Cuando usar laparoscopia en trauma abdominal

1. Trauma laparoscopy: when to start and when to convert?
Oleh Matsevych1,2 • Modise Koto1,2 • Moses Balabyeki1 • Colleen Aldous2
Received: 4 April 2017 / Accepted: 31 July 2017 / Published online: 10 August 2017
Ó Springer Science+Business Media, LLC 2017
Abstract
Background The use of laparoscopy for stable patients
with abdominal trauma is increasing and its accuracy is
nearly 100%. However, indications for laparoscopy and for
conversion differ among centers. The aim of this study was
to investigate indications for trauma laparoscopy and for
conversion to laparotomy.
Methods All trauma patients managed with laparoscopy
over a 4-year period were retrospectively analyzed. Indi-
cations for laparoscopy, morbidity, and reasons for con-
version were investigated and predictors of morbidity and
conversion were sought. The management algorithm of
trauma patients was reviewed and updated.
Results Laparoscopy was used in 318 stable trauma
patients. Thirty-five patients presented with blunt and 283
with penetrating abdominal injuries. The conversion rate
was 11.7% for penetrating and 22.9% for blunt abdominal
trauma patients. The most common reason for conversion
was continuous intraabdominal bleeding that could not be
controlled quickly. It was followed by multiple complex
injuries, hemodynamic instability, and intraoperative
visualization problems. Diagnostic laparoscopy was per-
formed in 45%, and therapeutic laparoscopy in 55% of
cases. There were no missed injuries. Complications
occurred in 21.2% in the converted group and in 9.6% in
the laparoscopic group. Among initial systolic blood
pressure, pulse, hemoglobin, lactate, and base deficit levels,
only lower pH was associated with conversion.
Conclusion The management of all stable trauma patients
with laparoscopy appears to be a safe approach. The use of
sound laparoscopic equipment by a well-coordinated
trauma team with adequate expertise in laparoscopy,
adherence to the algorithm, and strict compliance with
predetermined procedural steps are fundamental to success.
Continuous intraoperative bleeding, complexity of injuries,
deterioration of the patient, poor visibility, and equipment
failure are indications for conversion.
Keywords Trauma Laparoscopy Indication
Conversion Therapeutic laparoscopy Trauma
laparoscopy
Laparoscopy for trauma was initially criticized because of
the perceived high risk of missed injuries [1, 2]. However,
laparoscopic equipment and techniques have improved
over the last few years and the development of a standard
examination system for laparoscopy in trauma by Kawa-
hara et al. has increased its accuracy [3]. As a result, the
sensitivity, specificity, and accuracy of laparoscopy are
reported to be nearly 100% in recent studies [4, 5]. With
regard to missed injuries, the rate during laparoscopy has
decreased to as low as 0.12%, which does not differ sta-
tistically from the rate during laparotomy [5]. Although
laparotomy is reserved for unstable patients, it remains the
most commonly performed procedure for a definite eval-
uation of a stable patient with penetrating abdominal
trauma (PAT). Laparotomy carries a 0–5% mortality rate, a
20% morbidity rate, and a 6% long-term risk of adhesive
bowel obstruction [6, 7]. At least 45.6% of nontherapeutic
laparotomies could be avoided using laparoscopy for
Oleh Matsevych
info@matsevych.com
1
Department of Surgery, Dr George Mukhari Academic
Hospital, Sefako Makgatho Health Sciences University,
P.O. Box 231, Pretoria 0204, South Africa
2
University of KwaZulu – Natal, Nelson R Mandela
(NRMSM) Campus, Durban, South Africa
123
Surg Endosc (2018) 32:1344–1352
https://doi.org/10.1007/s00464-017-5812-6
and Other Interventional Techniques

2. trauma [5]. At centers with appropriate expertise in
laparoscopic surgery, even therapeutic laparotomies could
be avoided in most stable patients [8]. In cases of multiple
hollow viscus injuries, the laparoscopic-assisted approach
(LAA) can be utilized in order to avoid conversion to
laparotomy [9]. The conversion rate ranges from as high as
45% to as low as 7% [2, 8].
