The Role of Laparoscopy in Blunt Abdominal Trauma

Ari K. Leppaniemi’ and David C. Elliott2

In a collective analysis of 1 1 reports with a total of 355 blunt abdominal trauma patients,
the sensitivity and specificity of diagnostic laparoscopy in predicting the eventual need
for therapeutic laparotomy were 94% and 98%, respectively, with an overall accuracy of
97%. Although fairly accurate and safe (morbidity rate about 1.2%), the invasiveness,
cost and time-consuming nature of diagnostic laparoscopy limit its routine use in
trauma patients. It could, however, be useful in selecting patients with minor or
nonbleeding injuries for nonoperative management after positive peritoneal lavage or
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computed tomography, and in excluding occult bowel and diaphragmatic injuries in

patients with equivocal findings, thereby reducing the number of unnecessary laparo-
tomies. With the improvement of laparoscopic techniques and instrumentation, more
injuries can probably be managed laparoscopically with all the benefits observed with
the shift from open to laparoscopic procedures in other patient populations, and it is
likely that laparoscopy will find its place as an integral part of evaluating and treating
patients with blunt abdominal trauma. At present, however, laparoscopy cannot be
recommended as a routine tool for evaluating patients with blunt abdominal trauma,
except in controlled clinical trials. .
For personal use only.

Key words: abdominal trauma; blunt; laparoscopy.

(Annals of Medicine 28: 483-489,1996)

introduction signs of intraperitoneal injury, such as abdominal

The appropriate management of blunt abdominal
trauma depends on reliable initial evaluation, timely use
of diagnostic procedures and prompt management of
organ injuries requiring operative repair. Physical
examination, although notoriously unreliable in blunt
abdominal trauma with an accuracy rate of about 50%,
remains the most important means to determine the
need of urgent laparotomy in haemodynamically
unstable patients with physical signs indicating major
intra-abdominal haemorrhage. In haemodynamically
stable patients with a multisystem trauma, the
symptoms and signs of abdominal injury can be
masked in patients with altered sensorium from head
injury, alcohol or other intoxicants, anaesthesia
secondary to spinal cord injury or multiple truncal
fractures. Many patients may not exhibit the classical
From the ‘Department of Surgery, Helsinki University Central
Hospital, Helsinki, Finland and ‘Department of Surgery, Walter
Reed Army Medical Center, Washington, DC, USA.
Address and reprint requests: Ari Leppaniemi, MD,
Department of Surgery, Helsinki University Central Hospital,
Haartmaninkatu 4, FIN-00290 Helsinki, Finland.
tenderness, voluntary or involuntary abdominal
guarding and diminished bowel sounds. Haemoperito-
neum initially causes few or no peritoneal signs, and
several hours may pass before the abdominal examina-
tion becomes positive.
Diagnostic peritoneal lavage (DPL), introduced clini-
cally by Root in 1965 (l), was the first well-established,
objective method to diagnose intraperitoneal injuries,
and has remained as the benchmark against which
other diagnostic modalities have been compared. In a
collective review of 10 358 patients with blunt trauma,
the accuracy of DPL was 97.370,with 1.4% false
positives and 1.3% false negatives, and a complication
rate of less than 1% (2). Although simple, relatively safe
and cheap, the current major concerns with DPL are its
oversensitivity and nonspecificity. In one study, DPL
was associated with a 27% nontherapeutic laparotomy
rate in blunt abdominal trauma (3).Only about 30 mL of
blood in the peritoneal cavity is needed to produce a
microscopically positive lavage (4). The source of
bleeding, obviously, remains undetermined. With an
increasing trend towards nonoperative management of
blunt liver and splenic injuries, a coherent policy for the
management of specific organ injuries cannot be based
solely on the DPL result. Furthermore, DPL is notably

