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Laparoscopy in trauma
- 1. ABDOMINAL TRAUMA- EVALUATION ANDTREATMENT BY LAPAROSCOPIC APPROACH PROF. COL(Retd). DR ASHOK KUMAR PURANIK HEAD OF DEPARTMENT OF GENERAL SURGERY AIIMS JODHPUR
- 3. History • The earliestuse of laparoscopy in trauma was mentioned by a surgeon Rendle Short in the early 1920s.
- 4. • One ofthe early reports of laparoscopy in trauma was by Stone et al in 1942 to diagnose hemoperitoneum • In 1970, Heselson advocated the use of laparoscopy in penetrating trauma,Now lap assisted surgeries are getting popular • Where is the need-injury to diaphragm and intestines can not be detected by imaging's.Detects missed injuries. • 41% of laparotomies in penetrating trauma are nontherapeutic, hence it avoids negative laparotomies • Laparoscopy viable options for daignosis
- 5. Uses of laparoscopyin trauma-safe & Effective,Immediete or delayed • Diagnostic laparoscopy • Therapeutic laparoscopy
- 6. When to uselaparoscopy • In hemodynamically stable patients • In blunt trauma with • Free fluid not from solid organ injury • Persistent abdominal pain / tenderness • In penetrating trauma with suspected peritoneal breach including evisceration
- 7. Indications of Diagnosticlaparoscopy • In case of unclear abdomen, with equivocal findings on CT or discrepancy between examination and imaging • In penetrating trauma -> to rule out peritoneal perforation • To diagnose solid organ injuries like liver, spleen, pancreatic injury • To diagnose hollow viscus injuries like bowel perforation (however sensitivity and specificity varies across studies)
- 8. • To diagnosesmall diaphragmatic defects which may not be visualized on routine imaging • To identify mesenteric injury, commonly missed in radiological studies • To identify associated colorectal injury in pelvic fractures • To identify patients with intraperitoneal bladder injury • For creation of a transdiaphragmatic pericardial window to rule out cardiac injury
- 9. • In abdominalstab wounds, with suspected penetration of fascia • In abdominal gunshot wounds with doubtful intraperitoneal trajectory,omental or bowel evisceration • Useful in cases with unexplained free fluid without solid organ injury • In pregnant patients, where there is risk of radiation exposure with CT and in diagnostic laparoscopy can be used to detect injuries in highly suspicious cases • Thoracoabdominal stab wounds • Pediatric abdominal trauma • Mentally impaired ,unsafe for NOM. • Allergic to contrast,Urgent orthopedic surgery • Complex pelvic trauma with low rectal injuries
- 10. Technique of diagnosticlaparoscopy • Place first port at the umbilicus or left upper quadrant via open (Hasson) technique • Achieve pneumoperitoneum slowly and progressively. Stop in case of hypotension, bradycardia or increased respiratory pressure • Insert additional ports based on site of injury • Upper abdomen: right and left flank • Suspected bowel injury: both ports at left upper and lower quadrant • Inspect the entire peritoneal cavity from right upper quadrant in a clockwise direction
- 11. • Stab woundsto be covered with occlusive dressings to prevent leak of pneumoperitoneum • Inspect supramesocolic compartment in reverse Trendelenberg position and rectum, colon, pelvic organs in Trendelenberg position • Small bowel run is made in retrograde direction from ICJ to DJ flexure, inspecting both sides of bowel and mesentery • Lesser sac should always be inspected in all penetrating trauma and blunt trauma with suspicion of post. wall stomach, pancreas or duodenal injury
- 12. Therapeutic laparoscopy Diaphragm: • Simplerepair with single stitches or continuous repair • Prosthetic non-absorbable mesh in delayed presentation Stomach: • Simple repair with or without omental patch • Major high grade injury – gastric resection or even total gastrectomy
- 13. Small bowel andmesenteric injury: • Small perforations – primarily repaired in single or double layer • Large defects – intra/extra-corporeal resection and anastomosis or stoma Colonic trauma: • Small perforations <1cm – simple primary repair • Larger injuries – resection and anastomosis or stoma diversion • Hartmann procedure • Perineal injury requiring colostomy Liver: • Hemostasis with figure of 8 stitches • Liver resection only in hepatic necrosis following trauma or angioembolization
