Nontherapeutic Laparotomy Rate Research Articles

A clinical observation algorithm for anterior abdominal stab wound is safe in an Australian setting.

We previously published the outcomes associated with the use of diagnostic laparoscopy to determine peritoneal breach for AASW patients without an immediate indication for laparotomy. Although this pathway was 100% sensitive there was a 54% non-therapeutic laparotomy rate. Another option that has been extensively reported is the clinical observation algorithm (COA) however, majority of the data originate from high-volume centres. We hypothesized that a COA would also be a safe option in an Australian setting, and reduce the rate of non-therapeutic operative intervention in managing AASW. This was a prospective cohort study examining patients with AASW admitted to a level 1 trauma centre in Sydney, Australia, between June 2021 and August 2023. Patient, injury, management and outcome data were collected from electronic medical records and the hospital trauma registry. Data were then analysed to determine the diagnostic accuracy of the COA, complication rates and median hospital length-of-stay (LOS). A total of 48 patients presented with AASW. Of these patients, 11 (22.9%) proceeded to immediate laparotomy. Seven patients had a contraindication to COA and underwent diagnostic laparoscopy. Thirty patients were managed with the COA, with three (10%) patients subsequently requiring a laparotomy. Only one patient (3.3%) underwent a non-therapeutic laparotomy. There were no missed injuries. The COA sensitivity was 100%, specificity 92.7%, PPV 50% and NPV 100%. Patients managed with COA had no complications. Overall median hospital LOS was 1 day (1.0-2.3). A COA is a safe approach for evaluating patients with AASW in an Australian setting with adequate resources. It reduces the rate of non-therapeutic operative intervention and has acceptable outcomes compared with a diagnostic laparoscopy pathway.

CT evaluation of bowel wall enhancement in pneumatosis intestinalis: preventing non-therapeutic laparotomies.

To evaluate the diagnostic performance of bowel wall enhancement for diagnosing concomitant bowel ischemia in patients with parietal pneumatosis (PI) diagnosed at abdominal CT. From January 1, 2012 to December 31, 2021, 226 consecutive patients who presented with PI on abdominal CT from any bowel segment were included. Variables at the time of the CT were retrospectively extracted from medical charts. CT examinations were blindly analyzed by two independent radiologists. The third reader classified all disagreement of bowel enhancement in three categories: (1) normal bowel enhancement; (2) doubtful bowel wall enhancement; (3) absent bowel wall enhancement. Multivariable logistic regression analysis was performed. Concomitant bowel ischemia was defined as requirement of bowel resection specifically due to ischemic lesion in operated patients and death from bowel ischemia in non-operated patients. Overall, 78/226 (35%) patients had PI associated with concomitant bowel ischemia. At multivariate analysis, Only absence or doubtful bowel wall enhancement was associated with concomitant bowel ischemia (OR = 167.73 95%CI [23.39-4349.81], P < 0,001) and acute mesenteric ischemia associated with PP (OR = 67.94; 95%CI [5.18-3262.36], P < 0.009). Among the 82 patients who underwent a laparotomy for suspected bowel ischemia, rate of non-therapeutic laparotomy increased from 15/59 (25%), 2/6 (50%) and 16/17 (94%) when bowel wall enhancement was absent, doubtful and normal respectively. Absence of enhancement of the bowel wall is the primary feature associated with concomitant bowel ischemia. It should be carefully assessed when PI is detected to avoid non-therapeutic laparotomy.

Preoperative Management of Perihilar Cholangiocarcinoma.

