Abstract
The management of blunt abdominal trauma has evolved over time. While laparotomy is the standard of care in hemodynamically unstable patients, stable patients are usually treated by non-operative management (NOM), incorporating adjuncts such as interventional radiology. However, although NOM has shown good results in solid organ injuries, other lesions, namely those involving the hollow viscus, diaphragm, and mesentery, do not qualify for this approach and need surgical exploration. Laparoscopy can substantially reduce additional surgical aggression. It has both diagnostic and therapeutic potential and, when negative, may reduce the number of unnecessary laparotomies. Although some studies have shown promising results on the use of laparoscopy in blunt abdominal trauma, randomized controlled studies are lacking. Laparoscopy requires adequate training and experience as well as sufficient staffing and equipment.
Similar content being viewed by others
Avoid common mistakes on your manuscript.
Introduction
The majority of fatalities worldwide in people under the age of 35 years are caused by trauma [1]. Blunt mechanisms account for 78.9 to 95.6% of injuries [2–5], with the abdomen being affected in 6.0 to 14.9% of all traumatic injuries [2, 4, 6]. Non-operative management (NOM) has been widely implemented, especially in blunt abdominal trauma. However, apart from hemodynamic instability, other specific indications call for proactive surgical diagnosis and treatment. While laparotomy has been the standard procedure for these settings, laparoscopy may be considered as an alternative. This article aims to answer the threefold question about blunt trauma laparoscopy “for whom, when, and why?” highlighting the advantages but also addressing the possible complications and pitfalls.
Work-Up of Patients Sustaining Abdominal Trauma
Primary work-up of patients sustaining abdominal trauma relies on proper knowledge of trauma mechanism and clinical examination. The decision to operate urgently or to entertain non-operative treatment depends on the clinical presentation of the patient. Indications for urgent surgical intervention are hypotension with positive focused assessment with sonography in trauma (FAST) or diagnostic peritoneal lavage (DPL), evisceration, open pelvic fracture [7], hemodynamic instability, or diffuse peritonitis [8, 9].
The reliability of clinical examination of the abdomen can be largely compromised in case of concomitant head trauma, multiple injuries, substance abuse, and/or spinal trauma [10]. Furthermore, retroperitoneal injuries may not be associated with any relevant clinical signs. External signs such as the seat belt sign (Fig. 1) significantly (p < 0.0001) increase the likelihood of intraabdominal injuries [11, 12].
FAST has overall sensitivity and specificity rates between 43 to 86 and 96 to 99%, respectively [13–17]. Its main goal is to identify the presence of free fluid but cannot determine the source and may not detect retroperitoneal, hollow viscus, or solid organ injury without hemoperitoneum [16]. Depending on the intensity of bleeding, fluid accumulation may take some time to develop [18], making repeat examinations necessary [19]. FAST accuracy has been reported to be lower in patients with higher ISS (90.6% in ISS ≥25 vs. 97.1% in ISS <25, p < 0.001) [20].
DPL has a mean sensitivity of 98% (range from 90 to 100%) and a specificity of 92% (range from 73 to 100%) [21]. However, the possibility of unnecessary exploratory operations in about 15 to 20% due to the over-sensitivity and relatively low specificity of DPL has been reported [22].
Computed tomography (CT) is considered the imaging modality of choice in the hemodynamically stable and cooperative patients [23]. Holmes et al. [24] described a 0.3% missed injury rate in blunt abdominal trauma. In hollow viscus injuries (HVI), however, high rates of false-negative results (44.7 to 54.5%) have been reported by Lin et al. [25] and Bhagvan et al. [26••], independently. A large collective analysis by Fakhry et al. [27] observed normal CT scan results in 13% of patients with small bowel perforation. In blunt diaphragmatic injuries, overall sensitivity has been reported to be as low as 57% [28], with right-sided injuries being more difficult to identify [29].
In stable patients with blunt abdominal solid organ injuries, NOM is generally considered as the standard of care in the absence of indications for emergency surgery [30]. Consequent and safe implementation of NOM requires adequate staffing in terms of numbers, equipment, and skills [8]. Velmahos and colleagues [31] observed an overall NOM failure rate of 22% in blunt abdominal trauma, with marginally higher morbidity (29 vs. 45%, p = 0.08) as compared to successful NOM, while no difference was found in mortality rates.
Over the last decades, laparoscopy has been increasingly used as an additional tool for patients who are neither good candidates for NOM nor need an urgent laparotomy. Depending on the status of the patient and the surgical expertise of the surgeon in charge, laparoscopy offers valuable diagnostic and therapeutic possibilities.
For Whom?
Laparoscopy should be envisioned only in patients who are hemodynamically stable and when there are no indications for trauma laparotomy. Intracranial injuries, which are associated with blunt abdominal trauma in about 46.5% [32], constitute an additional risk especially if intracranial pressure (ICP) is elevated. Indeed, abdominal insufflation and elevated intraabdominal pressure have been shown to further increase ICP, leading to potentially worsening outcome [33–35]. Other potential limitations for laparoscopy include high-grade chest trauma, preexisting intraabdominal adhesions as well as pregnancy [36].
