Ninety-three percent were male. Diaphragmatic lesions were present in 18 patients (58%), and 13 (42%) had associated injuries. There were no missed injuries and no conversions. Radiography and computerized tomography yielded an accuracy of 52% and 75%, respectively.

CONCLUSION

Laparoscopy is a safe diagnostic and therapeutic procedure in stable patients with thoracoabdominal penetrating wound, with low complication rate, and may avoid unnecessary laparotomies. The poor diagnostic performance of preoperative imaging exams supports routine laparoscopic evaluation of the diaphragm to exclude injuries in these patients.

Use of laparoscopic colectomy increasing in trauma: comparison of laparoscopic vs. open colectomy

Laparoscopy accounts for > 70% of general surgical cases. Given the increased use of laparoscopy in emergent colorectal disease, we hypothesized that there would be an increased use of laparoscopic colectomy (LC) in trauma patients. In addition, we hypothesized increased length of stay (LOS) and mortality in trauma patients undergoing open colectomy (OC) vs. LC. This was a retrospective analysis using the National Trauma Data Bank (2008-2015). We included adult patients undergoing LC or OC. A multivariable logistic regression model was used for determining risk of LOS and mortality. We identified 19,788 (96.8%) patients undergoing OC and 644 (3.2%) who underwent LC. There was a 21-fold increased number of patients that underwent LC over the study period (p < 0.05), with approximately 119 per 10,000 trauma patients undergoing LC. The most common operation was a laparoscopic right hemicolectomy (27.5%). LC patients had a lower median injury severity score (ISS) (16 vs. 17, p < 0.001). There was no difference in LOS (p = 0.14) or mortality (p = 0.44) between the two groups. This remained true in patients with isolated colorectal injury. The use of LC has increased 21-fold from 2008 to 2015, with laparoscopic right hemicolectomy being the most common procedure performed. There was no difference in LOS, in-hospital complications, or mortality between the two groups. We suggest that LC should be considered in stable adult trauma patients undergoing colectomy. However, future prospective research is needed to help determine which trauma patients may benefit from LC.

Evaluation of Thoracoscopy with Single-Lumen Endotracheal Tube Intubation and Laparoscopy in the Diagnosis of Occult Diaphragmatic Injuries in Penetrating Thoracoabdominal Trauma

Background: The diagnosis of traumatic diaphragmatic injuries (TDIs) after penetrating thoracoabdominal trauma is challenging and conventional imaging is unreliable. Laparoscopy and thoracoscopy are minimally invasive modalities of choice in the diagnosis and management of TDI. A little is known on the value of thoracoscopy with single-lumen endotracheal tube intubation (SLETI) in the diagnosis of occult diaphragmatic injuries, and how it compares with laparoscopy. Methods: A prospective study evaluated thoracoscopy with SLETI as a diagnostic tool for occult TDI. Thoracoscopy was followed by diagnostic laparoscopy to confirm the findings and manage diaphragmatic and intra-abdominal injuries. Results: Thirty-one patients underwent thoracoscopy followed by laparoscopy. Majority were men (n = 27, 87%). The median age was 30 years. Twenty-six patients had stab wounds (83.8%), and 5 had gunshot wounds (16.1%). The incidence of diaphragmatic injury was 42% (n = 13). Thoracoscopy with SLETI correctly identified 12 (92%) patients with diaphragmatic injury, but 1 patient had dense pleural adhesions. Diagnostic laparoscopy identified all injuries. Conclusion: Thoracoscopy with SLETI and laparoscopy are feasible, safe, and accurate approaches in detecting TDI in stable patients with penetrating thoracoabdominal injuries. However, dense pleural adhesions may prevent thoracoscopy. Laparoscopy allows inspection of both hemidiaphragms and diagnoses associated intra-abdominal injuries. The choice of primary technique will depend on the individual clinical scenario.

Diagnosis of diaphragm injuries using modern 256-slice CT scanners: too early to abandon operative exploration

Background

Missed injury of the diaphragm may result in hernia formation, enteric strangulation, and death. Compounding the problem, diaphragmatic injuries are rare and difficult to diagnose with standard imaging. As such, for patients with high suspicion of injury, operative exploration remains the gold standard for diagnosis. As no current data currently exist, we sought to perform a pragmatic evaluation of the diagnostic ability of 256-slice multidetector CT scanners for diagnosing diaphragmatic injuries after trauma.

