Laparoscopic Management of Stab Wound of Anterior Abdominal Wall: A Prospective Stud

Laparoscopic Management of Stab Wound of Anterior Abdominal

Wall: A Prospective Study

Ahmed A Darwish, MD; Ashraf Hegab, MD; Moheb Shoraby, MD.

Department of Surgery, Faculty of Medicine, Ain Shams University, Egypt.

Background: The anterior abdominal wall is one of the most common regions affected in penetrating stab wound injuries. Tradionally, wound exploration and exploratory laparotomy are used as a diagnostic and therapeutic modality in the management of such injuries. Recently, laparoscopy has gained popularity in the management of such cases with favorable results in carefully selected patients. The aim of the present study was to assess the role of laparoscopy in the diagnosis and management of patients with stab wounds of the anterior abdominal wall.

Patients and methods: 52 hemodynamically stable patients with stab wound of the anterior abdominal wall were included in this study at the emergency department of Ain Shams University Hospitals. Patients were selectively subjected to, physical examinations, focused abdominal sonography in trauma (FAST), computed tomography (CT), exploratory laparotomy, diagnostic and therapeutic laparoscopy.

Results: Out of 39 patients that underwent laparoscopy, the laparoscopy succeeded to rule out visceral injury in 14 patients (35.9%) and was nontherapeutic in 5 patients (12.8%). 17 patients (43.6%) needed therapeutic management through laparoscopy and conversion to open laparotomy was done in 3 patients (7.7%). One case of missed injury with laparoscopy was recorded (accuracy 97.4%).

Conclusion: Laparoscopy is a feasible and useful modality for evaluating and managing hemodynamically stable patients with abdominal stab wounds. Increased use of laparoscopy will help to decrease the rate of negative and nontherapeutic laparotomies, thus lowering morbidity and decreasing length of hospitalization.

Key words: Laparoscopy, laparotomy, penetrating, stab, trauma, abdomen.

Introduction:

The   abdomen   is   the   most   common region affected in penetrating injuries from stab wounds. For many decades, wound exploration and exploratory laparotomy have been used for the diagnosis and treatment of such injuries. Currently, exploratory laparotomy is reserved for those with hemodynamic instability. However, there is a wide variation in practice in the management of haemodynamically stable patients post penetrating injury of the anterior abdominal wall.1

Minimally invasive surgery has become increasingly utilized in all areas of surgery.

Since the early 1990s, the learning curve in

laparoscopy is increasing. Thus, it will not be surprising to expand its use in trauma.2

Negative or non-therapeutic laparotomy is associated with up to 5% mortality and 20% morbidity  rates.3  A reliable  and  consistent tool for identification of those patients with visceral injury who require a laparotomy is needed. Diagnostic laparoscopy (DL) may provide  such  a  tool.  Minimally  invasive, using widely available equipment, DL also offers the advantage of allowing simultaneous therapeutic interventions.4

The aim of the present study is to assess the role of laparoscopy in the diagnosis and management of patients with penetrating stab

trauma of the anterior abdominal wall.

Ain-Shams J Surg 2016; 9(1): 77-84                                                                                                                                                                                                           77

Patients and methods:

This  prospective  study  was  conducted over a period of 3 years from May 2012 to June 2015 at the emergency department of Ain Shams university Hospitals, Cairo, Egypt.

The   study   included   52   patients   with single penetrating stab injury of the anterior abdominal wall who were selectively subjected to 1) Physical examination, 2) Focused abdominal sonography in trauma (FAST)  with  examination  of  four  areas for free fluid: peri-hepatic and hepatorenal space, perisplenic, pelvis and pericardium, 3) computed tomography (CT) (abdomen and pelvis) to assess the presence of free fluid and solid organ injuries and 4) Local wound exploration (LWE).

Patients underwent exploratory laparotomy (EL) if they were hemodynamically unstable (persistent systolic blood pressure <90 mmHg) or if they were hemodynamically stable with visceral evisceration through the stab wound.

If intra-abdominal fluid accumulation was detected by FAST in hemodynamically stable patients without visceral evisceration, they were also subjected to laparoscopy.

Evidence of fascial breach on LWE in patients without positive findings by FAST as well as positive findings in CT for patients with equivocal LWE test were also subjected to laparoscopy.

Otherwise,   patients   with   no   evidence of fascial breach on LWE or with negative CT findings were treated by non-operative regimen including simple wound repair and repeated physical assessment to exclude any signs of peritonitis that necessitated surgical intervention.

