Laparoscopic Versus Open Surgery for Abdominal Trauma: A Case-Matched Study

Introduction

Trauma is a global public health problem and it is the main cause of death during the first half of human life span and the fifth leading cause of death in all age groups. ¹

The morbidity rate of abdominal injuries caused by trauma in all kinds of injuries is about 0.4%–1.8%. ²

Since laparoscopy was first introduced to treat 2 patients with splenic injuries by Lamy in 1956, it had been increasingly applied to abdominal trauma as a diagnostic or therapeutic tool due to its potential advantages. ³

The use of laparoscopic surgery in abdominal emergencies, such as trauma, has had a slow acceptance. The advantages described with this approach include less postoperative pain, faster recovery, quicker return to everyday activities (work, exercise, etc.), and low incidence of incisional hernias and surgical site infections. ⁴ Another advantage described in trauma is that by selecting correctly the patients who are candidates for this approach, we can avoid unnecessary nontherapeutic laparotomies, thus reducing morbidity and mortality. ⁵

However, exploratory laparotomy is the traditional mainstay of management in patients with penetrating abdominal trauma. ⁶

The aim of this study was to compare outcomes of patients with blunt and penetrating abdominal trauma treated, in our institution, with minimally invasive or open surgery.

Materials and Methods

After approval from our Institutional Review Board, we performed a retrospective review of our prospectively maintained database (between January 1, 2013, and May 31, 2016) in which all patients with blunt or penetrating abdominal trauma who were admitted to the emergency room and underwent laparoscopic surgical treatment were included. A total of 19 patients who met these criteria were identified. These 19 patients were matched to 19 patients (1:1 ratio) who underwent open surgery for the same indication during the same period of time. The matching process was performed manually by the authors. Matching variables were age, gender, body–mass index (BMI), American Society of Anesthesiologists (ASA) score, hemodynamic stability (systolic pressure ≥90 mmHg), and injury mechanism (stab wounds, gunshot wounds, and blunt trauma).

The type of surgery was classified as diagnostic or therapeutic. Diagnostic surgery was considered when patients underwent surgical exploration, but did not require repair of any intra-abdominal organ. Therapeutic procedures were considered when repair or resection of any injured intra-abdominal organ was required.

The intraoperative variables were type of organ injuries (based on American Association for the Surgery of Trauma Injury Scoring Scale [AAST]), ⁷ conversion to open surgery, operative time (minutes), and estimated blood loss (mL). Postoperative variables were time to return to normal diet (days), 30-day postoperative complications in accordance with the Clavien-Dindo classification, ⁸ hospital length of stay (LOS), unplanned reexploration, and 30-day mortality.

Data are reported as means (standard deviations), medians (interquartile range), or percentages. Categorical variables were compared using Fisher's exact test. Continuous variables were compared with Student's t-test or with a Mann–Whitney U test. All statistical tests were two-tailed and a level of α < 0.05 was used to establish statistical significance of individual P-values. Data were analyzed using SPSS v18.0 for Windows (SPSS, Inc., Chicago, IL).

Results

A total of 19 patients with abdominal trauma who underwent laparoscopic surgery for trauma were included.

Baseline and intraoperative characteristics of the laparoscopic group are described in Table 1.

Baseline characteristics of the laparoscopic group were mean age of 25.5 years (SD = 7.7), 89.5% were men, mean BMI of 27.4 kg/m² (SD = 5.1), median ASA score of 1 (range = 2–3), and 73.3% patients had stab wounds as injury mechanism.

In 4 patients (21%), the laparoscopic procedure was only diagnostic. Three patients with a stab wound had penetrating injury and only abdominal wall hemostasis was required. We included in this group a patient with a gunshot wound. In this patient, we only identified abrasion and ecchymosis in the abdominal wall, with no sign of perforation of the peritoneum (tangential trajectory).

In 78.9% (n = 15) of patients, injury to intra-abdominal organs was identified (Table 2). The most frequently damaged organ was colon (36.8%), followed by small bowel (15.7%) and diaphragm (10.5%). In 94.7% patients, the procedure was completed laparoscopically, while only in one case, conversion to open surgery was required to completely characterize the injury.

