AAST 2014 PLENARY PAPER
Minimally invasive is maximally effective: Diagnostic and therapeutic laparoscopy for penetrating abdominal injuries Paul J. Chestovich, MD, Timothy D. Browder, MD, Shawna L. Morrissey, DO, Douglas R. Fraser, MD, Nichole K. Ingalls, MD, and John J. Fildes, MD, Las Vegas, Nevada
Laparoscopic techniques have evolved, allowing increased capabilities within most subspecialties of general surgery, but have failed to gain traction managing injured patients. We hypothesized that laparoscopy is effective in the diagnosis and treatment of penetrating abdominal injuries. METHODS: We retrospectively reviewed patients undergoing abdominal exploration following penetrating trauma at our Level 1 trauma center during a 6-year period from January 1, 2008, to December 31, 2013. Demographic and resuscitation data were obtained from our trauma registry. Charts were reviewed for operative details, hospital course, and complications. Hospital length of stay (LOS) and complications were primary end points. Patients were classified as having nontherapeutic diagnostic laparoscopy (DL), nontherapeutic diagnostic celiotomy (DC), therapeutic laparoscopy (TL), or therapeutic celiotomy (TC). TL patients were case-matched 2:1 with TC patients having similar intra-abdominal injuries. RESULTS: A total of 518 patients, including 281 patients (55%) with stab wounds and 237 patients (45%) with gunshot wounds, were identified. Celiotomy was performed in 380 patients (73%), laparoscopy in 138 (27%), with 44 (32%) converted to celiotomy. Nontherapeutic explorations were compared including 70 DLs and 46 DCs with similar injury severity. LOS was shorter in DLs compared with DCs (1 day vs. 4 days, p G 0.001). There were no missed injuries. Therapeutic explorations were compared by matching all TL patients 2:1 to TC patients with similar type and severity of injuries. Twenty-four patients underwent TL compared with 48 TC patients in the case matched group. LOS was shorter in the TL group than in the TC group (4 days vs. 2 days, p G 0.001). Wound infections were more common with open exploration (10.4% vs. 0%, p = 0.002), and more patients developed ileus or small bowel obstruction after open exploration (9.4% vs. 1.1%, p = 0.018). CONCLUSION: Laparoscopy is safe and accurate in penetrating abdominal injuries. The use of laparoscopy resulted in shorter hospitalization, fewer postoperative wound infection and ileus complications, as well as no missed injuries. (J Trauma Acute Care Surg. 2015;78: 1076Y1085. Copyright * 2015 Wolters Kluwer Health, Inc. All rights reserved.) LEVEL OF EVIDENCE: Therapeutic study, level IV. KEY WORDS: Laparoscopy; penetrating trauma; abdominal injury. BACKGROUND:
E
xploratory celiotomy has traditionally been the standard of care for evaluation and treatment of patients with penetrating abdominal trauma. Despite the high versatility and accuracy for diagnosing and treating penetrating injuries, some patients have few or no abdominal injuries. This results in a high rate of nontherapeutic celiotomies, with complications occurring in up to 41% of patients.1,2 The desire to avoid unnecessary celiotomy has resulted in several management strategies to evaluate penetrating abdominal injuries, including local wound exploration,3 computed tomography scanning,4,5 and observation with serial examinatios.6 Diagnostic laparoscopy (DL) has also been used as a method to evaluate intra-abdominal injury after penetrating trauma and treat selected injuries. For laparoscopy to be useful in treating traumatic injuries, it must be safe, expedient, and reliable in accounting for all Submitted: August 12, 2014, Revised: February 17, 2015, Accepted: February 18, 2015. From Department of Surgery (T.D.B), Stanford University, Stanford, California; and Division of Trauma and Critical Care (P.J.C., S.L.M., D.R.F., N.K.I., J.J.F.), University of Nevada School of Medicine, Las Vegas, Nevada. T.D.B. and J.J.F. are members of the American Association for the Surgery of Trauma. This study was presented at the 73rd annual meeting of the American Association for the Surgery of Trauma, September 9Y13, 2014, in Philadelphia, Pennsylvania. Address for reprints: Timothy D. Browder, MD, Department of Surgery, Stanford University, 300 Pasteur Dr, Grant Bldg, S-067, Stanford, CA 94305; email: [email protected]. DOI: 10.1097/TA.0000000000000655
injuries and must offer therapeutic ability in select patients. Although several reports have described laparoscopic exploration and treatment for traumatic injuries, there is still hesitancy among the trauma community to embrace it.7 This apprehension stems from early reports of missed injuries,8 perceived inability to visualize all areas of the abdomen,9 and increased operative time, which are of special concern during periods of high trauma volume. Some reports of laparoscopy described it strictly as a diagnostic method followed by celiotomy with peritoneal penetration or injury,10Y15 while more recent series have performed more thorough laparoscopic exploration and treatment of selected injuries.16Y24 Despite these reports, there remains little evidence showing the benefits of using laparoscopic techniques for the definitive management of traumatic injuries. Our trauma center has used laparoscopy on an increasing basis during the last several years, both as a diagnostic and a therapeutic tool. In this study, we aimed to review our experience using laparoscopy to diagnose and treat penetrating injuries and show the benefits of avoiding celiotomy in patients with injuries amenable to laparoscopic management.
PATIENTS AND METHODS We performed a retrospective review of 539 patients at our urban, American College of SurgeonsYverified Level 1 J Trauma Acute Care Surg Volume 78, Number 6
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trauma center during a 6-year period (January 1, 2008, to December 31, 2013). We queried our prospectively maintained trauma database for all patients with penetrating injuries requiring abdominal exploration. Patients who expired within 24 hours of admission were excluded, all of whom were explored via celiotomy. Demographic information including age, sex, injury type, mechanism, admission vital signs, Injury Severity Score (ISS), New ISS, Abbreviated Injury Scale (AIS), hospital length of stay (LOS), 28-day ventilator-free days, discharge disposition, and complications. This project was approved by the University Medical Center Institutional Review Board. Our database does not differentiate between laparoscopy and celiotomy for exploration; therefore, we reviewed all patient records with abdominal exploration for penetrating injuries. All patients were classified as stable or unstable based on documentation and admission vital signs. Patients were considered unstable if systolic blood pressure (SBP) was lower than 90 mm Hg or if the chart indicated hemodynamic instability. Procedures were classified as diagnostic celiotomy (DC) and DL for nontherapeutic procedures and therapeutic celiotomy (TC) and therapeutic laparoscopy (TL) for procedures resulting in surgical treatment, which includes all procedures in which surgical therapy was administered. This included hemostasis, evacuation of blood, and repair of any injured structure including both solid organ injury and abdominal wall repair. Procedures were considered diagnostic if no treatment was administered, including procedures in which minor injuries were found. Patients who first underwent DL and converted to celiotomy were kept in the celiotomy group (DC or TC) for analysis. Operative plan and technique were not standardized and varied by each individual surgeon. Decisions regarding initial DL, celiotomy, and conversion based on operative findings were surgeon dependent. Primary end points included missed injuries, hospital LOS, and complications. Hospital LOS was considered the number of full days in the hospital; patients who were discharged on the same day of admission were given a hospital LOS of 0.5. Complications were recorded from both the patient chart and through our trauma center registry. Missed injuries were those that were not diagnosed at initial exploration and were evaluated by monitoring each patient’s postoperative documentation including follow-up visits, imaging, and repeat explorations. Wound infection followed the National Surgical Quality Improvement Program definition for a superficial incisional surgical site infection.24 Intra-abdominal abscess followed the National Surgical Quality Improvement Program definition for deep/space surgical site infection.24 Pneumonia was consistent with the Centers for Disease Control and Prevention guidelines for diagnosis of pneumonia.25 Ileus and small bowel obstruction (SBO) were combined and were counted if the patient required nasogastric drainage for more than 72 hours or reinsertion of nasogastric tube after operation. Thromboembolic complications included both deep venous thrombosis (DVT) and pulmonary embolus and were diagnosed on imaging studies. Unplanned readmission and reexploration were considered if these occurred within 30 days of initial injury and were related to initial traumatic injury. All patients in each nontherapeutic group were compared, DC versus DL. TL patients were compared with a 2:1
case-matched group of patients with similar spectrum of injuries but were repaired via celiotomy (TC). For patients undergoing therapeutic operation, severity of abdominal injury was determined by the Penetrating Abdominal Trauma Index (PATI) score26 and abdominal AIS score.27 AIS scores were obtained through our trauma registry and verified by the authors. The PATI score was calculated after review of each patient’s operative report. The matching process was performed manually by the authors. Each patient undergoing TL was matched to two patients in the celiotomy group with similar mechanism of injury, organs injured, and type of repair (i.e., simple repair vs. resection). We excluded patients who were hemodynamically unstable upon presentation and patients who had a nonabdominal AIS score greater than 3. Injuries were considered similar when their overall injury pattern and repair were the same, that is, simple repair of viscus structure repaired laparoscopically was matched with simple repair performed by celiotomy. If an injury required resection, it was not matched to an injury undergoing simple repair. When exact matches were not possible, cases were substituted such that the sum total of organs injured in each population was similar. After matching was completed, we used the ISS and New ISS to verify that the overall injury spectrum was similar between the two groups and the abdominal AIS and PATI scores to verify that the abdominal injury severity was similar. Continuous variables were expressed as a median (interquartile range [IQR]) and were compared with a Wilcoxon ranksum test. Categorical variables were expressed as a frequency (percentage) and compared with a Fisher’s exact test. LOS survival curves were compared using log-rank test. Statistical analysis and Kaplan-Meier graphs were performed using STATA version 11 (StataCorp., College Station, TX), and significance was determined by p G 0.05.
RESULTS We identified 539 patients undergoing abdominal exploration for penetrating injury. Twenty-one patients expired within the first 24 hours and were excluded; laparoscopy was not performed on any of these patients. Of the remaining 518 patients, 88% were male and median age was 30 years. This included 281 patients (54.3%) with stab wounds (SWs) and 237 patients (45.8%) with gunshot wounds (GSWs). The majority (457 patients, 88.2%) of patients was hemodynamically stable, and the median initial Glasgow Coma Scale (GCS) score was 15. Median ISS was 9, New ISS was 17, and abdominal AIS score was 3. Median LOS was 6 days, median intensive care unit (ICU) LOS was 1 day, and the median number of ventilator-free days was 28. Further details and the spectrum of abdominal injuries encountered are shown in Table 1. Of the 518 patients included, 380 (73%) underwent immediate celiotomy, while the remaining 138 (27%) underwent initial laparoscopy. After laparoscopy, 44 of the 139 patients were converted to celiotomy. The most common reason for conversion was discovery of injuries not amenable to laparoscopic repair in 22 patients (50%), peritoneal violation in 11 (25%), surgeon preference in 6 (14%), hemoperitoneum in 2 (5%), as well as enteric contents, hemodynamic instability,
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TABLE 1. All Patients Undergoing Abdominal Exploration (Celiotomy or Laparoscopy) for Penetrating Abdominal Injuries N = 518 Age, median (IQR), y Male, n (%) Hemodynamically stable, n (%) Mechanism, n (%) SWs GSWs Presentation vitals Heart rate SBP Respiratory rate GCS score ISS (range) New ISS (range) Abdominal AIS score (range) Abdominal organ injuries Small intestine (%) Large intestine Liver Stomach Diaphragm Major vascular Spleen Pancreas/duodenum/biliary Kidney Hemoperitoneum Abdominal wall Bladder Hospital LOS, median (range), d ICU LOS, median (range), d Ventilator-free days (28 d) Disposition Home/AMA Rehabilitation/SNF Death
30 (22.6Y39.9) 457 (88.2) 417 (80.5) 281 (54.3) 237 (45.8) 98 (82Y112) 145 (120Y162) 20 (16Y24) 15 (15Y15) 9 (4Y18) 17 (5Y27) 3 (1Y3) 132 (25.5) 131 (25.3) 121 (23.4) 77 (14.9) 77 (14.9) 57 (11.0) 53 (10.2) 45 (8.7) 38 (7.3) 29 (5.6) 27 (5.2) 15 (2.9) 6 (2Y10) 1 (0Y2) 28 (26Y28) 447 (86.3) 24 (4.6) 47 (9.1)
Continuous data are expressed as median (IQR) and categorical data as frequency (percentage). AMA, against medical advice; SNF, skilled nursing facility.