Data extracted for analysis included demographic information, causes of injury, radiological findings, operative procedures, outcomes of laparoscopy and injuries that were treated. In addition, postoperative outcomes including length of hospital stay, complications, and mortalities were assessed.

Surgical Technique: Laparoscopic exploration was performed while the patient was supine. After clamping the stab wound with  towel  clips,  pneumoperitoneum  with

carbon  dioxide  (CO2)  was  established via the open Hasson technique at the umbilicus. The pressure was maintained at 12-15 mmHg. A 10-mm 30ᵒ laparoscope was inserted via a  10-mm  trocar  into  the  peritoneal  cavity. If there was no peritoneal perforation, the laparoscopic procedure was terminated and the abdominal wound was repaired.

In cases of peritoneal perforation, a 10-mm camera port was created at the suprapubic region for alternative use. Additionally, two further trocars of 5–10 mm were introduced at right and left paramedian sites as working ports.

The abdominal cavity was explored systematically including solid organs, stomach, omentum, transverse colon, and diaphragm  on  the  patient’s  left  side  from the umbilical camera port with the patient in the reverse Trendenlenberg position. The pancreas   and   the   posterior   gastric   wall were inspected after the scope was directed into the lesser sac by dissecting the gastro- colic ligament if a hematoma or fluid accumulation was found in the lesser sac. After close inspection of the upper abdominal structures, the patient was placed in a steep Trendenlenberg position, which allowed inspection of the pelvic structures, including the recto-sigmoid colon, the urinary bladder, and the iliac regions.

For complete evaluation of the ascending colon and the small bowel, the telescope was then inserted into the suprapubic port, and atraumatic grasping forceps were introduced through the umbilical port and through the left paramedian trocar. Using the two forceps, the bowel was inspected from the ascending colon, ileo-ceacal valve, and to the distal two thirds of the small bowel for any mesenteric tears or perforation. The surgeon then changed his position, moving to the patient’s right side to facilitate inspection of the proximal one- third of the small bowel and the descending colon utlizing the same maneuver. It was crucial to tilt the operating table right, left, up, and down for easier exposure by shifting the abdominal contents.

Once     a     significant     intra-abdominal

lesion  had  been  documented,  therapeutic

78                                                                                   Ain-Shams J Surg 2015; 98(1): 77-84

intervention was done in the form of the following:    (1)    hemostasis    of    bleeding solid organs, or mesenteric injuries with electrocautery or suture ligation; (2) repair of diaphragmatic tear with intracorporeal sutures; and (3) repair of perforated hollow organs with laparoscopic procedures.

Laparoscopy was classified as negative if there was no injury, as nontherapeutic if there was an injury but did not require a surgical intervention, therapeutic if an injury was identified and repaired, and positive if there was an injury that required conversion to open exploration for better management.

Results:

There were 65 patients identified with single abdominal stab injury over the 3 years study period in the emergency department of Ain Shams University Hospitals. 13 patients  were  excluded  from  the  study  as they were hypotensive on arrival that needed resuscitation and emergency exploratory laparotomy (EL). 52 hemodynamically stable patients  were  included  in  this  study,  their ages ranged from 18-50 years with a mean of 28.8±8.5 years. 49 (94.2%) of them were males while 3 (5.8%) were females.

The majority of injuries were caused by knives (84.6%), and the rest were with varied instruments including clasp knives, skewers and swords.

Visceral evisceration was diagnosed in 4 patients and they underwent EL, while 48 patients had no visceral evisceration and underwent   FAST   examination.   A   FAST was positive in 13 patients who underwent laparoscopy, while it was negative in 35 patients so; LWE was done for them to detect any fascial breach. LWE was positive in 20 patients who underwent laparoscopy while it was negative in 5 patients and equivocal in  10  patients.  CT  was  done  for  patients with equivocal LWE which was positive in

6 patients who underwent laparoscopy and negative in 4 patients. Patients with negative findings on LWE or CT were observed for

24 hours with serial physical examination to detect signs of peritonitis.

Out  of  the  39  patients  who  underwent

laparoscopy, peritoneal breach was detected in 33 patients with concomitant visceral injury in 25 patients of them.

Laparoscopy ruled out visceral injury (negative laparoscopy) in 14/39 (35.9%) patients  with  or  without  peritoneal  breach (8 and 6 patients respectively) that needed repair of abdominal wound ±peritoneal repair.

