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J. Connolly
b
c
Fig. 19.3 (continued)
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19.1.4 FAST Pearls
1. Always start with notch (US probe indicator) at the top to
orientate your image.
2. Make all rotations anticlockwise.
3. Look at the heart rst to dene uid as black.
4. Repeat! Repeat! Repeat!
5. Do not forget—YOU NEED BLOOD TO BLEED.
6. CLOTTED BLOOD MAY APPEAR GREY.
7. In patients who have lost output or who are peri-arrest
patients, do not use US and delay your decision to perform a resuscitative thoracotomy—in this situation, it
adds little to what should be a highly standardised
protocol- driven process. It also stands the chance of
falsely reassuring the team!
19.2 Pneumothorax
The detection of pneumothorax is an exciting use of pointof- care ultrasound much more sensitive than chest X-ray
(which at best picks up 60% of pneumothoraces). Even
US-naive practitioners can be taught this technique with a
short period of training.
It has the value of being fast, portable and repeatable, and
in the often-noisy world of trauma, particularly prehospital,
this ‘visual stethoscope’ has obvious advantages over an
auditory stethoscope.
Air is considered the enemy of ultrasound. In this scanning modality, it is not the detection of air; rather, it is looking for the absence of normal signs/artefacts. When
visualising the interface between the two layers of pleura,
certain signs are normal:
1. Sliding—you will see this as a sliding motion between
the two layers of the pleura; if air interposes between the
layers, then this will be lost.
2. Comet-tail artefacts—these are reverberation or ring-
down artefacts caused by uid in the interstitium of the
lung; if air has interposed between the two layers, this
artefact will be lost.
3. You can use M-mode to look for motion of the lung—
where there is motion of the lung, there is the appearance
of a seashore sign (Fig.19.4a, b).
In the context of penetrating trauma, US is valuable for
both detecting and ruling out a pneumothorax. The presence
of sliding and comet tails carries a negative LR of −0.06,
a
b
Fig. 19.4 Photo of seashore sign (a) M-mode—note the lower part of
image has texture like a beach with sea in the distance—this disappears
with a pneumothorax when it all looks the same (b)
making it a good test to exclude pneumothorax. In the prehospital arena and in resuscitation, this may well decrease
the need to undertake blind prophylactic thoracostomies/
needle thoracocenteses.
19.2.1 Pitfalls
1. Lack of sliding does not always equal a pneumothorax! In
effect, lack of sliding is the visual equivalent of no breath
sounds (e.g. in a right main bronchus intubation, only the
right lung moves), so before diagnosing a pneumothorax
in the intubated patient, check the tube distance at the
teeth and consider pulling the tube back a bit. You may of
course also nd this useful as an adjunct in noisy environments for checking the tube position.
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Looking for a lung point, the point where sliding
begins, is considered almost 100% sensitive but can be
time consuming.
2. Bullae can be confused for pneumothorax, so proceed
with caution in patients with chronic lung disease.
3. Surgical emphysema can make it difcult to see
anything.
4. A one-off anterior probe position in the same site as you
would listen for a pneumothorax will rapidly alert you to the
presence of a pneumothorax. It is possible to quantify the
size by multiple site sampling or a chest X-ray/trauma CT—
in this context, however, in a critically ill patient with signs
of a pneumothorax a drain should be seriouly considered
and a well patient sent for further imaging.
A PNEUMOTHORAX IS RECOGNISED BY THE
ABSENCE OF NORMAL SONOGRAPHIC SIGNS.
19.3 Haemothorax
Ultrasound is very sensitive at visualising the dependent costophrenic angles on both the right and left. In fact, this view is
seen on the standard FAST views as demonstrated in Fig.19.5.
The appearance above the diaphragm is normally made up
of a composite of the lung and the solid organs below the diaphragm being reected above the diaphragm (often producing
a mirror image of the liver or spleen above the diaphragm). If
uid is present above the diaphragm, this is lost and the space
appears black, indicating there is uid in the pleural space.
It is not normally possible to see the vertebrae above the
diaphragm. If uid is present, then the spine becomes visible, the spine sign.