and inability to completely visualize injury in one each (2.5%). The celiotomy group totaled 424 patients after adding the 44 patients converted. Of these, 378 patients were therapeutic and 46 were nontherapeutic. Of the 95 patients who were explored with laparoscopy only, 24 were considered therapeutic and 70 were nontherapeutic. Of the 44 patients who underwent initial laparoscopy and were converted, 15 were ultimately nontherapeutic and 29 were therapeutic. The breakdown of all patients in our review is seen in Figure 1. Comparison between DL and DC groups is shown in Table 2. There was no difference in age, sex, mechanism of injury, ISS, New ISS, or abdominal AIS score for patients undergoing nontherapeutic DL or DC. Presentation vital signs and GCS score were similar between groups. All patients in the DL group were hemodynamically stable, while the majority (95.7%) of DC patients was stable. Both hospital LOS and ICU LOS were 1078
significantly shorter for the laparoscopy group, although there was no difference in ventilator-free days. Disposition was similar between the two groups. Comparison between therapeutic explorations TL and 2:1 case-matched TC patients is shown in Table 3. There was no difference in age, sex, and mechanism of injury. Injury scoring systems including ISS, New ISS, abdominal AIS score, and PATI score showed no difference between groups. Presentation vital signs and GCS score were similar, and patients were hemodynamically stable in both groups. The quantity of injuries per abdominal organ system is shown in Table 3, which has no difference between the two groups. Hospital LOS was significantly shorter in the TL group compared with the TC group, while there was no difference in ICU LOS or ventilatorfree days. Hospital disposition was similar between groups. Complications are shown in Table 4. No patients in any group had a missed injury, regardless of method of exploration. We also did not detect any intra-abdominal abscesses, thromboembolic complications, unplanned reexploration, or patient deaths. When comparing all laparoscopy with all celiotomy patients, we detected significantly fewer wound infections and ileus/SBO in patients explored laparoscopically. When considering diagnostic and therapeutic categories separately, wound infections were lower in the laparoscopic group, but this finding did not reach statistical significance. Similarly, ileus/SBO was significantly lower in the DL group compared with the DC group but did not reach significance in the therapeutic comparison. Kaplan-Meier graphs of LOS for nontherapeutic and therapeutic explorations are shown in Figure 2A and B, respectively. Patients in the DL group were discharged significantly earlier than those undergoing DC (p G 0.001). Three patients in the DL group had an LOS of 7 days or greater, two for alcohol withdrawal and one for psychiatric hold. Eight patients in the DC group had an LOS of 7 days or greater, seven for psychiatric hold and one for chest tube management. Similarly, patients requiring treatment in the TL group were also discharged from the hospital earlier compared with the TC casematched group (p = 0.001). Two patients in the TL group had an LOS of 7 days or greater, one for psychiatric hold and one for a prolonged ileus following laparoscopic repair of stomach and diaphragm. There were 13 TC patients with an LOS of 7 days or greater, 8 for psychiatric hold, 3 for treatment of extra-abdominal injuries, and 1 each for narcotic withdrawal and wound infection.
DISCUSSION Minimally invasive techniques have been used selectively as diagnostic tools in managing abdominal injuries since the first series was published in 1976.10 Studies examining the diagnostic and therapeutic use of laparoscopy are few, and the results are conflicting. Several articles have shown that using DL in selected patients is safe21,28,29 and can decrease the rate of unnecessary celiotomies,16,30,31 while others have criticized it as being too expensive,32 ineffective,11 and at risk of missing important injuries.8,33 Our results confirm that DL can be used safely in hemodynamically stable patients and can be therapeutic in patients with selected injuries. Several options exist for evaluating hemodynamically stable patients with penetrating abdominal injuries. Local * 2015 Wolters Kluwer Health, Inc. All rights reserved.
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Figure 1. Breakdown of patients in our series, by method of exploration, and therapeutic versus nontherapeutic.
wound exploration has been shown to effectively determine the depth of injury for SWs, and our center uses this technique in determining the need for further diagnostic evaluation.3 If a positive local wound exploration is used as an indication for proceeding to celiotomy, the result is a nontherapeutic exploration rate of 43%.14 The practice of routine celiotomy for abdominal GSWs has also been questioned because of high nontherapeutic operative rates.34 Because of the 20% to 61% complication rate associated with non-TCs, many centers have begun using laparoscopy to diagnose peritoneal penetration. Unnecessary laparotomies are highest in patients with penetrating injuries,1 so laparoscopy is particularly useful as a diagnostic method in these patients. When peritoneal penetration is used as a trigger for celiotomy, the non-TC rate is decreased but still remains 28%.14 However, recent studies have shown that exploratory laparoscopy without converting to celiotomy can be used effectively to identify all intra-abdominal injuries.35 Proponents of conversion from DL to open celiotomy cite a sensitivity of only 20% for hollow viscus injury when exploratory laparoscopy alone is used as the treatment modality.11 In our series, laparoscopic evaluation was performed in 94 patients (18%) requiring abdominal exploration for penetrating injuries, and there were no missed injuries. We believe this improvement from previous reports is attributable
to improved instrumentation and the refinement of advanced laparoscopic techniques. Relatively few studies have reported on the therapeutic use of trauma laparoscopy, with most limiting the use to diaphragmatic repair. The reported literature as of 2012 had only described the laparoscopic repair of eight hollow viscus injuries.35 In 2013, Khubutiya et al.36 reported the use of TL for the management of 56 patients with blunt and penetrating abdominal injuries. Similar to our patient population, they demonstrated the successful repair of the liver, stomach, small intestine, colon, diaphragm, bladder, and abdominal wall. To ensure that injuries treated were similar between the TC and TL groups, we cross-matched our patients using abdominal AIS and PATI scores in a 2:1 ratio. Any surgical therapy performed without conversion to celiotomy was considered a TL. Our findings confirmed those of the Khubutiya et al. by demonstrating no missed injuries, decreased LOS, and fewer overall complications. Several authors have described shorter hospital LOS when using DL.9,14,16,28,37 The ability to rule out peritoneal penetration allows those patients to be safely discharged home instead of being admitted for observation. We similarly demonstrated a shorter LOS in patients undergoing strictly DL, but importantly, we also found a decreased LOS for patients
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TABLE 2. Nontherapeutic Explorations Number Age, median (IQR), y Male patients, n (%) Injury mechanism, n (%) GSW SW Hemodynamically stable, n (%) Presentation vitals Heart rate SBP Respiratory rate GCS score ISS New ISS Abdominal AIS score Hospital LOS, median (IQR), d ICU LOS, median (IQR), d Ventilator-free days (28 d) Disposition Home/AMA Rehabilitation/SNF Death
DL
DC
p
n = 70 28 (22Y42) 58 (82.9)
n = 46 31 (23Y42) 42 (91.3)
V 0.438 0.273 1.000
13 (18.6) 57 (81.4) 70 (100)
8 (16.7) 38 (83.3) 44 (95.7)
96 (86Y110) 148 (133Y170) 18 (14Y22) 15 (15Y15) 1 (1Y3) 1 (1Y3) 1 (1Y1) 1 (0.5Y2) 0 (0Y0) 28 (28Y28) 70 (100) 0 (0) 0 (0)
0.155
92 (86Y106) 0.509 144 (130Y154) 0.181 18 (16Y19) 0.472 15 (15Y15) 0.312 1 (1Y3) 0.798 1 (1Y3) 0.578 1 (1Y1) 0.231 4 (3Y6) G0.001 0 (0Y0) 0.013 28 (28Y28) 0.093 0.155 44 (95.7) 2 (4.3) 0 (0)
Comparison between patients undergoing DC and DL in which no surgical treatment was performed. Continuous data are presented as median (IQR) and categorical data as frequency (percentage). Statistical analysis performed using Wilcoxon rank-sum test for continuous and Fisher’s exact test for categorical variables, with p G 0.05 considered significant. AMA, against medical advice; SNF, skilled nursing facility.
undergoing TL. This is consistent with the general surgery literature demonstrating that laparoscopic procedures frequently result in shorter hospital LOS, earlier return to normal activities, and less postoperative pain when compared with equivalent operations with a large incision. An additional observed benefit of exploratory laparoscopy from our experience is that a smaller localized incision can be used if conversion to an open procedure is required. Hand-assisted repairs may also be possible, should injuries be found that the operative surgeon is not comfortable repairing completely laparoscopic. We have not yet used this technique, but it is well established in other laparoscopic abdominal procedures and may be a viable option. Despite celiotomy being considered the standard of care, we found that some postoperative complications were more common following open exploration when compared with laparoscopy. In our analysis of combined comparison of laparoscopic and open exploration, celiotomy resulted in more wound infections and more incidence of ileus than did the laparoscopic approach. Wound infections were the most common finding, and this is consistent with other studies that have shown fewer wound complications following laparoscopic procedures such as appendectomy38 and cholecystectomy.39 Another significant complication was the delayed postoperative return of bowel function. More patients were documented to have ileus after DC, which likely contributed 1080
to this group having a longer hospital LOS. Similar findings have been found comparing elective laparoscopic with open procedures such as colon resection.40 The remaining complications consisted of two patients developing pneumonia in the celiotomy group compared with no patients in the laparoscopy group. The small numbers of pneumonia complications make it difficult to draw definitive conclusions, but the trend seems to be consistent with elective general surgery findings that these complications occur more frequently in open procedures.41 A potential concern regarding laparoscopic procedures is the increased operative time and any associated risks that
TABLE 3. Therapeutic Explorations: Comparison Between TL and a 2:1 Case-Matched Group of Patients Undergoing TC
Number Age, median (IQR), y Age, range, y Male patients Injury mechanism GSW SW Hemodynamically stable Presentation vitals Heart rate SBP Respiratory rate GCS score ISS New ISS Abdominal AIS score PATI score25 Abdominal organ injuries Small intestine Large intestine Liver Stomach Diaphragm Major vascular Spleen Pancreas/duodenum/biliary Kidney Hemoperitoneum Abdominal wall Bladder Hospital LOS, median (IQR), d ICU LOS, median (IQR), d Ventilator-free days (28 d) Disposition Home/AMA Rehabilitation/SNF Death
TL
TC 2:1 Case Match
n = 24 29 (23Y37) 17.0Y52.9 24 (100)
n = 48 30 (22Y40) 15.2Y64.7 46 (95.8)
4 (16.7) 20 (83.3) 24 (100)
8 (16.7) 40 (83.3) 48 (100)
p V 0.816 0.549 1.000
V
109 (92Y115) 153 (132Y168) 20 (17Y24) 15 (15Y15) 8 (4Y13) 9 (4Y15) 2 (2Y3) 3 (2Y6)
100 (85Y107) 153 (141Y167) 20 (16Y24) 15 (15Y15) 9 (4Y12) 13 (5Y20) 3 (2Y3) 3 (2Y6)
0.169 0.508 0.541 0.629 0.663 0.296 0.122 0.649
5 (20.8) 2 (8.3) 4 (16.7) 4 (16.7) 4 (16.7) 0 (0) 0 (0) 0 (0) 0 (0) 4 (16.7) 11 (45.8) 1 (4.2) 2 (1Y4) 0 (0Y0) 28 (28Y28)
11 (22.9) 4 (8.3) 8 (16.7) 8 (16.7) 7 (14.6) 0 (0) 1 (2.1) 0 (0) 1 (2.1) 8 (16.7) 15 (31.3) 2 (4.2) 4 (3Y7) 0 (0Y0) 28 (28Y28)
1.000 1.000 1.000 1.000 1.000 V 1.000 V 1.000 1.000 0.299 1.000 G0.001 0.810 0.718 0.697
24 (100) 0 (0) 0 (0)
46 (95.8) 2 (4.2) 0 (0)
Continuous data are presented as median (IQR) and categorical data as frequency (percentage). Statistical analysis performed using Wilcoxon rank-sum test for continuous and Fisher’s exact test for categorical variables, with p G 0.05 considered significant. AMA, against medical advice; SNF, skilled nursing facility.
