Revisiting the critical role of minimal invasive surgery (laparoscopy) in the management of trauma patients at a dedicated trauma unit at the Dr George Mukhari Academic Hospital, Pretoria, South Africa.

Abstract

Background South Africa, as a low to middle income country (LMIC), is plagued by a quadruple burden on health-care, namely trauma; the human immuno-deficiency virus (HIV) with concomitant tuberculosis infection; maternal death; non-communicable diseases such as diabetes and hypertension. The impact of trauma on an already over-burdened public sector has been profound. Improving surgical outcomes is a global health priority according to the Lancet commission. One of the World Health Organization (WHO) mandates is to improve surgical care across the globe. In addressing this question, the WHO has suggested what is referred to as a list of Bellwether procedures. This is a list of important and common procedures that account for major mortalities in developing countries. The main goal of the list is to build proficiency and dexterity in these procedures so as to reduce mortality. This includes trauma laparotomy and other surgical procedures in emergencies. The traditional approach to managing trauma patients is premised on the well-established Advanced Trauma Life Support (ATLS) principles. This well documented approach has been shown to significantly improve health outcomes of trauma victims. Closely connected to this treatment pathway are surgical interventions that have also been shown to improve the health outcomes of trauma patients. At the heart of surgical intervention for abdominal trauma, is the tried and tested laparotomy. When one looks at this, from a health economics stand-point and a cost-effective platform, laparotomy has been shown to be cost-effective and life-saving. That said, laparotomy is not without major adverse outcomes; there has been significant morbidity and, in some cases, even mortality resulting from laparotomy reported by some investigators. Laparoscopy started in earnest during the 1980s with the first laparoscopic cholecystectomy described by Muhë from Germany and later popularised by Phillip Mourret of France. This was the start of a major surgical revolution that engulfed the whole surgical community. Laparoscopic cholecystectomy became the pivot around which this revolution evolved and gathered momentum. Indeed, there has been a sea-change of surgical procedures carried out laparoscopically since its evolution and rapid development of laparoscopic cholecystectomy. The benefits of laparoscopy and other minimally invasive procedures are well documented. Despite overwhelming evidence that supports the use of laparoscopy in surgery in general, there has been reluctance in the uptake of this procedure in trauma for a number of reasons; chief of which is the fear of missed injuries. This fear was fuelled by the publication by Ivatury and colleagues citing a high rate of missed small bowel injuries in trauma patients. Consequently, there was a large hiatus in the application of this technique in the management of trauma patients and, as expected, trauma has lagged behind in the uptake of laparoscopy and continues to do so today. A great deal has happened since the publication of the work by Ivatury and colleagues. The quality of laparoscopic cameras has improved significantly and more importantly, the average surgeon’s skills-set in laparoscopy has improved considerably. The rationale for my research was to look critically at our experience with laparoscopy, appraise the available data and see how this would impact on the tried and tested practice prevalent in the trauma arena, leading to a new paradigm being set in the laparoscopic management of trauma patients that are hemodynamically stable in the South African milieu. Aims The aim of this work was to critically evaluate the role and safety of laparoscopy in the management of stable trauma patients presenting at the dedicated trauma unit of the Dr George Mukhari Academic Hospital (DGMAH). Objectives We set out to investigate the role of laparoscopy in the following ways, in trauma scenarios: • laparoscopy as a diagnostic tool and how the risk of missed injuries should be addressed and minimized; • the role of laparoscopy in the management of thoraco-abdominal injuries, including right-sided injuries and also in patients with generalized peritonitis who are hemodynamically stable; • the appropriate access technique by a way of randomized controlled trial when offering these patients laparoscopy; • diagnostic accuracy of laparoscopy in trauma - how not to miss injuries; laparoscopic-assisted techniques as a strategy to address multiple injuries and therefore address gaps in skills-set and shorten the operative time of these trauma victims; • laparoscopic management of hemodynamically stable patients with blunt abdominal trauma; • the role of laparoscopy in the management of penetrating retroperitoneal injuries in hemodynamically stable patients. Methods The Trauma Unit of DGMAH has a prospectively collected database which was used to peruse the records of recruited participants for this work. Permission was sought from the Institutional Review Board of the Sefako Makgatho Health Sciences University (SMU) in accordance with the Helsinki Declaration that guides the conduct of biomedical research. Inclusion criteria were set for the various objectives of the study. We investigated the cohort of patients where laparoscopy was used within the setting of diagnosis of abdominal injuries and identified defined primary endpoints and outcomes. We also analysed the interventional strategies that were employed to achieve the desired end result. To begin with a laparoscope, the first step is safe access into the peritoneal cavity. A one-toone computer-generated randomized study was carried out comparing the traditional laparoscopic access to peritoneal cavity using Veress needle with the open Hasson technique. Unlike other studies, in this series we included patients who had had a previous laparotomy to address the question of safe