LAPAROTOMY VERSUS DIAGNOSTIC LAPAROSCOPY IN ABDOMINAL TRAUMA
DR. SUHAIL AHMED. M, MRCS (Edin)
Project submitted towards completion of Diploma in Minimal Access Surgery at World Laparoscopy Hospital, November 2010
The use of laparoscopy as a diagnostic modality dates back to early 20th century Following which it has been widely used in the specialities of Gastroenterology, Urology, thoracic surgery, gynecology and oncology. The use of laparoscopy in evaluation of abdominal trauma was suggested in the early 70’s by a number of surgeons but is now being practiced widely for both blunt and penetrating injuries of the abdomen more so with the advent of advancement in technology and the development of fine and high precision of instruments. In the situation of a patient with abdominal trauma, patients who are suspected to have visceral injury may not be subjected to unnecessary laparotomy if a diagnostic laparotomy may be available. A laparoscopy instead of a laparotomy can safely and effectively be used as a diagnostic and therapeutic modality. The assessment of a patient with trauma has been delayed in several situations and subjecting such patients to a laparotomy increases the morbidity and mortality. This increase in morbidity and mortality can be reduced by performing a diagnostic laparoscopy where in if no significant injury has been seen, an unwarranted laparotomy is avoided, Hence inproving the prognosis. Diagnostic laparoscopy also serves as a good tool of evaluation in situations where there is non availability or absence of result clarity of other non invasive assessment tools such as a CT or MRI. Studies  have analyzed several aspects of its application on trauma patient. Others studies  have expanded its role beyond simply a screening tool for injury, to being used as a diagnostic and therapeutic modality. Now it is utilized for both blunt and penetrating injuries. This article review has been done to emphasize the advantages of minimally invasive techniques over invasive techniques in abdominal trauma.
Laparoscopic surgery, Acute abdomen, Abdominal trauma, Diagnostic Laparoscopy, Diagnostic laparoscopy versus Laparotomy, Abdominal injuries, Abdominal trauma assessment, Blunt trauma abdomen, Therapeutic laparoscopy
With the advent of fine precision instruments, minimally invasive surgeries have been applied to various specialities. Current use of laparoscopy in the diagnosis and management of trauma patients has been a natural extension of this trend. Being widely utilized for both blunt and penetrating injuries, laparoscopy has gained popularity in the evaluation and management of patients with penetrating abdominal injuries. The ability of accurate diagnosis of anterior peritoneal penetration from stab and gunshot wounds has been proven. In various centers it is now being used more than just as a diagnostic tool. It is used as a therapeutic modality for non serious, non vascular injuries thereby preventing unnecessary laparotomies. It is an ideal procedure in patients with unclear diagnosis and in the absence of availability of computerized axial tomography (CAT) or MRI, Where there may be a delay in diagnosing abdominal lesions that may require laparotomy for treatment (hollow organ injury, bile leaks, pancreatic lesion, persistent bleeding, etc.).
This review is aimed at evaluating the role of emergency laparoscopy as a diagnostic and therapeutic tool in abdominal trauma and to highlight its advantages over an exploratory laparotomy. Diagnostic Laparoscopy and Laparotomy have been compared using the following criteria
MATERIALS AND METHODS:
Literature search and review was done using online search engines such as Google, High wire press, Wikipedia, Springer link at the Library in the World Laparoscopic Hospital. Using the above mentioned key words, search was conducted. Selected articles were checked from their references and the universally accepted papers at recognized institutions were considered for this review study.
Trauma is the leading cause of death between the ages of 1 and 44 years. In all age groups, it is surpassed only by cancer and atherosclerosis in mortality . Laparoscopy was first tried by lamy in 1956 in patients with splenic injury, following which Gazzaniga  suggested laparoscopy in determining the need for laparotomy. Berciet al  in 1991. reported a reduction in the number of diagnostic laparotomy performed for hemoperitoneum by 25% by performing laparoscopy in 150 patients with blunt abdominal trauma. Laparoscopic techniques are being used increasingly for the diagnosis and management of traumatic injuries. Although laparoscopy is an invasive intervention, it has a decreased the incidence of full laparotomy in patients with gunshot and stab wound. Examination of the intra-abdominal structures can be done in a minimally invasive fashion. The first step in diagnostic laparoscopy is systematic exploration of the abdominal organs and spaces to ensure no site of injury is missed. If there is any free fluid present, it is collected and sent for analysis.
