Presentation on theme: "LAPAROSCOPY AND THORACOSCOPY IN TRAUMA R"— Presentation transcript:
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 cervixKelling (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 SurgeryStone (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 anesthesiaShort recovery period (1-2 days)Special instruments not neededCan be performed at the patients homeAn option when laparotomy is too dangerous
5 HISTORY MID 20TH CENTURY CO2 insufflation Veress needle Trocars Specialized instrumentationRod-lens optics, fiber optic light source
7 THE MODERN ERA Computer chip video camera Laparoscopic Cholecystectomy Improved visualizationMade the use of assistants possibleLaparoscopic CholecystectomyMouret (1987) Lyon, FranceMcKernan and Saye (1987) USA“Big Bang” expansion of utilization in all areas of Surgery, including Trauma
8 CAVITARY ENDOSCOPY IN TRAUMA LAPAROSCOPYDiagnosticTherapeuricTHORACOSCOPYTherapeutic
17 BLUNT INJURY INDICATIONS FOR LAPAROSCOPY No Clear Indications in Blunt Trauma !!? Evaluation and treatment of solid organ injuryNO ! Better options!? Directed blood salvage for autotransfusionNo proven benefit? Evaluation and treatment for bowel injury: “seatbelt sign”Maybe ?
18 LAPAROSCOPY IN TRAUMA EARLY EXPERIENCE :PENETRATING Hesselson 1970 Gazzaniga 1976Carnivale 1977Zantut 1990Ivatury 1992Fabian 1993Smith
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 patientsSW-55%, GSW-36%, Blunt-9%No peritoneal penetration in 55% of patients with penetrating injuryRate of negative and nontherapeutic laparotomies decreased? Cost effective?
22 PENETRATING TRAUMA McQuay et al. Am Surg 69: 788, 2003 Penetrating Thoracoabdominal Injury: n = 80Negative scope – 58/80, 73 %Spared celiotomyPositive scope – 22/80, 27%17/22 had significant associated injuryConclusion: “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 injuryIncreased from 9% - 16%SW: Increased from 19% - 27%Decrease in rate of negative laparotomyObviated the need for laparotomy in 25 ptsLaparoscopic diaphragm repair: n = 4
24 PENETRATING TRAUMA Weinberg et al. Injury 38: 60, 2007 Awake laparoscopy in EDHemodynamically stable (n = 15)Compared to case cohort (n = 24) who received laparoscopy in OR11 / 15 discharged from ED4/ 11 with peritoneal penetration: laparotomyDecreased LOS ( 7 vs 18 hours, p =Decreased cost - $2227 / case
38 THERAPEUTIC LAPAROSCOPY Omori et al. J of Laparoendosc 13: 83, 2003Laparoscopy for isolated bowel injuryHistorical laparotomy controls11 / 13 injuries successfully treated with laparoscopyAge, gender, ISS, operative times, complications, LOS, mortality: No statistical difference between groupsBlood loss less in laparoscopy group. p = .0084
40 THERAPEUTIC LAPAROSCOPY Matthews et al. Surg Endosc 17: 254, 2003Attempted laparoscopic repair of acute (n=8) or chronic (n=9) diaphragmatic herniaeLaparoscopic repair n=13Conversion 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 embolismTrocar injuriesMissed injuryDelay of laparotomy ( improper patient selection)
42 TRAUMA LAPAROSCOPY SUMMARY Carefully selected, stable patients Most useful with thoracoabdominal or tangential penetrating woundsLow threshold to convert to laparotomy??? Utility in blunt traumaLimited, but real, therapeutic potential
43 EARLY TRAUMA THORACOSCOPY Jones et al. Emergency Thoracoscopy. J Trauma 1981; 21: 280-436 patients with traumatic hemothoraxED, local anesthetic, not intubatedRigid proctoscopeDiathermy of intercostal artery (n=2)Altered management in 44 %
44 THORACOSCOPY IN TRAUMA POTENTIAL INDICATIONS:Evaluation of the DiaphragmEvacuation of Clotted HemothoraxAssessment of Hemothorax (persistent bleeding)Pericardial / Mediastinal Assessment
45 THORACOSCOPY IN TRAUMA DELAYED DIAGNOSIS OF DIAPHRAGMATIC INJURYMiller et al J Trauma 1984Beal et al J Trauma 1984Feliciano et al J Trauma 1989Madden et al J Trauma 1989
46 INJURY OF THE DIAPHRAGM Madden et al J Trauma 29: 292, 198995 patients with penetrating thoracoabdominal injuryTreated with mandatory laparotomy18/95 patients had diaphragmatic injuryIsolated diaphragmatic injury in 5/95
47 MISSED DIAPHRAGMATIC INJURY Common in thoracoabdominal injuryNonoperative diagnostic adjuncts ( PE, DPL, FAST, CT) unreliable~ 20 % of missed injuries will result in strangulation of hollow visceraStrangulation: Mortality in 30 – 40 %
48 RETAINED HEMOTHORAX Helling et al J Trauma 1989 Patients who required tube thoracostomy for hemothorax18 % developed retained hemothrax6 % required thoracotomy to prevent fibrothorax (> 33 % of hemothorax)
49 POST-TRAUMATIC EMPYEMA Patterson et al J Thorac Cardiovasc Surg 1968Military setting (Viet Nam): 6 %Millikan et al Am J Surg 1980Civilian setting: 2 %
50 THORACOSCOPY IN TRAUMA Ochsner et al J Trauma 1993; 34:704 – 710Evaluated 14 patients with suspected diaphragmatic injuryThoracoscopy followed by thoracotomyCorrelation: 100 %
51 THORACOSCOPY IN TRAUMA Wong et al Surg Endosc 1996; 10:41 hemodynamically stable patients with thoracic injury3/6 intercostal artery injuries successfully coagulated7/9 diaphragmatic injuries repaired13/14 clotted hemothoraces successfully evacuated1 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 biasThoracoscopy groupLess postoperative painShorter return to normal activity81% 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: 102VATS by acute care surgeonsBlunt 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; 5:6323 stable patients at Cedars-Sinai from25 procedures, no mortalityIndicationsRetained 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)
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 GOODLAPAROSCOPYThoracoabdominal WoundsTangential Wounds
69 CAVITARY ENDOSCOPY IN TRAUMA THE GOODTHORACOSCOPYDiaphragmatic InjuryRetained Hemothorax
70 CAVITARY ENDOSCOPY IN TRAUMA THE BADTHORACOSCOPYObservational StudiesLAPAROSCOPYBlunt Trauma ?
71 CAVITARY ENDOSCOPY IN TRAUMA THE UGLYLAPAROSCOPYTrying to do too much
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