Abstract
Background:
There is minimal evidence evaluating the risks and benefits of laparoscopy use in hemodynamically stable children with suspected abdominal injuries. The objective of this study was to evaluate post-operative outcomes in a large cohort of hemodynamically stable pediatric patients with blunt abdominal injury.
Methods:
Using the 2015–2016 National Trauma Data Bank, all patients age <18 years with injury severity score (ISS) ≤25, Glasgow coma scale ≥13, and normal blood pressure who underwent an abdominal operation for blunt abdominal trauma were included. Patients were grouped into three treatment groups: laparotomy, laparoscopy, and laparoscopy converted to laparotomy. Treatment effect estimation with inverse probability weighting was used to determine the association between treatment group and outcomes of interest.
Results:
Of 720 patients, 504 underwent laparotomy, 132 underwent laparoscopy, and 84 underwent laparoscopy converted to laparotomy. Median age was 10 (IQR: 7–15) years and median ISS was 9 (IQR: 5–14). Mean hospital length of stay was 2.1 days shorter (95% CI: 0.9–3.2 days) and mean ICU length of stay was 1.1 days shorter (95% CI: 0.6–1.5 days) for the laparoscopy group compared to the laparotomy group. The laparoscopy group had a 2.0% lower mean probability of surgical site infection than the laparotomy group (95% CI: 1.0–3.0%).
Conclusions:
In this cohort of hemodynamically stable pediatric patients with blunt abdominal injury, laparoscopy may have improved outcomes over laparotomy.
Keywords: laparoscopy, pediatric trauma, blunt abdominal trauma, post-operative outcome
INTRODUCTION
Evaluation of blunt abdominal trauma in the hemodynamically stable patient presents a diagnostic and therapeutic conundrum.1 Most blunt abdominal trauma is managed non-operatively, however in patients with a worrisome physical exam and equivocal imaging, operative intervention is warranted, not only to diagnose, but also to potentially treat a hollow viscus injury. In children, accurate clinical assessment can be even more difficult with poor description of symptoms and challenging physical exam. Traditionally, operative blunt abdominal injuries have been managed via laparotomy, however laparoscopy has become more common in the management of both adults and children.2–4 Laparotomy is both accurate and effective in management of blunt abdominal trauma; however, this comes with a large incision, a risk of non-therapeutic laparotomy, and the long term risk of bowel obstruction. Laparoscopy has the potential to avoid non-therapeutic laparotomies, reduce post-operative pain, and reduce risk of bowel obstruction. However, laparoscopy has higher procedural costs and operations may take longer to complete.1,2,4–9
In adults, there is evidence supporting the use of laparoscopy both for diagnosis and management of blunt abdominal trauma in hemodynamically stable patients.2,5 Laparoscopy avoids non-therapeutic laparotomy and is associated with lower peri-operative mortality, lower intraoperative blood loss, shorter hospital and ICU stays, fewer post-operative complications, and less post-operative pain.5,7,10,11 In children, several retrospective case series demonstrate the feasibility of laparoscopy in management of abdominal trauma.13–17 A few small studies have shown similar mortality and no missed injuries when comparing laparoscopy and laparotomy patients.12,18,19 One additional study evaluated outcomes using the American College of Surgeons National Trauma Data Bank (NTDB) from 2010–2015 and found that laparoscopy was associated with fewer post-operative complications, specifically lower odds of surgical site infection.20
The prior pediatric studies are limited by the heterogeneity of the patient population evaluated. Patients who were hemodynamically unstable were included and these patients invariably underwent laparotomy. Laparotomy patients had higher injury severity scores (ISS) and lower Glasgow Coma Scores (GCS). As a result, the studies demonstrated longer hospital and ICU length of stays for the laparotomy group, but this is likely due to worse injury severity, rather than any true benefit of laparoscopy.12,19,20 Additionally, these studies included patients with both blunt and penetrating injury mechanisms. These two groups are expected to have differences in hospital length of stay and complications due to differences in concomitant non-abdominal injuries.
The objective of this study was to evaluate post-operative outcomes in a large cohort of hemodynamically stable pediatric patients with blunt abdominal injury and without moderate to severe traumatic brain injury or severe multi-system trauma who underwent either laparoscopy or laparotomy. We hypothesized that laparoscopy patients would have shorter hospital length of stay and potentially fewer peri-operative complications compared to laparotomy patients.
