The use of minimal access surgery in pediatric trauma: a preliminary report

Laparoscopy Compared With Laparotomy for the Management of Pediatric Blunt Abdominal Trauma

BACKGROUND

There is minimal evidence evaluating the risks and benefits of laparoscopy use in hemodynamically stable children with suspected abdominal injuries. The objective of this study was to evaluate postoperative outcomes in a large cohort of hemodynamically stable pediatric patients with blunt abdominal injury.

METHODS

Using the 2015-2016 National Trauma Data Bank, all patients aged <18 y with injury severity score (ISS) ≤25, Glasgow coma scale ≥13, and normal blood pressure who underwent an abdominal operation for blunt abdominal trauma were included. Patients were grouped into three treatment groups: laparotomy, laparoscopy, and laparoscopy converted to laparotomy. Treatment effect estimation with inverse probability weighting was used to determine the association between treatment group and outcomes of interest.

RESULTS

Of 720 patients, 504 underwent laparotomy, 132 underwent laparoscopy, and 84 underwent laparoscopy converted to laparotomy. The median age was 10 (IQR: 7-15) y, and the median ISS was 9 (IQR: 5-14). Mean hospital length of stay was 2.1 d shorter (95% confidence interval [CI]: 0.9-3.2 d) and mean intensive care unit length of stay was 1.1 d shorter (95% CI: 0.6-1.5 d) for the laparoscopy group compared with the laparotomy group. The laparoscopy group had a 2.0% lower mean probability of surgical site infection than the laparotomy group (95% CI: 1.0%-3.0%).

CONCLUSIONS

In this cohort of hemodynamically stable pediatric patients with blunt abdominal injury, laparoscopy may have improved outcomes over laparotomy.

Laparoscopic Management of Pediatric Abdominal Trauma: A National Trauma Data Bank Experience

Purpose: To characterize injury patterns and institutional trends associated with the utilization of laparoscopy in the management of pediatric abdominal trauma. Methods: The National Trauma Data Bank (2010-2014) was queried for encounters involving patients ≤14 years who underwent an open or laparoscopic abdominal operation within 48 hours of emergency department arrival. Patient, injury, and hospital characteristics associated with each approach were identified. Multivariate logistic regression was used to evaluate the influence of patient and hospital characteristics on operative approach. Results: Laparoscopy comprised 7.8% (n = 355) of all abdominal trauma operations. Patients undergoing laparoscopy had lower injury severity scores and higher Glasgow Coma Scale scores on arrival compared with laparotomy subjects (P < .001). Laparoscopic patients also had a shorter length of hospital stay (5.0 versus 8.6 days, P < .001), but longer time to the operating room (9.2 versus 6.3 hours, P < .001) compared with their open counterparts. The proportion of cases managed laparoscopically increased from 6.2% in 2010 to 10.1% in 2014 (P = .013), with increase in utilization primarily driven by university hospitals (P = .026) and level I pediatric trauma centers (P = .043). Conversion to laparotomy was uncommon (18.6%), and mortality in the laparoscopic cohort was low (0.4%). Conclusions: Use of laparoscopy has increased in the pediatric abdominal trauma population, typically in a less injured cohort of patients. As familiarity with and availability of minimally invasive techniques increase, this trend will likely continue.

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.

Pediatric thoracic trauma: Current trends

Pediatric thoracic trauma is relatively uncommon but results in disproportionately high levels of morbidity and mortality when compared with other traumatic injuries. These injuries are often more devastating due to differences in children׳s anatomy and physiology relative to adult patients. A high index of suspicion is of utmost importance at the time of presentation because many significant thoracic injuries will have no external signs of injury. With proper recognition and management of these injuries, there is an associated improved long-term outcome. This article reviews the current literature and discusses the initial evaluation, current management practices, and future directions in pediatric thoracic trauma.

The diagnostic value of serum pentraxin 3 levels in pulmonary contusion

PURPOSE

To investigate the difference in pentraxin 3 (PTX 3) levels between patients with pulmonary contusion and healthy volunteers.

MATERIALS AND METHODS

This study was conducted with a group of 20 trauma patients diagnosed with pulmonary contusion and 30 healthy individuals enrolled as a control group in a tertiary university hospital.

RESULTS

Median PTX 3 levels were 7.05 (3.29-13.1), ng/ml in the contusion group and 1.03 (0.7-1.58) ng/ml in the control group. PTX 3 titers were significantly higher in patients with pulmonary contusion compared to those of the control group (p<0.001). An area under the curve (AUC) value of 0.968 investigated using ROC analysis to determine the diagnostic value of the PTX-3 in pulmonary contusion patients was measured. A PTX-3 cut-off value of 2.06 produced 95.5% sensitivity and 86.7% specificity.