The indications for laparoscopy in trauma and for con-
version to laparotomy differ significantly among centers.
For example, in some centers, the presence of organ evis-
ceration, multiple bowel injuries, or even any injury
requiring therapeutic procedures were reported to be the
indications for conversion; however, such injuries are
successfully managed laparoscopically in other centers.
The aim of this study was to investigate the indications for
trauma laparoscopy, for conversion to laparotomy, and to
update the algorithm for trauma laparoscopy. The sec-
ondary aim was to identify predictors of complications and
conversion.
Methods
Data from the prospectively collected trauma database
were extracted and analyzed. The data were collected at a
single institution (Dr George Mukhari Academic Hospital,
Pretoria, South Africa) providing trauma services for a
population of 7.3 million people, most of whom live in
Gauteng Province, South Africa. All adult trauma patients
approached with laparoscopy from January 2012 to
December 2015 were included in the study. The cases
recorded as converted-to-laparotomy, laparoscopic, or
laparoscopic-assisted were analyzed. Patients younger than
12 years, patients managed with initial laparotomy, or
those who had undergone successful nonoperative man-
agement (NOM) were excluded from the study. Cases with
missing records were also excluded from the study. All
patients included in the study were allocated to either the
laparoscopic or converted group. Laparoscopy was divided
into diagnostic laparoscopy (DL) and therapeutic laparo-
scopy (TL). All operations were performed under general
anesthesia by a surgeon equally dexterous with advanced
laparoscopic techniques and open procedures. Depending
on maturity level, surgeons in training were allowed to
perform procedures under supervision. The Injury Severity
Score (ISS), the abdominal New Injury Severity Score
(aNISS), the Penetrating Abdominal Trauma Index (PATI),
outcomes, and the length of hospital stay (LOS) were
calculated and compared between both groups. LOS was
calculated from date of admission to date of discharge from
hospital. In order to describe and compare the severity of
intraabdominal injuries, the New Injury Severity Score
(NISS) was modified to aNISS and calculated within the
abdominal region of abbreviated injury regions. Initial
systolic blood pressure (SBP), pulse (Ps), hemoglobin
(Hb), pH, lactate, base deficit (BE), and outcomes were
recorded and analyzed in patients with PAT. The compli-
cations of Clavien–Dindo (CD) grades 3–5 were consid-
ered significant and were analyzed [10]. Demographic data,
mechanism of injury, location of injury, trauma scoring,
comorbidities, complications, and LOS were recorded for
converted-to-laparotomy patients with PAT and BAT. The
reasons for conversion were analyzed in detail.
Diagnostic procedures were with, or without, penetra-
tion of the abdominal cavity and not requiring any thera-
peutic procedures (nontherapeutic). Evacuation of liquid
blood or clots, placement of hemostatic agents, and
mobilization of any intra- or retroperitoneal organs for
diagnostic purposes were not considered as TL. TL was
defined as the laparoscopic management of intraabdominal
injuries (more than observation or hemostatic agent appli-
cation). Therapeutic procedures were fully laparoscopic or
laparoscopic-assisted. In the fully laparoscopic procedures,
all interventions were performed intracorporeally. During
LAA, the injured bowel was eviscerated through assisted
access in order to perform the extracorporeal repair,
resection, or anastomosis in patients with multiple injuries.
Assisted access was a 4- to 8-cm incision of the abdominal
wall, usually incorporating the injury site. During each
laparoscopic procedure for trauma, the standard diagnostic,
decision-making and therapeutic steps (Fig. 1) were fol-
lowed, as described by Koto et al. [9] The departmental
algorithm for trauma laparoscopy reported by Koto was
reviewed and updated [11].
