ROLE OF LAPAROSCOPIC

SURGERY IN TRAUMA
Alexander Surya Agung M,D General Surgeon
Epidemiology
• Peak incidence Abdominal Trauma 15 – 30 yr
• More than 15,000 people die every year as a
result of injuries by motor vehicle accident, fall
• Injury accounts for 10% of all deaths
• Estimates indicate that by 2022, 8.4 million
people will die yearly
• Prevalence : 13%
History
• Lenny et al (1956): performed
laparoscopic spleen trauma
• Gazzaniga: Laparoscopic reduced
negative Laparotomy
• Berci et al(1991): Laparoscopic
reduced negative laparotomy 25%
(150 cases)
 Introduction
• The introduction of laparoscopy has provided
trauma surgeons with a valuable diagnostic
and, at times, therapeutic option.
• The minimally invasive nature of laparoscopic
surgery, combined with potentially quicker
postoperative recovery, simplified wound care,
as well as a growing number of viable
intraoperative therapeutic modalities, presents
an attractive alternative for many
traumatologists when managing
hemodynamically stable patients with selected
penetrating and blunt traumatic abdominal
CHOL YB, LIM KS. THERAPEUTIC LAPAROSCOPY FOR ABDOMINAL
TRAUMA. SURG ENDOSC. 2003;17(3):421–7. DOI:10.1007/S00464-002-8808-8. injuries.
Introduction
92,7%
• The role of laparoscopy in abdominal trauma
has increased in the last years in diagnosis as
well as therapeutic interventions. It is a viable
alternative for the diagnosis of intra-
abdominal injury in both penetrating and
blunt trauma.
• The number of negative laparotomies
decreased since the use of laparoscopy in
trauma patient
Methods
• Retrospective study 23 cases with penestrating and blunt
trauma
• From January 2016 – December 2021
• Hemodinamically stable
• Resuscitated ATLS standard
• Laparoscopically by General Anesthesia
• Trocar : 3 ( 11 mm, 5 mm) added 1 more if needed
• Exploration and therapeutic : suturing, cauteritation, no fibrin
glue, inserted drain (NGT/Rectal tube)
Result
• 7 penetrasting, 16 blunt trauma
• Male: 21 Female 2 patients
• Age: 17 – 61 (mean: 36) years old
• Penestrating: 2 stab injuries, 5 Gun
shot injuries
• Length of stay: 2 – 5 days ( mean 3
days)
• Converted to Laparotomy : 2 patients
Injured Organs

•Solid Organ: Liver and spleen

•Omentum
•Utherus and Ovarian tubes
•Bleeding: 100 – 1500 cc
•Operation time: 60 – 120
minutes ( mean: 90 minutes)
•No mortality
Blunt Trauma
 Abdominal Trauma

• Blunt Trauma
• Penetrating Trauma
- Stab
- Gun shot Injury
• Explosion
Assesment
(ATLS)
• ABCDEs
• Mechanism of trauma
• Early Physical
Examination
• Diagnostic Examination
(Procedure)
• High index of suspicion
• Early recognition /prompt
celiotomy
2018 ATLS Edisi 10/ Advanced Trauma Life
Support
LAPAROSCOPIC OF
ABDOMINAL TRAUMA

Laparoscopy in Trauma
• Diagnostic
• Therapeutic
Diagnostic Procedures
• Physical Diagnostic
• Diagnostic Peritoneal Lavage
(DPL)
• Ultrasound (FAST)
• CT Scan
• Laparoscopy
Comparison of DPL, FAST, and CT in Blunt
Abdominal Trauma
 RATIONALE FOR USE OF LAPAROSCOPY
– FAST: poor specificity
– DPL : poor specificity, invasive, not informative
for retroperitoneal injuries
– CT : hollow viscus injuries difficult to identify

SAGES Society of American Gastrointestinal and

Endoscopic Surgeons http://www.sagescms.org

– Reduction of nontherapeutic laparotomy

rates
– Reduction of short and long-term morbidity
– ↓ ICU stay, ↓ overall LOS
– ↓ risk future adhesive bowel obstruction
GUIDELINES FOR DIAGNOSTIC LAPAROSCOPY

