Diagnostic and therapeutic laparoscopy for stab wounds of the anterior abdomen

Paradigms in trauma laparoscopy for anterior abdominal stab wounds: A scoping review

INTRODUCTION

Anterior abdominal stab wounds (AASW) are a heterogeneous presentation with evolving management over time and heterogenous practice between centres. The aim of this scoping review was to identify, characterise and classify paradigms for trauma laparoscopies for AASW.

METHODOLOGY

Studies were screened from Embase, Medline, Scopus, Cochrane Library and Web of Science from 1 January 1947 until 1 January 2023. Extracted data included indications for trauma laparoscopies vs laparotomies, and criteria for conversion to an open procedure.

RESULTS

Of 72 included studies, 35 (48.6 %) were published in the United States, with an increasing number from South Africa since 2014. Screening tests to determine an indication for surgery included local wound exploration, computed tomography, and serial clinical examination. Two studies proposed no absolute contraindications to laparoscopy, whereas most papers supported trauma laparoscopies over laparotomies in hemodynamically stable patients with positive or equivocal screening tests. However, clinical decision trees were used inconsistently both between and within many hospital centres. Triggers for conversion to laparotomy were diverse. Older studies typically reported conversion if peritoneal breach was identified. More recent studies reported advances in technical skills and technology allowed attempt at laparoscopic repair for organ and/or vascular injury.

CONCLUSION

This review emphasises that there are many different paradigms of practice for AASW laparoscopy, which are evolving over time. Significant heterogeneity of these studies highlights that meta-analysis of outcomes for trauma laparoscopy is not appropriate unless the included studies report homogenous treatment paradigms and patient cohorts. The decision to perform a trauma laparoscopy should be based on surgeon/hospital experience, patient factors, and resource availability.

Evaluation of diagnostic laparoscopy for penetrating abdominal injuries: About 131 anterior abdominal stab wound

BACKGROUND

The management of hemodynamically stable patients with anterior abdominal stab wounds (AASW) is debated. Mini-invasive techniques using laparoscopy and non-operative management (NOM) have reduced the rate of nontherapeutic laparotomies after AASW leading to unnecessary morbidity. The aim of this study was to determine with a systematic diagnostic laparoscopy of peritoneal penetration (PP), patients who do not require abdominal exploration in the management of stable patient with an AASW.

METHODS

All patients with AASW were retrospectively recorded from 2006 to 2018. Criteria of inclusion were AASW patients who underwent a systematic diagnostic laparoscopy. Criteria of exclusion were patients with an evisceration, impaling, clinical peritonitis, and hemodynamic instability. If no PP was detected, laparoscopy was terminated. If defects of peritoneum were found, a laparotomy was performed looking for diagnosis and treatment of intra-abdominal injuries.

RESULTS

On 131 AASW patients, 35 underwent immediate emergency laparotomy, 96 underwent diagnostic laparoscopy, 47 were positive (PP) and had an intra-abdominal exploration by laparotomy, 32 (68.1%) had intra-abdominal injuries which required treatment. All patients with an intra-abdominal injury had a positive diagnostic laparoscopy. For the 49 patients with a negative laparoscopy, the mean hospital stay was 1.6 days with ambulatory care for some patients. No patient presented a delayed injury. Non-therapeutic laparotomy rate was 15.6%. For patients who did not have an intra-abdominal injury the morbidity rate was low (3%).

CONCLUSION

Our study shows that diagnostic laparoscopy was safe, with a low duration of hospitalization, a possible ambulatory care and had an excellent ability to screen the patients who did not need a abdominal exploration. This management can avoid many unnecessary laparotomies with an acceptable rate of negative laparotomy, without any delayed diagnosis of intra-abdominal injuries and with a low morbidity rate.

Laparoscopy for Trauma and the Changes in its Use From 1990 to 2016: A Current Systematic Review and Meta-Analysis

BACKGROUND

The role of laparoscopy in the diagnosis and treatment of stable abdominal trauma patients is still a matter of serious debate and only incomplete data are available.

MATERIALS AND METHODS

We performed a systematic review and meta-analysis of the literature between January 1990 and August 2016.

RESULTS

Overall, 9817 laparoscopies were performed for abdominal trauma; only 26.2% of the cases were converted to a laparotomy. The incidence of therapeutic laparotomies showed a reduction from 69% to 47.5%, whereas the incidence of therapeutic laparoscopies increased from 7.2% to 22.7%.The overall perioperative mortality rate was significantly lower in the laparoscopy group [odds ratio (M-H, random); 95% confidence interval, 0.35 (0.26-0.48)]. The same group showed shorter length of hospital stay [odds ratio (M-H, random); 95% confidence interval, -3.48 (-8.91 to 1.96)].

CONCLUSIONS

This systematic review shows a significant decrease in the use of laparoscopy in trauma patients. Most likely the widespread use of imaging techniques allows a more accurate selection of patients for diagnostic laparoscopy. Infact, a reduction in incidence of nontherapeutic laparotomies is evident in these selected patients undergoing diagnostic laparoscopy. Moreover, the literature reported an increasing trend of therapeutic laparoscopy, demonstrating that it is safe and effective. The small number and poor quality of the studies identified, the retrospective observational nature of the studies (low level of evidence), the high risk of bias, and the high heterogeneity of some outcomes make the applicability of the results of this meta-analysis unclear.