Details of the patients were summarized descriptively by
mean, median, minimum, and maximum values for con-
tinuous variables, and by frequency count and percentage
calculations for categorical variables. BAT patients were
1. Access, pneumoperitoneum, and ports placement.
2. Quick assessment of the abdomen and bleeding control.
3. Systematic inspection of intraperitoneal and retroperitoneal organs.
4. Decision to proceed with laparoscopy, laparoscopic-assisted approach or conversion.
5. Therapeutic procedures (fully laparoscopic, laparoscopic-assisted).
6. Intracorporeal completion of inspection or re-inspection of intraabdominal organs.
7. Extracorporeal repair of port sites, site of injury or assisted incision.
Fig. 1 Procedure steps of laparoscopy for abdominal trauma
Surg Endosc (2018) 32:1344–1352 1345
123

3. excluded from further statistical analysis because of their
very small numbers.
The Fisher’s exact test was used for comparisons of
frequency counts/percentages. Mean values were compared
using the two-sample t test. Median values were compared
by the nonparametric Wilcoxon rank-sum test. A logistic
regression was performed with complications as a depen-
dent variable and SBP, Ps, Hb, pH, lactate, and BE as the
predictor variables. A backward elimination logistic
regression was performed with conversion as a dependent
variable and SBP, Ps, Hb, pH, lactate, and BE as the pre-
dictor variables. All statistical procedures were performed
with SAS software (SAS Institute, Cary, NC). A value of
p 0.05 was considered significant.
The study was approved by the Sefako Makgatho Univer-
sity Research Ethics Committee, Pretoria, South Africa.
Results
A total of 318 patients were approached with laparoscopy
over the 4-year period. All patients were managed along
the Advanced Trauma Life Support guidelines and were
considered to be stable after initial resuscitation. Thirty-
five patients presented with BAT and 283 with PAT. Eight
(22.9%) patients were converted to laparotomy in the BAT
group and 33 (11.7%) patients in the PAT group. The other
277 patients were managed with fully laparoscopic or
laparoscopic-assisted techniques (Fig. 2).
For converted-to-laparotomy patients, demographic
data, mechanism of injury, location of injury, trauma
scoring, comorbidities, complications, and LOS are shown
in Table 1. In the converted group, the most common
mechanism of injury was gunshot wound (GSW) (72.7%),
and the location of injury was on the anterior abdominal
wall in 69.7% of patients with penetrating injuries. The
most common mechanism of injury in BAT patients was a
motor vehicle accident (MVA). ISS was similar in both
groups, but aNISS and PATI were higher in patients with
PAT. The most common reason for conversion was con-
tinuous intraabdominal bleeding that could not be con-
trolled quickly. It was followed by multiple complex
injuries, hemodynamic instability, and intraoperative
visualization problems. Respiratory instability and equip-
ment failure, as a reason for conversion, were recorded in a
single case in each group. Most patients had more than one
reason for conversion to laparotomy. Intraabdominal
bleeding was often associated with multiple complex
injuries and hemodynamic instability (Table 2).
In patients with PAT, the ISS, aNISS, and PATI scores
were significantly higher in the converted group (10 vs. 13;
9 vs. 19; 5 vs. 17, respectively). LOS was significantly
longer in the converted than in the laparoscopic group (13
vs. 6.6 days) (Table 3). Complications occurred in 21.2%
in the converted group and in 9.6% in the laparoscopic
group, but the difference did not reach statistical signifi-
cance. The SBP, Ps, Hb, lactate, and BE were not statis-
tically different between the two groups, but pH was
statistically lower in the converted group. A logistic
regression showed that SBP, Ps, Hb, pH, lactate, and BE
values could not be predictor variables for complication in
both groups. At the elimination procedure, only pH was
found to be a statistically significant predictor variable for
conversion (p = 0.0074) (Table 4).
