Lap en Trauma

Machine Translated by Google
CURRENT OPINION
Trauma laparoscopy and the six w's: Why, where,

who, when, what, and how?
Salomone Di Saverio, MD, Arianna Birindelli, MD, Mauro Podda, MD, Edoardo Segalini, MD,
Alice Piccinini, MD, Carlo Coniglio, MD,
Cristina Frattini, MD, and Gregorio Tugnoli, MD, PhD, Cambridge, United Kingdom
in dangerous and long-lasting laparoscopic procedures (how).

The first
portedreported laparoscopy
as early in traumaHowever,
as the mid-1920s.1 patients has been re
probably because The experience is based on the cases gathered and managed
of the extremely limited experience of surgeons with laparoscopy by a single attending surgeon with specific expertise in acute
and the concerns about the effects of pneumoperitoneum on such care and trauma and a subspecialty experience in gastrointesti nal
high-risk patients, this technique failed to become popular. Over minimally invasive surgery, within an 8-year period in a major (level
the second part of the 20th century instead, laparoscopy has III) trauma center in northern Italy.
increasingly gained success in elective surgery, and from the beginning
of the 21th century, it has been introduced also in emergency
surgery and, more recently, in trauma surgery.2
Although the feasibility and benefits of diagnostic and,
WHY?
eventually, therapeutic laparoscopy in selected hemodynamically
Although firstly and widely investigated and accepted in
stable trauma patients have already been demonstrated, the role of
elective surgery, the multiple potential benefits of laparoscopy
laparoscopy in this setting is still under strong debate within the
in terms of reduced morbidity and mortality have been demon
trauma community and the evidence on this topic is poor.3–6
strated to significantly affect the overall clinical outcome also
The aim of this article is to explore and discuss the surgical
in acute care patients.2,7 Up to date, only some of these advan
techniques for the minimally invasive approach in hemodynamically
tages of minimally invasive surgery have been investigated in
stable trauma patients. The article is accompanied
trauma. However, it is reasonable to think that these patients could
by several videos and images showing the surgical procedures
take great advantage from this approach as well.
that can be performed at level I trauma centers, by highly
experienced trauma surgeons with both advanced laparoscopic skills Lower Inflammation and Trauma
and trauma surgery expertise. Through video- and image-based The physiopathologic response to trauma is characterized
cases discussion, this procedures and techniques article is aiming by the release of proinflammatory mediators (cytokines, ara
to clarify the rationale (why), selection criteria for identifying patients chidonic acid metabolites, complement factors, acute phase
best candidates (who), settings, resources and equipment required proteins, and hormonal mediators) that lead to systemic inflammatory
(where and how), and timing (when); identify indications response syndrome. The endothelial cell damage, accumulation of
and injuries suitable for diagnostic and/or therapeutic laparoscopy leukocytes, disseminated intravascular coagulation,
(que); and finally describes surgical techniques for each proce- and microcirculatory disturbances finally lead to apoptosis and
dure with educational tips and tricks, including showing those necrosis of parenchymal cells, with the development of multiple
situations/cases when conversion to open median laparotomy organ dysfunction syndrome or multiple organ failure. Several
is mandatory and a safer option rather than avoiding persisting studies about nontraumatic surgical procedures showed lower
inflammatory response induced by laparoscopy when compared
with open surgery.8,9
Submitted: September 16, 2018, Accepted: October 23, 2018, Published online:
November 27, 2018. High Diagnostic Accuracy and Fewer Negative
From the General, Emergency and Trauma Surgery Unit (SDS, AB, ES, AP, CF,
Laparotomies
GT); Trauma ICU (CC), Maggiore Hospital Trauma Centre, Bologna Local
Health District, Bologna, Italy; Cambridge Colorectal and Emergency Surgery Three-phase computed tomography (CT) scan is the criterion
Unit (SDS), Cambridge University Hospitals NHS Foundation Trust, Addenbrooke's standard in the diagnosis of abdominal injuries. However, although
Hospital, Cambridge Biomedical Campus, Cambridge, UK; and Department of some authors have recently described a good diagnostic
General (MP), Emergency and Robotic Surgery, San Francesco Hospital,
Nuoro, Italy. value of multidetector CT scan in identifying diaphragmatic injuries,
Address for reprints: Salomone Di Saverio, MD, FACS, FRCS (Eng), Consultant the overall accuracy of CT scan for mesenteric and hollow
Surgeon Cambridge Colorectal Unit, Box 201, Cambridge University Hospitals viscus injuries as well as peritoneal violation is quite low.10,11 In
NHS Foundation Trust, Addenbrooke's Hospital, Cambridge Biomedical Campus,
case of diagnostic doubts and in presence of appropriate surgical
Hills Road, Cambridge CB2 0QQ, United Kingdom; email: salo75@inwind.it or
salomone.disaverio@addenbrookes.nhs.uk. skills, many studies have demonstrated the high accuracy of lap
Supplemental digital content is available for this article. Direct URL citations appear in aroscopy in precisely detecting such abdominal injuries in stable
the printed text, and links to the digital files are provided in the HTML text of this
either penetrating or blunt trauma patients.4,12–20 In addition, di
article on the journal's Web site (www.jtrauma.com).
agnostic laparoscopy has been reported to significantly reduce
DOI: 10.1097/TA.0000000000002130 the rate of nontherapeutic laparotomies up to 73%.4,21–30
J Trauma Acute Care Surg
344 Volume 86, Number 2
Copyright © 2019 Wolters Kluwer Health, Inc. All rights reserved.


Volume 86, Number 2 Di Saverio et al.
The systematic review by O'Malley et al.14 included 2569 from two main elements: a careful selection of patients and a
patients (51 studies) who underwent diagnostic laparoscopy for highly skilled laparoscopic trauma surgeon.
penetrating abdominal trauma and found a sensitivity of 67% to
100%, specificity of 33% to 100%, and accuracy of 50%. to 100%.
WHERE?
Overall, 58% patients were spared a negative laparotomy.
To date, only two RCTs on trauma patients were ever per A level I trauma center is the most desirable setting where
formed: the first one compared laparoscopy with peritoneal la to safely perform laparoscopic procedures in trauma patients.
vage and found higher diagnostic specificity in the laparoscopic Moreover, the presence of a multidisciplinary trauma team and
group, while the second one demonstrated a significant reduction ideally interventional radiology service and full availability of
of nontherapeutic laparotomy rate and hospital length of stay neurotrauma service, neurosurgeons, orthopedic surgery and
(LOS) in patients with abdominal penetrating trauma managed spinal unit are of primary importance, and a dedicated trauma in
with diagnostic laparoscopy if compared with laparotomy.30,31 tensive care unit should be available. Certainly, a trauma
laparoscopic approach should not be undertaken if not by
Better Respiratory Management and Less Postoperative experienced trauma surgeon able to correctly select the suitable
Pain Most trauma patients are polytraumatic and have patients and deal with immediate need of conversion to open
multiple organ injuries at the same time. For this reason, procedures but also having advanced laparoscopic skills and
especially in case of thoracic trauma with rib fractures and lung being confident with his/her ability to adequately inspect the
contusions, a minimally invasive procedure may allow avoiding a abdominal cavity and thoroughly rule out potential injuries and
laparotomy and lead to a better respiratory function (lower rate of eventually decide either to convert to an open procedure after
lung failure), an earlier/faster ventilator weaning and recovery , diagnosis for proper treatment or manage a therapeutic minimally
lower rate of respiratory infections, and fewer tracheostomies.32– invasive procedure when feasible and safe to do so.12,13,51–53
35 The availability of lap aroscopic equipment 24 hours a day, 7 days
Furthermore, laparoscopy is well known to cause less a week (24/7) and adequate support by collaborating and
postoperative pain.36 This factor is particularly important in trauma specifically trained theater nurses and anesthetists are another
patients, if we consider that associated musculoskeletal injuries fundamental condition. Although still uncommon, the presence of
are considered to account for additional pain. a hybrid angio-computed tomography-operating room suite may
further improve the feasibility and effectiveness of such minimally invasive pr
Lower Rate of Adhesions, Incisional Hernias, and Surgical Site Occasionally, a minimally invasive approach in stable
Infection In addition, laparoscopy has the great advantage of trauma can be usefully performed by highly skilled surgeons in
very low rates of adhesions, incisional hernias and surgical peripheral/rural hospitals, in case of unavailability of a 24/7
site infection when compared with open surgery.37–42 Finally, angioembolization or CT scan service, to diagnose and eventually
although it is not of primary interest in trauma patients, since the definitively treat selected and suitable abdominal injuries.
incidence of trauma is higher in the young ster, the better
cosmetic outcome of laparoscopy may be taken into account. QUIEN?
The correct selection of candidates is extremely important

