Laparoscopy in the Context of Trauma: Too Slow or Too Fast?

Cholecystitis and appendicitis are treated laparoscopically as the gold standard worldwide. Laparoscopy has been used in numerous surgical procedures with good results, even in Trauma Surgery with careful patient selection. The advantages of laparoscopy include faster recovery, earlier return to work, shorter hospital stay, decreased postoperative pain, lower readmission rates, resumption of normal daily activity, and aesthetic benefits.¹ Regardless of the variety of management tools, exploratory laparotomy (EL) has been the traditional approach for trauma patient management. Despite the advantage of being an effective diagnostic and therapeutic modality, this intervention may result in numerous non-therapeutic laparotomies,² with high morbidity and mortality rates.^3,4

Considering this reality, alternatives have been developed looking for less invasive strategies, with minor surgical risk to the patient, who is already quite debilitated by their trauma.⁵ The classic exploratory laparotomy has also been partly replaced by nonoperative treatments (NOT) or less invasive modalities, such as the diagnostic laparoscopy (DL) and the therapeutic laparoscopy (TL). Nonetheless, the EL undoubtedly remains important for critically ill patients with hemodynamic instability and immediate surgical indication. 

Through careful selection of patients, large trauma centers showed good results in the conservative treatment of blunt abdominal trauma presenting with hemodynamic stability and solid organ damage, without injury to hollow viscera.^6,7 In patients suffering from penetrating abdominal trauma, NOTs can be safe in select patients. However, this selection is overly specific and requires adequate care and a trained experienced team, because despite advances in imaging technology, the occurrence of late presentation of hollow viscus injury can compromise the treatment modality, leading to NOT failure.^8,9

Another alternative, first described as exploratory "celioscopy," was first executed with trauma patients in 1925,¹⁰ and the practice of laparoscopy with this group continued to appear in the literature during the following decades, with many publications reporting on the subject during the 1980s. This modality emerged and occupied the gap left by the non-therapeutic EL and NOT with diagnostic doubt or management failure.

Whereas it is largely used for elective surgery, laparoscopy for trauma surgery is still considered too challenging and is not usually recommended. There are numerous reasons, including technical difficulties associated with diffuse hemoperitoneum, extensive injury in solid organs, adhesions, and non-apparent hollow viscus injury that demand technical experience.¹¹ It also is often difficult to plan a laparoscopic approach for after-hours emergency procedures or during a night shift because the procedure is affected by time, and these procedures are typically performed outside normal working hours when prolonged or unpredictable operating time would be a particular disadvantage.^12,13 Another important obstacle to overcome is the accessibility of equipment and surgical personnel, especially in rural and non-tertiary hospitals in low-income countries, compared to the US and other countries with more structured economies.^14,15 Nonetheless, the potential advantages of laparoscopy have been highlighted, both in terms of diagnosis and therapy for trauma.

Evidence of Benefit of the Laparoscopic Approach in Trauma

Laparoscopy in trauma has both diagnostic and therapeutic use and has demonstrated that, when used in selected trauma patients, it reduces morbidity, mortality, postoperative pain, surgical wound infection rate, hospital stay, and hospital costs.¹⁶ These results were presented in comparison between the use of laparoscopy and laparotomy in blunt and penetrating abdominal trauma, showing that when properly indicated, there are positive outcomes.^17-19

The success of the procedure is highly dependent on the patient selection. There is no consensus regarding the indications for laparoscopy in abdominal trauma, but it is formally accepted that the main eligibility criteria for laparoscopy in trauma are hemodynamic stability and systolic blood pressure >90 mmHg without vasopressor infusion. Other potential indications are hollow viscus injury, diaphragmatic injury, intraperitoneal bladder rupture, and hemoperitoneum without massive transfusion.²⁰ Low-energy penetrating injuries, such as stab wounds and low-velocity tangential gunshot wounds (GSW) constitute other commonly accepted mechanisms for the initial consideration of DL.²¹ Studies have also examined the use of laparoscopy in hemodynamically stable patients with abdominal non-tangential high velocity penetrating injuries, showing good results in patients submitted to laparoscopy just after the trauma and as a background tool in patients after NOT failure.^22-24