Laparoscopy for Penetrang
abdominal trauma (PAT)
n=283
Converted
n=33 (11.7%)
Laparoscopy
n=250
Diagnosc
n=113 (45%)
Therapeuc
n=137 (55%)
FL
n=111
(44.4%)
FL
n=72
(28.8%)
LAA
n=2
(0.8%)
LAA
n=65
(26%)
Laparoscopy for Blunt
abdominal trauma (BAT)
n=35
Converted
n=8 (22.9%)
Diagnosc
n=12 (44%)
Therapeuc
n=15 (56%)
Laparoscopy
n=27
FL
n=12
(100%)
FL
n=9
(60%)
LAA
n=0
(0%)
LAA
n=6
(40%)
Laparoscopy for
trauma
2012-15, n=318
Fig. 2 Laparoscopy for
abdominal trauma. FL fully
laparoscopic, LAA laparoscopic-
assisted approach
1346 Surg Endosc (2018) 32:1344–1352
123

4. Our algorithm for the management of blunt and pene-
trating abdominal trauma with laparoscopy is depicted in
Fig. 3. All stable patients or those that responded to initial
resuscitation who needed surgical treatment were offered
laparoscopy. The patients who failed selective nonopera-
tive management were also offered laparoscopic explo-
ration. The laparoscopic procedure could be either
diagnostic or therapeutic and was performed fully laparo-
scopically or LAA was used. All patients were continu-
ously assessed for indications for conversion. If the
conversion criteria were met, the patient was promptly
converted to laparotomy.
Only less than two-third of patients came for follow-up
visit in 1 week after discharge and there were no significant
complications recorded.
Discussion
In the early development of laparoscopy in trauma, the
sensitivity of DL was reported to be as low as 18% [1].
Since then, laparoscopic equipment and surgical techniques
have improved. Systematic laparoscopic examination of
the abdominal cavity was first reported by Kawahara et al.
Table 1 Characteristics of converted-to-laparotomy trauma patients
Penetrating abdominal trauma (PAT) Blunt abdominal trauma (BAT)
Total 33 8
Male 31 7 (87.5%)
Female 2 1 (12.5%)
Age 31 (17–65) 47 (27–66)
Mechanism
MVA – 4
PVA – 2
Crush – 1
Fall from height – 1
GSW 24 (72.7%) –
Stab 9 (27.3%) –
Single 32 –
Multiple 1 –
Location
Anterior 23 (69.7%) –
Lower chest 6 (18.2%) –
Flank 2 (6.1%) –
Back 2 (6.1%) –
Chest injury
Hemopneumothorax 6 (18.2%) 0
None 27 (81.8%) 8
Scoring
ISS 12.7 (4–20) 12 (4–18)
aNISS 19.4 (4–42) 14 (4–34)
PATI 17 (0–42) 10 (2–28)
Complications 7 (21.2%) 3 (37.5%)
Clavien–Dindo (CD) grades
CD 3 7 (21.2%) 1
CD 5 0 2
No complications 26 (78.8%) 5 (62.5%)
Length of hospital stay (LOS) mean/median (range) 13/9 (2–47) 9.25 (1–19)
MVA motor vehicle accident, PVA pedestrian vehicle accident, GSW gunshot wound, ISS the Injury Severity Score, aNISS the abdominal New
Injury Severity Score, PATI the Penetrating Abdominal Trauma Index, CD Clavien–Dindo classification
Surg Endosc (2018) 32:1344–1352 1347
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5. [3]. The accuracy of DL has improved dramatically with
reported sensitivity and specificity at nearly 100% in recent
studies [4, 6, 12]. Nevertheless, the current rate of missed
injuries reported in the literature is 0.4% [13]. In our study,
laparoscopic surgery in trauma follows several distinct
steps, which include careful systematic examination of
intra- and retroperitoneal abdominal organs. Adherence to
these steps minimizes the possibility of missing injuries
and enhances appropriate therapeutic options for each
particular patient. There were no known missed injuries in
Table 2 Reasons for conversion in patients with penetrating and blunt abdominal trauma
Penetrating abdominal
trauma (PAT)
Blunt abdominal
trauma (BAT)
Total
Continuous intraabdominal bleeding (liver Gr 4, IVC, mesentery, iliac vein,
retroperitoneal hematoma, spleen Gr 3–4, right kidney hilum)
17 4 21
Unstable respiratory 1 0 1
Unstable hemodynamically 5 0 5
Multiple complex injuries 7 1 8