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TABLE 4. Comparison of Complications Between Laparoscopy and Celiotomy for Nontherapeutic and Therapeutic Groups
Missed injury Wound infection Abscess Pneumonia DVT/PE Ileus/SBO Readmission Reexploration Death
DL
DC
n = 70
n = 48
p
0 (0) 3 (6.5) 0 (0) 2 (4.4) 0 (0) 5 (10.4) 3 (6.3) 0 (0) 0 (0)
V 0.060 V 0.155 V 0.023 0.299 V V
0 (0) 0 (0) 0 (0) 0 (0) 0 (0) 0 (0) 1 (1.4) 0 (0) 0 (0)
TL
TC
n = 24
n = 48
0 (0) 0 (0) 0 (0) 0 (0) 0 (0) 1 (4.2) 0 (0) 0 (0) 0 (0)
0 (0) 7 (14.6) 0 (0) 0 (0) 0 (0) 4 (8.3) 2 (4.2) 0 (0) 0 (0)
p V 0.087 V V V 0.659 0.549 V V
DL + TL
DC + TC
n = 94
n = 96
0 (0) 0 (0) 0 (0) 0 (0) 0 (0) 1 (1.1) 1 (1.1) 0 (0) 0 (0)
0 (0) 10 (10.4) 0 (0) 2 (2.1) 0 (0) 9 (9.4) 5 (5.2) 0 (0) 0 (0)
p V 0.002 V 0.497 V 0.018 0.211 V V
All comparisons performed using Fisher’s exact test, with p G 0.05 considered significant. TC, 2:1 Case matched group of TC; PE, pulmonary embolus.
may result. Because of the retrospective nature of this study, it was not possible to obtain accurate operative times. In our experience, the comfort level of the operating surgeon with advanced laparoscopic techniques seems to predict longer operative times. The operating surgeon should choose the approach that is safest for each patient in their institution and minimize unnecessary delays. The decision to convert from laparoscopic to open procedures should not significantly increase the operative time because the decision can and should be made quickly after initial exploration. Major vascular injury, large retroperitoneal hematoma, clinical deterioration, or highly destructive injuries clearly not amenable to minimally invasive repair should prompt rapid conversion to open exploration. Surgeon experience and skill level are instrumental in providing good patient outcomes. Of the patients in our study initially explored with laparoscopy, 44 patients were converted to open celiotomy. Our complication rate was highest in the celiotomy group, and there was no evidence that laparoscopy or conversion to an open procedure contributed to patient complications. Only 2 of the 10 wound complications and 1 of the 9 ileus/SBO patients were in the conversion group. There were no wound complications and one ileus in the laparoscopy patients (Table 4). The time-sensitive nature of traumatic injuries, however, makes this is an important area to address in further prospective studies. While our study is confined to patients with penetrating injuries, other authors have described laparoscopy to diagnose and treat abdominal injury from blunt trauma.10,16,17,22,30,36 We have focused on penetrating injuries for this study because the majority of our experience has been for this indication, and we feel that civilian low-velocity penetrating injuries are highly amenable to laparoscopic repair. Patients who need acute operative intervention for blunt abdominal injuries frequently have major physiologic derangements or severe associated systemic injuries, often making them poor candidates for laparoscopy. The two most likely contraindications that will be encountered are hypotension and associated head injury. Of those who are safe to undergo laparoscopy, many have associated organ system injuries, with recovery dependent mostly on orthopedic, thoracic, or neurologic convalescence. The protracted management
Figure 2. A, Kaplan-Meier survival curves of hospital LOS comparing nontherapeutic laparoscopy (DL) and celiotomy (DC). B, Kaplan-Meier survival curves of hospital LOS comparing TL with a 2:1 case-matched group of patients with similar injury types but repaired via open celiotomy (TC).
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of these complex injuries seems to mitigate some of the potential benefits seen by performing laparoscopy, such as LOS and ventilator-free days. Lower wound complication rates should continue to be an important beneficial outcome in this group of highly injured patients and warrant further study. Patients with isolated blunt abdominal trauma and suspicion for hollow viscus injury, such as abdominal tenderness or a seat belt sign, do seem to benefit from DL and potentially TL. We have successfully used laparoscopy in this group of patients, but they were not included in this review. The principles of operative trauma care should not be compromised by a minimally invasive approach to abdominal exploration and injury repair. The operative surgeon must be appropriately trained and comfortable using advanced laparoscopic techniques. Although some authors have described methods for laparoscopic evaluation, there is no established standard for performing a laparoscopic exploration for trauma.19,20 We perform and recommend that all of these explorations occur in the operating room under general anesthesia. Following the insertion of a nasogastric tube and a Foley catheter, we begin the exploration with a periumbilical 10-mm trocar followed by the placement of two lateral trocars. The size and placement of initial trocars can vary depending on the potential injuries, but the most important determinant is ensuring that the surgeon can explore the entire abdomen. Patient positioning can also be very important in assisting with intra-abdominal visualization. The patients should be securely strapped to the operating room table, and aggressive manipulation of the operating room table can use gravity to assist with organ retraction. We feel that at a minimum, operating surgeons should have successfully taken and passed the Fundamentals of Laparoscopic Surgery course or an equivalent training program that documents competency with basic laparoscopic skills. Further standardizing the specific skills required for DL and TL for trauma will likely improve the confidence and skill of trauma surgeons in using this technique. To help facilitate this, we have designed and implemented an animate porcine educational course for minimally invasive trauma exploration. The course involves didactics, dry laboratory skills stations, and live animal exploration for identification and repair of standardized injuries. Our initial experience with this course has been very positive and warrants further study in this specific area of skills acquisition. Despite our encouraging findings, there are limitations to the use of laparoscopy for patients with penetrating abdominal injuries. Our series did not include any repairs of injuries to the pancreas, duodenum, biliary tree, spleen, kidney, or major vascular structures. Thus, we are unable to comment on the safety or efficacy of TL for these injuries. The majority (83%) of TL was primarily used in SWs, despite only 55% of penetrating injuries at our center from SWs. However, SWs make up the majority of injuries explored using laparoscopy in published series.17,21,42 There may be selection bias in cases chosen for laparoscopic exploration, but we have attempted to minimize this through case matching in our comparison group. A common concern of using laparoscopy for evaluation of trauma patients is the cost associated with the equipment, personnel, increased operative time, and resource use. We did not specifically measure the costs associated with laparoscopic 1082
management. However, our results show that penetrating abdominal trauma managed laparoscopically can significantly decrease LOS, which translates to less patient care expenses. The potential benefits of laparoscopy in decreasing hospitalization will need to be weighed against the costs associated with laparoscopy in future work. The limitations of our study are largely attributable to the limited availability of registry data and the retrospective methodology used. The reasons for each surgeon choosing between an open or laparoscopic abdominal exploration are difficult to ascertain from the retrospective chart review. Therefore, surgeon selection bias may have resulted in less severely injured patients being chosen for laparoscopy. We attempted to correct for this potential bias by matching the therapeutic comparison groups using abdominal AIS scores and PATI scores. The PATI has limitations, however, since it does not account for injuries to the diaphragm or the abdominal wall. Another limitation is the use of hospital LOS as an outcome measurement, as this can often be a skewed variable. Increased LOS experienced by several of the patients was caused by reasons unrelated to their abdominal injury; however, removing these patients from the LOS analysis still resulted in significantly decreased LOS in the laparoscopic groups. Since this was a retrospective study, some of the complications we measured were difficult to determine and were dependent on adequate documentation. Others, such as ileus, have no standard definition, are operator dependent, and should be verified prospectively. We had no thromboembolic complications in any of our comparison groups, but screening asymptomatic trauma patients for DVT is controversial, and at our center, we only evaluated patients with clinical symptoms. We also have no reliable long-term follow-up data for this patient population, making the evaluation of potential late outcomes impossible. With improvements in minimally invasive technology and the refinement of laparoscopic techniques, we have demonstrated that exploratory laparoscopy can identify all clinically relevant injuries following penetrating abdominal trauma. In addition, it can allow for the immediate treatment of those injuries without routine conversion to celiotomy. Patients seem to benefit from this approach by having fewer non-TCs, less postoperative complications, and shorter hospital LOS. As surgeons become more confident with minimally invasive techniques, laparoscopy will likely become a standard therapy for managing abdominal injuries. AUTHORSHIP P.J.C., T.D.B., and J.J.F. designed this study, which J.J.F. sponsored. P.J.C., T.D.B., S.L.M., D.R.F., and N.K.I. contributed to data acquisition and analysis. P.J.C. drafted the manuscript and created tables/figures, which T.D.B. and J.J.F. reviewed and finalized. P.J.C., T.D.B., S.J.M., D.R.F., and N.K.I. revised the manuscript. ACKNOWLEDGMENTS We thank Elizabeth Snavely, our trauma registry administrator, for her assistance obtaining patient data from the University Medical Center trauma registry. DISCLOSURE The authors declare no conflicts of interest.
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REFERENCES 1. Renz BM, Feliciano DV. Unnecessary laparotomies for trauma: a prospective study of morbidity. J Trauma. 1995;38(3):350Y356. 2. Weigelt JA, Kingman RG. Complications of negative laparotomy for trauma. Am J Surg. 1988;156:544Y547. 3. Cothren CC, Moore EE, Warren FA, Kashuk JL, Biffl WL, Johnson JL. Local wound exploration remains a valuable triage tool for the evaluation of anterior abdominal stab wounds. Am J Surg. 2009;198:223Y226. 4. Castrillon GA, Soto JA. Multidetector computed tomography of penetrating abdominal trauma. Semin Roentgenol. 2012;47(4):371Y376. 5. Phillips T, Sclafani SJA, Goldstein A, Scalea T, Panetta T, Shaftan G. Use of contrast-enhanced CT enema in the management of penetrating trauma to the flank and back. J Trauma. 1986;26(7):593Y601. 6. Zubowski R, Nallathambi M, Ivatury R, Stahl W. Selective conservatism in abdominal stab wounds: the efficacy of serial physical examination. J Trauma. 1988;28(11):1665Y1668. 7. Ball CG, Karmali S, Rajani RR. Laparoscopy in trauma: an evolution in progress. Injury. 2009;40:7Y10. 8. Ivatury RR, Simon RJ, Stahl WM. A critical evaluation of laparoscopy in penetrating abdominal trauma. J Trauma. 1993;34(6):822Y828. 9. Livingston DH, Tortella BJ, Blackwood J, Machiedo GW, Rush BF. The role of laparoscopy in abdominal trauma. J Trauma. 1992;33(3):471Y475. 10. Gazzaniga AB, Stanton WW, Bartlett RH. Laparoscopy in the diagnosis of blunt and penetrating injuries in the abdomen. Am J Surg. 1974; 131:315Y318. 11. Kopelman TR, O’Neill PJ, Macias LH, Cox JC, Matthews MR, Drachman DA. The utility of diagnostic laparoscopy in the evaluation of anterior abdominal stab wounds. Am J Surg. 2008;196:871Y877. 12. Sosa JL, Arrillaga A, Puente I, Sleeman D, Ginzberg E, Martin L. Laparoscopy in 121 consecutive patients with abdominal gunshot wounds. J Trauma. 1995;39(3):501Y506. 13. Ivatury RR, Simon RJ, Weksler B, Bayard V, Stahl WM. Laparoscopy in the evaluation of the intrathoracic abdomen after penetrating injury. J Trauma. 1992;33(1):101Y109. 14. Sumislawski JJ, Zarzaur BL, Paulus EM, Sharpe JP, Savage SA, Nawaf CB, Croce MA, Fabian TC. Diagnostic laparoscopy after anterior abdominal stab wounds: worth another look? J Trauma Acute Care Surg. 2013;75: 1013Y1018. 15. Miles EJ, Dunn E, Howard D, Mangram A. The role of laparoscopy in penetrating abdominal trauma. JSLS. 2004;8:304Y309. 16. Johnson JJ, Garwe T, Raines AR, Thurman JB, Carter S, Bender JS, Albrecht RM. The use of laparoscopy in the diagnosis and treatment of blunt and penetrating abdominal injuries: 10-year experience at a level 1 trauma center. Am J Surg. 2013;205:317Y321. 17. Barzana DC, Kotwall CA, Clancy TV, Hope WW. Use of laparoscopy in trauma at a level II trauma center. JSLS. 2011;15:179Y181. 18. Zantut LF, Ivatury RR, Smith RS, Kawahara NT, Porter JM, Fry WR, Poggetti R, Birolini D, Organ CH. Diagnostic and therapeutic laparoscopy for penetrating abdominal trauma: a multicenter experience. J Trauma. 1997;42(5):825Y831. 19. Kawahara NT, Alster C, Fujimura I, Poggetti RS, Birolini D. Standard examination system for laparoscopy in penetrating abdominal trauma. J Trauma. 2009;67:589Y595. 20. Gorecki PR, Cottam D, Angus LDG, Shaftan GW. Diagnostic and therapeutic laparoscopy for trauma: a technique for safe and systematic exploration. Surg Laparosc Endosc Percutan Tech. 2002;12(3):195Y198. 21. Choi YB, Lim KS. Therapeutic laparoscopy for abdominal trauma. Surg Endosc. 2003;17:421Y427. 22. Smith RS, Fry WR, Morabito DJ, Koehler RH, Organ CH. Therapeutic laparoscopy in trauma. Am J Surg. 1995;170:632Y637. 23. Matthews BD, Bui H, Harold KL, Kercher KW, Adrales G, Park A, Sing RF, Heniford BT. Laparoscopic repair of traumatic diaphragmatic injuries. Surg Endosc. 2003;17:254Y258. 24. American College of Surgeons NSQIP Operations Manual. Chapter 4; 2013:85Y92. Available at: http://site.acsnsqip.org. Accessed November 1, 2014. 25. Centers for Disease Control. CDC/NHSN Surveillance Definitions for Specific Types of Infections. 2014:31Y33. Available at: http://www.cdc.gov/