to safely perform laparoscopic procedures in trauma patients
Faster Recovery and Less Costs Even if (Table 1).
in trauma patients with multiple injuries the LOS is commonly
Hemodynamic Stability The
quite long, in some cases (single organ injury and/or negative
only trauma patients appropriate for laparoscopy are those
laparoscopy), the use of minimally invasive surgery can significantly
patients who are fully hemodynamically stable or those having a
decrease the LOS and allow an earlier return to work and daily
hypovolemic shock of advanced trauma life support (ATLS) class
physical activities.12,13,29,31,36,43,44 As a result, all these
I and full responders to fluid resuscitation. Selected patients with
factors may lead to a considerable reduction of social and health-
care costs.45–49 class II who are rapidly and fully
Potential Risks of Laparoscopy The

previously mentioned advantages must be balanced against TABLE 1. Contraindications to Laparoscopic Approach in
Trauma Patients
a 16% to 19% of false-negative rate of trauma laparos copy.
Additional risks include trocar site injury, air embolism, increased absolutely Relative
intracranial pressure, and bowel injury. There are potential risks
hemodynamic instability Diffuse peritonitis
of hemodynamic compromise associated with the pneumoperitoneum
Hypovolemic shock classes II-III-IV* Severe COPD with severe hypercapnia
due to a reduction in venous return, of gas embolization due to
septic shock obvious evisceration
venous injuries, and tension pneumothorax due to undiagnosed
Serious cardio-pulmonary dysfunction impalement
diaphragmatic injury. Furthermore, there may be a trend toward
Severe traumatic brain injury Laparotomy history
increased operative time with laparoscopy, which could potentially
Inability to tolerate pneumoperitoneum Serious intra-abdominal adhesions
exacerbate temperature shifts, coagulopa thy, and hemodynamic
instability.50 For all these reasons, advantages of laparoscopic *ATLS classification of hemorrhagic shock. COPD, chronic obstructive pulmonary
disease.
approach in trauma cannot be separated
© 2018 Wolters Kluwer Health, Inc. All rights reserved. 3. 4. 5


Di Saverio et al. Volume 86, Number 2
TABLE 2. ATLS Classification of Hemorrhagic Shock

Class I Class II ClassIII Class IV
Blood loss, mL <750 750–1500 1500–2000 >2000

Pulse rate, per minute <100 >100 >120 >140
blood pressure Normal Normal decreased decreased
Pulse pressure, mm Hg Normal decreased decreased decreased
Respiratory rate, per minute 14–20 20–30 30–40 >40
Urine output, mL/h >30 20–30 5–15 negligible
Central venous system (mental status) Slightly anxious Mildly anxious Anxious confused lethargic
responds to initial small-volume fluid bolus administration and potentially therapeutic laparoscopy represents a valuable
(Table 2) may be suitable for diagnostic laparoscopy and diagnostic tool.
approached laparoscopically. All other ATLS hypovolemic Large vessels, retroperitoneal, and renal injuries should
shock classes (class II, even if transient-responders to fluid be investigated or diagnosed laparoscopically as their diagnosis
resuscitation, class III and class IV) and any trauma patients is easier, safer, and more reliable with three-phase contrast
who is not fully or persistently stable after initial resuscitation enhanced CT scan, including urographic phase. After a careful
with a complete return to normal vital signs must be considered CT scan assessment, large vessels, retroperitoneal, and renal in
as a contraindication to laparoscopy. juries should only be explored and treated in highly selected
Historically, the presence of peritonitis has been considered cases, in presence of high skilled trauma/vascular surgeons
as a contraindication to laparoscopy, because of the the oretical and never approached laparoscopically in a trauma setting,
risk of malignant hypercapnia, due to an increased where retroperitoneal injuries remain best managed by open
absorption of carbon dioxide in the presence of severe intra surgery (as most trauma patients requiring retroperitoneal
abdominal infection and inflammation of the peritoneum, examination, eg, after penetrating trauma) and are usually
and, secondly, because of the risk of toxic shock syndrome hemodynamically unstable.
by increased passage of toxins and bacteria into the circulation
favored by the high intraperitoneal pressure. over the last Unclear Abdomen (Either Blunt or Penetrating)
decades, this controversial issue has been further investigated Laparoscopy is particularly indicated either in blunt or
and the benefits of laparoscopy have been demonstrated also penetrating abdominal trauma with CT scan equivocal findings
in case of peritonitis.54–59 or discrepancy between the clinical examination and the imaging,
Patients with either septic shock or heart failure are not the so-called unclear abdomen, but also in case of unclear
suitable for laparoscopy, since the pneumoperitoneum may source of potentially active bleeding.61
cause a lower venous back-flow return that may be easily fatal
in such cases. Blunt or Penetrating Trauma With Unexplained
Another absolute contraindication to laparoscopy is a se Free Fluid and No Parenchymal Injury
vere traumatic brain injury, since pneumoperitoneum seems to A common indication to laparoscopy in either blunt or
increase the intracerebral pressure.60 penetrating trauma is the CT scan finding of unexplained free
Severe respiratory failure (chronic obstructive pulmonary abdominal fluid (no parenchymal injuries), with the suspicion
disease) with severe hypercapnia is a relative contraindication to of a hollow viscus injury or a mesenteric laceration, frequently
pneumoperitoneum, owing to the possible reabsorption of CO2 missed at the CT scan.11,61,62 (Figs. 4 and 10; Videos 3, 4,
and development of malignant hypercapnia and toxic shock 13–16, 27, and 29–32, Supplemental Digital Content 1, http://
syndrome. However, some shrewdness, such as keeping low links.lww.com/TA/B234).
intra abdominal pressures, minimal bed rotation angles, and a
wise ven tilation strategy with increased minute volume, might be helpful in
mitigating this challenge. Blunt Abdominal Trauma With Suspicion or
Imaging-Proven Mesenteric Injury
CT Scan Findings and Diagnostic Uncertainties Blunt abdominal trauma may be associated with small
When available and in stable or fully stabilized trauma bowel and/or mesenteric injuries (SBMIs). This kind of injury
patients, contrast-enhanced three-phase CT scan is recommended may occur in 1.2% to 5% of patients following abdominal blunt
to obtain a proper assessment of injuries. According trauma. Delayed diagnosis in such cases is strongly related to
to the physical observation, but also based upon the mecha nism increased risk of bowel ischemia and perforation with ongoing
of injury and dynamics of blunt or penetrating trauma, sepsis, ultimately leading to higher morbidity and mortality.
the physician in charge should carefully evaluate the possibility Early diagnosis and early treatment of major mesenteric
of adding oral or rectal hydrosoluble contrast and/or a lacerations with “bucket handle” bowel devascularization is crucial.
urethracystogram for increasing diagnostic sensitivity. How ever, for better outcomes. Typically, CT scan is not accurate enough
in case of suspicion of gastroduodenal or colorectal or to pick up early major mesenteric lacerations and small bowel
urinary bladder injuries (intraperitoneal injuries), diagnose (SB) devascularization. Specific signs of bowel wall injury,
346 © 2018 Wolters Kluwer Health, Inc. All rights reserved.


