International Journal of Surgery 34 (2016) 127e136

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International Journal of Surgery

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Review

Laparoscopy versus laparotomy for the management of penetrating

abdominal trauma: A systematic review and meta-analysis
Shahin Hajibandeh a, *, 1, Shahab Hajibandeh b, 1, Ashutosh O. Gumber a,
Chee Siong Wong a
a
General Surgery Department, Blackpool Victoria Hospital, Blackpool, UK
b
General Surgery Department, Queen's Medical Centre, Nottingham, UK

h i g h l i g h t s

Laparoscopic evaluation of haemodynamically stable patients with PAT is safe and can reduce post-operative complications.

It is associated with a very low missed injury rate as reflected by its high sensitivity.

The most important advantage of laparoscopy is avoidance of non-therapeutic laparotomies.

The best available evidence comes mainly from heterogeneous observational studies.

High level evidence from well-designed RCTs are indeed required to facilitate more reliable meta-analysis.

a r t i c l e i n f o a b s t r a c t

Article history:
Background: Controversy exists regarding the role of laparoscopy in the evaluation of patients with
Received 8 May 2016
penetrating abdominal trauma (PAT). Our objective was to perform a comprehensive review of the
Received in revised form
21 August 2016 literature and conduct a meta-analysis to compare outcomes of laparoscopy and laparotomy in PAT.
Accepted 24 August 2016 Methods: In accordance with Preferred Reporting Items for Systematic Reviews and Meta-Analyses
Available online 26 August 2016 (PRISMA) statement standards, we conducted a systematic search of electronic information sources,
including MEDLINE; EMBASE; CINAHL; the Cochrane Central Register of Controlled Trials (CENTRAL); the
Keywords: World Health Organization International Clinical Trials Registry; ClinicalTrials.gov; ISRCTN Register, and
Penetrating abdominal trauma bibliographic reference lists. We applied a combination of free text and controlled vocabulary search
Laparoscopy adapted to thesaurus headings, search operators and limits in each of the above databases. Missed injury,
Laparotomy mortality, and complications were defined as the primary outcome parameters. Procedure time, length of
hospital stay, sensitivity and specificity of the procedure were the secondary outcomes. Combined overall
effect sizes were calculated using fixed-effect or random-effects models.
Results: We identified one randomised controlled trial (RCT) and 8 observational studies comparing
outcomes of laparoscopy with laparotomy in PAT. Laparoscopy was associated with a significantly lower
risk of wound infection (Odd ratio (OR): 0.55; 95% Confidence interval (CI), 0.37e0.81, P ¼ 0.003) and
pneumonia (OR: 0.22; 95% CI, 0.13e0.37, P < 0.00001), and a significantly shorter length of hospital stay
(Mean difference (MD): 3.05; 95% CI, 4.68 to 1.42, P ¼ 0.0002) and procedure time (MD: 27.99;
95% CI, 43.17 to 12.80, P ¼ 0.0003) compared with laparotomy. Laparoscopy was 100% sensitive in
most of the included studies and avoided non-therapeutic laparotomies in 45.6% of patients.
Conclusions: Our analysis of best available evidence mainly from heterogeneous observational studies
has demonstrated that laparoscopic evaluation of haemodynamically stable patients with PAT may be
safe and can reduce post-operative complications and length of hospital stay. The most important
advantage of laparoscopy is avoidance of non-therapeutic laparotomies which are associated with

* Corresponding author.
E-mail address: shahin_hajibandeh@yahoo.com (S. Hajibandeh).
1
Shahin Hajibandeh and Shahab Hajibandeh equally contributed to this paper
and joined first authorship is proposed.

