ABSTRACT
BACKGROUND: Laparoscopy is increasingly utilised in the trauma setting. However, its safety and reliability in evaluating and managing retroperitoneal injuries are not known. AIM: The aim of this study was to analyse our experience with laparoscopic management of retroperitoneal injuries due to penetrating abdominal trauma (PAT) and to investigate its feasibility, safety and accuracy in haemodynamically stable patients. METHODS: Over a 4-year period, patients approached laparoscopically with retroperitoneal injuries were analysed. Mechanism, location and severity of injuries were recorded. Surgical procedures, conversion rate and reasons for conversion and outcomes were described. RESULTS: Of the 284 patients with PAT, 56 patients had involvement of retroperitoneum. Stab wounds accounted 62.5% of patients. The mean Injury Severity Score was 7.4 (4-20). Among retroperitoneal injuries, the colon (27%) was the most commonly involved hollow viscera followed by duodenum (5%). The kidney (5%) and the pancreas (4%) were the injured solid organs. The conversion rate was 19.6% and was mainly due to active bleeding (73%). Significantly more patients with gunshot wound were converted to laparotomy (38% vs. 9%). Therapeutic laparoscopy was performed in 36% of patients. There were no recorded missed injuries or mortality. Five (9%) patients developed the Clavien-Dindo Grade 3 complications, three were managed with reoperation, one with drainage/debridement and one with endovascular technique. CONCLUSION: Laparoscopic management of retroperitoneal injuries is safe and feasible in haemodynamically stable patients with PAT. However, a high conversion rate indicates difficulties in managing these injuries. The requirements are the dexterity in laparoscopy and readiness to convert in the event of bleeding.
ABSTRACT
BACKGROUND: The use of laparoscopy in managing haemodynamically stable patients with penetrating thoracoabdominal injuries in developed countries is wildly practiced, but in Africa, the use of laparoscopy is still in its infancy stage. We reviewed a single centre experience in using laparoscopy in Africa for management of patients with both isolated diaphragmatic injuries as well as diaphragmatic injuries associated with intra-abdominal injuries requiring intervention. METHODS: A retrospective analysis of prospectively collected data of patients presenting with penetrating thoracoabdominal injuries was done. All patients offered laparoscopic exploration and repair from January 2012 to December 2015 at Dr. George Mukhari Academic Hospital were analysed. Means (±SD) were presented for continuous variables, and frequencies (%) were presented for categorical variables. All analyses were performed using SAS version 9.3 (SAS Institute, Cary, NC). RESULTS: A total of 83 stable patients with penetrating thoracoabdominal injuries managed with laparoscopy met the inclusion criteria and were included in the study. The Injury Severity Score ranged from 8 to 24, with a median of 18. The incidence of diaphragmatic injuries was 54%. Majority (46.8%) of patients had Grade 3 (2-10 cm defect) diaphragmatic injury. Associated intra-abdominal injuries requiring intervention were encountered in 28 (62%) patients. At least 93.3% of the patients were treated exclusively with laparoscopy. The morbidity was encountered in 7 (16%) patients; the most common cause was a clotted haemothorax Clavien-Dindo III-b, but only 1 patient required a decortication. There was one non-procedure-related mortality. CONCLUSIONS: A success rate of 93% in using laparoscopy exclusively was documented, with an overall 82% uneventful outcome. The positive outcomes found in this study when laparoscopy was used in stable patients with thoracoabdominal injuries support similar work done in other trauma centres. However, in addition, this study seem to suggest that the presence of peritonitis in stable patient is not a contra-indication to laparoscopy and thoracoscopy may be useful especially in right side diaphragmatic injury where the liver can preclude adequate visualization of the entire diaphragm and to thoroughly clean the chest cavity and prevent future complication such as residual clotted haemothorax. Clinical relevance: The presence of peritonitis in stable patients with penetrating thoracoabdominal injury is not a contra-indication to laparoscopy provided the operating surgeon has adequate laparoscopic skills.
