Manuscript 23-2-08 Jtrauma

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Standardization for Laparoscopy in Penetrating Abdominal Trauma

Nilton Tokio Kawahara, MD PhD

Clarissa Alster, MD PhDIkurou Fujimura, MD PhD

Renato Sergio Poggetti, MD PhD, FACSDario Birolini, MD PhD, FACSSamir Rasslam, MD PhD, FACS

University of Sao Paulo Medical SchoolHospital das ClinicasDepartment of TraumaLaboratory of Surgical Pathophysiology Investigation, Lim 62.

So Paulo, Brazil

Correspondence and requests for reprints:Nilton T. Kawahara, MD PhD; Av. Indianpolis 2244, zip 04062-002, SP, Brazil. E-mail:

[email protected]/Fax: +55 11 558859119

Emails:

+55 11 [email protected]

+55 11 558859119

+55 11 [email protected]

[email protected]

Clinical Study awarded and presented as a technical exhibit at the American College of

Surgeons Clinical Congress on October 2001.

Disclosure statement: The authors of this manuscript have nothing to declare.

Running head: Standardization for Laparoscopy in Trauma


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Introduction

Mandatory surgical intervention for penetrating abdominal wounds (PAW) yields a high rate of

negative laparotomies.1-4 However, subjective preference seems to drive decisions when

performing laparoscopy in trauma (LIT). There is no standardized laparoscopic procedure

described for trauma surgeons to inspect the whole abdominal cavity to achieve missed injuries

rate as similar as conventional surgery. That seems to be one of the major reasons why some

surgeons still fear and preclude LIT. Complication rates as high as 20% have been described for

negative trauma celiotomies.2,3,5,6 Perhaps one of the greatest concerns is the unreliability of LIT

for the detection of small bowel injuries (SBI).7-10 Ivatury et al.9 has reported that only 20% of

SBI were correctly identified at the time of laparoscopic examination. Becker et al.8 described a

sensitivity of only 25% to identify reliably hollow viscus perforation and retroperitoneal injury in

a review study. Our previous experience, has demonstrated that LIT is feasible in trauma victims

when used in selected patients and with appropriate technique.11-16 We hypothesize that if a rigid

protocol of standard LIT is followed, no SBI would be missed. Besides, not only the rate of

negative and nontherapeutic laparotomies would decrease but also the missing injuries rate.

Materials and Methods

Experimental Protocol

The experimental protocol was approved by the Institutional Review Board of the University of

Sao Paulo Medical School, in accordance with the Principles of Laboratory Animal Care

formulated by the National Society for Medical Research and the Guide for the Care and Use of

Laboratory Animals by the National Institutes of Health. Dogs were fasted for 12 hours before the

study. Anesthesia was induced with IV injection of sodium pentobarbital 25mg/Kg and morphine

0.1mg/Kg 30min before the beginning of the experiment. After intubation, anesthesia was

maintained with Fentanyl 0.2g/Kg/h, and Isoflurane 1% at Takaoka ventilator 675 plus KT 13,

(So Paulo, Brazil). Twelve mongrel dogs (20-25Kg) were submitted to trauma, laparoscopy,


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laparotomy and finally necropsy by 4 different teams of surgeons. The mechanism of trauma was

standardized previously,17 and a PAW at the flank was made directing the stab wound towards the

umbilicus. After the diagnosis of the injuries in both groups the dogs were sacrificed with

hypertonic Kcl and submitted to necropsy. The trauma, the surgeries and the necropsy were

performed by 4 different surgeons who didnt communicate to each other to warrant a blind

study.

Patient Selection Clinical Protocol

From March 1993 to March 1997, on the basis of previously validated criteria from our

Institution,11-13,15

patients sustaining PAW were evaluated by our trauma service at University of

Sao Paulo School of Medicine, in Sao Paulo, Brazil, according to algorithms showed in Figure

1A for stab wounds (SW) and 1B for gunshot wounds (GSW). All 75 patients were treated by

only one surgeon (Nilton Kawahara) whom had experience in laparoscopy since 1989.The

postoperative treatment was performed on surgical wards led by staff surgeons, and standard

criteria for discharge and length of sick leave were used independent of the study protocol. This

study was approved by the review board of our Institution, and informed consent was obtained

from all patients or a close relative.