Methods

A retrospective review of trauma patients from 2011 to 2018 was performed at an American College of Surgeons-verified level 1 trauma center to identify the diagnostic accuracy of CT scan for acute diaphragm injury. All patients undergoing abdominal operation were eligible for inclusion. Two separate levels of CT scan technology, 64-slice and 256-slice, were used during this time period. The prospective imaging reports were reviewed for the diagnosis of diaphragm injury and the results confirmed with the operative record. Injuries were graded using operative description per the American Association for the Surgery of Trauma guidelines.

Results

One thousand and sixty-eight patients underwent operation after preoperative CT scan. Acute diaphragm injury was identified intraoperatively in 14.7%. Most with diaphragmatic injury underwent 64-slice CT (134 of 157, 85.4%). Comparing patients receiving 64-slice or 256-slice CT scan, there was no difference in the side of injury (left side 57.5% vs. 69.6%, p=0.43) or median injury grade (3 (3, 3) vs. 3 (2, 3), p=0.65). Overall sensitivity, specificity, and diagnostic accuracy of the 256-slice CT were similar to the 64-slice CT (56.5% vs. 45.5%, 93.7% vs. 98.1%, and 89.0% vs. 90.2%).

Discussion

The new 256-slice multidetector CT scanner fails to sufficiently improve diagnostic accuracy over the previous technology. Patients with suspicion of diaphragm injury should undergo operative intervention.

Level of evidence

I, diagnostic test or criteria.

Laparoscopic Management of Penetrating Thoracoabdominal Trauma

BACKGROUND

Traumatic thoracoabdominal injuries can involve multiple organs and multiple cavities, which increases the complexity of surgical management. Traditionally, these injuries required laparotomy and thoracotomy. However, minimally invasive intervention may be reasonable for stable patients.

MATERIALS AND METHODS

We present a case of a thoracoabdominal gunshot wound resulting in multiorgan, multicavity injury to the lung, diaphragm, and liver. We performed hepatorrhaphy and diaphragm repair, and addressed a retained hemothorax through a transabdominal laparoscopic approach.

RESULTS

The patient tolerated the procedure well. He required no further procedures, and had no evidence of retained hemothorax or bile leak from the liver injury. After a short stay in the hospital, the patient recovered uneventfully.

CONCLUSIONS

In hemodynamically stable patients, the transabdominal laparoscopic approach is a feasible and effective approach to penetrating thoracoabdominal trauma.

The use of laparoscopy in managing penetrating thoracoabdominal injuries in Africa: 83 cases reviewed

Background

The use of laparoscopy in managing haemodynamically stable patients with penetrating thoracoabdominal injuries in developed countries is wildly practiced, but in Africa, the use of laparoscopy is still in its infancy stage. We reviewed a single centre experience in using laparoscopy in Africa for management of patients with both isolated diaphragmatic injuries as well as diaphragmatic injuries associated with intra-abdominal injuries requiring intervention.

Methods

A retrospective analysis of prospectively collected data of patients presenting with penetrating thoracoabdominal injuries was done. All patients offered laparoscopic exploration and repair from January 2012 to December 2015 at Dr. George Mukhari Academic Hospital were analysed. Means (±SD) were presented for continuous variables, and frequencies (%) were presented for categorical variables. All analyses were performed using SAS version 9.3 (SAS Institute, Cary, NC).

Results

A total of 83 stable patients with penetrating thoracoabdominal injuries managed with laparoscopy met the inclusion criteria and were included in the study. The Injury Severity Score ranged from 8 to 24, with a median of 18. The incidence of diaphragmatic injuries was 54%. Majority (46.8%) of patients had Grade 3 (2–10 cm defect) diaphragmatic injury. Associated intra-abdominal injuries requiring intervention were encountered in 28 (62%) patients. At least 93.3% of the patients were treated exclusively with laparoscopy. The morbidity was encountered in 7 (16%) patients; the most common cause was a clotted haemothorax Clavien-Dindo III-b, but only 1 patient required a decortication. There was one non-procedure-related mortality.