- 14. Pancreatic injury: • GradeI and II injury, if found at laparoscopy – secure hemostasis, place drain • Grade III – distal pancreatectomy • Grade IV and V – usually unstable, not amenable to laparoscopy Laparoscopic Splenectomy: • Preferably in supine position in trauma (to be prepared for laparotomy) • After failed non-operative management or angioembolization • Associated spinal injuries requiring surgery in prone (risk of bleeding from splenic injury) • Hemostasis of splenic injury and splenorrhaphy can also be done in select cases
- 15. Gall bladder andbiliary tract: • Gall bladder injury – laparoscopic cholecystectomy • Laparoscopic treatment of biliary leak – only after ERCP or PTBD Bladder injury: • Laparoscopic repair with absorbable suture Mesenteric vascular injury: • Hemostasis with clips / hemolock / suturing • Overlying bowel, if gangrenous – resection and stoma Pediatric,Pregnant,Mentally Impaired Nephropathic trauma patients
- 16. Laparoscopy for delayedpresentation may reveal… • Diaphragm laceration with incarcerated hernias • Mesenteric injury with bowel ischemia • Expanding pancreatic hematoma or collections following traumatic pancreatitis • Hematomas and abdominal abscesses requiring drainage
- 17. Advantages of laparoscopy •Lower inflammation and trauma to tissues • Shorter hospital stay and early recovery • Less postoperative pain • Reduction in rate of non-therapeutic laparotomy (73%) • By O’Malley et al.Sensitivity 67-100%,Specificity 33-100%,Accuracy 50-100% in PAT • Only 2 RCT available • High diagnostic accuracy (especially for mesenteric and hollow viscus injuries)
- 18. • Better respiratoryfunction and early weaning from ventilator (especially in thoracic trauma patients) • Lower rate of adhesions, surgical site infections and incisional hernias • Faster recovery ,less costs. • Helps to diagnose occult injuries like small diaphragmatic tear, which could not be detected on CT • Provide a means to diagnose and treat patients with delayed presentation following trauma
- 19. Limitations • Limited rolein hemodynamically unstable patients • Possibility of missed injury, especially of hollow viscus perforations • Difficult to explore duodenal injuries laparoscopically • Laparotomy recommended in retroperitoneal injury with pulsatile or expanding hematoma • Ambiguous findings often leading to laparotomy • Trocar injury, air embolism, bowel injury, increase operative time, coagulopathy, hypothermia • Therapeutic laparoscopy depends on surgeon’s training and skills
- 20. Contraindications to laparoscopy •Severe hypovolemic shock (systolic pressure < 90 mmHg) • Severe cardiopulmonary dysfunction • Severe traumatic brain injury • Inability to tolerate pneumoperitoneum • Clear indication for immediate laparotomy such as frank peritonitis, hemorrhagic shock or evisceration
- 21. Relative contraindications tolaparoscopy • Posterior penetrating trauma with high likelihood of bowel injury • Known or obvious intra-abdominal injury with peritonitis and septicaemia • Impalement ,Retroperitoneal injuries • Gaseous distension,severe serious adhesions • COPD with severe hypercapnoea,causes toxic shock syndrome • Limited laparoscopic expertise
- 22. Diagnostic accuracy oflaparoscopy The sensitivity, specificity and diagnostic accuracy of laparoscopy to predict the need for laparotomy are high (75 – 100%) (Level I – III evidence)
- 23. Drawbacks • The impactof laparoscopic expertise on diagnostic accuracy has not been studied 1 • The sensitivity, specificity and number of missed injuries can be influenced by surgeon’s experience, hence difficult to provide firm recommendations 2
- 24. Recommendations • Diagnostic laparoscopyis safe and feasible in appropriately selected trauma patients (Grade B),Unclear abdomen, Equivocal CT Scan, Unclear source of bleeding,Unexplained fluid • Laparoscopy should be considered in hemodynamically stable blunt trauma patients • with suspected intra-abdominal injuries • equivocal findings on imaging • negative imaging but a high clinical suspicion (Grade C) • It is particularly helpful in penetrating abdominal trauma with documented or equivocal penetration of anterior fascia (Grade C)
- 25. Recommendations • Diagnostic laparoscopyshould be used in patients with suspected diaphragmatic injuries as it offers better diagnostic accuracy than imaging (Grade C) • A risk of missed injuries should be borne in mind and patients should be followed meticulously in the post-operative period. Therapeutic procedures can be performed whenever laparoscopic expertise is available. • The procedure should be incorporated into the institution’s algorithm for trauma management to optimize results
