LAPAROSCOPY AND THORACOSCOPY IN

TRAUMA

R. STEPHEN SMITH MD RDMS FACSPROFESSOR and CHAIR

DEPARTMENT OF SURGERYUNIVERSITY OF SOUTH CAROLINA

SCHOOL of MEDICINE

HISTORY

• A CANDLE IN THE DARKNESS• Abulkasim (936-1013) – used reflected light to

examine the cervix

• Kelling (1901) – introduced “koelioskopie” by examining the peritoneal cavity (canine) with a cystoscope (platinum wire light source)

• Jacobaeus (1910) – reported the use of “laparothorakoskopie” in humans

HISTORY

• “PROGRESS” CONTINUES• Bernheim (1911) – introduced laparoscopy

(proctoscope) to the USA, 2 case histories, Annals of Surgery

• Stone (1924) – reported the use of a nasopharyngoscope to perform “peritoneoscopy in his Topeka, Kansas office

HISTORY

• A. R. Stone (1925), England

• Advantages of celioscopy• Local anesthesia

• Short recovery period (1-2 days)

• Special instruments not needed

• Can be performed at the patients home

• An option when laparotomy is too dangerous

HISTORY

• MID 20TH CENTURY• CO2 insufflation

• Veress needle

• Trocars

• Specialized instrumentation

• Rod-lens optics, fiber optic light source

THE MODERN ERA

• Computer chip video camera• Improved visualization• Made the use of assistants possible

• Laparoscopic Cholecystectomy• Mouret (1987) Lyon, France• McKernan and Saye (1987) USA

• “Big Bang” expansion of utilization in all areas of Surgery, including Trauma

CAVITARY ENDOSCOPY IN TRAUMA

• LAPAROSCOPY• Diagnostic

• Therapeuric

• THORACOSCOPY• Diagnostic

• Therapeutic

LAPAROSCOPY IN TRAUMA

• ABDOMINAL DIAGNOSTIC EVALUATION• Physical Examination• Paracentesis• DPL• Sonography (EFAST)• Computed Tomography• LAPAROSCOPY

• Adjunct

TRAUMA LAPAROSCOPY

• RATIONALE• Improve/Streamline Care

• Decrease Cost, Decrease Length of Stay

• Rule Out Significant Injury

• Determine the Need for Laparotomy

• ? Therapeutic Laparoscopy ?

TRAUMA LAPAROSCOPY

• PATIENT SELECTION• ~ 15 % of patients with penetrating abdominal

trauma are candidates

• Rarely indicated in blunt trauma

• Hemodynamic stability

• Thoracoabdominal wounds

• Tangential wounds

• Stab wounds > GSW

TRAUMA LAPAROSCOPY

• GOAL: • DECREASE UNNESSARY

LAPAROTOMY• Rule out peritoneal penetration• Rule out diaphragmatic injury• ? Inspection of individual organs (colon, small

bowel, liver, spleen, etc.) ?• Therapeutic laparoscopic intervention

TRAUMA LAPAROSCOPY

• OPERATIVE TECHNIQUE• Standard videoscopic set; 30 degree scope

• Nasogastric, bladder deompression

• Periumbilical trocar 1st; additional ports as needed

• CO2 insufflation: 8-10 mm Hg > 15 mm Hg• Beware tension pneumothorax, hypotension, gas

embolism

LAPAROSCOPY IN TRAUMA

• EARLY EXPERIENCE: BLUNT• Sherwood 1980• Berci 1983• Cuschieri 1988• Wood 1988• Nagy 1989• Fabian 1993 • Smith 1993

BLUNT TRAUMA

• Berci et al. Am J Surg 146: 26, 1983• Blunt Trauma Victims (n=106)

• Minilaparoscopy in ED (5 mm)

• Local anesthesia + sedation

• Conclusions• More specific than DPL

• Advocated wider use in trauma

BLUNT INJURY• INDICATIONS FOR LAPAROSCOPY

• No Clear Indications in Blunt Trauma !!

• ? Evaluation and treatment of solid organ injury• NO ! Better options!

