Laparoscopic Procedures in Trauma Care

Abstract

The modern concept of diagnostic laparoscopy for trauma patients emerged in the early 1970s. The literature shows that a variety of laparoscopic techniques are applicable to patients with abdominal trauma. Treatment of abdominal trauma requires a precise diagnosis that is not always possible with imaging techniques. As the danger is particularly great that an injury to the diaphragm or intestines might be overlooked, exploratory laparotomy can be warranted; however, up to 41% of exploratory laparotomies are nontherapeutic and could have been avoided with laparoscopy.

The ultimate value of laparoscopy for diagnosis and treatment depends on identifying the benefits and risks. The main benefit of laparoscopy for trauma is reduction of the rate of nontherapeutic, negative laparotomies with a subsequent decrease in hospitalization. The major risk of applying laparoscopy to the care of trauma patients is the potential delay in definitive treatment. Laparoscopy also entails a potential risk of missed injuries and, of course, procedure-related complications.

The basic prerequisite for laparoscopy in trauma is the stability of the injured patient. The current approach to abdominal trauma is the judicious use of laparoscopy to determine the need for further surgery. In blunt trauma, laparoscopy may have a role as an adjunct to computed tomography (CT) in nonoperative management of solid organ injuries. In these cases, laparoscopy can be helpful in evaluating the injury, detecting occult lesions, and selecting patients for nonoperative treatment.

In penetrating trauma, laparoscopy appears to offer greater scope. It can be of importance in the evaluation of peritoneal penetration. The difficulty in evaluating peritoneal penetration in lower chest stab wounds and the efficacy of laparoscopy have both been documented in the literature. In patients with entry and exit gunshot wounds, but without diffuse peritoneal signs or hemodynamic instability, laparoscopy can also establish the diagnosis of peritoneal penetration.

Besides its role as a diagnostic tool, laparoscopy offers exciting therapeutic potential. Small gunshot wounds of the diaphragm can be sutured, stapled, or covered with prosthetic mesh laparoscopically. Further potential applications for laparoscopy in trauma involve the closure of gastrointestinal perforations and achieve hemostasis of low grade liver and splenic lacerations using adhesives.

In summary, minimally invasive surgery has already established itself as a useful tool in the management of trauma patients. Laparoscopy can be performed safely and effectively in stable patients with abdominal trauma. The most important advantages are reduction of morbidity, shorter duration of hospital stay, and cost effectiveness. In the future, new developments in laparoscopy equipment and the introduction of computer technology and robotic devices can be expected to have a decisive influence on the treatment of trauma patients.