Laparoscopy for Trauma: When, What, How?

Abstract

Since its conception and introduction in the early 1970s, diagnostic and therapeutic laparoscopy in trauma surgery has evolved rapidly. The literature on the advantages and feasibility of diagnostic and therapeutic laparoscopy in patients with abdominal trauma is extensive. Modern imaging techniques usually diagnose intra-abdominal lesions accurately but sometimes fail to detect an injury. It is particularly likely that diaphragmatic or small bowel injuries, which often require laparotomy, will be missed. But if an exploratory operation is performed routinely for every suspected abdominal injury, up to 41 % of those laparotomies will be nontherapeutic, i.e., pointless, and will place an unnecessary burden on patients and healthcare providers alike.

Diagnostic laparoscopy is performed to determine whether further surgery is needed, laparoscopic or conventional. Used in conjunction with computed tomography (CT) in the management of solid organ injuries, the presence or absence of occult lesions and the state of known injuries can be determined, allowing patients to be selected correctly for operative or nonoperative management.

With penetrating trauma laparoscopy is superior to conventional methods for assessing peritoneal damage, particularly lower chest stab wounds and entry and exit gunshot wounds in patients without diffuse peritoneal signs who are hemodynamically stable.

Laparoscopy is a valuable tool not only for diagnosis but also for treatment: Small diaphragmatic wounds can be sutured, stapled, or covered with prosthetic mesh; gastrointestinal perforations can be closed; and hemostasis be achieved in low-grade liver and splenic lacerations with simple sutures, collagen fleece tamponade, or biological sealants, applied through the laparoscope.

Laparoscopy in the trauma setting has its benefits and risks, which must be weighed in establishing indications. Laparoscopy reduces the rate of nontherapeutic negative laparotomies and allows shorter hospitalization. The main risk with trauma patients is that in case of conversion definitive treatment may be delayed; other risks are missed injuries and naturally procedure-related complications that can occur with any laparoscopy. It cannot be overstressed that hemodynamic stability is an absolute prerequisite for laparoscopy.

In summary, laparoscopy can be a safe and effective option in the management of stable patients with abdominal trauma. The most important advantages are reduction of morbidity and avoidance of prolonged hospitalization for observation, both of which reduce costs.

Technological advances have continuously improved laparoscopy equipment, and this trend can be expected to carry on and embrace computer technology and robotic devices, all of which will have a positive influence on treatment of trauma patients.