- 26. Confusing CT Scan •SB devascularization • Extra liminal contrast • Pneumoperitoneum • Focal wall defect • Free fluid,interbowel fluids • Hematoma • Hypo enhancement of bowel loop • Abrupt interruption of mesenteric vessels • Bowel wall thickening • Abnormal enhancement
- 27. Conduct of laparoscopy •10 mm umbilical trocar; 2 or more 5 mm trocars in left flank and suprapubic region • 4 quadrant evaluation for blood, bile, urine, fecal contamination • Examination of diaphragm and peritoneal surfaces • Examination of liver, spleen, small bowel along with mesentery, stomach, duodenum, colon and rectum • Exploration of lesser sac and pancreas as directed by CT imaging
- 28. Indications for conversionto laparotomy • Dense adhesions • Gross bowel distension • Major bleeding not amenable to • • laparoscopically • Injuries that are difficult to repair laparoscopically • Acute hemodynamic deterioration • Not confident to deal • Suspect missing injuries • Expanding haematoma
- 29. ALGORITHM FOR PENETRATINGTRAUMA STABLE HEMODYNAMICS UNSTABLE HEMODYNAMICS EXPLORATORY LAPAROTOMY DIAGNOSTIC LAPAROSCOPY THERAPEUTIC LAPAROSCOPY OBSERVATION PENETRATION OF ANTERIOR FASCIA LOCAL WOUND EXPLORATION NO PENETRATION OF ANTERIOR FASCIA ORGAN INJURY NO ORGAN INJURY
- 30. ALGORITHM FOR BLUNTTRAUMA STABLE HEMODYNAMICS UNSTABLE HEMODYNAMICS EXPLORATORY LAPAROTOMY FREE PERITONEAL FLUID SEAT BELT SIGNS DOUBTFUL PHYSICAL EXAM HOLLOW VISCUS INJURY SOLID ORGAN INJURY DIAGNOSTIC LAPAROSCOPY THERAPEUTIC LAPAROSCOPY OBSERVATION UNSTABLE STABLE
- 31. Our experience :CASE I 30/M, case of head on collision of truck with truck Brought to AIIMS-J emergency, 12 hours later Airway – patent Breathing – spontaneous, air entry diminished on left side, RR 22/min Circulation – Pulse: 120/min, BP: 112/74mmHg, Disability – GCS E4V5M6 Chest compression test +, Pelvic compression test – negative P/A: tenderness in right hypochondrium and lumbar region
- 32. Chest X-ray USG-FAST :positive HRCT chest and abdomen: - Lower 6-8 rib fractures on right side, left diaphragmatic tear with herniation of stomach and jejunal loops - Grade 4 liver laceration - Grade 3 renal injury
- 33. Intraoperative findings • Diagnosticlaparoscopy done. 200 ml hemoperitoneum drained. Defect in left hemidiaphragm, starting from left crus to 6 cm laterally Three gangrenous patches (1*1cm) over anterior wall of stomach
- 34. • Laparoscopic repairof diaphragmatic defect was performed • Laparoscopic modified Graham’s patch of all gangrenous patches over stomach done. • Lesser sac opened, no gangrenous patch over posterior wall of stomach • Patient recovered well postoperatively with adequate lung expansion
- 37.
- 38. CASE II 28/M, H/Ofall of heavy object over lower abdomen Patient was resuscitated and vitals stabilized Injuries sustained – Right acetabular fracture, left superior and inferior pubic rami fracture, fluid collection in pelvis Initially, patient was managed conservatively
- 39. Day 14 ofadmission, patient developed vomitings, abdominal distension, tenderness and obstipation CECT abdomen showed dilated small bowel loops (diameter of 4cm) with mesenteric fat stranding in pelvis Patient was taken up for diagnostic laparoscopy Mesenteric tear with bowel perforation identified in the pelvis -> converted to laparotomy
- 40. Adherent bowel loopsin pelvis
- 41. Intraoperative findings 10*8cm mesenterictear with overlying part of terminal ileum congested and perforated • Resection of perforated segment with double barrel ileostomy was made • A 2*1 cm perforation in the sigmoid colon was found, which was repaired primarily • Patient recovered well post- operatively and later underwent stoma closure, which was uneventful
- 42. CASE III 16/M, H/ORTA with injury to abdomen with bike handle O/E: Laceration of 5*3cm over epigastrium, fracture of both bones right forearm He was initially managed non-operatively. However, in view of increasing bilious discharge from the laceration, he underwent diagnostic laparoscopy with lavage and drainage of bilious peritoneal fluid
- 43. Intraoperative findings 500 mlof bilious collection with liver laceration of 3*4cm of right lobe lateral to falciform ligament Adhesions of liver and omentum to anterior abdominal wall
