current use of laparoscopy in the evaluation and management of trauma patients has been a natural extension of this trend .
although utilized for both blunt and penetrating injuries , laparoscopy has gained the most widespread acceptance as a useful tool in the management of patients with penetrating abdominal injuries . its ability to accurately determine anterior peritoneal penetration from stab and
others have expanded its role beyond simply a screening tool for injury , to its current use in some centers as a diagnostic and therapeutic modality .
the purpose of this study was to evaluate the role of laparoscopy in the trauma setting at our urban level ii trauma center .
more specifically , we examined its use in the management of hemodynamically stable trauma patients with penetrating anterior abdominal injuries .
we also sought to determine how our results compared with those of other centers regarding the widely accepted laparoscopic advantages of reduced morbidity , decreased rates of negative laparotomy , and shortened length of hospital stay ( los ) .
we conducted a retrospective chart review of 4541 trauma patients who were admitted to our level ii trauma center between july 1 , 1999 and july 31 , 2002 . penetrating injuries accounted for 817 ( 18% ) of these trauma admissions .
there were 209 penetrating injuries isolated to the abdomen , of which 116 were gunshot wounds ( gsw ) and 93 were stab wounds ( sw ) .
the first group consisted of hemodynamically stable patients without evidence of abdominal peritoneal penetration based on physical examination , local wound exploration , or further confirmatory studies , including focused abdominal sonography for trauma ( fast ) , computed axial tomography ( ct ) , or diagnostic peritoneal lavage ( dpl ) , or all of these .
the additional confirmatory studies were not applied in a standard fashion to all patients , but rather selected based on clinical indication and attending physician preference .
in addition , stab wounds with peritoneal penetration , but no peritoneal signs , also underwent a course of observation .
the second group of patients was those with peritoneal signs or confirmed evidence of abdominal peritoneal penetration based on physical examination , local wound exploration , or further confirmatory studies .
the third group of patients was taken to the operating room for laparoscopic evaluation due to questionable peritoneal penetration .
criteria for laparoscopy was a hemodynamically stable patient with an injury trajectory suggestive of peritoneal penetration that could not reliably be ruled out based on physical examination or further confirmatory studies .
no attempt was made to laparoscopically assess the extent of the intraabdominal injuries or make therapeutic interventions .
laparotomy was negative if it was discovered after the abdomen was opened that no peritoneal penetration had occurred .
a nontherapeutic laparotomy was one that confirmed peritoneal penetration with either no intraabdominal injuries or injuries so minor that they did not require surgical repair .
the patients in these 2 groups were closed without therapeutic intervention and admitted to the floor for postoperative recovery .
the laparoscopic findings were described as either positive or negative based on evidence of peritoneal penetration .
figure 1 details the algorithm used for management of our patients with penetrating abdominal wounds .
injury severity score ( iss ) and length of hospital stay ( los ) were calculated for each patient in the study .
morbidity and mortality figures were also generated for each patient from our computer database by using standard methodology to define associated complications .
penetrating abdominal injuries accounted for 209 of our trauma admissions , of which 116 were gsw and 93 were sw .
gender breakdown of these patients was male , 171 ( 82% ) and female , 38 ( 18% ) .
thirty - three patients ( gsw=9 , sw=24 ) were observed in the emergency department based on their initial physical examination , radiologic studies , or additional confirmatory studies , or all of these .
the majority of the gsw patients received immediate laparotomies due to the higher ballistic forces associated with these injuries . in general , gsw to the anterior abdomen required laparotomy unless the wound was tangential .
table 1 provides the negative , nontherapeutic , and therapeutic outcomes in the formal laparotomy group with regards to the number and percentage of procedures and los for patients with gsw and sw .
a review of the negative laparotomies revealed that possibly 8 of 10 gsw and all 14 stab wounds could have been done laparoscopically , based on the location of the entrance wound in the anterior abdominal wall . however , 2 of the negative gsw laparotomies assessed tangential wounds that would not have been well visualized by laparoscopy alone .
all of these patients had anterior abdominal wounds , and 2 patients had flank wounds in addition to the anterior wounds .
of these 22 patients , 7 had an additional confirmatory test prior to going to the operating room ( table 2 ) .
eight sw were converted to an open procedure , and 7 had laparoscopy only ( table 3 ) .
additional confirmatory test in patients managed with laparoscopy * gsw = gunshot wound ; ct = computed tomography ; fast = focused abdominal sonography for trauma ; sw = stab wounds ; los = length of hospital stay .
results of laparoscopy group results of laparotomies after conversion table 5 lists the number and percentage of gsw and sw patients who underwent laparotomy , laparoscopy , or were observed .
mortality was 13% ( gsw=20 , sw=0 ) for the laparotomy group , and 0% ( gsw=0 , sw=0 ) for the laparoscopy group .