0 1996 The Finnish Medical Society DUODECIM, Ann Med 28,483-489

 484 Leppaniemi
inaccurate in assessing many retroperitoneal and
diaphragmatic injuries (5) as well as bowel injuries, if it
is performed within a few hours after injury (6).
In 1982, a retrospective study showed that computed
tomography (CT) of the abdomen can be used to
assess blunt abdominal trauma in adults (7), and it has
gradually replaced DPL as the routine method of
screening of blunt abdominal trauma in many centres.
Peitzman et al. (8) reported an accuracy rate of 98%
with CT but emphasized good patient selection.
Although CT is reliable in identifying retroperitoneal
organ injuries and determining the extent of solid organ
injuries, it is questionable in detecting intestinal,
diaphragmatic and early pancreatic injuries (8-1 0). The
comparison between DPL and CT in blunt abdominal
trauma is beyond the scope of this article, but both
methods have inherent limitations and the two
techniques should be rather considered complementary
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than mutually exclusive (1 1).
Abdominal ultrasonography (US) has been widely
used in Europe for more than a decade, but has
recently gained wider interest also in the United States.
Although less accurate than DPL (12), its relatively low
cost, rapidity, noninvasiveness, sensitivity (80-95% in
detecting intra-abdominalhaemorrhage), and possibility
for serial examination may cause it to replace DPL as
the primary screening method for intra-abdominal injury
For personal use only.
(4). At its current stage, however, US is inferior to CT in
determining the extent of organ injuries, and is unlikely
to replace it in evaluating stable patients with solid
organ injuries amenable to nonoperative management.
Diagnostic Laparoscopy
In 1902, Georg Kelling from Dresden described the
principles of diagnostic coelioscopy (1 3), and in 1934,
Ruddock devised a method of examining the peritoneal
cavity with an optical instrument known as peritoneo-
scope and reported 200 clinical examinations (14).
Among the 10 indications for diagnostic peritoneo-
scopy, he included the determination of the extent of
intra-abdominal injuries. It was not, however, until the
1970s when two reports emerged concerning the use of
diagnostic laparoscopy in the evaluation of abdominal
trauma (15, 16). Although the limitations in laparoscopic
instrumentation at that time prevented its wider accept-
ance, recent technical innovations and the revolutionary
effect of the wide-spread use of laparoscopic chole-
cystectomy have challenged the trauma surgeons to
re-evaluate the possible benefits of cavitary endoscopy
in the management of abdominal and thoracoabdominal
injuries.
Potentially, diagnostic laparoscopy could identify
patients with no or insignificant intra-abdominal injuries
not requiring operative treatment, and those that have
occult injuries that require surgical repair (17). In
penetrating abdominal trauma, laparoscopy has been
useful in detecting peritoneal penetration (1 8-21), and
evaluating the intrathoracic abdomen, diaphragm and
upper abdominal solid-organ injuries (21-23). In
0 1996 The Finnish Medical Society DUODECIM, Ann Med 28,483-489
0 Elliott
addition, it is highly accurate in detecting haemo-
peritoneum and retroperitoneal haematomas, but less
sensitive in excluding hollow viscus injuries (24). In
patients with abdominal gunshot wounds, the use of
diagnostic laparoscopy can reduce the incidence of
negative and nontherapeutic laparotomies, and result in
lower morbidity and hospital stay (25, 26).
The role of diagnostic laparoscopy in evaluating blunt
abdominal trauma is less clear. In their pioneering study
in 1976, Gazzaniga et al. (15) evaluated laparo-
scopically a group of 24 patients with blunt abdominal
trauma, selected on the basis of equivocal indications
for operation, patient condition and availability of equip-
ment and personnel. The most common injury found
was a ruptured spleen. Although complete visualization
of the spleen was not possible, the tip of the spleen was
usually identified, and if blood was superior to it or
under the omentum that had migrated to the left upper
quadrant, splenic injury was always found. The second
most common injury diagnosed was jejunal perforation,
which was obvious in each patient by observation of
small bowel contents along the gutters and small bowel
serosal inflammatory changes. Laparoscopy was also
accurate in assessing the need for surgical repair of
minor injuries of the liver and the falciform ligament. The
authors recommended that initial evaluation of the
abdomen in patients with blunt trauma is best made
with abdominal paracentesis. Laparoscopy is indicated
in haemodynamically stable patients with bloody return
clearing rapidly after fluid resuscitation, in patients with
negative paracentesis with physical findings, and in
comatose patients.
In a prospective, randomized multicentre study,
Cuschieri et al. (27) compared minilaparoscopy with
peritoneal lavage in 55 patients with blunt abdominal
trauma. Although both procedures were highly sensitive
for the detection of significant intra-abdominal injury
(loo%),the specificity was 83% for peritoneal lavage
and 84% for minilaparoscopy. The predictive value of a
positive laparoscopy was 92% compared to 72% for
peritoneal lavage. The results suggested that mini-
laparoscopy may have an advantage over peritoneal
lavage in reducing the number of unnecessary laparo-
tomies. The difference in the diagnostic discrimination
of the two procedures was the result of small incon-
sequential static haemoperitoneum from small tears of
the peritoneal folds/ligaments or minor lacerations of the
liver, which can be identified and watched for several
minutes by laparoscopy but which give rise to a positive
lavage test.
In 1991, Berci et al. (28) used a 4-mm miniature
laparoscope to evaluate 150 blunt abdominal trauma
cases. The examination was performed in the
emergency room, intensive care unit or operating room,
mostly under local anaesthesia with intravenous
sedation. The indications for laparoscopic examination
were exclusion of abdominal trauma in patients with a
decreased level of consciousness, history or evidence
of blunt abdominal trauma, unexplained hypotension,
and equivocal physical examination in a conscious
patient. A severe haemoperitoneum - defined as clear
blood obtained during aspiration through the pneumo-
 Laparoscopy in Blunt Abdominal Trauma
needle, or intestinal loops floating or surrounded by a