• ? Directed blood salvage for autotransfusion• No proven benefit

• ? Evaluation and treatment for bowel injury: “seatbelt sign”

• Maybe ?

LAPAROSCOPY IN TRAUMA

• EARLY EXPERIENCE :PENETRATING • Hesselson 1970• Gazzaniga 1976• Carnivale 1977• Zantut 1990• Ivatury 1992• Fabian 1993• Smith 1993

PENETRATING TRAUMA

• Ivatury et al. J Trauma 33: 101, 1992• Evaluation of thoracoabdominal wounds (n=40)

• No peritoneal penetration (n=20)

• Undiagnosed diaphragm injury (n=7)

• Rate of negative and nontherapeutic laparotomy decreased with use of laparoscopy

PENETRATING TRAUMA

• Fabian et al. Ann Surg 217: 557, 1993• 162 stable patients

• SW-55%, GSW-36%, Blunt-9%

• No peritoneal penetration in 55% of patients with penetrating injury

• Rate of negative and nontherapeutic laparotomies decreased

• ? Cost effective?

PENETRATING TRAUMA

• Zantut, Ivatury, Smith, et al: J Trauma 42: 825, 1997• Multicenter Trial (n=510)

• Laparotomy unnecessary – 54 %

• Rate of therapeutic laparotomy – 80%

• Definitive laparoscopic repair ~ 5 % (n=26) • Diaphragm, enterotomies

PENETRATING TRAUMA

• McQuay et al. Am Surg 69: 788, 2003• Penetrating Thoracoabdominal Injury: n = 80

• Negative scope – 58/80, 73 %• Spared celiotomy

• Positive scope – 22/80, 27%• 17/22 had significant associated injury

• Conclusion: “Essential and safe modality”

• All repairs by celiotomy

PENETRATING TRAUMA

• Simon et al. J of Trauma. 53: 297, 2002• 5 year retrospective review (1991 – 2001)

• Use of laparoscopy in penetrating injury• Increased from 9% - 16%

• SW: Increased from 19% - 27%

• Decrease in rate of negative laparotomy

• Obviated the need for laparotomy in 25 pts

• Laparoscopic diaphragm repair: n = 4

PENETRATING TRAUMA

• Weinberg et al. Injury 38: 60, 2007• Awake laparoscopy in ED

• Hemodynamically stable (n = 15)

• Compared to case cohort (n = 24) who received laparoscopy in OR

• 11 / 15 discharged from ED

• 4/ 11 with peritoneal penetration: laparotomy

• Decreased LOS ( 7 vs 18 hours, p = 0.0003

• Decreased cost - $2227 / case

PENETRATING TRAUMA

• Powell et al. Injury 39: 530, 2008• Laparoscopic evaluation of patients with

thoracoabdominal wounds (n = 108)• No clinical indication for laparotomy

• 20 % of patients had occult diaphragmatic injuries

• Diaphragmatic injuries (n = 22) were associated with injuries of the spleen (n = 5), stomach (n = 3), liver (n = 2)

PENETRATING TRAUMA• Kawahara, et al. J Trauma 67: 589, 2009

• 75 hemodynamically stable patients

• Indications for laparotomy• Previous laparotomy

• Bowel injury

• “Blind spot” injuries– Retroperitoneal hematoma, hepatic segments VI and VII,

posterior spleen

• 73% avoided unnecessary laparotomy

• Therapeutic laparoscopy (23%)

• One missed injury: pancreas

PENETRATING INJURY

• INDICATIONS FOR LAPAROSCOPY

• Hemodynamic Stability

• Thoracoabdominal Wounds: ? Diaphragm

• ? Penetration of Anterior Fascia (SW)

• Tangential and Flank Wounds (GSW)

Laparoscopy for Abdominal Gunshot Wounds

Gunshot Wound(Stable Patient)