http://dx.doi.org/10.1016/j.ijsu.2016.08.524
1743-9191/Crown Copyright © 2016 Published by Elsevier Ltd on behalf of IJS Publishing Group Ltd. All rights reserved.
128 S. Hajibandeh et al. / International Journal of Surgery 34 (2016) 127e136
considerable morbidity. However, no definitive conclusion can be made regarding the therapeutic role of
laparoscopy in PAT based on the available evidence and future research is indeed required.
Crown Copyright © 2016 Published by Elsevier Ltd on behalf of IJS Publishing Group Ltd. All rights
1. Introduction
Exploratory laparotomy has traditionally been the most popular
procedure for a definite evaluation of patients with penetrating
abdominal trauma (PAT) [1]. Mandatory surgical intervention for
PAT has been associated with a non-therapeutic laparotomy rate of
up to 61% [2e5] due to the absence of peritoneal penetration or the
presence of peritoneal penetration with no visceral injuries. How-
ever, the morbidity of non-therapeutic laparotomy can be as high as
33.3% and is related to pulmonary problems, wound infections,
postoperative ileus, and ventral hernia [3,6].
The ability of various diagnostic modalities, including local
wound exploration, diagnostic peritoneal lavage (DPL), abdominal
sonography, and computed tomography (CT) to determine the
presence and severity of intra-abdominal injuries caused by PAT is
controversial [7,8]. Diagnostic laparoscopy, which offers simulta-
neous therapeutic interventions, has been increasingly used in the
evaluation of patients with PAT [9]. A successful diagnostic lapa-
roscopy must identify all trauma induced injuries as effectively as
other diagnostic modalities, and a successful therapeutic laparos-
copy must allow complete repair of all the identified injuries [9].
The use of diagnostic laparoscopy in trauma initially led to a high
rate of missed injuries (41e77%), particularly small bowel injuries
[10].
A recent systematic review and meta-analysis compared the
outcomes of laparoscopy and laparotomy for the management of
abdominal trauma [11]. However, serious concerns on the meth-
odology of this study have been raised [12]. The authors included
studies investigating the outcomes of both blunt and penetrating
abdominal trauma; however, no sub-group analysis was conducted.
Moreover, data from some of the included studies has not been
extracted accurately. Most importantly, a large number of their
included studies were not indexed in the well-recognised elec-
tronic databases and their full texts are not available; therefore, the
methodological quality of those studies cannot be assessed. Finally,
the authors missed some important studies indexed in the well-
recognised databases.
To our knowledge, a review and meta-analysis focusing specif-
ically on comparison of outcomes of laparoscopy and laparotomy in
patients with PAT has not been previously undertaken. Our objec-
tive was to perform a comprehensive review of the literature and
conduct a meta-analysis to compare outcomes of laparoscopy and
laparotomy for the management of PAT.
2. Methods
2.1. Design and study selection
The criteria for study selection, methods of analysis, and
investigated outcomes were pre-specified and documented in a
review protocol. The review conformed to the Preferred Reporting
Items for Systematic Reviews and Meta-Analyses (PRISMA) state-
ment standards [13].
We planned to select randomised controlled trials (RCT) and
observational studies comparing the outcomes of laparoscopy and
laparotomy in patients with PAT. A PAT was defined as any
reserved.
penetrating injury to the abdomen or flank caused by gun pallet,
knife, fractured ribs, or any other sharp weapon. Patients aged 16
years or older and of any gender undergoing diagnostic or thera-
peutic laparoscopy and laparotomy for PAT were considered.
The intervention of interest was diagnostic or therapeutic lap-
aroscopy. Laparoscopy was defined as a surgical procedure in which
a laparoscope is used through the abdominal wall with the aim of
visualising the pelvic and abdominal cavities to diagnose or treat an
underlying trauma induced visceral injury. The primary interven-
tion was compared with laparotomy.
Primary outcome parameters were defined as missed injury,
perioperative mortality, and perioperative complications including
wound infection, abscess formation, small bowel obstruction or
ileus, pneumonia, and thromboembolism. Procedure time, length
of hospital stay, re-exploration, readmission, and sensitivity and
specificity of the procedure were defined as the secondary outcome
parameters.
2.2. Literature search strategy
Two authors (SH and AG) independently searched the following
electronic databases: MEDLINE, EMBASE, CINAHL, and the
Cochrane Central Register of Controlled Trials (CENTRAL). The last
search was run on 16 April 2016. The search strategy, which was
adapted according to thesaurus headings, search operators and
limits in each of the above databases, is outlined in Appendix 1. In
addition, the following trial databases were searched for ongoing
and unpublished studies: World Health Organization International
Clinical Trials Registry http://apps.who.int/trialsearch/,
ClinicalTrials.gov http://clinicaltrials.gov/, and ISRCTN Register
http://www.isrctn.com/. We searched the bibliographic lists of
relevant articles and reviews for further potentially eligible trials.
2.3. Selection of studies
Two authors (SH and CSW) independently assessed the title and
abstract of articles identified through literature searches. The full-
texts of relevant reports were retrieved and those articles that
met the eligibility criteria of our review were selected. We resolved
discrepancies in study selection by discussion between the review
authors. An independent third review author (SH) was consulted in
the event of disagreement.
2.4. Data extraction and management
We created an electronic data extraction spreadsheet in line
with the Cochrane's data collection form for intervention reviews.
We pilot-tested the spreadsheet in randomly selected articles and
adjusted it accordingly. Our data extraction spreadsheet included
the following information:

Study-related data (first author, year of publication, country of
origin of the corresponding author, journal in which the study
was published, study design, study size, clinical condition of the
study participants, and type of intervention)
 S. Hajibandeh et al. / International Journal of Surgery 34 (2016) 127e136

Baseline demographic and clinical information of the study
populations (age, the injury severity score (ISS), the new ISS
(NISS), abdominal abbreviated injury scale (AIS) score/abdom-
inal trauma index (ATI) score, haemodynamic status, and the
injured viscera)

Number of true positives (TP) defined as a patient with organ
injury and positive laparoscopy, false positives (FP) defined as a
patient without organ injury that was perceived to have organ
injury by laparoscopy incorrectly, true negatives (TN) defined as
a patient without organ injury and negative laparoscopy, and
false negatives (FN) defined as a patient with organ injury that
was perceived to have negative laparoscopy incorrectly

Primary and secondary outcome data
Two authors (SH and AG) independently collected and recorded
data in the data extraction spreadsheet. Disagreements were
resolved by discussion. If no agreement could be reached, a third
author (SH) was consulted.
2.5. Assessment of risk of bias
The methodological quality and risk of bias of the included ar-
ticles were assessed independently by two authors (SH and CSW).
We used the Cochrane's tool [13] and the Newcastle-Ottawa scale
(NOS) [14] for assessing the risk of bias of randomised trials and
observational studies, respectively. The Cochrane's tool assesses the
following domains: selection bias, performance bias, detection bias,
attrition bias, reporting bias, and other sources of bias and, for each
individual domain, classifies studies into low, unclear, or high risk
of bias. The NOS uses a star system with a maximum of nine stars to
evaluate a study in three domains: the selection of the study
groups, the comparability of the groups, and the ascertainment of
outcome of interest. We judged studies that received a score of nine
stars to be at low risk of bias, studies that scored seven or eight stars
to be at medium risk, and those that scored six or less to be at high
risk of bias. We resolved disagreements by discussion between the
two assessing authors. If no agreement could be reached, a third
reviewer (SH) acted as an adjudicator.
2.6. Summary measures and synthesis
For dichotomous outcome variables we calculated the risk dif-
ference (RD) (when more than three studies had zero events in both
laparoscopy and laparotomy groups) or odds ratio (OR) as the
summary measures. The RD is the difference in risk of an adverse
event in the laparoscopic group compared to the laparotomy group.
The OR is the odds of an adverse event in the laparoscopic group
compared to the laparotomy group. An OR of less than one would
favour the laparoscopic group compared to the laparotomy group.
For continuous parameters we calculated the mean difference (MD)
between the laparoscopy and laparotomy groups.
We used the individual patient as the unit of analysis. We
recorded information about dropouts, withdrawals and other
missing data and, if not reported, we contacted the study authors.
The final analysis was based on intention-to-treat data from the
individual clinical studies where possible.
We used the Review Manager 5.3 software for data synthesis
[14]. The extracted data were entered into Review Manager by the
first independent author (SH) and checked by a second indepen-
dent author (SH). We used random-effects or fixed-effect model-
ling, as appropriate, for analysis. We applied random-effects
models if considerable heterogeneity among the studies, as defined
by Higgins et al., [13] was identified. The results were reported in a
forest plot with 95% confidence intervals (CIs).
Heterogeneity among the studies was assessed using the
129
Cochran Q test (c2). We quantified inconsistency by calculating I2
and interpreted it using the following guide [13]: 0%e25% might
not be important; 25%e75%: may represent moderate heteroge-
neity; 75%e100% may represent substantial heterogeneity. We
planned to use the Comprehensive Meta-Analysis (CMA) software
(Biostat, Englewood, NJ) to calculate the Egger's regression inter-
cept to formally assess reporting bias in our review. Also, we
planned to construct funnel plots and evaluate their symmetry to
visually assess publication bias, as long as a sufficient number of
studies (more than 10) were available.
Additional analyses were planned to explore potential sources
of heterogeneity and assess the robustness of our results. For each
outcome, we repeated the primary analysis using random-effects or
fixed-effect models. In addition, we calculated the pooled OR, risk
ratio (RR), or RD for each dichotomous variable. We assessed the
effect of each study on the overall effect size and heterogeneity by
repeating the analysis after removing one study at a time.
3. Results
Literature searches via the databases identified 2513 articles.
Following screening retrieved titles or abstracts and after assessing
the full texts of relevant reports, 9 articles [1523] were selected
for analysis (Fig. 1). These included 1 RCT, 2 prospective cohort
studies, and 6 retrospective cohort studies, reporting a total of 3362
patients, of whom 1604 patients underwent laparoscopy and the
remaining 1758 patients underwent laparotomy for PAT. Conver-
sion from laparoscopy to laparotomy happened in 442 (27.6%) pa-
tients (Table 1).
Baseline demographic and clinical characteristics of the study
populations are outlined in Table 2. All studies, except one, included
only haemodynamically stable patients. In fact, one study included
patients with mild (50.7%), moderate (24.7%), and severe (15.9%)
shock in addition to patients with stable hemodynamic status
(8.7%). Five studies reported the ISS of their laparoscopy and lapa-
rotomy groups of which 4 studies reported similar ISS between
both groups. The new ISS and abdominal AIS or ATI were poorly
reported by the included studies (Table 3).
Five studies [15e18,20] provided data regarding the injured
viscera after PAT. The small intestine, spleen, liver, colon, and
mesentery were the 5 most common injured organs (Fig. 2).
3.1. Methodological appraisal
The methodological appraisal of the 8 observational studies is
presented in Supplementary Table 1. The risk of bias was low in 3
studies [15e17] and moderate in 4 [18,19,21e23]. Supplementary
Table 2 presents the risk of bias assessment of the included RCT
[20].
3.2. Laparoscopy versus laparotomy
Outcomes are summarised in Figs. 2e4.
3.2.1. Missed injury
All included studies [15e23] (3362 patients) reported missed
injury as an outcome (see Fig. 5). Only 3 missed injuries were re-
ported, 2 in the laparoscopic group and one in the laparotomy
group. The pooled analysis did not find a significant difference
between both groups (0.12% vs 0.06%, RD: 0.00; 95% CI, 0.00e0.00,
P ¼ 0.99). Low heterogeneity among the studies existed (I2 ¼ 0%,
P ¼ 0.94).
3.2.2. Mortality
This outcome was evaluated by all included studies [15e23].
130 S. Hajibandeh et al. / International Journal of Surgery 34 (2016) 127e136