CONCLUSION

PTX 3 levels in pulmonary contusion increased significantly compared to the healthy control group. If supported by wider series, PTX 3 may be expected to be capable of use as a marker in pulmonary contusion.

Role of thoracoscopy in traumatic diaphragmatic hernia

Thoraco-abdominal trauma can in rare cases involve diaphragmatic rupture and subsequent herniation of intra-abdominal contents. We report a case of this complication in a 5-year-old boy who was injured in a car crash, and who manifested respiratory distress and hemodynamic instability after 48 h of being monitored in the pediatric intensive care unit. Multiple radiologic investigations were inconclusive and the definite diagnosis was established only on thoracoscopic exploration.

The role of minimally invasive surgery in pediatric trauma: a collective review

Although minimally invasive surgery (MIS) has been utilized in selective trauma patients, there a relative paucity of literature on its role in both blunt and penetrating trauma in the pediatric population. Our purpose is to review the current literature on the role of MIS in abdominal and thoracic pediatric trauma. A review of the literature, indications, risks, and benefits of MIS in trauma will be presented. Relevant literature was obtained from use of the PubMed database.

A case of complete transection of right main bronchus in a child: Role of thoracoscopy and bronchoscopy

Isolated tracheobronchial injuries are extremely rare in children and challenging due to life threatening complications. Blunt trauma to chest, especially in pediatric age group, is usually associated with multi-organ involvement and high mortality rate. These patients rarely reach a hospital. We have described here a case of complete transection of right main bronchus in a child, without hilar vascular injury, and its successful management, emphasizing the role of bronchoscopy and thoracoscopy.

Management of chest trauma in children

Chest trauma in children is caused by high-energy blows, due in general to traffic accidents, that involve several other body regions. They occur mainly in the first decade of life and can be penetrating but are more often non-penetrating. Rib fractures and lung contusions, sometimes associated with pneumothorax or haemothorax, are the more usual injuries, but tracheobronchial rupture, cardiac, oesophageal or diaphragmatic injuries may also occur. These injuries are treated with supportive respiratory and haemodynamic measures, drainage of air or blood from the pleural space and, at times, surgical repair of the injured organ(s). Ruptures of the airway may be difficult to treat and occasionally require suture, anastomosis or resection. Oesophageal injuries can be treated conservatively with antibiotics, drainage and parenteral nutrition. Diaphragmatic tears should be repaired operatively. Overall mortality ranges from 6 to 20%. Mortality is high but this is mainly due to the associated presence of extra-thoracic trauma, and particularly to head injuries.

The lung and pediatric trauma

Thoracic trauma is relatively frequent in children and causes considerable mortality. This is mainly due to the multiorganic nature of the trauma. The lung is more often affected even in the absence of rib fractures because of the considerable pliability of the chest wall that allows direct transfer of energy to this organ. Injuries to the heart, the aorta, the esophagus, and the diaphragm are rare. Lung contusion and laceration cause parenchymal hemorrhage and consolidation sometimes accompanied by pneumothorax and/or hemothorax. Tracheobronchial disruption is rare but life-threatening. Most traumatic lung injuries may be treated with rest, respiratory support, and eventually intercostal drainage. Large hemorrhage may require thoracotomy, and persistent pneumothorax (indicative of tracheobronchial disruption) may require intubation with fiberoptic bronchoscopic assistance and eventually reparative or ablative surgery. Adult respiratory distress syndrome is very rarely seen in children with thoracic trauma, but it remains highly lethal.

Outcomes of management in stable children with intra-abdominal free fluid without solid organ injury after blunt abdominal injury

BACKGROUND

The optimal management of hemodynamically stable children without solid-organ injury and with intra-abdominal free fluid on computed tomographic (CT) scan is highly debatable. The possibility of hollow viscus injury in this setting has led many to propose mandatory exploration. We think that stable children with intra-abdominal fluid without solid organ injury can be managed nonoperatively.

METHODS

The charts of all children less than 18 years of age who had an abdominopelvic CT scan after a blunt abdominal trauma between January 2001 and July 2004 were queried. Patient demographics, mechanism of injury, vital signs, physical examination, laboratory data, CT findings, and outcomes of management were reviewed.