Tangential

Laparoscopy

Thoraco-Abdominal Mid-Abdominal

Laparoscopy

PeritonealPenetration

NoPenetration

Diaphragm Injury

DiaphragmIntact

FormalExploration

ExploratoryLaparotomy orLaparoscopicRepair

Observation ExploratoryLaparotomy

LaparoscopicRepair

Observation

Laparoscopy for Abdominal Stab Wounds: I

Abdominal Stab Wound

Stable Unstable

ExploratoryLaparotomy

Local WoundExploration

No Penetration ofAnterior Fascia

PenetratesAnterior Fascia

LaparoscopyObservation

Continued

Laparoscopy for Abdominal Stab Wounds: II

Laparoscopy

PeritonealPenetration

No PeritonealPenetration

ObservationExtensiveLaparoscopicExam & Minilap

No Injury Injury Identified

Observation Minimally Invasive Repair

ExploratoryLaparotomy

THERAPEUTIC LAPAROSCOPY

• REPORTED:

• Repair of Diaphragmatic Laceration

• Closure of Gastrotomy / Enterotomy

• Cholecystectomy

• Hepatorrhaphy (minor injury)

• Splenorrhaphy

DO NOT DO THIS !

THERAPEUTIC LAPAROSCOPY

• Omori et al. J of Laparoendosc 13: 83, 2003• Laparoscopy for isolated bowel injury

• Historical laparotomy controls

• 11 / 13 injuries successfully treated with laparoscopy

• Age, gender, ISS, operative times, complications, LOS, mortality: No statistical difference between groups

• Blood loss less in laparoscopy group. p = .0084

THERAPEUTIC LAPAROSCOPY

• Choi et al. Surg Endosc 17: 421, 2003

• Hemodynamically stable - n=78

• Injury suspected by CT

• Blunt n=52, SW n=26

• Therapeutic n=65• Small bowel, stomach, colon, mesentery,GB,

pancreas, spleen

THERAPEUTIC LAPAROSCOPY

• Matthews et al. Surg Endosc 17: 254, 2003

• Attempted laparoscopic repair of acute (n=8) or chronic (n=9) diaphragmatic herniae

• Laparoscopic repair n=13• Conversion to open: Acute (n=2)

• Conversion to open: Chronic (n=2)

• Conversion to open: Long (>10 cm) or Hiatus tears

TRAUMA LAPAROSCOPY

• POTENTIAL COMPLICATIONS• Tension pneumothorax

• Gas embolism

• Trocar injuries

• Missed injury

• Delay of laparotomy ( improper patient selection)

TRAUMA LAPAROSCOPY

• SUMMARY• Carefully selected, stable patients

• Most useful with thoracoabdominal or tangential penetrating wounds

• Low threshold to convert to laparotomy

• ??? Utility in blunt trauma

• Limited, but real, therapeutic potential

EARLY TRAUMA THORACOSCOPY

• Jones et al. Emergency Thoracoscopy. J Trauma 1981; 21: 280-4• 36 patients with traumatic hemothorax

• ED, local anesthetic, not intubated

• Rigid proctoscope

• Diathermy of intercostal artery (n=2)

• Altered management in 44 %

THORACOSCOPY IN TRAUMA

• POTENTIAL INDICATIONS:• Evaluation of the Diaphragm

• Evacuation of Clotted Hemothorax

• Assessment of Hemothorax (persistent bleeding)

• Pericardial / Mediastinal Assessment

THORACOSCOPY IN TRAUMA

• DELAYED DIAGNOSIS OF DIAPHRAGMATIC INJURY• Miller et al J Trauma 1984

• Beal et al J Trauma 1984

• Feliciano et al J Trauma 1989

• Madden et al J Trauma 1989

INJURY OF THE DIAPHRAGM

• Madden et al J Trauma 29: 292, 1989• 95 patients with penetrating thoracoabdominal

injury

• Treated with mandatory laparotomy

• 18/95 patients had diaphragmatic injury

• Isolated diaphragmatic injury in 5/95

MISSED DIAPHRAGMATIC INJURY

• Common in thoracoabdominal injury

• Nonoperative diagnostic adjuncts ( PE, DPL, FAST, CT) unreliable

• ~ 20 % of missed injuries will result in strangulation of hollow viscera

• Strangulation: Mortality in 30 – 40 %

RETAINED HEMOTHORAX

• Helling et al J Trauma 1989• Patients who required tube thoracostomy for

hemothorax

• 18 % developed retained hemothrax

• 6 % required thoracotomy to prevent fibrothorax (> 33 % of hemothorax)