such as pneumoperitoneum, the presence of extraluminal in teric to proceed with orthopedic procedures of stabilization/fixation
contrast, or focal wall defect, are rarely seen in acute and ultimately a faster recovery and more quick rehabilitation
SBMIs even if associated with bucket-handle injuries because after the polytrauma.
of the underlying mechanism of devascularization, which
takes long to cause bowel perforation.63 (Fig. 3; Videos 16,
27, and 30, Supplemental Digital Content 1, http://links.lww. Penetrating Abdominal Injuries With Uncertainty
com/TA/B234) Peritoneal Violation
Indirect signs on CT scan of a mesenteric injury are In case of penetrating injuries with uncertain peritoneal vio
represented by unexplained free fluid, hematoma, and/or fat stranding lation, a local wound exploration (LWE) can be performed in first
within the mesentery (Fig. 6). Subtle hypoenhancement of the instance. However, often this is not done properly especially when
underlying bowel loop may or may not be present and is rarely general surgeons or trainees who may be inexperienced are per
detected. Also rare are the findings of active bleeding, abruptly forming. Therefore LWE can easily get in the wrong hands,
interrupted mesenteric vessels. More common but less specific ending up to be a simple and blind probing of the wound which is
are imaging findings such as bowel-wall thickening or abnormal perhaps harmful, with risk of popping the clot, triggering intra
bowel wall enhancement (Fig. 3). abdominal bleeding or causing bleeding of the abdominal wall
Definitive diagnosis of a bucket-handle tear can only be muscles or epigastric vessels, and enlarging or causing tears and
made intraoperatively. CT findings such as mesenteric hema injuries to the bowel, which can eventually be stuck underneath.
toma with active hemorrhage, bowel wall abnormalities including Therefore, LWE must be done by experienced surgeons with ap
intramural hematoma or hypoenhancement, interloop fluid propriate technique65; otherwise, it may paradoxically represent
or blood, or a concomitant traumatic abdominal wall hernia such a waste of time in getting the diagnosis and be painful for the
as lumbar hernia have been associated with surgically significant patient, even if done with local anesthesia. Moreover, large defects
bowel injuries. However, CT has limitations with the accuracy of need OR anyway to be fixed, while small defects with positive
CT in differentiating surgical from nonsurgical injuries. LWE can still get a high rate of negative and unnecessary
being lower than 75%.64 laparotomy. In addition, a false-negative LWE can lead to a late
Moreover, often, such patients have pelvic or spinal diagnosis and therefore to bring the patient to theater with peritonitis after
fractures associated and need early stabilization. having assessed a negative LWE. Some high-volume centers
Nonoperative management (NOM) with watchful waiting proposed NOM with serial clinical examination of penetrating
and clinical serial examination is undertaken in many traumas. injuries with no signs of peritonism.66 In low-volume centers, where
Often, several repeated CT scans are scheduled to aid the such cases are rare and there is no experience in NOM of penis
diagnosis and following up the suspicion of SBMIs, but even serial trating trauma, a good option can be to proceed with a diagnosis
imaging most of the times does not clarify whether there is a laparoscopy and early discharge if it is negative or, if diagnostic
surgically significant bowel injury, until more specific but late signs laparoscopy is positive, eventually fix the injury in minimally
develop such as bowel wall discontinuity or pneumatosis or invasive fashion (Figs. 5–20). Moreover, in case of hollow
extraluminal free air. However, even when only indirect signs viscus injuries, early diagnosis without significant sepsis and
such as unexplained free intra-abdominal fluid or the aspecific contamination means better chances of primarily repairing and
previously mentioned CT signs are present, surgically significant better outcome. (Figs. 4, 5, 9, 11, 18, and 20; Videos 1, 4, 9,
bowel injuries can be present in up to 35% to 40% 17, 18, 21, 29, and 32, Supplemental Digital Content 1, http://
of the cases and an expectant strategy is shamefully leading links.lww.com/TA/B234).
to a delayed diagnosis and late treatment of SBMIs and
bucket handle injuries with morbid consequences both for
the development of peritonitis and need for a laparotomy Clinical Peritonitis or Peritoneal Free Air After
and bowel resection ± stoma ± open abdomen in the most severe Either Blunt or Penetrating Abdominal Trauma
cases, as well as for the delayed treatment and fixation of the Peritonitis and/or intra-abdominal free abdominal air
potentially associated skeletal fractures. detected at CT scan in a stable trauma patient are highly
Remarkably, even if the 65% to 70% of the patients have suggestive of a gastrointestinal injury. In such cases, the
indirect and subtle CT findings suspicious of SBMIs but who do laparoscopic approach can provide a diagnosis, and according to
not actually have a surgically significant injury, the expectant the surgeon's skills, most times it can play a therapeutic role
management has its own drawbacks in terms of LOS, resource as well (Figs. 1 and 2). (Figs. 1, 2, 4–6, and 18–20; Videos
utilization, radiation exposure, and early fixation of the associated 4, 9–12, 14, 16–18, 27, 29, and 31, Supplemental Digital
orthopedic injuries with subsequent earlier recovery. Whereas a Content 1, http://links.lww.com/TA/B234).
minimally invasive diagnostic laparoscopy,
when done early in patients with event subtle or aspecific
signs on the initial CT raising the suspicion of SBMI, can Intraperitoneal Bladder Injury Either Blunt
rule out significant bowel injuries (eg, bucket handle, major or Penetrating
devascularization, focal or tiny early perforations/serosal tears) In stable trauma with positive retrograde cystography with
and eventually allow minimally invasive treatment of those intraperitoneal leak or with preoperative unexplained free
injuries, ultimately leading to a more rational resource utilization intra-abdominal fluid in absence of parenchymal injuries and
avoiding compulsively repeat of multiple CT scan and avoiding intraoperative detection at diagnostic laparoscopy of a bladder
radiation exposure, contrast medium side effects, and allowing laceration, the bladder suture repair can be successfully
© 2018 Wolters Kluwer Health, Inc. All rights reserved. 347


Figure 1. Small bowel resection and intracorporeal anastomosis for penetrating perineal and abdominal trauma. (A) Diagnostic
laparoscopy demonstrating large peritoneal violation. (B) Diagnostic laparoscopy demonstrating small bowel laceration. (C) Intracorporeal side-
to-side stapled anastomosis. (D) The patient was discharged home on post-operative day (POD) 12. Case description: A 70-year-old
hemodynamically stable lady is admitted to the emergency department after a domestic fall from a ladder reporting a penetrating perineal
trauma. Computed tomography scan abdomen-pelvis shows abdominal free air, left pelvic hematoma, a thickened small bowel loop, a
suspected mesenteric injury, and some free fluid. Diagnostic laparoscopy demonstrates hemoperitoneum with some murky free fluid, a large
peritoneal violation in the left hemipelvis (A) associated with a large through-and-through jejunal laceration on the mesenteric border (B). An
intracorporeal side-to-side stapled anastomosis is performed (C). Postoperative outcome (D).
performed laparoscopically (Fig. 11; Video 3, Supplemental Digital Content 1, isolated lower chest or upper quadrant penetrating abdominal
http://links.lww.com/TA/B234). trauma (Figs. 11 and 20).20,67,68 In fact, especially in case
of concomitant splenic injury treated with NOM, diagnostic lap
Penetrating Trauma of the Lower Chest or aroscopy remains a critical adjunct for stable patients, as
Anterior and Upper Abdominal Quadrants occult 66 Nevertheless, ac cording to the local protocols and
A further indication to a laparoscopic procedure is the attitudes, concurrent spleen or liver injuries can be successfully
suspicion of an occult diaphragmatic laceration after an managed with or without diaphragmatic injuries occur in up to 30% .
Figure 2. Small bowel primary repair for blunt abdominal trauma. (A) Diagnostic laparoscopy demonstrating blast small bowel perforation.
(B) Intracorporeal primary repair. (C) View of the small bowel repair. (D) The patient was discharged home on POD 5. Case description: A 61-
year-old hemodynamically stable male patient is admitted to the emergency department after a blunt abdominal trauma caused by a heavy
piece of wood. Computed tomography scan abdomen-pelvis shows free air and signs of a small bowel contusion. Diagnostic laparoscopy
demonstrates initial signs of peritonitis and a small bowel perforation (blow injury) (A). An intracorporeal primary repair is performed (B and C).
Postoperative outcome (D).