A potential advantage of laparoscopy over laparotomy is small incision, quick recovery, less pain, and shorter postoperative hospital stay. The limitations include inability to visualize the entire abdominal cavity, especially the retro peritoneum and posterior diaphragm. Patients with hemodynamic instability or hemoperitoneum may not be suitable candidates due to unclear field. In a retrospective study from three institutions with large volume of expertise in laparoscopy for trauma, 510 patients underwent initial evaluation for penetrating abdominal trauma and their files were reviewed. Of theses, 194 suffered gunshot wounds, and the remaining were stab wounds. Diagnostic Laparoscopy was helpful in determining the absence of peritoneal penetration in 113 (58%) gunshot wounds. Exploration performed on the remaining 81 patients with gunshot wounds with peritoneal penetration resulted only in non-therapeutic exploration, the most frequent sites of the injury begin the diaphragm, liver, and spleen   .. . The evaluation and treatment of abdominal injuries are critical components in the management of severely injured trauma patients. Because missed intra-abdominal injuries are a frequent cause of preventable trauma deaths, a high index of suspicion is warranted.
CLASSIFICATION OF ABDOMINAL TRAUMA
BLUNT abdominal TRAUMA:
The etiology of blunt abdominal trauma (BAT) depends on the environment of the receiver. The most common cause of BAT are the motor vehicle collision (MVC), responsible for 45% to 50% of BAT’s followed by Assaults, falls, automobile–pedestrian accidents and work-related injuries. Abdominal injuries in blunt trauma may be due to compression, crushing, shearing, or deceleration mechanisms. The incidence of BAT requiring laparotomy is only 6%. The most frequently injured organs are the spleen (40% to 55%), the liver (35% to 45%), and the retro peritoneum (15%) . The utility of diagnostic laparoscopy in patients with blunt trauma abdomen is one of the best applications of this procedure. When performed in hemodynamically stable patients, laparoscopy is safe and technically feasible. Chot et al reported reduced negative and non therapeutic laparotomy rates in this identified population  
Diagnostic laparoscopy for the evaluation of penetrating trauma is useful more in thoracic and abdominal stab wounds. laparoscopy helps in diagnosis of diaphragmatic and other intra abdominal injuries, thus avoiding unnecessary laparotomies . The necessity of urgent explorative laparotomy as a standard procedure in the treatment of abdominal stab wounds is controversial. Many surgeons especially from the United States, follow a conservative approach in uncomplicated cases, arguing that 30–50% of stab wounds do not even perforate the peritoneum and 20–40% cases with perforated peritoneum do not cause visceral injuries requiring surgical interventions, resulting in non-therapeutic laparotomy rates of up to 70% . The argument from some other surgeons, being that even if there are no clinical signs of intra abdominal injuries, the disadvantages associated with an unnecessary laparotomy are minor compared to the danger of peritonitis in cases of delayed diagnosis of intestinal perforation. An alternative to these extremes is laparoscopy which allows the inspection of the peritoneum for sign of perforation and further more, in selected case, the treatment of intra-abdominal injuries    ... . Fabian et al while working at Memphis, Tennessee concluded that diagnostic laparoscopy is a safe, efficacious means of evaluating patients with equivocal peritoneal penetration
Gunshot wounds are the most common cause (64%) of penetrating abdominal trauma, followed by stab wounds (31%) and shotgun wounds (5%) . Injury patterns differ depending on the weapon and motive. Stab wounds are less destructive and have a lower degree of morbidity and mortality than gunshot wounds and shotgun blasts. The most commonly injured organs are the liver (40%), small bowel (30%), diaphragm (20%), and colon (15%)  . Gunshots and other projectiles have a higher degree of energy and produce fragmentation and cavitations, resulting in greater morbidity . These mechanisms result in multiple intra-abdominal injuries of the small bowel (50%), colon (40%), liver (30%), and abdominal vascular structures (25%)  .Consequently, exploratory laparotomy traditionally has been warranted for gunshot wounds between the nipple line and the inguinal crease.
