|Year : 2019 | Volume
| Issue : 1 | Page : 25-30
Laparoscopic management of retroperitoneal injuries from penetrating abdominal trauma in haemodynamically stable patients
Modise Zacharia Koto1, Oleh Y Matsevych1, Fusi Mosai2, Moses Balabyeki2, Colleen Aldous3
1 Department of Surgery, Sefako Makgatho Health Sciences University, Dr. George Mukhari Academic Hospital, Pretoria; University of KwaZulu-Natal, Nelson R Mandela School of Medicine Campus, Durban, South Africa
2 Department of Surgery, Sefako Makgatho Health Sciences University, Dr. George Mukhari Academic Hospital, Pretoria, South Africa
3 University of KwaZulu-Natal, Nelson R Mandela School of Medicine Campus, Durban, South Africa
|Date of Submission||08-Oct-2017|
|Date of Acceptance||12-Dec-2017|
|Date of Web Publication||4-Dec-2018|
Dr. Oleh Y Matsevych
Department of General Surgery, P. O. Box: 231, Medunsa, 0204
Source of Support: None, Conflict of Interest: None
Background: Laparoscopy is increasingly utilised in the trauma setting. However, its safety and reliability in evaluating and managing retroperitoneal injuries are not known.
Aim: The aim of this study was to analyse our experience with laparoscopic management of retroperitoneal injuries due to penetrating abdominal trauma (PAT) and to investigate its feasibility, safety and accuracy in haemodynamically stable patients.
Methods: Over a 4-year period, patients approached laparoscopically with retroperitoneal injuries were analysed. Mechanism, location and severity of injuries were recorded. Surgical procedures, conversion rate and reasons for conversion and outcomes were described.
Results: Of the 284 patients with PAT, 56 patients had involvement of retroperitoneum. Stab wounds accounted 62.5% of patients. The mean Injury Severity Score was 7.4 (4–20). Among retroperitoneal injuries, the colon (27%) was the most commonly involved hollow viscera followed by duodenum (5%). The kidney (5%) and the pancreas (4%) were the injured solid organs. The conversion rate was 19.6% and was mainly due to active bleeding (73%). Significantly more patients with gunshot wound were converted to laparotomy (38% vs. 9%). Therapeutic laparoscopy was performed in 36% of patients. There were no recorded missed injuries or mortality. Five (9%) patients developed the Clavien-Dindo Grade 3 complications, three were managed with reoperation, one with drainage/debridement and one with endovascular technique.
Conclusion: Laparoscopic management of retroperitoneal injuries is safe and feasible in haemodynamically stable patients with PAT. However, a high conversion rate indicates difficulties in managing these injuries. The requirements are the dexterity in laparoscopy and readiness to convert in the event of bleeding.
Keywords: Diagnostic laparoscopy, penetrating abdominal trauma, retroperitoneal traumatic injuries, therapeutic laparoscopy, trauma
|How to cite this article:|
Koto MZ, Matsevych OY, Mosai F, Balabyeki M, Aldous C. Laparoscopic management of retroperitoneal injuries from penetrating abdominal trauma in haemodynamically stable patients. J Min Access Surg 2019;15:25-30
|How to cite this URL:|
Koto MZ, Matsevych OY, Mosai F, Balabyeki M, Aldous C. Laparoscopic management of retroperitoneal injuries from penetrating abdominal trauma in haemodynamically stable patients. J Min Access Surg [serial online] 2019 [cited 2018 Dec 11];15:25-30. Available from: http://www.journalofmas.com/text.asp?2019/15/1/25/225854
| ¤ Introduction|| |
The role of laparoscopy in penetrating abdominal trauma (PAT) is increasing.,, The safety and the efficacy of laparoscopy in detecting injuries in haemodynamically stable patients with PAT were the main point of concerns. This was due to the earlier publication which had demonstrated a high missed rate. However, subsequent studies have shown a much lower rate of missed injuries., This difference has been suggested to be due to the current improvement of laparoscopic skills and better-operating equipment as compared with previous experience.