POST-TRAUMATIC EMPYEMA

Patterson et al J Thorac Cardiovasc Surg 1968

Military setting (Viet Nam): 6 %

Millikan et al Am J Surg 1980

Civilian setting: 2 %

THORACOSCOPY IN TRAUMA

• Ochsner et al J Trauma 1993; 34:704 – 710

• Evaluated 14 patients with suspected diaphragmatic injury

• Thoracoscopy followed by thoracotomy

• Correlation: 100 %

THORACOSCOPY IN TRAUMA

• Wong et al Surg Endosc 1996; 10: 118-121• 41 hemodynamically stable patients with

thoracic injury• 3/6 intercostal artery injuries successfully

coagulated• 7/9 diaphragmatic injuries repaired• 13/14 clotted hemothoraces successfully

evacuated• 1 aortic injury excluded

THORACOSCOPY IN TRAUMA

• Ben-Nun et al. Ann Thorac Surg 2007; 83-383• Thoracoscopy (n=37) vs Thoracotomy (n=40)

• Non randomized, retrospective, selection bias

• Thoracoscopy group• Less postoperative pain

• Shorter return to normal activity

• 81% had normal lifestyle after 2 years (vs 60% after thoracotomy)

• Patients more satisfied with results

THORACOSCOPY IN TRAUMA

• Smith et al. J Trauma 2011; 71: 102• VATS by acute care surgeons

• Blunt thoracic injury (n = 83)• Retained hemothorax (n = 61)

• Empyema (n = 15)

• Persistent airleak (n = 8)

• VATS performed < 5 days less frequently converted to thoracotomy (8% vs. 29%, p<0.05) and shorter LOS (11 vs 18 days, p<0.05

THORACOSCOPY IN TRAUMA

• Milanchi et al. J Minim Access Surg 2009; 5:63• 23 stable patients at Cedars-Sinai from 200-2007

• 25 procedures, no mortality

• Indications• Retained hemothorax (n = 14)

• Continued bleeding (n=2)

• Decortication (n=2)

• Removal of foreighn body (n=2)

• Lobectomy (n=1)

• Pricardial window (n=1)

• Ligation of thoracic duct (n = 1)

VIDEO-THORACOSCOPY

• TECHNIQUE• Lateral decubitus position• General anesthesia• Dual-lumen endotracheal tube• 30 degree endoscope• 3 – 4 intercostal incisions (1-2 cm)• Valveless operating ports• No insufflation

VIDEO-THORACOSCOPY

• CONVENTIONAL INSTRUMENTS• Ring forceps

• Stryker Irrigation

• Suction Catheters

• Hemostats

• Needle drivers

THORACOSCOPY IN TRAUMA

• Leppaniemi AK. Trauma 2001; 3: 111-117

• “ Thoracoscopy …. has the potential to replace open surgery in the management of more than 50 % of civilian and military thoracic injuries previously considered candidates for open surgical management with all the benefits of minimally invasive surgery”

CAVITARY ENDOSCOPY IN TRAUMA

• THE GOOD !

• THE BAD !!

• THE UGLY !!!

CAVITARY ENDOSCOPY IN TRAUMA

• THE GOOD• LAPAROSCOPY

• Thoracoabdominal Wounds

• Tangential Wounds

CAVITARY ENDOSCOPY IN TRAUMA

• THE GOOD• THORACOSCOPY

• Diaphragmatic Injury

• Retained Hemothorax

CAVITARY ENDOSCOPY IN TRAUMA

• THE BAD• THORACOSCOPY

• Observational Studies

• LAPAROSCOPY• Blunt Trauma ?

• Observational Studies

CAVITARY ENDOSCOPY IN TRAUMA

• THE UGLY• LAPAROSCOPY

• Trying to do too much