The potential for multiple abdominal injuries is widely considered a contraindication of laparoscopy in blunt abdominal trauma because it makes laparoscopy more difficult and advanced laparoscopic skills are required. However, for hemodynamically stable patients it is feasible and safe when performed by experienced surgeons.²⁵ In penetrating abdominal trauma, a laparoscopic-assisted approach is safe in the management of hemodynamic stable patients with abdominal penetrating trauma and multiples injuries to the bowel. This approach does not appear to be inferior to entirely laparoscopic therapeutic procedures, which is demonstrated by KANLIÖZ and EKICI (2019) after treating 17 patients in these conditions with no morbidity and no mortality.^26,27

For trauma patients presenting with traumatic brain injury (TBI) with intracranial injury, absence of an experienced surgeon in the operating room or near the hospital and lack of equipment immediately available are considered contraindications for laparoscopy in trauma. Hemodynamic instability also is considered a contraindication. Although there are studies that report laparoscopy in hemodynamically unstable patients with promising results,²⁸ there still is little evidence of the benefit and safety of the procedure in this group. Future studies targeting “gasless laparoscopy” can offer the minimally invasive technique without intraabdominal hypertension needed in the conventional laparoscopy, which could expand the indication in other physiologic conditions.^29,30

Despite the benefits reported in the literature and current experience, the beginning of laparoscopy usage as a diagnostic tool in trauma was not very encouraging,³¹ because data from previous reports showed high rates of missed injuries (41% to 77%), generating much criticism to the procedure.^32,33 With time, advances in technology, surgical technique, and surgeon experience, missed injury rates dropped to 0 to 3.2%,^34-37 demonstrating that the technique can be reproduced effectively and safely.

Diagnostic Laparoscopy in Trauma

The diffusion of DL, however, remained restricted to trauma centers linked to teaching and research hospitals because the lack of standardization and systematization of the procedure (diagnostic laparoscopy) impair a greater diffusion and reproducibility of the method, depending on the personal experience of each surgeon. Research conducted by KOTO et al(2017) proposed a systematic exploration protocol, intending to offer a step-by-step exploration procedure.³⁸ In addition to these studies, others descriptively reported, as a secondary objective, some exploration patterns and good results when there is a model to follow. ^31,39-41 Generally, in publications, the technique guides the exploration of the four quadrants: 1) observation of damage to massive viscera (liver, spleen and kidney); 2) evaluation of the gastrointestinal tract, including anterior and posterior stomach and pancreas; 3) evaluation of small loops from the angle of Treitz to the cecal ileum valve; and 4) observation of the portion from the colon to the rectum and then retro uterine pouch.

The exploration of the cavity by laparoscopy, considering careful selection of patients, should include exploration techniques mentioned in previous studies and other auxiliary tasks that are critical to the success of the procedure. These tasks involve positioning and moving of the surgical table and choosing the location of the punctures for better evaluation of the organs in the search for injuries and sources of bleeding. Each surgeon has a personal technique and trocar placement, but, in general, it is advisable to use an umbilical port for a laparoscope (10 mm), working port in the right iliac fossa (5 mm or 12 mm), paramedial assist port, right upper quadrant (5 mm), optional port (5 mm, left iliac fossa), optional port (5 mm or 12 mm, left upper quadrant).⁴² In addition, the variation in the patient's decubitus must be constant according to the region of the abdomen to be explored.  Furthermore, the surgeon, assistants, and the video monitor must be repositioned for better exposure and presentation of regions to be assessed. The ergonomics of the surgical team is essential for this technique and directly affects the surgical time and the procedure outcome.^43,44