Non-therapeutic laparoscopy was performed in 5 patients (12.8%): 4 patients presented with minor liver lacerations and one with a retroperitoneal hematoma related to the ascending colon with no significant colonic injury.

Therapeutic  laparoscopy  was  performed in  17  patients  (43.6%):  2  patients  with liver   lacerations   that   needed   hemostasis by electrocautery, 4 patients with stomach perforation were repaired with or without omental patch, 7 patients with bowel injuries,

2 patients with mesenteric injuries, 1 patient with a diaphragmatic injury, and 1 patient with a splenic tear that all needed laparoscopic management.

Conversion to open EL (positive laparoscopy)  was  done  in  3  patients (7.7%): one with a splenic tear that needed splenectomy from a left subcostal incision, one with a retroperitneal hematoma and one with a combined injury Table (1).

Peritonitis  occurred  in  a  single  patient due to a missed intestinal perforation that necessitated an EL with an accuracy of the laparoscope  to  diagnose  visceral  injury  of

97.4% (38/39 patients).

Among patients who required EL, one patient had a minor complication in the form of wound infection.

The average length of hospital stay was

3±2.5 days for all patients.

Laparoscopy was negative in 14 patients and was non-therapeutic in 5 patients. Also,

16 patients were managed successfully with laparoscopy.  Overall,  because  of  the  use of laparoscopy, laparotomy was avoided in

35/52 (67.3%) of the patients in this study.

Discussion:

The evaluation of a trauma patient starts with   the   advanced   trauma   life   support

Ain-Shams J Surg 2015; 98(1): 77-84                                                                                                                                                                                                           79

primary survey followed by a thorough physical examination. LWE is limited in its ability to determine specific intra-abdominal injuries, but it can often determine fascial penetration and thereby avoid the need for further studies.5

The usual diagnostic procedures, FAST, and even CT, all have their strengths and weaknesses and none of them are 100% reliable. For this reason, exploratory laparotomy is often performed in the case of stab wounds, but with a high morbidity percentage that reaches up to 40%.6 Therefore, the main benefits of laparoscopy are that it can reduce the rate of non-therapeutic and negative laparotomies, and even provide a therapeutic option.7

Different algorithms have been developed by   many   trauma   centers   worldwide   for the management of PAT to aid the fast and effective diagnosis and management of visceral injuries.7 In our study, we proposed a modified algorithm for diagnosis and management   of   patients   presented   with stab injury of the anterior abdominal wall Figure (1).

Recent literature suggested that the role of laparoscopy in trauma was not fully established. However; with accumulated experience in laparoscopic surgery and the advent of new instrumentation, laparoscopic surgery has gained acceptance in intra- abdominal operations as well as in the trauma setting. The role of laparoscopy in trauma thus is continually evolving.4

For trauma patients, laparoscopy provides clear  visualization  of  the  peritoneal  space and  anterior  abdominal  wall,  and  unlike other  diagnostic  modalities,  has  the additional benefit of potential for therapeutic intervention.5

The first reports demonstrating the utility of laparoscopic surgery in the evaluation of trauma patients were published in the 1920s which investigated its use as a method to diagnose internal bleeding in patients with PAT.8,9

The present study adds to the growing data indicating that laparoscopy can play a major role in the evaluation and management of

80

stable patients with penetrating trauma to the abdomen.10,11,12

The main aim of our study is to assess the role of laparoscopy in: (1) Reducing nontherapeutic laparotomy; (2) Avoiding missed injuries; and (3) Maximizing therapeutic laparoscopy.

Villavicencio     and    Aucar10      authored

an   extensive   review   in   1997   in   which they  compared  outcomes  collected  from

37  separate  studies,  involving  over  1900 patients,  they  found  that  63%  of  patients who           underwent    laparoscopic     evaluation avoided  laparotomy.  When  comparing  DL and EL in abdominal stab wounds, the results showed that DL reduced the nontherapeutic laparotomy rate from 65% to 11% (lowest) or  50%  (highest).  Besides,  DL  reduced unnecessary    laparotomies    (calculated    as

100% conversion to laparotomy rate) in 55–

87% of trauma cases.

In 1976, Gazzangia et al.13 evaluated 37 patients; in 14 of these patients, laparotomy was avoided because of a negative diagnostic laparoscopy (DL). There were no false- negative   investigations.   They   concluded that the use of diagnostic laparoscopy in abdominal trauma was useful to decrease the rate of negative laparotomy.