Definitions

A negative laparotomy or laparoscopy was defined as the one with no abdominal cavity

penetration. Besides, a nontherapeutic laparotomy or laparoscopy was a surgery where there was

peritoneal penetration, but no surgical treatment was necessary. Unnecessary laparotomies

included nontherapeutic and negative laparotomies. Inclusion criteria for LIT were: (1) equivocal

evidence of intra-abdominal injuries with peritoneal penetration; (2) systolic blood pressure

>90mmHg and less then 3L of IV fluids at the first hour of admission; (3) Glasgow >12; (4) age

>12 years. Exclusion criteria: Injuries to the back, pregnancy, previous laparotomy or associated

chronic cardiorespiratory disease. Injuries to the blind spots zones were defined as any signs of

lesions to the retroperitoneum (eg. hematoma), injuries to the bare area or segments VI and VII of


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the liver; trauma to the greater curvature of the spleen, lesser sac and hollow viscus injuries. A

missed injury was characterized if the diagnosis of a lesion was not done before laparotomy.

Rationale for Laparoscopy

Laparoscopy was used as a screening and therapeutic tool. It did not mandate conversion to

laparotomy (as a gold standard) to confirm the diagnostic accuracy of laparoscopic findings.

Indications for conversion to laparotomy included injuries to the blind spot zones.

Endpoints

The primary endpoints of the study were SBI and general missing injuries rate, hospital morbidity

and length of stay (LOS). In addition, conversion rates were assessed. A two year follow-up of

the study population was performed. Hospital costs were not evaluated.

Laparoscopic Technique

Clinical (Study A): A 30-angle-degree laparoscope and an open trocar insertion (Hassons

technique) were used for each procedure. CO2 pneumoperitoneum (PP) was maintained at

15mmHg. Laparoscopic operating ports were placed under direct vision, according to the old

1997 protocol (Fig 2A): Scope initially 4 cm above the umbilicus (port 1), another port at the

suprapubic region (port 2), and a third port pararectus in proximity to the umbilicus (port 3).

Following inspection of the peritoneal cavity for penetration, one should search for blood, enteric

or urine secretions, and the scope was moved to port 2; the bowel was run, to search for traumatic

lesions, from the ligament of Treitz to the ileocecal valve (Fig 3A). Two atraumatic bowel

graspers are used: the bowel is grabbed approximately 10cm apart and an intestinal rotation is

done, so that both sides (Fig 3B) anterior and posterior - besides the mesentery, can be seen.

Then, all colon is inspected from the cecum to the rectum. Once the inframesocolic space was

visualized, the supramesocolic space would be then inspected from the abdominal esophagus to

the duodenum. Finally, liver, gallbladder, Morrisons pouch and spleen were examined.

Treatment of parenchymatous viscerae and stomach injuries were feasible by LIT. Whenever

indicated, sutures were performed using laparoscopic instruments 60o and 120o apart from each


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other. If one could estimate the abdominal entry and exit of a wound, the port 3 trocar would be

placed opposite to that wound (eg. GSW at right flank, the trocar was placed on the left flank; left

GSW, port 3 was placed on the right), so the pathway of the injury could be better evaluated. If

there was a thoracoabdominal (TA) wound, port 3 would be placed preferentially at the same side

of the injured hemithorax. Thus, if another port was needed, a subxyphoid trocar might be placed

to perform therapeutic LIT.

Experimental (Study B): Instead of a Veress needle, an optic view trocar insertion guided by 0o

scope and then exchanged to 30o scope was used. PP was maintained at 12mmHg. Laparoscopic

operating ports in dogs were placed under direct vision, in a similar way to our clinical protocol

used nowadays (Figure 2B): Umbilical scope (port 1), and two other pararectus ports. The same

sequence described to the clinical study was also performed.