Visualization (bowel distension, retroperitoneal hematoma, omental caking, multiple
adhesions)
3 2 5
Equipment failure (suction) 0 1 1
Total 33 8 41
Gr grade, IVC inferior vena cava
Table 3 Trauma scores, length of hospital stay, and complications in patients with penetrating abdominal trauma
Diagnostic laparoscopy (DL) Therapeutic laparoscopy (TL) DL ? TL Converted p value
Total 113 137 250 33
ISS 7/4 (4–27) 12/9 (4–24) 10/9 (4–27) 13/16 (4–20) 0.001
aNISS 5/4 (0–18) 13/9 (4–27) 9/9 (0–27) 19/18 (4–42) 0.001
PATI 1/0 (0–14) 8/7 (0–28) 5/2 (0–28) 17/13 (0–44) 0.001
LOS (days) 4/4 (1–14) 8.7/5 (1–128) 6.6/5 (1–128) 13/9 (2–47) 0.001
Complications
(CD 3–5)
2 (1.8%) 22 (16%) 24 (9.6%) 7 (21.2%) 0.06
Data presented as mean/median (range), frequency count (percentage)
DL diagnostic laparoscopy, TL therapeutic laparoscopy, DL ? TL, diagnostic and therapeutic laparoscopy, ISS the Injury Severity Score, aNISS
the abdominal New Injury Severity Score, PATI the Penetrating Abdominal Trauma Index, LOS length of hospital stay, CD Clavien–Dindo
classification
Table 4 Hemodynamic and metabolic variables in patients with penetrating abdominal trauma
Diagnostic and therapeutic
laparoscopy (DL ? TL)
Converted p value Prediction of
complication
Prediction of
conversion
SBP 128/127 (83–198) 125/125 (89–165) 0.51 0.55 0.25
Ps 90/87 (50–198) 97/83 (64–180) 0.59 0.58 0.67
Hb 13.2/13.5 (6.2–18.3) 12.8/12.2 (7.7–20) 0.39 0.64 0.25
pH 7.36/7.38 (7.10–7.50) 7.30/7.32 (6.95–7.50) 0.002 0.20 0.007
Lactate 2.2/1.8 (0.5–6.8) 2.6/2.4 (0.5–5.6) 0.1 0.17 0.97
BE 3.3/2.6 (0–14.7) 4/3.3 (0.1–12) 0.26 0.59 0.67
Data presented as mean/median (range); p value
DL ? TL diagnostic and therapeutic laparoscopy, SBP initial systolic blood pressure, Ps pulse, Hb hemoglobin, BE lactate and base deficit
1348 Surg Endosc (2018) 32:1344–1352
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6. this study. We emphasize the importance of following a
standard systematic approach in trauma laparoscopy to
avoid missing injuries.
Using laparoscopy on all stable trauma patients, non-
therapeutic laparotomies can be avoided in 55–100% of
cases [2, 6]. If appropriate expertise is available to conduct
TL, laparotomy can be avoided in 91.5% of cases [12]. In
this study, 88% of stable patients with PAT and 77% of
BAT patients avoided laparotomy.
The rate of TL is reported from as low as 13.8% to as
high as 94.1% [4, 6]. Possession of advanced laparoscopic
skills is the key requirement for TL in trauma patients. The
other possible reason for such a difference in the rate is the
definition of TL. Strict criteria for therapeutic procedures
were used in this study. The mobilization of retroperitoneal
organs, evacuation of blood clots from the abdominal
cavity, application of a topical hemostatic agent on injured
organs, and extracorporeal repair of traumatic hernia were
not considered a TL. This study reported a TL rate of 55%.
We believe that all stable patients should be approached
laparoscopically. Although the definition of a stable trauma
patient will differ from surgeon to surgeon, SBP is the most
commonly used criterion to define a stable trauma patient,
but the numbers differ significantly. SBP values below 90,
100, and 110 mmHg were used to indicate hemodynamic
instability [14–17]. In this study, the operating surgeon
made a decision of instability of the patient based on
hemodynamic, metabolic, and respiratory parameters. An
SBP below 90 mmHg and a mean inspiratory pressure
greater than 30 mmHg were the most common isolated
values to define an unstable patient; such patients were
offered laparotomy. More studies are needed to clarify the
definition of instability for laparoscopy.