There were 118 deaths in the laparoscopy group and 205 deaths in
the laparotomy group. Our pooled analysis of 3362 patients did not
find a significant reduction in mortality associated with either
groups (7.35% vs 11.66%, RD: 0.02; 95% CI, 0.05e0.01, P ¼ 0.23).
Heterogeneity among the analysed studies was moderate (I2 ¼ 72%,
P ¼ 0.0003).

3.2.3. Wound infection

All studies [15e23] investigated this outcome as a perioperative
complication. A total of 108 wound infections were reported, 38 in
the laparoscopy group and 70 in the laparotomy group. The pooled
analysis of 3362 patients demonstrated that laparoscopy signifi-
cantly reduced the risk of wound infection compared to laparotomy
(2.37% vs 3.98%, OR: 0.55; 95% CI, 0.37e0.81, P ¼ 0.003). Moderate
between-study heterogeneity was identified (I2 ¼ 38%, P ¼ 0.17).

3.2.4. Abscess
The pooled analysis included 667 patients from 8 studies
[15e17,19e23]. Three patients developed abscesses after laparos-
copy, whereas only one patient in the laparotomy group developed
an intra-abdominal abscess. No significant difference in favour of
either intervention was identified (1.10% vs 0.25%, RD: 0.00; 95%
CI, 0.02e0.02, P ¼ 0.85). Heterogeneity among the analysed
studies was low (I2 ¼ 0%, P ¼ 0.98).