METHODS
Data Source
The NTDB includes data on over 5 million trauma patients from over 900 facilities. All procedure and diagnosis codes and patient outcomes are reported. The NTDB was chosen for this study, because it is the largest source of data on pediatric patients with blunt abdominal trauma who underwent operative intervention. This study, which uses deidentified data, is not considered human subjects research by the University of Washington Human Subjects Division; therefore, institutional review board approval was not required.
Study Population
All pediatric patients (age <18 years) who underwent an abdominal operation for blunt abdominal trauma as coded by International Classification of Diseases, Tenth Edition (ICD-10) within 48 hours of admission were included in the study. Patients with ICD-9 coding were not included due to non-specific coding for laparoscopy vs. laparotomy. We included patients with operation within 48 hours to include both those immediately taken to the operating room and those who underwent a period of observation prior to operation. We did not include patients with operation after 48 hours to exclude operations for delayed complications of injury. Patients were excluded if their age was unknown or they had a non-blunt mechanism. In order to create comparable groups of patients who underwent laparoscopy and laparotomy, patients with documented age-adjusted hypotension, ISS>25, and GCS<13 were excluded.
Exposure and Outcome Measures
Data on patient demographics, injury characteristics, facility characteristics, diagnosis codes, procedure codes, and patient outcomes were retrieved from the database. The patients were grouped into three groups: laparotomy, laparoscopy only, and laparoscopy converted to laparotomy. All procedure codes for the first abdominal operation were collected. If the fifth character (denoting approach) for all codes was “percutaneous” (3) or “percutaneous endoscopic” (4), the procedure was considered to be completed laparoscopically. If all codes were “open” (0), the procedure was considered to be completed via laparotomy. If there was a mixture of approach codes, the procedure was considered to be started laparoscopically and converted to laparotomy. If the third character (denoting root operation) for all codes was “inspection” (J), the procedure was considered to be diagnostic only. If any of the third characters were other root operations (e.g. repair, resection, drainage, etc.), the procedure was considered to be therapeutic. If appendectomy was the only procedure performed, the procedure was considered to be diagnostic. Isolated gastrostomy tube placement procedures were excluded.
The outcomes of interest were hospital length of stay, intensive care unit (ICU) length of stay, ventilator days, number of abdominal procedures, in-hospital mortality, and a predetermined list of complications available in the NTDB including: unplanned return to the operating room, surgical site infection, venous thromboembolism, urinary tract infection, pneumonia, acute kidney injury, and acute respiratory distress syndrome.
Statistical Analysis
Multiple imputation was used to account for missing variables. Prior to excluding unstable and severely injured patients, 16% (215) of 1,309 individuals had at least one missing value. Possible patterns of missingness were assessed, and the data were assumed to be missing at random. Ten multiply imputed datasets were created. After multiple imputation, patients with hypotension, ISS>25, and GCS<13 were excluded.
Propensity scores were determined for initial approach of laparoscopy (1) vs. laparotomy (0) based on patient, injury, and facility characteristics including: age, GCS, abnormal heart rate, intubation, ISS, hospital trauma level (highest designation by American College of Surgeons verification or state designation), hospital teaching status, and number of facility pediatric abdominal trauma operations performed per year. Clustering by facility was accounted for using cluster-robust standard errors. The propensity score represents the probability a patient would receive laparoscopy based on their characteristics. There was large overlap in propensity scores in the laparotomy and laparoscopy groups (Appendix). There were no patients with a propensity score of less than 0.05 (i.e. less than 5% probability of laparoscopy) who underwent laparoscopy; therefore, patients with a propensity score of less than 0.05 were excluded from the analysis.
Patient and injury characteristics, abdominal injuries, and abdominal procedures were summarized using descriptive statistics. We used treatment effects estimation with inverse probability weighting to account for confounding by indication to determine the association between treatment group and the outcomes of interest. Level of significance was set at α=0.05 and hypothesis tests were two-sided. STATA/SE version 14 was used for all data analysis. (StataCorp LP, College Station, TX).
