Laparoscopy in abdominal trauma

Abstract

The role of lap aroscopy in the evaluation and management of abdominal trauma has been the subject of numerous studies and debates [181. Little argument exists in the role (utility) of laparoscopy in the unstable patient. Similarly, the utility of laparoscopy in blunt trauma is very limited [5,9 101. The accuracy of diagnostic peritoneal lavage (DPL), the emergence of ultrasonography (US) as a screening tool in the emergency department, and the accurate definition of organ injuries on spiral computed tomography (CT) scan have limited the use of laparoscopy as a primary diagnostic tool in blunt abdominal trauma. Laparoscopy can be used as an adjunct to CT scan, especially in the presence of peritoneal fluid and the absence of solid organ injuries [s, ioj. The greatest challenge in abdominal trauma is the optimal management of penetrating abdominal injuries in a stable patient with doubtful intraperitoneal trajectory (tangential abdominal and lower thoracic wounds). A policy of mandatory exploration results in a 3040% negative laparotomy rate. This is unacceptable in todays vast diagnostic armamentarium [local wound exploration (LWE), DPL, US, CT, and laparoscopyl. In both retrospective and prospective studies, significant postoperative complication rates (2143%) resulted from these negative laparotomies [11161. Over the last decade laparoscopy established its role in the evaluation and management of penetrating abdominal trauma, and challenged various dicta including (i) mandatory lap- arotomy for all penetrating injuries, (2) mandatory laparotomy upon documentation of peritoneal violation, () mandatory laparotomy upon documentation of diaphragmatic and solid organ injuries, and recently () mandatory laparotomy upon suspicion or diagnosis of hollow organ and retroperitoneal injuries. The controversies remain regarding whether laparoscopy can minimize unnecessary laparotomies while avoiding missed injuries, and whether it can safely manage these injuries in a cost-effective manner without significant complications. © 2006 Springer-Verlag Berlin Heidelberg.