The history of non-operative management of gunshot injuries stems from work by Shaftan  . In 1960 he reported patients with stab wounds to the anterior abdominal wall that were triaged as per physical examination and diagnostic maneuvers such as nasogastric tube contents, urinanalysis, and plain radiographs. It was found that a patient with normal abdominal examination, without associated hematuria, hematochezia, or free air under the diaphragm, excluded intra-abdominal injury that would necessitate a laparotomy.
A later report by Nance et al  where 1,180 patients either underwent mandatory exploration or a selective non-operative approach with observation. Of them, 432 patients underwent mandatory exploration. 53% had no injuries (i.e., negative laparotomy), and 10% had minor injuries that did not require surgical intervention (i.e., nontherapeutic laparotomy), which was in contrast to only a 10% negative and 3% non-therapeutic rate in the 126 patients treated with a selective non-operative approach. In addition, the overall complication rate was found to be higher in the mandatory laparotomy group (13.9%) compared with the selective non-operative group (6.3%). Most important, in the group that was observed without an operation, only 10(4%) of 266 patients required a delayed operation for progressive symptoms, with no deaths and only 1 had wound infection. Some other groups had demonstrated low delayed laparotomy rates and low complication rates with non-operative management for stab wounds.
Leppaniemi and Haapiainen  in 1966 presented one of the few prospective randomized controlled trials of non-operative management of stab wounds. Equivalent mortality was found with selective non-operative management compared with mandatory exploration (18% versus 19%; P=.26). They also showed a decreased length of hospital stay and an overall cost reduction in patients treated by observation. 4 (17%) patients originally randomized to observation required delayed exploration, with no deaths; 1 patient developed an incarcerated diaphragmatic hernia from a missed injury, and 1 patient’s course was complicated by an empyema.
Ortega et al.  described the advantages of laparoscopy for abdominal stab wounds. Laparoscopy avoids unnecessary laparotomy, also prevents the risk of undiagnosed hollow viscous injury leading to delayed laparotomy. The average hospital stay for the group that underwent totally therapeutic laparoscopy (n = 43) was 8.9days, but the stay for the nontherapeutic (diagnostic) laparoscopy group (n = 13) was 2.2 days. These long stays were the result of other associated injuries.
Recent trend in management of all forms of surgical problems are towards minimally invasive techniques.. Current use of laparoscopy in the diagnosis and management of trauma patients is a natural extension of this trend. Several studies show that laparoscopy is a useful modality in evaluating and managing hemodynamically stable trauma patients with blunt or penetrating injuries. Use of laparoscopy in select patients with abdominal trauma will decrease the rate of negative and nontherapeutic laparotomies, thereby lowering morbidity and mortality, decreasing length of hospitalization, and provide more efficient utilization of available resources. As technology and surgeons expertise continues to improve, more standard therapeutic interventions may be done laparoscopically in the future. For a long time mandatory surgical exploration for penetrating wounds to the abdomen has been a surgical dictum. Although non-operative management of blunt solid organ injuries and low-energy penetrating injuries is well established, the same may not true for gunshot wounds. Majority of patients sustaining gunshot injury to the abdomen warrant immediate laparotomy to control bleeding and contain contamination. Non-operative treatment of patients with a penetrating injury is acceptable only in a highly selected subset of hemodynamically stable adult patients without peritonitis. Although the physical examination remains the cornerstone in the evaluation of patients with abdominal trauma, other techniques such as computed tomography, diagnostic peritoneal lavage are available, but diagnostic laparoscopy allows accurate diagnosis of intra-abdominal injury especially in patients where the clinical examination or other above mentioned investigations are equivocal and may warrant the necessity for a laparotomy.. The ability to exclude internal organ injury non-operatively avoids the potential complications of unnecessary laparotomy. Clinical data to support selective non-operative management of certain gunshot injuries to the abdomen are accumulating, but the approach has risks and requires careful collaborative management by emergency physicians and surgeons experienced in the care of penetrating injury.