The Patient with Suspected Diaphragmatic Injury
Diaphragmatic injuries (Fig. 2) mostly occur due to penetrating mechanisms and are a rare entity in blunt trauma. Two trauma database reviews from Israel [37] and the USA [38•], retrospectively analyzing more than 354,000 and 833,000 admissions, respectively, reported incidences of 0.065 to 0.148% for blunt diaphragmatic injury in all trauma patients.
Patients with blunt diaphragmatic trauma are more severely injured and have more concomitant injuries (including lesions of the thoracic aorta, lung, spleen, bladder, and pelvis) than after penetrating trauma [37, 38•]. Fair et al. [38•] described a statistically significantly higher mortality (19.8% blunt vs. 8.8% penetrating, p < 0.001). Whether the mortality rates were related to the diaphragmatic lesion or to concomitant injuries is not clear [39]. However, early diagnosis seems important as mortality was 25% when diagnosis was delayed compared to 3% after early diaphragm repair for penetrating injury [40].
CT scans have only limited sensitivity for diaphragmatic injury [28, 29]; thus, laparoscopy can be used to assess for and treat diaphragmatic injuries, if no other indications require laparotomy. In their 10-year experience with laparoscopy both for suspected blunt and penetrating injuries, Johnson and colleagues [41] avoided laparotomy in 89.3% applying minimally invasive diagnosis and repair.
A large analysis of the US national trauma database [42•] found laparoscopic repair of the diaphragm to be the most common therapeutic minimally invasive procedure (19.2%) in blunt and penetrating trauma. In large diaphragmatic ruptures with herniation of abdominal content into the thoracic cavity, laparoscopy alone may not be sufficient and a more complex, combined approach including double-lumen endotracheal intubation and thoracoscopy may be necessary [43–45].
The Patient with Suspected Hollow Viscus Injury
About 0.9 to 2.5% of all trauma patients sustain HVI, most involving the small bowel [2, 5, 46]. Watts et al. [5] observed full-thickness perforations requiring urgent surgical repair in 41.5% of such patients. Morbidity was 27.6% and mortality was statistically significantly higher (19.8% with HVI vs. 12.2% without HVI, p < 0.001). Severe symptoms may develop after HVI, sometimes with a delay of several days after initial trauma [47]. Signs of intraperitoneal free air or free fluid on CT without detectable solid organ injury paired with signs of peritoneal irritation should prompt surgical exploration [25].
Omori et al. [48] compared 12 consecutive cases of therapeutic laparoscopy in isolated ruptured small bowel with 13 patients managed by laparotomy in a previous study. While operative time did not differ significantly (132 ± 58.7 min in laparotomy vs. 143.6 ± 27.3 min in laparoscopy, p = 0.296), blood loss was statistically significantly reduced (266.8 ± 277.8 mL in laparotomy vs. 57.6 ± 57.1 mL in laparoscopy, p < 0.05). Conversion to laparotomy was necessary in one patient, while morbidity, mortality, and duration of hospital stay were not found to be statistically significantly different.
Lin and colleagues [25] reported similar results in their case series of 135 patients, comparing two historical cohorts. Group A (62 patients, 1999–2006) was explored by laparotomy and group B (59 patients, 2007–2016) underwent exploratory laparoscopy. Conversion rate was 8.5% as opposed to a 100% laparotomy rate in the first group. While the difference in blood loss was not statistically significant, the authors observed statistically significant differences in duration of hospital stay (17.6 vs. 11.0 days, p < 0.001) and wound infections (16.1% [10/62] vs. 5.1% [3/59], p < 0.049) [25].
The Patient with Free Fluid Without Detectable Organ Injury: Suspected Mesenteric Laceration
The hemodynamically stable patient with free fluid without signs of solid organ injury on CT [25, 49] can be managed in several ways. While in the majority of cases NOM may be sufficient, patients with suspected mesenteric or HVI (see above) must be identified.
Mesenteric lacerations (Fig. 3) in blunt abdominal trauma often occur in high-speed vehicle accidents frequently due to seatbelt restraints [50•]. A retrospective report by Frick et al. [51] showed that 29.7% of mesenteric lacerations lead to bowel devascularization (Fig. 4) and consecutive complications (e.g., perforation). Thus, expectant management in these patients is risky. While CT sensitivity ranges from 75 to 99% [52–54], it may not be as accurate to determine the need for surgical intervention [52].
Laparoscopy can be used to check for bowel perfusion and resect affected bowel segments accordingly [25, 55, 56]. In cases, where sufficient blood supply is not clear, new techniques such as indocyanine green-enhanced fluorescence screening for bowel perfusion [57••] may be beneficial.
The Unclear Abdomen
The term “unclear abdomen” includes hemodynamically stable patients with equivocal imaging studies, a substantial discrepancy between imaging studies and clinical presentation or non-specific diffuse symptoms that persist after conservative treatment [36, 58–60]. Possible causes may be preexisting pathologies (e.g., internal hernia, adhesions) unrelated to the respective trauma. In these scenarios, laparoscopy may be used to identify and treat possible preexisting conditions.