morbidity was 27% ( gsw=42 , sw=7 ) in the laparotomy group and 14% ( gsw=1 , sw=2 ) in the laparoscopy group .
these numbers reflect the increased severity of injury with the laparotomy group . however , we found no difference in morbidity or mortality when we compared data for the negative laparotomy group and the negative laparoscopy group .
management of gunshot wounds versus stab wounds mean los was 7.9 days for the laparotomy patients and 3.0 days for the laparoscopy patients .
this difference can be attributed to the higher severity of injury associated with the laparotomy group . however
, a more useful comparison of los is that between the negative laparotomy group and the negative laparoscopy group , which revealed an los of 4.1 and 1.9 , respectively .
laparoscopic evaluation of the peritoneal cavity is not a new concept , having first been described by kelling over a century ago .
the first reports demonstrating the utility of laparoscopic surgery in the evaluation of trauma patients were published soon thereafter in the 1920s .
these early trauma studies investigated laparoscopy as a method to diagnose internal bleeding in patients with traumatic abdominal injuries . reports describing similar experiments were published sporadically throughout most of the last century .
however , mainly due to technological limitations , it would be many years before laparoscopic surgical techniques would prove their practical utility and gain widespread acceptance .
it is now evident that despite the lack of early enthusiasm in the surgical community for these new techniques , the laparoscopic pioneers correctly recognized the potential benefits of minimally invasive surgery in the trauma patient .
recent technologic advances in optics and laparoscopic instrumentation have greatly broadened the applications for minimally invasive surgery .
we now have a better understanding of the physiologic changes and complications associated with these procedures .
increased training and utilization of minimally invasive procedures in all areas of surgery has come an increase in expertise among trauma surgeons .
these techniques have evolved from what was once a novelty into an important part of every surgeon 's practice . for trauma patients
, laparoscopy provides clear visualization of the peritoneal space and anterior abdominal wall , and unlike other diagnostic modalities , has the additional benefit of potential for therapeutic intervention .
however , despite its increased use in trauma , the optimum role of laparoscopy in this setting has not yet been clearly defined .
there continues to be variation among trauma centers on how best to optimize its application , taking full advantage of its benefits while overcoming its limitations .
laparoscopy has been used as a screening , diagnostic , and therapeutic tool to evaluate both blunt and penetrating trauma at various centers .
villavicencio and aucar authored an extensive review in 1997 in which they compared outcomes collected from 37 separate studies , involving over 1900 patients .
a review of the data showed that it was most useful as a screening tool , missing only 1% of injuries and preventing 63% of patients from unnecessary laparotomies .
the data were less encouraging when laparoscopy was used as a diagnostic tool , with missed injury rates reported between 41% and 77% .
these numbers reflect a diagnostic accuracy that is unacceptable to most surgeons who have used the laparoscope less frequently in this manner .
laparoscopy is infrequently used as a therapeutic tool ; however , several reports have demonstrated favorable results with laparoscopic repair of a variety of intraabdominal injuries , including the dia - phragm , liver , gallbladder , spleen and bowel .
emergency department evaluation of the injured patient has evolved greatly over the years , based mainly on the technology of the time .
trauma surgeons have had available a variety of diagnostics tools to assist with the management of their patients , including dpl , fast , and ct .
the increased availability of laparoscopy now offers them even more flexibility during the workup of injured patients .
certainly the evaluation of every trauma patient starts with the advanced trauma life support ( atls ) primary survey followed by a thorough physical examination .
it is important to carefully inspect the patient 's wounds , because findings on the initial physical assessment usually determine the decision - making algorithm .
local wound exploration is limited in its ability to determine specific intraabdominal injuries , but it can often determine peritoneal penetration and thereby avoid the need for further studies . in patients who are obtunded due to central nervous system dysfunction or intoxication as well as in those with distracting injuries to multiple body systems , the physical examination may be less reliable .
wounds with tangential trajectories can also be difficult to accurately assess , necessitating additional diagnostic studies .
diagnostic peritoneal lavage is simple , inexpensive , and can be quickly performed in the emergency department .
however , dpl is limited by poor specificity , inability to accurately assess the retroperitoneum , and potential for missed hollow viscus or diaphragmatic injuries .
it is also an invasive test that has some risk , albeit low , for procedural complications .
although dpl has been considered the standard modality to assess traumatic intraabdominal injury for many years , its use is now declining in favor of more accurate , less invasive modalities , such as ultrasound ( fast ) and ct .
we have significantly decreased the number of dpls performed at our institution in recent years as well , relegating its use to screening for late presenting potential hollow viscus injuries or rapid evaluation of blunt injuries if fast is unequivocal or unavailable .
technological improvements have greatly enhanced the capabilities of ct and ultrasound , both of which now have an important role in trauma management .
fast is now widely used in most trauma centers ; however , its major role is in blunt trauma .