Theconversionratewasreportedas7–45% [2, 3,8, 12,14].
Conversion rates at our institution increased from previously
reported 7% to 11.7% for PAT and to 22.9% for BAT [8].
The most common indications for conversion were
patient instability, intraoperative bleeding, and inadequate
intraoperative visualization [2, 8, 14, 18]. Organ eviscera-
tion was reported as an indication for conversion in some
studies [6, 19–23]. On the contrary, Matsevych et al.
reported that laparoscopy is feasible and safe in patients
with organ evisceration with no conversion to laparotomy
[11]. Multiple hollow viscera injuries were reported as
another reason for conversion [2, 6, 12, 14, 24]. In such a
challenging scenario, intracorporeal mobilization of injured
organs was performed and LAA could be utilized for
extracorporeal repair, resection, and anastomosis [6, 9, 25].
Retroperitoneal injuries remain a potentially dangerous
area for laparoscopic surgery and many surgeons would opt
for laparotomy in these cases [2, 3, 26]. In this study,
retroperitoneal injuries in stable patients were approached
laparoscopically and only ongoing bleeding that could not
be promptly controlled was the main reason for conversion.
Surgeon preference was reported in 14% of cases as a
reason for conversion by Chestovich [14]. However, we did
consider the surgeon’s preference as an indication for
conversion. The surgeon’s preference must match patient’s
benefits, unless inadequate laparoscopic skills are present.
In addition to a high-performing operating team and the
presence of advanced laparoscopic skills, laparoscopy for
trauma is strongly dependent on well-functioning equip-
ment [27]. The well-tuned insufflation of carbon dioxide
and properly functioning lenses and light source provide
good visualization during an operation. Suction irrigation
and atraumatic graspers are the basic equipment needed for
the successful abdominal exploration of a trauma patient.
In this study, one patient had to be converted due to
equipment failure; malfunctioning suction precluded con-
tinuation of the laparoscopic procedure.
As previously argued, carbon dioxide pneumoperi-
toneum might worsen head injury [28]. That view was not
confirmed during trauma laparoscopy [25]. In this cohort,
few patients had concomitant head injuries and any dete-
rioration of head injuries by laparoscopy was not con-
firmed, although the numbers were too small to make any
conclusion. The decrease of pneumoperitoneum pressure to
10–12 mmHg, use of a completely gasless technique, and
the increase of the ventilation rate are important adjuncts to
alleviate the side effects of carbon dioxide
pneumoperitoneum.
Deranged hemodynamic (SBP, Ps) and metabolic (pH,
lactate, BE) parameters were correlated with increased
mortality in trauma patients [29, 30]. An increase in PaCO2
during the pneumoperitoneum resulted in a decrease in pH,
which promptly returned to a normal value after desuffla-
tion. On the other hand, a decrease in pH after laparotomy
was affected by metabolic factors, which persisted an hour
after elective surgery [31]. It seems that laparotomy causes
Nonoperative Management (NOM)
Laparoscopy Laparotomy
Laparoscopic
-assisted
Unstable
Stable or
Responder
Failed NOM
Diagnostic
Therapeutic
Convert if:
• Continuous bleeding
• Complexity of injury
• Deterioration of the patient
• Poor visibility
• Equipment failure
Trauma patient
Fig. 3 Algorithm of management of patient with abdominal trauma
Surg Endosc (2018) 32:1344–1352 1349
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7. more metabolic derangement in trauma patients than
laparoscopy does. In this study, SBP, Ps, pH, lactate, and
BE were investigated as possible predictors of complica-
tions or conversion in trauma laparoscopy. Although the
only statistically significant parameter was pH, the differ-
ences in numbers were so small that it could not be used in
practice. More studies are needed to investigate the role of
metabolic parameters as predictors of adverse outcomes
during trauma laparoscopy.