In  the  largest  study  on  laparoscopy  in PT, Zantut et al.,14 reported a multicenter retrospective study of 510 hemodynamically stable patients  who  underwent  DL for  PT. The  inclusion  criterion  for  the  study  was a   hemodynamically   stable   patient   who had  penetration  of  the  anterior  fascia  by a stab wound or a gunshot wound with a possible   intraperitoneal   injury.   Negative or nontherapeutic laparotomy was avoided in   303   (59.4%)   patients,   of   whom   26 patients received a therapeutic laparoscopic intervention.

The results of our study showed that the laparoscopy-based strategy to reduce the nontherapeutic  laparotomy  had  succeeded to decrease the rate from 35.8% to 0% and prevented laparotomies in 89.7% of trauma cases.

The use of laparoscopy as a diagnostic and therapeutic tool led to avoidance of an open

Ain-Shams J Surg 2016; 9(1): 77-84

Figure (1): Diagnosis and treatment algorithm for stab injury of anterior abdominal wall.

Figure (2): Site of peritoneal penetration.

Figure (3): Small bowel exploration.

Figure (4): Liver tear without active bleading.

surgery in more than 67% (35/52) of patients in our study.

A  major  drawback  of  utilizing  DL  for

abdominal  stab  wounds  is  missed  injuries.

Visualization   of   solid   organs   is   simple to          perform   and   reliable,   but   complete examination  of  the  intestines  presents  a

greater challenge for surgeons with a reported

Ain-Shams J Surg 2016; 9(1): 77-84                                                                                                                                                                                                           81

Figure (5): Splenic tear before and after cauterization.

Figure  (6):  Small      intestinal  perforation

suturing  with  omental  flap.

Figure (7): Repair of the Rt. colon.

Table (1): Laparoscopic findings and managements of patients with penetrating abdominal

injuries:

missed injury rate of 40%.2,15

The key points to avoid missed injuries in DL include the following: (1) a systematic and careful inspection; (2) changing the patient’s position during laparoscopic procedures for

inspection; and (3) use of atraumatic grasping forceps for bowel manipulation. Nevertheless, we should not hesitate to convert DL to laparotomy if complete visualization of the intra-abdominal structures cannot be obtained.

82                                                                                   Ain-Shams J Surg 2016; 9(1): 77-84

Table (2): Patient characteristics and outcomes:

Despite optimum strategy not to miss an injury, a case of missed intestinal perforation was documented in this study probably because it was a small perforation at the mesenteric border of a jujenal loop with an accuracy of laparoscopy to diagnose visceral injury of 97.4% (38 out of 39 patients).

Althoughseveralpreviouslypublishedtrials have reported on the laparoscopic treatment of  certain  injuries  in  hemodynamically stable abdominal trauma patients, the role of laparoscopy as a therapeutic tool for PAT is still uncertain.14,16,17

Chol and Lim used laparoscopy to treat bowel perforations by totally laparoscopic, laparoscopically-assisted,   and   hand- assisted procedures with a high success rate. Treating patients with injuries such as bowel perforations is technically demanding.18

In  the  present  study,  we  attempted  to apply laparoscopically based procedures for the hemodynamically stable abdominal stab wound patients. Significant intra-abdominal injuries were identified and treated by laparoscopic  procedures  in  17  patients:  2 liver lacerations needed hemostasis by electrocautery, 4 stomach perforations, 7 bowel injuries, 2 mesenteric injuries, 1 diaphragmatic injury, and 1 splenic tear that all needed laparoscopic management.

However, conversion to laparotomy was

done in 3 patients: one splenic tear that needed

splenectomy by left subcostal incision, one retroperitneal hematoma and one combined injury.

With respect to outcomes, most authors report a decreased complication rate, shorter length of hospital stay, and decreased costs when negative laparoscopy is compared with a negative or nontherapeutic laparotomy.14,19,20

The results in the present study, like most other studies, show that nontherapeutic laparoscopy is lesser invasive than nontherapeutic laparotomy with short length of hospital stay and less postoperative morbidity and mortality.

Laparoscopy in the trauma setting has been associated with some complications including tension pneumothorax, raised intracranial pressure and gas embolism.21  Although Small numbers of such complications were reported in the 1990s, none was detected in this study as they now seem to be preventable if suitable measures are adopted.