angioembolization. (Figs. 5, 9, 11, 18, and 20; Videos 1, 4, 7, 8, scan has been demonstrated to be significant predictors of
and 21, Supplemental Digital Content 1, http://links.lww.com/ NOM failure.
TA/B234) In fact, in a comparative series of 312 patients, of those
In case of a stable patient with isolated stab wound of the undergoing NOM, 34 had SCH and 12 failed (35.3% vs. 1.5%
anterior and upper quadrants, in some high-volume trauma centers, without SCH, p = 0.0001) and failure rates in Grades 1 to 4 were
the CT scan can even be avoided and a straight diagnosis/ 2.3%, 3.8%, 8.8%, and 19.2%, respectively. Nonoperative man
therapeutic laparoscopy may be performed to rule out and even agement failure rates in the subset with SCH for Grades I to IV
tually treat a peritoneal violation and a hollow viscus, splenic, were 20%, 25%, 30.8%, and 80%, respectively. These are
and/or diaphragmatic injury (Figs. 9–11). significantly higher than patients without SCH in Grades II to IV (0%,
p = 0.003; 2.3%, p = 0.008; and 4.8%, p = 0.016). These authors
Diaphragmatic Penetrating or Blunt Injury concluded recommending that splenectomy should be considered
Diaphragmatic injuries are relatively rare, from either in patients with Grade IV blunt splenic injuries (BSI) with
blunt or penetrating trauma. In case of stable patients with CT SCH, as NOM failure rate is 80%.74
Findings of diaphragmatic injury, after blunt or penetrating trauma, It is also known that there is conflicting evidence regarding
a laparoscopic/thoracoscopic suture repair or prosthetic repair the natural history and appropriate management of patients.
can be achieved (Fig. 7).20,67,68 with vascular injuries of the spleen, such as pseudoaneurysms
Computed tomography scan is also often inconclusive or blushes. Among 200 patients with vascular abnormalities
and/or has low sensitivity for diaphragmatic injuries, and the lat est (blushes and/or pseudoaneurysms) on CT, the presence of an
EAST Guidelines have made recommendations in favor of actively bleeding vascular injury was associated with a 40.9% risk
laparoscopy over CT for diagnosis, nonoperative versus operative of splenectomy. This study therefore demonstrated that patients
approach for right-sided penetrating injuries, abdominal with a bleeding vascular injury of the spleen are at high risk of
versus thoracic approach for acute TDI, and laparoscopy (with nonoperative failure, no matter the strategy used for management.
the appropriate skill set and resources) versus open approach This group may warrant closer observation or an alternative man
for isolated TDI (Fig. 8).69 (Figs. 7–9 and 18; Videos 7, 8, and agement strategy, according to the author's conclusions.75
19–21, Supplemental Digital Content 1, http://links.lww.com/ Such situations and the figures of NOM failures cited
TA/B234) previously may represent the rationale of the selective use of
laparoscopic splenectomy representing the advocated alternative
management strategy as well as a minimally invasive alter native,
Penetrating Injuries With Evisceration being in-between extreme NOM and its risks of failures
Although evisceration has been traditionally considered a in such cases and a maximally invasive open splenectomy and
contraindication to laparoscopy, interesting and encouraging results its significant postoperative morbidity and LOS (Figs. 12–14
come from a series of 39 stable penetrating injuries with and 16).
evisceration assessed and treated with a minimally invasive ap In details, we have encountered several cases where a de
proach, without missed injuries nor significant postoperative definitive laparoscopic splenectomy can be considered:
complications. The authors conclude that the laparoscopic man – Failed angioembolization (AE) or AE contraindicated:
agement of organ evisceration in stable patients with penetrating that is, whenever AE is contraindicated or not available, or AE
abdominal trauma is feasible, has a high accuracy in identifying fails because of a tortuous kinking of the splenic artery and the
intra-abdominal injuries, provides all benefits of minimal inva sive interventional radiologist is unable to reach the blushes for re
surgery, and avoids possible nontherapeutic laparotomy.70 leasing coils and embolize, or when the patient shows a persis tent
ongoing (usually venous) bleeding even after embolization
Stable High-Grade Blunt Splenic Injury Associated requiring multiple and repeated blood transfusions. A few patients
With Unavailable, Contraindicated, or Failed may still bleed (venous) after AE. The splenic artery or
Angioembolization/Penetrating Splenic Injuries its branches are embolized, but the patient, although remaining
With Need of Lap Exploration of the Hollow Viscus perfectly hemodynamically stable with normal BP and normal
and Diaphragm HR, has an ongoing continuous drop of hemoglobin in the following
Nowadays, NOM with angioembolization is the standard hours or in the following days.
of choice in stable blunt splenic injuries, with or without blush, – Furthermore, when the patient has persistent blushes/
and the need for surgery is considered as a defeat or failure. pseudoaneurysms, especially if these are multiple and diffuse
However, the rate of NOM failure after angioembolization in in the splenic parenchyma, despite proximal SA embolization.
high-grade splenic trauma (III-IV-V according to the American In such cases, a minimally invasive splenectomy can be
Association for the Surgery of Trauma [AAST] classification) preferred against the potential risk of delayed rupture of such
has been reported from 4% to 80%, and strong evidence exists pseudoaneurysms.
that age of 40 years or above, Injury Severity Score of 25 or – Another potential indication for laparoscopic splenectomy
greater, and splenic injury grade of 3 or greater are prognostic without NOM in BSI is when the patient is hemodynamically stable
factors for failure of NOM.71–75 (Figs. 11–17; Videos 1, 2, and and has multiple and severe skeletal or spine fractures needing
21–28, Supplemental Digital Content 1, http://links.lww.com/ spine surgery in a prone position or prolonged and invasive or
TA/B234) thethopedic procedures with significant risk of bleeding.
The presence of subcapsular hematoma (SCH) in blunt – A further possible contraindication to angioembolization
splenic injury and/or of vascular abnormalities detected on CT and therefore an indication not to pursue NOM and proceed to a


laparoscopic splenectomy are stable patients severely allergic should be taken urgently for laparotomy, NOM of blunt hepatic
to in travenous iodine contrast and with large contrast blushes or injuries currently is the standard of care for hemodynamically
pseudoaneurysms, which cannot be otherwise embolized. stable patients and absence of other abdominal injuries requiring
– In addition, in most peripheral hospitals, the interventional surgery, irrespective of the grade of injury, neurologic status, and
radiology service is not 24/7 available, while in some other cases, patient age.80 Reported success rates of NOM range from 82%
angioembolization can be technically not feasible or may fail (eg, to 100%.81,82 Nonoperative management of high-grade (IV-
celiac trunk stenosis and inability to cannulate the splenic artery Vaccording to the AAST classification) liver injuries should
and proceed to embolization, a tortuous splenic artery, technical only be considered in an environment that provides resources
failure to release the coils, etc.).76,77 for patient intensive monitoring, angiography, serial clinical
– Moreover, even if the angioembolization is available and evaluations , immediate access to blood and blood products, and
technically succeeds, sometimes pseudoaneurysms are detected an OR available 24/7 for urgent laparotomy.83 The complication
at the follow-up CT scan or contrast-enhanced ultrasound (CEUS) rate following NOM increases with the grade of injury (from 1%
during the following days of observation (Figs. 17 and 18). In in Grade III to 63% in Grade V). About 30% of the patients
other cases, angioembolization fails to control the bleeding or have complications including bile leaks, hemobilia, biliary
causes splenic ischemia and abscess, ultimately requiring a peritonitis, hemoperitoneum, missed injuries, hepatic necrosis,
splenectomy, which is feasible laparoscopically in experienced gallbladder necrosis, hepatic abscess, and delayed hemorrhage.81
hands (Fig. 15; Video 15, Supplemental Digital Content 1, http:// Successful laparoscopic management of retained hemoperitoneum,
links.lww. com/TA/B234).78 infective perihepatic collections, and treatment of biliary peritonitis
– Keeping in mind predictors of NOM failure, potential after severe hepatic trauma initially treated nonoperatively are
drawbacks, contraindications, downfalls, or unavailability of recommended by several guidelines.80,83 Laparoscopic washout
angioembolization, laparoscopic splenectomy can represent a of biliary peritonitis is gaining acceptance, and it is thought that it
convenient and safe alternative to pushing the envelope towards helps to resolve the biliary sepsis that is a result of the biliary
an extreme NOM in selected stable patients with blunt or pene peritonitis in approximately 3.2% of all hepatic trauma
treating splenic injuries of high grades and/or associated with patients84 (Fig. 19; Video 27, Supplemental Digital Content 1,
vascular injuries and need of heavy angioembolization or with http://links.lww.com/TA/B234). Not rarely gallbladder necrosis
other associated intra-abdominal or extra-abdominal severe in after angioembolization may occur, leading to gangrene and
juries and may allow patient's faster and safe resumption to possible perforation of the GB, and such cases may be
normal life.79 – Last but not the least, penetrating splenic injuries approached laparoscopically for a laparoscopic cholecystectomy
in stable patients may represent an excellent indication for and washout and drainage (Video 33, Supplemental Digital
a definitive minimally invasive splenectomy. Nonoperative Content 1, http://links.lww .com/TA/B234). In the presence of
management fail ures after penetrating splenic injuries may be necrosis and extensive devascularization of hepatic segments,
more frequent than after BSI, and the risks of NOM/spleen surgical resections via laparoscopy might be indicated in
preservation in penetrating spleen injuries for nonpediatric experienced hands and in a delayed timing. Furthermore, in rare
patients can overcome the benefits of leaving the spleen behind. cases of large SCHs leading to liver compartment syndrome,
In addition, penetrating left-upper quadrant (LUQ) and splenic drainage by laparoscopy has been described.85
injuries may have a high risk of associated hollow viscus (HV)
and diaphragmatic injuries, accounting for the high rate of NOM
failures and requiring a combination of diagnostic and possibly
therapeutic laparoscopy for exploration and definitive splenic Complex Pelvic or Perineal Trauma Some
hemostasis. complex pelvic trauma with perineal injuries and/or rectal
perforation may benefit from a laparoscopic double barreled or
Concomitant Urgent Orthopedic Surgery and High-Grade an end colostomy formation (with or without colorectal resection)
BSI Trauma patients with abdominal injuries frequently to divert the transit and allow a better healing (Fig. 4 ).
have associated bone fractures. Open bone fractures,
spine fractures, or unstable pelvic fractures often need urgent Pediatric, Pregnant, Mentally Impaired, and Nephropathic
surgical repair, and some orthopedic interventions are known Trauma Patients In pediatric trauma, where the physical
to be long lasting, blunt, and performed in a prone position examination is of ten unreliable and the radiation exposure
(Fig. 15). Even if the patient is stable, it may be dangerous to should be avoided or minimized, diagnostic laparoscopy can be
perform such procedures in the presence of a high-grade useful.
parenchymal injury, even if an angioembolization was carried Most intra-abdominal injuries in children can be
out. In addition, as already outlined before, the laparoscopic successfully managed nonoperatively.
treatment can play an important role in case of failed or Although clear indications for laparoscopy in pediatric
unavailable interventional radiology.(Figs. 12–14 and 17; trauma patients have yet to be fully delineated, hemodynamically
Videos 23–26, Supplemental Digital Content 1, http:// stable children without clear signs of injury and with equivocal
links.lww.com/TA/B234) imaging may be excellent candidates for laparoscopy.86 Similar
indications can be used in pregnant, geriatric, or mentally im
Stable Hepatic Injury paired patients. In addition, to avoid the administration of intra
While patients who are hemodynamically unstable or who venous contrast, nephropathic patients can take great advantage
have diffuse peritonitis after blunt or penetrating liver trauma from laparoscopic procedures as well.