pool of blood - was discovered in 28 cases (19%), and
laparotomy revealed 11 splenic and seven liver lacera-
tions, four organ perforations, and six arterial bleeders.
In one case, the source of a 700-mL haemoperitoneum
was not found. Moderate (5-10-mm deep blood level in
the paracolic gutters) or minimal (small amount of blood
in the lateral gutter or streaks of blood between the
intestinal loops) haemoperitoneum but no identifiable
injury or only minor lacerations were found in 38 cases
(25%). One patient in this group required a delayed
laparotomy for a missed sigmoid perforation, the
remaining 37 patients were managed expectantly
without complications. In 84 patients (56%) the laparo-
scopy was completely negative, and none of the
patients subsequently required an explorative
laparotomy.
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Livingston et al. (29) evaluated prospectively 39
haemodynamically stable trauma patients (including
eight blunt trauma cases) by laparoscopy before
planned laparotomy. Positive result on either DPL or CT
constituted an indication for laparotomy in blunt trauma
patients. The extent of haemoperitoneum was under-
estimated by laparoscopy in all nine patients with perito-
neal blood of more than 750 mL, four of whom had
laparoscopically undetected active bleeding. The
authors concluded that laparoscopy may decrease the
For personal use only.
need for laparotomy in selected patients but the inability
to ‘run the small bowel’, visualize the spleen, and
evacuate haemorrhage limit the utility of laparoscopy in
determining which patients with laparoscopically visual-
ized injuries will require operative repair.
In a prospective series of 15 patients with
documented blunt liver or spleen injuries on CT, laparo-
scopy was performed to characterize the solid organ
injury, detect associated occult injuries, and select
patients for conservative or operative management (30).
Conservative management was successfully employed
in eight patients with findings of minor injury or
adequate haemostasis on laparoscopy. Therapeutic
laparotomy was performed in four patients with ongoing
haemorrhage, two cases with bowel injury (jejunum,
sigmoid colon), and in one patient with poor visualiza-
tion. The mean length of hospital stay was 7.3 days
after operative and 7.1 days after conservative manage-
ment with one minor complication in each group.
Although all patients included in the study had negative
or equivocal findings on abdominal examination, two
patients (13%) had occult bowel injuries undetected
with CT but visualized during laparoscopy. It was
concluded that diagnostic laparoscopy may become an
effective adjunct in patient selection for conservative
management of blunt liver and spleen injuries.
Salvino et al. (31) evaluated 59 blunt abdominal
trauma patients prospectively with diagnostic laparo-
scopy followed by DPL, and found that laparoscopy
possibly improved care in two (3%) patients. The cost of
DPL was about USD 430 per patient compared with
USD 3050 for laparoscopy performed in the operating
room. The study suggested that laparoscopy offers no
advantage over DPL as a primary assessment tool in
blunt trauma, but may have a role in selected cases in
0 1996 The Finnish Medical Society DUODECIM, Ann Med 28,483-489
485
detecting injuries of the diaphragm, mesentery and
bowel, and in assessing the need of operative repair in
identified organ injuries.
In a prospective study of 32 patients (six with blunt
injuries) undergoing diagnostic laparoscopy prior to
explorative laparotomy, six patients (19%) had signifi-
cant injuries of the liver, stomach, duodenum, small
bowel, mesentery, ureter and urinary bladder which
were missed at laparoscopy (32). Because of the signifi-
cant number of missed injuries, the authors did not
recommend - at this stage - the routine use of laparo-
scopy in evaluating abdominal trauma.
Fabian et al. (33) examined prospectively 17 blunt
abdominal trauma patients with equivocal evidence of
intra-abdominal injury on DPL or CT laparoscopically
under general anaesthesia. In 10 cases, laparoscopy
prompted an explorative laparotomy, which was thera-
peutic in nine, and included liver, spleen, gall bladder
and small bowel injuries. The charges of the laparo-
scopy were USD 3325 per patient compared with USD
3320 for similar patients undergoing negative lapar-
otomy in a previous series. The authors concluded that
significant cost savings could be gained by perform-
ance of laparoscopy under local anaesthesia, and with
the development of miniaturized optics, bowel clamp,
retractors and stapling devices, which would also permit
some therapeutic applications.
Smith et al. (34) used diagnostic laparoscopy in 18
haemodynamically stable blunt trauma patients with
suspicion of significant intra-abdominal injury with
continued haemorrhage as indicated by CT, US or DPL.
Eight patients had organ injuries, and there were no
missed injuries or nontherapeutic laparotomies. The
mean length of the laparoscopic procedure was 92 min.
The mean length of hospital stay was 6.3 days after
laparoscopy only, and 7.5 days after laparoscopy
followed by laparotomy.
In a series of 24 haemodynamically stable patients
with haemoperitoneum following blunt abdominal
trauma, laparoscopy estimated the need of laparotomy
accurately in all but one patient, in which the under-
estimation of the severity of a splenic injury lead to a
delayed splenectomy (35). It was concluded that
diagnostic (and therapeutic) laparoscopy may be a valid
alternative to nonoperative or operative management of
stable patients with haemoperitoneum, but requires
considerable skill when performed in the presence of
significant amounts of blood-stained peritoneal fluid.
In order to assess the accuracy of diagnostic laparo-
scopy in predicting the need of an eventually thera-
peutic laparotomy, an analysis of 11 reports (15, 16,
27-35) with a total of 355 blunt abdominal trauma
patients who underwent laparoscopic assessment was
performed. The studies differ considerably with respect
to indications and techniques varying from minilaparo-
scopy in the emergency department to prelaparotomy
laparoscopy to avoid exploration. Other diagnostic
studies, such as DPL or CT, were performed before or
instead of laparoscopy. The results are summarized in
Table 1. Allowing for the heterogenity of the material, an
analysis of the combined total of 355 patients in these
11 studies gives a sensitivity of 94.1%, a specificity of
 486 Leppaniemi 0 Elliott