Simple SummaryIn patients diagnosed with potentially resectable perihilar cholangiocarcinoma, deliberate and coordinated preoperative workup and optimization of the patient and future liver remnant are crucial. Strategic optimization and multidisciplinary evaluation may reduce the rate of unnecessary procedures, perioperative complications, and non-therapeutic laparotomy for unresectable disease. In this review, we describe preoperative assessment and optimization of patients with perihilar cholangiocarcinoma, including imaging workup, evaluation of resectability, preoperative drainage and hypertrophy-inducing procedures, and the role of diagnostic laparoscopy.Perihilar cholangiocarcinoma is a rare hepatobiliary malignancy that requires thoughtful, multidisciplinary evaluation in the preoperative setting to ensure optimal patient outcomes. Comprehensive preoperative imaging, including multiphase CT angiography and some form of cholangiographic assessment, is key to assessing resectability. While many staging systems exist, the Blumgart staging system provides the most useful combination of resectability assessment and prognostic information for use in the preoperative setting. Once resectability is confirmed, volumetric analysis should be performed. Upfront resection without biliary drainage or portal venous embolization may be considered in patients without cholangitis and an estimated functional liver remnant (FLR) > 40%. In patients with FLR < 40%, judicious use of biliary drainage is advised, with the goal of selective biliary drainage of the functional liver remnant. Percutaneous biliary drainage may avoid inadvertent contamination of the contralateral biliary tree and associated infectious complications, though the relative effectiveness of percutaneous and endoscopic techniques is an ongoing area of study and debate. Patients with low FLR also require intervention to induce hypertrophy, most commonly portal venous embolization, in an effort to reduce the rate of postoperative liver failure. Even with extensive preoperative workup, many patients will be found to have metastatic disease at exploration and diagnostic laparoscopy may reduce the rate of non-therapeutic laparotomy. Management of perihilar cholangiocarcinoma continues to evolve, with ongoing efforts to improve preoperative liver hypertrophy and to further define the role of transplantation in disease management.

Work-Up and Outcome of Hepatic Resection for Peri-Hilar Cholangiocarcinoma (PH-CCA) without Staging Laparoscopy.

Simple SummaryThis is a single centre cohort of patients undergoing surgery for PH-CCA suggests that routine staging laparoscopy may not be necessary in the pre-operative work-up.Background: This study reports the outcome of a work-up programme for resection of peri-hilar cholangiocarcinoma (PH-CCA) without the use of staging laparoscopy. Methods: This is a clinical case cohort series of patients undergoing surgical resection of PH-CCA without the use of staging laparoscopy in the work-up algorithm. During the 13 years from 1 January 2009 to 1 January 2022, 32 patients underwent laparotomy for planned surgical resection of PH-CCA. Data were collected on demographic profile, admission biochemistry, radiology, pre-operative intervention, operation and outcome, together with post-operative complications and disease-free and overall survival. Results: All patients underwent pre-operative contrast-enhanced CT. Twenty-four (75%) underwent pre-operative MR. Twenty-three (72%) underwent pre-operative biliary drainage. Twenty-nine patients (91%) had either type III or IV peri-hilar cholangiocarcinoma. One patient (3%) in this series underwent a non-resectional laparotomy. Twenty-nine (91%) had a final histopathological diagnosis of PH-CCA. One further patient had a final diagnosis of an intraductal papillary neoplasm of the biliary tree (IPNB) with high-grade dysplasia but no invasive cancer. Eleven patients (36%) received chemotherapy after surgery. The median (95% CI) time to recurrence was 14 (7–31) months. The median survival was 25 (18-upper limit not reached) months. Conclusion: This cohort of 32 patients undergoing attempted resection for PH-CCA without the use of staging laparoscopy in the work-up algorithm indicates that with careful attention to patient fitness and cross-sectional and interventional radiologic/endoscopic imaging, a very low non-therapeutic laparotomy rate of 3% can be achieved and sustained.

EP.FRI.99 Penetrating Abdominal Trauma: Comperative Study Between Operative and Conservative Management

Abstract Aim to Assess the feasibility and safety of selective non-operative management in penetrating abdominal injuries and to identify a protocol for selection of patient candidates for non-operative management. Methods In this comparative study 40 abdominal stab victims (admitted to Emergency Department) were selected during a 6 months period where 20 patients were suitable for non-operative management according to strict selection criteria whereas the other 20 patients were operated according to clinical and/or radiological indications or on basis of department protocol, the results were compared in view of final outcome. Results In our study, 15 patients were assigned for operative management according to selected clinical and/or radiological indications only 3 of them (20%) had non-therapeutic laparotomies, On the other hand, five patients were explored on basis of department protocol in violation of our indications for exploration; four of them (80%) were non-therapeutic. So, the rate of non-therapeutic laparotomies was significantly higher when done mandatory without selected clinical and radiological indications. Conclusion Assessment of vital signs together with abdominal examination are the most important and dependable tools in decision making in penetrating abdominal trauma patients. Patients with shock on admission (but responding to resuscitation), proved low grade solid organ injury (by CT), and proved intraperitoneal collection (by US or CT) could be managed conservatively regarding that they remain vitally and clinically stable. If failure of conservation occurs, it is usually during the 1st 24 hours after admission.