The Patient with Complications After Initial NOM
Laparoscopy has been proven useful in the treatment of complications after NOM for severe hepatic trauma, when interventional radiology (e.g., percutaneous drainage) fails. Successful laparoscopic management of retained hemoperitoneum, infective perihepatic collections, and treatment of bile peritonitis after severe hepatic trauma initially treated by NOM have been described [61, 62] and are recommended by several guidelines [8, 9, 63]. These interventions are usually necessary 3 to 5 days post-injury [62, 64]. Since delayed operations may be considered as a failure of NOM, Letoublon et al. [64] argued that in these cases laparoscopy is “an actual part of the so-called non-operative treatment.” Similarly, the 2012 Eastern Association for the Surgery of Trauma (EAST) guidelines on NOM for blunt hepatic trauma [8] state that “Adjunctive therapies such as angiography, percutaneous drainage, endoscopy/endoscopic retrograde cholangiopancreatography and laparoscopy remain important adjuncts to nonoperative management of hepatic injuries.”
Laparoscopy can also be of use to debride subsequent necrosis after NOM for grade I and II pancreatic injuries [65] (Figs. 5 and 6). High-grade injuries involving the pancreatic duct usually are a domain of laparotomy, although laparoscopic and even non-operative approaches have been described [66–69].
Splenic Injuries
The treatment of splenic injuries in stable patients is non-operative, irrespective of the degree of injury [70]. In unstable patients with low-grade injuries of the spleen and if the main source of blood loss can be controlled quickly, spleen preservation can be considered [71]. Otherwise, splenectomy is the treatment of choice in hemodynamically unstable patients. Hemodynamic instability is an indication for trauma laparotomy and a contraindication for laparoscopy. Furthermore, positioning for laparoscopy in splenic surgery usually requires the patient to be in a right semilateral recumbent position, which does not allow adequate exploration of the abdomen. However, minor splenic injuries as an incidental finding during a diagnostic laparoscopy for one of the abovementioned indications can be treated laparoscopically (Fig. 2). By definition, this is an adjunct maneuver during a primarily indicated laparoscopic procedure performed for other reasons than splenic injury. Laparoscopy as a primary treatment modality in isolated splenic injuries has been reported for both splenectomy and splenic preservation with mesh splenorrhaphy in isolated cases [72–76].
Complications of Laparoscopy in Blunt Trauma
Apart from iatrogenic access injuries, missed injuries can result in severe complications and need for delayed surgical repair. Studies from the beginning of the laparoscopic era reported missed injury rates as high as 77% [77]. More recent data, however, has revealed substantially lower missed overall injury rates ranging from 0 to 3.2% [25, 42•, 56, 78–80]. Data available specifically for blunt trauma, while scarce, have reported missed injury rates of only 0 to 0.5% [25, 56, 78, 81, 82]. Systematic approaches to abdominal exploration in minimal access surgery [83] as described previously [84] may be responsible. An open first trocar placement technique should reduce iatrogenic access injuries [85, 86].
While cases of (tension-) pneumothorax in the presence of diaphragmatic injury have been described in penetrating injuries [80, 87], to the best of our knowledge, no case reports in blunt trauma have been published. However, this complication remains possible in blunt trauma and should be entertained if patients deteriorate during laparoscopy without an explainable cause.
The possible consequences of increased ICP due to intraabdominal insufflation have been mentioned above. To the best of our knowledge, venous gas embolism [88], following laparoscopy for trauma, has not been reported so far. It has, however, been observed after ERCP for blunt hepatic trauma [89].
When Should Laparoscopy Be Performed?
Timing of laparoscopic intervention depends on the clinical scenario. In patients presenting without indications for immediate laparotomy but need for surgical exploration (e.g., suspected mesenteric tears, HVI…) exploration should be performed after initial resuscitation is completed. Interval laparoscopy may be needed in prevention or treatment of complications after NOM.
Why Laparoscopy?
Although NOM has reduced the rate of surgical exploration in blunt abdominal trauma with hemodynamic stability, it is still indicated in certain situations. Laparotomy as the standard approach, however, is associated with high morbidity rates up to 41.3% [90] in negative laparotomy and adds additional surgical trauma.
Several surgical societies [8, 9, 59, 63, 91–93] recommend laparoscopy for diagnosis and therapeutic intervention in selected cases as well as an approach for control of complications after hepatic NOM. However, due to the lack of randomized controlled studies and small sample sizes, these recommendations are based on low evidence levels and thus have to be interpreted accordingly [8, 59, 92, 93].
As observed by Velmahos et al. [31], more than one third of NOM failure is due to injuries, namely HVI and diaphragmatic and vascular lacerations.
Implementation of minimally invasive surgery in trauma has been reported to avoid trauma laparotomies in 7.7 to 60.7% [82, 94, 95]. Conversion rates in blunt trauma laparoscopy ranged from 8.5 to 23.8% [25, 41, 55, 82] depending on patient selection criteria. A systematic review by Zafar et al. [42•] showed an overall conversion rate of 20.2% in (blunt and penetrating) abdominal trauma.