Table 1. Diagnostic laparoscopy in blunt abdominal trauma.

Authors (Ref.) No. of patients True positive True negative False positive False negative

Gazzaniga et al. (15) 24 13 10 1 0

Carnevale et al. (16)
Cuschieri et al. (27)
Berci et al. (28)
Livingston et al. (29)
Townsend et al. (30)
Salvino et al. (31)
Rossi et al. (32)
Fabian et al. (33)
Smith et al. (34)
Lujan-Mompean et al. (35)
Total
5 0 5 0 0
29 12 16 1 0
150 27 121 1 1
8 5 2 0 1
15 7 8 0 0
59 2 56 0 1
6 4 1 0 1
17 9 6 1 1
18 8 10 0 0
24 8 15 0 1
355 95 250 4 6

98.4%, a positive predictive value of 96.0%, a negative ence gained from performing elective and emergency
predictive value of 97.7%, and an accuracy of 97.2%. laparoscopic procedures, the range of organ injuries
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Table 2 shows the range of the parameters in eight
studies with at least 10 patients.
There were four false positive findings leading to
nontherapeutic laparotomy among the 355 cases. Two
of them were caused by a minor liver injury eventually
not requiring operative repair (15, 33). In two cases, a
moderate haemoperitoneum was detected at laparo-
scopy not requiring operative haemostasis; the source
of the bleeding was a pelvic fracture in one case (27),
For personal use only.
amenable to laparoscopic repair can be expected to
increase dramatically. At present, several reports have
described the use of laparoscopy in splenic trauma
applying mesh splenorrhaphy (34, 36), partial
splenectomy (37), application of topical haemostats or
electrocautery (30), and laparoscopically guided blood
salvage and autotransfusion (38, 39). In an experimental
study with dogs, Salvino et al. (40) used laparoscopy to
inject fibrin glue to arrest bleeding from uniform injuries