90 Penetrating Abdominal Trauma: Comperative Study Between Operative and Conservative Management

Abstract Aim to Assess the feasibility and safety of selective non-operative management in penetrating abdominal injuries and to identify a protocol for selection of patient’s candidates for non-operative management. Method In this comparative study 40 abdominal stab victims (admitted to Emergency Department of Alexandria Main University Hospital) were selected during 6 months period where 20 patients were suitable for non-operative management according to strict selection criteria whereas the other 20 patients were operated according to clinical and/or radiological indications or on basis of department protocol, the results were compared in view of final outcome. Results In our study, 15 patients were assigned for operative management according to selected clinical and/or radiological indications only 3 of them (20%) had non-therapeutic laparotomies, On the other hand, five patients were explored on basis of department protocol in violation of our indications for exploration; four of them (80%) were non-therapeutic. So, the rate of non-therapeutic laparotomies was significantly higher when done mandatory without selected clinical and radiological indications. Conclusions Assessment of vital signs together with abdominal examination are the most important and dependable tools in decision making in penetrating abdominal trauma patients. Patients with shock on admission (but responding to resuscitation), proved low grade solid organ injury (by CT), and proved intraperitoneal collection (by US or CT) could be managed conservatively regarding that they remain vitally and clinically stable. If failure of conservation occurs, it is usually during the 1st 24 hours after admission.

Evaluation of diagnostic laparoscopy for penetrating abdominal injuries: About 131 anterior abdominal stab wound.

The management of hemodynamically stable patients with anterior abdominal stab wounds (AASW) is debated. Mini-invasive techniques using laparoscopy and non-operative management (NOM) have reduced the rate of nontherapeutic laparotomies after AASW leading to unnecessary morbidity. The aim of this study was to determine with a systematic diagnostic laparoscopy of peritoneal penetration (PP), patients who do not require abdominal exploration in the management of stable patient with an AASW. All patients with AASW were retrospectively recorded from 2006 to 2018. Criteria of inclusion were AASW patients who underwent a systematic diagnostic laparoscopy. Criteria of exclusion were patients with an evisceration, impaling, clinical peritonitis, and hemodynamic instability. If no PP was detected, laparoscopy was terminated. If defects of peritoneum were found, a laparotomy was performed looking for diagnosis and treatment of intra-abdominal injuries. On 131 AASW patients, 35 underwent immediate emergency laparotomy, 96 underwent diagnostic laparoscopy, 47 were positive (PP) and had an intra-abdominal exploration by laparotomy, 32 (68.1%) had intra-abdominal injuries which required treatment. All patients with an intra-abdominal injury had a positive diagnostic laparoscopy. For the 49 patients with a negative laparoscopy, the mean hospital stay was 1.6days with ambulatory care for some patients. No patient presented a delayed injury. Non-therapeutic laparotomy rate was 15.6%. For patients who did not have an intra-abdominal injury the morbidity rate was low (3%). Our study shows that diagnostic laparoscopy was safe, with a low duration of hospitalization, a possible ambulatory care and had an excellent ability to screen the patients who did not need a abdominal exploration. This management can avoid many unnecessary laparotomies with an acceptable rate of negative laparotomy, without any delayed diagnosis of intra-abdominal injuries and with a low morbidity rate.

The role of laparoscopy in the management of patients with isolated blunt abdominal trauma