RESULTS
Of nearly 850,000 individuals in the NTDB from 2015–2016 with ICD-10 codes, 27,099 underwent an abdominal operation (Figure 1). After excluding adults, 1,195 pediatric patients underwent an operation for blunt abdominal trauma within the first 48 hours of admission. An additional 444 patients were excluded for hypotension, low GCS, or severe, multisystem injury and 30 patients were excluded for a propensity score of <5% probability of laparoscopy. Of the 720 patients in the final cohort, 504 (70.0%) underwent laparotomy and 216 (30.0%) underwent laparoscopy. In the laparotomy group, 106 (21.0%) did not receive any therapeutic intervention. In the laparoscopy group, 61 (28.2%) did not receive a therapeutic intervention and 84 (38.9%) were converted to laparotomy.
Figure 1.
Patient selection from the 2015–2016 National Trauma Data Bank. Abbreviations: GCS, Glasgow coma score; ISS, injury severity score.
The median age of the cohort was 10 (IQR: 7 to 15) years and 65.8% (473) were male. The laparoscopy group was slightly younger than the laparotomy and laparoscopy converted to laparotomy groups (Table 1). The laparotomy group was more severely injured than the laparoscopy group with a median ISS of 10 (IQR: 5 to 16) vs. 6 (IQR: 4 to 12), respectively and the laparotomy group had a higher rate of intubation (11.5% vs. 1.5%). Patients who underwent laparoscopy were more frequently cared for at pediatric only level I/II centers compared to patients who underwent laparotomy (38.6% vs. 24.2%). Other differences between treatment groups are shown in Table 1.
Table 1.
Patient and facility characteristics.
| Characteristic | Laparotomy n=504 | Laparoscopy Only n=132 | Laparoscopy converted to Laparotomy n=84 |
|---|---|---|---|
| Age, median (IQR), y | 11 (7 to 15) | 9 (6 to 13) | 11 (8 to 15) |
| Male, No. (%) | 338 (67.1) | 81 (62.8) | 54 (64.3) |
| Mechanism, No. (%) | |||
| Motor vehicle collision | 287 (57.4) | 62 (47.7) | 56 (66.7) |
| Pedestrian | 81 (16.2) | 20 (15.4) | 11 (13.1) |
| Fall | 48 (9.6) | 23 (17.7) | 5 (6.0) |
| Struck by | 41 (8.2) | 13 (10.0) | 9 (10.7) |
| Other | 43 (8.6) | 12 (9.2) | 3 (3.6) |
| ED GCS, median (IQR) | 15 (15 to 15) | 15 (15 to 15) | 15 (15 to 15) |
| ED heart rate, No. (%)a | |||
| Normal | 377 (75.7) | 103 (78.0) | 57 (69.5) |
| Tachycardia | 80 (16.1) | 17 (12.9) | 14 (17.1) |
| Bradycardia | 41 (8.2) | 12 (9.1) | 11 (13.4) |
| Mechanical ventilation, No. (%) | 57 (11.5) | 2 (1.5) | 5 (6.3) |
| Severe injury (AIS≥3) | |||
| Head | 6 (1.2) | 0 (0.0) | 0 (0.0) |
| Thorax | 29 (5.8) | 9 (6.8) | 9 (10.7) |
| Abdomen | 291 (58.4) | 43 (32.6) | 43 (51.2) |
| ISS, median (IQR) | 10 (5 to 16) | 6 (4 to 11) | 10 (5 to 14) |
| Transfer from another facility, No. (%) | 234 (46.4) | 58 (43.9) | 32 (38.1) |
| Hospital level, No. (%) | |||
| Adult I/II only | 156 (31.0) | 24 (18.2) | 25 (29.8) |
| Pediatric I/II only | 122 (24.2) | 51 (38.6) | 30 (35.7) |
| Adult & Pediatric I/II | 215 (42.7) | 56 (42.4) | 29 (34.5) |
| Level III/IV or non-trauma hospital | 10 (2.0) | 1 (0.8) | 0 (0.0) |
| Teaching status, No. (%) | |||
| Community | 149 (29.6) | 39 (29.6) | 13 (15.5) |
| Non-teaching | 44 (8.7) | 6 (4.6) | 7 (8.3) |
| University | 311 (61.7) | 87 (65.9) | 64 (76.2) |
| Number of pediatric trauma abdominal procedures per year, No. (%) | |||
| <5 cases | 165 (32.9) | 28 (21.5) | 21 (25.0) |
| 5–9 cases | 153 (30.5) | 47 (36.2) | 33 (39.3) |
| ≥10 cases | 183 (36.5) | 55 (42.3) | 30 (35.7) |
| Number of pediatric trauma laparoscopies per year, No. (%) | |||
| <3 cases | 383 (76.5) | 55 (42.3) | 39 (46.4) |
| ≥3 cases | 118 (23.6) | 75 (57.7) | 45 (53.6) |
Abnormal heart rate determined by age-based criteria.
