LAPAROSCOPY IN PENETRATING ABDOMINAL STAB WOUNDS: DOES IT HAVE A ROLE???
Mohamed Riad (MD), Hatem Mohammed (MD), Yasser Hussein (MD), Mohammad Lotfy (MD).
General Surgery department Zagazig University
Abstract
Background: If the patient of penetrating abdominal stab wound is hemodynamically stable and has equivocal abdominal examination finding. Surgeons poses a significant challenge to take decision which favor of surgery or nonoperative conservative treatment. This decision requires a precise diagnosis that is not always possible with imaging techniques. In consequence of this circumstance; Laparoscopy can be a diagnostic or therapeutic tool in these cases. So that leads to avoid negative exploratory laparotomies.
Methods: It randomized study included 51 patients of penetrating abdominal stab wound. The patients were selected according to the following criteria; hemodynamically stable, no signs of peritonitis and fully conscious without evidence of raised intracranial pressure and absence of contraindication for pneumoperitoneum. So we can evaluate the diagnostic and therapeutic role of laparoscopy.
Results: Patients were divided into two groups. Group I underwent exploratory laparotomy (26patients). Group II underwent laparoscopic laparotomy (25patients). The mean operative time in both groups was (89 ± 23.5 vs. 55±19 minutes, (P < 0 .05) respectively. The length of hospital stay was (9.3 vs. 4.1 days, P < 0 .05) respectively in both groups. Postoperative morbidity in both groups was (19.23% vs. 12%, P > 0 .05) respectively. No mortality in both groups. Accurate diagnosis was done to all patients in Group II except one patient (96.15%) of missed intestinal injury (this was happened in the first cases of the study). Treatment was done for four patients from eight patients with discovered organs injuries (50%). Other four patients converted to exploratory laparotomy (50%) due to severe injuries.
Conclusion: The use of laparoscopy as a diagnostic or therapeutic method in patients with penetrating abdominal stab wounds is an efficient, safely and effective method. The most important advantages are reduction of morbidity, shortening of hospitalization and cost-effectiveness.
Keywords: penetrating abdominal stab trauma, laparoscopy, laparotomy.
Introduction: Penetrating injuries of the abdomen are traditionally treated with exploratory laparotomy .The high non-therapeutic laparotomy rate and associated morbidity after mandatory laparotomy for abdominal stab wounds led to the current selective non-operative management strategy [1–3]. It is reported that 50–70% of abdominal stab injuries penetrate the peritoneum, but 20–40% of these penetrating wounds do not lead to significant organ injury [4]. Despite the growing use of diagnostic methods such as abdominal ultrasonography (US), computed tomography (CT), diagnostic peritoneal lavage (DPL), intravenous pyelography (IVP), and angiography, it is still difficult to evaluate the severity of penetrating abdominal stab wounds [5].
Patients with penetrating abdominal stab wounds are managed non-operatively in many centers, despite the fact that an explorative laparotomy may be an appropriate treatment strategy in selected patients. The criteria defining when an explorative laparotomy is appropriate state that hemodynamic instability and signs of peritonitis must be present. Hemodynamically stable patients without signs of peritonitis may be carefully followed non-operatively [6, 7].
Although good results can be obtained with observation, there are inherent limitations to this approach. Observation requires that serial abdominal examinations be performed by an experienced surgeon able to detect subtle changes in physical findings (who may not be available at every time). Observation also requires hospital admission for several days, taxing the resources of overburdened institutions [8]. These reasons have prompted the search for a less invasive and more reliable method of evaluation. This is the basis of laparoscopy for abdominal trauma [9].
Patients and Methods: This study included 51 patients who were admitted to the emergency unit of Zagazig University hospitals during a period from April 2010 to October 2012. The patients were divided randomly into two groups: group I included patients who underwent exploratory laparotomy and group II included patients who underwent laparoscopic exploration.
Preoperatively all patients were submitted to full history, careful general and abdominal examination, abdominal ultrasonography, laboratory tests and chest x-ray (for patients with stab wounds in the upper abdomen to exclude peumothorax).
The following criteria were followed for patients’ selection: penetrating stab injuries in the abdomen with stable vital signs, no signs of peritonitis and ability to give informed consent for the study added to them intact sensations without evidence of raised intracranial pressure and absence of contraindication for pneumoperitoneum (i.e. cardiopulmonary disease).
Surgical Procedure: In preparing the patient for laparoscopic exploration, the usual rules of trauma care were followed, including adequate intravenous access, Foley catheterization, and stomach decompression with N/G tube. The procedure was conducted under general anesthesia and patients were prepped in the supine position from chin to thighs for a possible conversion to an open procedure. The operating table allowed Trendelenburg, reverse Trendelenburg positions, and side-to-side tilting of the table.