Objective To assess the role of laparoscopy in diagnosis and management of patients with isolated blunt abdominal trauma (IBAT). Patients and methods This was a prospective study of 50 patients who were hemodynamically stable (systolic blood pressure ≥90 mmHg) experiencing IBAT who underwent diagnostic and/or therapeutic laparoscopy at the emergency department of Sohag University Hospital. Inclusion criteria were hemodynamically stable patients with IBAT. Exclusion criteria were marked hemodynamic instability, penetrating abdominal trauma, polytraumatized patients, increased intracranial tension, and contraindications for laparoscopy. After a primary survey according to Advanced Trauma Life Support principles, all patients were investigated by pelvi-abdominal ultrasound, computed tomography, chest and abdominal plain radiograph, and other routine laboratory investigations. Results A total of 50 stable patients with IBAT underwent urgent laparoscopy. Of them, 32 (64%) patients had therapeutic laparoscopy, whereas 18 (36%) patients had diagnostic laparoscopy. A total of 18 (36%) patients were converted to therapeutic laparotomy. Severely damaged spleen, liver, small intestinal, colon, and stomach injuries were the causes of conversion. Road traffic accident (24%) was the commonest cause of injury. Spleen was the commonest affected organ [18 (36%) patients], followed by the liver [10 (20%) patients]. Pain (visual analog scale of pain) and hospital stay were significantly increased (P˂0.0001and 0.001, respectively) in converted (laparotomy) cases in comparison with nonconverted (completed laparoscopy) cases. Postoperative complications, such as wound infection, hematoma, intra-abdominal hemorrhage, wound dehiscence, and reexploration were significantly increased in converted cases in comparison with nonconverted cases (P=0.002, 0.01, 0.01, 0.01, and 0.001, respectively). Conclusion Laparoscopy in blunt abdominal trauma is safe, accurate, and feasible. Hemodynamic stability of the patient and surgical expertise in advanced laparoscopy are the prerequisites. The most important advantages of laparoscopy are reduction of nontherapeutic laparotomy rate, reduction of operative period, shortening of hospital stay, and reduction of postoperative pain and postoperative complications.

Does the problem of foreign language and substance / alcohol usage increase the rate of non-therapeutic laparotomy in penetrating abdominal stab injuries?

Does the problem of foreign language and substance / alcohol usage increase the rate of non-therapeutic laparotomy in penetrating abdominal stab injuries?

Patient selection for cytoreductive surgery and hyperthermic intraperitoneal chemotherapy in colorectal cancer

Colorectal cancer is the most common origin of peritoneal metastasis in total, with 15% metastasizing to the peritoneum. In order to provide satisfactory peritoneal recurrence-free survival and low morbidity and mortality rates appropriate patient selection is crucial. Literature research (Pubmed) from 2013 to 2020 was performed including the terms “colorectal”, “peritoneal”, “metastasis”, “cytoreductive surgery”, “HIPEC” and “patient selection”. Despite predictive models the rate of non-therapeutic laparotomy is still high. Patients evaluated for cytoreductive surgery (CRS) and hyperthermic intraperitoneal chemotherapy (HIPEC) should ideally undergo laparoscopy. CRS and HIPEC should be scheduled if a completeness of cytoreduction (CC)-0 score is achievable with a moderate peritoneal cancer index (PCI) (<15), ≤ three resectable liver metastases and, if applied, response to systemic chemotherapy. Signet ring histology can be seen as a relative contraindication. Presence of mutations (RAS/RAF), disease setting, primary tumor side, lymph node ratio and time point of systemic chemotherapy do not impact the treatment algorithm as yet.

Selective non-operative management for penetrating abdominal injury in a Dutch trauma centre.

Selective non-operative management (SNOM) for penetrating abdominal injury (PAI) is accepted in trauma centres in South Africa and the US. Owing to the low incidence of gunshot wounds (GSWs) in Western Europe, few are inclined to practise SNOM for such injuries although it is considered for stab wounds (SWs). This study evaluated the outcome of patients admitted to a Dutch level 1 trauma centre with PAI. A retrospective study was undertaken of all PAI patients treated over 15 years. In order to prevent bias, patients admitted six months prior to and six months following implementation of a treatment algorithm were excluded. Data concerning type of injury, injury severity score and treatment were compared. A total of 393 patients were included in the study: 278 (71%) with SWs and 115 (29%) with GSWs. Of the 178 SW patients in the SNOM group, 111 were treated before and 59 after introduction of the protocol. The SNOM success rates were 90% and 88% respectively (p=0.794). There were 43 patients with GSWs in the SNOM cohort. Of these, 32 were treated before and 11 after implementation of the algorithm, with respective success rates of 94% and 100% (p=0.304).The protocol did not bring about any significant change in the rate of non-therapeutic laparotomies for SWs or GSWs. However, the rate of admission for observation for SWs increased from 83% to 100% (p<0.001). There was a decrease in ultrasonography for SWs (from 84% to 32%, p<0.001) as well as for GSWs (from 87% to 43%, p<0.001). X-ray was also used less for GSWs after the protocol was introduced (44% vs 11%, p=0.001). SNOM for PAI resulting from either SWs or GSWs can be safely practised in Western European trauma centres. Results are comparable with those in trauma centres that treat high volumes of PAI cases.