Abbreviations: IQR, interquartile range; ED, emergency department; GCS, Glasgow coma score; AIS, abbreviated injury score; ISS, injury severity score;
The most common abdominal injury was bowel injury (64.6%), followed by splenic injury (11.4%) (Table 2). Bowel resection or repair was the most common abdominal procedure (50.7%) and was more common in the laparotomy group (52.8%) and the laparoscopy converted to laparotomy group (75.0%) than the laparoscopy group (27.3%). A breakdown of the types of bowel resection and repairs performed, along with other abdominal procedures is in Table 3. Incidental appendectomy was performed in 3.9% (28/720) of cases and was the only bowel procedure performed in 1.3% (9/720) of cases.
Table 2.
Abdominal Injuries.
| Injury, No. (%) | Laparotomy n=504 | Laparoscopy Only n=132 | Laparoscopy converted to Laparotomy n=84 |
|---|---|---|---|
| Bowel injury | 330 (65.5) | 65 (49.2) | 70 (83.3) |
| Splenic injury | 70 (13.9) | 8 (6.1) | 4 (4.8) |
| Liver injury | 49 (9.7) | 6 (4.6) | 7 (8.3) |
| Kidney injury | 22 (4.4) | 5 (3.8) | 2 (2.4) |
| Vascular injury | 66 (13.1) | 4 (3.0) | 6 (7.1) |
| Bladder injury | 27 (5.4) | 5 (3.8) | 1 (12) |
| Pancreas injury | 46 (9.1) | 10 (7.6) | 7 (8.3) |
| Other abdominal injury | 220 (43.7) | 59 (44.7) | 42 (50.0) |
Table 3.
Abdominal procedures.
| Procedure, No. (%) | Laparotomy n=504 | Laparoscopy Only n=132 | Laparoscopy converted to Laparotomy n=84 |
|---|---|---|---|
| Diagnostic only | 106 (21.0) | 61 (46.2) | 3 (3.6) |
| Bowel resection or repair | 266 (52.8) | 36 (27.3) | 63 (75.0) |
| Stomach repair | 8 (1.6) | 0 (0.0) | 2 (2.4) |
| Stomach resection | 0 (0.0) | 0 (0.0) | 1 (12) |
| Duodenum repair | 26 (5.2) | 1 (0.8) | 0 (0.0) |
| Duodenum resection | 6 (1.2) | 0 (0.0) | 1 (1.2) |
| Small bowel repair | 65 (12.9) | 18 (13.6) | 22 (26.2) |
| Small bowel resection and anastomosis | 101 (20.0) | 3 (2.3) | 20 (23.8) |
| Small bowel resection and ostomy | 5 (1.0) | 0 (0.0) | 2 (2.4) |
| Large bowel repair | 67 (13.3) | 9 (6.8) | 13 (15.5) |
| Large bowel resection and anastomosis | 49 (9.7) | 6 (4.6) | 13 (15.5) |
| Large bowel resection and ostomy | 11 (2.2) | 3 (2.3) | 3 (3.6) |
| Appendectomy | 20 (4.0) | 2 (1.5) | 7 (7.1) |
| Other bowel manipulation | 19 (3.8) | 2 (1.5) | 2 (2.4) |
| Spleen resection or repair | 38 (7.5) | 1 (0.8) | 1 (12) |
| Spleen repair | 6 (1.2) | 1 (0.8) | 0 (0.0) |
| Splenectomy | 32 (6.4) | 0 (0.0) | 1 (1.2) |
| Vascular repair | 50 (9.9) | 4 (3.0) | 6 (7.1) |
| Liver resection or repair | 11 (2.2) | 0 (0.0) | 1 (12) |
| Kidney resection or repair | 4 (0.8) | 1 (0.8) | 0 (0.0) |
| Pancreas drainage, repair, or resection | 26 (5.2) | 7 (5.3) | 5 (5.6) |
| Bladder repair | 24 (4.8) | 4 (3.0) | 1 (12) |
| Other abdominal procedure | 67 (13.3) | 26 (19.7) | 25 (29.8) |
There was one death in the laparotomy group and no deaths in the laparoscopy or laparoscopy converted to laparotomy group (Table 4). Mean hospital length of stay was 2.1 days shorter (95% CI: 0.9–3.2 days) and mean ICU length of stay was 1.1 days shorter (95% CI: 0.6–1.5 days) for the laparoscopy group compared to the laparotomy group. There was no difference in length of stay or ICU length of stay between the laparoscopy converted to laparotomy group and the laparotomy group. There was no difference in ventilator days or number of abdominal procedures between any of the groups. There was no difference in post-operative complications, except the laparoscopy group had a 2.0% lower mean probability of surgical site infection than the laparotomy group (95% CI: 1.0–3.0%).