Statistical Analysis

Statistical analysis was performed using the Statistical Package for the Social Sciences for

Windows software (Version 11.0, SPSS, Inc., Chicago, IL). Group variables are expressed as

mean + SD. Comparison of continuous data with normal distribution was performed with

Students t test, and data with nonnormal distribution was performed using the Mann-Whitney U

test.Values of p


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hemostasis to the spleen (1). Nontherapeutic laparotomies (n=5) and negative laparotomies

(n=33) added to therapeutic laparotomies (n=17) showed that overall avoided laparotomy rates

were actually 73.33% (n=55). Besides, 20 patients (26,6%) underwent laparotomy due to protocol

(Table 1C). No one died. The average length of LIT was 70 + 20.4 minutes when there was

peritoneal violation, and 50 + 10.2 minutes when there wasnt (p


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Today, at the beginning of the 21st century, exploratory celiotomy remains the standard

diagnostic and therapeutic approach for PAW in unstable patients with multiple system

intraabdominal injuries, despite others think otherwise19. However, if laparotomy is to be

performed in every abdominal trauma patient who is stable, a high number of unnecessary

laparotomies would have occurred.11,20-22 In the beginning, LIT as a diagnostic tool,10 yielded a

high missed-injuries rate (41-77%), and it was criticized by several surgeons.23,24Anyone who

reads those figures suddenly might think LIT should not be performed at all. The missing injuries

rate reported is difficult to consider because the study mixed prospective and retrospective

analysis which did not have the same standard laparoscopic inspection protocol to be followed.

Besides, several papers reflected the beginning of LIT, and the learning curve of the method did

not seem to be taken into consideration. Nevertheless, good results are expected if selected and

hemodynamically stable patients are considered for LIT when there is doubt of penetration of the

abdominal cavity during tangential and PAW (GSW and SW) at the flank and TA area.11-13. In the

manual of the ATLS,14

LIT is quoted as one of the diagnostic modalities in stable patients with

penetrating TA wounds in whom there ispossible extra-abdominal trajectories, and/or a

diaphragmatic lesion is suspected. Blunt and trauma to the back pose an increased risk to injuries

at the blind spots of the abdomen where LIT fails to diagnose. The retroperitoneum is one of the

main limitations of LIT, and its full assessment is difficult even with all the evolution in urologic

surgery.25,26Nowadays, LIT in blunt trauma and injuries to the back are still a relative

contraindication to the method, and were considered, in study A, as an exclusion criteria. In spite

of its use by some centers,27,28,29 we do not believe that, in those cases, LIT can be indicated as a

routine procedure, except perhaps as demonstrated in table 3A in controlled protocols as quoted

by others.30Thats why we used an experimental mechanism of trauma intending not to injure

the retroperitoneum, so the blind spot zones were avoided. The inclusion of flank wounds but not

posterior wounds was based on our previously reports,11,12,13,15 considering the anatomic extension

of the lateral peritoneal reflection to the paracolic gutters, which are easily accessible with LIT,


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unlike the posterior parts of the centrally located retroperitoneal organs more easily assessed with

a CT scan. LIT is feasible and safe, if a rigid protocol of standard procedures is used by those

who have appropriate training and have bypassed the learning curve. Thus, serious concern about

early reported missed-injuries rate,10 can be avoided if one focus on performing LIT as indicated

(Table 3B). Data from this study and others,11,15,20-22,24,25,31-33 support the fact that LIT is safe for