Gasless laparoscopic assisted surgery for abdominal trauma

BACKGROUND

Numerous studies have described the effectiveness of laparoscopy for trauma patients. In gas-filling laparoscopic surgery, most of the disadvantages are related to a positive pressure pneumoperitoneum that compromises the cardiopulmonary function. The main advantage of gasless laparoscopic assisted surgery (GLA) is that it does not affect the haemodynamic status, which is particularly critical for trauma patients. The purpose of this study was to investigate the feasibility and safety of GLA for abdominal trauma.

MATERIALS AND METHODS

This was a retrospective, 1:2 matched case-control study of all trauma gasless assisted laparoscopies performed from January 2010 until January 2013 in a Level I trauma centre. In total, 965 patients with abdominal trauma were admitted. According to the abdominal trauma protocol, a total of 93 hemodynamically stable patients required the operation; we selected fifteen patients to undergo GLA and matched 30 other patients to undergo laparotomy. Demographic information, perioperative findings, injury severity score, and postoperative recovery were recorded and analyzed.

RESULTS

A total of fifteen patients (ten men, five women) with a mean age of 44.4, standard deviation (SD) 13.2 years underwent GLA for abdominal trauma. Eight patients had penetrating injuries, while seven had blunt injuries. Overall, 73% patients had multiple injuries. The mean time to the identified lesion was 23.1, SD 10.9min, and the mean operative time was 109.7, SD 33.5min. Most of the lesions were repaired concurrently by GLA. One conversion to laparotomy was done. The mean length of hospital stay (HLOS) was 9.1, SD 4.5 days. No mortality occurred in this series. The mean follow-up was 22.0, SD 7.9 months, and there were no significant events during this period. The mean operative times were comparable in the GLA and open surgery group (109.7, SD 33.5 vs. 131.2, SD 43.6min; p=0.076). Compared with the open surgery group, the HLOS was significantly shorter in the GLA group (9.1, SD 4.5 vs.16.3, SD 6.4 days; p=0.030).

CONCLUSION

GLA offers both therapeutic and diagnostic advantages for patients with abdominal trauma. GLA shares the advantages of laparoscopy and prevents the cardiopulmonary function from being compromised due to pneumoperitoneum, which is especially critical for trauma patients.

Traumatic appendicitis misdiagnosed as a case of haemoperitoneum

Acute appendicitis is one of the most common emergencies handled by a surgeon. Various aetiologies of acute appendicitis have been proposed but none have been proved. Trauma too has been proposed as a cause of acute appendicitis. Here we present a case of blunt trauma abdomen which was explored to rule out a perforation of hollow viscous organ and haemoperitoneum, but at the time of exploration a perforated appendicitis was found. The chronological order of events points towards blunt trauma as the probable cause of this appendicitis. This case also highlights the fact that even if trauma was not the cause of acute appendicitis, acute appendicitis should still be kept in the differential diagnosis of a patient presenting with pain in the right lower abdomen and a history of trauma.

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.

The role of diagnostic laparoscopy for acute abdominal conditions: an evidence-based review

Diagnostic laparoscopy is minimally invasive surgery for the diagnosis of intraabdominal diseases. This study aim was a critical examination of the available literature on the role of laparoscopy for the diagnosis and treatment of acute intraabdominal conditions. A systematic literature search of English-language articles on MEDLINE, the Cochrane database of evidence-based reviews, and the Database of Abstracts of Reviews of Effects was performed for the period 1995-2006. The level of evidence in the identified articles was graded. This review examines the role of diagnostic laparoscopy for acute nonspecific abdominal pain, trauma, and the acute abdomen experienced by the critically ill patient. The indications, contraindications, risks, benefits, diagnostic accuracy of the procedure, and associated morbidity are discussed. The limitations of the available literature are highlighted, and evidence-based recommendations for the use of diagnostic laparoscopy to determine acute intraabdominal conditions are provided.

Role of laparoscopy in the management of visceral injuries following abdominal stab wounds

BACKGROUND

Laparoscopy offers several advantages in the treatment of abdominal stab wounds. In this paper, we report our experience during 2004, where hemodynamically stable patients with stab wounds were managed laparoscopically.

PATIENTS AND METHODS

Between January and December 2004, 8 hemodynamically stable patients (7 men, 1 woman) underwent laparoscopy for anterior abdominal stab wounds. Median age was 28.5 years (range, 17-55). All patients underwent an abdominal computed tomography (CT) prior to the laparoscopy.

RESULTS

Exploration of the wound under aseptic conditions, carried out as a part of the physical examination, confirmed peritoneal penetration in 7 of the 8 cases. Abdominal CT revealed positive findings in 7 (87.5%) cases. Laparoscopy was performed after a median time of 60 minutes (range 30-90). Laparoscopic exploration evidenced peritoneal penetration in 100% of the cases and visceral lesions in 87.5% of the cases. All visceral injuries were managed laparoscopically. Median operative time was 135 minutes (range, 45-200). Operative mortality was 0% and early morbidity was 12.5%. Median hospital stay was 5 days (range, 1-11). After a median follow-up of 12 months (range, 1-28), 1 patient complained of persistent chest pain and a ventral hernia at the site of the abdominal stab wound was diagnosed in another patient.

CONCLUSIONS

Laparoscopy should be included in management algorithms in patients with anterior abdominal stab wounds who are hemodynamically stable. In addition to its diagnostic ability, this study demonstrates that laparoscopy can be an effective management modality with minimal morbidity and no mortality.

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.