RESULTS

There were 37 pediatric patients identified during the study period who met the selection criteria. Twenty were boys and 17 were girls. Thirty-one patients had a small amount of fluid and six had a moderate amount of fluid. The most common mechanism of injury was motor vehicle crash (MVC). Thirty-one patients were successfully managed nonoperatively. Six patients received an exploratory laparotomy. Intraoperative findings included mesenteric injuries with or without ischemic bowel. There were no cases of hollow viscus perforation.

CONCLUSIONS

Nonoperative management of stable patients with small amounts of free fluid in the absence of significant abdominal findings is appropriate in the pediatric population. Increasing amounts of tenderness elicited on physical examination correlates well with the presence of more than a small amount of fluid. The presence of seat belt sign and more than a small amount of fluid may be associated with an increased likelihood of operative intervention.

The Role of Laparoscopy in Penetrating Abdominal Stab Wounds

The role of diagnostic laparoscopy (DL) in abdominal stab wounds (ASWs) is not clearly defined. We hypothesized that peritoneal penetration (PP) during DL was a valid indication to convert to an exploratory laparotomy (EL). Retrospective review of hemodynamically stable ASWs requiring operation. A total of 161 patients with ASWs were identified, with 36 of 92 patients (39.1%) undergoing DL converted to EL. All 36 patients had PP; 20 of 36 (55.6%) ELs were therapeutic (TL). The number of nontherapeutic laparotomies (NTLs) prevented was 56 (60.9%). Five of 92 patients had PP on DL but did not undergo EL. Twenty-four of 69 patients who underwent initial EL had an NTL (34.8%). If this group had undergone an initial DL, and PP was used to determine need for EL, the number of NTLs would have been reduced to 10 (14.5%), a 58.3% reduction. Evidence of PP during DL is a reasonable indicator to determine the need for EL and reduce the number of NTLs.

Current concepts in minimal access surgery for children

Since the introduction of minimal access surgery to general surgeons in the 1980s, pediatric surgeons have been employing this innovative technology to perform surgery on children. Video technology and miniaturized instruments have brought the laboratory to the operating room; in many cases several small incisions are the only access necessary to perform complicated procedures that would otherwise require a large wound. Additional benefits of minimal access surgery may include reduced postoperative analgesic requirements, shortened length of stay, and faster resumption of normal activities. Increased operative costs offset some of these gains. The pediatric surgical community has embraced minimal access techniques for some operations; others remain controversial.

Video-assisted thoracic surgical procedures in children

The general principles and current applications of pediatric video-assisted cardiothoracic surgery (PVACTS) are reviewed. The purpose of PVACTS is to improve surgical quality and precision in selected operations. In the 1990s PVACTS has expanded to include the management of a variety of pulmonary, mediastinal, and cardiac lesions. Currently, PVACTS is carried out using a video camera connected to a low-profile scope and a specialized set of surgical instruments. PVACTS is an accepted modality for the diagnosis (by biopsy) of pleuropulmonary and mediastinal disease, and the treatment of pediatric empyema, spontaneous pneumothorax, and mediastinal cysts. Diaphragmatic plication, repair of chylous leak, and ligation of collateral vessels have all been done using PVACTS. PVACTS patent ductus arteriosus (PDA) ligation and vascular ring repair are being successfully carried out in several institutions. The technique at The Children's Hospital of Philadelphia is described. Indications and techniques for PVACTS lobectomy and pneumonectomy are less well established. Suggested anecdotal methods are described. Cardioscopy carries the hope of improving intracardiac repair, and has been applied to several lesions. The future of PVACTS depends on the surgeon's willingness to master it, industry's willingness to customize instruments for pediatric use, and developments in the fields of virtual imaging and augmented reality. Copyright 1998 by W.B. Saunders Company

Pediatric trauma. Anesthesia management

Prevention of childhood injury remains the cornerstone of reducing the number of children who present for post-traumatic surgical intervention. Beyond prevention, the next best step is the accurate diagnosis and treatment of traumatic injury. Anesthesiologists contribute to this step by providing timely resuscitation and optimal care to avoid secondary injury. This article classifies trauma in children into different categories depending on the location of the injury. Trauma, of course, is rarely focal, and is often a multisystem entity. With knowledge in management for each subset of trauma, one may be efficient in prioritizing injury and have a good understanding of the appropriate management of the pediatric patient with multiple traumatic injuries.