The entrance site of the stab was sutured and covered with an occlusive dressing to allow for creation of pneumoperitoneum. The first trocar for 10 mm laparoscope (30º) was inserted at the umbilicus. After the abdomen has been entered, the anterior abdominal wall at the site of the stab (that was depressed with a finger) was examined to detect peritoneal violation. If the peritoneum was intact the procedure was terminated. If there is violation of the peritoneum another two 5 mm trocars were inserted at the right and left paramedian sites at the level of the umbilicus for systemic examination of the abdomen using a traumatic bowel graspers. If no injury was identified, the procedure was terminated and the patient was put under observation. If injury was found, it was either managed laparoscopically or with exploratory laparotomy.
Figure (1) shows the used algorithm for the laparoscopic management of abdominal stab wounds [adapted from Choi and Lim [10]
Figure (1): algorithm for the laparoscopic management of abdominal stab wounds.
Results: This study was conducted on 51 patients with penetrating abdominal stab wound. They were divided into two groups and underwent operations either exploratory laparotomy for group I and laparoscopic exploration for group II. Group I included 26 patients (about 51%) and group II included 25 patients (about 49%). The mean age in group I 25 ± 3.5 years; 23 patients were males (88.5%) and 3 females (11.5%). The mean age in group II was 28 ± 2.3 years; all patients were males in this group.
The patients were divided into three categories according to results of exploration. 1ST patients have no peritoneal penetration, 2nd patients have peritoneal penetration without intra-abdominal organs injuries, and 3rd patients have peritoneal penetration with intra-abdominal organs injuries, as shown in table (1).
Table (1) results of exploration in both groups:
Results Group I Group II
No. of patients 26(23 male) 25(all male)
No peritoneal penetration 8 (30.77 %) 7 (28%)
Peritoneal penetration without intra-abdominal organs injuries 11 (42 .31 %) 10 (40 %)
Peritoneal penetration with intra-abdominal organs injuries 7 (26.92 %) 8 (32%)
In group II; all patients were accurate diagnosed except in one case with missed intestinal injury (96.15%); this was happened in the first cases of the study. This perforation was found in the posterior gastric wall, who managed by exploratory laparotomy which done for that patient, 2 days later; when signs of peritonitis were developed.
In group I, there is seven patients have peritoneal penetration with intra-abdominal organs injuries (26.92%); three patients have small intestinal injury only, two patients have small intestinal injury with mesenteric injury and two patients have liver injury. In other hand, in group II there is eight patients have peritoneal penetration with intra-abdominal organs injuries (32%); three patients have small intestinal injury only, two patients have small intestinal injury with mesenteric injury, one patient has colonic injury, one patient has liver injury and one patient has splenic injury, are shown in table (2).
Table (2) shows the type of injury in both groups on initial evaluation:
Type of injury Group I Group II
Small intestinal injury 3 3
Small intestinal and mesenteric injury 2 2
Colonic injury 0 1
Liver injury 2 1
Splenic injury 0 1
Four cases (50 %) in group II were managed laparoscopically: two cases with single small intestinal injury (less than 1 cm) were managed with intra-corporeal suturing. One case with small intestinal and mesenteric injury; the intestinal injury was managed with intra-corporeal suturing due to the wound size was small and the mesenteric injury also was small and controlled with clips used for laparoscopic cholecystectomy (additional 10 mm port was added in the supra-pubic region), and the 4th case was liver tear that was superficial and controlled with bipolar diathermy coagulation and compression by a piece of gauze for ten minutes.
The other four cases who converted to open laparotomy.1st case complain from splenic injury which was near to the hilum with blood clot over it and open splenectomy was done. 2nd case complains from intestinal injury with big mesenteric injury with sign of ischemia appear at affected intestinal part; resection-anastomosis was done to affected part. 3rd case complains from colonic injury (transverse colon) with faecal soiling, in this patient colostomy was done at the perforation site. 4th case, he has a multiple small bowel perforation that needed resection-anastomosis of the affected segment.
Postoperative morbidity in group I recorded in five patients, while in group II it was found in three patients (19.23% vs. 12%, P>0 .05). There was a significant difference between both groups regarding to mean operative time; in group I it was 89 ± 23.5 minutes, while in group II it was 55±19 minutes (P < 0 .05).The length of hospital stay was (9.3 vs. 4.1 days, P < 0 .05) respectively in both groups. In consequence of decrease Postoperative morbidity and length of hospital stay in group II that leads to reduction in cost-effectiveness. No mortality was detected in both groups. Postoperative characters of patients are showed in table (3).