Laparoscopy may be especially useful in case of trauma abdomen or to rule out a peritoneal violation and hollow viscus
patients with computed tomography (CT)/ultrasound (US) injuries (HVI) in a penetrating trauma. Based on the intraoperative
imaging of free intra-abdominal fluid that cannot be attributed to findings, laparoscopic skills available, degree of contamination,
hepatic or splenic injury or in those with worsening abdominal and general conditions of the patients, the laparoscopic
pain, tenderness, and signs of ongoing sepsis, which is procedure can be continued laparoscopically or converted to an
concerned for hollow viscus injury (Video 27). In frail patients open procedure to treat a peritonitis by obtaining early source
(pediatrics, elderly, patients with relevant comorbidities), control definitive repair or bowel resection . Further cases of an
additional benefits of laparoscopy include the maintenance of immediate laparoscopic procedure to be performed at admission
the bowel within the abdomen, which results in less fluid and or within the first few hours are to perform a definitive hemo
temperature shifts, coagulopathy, and postoperative paralytic ileus. static splenectomy for a high-grade blunt or penetrating splenic
injury in case of NOM contraindicated or AE not feasible, or in
Pancreatic Injuries case of suspicion of concomitant HVI or SBMI or a suspected di
Pancreas trauma is usually managed nonoperatively if aphragmatic injury, or even to obtain a safe hemostasis by
Grade I or II, but occasionally enlarging hematomas from definitive splenectomy in case of high-grade BSI associated to
superficial pan creatic lacerations and bleeding capsular tears complex spine fractures with cord compression needing immedi
in stable patients may be approached laparoscopically for ate long procedures for spine stabilization in prone position or
exploration, after a trast-enhanced CT scan ruled out duct high-grade BSI associated with complex pelvic or complex mul
injuries and treated with local hemostatic agents, evacuation, tiple long bones fractures needing prolonged orthopedic proce-
and drainage (Video 5, Supplemental Digital Content 1, http://links.lww.com/TA/B234).
dures when significant intraoperative blood losses are foreseen
Posttraumatic Acute Pancreatitis In a later and the concomitant high-grade parenchymal injury may suggest
a timely splenectomy for definitive hemostasis to be a safer
stage, a missed posttraumatic acute pancreatitis can be
option before undertaking an urgent and complex orthopedic surgery.
diagnosed laparoscopically (Video 6, Supplemental Dig ital
Laparoscopy can otherwise be decided as a delayed
Content 1, http://links.lww.com/TA/B234) and possible abdominal
collections drained. proce dure, for instance, in cases when a failed NOM and
persistent blushes/pseudoaneurysms within the spleen are
All possible indications to laparoscopic procedures in
detected on repeated CT/CEUS without any possibility for a
trauma patients are summarized in Table 3.
redo angioembolization (eg, after initial proximal splenic artery
embolization [PSAE]), and/or persistent venous bleeding/oozing
WHEN? from destructive parenchymal splenic injuries and/or for
splenectomy/drainage of abscesses after development of
The timing of a laparoscopic procedure in trauma patients ischemia/superinfection and splenic abscess as a consequence
is an important issue to take into consideration. Usually, the of heavy angioembolization (Fig. 15; Video 15, Supplemental
timing of a diagnostic and/or therapeutic laparoscopy can be im Digital Content 1, http://links.lww.com/TA/B234 ). Also, a delayed
mediate (within 6 hours) or delayed (>6 hours up to several days diagnostic and possibly therapeutic laparoscopy may be
after the trauma). undertaken to assess SBMIs and rule out major devascularization
A laparoscopic procedure can be needed either at of the bowel during the observation and NOM of blunt abdominal
admission, with diagnostic purpose and to investigate an unclear trauma with free fluid and absence of parenchymal injuries (Figs.
3, 10 and 19; Videos 3, 6, 16 and 30, Supplemental Digital
TABLE 3. Indications to Laparoscopic Procedures in Content 1, http:// links.lww.com/TA/B234), or for any enlarging
Trauma Patients hematoma/ hemoperitoneum from pancreatic injuries or
Indications to Laparoscopic Procedures in Trauma Patients mesenteric injuries for hemostasis, washout, and drainage
(Video 5, Supplemental Digital Content 1, http://links.lww.com/
Hemodynamic stability TA/B234); for delayed diagnosis and treatment of diaphragmatic
• Unclear abdomen
laceration and possible incarcerated diaphragmatic hernias; or
• Unexplained free fluid with no parenchymal injury • for detection of late consequences of pancreatic traumas such
Penetrating injuries with uncertain peritoneal violation • as late pancreatitis and eventually drainage of collections. All
Peritonitis or peritoneal free air • Intraperitoneal bladder the delayed procedures can be undertaken at any time during
rupture • Penetrating trauma of the lower chest or the observation period of an initial NOM for abdominal trauma,
anterior and upper whenever clinical signs and symptoms may suggest the
abdominal quadrants
opportunity of a timely diagnosis and treatment of an unclear
• Diaphragmatic injury (penetrating or blunt)
abdomen and minimally invasive surgery may represent a
• Penetrating injuries with evisceration • High-
feasible alternative to an open midline laparotomy (Videos 6, 12,
grade splenic injury in >40-y-old patients • Stable
13, 16, 27 and 30, Supplemental Digital Content 1, http://links.lww.com/TA
splenic injury with unavailable or failed angioembolization • Urgent
When discussing the timing of a trauma laparoscopy, the
orthopedic surgery and high-grade BSI not amenable to safe AE •
possibility of doing it at night if necessary versus delaying to the
Penetrating splenic injuries from penetrating LUQ trauma • Complex
next morning is also a matter of debate. Operating on nighttime
pelvic trauma with low rectal injuries • Mentally impaired trauma patients
is not a contraindication to laparoscopy in trauma patients; how
not suitable for NOM and safe observation • Pregnant patients or allergic to
ever, most of the previously cited indications can be delayed
contrast for diagnostic purpose
until the next morning and the daytime represents the safest timing,


Figure 3. Small bowel resection and intracorporeal anastomosis for blunt abdominal trauma. (A) Diagnostic laparoscopy
demonstrating a large bucket handle injury to the small bowel. (B) The small bowel loop involved in the injury is ischemic. (C)
Intracorporeal stapled small bowel resection. (D) Intracorporeal side-to-side stapled anastomosis. (E) The patient was discharged home on
POD 14. Case description: A 54-year-old hemodynamically stable female patient is admitted to the emergency department after blunt abdominal
trauma caused by a car accident (seat-belt mark). Computed tomography scan abdomen-pelvis shows diffuse hemoperitoneum, minimal splenic
injury, hypoenhanced sigmoid mesentery, bilateral rectus muscle hematoma, and fractures of C6-C7. Diagnostic laparoscopy demonstrates a
large bucket handle injury to the small bowel (A). Since the small bowel loop involved in the injury looks ischemic (B), an intracorporeal stapled
small bowel resection (C) and side-to-side stapled anastomosis was performed (D).
Postoperative outcome (E).
since it allows to operate on better conditions, when more staff hospital, and, if needed, more seniors and experienced sur
and resources are available, with better anesthesiologic geons can be around to help out.
assistance, blood bank more readily available, more nursing Therefore, while trauma laparoscopy having immediate
staff and interventional radiology (IR) available in the indications and with a diagnostic purpose (eg, unclear abdomen,
Figure 4. Laparoscopic Hartmann's procedure for penetrating rectosigmoid injury. (A) Diagnostic laparoscopy demonstrating a full thickness
laceration of the high rectum. (B) View of the rectal stump and dissection of the sigmoid mesentery. (C) Extracorporeal view of the specimen
(rectal laceration). (D) Intracorporeal view of the left colostomy. (E) The patient was discharged home on POD 11. Case description: A 72-year-
old hemodynamically stable gentleman with multiple comorbidities is admitted to the emergency department for increasing abdominal pain after
a rectal penetrating trauma. Computed tomography scan abdomen-pelvis shows free air and free fluid, as well as inflamed rectal and sigmoid
wall. Diagnostic laparoscopy demonstrates a fecal peritonitis with a large full thickness laceration at the rectosigmoid junction (A). According to
the extent of the injury and patient's comorbidities, a laparoscopic Hartmann's procedure was performed. Figure B shows an intraoperative view
of the rectal stump and dissection of the sigmoid mesentery. Figure C shows an extracorporeal view of the specimen (sigmoid laceration).
Figure D shows the intracorporeal view of the left colostomy.
Postoperative outcome (E).