abdominal access during laparoscopic procedures. We identified all major and minor complications as the primary outcome. We determined the outcomes of patients offered laparoscopic procedure in the following situations: thoraco-abdominal injuries where the primary focus was diaphragmatic injuries both on the left and right diaphragms. In this study we included patients with both peritonitis and right sided thoraco-abdominal injuries. We studied the outcomes of laparoscopy in the case of blunt trauma, penetrating retroperitoneal injuries. We also investigated the role of laparoscopy in the context of diagnosis and specifically identified factors that mitigate against missing injuries and suggested a management pathway to minimize the incidence of missed injuries. The overall primary outcome was all-cause mortality and complications. Findings Fifty (52%) patients were randomized to the closed Veress needle and 46 (48%) patients to the open Hasson technique. Six (6%) adverse events were recorded in the Veress needle arm (p=0.03). The Veress needle technique failed to establish pneumoperitoneum in three patients (6%), the port-site bleeding was observed in one (2%) and extraperitoneal insufflation in two (4%) patients. All patients with the adverse events had previous abdominal surgery. There were no adverse events in the open Hasson group. In the work on laparoscopy and how not to miss injuries, out of 250 patients managed with laparoscopy for penetrating abdominal trauma(PAT), 113(45%) underwent diagnostic laparoscopy (DL), of these 94(83%) of patients underwent stab wounds. The penetration of the peritoneal cavity or retroperitoneal cavity or peritoneal cavity was documented in 67(59%) of the patients. Organ evisceration was present in 21(19%) of patients. Multiple injuries were present in 22% of cases. The chest was most common associated injury. Two (1,8%) iatrogenic injuries were recorded. There was conversion rate of 1,7%(2/115). The mean length of hospital stay was 4 days. There were no missed injuries. Laparoscopic assisted approach (LAA)in multiple injuries is work aimed at addressing the problem of multiple injuries in laparoscopy. This work demonstrates the utility of laparoscopy in this setting. The procedure is to evaluate the effect LAA in multiple injuries. Over 2-year period 23 patients were managed with LAA and of these 13 were patients with stab wounds and 10 with gunshot wounds. Commonly performed procedure was repair of hollow viscus injury For thoracoabdominal injury, a total of 83 patients with thoracoabdomial injuries met the seletcion criteria. The injury sverity score (ISS) ranged from 8 to 24 with a median of 18. The incidence of diaphragmatic hernia was 54%. Majority (46,8%) had grade3 (2-10cm) laceration. Associated injuries encountered reqiring interventions we encountered in 28(62%). At least 93,3% of the patients wee treated exclusively with laparoscopy . the morbidity was encountrerd in 7(16%) of the patients. The commonest was cloteed hemothorax Clavian Dindo (ii)b , but only one patient required decortication.There was one procedure related mortality. In laparoscopy management of retropritoneal injuries in hemodynamically stable patients, of 284 with PAT 56 had involvement of the retroperitoneum. Stab wounds accounted accounted for 62,5% of the patients . the mean ISS score was 7,4(4-20). Amongst the the retroperitoneal injuries the colon (27%) was the most commonly injured hollow viscus followed bt the duodenum (5%). The kidney (5%) and pancrease(4%) were the commonly injured solid organs. The conversion rate was 19,6% and this was mainly due to active bleeding. Significantly more patients were with GSW had their procedures converted to open laparotomy(38% vs 9%). Therapeutic laparoscopy wa sperformed in 36% of the pateints. The were no recorded missed injuries. Five (9%) patients developed Clavien-Dindo grade 3 complications , three were managed with reoperation, one with drainage and one with endovascular technique In laparoscopy for blunt trauma, a chalenging endeavour- Thirty-five stable patients underwent laparoscopy. The mean Injury Severity score was 12 (4-38). Therapeutic laparoscopy was performed in 15 (56%) and diagnostic in 12 (44%) patients. Eight (23%) patients were converted to therapeutic laparotomy. Intraoperative bleeding, complex injuries, visualization problem and equipment failure necessitated conversion. Three (30%) patients with negative CT scan had therapeutic laparoscopy for mesenteric injuries. There were no missed injuries. The mean length of hospital stay was 11 days in both groups. This series of studies shows that laparoscopy in all the stated objectives was safe and feasible. Multiple laparoscopic interventions in the different trauma scenarios have demonstrated the safety of laparoscopy in haemodynamically stable trauma patients. Contrary to the suggestion by other investigators, that laparoscopy is contraindicated in retroperitoneal injuries, the current study in retroperitoneal trauma has shown that it was safe and accurate in this cohort of patients. Therapeutic laparoscopy was feasible in 36% of the patients and the conversion rate was 19%. Importantly there were no missed injuries or mortality when managing penetrating trauma patients with retroperitoneal injuries. Therapeutic laparoscopy was feasible in thoraco-abdominal injuries and these patients were successfully managed, including those with generalized peritonitis. The study of thoracoabdominal injuries, including those with peritonitis, also included patients with injuries to the right side of the abdomen, as well as individuals with generalized peritonitis. We were able to offer therapeutic and diagnostic laparoscopy to this cohort of patient.

Conclusions In conclusion, laparoscopy is feasible and safe in hemodynamically stable trauma patients in the context of thoraco-abdominal injuries, blunt abdominal trauma, in the presence of peritonitis as well as in laparoscopic-assisted setting, both as a strategy to reduce the incidence of nonremedial laparotomies as well as a diagnostic tool.