The efficacy of serial physical examination in management of penetrating abdominal trauma to avoid negative laparotomy in selected cases

Background: Patients with Penetrating Abdominal Injury (PAI) are at risk of harboring life-threatening injuries. Many patients are in need of emergency operative intervention. However, there are some patients who can be safely managed non-operatively. Every patient with an abdominal penetrating trauma should have a thorough clinical examination. Repeating the clinical examination at regular intervals is the cornerstone of selective management, as symptoms and signs that were initially absent may appear later.&#x0D; Objective: To see the efficacy of serial physical examination in patients with penetrating abdominal injury thus avoiding non-therapeutic laparotomy in the overall management of patients.&#x0D; Methods: Convenient and purposive 60 PAI patients admitted in casualty block of Dhaka Medical College &amp; Hospital were selected for selective non operative management (SNOM). On admission the abdominal wound was inspected and neither digital nor direct probing of the wound was attempted. Patients selected for admission had an intravenous line established, a thoracic and abdominal X-ray taken and urine and blood samples were taken. If necessary, a nasogastric tube was inserted. Asymptomatic haemodynamically stable patients were admitted for clinical observation in a single unit during which period the patient was examined by a senior surgeon for clinical re-assessment. Patients were discharged when feeding was normal and if there were clear signs of improvement. Results: Over a 6 month period 60 consecutive patients with penetrating abdominal wound were reviewed. In total 52 patients (86.67%) were managed with clinical re-assessment and discharged without laparotomy. Eight patients (13.33%) underwent laparotomy after observation. Small bowel, liver, mesenteric vessels were most frequently affected. Non-therapeutic laparotomy rate was 0%. After laparotomy the morbidity rates were 62.5% (p = 0.92). One local wound infection occurred without prior laparotomy. Average hospital stay after observation was 2.8 days, after laparotomy 9.8 days. Delayed laparotomy did not increase morbidity or hospitalization.&#x0D; Conclusion: Our experience with penetrating abdominal trauma supports the concept of selective conservatism based on repeated physical examination. In a well-established trauma center this has proven to be highly effective with remarkably low rates of non-therapeutic laparotomies and absence of missed diagnosis of visceral injuries.&#x0D; Journal of Surgical Sciences (2017) Vol. 21 (2): 76-79

Review of Different Management Modalities of Penetrating Thoracic and Abdominal Trauma

Abstract Introduction The advanced trauma life support (ATLS) training program was developed to provide uniformity in the assessment and management of trauma patients. Every trauma patient is evaluated using the primary survey; a rapid reproducible physical exam designed to diagnose those conditions that are immediately life-threatening first. The primary survey consists of the sequential assessment and treatment of airway, breathing, circulation, disability and exposure/environment, represented by the mnemonic (A.B.C.D.E) Objectives To review the different management strategies of penetrating abdominal and thoracic trauma. Data Sources Medline databases (PubMed, Medscape, ScienceDirect. EMF-Portal) and all materials available in the Internet till 2018. Conclusions In summation, most patients with PAT, especially gunshot wounds, still require surgery. On initial survey, patients who are hemodynamically unstable, have diffuse abdominal pain; evisceration, or peritoneal findings must go to the operating room. Patients with an altered sensorium, head injury, inability to cooperate with serial abdominal exams, or patients who will be undergoing an operative procedure somewhere other than the abdomen may be explored as well, depending on the comfort level of the trauma surgeon. This leaves a clinical subset that can be managed non operatively. In these patients, SNOM can drastically reduce the rates of negative and nontherapeutic laparotomies and result in a cost savings and safety benefit to the patient.