Table 4.
Post-operative outcomes.
| Outcome | Laparotomy n=506 | Laparoscopy Only n=132 | Laparoscopy converted to Laparotomy n=82 | Laparoscopy onlya | Laparoscopy converted to laparotomya | ||
|---|---|---|---|---|---|---|---|
| ATE | 95% CI | ATE | 95% CI | ||||
| Length of stay, median (IQR) | 6 (4 to 9) | 4 (2 to 7) | 6 (5 to 10) | −2.10 | −3.26 to −0.94 | −0.17 | −1.39 to 1.06 |
| ICU length of stay, median (IQR) | 0 (0 to 3) | 0 (0 to 0) | 0 (0 to 3) | −1.05 | −1.51 to −0.58 | −0.12 | −0.82 to 0.57 |
| Ventilator days, median (IQR) | 0 (0 to 0) | 0 (0 to 0) | 0 (0 to 0) | −0.27 | −0.54 to 0.01 | −0.11 | −0.42 to 0.20 |
| Multiple abdominal procedures, No. (%) | 42 (8.3) | 4 (3.0) | 3 (3.6) | −0.03 | −0.08 to 0.02 | −0.03 | −0.09 to 0.03 |
| In-hospital mortality, No. (%) | 1 (0.2) | 0 (0.0) | 0 (0.0) | −0.002 | −0.005 to 0.002 | −0.002 | −0.005 to 0.002 |
| Complications, No. (%) | |||||||
| Unplanned return to the operating room | 8 (1.6) | 2 (1.5) | 2 (2.4) | 0.01 | −0.03 to 0.05 | 0.01 | −0.03 to 0.06 |
| Surgical site infection | 11 (2.2) | 0 (0.0) | 1 (1.2) | −0.02 | −0.03 to −0.01 | −0.01 | −0.03 to 0.01 |
| Venous thromboembolismb | 0 (0.0) | 0 (0.0) | 1 (1.2) | ||||
| Urinary tract infection | 1 (0.2) | 0 (0.0) | 0 (0.0) | −0.002 | −0.005 to 0.002 | −0.002 | −0.005 to 0.002 |
| Pneumonia | 0 (0.0) | 0 (0.0) | 0 (0.0) | 0 | 0 | ||
| Acute kidney injury | 1 (0.2) | 0 (0.0) | 0 (0.0) | −0.002 | −0.005 to 0.002 | −0.002 | −0.005 to 0.002 |
| Acute respiratory distress syndrome | 2 (0.4) | 0 (0.0) | 0 (0.0) | −0.003 | −0.008 to 0.001 | −0.003 | −0.008 to 0.001 |
Laparotomy group as reference group. Adjusted for propensity score accounting for age, Glasgow coma score, abnormal heart rate, intubation status, injury severity score, hospital trauma level, hospital teaching status, and number of facility pediatric abdominal trauma operations performed per year.
Unable to determine ATE due to no events in the reference group.
