Minimally invasive is maximally effective

Abstract

BACKGROUND: Laparoscopic techniques have evolved, allowing increased capabilities within most subspecialties of general surgery, but have failed to gain traction managing injured patients. We hypothesized that laparoscopy is effective in the diagnosis and treatment of penetrating abdominal injuries. METHODS: We retrospectively reviewed patients undergoing abdominal exploration following penetrating trauma at our Level 1 trauma center during a 6-year period from January 1, 2008, to December 31, 2013. Demographic and resuscitation data were obtained from our trauma registry. Charts were reviewed for operative details, hospital course, and complications. Hospital length of stay (LOS) and complications were primary end points. Patients were classified as having nontherapeutic diagnostic laparoscopy (DL), nontherapeutic diagnostic celiotomy (DC), therapeutic laparoscopy (TL), or therapeutic celiotomy (TC). TL patients were case-matched 2:1 with TC patients having similar intra-abdominal injuries. RESULTS: A total of 518 patients, including 281 patients (55%) with stab wounds and 237 patients (45%) with gunshot wounds, were identified. Celiotomy was performed in 380 patients (73%), laparoscopy in 138 (27%), with 44 (32%) converted to celiotomy. Nontherapeutic explorations were compared including 70 DLs and 46 DCs with similar injury severity. LOS was shorter in DLs compared with DCs (1 day vs. 4 days, p < 0.001). There were no missed injuries. Therapeutic explorations were compared by matching all TL patients 2:1 to TC patients with similar type and severity of injuries. Twenty-four patients underwent TL compared with 48 TC patients in the case matched group. LOS was shorter in the TL group than in the TC group (4 days vs. 2 days, p < 0.001). Wound infections were more common with open exploration (10.4% vs. 0%, p = 0.002), and more patients developed ileus or small bowel obstruction after open exploration (9.4% vs. 1.1%, p = 0.018). CONCLUSION: Laparoscopy is safe and accurate in penetrating abdominal injuries. The use of laparoscopy resulted in shorter hospitalization, fewer postoperative wound infection and ileus complications, as well as no missed injuries. LEVEL OF EVIDENCE: Therapeutic study, level IV.