Role of Laparoscopic Exploration Under Local Anesthesia in the Management of Hemodynamically Stable Patients with Penetrating Abdominal Injury

Introduction

In the last few years the incidence of penetrating abdominal injuries has increased all over the world, especially in young adults, and is accompanied by an increasing debate over the way of managing this kind of trauma. ¹

Surgical exploration remains the standard operation for all penetrating injuries, especially for patients with peritonitis, hemodynamic instability, or evisceration of an internal organ and who should undergo urgent laparotomy after the injury. However, it is currently clear that in certain conditions, hemodynamically stable patients without peritonitis may be managed conservatively.^2,3

In many trauma centers there is a huge debate over the way of managing hemodynamically stable patients with penetrating abdominal injuries, and the area is still the subject of continuous research.^4–8

Different diagnostic methods are used to evaluate patients with this kind of injury and to help in determining their need for laparotomy. Examples of these methods include wound exploration with subsequent diagnostic peritoneal lavage, serial clinical evaluation, or both, radiological investigations such as computed tomography with contrast, and ultrasonography (focused assessment with sonography for trauma [FAST] scan). All of these methods are used to reduce the number of patients who undergo laparotomy without the presence of intraperitoneal injury with subsequent reduction in unnecessary hospitalization. However, their diagnostic accuracy is still not completely reliable.^9,10

With the advances in minimal invasive surgical techniques in all area of surgery, the use of laparoscopy in the evaluation and management of patients with penetrating abdominal injuries will be a natural extension to this trend with the aim of decreasing the rate of unnecessary laparotomy. ¹¹

This study was conducted to evaluate the role of diagnostic laparoscopy performed with hemodynamically stable patients havingr local anesthesia for the management of penetrating abdominal injury.

Patients and Methods

Thirty patients (27 males and 3 females) with a stab wound in the anterior abdomen wall with an age range of 20–50 years were enrolled in this study. These patients were admitted as casualties to the General Surgery Department at El Demrdash Hospital at Ain Shams University in Cairo, Egypt, from January 2013 to December 2014. Approval from the ethical committee of Faculty of Medicine at Ain Shams University was obtained to conduct this study.

All patients were hemodynamically stable and were suffering from recent (within 6 hours) penetrating injury (single or double) to the anterior abdominal wall with no clinical signs of peritonitis, shock, or evisceration.

Patients with the following criteria were excluded from our study: having signs of peritonitis, shock, or visceral evisceration, having multiple injuries, gunshot wounds, having head or cardiothoracic injuries, had previous abdominal surgeries, having major medical comorbidity (cardiac patients), pregnant female patients, or patients who refused the laparoscopic procedure.

All patients were managed according to the guidelines of advanced trauma life support. During the primary survey all patients received oxygen through a nasal mask and intravenous normal saline through a wide-bore peripheral venous cannula, their breathing was checked, and signs of internal hemorrhage were examined. Blood samples for lab investigations (complete blood count, as well as chemical and bleeding profiles) were taken.

During the secondary survey, a detailed history of all patients was taken. A thorough general examination was performed for vital signs (heart rate, blood pressure in the lying down and standing positions, respiratory rate, and temperature), pallor, sweating, chest examination, cardiac examination, and peripheral pulsation. Results of all examinations should be within the normal limits.

During local abdominal examination, the patient's abdomen was inspected to examine the exact number, site, size, and shape of the wound, abdominal mobility with respiration, and any discharge from the wound. In addition, the abdomen was palpated to detect any rigidity or tenderness away from the wound. Furthermore, percussion was performed to exclude any abdominal fluid collection, and finally intestinal sound was examined by auscultation. All patients underwent radiological examinations, including pelvi-abdominal ultrasound (FAST scan) and pelvi-abdominal computed tomography to detect any presence of free fluid or organ injury in the abdomen.