In terms of duration of hospital stay after open vs. minimally invasive surgery, reductions have been described in laparoscopy. Comparing two groups with similar ISS after repair for blunt HVI and mesenteric injuries, Lin et al. [25] reported a mean hospital stay of 11.0 days after laparoscopy as compared to 17.6 days (p < 0.001) after open surgery. Similar results have been reported by Lee et al. [95] (11 vs. 21 days, p < 0.001) and Lim and colleagues [81] (11.5 vs. 17.6 days, p = 0.004).
From an economic point of view, laparoscopy might be more cost-effective than non-therapeutic laparotomy. Taner and colleagues [94] described 1.78 times higher costs in unnecessary laparotomy as compared to laparoscopy.
However, data on laparoscopy in blunt abdominal trauma are scarce and, to our knowledge, no randomized controlled trials have been published on this topic so far.
Conclusions
In conclusion, laparoscopy in blunt abdominal trauma is safe and feasible. The prerequisites are the hemodynamic stability of the patient and surgical expertise in advanced laparoscopy. Increasing implementation of a minimally invasive approach might further reduce the gap between NOM and trauma laparotomy, thus helping to further reduce complications and longer hospital stay following unnecessary laparotomies.
References
Papers of particular interest, published recently, have been highlighted as: • Of importance •• Of major importance
Soreide K. Epidemiology of major trauma. Br J Surg. 2009;96(7):697–8. doi:10.1002/bjs.6643.
Smith J, Caldwell E, D’Amours S, et al. Abdominal trauma: a disease in evolution. ANZ J Surg. 2005;75(9):790–4. doi:10.1111/j.1445-2197.2005.03524.x.
Champion HR, Copes WS, Sacco WJ, et al. The major trauma outcome study: establishing national norms for trauma care. J Trauma. 1990;30(11):1356–65.
Lefering R NU (2015) Annual Report 2015 TraumaRegister DGU. http://www.traumaregister-dgu.de/fileadmin/user_upload/traumaregister-dgu.de/docs/Downloads/TR-DGU-Jahresbericht_2015.pdf. Accessed 22 May 2016
Watts DD, Fakhry SM. Incidence of hollow viscus injury in blunt trauma: an analysis from 275,557 trauma admissions from the EAST multi-institutional trial. J Trauma. 2003;54(2):289–94. doi:10.1097/01.TA.0000046261.06976.6A.
Ogura T, Lefor AT, Nakano M, et al. Nonoperative management of hemodynamically unstable abdominal trauma patients with angioembolization and resuscitative endovascular balloon occlusion of the aorta. J Trauma Acute Care Surg. 2015;78(1):132–5. doi:10.1097/TA.0000000000000473.
Feliciano DV, Rozycki GS (2003) Evaluation of abdominal trauma: American College of Surgeons. https://www.facs.org/∼/media/files/quality%20programs/trauma/publications/abdominal.ashx
Stassen NA, Bhullar I, Cheng JD, et al. Nonoperative management of blunt hepatic injury: an eastern association for the surgery of trauma practice management guideline. J Trauma Acute Care Surg. 2012;73(5 Suppl 4):S288–93. doi:10.1097/TA.0b013e318270160d.
Coccolini F, Catena F, Moore EE, et al. WSES classification and guidelines for liver trauma. World J Emerg Surg. 2016;11:50. doi:10.1186/s13017-016-0105-2.
Schurink GW, Bode PJ, van Luijt PA, et al. The value of physical examination in the diagnosis of patients with blunt abdominal trauma: a retrospective study. Injury. 1997;28(4):261–5.
Chandler CF, Lane JS, Waxman KS. Seatbelt sign following blunt trauma is associated with increased incidence of abdominal injury. Am Surg. 1997;63(10):885–8.
Velmahos GC, Tatevossian R, Demetriades D. The “seat belt mark” sign: a call for increased vigilance among physicians treating victims of motor vehicle accidents. Am Surg. 1999;65(2):181–5.
Natarajan B, Gupta PK, Cemaj S, et al. FAST scan: is it worth doing in hemodynamically stable blunt trauma patients? Surgery. 2010;148(4):695–700. doi:10.1016/j.surg.2010.07.032. discussion 700-1.
Rozycki GS, Ballard RB, Feliciano DV, et al. Surgeon-performed ultrasound for the assessment of truncal injuries: lessons learned from 1540 patients. Ann Surg. 1998;228(4):557–67.
Dolich MO, McKenney MG, Varela JE, et al. 2,576 ultrasounds for blunt abdominal trauma. J Trauma. 2001;50(1):108–12.
Brown MA, Casola G, Sirlin CB, et al. Blunt abdominal trauma: screening us in 2,693 patients. Radiology. 2001;218(2):352–8. doi:10.1148/radiology.218.2.r01fe42352.
Lee BC, Ormsby EL, McGahan JP, et al. The utility of sonography for the triage of blunt abdominal trauma patients to exploratory laparotomy. AJR Am J Roentgenol. 2007;188(2):415–21. doi:10.2214/AJR.05.2100.
Branney SW, Wolfe RE, Moore EE, et al. Quantitative sensitivity of ultrasound in detecting free intraperitoneal fluid. J Trauma. 1995;39(2):375–80.