It is possible to rapidly quantify the volume—the maximal depth of uid in mm multiplied by 20 gives an approximate quantication in ml of the volume.
When considering how accurate a test it is compared with
physical examination seeing free uid has an LR+ of 47 and
LR− of 0.06, making it extremely accurate at ruling thoracic
cavity-free uid both in and out.
ON THE LEFT FAST VIEW, FLUID IS AT THE TOP AND
ON THE RIGHT, AT THE BOTTOM.
19.4 Pericardial Tamponade
This is normally seen well on the sub-costal FAST view. In
those patients with poor access to this view, alternative views
may be needed. In this case, a simple transverse scan in the
fth intercostal space may sufce for a rapid view or a parasternal long-axis (PLAX) view. Further echo views are
beyond the scope of this text but are relatively easily learnt.
19.4.1 Pitfalls
1. Clotted blood may be grey rather than black, so mislead
the unwary.
2. A very small amount of uid is normal physiologically. If
the uid goes all the way around the heart, it is likely to
be signicant.
3. Diastolic collapse of the right (R) ventricle and IVC non-
collapsibility are considered echo indicators of physiological compromise. However, in the context of a penetrating
wound, with haemodynamic compromise, anything but the
smallest amount of uid should be considered signicant.
TAMPONADE IS A CLINICAL NOT RADIOLOGICAL
DIAGNOSIS.
19.5 Assessment ofVolumetric Status
Fig. 19.5 Image of haemothorax—note black above the diaphragm
A major value of point-of-care ultrasound is its ability during
the primary survey and resuscitation stage to aid assessment
of volume status. Signs that you will nd of use include the
following :
1. Kissing ventricle sign: You signify an empty heart when
in systole the front wall of the left ventricle touches the
back wall, the ‘kissing ventricle sign’.
2. IVC collapse: Even when you are a relative beginner,
direct observation of the IVC will give you a rapid indication of volume status. The IVC is often visualised in the
pericardial FAST view and occasionally seen at the back
of the liver in the perihepatic views (Fig.19.6 IVC). Care
should be taken not to confuse the IVC with the aorta.
Simple eyeballing of the IVC can be of value. In a normovolaemic patient, its diameter is normally 2cm, a few cm
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For peripheral access, after applying a tourniquet, set the
machine at the lowest depth using a high-frequency probe;
apply only light pressure (as you will easily compress vessels). Veins are black and if they are patent are
compressible.
If peripheral access is not possible, you can use the probe
to identify the location of central vessels (most commonly
femoral/internal jugular). This can initially be just the placement of a large-bore cannula to allow rapid blood replacement (the so-called dirty IJ). When time allows, it is becoming
the standard for line placement, improving rst-pass success
and speed to gain a line.
Fig. 19.6 Image of IVC collapse—black structure is IVC. Note as
M-mode is applied how it collapses with inspiration by about 30%
(normal)
below the diaphragm, and it collapses by between a quarter and a third. In extreme hypovolaemia, the collapse is
almost the total and the diameter less than 2cm.
The IVC can be distinguished from the aorta as it is thin
walled with a less forceful beat. It can be visualised behind
the liver into the right atrium. Even in the intubated patient
(when inspiratory collapse will not occur), a small diameter
or visibly collapsed IVC will alert you to hypovolaemia.
Total or near collapse of the IVC or a small diameter however can still indicate a depleted volume status.
Non-collapse on the other hand may indicate a right-sided
pressure problem (tension/tamponade/pulmonary embolus
(PE)) or may be present chronically in right heart failure.
Other measures such as measuring the change in size of
the ventricle or carotid ow times before and after passive
leg raise are gaining acceptance. Modern machines with articial intelligence mean such measures can be obtained with
limited training.
VISUALISING THE IVC CAN PROVIDE A RAPID
ASSESSMENT OF VOLUME STATUS.
19.6 Using Ultrasound toManage
Penetrating Trauma
19.6.1 Vascular Access
Ultrasound is very valuable in severe hypovolaemia both for
gaining peripheral and central access.
