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LAPAROSCOPY AND THORACOSCOPY IN TRAUMA R

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

2 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

3 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

4 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

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

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7 THE MODERN ERA Computer chip video camera Laparoscopic Cholecystectomy
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

8 CAVITARY ENDOSCOPY IN TRAUMA
LAPAROSCOPY Diagnostic Therapeuric THORACOSCOPY Therapeutic

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

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

11 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

12 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

13 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

14 LAPAROSCOPY IN TRAUMA EARLY EXPERIENCE: BLUNT Sherwood 1980 Berci 1983
Cuschieri 1988 Wood Nagy Fabian Smith

15 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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17 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 ?

18 LAPAROSCOPY IN TRAUMA EARLY EXPERIENCE :PENETRATING Hesselson 1970
Gazzaniga 1976 Carnivale 1977 Zantut 1990 Ivatury 1992 Fabian 1993 Smith

19 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

20 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?

21 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

22 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

23 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

24 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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26 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)

27 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

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

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

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

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

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

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37 DO NOT DO THIS !

38 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

39 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

40 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

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

42 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

43 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 %

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

45 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

46 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

47 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 %

48 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)

49 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 %

50 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 %

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

52 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

53 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

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

55 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

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

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66 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”

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

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

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

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

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


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