Laproscopy approach In abdominal Trauma.pptx

Management of Abdominal trauma by laproscopic approach

1. ABDOMINAL TRAUMA- EVALUATION AND TREATMENT BY LAPAROSCOPIC APPROACH DR TARANPREET SINGH 3 RD YEAR GENERAL SURGERY RESIDENT SPMC, BIKANER

2. History The earliest use of laparoscopy in trauma was mentioned by a surgeon Rendle Short in the early 1920s.

3. One of the early reports of laparoscopy in trauma was by Stone et al in 1942 to diagnose hemoperitoneum In 1970, Heselson advocated the use of laparoscopy in penetrating trauma,Now lap assisted surgeries are getting popular Where is the need-injury to diaphragm and intestines can not be detected by imaging's.Detects missed injuries. 41% of laparotomies in penetrating trauma are nontherapeutic, hence it avoids negative laparotomies Laparoscopy viable options for daignosis

4. Uses of laparoscopy in trauma-safe & Effective,Immediete or delayed Diagnostic laparoscopy Therapeutic laparoscopy

5. When to use laparoscopy In hemodynamically stable patients In blunt trauma with Free fluid not from solid organ injury Persistent abdominal pain / tenderness In penetrating trauma with suspected peritoneal breach including evisceration

6. Indications of Diagnostic laparoscopy In case of unclear abdomen, with equivocal findings on CT or discrepancy between examination and imaging In penetrating trauma -> to rule out peritoneal perforation To diagnose solid organ injuries like liver, spleen, pancreatic injury To diagnose hollow viscus injuries like bowel perforation (however sensitivity and specificity varies across studies)

7. To diagnose small diaphragmatic defects which may not be visualized on routine imaging To identify mesenteric injury, commonly missed in radiological studies To identify associated colorectal injury in pelvic fractures To identify patients with intraperitoneal bladder injury For creation of a transdiaphragmatic pericardial window to rule out cardiac injury

8. In abdominal stab wounds, with suspected penetration of fascia In abdominal gunshot wounds with doubtful intraperitoneal trajectory,omental or bowel evisceration Useful in cases with unexplained free fluid without solid organ injury In pregnant patients, where there is risk of radiation exposure with CT and in diagnostic laparoscopy can be used to detect injuries in highly suspicious cases Thoracoabdominal stab wounds Pediatric abdominal trauma Mentally impaired ,unsafe for NOM. Allergic to contrast,Urgent orthopedic surgery Complex pelvic trauma with low rectal injuries

9. Technique of diagnostic laparoscopy Place first port at the umbilicus or left upper quadrant via open (Hasson) technique Achieve pneumoperitoneum slowly and progressively. Stop in case of hypotension, bradycardia or increased respiratory pressure Insert additional ports based on site of injury Upper abdomen: right and left flank Suspected bowel injury: both ports at left upper and lower quadrant Inspect the entire peritoneal cavity from right upper quadrant in a clockwise direction

10. Stab wounds to be covered with occlusive dressings to prevent leak of pneumoperitoneum Inspect supramesocolic compartment in reverse Trendelenberg position and rectum, colon, pelvic organs in Trendelenberg position Small bowel run is made in retrograde direction from ICJ to DJ flexure, inspecting both sides of bowel and mesentery Lesser sac should always be inspected in all penetrating trauma and blunt trauma with suspicion of post. wall stomach, pancreas or duodenal injury

11. Therapeutic laparoscopy Diaphragm: Simple repair with single stitches or continuous repair Prosthetic non-absorbable mesh in delayed presentation Stomach: Simple repair with or without omental patch Major high grade injury – gastric resection or even total gastrectomy

12. Small bowel and mesenteric injury: Small perforations – primarily repaired in single or double layer Large defects – intra/extra-corporeal resection and anastomosis or stoma Colonic trauma: Small perforations <1cm – simple primary repair Larger injuries – resection and anastomosis or stoma diversion Hartmann procedure Perineal injury requiring colostomy Liver: Hemostasis with figure of 8 stitches Liver resection only in hepatic necrosis following trauma or angioembolization

13. Pancreatic injury: Grade I and II injury, if found at laparoscopy – secure hemostasis, place drain Grade III – distal pancreatectomy Grade IV and V – usually unstable, not amenable to laparoscopy Laparoscopic Splenectomy: Preferably in supine position in trauma (to be prepared for laparotomy) After failed non-operative management or angioembolization Associated spinal injuries requiring surgery in prone (risk of bleeding from splenic injury) Hemostasis of splenic injury and splenorrhaphy can also be done in select cases

14. Gall bladder and biliary tract: Gall bladder injury – laparoscopic cholecystectomy Laparoscopic treatment of biliary leak – only after ERCP or PTBD Bladder injury: Laparoscopic repair with absorbable suture Mesenteric vascular injury: Hemostasis with clips / hemolock / suturing Overlying bowel, if gangrenous – resection and stoma P edi a tri c ,P r eg n a n t , M e n t ally Impai r e d N e ph r op a thic t r auma p a tie n ts

15. Laparoscopy for delayed presentation may reveal… Diaphragm laceration with incarcerated hernias Mesenteric injury with bowel ischemia Expanding pancreatic hematoma or collections following traumatic pancreatitis Hematomas and abdominal abscesses requiring drainage

16. Advantages of laparoscopy Lower inflammation and trauma to tissues Shorter hospital stay and early recovery Less postoperative pain Reduction in rate of non-therapeutic laparotomy (73%) By O’Malley et al.Sensitivity 67-100%,Specificity 33-100%,Accuracy 50-100% in PAT Only 2 RCT available High diagnostic accuracy (especially for mesenteric and hollow viscus injuries)