Therapeutic Laparoscopy in Trauma

Due to this advance in DL, unnecessary EL can be avoided in most cases⁴⁵ and therapeutic laparoscopy (TL) can gain more space in the treatment of trauma patients. Advances of laparoscopy in trauma have been slow, and only in the last 20 years has evidence reporting the feasibility of TL in stable patients been presented.^46,47

The lack of systematization and standardization of treatments for injuries associated with the diagnostic exploration of a hostile environment may influence many surgeons to be more careful about the indication of TL. However, DL has served not only to prevent unnecessary EL but also to offer the possibility of definitive treatment of trauma injuries. In a series of cases reported by Saribeyoglu et al(2007), 88 patients who were victims of stab wounds underwent laparoscopy, from which 51.1% had DL without the need for treatment and 28.4% had some injury repaired by laparoscopy after exploration. In this study, laparoscopy has avoided a total of 79.5% of EL, showing expressive and positive numbers when using TL.⁴⁸ Successful results also were presented in the use of laparoscopy for the treatment of  GSW victims and blunt trauma in a matched-pair analysis.¹⁴ Other good results were presented after TL requiring gastric and intestinal suturing, intestinal resection, ligation of mesentery and omentum vessels, repair of colon injuries, Hartmann surgery, cholecystectomy, distal pancreatectomy, and splenectomy. All of these procedures were performed by exclusive or video-assisted laparoscopy (25%), evolving with no unnoticed lesions and no mortality.^37,39,49

The surgeon's experience and safety in performing the laparoscopic procedure in trauma remains a major limiting factor for the dissemination and standardization of techniques. A systematic review conducted by Cirocchi et al(2017) showed that the skill of the surgeon, reported only in 25.7% of the studies, was heterogeneous, making it difficult to assess the role of the experience in managing these patients.⁵⁰ There is a significant variety of issues analyzed amongst the considered studies, such as characteristic of the studied groups, indications for laparoscopy, trauma mechanisms, anatomical location of the lesions, the location where the procedure was performed, surgeon skill, and surgical technique. These variables are difficult to standardize or categorize for comparisons and quantitative studies.^51,52

Laparoscopic Technical Skills in the Trauma Patient

This gap left by the lack of standardized techniques, skills training, and comparisons that would enrich the literature studies was shown by Matsevych et al (2018), who published that therapeutic laparoscopy is still much debated, used with caution, and practiced in few centers   and criticized by others due to the lack of more robust data in the literature.^53,54 One possible reason for the trauma surgeon's lack of training and confidence in laparoscopy skills can be explained by the difference between learning in open surgery and laparoscopic surgery. The old saying, “see one, do one, teach one,” is no longer applicable, mainly in the acquisition of laparoscopic skills. This is due to the lack of structured training and the potential for insecurity generated in the practices.⁵⁵ Balancing the safety of current patients with the need to promote procedural competency for future surgeons requires a combination of simulated practice and direct patient care experiences, all under the guidance of expert trainers.⁵⁶

Critical laparoscopic skills require camera navigation technique, mobilization of organs in the abdominal cavity, loop inspection ("running loops"), and laparoscopic suturing. Camera navigation allows efficient viewing in a limited space. In a trauma environment, blood in the abdominal cavity and secretions from hollow organs can often foul the lens. The ability to mobilize intraabdominal organs quickly and safely is necessary for proper exploration and management of identified injuries. Loop inspection is an essential component of all trauma surgery, and the trauma surgeon should feel comfortable performing it with the laparoscopic technique.

