Acute abdominal trauma is a very common situation to deal for any general surgeon. One must know how to deal with this and how laparoscopy is helpful in this.

1. Dr. Keyur Bhatt
(M.S., M.R.C.S Ed.)
Department of GI & Minimal Access Surgery
SIDS Hospital & Research Center
www.gisurgerysurat.com www.sidshospital.com

2. Laparoscopic management in
acute abdomen & Trauma
14.04.2018

3. Acute abdomen
• Acute appendicitis
• Acute cholecystitis
• Acute Pancreatitis
• Ectopic pregnancy rupture
• Torsion of ovarian cyst
• Visceral perforation
• Small bowel obstruction due to adhesions/band
• Incarcerated or strangulated hernias
• Nonspecific abdominal pain Diagnostic laparoscopy is
technically feasible and can be applied safely for selected
patients with acute nonspecific abdominal pain after a
complete diagnostic work-up

4. Indications
Abdominal traumas
Iatrogenic trauma
Blunt trauma
Penetrating trauma

5. Indications
• Suspected but unproven intra-abdominal injury after blunt
or penetrating trauma
• More specific indications include:
• Suspected intra-abdominal injury despite negative initial
workup after blunt trauma
• Abdominal stab wounds with proven or equivocal
penetration of fascia
• Abdominal gunshot wounds with doubtful intraperitoneal
trajectory
• Diagnosis of diaphragmatic injury from penetrating trauma
to the thoracoabdominal area
• Creation of a transdiaphragmatic pericardial window to rule
out cardiac injury

6. What all can be done
• 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

7. Contraindications (Absolute or
Relative)
• Hemodynamic instability (defined by most
studies as systolic pressure < 90 mm Hg)
• A clear indication for immediate laparotomy
such as frank peritonitis, hemorrhagic shock,
or evisceration
• Posterior penetrating trauma with high
likelihood of bowel injury
• Known or obvious intra-abdominal injury **
• Limited laparoscopic expertise *

8. Risks
• Delay to definitive treatment ! (sometimes)
• Missed injuries with their associated
morbidity
• Procedure- and anesthesia-related
complications

9. Benefits
• Reduction in the rate of negative and
nontherapeutic laparotomies (with a
subsequent decrease in hospitalization,
morbidity, and cost after negative
laparoscopy)
• Accurate identification of diaphragmatic injury
• Ability to provide therapeutic intervention

10. 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)

11. Procedure-related Complications and
Patient Outcomes
• A 1999 review of 37 studies, which included more than 1,900
patients demonstrated a procedure-related complication rate of 1%
» Journal of the American College of Surgeons 1999;189(1):11-20
• Intraoperative complications can occur during creation of the
pneumoperitoneum, trocar insertion, or during the diagnostic
examination.
• Includes
– Tension pneumothorax caused by unrecognized injuries to the
diaphragm, perforation of a hollow viscus
– Laceration of a solid organ
– Vascular injury (usually trocar injury of an epigastric artery or
lacerated omental vessels)
– Subcutaneous or extraperitoneal dissection by the insufflation gas.
– Port site infections.

12. MORBIDITY
• Comparative studies suggest lower morbidity
rates after negative DL compared with
negative exploratory laparotomy (level II, III)
» Journal of the Society of Laparoendoscopic Surgeons 2004;8(4):304-9.
» The Accuracy of Diagnostic Laparoscopy in Trauma Patients: a
Prospective, Controlled Study. International Surgery 1998;83(4):294-8.

13. LIMITATIONS / ISSUES
The impact of laparoscopic
expertise on the diagnostic
accuracy of the procedure
has not been assessed
The sensitivity, specificity, accuracy,
and number of missed injuries can
be substantially influenced by
EXPERIENCE, it is difficult to
provide firm recommendations on
the role of DL in trauma patients

14. Recommendations
• Diagnostic laparoscopy is technically feasible and can
be applied safely in appropriately selected trauma
patients (grade B).
• It should be considered in hemodynamically stable
blunt trauma patients with suspected intra-abdominal
injury and equivocal findings on imaging studies or
even in patients with negative studies but a high
clinical likelihood for intra-abdominal injury (grade C).
• It may be particularly useful and should be considered
in patients with penetrating trauma of the abdomen
with documented or equivocal penetration of the
anterior fascia (grade C).

15. Recommendations
• It should be used in patients with suspected
diaphragmatic injury, as imaging occult injury rates are
significant, and DL offers the best diagnostic accuracy
(grade C).
• Patients should be followed cautiously postoperatively
for the early identification of missed injuries.
Therapeutic intervention can be provided safely when
laparoscopic expertise is available (grade C).
• To optimize results, the procedure should be
incorporated in institutional diagnostic and treatment
algorithms for trauma patients.

16. Precautions
• Keep matched PCVs available
• Be prepared for rapid conversion to open
• GA
• NG/OG
• Foley
• Fully equipped OR

17. Conduct of Laparoscopy
• 5mm umbilical trocar
• 2 or more 3-5mm trocars → L flank, suprapubic
• 4 quadrant evaluation for blood, bile, urine, fecal
contamination
• Liver, spleen
• Diaphragm, peritoneal surfaces
• SB + mesentery (very important)
• Stomach, duodenum, colon, rectum.
• Explore lesser sac + pancreas as directed by CT

18. Indications for Conversion to
Laparotomy
Acute hemodynamic deterioration
Dense adhesions
Gross intestinal distention
Bleeding that cannot be controlled laparoscopically
Injuries not amenable to laparoscopic repair

19. Blunt trauma

20. Penetrating trauma