In its most simple form, you can use the high-frequency
probe to identify patent vessels. With relatively limited training, the probe may be used to guide a cannula into the vessel
using an ‘in-plane’ or ‘out-of-plane’ technique.
19.6.2 Pericardial andPleural Drainage
Ultrasound guidance can be used to more accurately
localise uid. Guided spiration can best be achieved by a
longitudinal approach (in-plane) so that the needle depth
is more accurately assessed to ensure no injury occurs to
deeper structures.
However drainage is more likley to need a drain and
remember that pericardial blood in the initial stages is clot-
ted and so is likely to need open drainage.
19.6.3 Airway Management
In extreme swelling (e.g. haematoma), US can help in the
rapid assessment of the position of the trachea in order to
allow urgent access to the airway by means of a needle or
open cricothyroidotomy.
The trachea is easily recognised as an air-lled structure
allowing more rapid identication for surgical airways.
Ultrasound can also be used to directly watch intubation,
specically ensuring the ET tube is not inadvertently place
into the oesophagus.
19.6.4 Depth ofTract/Foreign Body
Localisation
Although the use of US has been described to estimate tract
depth, the skill needed to be accurate does not justify the use
of US by non-expert to judge the depth of penetration.
Retained metallic foreign bodies (FB) can however be
detected easily by US.A good approach for localising FBs
is to use a two-needle placement technique, where two needles are directed individually using US towards the foreign
body. The meeting point of the needles can then be cut
down onto in order to nd the FB at the point where the
needles meet.
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19.7 Postoperative Management
With more training, you will increase your skills and be able
to use US in the postoperative period.
Even with simple FAST scanning experience, you can
start to use ultrasound as a valuable adjunct in the shocked
postoperative patient.
You can look at the following:
1. Heart function: Is it beating? Is it beating well or poorly?
Even simple eyeballing of how effective cardiac function
is has been shown by multiple authors to correlate well
with ejection fractions.
Assessment for pericardial uid and right ventricle
size and simple valvular colour assessments are easily
learnt. A sudden massive dilation of the RV may suggest
a pulmonary embolus.
2. Vascular status: Visualisation of the IVC can aid uid
resuscitation.
3. Lung status: Lung abnormalities (wet lung, consolida-
tion, pneumothorax, empyema, pleural effusion, etc.).
FOCUSSED US IS INVALUABLE IN ASSESSING THE
SHOCKED PATIENT.
19.8.3 IVC Scanning
• The IVC in an intubated patient does not collapse in
inspiration.
• The scan should add to your judgement, not replace it!
Important Points
DO NOT USE THE US SCAN TO DELAY A DECISION IN
PATIENTS IN EXTREMIS OR TRAUMATIC CARDIAC
ARREST.
• A poorly performing doctor with an ultrasound probe is
still a poorly performing doctor.
• You need blood to bleed.
• Pneumothorax detection is possible by looking for the
absence of normality.
• Direct visualisation of the IVC enables a rapid assessment
of volumetric status.
• Focussed ultrasound is rapidly becoming an important
part of the assessment of the critically ill and injured.
• The scan should add to your judgement, not replace it!
• Blood is not always black.
19.8 Summary ofImportant Pitfalls
19.8.1 FAST Scanning
• You need blood to bleed!
• Do not call a scan positive unless you have one of the
standard images!
• Clotted blood in the pericardium can look grey.
• Do not rely on a one-off scan! Repeat! Repeat! Repeat!
• The scan should add to your judgement of the situation,
not replace it!
• IF THE PATIENT HAS ARRESTED, DO NOT USE
SCANS TO DELAY DECISIONS—THEY NEED
RESUSCITATIVE PROCEDURES.
19.8.2 Pneumothorax
• In the intubated patient, a right main bronchus intubation
will look like a pneumothorax on the left.
• Bullae appear the same as pneumothoraces.
• The scan should add to your judgement of the situation,
not replace it!
Suggested Reading
Balik M, Plasil P, Waldauf P, et al. Ultrasound estimation of volume
of pleural uid in mechanically ventilated patients. Intensive Care
Med. 2006;32(2):318–21.
Bowra J, McLaughlin RE.Emergency ultrasound made easy. 2nd ed.