According to this study protocol, all unstable patients
were offered open laparotomy. This is in agreement with
other studies [3, 13, 14, 19, 27, 32, 33]. However, in the
literature this approach was challenged by Cherkasov et al.
who approached even unstable patients with laparoscopy
[34]. All stable patients or patients who responded to initial
resuscitation, and patients who failed NOM were approa-
ched laparoscopically. The laparoscopic procedure fol-
lowed the specific steps described above (Fig. 1). Initially,
the main aim of laparoscopy was to diagnose the penetra-
tion and abdominal organ injuries, which was achieved by
examination of the peritoneum for penetration after evac-
uating all pathological content and systematically inspect-
ing all intra- and retroperitoneal organs. Retroperitoneal
organs were mobilized and inspected if necessary. In the
presence of injuries requiring therapeutic procedures, the
decision was made whether to repair fully laparoscopically
or to utilize LAA. If, at any stage, the patient met the
criteria for conversion, laparotomy was performed. By
following this protocol, 88% of patients in the PAT group
and 77% in the BAT group avoided laparotomy.
Although limited, the existing data comparing laparo-
scopy with laparotomy in trauma patients show a statisti-
cally significant reduction of operative complication and
perioperative mortality rate, earlier recovery of bowel
function, less postoperative pain, shorter LOS, and a lower
infection rate in the laparoscopy group [6, 12, 18, 33, 35].
Lin et al. reported a significantly shorter operation time for
laparoscopy as compared with laparotomy [6].
The data from nontraumatic colorectal surgery suggest
that laparoscopy has a significant protective effect on the
development of small bowel obstruction (SBO) and inci-
sional hernia (IH) after surgery [36]. Of note, conversion to
an open procedure has been associated with an increased
rate of SBO [37]. After laparotomy for trauma, the rates of
SBO and IH requiring readmission were 6 and 9%,
respectively [7]. The rates of SBO and IH after laparoscopy
for trauma are unknown.
A negative DL was compared with a negative laparotomy
and resulted in similar estimated costs [21]. Costs were not
assessed by this study. The cost of a laparoscopic procedure
may be higher than that for standard laparotomy, as laparo-
scopic equipment and at least three disposable ports were
used. Theater time may also be longer in some cases. But all
these extra expenses are compensated by the benefits of
minimally invasive surgery in the postoperative period. The
total cost of laparoscopy for trauma has not been compared
with that for open procedures. In nontrauma patients
undergoing colectomy, the total cost of laparoscopic surgery
is shown to be lower as compared to open surgery [38].
This study has several limitations. Firstly, the prospec-
tively collected data were analyzed retrospectively. Sec-
ondly, the results may be reproducible only in institutions
with comparable expertise in laparoscopic surgery. Thirdly,
LOS calculations were done from the day of admission to the
actual discharge, which in most cases was prolonged because
of logistics (transport issues and the absence of some spe-
cialized services in the patient’s area of residence). Finally,
more than one-third of patients were lost to follow-up (many
patients without problems opted not to come for follow-up in
order to save on transport expenses).
Conclusion
The management of all stable trauma patients with
laparoscopy appears to be a safe approach. Sound laparo-
scopic equipment, a well-coordinated trauma team with
adequate expertise in laparoscopic surgery, adherence to
the algorithm, and strict compliance with predetermined
procedural steps are all fundamental to success.
Laparotomy can be avoided in more than 80% of cases.
Continuous intraoperative bleeding, complexity of injuries,
deterioration of the patient, poor visibility, and equipment
failure are indications for conversion. The rate of missed
injuries in laparoscopy is negligible and comparative with
laparotomy. Lower complication rates and a shorter length
of hospital stay are associated with laparoscopy. However,
further studies are needed to identify specific predictors for
complications and conversion.
Compliance with ethical standards
Disclosures Oleh Matsevych, Modise Koto, Moses Balabyeki, and
Colleen Aldous have no conflicts of interest or financial ties to
disclose.
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