- 44. CASE IV 24/M, c/oRTA with blunt abdominal trauma Pulse 73/min, BP 99/53mmHg O/E: Abdominal distended, tenderness +, FAST positive CECT s/o jejunal perforation with ascites
- 45. Intraoperative findings Diagnostic laparoscopyperformed, however perforation could not be localized Conversion to laparotomy with primary repair of 5mm*5mm jejunal perforation done Postoperatively, patient recovered uneventfully
- 46. CASE V A 28/Mpresented 7 days after blunt trauma abdomen following slip from bike Pulse: 88/min; BP:110/76 mmHg O/E: abdomen distended and tender, FAST - positive CECT abdomen – s/o grade 3 liver injury with hemoperitoneum and suspected Gall bladder perforation
- 47. Intraoperative findings Diagnostic laparoscopywas performed, however no perforation could be identified due to dense adhesions Conversion to laparotomy was done followed by peritoneal lavage and placement of sub-hepatic drain Patient recovered well post-operatively
- 48. CASE VI A 25/M,presented with fall from bike Chest : B/L hemothorax +, for which B/L ICD was inserted, P/A : distended Pseudoaneurysm of thoracic aorta identified on CT, endovascular stenting of the same done However, 20 days following trauma, patient developed abdominal distension with tenderness, not resolving on non-operative management
- 49. Intraoperative findings • Diagnosticlaparoscopy revealed dense adhesions between bowel loops, liver and anterior abdominal wall • On conversion to laparotomy, following adhesiolysis and peritoneal lavage, a mesenteric rent of 6cm was identified and repaired. • An iatrogenic perforation of ileum (1*1mm) was repaired primarily
- 50. CASE VII Case ofbull horn injury with laceration over epigastrium Local wound exploration- peritoneal breach + CECT Abdomen was done (s/o thickening around the stomach) Day 2 of admission, Diagnostic Laparoscopy with repair of anterior wall stomach perforation However in view of unresolved distension, CECT Abdomen was repeated - collection in lesser sac Exploratory Laparotomy with repair of perforation in posterior wall stomach done
- 51. CASE VIII • C/ORTA with liver trauma; Diagnostic laparoscopy with peritoneal lavage of hemoperitoneum done Liver injury with hemoperitoneum Adhesions to wall and inter-bowel
- 52. CASE IX A 25/Mpresented with stab injury over abdomen Pulse – 107/min, BP-117/68 mmHg L/E: 3 x 1 cm stab wound over right iliac fossa with peritoneal breach Diagnostic laparoscopy revealed contamination and gross hemoperitoneum with bowel injury
- 53. • The procedurewas converted to laparotomy in view of contamination and to avoid any missed injury. • 3 perforations were identified at the antimesenteric border of ileum 180cm proximal to ICJ. This segment was resected and anastomosed. • Postoperatively, patient recovered well.
- 54. CASE X 20/M, H/Openetrating trauma to right lower abdomen due to metallic projectile while working at a steel factory C/O abdominal pain and bleeding from wound site O/E: PR 92/min, BP 94/54mmHg, responded to intravenous 1L warmed RL P/A: 3 x 2 cm penetrating wound in right iliac fossa with peritoneal breach
- 55. Intraoperative findings • Patientunderwent diagnostic laparoscopy, however had to be converted to laparotomy in view of gross hemoperitoneum and active bleeding.
- 56. Intraoperative findings • Atlaparotomy, a metallic foreign body from mesentery of terminal ileum removed and active bleeder (branch of ileocolic artery) was identified and ligated
- 57. CASE X 35/M, C/Openetrating trauma with metallic foreign body over left flank region O/E: 3 x 1 cm laceration over left flank region Diagnostic laparoscopy revealed no peritoneal breach.
- 58. CASE XI A 55/Mpresented with penetrating injury to abdomen by a metallic splinter O/E: Pulse 118/min, BP 106/70mmHg P/A: 2 x 1 cm laceration over left hypochondrium
- 59. • Diagnostic laparoscopyrevealed gross hemoperitoneum with active bleeding from omentum and free margin of left lobe of liver • On conversion to laparotomy, hemostasis was achieved and metallic splinter retrieved from lesser sac. • Post-operative recovery was uneventful.
- 61. CASE XII A 27/M,presented with history of stab injury to abdomen O/E: 3 x 2 cm stab wound over right iliac fossa Diagnostic laparoscopy revealed minimal blood at stab site in the peritoneal cavity. Bowel and mesentery normal.