Amsterdam: Elsevier; 2011. ISBN-10 0443101507
Brooke M, Walton J. Acquisition and interpretation of focused diag-
nostic ultrasound images by ultrasound-naive advanced paramedics: trialing a PHUS education programme. Emerg Med J.
2012;29(4):322–6. https://doi.org/10.1136/emj.2010.106484. Epub
2011 Apr 21
Connolly J, Dean A, Jarman R, Hoffman B. Emergency point of care
ultrasound. Wiley-Blackwell; 2016. 2015. ISBN-9780470657577
Istral Larry. The POCUS Manifesto -Expanding the limits of the physi-
cal examination with point of care Ultrasound ASIN B09K5SC2KK.
John Ma O. Ma and Mateer’s emergency ultrasound. 3rd ed. The
McGraw-Hill Companies, Inc; 2014. ISBN-10 007147904X
Jones AE, Vivek ST, et al. RCT of immediate versus delayed Goa;
directed ultrasound to identify the aetiology of non-traumatic hypotension in ED patients. Acad Emerg Med. 2004;11(5):445.
Lichtenstein D.General ultrasound in the critically ill. Springer; 2005.
ISBN-10 3540736239
Lichtenstein D, Goldstein I, Mourgon E, etal. Comparative diagnostic
performances of auscultation, chest radiography, and lung ultrasonography in acute respiratory distress syndrome. Anesthesiology.
2004;100(1):9–15.
McKenzie D, Khan NA, Blehar D, etal. Carotid ow time changes
with volume status in acute blood loss. Ann Emerg Med.
2015;66(3):277–82.
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Melniker LA, etal. Randomized controlled clinical trial of point-of-
care, limited ultrasonography for trauma in the emergency department: the rst sonography outcomes assessment program trial. Ann
Emerg Med. 2006;48(3):227–35.
Rozycki GS, Oschner MG, Schmidt JA.A prospective study of surgeon
performed ultrasound as the primary adjunctive modality for injured
patient assessment. J Trauma. 1995;39:492–500.
Simel David L. The rational clinical examination evidence based
clinical diagnosis. JAMA. ISBN 978-0-07-159030-2. www.
JAMAevidence.com
The POCUS Atlas, POCUS Evidence. https://thepocusatlas.com
Laparoscopy andPenetrating Trauma
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NicolasMelo andDanielR.Margulies
20
Although not always the primary modality to treat the injured
patient, laparoscopy has been used in trauma since the early
twentieth century. In the 1920s, laparoscopy was rst proposed as a means of identifying hemoperitoneum. In the
1960s, Hesselson performed the rst diagnostic laparoscopy,
and in 1976, Gazzaniga successfully used laparoscopy for
evaluation of 37 patients who suffered abdominal trauma. A
year later, Carnevale described the use of laparoscopy to
evaluate patients with anterior abdominal stab wounds and
tangential gunshot wounds with acceptable outcomes. Over
the past 30years, laparoscopy has become the standard in
diagnosis and treatment of many surgical diseases. As such,
the technology and availability of equipment, as well as surgeons’ ability, have all greatly improved.
Laparoscopy, when used as a means of diagnosing perito-
neal penetration or intra-abdominal organ injury, has become
an accepted practice. In so doing, the majority of literature
has shown a signicant decrease in the number of negative
laparotomies being performed. A recent retrospective analysis by Chestovich etal. described a series of 518 patients that
underwent laparoscopic evaluation of penetrating injuries,
and although it had a 32% conversion rate to an open procedure, they did not have any missed injuries and had shorter
lengths of stay. Other studies demonstrated that when laparoscopy was used as a screening tool, it prevented 63% of
patients from unnecessary laparotomies which subsequently
led to lower hospital costs secondary to a shorter length of
stay. Laparotomy patients have an overall higher morbidity
and mortality, with a higher incidence of complications such
as deep vein thrombosis, pulmonary embolism, pneumonia,
wound infection, wound dehiscence, and abscess formation.