and unidentified in the other (28).
Among the six false negative findings, three were
caused by a splenic injury deemed to be a minor one in
laparoscopic assessment, but requiring subsequent
splenectomy (31, 33, 35). Two significant injuries were
missed at laparoscopy, a sealed perforation of the
sigmoid colon leading to delayed laparotomy 2 days
later (28), and a transection of the midbody of the
pancreas requiring distal pancreatectomy (32). In one
case, a central (zone I) retroperitoneal haematoma in a
patient with liver cirrhosis and portal hypertension was
not visualized during laparoscopy which demonstrated
macronodular cirrhosis and bloody ascites. At opera-
tion, the haematoma was found but left undisturbed in
light of the patient’s liver disease, and the patient died
12 days later of progressive liver failure (29).
Therapeutic Laparoscopy
With the development of new laparoscopic instrumenta-
tion and techniques, as well as with increased experi-
Table 2. The accuracy of diagnostic laparoscopy in blunt
abdominal trauma in eight studies with at least 10 cases
(15, 27, 28, 30, 31, 33-35).
Parameter Range (%)
~
Sensitivity 66.7-1 00.0
Specificity 85.7-100.0
Positive predictive value 90.0-100.0
Negative predictive value 85.7-100.0
Accuracy 88.2-100.0
of the liver and spleen. Lujan-Mompean et al. (35)
reported the use of endoloop to arrest active arterial
bleeding from a mesenteric tear.
Diaphragmatic injuries are amenable to both laparo-
scopic (34, 41) and thoracoscopic repair (40-43). Other
potential laparoscopic interventions in trauma patients
include repair of lacerations of the stomach and small
bowel (31), and placing a jejunostomy to allow enteral
feeding (46).
Technique
Although variability exists from institution to institution
regarding the specific methodology employed, a
general routine for exploration of the injured abdomen
using laparoscopy appears commonly to follow a set
technique. The method outlined herein represents a
compilation of procedural practices related to a number
of prospective series evaluating laparoscopy for ab-
dominal trauma (15, 24, 31, 33, 47). After the admin-
istration of a general anaesthetic and the emplacement
of nasogastric and bladder decompression catheters,
diagnostic laparoscopy proceeds using either COP
insufflation (via Veress needle or open access), or a
gasless peritoneal retraction device, in order to gain full
intra-abdominal exposure. If COP insufflation is used,
intra-abdominal pressure is monitored and kept below
15 mmHg. Pulse oximetry and end-tidal C 0 2 levels are
monitored as well. The videolaparoscope is then
inserted through an access trocar in the infraumbilical
position. Of note, a 10-mm, 30-degree laparoscope is
preferred, as the angled instrument permits optimal
views of the dome of the liver and the diaphragmatic

0 1996 The Finnish Medical Society DUODECIM, Ann Med 28,483-489

 Laparoscopy in Blunt Abdominal Trauma 487

surface of the spleen, and the larger-sized scope allows
greater light penetration. This is particularly important
for abdominal trauma, as intraperitoneal blood collec-
tions can absorb a considerable amount of light.
Lighting is further enhanced by using a high-quality
xenon light source and a high-quality, latest-generation
videocamera. One to three additional laparoscopic
access ports are emplaced under direct visualization,
employed on an ‘as needed’ basis to allow retraction
and exposure of the abdominal viscera, as well as
aspiration of blood. A high-powered suction/irrigation
system is mandatory for evacuating liquid and clotted
blood, allowing adequate visualization beneath.
Every effort is made to ensure that the laparoscopic
examination is systematic and comprehensive, including
careful study of the liver and spleen, diaphragm,
stomach, colon, small bowel and pelvis. Examination of
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does not necessarily imply ‘complication-free’. When
utilized for eliciting abdominal injuries, diagnostic
laparoscopy has been shown to result in few complica-
tions, but at times these can be life-threatening risks.
Table 3 displays the results of 12 prospective studies in
the use of diagnostic laparoscopy for abdominal trauma
with respect to development of complications. Of note,
complications attributable to diagnostic laparoscopy
were generally uncommon (11 of 925 cases, or 1.2%).
Major complications, those requiring further surgical
repair or those immediately life-threatening, occurred in
four patients (0.4%) of these combined series. The most
frequent major complications were iatrogenic enter-
otomy and tension pneumothorax. The latter resulted
from COP insufflation through occult diaphragmatic
injuries during the initial phase of laparoscopy,
mandating close monitoring of blood pressure, airway