3.2.5. Pneumonia
Eight studies [15e18,20e23] (3186 patients) investigated
pneumonia as an outcome. Ninety four patients developed pneu-
monia, 16 in the laparoscopy group and 78 in the laparotomy group.
Laparoscopy was associated with a significantly lower incidence of
pneumonia (1.01% vs 4.86%, OR: 0.22; 95% CI, 0.13e0.37,
P < 0.00001). Low heterogeneity among the studies existed
(I2 ¼ 0%, P ¼ 1.00).

3.2.6. Length of stay

All studies [15e23] reported the length of hospital stay as an
outcome. However, only 6 studies (2937 patients) were included in
the pooled analysis as 3 studies [15,19,22] did not provide the
standard deviation of the mean. Laparoscopy was associated with
significantly shorter length of stay (4.93 days vs 7.98 days,
MD: 3.05; 95% CI, 4.68 to 1.42, P¼0.0002). Substantial het-
erogeneity among the analysed studies was detected (I2¼99%,
P < 0.00001). All of the 3 studies which were not included in the
analysis reported significantly shorter length of stay in their lapa-
roscopy group.

3.2.7. Procedure time

Three studies [16,17,23] reported mean procedure time. The
pooled analysis of 171 patients showed that laparoscopy was
associated with a significantly shorter procedure time than lapa-
rotomy (52.02 min vs 80.19 min, MD: 27.99; 95% CI, 43.17
to 12.80, P¼.0003). Heterogeneity among the studies was sub-
stantial (I2¼88%, P ¼ 0.0002).
The included studies did not report analysable data on small
bowel obstruction or ileus, thromboembolism, re-exploration, and
readmission.

3.2.8. Sensitivity and specificity

The sensitivity of laparoscopy was 100% in all of the included
studies, except Karateke et al. [16] in which the sensitivity was 92%
because of 2 missed injuries (FN ¼ 2). The specificity was 100% in 5
of the included studies. The lowest specificity associated with
laparoscopy was reported by DeMaria et al. [21] (74%, FP ¼ 6).
Moreover, Cherkasov et al. [18], Leppa €niemi et al. [20], and Marks
Fig. 1. Study flow diagram. et al. [23] reported the specificity of 88%, 92%, and 93%, respectively,
 S. Hajibandeh et al. / International Journal of Surgery 34 (2016) 127e136 131

Table 1
Summary characteristics of included studies.

Author Year Country Journal Type of study

Chestovich [15] 2015 USA J Trauma Acute Care Surg Retrospective observational study
Karateke [16] 2013 Turkey Ulus Travma Acil Cerrahi Derg Prospective observational study
Lin [17] 2010 Taiwan World J Surg Retrospective observational study
Cherkasov [18] 2008 Russia Surg Endosc Retrospective observational study
Miles [19] 2004 USA JSLS Retrospective observational study
Leppa€niemi [20] 2003 Finland J Trauma Randomised controlled trial
DeMaria [21] 2000 USA J Laparoendosc Adv Surg Tech A Prospective observational study
Mutter [22] 1997 France Dig Surg Retrospective observational study
Marks [23] 1997 USA Surg Endosc Retrospective observational study

Table 2
Number of patients.

Author Number of patients Laparotomy Laparoscopy Conversion to open

Chestovich [15] 188 94 94 44 (46.8%)

Karateke [16] 52 26 26 1 (3.8%)
Lin [17] 86 38 48 1 (2.1%)
Cherkasov [18] 2695 1363 1332 356 (26.7%)
Miles [19] 176 154 22 9 (41.0%)
Leppa€niemi [20] 43 23 20 9 (45.0%)
DeMaria [21] 54 23 31 14 (45.1%)
Mutter [22] 35 18 17 4 (23.6%)
Marks [23] 33 19 14 4 (28.6%)

Total 3362 1758 1604 442 (27.6%)

Table 3
Baseline demographic and clinical characteristics.