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nhsn/PDFs/pscManual/17pscNoslnfDef_current.pdf. Accessed November 1, 2014. Moore EE, Dunn EL, Moore JB, Thompson JS. Penetrating abdominal trauma index. J Trauma. 1981;21:439Y445. Baker SP, O’Neill P, Haddon W, Long WB. The Injury Severity Score: a method for describing patients with multiple injuries and evaluating emergency care. J Trauma. 1974;14:187Y196. Lin HF, Wu JM, Tu CC, Chen HA, Shih HC. Value of diagnostic and therapeutic laparoscopy for abdominal stab wounds. World J Surg. 2010; 34:1653Y1662. Ahmed N, Whelan J, Brownlee J, Chari V, Chung R. The contribution of laparoscopy in evaluation of penetrating abdominal wounds. J Am Coll Surg. 2005;201:213Y216. Taner AS, Topgul K, Kucukel F, Demir A, Sari S. Diagnostic laparoscopy decreases the rate of unnecessary laparotomies and reduces hospital cost in trauma patients. J Laparoendosc Adv Tech A. 2001;11(4):207Y211. Simon RJ, Rabin J, Kuhls D. Impact of increased use of laparoscopy on negative laparotomy rates after penetrating trauma. J Trauma. 2002;53: 297Y302. Leppaniemi A, Haapianiem R. Diagnostic laparoscopy in abdominal stab wounds: a prospective, randomized study. J Trauma. 2003;55:636Y645. Villavicencio RT, Aucar JA. Analysis of laparoscopy in trauma. J Am Coll Surg. 1999;189:11Y20. Demetriades D, Hadjizacharia P, Constantinou C, Brown C, Inaba K, Rhee P. Selective nonoperative management of penetrating abdominal solid organ injuries. Ann Surg. 2006;244(4):620Y628. O’Malley E, Boyle E, O’Callaghan A, Coffey J, Walsh SR. Role of laparoscopy in penetrating abdominal trauma: a systematic review. World J Surg. 2013;37(1):113Y122. Khubutiya MSh, Yartsev PA, Guliaev AA, Levitsky VD, Tlibekova MA. Laparoscopy in blunt and penetrating abdominal injuries. Surg Laparosc Endosc Percutan Tech. 2013;23:507Y512. Chelly MR, Major K, Spivak J, Hui T, Hiatt JR, Margulies DR. The value of laparoscopy in management of abdominal trauma. Am Surg. 2003; 69:957Y960. Chung RS, Rowland DY, Li P, Diaz J. A meta-analysis of randomized controlled trials of laparoscopic versus conventional appendectomy. Am J Surg. 1999;177:250Y256. Veldkamp R, Kuhry E, Hop WC, Jeekel J, Kazemier G, Bonjer HJ, Haglind E, Pahlman L, Cuesta MA, Msika S, Morino M, Lacy AM. Laparoscopic surgery versus open surgery for colon cancer: short term outcomes of a randomized trial. Lancet Oncol. 2005;6:477Y484. Lujun JA, Parrilla P, Robles R, Marin P, Torralba JA, Garcia-Ayllon J. Laparoscopic cholecystectomy vs open cholecystectomy in the treatment of acute cholecystitis. Arch Surg. 1998;133:173Y175. Tiwari MM, Reynoso JF, High R, Tsang AW, Oleynikov D. Safety, efficacy, and cost-effectiveness of common laparoscopic procedures. Surg Endosc. 2011;25:1127Y1135. Fabian TC, Croce MA, Stewart RM, Pritchard FE, Minard G, Kudsk KA. A prospective analysis of diagnostic laparoscopy in trauma. Ann Surg. 1993;217(5):557Y565.
DISCUSSION Dr. Rao R. Ivatury (Richmond, Virginia): In the early 1990s, several of us firmly established the role of diagnostic laparoscopy in penetrating abdominal trauma, especially in the area of intra-thoracic abdomen. The late 1990s saw a critical evaluation of diagnostic laparoscopy and the initial forays into the therapeutic laparoscopy in penetrating trauma. This, however, did not receive a wide acceptance in the U.S., presumably from several concerns: the fear of missing bowel perforations, perceived low cost-effectiveness of laparoscopy, and a general reluctance to employ laparoscopy for trauma and acute abdomen in the middle of the night. So much so, one of the recent presidential addresses of the AAST cautioned that acute care surgeons need to be more facile in
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minimally-invasive surgery to be competitive among all the specialties of surgery. This is in stark contrast to Europe, South America, and China and many other countries, where both diagnostic and therapeutic laparoscopy were employed frequently, effectively and with excellent results. The Brazilians have an elaborate technical course in evaluating the abdomen for injuries and running the small bowel, looking for perforations. The good news is that the era of minimally-invasive surgery for abdominal trauma may finally be here. Unlike the old guards, the younger acute care surgeons are better trained at laparoscopic techniques and are more comfortable to employ these even for trauma patients. As we just heard, a group of young acute care surgeons V mean age, I am guessing 37Vemployed minimally-invasive techniques to diagnose and treat 138 patients. Non-therapeutic explorations were comparable to celiotomy group but with shorter length of stay and less wound infections. When matched groups of open and laparoscopic therapeutic explorations were compared, similar favorable results were seen in the laparoscopy group. Most significant, there were no missed injuries. Not a Class I data for sure, but I believe this will be as close as we will ever get to comparable groups randomized to celiotomy versus laparoscopy. I totally agree with the authors’ conclusions but I must play the devil’s advocate, if only to give the authors a chance to take on all the nay-sayers of the past and future. My questions are: What do you think is the learning curve for therapeutic laparoscopy? And what limits do you recommend in terms of time spent and the complexity of procedures before conversions, to laparotomy example: retroperitoneal hematomas, multiple bowel perforations, large diaphragmatic rents and so on? You had 44 patients in the laparoscopy group that were converted to celiotomy. What were the factors for this conversion? Have you had experience with hand-assisted laparoscopic techniques such as segmental bowel resection and anastomosis though a small incision and do you recommend it? Would you comment on the cost comparison between the laparoscopy and celiotomy groups? Finally, do you think minimally-invasive surgery for trauma is ready for prime time? If not, how do you suggest we go about it? I enjoyed the paper and thank the AAST for the privilege of discussing it. Dr. Michel Aboutanos (Richmond, Virginia): I also commend the authors for their effort. I agree that we now have better technology and better-refined techniques to be more facile in laparoscopy, which leads to my quick questions. In your manuscript you stated that the decision to use laparoscopy was the surgeon’s choice. Did you stratify or analyze the data by the operative surgeon? Was it the same surgeon or surgeons performing one technique because they were better trained and more comfortable with that specific technique? My second question, regarding the mechanism of injury: many of us are more comfortable with a low energy, for example, stab wound versus a gunshot wound when there is a laparoscopy. Did you analyze specifically that subset? And apart from physiological parameters which factor such as trajectory or location of injury influenced the type of operation performed? 1084
And my last question: you reported no missed injuries. These patients, if they are anything like the patients that we see in our shop in Richmond, have a very poor follow-up rate. How long did you follow these patients? Did you have confirmation of 100% follow-up on all 138 patients, meaning that you have no loss to follow-up at all? Dr. Charles Yowler (Cleveland, Ohio): Some of the early studies on laparoscopic surgery for stab wounds were troubled by the fact that 20% to 30% of the patients had no evidence of peritoneal penetration at all. In other words, it was being used instead of observation for stab wounds. How did you screen patients to go to the operating room in both arms? In other words, a guy comes in with a stab to the abdomen and he is stable, what is your screening to convince you he needs to be explored or undergo laparoscopic surgery? And were there any patients in the laparoscopic group that had no evidence of penetration of the abdominal cavity at the time of surgery? Dr. Michael T. White (Detroit, Michigan): Did you have enough cases that you got an idea of what your indications would be for opening in the OR when you’ve made the decision to put the laparoscope in? Based on what you found, did you kind of develop an algorithm for what things you would do that would make you decide to do an open instead of continuing on laparoscopically? Dr. Paul Chestovich (Las Vegas, Nevada): Thank you very much for those kind comments. There were quite a few questions, so I will try to go through these one at a time. Dr. Ivatury inquired about the learning curve, and we believe this is highly surgeon-dependent. For people with extensive laparoscopic experience, I think the learning curve is shorter. For people who haven’t had as much experience with laparoscopy, I’m sure it’s longer, as we might expect. But we do not have specific data on this. There was a question about time spent doing laparoscopic procedures. Our time spent performing one of these repairs is anywhere from 30 minutes to just over an hour. If we have to spend much more than that, then the potential patient benefit starts to decrease with increased anesthesia time and the risks associated with that. We don’t think it makes sense to do a three-to-four hour exploration laparoscopic if we can do a 30minute exploration open. I would like to briefly mention contraindications. We believe there are only two absolute contraindications to performing laparoscopy in a patient with a penetrating abdominal injury, and those are hemodynamic instability and concomitant head injuries, due to potential for increased ICP from the insufflation. Nearly any other penetrating injury can be explored laparoscopically. If the patient becomes unstable at any point, we convert immediately and this takes about a minute to do, so we really haven’t lost much time. Once the laparoscope is inserted and the exploration begins, the next step depends on what we find. If the abdomen can be adequately evaluated and the injury tract followed in its entirety, then any injury found can be fixed using whatever means deemed appropriate by the surgeon. The spectrum of injuries fixed laparoscopically are surgeon-dependent, and is determined by surgeon experience, confidence doing laparoscopic techniques, and familiarity with the latest laparoscopic technology. * 2015 Wolters Kluwer Health, Inc. All rights reserved.
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Dr. Ivatury asked about our experience with hand-assisted procedures. We don’t really have any experience with that yet, although the potential is definitely there for the right patient and the right injury. I do think that if a thorough exploration is done and a specific injury is found, a smaller incision can be made to repair that injury if it cannot be fixed laparoscopically. A hand port is another possibility which might expand the ability to fix injuries which otherwise might require conversion. There was a question about cost comparison. We considered including that in this study. The challenge with cost comparison is that hospital charges are not too hard to obtain; however, figuring out what the actual cost, which we would say is related to the equipment, personnel, and operative time, and hospital stay is much harder to obtain. This is something that we are starting to put together another study for the future to figure that out. We did not stratify specifically based on the operative surgeon. At our center, we have a number of surgeons who feel very comfortable performing laparoscopic explorations but have others who do not. We did not have a standard protocol to say which patients get explored laparoscopically. Although we did not look specifically at each surgeon, I can tell you that there were two or three surgeons who performed the majority of the laparoscopic explorations and there were roughly the same number who performed most of the open explorations. This related primarily to their personal comfort level with doing a thorough laparoscopic exploration. As far as stab wounds versus gunshot wounds, our overall population was nearly 50/50. However we clearly had far more stab wounds that could be explored and repaired laparoscopically. The reasons for this are pretty clear, since gunshot wounds have much more energy and blast effect associated with them. We believe it is less likely that a gunshot injury could be evaluated and fixed laparoscopically than a stab wound. Our series numbers reflect this bias. Dr. Aboutanos asked about whether we used trajectory of injury for our decision making. The answer is yes, we do use the trajectory to determine whether they are a laparoscopic candidate, although it was impossible to determine that retrospectively for the purpose of the paper. Dr. Aboutanos also asked about our follow-up rate. That definitely is a weakness. I believe our follow-up rate is pretty
comparable to a lot of trauma centers around the country, which is relatively poor. I can’t give you the exact number of patients that did follow up long term, but I can guess it is a small number. I can tell you that in the past we have attempted to contact these patients for these kind of studies and we are lucky if we get 2 out of 20 who will even call us back, let alone come in for follow-up evaluation. Dr. Yowler asked about what we use to screen patients to decide whether to go to the operating room. For stab wounds, we use local wound exploration to determine fascial penetration. If we determine it penetrates the fascia, then we go to the operating room to determine if it penetrates the peritoneum. If it does, the patient gets a thorough diagnostic exploration to evaluate all injuries. All gunshot wounds to the abdomen get explored. We did not include details on local wound exploration in our series because we included both stab wounds and gunshot wounds, and wound exploration is not really relevant for a gunshot wound. Dr. White asked about what we used to determine when we convert to an open procedure. This is largely based upon surgeon preference, with some clear indications. Some surgeons used the laparoscope simply to determine peritoneal penetration, and would convert if they saw that. Others would do a more thorough exploration, and we had several conversions where the laparoscope was inserted, and injuries were found that we know we can’t fix laparoscopically. These patients were converted immediately. If we see a major vascular injury, or any injury to the hepatobiliary system, these are unlikely to be amenable to laparoscopic treatment and thus would warrant conversion. If the patient becomes unstable at any point during exploration, then we would immediately convert to an open procedure. There is one final point I want to emphasize. We adhere to the same principles for laparoscopic exploration as we do for open exploration for penetrating injuries. We examine all the organs and structures and we follow the tract of injury. If we cannot do that successfully and safely, then we convert to an open procedure. Thus, the principles are the same whether we do the exploration open or laparoscopic. Thank you very much for all your comments and questions.