The most common type of injury identified was a grade II AAST colon injury (laceration of < 50% of the circumference) in 36.8% of patients. As for the most common site of perforation, there were three cases in the splenic flexure, two in left colon, one in sigmoid colon, and one in the hepatic flexure. These patients were treated by laparoscopic primary closure. In 3 patients, an intraoperative colonoscopy was performed, after the repair, to rule out leakage and/or any missed injury.

Three of the patients with stab wound injury had an identifiable lesion in the small bowel, 2 patients had a grade II AAST lesion (laceration of < 50% of the circumference) in which a laparoscopic primary closure was performed, and 1 patient had a grade III AAST lesion (≥50% of the circumference), which required conversion to open surgery, with bowel resection and anastomosis.

Two patients with a stab wound injury in the left thoracic–abdominal region had a diaphragmatic injury, classified as grade II AAST (< 2 cm laceration). In these patients, a laparoscopic primary diaphragmatic closure was performed and a chest tube was placed due to pneumothorax.

In 1 patient with blunt abdominal trauma, a pancreatic grade III AAST injury was identified (distal transection with duct injury) on the CT scan. After performing a diagnostic laparoscopy, the patient underwent laparoscopic distal pancreatectomy.

In one of the patients with blunt abdominal trauma, a liver laceration was identified and classified as grade II AAST (capsular tear 3 cm parenchymal depth) for which homeostasis was performed with compression, monopolar cauterization, and local hemostatic techniques.

Last, one of the patients with blunt abdominal trauma had a grade IV AAST splenic lesion (laceration involving segmental vessel) and a laparoscopic splenectomy was performed.

Comparisons between the two case-matched groups are shown in Table 3.

No differences were detected in the type of surgery performed (diagnostic: 21% versus 26.3%; P = 1.000; and therapeutic: 79% versus 73.6%; P = 1.000).

The laparoscopic group displayed a significantly shorter operative time (93.3 versus 134.2 minutes; P < .009), lower estimated blood loss (100 versus 600 mL; P < .019), faster return to normal diet (1.6 versus 2.4 days; P < .039), and shorter hospital LOS (3.8 versus. 5.6 days; P < .042) compared with the open surgery group.

Complications occurred more frequently in the open surgery group (10.5% versus 0%, P = .486), although this difference was not statistically significant. The complications were a seroma in a patient who underwent a laparotomy with bowel resection and ileostomy (Clavien-Dindo Grade I) and a leakage of the rectal stump in a patient with Hartmann procedure due to trauma of the sigmoid colon (Clavien-Dindo Grade IIIb).

Only one nonplanned reexploration was needed in the patient who had a leak of the rectal stump, and no reexplorations were necessary in the laparoscopic group (P = 1.000). No mortality was recorded in 30 postoperative days in either group.

Discussion

The modern concept of diagnostic laparoscopy was described by Heselson in the 60s, calling his procedure peritoneoscopy.^9,10

Due to a high rate of missed injuries, laparoscopy was not well received for diagnostic evaluation of abdominal trauma at the beginning. ⁶

There is no consensus yet regarding the optimal procedure treating penetrating abdominal trauma. Exploratory laparotomy was long standard in these cases, but routine laparotomy is associated with significant morbidity. ¹¹ Even though it is the standard of care, as many as 45% laparotomies are nontherapeutic. Bowel injuries are found in less than 50% of patients with stab wound trauma. ⁵ These nontherapeutic laparotomies have a 5% mortality rate and a 20% morbidity rate.^5,12

Diagnostic laparoscopy used in penetrating trauma has a sensibility of 80%–100% and a specificity of 73%–100% for identification of intra-abdominal injuries, having the advantage of being therapeutic. This approach has an associated 1.3% morbidity, but avoids unnecessary laparotomy in 63% of patients.^5,12 The only absolute contraindication is if the patient is hemodynamically unstable.^4,12 According to this, diagnostic laparoscopy is considered a therapeutic alternative in patients with probable diaphragmatic lesions and for diagnosis of peritoneal perforation (level of recommendation = 2). ¹³