Author Agea ISSa New ISSa Abdominal AIS/ATIa Haemodynamically

stablea

Chestovich [15] 31 vs 28 P ¼ 0.438 1.00 vs 1.00 P ¼ 0.798 1.00 vs 1.00 P ¼ 0.578 1.00 vs 1.00 P ¼ 0.231 95.6% vs 100% P ¼ 0.155
Karateke [16] 35.2 ± 10.6 vs 33.2 ± 9,2 P ¼ 0.512 NR NR NR 100% vs 100%
Lin [17] 43.8 ± 11.6 vs 41.1 ± 14.3 P ¼ 0.408 5.7 ± 5.0 vs 4.3 ± 4.8 P ¼ 0.171 NR 5.1 ± 5.5 vs 3.9 ± 4.7 P ¼ 0.28 100% vs 100%
Cherkasove NR NR NR NR 8.7% of total patients
[18]
Miles [19] 32.8 13.6 vs 6.4 P¼ S NR NR 100% vs 100%
Leppa€niemi 41 ± 13 vs 39 ± 11 8 ± 5 vs 6 ± 3 P ¼ 0.450 9 ± 7 vs 8 ± 6 P ¼ 0.780 6 ± 6 vs 9 ± 9 P ¼ 0.436 100% vs 100%
[20]
DeMaria [21] NR NR NR NR 100% vs 100%
Mutter [22] NR NR NR NR 100% vs 100%
Marks [23] 31.2 ± 2.23 vs 30.5 ± 2.41 3.21 ± 0.66 vs 2.43 ± 0.63 NR NR 100% vs 100%

ISS: Injury severity score, AIS: abbreviated injury scale, ATI: abdominal trauma index, NR: not reported.
a
Laparotomy versus Laparoscopy.

Fig. 2. Organs involved in patients with penetrating abdominal trauma.

132 S. Hajibandeh et al. / International Journal of Surgery 34 (2016) 127e136

associated with laparoscopy. Figs. 4 and 5 present the Forest plot by dividing the number of negative laparoscopies (TN) (n ¼ 732) by
and SROC plot of sensitivity and specificity. the total number of laparoscopies (n ¼ 1604).

3.2.9. Avoidance of non-therapeutic laparotomy 3.3. Sensitivity analyses

A non-therapeutic laparotomy was avoided in 45.6% of patients
who underwent laparoscopic evaluation of PAT. This was calculated The use of random-effects or fixed-effect models did not affect

Fig. 3. Forest plots of comparison of a) Missed injury, b) Mortality, c) Wound infection, d) Abscess, e) Pneumonia, f) Length of stay, and g) Procedure time The solid squares denote
the risk difference (RD), odds ratios (ORs), or mean difference (MD). The horizontal lines represent the 95% confidence intervals (CIs), and the diamond denotes the pooled effect
size. M-H, Mantel Haenszel test.
S. Hajibandeh et al. / International Journal of Surgery 34 (2016) 127e136 133