Diagnostic Laparoscopy as a Selection Tool for Patients with Colorectal Peritoneal Metastases to Prevent a Non-therapeutic Laparotomy During Cytoreductive Surgery

ObjectiveThe aim of this study was to evaluate the introduction of diagnostic laparoscopy (DLS) in patients with colorectal peritoneal metastases (PM) to prevent non-therapeutic laparotomies during cytoreductive surgery with hyperthermic intraperitoneal chemotherapy (CRS + HIPEC).MethodsPatients with histologically proven colorectal PM who underwent a laparotomy for potential CRS + HIPEC from January 2006 to January 2019 were retrospectively identified from a prospectively maintained database. In 2012, DLS was introduced in the preoperative work-up for CRS + HIPEC in our academic center. The rates of non-therapeutic laparotomies, major postoperative complications (Clavien–Dindo grade III or higher), and survival outcomes were investigated for patients who underwent a laparotomy before (cohort A) and after (cohort B) the introduction of DLS. In cohort B, the reasons to refrain from DLS were retrospectively explored from medical records.ResultsOverall, 172 patients were included [cohort A: 48 patients (27.9%); cohort B: 124 patients (72.1%)]. A significant drop in the rate of non-therapeutic laparotomies occurred in cohort B compared with cohort A (21.0 vs. 35.4%: p = 0.044), despite only 85 patients (68.5%) from cohort B undergoing DLS in our academic center. The most important reason to refrain from DLS was a recently performed DLS or laparotomy in the referring hospital (48.7%). Major postoperative complications, in-hospital mortality, and survival outcomes were similar for both cohorts.ConclusionsPerforming DLS during the preoperative work-up for CRS + HIPEC prevents non-therapeutic laparotomies in patients with colorectal PM. We recommend performing this laparoscopic screening in an experienced HIPEC center.

"Pop in a scope": attempt to decrease the rate of unnecessary nontherapeutic laparotomies in hemodynamically stable patients with thoracoabdominal penetrating injuries.

Management of patients with thoracoabdominal penetrating injuries is challenging. Thoracoabdominal penetrating trauma may harbor hollow viscus injuries in both thoracic and abdominal cavities and occult diaphragmatic lesions. While radiological tests show poor diagnostic performance in these situations, evaluation by laparoscopy is highly sensitive and specific. Furthermore, minimally invasive surgery may avoid unnecessary laparotomies, despite concerns regarding complication and missed injury rates. The objective of thepresentstudy is to evaluate the diagnostic and therapeutic performance of laparoscopy in stable patients with thoracoabdominal penetrating injuries. Retrospective analysis of hemodynamically stable patients with thoracoabdominal penetrating wounds was managed by laparoscopy.We collected data regarding the profile of the patients, the presence of diaphragmatic injury, perioperative complications, and the conversion rate. Preoperative imaging tests were compared to laparoscopy in terms of diagnostic accuracy. Thirty-one patients were included, and 26 (84%) were victims of a stab wound. Mean age was 32years. Ninety-three percent were male. Diaphragmatic lesions were present in 18 patients (58%), and 13 (42%) had associated injuries. There were nomissed injuries and noconversions. Radiography and computerized tomography yielded an accuracy of 52% and 75%, respectively. Laparoscopy is a safe diagnostic and therapeutic procedure in stable patients with thoracoabdominal penetrating wound, with low complication rate,andmayavoidunnecessary laparotomies.The poor diagnostic performance of preoperative imaging exams supports routine laparoscopic evaluation of the diaphragm to exclude injuries in these patients.

The Role of Staging Laparoscopy in Resectable and Borderline Resectable Pancreatic Cancer: A Systematic Review and Meta-Analysis

Aim: The study aimed to determine the additional value of staging laparoscopy in patients with pancreatic cancer deemed potentially resectable based on computed tomography imaging. Methods: A systematic literature search was performed using MEDLINE and the Cochrane Register of Controlled Trials (January 1995 to June 2017). Primary outcome measures were the overall yield and sensitivity to detect non-resectable disease. Quality of studies was assessed with the Newcastle-Ottawa Scale. Results: From 156 records, 15 studies including 2,776 patients met the inclusion criteria. In 12 studies, reporting outcomes on 1,756 patients with resectable disease after standard imaging, 350 (20%, range 14–38%) cases of non-resectable cancer were detected with staging laparoscopy. In 3 studies on 242 patients with locally advanced disease after standard imaging, staging laparoscopy detected metastases in 86 patients (36%). The failure rate of staging laparoscopy to detect non-resectable disease was 5% (64 of 1,406). Conclusion: Staging laparoscopy reduces the non-therapeutic laparotomy rate, and in locally advanced or borderline resectable disease, staging laparoscopy could more accurately select patients for neoadjuvant protocols.