Fiber-endoscopic thoracoscopy for diaphragmatic injury in children

Diagnosis of a diaphragmatic injury is important to prevent late sequelae of herniation of abdominal viscera and intestinal gangrene. A safe, simple, reliable and inexpensive method of assessing the diaphragm was devised for use in the emergency department. A standard fiberoptic upper gastrointestinal endoscope was used as a thoracoscope to visualize the diaphragm, using the thoracostomy tube incision as the portal of entry to the thoracic cavity. Two cases in which this technique was used are presented. The procedure was well tolerated and allowed for an adequate view of the diaphragm and prompt decision making.

Abdominal trauma in infants and children: prompt identification and early management of serious and life-threatening injuries. Part I: injury patterns and initial assessment

Evaluation of children with abdominal trauma can be a difficult process. Unique anatomic features predispose children to specific injuries and potentially make identification of life-threatening injuries difficult. While Part I of this review discusses the initial assessment and diagnostic testing in children with abdominal trauma, Part II will review specific injuries and ED management of children with possible abdominal trauma. Knowledge of each of these factors will improve the ability of general and pediatric emergency physicians to expeditiously identify children with potential serious injury and initiate appropriate treatment.

Analysis of laparoscopy in trauma

BACKGROUND

The optimum roles for laparoscopy in trauma have yet to be established. To date, reviews of laparoscopy in trauma have been primarily descriptive rather than analytic. This article analyzes the results of laparoscopy in trauma.

STUDY DESIGN

Outcome analysis was done by reviewing 37 studies with more than 1,900 trauma patients, and laparoscopy was analyzed as a screening, diagnostic, or therapeutic tool. Laparoscopy was regarded as a screening tool if it was used to detect or exclude a positive finding (eg, hemoperitoneum, organ injury, gastrointestinal spillage, peritoneal penetration) that required operative exploration or repair. Laparoscopy was regarded as a diagnostic tool when it was used to identify all injuries, rather than as a screening tool to identify the first indication for a laparotomy. It was regarded as a diagnostic tool only in studies that mandated a laparotomy (gold standard) after laparoscopy to confirm the diagnostic accuracy of laparoscopic findings. Costs and charges for using laparoscopy in trauma were analyzed when feasible.

RESULTS

As a screening tool, laparoscopy missed 1% of injuries and helped prevent 63% of patients from having a trauma laparotomy. When used as a diagnostic tool, laparoscopy had a 41% to 77% missed injury rate per patient. Overall, laparoscopy carried a 1% procedure-related complication rate. Cost-effectiveness has not been uniformly proved in studies comparing laparoscopy and laparotomy.

CONCLUSIONS

Laparoscopy has been applied safely and effectively as a screening tool in stable patients with acute trauma. Because of the large number of missed injuries when used as a diagnostic tool, its value in this context is limited. Laparoscopy has been reported infrequently as a therapeutic tool in selected patients, and its use in this context requires further study.

Laparoscopic surgery in children

The surgeon should be aware of the extensive applications of endoscopic surgery in the pediatric patient. The ability to provide surgical care in association with either outpatient or short-stay hospitalizations appear to be cost-effective and appropriate state-of-the-art medical care. Because the array of surgical instruments continues to evolve, new and innovative endoscopic procedures will continue to become increasingly available.

Minimally invasive surgery: the pediatric surgery experience

BACKGROUND

Minimally invasive surgery (MIS) has become an important aspect of general surgery. The degree to which pediatric surgeons have incorporated MIS into their practice is not known.

STUDY DESIGN

An MIS survey was sent to all members of the American Pediatric Surgical Association. Respondents were separated into two groups: nonperformers and performers of MIS. Performers were asked how they were trained in MIS and the total number and types of minimally invasive procedures they have performed.

RESULTS

Eighty-two percent of surveyed pediatric surgeons perform MIS. Eighty-seven percent received some or all of their training in a postgraduate course. Two percent received their only training during their general surgery residency. Forty-seven percent of performers reported 50 or fewer total procedures. A wide variety of procedures were reported, but laparoscopic cholecystectomy (95%) was the procedure most frequently reported. Thoracoscopic procedures (71%) were also reported at high rates.

CONCLUSIONS

Most pediatric surgeons in our survey perform MIS. The high rate of laparoscopic cholecystectomies reported suggests that the initial MIS experience of pediatric surgeons in our survey is similar to adult general surgeons. The frequency, however, of thoracic cases reported indicates that MIS techniques are being applied to all areas of pediatric surgery. The total minimally invasive procedure experience of our respondents also suggests that pediatric surgeons are early in their learning curve.