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.
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Date
2018
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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.
Description
Doctoral Degree. University of KwaZulu-Natal, Durban.