17. Better respiratory function and early weaning from ventilator (especially in thoracic trauma patients) Lower rate of adhesions, surgical site infections and incisional hernias Faster recovery ,less costs. Helps to diagnose occult injuries like small diaphragmatic tear, which could not be detected on CT Provide a means to diagnose and treat patients with delayed presentation following trauma

18. Limi t a tions Limited role in hemodynamically unstable patients Possibility of missed injury, especially of hollow viscus perforations Difficult to explore duodenal injuries laparoscopically Laparotomy recommended in retroperitoneal injury with pulsatile or expanding hematoma Ambiguous findings often leading to laparotomy Trocar injury, air embolism, bowel injury, increase operative time, coagulopathy, hypothermia Therapeutic laparoscopy depends on surgeon’s training and skills

19. Contraindications to laparoscopy Severe hypovolemic shock (systolic pressure < 90 mmHg) Severe cardiopulmonary dysfunction Severe traumatic brain injury Inability to tolerate pneumoperitoneum Clear indication for immediate laparotomy such as frank peritonitis, hemorrhagic shock or evisceration

20. Relative contraindications to laparoscopy Posterior penetrating trauma with high likelihood of bowel injury Known or obvious intra-abdominal injury with peritonitis and septicaemia Impalement ,Retroperitoneal injuries Gaseous distension,severe serious adhesions COPD with severe hypercapnoea,causes toxic shock syndrome Limited laparoscopic expertise

21. Diagnostic accuracy of laparoscopy The sensitivity, specificity and diagnostic accuracy of laparoscopy to predict the need for laparotomy are high (75 – 100%) (Level I – III evidence)

22. D r a wbac k s • The impact of laparoscopic expertise on diagnostic accuracy has not been studied 1 • The sensitivity, specificity and number of missed injuries can be influenced by surgeon’s experience, hence difficult to provide firm recommendations 2

23. Recommendations Diagnostic laparoscopy is safe and feasible in appropriately selected trauma patients (Grade B),Unclear abdomen, Equivocal CT Scan, Unclear source of bleeding,Unexplained fluid Laparoscopy should be considered in hemodynamically stable blunt trauma patients with suspected intra-abdominal injuries equivocal findings on imaging negative imaging but a high clinical suspicion (Grade C) It is particularly helpful in penetrating abdominal trauma with documented or equivocal penetration of anterior fascia (Grade C)

24. Recommendations Diagnostic laparoscopy should be used in patients with suspected diaphragmatic injuries as it offers better diagnostic accuracy than imaging (Grade C) A risk of missed injuries should be borne in mind and patients should be followed meticulously in the post-operative period. Therapeutic procedures can be performed whenever laparoscopic expertise is available. The procedure should be incorporated into the institution’s algorithm for trauma management to optimize results

25. Confusing CT Scan SB devascularization Extra liminal contrast Pneumoperitoneum Focal wall defect Free fluid,interbowel fluids Hematoma Hypo enhancement of bowel loop Abrupt interruption of mesenteric vessels Bowel wall thickening Abnormal enhancement

26. Conduct of laparoscopy 10 mm umbilical trocar; 2 or more 5 mm trocars in left flank and suprapubic region 4 quadrant evaluation for blood, bile, urine, fecal contamination Examination of diaphragm and peritoneal surfaces Examination of liver, spleen, small bowel along with mesentery, stomach, duodenum, colon and rectum Exploration of lesser sac and pancreas as directed by CT imaging

27. Indications for conversion to laparotomy Dense adhesions Gross bowel distension Major bleeding not amenable to control. Injuries that are difficult to repair laparoscopically Acute hemodynamic deterioration Not confident to deal Suspect missing injuries Expanding haematoma

28. ALGORITHM FOR PENETRATING TRAUMA STABLE HEMODYNAMICS UNSTABLE HEMODYNAMICS EXPLORATORY LAPAROTOMY DIAGNOSTIC LA P A R OS C O P Y THERAPEUTIC LA P A R OS C O P Y OBSERVATION P ENET R A TION OF ANTERIOR FASCIA LOCAL WOUND EXPLORATION NO PENETRATION OF ANTERIOR FASCIA ORGAN INJURY NO ORGAN INJURY

29. ALGORITHM FOR BLUNT TRAUMA STABLE HEMODYNAMICS UNSTABLE HEMODYNAMICS EXPLORATORY LAPAROTOMY FREE PERITONEAL FLUID SEAT BELT SIGNS DOUBTFUL PHYSICAL EXAM HOLLOW VISCUS INJURY SOLID ORGAN INJURY DIAGNOSTIC LA P A R OS C O P Y THERAPEUTIC LA P A R OS C O P Y OBSERVATION UNSTABLE S T A B LE

30. Conclusion Laparoscopy is an useful tool for diagnosis of traumatic injury when the diagnosis is unclear Management of some traumatic injuries can be carried out completely via laparoscopy or through a limited incision The main prerequisite for successful laparoscopy in trauma is the hemodynamic stability of the patient. Trained Surgeon and Equipped setting Risks are there if surgeon has limited experience, misses the injury, Wrong selection of patient.

31. Expanding horizons…. Explicit surgical training for laparoscopy in emergent trauma settings Development of guidelines for selection of appropriate patients for laparoscopy following trauma Efficient resuscitation facilitates effective minimally invasive management, so never forget to strengthen the grassroots .

32. THANK YOU!