Currently, many studies are emerging demonstrating the safety and efficacy of laparoscopy in haemodynamically stable patients with PAT., However, there is a major concern about the possibility of missed retroperitoneal injuries. Patients with retroperitoneal injuries may show minimal or no clinical signs at all. The current approach of using triple-contrast multi-detector computed tomography (CT) scan to detect retroperitoneal injuries has certainly improved the diagnostic yield. However, the scatter of metal fragments, the reliance on indirect findings, inability to distinguish injuries that can be managed nonoperatively, and administration of oral contrast in patients who needs general anaesthesia impose significant limitations on CT scan.
Kawahara demonstrated the reliability of systemic examination of the abdominal cavity, thereby reducing the rate of missed injuries. The role of laparoscopy in PAT has been well established.,,, However, the concern was raised, that the laparoscopic exploration of the retroperitoneum is technically very challenging. At present, the safety and reliability of laparoscopic surgery in evaluating and managing retroperitoneal injuries are not known.
The aim of this study was to analyse our experience with laparoscopic management of retroperitoneal injuries in haemodynamically stable patients due to PAT and to investigate its feasibility, safety and accuracy.
| ¤ Methods|| |
This was a retrospective study of prospectively collected data from a trauma unit at Dr. George Mukhari Academic Hospital (DGMAH). DGMAH is a tertiary hospital in Northwest of Pretoria, South Africa. All haemodynamically stable patients with penetrating abdominal injuries offered laparoscopy from January 2012 to December 2015 were reviewed. We defined retroperitoneal injuries as those involving the retroperitoneum, retroperitoneal structures and the root of the mesentery of the bowel. The injuries with the potential to enter the retroperitoneal space and required exploration of retroperitoneal organs were considered as retroperitoneal injuries.
The following patients were included in the study: penetrating injuries to the back, flank, anterior abdominal wall and lower chest with the involvement of the retroperitoneum. The retroperitoneal injuries to the colon, kidneys and ureters, pancreas, duodenum and root of the mesentery were also included in the study.
The anterior abdominal area extended from the lower costal margin superiorly to the iliac crest, the ilioinguinal ligament and the pubic bone inferiorly, between the anterior axillary lines anteriorly. The right and left lower chest areas were defined as the areas above the lower costal margin anteriorly and posteriorly and below the nipple line circumferentially on each side of the midline. The flank was defined as the area extending from the lower costal margin to the iliac crest, between the anterior and posterior axillary lines. The back was defined as the area extending from the lower costal margin to the iliac crests and medial to the posterior axillary line.
Injuries to intraperitoneal organs without any suspicious of violation of the retroperitoneum were excluded. Haemodynamically unstable patients were also excluded from the study.
Data regarding patient's demographics such as age and gender were collected. The Injury Severity Score (ISS), intraoperative findings as well as their management were documented. Outcomes such as conversions, complications, missed injuries and mortality were recorded. The complications were recorded according to the Clavien-Dindo classifications and the grades of three and more were considered as statistically significant.
The operative technique and standard steps of procedure were followed, as described by Koto at all. The peritoneal cavity would be meticulously inspected and where necessary, the retroperitoneal viscera would be extensively mobilised to ensure adequate exposure. When injuries are encountered, the surgeon would proceed with therapeutic laparoscopy or laparoscopic-assisted repair of the injuries. Decision to convert would be made in cases of continuous intraoperative bleeding, the patient becomes haemodynamically or metabolically unstable, the complexity of injuries, visibility is compromised or equipment failure. Complex injuries were defined as multiple injuries not amenable for the laparoscopic repair or requiring prolong laparoscopic procedure. Diagnostic laparoscopy was defined as an absence of significant injuries or identified injuries that did not require repair. Evacuation of liquid blood or clots and mobilisation of any intra-peritoneal or retroperitoneal organs for diagnostic purposes were not considered therapeutic.