Diercks DB, Mehrotra A, Nazarian DJ, et al. Clinical policy: critical issues in the evaluation of adult patients presenting to the emergency department with acute blunt abdominal trauma. Ann Emerg Med. 2011;57(4):387–404. doi:10.1016/j.annemergmed.2011.01.013.
Becker A, Lin G, McKenney MG, et al. Is the FAST exam reliable in severely injured patients? Injury. 2010;41(5):479–83. doi:10.1016/j.injury.2009.10.054.
Catre MG. Diagnostic peritoneal lavage versus abdominal computed tomography in blunt abdominal trauma: a review of prospective studies. Can J Surg. 1995;38(2):117–22.
Wood D, Berci G, Morgenstern L, et al. Mini-laparoscopy in blunt abdominal trauma. Surg Endosc. 1988;2(3):184–9.
Sudakoff GS (2012) ACR Appropriateness Criteria: Blunt Abdominal Trauma. https://acsearch.acr.org/docs/69409/Narrative/. Accessed 03 Oct 2016
Holmes JF, McGahan JP, Wisner DH. Rate of intra-abdominal injury after a normal abdominal computed tomographic scan in adults with blunt trauma. Am J Emerg Med. 2012;30(4):574–9. doi:10.1016/j.ajem.2011.02.016.
Lin H, Chen Y, Lin K, et al. Laparoscopy decreases the laparotomy rate for hemodynamically stable patients with blunt hollow viscus and mesenteric injuries. Am J Surg. 2015;210(2):326–33. doi:10.1016/j.amjsurg.2014.11.009.
•• Bhagvan S, Turai M, Holden A, et al. Predicting hollow viscus injury in blunt abdominal trauma with computed tomography. World J Surg. 2013;37(1):123–6. doi:10.1007/s00268-012-1798-3. This study retrospectively reevaluated CT scans for hollow viscus injury in patients with suspected abdominal injuries and subsequent exploration by laparotomy. Correlating CT with operative finding, they described a 55.3% sensitivity and 92.06% specificity of CT in predicting hollow viscus injury. Thus, CT alone does not qualify as a stand-alone screening tool for hollow viscus injuries.
Fakhry SM, Watts DD, Luchette FA. Current diagnostic approaches lack sensitivity in the diagnosis of perforated blunt small bowel injury: analysis from 275,557 trauma admissions from the EAST multi-institutional HVI trial. J Trauma. 2003;54(2):295–306. doi:10.1097/01.TA.0000046256.80836.AA.
Sprunt JM, Brown CVR, Reifsnyder AC, et al. Computed tomography to diagnose blunt diaphragm injuries: not ready for prime time. Am Surg. 2014;80(11):1124–7.
Killeen KL, Mirvis SE, Shanmuganathan K. Helical CT of diaphragmatic rupture caused by blunt trauma. AJR Am J Roentgenol. 1999;173(6):1611–6. doi:10.2214/ajr.173.6.10584809.
Schroeppel TJ, Croce MA. Diagnosis and management of blunt abdominal solid organ injury. Curr Opin Crit Care. 2007;13(4):399–404. doi:10.1097/MCC.0b013e32825a6a32.
Velmahos GC, Toutouzas KG, Radin R, et al. Nonoperative treatment of blunt injury to solid abdominal organs: a prospective study. Arch Surg. 2003;138(8):844–51. doi:10.1001/archsurg.138.8.844.
Brady RRW, Bandari M, Kerssens JJ, et al. Splenic trauma in Scotland: demographics and outcomes. World J Surg. 2007;31(11):2111–6. doi:10.1007/s00268-007-9218-9.
Kamine TH, Elmadhun NY, Kasper EM, et al. Abdominal insufflation for laparoscopy increases intracranial and intrathoracic pressure in human subjects. Surg Endosc. 2016;30(9):4029–32. doi:10.1007/s00464-015-4715-7.
Josephs LG, Este-McDonald JR, Birkett DH, et al. Diagnostic laparoscopy increases intracranial pressure. J Trauma. 1994;36(6):815–8. discussion 818-9.
Mobbs RJ, Yang MO. The dangers of diagnostic laparoscopy in the head injured patient. J Clin Neurosci. 2002;9(5):592–3. doi:10.1054/jocn.2001.1070.
Nicolau AE. Is laparoscopy still needed in blunt abdominal trauma? Chirurgia (Bucur). 2011;106(1):59–66.
Mahamid A, Peleg K, Givon A, et al. Blunt traumatic diaphragmatic injury: a diagnostic enigma with potential surgical pitfalls. Am J Emerg Med. 2016. doi:10.1016/j.ajem.2016.10.046.
• Fair KA, Gordon NT, Barbosa RR, et al. Traumatic diaphragmatic injury in the American College of Surgeons National Trauma Data Bank: a new examination of a rare diagnosis. Am J Surg. 2015;209(5):864–8. doi:10.1016/j.amjsurg.2014.12.023. discussion 868-9. In this National Trauma Data Bank analysis, the authors describe incidences, injury severity and associated injuries in traumatic diaphragmatic injury. They reported statistically significantly higher injury severity scores, mortality and morbidity in blunt diaphragmatic injury as compared to penetrating etiology. Injuries to the aorta, lung, spleen and bladder were shown to be associated with blunt diaphragmatic injury.