the pancreas and the posterior gastric wall is attempted
by grasping and raising the greater curvature of the
stomach and gaining laparoscopic entry into the lesser
sac through a clear space in the gastrocolic ligament.
Views of the retroperitoneum, as well as dynamic views
of the small intestine, are attempted by rotation of the
patient on the operating table to the right and left as
well as by achieving a Trendelenburg and reverse
Trendelenburg position. Visualization of all surfaces is
further enhanced by retraction by blunt instruments
For personal use only.
pressure and pulse oximetry during this part of the
procedure. The most frequent minor complication in the
combined series was preperitoneal insufflation, which is
of no long-term consequence, but can make subse-
quent laparoscopic access problematic.
In one experimental study, Josephs et al. (52) evalu-
ated the effect of increased intra-abdominal pressure
due to COP insufflation upon intracranial pressure in a
porcine model of head injury. They found that standard
insufflation to an intra-abdominal pressure of 15 mmHg

combined with the repositioning manoeuvres described
above.
The purpose of diagnostic laparoscopy for trauma in
most series ostensibly is to elicit the need for formal
laparotomy; therefore, generally, there is no prolonged
effort expended to identify every intra-abdominal injury.
Rather, most studies reflect the desire to elicit (i)
massive or continuing haemorrhage, (ii) the presence of
succus entericus, or (iii) peritoneal penetration (when
projectile injury is suspected).
Complications
Although laparoscopy holds a safe track record for
many elective surgical procedures, ‘minimally invasive’
resulted in a significant increase in intracranial pressure
(from 22.6 mmHg to 27.4 mmHg), exclusive of changes
in PaC02 or serum pH. These findings suggest caution
in the use of diagnostic laparoscopy with pneurno-
peritoneum in patients with concomitant head trauma,
to prevent the potential complication of worsening intra-
cranial hypertension.
Conclusions
At present, diagnostic laparoscopy cannot be recom-
mended as a primary tool in evaluating patients with
blunt abdominal trauma. Although the accuracy of
laparoscopy in detecting intra-abdominal injuries is
comparable to other available methods, it has not yet

Table 3. Complications resulting from diagnostic laparoscopyfor abdominal trauma.

Authors (Ref.) No. of patients No. of complications Type of complications

Gazzaniga et al. (15) 37 0

Berci et al. (49) 106 1 Omental bleeding
Livingston et al. (29) 39 0
Townsend et al. (30) 15 0
Salvino et al. (31) 75 1 Enterotomy*
Fabian et al. (33) 1a2 3 Enterotomy*, tension pneumothorax*, preperitoneal insufflation
Smith et al. (48) 34 0
lvatury et al. (24) 100 2 Tension pneumothorax*, preperitoneal insufflation
Cortesi et al. (50) 106 0
Sosa et al. (26) 121 1 Urinary retention
Zantut et al. (51) 63 0
Elliott et al. (47) 47 3 Surgical drape fire, preperitoneal insufflation (2)
Total 925 11 (1.2%) major: 4 (0.4%)
minor: 7 (0.8%)

*Indicates a major complication.

0 1996 The Finnish Medical Society DUODECIM, Ann Med 28,483-489

 4aa Leppaniemi 0 Elliott
been shown to be able to elicit reliably all significant
injuries. Its invasiveness, cost and time-consuming
nature limit the routine use of diagnostic laparoscopy in
trauma patients. However, because of its ability to
establish whether bleeding has stopped from injuries of
the solid abdominal organs, mesentery and peritoneal
folds and attachments, laparoscopy could be useful in
selecting patients for nonoperative management after
positive DPL or CT, thereby reducing the number of
unnecessary laparotomies. In patients with equivocal or
controversial findings on physical examination, DPL or
CT, laparoscopy, rather than explorative laparotomy,
could be used to exclude occult bowel and diaphrag-
matic injuries.
With the improvement of laparoscopic techniques and
instrumentation, and the expansion of cost-effective,
gasless, bedside laparoscopic procedures, more
injuries could probably be managed laparoscopically
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with all the benefits observed with the shift from open to
laparoscopic procedures in other patient populations.
Finally, with more controlled studies evaluating the
strong and weak properties of diagnostic and thera-
peutic laparoscopy, it is likely that laparoscopy will find
its place as an integral part of evaluating and treating
patients with blunt abdominal trauma.
For personal use only.
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