Abbreviations: ATE, Average treatment effect; CI, confidence interval; IQR, interquartile range
DISCUSSION
We compared outcomes of a similar group of children who underwent laparoscopy or laparotomy after blunt abdominal trauma. We found that patients who underwent laparoscopy had a shorter hospital length of stay compared to those who underwent laparotomy (from 6 days to 4 days). By excluding severely injured patients who would not have been candidates for laparoscopy and accounting for confounding by indication in our analysis, we believe this demonstrates a true benefit in hospital length of stay of laparoscopy over laparotomy for normotensive children with blunt abdominal trauma without severe traumatic brain injury or severe multi-system trauma. Shortened hospital length of stay for laparoscopy, is likely due to reduced post-operative pain, earlier ambulation, and earlier return of bowel function.5,15
In determining the optimal operative approach, the potential costs and benefits of laparoscopy vs. laparotomy must be considered. In this study, 28% of laparoscopic procedures and 21% of open procedures were non-therapeutic. Use of laparoscopy resulted in avoidance of 61 negative laparotomies (8% of all cases), avoiding the morbidity of laparotomy, particularly increased wound complications, post-operative pain, and long-term risk of bowel obstruction.1,2,5,6 An additional 106 non-therapeutic laparotomies (15% of all cases) could potentially have been avoided if diagnostic laparoscopy was performed initially instead of exploratory laparotomy. This has large potential benefits, both for individual patients and the health care system, if there are indeed lower rates of complications and decreased length of stay with laparoscopy. However, laparoscopy is associated with higher operative costs and potentially longer operative times, particularly when performing therapeutic laparoscopic procedures. In busy trauma centers with high operative volume, laparoscopy may not be feasible. The NTDB does not include operative time, so this could not be directly evaluated, however a meta-analysis of adult trauma patients showed shorter operative time with laparoscopy5 and a single-center institutional study showed no difference in operative time between laparoscopy and laparotomy.20
We observed no difference between treatment groups in the proportion of patients requiring multiple abdominal procedures. This metric served as a proxy for missed injury, since, if a patient had a clinically important missed injury at the initial operation, they would require an additional operation to repair this injury. However, the rate of multiple operations likely overestimates the rate of missed injury since many of these operations were likely planned re-assessment of the abdomen after an initial operation. Given the low number of patients requiring multiple operations, we believe the rate of missed injury to be low for all treatment groups, similar to prior studies.12,18–20 Historically, there has been concern for an increased risk of missed injury with laparoscopy; however as laparoscopic techniques and surgeon skills have improved, the rate of missed injury in laparoscopy has improved.8,21 Our study does not suggest any increased risk of missed injury with laparoscopy in pediatric blunt abdominal injuries, but given the low number of repeat operations, the study was not powered to detect a small difference.
The conversion rate in this study was 39%, which is similar to prior studies on blunt abdominal trauma in children.12,16–19,22 This rate is much higher than the conversion rate for other commonly performed laparoscopic procedures, such as appendectomy (1–6%) or cholecystectomy (8–12%).23–26 This is likely because many surgeons view laparoscopy as a diagnostic procedure, rather than a therapeutic procedure in bunt abdominal trauma. In patients with non-diagnostic CT scan and concern for hollow viscus injury, laparoscopy allows for diagnostic certainty.1 Bowel resection or repair was performed in 75% of converted cases. One advantage of starting a procedure laparoscopically is that a small, more directed incision can be made for injury repair. In addition, 13% of therapeutic procedures, including bowel repair and resection, were performed laparoscopically. Other studies have demonstrated the feasibility and safety of therapeutic laparoscopic procedures in blunt abdominal trauma in children.12,18,19,22
Interestingly, patients evaluated at a level I/II pediatric only facility as compared to an adult only level I/II facility were more likely to undergo laparoscopy. There is no literature exploring reasons for surgeon’s choice of laparoscopy vs. laparotomy in pediatric blunt abdominal trauma. However, in the appendicitis literature, choice of open vs. laparoscopic procedure has been associated with teaching status of the hospital, perceived advantage of laparoscopic procedure over open procedure, previous laparoscopic experience, and operative time constraints.27,28 We suspect that surgeons working at pediatric only facilities have more general laparoscopic experience in the pediatric population and therefore are more likely to choose laparoscopy in a pediatric patient with blunt abdominal trauma.