Lopez PP, Arango J, Gallup TM, et al. Diaphragmatic injuries: what has changed over a 20-year period? Am Surg. 2010;76(5):512–6.
Degiannis E, Levy RD, Sofianos C, et al. Diaphragmatic herniation after penetrating trauma. Br J Surg. 1996;83(1):88–91.
Johnson JJ, Garwe T, Raines AR, et al. The use of laparoscopy in the diagnosis and treatment of blunt and penetrating abdominal injuries: 10-year experience at a level 1 trauma center. Am J Surg. 2013;205(3):317–20. doi:10.1016/j.amjsurg.2012.10.021. discussion 321.
• Zafar SN, Onwugbufor MT, Hughes K, et al. Laparoscopic surgery for trauma: the realm of therapeutic management. Am J Surg. 2015;209(4):627–32. doi:10.1016/j.amjsurg.2014.12.011. A retrospective analysis of 4,755 US National Trauma Data Bank patients with abdominal trauma undergoing diagnostic laparoscopy. A 19.3% therapeutic laparoscopic intervention rate was observed and the most common indications as well as missed injury and conversion rates are described.
Carey JE, Koo R, Miller R, et al. Laparoscopy and thoracoscopy in evaluation of abdominal trauma. Am Surg. 1995;61(1):92–5.
Zubaidah NH, Azuawarie A, Ong KW, et al. Combined laparoscopic and thoracoscopic repair of a large traumatic diaphragmatic hernia: a case report. Med J Malaysia. 2015;70(2):108–9.
Kurata K, Kubota K, Oosawa H, et al. Thoracoscopic repair of traumatic diaphragmatic rupture. Surg Endosc. 1996;10(8):850–1. doi:10.1007/BF00189549.
Chichom Mefire A, Weledji PE, Verla VS, et al. Diagnostic and therapeutic challenges of isolated small bowel perforations after blunt abdominal injury in low income settings: analysis of twenty three new cases. Injury. 2014;45(1):141–5. doi:10.1016/j.injury.2013.02.022.
Gonser-Hafertepen LN, Davis JW, Bilello JF, et al. Isolated free fluid on abdominal computed tomography in blunt trauma: watch and wait or operate? J Am Coll Surg. 2014;219(4):599–605. doi:10.1016/j.jamcollsurg.2014.04.020.
Omori H, Asahi H, Inoue Y, et al. Selective application of laparoscopic intervention in the management of isolated bowel rupture in blunt abdominal trauma. J Laparoendosc Adv Surg Tech A. 2003;13(2):83–8. doi:10.1089/109264203764654696.
Banz VM, Butt MU, Zimmermann H, et al. Free abdominal fluid without obvious solid organ injury upon CT imaging: an actual problem or simply over-diagnosing? J Trauma Manag Outcomes. 2009;3:10. doi:10.1186/1752-2897-3-10.
• Kordzadeh A, Melchionda V, Rhodes KM, et al. Blunt abdominal trauma and mesenteric avulsion: a systematic review. Eur J Trauma Emerg Surg. 2016;42(3):311–5. doi:10.1007/s00068-015-0514-z. This literature review focused on the rare entity of mesenteric avulsion in blunt abdominal trauma. Analyzing 20 cases reported over a period of 63 years, the authors identified seat belt restraint as the mechanism of injury in 60%.
Frick Jr EJ, Pasquale MD, Cipolle MD. Small-bowel and mesentery injuries in blunt trauma. J Trauma. 1999;46(5):920–6.
Killeen KL, Shanmuganathan K, Poletti PA, et al. Helical computed tomography of bowel and mesenteric injuries. J Trauma. 2001;51(1):26–36.
Matsushima K, Mangel PS, Schaefer EW, et al. Blunt hollow viscus and mesenteric injury: still underrecognized. World J Surg. 2013;37(4):759–65. doi:10.1007/s00268-012-1896-2.
Dowe MF, Shanmuganathan K, Mirvis SE, et al. CT findings of mesenteric injury after blunt trauma: implications for surgical intervention. AJR Am J Roentgenol. 1997;168(2):425–8. doi:10.2214/ajr.168.2.9016219.
Kaban GK, Novitsky YW, Perugini RA, et al. Use of laparoscopy in evaluation and treatment of penetrating and blunt abdominal injuries. Surg Innov. 2008;15(1):26–31. doi:10.1177/1553350608314664.
Chol YB, Lim KS. Therapeutic laparoscopy for abdominal trauma. Surg Endosc. 2003;17(3):421–7. doi:10.1007/s00464-002-8808-8.
•• Boni L, David G, Dionigi G, et al. Indocyanine green-enhanced fluorescence to assess bowel perfusion during laparoscopic colorectal resection. Surg Endosc. 2016;30(7):2736–42. doi:10.1007/s00464-015-4540-z. The authors report their experience with indocyanine green (ICG)-enhanced laparoscopy to check bowel perfusion in colorectal anastomosis. Due to intraoperative use of ICG margins for anastomosis were changed in 3.7% of patients. The authors observed no anastomotic leak due to bowel ischemia.