SAGES Society of American Gastrointestinal

and Endoscopic Surgeons
http://www.sagescms.org
DIAGNOSTIC LAPAROSCOPIC

• Acute abdominal pain unknown etiology

• Generalized peritonitis
• Diagnostic laparoscopy after operations
or invasive procedur (post colonoscopy,
extraordinary pain)
• Sepsis of unknown origin
DIAGNOSTIC LAPAROSCOPIC

DIAGNOSTIC ACCURACY OF THE PROCEDURE

• The sensitivity, specificity, and diagnostic accuracy of the

procedure when used to predict the need for laparotomy are
high (75-100%) (level I-III)
• When DL has been used as a screening tool (i.e., early
conversion to open exploration with the first encounter of a
positive finding like the identification of peritoneal
penetration in penetrating trauma or active
bleeding/peritoneal fluid in blunt trauma patients), the
number of missed injuries
Hori Y. Diagnostic laparoscopy guidelines: this guideline was prepared by the SAGES guidelines committee and
reviewed and approved by the board of governors of the Society of American Gastrointestinal and Endoscopic
Surgeons (SAGES), November 2007. Surg Endosc. 2008;22(5):1353–83. doi:10.1007/s00464-008-9759-5.
DIAGNOSTIC LAPAROSCOPIC

DIAGNOSTIC ACCURACY OF THE PROCEDURE

• Diagnostic laparoscopy for trauma has been shown to

be effective in preventing negative laparotomy in 21%
to 59% of patients,which can be associated with
significant morbidity
• However, the non-therapeutic laparotomy rate after
laparoscopy positive for peritoneal penetration of up to
45% remains a concern

SAGES Society of American Gastrointestinal and Endoscopic Surgeons http://www.sagescms.org

THERAPEUTIC Of Emergency LAPAROSCOPIC
Stable Hemodynamic
• Criteria: (Choi, et al)
• Blood Pressure: Systole > 100
mmHg
• Dyastole > 60 mmHg
• Pulse: < 110x per minute with
resuscitation crystalloid 2 ltr
 INDICATIONS FOR
LAPAROSCOPY
• Blunt or penestrating abdominal trauma + HD stable
• Suspicious physical exam eq. abdominal contusion,
peritonitis
• Labs eq declining Hematocrit
• CT diagnostic or suspicious for hollow viscus injury
eq. FA, enteral contrast extravacation, FF in absence
of solid organ injury, thickened bowel loops,
mesenteric infiltration
INDICATIONS OF
LAPAROSCOPY TRAUMA
Trauma : blunt or penestrating (solid organ
injury, diaphragmatic injuries)

Selman Uranüs. Laparoscopy in Abdominal Trauma.

Eur J Trauma Emerg Surg 2010;36:19–24
 INDICATION LAPAROSCOPIC IN EMERGENCY CASE

It is indicated in Hemodynamically stable patients with

suspect intra-abdominal lesions and equivocal findings on
imaging studies, and when non-operative management is
not indicated (suspect hollow viscus injuries with peritonitis,
potential diaphragmatic lesion).
The procedure decreases the rate of negative laparotomies
and minimizes patients morbidity.
(Diagnostic accuracy about 75%). (EL 2b)
Leppäniemi A, Haapiainen R. (2003) Diagnostic laparoscopy in abdominal stab wounds: a prospective, randomized study. J Trauma Oct;55(4):636-45.
National Guideline Clearinghouse. Diagnostic Laparoscopy for trauma. Guideline Summary NGC – 6829(NCG Status: Update information was verified by the
guideline developer on March 9, 2009)
Choi YB., Lim KS. (2003) Therapeutic laparoscopy for abdominal trauma. Surg Endosc 17: 421–427
BENEFITS OF MINIMALLY INVASIVE SURGERY
Negative diagnostic laparotomy in trauma is associated with a high
complication rate (14.5%) and prolonged length of stay (2,3). The rate of
negative / non-therapeutic laparotomy in trauma is variable ranging from 1.7%
to 38% (1). Negative laparotomy incidence in both blunt and penetrating
trauma is widely accepted as around 20%, but this number is decreasing with
increased utilization of advanced imaging and laparoscopy in trauma.