The ability of diagnostic laparoscopy to accurately determine anterior peritoneal penetration from stab and gunshot wounds has been proven. In patients presenting with hemoperitoneum with hemodynamic instability, the management is emergency exploratory laparotomy to check the bleeding. If, on the other hand, the patient is hemodynamically stable, the management is controversial. Such patients usually undergo emergency exploratory laparotomy, and in 15-30% of the cases the operation is unnecessary, as there is spontaneous homeostasis of the lesion producing the hemoperitoneum . In these patients, in order to avoid the unnecessary laparotomy, diagnostic laparoscopy serves as a better tool.
For diagnosis and management of the abdominal injury, current diagnostic methods have a defined sensitivity, specificity, and accuracy, but none of these represents a gold standard. Thus abdominal exploration by laparotomy should not be discarded as an unworthy diagnostic and therapeutic procedure for patients with equivocal and unreliable findings. It is associated with complication rates as high as 40% including a 10% to40% negative laparotomy rate, a 20% morbidity rate, a 0% to 5% mortality rate, and a 3% long-term risk of bowel obstruction secondary to adhesions. Hence an easier way of acquiring the same information with much reduced rate of complications is offered by Diagnostic laparoscopy.
Laparoscopy has been used frequently as a therapeutic tool in selected trauma patients. Examples of therapeutic laparoscopy include repair of diaphragmatic lacerations, treatment of gastrointestinal perforations, repair of low-grade liver and splenic lacerations; resection of small bowel and colon . Auto-transfusion of collected blood from the hemoperitoneum is another potential application .Fabian et al  in a large study of 182 trauma patients, reported one suture repair of diaphragmatic injury. Successful laparoscopic repair of small bowel, colon ,and rectal injuries, and laparoscopic repair of a small gastric stab wound using hernia stapler have been reported recently  .Repair of solid visceral injuries, can be either by the totally laparoscopic procedure, the laparoscopically assisted procedure, or hand assisted laparoscopic surgery (HALS). The complications of laparoscopy in trauma include not only the usual complications of anesthesia and laparoscopy, but also some that are unique to the trauma patient. Fabian et al.  reported the development of tension pneumothorax in patients with diaphragmatic injury from positive-pressure pneumoperitoneum. If suspected, pneumoperitoneum is stopped, and an immediate needle thoracocentesis is performed, followed by a tube thoracostomy. The risks of gas embolism in patients with intra abdominal venous injuries, especially liver lacerations, also poses as a big problem. Smith et al encountered this complication in two patients with injuries of the inferior vena cava tamponaded by clot. This potential problem of laparoscopy has inculcated interest in ‘‘gasless’’ laparoscopy  by expansion of the peritoneal cavity by mechanical retractors. In carries added advantage of averting the risks of tension pneumothorax and gas embolism and it facilitates the use of conventional instruments such as hemostats, needles, sutures, and electrocautery with significant cost savings. The major disadvantage of gasless laparoscopy is the excessive cost of the powered mechanical arm and the poor exposure in the lateral gutters  . Less expensive apparatus to lift the abdominal wall is expected. The transperitoneal absorption of carbon dioxide may cause complications such as acidosis, cardiac suppression, atelectasis, subcutaneous emphysema, and increased intracranial pressure, resulting in more profound consequences for the trauma patient . Missed intra-abdominal injuries are among the most frequent causes of potentially preventable trauma deaths. The evaluation and management of abdominal trauma is multifactorial and includes mechanism of injury, location of injury, hemodynamic status of the patient, neurological status of the patient, associated injuries, and institutional resources. Therefore careful selection, high index of suspicion, and a low threshold for laparotomy will provide the patient the benefits of minimal invasive surgery and reducing the rates and morbidity of unnecessary laparotomy. The use of Laparoscopy has cut down the expenses by $1,059 per patient compared to laparoscopy in patients who would have had negative or non therapeutic laparotomies.  With current technology, Diagnostic Laparoscopy is most efficacious for evaluation of equivocal penetrating wounds 
Diagnostic laparoscopy is an important method of investigation for patients who suffered trauma, in whom the there is suspicion or an equivocal report from other investigations. Diagnostic laparoscopy is the most commonly performed surgical procedure in case of abdominal trauma and is being done even under local anaesthesia where warranted for early diagnosis or intervention.. Its greatest advantage is that it is rapidly replacing exploratory laparotomy even in small medical units.
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