Uranus S, Dorr K. Laparoscopy in abdominal trauma. Eur J Trauma Emerg Surg. 2010;36(1):19–24. doi:10.1007/s00068-010-9219-5.
Agresta F, Ansaloni L, Baiocchi GL, et al. Laparoscopic approach to acute abdomen from the Consensus Development Conference of the Societa Italiana di Chirurgia Endoscopica e nuove tecnologie (SICE), Associazione Chirurghi Ospedalieri Italiani (ACOI), Societa Italiana di Chirurgia (SIC), Societa Italiana di Chirurgia d’Urgenza e del Trauma (SICUT), Societa Italiana di Chirurgia nell’Ospedalita Privata (SICOP), and the European Association for Endoscopic Surgery (EAES). Surg Endosc. 2012;26(8):2134–64. doi:10.1007/s00464-012-2331-3.
Biswas S, Vedanayagam M, Hipkins G, et al. Acute direct inguinal hernia resulting from blunt abdominal trauma: case report. World J Emerg Surg. 2010;5:16. doi:10.1186/1749-7922-5-16.
Carrillo EH, Reed Jr DN, Gordon L, et al. Delayed laparoscopy facilitates the management of biliary peritonitis in patients with complex liver injuries. Surg Endosc. 2001;15(3):319–22. doi:10.1007/s004640000300.
Franklin GA, Richardson JD, Brown AL, et al. Prevention of bile peritonitis by laparoscopic evacuation and lavage after nonoperative treatment of liver injuries. Am Surg. 2007;73(6):611–6. discussion 616-7.
Kozar RA, Moore FA, Moore EE, et al. Western Trauma Association critical decisions in trauma: nonoperative management of adult blunt hepatic trauma. J Trauma. 2009;67(6):1144–8. doi:10.1097/TA.0b013e3181ba361f. discussion 1148-9.
Letoublon C, Chen Y, Arvieux C, et al. Delayed celiotomy or laparoscopy as part of the nonoperative management of blunt hepatic trauma. World J Surg. 2008;32(6):1189–93. doi:10.1007/s00268-007-9439-y.
Subramanian A, Dente CJ, Feliciano DV. The management of pancreatic trauma in the modern era. Surg Clin North Am. 2007;87(6):1515–32. doi:10.1016/j.suc.2007.08.007.
Reynolds EM, Curnow AJ. Laparoscopic distal pancreatectomy for traumatic pancreatic transection. Journal of Pediatric Surgery. 2003;38(10):E7–9. doi:10.1016/S0022-3468(03)00519-0.
Nikfarjam M, Rosen M, Ponsky T. Early management of traumatic pancreatic transection by spleen-preserving laparoscopic distal pancreatectomy. J Pediat Surg. 2009;44(2):455–8. doi:10.1016/j.jpedsurg.2008.09.026.
Hiremath B, Hegde N. Non-operative management of a grade IV pancreatic injury. BMJ Case Rep. 2014. doi:10.1136/bcr-2014-203805.
Vijay A, Abdelrahman H, El-Menyar A et al. (2014) Early laparoscopic approach to pancreatic injury following blunt abdominal trauma. J Surg Case Rep 2014(12). doi: 10.1093/jscr/rju129.
Stassen NA, Bhullar I, Cheng JD, et al. Selective nonoperative management of blunt splenic injury: an eastern association for the surgery of trauma practice management guideline. J Trauma Acute Care Surg. 2012;73(5 Suppl 4):S294–300. doi:10.1097/TA.0b013e3182702afc.
Uranues S, Fingerhut A. Splenic injuries. In: Head, thoracic, abdominal and vascular injuries (Eds. Hans-Joerg Oestern, Otmar Trentz, Selman Uranues).Springer Verlag, Berlin, Heidelberg 2011; 285–295.
Uranues S, Kilic YA. Injuries to the spleen. Eur J Trauma Emerg Surg. 2008;34(4):355. doi:10.1007/s00068-008-8102-0.
Ayiomamitis GD, Alkari B, Owera A, et al. Emergency laparoscopic splenectomy for splenic trauma in a Jehovah’s Witness patient. Surg Laparosc Endosc Percutan Tech. 2008;18(6):626–30. doi:10.1097/SLE.0b013e31818133c6.
Koehler RH, Smith RS, Fry WR. Successful laparoscopic splenorrhaphy using absorbable mesh for grade III splenic injury: report of a case. Surg Laparosc Endosc. 1994;4(4):311–5.
Agarwal N. Laparoscopic splenectomy in a case of blunt abdominal trauma. J Minim Access Surg. 2009;5(3):78–81. doi:10.4103/0972-9941.58503.
Carobbi A, Romagnani F, Antonelli G, et al. Laparoscopic splenectomy for severe blunt trauma: initial experience of ten consecutive cases with a fast hemostatic technique. Surg Endosc. 2010;24(6):1325–30. doi:10.1007/s00464-009-0768-9.