it has a low specificity for organ injury , but can effectively determine the presence of free fluid in the gravity dependent spaces of the peritoneal cavity .
some centers have used positive fast examination findings as an indicator for laparotomy in penetrating trauma .
improvements in ct speed and resolution have allowed for reliable evaluation of both the peritoneum and retroperitoneum .
ct findings can often confirm or rule out peritoneal penetration based on a more clearly delineated wound trajectory or evidence of intraabdominal injury .
unlike blunt injuries that can often be managed by observation and monitoring , ct confirmation of penetrating intraabdominal injury warrants laparotomy at our institution .
the results of our study were consistent with those of other centers regarding the generally accepted laparoscopic advantages of decreased rates of negative laparotomy , shortened length of hospital stay , and quicker return to normal activity .
the laparotomy patients had many more pulmonary complications including atelectasis , pneumonia , and respiratory failure .
they also were found to have more wound complications including dehiscence , infection , and abscess formation .
the decreased mobility of the laparotomy patients led to one deep vein thrombosis in this group .
the results of our study did not show any difference in morbidity or mortality between the negative laparoscopy and the negative laparotomy groups .
we found that a decrease occurred in los from 4.1 days in the negative laparotomy group to 1.9 days in the negative laparoscopy group .
brandt et al looked at 21 trauma patients who underwent laparoscopic evaluation of both penetrating and blunt injuries , and found that emergency laparoscopy was 100 percent accurate in determining the need for laparotomy .
a more recent retrospective review demonstrated a direct correlation between increased use of laparoscopy and decreased rates of negative laparotomy .
our study revealed that laparoscopic evaluation spared many patients unnecessary laparotomies . after reviewing the operative reports of patients with negative laparotomies
, it was determined that possibly 8 of 10 gsw and all 14 stab wounds could have been done laparoscopically .
two of the 10 gsw patients had lateral or posterior injuries that required a more detailed evaluation of the retroperitoneum than would have been possible by laparoscopy alone .
although we currently use the laparoscope solely as a screening tool for peritoneal penetration , the next logical progression for us is to conduct a more effective laparoscopic evaluation of specific organ structures in the trauma setting . this could potentially decrease or eliminate the conversions from laparoscopy to laparotomy that were nontherapeutic .
this would entail a systematic laparoscopic evaluation of the entire peritoneal cavity , including running the small bowel , visualizing the diaphragm and solid organs , and accurately assessing for evidence of pelvic or retroperitoneal injury .
the threshold for conversion would vary among surgeons based on laparoscopic expertise and confidence in the laparoscopic examination .
data show that laparoscopy is a useful modality for evaluating and managing trauma patients with penetrating injuries .
we have found that it is particularly helpful as a screening tool for anterior abdominal wall wounds and lower chest injuries to rule out peritoneal penetration .
increased use of laparoscopy in select patients with penetrating abdominal trauma will decrease the rate of negative and nontherapeutic laparotomies , thus lowering morbidity , decreasing length of hospitalization , and provide for more efficient utilization of available resources . as technology and expertise among surgeons continues to improve ,
 background : minimally invasive surgery has become increasingly utilized in the trauma setting . 
 when properly applied , it offers several advantages , including reduced morbidity , lower rates of negative laparotomy , and shortened length of hospital stay . 
 the purpose of this study was to evaluate the role of laparoscopy in the management of trauma patients with penetrating abdominal injuries.methods:we conducted a 3-year retrospective chart review of 4541 trauma patients admitted to our urban level ii trauma center . penetrating abdominal injuries accounted for 209 of these admissions . 
 patients were divided into 3 treatment groups based on the characteristics of their abdominal injuries . 
 management was either observation , immediate laparotomy , or screening laparoscopy.results:thirty-three patients were observed in the emergency department based on their initial physical examination and radiologic studies . 
 after emergency department evaluation , 154 patients underwent immediate laparotomy . in this group , 119 therapeutic laparotomies , 11 nontherapeutic laparotomies , and 24 negative laparotomies were performed . 
 a review of the negative laparotomies revealed that possibly 8 of 10 gun shot wounds and all 14 stab wounds could have been done laparoscopically . 
 twenty - two patients underwent laparoscopic evaluation , 9 of which were converted to open procedures.conclusion:minimally invasive surgical techniques are particularly helpful as a screening tool for anterior abdominal wall wounds and lower chest injuries to rule out peritoneal penetration . 
 increased use of laparoscopy in select patients with penetrating abdominal trauma will decrease the rate of negative and nontherapeutic laparotomies , thus lowering morbidity and decreasing length of hospitalization . as technology and expertise among surgeons continues to improve , more therapeutic intervention may be done laparoscopically in the future . 
INTRODUCTION
METHODS
RESULTS
DISCUSSION
CONCLUSION