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Minimally invasive is maximally effective: Diagnostic and therapeutic laparoscopy for penetrating abdominal injuries Paul J. Chestovich, MD, Timothy D. Browder, MD, Shawna L. Morrissey, DO, Douglas R. Fraser, MD, Nichole K. Ingalls, MD, and John J. Fildes, MD, Las Vegas, Nevada
Laparoscopic techniques have evolved, allowing increased capabilities within most subspecialties of general surgery, but have failed to gain traction managing injured patients. We hypothesized that laparoscopy is effective in the diagnosis and treatment of penetrating abdominal injuries. METHODS: We retrospectively reviewed patients undergoing abdominal exploration following penetrating trauma at our Level 1 trauma center during a 6-year period from January 1, 2008, to December 31, 2013. Demographic and resuscitation data were obtained from our trauma registry. Charts were reviewed for operative details, hospital course, and complications. Hospital length of stay (LOS) and complications were primary end points. Patients were classified as having nontherapeutic diagnostic laparoscopy (DL), nontherapeutic diagnostic celiotomy (DC), therapeutic laparoscopy (TL), or therapeutic celiotomy (TC). TL patients were case-matched 2:1 with TC patients having similar intra-abdominal injuries. RESULTS: A total of 518 patients, including 281 patients (55%) with stab wounds and 237 patients (45%) with gunshot wounds, were identified. Celiotomy was performed in 380 patients (73%), laparoscopy in 138 (27%), with 44 (32%) converted to celiotomy. Nontherapeutic explorations were compared including 70 DLs and 46 DCs with similar injury severity. LOS was shorter in DLs compared with DCs (1 day vs. 4 days, p G 0.001). There were no missed injuries. Therapeutic explorations were compared by matching all TL patients 2:1 to TC patients with similar type and severity of injuries. Twenty-four patients underwent TL compared with 48 TC patients in the case matched group. LOS was shorter in the TL group than in the TC group (4 days vs. 2 days, p G 0.001). Wound infections were more common with open exploration (10.4% vs. 0%, p = 0.002), and more patients developed ileus or small bowel obstruction after open exploration (9.4% vs. 1.1%, p = 0.018). CONCLUSION: Laparoscopy is safe and accurate in penetrating abdominal injuries. The use of laparoscopy resulted in shorter hospitalization, fewer postoperative wound infection and ileus complications, as well as no missed injuries. (J Trauma Acute Care Surg. 2015;78: 1076Y1085. Copyright * 2015 Wolters Kluwer Health, Inc. All rights reserved.) LEVEL OF EVIDENCE: Therapeutic study, level IV. KEY WORDS: Laparoscopy; penetrating trauma; abdominal injury. BACKGROUND:
E
xploratory celiotomy has traditionally been the standard of care for evaluation and treatment of patients with penetrating abdominal trauma. Despite the high versatility and accuracy for diagnosing and treating penetrating injuries, some patients have few or no abdominal injuries. This results in a high rate of nontherapeutic celiotomies, with complications occurring in up to 41% of patients.1,2 The desire to avoid unnecessary celiotomy has resulted in several management strategies to evaluate penetrating abdominal injuries, including local wound exploration,3 computed tomography scanning,4,5 and observation with serial examinatios.6 Diagnostic laparoscopy (DL) has also been used as a method to evaluate intra-abdominal injury after penetrating trauma and treat selected injuries. For laparoscopy to be useful in treating traumatic injuries, it must be safe, expedient, and reliable in accounting for all Submitted: August 12, 2014, Revised: February 17, 2015, Accepted: February 18, 2015. From Department of Surgery (T.D.B), Stanford University, Stanford, California; and Division of Trauma and Critical Care (P.J.C., S.L.M., D.R.F., N.K.I., J.J.F.), University of Nevada School of Medicine, Las Vegas, Nevada. T.D.B. and J.J.F. are members of the American Association for the Surgery of Trauma. This study was presented at the 73rd annual meeting of the American Association for the Surgery of Trauma, September 9Y13, 2014, in Philadelphia, Pennsylvania. Address for reprints: Timothy D. Browder, MD, Department of Surgery, Stanford University, 300 Pasteur Dr, Grant Bldg, S-067, Stanford, CA 94305; email: [email protected]. DOI: 10.1097/TA.0000000000000655
injuries and must offer therapeutic ability in select patients. Although several reports have described laparoscopic exploration and treatment for traumatic injuries, there is still hesitancy among the trauma community to embrace it.7 This apprehension stems from early reports of missed injuries,8 perceived inability to visualize all areas of the abdomen,9 and increased operative time, which are of special concern during periods of high trauma volume. Some reports of laparoscopy described it strictly as a diagnostic method followed by celiotomy with peritoneal penetration or injury,10Y15 while more recent series have performed more thorough laparoscopic exploration and treatment of selected injuries.16Y24 Despite these reports, there remains little evidence showing the benefits of using laparoscopic techniques for the definitive management of traumatic injuries. Our trauma center has used laparoscopy on an increasing basis during the last several years, both as a diagnostic and a therapeutic tool. In this study, we aimed to review our experience using laparoscopy to diagnose and treat penetrating injuries and show the benefits of avoiding celiotomy in patients with injuries amenable to laparoscopic management.
PATIENTS AND METHODS We performed a retrospective review of 539 patients at our urban, American College of SurgeonsYverified Level 1 J Trauma Acute Care Surg Volume 78, Number 6
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trauma center during a 6-year period (January 1, 2008, to December 31, 2013). We queried our prospectively maintained trauma database for all patients with penetrating injuries requiring abdominal exploration. Patients who expired within 24 hours of admission were excluded, all of whom were explored via celiotomy. Demographic information including age, sex, injury type, mechanism, admission vital signs, Injury Severity Score (ISS), New ISS, Abbreviated Injury Scale (AIS), hospital length of stay (LOS), 28-day ventilator-free days, discharge disposition, and complications. This project was approved by the University Medical Center Institutional Review Board. Our database does not differentiate between laparoscopy and celiotomy for exploration; therefore, we reviewed all patient records with abdominal exploration for penetrating injuries. All patients were classified as stable or unstable based on documentation and admission vital signs. Patients were considered unstable if systolic blood pressure (SBP) was lower than 90 mm Hg or if the chart indicated hemodynamic instability. Procedures were classified as diagnostic celiotomy (DC) and DL for nontherapeutic procedures and therapeutic celiotomy (TC) and therapeutic laparoscopy (TL) for procedures resulting in surgical treatment, which includes all procedures in which surgical therapy was administered. This included hemostasis, evacuation of blood, and repair of any injured structure including both solid organ injury and abdominal wall repair. Procedures were considered diagnostic if no treatment was administered, including procedures in which minor injuries were found. Patients who first underwent DL and converted to celiotomy were kept in the celiotomy group (DC or TC) for analysis. Operative plan and technique were not standardized and varied by each individual surgeon. Decisions regarding initial DL, celiotomy, and conversion based on operative findings were surgeon dependent. Primary end points included missed injuries, hospital LOS, and complications. Hospital LOS was considered the number of full days in the hospital; patients who were discharged on the same day of admission were given a hospital LOS of 0.5. Complications were recorded from both the patient chart and through our trauma center registry. Missed injuries were those that were not diagnosed at initial exploration and were evaluated by monitoring each patient’s postoperative documentation including follow-up visits, imaging, and repeat explorations. Wound infection followed the National Surgical Quality Improvement Program definition for a superficial incisional surgical site infection.24 Intra-abdominal abscess followed the National Surgical Quality Improvement Program definition for deep/space surgical site infection.24 Pneumonia was consistent with the Centers for Disease Control and Prevention guidelines for diagnosis of pneumonia.25 Ileus and small bowel obstruction (SBO) were combined and were counted if the patient required nasogastric drainage for more than 72 hours or reinsertion of nasogastric tube after operation. Thromboembolic complications included both deep venous thrombosis (DVT) and pulmonary embolus and were diagnosed on imaging studies. Unplanned readmission and reexploration were considered if these occurred within 30 days of initial injury and were related to initial traumatic injury. All patients in each nontherapeutic group were compared, DC versus DL. TL patients were compared with a 2:1
case-matched group of patients with similar spectrum of injuries but were repaired via celiotomy (TC). For patients undergoing therapeutic operation, severity of abdominal injury was determined by the Penetrating Abdominal Trauma Index (PATI) score26 and abdominal AIS score.27 AIS scores were obtained through our trauma registry and verified by the authors. The PATI score was calculated after review of each patient’s operative report. The matching process was performed manually by the authors. Each patient undergoing TL was matched to two patients in the celiotomy group with similar mechanism of injury, organs injured, and type of repair (i.e., simple repair vs. resection). We excluded patients who were hemodynamically unstable upon presentation and patients who had a nonabdominal AIS score greater than 3. Injuries were considered similar when their overall injury pattern and repair were the same, that is, simple repair of viscus structure repaired laparoscopically was matched with simple repair performed by celiotomy. If an injury required resection, it was not matched to an injury undergoing simple repair. When exact matches were not possible, cases were substituted such that the sum total of organs injured in each population was similar. After matching was completed, we used the ISS and New ISS to verify that the overall injury spectrum was similar between the two groups and the abdominal AIS and PATI scores to verify that the abdominal injury severity was similar. Continuous variables were expressed as a median (interquartile range [IQR]) and were compared with a Wilcoxon ranksum test. Categorical variables were expressed as a frequency (percentage) and compared with a Fisher’s exact test. LOS survival curves were compared using log-rank test. Statistical analysis and Kaplan-Meier graphs were performed using STATA version 11 (StataCorp., College Station, TX), and significance was determined by p G 0.05.