Laparoscopic suturing is an essential technique required in many advanced laparoscopic procedures, in addition to being necessary for the management of intraoperative complications. Bilgic et al(2017) defined six elements of effective laparoscopic sutures, including needle handling, suturing (forehand and backhand), confined space suture, tension suture, and continuous suture.⁵⁷ The training of laparoscopic skills, specifically for trauma, has not yet been described in the literature. However, the advanced laparoscopic skills acquired in non-traumatic elective surgery can be transferred to the trauma environment. Buckley et al(2000) demonstrated that skills acquired in the laboratory can be transferred to the operating room and is therefore an important tool for teaching laparoscopy.⁵⁸ Both in laboratories and elective surgery, training ensures clinical safety for complex procedures. It offers the trainee the possibility to learn all the steps of the procedure and the associated anatomy as an observer and to later acquire the necessary technical skills through experience as an assistant.⁵⁹  

All of these competencies are encouraged to be taught as learning objectives within multiple sequential structured repetitive training modules and sub-modules. This methodology leads to rapid proficiency gain in laparoscopic skills and reduces required training cases.⁶⁰ There is no consensus about an ideal training model or exercise progression for acquiring specific skills; however, some studies show the simulator as an important part of the training process, resulting in more rapid competence acquisition in surgical techniques.⁶¹ Trainees with no accessibility to this resource may practice with “homemade” dry boxes. Both box trainers and virtual reality simulators are equally effective means of teaching laparoscopic skills to novice learners.⁶² Yamada et al (2017) developed a stepwise training method to teach young surgeons to perform the standardized procedure. This model is a three-step training composed of a dry box, 3D simulator followed by practice in the operating room.⁶³

The process of acquiring laparoscopic and surgical skills depends on many factors. Appropriate training also is difficult due to the lack of dry and wet lab facilities and unaffordable trained specialists.⁶⁴ Moreover, in many low-income countries, it is difficult to promote new ideas in surgery, not only among patients but also among local surgeons due to cultural and social barriers.^65,66 Furthermore, an ideal surgical environment for training surgeons depends on the laws of each country, associated with financial and human resources. Laparoscopy performed on anesthetized animals is an established model but is costly and is not easily available in some regions. In other regions, human cadavers are available for training. A study conducted by Supe et al (2005) reported that this modality may offer an ideal surgical environment for laparoscopy training courses, allowing dissection and performance of complicated procedures.⁶⁷

Conclusion

The role of laparoscopy in trauma is controversial. One possible reason for the resistance to accepting laparoscopy in trauma is the lack of advanced laparoscopic skills among trauma surgeons and the difficulty of acquiring them in a trauma setting. Preferably, skills in laparoscopy should be acquired in elective, non-traumatic procedures and transferred to the trauma environment. Goal-oriented multimodal training with regular assessments and feedback is effective, enabling skills to be transferred to a trauma setting. There is sufficient evidence to affirm that diagnostic and therapeutic laparoscopy in trauma is safe and feasible.^18,19,39,68 The reported rate of missed injuries is less than 1%, which is equivalent to open laparotomy.^18,39 These data reinforce the trend towards using the minimally invasive technique in selected patients, ensuring good results and optimizing treatment, rational use of health service resources, and early return of the patient to activities. Another important issue in the training of new surgeons is the consideration of whether the patient is fit for the laparoscopic procedure or not. Checking the patient's stability is critical before adopting a course of action. A surgeon’s training process is unavoidably slow and does not allow for fast diffusion of a technique, but the most important lesson is to carry on the process of improvement toward the best possible practice.

So, will laparoscopic surgery lead to the end of open surgery? The answer is no,⁶⁹ and in trauma, the answer would be a definitive no, at that. EL has its clear function in the management of severe trauma when you need to perform damage control surgery or repair a major vascular injury. Although there is a study describing techniques for laparoscopic repair of major intraoperative vascular injury,⁷⁰ severe trauma vascular injuries are unpredictable and need immediate exposition to control the bleeding. A laparoscopic repair in this situation may increase the operating time and worsen the prognosis because it requires experience and specific training. Trauma surgery often entails easy procedures with complex decision making. Rapid and adequate responses to hemodynamically unstable patients are required to lower mortality rates.^71-73

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Marcus Cezillo, MD, TCBC; Robson Uwagoya, MD; Paola Panadés, MD; Samanta Bueno, MD; and Hugo Gregoris, MD, are affiliated with the Department of Acute Care Surgery and Trauma, Municipal Hospital Antônio Giglio, Osasco, Brazil.