All operating surgeons were proficient in advanced laparoscopic skills.
Means (±standard deviation) were presented for continuous variables and frequencies (%) were presented for categorical variables. All analyses were performed using SAS version 9.3 (SAS Institute, Cary, NC, USA).
The ethics clearance for the study was obtained from the Sefako Makgatho Health Sciences University Ethics Committee. Reciprocal approval was obtained by the Biomedical Research Ethics Committee of the University of KwaZulu-Natal.
| ¤ Results|| |
A total of 284 patients with PAT were reviewed, and of these, 56 (20%) patients met the inclusion criteria and were included in the study. The mean age was 31 years (15–60 years) and males constituted 87.5% of the study population. The mean ISS was 7.4 (4–20) with the most common mechanism of injury been penetrating stab wounds in 35 (62.5%) patients. Significantly, more patients with gunshot wound (GSW) were converted to laparotomy (38% vs. 9%) [Table 1].
The grades of injuries and performed procedures are listed in [Table 2]. In many cases, injuries were multiple. The most encountered retroperitoneal hollow viscus was the colon in 15 (27%) followed by the duodenum in 3 (5%) patients. The most commonly injured solid organs were the kidney in 3 (5%) and the pancreas in 2 (4%) patients [Table 2].
The most common location of injury was the flank (63%) followed by back, anterior abdominal wall and lower chest [Table 1]. Nine patients with the anterior abdominal wall injuries had retroperitoneal and multiple intra-abdominal organ injuries at the same time. Three patients were managed laparoscopically, including one patient with inferior vena cava injury. Other six were converted. In three patients, the injury was located posteriorly on the lower chest. All patients had retroperitoneal haematoma and two of them had pneumothorax. One patient had kidney injury and consequently developed arteriovenous fistula which was managed endovascularly. Other patient had haematoma in zone 1 which started to bleed during laparoscopic exploration and patient was converted.
The conversion rate was 19.6% (n = 11) with the most common indication for conversion been active bleeding in eight (73%) patients. The intraoperative bleeding did not cause any haemodynamic instability. Other reasons for conversion in this study are listed in [Table 3].
Forty-five patients (80.3%) were managed laparoscopically. Of these, 16 (36%) patients had injuries that required therapeutic interventions and in three patients, the laparoscopic-assisted approach was utilised. All converted cases were recorded as therapeutic [Table 1]. There were no recorded missed injuries and mortality in this group. Five (9%) patients developed the Clavien-Dindo Grade 3 complications. One patient had debridement, two had relaparotomy, one relaparoscopy and another patient was managed endovascular techniques. All patients successfully recovered [Table 4].
| ¤ Discussion|| |
Challenges in managing patients with penetrating retroperitoneal injuries principally revolve around the lack of clinical signs even in the setting of significant injuries to the retroperitoneum. Trauma surgeons have relied on various imaging modalities to detect these injuries. Although Focused Assessment with Sonography in Trauma is widely used for quick imaging of intraperitoneal bleeding, its diagnostic value in the assessment of retroperitoneal injuries is poor. CT scan has been the cornerstone of the management decision-making process of these injuries. In the study by Pham et al., CT scan showed the sensitivity of 100% and a specificity of 96% in detecting injuries requiring laparotomy. The concern with CT scan is that the findings are often non-specific and this would lead to an exploratory laparotomy which in many cases turns out to be non-therapeutic. However, we found pre-operative CT scan to be very helpful in selecting patients for non-operative management or laparoscopy. In case of surgery, CT scan imaging was useful in planning the extent of laparoscopic exploration of the retroperitoneum.
Our report represents a significant number of patients with retroperitoneal injuries managed laparoscopically. The majority of patients were males and the mean age was 30 years. The mechanism of injury was mainly due to stab wounds in 62.5% and GSWs accounting for 37.5% of the patients.