PAW when used judiciously. Thus, laparotomies were actually avoided in 73.33% in similar rates

to Ahmed et al,34 in contrast to earlier reports,9,11,27,35,36 which ranged from 30-65%. Thus, LIT

was also estimated to bring down the cost of hospitalization to 50%34 due to less LOS. Various

diagnostic modalities, such as LIT, ultrasonography, DPL and CT, have a defined sensitivity,

specificity, and accuracy, but none of them represents a gold standard tool.1,37-42. We did not

indicate LIT for patients who could be followed by nonoperative treatment or used LIT before

other diagnostic exams.The indication was associated to routine laparotomy previous

recommendations for tangential and TA trauma to avoid the potential of missed injury, mainly

diaphragm.14,43

Our study has established two algorithms for LIT for GSW and SW that has been

missing so far, enabling a higher number of PAW repair in SW, different from the low

therapeutic rates reported for SW.44,45

Complications associated with unnecessary laparotomies

can reach 22%2,3,5,6,20 and a 1,3% potential early laparoscopy-related complications incidence is

described10 but technical limitations of LIT depend also on associated injuries. Our hypothesis

was that the serious concern regarding the laparoscopic high rate of missed injuries found in

literature, mainly intestine9, exists because there is no official LIT standardization and the spread

use of the two-port approach in the past. We also hypothesized that LIT alone is sufficient to

exclude SBI inside the peritoneal cavity. As far as we are concerned, the two-port approach does

not seem to make possible to perform a safe, effective and trustable running of the bowel, as

demonstrated in our experimental protocol in dogs in 1993 (unpublished). At that time, we

performed the running of the bowel to evaluate the potential to reduce the rate of unnecessary

laparotomies with LIT before proceeding to study A. In 2007, we decided to repeat the


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experimental study because the devices and laparoscopic settings then had improved (long

scopes, high insufflations laparoflator, xenon light, three-chip camera, etc). Hence, the operating

room time diminished, and the image from the camera was more accurate. Our method proved to

have a 97.61% sensitivity in 1997, higher than the 87.5% reported only for identification of

diaphragmatic injuries by Friese et al28. Study B showed that the sensitivity and specificity were

much better than before, probably because of the technological evolution. If study A were to be

repeated now, one could expect perhaps similar or better results. The three-port approach had no

missing injury, but the ultimate value of LIT for the diagnosis and treatment of traumatic injuries

will depend on the surgeons experience. Data from this study show clearly the value of LIT

standardization to achieve better results in the missing injuries rate in PAW. Our results were

similar to the largest study about LIT described before (n=510), which included our previous

experience 11. Nevertheless, our multicenter study had a flaw because there was no differentiation

between laparoscopic surgery (as a diagnostic and therapeutic tool) versus old-fashioned LIT (a

diagnostic procedure and screening performed without a microcamera). LIT is also useful to

determine the need for laparotomy.11,21,46,47 It has been described under local anesthesia and IV

sedation in the emergency department and ICU setting.1,2,21,22

Low pressure PP and gasless

laparoscopy are other alternatives to avoid PP related complications.11,22,47,48 Besides, some

surgeons are still afraid of the hypertensive pneumothorax risk during LIT and routinely

preoperative drainage has been reported.34

In our study, when there was no immediate need for

thoracic drainage, but if a diaphragmatic lesion was suspicious, the anesthesia team was warned

about a possible occurrence of a hypertensive pneumothorax. If during low flow PP, a

pneumothorax was diagnosed, the PP was evacuated and thoracostomy and drainage were

performed to still proceed with LIT. No conversions were necessary due to hypertensive

pneumothorax. In some cases, whenever there was a diaphragmatic rupture, drainage was not

necessary since transdiaphragmatic videothoracoscopy could identify intrathoracic and pleural

lesions requiring drainage. Therefore, at the end of the diaphragmatic suture, the lung was


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hyperinsufflated, so the CO2 pneumothorax, induced by LIT, could automatically be evacuated.