RESULTS We identified 539 patients undergoing abdominal exploration for penetrating injury. Twenty-one patients expired within the first 24 hours and were excluded; laparoscopy was not performed on any of these patients. Of the remaining 518 patients, 88% were male and median age was 30 years. This included 281 patients (54.3%) with stab wounds (SWs) and 237 patients (45.8%) with gunshot wounds (GSWs). The majority (457 patients, 88.2%) of patients was hemodynamically stable, and the median initial Glasgow Coma Scale (GCS) score was 15. Median ISS was 9, New ISS was 17, and abdominal AIS score was 3. Median LOS was 6 days, median intensive care unit (ICU) LOS was 1 day, and the median number of ventilator-free days was 28. Further details and the spectrum of abdominal injuries encountered are shown in Table 1. Of the 518 patients included, 380 (73%) underwent immediate celiotomy, while the remaining 138 (27%) underwent initial laparoscopy. After laparoscopy, 44 of the 139 patients were converted to celiotomy. The most common reason for conversion was discovery of injuries not amenable to laparoscopic repair in 22 patients (50%), peritoneal violation in 11 (25%), surgeon preference in 6 (14%), hemoperitoneum in 2 (5%), as well as enteric contents, hemodynamic instability,
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TABLE 1. All Patients Undergoing Abdominal Exploration (Celiotomy or Laparoscopy) for Penetrating Abdominal Injuries N = 518 Age, median (IQR), y Male, n (%) Hemodynamically stable, n (%) Mechanism, n (%) SWs GSWs Presentation vitals Heart rate SBP Respiratory rate GCS score ISS (range) New ISS (range) Abdominal AIS score (range) Abdominal organ injuries Small intestine (%) Large intestine Liver Stomach Diaphragm Major vascular Spleen Pancreas/duodenum/biliary Kidney Hemoperitoneum Abdominal wall Bladder Hospital LOS, median (range), d ICU LOS, median (range), d Ventilator-free days (28 d) Disposition Home/AMA Rehabilitation/SNF Death
30 (22.6Y39.9) 457 (88.2) 417 (80.5) 281 (54.3) 237 (45.8) 98 (82Y112) 145 (120Y162) 20 (16Y24) 15 (15Y15) 9 (4Y18) 17 (5Y27) 3 (1Y3) 132 (25.5) 131 (25.3) 121 (23.4) 77 (14.9) 77 (14.9) 57 (11.0) 53 (10.2) 45 (8.7) 38 (7.3) 29 (5.6) 27 (5.2) 15 (2.9) 6 (2Y10) 1 (0Y2) 28 (26Y28) 447 (86.3) 24 (4.6) 47 (9.1)
Continuous data are expressed as median (IQR) and categorical data as frequency (percentage). AMA, against medical advice; SNF, skilled nursing facility.
and inability to completely visualize injury in one each (2.5%). The celiotomy group totaled 424 patients after adding the 44 patients converted. Of these, 378 patients were therapeutic and 46 were nontherapeutic. Of the 95 patients who were explored with laparoscopy only, 24 were considered therapeutic and 70 were nontherapeutic. Of the 44 patients who underwent initial laparoscopy and were converted, 15 were ultimately nontherapeutic and 29 were therapeutic. The breakdown of all patients in our review is seen in Figure 1. Comparison between DL and DC groups is shown in Table 2. There was no difference in age, sex, mechanism of injury, ISS, New ISS, or abdominal AIS score for patients undergoing nontherapeutic DL or DC. Presentation vital signs and GCS score were similar between groups. All patients in the DL group were hemodynamically stable, while the majority (95.7%) of DC patients was stable. Both hospital LOS and ICU LOS were 1078
significantly shorter for the laparoscopy group, although there was no difference in ventilator-free days. Disposition was similar between the two groups. Comparison between therapeutic explorations TL and 2:1 case-matched TC patients is shown in Table 3. There was no difference in age, sex, and mechanism of injury. Injury scoring systems including ISS, New ISS, abdominal AIS score, and PATI score showed no difference between groups. Presentation vital signs and GCS score were similar, and patients were hemodynamically stable in both groups. The quantity of injuries per abdominal organ system is shown in Table 3, which has no difference between the two groups. Hospital LOS was significantly shorter in the TL group compared with the TC group, while there was no difference in ICU LOS or ventilatorfree days. Hospital disposition was similar between groups. Complications are shown in Table 4. No patients in any group had a missed injury, regardless of method of exploration. We also did not detect any intra-abdominal abscesses, thromboembolic complications, unplanned reexploration, or patient deaths. When comparing all laparoscopy with all celiotomy patients, we detected significantly fewer wound infections and ileus/SBO in patients explored laparoscopically. When considering diagnostic and therapeutic categories separately, wound infections were lower in the laparoscopic group, but this finding did not reach statistical significance. Similarly, ileus/SBO was significantly lower in the DL group compared with the DC group but did not reach significance in the therapeutic comparison. Kaplan-Meier graphs of LOS for nontherapeutic and therapeutic explorations are shown in Figure 2A and B, respectively. Patients in the DL group were discharged significantly earlier than those undergoing DC (p G 0.001). Three patients in the DL group had an LOS of 7 days or greater, two for alcohol withdrawal and one for psychiatric hold. Eight patients in the DC group had an LOS of 7 days or greater, seven for psychiatric hold and one for chest tube management. Similarly, patients requiring treatment in the TL group were also discharged from the hospital earlier compared with the TC casematched group (p = 0.001). Two patients in the TL group had an LOS of 7 days or greater, one for psychiatric hold and one for a prolonged ileus following laparoscopic repair of stomach and diaphragm. There were 13 TC patients with an LOS of 7 days or greater, 8 for psychiatric hold, 3 for treatment of extra-abdominal injuries, and 1 each for narcotic withdrawal and wound infection.
DISCUSSION Minimally invasive techniques have been used selectively as diagnostic tools in managing abdominal injuries since the first series was published in 1976.10 Studies examining the diagnostic and therapeutic use of laparoscopy are few, and the results are conflicting. Several articles have shown that using DL in selected patients is safe21,28,29 and can decrease the rate of unnecessary celiotomies,16,30,31 while others have criticized it as being too expensive,32 ineffective,11 and at risk of missing important injuries.8,33 Our results confirm that DL can be used safely in hemodynamically stable patients and can be therapeutic in patients with selected injuries. Several options exist for evaluating hemodynamically stable patients with penetrating abdominal injuries. Local * 2015 Wolters Kluwer Health, Inc. All rights reserved.
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Figure 1. Breakdown of patients in our series, by method of exploration, and therapeutic versus nontherapeutic.
wound exploration has been shown to effectively determine the depth of injury for SWs, and our center uses this technique in determining the need for further diagnostic evaluation.3 If a positive local wound exploration is used as an indication for proceeding to celiotomy, the result is a nontherapeutic exploration rate of 43%.14 The practice of routine celiotomy for abdominal GSWs has also been questioned because of high nontherapeutic operative rates.34 Because of the 20% to 61% complication rate associated with non-TCs, many centers have begun using laparoscopy to diagnose peritoneal penetration. Unnecessary laparotomies are highest in patients with penetrating injuries,1 so laparoscopy is particularly useful as a diagnostic method in these patients. When peritoneal penetration is used as a trigger for celiotomy, the non-TC rate is decreased but still remains 28%.14 However, recent studies have shown that exploratory laparoscopy without converting to celiotomy can be used effectively to identify all intra-abdominal injuries.35 Proponents of conversion from DL to open celiotomy cite a sensitivity of only 20% for hollow viscus injury when exploratory laparoscopy alone is used as the treatment modality.11 In our series, laparoscopic evaluation was performed in 94 patients (18%) requiring abdominal exploration for penetrating injuries, and there were no missed injuries. We believe this improvement from previous reports is attributable
to improved instrumentation and the refinement of advanced laparoscopic techniques. Relatively few studies have reported on the therapeutic use of trauma laparoscopy, with most limiting the use to diaphragmatic repair. The reported literature as of 2012 had only described the laparoscopic repair of eight hollow viscus injuries.35 In 2013, Khubutiya et al.36 reported the use of TL for the management of 56 patients with blunt and penetrating abdominal injuries. Similar to our patient population, they demonstrated the successful repair of the liver, stomach, small intestine, colon, diaphragm, bladder, and abdominal wall. To ensure that injuries treated were similar between the TC and TL groups, we cross-matched our patients using abdominal AIS and PATI scores in a 2:1 ratio. Any surgical therapy performed without conversion to celiotomy was considered a TL. Our findings confirmed those of the Khubutiya et al. by demonstrating no missed injuries, decreased LOS, and fewer overall complications. Several authors have described shorter hospital LOS when using DL.9,14,16,28,37 The ability to rule out peritoneal penetration allows those patients to be safely discharged home instead of being admitted for observation. We similarly demonstrated a shorter LOS in patients undergoing strictly DL, but importantly, we also found a decreased LOS for patients
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TABLE 2. Nontherapeutic Explorations Number Age, median (IQR), y Male patients, n (%) Injury mechanism, n (%) GSW SW Hemodynamically stable, n (%) Presentation vitals Heart rate SBP Respiratory rate GCS score ISS New ISS Abdominal AIS score Hospital LOS, median (IQR), d ICU LOS, median (IQR), d Ventilator-free days (28 d) Disposition Home/AMA Rehabilitation/SNF Death
DL
DC
p
n = 70 28 (22Y42) 58 (82.9)
n = 46 31 (23Y42) 42 (91.3)
V 0.438 0.273 1.000
13 (18.6) 57 (81.4) 70 (100)
8 (16.7) 38 (83.3) 44 (95.7)
96 (86Y110) 148 (133Y170) 18 (14Y22) 15 (15Y15) 1 (1Y3) 1 (1Y3) 1 (1Y1) 1 (0.5Y2) 0 (0Y0) 28 (28Y28) 70 (100) 0 (0) 0 (0)
0.155
92 (86Y106) 0.509 144 (130Y154) 0.181 18 (16Y19) 0.472 15 (15Y15) 0.312 1 (1Y3) 0.798 1 (1Y3) 0.578 1 (1Y1) 0.231 4 (3Y6) G0.001 0 (0Y0) 0.013 28 (28Y28) 0.093 0.155 44 (95.7) 2 (4.3) 0 (0)
Comparison between patients undergoing DC and DL in which no surgical treatment was performed. Continuous data are presented as median (IQR) and categorical data as frequency (percentage). Statistical analysis performed using Wilcoxon rank-sum test for continuous and Fisher’s exact test for categorical variables, with p G 0.05 considered significant. AMA, against medical advice; SNF, skilled nursing facility.
undergoing TL. This is consistent with the general surgery literature demonstrating that laparoscopic procedures frequently result in shorter hospital LOS, earlier return to normal activities, and less postoperative pain when compared with equivalent operations with a large incision. An additional observed benefit of exploratory laparoscopy from our experience is that a smaller localized incision can be used if conversion to an open procedure is required. Hand-assisted repairs may also be possible, should injuries be found that the operative surgeon is not comfortable repairing completely laparoscopic. We have not yet used this technique, but it is well established in other laparoscopic abdominal procedures and may be a viable option. Despite celiotomy being considered the standard of care, we found that some postoperative complications were more common following open exploration when compared with laparoscopy. In our analysis of combined comparison of laparoscopic and open exploration, celiotomy resulted in more wound infections and more incidence of ileus than did the laparoscopic approach. Wound infections were the most common finding, and this is consistent with other studies that have shown fewer wound complications following laparoscopic procedures such as appendectomy38 and cholecystectomy.39 Another significant complication was the delayed postoperative return of bowel function. More patients were documented to have ileus after DC, which likely contributed 1080
to this group having a longer hospital LOS. Similar findings have been found comparing elective laparoscopic with open procedures such as colon resection.40 The remaining complications consisted of two patients developing pneumonia in the celiotomy group compared with no patients in the laparoscopy group. The small numbers of pneumonia complications make it difficult to draw definitive conclusions, but the trend seems to be consistent with elective general surgery findings that these complications occur more frequently in open procedures.41 A potential concern regarding laparoscopic procedures is the increased operative time and any associated risks that
TABLE 3. Therapeutic Explorations: Comparison Between TL and a 2:1 Case-Matched Group of Patients Undergoing TC
Number Age, median (IQR), y Age, range, y Male patients Injury mechanism GSW SW Hemodynamically stable Presentation vitals Heart rate SBP Respiratory rate GCS score ISS New ISS Abdominal AIS score PATI score25 Abdominal organ injuries Small intestine Large intestine Liver Stomach Diaphragm Major vascular Spleen Pancreas/duodenum/biliary Kidney Hemoperitoneum Abdominal wall Bladder Hospital LOS, median (IQR), d ICU LOS, median (IQR), d Ventilator-free days (28 d) Disposition Home/AMA Rehabilitation/SNF Death
TL
TC 2:1 Case Match
n = 24 29 (23Y37) 17.0Y52.9 24 (100)
n = 48 30 (22Y40) 15.2Y64.7 46 (95.8)
4 (16.7) 20 (83.3) 24 (100)
8 (16.7) 40 (83.3) 48 (100)
p V 0.816 0.549 1.000
V
109 (92Y115) 153 (132Y168) 20 (17Y24) 15 (15Y15) 8 (4Y13) 9 (4Y15) 2 (2Y3) 3 (2Y6)
100 (85Y107) 153 (141Y167) 20 (16Y24) 15 (15Y15) 9 (4Y12) 13 (5Y20) 3 (2Y3) 3 (2Y6)
0.169 0.508 0.541 0.629 0.663 0.296 0.122 0.649
5 (20.8) 2 (8.3) 4 (16.7) 4 (16.7) 4 (16.7) 0 (0) 0 (0) 0 (0) 0 (0) 4 (16.7) 11 (45.8) 1 (4.2) 2 (1Y4) 0 (0Y0) 28 (28Y28)
11 (22.9) 4 (8.3) 8 (16.7) 8 (16.7) 7 (14.6) 0 (0) 1 (2.1) 0 (0) 1 (2.1) 8 (16.7) 15 (31.3) 2 (4.2) 4 (3Y7) 0 (0Y0) 28 (28Y28)
1.000 1.000 1.000 1.000 1.000 V 1.000 V 1.000 1.000 0.299 1.000 G0.001 0.810 0.718 0.697
24 (100) 0 (0) 0 (0)
46 (95.8) 2 (4.2) 0 (0)
Continuous data are presented as median (IQR) and categorical data as frequency (percentage). Statistical analysis performed using Wilcoxon rank-sum test for continuous and Fisher’s exact test for categorical variables, with p G 0.05 considered significant. AMA, against medical advice; SNF, skilled nursing facility.