Under complete aseptic conditions, the depth of the wound was examined using a sterile Nelaton catheter. If the anterior fascia was found to be intact, the patient was observed for 48 hours. If the anterior abdominal fascia was found to be penetrated or if the examination was queried, laparoscopic evaluation of the patients was decided.

After patients' consent to do laparoscopy under local anesthesia was obtained, patients were transferred to the operating room. With the patient having local anesthesia and intravenous sedation, the Hasson trocar system was introduced through a separate infraumbilical incision using the open technique; slow insufflation was administered at a rate of 0.5 L/minute, and pressure was kept below 8 mm Hg to prevent pain. Subsequently, a camera was inserted through the Hasson port to visualize the peritoneal cavity. If no blood, bile, or intestinal content was seen, another 5-mm port was introduced with local anesthesia in the opposite quadrant to the quadrant in which the wound was located (i.e., if the wound was located in the right iliac fossa, the second port would be introduced to the left hypochondrium). This port aimed to examine the abdominal organs thoroughly, and in some cases a third port was needed for proper examination.

If there was bleeding or intestinal content in the peritoneal cavity, a visible bowel injury, or mesenteric or solid organ injury, laparoscopic exploration was shifted to open exploration through a midline incision passing through the umbilical port site, and prompt operative management was performed. The port site can be used as a drain.

On the other hand, if the peritoneal cavity had no fluid collection or had no injury to the abdominal viscera after meticulous examination for the affected quadrant, the laparoscope was withdrawn, and the stab wound was sutured in layers under local anesthesia. Patients were followed up afterward every hour for the first 8 hours and then every 8 hours for the next 72 hours for signs of bleeding or peritonitis.

Results

Thirty adult patients (27 males and 3 females) who were admitted to our casualty ward with a penetrating stab wound to the anterior abdominal wall and having an age range of 20–50 years old were enrolled in this study. Twenty-five patients presented with a single stab wound, and 5 patients presented with two stab wounds with an average size of 3–5 cm (Tables 1 and 2).

Positive laparoscopy with conversion to open exploration was performed in 12 patients. Two patients had a small colonic perforation (1 in the sigmoid colon and 1 in the cecum), 3 patients had a small intestinal tear, 2 patients had splenic injury, 2 patients had stomach injury, and 1 patient had liver injury. One patient was converted to laparotomy for a mesenteric tear that was seen by the laparoscope after the diagnosis of intraperitoneal hemorrhage, and 1 patient underwent laparotomy for intraperitoneal blood collection where the cause of bleeding was not identified by laparoscopy but after open exploration the wound in the anterior abdomen was found to be the source of bleeding (Table 3).

On the other hand, laparoscopy was negative in 18 patients. Three patients had no peritoneal penetration, whereas the other 15 patients had peritoneal penetration without abdominal fluid collection or injury to the abdominal viscera. Among these 15 patients, 14 cases did not show any signs of bleeding or peritonitis during the follow-up period, whereas 1 patient suffered from acute pains in the abdomen 48 hours after the operation. This patient underwent laparotomy, where leakage from a minute intestinal tear was found.

Hospital stay varied according to the type of procedure. Patients who underwent laparoscopic exploration were discharged after 2–3 days, whereas patients who underwent laparotomy were discharged after 5–8 days (Table 4).

In this study, the mortality was 0%. The morbidity among patients who underwent laparoscopic exploration was 11.7%: 1 patient had a missed injury, and 1 patient had a superficial wound infection that was treated within a day. In contrast, among patients who underwent laparotomy the morbidity was 23.1%: there were 3 cases of wound infection that were treated within days (Table 5).