Figure 3. (continued).
134 S. Hajibandeh et al. / International Journal of Surgery 34 (2016) 127e136
Fig. 4. Forest plot of sensitivity and specificity.
the pooled effect size in any of the outcomes, except mortality.
There was a significant difference in mortality between the lapa-
roscopy and laparotomy groups in favour of the former when fixed-
effect model was applied but not when random-effects model was
used. Considering the significant heterogeneity in this analysis,
random-effects model was deemed more appropriate. The direc-
tion of pooled effect size remained unchanged when OR, RR, or RD
were calculated for all dichotomous variables, except mortality.
There was a significant difference in mortality between the lapa-
roscopy and laparotomy groups in favour of the former when OR or
RR were applied but not when RD was used. However, because 7
studies reported zero events in both laparoscopy and laparotomy
groups, RD was deemed more appropriate Cherkasov et al. [18] was
the only study which included haemodynamically unstable pa-
tients with the greatest number of patients. Removal of Cherkasov
et al. [18] made the results statistically non-significant in the
analysis of pneumonia although there was still a trend in favour of
laparoscopy (0% vs 2.49%, OR: 0.28; 95% CI, 0.07e1.17, P ¼ 0.08). The
between-study heterogeneity remained non-significant (I2 ¼ 0%,
P ¼ 1.0). However, removal of Cherkasov et al. [18] did not change
the direction of pulled effect size in the analysis of other outcomes.
In fact, laparoscopy remained to be associated with a significantly
lower rate of wound infection (0.37% vs 4.55%, OR: 0.11; 95% CI,
Fig. 5. The SROC plot of sensitivity and specificity.
0.03e0.42, P ¼ 0.001) and a shorter length of hospital stay (3.48
days vs 5.89 days, MD: 2.24; 95% CI, 2.99 to 1.49, P < 0.0001).
Furthermore, there was no significant difference between both
groups in mortality (P ¼ 0.40) and missed injury (P ¼ 0.93) after
removal of Cherkasov et al. [18]. Moreover, removal of Cherkasov
et al. [18] reduced the overall heterogeneity in the analyses of
wound infection (reduced the I2 from 38% to 0%) and mortality
(reduced the I2 from 72% to 41%).
4. Discussion
In view of the existing controversy regarding the role of lapa-
roscopy in the evaluation of PAT, we undertook a comprehensive
literature review and meta-analysis of outcomes and identified 1
RCT and 8 observational studies [15e23], reporting a total of 3362
patients, of whom 1604 patients underwent laparoscopy and the
remaining 1758 patients underwent laparotomy for PAT. Subse-
quent analysis suggested that laparoscopy is a safe, fast, and highly
sensitive procedure for the evaluation of PAT with a very low
missed injury rate. Moreover, our analysis showed that laparoscopy
is associated with a significantly lower incidence of wound infec-
tion and pneumonia compared to laparotomy. The statistical het-
erogeneity among the included studies regarding wound infection
and pneumonia were low which makes our conclusion about these
outcome parameters robust. Significantly shorter procedure time
and length of hospital stay were other important advantages of
laparoscopy over laparotomy, despite the existence of considerable
statistical heterogeneity among the analysed studies.
In the context of role of laparoscopy in PAT, there is only one
available RCT to date which highlights lack of sufficient high level
evidence on this subject. In this RCT, Lepp€ aniemi et al. [20]
concluded that in patients with demonstrated peritoneal viola-
tion, laparoscopy offers little benefit over laparotomy. They found
that laparoscopy is associated with a significantly lower rate of
non-therapeutic laparotomies (P ¼ 0.016) and length of hospital
stay (0.049) and similar hospital morbidity and mortality. We agree
with the fact that no definitive conclusion can be made on the role
of laparoscopy in PAT considering the available evidence; however,
the glass needs to be seen half full as the only available RCT pro-
duced promising results indicating that diagnostic laparoscopy
does not increase hospital morbidity and mortality in haemody-
namically stable patients with PAT and may be associated with
shorter length of hospital stay and indeed lower non-therapeutic
laparotomies.
We did not find any significant difference in mortality between
the laparoscopy and laparotomy groups although there was a
reduced trend in favour of the former. Interestingly, six of the
included studies reported no deaths in their study groups. Un-
doubtedly, the fact that most of the analysed studies included only
haemodynamically stable patients contributed to this very low
 S. Hajibandeh et al. / International Journal of Surgery 34 (2016) 127e136 135

