laparoscopy and thoracoscopy in trauma r. stephen smith md rdms facs professor and chair department...
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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