Role of Laparoscopy in Patients With Abdominal Trauma at Level-I Trauma Center.

Abdominal trauma is one of the preventable causes of death in polytrauma patients. Decision and timing of laparotomy is a major challenge. Rate of nontherapeutic laparotomy is still high. Laparoscopy can avoid nontherapeutic laparotomy and also provide a reliable and accurate diagnosis of injury. This ambispective observational study was conducted in the division of Trauma Surgery and Critical Care, JPN Apex Trauma Centre, All India Institute Medical Sciences, New Delhi. Retrospective analysis of prospectively maintained data of cases from January 1, 2008 through April 30, 2013 and prospective analysis of cases from May 1, 2013 through March 31, 2015 was done using appropriate measures. Hemodynamically stable or responders fulfilling inclusion criteria were included. Selected patients underwent the laparoscopic procedure and if required converted to laparotomy. Of the 3610 patients of abdominal trauma, laparotomy was done in 1666 (46.14%) patients and laparoscopy was done in 119 (3.29%) patients. Rate of reduction of nontherapeutic laparotomy in patients with abdominal trauma using diagnostic laparoscopy was 55.4%. However laparotomy could be avoided in 59.7%. Laparoscopy was 100% accurate in identifying injuries in our study. No injuries were missed in these patients. Fever and wound infection were significantly higher in laparotomy group. Chest infection and sepsis were also higher in laparotomy group but the difference was not statistically significant. Median length of hospital stay in laparoscopy group was 4 days (range: 1 to 28 d) and in laparotomy group was 9.5 days (range: 2 to 55 d) with P-value of 0.001. Laparoscopy has a role in management of hemodynamically stable patients with suspected abdominal injury to prevent nontherapeutic laparotomies, and thereby decreasing postoperative complications.

Abdominal Trauma Revisited

Although abdominal trauma has been described since antiquity, formal laparotomies for trauma were not performed until the 1800s. Even with the introduction of general anesthesia in the United States during the years 1842 to 1846, laparotomies for abdominal trauma were not performed during the Civil War. The first laparotomy for an abdominal gunshot wound in the United States was finally performed in New York City in 1884. An aggressive operative approach to all forms of abdominal trauma till the establishment of formal trauma centers (where data were analyzed) resulted in extraordinarily high rates of nontherapeutic laparotomies from the 1880s to the 1960s. More selective operative approaches to patients with abdominal stab wounds (1960s), blunt trauma (1970s), and gunshot wounds (1990s) were then developed. Current adjuncts to the diagnosis of abdominal trauma when serial physical examinations are unreliable include the following: 1) diagnostic peritoneal tap/lavage, 2) surgeon-performed ultrasound examination; 3) contrast-enhanced CT of the abdomen and pelvis; and 4) diagnostic laparoscopy. Operative techniques for injuries to the liver, spleen, duodenum, and pancreas have been refined considerably since World War II. These need to be emphasized repeatedly in an era when fewer patients undergo laparotomy for abdominal trauma. Finally, abdominal trauma damage control is a valuable operative approach in patients with physiologic exhaustion and multiple injuries.

Selective Nonoperative Management of Abdominal Gunshot Wounds from Heresy to Adoption: A Multicenter Study of the Research Consortium of New England Centers for Trauma (ReCoNECT)

Selective nonoperative management (SNOM) of abdominal gunshot wounds is being practiced in certain trauma centers, but its broader acceptance in the surgical community is unknown. We hypothesized that SNOM has been adopted in New England as an acceptable method of abdominal gunshot wound management. We reviewed the medical records of abdominal gunshot wound patients admitted from January 1996 to June 2015, in 10 New England Level I and II trauma centers. Outcomes included the incidence, success, and failure of SNOM, and morbidity and mortality related to SNOM. Of 922 patients, 707 (77%) received immediate laparotomy (IMMLAP) and 215 (23%) were managed by SNOM. Compared with IMMLAP patients, those with SNOM had a lower median Injury Severity Score (16 vs 8; p < 0.001), lower incidence of complications (34.7% vs 8.5%; p < 0.001) and mortality (5.2% vs 0.5%; p= 0.002), and shorter ICU and hospital stays (median days 1 of 8 vs 0 of 2, respectively; p < 0.001). One SNOM patient died after 3days due to a gunshot wound to the head. The overall incidence of SNOM increased from 18% before 2010 to 27% in the following years (p= 0.001). Eighteen patients (8.4%) had unsuccessful SNOM and underwent delayed laparotomy at an average of 12.5 hours (range 141 minutes to 48 hours) after arrival. Nine of them (4.2%) experienced complications that were not directly related to the delayed laparotomy, and none died. The rate of nontherapeutic laparotomies was 14.7% among IMMLAP and 5.5% among delayed laparotomy patients (p= 0.49). Selective nonoperative management of abdominal gunshot wounds, despite being a heresy only a few years ago, has now been established as an acceptable method of management inLevel I and II trauma centers in New England.