Although no study has documented long-term follow-up, it
could be reasoned that a lower laparotomy rate also leads to
fewer long-term complications such as bowel obstructions
from adhesions as well as a lower number of ventral hernias
N. Melo · D. R. Margulies (*)
Department of Surgery, Cedars-Sinai Medical Center,
Los Angeles, CA, USA
e-mail: Daniel.margulies@cshs.org; marguliesd@cshs.org
subsequently requiring repair. Diagnostic laparoscopy for
penetrating trauma has been shown to have a 3% complication rate in comparison to a 22% complication rate associated with negative laparotomies.
Nevertheless, the fear of a missed injury still exists. Early
studies reported missed injury rates as high as 82%. Multiple
studies since that time, however, report a 0–1% incidence of
missed injuries. Studies evaluating laparoscopy solely as a
diagnostic tool have shown that it was 100% accurate in
determining the need for laparotomy. The goal of diagnostic
laparoscopy is to prevent unnecessary laparotomies with
complete condence that no injury went unrecognized.
Laparotomy must be performed in patients where any doubt
of injury remains.
Therapeutic laparoscopy becomes a topic of debate. There
are increasing numbers of studies citing laparoscopy as an
appropriate means of diagnosis and treatment of penetrating
trauma. The use of laparoscopy, not only as a diagnostic tool
but also as a means of therapy, is expanding as the skills and
comfort level of trauma surgeons improve. In addition, the
resources available to perform an open procedure must be
present in the room when undertaking this modality.
Extreme care must be taken in selecting injured patients
to undergo this form of management. The ideal patient will
have limited penetrating injury to the thoracoabdominal
region or abdomen. Contraindications to diagnostic laparoscopy include patients with hemodynamic instability with
evidence of shock or active bleeding. Relative contraindications include peritonitis, known intra-abdominal injury, or
posterior penetrating trauma with high likelihood of bowel
injury, concern for retroperitoneal injury, previous abdominal surgery, and lack of equipment and expertise. The positive predictive value of shock and generalized peritonitis in
predicting the presence of abdominal organ injury requiring
surgical repair is well over 80%. Laparoscopy holds no
advantage over laparotomy in someone suspected of having
multiple intra-abdominal injuries that will require attention.
In addition, the possibility of an intraoperative pneumothorax occurring while obtaining pneumoperitoneum from an
© The Author(s), under exclusive license to Springer Nature Switzerland AG 2023
E. Degiannis et al. (eds.), Penetrating Trauma, https://doi.org/10.1007/978-3-031-47006-6_20
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undiagnosed diaphragmatic injury exists and must be something that the operating surgeon and anesthesiologist are
monitoring and are prepared to handle quickly if the problem
should arise. Another consideration in patient selection
includes those with traumatic brain injury (TBI). It has been
shown that intracranial pressure rises with the pneumoperitoneum required to perform laparoscopy, and as such, this may
not be the best means of diagnosing and treating multitrauma patients with a component of TBI.
20.1 General Techniques ofLaparoscopy
To begin, prep and drape the patient in a position that allows
for easy conversion to exploratory laparotomy if need be.
Secure the patient to the table as to facilitate positioning in
Trendelenburg, reverse Trendelenburg, and left or right side
up as to give you optimal visibility when examining each of
the four quadrants. If possible, place a towel at the head and
foot of the bed. Insert the Veress needle with standard technique and insufation obtained to 15mmHg. If a penetrating
wound to the abdomen is large enough, it may not allow for
insufation and thus may require fascial or skin closure.
Alternatively, you may place a blunt trocar through the
wound if you can elevate the fascia or guide the trocar with a
nger. If chest tubes were previously placed, position the
Pleur-evac lateral to the bed in a position of visibility to facilitate monitoring for the presence of a new air leak during
insufation.