mortality rate. Only one study, Cherkasov et al. [18], included evidence comes mainly from retrospective and prospective cohort
haemodynamically unstable patients and the mortality was rela- studies that are inevitably subject to selection bias. The risk of bias
tively higher in that study indicating that haemodynamic status in 4 studies was moderate or high, which may bias our results in
may be an important predictor of mortality in patients with PAT. favour of an intervention. Furthermore, between-study heteroge-
Although Cherkasov et al. [18] demonstrated successful use of neity was significant for some of the outcomes such as procedure
laparoscopy in haemodynamically unstable patients, the impor- time and length of hospital stay. Finally, we would like to highlight
tance of stable haemodynamic status has been emphasized as an that in our search strategy we identified 2 potentially eligible
indication for laparoscopy in patients with PAT [24,25]. Lin et al. studies [29,30] which were excluded because of including patients
[17] discouraged any attempt to repair complex injuries lapa- with penetrating and/or blunt abdominal trauma without reporting
roscopically as the potential benefits of the minimally invasive the outcomes with respect to the mechanism of abdominal trauma.
approach do not outweigh the risks.
In our study, 45.6% of patients who underwent laparoscopic
5. Conclusion
evaluation avoided non-therapeutic laparotomy. This is an
extremely important advantage associated with laparoscopy as the
Our analysis of best available evidence has demonstrated that
ability to decrease or even eliminate negative or non-therapeutic
laparoscopic evaluation of haemodynamically stable patients with
laparotomy could impact the overall morbidity and mortality of
PAT is safe and can reduce post-operative complications without
the trauma population [26,27]. Morbidity of non-therapeutic lap-
increasing mortality. It is associated with a very low missed injury
arotomy can be as high as 33.3% [3,6]. The avoidance of non-
rate as reflected by its high sensitivity. The most important
therapeutic laparotomies in 51.8% and 63.0% of patients who un-
advantage of laparoscopy is avoidance of non-therapeutic laparot-
derwent laparoscopy were reported previously [9,28].
omies which are associated with considerable morbidity. Moreover,
The sensitivity of laparoscopic procedure was 100% in most of
we have found that laparoscopy is a potentially faster approach and
our included studies (8 out of 9) while specificity was 100% in 5
has a shorter associated length of hospital stay. It must be taken
studies. This is consistent with findings of O'Malley et al. [9] who
into account that the best available evidence comes mainly from
reviewed 51 studies to evaluate the role of laparoscopy in patients
heterogeneous observational studies which suggest that laparos-
with PAT and found that the sensitivity of laparoscopy in most of
copy is an effective screening tool for peritoneal violation; How-
their included studies were 100%. They classified their included
ever, no definitive conclusion can be made regarding its therapeutic
studies in to 3 groups on the basis of the use of laparoscopy as a
roles in PAT. Without any doubt, high level evidence from well-
screening, diagnostic or therapeutic tool. Despite being an exten-
designed RCTs are indeed required to facilitate more reliable
sive review of the literature with the main focus on the sensitivity
meta-analysis; however, the nature of PAT, particularly in haemo-
and specificity of the laparoscopy, O'Malley et al. [9] did not provide
dynamically unstable patients, will be a big challenge to design
any comparative evidence regarding the outcomes of laparoscopy
such a research.
versus laparotomy in patients with PAT. In fact, the authors
included a large number of heterogeneous case-series and even
simple audits which did not directly compare outcomes of lapa- Ethical approval
roscopy with those of laparotomy. In our analysis, we included
studies which defined laparoscopy and laparotomy groups and No Ethical Approval required.
provided total number of events and patients in these groups.
A recent systematic review and meta-analysis conducted by Li
Sources of funding
et al. [11] compared the outcomes of laparoscopy and laparotomy
for the management of abdominal trauma. However, serious con-
None.
cerns have been raised regarding the methods of inclusion and
assessment of their included studies [12]. To our knowledge, there
is only one RCT, Lepp€ aniemi et al. [20], in the context of the role of Author contribution
laparoscopy in PAT. However, Li et al. [11] included 5 studies as RCTs
in their meta-analysis. This was found to be due to an inaccurate Please specify the contribution of each author to the paper, e.g.
assessment of the included studies by the authors [12]. Moreover, study design, data collections, data analysis, writing. Others, who
the authors included 10 studies that are only available in Chinese have contributed in other ways should be listed as contributors.
language and their full texts are not available; therefore, their Shahin Hajibandeh and Shahab Hajibandeh equally contributed
methodological quality cannot be assessed by a third party [12]. to this paper and joined first authorship is proposed.
Furthermore, the authors included patients with either blunt or Conception and design: SH, SH.
penetrating abdominal trauma and no sub-group analyses of the Literature search and study selection: SH, AG, SH.
outcomes were conducted. In terms of the postoperative compli- Data collection: SH, CSW, SH.
cations, no analysis of the actual pathology was conducted and the Analysis and interpretation: SH, SH.
authors compared the overall post-operative complications be- Writing the article: SH, SH.
tween the laparoscopy and laparotomy groups. Finally, some data Critical revision of the article: SH, SH, AG, CSW.
were extracted inaccurately which subsequently affected the Final approval of the article: SH, SH, AG, CSW.
analysis. For example, regarding the study of Karateke et al. [16], the
length of hospital stay and the number of patients were inserted
Conflicts of interest
incorrectly in their Forest plots. To our knowledge, a review and
meta-analysis focusing specifically on comparison of outcomes of
None.
laparoscopy and laparotomy in patients with PAT has not been
previously undertaken.
The results of our study should be interpreted in the context of Guarantor
its limitations. Only one of the included studies was RCT, the gold
standard study design for comparative studies. The available Shahin Hajibandeh.
136 S. Hajibandeh et al. / International Journal of Surgery 34 (2016) 127e136
Appendix A. Supplementary data
Supplementary data related to this article can be found at http://
dx.doi.org/10.1016/j.ijsu.2016.08.524.
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