Multiple small single institution observational studies note a decreased negative

laparotomy rate, decreased complications, faster return of bowel function, and
decreased length of stay with the use of diagnostic laparoscopy in trauma (2,4,5).
In penetrating trauma, the ability to rule out peritoneal penetration with
laparoscopy allows patients to be discharged without admission for observation.
Limited investigations show that therapeutic laparoscopy in trauma also results in
decreased length of stay relative to therapeutic laparotomy (4).
SAGES Society of American Gastrointestinal and Endoscopic Surgeons
http://www.sagescms.org
 THERAPEUTIC OF LAPAROSCOPY TRAUMA

In a highly selected group of patients therapeutic laparoscopy should be

performed only by surgeons skilled in advanced mini-invasive surgery (EL3a).
Warren O, Kinross J, Paraskeva P ,Darzi A (2006) Emergency laparoscopy – current best practice. World Journal of Emergency Surgery, 1:24

Laparoscopy allows to manage hemoperitoneum, diaphragmatic, mesentery and

hollow viscus injuries and avoid non-therapeutic laparotomy. Diaphragmatic
laceration and perforating stab wounds of the gastrointestinal tract can be sewn
or stapled safely when laparoscopic expertise is available (EL 4)
Smith RS, Fry WR, Morabito DJ, Koehler RH, Organ CH Jr (1995) Therapeutic laparoscopy in trauma. Am J Surg 170:632–637
Matthews BD, Bui H, Harold KL, Kercher KW, Adrales G, ParkA, Sing RF, Heniford BT (2003) Laparoscopic repair of traumatic diaphragmatic injuries. Surg Endosc. 17: 254–258
Smith CH, Novick TL, Jacobs DG, Thomason MH (2000) Laparoscopic repair of a ruptured diaphragm secondary to blunt trauma. Surg Endosc 14: 501–502
Zantut LF, Ivatury RR, Smith RS, Kawahara NT, Porter JM, Fry WR, Poggetti R, Birolini D, Organ CH Jr(1997) Diagnostic and therapeutic laparoscopy for penetrating abdominal trauma: a multicenter experience. J Trauma 42: 825–831.
Mathonnet M, Peyrou P, Gainant A, Bouvier S, Cubertafond P (2003) Role of laparoscopy in blunt perforations of the small bowel. Surg Endosc 17: 641–645
Laparoscopy and Penestrating Trauma
Debate remains regarding the optimum role of laparoscopy in the setting of
trauma although it can offer advantages over traditional exploratory
laparotomy.
Laparoscopy can be a screening, diagnostic or therapeutic tool in trauma.
The purpose of this review is to evaluate the role of laparoscopy in
penetrating abdominal trauma
 Laparoscopy and Penestrating
Trauma
• The role of laparoscopy in diagnosis as
well as therapeutic interventions has
increased markedly in the last few years.
• In trauma, it has become a viable
alternative for the diagnosis of intra-
abdominal injury following penetrating
and blunt trauma.
• The number of negative and/or
nontherapeutic laparotomies performed
has decreased since the use of
laparoscopy in diagnosis and
management.
Algorithm
for
Management
of
Penetrating
Abdominal
Trauma
Algorithm for Laparoscopy in Abdominal Trauma
Algorithm
for
Laparoscopy
in
Blunt
Abdominal
Trauma
 Algorithm for laparoscopy in penetrating abdominal trauma
(abdominal stab wounds or tangential gunshot wound injuries)
Algorithm for
laparoscopy in
penetrating
abdominal
trauma
(abdominal
stab wounds
or tangential
gunshot
wound
injuries)
PENETRATING ABDOMINAL TRAUMA
PENETRATING ABDOMINAL TRAUMA

Laparoscopy actually has advantages over

other diagnostic tests in diagnosing
diaphragmatic injury from lower chest and
abdominal penetrating wounds or blunt
abdominal trauma Delayed or missed
diagnosis of diaphragmatic injuries are known
to be associated with significant morbidity
CONTRAINDICATIONS
(Absolute or Relative)
• Patients unable to tolerate pneumoperitoneum or who are so sick that there is no
realistic chance of survival even if a “treatable” intra-abdominal process were found
• Patients with EDH/SDH
• Patients with an obvious indication for surgical intervention such as a bowel
obstruction or perforated viscus (massive instestinal dilatation with abdominal
distension)
• Patients with an uncorrectable coagulopathy or uncorrectable hypercapnia >50 torr
• Patients with a tense and distended abdomen (i.e., clinically suspected abdominal
compartment syndrome)
• Patients with abdominal wall infection (e.g., cellulitis, soft tissue infection, open
wounds)
• Patients with extensive previous abdominal surgery with multiple incisional scars or
after a laparotomy within the last 30 days
• Pregnancy
PHYSIOLOGIC
CONTRAINDICATION
• Cardiac “The heart is the Achilles
heel of every laparoscopic
operation“
• Pulmonary
• Haemodynamic instability
 CONDUCT OF LAPAROSCOPY