Table (3): postoperative characters
postoperative characters Group I Group II P value
Mean Operative time (minutes) 89 ± 23.5 55±19 <0.05
Length of stay in the hospital (days) 9.3 4.1 <0.05
Postoperative morbidity
5(19.23%)
3(12%)
>0.05
1-Seroma 1 1
2-Wound infection 1 0
4-Ileus 2 1
5-Chest infection 1 1
Fig (2): peritoneal stab perforation.
Discussion: Laparoscopy raises many safety concerns in the trauma setting, including tension pneumothorax while the patient is under anesthesia, increase in intracranial pressure, and gas embolism induced by pneumoperitoneum, not to mention the risk of missed injuries and medico-legal consequences [11-13]. Although these risks are real, they can be reduced by careful selection of patients, judicious use of chest tubes, and meticulous technique. Although stable vital signs do not preclude major internal injuries requiring prompt repair, initial laparoscopy would yield further localizing data and should not significantly delay open operative treatment [14].
In the current study, included 51 patients; 15 patients (29.41%) did not have peritoneal penetration and 20 patients (39.21%) had peritoneal penetration without intra-abdominal injury (the missed case of gastric perforation from group II was excluded) this coincides with what is stated by Thal and Fabian et al [4, 15] who said; approximately one third of patients presenting with anterior abdominal wall stab wounds actually sustain an injury that requires surgical intervention. This finding is related to the fact that 25% of anterior abdominal wall stab wounds do not penetrate the peritoneal cavity, but approximately one half of wounds that do violate the peritoneum cause visceral injury requiring surgical repair.[16]
In our study, we found; non-therapeutic laparotomy in group I was about 73.1% (19 patients from 26 patients) this is more than the ranges reported by other reviews that the incidence of unnecessary laparotomy rates range from 23% to 65% in patients presenting with abdominal wall stab wounds [4, 9, 16-19] .
On the other hand in this study, the non-therapeutic exploratory laparotomy could be avoided in 16 patients (64%) from group II (the missed case of gastric perforation from group II was excluded), this is near to the result of Ahmed et al and others [14, 20, 21] who suggested that, when laparoscopy is deployed in the algorithm for management of penetrating injuries of the abdomen, non-therapeutic exploratory laparotomy can be avoided in 55-87% of trauma patients. The laparoscopic success rate to diagnose peritoneal penetration with or without intra-abdominal injury was (96.15%).
There was one case of missed intestinal injury (4%) this a little more than what is reported by Kopelman et al [19] in their study (on 38 patients) that missed injuries incidence was 0% and much less than what is reported by Fabian et al and Rossi et al [4, 22] who reported missed injury rate of 40%. This missed case in our study could be referred to our starting experience in that new approach.
In group II, 4 cases (50%) were needed surgical intervention; could be managed laparoscopically. This percentage is much less what reported by Lin et al [9] who stated a success rate of laparoscopic repair 94.1% and referred their high success rate to that their attending surgeons were highly skilled in advanced laparoscopic techniques.
By adding these 4 cases treated laparoscopically to the other cases that did not need intervention, the total number of patients that avoided exploratory laparotomy in group II became 20 patients (out of 25 patients) (80%). Although most of our patients did not have long term follow-up we agree with Ahmed et al [14] that there will be reduction in the incidence of hernias, adhesions and intestinal obstruction.
There was no significant difference in the incidence of postoperative complications in both groups included in the study, and this agreed with Leppaniemi A. and Haapiainen R. [21].
There was a significant difference as regard the average hospital stay between the two groups (P <0.05) in favor of group II (the average hospital stay in group I was 9.3 days and in group II it was 4.1 days).
The shorter length of hospital stays in group I than in group II reflects the nature of minimal invasiveness of the laparoscopic approach. With respect to outcomes, most authors reported a decreased complication rate, shorter length of hospital stay, and decreased costs when negative laparoscopy is compared with a negative or non-therapeutic open laparotomy [17, 20, 23-26].
We agree with Lin et al [9] that visualization of solid organs is simple to perform and reliable, but complete examination of the intestines presents a greater challenge for surgeons. The key points to avoid missed injuries in diagnostic laparoscopy include the following: (1) a systematic and careful inspection; (2) changing the patient’s position during laparoscopic procedures for inspection; and (3) use of a traumatic grasping forceps for bowel manipulation. And the keys to success in therapeutic laparoscopy include the following: (1) appropriate change of the patient’s posture; (2) careful planning of port placement; and (3) technical ability in advanced laparoscopic procedures.
Conclusion: From the data collected in this study we can conclude that diagnostic laparoscopy is feasible, effective and safe procedure for hemodynamically stable patients with abdominal stab wounds. Not only because of shorter hospital stay but also the complications from non-therapeutic laparotomies and delayed treatment of significant intra-abdominal injuries may be minimized. Therapeutic laparoscopy also can be applied for selected patients but it demands from the trauma surgeons to have advanced laparoscopic skills.