Laparoscopy in penetrating abdominal stab wounds: Does it have a role?

Laparoscopy in penetrating abdominal stab wounds: Does it have a role?

Mohamed Riad,MD; Hatem Mohammed, MD;

Yasser Hussein,MD; Mohammad  Lofty,MD General Surgery Department Zagazig University

Abstract

Background:  If the patient of penetrating abdominal stab wound is hemodynamically  stable and has equivocal abdominal  examination findings,  surgeons pose a significant challenge to take decision in 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. It also leads to avoid negative exploratory laparotomies.

Methods: This is a randomized study including 51 patients with penetrating abdominal stab wounds. 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 were able to evaluate the diagnostic and therapeutic role oflaparoscopy.

Results: Patients were divided into two groups. Group I underwent exploratory laparotomy (26 patients). Group II underwent laparoscopic laparotomy (25 patients). The mean operating time in both groups  was (89±23.5  vs. 55±19 minutes,  (P<O.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>O.05) respectively. There was no mortality in both groups. Accurate diagnosis was done to all patients in Group II except one patient (96.15%) with missed intestinal injury (this happened in the first cases of the study). Treatment was done for four patients from eight patients with discovered organ injuries (50%). Other four patients were converted to exploratory laparotomy (50%) due to severe injuries.

Conclusion: The use oflaparoscopy as a diagnostic or therapeutic method in patients with penetrating abdominal stab wounds is an efficient, safe and effective method. The most important advantages are reduction of morbidity, shortening of hospitalization and cost-effectiveness.

Key words: Penetrating abdominal stab trauma, laparoscopy, laparotomy.

Introduction:

Penetrating    mJunes    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.l-3

It is  reported  that  50-70%  of  abdominal stab  mJunes  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.s

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 April2010 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 (30°) 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 was  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 atraumatic 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(l) shows  the  used  algorithm  for the laparoscopic management of abdominal stab wounds [adapted from Choi and Lim].1o

IAbdomina l  Stab  Wounds I

/

------Stable

Un.'!able

::-.lo Suspicion for

Abdominal  Penetration

Suspicious for

Abdom i nal Penet ration

Exploratory  Laparotomy

!                         !

Observa tion                                         l.apa roscopy

. o Peril                           Per itoneal

Viol ation                                   Violat ion

!             !

Observa tion                               Laparoscopic

Exploration

::-.lo I njury

Id entified

!

Observation

I njury If ntified

Thera peutic  Intervention

Figure (1): Algorithm for the laparoscopic management of abdominal stab wounds.

Results:

This study was conducted  on 51 patients with   penetrating   abdominal   stab   wounds. They were divided into two groups and underwent operations either exploratory laparotomy for group I or 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 was 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 having no peritoneal penetration,

2nd patients  having  peritoneal  penetration without  intra-abdominal  organ  injuries,  and

3fd  patients   having   peritoneal   penetration with intra-abdominal organ injuries, as shown in Table(l).

Table (1): Results of exploration in both groups.

In group II; all patients were accurately diagnosed except in one case with missed intestinal injury  (96.15%); this happened  in the first cases of the study. This perforation was found in the posterior gastric wall, which was   managed   by   exploratory   laparotomy which   done  2  days  later;  when  signs  of

peritonitis developed.

In group I, there were seven patients having peritoneal penetration with intra-abdominal organ injuries (26.92%); three patients had small   intestinal   injury   only,  two   patients had small intestinal injury with mesenteric injury and two patients had liver injury. On

the other hand, in group II there were eight patients having peritoneal penetration with intra-abdominal  organs injuries (32%); three patients  having  small  intestinal  injury only, two  patients  having  small  intestinal  injury

with  mesenteric  mJury, one patient  had colonic  injury,  one  patient  had  liver  injury and one patient has splenic injury, as shown in Table(2).

Table (2): Shows the type of injury in both groups on initial evaluation.

Four cases (50%) in group II were managed laparoscopically:    Two   cases   with   single small intestinal injury (less than 1 em) were managed   with  intra-corporeal   suturing.   In one case with small intestinal and mesenteric injury;  the  intestinal   injury  was  managed with intra-corporeal suturing due to the small wound  size  and  the  mesenteric  injury  was also small and was controlled with clips used for laparoscopic cholecystectomy  (additional

1Omm port was added in the supra-pubic region). The 4th case had a liver tear that was superficial and was controlled with bipolar diathermy coagulation and compression  by a piece of gauze for ten minutes.

The other four cases who were converted to  open  laparotomy:   1st   case  had  splenic injury  which  was  near  to  the  hilum  with blood clot over it and open splenectomy  was done. 2nd  case had intestinal injury with big mesenteric injury with sign of ischemia at the affected intestinal part; resection-anastomosis

was done. 3rd case had colonic injury (transverse   colon)  with  faecal   soiling,   in this patient colostomy was done at the perforation site. 4th case, had multiple small bowel perforations that needed resection­ anastomosis     of    the     affected    segment.

Postoperative  morbidity  in group  I was

recorded   in  five  patients,  while  in  group II  it  was  found  in  three  patients  (19.23% vs. 12%, P>O .05). There was a significant difference  between   both  groups   regarding mean   operative   time;   in  group   I  it  was

89±23.5  minutes,  while  in  group  II  it  was

55±19 (P<O .05).   The length ofhospital stay was (9.3 vs. 4.1 days, P<O  .05) respectively in  both  groups.  In  consequence,  there  was decreasing          postoperative   morbidity                      and length of hospital stay in group II that led to improved   cost-effectiveness.   No  mortality was detected  in both groups.   Postoperative characters of patients are showed in Table(3).

Table (3): Postoperative characters.

Figure (2): Peritoneal stab perforation.

Figure (3): Small intestinal stab perforation.         Figure (4): Intra-corporeal intestinal repair.

Discussion:

Laparoscopy   rmses   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 of those patients did not have peritoneal penetration(29.41%)and20patients (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  al4·15  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.

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, non-therapeutic exploratory  laparotomy  could be avoided  in

16 patients from group II (64%), this is near

to the results of Ahmed et al and others14,20,21 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  al19 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 al4,22 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%)  hwo  needed

surgical intervention; could be managed laparoscopically.   This  percentage  is  much less than what was reported by Lin et al9 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  ai14 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 bothgroupsincludedinthestudy,andthisagreed 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  stay  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 al9 that visualization of solid organs  is simple to perform  and is

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 atraumatic 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.

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