We did observe a lower rate of surgical site infection in the laparoscopy group compared to the laparotomy group (0% vs. 2%). This is consistent with the previous NTDB study of pediatric patients from 2010–2015, which showed a lower rate of surgical site infection in laparoscopy compared to laparotomy (0% vs. 3%).20 Li et al’s meta-analysis on laparoscopy for abdominal trauma did not separately evaluate surgical site infections; however, they did find a 63% lower risk of post-operative complications with laparoscopy compared to laparotomy.5 A meta-analysis evaluating laparoscopy for penetrating adult trauma demonstrated a lower rate of wound infection with laparoscopy (2.4% vs. 4.0%).29 In addition, laparoscopy has been shown to be associated with lower rates of surgical site infection in acute care operations.30–32
The main strength of this study is use of a comparable cohort of patients. By excluding patients with hypotension, ISS>25, GCS<13, and low propensity score for laparoscopy, we only included patients who were likely good candidates for laparoscopy. Our analysis accounted for remaining differences in the patient groups, and thus we believe the observed differences in outcomes are reflective of the treatment received, rather than differences in demographic or injury characteristics. We also limited our analysis to patients with blunt abdominal trauma, reducing the variability in outcomes across patients with different patterns of injury. An additional strength of our study is the use of ICD-10 codes to determine treatment group. Each ICD-10 procedure code includes the approach, and thus we avoid misclassification of the treatment group, as opposed to prior studies.20
Our study has several limitations. The NTDB reports only one emergency department blood pressure. While we excluded all patients with reported age-adjusted hypotension, we do not know if some of the included patients became unstable later in their hospital course, requiring emergent laparotomy. This may explain why all splenectomies were performed via laparotomy. If a patient became hypotensive due to splenic hemorrhage, this patient would undergo emergent laparotomy. Therefore, differences in between the patient groups may not be completely accounted for in our analysis. However, with the available data, we have accounted for differences in patient, injury, and facility characteristics that may affect surgeons’ choice in management and patient outcomes.
An additional limitation is that we rely on accurate and complete ICD codes to determine the treatment group and presence of peri-operative complications. Complications are rare in this pediatric population and also may be underreported, thus there may be true differences in complication rates that we were unable to detect. We were also limited by the specific complications assessed in the NTDB and were unable to examine other potential complications such as need for blood transfusion prior to operation or post-operative small bowel obstruction. In addition, we could not evaluate more granular post-operative outcomes such as post-operative pain, timing of return of bowel function, post-operative ileus, operative time, and total cost, as these are not included in the NTDB. Also, we only assessed outcomes of patients who underwent operative intervention. It may be that some of the patients with operative intervention may have had improved outcomes with observation alone, particularly those with non-therapeutic procedures or those with minor procedures such as repair of serosal tears.
In conclusion, we found that laparoscopy was associated with shorter hospital length of stay and decreased incidence of surgical site infection. The use of laparoscopy resulted in a decrease in negative laparotomies, and additional non-therapeutic laparotomies could potentially have been avoided if diagnostic laparoscopy was performed initially instead of exploratory laparotomy. In appropriately selected hemodynamically stable pediatric patients with blunt abdominal trauma and without severe-multisystem injury or traumatic brain injury, laparoscopy may result in improved outcomes and reduce the rate of non-therapeutic laparotomy.
Supplementary Material
Propensity score results. Propensity score represents the probability of laparoscopy based on age, mechanism of injury, Glasgow Coma Score, abnormal heart rate, intubation status, injury severity score, hospital trauma level, hospital teaching status, and number of facility pediatric abdominal trauma operations performed per year. Patients with propensity score <0.05 were excluded (n=30).
Highlights.
Laparoscopy may be better than laparotomy for children with blunt abdominal injury
Evaluated outcomes in hemodynamically stable children
Hospital and ICU length of stay was shorter for laparoscopy group
Lower risk of surgical site infection with laparoscopy
DISCLOSURE
The authors report no proprietary or commercial interest in any product mentioned or concept discussed in this article. Dr. Butler was supported by the National Institutes of Health T-32 Pediatric Injury Research Training Program [5T32HD057822-09].
Footnotes
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Associated Data
This section collects any data citations, data availability statements, or supplementary materials included in this article.
Supplementary Materials
Propensity score results. Propensity score represents the probability of laparoscopy based on age, mechanism of injury, Glasgow Coma Score, abnormal heart rate, intubation status, injury severity score, hospital trauma level, hospital teaching status, and number of facility pediatric abdominal trauma operations performed per year. Patients with propensity score <0.05 were excluded (n=30).