In our study, only 1 patient had conversion to laparotomy, but it is important to mention that conversion to open surgery depends on the hospital resources and the laparoscopic surgical skills of the surgeon. This is why it is not rare to find a high conversion rate in literature. In 2013, O'Malley et al. ⁵ published a systematic review about the role of laparoscopic surgery in penetrating abdominal trauma. Fifty-one studies were found, 13 of them were prospective. A diagnostic laparoscopy was done in 2569 patients of whom 43.95% had some type of injury, 33.8% were converted to open surgery. In 24.49%, laparoscopy was therapeutic; the organ that most commonly required repair was the diaphragm in 54% of the cases. Seventy-two patients had some type of complication, three deaths were registered, and 83 patients had inadvertent injuries.

In our study, we can appreciate the variability of injuries identified in a diagnostic laparoscopy. Nowadays with the progress of techniques and technology, many injuries can be repaired totally by laparoscopic surgery. Matsevych et al., ¹⁴ in their series of 189 stable patients, confirmed the feasibility of treating lesions with a laparoscopic approach, maintaining high precision in identifying lesions, with all the benefits of a minimally invasive procedure, and avoiding nontherapeutic laparotomies.

Even with these studies and new information, the majority of laparoscopies are only diagnostic. This was published by Zafar et al. ¹⁵ who observed 4755 of the patients in whom a diagnostic laparoscopy was performed, and only in 916 of the patients (19.3%), the treatment was completed laparoscopically.

We cannot standardize yet the use of laparoscopy in trauma, but in selected patients of our population, with hemodynamic stability, we can achieve significant benefits, including less operative time, less estimated blood loss, early return to normal diet, and short hospital stay. We were also able to describe laparoscopy as a safe procedure because there were no postoperative complications associated.

In a retrospective study, Lim et al. ⁶ analyzed the use of laparoscopy in abdominal trauma, 111 patients were included (41 with laparoscopy; 70 with laparotomy) in a period of 7 years. Conversion to open surgery was needed in 18% of cases. When compared with open surgery, laparoscopy had a rate of less surgical site infections (P = .0000), early passage of gas (P = .006), and less hospital stay (P = .004). These benefits are equal to those found in our population, but in our study, we also found less operative time (P < .009) during a laparoscopic procedure.

Li et al. ³ published a meta-analysis and a systematic review about open surgery and laparoscopy for abdominal trauma. Sixty-four studies were included (n = 9085). Significant reductions in postoperative complications, mortality, mean operative time, hospital stay, estimated blood loss, return to normal diet, and duration of postoperative pain were found in patients treated with laparoscopy compared with patients treated with open surgery. In patients treated with laparoscopy, the accumulated incidence was 0.04% (95% confidence interval [CI] 0.03–0.06), inadvertent lesions 0.01% (95% CI 0.01–0.02), conversion to laparotomy 0.24% (95% CI 0.20–0.028), and postoperative mortality 0.01% (95% CI 0.01–0.02).

Although in our study we included only hemodynamic stable patients, some previous groups have reported the possibility of using laparoscopic surgery in unstable patients. Cherkasov et al. ¹ reported that the absolute indications for conversion to laparotomy in hemodynamic unstable subjects are massive solid-organ involvement, multiple abdominal organ fractures, hemorrhage greater than 1500 mL, hemoperitoneum greater than 500 mL, and continuing heavy internal bleeding.

The limitations of our study are largely attributable to the sample size, selection bias, and retrospective design. Thus, we consider that our results should be applied only to similar patients (hemodynamically stable, low-grade trauma) and to surgeons with advanced laparoscopic skills.

There are no existing comparative studies in a Mexican population, but we were able to find out that our results are similar to those of larger case series, meta-analysis, and systematic reviews previously written in other populations.

Conclusions

Laparoscopic surgery for abdominal trauma, either blunt or penetrating, is safe and technically feasible in hemodynamically stable patients. We found in our study that laparoscopic surgery was associated with shorter operative time, lower estimated blood loss, faster return to normal diet, and shorter hospital LOS.