Conclusions

A success rate of 93% in using laparoscopy exclusively was documented, with an overall 82% uneventful outcome. The positive outcomes found in this study when laparoscopy was used in stable patients with thoracoabdominal injuries support similar work done in other trauma centres. However, in addition, this study seem to suggest that the presence of peritonitis in stable patient is not a contra-indication to laparoscopy and thoracoscopy may be useful especially in right side diaphragmatic injury where the liver can preclude adequate visualization of the entire diaphragm and to thoroughly clean the chest cavity and prevent future complication such as residual clotted haemothorax.

Clinical relevance: The presence of peritonitis in stable patients with penetrating thoracoabdominal injury is not a contra-indication to laparoscopy provided the operating surgeon has adequate laparoscopic skills.

Comparison of single incision and multi incision diagnostic laparoscopy on evaluation of diaphragmatic status after left thoracoabdominal penetrating stab wounds

AIM:

Single incision diagnostic laparoscopy (SIDL) may be an alternative procedure to multi-incision diagnostic laparoscopy (MDL) for penetrating thoracoabdominal stab wounds. The purpose of this study is sharing our experience and comparing two techniques for diaphragmatic status.

MATERIALS AND METHODS:

Medical records of 102 patients with left thoracoabdominal penetrating stab injuries who admitted to Istanbul School of Medicine, Trauma and Emergency Surgery Clinic between February 2012 and April 2016 were examined. The patients were grouped according to operation technique. Patient records were retrospectively reviewed for data including, age, sex, length of hospital stay, diaphragm injury rate, surgical procedure, operation time and operation time with wound repair, post-operative complications and accompanying injuries.

RESULTS:

The most common injury location was the left anterior thoracoabdomen. SIDL was performed on 26 patients. Nine (34.6%) of the 26 patients had a diaphragm injury. Seventy-six patients underwent MDL. Diaphragmatic injury was detected in 20 (26.3%) of 76 patients. The average operation time and post-operative complications were similar; there was no statistically significant difference between MDL and SIDL groups.

CONCLUSION:

SIDL can be used as a safe and feasible procedure in the repair of a diaphragm wounds. SIDL may be an alternative method in the diagnosis and treatment of these patients.

Evaluation of diaphragm in penetrating left thoracoabdominal stab injuries: The role of multislice computed tomography

INTRODUCTION

Penetrating left thoracoabdominal stab injuries are accompanied by diaphragmatic injury in 25-30% of cases, about 30% of which later develop into diaphragmatic hernia. This study aimed to determine the role of multislice computed tomography in the evaluation of left diaphragm in patients with penetrating left thoracoabdominal stab wounds.

MATERIALS AND METHODS

This study reviewed penetrating left thoracoabdominal stab injuries managed in our clinic between April 2009 and September 2014. The thoracoabdominal region was defined as the region between the sternum, fourth intercostal space, and arcus costa anteriorly and the vertebra, lower tip of scapula, and the curve of the last rib posteriorly. Unstable cases and cases with signs of peritonitis were operated with laparotomy; the remaining patients were closely monitored. Forty-eight hours later, a diagnostic laparoscopy was applied to evaluate the left hemidiaphragma in asymptomatic patients who did not need laparotomy. The preoperatively obtained multislice thoracoabdominal computed tomography images were retrospectively examined for the presence of left diaphragm injury. Then, operative and tomographic findings were compared.

RESULTS

This study included a total of 43 patients, 39 (91%) males and 4 (9%) females of mean age 30 years (range 15-61 years). Thirty patients had normal tomography results, whereas 13 had left diaphragmatic injuries. An injury to the left diaphragm was detected during the operation in 9 (1 in laparotomy and 8 in diagnostic laparoscopy) of 13 patients with positive tomography for left diaphragmatic injury and 2 (in diagnostic laparoscopy) of 30 patients with negative tomography. Multislice tomography had a sensitivity of 82% (95% CI: 48-98%), a specificity of 88% (71-96%), a positive predictive value of 69% (39-91%), and a negative predictive value of 93% (78-99%) for detection of diaphragmatic injury in penetrating left thoracoabdominal stab injury.

CONCLUSIONS

Although diagnostic laparoscopy is the gold standard for diaphragmatic examination in patients with penetrating left thoracoabdominal stab wounds, multislice computed tomography is also valuable for detecting diaphragmatic injury.