• Matched pRBCs
available
• Be prepared for rapid
conversion to open
• GA/ETT
• NG/OG
• Foley
CHOL YB, LIM KS. THERAPEUTIC LAPAROSCOPY FOR ABDOMINAL
TRAUMA. SURG ENDOSC. 2003;17(3):421–7. DOI:10.1007/S00464-002-8808-8.
CONDUCT OF
LAPAROSCOPY
• 5mm umbilical trocar
• 2+ 3-5mm trocars → L flank,
suprapubic
• 4 quadrant evaluation for blood,
bile, urine, fecal contamination
Liver, spleen
• Diaphragm, peritoneal surfaces
• SB + mesentery
• Stomach, duodenum, colon
Explore lesser sac + pancreas as
directed by CT
 CONDUCT OF LAPAROSCOPY
• The Hasson or open technique at the
umbilicus is recommended to
introduce the initial trocar for
insufflation of the abdominal cavity
• The insufflation pressure is generally
limited to 15 mmHg
• Bilateral perirectus 5-mm and 10- or 12-
mm trocars, may be added ports as
needed
• Blood or succus is aspirated and the
abdominal cavity is irrigated
NO: Veress needle
Hasson Technique
LAPAROSCOPY SUTURING
Exploration of small intestine
COMPLICATIONS
Laparoscopic procedure-related complications
occur in only 1% of cases similar to that seen with
other general surgical applications of minimally
invasive surgical techniques.

These include visceral and vascular injuries from

trocar insertion or instrument manipulations
 INDICATIONS FOR
CONVERSION LAPAROTOMY
• Acute hemodynamic deterioration
• Dense adhesions
• Gross intestinal distention
• Bleeding that cannot be controlled
laparoscopically
• Injuries not amenable to laparoscopic
repair
Di Saverio S., Birindelli A., Podda M., Segalini E., Piccinini A., Coniglio C., Frattini C., Tugnoli G. Trauma laparoscopy and the six w’s: Why, where, who, when, what, and how?
J. Trauma Acute Care Surg. 2019;86:344–367. doi: 10.1097/TA.0000000000002130. - DOI - PubMed
INJURIES AMENABLE TO LAPAROSCOPIC REPAIR

• Duodenal lacerations, decompression of

hematomas
• SB perforations (lap, lap-assisted)
• Colonic perforations without significant
contamination
• Stoma formation for colonic + intraperitoneal rectal
injuries
• Splenic hemostasis, splenorrhaphy, splenectomy
• Liver hemostasis
• Distal pancreatectomy
• Cholecystectomy
CONTRA INDICATIONS
(Absolute or Relative)
• Many trauma patients are not candidates for minimally
invasive surgery due to hemodynamic instability or complexity
of injuries Control of life-threatening, complex intraabdominal
injuries requires rapid exposure of the organs that can only be
accomplished through an open celiotomy incision
• The time required to set up and perform a laparoscopic
procedure along with the limited exposure makes laparoscopy
an unrealistic option in the critically injured patient
CONCLUSIONS
• Laparoscopy can be safely performed in hemodynamically
stable patients with abdominal trauma for both diagnostic
and therapeutic purposes; also it helps to cut down the
number of non-therapeutic laparotomies.
• Diagnostic and therapeutic laparoscopy in abdominal
pentrating and blunt trauma in higly selected patients is
safe and technically feasible
• It reduces the negative and non-therapeutic laparotomies
• It offers a profound therapeutic potential
• It should be used by surgeons with expertise in advanced
laparoscopic techniques
• The surgeon must always be prepared to rapidly open the
abdomen to gain control of hemorrhage
Thank
You