To study the incidence of organ damage and post-operative care in patients of blunt abdominal trauma with haemoperitoneum managed by laparoscopy

Abstract

BACKGROUND:

Laparoscopy is safe and effective in the management of blunt trauma abdomen (BTA) with haemoperitoneum, with all benefits of minimal access surgery.

AIMS:

To study the incidence of organ damage and post-operative care in patients of blunt abdominal trauma with haemoperitoneum, managed by a new modality of treatment — laparoscopy.

MATERIALS AND METHODS:

Prospectively collected data on laparoscopy performed in patients with blunt abdominal injury, between the years 2004 to 2006, were analysed. Under general anaesthesia pneumoperitoneum was created. A 10 mm umbilical port, right-sided port in the anterior axillary line (5 mm / 10 mm), left-sided port in the anterior axillary line (5 mm / 10 mm) and an extra port were made according to the organ injury, and laparoscopy was performed and managed according to the organ injury.

RESULT:

Twenty-five patients had laparoscopy for blunt trauma abdomen with haemoperitoneum. Liver followed by the spleen were the most common sites of injuries. The overall failure rate was 4%. Post-operative stay and complications were much less. Laparoscopy reduced the number of negative laparotomies, with a limitation that it could not be performed in haemodynamically unstable patients.

CONCLUSION:

The liver and spleen are the most common organs involved in patients with blunt abdominal trauma with haemoperitoneum. Laparoscopy is safe and efficient in patients with blunt trauma abdomen with haemoperitoneum, with fast recovery and low hospital stay.

INTRODUCTION

A human being exposes himself to a variety of injuries caused by numerous forces like vehicular accident, social conflict, terrorism, crimes, wars, industrial accident and fall from a height. The commonly injured organs are the liver, spleen, kidney, intestines, stomach, pancreas, urinary bladder and vessels.[1] Previously all patients with BTA ended up in laparotomy and were managed according to the organ injuries.

The advent and development of new techniques like laparoscopy — minimally invasive surgery (MIS) — have a diagnostic as well as definitive therapeutic role in BTA. The availability of sophisticated instruments, equipments and expert anaesthesiologists make laparoscopy an attractive technique for diagnostic and therapeutic measures in BTA.[2] Haemoperitoneum with stable vitals and injury to the liver, spleen, bowel, mesentery and bladder can be managed by laparoscopy. Advanced laparoscopic techniques include bowel resection and anastomosis, ligation of blood vessels can be as efficiently utilised in BTA as an elective open surgery.[3–5] One can visualise the peritoneal cavity and act expeditiously if needed (i.e., laparotomy, laparoscopic-assisted intervention, or only observation) at the time of laparoscopy.[6]

This study was planned with the objective of evaluating the therapeutic efficacy of laparoscopy in managing the organ damage in BTA.

MATERIALS AND METHODS

After institutional ethical committee approval and informed written consent from the patients, a prospective randomised clinical study was carried out in 25 adult patients of either sex, scheduled for laparoscopic intervention in the surgical ward of the Government Medical College and Sir T. Hospital, Bhavnagar. Patients who sustained haemoperitoneum, confirmed in ultrasonography (USG) or Computed Tomogram (CT scan), with relatively stable haemodynamics, were enrolled in this study (blood pressure > 80 mm of mercury systolic and > 15 ml/hour urine output).

Patients with unstable haemodynamics, even after three units of whole blood transfusion (1 unit = 300 cc) and associated EDH (extradural haemorrhage) / SDH (subdural haemorrhage), compound fracture, spine fracture, severe chest injury with low Spo2 (< 90%), haemodynamically unstable, anticipated difficult endotracheal intubation and pregnancy,[4] were excluded. General anaesthesia (GA) was administered to all patients.

Trocar placement:[7]

The three main ports are:

1. Umbilical port (10 mm)

2. Right-sided port (5 mm / 10 mm) — lumbar at anterior axillary line

3. Left-sided port (5mm/10mm) — lumbar at anterior axillary line

4. Extra port, if required, is made according to the organ injury usually in the subxiphoid region or in the lower abdomen.

If no complex injuries are found and the patient is haemodynamically stable, focussed therapeutic laparoscopic intervention is done, such as, primary closure of the bowel perforation, primary repair of the bladder rupture in two layers, electrocauterization and spraying of feracryline (hemolock) solution at the injury site on the liver and spleen (contusion, laceration or tear), with no active bleeding, without disturbing the preformed hematoma.[8–11,14]

RESULTS [TABLES 1–3]

Table 1.

Demographic profile of patients

Table 3.

Laparoscopic intervention required in blunt trauma abdomen

Table 2.

Laparoscopic intervention required in different patients

Data suggested that two-thirds of the cases are due to road traffic accidents [Figures 1–5].

Figure 1.

Splenic laceration near hilum (Grade-2 injury)

Figure 5.

Drain placement in the right sub-diaphragmatic space in a liver injury

Figure 2.

Trocars placement

Figure 3.

Laparoscopic Urinary Bladder repair

Figure 4.

Post laparoscopy scar on discharge

In the present study a total of 25 cases of BTA were studied, out of which 24 cases (96%) were managed laparoscopically and one was converted into an open mini-laparotomy.

Graph 1 suggests different organ injuries in BTA, liver being the most common in our study, in contrast to western countries where the spleen is the most common.[15]

Garph 1.

Incidence of organ injury

Table 3 depicts laparoscopic intervention required in various patients. No injuries were detected in two patients other than the non-expanding retroperitoneal haematomas which were left untouched. Hence, the diagnostic value of laparoscopy (98%) has a tremendous value, which corresponds to the Hamish foster series (89%)[11] with zero% negative laparotomy.

With 04% failure rates, a single laparoscopy is converted into a mini-laparotomy, for large ileal perforation and hematoma, and managed by resection and anastomosis with the help of a small umbilical port cosmetic incision.[12]

Another single patient, who was referred to a higher centre of management of pulmonary embolism on the first post-operative day, not maintaining SpO₂ even with 6 L of O₂ support, due to pulmonary embolism, was not included in the study.

Table 4 reveals the post-operative management in patients of BTA treated by laparoscopy and supports the conclusion.

Table 4.

Post-operative management[12,13]

Practically no complication was found related to laparoscopy in present study. No morbidity and mortality recorded. There were no missed injuries found [Table 5].

Table 5.

Rate of complication

CONCLUSION

In second and third decade of life the liver and spleen are common organs involved in BTA.

With the advent of the current laparoscopy, negative laparotomy has reached almost zero per cent in our study.

Laparoscopy provides early mobilisation, early oral intake, fast recovery, early resumption of work, reduced post-operative stay in the hospital and analgesic requirement, with early discharge as compared to laparotomy. The ultimate outcome for the patient is satisfactory and cost-effective.

Limitations: It requires sophisticated instruments and general anaesthesia; hemodynamic stability of the patient, poor visualisation of the seventh and eighth segments of the liver, posterior surface spleen, retroperitoneal organ, pancreas and second part of duodenum.

The question addressed by this study is whether introduction of an aggressive laparoscopy programme would find its acceptance, and will it make a difference or not?

Our data clearly shows that this indeed will occur, however, it requires a further, prolonged, prospective study for obtaining an even better conclusion and interpretation. With advancement in equipment, more people getting trained and the surgeon's being able to perform technically difficult manoeuvres laparoscopically, it appears that laparoscopy is now closer to replacing emergency laparotomy in the forthcoming future, for the management of Blunt Abdominal Injury.