We’ve gotten the young man with the teensy weensy stab to the abdomen with a bit of omental evisceration to the operating room. Now what should we do? We’ve already decided that he needs an exploration because of the known penetration. How should we go about it?
There are two choices: diagnostic laparoscopy vs laparotomy. Which is better? Let’s talk about laparoscopy first. This tool has been around now for over 25 years. There has been variable acceptance for use in trauma during that time because it tends to take more time and may have a higher rate of missed injury. Both factors have major implications in patients who have active bleeding and small injuries, respectively.
On the plus side, a truly negative (nontherapeutic) exploration tends to be more benign, with rapid recovery, faster time to discharge, and potentially fewer complications when evaluated with a scope. But on the minus side, small injuries can be notoriously difficult to find. What does that small wisp of blood mean? This is not nearly as clear as the meaning of other colors (green, brown). The decision to open can be difficult, particularly for surgeons who perform a high number of laparoscopies in the non-trauma portion of their practice.
Trauma laparotomy is traditionally a large operation with a generous incision and meticulous exploration. This can lead to significant postop pain and morbidity, particularly when no significant pathology is found. Unfortunately, the literature appears to be quite polarized. The surgeon is either pro-laparoscopy, or pro-big incision, and tends to brace their preferred procedure almost exclusively.
But there is a middle ground, and that is what I would choose in a case like this. The surgeon must consider the likelihood of reliably finding the size of internal injury based on his or her assessment of the external wound, as well as the probability that the exploration would be non-therapeutic. So in this case, I would worry that a bowel injury could be only a few millimeters in size and might be missed using only the laparoscope. But I also think that there is a good chance there may not be an injury at all, so I would not be inclined to start with a huge incision.
My choice is to perform a “mini-laparotomy”, making an incision just large enough to explore all of the bowel and visualize the retroperitoneum. I can generally do this through an incision large enough to get my palm into the abdomen, about 6cm. I am confident that I can easily find all injuries, and make the incision larger if warranted. Postoperative pain is better, and discharge if no injuries were found can happen in 1-2 days.
Unfortunately, I can’t find any papers that examine this middle ground between laparoscopy and full laparotomy. But I’ll keep looking! How would you have managed this case? Comment or tweet, please!
In my next post, I’ll review the official algorithm for evaluating stabs to the abdomen recently published by the western Trauma Trauma Association.
References:
- The role of laparoscopy in management of stable patients with
penetrating abdominal trauma and organ evisceration. J Trauma 81(2):307-311, 2016. - Diagnostic Laparoscopy for Trauma: How Not to Miss Injuries. J Laparoscopic Adv Surg Tech 28(5):506-513, 2018.