Villavicencio RT, Aucar JA. Analysis of laparoscopy in trauma. J Am Coll Surg. 1999;189(1):11–20. doi:10.1016/S1072-7515(99)00052-6.
Johnson JW, Gracias VH, Gupta R, et al. Hepatic angiography in patients undergoing damage control laparotomy. J Trauma. 2002;52(6):1102–6.
Kawahara NT, Alster C, Fujimura I, et al. Standard examination system for laparoscopy in penetrating abdominal trauma. J Trauma. 2009;67(3):589–95. doi:10.1097/TA.0b013e3181a60593.
Fabian TC, Croce MA, Stewart RM, et al. A prospective analysis of diagnostic laparoscopy in trauma. Ann Surg. 1993;217(5):557–64. discussion 564-5.
Lim KH, Chung BS, Kim JY, et al. Laparoscopic surgery in abdominal trauma: a single center review of a 7-year experience. World J Emerg Surg. 2015;10:16. doi:10.1186/s13017-015-0007-8.
Mathonnet M, Peyrou P, Gainant A, et al. Role of laparoscopy in blunt perforations of the small bowel. Surg Endosc. 2003;17(4):641–5. doi:10.1007/s00464-002-9049-6.
Gorecki PJ, Cottam D, Angus LDG, et al. Diagnostic and therapeutic laparoscopy for trauma: a technique of safe and systematic exploration. Surg Laparosc Endosc Percutan Tech. 2002;12(3):195–8.
Ozkan OV, Justin V, Fingerhut A, et al. Laparoscopy in abdominal trauma. Curr Trauma Rep. 2016. doi:10.1007/s40719-016-0067-6.
Uranues S, Ozkan OV, Tomasch G. Safe and easy access technique for the first trocar in laparoscopic surgery. Langenbecks Arch Surg. 2016;401(6):909–12. doi:10.1007/s00423-016-1474-4.
Azevedo JLMC, Azevedo OC, Miyahira SA, et al. Injuries caused by Veress needle insertion for creation of pneumoperitoneum: a systematic literature review. Surg Endosc. 2009;23(7):1428–32. doi:10.1007/s00464-009-0383-9.
Zantut LF, Ivatury RR, Smith RS, et al. Diagnostic and therapeutic laparoscopy for penetrating abdominal trauma: a multicenter experience. J Trauma. 1997;42(5):825–9. discussion 829-31.
Cottin V, Delafosse B, Viale J. Gas embolism during laparoscopy. Surg Endosc. 1996;10(2):166–9. doi:10.1007/BF00188365.
Mohammedi I, Ber C, Peguet O, et al. Cardiac air embolism after endoscopic retrograde cholangiopancreatography in a patient with blunt hepatic trauma. J Trauma. 2002;53(6):1170–2. doi:10.1097/01.TA.0000030050.69240.DD.
Renz BM, Feliciano DV. Unnecessary laparotomies for trauma: a prospective study of morbidity. J Trauma. 1995;38(3):350–6.
Redmond HP, Andrews E, Hill DK (2005) Diagnostic laparoscopy—clinical guidelines of the RCSI. https://www.rcsi.ie/files/surgery/docs/20101221085858_7433%20RCSI%20Laparoscopy%20Guide.pd.pdf. Accessed 26 May 2016
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.
Hoff WS, Holevar M, Nagy KK, et al. Practice management guidelines for the evaluation of blunt abdominal trauma: the EAST Practice Management Guidelines Work Group. J Trauma. 2002;53(3):602–15. doi:10.1097/01.TA.0000025413.43206.97.
Taner AS, Topgul K, Kucukel F, et al. Diagnostic laparoscopy decreases the rate of unnecessary laparotomies and reduces hospital costs in trauma patients. J Laparoendosc Adv Surg Tech A. 2001;11(4):207–11. doi:10.1089/109264201750539718.
Lee P, Lo C, Wu J, et al. Laparoscopy decreases the laparotomy rate in hemodynamically stable patients with blunt abdominal trauma. Surg Innov. 2014;21(2):155–65.
Acknowledgments
Open access funding provided by Medical University of Graz.
Author information
Authors and Affiliations
Corresponding author
Ethics declarations
Conflict of Interest
Drs. Justin, Fingerhut, and Uranues declare no conflicts of interest relevant to this manuscript.
Human and Animal Rights and Informed Consent
This article does not contain any studies with human or animal subjects performed by any of the authors.
Additional information
This article is part of the Topical Collection on Blunt Abdominal Trauma
Rights and permissions
Open Access This article is distributed under the terms of the Creative Commons Attribution 4.0 International License (http://creativecommons.org/licenses/by/4.0/), which permits unrestricted use, distribution, and reproduction in any medium, provided you give appropriate credit to the original author(s) and the source, provide a link to the Creative Commons license, and indicate if changes were made.
About this article
Cite this article
Justin, V., Fingerhut, A. & Uranues, S. Laparoscopy in Blunt Abdominal Trauma: for Whom? When?and Why?. Curr Trauma Rep 3, 43–50 (2017). https://doi.org/10.1007/s40719-017-0076-0
Published:
Issue Date:
DOI: https://doi.org/10.1007/s40719-017-0076-0