Figure 5. Transverse colon primary repair for stab abdominal injury. (A) Preoperative picture showing one epigastric stab wound and on left upper
quadrant stab wound. (B) Diagnostic laparoscopy demonstrating peritoneal violation. (C) Diagnostic laparoscopy demonstrating transverse colon
full thickness injury. (D) View of intracorporeal primary suture repair (first layer). (E) View of intracorporeal primary suture repair (second serosal
layer). (F) Postoperative outcome. Case description: A 74-year-old hemodynamically stable lady is admitted to the emergency department with
two abdominal stab wounds, one in the epigastrium and one in the left flank (A). Computed tomography scan of the thorax, abdomen, and pelvis
shows tiny free air bubbles, some free fluid, and thickened transverse colon. Diagnostic laparoscopy confirms the epigastric (B) and left flank
peritoneal violations. Laparoscopic inspection of the transverse colon demonstrates the presence of a full-thickness hollow viscus injury (C).
According to the extent of the injury and the absence of significant peritoneal contamination, an intracorporeal primary double layer hand-sewn
repair was performed (D, E).
Postoperative outcome (F).
Figure 6. Emergency Hartmann's procedure for blunt abdominal trauma with severe colonic injury. (A) Diagnostic laparoscopy demonstrating
hemoperitoneum and free colonic perforation with minimal enteric content leak. (B) Diagnostic laparoscopy demonstrating destructive injury
to the descending mesocolon. (C) Diagnostic laparoscopy demonstrating laceration and ischemia of the descending colon. (D) mesocolon stapling
with vascular load and venous mesenteric oozing rapidly controlled. (E) Postoperative outcome. Case description: A 77-year-old hemodynamically
stable gentleman is admitted to the emergency department after a blunt abdominal trauma caused by a car accident. Computed tomography scan
of the thorax, abdomen, and pelvis shows free air, diffuse hemoperitoneum with no parenchymal injuries and a descending mesocolon hematoma.
Diagnostic laparoscopy confirms the diffuse hemoperitoneum with minimal enteric content leak (A) caused by a significant contusion/laceration of
the descending colon/proximal sigmoid (B), descending mesocolon disruption with active venous oozing (C) with left colon ischemia and hollow
viscus full laceration thickness (D). According to the extent of the injury a laparoscopic Hartmann's procedure was performed. Figure E shows left
mesocolon stapling. Postoperative outcome (E).


Figure 7. Large left diaphragmatic hernia in blunt trauma. Case description: A 43-year-old hemodynamically stable lady is admitted to the
emergency department about 12 days after a blunt thoracoabdominal trauma caused by a car accident. Computed tomography scan of the
thorax, abdomen, and pelvis shows a large incarcerated left diaphragmatic hernia containing the omentum and the transverse colon (A, B).
Diagnostic laparoscopy confirms the large left diaphragmatic hernia (C). A laparoscopic diaphragmatic hernia reduction and repair is performed
(D).
Figure 8. Diagnostic laparoscopy for large right diaphragmatic laceration in blunt thoracoabdominal trauma. (A) Atraumatic grasper is lifting the
diaphragmatic edge and lung parenchyma is clearly visible on top of the liver. (B) Chest drain is visualized through the diaphragmatic breach.
(C) Lung parenchyma within the chest cavity is visible through the defect. (D) Extensive diaphragmatic laceration. Case description: A 52-year-
old hemodynamically stable lady is admitted to the emergency department after a blunt thoracoabdominal trauma caused by a car accident.
Computed tomography scan of the thorax, abdomen, and pelvis shows severe right lung basal contusion and tiny right pleural effusion with
supraelevated right hemidiaphragm, but no obvious signs of diaphragmatic rupture. In the next 48 hours, the patient's respiratory conditions
deteriorated, needing intubation and invasive ventilation. Repeated CT scan of chest and abdomen was unchanged apart increased right pleural
effusion, which was drained and inconclusive to rule out diaphragmatic injury. A diagnostic laparoscopy was performed and showed a large right
diaphragmatic hernia by using atraumatic grasper to lift the diaphragmatic edge allowing visualization of the right lung parenchyma on top of the
liver (A).
Figure B shows the chest drain that is clearly visualized through the diaphragmatic breach, while Figure D demonstrates the extent of the
diaphragmatic laceration.


Figure 9. Laparoscopic diagnosis and repair of diaphragmatic injuries after LUQ penetrating abdominal trauma. Case description: Two
hemodynamically stable patients with penetrating stab wound to the LUQ. Diagnostic laparoscopy was performed with finding of left
diaphragmatic laceration repaired laparoscopically by primary suture (Case 1 A, B, C, note the chest drain inserted in the emergency department
for pneumothorax, visible through the diaphragmatic injury; Case 2 D, E, F) .
clinical peritonitis with suspicion of HVI for simple and making the diagnosis and if this is confirming the presence
technically easy diagnostic and/or therapeutic procedures; significant intra-abdominal injuries, the remaining options of
Figs. 2–18; Videos 29, 30, and 32, Supplemental Digital performing a delayed diagnostic and therapeutic trauma
Content 1, http:// links.lww.com/TA/B234) can be safely laparoscopy involving more complex and advanced MIS
attempted even at night with a low threshold for conversion to open surgery after
procedures, such as splenectomies, repair of diaphragmatic
Figure 10. Bladder blow-out injury after blunt abdominal trauma (seat belt). (A) Diagnostic laparoscopy demonstrating a large full-
thickness laceration (suction tube is in the bladder). (B) View of the intracorporeal suturing of the bladder injury. (C) View at the end of the
primary repair of the bladder laceration. (D) Patient was discharged on POD 6. Case description: A 41-year-old hemodynamically stable
gentleman is admitted to the emergency department after a blunt abdominal trauma caused by a car accident (seat-belt marks).
Computed tomography scan of the abdomen and pelvis demonstrates abundant abdominal free fluid with no parenchymal injuries.
According to these findings, a diagnostic laparoscopy was performed and showed diffuse hemo-uroperitoneum and a large full thickness
bladder laceration (A). An intracorporeal hand-sewn suture of the bladder laceration has been performed (B and C).
Postoperative outcome (D).


Figure 11. Laparoscopic splenectomy for penetrating stab wound injury to the left upper quadrant with large intraparenchymal splenic
blush. (A) Preoperative picture. (B) Axial CT scan finding of arterial splenic blush. (C) Coronal CT scan finding of arterial splenic blush in
the lower pole. (D) Intraoperative finding of splenic penetrating injury in the lower pole. (E) Intraoperative step of splenic hilar stapling. F,
Intraoperative view of the splenic hilum after stapling. G, Postoperative outcome. Case description: A 41-year-old hemodynamically
stable gentleman is admitted to the emergency department after two stabbings, one in the abdominal left upper quadrant and one in
the left side of the back (A). Computed tomography scan of the thorax, abdomen, and pelvis demonstrates an arterial blush in the lower
splenic pole (B and C). Diagnostic laparoscopy confirms splenic penetrating injury (D). By stapling the splenic hilum, a laparoscopic
splenectomy was performed (E and F). The specimen was morcellated and extracted through the umbilical port (G).
injuries, hemostasis, and drainage of hematomas and ab scesses Laparoscopy does not play an important role in the treatment of
which are increasing in size at serial imaging, should duodenal injuries. In fact, low-grade duodenal injuries do not
better be done in a daytime semi-urgent setting in a safer man ner usually need any surgical treatment, while, in high-grade duodenal
and when appropriate expertise by senior attending sur geons injuries, laparotomy is the treatment of choice because of the
and resources are available. involvement of the pancreatic head, the diagnosis is frequently late,
and the patient is in septic shock. Laparoscopy allows to treat
QUE? selected parenchymal organ injuries in stable patients needing
definitive surgery, by performing a splenectomy, a distal
The minimally invasive approach in trauma patients pancreatectomy, hepatic hemostatic procedures, or a hepatic
allows to perform a wide range of procedures (Figs. 1–20; resection in a semiurgent setting. The AAST Grade I and II
Videos 1–33, Supplemental Digital Content 1, http://links. pancreatic injury can be nonoperatively managed, but if found during
lww.com/TA/B234). diagnostic laparoscopy, hemostasis and drain placement can be
The first, most simple and largely feasible procedure is a performed with a minimally invasive procedure. The treatment
diagnostic laparoscopy, to rule out a suspected of Grade III pancreatic injuries depends on the location of the
peritoneal violation and/or to assess or confirm intra abdominal ductal tear along the organ: traumas of the pancreatic head are
injuries (Figs. 18 and 19; Videos 30–32, preferably just drained, while those of the tail can be treated with
Supplemental Digital Content 1, http://links.lww.com/ a distal pancreatectomy (“suck the head and eat the tail”). Grades
TA/B234). IV and V pancreatic injuries are usually hemodynamically unstable
According to the expertise and confidence of the surgeon, and cannot be treated laparoscopically. However, laparoscopy
many abdominal injuries can be treated laparoscopically. Ad can be useful in delayed setting to drain pancreatic collections
vanced laparoscopic procedures for abdominal trauma include which cannot be reached percutaneously and to drain and manage
hollow viscus injuries primary repair or resection and anastomo conservatively low output pancreatic fistulas. Hepatic resection
sis (stomach and duodenum, small bowel, colon and rectum), may be indicated if major hepatic necrosis will develop after
end or double barreled colostomy formation, cholecystectomy, trauma or as a complication of angioembolization but requires
biliary laparoscopic suturing or positioning of a biliary transcystic a significant hepatobiliary and minimally invasive expertise to
or T-tube drain, diaphragmatic suturing, or prosthetic repair. be safely performed laparoscopically.


