Use of Laparoscopy in Trauma at a Level II Trauma Center.

2011·0.17 MB·English

by  Barzana, Daniel C.

S P
CIENTIFIC APER
Use of Laparoscopy in Trauma at a Level II
Trauma Center
Daniel C. Barzana, DO, Cyrus A. Kotwall, MD, Thomas V. Clancy, MD, William W. Hope, MD
ABSTRACT INTRODUCTION
Background and Objectives: Enthusiasm for the use of The use of laparoscopy in general surgery has expanded
laparoscopy in trauma has not rivaled that for general since the introduction and widespread adoption of the
surgery. The purpose of this study was to evaluate our laparoscopiccholecystectomy.Laparoscopyhasbeenap-
experience with laparoscopy at a level II trauma center. plied to most abdominal surgical procedures and has
become the standard of care for appendectomy, adrenal-
Methods: A retrospective review of all trauma patients
ectomy,cholecystectomy,andsplenectomy;however,the
undergoing diagnostic or therapeutic laparoscopy was
useoflaparoscopyfortraumapatientshasbeenslowerto
performed from January 2004 to July 2010.
evolve partly due to factors inherent in the trauma popu-
Results: Laparoscopy was performed in 16 patients dur- lationandsomelimitationsofthelaparoscopictechnique.
ing the study period. The average age was 35 years.
Injuries included left diaphragm in 4 patients, mesenteric Initially,theevaluationofperitonealviolationinhemody-
injury in 2, and vaginal laceration, liver laceration, small namically stable patients was seen as the greatest benefit
bowel injury, renal laceration, urethral/pelvic, and colon of laparoscopy for trauma.1,2 Improvements in laparo-
injury in 1 patient each. Diagnostic laparoscopy was per- scopic training and technology have enabled an increase
formed in 11 patients (69%) with 3 patients requiring in the use of diagnostic and therapeutic procedures in
conversion to an open procedure. Successful therapeutic trauma patients.
laparoscopy was performed in 5 patients for repair of
isolated diaphragm injuries (2), a small bowel injury, a The purpose of this study was to evaluate the use of
coloninjury,andplacementofasuprapubicbladdercath- diagnostic and therapeutic laparoscopy at a Level II
eter.Averagelengthofstaywas5.6days(range,0to23), trauma center and to gain a better understanding of the
and75%ofpatientsweredischargedhome.Morbidityrate subset of patients who may benefit from these proce-
was 13% with no mortalities or missed injuries. dures.
Conclusions: Laparoscopy is a seldom-used modality at
ourtraumacenter;however,itmayplayaroleinaselect
METHODS
subset of patients.
A retrospective review of all trauma patients undergoing
Key Words: Laparoscopy, Trauma, Therapeutic, Diag-
diagnostic or therapeutic laparoscopy was performed at
nostic.
NewHanoverRegionalMedicalCenterfromJanuary2004
toJuly2010followinginstitutionalreviewboardapproval.
Our Level II trauma center services Southeastern North
Carolina and has over 1400 admissions annually. The
majorityofadmissionsresultfromblunttrauma,including
motor vehicle crashes (41%) and falls (33%) with pene-
trating trauma (14%) representing a smaller volume. Our
trauma program is staffed by 8 general surgeons who
SouthEastAreaHealthEducationCenter,DepartmentofSurgery,NewHanover
RegionalMedicalCenter,Wilmington,NorthCarolina,USA(allauthors). serve as faculty for our general surgery residency pro-
Addresscorrespondenceto:WilliamW.Hope,MD,AssistantProfessor,Depart- gram. Operations were performed with the trauma/gen-
mentofSurgery,NewHanoverRegionalMedicalCenter,2131South17thStreet, eral surgery personnel available or on call and not a
POBox9025,Wilmington,NorthCarolina28401,USA.Telephone:[phone]
specificdedicatedlaparoscopicteam.Demographicinfor-
ext233,Fax:[phone],E-mail:[email protected]
mation, mechanism and type of injury, operative details,
DOI:10.4293/108680811X13071180406358
and outcomes were documented. Descriptive statistics
©2011byJSLS,JournaloftheSocietyofLaparoendoscopicSurgeons.Publishedby
theSocietyofLaparoendoscopicSurgeons,Inc. were calculated using standard methods.
JSLS(2011)15:179–181 179
UseofLaparoscopyinTraumaataLevelIITraumaCenter,BarzanaDCetal.
RESULTS eter. Overall mean operating room time was 91 minutes
(range, 29 to 200). The average operating room time for
Laparoscopy was performed in 16 patients during the
the 5 therapeutic cases was 129 minutes. Average length
study period. The average age was 35 years (range, 16 to
of stay was 5.6 days (range, 0 to 23), and 75% of patients
55) with the majority of patients being Caucasian (69%)
were discharged home. One patient, who underwent a
andmale(75%).Themostcommonmechanismsofinjury
laparoscopic-assistedsuprapubiccatheterplacement,was
werestabwoundsandmotorvehiclecrashes(Figure1).
subsequently transferred to a Level 1 trauma center for
Computed tomography scanning was used for diagnosis
definitive management of an unstable pelvic fracture.
in 81% of patients. Injuries included left diaphragm rup-
Morbidity and mortality rates were 13% and 0, respec-
ture (4), mesenteric injury (2), and singular lacerations to
tively. The 2 complications, unrelated to the surgical pro-
the vagina, liver, small bowel, kidney, urethra, and colon
