The value is limited.

1. Diagnostic Laparoscopy in Trauma:
Evidences and Indications
Raimundas Lunevicius MD PhD
Major Trauma & Emergency Surgery Centre
King’s College Hospital London
11 March 2011
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2. All good things are good
• Evidence based approach / medicine
– Evidences:
• Grades A, B, C
• Classes I, II, III
– Opinions, guidelines of experts / committees (VALUABLE INFO !):
» class IV evidence
» summary of ABC grades evidences
• Level I, II, III recommendations
• Experience based approach / medicine
• Common sense based approach / medicine
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3. PubMed / Medline
Relevant articles selected
• Metaanalysis – 0
• Randomized trials – 2 (by Cuschieri, by Leppäniemi)
• Not-randomized clinical trials – 9
• Retrospective reviews – 34
• Literature review with / without guidelines – 5 (!)
• Case reports - 750 Laparoscopy [Mesh] +Wounds, Injuries [Mesh]
Not taken into account
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4. Grade A evidences:
two randomized trials Scotland and Finland
• Cuschieri A, Hennessy TP, Stephens RB, Berci G. Ann R Coll Surg
Engl. 1988 May;70(3):153-5.
– Diagnosis of significant abdominal trauma after road traffic accidents: preliminary
results of a multicentre clinical trial comparing minilaparoscopy with peritoneal lavage.
• Key message: The results of the trial to date suggest that minilaparoscopy may
have an advantage over peritoneal lavage in reducing the number of
unnecessary laparotomics.
• Leppäniemi A, Haapiainen R. J Trauma. 2003 Oct;55(4):636-45.
– Diagnostic laparoscopy in abdominal stab wounds: a prospective, randomized study.
• Key message: Diagnostic laparoscopy cannot be recommended as a routine
diagnostic tool in anterolateral abdominal and thoracoabdominal stab
wounds.
• INTERPRETATION…
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5. Interpretation
• Laparoscopy may be selectively considered as
a diagnostic tool in abdominal stab /
penetrating wounds in reducing the number
of unnecessary laparotomies
Como, et all. J Trauma 2010, 68 (3): 721-33 (guidelines: summary)
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6. Diagnostic laparoscopy (DL):
towards selective nonoperative management
• What are indications for DL ?
• Comprehensive literature reviews available
– Summarize evidences
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7. REVIEW 1
Laparoscopy in trauma, 1999
Villavicencio, J Am Coll Surg 1999; 189:11-20 : 62 articles reviewed
• Laparoscopy is effective as a screening tool in
stable pts
• DL value is limited when it is applied as a
diagnostic tool
– because of the large number of missed injuries:
41-77%
• Laparoscopy for definitive operative repair must be applied
carefully at the discretion of an experienced laparoscopist
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8. Review 2
Goettler, et al. Current Surgery 2004; 61 (6): 554-559: 45 articles reviewed
DL in trauma has a role in a small group of pts
PAT: hemodynamically stable pts with limited
penetrating injuries to the abd or tho-abdo area
1. evaluation of the diaphragm in thoracoabdo wounds
2. for determination of peritoneal penetration for APT
BAT: if diaphragmatic rupture is suspected
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9. Review 3
Diagnostic laparoscopy guidelines. SAGES. Surg Endosc 2008; 22:1353-1383
25 articles reviewed in ‘Diagnostic laparoscopy for trauma’ section
• Suspected but unproven intra-abdominal injury after
blunt or penetrating trauma in stable pts
• In stable patients with suspected diaphragmatic
injury, as imaging occult injury rates are significant
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10. Review 4:
one indication !
Como, Bokhari, Chiu, Duane, Holevar, Tandoh, Ivatury, Scalea. J Trauma 2010; 68(3): 721-733.
95 articles reviewed (1960 - 2007).
+ DL should be strongly considered in patients with
penetrating trauma to the left thoracoabdominal area
who have no other indications for laparotomy to rule
out and to potentially repair diaphragmatic injuries.
Observation is not appropriate for wounds located in the
left upper quadrant (LUQ)
– The use of DL to identify hollow viscus injuries is not
recommended at the present time (three papers: 1987, 1992, 1993).
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11. Obvious left diaphragm injury
Injury on chest X-ray Stomach herniation on CT-san
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12. Small size L diaphragm injury
Rupture of posterior medial L
diaphragm: upper pole of spleen
Surgery:
2 cm size L diaphragm injury
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13. Review 5
Ball. Laparoscopy in trauma, 2009
Laparoscopic treatment
1. Repair of the diaphragm
2. Diverting colostomy for extraperitoneal rectal
injury
NB! The acceptance of therapeutic MIS into trauma surgery
will continue to depend on the skill sets of individual surgeons
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14. Message to remember (gr B)
• PT to the L thoracoabdo region / to the LUQ:
L diaphragm
in stable pts
Thank you
NB! Laparoscopy, like all areas of surgical science, is a process in evolution and
must be reassessed periodically for safety and efficacy.
Villavicencio, Aucar. J Am Coll Surg 1999; 189:11-20
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