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TABLE 4. Comparison of Complications Between Laparoscopy and Celiotomy for Nontherapeutic and Therapeutic Groups
Missed injury Wound infection Abscess Pneumonia DVT/PE Ileus/SBO Readmission Reexploration Death
DL
DC
n = 70
n = 48
p
0 (0) 3 (6.5) 0 (0) 2 (4.4) 0 (0) 5 (10.4) 3 (6.3) 0 (0) 0 (0)
V 0.060 V 0.155 V 0.023 0.299 V V
0 (0) 0 (0) 0 (0) 0 (0) 0 (0) 0 (0) 1 (1.4) 0 (0) 0 (0)
TL
TC
n = 24
n = 48
0 (0) 0 (0) 0 (0) 0 (0) 0 (0) 1 (4.2) 0 (0) 0 (0) 0 (0)
0 (0) 7 (14.6) 0 (0) 0 (0) 0 (0) 4 (8.3) 2 (4.2) 0 (0) 0 (0)
p V 0.087 V V V 0.659 0.549 V V
DL + TL
DC + TC
n = 94
n = 96
0 (0) 0 (0) 0 (0) 0 (0) 0 (0) 1 (1.1) 1 (1.1) 0 (0) 0 (0)
0 (0) 10 (10.4) 0 (0) 2 (2.1) 0 (0) 9 (9.4) 5 (5.2) 0 (0) 0 (0)
p V 0.002 V 0.497 V 0.018 0.211 V V
All comparisons performed using Fisher’s exact test, with p G 0.05 considered significant. TC, 2:1 Case matched group of TC; PE, pulmonary embolus.
may result. Because of the retrospective nature of this study, it was not possible to obtain accurate operative times. In our experience, the comfort level of the operating surgeon with advanced laparoscopic techniques seems to predict longer operative times. The operating surgeon should choose the approach that is safest for each patient in their institution and minimize unnecessary delays. The decision to convert from laparoscopic to open procedures should not significantly increase the operative time because the decision can and should be made quickly after initial exploration. Major vascular injury, large retroperitoneal hematoma, clinical deterioration, or highly destructive injuries clearly not amenable to minimally invasive repair should prompt rapid conversion to open exploration. Surgeon experience and skill level are instrumental in providing good patient outcomes. Of the patients in our study initially explored with laparoscopy, 44 patients were converted to open celiotomy. Our complication rate was highest in the celiotomy group, and there was no evidence that laparoscopy or conversion to an open procedure contributed to patient complications. Only 2 of the 10 wound complications and 1 of the 9 ileus/SBO patients were in the conversion group. There were no wound complications and one ileus in the laparoscopy patients (Table 4). The time-sensitive nature of traumatic injuries, however, makes this is an important area to address in further prospective studies. While our study is confined to patients with penetrating injuries, other authors have described laparoscopy to diagnose and treat abdominal injury from blunt trauma.10,16,17,22,30,36 We have focused on penetrating injuries for this study because the majority of our experience has been for this indication, and we feel that civilian low-velocity penetrating injuries are highly amenable to laparoscopic repair. Patients who need acute operative intervention for blunt abdominal injuries frequently have major physiologic derangements or severe associated systemic injuries, often making them poor candidates for laparoscopy. The two most likely contraindications that will be encountered are hypotension and associated head injury. Of those who are safe to undergo laparoscopy, many have associated organ system injuries, with recovery dependent mostly on orthopedic, thoracic, or neurologic convalescence. The protracted management
Figure 2. A, Kaplan-Meier survival curves of hospital LOS comparing nontherapeutic laparoscopy (DL) and celiotomy (DC). B, Kaplan-Meier survival curves of hospital LOS comparing TL with a 2:1 case-matched group of patients with similar injury types but repaired via open celiotomy (TC).
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of these complex injuries seems to mitigate some of the potential benefits seen by performing laparoscopy, such as LOS and ventilator-free days. Lower wound complication rates should continue to be an important beneficial outcome in this group of highly injured patients and warrant further study. Patients with isolated blunt abdominal trauma and suspicion for hollow viscus injury, such as abdominal tenderness or a seat belt sign, do seem to benefit from DL and potentially TL. We have successfully used laparoscopy in this group of patients, but they were not included in this review. The principles of operative trauma care should not be compromised by a minimally invasive approach to abdominal exploration and injury repair. The operative surgeon must be appropriately trained and comfortable using advanced laparoscopic techniques. Although some authors have described methods for laparoscopic evaluation, there is no established standard for performing a laparoscopic exploration for trauma.19,20 We perform and recommend that all of these explorations occur in the operating room under general anesthesia. Following the insertion of a nasogastric tube and a Foley catheter, we begin the exploration with a periumbilical 10-mm trocar followed by the placement of two lateral trocars. The size and placement of initial trocars can vary depending on the potential injuries, but the most important determinant is ensuring that the surgeon can explore the entire abdomen. Patient positioning can also be very important in assisting with intra-abdominal visualization. The patients should be securely strapped to the operating room table, and aggressive manipulation of the operating room table can use gravity to assist with organ retraction. We feel that at a minimum, operating surgeons should have successfully taken and passed the Fundamentals of Laparoscopic Surgery course or an equivalent training program that documents competency with basic laparoscopic skills. Further standardizing the specific skills required for DL and TL for trauma will likely improve the confidence and skill of trauma surgeons in using this technique. To help facilitate this, we have designed and implemented an animate porcine educational course for minimally invasive trauma exploration. The course involves didactics, dry laboratory skills stations, and live animal exploration for identification and repair of standardized injuries. Our initial experience with this course has been very positive and warrants further study in this specific area of skills acquisition. Despite our encouraging findings, there are limitations to the use of laparoscopy for patients with penetrating abdominal injuries. Our series did not include any repairs of injuries to the pancreas, duodenum, biliary tree, spleen, kidney, or major vascular structures. Thus, we are unable to comment on the safety or efficacy of TL for these injuries. The majority (83%) of TL was primarily used in SWs, despite only 55% of penetrating injuries at our center from SWs. However, SWs make up the majority of injuries explored using laparoscopy in published series.17,21,42 There may be selection bias in cases chosen for laparoscopic exploration, but we have attempted to minimize this through case matching in our comparison group. A common concern of using laparoscopy for evaluation of trauma patients is the cost associated with the equipment, personnel, increased operative time, and resource use. We did not specifically measure the costs associated with laparoscopic 1082
management. However, our results show that penetrating abdominal trauma managed laparoscopically can significantly decrease LOS, which translates to less patient care expenses. The potential benefits of laparoscopy in decreasing hospitalization will need to be weighed against the costs associated with laparoscopy in future work. The limitations of our study are largely attributable to the limited availability of registry data and the retrospective methodology used. The reasons for each surgeon choosing between an open or laparoscopic abdominal exploration are difficult to ascertain from the retrospective chart review. Therefore, surgeon selection bias may have resulted in less severely injured patients being chosen for laparoscopy. We attempted to correct for this potential bias by matching the therapeutic comparison groups using abdominal AIS scores and PATI scores. The PATI has limitations, however, since it does not account for injuries to the diaphragm or the abdominal wall. Another limitation is the use of hospital LOS as an outcome measurement, as this can often be a skewed variable. Increased LOS experienced by several of the patients was caused by reasons unrelated to their abdominal injury; however, removing these patients from the LOS analysis still resulted in significantly decreased LOS in the laparoscopic groups. Since this was a retrospective study, some of the complications we measured were difficult to determine and were dependent on adequate documentation. Others, such as ileus, have no standard definition, are operator dependent, and should be verified prospectively. We had no thromboembolic complications in any of our comparison groups, but screening asymptomatic trauma patients for DVT is controversial, and at our center, we only evaluated patients with clinical symptoms. We also have no reliable long-term follow-up data for this patient population, making the evaluation of potential late outcomes impossible. With improvements in minimally invasive technology and the refinement of laparoscopic techniques, we have demonstrated that exploratory laparoscopy can identify all clinically relevant injuries following penetrating abdominal trauma. In addition, it can allow for the immediate treatment of those injuries without routine conversion to celiotomy. Patients seem to benefit from this approach by having fewer non-TCs, less postoperative complications, and shorter hospital LOS. As surgeons become more confident with minimally invasive techniques, laparoscopy will likely become a standard therapy for managing abdominal injuries. AUTHORSHIP P.J.C., T.D.B., and J.J.F. designed this study, which J.J.F. sponsored. P.J.C., T.D.B., S.L.M., D.R.F., and N.K.I. contributed to data acquisition and analysis. P.J.C. drafted the manuscript and created tables/figures, which T.D.B. and J.J.F. reviewed and finalized. P.J.C., T.D.B., S.J.M., D.R.F., and N.K.I. revised the manuscript. ACKNOWLEDGMENTS We thank Elizabeth Snavely, our trauma registry administrator, for her assistance obtaining patient data from the University Medical Center trauma registry. DISCLOSURE The authors declare no conflicts of interest.
