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LAPAROSCOPY AND THORACOSCOPY IN TRAUMA R. STEPHEN SMITH MD RDMS FACS PROFESSOR and CHAIR DEPARTMENT OF SURGERY UNIVERSITY OF SOUTH CAROLINA SCHOOL of.

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Presentation on theme: "LAPAROSCOPY AND THORACOSCOPY IN TRAUMA R. STEPHEN SMITH MD RDMS FACS PROFESSOR and CHAIR DEPARTMENT OF SURGERY UNIVERSITY OF SOUTH CAROLINA SCHOOL of."— Presentation transcript:

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2 LAPAROSCOPY AND THORACOSCOPY IN TRAUMA R. STEPHEN SMITH MD RDMS FACS PROFESSOR and CHAIR DEPARTMENT OF SURGERY UNIVERSITY OF SOUTH CAROLINA SCHOOL of MEDICINE

3 HISTORY A CANDLE IN THE DARKNESS Abulkasim ( ) – 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

4 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

5 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

6 HISTORY MID 20 TH CENTURY CO2 insufflation Veress needle Trocars Specialized instrumentation Rod-lens optics, fiber optic light source

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8 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

9 CAVITARY ENDOSCOPY IN TRAUMA LAPAROSCOPY Diagnostic Therapeuric THORACOSCOPY Diagnostic Therapeutic

10 LAPAROSCOPY IN TRAUMA ABDOMINAL DIAGNOSTIC EVALUATION Physical Examination Paracentesis DPL Sonography (EFAST) Computed Tomography LAPAROSCOPY Adjunct

11 TRAUMA LAPAROSCOPY RATIONALE Improve/Streamline Care Decrease Cost, Decrease Length of Stay Rule Out Significant Injury Determine the Need for Laparotomy ? Therapeutic Laparoscopy ?

12 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

13 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

14 TRAUMA LAPAROSCOPY OPERATIVE TECHNIQUE Standard videoscopic set; 30 degree scope Nasogastric, bladder deompression Periumbilical trocar 1 st ; additional ports as needed CO2 insufflation: 8-10 mm Hg > 15 mm Hg Beware tension pneumothorax, hypotension, gas embolism

15 LAPAROSCOPY IN TRAUMA EARLY EXPERIENCE: BLUNT Sherwood 1980 Berci1983 Cuschieri1988 Wood 1988 Nagy1989 Fabian 1993 Smith 1993

16 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

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18 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 ?

19 LAPAROSCOPY IN TRAUMA EARLY EXPERIENCE :PENETRATING Hesselson1970 Gazzaniga1976 Carnivale1977 Zantut1990 Ivatury1992 Fabian1993 Smith 1993

20 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

21 PENETRATING TRAUMA Fabian et al. Ann Surg 217: 557, 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?

22 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

23 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

24 PENETRATING TRAUMA Simon et al. J of Trauma. 53: 297, 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

25 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 = Decreased cost - $2227 / case

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27 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)

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

29 PENETRATING INJURY INDICATIONS FOR LAPAROSCOPY Hemodynamic Stability Thoracoabdominal Wounds: ? Diaphragm ? Penetration of Anterior Fascia (SW) Tangential and Flank Wounds (GSW)

30 Laparoscopy for Abdominal Gunshot Wounds Gunshot Wound (Stable Patient) Tangential Laparoscopy Thoraco-Abdominal Mid-Abdominal Laparoscopy Peritoneal Penetration No Penetration Diaphragm Injury Diaphragm Intact Formal Exploration Exploratory Laparotomy or Laparoscopic Repair Observation Exploratory Laparotomy Laparoscopic Repair Observation

31 Laparoscopy for Abdominal Stab Wounds: I Abdominal Stab Wound Stable Unstable Exploratory Laparotomy Local Wound Exploration No Penetration of Anterior Fascia Penetrates Anterior Fascia Laparoscopy Observation Continued

32 Laparoscopy for Abdominal Stab Wounds: II Laparoscopy Peritoneal Penetration No Peritoneal Penetration Observation Extensive Laparoscopic Exam & Minilap No Injury Injury Identified Observation Minimally Invasive Repair Exploratory Laparotomy

33 THERAPEUTIC LAPAROSCOPY REPORTED: Repair of Diaphragmatic Laceration Closure of Gastrotomy / Enterotomy Cholecystectomy Hepatorrhaphy (minor injury) Splenorrhaphy

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38 DO NOT DO THIS !

39 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

40 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

41 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

42 TRAUMA LAPAROSCOPY POTENTIAL COMPLICATIONS Tension pneumothorax Gas embolism Trocar injuries Missed injury Delay of laparotomy ( improper patient selection)

43 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

44 EARLY TRAUMA THORACOSCOPY Jones et al. Emergency Thoracoscopy. J Trauma 1981; 21: patients with traumatic hemothorax ED, local anesthetic, not intubated Rigid proctoscope Diathermy of intercostal artery (n=2) Altered management in 44 %

45 THORACOSCOPY IN TRAUMA POTENTIAL INDICATIONS: Evaluation of the Diaphragm Evacuation of Clotted Hemothorax Assessment of Hemothorax (persistent bleeding) Pericardial / Mediastinal Assessment

46 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

47 INJURY OF THE DIAPHRAGM Madden et al J Trauma 29: 292, patients with penetrating thoracoabdominal injury Treated with mandatory laparotomy 18/95 patients had diaphragmatic injury Isolated diaphragmatic injury in 5/95

48 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 %

49 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)

50 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 %

51 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 %

52 THORACOSCOPY IN TRAUMA Wong et al Surg Endosc 1996; 10: 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

53 THORACOSCOPY IN TRAUMA Ben-Nun et al. Ann Thorac Surg 2007; 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

54 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

55 THORACOSCOPY IN TRAUMA Milanchi et al. J Minim Access Surg 2009; 5:63 23 stable patients at Cedars-Sinai from 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)

56 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

57 VIDEO-THORACOSCOPY CONVENTIONAL INSTRUMENTS Ring forceps Stryker Irrigation Suction Catheters Hemostats Needle drivers

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67 THORACOSCOPY IN TRAUMA Leppaniemi AK. Trauma 2001; 3: “ 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”

68 CAVITARY ENDOSCOPY IN TRAUMA THE GOOD ! THE BAD !! THE UGLY !!!

69 CAVITARY ENDOSCOPY IN TRAUMA THE GOOD LAPAROSCOPY Thoracoabdominal Wounds Tangential Wounds

70 CAVITARY ENDOSCOPY IN TRAUMA THE GOOD THORACOSCOPY Diaphragmatic Injury Retained Hemothorax

71 CAVITARY ENDOSCOPY IN TRAUMA THE BAD THORACOSCOPY Observational Studies LAPAROSCOPY Blunt Trauma ? Observational Studies

72 CAVITARY ENDOSCOPY IN TRAUMA THE UGLY LAPAROSCOPY Trying to do too much


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