In the inferior umbilical position, insert a 5mm trocar for
use with 30° camera. If the patient has a known pelvic fracture, however, the trocar should be placed superior to the
umbilicus, and use blunt trocars over bladed ones if available. If you nd that visualization is insufcient with a
5mm camera, you may easily convert your trocar to accommodate a 10mm scope. Place two additional 5mm trocars
lateral to the umbilicus and rectus, one to the right and the
other to the left, to facilitate easy manipulation and examination of the entire small bowel (Fig.20.1). These trocars
should be placed in a position distanced from the penetrating wound. Use atraumatic graspers with a hand-over-hand
technique in order to examine the small bowel from ligament of Treitz to cecum (Fig. 20.2). Keep the graspers
always in view of the camera. Examine the colon along its
N. Melo and D. R. Margulies
Scope
Fig. 20.1 Trocar positions for best overview
entire length. The right and left colon are easily mobilized
along the white line of Toldt via laparoscopy. This should be
done particularly if blood or hematoma is visualized along
the colon or its mesentery as the likelihood of retroperitoneal colon injury is increased. If an anterior colon injury is
observed, suspect a posterior injury. The lesser sac is also
able to be dissected, opened, and examined completely laparoscopically. You can inject methylene blue via a nasogastric tube or intravenously to further assist you in the
identication of injuries. Additional 5 or 10mm trocars may
easily be placed as needed if proceeding with therapeutic
laparoscopy.
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Camera
Fig. 20.2 Lift and inspect the bowels from both sides from the
Ligament of Treitz to the rectum
20.2 Technical Considerations
In the obese patient, an Optiview© or similar trocar is recommended for use if available. The trocar should be placed
lateral to the umbilicus but still within the rectus. Place the
trocar with a 0° scope and then change to a 30° scope.
If hemoperitoneum is seen, evacuate the blood, and examine the abdomen completely if the patient remains hemodynamically stable. The blood may be from a small liver or
spleen injury or from the abdominal wall, all of which can be
managed laparoscopically.
20.3 Laparoscopy andAnterior Abdominal
Wall Stab Wounds
Patients with penetrating trauma to the anterior abdominal
wall can present a challenge in management as up to 45% of
hemodynamically stable patients may not have suffered peritoneal penetration. Diagnostic laparoscopy in this circumstance provides a clear benet as a minimally invasive means
of evaluating for peritoneal penetration.
Local wound exploration with subsequent diagnostic
peritoneal lavage (DPL) if peritoneal penetration is found
has been used in combination for evaluation of bowel or
solid organ injury. However, DPL can have false positives
secondary to blood from insignicant liver or splenic injuries
as well as bleeding from the anterior abdominal wall.
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Selective nonoperative management has been used as a treatment strategy as a means of decreasing the rate of negative
exploratory laparotomies. However, concern exists over the
delay in diagnosis of an injury as the management is based
on subjective physical exam ndings. In this circumstance,
diagnostic laparoscopy provides abdominal exploration in a
minimally invasive fashion as well as information regarding
the extent of injury. Hospital length of stay and cost are
higher for patients managed nonoperatively versus those
who undergo negative diagnostic laparoscopy. If diagnostic
laparoscopy is completely negative, considerations for discharge of the patient from the PACU avoid unnecessary
hospitalization.
20.4 Laparoscopy andGunshot Wounds
It has long been the accepted standard that all abdominal
gunshot wounds (GSWs) must be evaluated by laparotomy.
However, with the use of focused assessment with sonography for trauma (FAST) scans as well as improvement in
computed tomography (CT) imaging and the increasing
utilization of diagnostic laparoscopy, this standard is being
challenged. Zantut etal. reported that 58% (113 of 194) of
stable patients with gunshot wounds who were evaluated
with laparoscopy were discharged home with condence
after a brief hospital stay without the need for
laparotomy.
20.5 Laparoscopy andThoracoabdominal
Trauma
The risk of diaphragmatic injury exists with penetrating
trauma in the thoracoabdominal region. Several studies have
shown that penetration in the thoracoabdominal region has
an 18–35% incidence of diaphragmatic injury. A stab wound
below the areolae, from the xiphoid around to the scapula
that traverses the ribs, has a chance of causing a diaphragmatic injury. Laparoscopy is particularly useful in making
this diagnosis. Spann etal. found that 31% of patients with a
hemo- or pneumothorax on chest X-ray had a diaphragmatic
injury later identied with laparoscopy. Multiple studies
have found that laparoscopy is safe and effective not only for
diagnosis but also for treatment of such an injury.