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REFERENCES 1. Renz BM, Feliciano DV. Unnecessary laparotomies for trauma: a prospective study of morbidity. J Trauma. 1995;38(3):350Y356. 2. Weigelt JA, Kingman RG. Complications of negative laparotomy for trauma. Am J Surg. 1988;156:544Y547. 3. Cothren CC, Moore EE, Warren FA, Kashuk JL, Biffl WL, Johnson JL. Local wound exploration remains a valuable triage tool for the evaluation of anterior abdominal stab wounds. Am J Surg. 2009;198:223Y226. 4. Castrillon GA, Soto JA. Multidetector computed tomography of penetrating abdominal trauma. Semin Roentgenol. 2012;47(4):371Y376. 5. Phillips T, Sclafani SJA, Goldstein A, Scalea T, Panetta T, Shaftan G. Use of contrast-enhanced CT enema in the management of penetrating trauma to the flank and back. J Trauma. 1986;26(7):593Y601. 6. Zubowski R, Nallathambi M, Ivatury R, Stahl W. Selective conservatism in abdominal stab wounds: the efficacy of serial physical examination. J Trauma. 1988;28(11):1665Y1668. 7. Ball CG, Karmali S, Rajani RR. Laparoscopy in trauma: an evolution in progress. Injury. 2009;40:7Y10. 8. Ivatury RR, Simon RJ, Stahl WM. A critical evaluation of laparoscopy in penetrating abdominal trauma. J Trauma. 1993;34(6):822Y828. 9. Livingston DH, Tortella BJ, Blackwood J, Machiedo GW, Rush BF. The role of laparoscopy in abdominal trauma. J Trauma. 1992;33(3):471Y475. 10. Gazzaniga AB, Stanton WW, Bartlett RH. Laparoscopy in the diagnosis of blunt and penetrating injuries in the abdomen. Am J Surg. 1974; 131:315Y318. 11. Kopelman TR, O’Neill PJ, Macias LH, Cox JC, Matthews MR, Drachman DA. The utility of diagnostic laparoscopy in the evaluation of anterior abdominal stab wounds. Am J Surg. 2008;196:871Y877. 12. Sosa JL, Arrillaga A, Puente I, Sleeman D, Ginzberg E, Martin L. Laparoscopy in 121 consecutive patients with abdominal gunshot wounds. J Trauma. 1995;39(3):501Y506. 13. Ivatury RR, Simon RJ, Weksler B, Bayard V, Stahl WM. Laparoscopy in the evaluation of the intrathoracic abdomen after penetrating injury. J Trauma. 1992;33(1):101Y109. 14. Sumislawski JJ, Zarzaur BL, Paulus EM, Sharpe JP, Savage SA, Nawaf CB, Croce MA, Fabian TC. Diagnostic laparoscopy after anterior abdominal stab wounds: worth another look? J Trauma Acute Care Surg. 2013;75: 1013Y1018. 15. Miles EJ, Dunn E, Howard D, Mangram A. The role of laparoscopy in penetrating abdominal trauma. JSLS. 2004;8:304Y309. 16. Johnson JJ, Garwe T, Raines AR, Thurman JB, Carter S, Bender JS, Albrecht RM. The use of laparoscopy in the diagnosis and treatment of blunt and penetrating abdominal injuries: 10-year experience at a level 1 trauma center. Am J Surg. 2013;205:317Y321. 17. Barzana DC, Kotwall CA, Clancy TV, Hope WW. Use of laparoscopy in trauma at a level II trauma center. JSLS. 2011;15:179Y181. 18. Zantut LF, Ivatury RR, Smith RS, Kawahara NT, Porter JM, Fry WR, Poggetti R, Birolini D, Organ CH. Diagnostic and therapeutic laparoscopy for penetrating abdominal trauma: a multicenter experience. J Trauma. 1997;42(5):825Y831. 19. Kawahara NT, Alster C, Fujimura I, Poggetti RS, Birolini D. Standard examination system for laparoscopy in penetrating abdominal trauma. J Trauma. 2009;67:589Y595. 20. Gorecki PR, Cottam D, Angus LDG, Shaftan GW. Diagnostic and therapeutic laparoscopy for trauma: a technique for safe and systematic exploration. Surg Laparosc Endosc Percutan Tech. 2002;12(3):195Y198. 21. Choi YB, Lim KS. Therapeutic laparoscopy for abdominal trauma. Surg Endosc. 2003;17:421Y427. 22. Smith RS, Fry WR, Morabito DJ, Koehler RH, Organ CH. Therapeutic laparoscopy in trauma. Am J Surg. 1995;170:632Y637. 23. Matthews BD, Bui H, Harold KL, Kercher KW, Adrales G, Park A, Sing RF, Heniford BT. Laparoscopic repair of traumatic diaphragmatic injuries. Surg Endosc. 2003;17:254Y258. 24. American College of Surgeons NSQIP Operations Manual. Chapter 4; 2013:85Y92. Available at: http://site.acsnsqip.org. Accessed November 1, 2014. 25. Centers for Disease Control. CDC/NHSN Surveillance Definitions for Specific Types of Infections. 2014:31Y33. Available at: http://www.cdc.gov/
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DISCUSSION Dr. Rao R. Ivatury (Richmond, Virginia): In the early 1990s, several of us firmly established the role of diagnostic laparoscopy in penetrating abdominal trauma, especially in the area of intra-thoracic abdomen. The late 1990s saw a critical evaluation of diagnostic laparoscopy and the initial forays into the therapeutic laparoscopy in penetrating trauma. This, however, did not receive a wide acceptance in the U.S., presumably from several concerns: the fear of missing bowel perforations, perceived low cost-effectiveness of laparoscopy, and a general reluctance to employ laparoscopy for trauma and acute abdomen in the middle of the night. So much so, one of the recent presidential addresses of the AAST cautioned that acute care surgeons need to be more facile in
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Copyright © 2015 Wolters Kluwer Health, Inc. All rights reserved.
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minimally-invasive surgery to be competitive among all the specialties of surgery. This is in stark contrast to Europe, South America, and China and many other countries, where both diagnostic and therapeutic laparoscopy were employed frequently, effectively and with excellent results. The Brazilians have an elaborate technical course in evaluating the abdomen for injuries and running the small bowel, looking for perforations. The good news is that the era of minimally-invasive surgery for abdominal trauma may finally be here. Unlike the old guards, the younger acute care surgeons are better trained at laparoscopic techniques and are more comfortable to employ these even for trauma patients. As we just heard, a group of young acute care surgeons V mean age, I am guessing 37Vemployed minimally-invasive techniques to diagnose and treat 138 patients. Non-therapeutic explorations were comparable to celiotomy group but with shorter length of stay and less wound infections. When matched groups of open and laparoscopic therapeutic explorations were compared, similar favorable results were seen in the laparoscopy group. Most significant, there were no missed injuries. Not a Class I data for sure, but I believe this will be as close as we will ever get to comparable groups randomized to celiotomy versus laparoscopy. I totally agree with the authors’ conclusions but I must play the devil’s advocate, if only to give the authors a chance to take on all the nay-sayers of the past and future. My questions are: What do you think is the learning curve for therapeutic laparoscopy? And what limits do you recommend in terms of time spent and the complexity of procedures before conversions, to laparotomy example: retroperitoneal hematomas, multiple bowel perforations, large diaphragmatic rents and so on? You had 44 patients in the laparoscopy group that were converted to celiotomy. What were the factors for this conversion? Have you had experience with hand-assisted laparoscopic techniques such as segmental bowel resection and anastomosis though a small incision and do you recommend it? Would you comment on the cost comparison between the laparoscopy and celiotomy groups? Finally, do you think minimally-invasive surgery for trauma is ready for prime time? If not, how do you suggest we go about it? I enjoyed the paper and thank the AAST for the privilege of discussing it. Dr. Michel Aboutanos (Richmond, Virginia): I also commend the authors for their effort. I agree that we now have better technology and better-refined techniques to be more facile in laparoscopy, which leads to my quick questions. In your manuscript you stated that the decision to use laparoscopy was the surgeon’s choice. Did you stratify or analyze the data by the operative surgeon? Was it the same surgeon or surgeons performing one technique because they were better trained and more comfortable with that specific technique? My second question, regarding the mechanism of injury: many of us are more comfortable with a low energy, for example, stab wound versus a gunshot wound when there is a laparoscopy. Did you analyze specifically that subset? And apart from physiological parameters which factor such as trajectory or location of injury influenced the type of operation performed? 1084
And my last question: you reported no missed injuries. These patients, if they are anything like the patients that we see in our shop in Richmond, have a very poor follow-up rate. How long did you follow these patients? Did you have confirmation of 100% follow-up on all 138 patients, meaning that you have no loss to follow-up at all? Dr. Charles Yowler (Cleveland, Ohio): Some of the early studies on laparoscopic surgery for stab wounds were troubled by the fact that 20% to 30% of the patients had no evidence of peritoneal penetration at all. In other words, it was being used instead of observation for stab wounds. How did you screen patients to go to the operating room in both arms? In other words, a guy comes in with a stab to the abdomen and he is stable, what is your screening to convince you he needs to be explored or undergo laparoscopic surgery? And were there any patients in the laparoscopic group that had no evidence of penetration of the abdominal cavity at the time of surgery? Dr. Michael T. White (Detroit, Michigan): Did you have enough cases that you got an idea of what your indications would be for opening in the OR when you’ve made the decision to put the laparoscope in? Based on what you found, did you kind of develop an algorithm for what things you would do that would make you decide to do an open instead of continuing on laparoscopically? Dr. Paul Chestovich (Las Vegas, Nevada): Thank you very much for those kind comments. There were quite a few questions, so I will try to go through these one at a time. Dr. Ivatury inquired about the learning curve, and we believe this is highly surgeon-dependent. For people with extensive laparoscopic experience, I think the learning curve is shorter. For people who haven’t had as much experience with laparoscopy, I’m sure it’s longer, as we might expect. But we do not have specific data on this. There was a question about time spent doing laparoscopic procedures. Our time spent performing one of these repairs is anywhere from 30 minutes to just over an hour. If we have to spend much more than that, then the potential patient benefit starts to decrease with increased anesthesia time and the risks associated with that. We don’t think it makes sense to do a three-to-four hour exploration laparoscopic if we can do a 30minute exploration open. I would like to briefly mention contraindications. We believe there are only two absolute contraindications to performing laparoscopy in a patient with a penetrating abdominal injury, and those are hemodynamic instability and concomitant head injuries, due to potential for increased ICP from the insufflation. Nearly any other penetrating injury can be explored laparoscopically. If the patient becomes unstable at any point, we convert immediately and this takes about a minute to do, so we really haven’t lost much time. Once the laparoscope is inserted and the exploration begins, the next step depends on what we find. If the abdomen can be adequately evaluated and the injury tract followed in its entirety, then any injury found can be fixed using whatever means deemed appropriate by the surgeon. The spectrum of injuries fixed laparoscopically are surgeon-dependent, and is determined by surgeon experience, confidence doing laparoscopic techniques, and familiarity with the latest laparoscopic technology. * 2015 Wolters Kluwer Health, Inc. All rights reserved.
Copyright © 2015 Wolters Kluwer Health, Inc. All rights reserved.
J Trauma Acute Care Surg Volume 78, Number 6
Chestovich et al.
Dr. Ivatury asked about our experience with hand-assisted procedures. We don’t really have any experience with that yet, although the potential is definitely there for the right patient and the right injury. I do think that if a thorough exploration is done and a specific injury is found, a smaller incision can be made to repair that injury if it cannot be fixed laparoscopically. A hand port is another possibility which might expand the ability to fix injuries which otherwise might require conversion. There was a question about cost comparison. We considered including that in this study. The challenge with cost comparison is that hospital charges are not too hard to obtain; however, figuring out what the actual cost, which we would say is related to the equipment, personnel, and operative time, and hospital stay is much harder to obtain. This is something that we are starting to put together another study for the future to figure that out. We did not stratify specifically based on the operative surgeon. At our center, we have a number of surgeons who feel very comfortable performing laparoscopic explorations but have others who do not. We did not have a standard protocol to say which patients get explored laparoscopically. Although we did not look specifically at each surgeon, I can tell you that there were two or three surgeons who performed the majority of the laparoscopic explorations and there were roughly the same number who performed most of the open explorations. This related primarily to their personal comfort level with doing a thorough laparoscopic exploration. As far as stab wounds versus gunshot wounds, our overall population was nearly 50/50. However we clearly had far more stab wounds that could be explored and repaired laparoscopically. The reasons for this are pretty clear, since gunshot wounds have much more energy and blast effect associated with them. We believe it is less likely that a gunshot injury could be evaluated and fixed laparoscopically than a stab wound. Our series numbers reflect this bias. Dr. Aboutanos asked about whether we used trajectory of injury for our decision making. The answer is yes, we do use the trajectory to determine whether they are a laparoscopic candidate, although it was impossible to determine that retrospectively for the purpose of the paper. Dr. Aboutanos also asked about our follow-up rate. That definitely is a weakness. I believe our follow-up rate is pretty
comparable to a lot of trauma centers around the country, which is relatively poor. I can’t give you the exact number of patients that did follow up long term, but I can guess it is a small number. I can tell you that in the past we have attempted to contact these patients for these kind of studies and we are lucky if we get 2 out of 20 who will even call us back, let alone come in for follow-up evaluation. Dr. Yowler asked about what we use to screen patients to decide whether to go to the operating room. For stab wounds, we use local wound exploration to determine fascial penetration. If we determine it penetrates the fascia, then we go to the operating room to determine if it penetrates the peritoneum. If it does, the patient gets a thorough diagnostic exploration to evaluate all injuries. All gunshot wounds to the abdomen get explored. We did not include details on local wound exploration in our series because we included both stab wounds and gunshot wounds, and wound exploration is not really relevant for a gunshot wound. Dr. White asked about what we used to determine when we convert to an open procedure. This is largely based upon surgeon preference, with some clear indications. Some surgeons used the laparoscope simply to determine peritoneal penetration, and would convert if they saw that. Others would do a more thorough exploration, and we had several conversions where the laparoscope was inserted, and injuries were found that we know we can’t fix laparoscopically. These patients were converted immediately. If we see a major vascular injury, or any injury to the hepatobiliary system, these are unlikely to be amenable to laparoscopic treatment and thus would warrant conversion. If the patient becomes unstable at any point during exploration, then we would immediately convert to an open procedure. There is one final point I want to emphasize. We adhere to the same principles for laparoscopic exploration as we do for open exploration for penetrating injuries. We examine all the organs and structures and we follow the tract of injury. If we cannot do that successfully and safely, then we convert to an open procedure. Thus, the principles are the same whether we do the exploration open or laparoscopic. Thank you very much for all your comments and questions.
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