Figure 12. Laparoscopic splenectomy for blunt abdominal injury after BSI of high grade (V) without blushes, performed for achieving definitive
hemostasis in a polytrauma patient needing complex urgent ortho fixation of exposed femur and pelvic fractures in prone position. (A)
Intraoperative view of large hemoperitoneum. (B) Intraoperative view of extensive splenic injury. (C) Intraoperative step of splenic hilar stapling.
(D) Postoperative outcome. Case description: A 59-year-old hemodynamically stable lady is admitted to the emergency department after a blunt
abdominal trauma caused by a car accident. Total body CT scan demonstrates a complex exposed left femur with pelvic fracture, a left leg and
a complex left superior limb, L1-L2, bilateral multiple uncompound rib, bilateral pleural effusions and contusions, and high-grade splenic injury
with perisplenic fluid. Definitive splenectomy is considered a safer option given the requirement of urgent complex and long-lasting orthopedic
procedure in prone position for fixation and stabilization of her multiple skeletal fractures. Diagnostic laparoscopy confirmed a high-grade splenic
injury (A and B). By stapling the splenic hilum, a laparoscopic splenectomy was performed (C). The specimen was morcellated and extracted
through the umbilical port which is hardly visible and a long midline laparotomy incision was avoided, allowing a much better respiratory function
postoperatively with much less pain (D).
Overall, a low threshold for open conversion should be fully secured on both sides and strapped with belts, to be able
maintained if the surgeon is not confident and missing injuries to safely achieve a moderate tilt in all directions and shift of the
are suspected. We do not recommend laparoscopic exploration abdominal organs during the exploration to guarantee an
and opening of the retroperitoneum in trauma patients. Nonex adequate laparoscopic intraoperative view and exposure. The
panding retroperitoneal or pelvic hematomas in stable patients sur geon stands on the left to explore the right abdomen (liver,
should never be explored or the retroperitoneum opened neither right colon, and small bowel) and on the right to explore the left
laparoscopically nor in open surgery. Hemodynamically stable abdomen (left diaphragm, stomach, spleen, left colon, sigmoid,
patients with expanding and/or pulsatile retroperitoneal or pelvic bladder, and rectum).
hematomas should be immediately converted to open surgery.
Diagnostic Laparoscopy The
HOW? first access is best achieved at the navel with an open
technique using a 10/12 mm trocar. We do not recommend
Apart from occasional experiences of local anesthesia using Verres needle in trauma patients, who may have a
with intravenous sedation (“awake laparoscopy”) in emergency distended bowel and may cause misleading iatrogenic bowel
department, diagnostic laparoscopy for trauma is usually per or vascular injuries. Pneumoperitoneum should be slowly and
formed under general anesthesia and in a fully equipped OR.87 progressively established, avoiding hyper pressure (reaching
The patient should always be in a supine position, the no more than 12–14 mmHg); insufflation should be stopped in
same as for a trauma open approach to be ready for immediate case of abrupt rise in respiratory pressure, blood hypotension,
conversion to laparotomy and/or thoracotomy, in case of finding or tachycardia; and a low threshold for immediate conversion
of abdominal injuries, which cannot be treated laparoscopically, to open should be kept. Either a 30-degree or 0-degree
or of sudden onset of hemodynamic instability or suspected of laparoscope can be used in diagnostic procedures, whereas a
tho racic injuries. In case of a blunt trauma with concomitant 30-degree scope is better performing in case of operative
lower spinal, pelvic, and/or inferior extremities orthopedic laparoscopy. Once preliminary exploration of the abdominal
fractures, the legs must be kept closed and straight, while in a cavity has shown no urgent need to convert to laparotomy, we
thora coabdominal penetrating trauma, the legs may be kept suggest to insert two further trocars (5 or 12 mm), preferably
open and the operating surgeon can stand in between to better bladeless and under direct vision, lo cated according to the preoperative i
access to the upper abdominal quadrants (diaphragm, stomach, For instance, in case of a penetrating upper quadrant injury, it
lesser sac, spleen, and splenic colic flexure). The patient should be would be better to insert one trocar in the right flank and one


Figure 13. Laparoscopic splenectomy for blunt abdominal trauma with urgent orthopedic surgery required. (A) Preoperative CT scan
showing high-grade splenic injury arterial blushes. (B) Intraoperative view of hemoperitoneum. (C) Intraoperative view of high-grade splenic
injury. (D) Intraoperative view of splenic hilar stapling. (E) Spleen fully mobilized and medialized with hilar vessels stapled and short gastric
vessels only left to be stapled off. (F) Postoperative outcome. Case description: A 27-year-old hemodynamically stable gentleman is admitted
to the emergency department after a blunt trauma (car vs. car). Computed tomography scan showed Grade IV AAST splenic injury with multiple
blushes (A) and complex pelvic fracture with destruction of acetabulum and fracture-luxation of head and neck of the right femur alongside
sciatic nerve sprain requiring urgent orthopedic definitive surgery in prone position. Intraoperative steps of laparoscopic splenectomy (B, C, D,
E). Postoperative results allowing early mobilization thanks to the absence of a midline laparotomy incision (F).
Figure 14. Laparoscopic splenectomy performed for achieving definitive hemostasis in high-grade blunt splenic injury and unstable T-spine
fracture need urgent fixation and stabilization in prone position. Case description: A 33-year-old hemodynamically stable gentleman is admitted
to the emergency department after a blunt trauma motor vehicle accident. Computed tomography scan showed Grade IV AAST splenic injury
with extensive sub capsular hematoma involving both superior and inferior splenic poles and surrounding free fluid with concomitant unstable
thoracic spine fractures. Underwent urgent laparoscopic splenectomy and immediately after stabilization of unstable T-spine fracture in prone
position. Intraoperative findings with free fluid around the spleen and signs of posttraumatic pancreatitis of the tail (A). Sequential steps of
stapled laparoscopic splenectomy (B and C). Note in panel B how the stapler must be positioned strictly close to the splenic medial surface in
order to avoid iatrogenic injuries/stapling on the pancreatic tail and/or gastric wall. In fact the staple line visible in panel C is clearly on a safe
plane far enough from the pancreatic tail.
Postoperative results allowing early mobilization thanks to the absence of a midline laparotomy incision (D).


Figure 15. Laparoscopic splenectomy for large splenic abscess and severe sepsis subsequent to angioembolization (failed NOM). Case
description: A 37-year-old hemodynamically stable gentleman with a background of hepatitus C virus-related cirrhosis, diabetes mellitus,
smoker, anxious-depressant syndrome, and drug abuse is admitted to the emergency department in a rural hospital after a blunt abdominal
trauma. The CT scan demonstrated splenomegaly and a 2-cm SCH with no blush or free fluid. Since after 3 days of observation a repeated CT
showed increase in size of the hematoma up to 6.5 4.5 cm, PSAE was advised by the interventional radiologist. In the following days, the
patient developed progressively worsening systemic sepsis. A further CT scan showed an extensive splenic abscess with large air-fluid level in
LUQ (A), and laparoscopic splenectomy was performed. Intraoperative view of large splenic abscess (B). The spleen is carefully isolated from
the surrounding pus with blunt dissection using suction tube (C). The splenic hilum is controlled by a linear vascular stapler, making sure of
staying close to the splenic surface (D). Surgical field, diaphragmatic surface, and abscess cavity after completion of splenectomy and extraction
of the specimen (E). Postoperative outcome (F).
in the left flank, while in case of a suspected small bowel or the small bowel is entirely run with two atraumatic grasping for
blad der blast injury in a blunt trauma, it would be better to insert ceps, in a retrograde fashion from the ileocecal valve to the
both trocars in left upper and lower quadrants to run the bowel. duodenal-jejunal flexure, always exploring both sides of the
Two more trocars in the right quadrants can be added to explore bowel wall and both mesenteric and antimesenteric borders.
the left quadrants, if needed, and the trocar position tailored During laparoscopy, we should also be looking for either mesen
upon the site, mechanism, and site of the traumatic injuries. teric lacerations and hematomas, or bowel injuries such as blast
(Figs. 3, 5, 8–10, 18, and 19; Videos 3–6, 12, 13, 16, 19, 27, 29, full thickness laceration or tears as well as through-and-through
30, and 32, Supplemental Digital Content 1, http://links.lww .com/ lesions or superficial serosal injuries. The bowel should be tirely
TA/B234) and thoroughly explored by running the bowel technique grasping
After inserting the operating trocars, similarly to what is the mesenteric fat and avoiding manipulation of the bowel wall
usually done in the open approach, the peritoneal cavity is as much as possible. Both sides of the bowel wall should be
examined systematically, beginning with the right-upper quadrant explored to rule out through-and-through injuries, especially after
and proceeding clockwise. In penetrating injuries, peritoneal penetrating trauma. The SB exploration should start with the
violation can be reliably determined with laparoscopy. CO2 leak identification of the cecum and ileo-cecal valve and proceed in a
from stab would (SW) can occur if fascial penetration and can systematic distal to proximal fashion up to the duodeno-jejunal
be prevented by applying occlusive dressings. flexure and Treitz ligament. Duodenal injuries cannot be reliably
To explore the supramesocolic region, the patient is tilted explored laparoscopically, and if a lesion of D2-D3 is suspected,
in reverse Trendelenburg position and liver, gallbladder, spleen, open surgery remains the way to deal with such in juries. The
diaphragm, lesser sac, pancreas, stomach and duodenum lesser sac should always be opened and explored in every
should be carefully inspected. Especially, the deepest areas in penetrating abdominal trauma or even for blunt trauma whenever
the left upper quadrant (LUQ) and right upper quadrant (RUQ) an injury to the posterior gastric wall, duodenum, or pancreas is
such as the diaphragmatic injuries can sometimes be better suspected; when unclear findings or hematomas of these organs
explored laparoscopically than with a laparotomy. Afterwards, are seen on CT images; or if a proper IV contrast enhanced CT
the transverse and descending colon and the mesocolon are scan was not preoperatively performed.
carefully inspected and then, moving the patient to a Thorough suction and/or peritoneal irrigation may be
Trendelenburg position, the rectum and Douglas pouch along needed for optimal visualization; methylene blue can be
with the pelvic organs, and then the cecum and right colon. After cranially moving the
administered omentum,through the naso-gastric tube (NGT), or
transanally,