Laparoscopic repair of a diaphragmatic injury is the most
commonly reported therapeutic laparoscopic intervention
(Fig.20.3).
When repairing a diaphragmatic injury laparoscopically,
you should use a braided permanent suture. However, large
traumatic diaphragmatic injuries adjacent to or including the
esophageal hiatus are best approached via laparotomy.
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Fig. 20.3 Laparoscopic repair of a diaphragmatic injury is the most
commonly reported therapeutic laparoscopic intervention
20.6 Laparoscopy andExtraperitoneal
Rectal Injury
The current consensus in regard to rectal injuries is that intraperitoneal injuries are repaired primarily. Extraperitoneal
injuries are also repaired primarily if minimal dissection is
needed or if the injury is exposed during dissection to examine and repair other injuries. The feasibility of laparoscopic
fecal diversion as a means of managing an isolated extraperitoneal GSW injury has been documented. With laparoscopy,
you are able to rule out other injuries and perform mobilization of the colon, allowing for creation of a loop sigmoid
colostomy. Presacral drainage is also able to be established
laparoscopically. The urinary tract is also evaluated to
exclude injury.
20.7 Laparoscopy andDenitive Repair
ofInjuries Secondary toPenetrating
Trauma
Several series demonstrate the utility of laparoscopy for
denitive repair. One small series documents 26 of 28
patients undergoing successful repair of intra-abdominal
injury following penetrating trauma. Repairs included closure of gastrostomies, repair of liver lacerations, cholecystectomy, and repair of diaphragmatic injuries. Another small
series in children demonstrates successful repair of bowel
injury secondary to trauma. When small bowel injuries are
identied, all of the following are able to be performed laparoscopically: primary repair and stapled resections with side-
N. Melo and D. R. Margulies
to- side anastomosis as done in laparoscopic bariatric surgery.
For liver and spleen injuries, laparoscopy allows for evacuation of blood and establishment of hemostasis with electrocautery, argon beam, and/or hemostatic agents. Drains
should only be left in place for large injuries. Gallbladder
injuries can be treated with cholecystectomies performed in
a standard fashion. Bladder injuries can be repaired with a
laparoscopic suturing device. However, the inside of the
bladder must be fully examined with the laparoscope or cystoscope prior to closure.
20.8 Robotic-Assisted Surgical Treatment
ofTraumatic Injuries
With the increasing popularity and access of roboticassisted surgery, primarily the da Vinci Surgical System
TM, there has been applications of this technology to traumatic injuries. Use of this modality is similar to the guidelines for laparoscopy in trauma in that it should not be used
in the hemodynamically unstable patient and that it depends
on the comfort and skill of the surgeon. The use of this has
a variety of applications, especially in the treatment of stable urogenital and rectal injuries. Given the increased dexterity the system provides, it also has application in the
treatment of penetrating thoracoabdominal stab wounds
that follow protocols for diaphragm injuries (observation
and subsequent minimally invasive evaluation of the diaphragm). Barbed suture (V-Loc™) has been used given that
it avoids minimally invasive knot tying but should not be
used for luminal structures. There is also the concern that
exposed barbs may be lead points for organ injury or
obstruction, so caution is used in the recommendation of
this suture.
Important Points
• Laparoscopy as a diagnostic tool in penetrating trauma
can reduce the rate of negative laparotomies. Its use as a
therapeutic means is also increasing. Limitations to its
use for diagnosis and denitive repair include patient stability as well as surgeons’ ability.
• If the patient is hemodynamically unstable or multiple
injuries are suspected, do not attempt laparoscopy.
• Prep and drape the patient in such a way as to facilitate
easy conversion to laparotomy.
• Blood identied with laparoscopy may be from a liver
or splenic injury or from the anterior abdominal wall
and is not an indication alone for conversion to
laparotomy.
• The entire small bowel can be evaluated with meticulous
care via laparoscopy.
• Stab wounds to the left lower chest should be evaluated to
rule out diaphragmatic injury. Inspection as well as repair
of such injuries can be accomplished laparoscopically.
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