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SEATTLE -- Laparoscopy can be a safe and effective alternative to laparotomy for the management of penetrating abdominal injury, a researcher reported here.
In a group of 56 patients who initially underwent minimally invasive laparoscopy to quickly assess intra-abdominal organ injury, only 17.9% had to be converted to laparotomy for treatment, according to Kevin Bain, DO, of NYU Langone Hospital in Brooklyn, N.Y.
Laparotomy has traditionally been viewed as the gold standard for managing patients with penetrating abdominal injuries. However, exploratory laparotomy for these injuries has had failure rates of up to 61%.
As laparoscopy has become the standard of care in other surgical fields, its utility in trauma has increasingly been investigated. Initially it was criticized for having rates of missed injuries as high as 13%, but with advances in technology and surgical experience, those rates have dropped to 0.12%, Bain said.
To analyze the overall safety and efficacy of using laparoscopy as a first-line therapy for hemodynamically stable patients with penetrating intra-abdominal injury, he and his colleagues conducted a retrospective review of cases seen at their level 1 trauma center from 2006 to 2016.
For the analysis, they divided their 56 patients into three groups: those who had diagnostic laparoscopy to screen for peritoneal violation but no injuries were identified or those identified were not considered as needing repair; those who had diagnostic laparoscopy and proceeded to therapeutic laparoscopy for injury repair; and those with diagnostic laparoscopy who required conversion to exploratory laparotomy.
Patient characteristics included mean age of 40 years, mean Glasgow coma score of 14, and mean injury severity score of 4. Causes of injury included stab and gunshot wounds in 48 and eight patients, respectively.
The procedure itself began with port placement and assessment of the abdominal cavity, quickly controlling any abdominal bleeding. The surgeon then performed a stepwise examination of the intraperitoneal and retroperitoneal organs, and once an injury was identified, the decision on therapeutic intervention (via laparoscopy or laparotomy) was made.
They also defined criteria that could help optimize results, with the first being surgeon experience, but the type of injury also was considered. For instance, small bowel and retroperitoneal organ injuries can be very difficult to manage even in the hands of a skilled laparoscopist, so careful consideration must be given to whether to proceed laparoscopically or to proceed to laparotonomy, Bain cautioned.
In his series, only 10 patients required conversion to laparotomy, while 13 underwent therapeutic laparoscopy, with organ repair, and 33 patients had diagnostic laparoscopy alone. "This is important because a nontherapeutic laparotomy was avoided in these 33 patients for a nontherapeutic rate of 58.9%," he said.
Mean length of stay in the hospital was four days for those who had diagnostic laparoscopy alone, three days for those who had therapeutic laparoscopy, and six days for those who had exploratory laparotomy.
With regard to postoperative complications, in the diagnostic laparoscopy group there was one case of hospital-acquired pneumonia and one postoperative ileus that required prolonged NPO status, he reported. In the conversion to laparotomy group, a patient had a deep surgical site infection which necessitated a return to the operating room.
"Of note, in all three groups there were no missed injuries and no deaths," he said.
"Overall, our study adds to the body of literature that shows laparoscopy can be safely and effectively utilized in patients with penetrating abdominal trauma. Diagnostic laparoscopy can be converted to therapeutic laparoscopy in the hands of a skilled surgeon, and laparoscopy can be converted to laparotomy if needed without delay," he said.