Conclusion:

Current  trends  in  all  areas  of  surgery are towards less invasive techniques, laparoscopy   is   feasible   and   useful modality for evaluating and managing hemodynamically stable patients with abdominal stab wounds. Increased use of laparoscopy will help to decrease the rate of negative  and  nontherapeutic  laparotomies,

Ain-Shams J Surg 2016; 9(1): 77-84                                                                                                                                                                                                           83

thus lowering morbidity, decreasing length of hospitalization.

Reference:

1-         Mitra B, Gocentas R, O’Reilly G, Cameron PA, Atkin C: Management of haemodynamically stable patients with abdominal stab wounds. Emergency Medicine Australasia 2007; 19:

269–275.

2-   Fabian TC, Croce MA, Stewart RM, Pritchard FE, Minard G, Kudsk KA: A prospective analysis of diagnostic laparoscopy in trauma. Ann Surg 1993; 217: 557–565.

3-   Shih HC, Wen YS, Ko TJ, Wu JK, Su CH, Lee CH: Noninvasive evaluation of blunt abdominal trauma: Prospective study using algorithms           to    minimise    nontherapeutic laparotomy. World Surg 1999; 123: 263–270.

4-   O’Malley   E,   Boyle   E,   O’Callaghan   A, Coffey JC, Walsh SR: Role of laparoscopy in penetrating abdominal trauma: A systematic review. World J Surg 2013; 37: 113–122.

5-         Miles  EJ,  Dunn  E,  Howard  D,  Mangram A: The role of laparoscopy in penetrating abdominal trauma. JSLS 2004; 8: 304–309.

6-   Leppäniemi   A,   Salo   J,   Haapiainen   R: Complications of negative laparotomy for truncal  stab  wounds.  J  Trauma  1995;  38:

54–58.

7-   Uranüs S, Dorr K: Laparoscopy in abdominal

trauma. Eur J Trauma Emerg Surg 2010; 36:

19–24.

8-   Short AR: The uses of celioscopy. BMJ 1925;

2: 254–255.

9-   Stone WE: Intra-abdominal examination by the aid of the peritoneoscope. J Kansas Med Soc 1924; 24: 63–65.

10-  Villavicencio  RT,  Aucar  JA:  Analysis  of

laparoscopy in trauma. J Am Coll Surg 1999;

189: 11–20.

11-  Ivatury RR, Simon RJ, Stahl WM: Selective celiotomy for missile wounds of the abdomen based on laparoscopy. Surg Endosc 1994; 8:

366–370.

12- Matthews BD, Bui H, Harold KL, Kercher KW, Adrales G, Park A, et al: Laparoscopic repair of traumatic diaphragmatic injuries. Surg Endosc 2003; 17: 254–258.

13- Gazzaniga AB, Stanton WW, Bartlett RH: Laparoscopy in the diagnosis of blunt and penetrating injuries to abdomen. Am J Surg

1976; 131: 315–318.

14-  Zantut LF, Ivatury RR, Smith RS, Kawahara NT, Porter JM, Fry WR, et al: Diagnostic and therapeutic laparoscopy for penetrating abdominal trauma: A multicenter experience. J Trauma 1997; 42: 825–831.

15- Rossi P, Mullins D, Thal E: Role of laparoscopy in the evaluation of abdominal trauma. Am J Surg 1993; 166: 707–711.

16-  Chen RJ, Fang JF, Lin BC, Hsu YB, Kao JL, Kao YC, et al: Selective application of laparoscopy and fibrin glue in the failure of nonoperative management of blunt hepatic trauma. J Trauma 1998; 44: 691–695.

17-  Kawahara NT, Alster C, Fujimura I, Poggetti RS, Biroloni D: Standard examination system for laparoscopy in penetrating abdominal trauma. J Trauma 2009; 67: 589–595

18-  Chol YB, Lim KS: Therapeutic laparoscopy

for abdominal trauma. Surg Endosc 2003;

17: 421–427.

19-  Hallfeldt KK, Trupka AW, Erhard J, Waldner H, Schweiberer L: Emergency laparoscopy for  abdominal  stab  wounds.  Surg  Endosc

1998; 12: 907–910.

20- DeMaria EJ, Dalton JM, Gore DC, Kellum JM,  Sugerman  HJ:  Complementary  roles of laparoscopic abdominal exploration and diagnostic peritoneal lavage for evaluating abdominal stab wounds: A prospective study. J Laparoendosc Adv Surg Tech A 2000; 10:

131–136.

21- Leppäniemi A, Haapiainen R: Diagnostic laparoscopy in abdominal stab wounds: A prospective,  randomized  study.  J  Trauma

2003; 55: 636–645.