Retroperitoneal injuries carry the high potential for occult injuries of which the most commonly encountered is colonic injury, followed by injuries to the spleen and kidney. In this study, fifteen patients had colonic injury either isolated or combined with injury to the kidney, spleen or mesentery. The location of injury can raise suspicious for possible retroperitoneal involvement. Injuries to the flank, back and the posterior aspect of lower chest carry the highest potential for retroperitoneal penetration. However, this study demonstrated that anterior abdominal wall injuries can also penetrate the retroperitoneum and usually associated with multiple intraperitoneal and retroperitoneal injuries.
The attempt of non-operative management over 48 h was reported by Kong et al., but resulted in 100% of failure rate.
There is no doubt that violation of retroperitoneum carries a high risk for life-threatening injuries and all unstable patients should undergo immediate laparotomy. Concerning haemodynamically stable patients, the laparoscopy is not reported in the literature as an option for management of retroperitoneal injuries.,,, On the contrary, in this study, 80.4% of stable patients with retroperitoneal injuries were successfully managed with laparoscopy. The retroperitoneal organs were mobilised and haematoma explored to inspect for injuries. There were no missed injuries in this series.
Diagnostic laparoscopy was performed in 29 (64%) patients. Therefore, 64% of patients avoided non-therapeutic laparotomy with its associated morbidity. Therapeutic laparoscopy was performed in 16 (28.6%) cases. Three of these patients were offered a laparoscopic-assisted approach due to complex bowel injuries. The laparoscopic-assisted approach seems to be effective for complex bowel injuries and retroperitoneal injuries to the colon. There is a paucity of data about the role of therapeutic laparoscopy for retroperitoneal injuries. This report shows that therapeutic laparoscopy was feasible and successful in 36% of the patients with retroperitoneal injuries. The length of hospital stay was shortened significantly in the laparoscopy group (4.6 vs. 13.6 days in the converted to laparotomy group).
The surgeon involved in retroperitoneal exploration for trauma has to be proficient in advanced laparoscopic skills. Even simple diagnostic laparoscopy requires an extensive mobilisation of retroperitoneal organs and an ability to control possible bleeding.
The laparoscopic exploration of retroperitoneum remains technically challenging resulting in the higher conversion rate. In this study, the conversion rate was 19.6%. The conversion rate was higher compared to our reported 7% conversion of overall laparoscopy for penetrating abdominal injuries. Due to potential danger of massive bleeding, the threshold to convert was very low. There is no available data to compare this conversion rate with. Conventionally, the retroperitoneal injuries are managed with laparotomy. Moreover, the presence of retroperitoneal haematoma is considered by many surgeons as an absolute indication for laparotomy or conversion to laparotomy.,, This study indicates that a significant number of patients with retroperitoneal injuries can be safely managed laparoscopically. As expected, the major cause of conversion in this study was bleeding. All eleven patients were converted due to active bleeding or high potential for bleeding; five patients had bleeding from the retroperitoneal vessels, one patient bled from the spleen, and two patients had bleeding from the mesentery, two patients had large retroperitoneal haematoma and one patient had large mesenteric haematoma. Besides the potential for bleeding, the penetration of retroperitoneum carries a high rate of complex injuries. All injuries were identified and if needed corrected. No missed injuries were reported in this study. Laparoscopic exploration was feasible, however, with a high conversion rate.
Although the numbers in our study were small to draw a firm conclusion, a very important trend emerged that laparoscopic intervention is a safe strategy in retroperitoneal injuries.
| ¤ Conclusion|| |
The laparoscopic management of retroperitoneal injuries is safe and feasible in haemodynamically stable patients with PAT. There is a high conversion rate indicating the difficulties in a managing these injuries. The requirements are the dexterity in laparoscopy and readiness to convert in the event of bleeding or complex injuries extending beyond laparoscopic capabilities of operating surgeon.
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Conflicts of interest
There are no conflicts of interest.
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[Table 1], [Table 2], [Table 3], [Table 4]