Moreover, in spite of its therapeutic possibility, most papers have associated LIT to a very good

screening with possible diagnostic tool in trauma for selected patients.11,48 Our protocol was

98.66% accurate on diagnosis of operative findings. If one considers only detection of SBI our

protocol proved to be effective in 100% of cases and standardized training for trauma residents

might change the missing injury rates in the future. Therefore, injuries at the blind spot zones,

where LIT poorly evaluates, should be used as a guide to conversion to laparotomy for better

results in the missing injury rates. Our data showed that 80.95% of the peritoneal violations had a

significant injury, being 32.43% for GSW(n=3) and 57.89% for SW(n=22) similar to other

reports for SW49. Potentially, LIT has the ability to diagnose occult injuries requiring surgical

treatment earlier, avoiding the morbidity associated with delayed treatment of hollow organ and

diaphragmatic injuries.11,27,50 Caution must be exercised when drawing clinical implications. We

had some limitations in our study: active minor bleeding injuries to the abdominal wall, near to

the scope entrance, may be missed by LIT, similar to injuries at the blind spots as we had recently

in our Service, demanding conversion. The laparoscopic devices used in 1997 were not as good

as the xenon light source, a high insufflation laparoflator and the three-chip camera which would

have allowed a faster and accurate procedure today. Besides, when this study was performed, we

used the suprapubic port, not necessary today. The new 43-50cm-long scope could have been

used instead of the standard 36cm scope through the regular umbilical port. Therefore, the long

scope could also be used for transdiaphragmatic access11,16,50. Moreover, the Optic view trocar

used in 2007, should be used instead of the Hassons technique used in 1997, since it is faster,

easily handled and avoids PP leakage. We have shown that LIT has the advantage of identifying

defects of the peritoneum, diaphragm,24,40 bleeding mesenteric, omental, hepatic and splenic

injuries. It can also be used when all diagnostic modalities do not elucidate the diagnosis, and

there are still equivocal evidence about parenchymatous trauma, bladder injuries51 and

hemopericardium11. It bears emphasizing that missed SBI are a potentially fatal complication and


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must be avoided. In 1997, we considered hollow viscus injuries as a blind spot zone due to the

high index of SBI rate associated.8,9 Nevertheless, study B showed that SBI could be diagnosed

and repaired successfully and should not be considered a blind spot zone today. In parallel to the

advances of obesity surgery, trauma surgery has evolved to better laparoscopic sutures and

anastomosis, allowing for a feasible therapeutic approach for LIT.42,52 The bowel is held and run

for lesions systematically and didnt increase operative time as thought.35 We decided not to

suture intestinal lesions, in 1997, because our protocol demanded the procedure to be converted

promptly to laparotomy. In summary, LIT can be safely performed in selected patients who are

stable and whenever a skilled team is available. The number of unnecessary laparotomies and the

missing injuries rate decrease and can be ruled out, at least at the blind spot zones, if a rigid LIT

inspection protocol is used. Besides, with LIT standardization, future prospective randomized

series in penetrating TA trauma might be performed more reliably and accurately. Performing a

standardized training protocol in LIT might show that typically required advanced laparoscopic

training is not necessary for therapeutic laparoscopy.

Acknowledgments

We would like to thank K. Takaoka Industria e Comercio Ltda for lending the Fuji Maximus

ventilator and the Takaoka 675 plus KT to standardize the ventilatory mechanics for the clinical

and experimental protocol respectively. Besides, a special thanks to Ms. Regina Garcez for the

English corrections is also noteworthy.

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50. Ivatury RR, Simon RJ, Weksler B et al. Laparoscopy in the evaluation of the intrathoracic

abdomen after penetrating injury. J Trauma 1992; 33(1):101-08. Discussion 109.

51. Wright JL, Porter JR. Laparoscopy and the Management of Blunt Bladder Trauma. J

Trauma 2007; 63(5):1165-66.

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small bowel. Surg Endosc 2003; 17(4):641-45.

Figures

Fig 2 Position of the

Trocars in study A (2A)and Stud B 2B .

Fig 1 Algorithmsperformed according

to mechanism oftrauma: SW (1A) andGSW (1B)


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Fig 3 The

running of thebowel with

anterior (3A) and

posterior view(3B). The search

for injuries

continues.


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