cedures, were pneumonia (1) and postoperative respira-
(6).Diagnosticlaparoscopywasperformedin11patients
toryfailurerequiringtracheostomy(1).Thelatteroccurred
(69%) with 3 patients requiring conversion to an open
inapatientwhohadsufferedsignificantleftchesttrauma
procedure. Successful therapeutic laparoscopy was per-
with flail chest and pulmonary contusion. No patients
formed in 5 patients for repair of isolated injuries to the
who underwent diagnostic laparoscopy had missed inju-
diaphragm (2), small bowel (Figure 2), colon, and for
ries;however,onepatientwhohadanegativediagnostic
assistance with placement of a suprapubic bladder cath-
laparoscopy for suspected small bowel injury ultimately
underwentapartialnephrectomyforpersistentfeverwith
urinary extravasation despite stent placement.
DISCUSSION
Accurate diagnosis of abdominal injuries in patients with
traumatictorsoinjuryremainschallenging.Severalmodal-
ities are available to assist in assessing intraabdominal
injuries, which range from noninvasive methods, such as
hemodynamic monitoring, physical examination, and im-
agingstudies,tomoreinvasivemethods,suchasparacen-
tesis, diagnostic peritoneal lavage, diagnostic laparos-
copy,andultimatelyexploratorylaparotomy.3Theroleof
laparoscopy in trauma has not paralleled the popularity
Figure 1. Mechanisms of injuries for patients undergoing lapa- for general surgery for several reasons, including the
roscopy. emergent nature of many of the operations, the lack of
expertise and comfort level of surgeons, the added time
forequipmentsetup,thedifficultyassessingtheretroperi-
toneum, and the fear of missed injuries.3
Ivatury et al4 was among the first to define the role of
laparoscopy in trauma. In his prospective study of 100
patients, he reported that laparoscopy was accurate for
the detection of hemoperitoneum, solid organ injuries,
diaphragmatic lacerations, and retroperitoneal hemato-
mas; however, it had a low sensitivity for gastrointestinal
injuries and he concluded that the major role of laparos-
copy in patients with penetrating abdominal trauma was
intheavoidanceofunnecessarylaparotomiesandineval-
uation of the diaphragm.4 Since that time, concern has
remained about the use of laparoscopy for the detection
of bowel injuries; however, with improvements in tech-
Figure 2. Laparoscopic closure of small bowel enterotomy in nology and surgeons’ skill, some of these concerns are
blunttraumafromamotorvehiclecrash. waning. Kawahar and colleagues5 recently reported that
180 JSLS(2011)15:179–181
with a standard examination protocol for laparoscopic suprapubicbladdercatheterplacementinapatientwitha
exploration,detectionofsmallbowelinjuriesinpenetrat- large pelvic hematoma from an extensive pelvic fracture,
ing trauma may be minimized to zero, as they noted in atechniquethattoourknowledgehasnotbeendescribed
their series. inthetraumaliterature.Despiteafairamountofliterature
on diagnostic laparoscopy for trauma, very few reports
The current investigation demonstrated no missed inju-
exist on therapeutic laparoscopy for traumatic bowel in-
ries, bowel or otherwise, when laparoscopic evaluations
jurieswithmostbeingcasereportsorsmallcaseseries.5–7
wereundertaken.Threeofthepatientsintheserieshadto
All of the 5 therapeutic laparoscopic procedures have
have their case converted to an open operation. Reasons
occurredinthelast2years.Thismayberelatedtoadding
forconversionincludedsurgeonpreferencein2casesand
a fellowship-trained laparoscopic surgeon who is in-
patient inability to tolerate pneumoperitoneum in the
volved with the trauma program to the faculty and in-
third.Onepatientwhounderwentdiagnosticlaparoscopy
creasedawarenessofthepotentialroleforlaparoscopyin
to evaluate a possible small bowel/colon injury returned
trauma.
totheoperatingroomtoundergopartialnephrectomyfor
failure of nonoperative management of a right kidney
CONCLUSION
laceration.
Althoughoursmallseriesshowslaparoscopytobeasafe
Overall, our experience with laparoscopy in trauma pa-
and effective diagnostic and therapeutic tool, particularly
tients remains somewhat limited with the most common
in patients with isolated bowel and diaphragm injuries, it
indication being the evaluation of stab wounds. Whether
must be used judiciously and by surgeons with expertise
our results can be generalized to other trauma centers or
in advanced laparoscopic techniques. The complications
surgeonstakingcareoftraumaremainsunknownsecond-
of a missed injury by inadequate surgical exploration are
ary to our small sample size and our model of having
much greater than the potential benefits of laparoscopy.
general/laparoscopicsurgeonstakingtraumacall.If,how-
Surgeons should not hesitate to convert to an open oper-
ever, trauma centers or surgeons have the laparoscopic
ation if there is concern that an adequate examination of
expertiseandexperience,thereisnoreasonwhylaparos-
the peritoneal cavity cannot be achieved.
copy should not be part of the treatment armamentarium
for both the diagnosis and possible therapy of select
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JSLS(2011)15:179–181 181