- 62. Laparoscopy revealed bloodor bowel contents in peritoneal cavity
- 63. CASE XIII 23/F, H/Oassault with multiple stab injuries over chest, abdomen and right forearm 3 days back Airway – patent, Breathing – Air entry decreased on left chest-> ICD inserted Circulation – Pulse 140/min, BP 97/67mmHg FAST positive, CECT s/o left hemothorax and suspected ileal perforation with free fluid in abdomen
- 64. Intraoperative findings • Diagnosticlaparoscopy revealed inter-bowel adhesions with purulent fluid in the abdomen. However, no obvious injury identified • On conversion to laparotomy, a 5 x 5mm perforation identified 100cm distal to DJ flexure. • Primary repair of perforation done. • Post-operative recovery was uneventful.
- 65. CASE XIV 24/M, presentedwith complaints of stab injury over abdomen O/E: laceration of size 3 x 2 cm was found in left iliac fossa Diagnostic laparoscopy revealed peritoneal breach at the stab site, which was repaired. However, there was no bowel or mesenteric injury.
- 66. A summary ofour experience S.NO TRAUMA PRESENTATION ORGAN INJURED THERAPEUTIC LAPAROSCOPY REASON FOR CONVERSION 1 BLUNT IMMEDIATE DIAPHRAGM + STOMACH YES - 2 BLUNT DELAYED ILEUM + SIGMOID COLON NO NEED FOR RESECTION 3 PENETRATING DELAYED LIVER YES - 4 BLUNT IMMEDIATE JEJUNUM NO IDENTIFICATION OF PERFORATION 5 BLUNT DELAYED LIVER NO INABILITY TO IDENTIFY GB PERFORATION 6 BLUNT DELAYED MESENTERY NO DENSE ADHESIONS 7 PENETRATING IMMEDIATE + DELAYED STOMACH NO RE-EXPLORATION FOR POSTERIOR WALLOF STOMACH PERFORATION
- 67. S.NO TRAUMA PRESENTATIONORGAN INJURED THERAPEUTIC LAPAROSCOPY REASON FOR CONVERSION 8 BLUNT DELAYED LIVER YES - 9 PENETRATING IMMEDIATE SMALL BOWEL NO CONTAMINATION AND GROSS HEMOPERITONEUM 10 PENETRATING IMMEDIATE MESENTERY NO GROSS HEMOPERITONEUM WITH ACTIVE BLEEDING 11 PENETRATING IMMEDIATE NONE DIAG LAP - 12 PENETRATING IMMEDIATE LIVER AND OMENTUM NO ACTIVE BLEEDING AND GROSS HEMOPERITONEUM 13 PENETRATING IMMEDIATE SMALL BOWEL NO INABILITY TO IDENTIFY SITE OF INJURY 14 PENETRATING IMMEDIATE PERITONEAL BREACH, NO BOWEL OR MESENTERY INJURY DIAG LAP -
- 72. Randomized trial Diagnosis ofsignificant abdominal trauma after road traffic accidents: preliminary results of a multicentre clinical trial comparing minilaparoscopy with peritoneal lavage Cuschieri A, Hennessy TP, Stephens RB et al, Ann R Coll Surg Eng. 1988 May;70 (3): 153-5 “Minilaparoscopy may have a advantage over peritoneal lavage in reducing the number of unnecessary laparotomies”
- 73. Practice management guidelinesfor selective nonoperative management of penetrating abdominal trauma Como et al, J Trauma 2010, 68(3): 721-33 (guidelines : summary) “Laparoscopy may be selectively considered as a diagnostic tool in abdominal stab / penetrating wounds in reducing the number of unnecessary laparotomies”
- 74. Conclusion • Laparoscopy isan useful tool for diagnosis of traumatic injury when the diagnosis is unclear • Management of some traumatic injuries can be carried out completely via laparoscopy or through a limited incision • The main prerequisite for successful laparoscopy in trauma is the hemodynamic stability of the patient. Trained Surgeon and Equipped setting • Risks are there if surgeon has limited experience, misses the injury, Wrong selection of patient.
- 75. Expanding horizons…. • Explicitsurgical training for laparoscopy in emergent trauma settings • Development of guidelines for selection of appropriate patients for laparoscopy following trauma • Efficient resuscitation facilitates effective minimally invasive management, so never forget to strengthen the grassroots.
- 76.
Editor's Notes
- #18 Reference : Trauma laparoscopy and the six w's: Why, where, who, when, what, and how? By Salomone Di Saverio et al, J Trauma Acute Care Surg Volume 86, Number 2