Laparoscopy in Management of Blunt and Penetrating Abdominal Trauma: Single Center Experience

Introduction: Exploratory laparotomy in either blunt or penetrating abdominal trauma with suspected intra-abdominal injuries is associated with a high negative (non-therapeutic) laparotomy rate and a high procedure-related morbidity. In abdominal trauma, laparoscopy may be used either as a diagnostic or therapeutic tool in hemodynamically stable patients. Laparoscopy can avoid unnecessary (non-therapeutic) laparotomy and may allow laparoscopic repair of these injuries. Diagnostic laparoscopy can reliably rule out a significant intra-abdominal injury in patients with equivocal abdominal examination following trauma. In sharp abdominal trauma laparoscopy has been shown to be very effective in determining violation of the peritoneal cavity by tangential wounds. Patients and methods: 38 patients with abdominal trauma were enrolled for this study. Exclusion criteria for all patients included; hemodynamic instability, clinical or radiological evidence of major abdominal organs or vascular injuries, posterior abdominal wall penetrating injuries, bowel evisceration, evidence of 2 thoracic injuries (as pneumothorax), or head injuries. Pneumo-peritoneum is achieved with low CO flow and maintained at low pressures (10–12 mmHg). We started by exploration of abdominal cavity and suction of the free blood from the peritoneal cavity. In sharp injuries, inspection of the peritoneal membrane was done for evidence of penetration. Small hepatic and splenic hematomas were left undisturbed. Small and accessible tears ware sutured. Deep or inaccessible liver and splenic tears needed conversion to laparotomy. Small intestinal simple tears were sutured laparoscopically while complex tears needed laparotomy conversion. Left colonic tears needed laparotomy conversion and colonic diversion. Results: Patients with blunt trauma (26 patients), in whom laparoscopic management was completed were18 patients (69%). 5 patients (26%) of the later, had negative laparoscopic exploration, for which the operations were terminated, 6 patients (37%) had retroperitoneal hematomas with free hemo-peritoneum, 2 cases (10.5%) showed only right hepatic lobe small sub-capsular hematomas, 3 cases (16%) showed small liver tears, and 2 cases (10.5%) showed small splenic sub-capsular hematomas and small superficial tear. All the previous injuries were left undisturbed with laparoscopic suturing of the 2 cases with liver tears. 12 cases (31.5%) with sharp penetrating anterior abdominal wall trauma were included in this study. The cases with penetrating abdominal trauma that could be completed laparoscopically were 8 cases (67%) and those who needed laparotomy conversion were 4 cases (33%). The mean operative time in the cases that were completed laparoscopically was 85 minutes and in the laparotomy converted group was 67 minutes. Analysis of postoperative pain in all patients was done using the Numeric Rating Scale (NRS) for pain. Pain was subjectively more severe and statistically different in the laparotomy group than laparoscopic group. The range of hospital stay in the laparoscopy group was 2 to 5 days, and in the laparotomy group it was from 6 to 8 days. No cases in the laparoscopy group showed wound infection; while it was 3 cases (25%) in the laparotomy converted group. Long term follow up showed one case (8.3%) in the laparotomy group developed incisional hernia related to the main abdominal wound, while no similar case was detected in the laparoscopy completed group. Conclusion: The evaluation and management of abdominal trauma are multi-factorial. Careful selection of trauma patients, high index of suspicion, and a low threshold for laparotomy will provide them the benefits of laparoscopic management and reduce the rates and morbidity of unnecessary laparotomy.