Discussion

In the last decade the number of abdominal stab injuries has increased markedly, which grasped the attention of the medical society toward the importance of optimizing the way of managing patients with this type of injury. However, there is an ongoing controversy about the best way of managing abdominal stab injuries, and up until now no significant advancements have been achieved. ¹² Laparotomy is considered the gold-standard procedure in managing abdominal stab injuries; however, it is associated with a 20% rate of complications, and its rate of morbidity may reach 40%. Furthermore, diagnostic procedures that are used in the preoperative evaluation of cases such as diagnostic peritoneal lavage, FAST scan, and computed tomography are not 100% accurate. ¹³

The increasing technological advances in laparoscopy make it very promising in managing abdominal stab injuries and can reduce the number of cases with negative laparotomy and the associated rates of morbidity and mortality. In addition, laparoscopy plays an important role in detecting injuries in hidden sites (e.g., diaphragmatic injury). ¹⁴

In our study laparoscopic exploration was performed on 30 hemodynamically stable patients with penetrating abdominal injury. Twelve patients (40%) were converted to open exploration, of which 11 cases had intraabdominal organ injuries and 1 case had intraabdominal blood collection, but the source of this bleeding could not be identified. However, when laparotomy was performed a wound in the anterior abdominal wall was identified to be the source of bleeding. For the remaining 18 patients (60%) laparoscopy was negative, and all patients were put under observation for 3 days postoperatively. One case had acute abdomen after 48 hours of observation, and upon exploration a missed intestinal tear was found.

In a study performed by Leppäniemi et al. ¹⁵ they stated that 50% of penetrating abdominal wounds require surgical intervention. In contrast, in our study open exploration was needed only in 43.3% of patients, which indicates that laparoscopy decreases the number of patients who require laparotomy.

This study showed that with the use of laparoscopy, the rate of unnecessary open explorations was 0%. In contrast, with the use of other diagnostic methods such as diagnostic peritoneal lavage, local wound exploration, FAST scan, and computed tomography scan, the rate of unnecessary open explorations can reach 10%.^16–18

In our experience, the use of laparoscopy allows full and reliable visualization of abdominal organs, which has also been previously shown in another study ¹⁹ in which the authors stated that the use of laparoscopy was helpful in achieving a reliable and less invasive exploration allowing the detection of the peritoneal penetration and complete visceral exploration.

In this study, the overall sensitivity and specificity of laparoscopy were 100% and 92.3%, respectively. In another study performed by Pham et al., ²⁰ they stated that diagnostic peritoneal lavage sensitivity and specificity for penetrating abdominal injuries requiring operative intervention were 92% and 83%, respectively.

In accordance with our results, Lin et al. ²¹ showed that laparoscopy decreased the nontherapeutic laparotomy rate with a diagnosis accuracy of 100%, and in another study performed by Ahmed et al., ²² they showed that laparoscopy is an accurate and a safe diagnostic tool for hemodynamically stable patients with penetrating abdominal injuries and can decrease the number of nontherapeutic laparotomies and can shorten the duration of hospitalization.

In our study the mortality rate was 0%, and the morbidity rate in the cases that underwent laparoscopy was 11.7%, whereas that in the cases that underwent laparotomy it was 23.1%. This indicates that laparoscopy is a safe procedure and can decrease the rate of morbidity in comparison with laparotomy. Moreover, the average duration of hospitalization after laparoscopy was 2.4 days, which was much shorter compared with laparotomy, for which the average duration of hospitalization was 6.1 days.

In this study laparotomy was not needed in 17 out of 30 cases (56.7%). This was also shown in another study performed by Brefort et al. ²³ in which laparotomy was avoided in 9 patients out of 13 and no lesions were missed with the use of laparoscopy. These results show that laparoscopy is a reliable method in the management of patients suffering from abdominal wounds and allows sensitive and specific diagnosis of penetration and visceral injuries.

Although our results and that of many other studies mentioned above indicate that laparoscopy is a safe and accurate diagnostic tool for penetrating abdominal injuries, there is still an ongoing debate among trauma centers on the way of optimizing laparoscopy application that can make use of all its benefits and overcome its limitations. ¹¹

Conclusions

Laparoscopy performed with the patient having local anesthesia is an accurate and safe diagnostic tool in the management of patients with an equivocal penetrating stab wound in the abdominal wall and can reduce the number of patients with negative open exploration.