Figure 16. Laparoscopic salvage splenectomy after failed NOM and PSAE for multiple blushes, with three residual large
pseudoaneurysms on the follow-up CT scan 3 days after AE. Case description: A 41-year-old hemodynamically stable gentleman is admitted
to the emergency department after a blunt thoracoabdominal trauma (motor vs. car). The CT scan shows a Grade IV AAST splenic injury with
multiple arterial blushes. The patient underwent PSAE. Seventy-two hours later, CT demonstrated multiple and diffuse pseudoaneusysms
throughout the entire splenic parenchyma (A). Since further angioembolization was not feasible (splenic artery no longer accessible due to
previous coils), the patient was a candidate for laparoscopic splenectomy. Intraoperative images of medial mobilization of the spleen after
splenocolic and splenorenal ligament have been divided (B). Splenic hilar vessels are stapled with endostapler, making sure to keep the stapler
adjacent to the splenic medial surface and avoid injury of the pancreatic tail (C). Short gastric vessels are divided with a further vascular reload
(D). Note how the staple line on the splenic hilum is closely adjacent to the splenic surface. Surgical splenic bed after extraction of the specimen
is clean and dry (E). Postoperative outcome with avoidance of a morbid long midline laparotomy incision (avoiding postoperative pain, SSI and
incisional hernias) (E).
intravenously to help identify colorectal, gastroduodenal, or Injuries are frequent and typically small in size after penetrating trauma of the
urinary tract injuries, respectively. upper abdominal quadrants, more rare, and mostly large after high-energy
A low threshold for open conversion should be maintained blunt trauma due to sudden increased ab dominal pressure. Small defects can
if the surgeon is not confident and missing injuries are suspected. be repaired either with single stitches or running suture, preferring
nonabsorbable thread; however, in case of diaphragmatic disruption, prosthetic
Therapeutic Laparoscopy nonabsorbable mesh may be used to reconstruct the diaphragm especially in
Once the diagnosis is achieved, either by CT scan or by delayed setting. In the majority of cases, a chest tube is also placed. In the
di agnostic laparoscopy, the possibility of performing a absence of abdominal free fluid or free air, a thoracoscopic approach and
laparoscopic treatment depends on the type and extent of the repair of a small diaphragmatic tear can be achieved. However, the main
injuries, on the patient's hemodynamic stability and, last but not disadvantage of the thoracoscopic approach is that the patient has to be
the least, on the surgeon's technical laparoscopic skills. positioned on a lateral decubitus. Laparoscopic suturing skills and ability to
Therapeutic laparoscopic copy should be performed under make intracorporeal knots is essential although Roeder knots with extracorporeal
general anesthesia and by a highly experienced laparoscopic knotting can be used. (Figs. 7–9 and 18; Videos 7, 8, and 19–21, Supplemental
surgeon. If the injury was detected preoperatively at CT scan, Digital Content 1, http://links.lww.com/TA/B234).
then it is possible to adjust and tailor the position of both the
patient and the trocars according to the location and type of injury.
Diaphragm All
diaphragmatic injuries must be surgically repaired to Stomach
prevent early delayed complications such as respiratory Gastric injuries occur more often in case of penetrating ab
compromise, pneumonia, diaphragmatic hernia with possible dominal traumas. These injuries can be treated laparoscopically
strangulation and gangrene of the herniated abdominal viscera, with a simple repair with or without omental patch, followed by
and eventually deadly HV perforations in the chest. diaphragmatic intraoperative testing for leaks using methylene blue injection


Figure 17. Laparoscopic salvage splenectomy after initial NOM and PSAE in Grade IV BSI with persistent pseudoaneurysms and the patient
needing psine surgery stabilization and vertebral fixation in prone position. Case description: A 77-year-old hemodynamically stable lady is
admitted to the emergency department after a blunt polytrauma (pedestrian vs. bus). The CT scan shows a Grade IV AAST splenic injury with
contrast blush (A), pelvic and multiple lumbar unstable fractures. Patient underwent initial NOM and PSAE. Because of gradual HB dropping
and in view of planning expedited orthopedic spinal stabilization in prone position, further CT scan was performed 3 days later and showed
persistent splenic pseudoaneurysm not amenable to repeated AE (B). Being hemodynamically stable, the patient was a candidate for
laparoscopic splenectomy. Intraoperative findings are shown in panel C. After splenic mobilization and medial rotation (D), the hilum is controlled
with a vascular endostapler (E). Panel F shows a view of the large clot covering the superior splenic pole high-grade injury. View after the
laparoscopic splenectomy with the staple line at the hilum. The greater gastric curvature and pancreatic tail safely preserved (G). Postoperative
results after laparoscopic splenectomy and immediate subsequent vertebral stabilization allowing earlier mobilization (H).
through NGT to verify the effective closure. In case of a major, high-grade, from SW can occur if fascial penetration and can be prevented
by applying occlusive dressings over the SW. Furthermore,
through-and-through injury, a gastric resection or even a total gastrectomy may
be needed. (Video 17, Supplemen tal Digital Content 1, http://links.lww.com/ three cars are preferably inserted in left quadrants allowing
TA/B234) thorough exploration of the entire SB. Exploring the lesser sac
should not be forgotten. Colon, SB, and mesentery must be
Penetrating HVI carefully examined, by gently running the bowel, exploring both bowel side
Pneumoperitoneum is established with open Hasson Small lacerations with viable margins and minimal contamination
tech nique or optical trocar entry in the umbilicus or LUQ. CO2 leak can be safely repaired primarily. Larger lacerations with
Figure 18. Value of diagnostic laparoscopy in penetrating thoracoabdominal trauma for confirmation of peritoneal violation. Case description:
Four cases of diagnostic laparoscopy after abdominal or thoracoabdominal region stab wound with suspicion of peritoneal penetration and
unclear abdomen, to rule out HVI.


Figure 19. Diagnostic laparoscopy for development of clinical peritonitis and sepsis after blunt abdominal trauma with CT findings of
free fluid without clear parenchymal injuries. Laparoscopic findings of diffuse biliary peritonitis without actual LVH or gallbladder/CBD
injuries, conversion to open finding of small liver laceration hidden by the falciform ligament and on the origin of it, with tear of a small
biliary duct. Case description: A 67-year-old hemodynamically stable lady is admitted to the emergency department after a blunt trauma
(bike vs. car). The CT scan showed mild lung contusions, perihepatic and perisplenic free fluid, without evident parenchymal injuries. At
physical examination, the abdomen was soft and nontender. Forty-eight hours later, the patient developed clinical signs of peritonitis.
Repeated CT scan showed increased free fluid but no free air. Diagnostic laparoscopy demonstrated diffuse biliary peritonitis. Accurate
small and large bowel exploration was negative (A). The site of previous cholecystectomy and the liver surface of both lobes looked
intact (B and C). After conversion to laparotomy, a liver laceration underneath the falciform ligament was found with an active biliary leak
from a lacerated secondary biliary duct (D) repaired with primary suture.
shattered/devascularized margins, associated with gross contamination avoid internal hernias or control bleeding. Larger tears with major
nation or involving the mesenteric border, usually require resection, devascularization and ischemic SB require resection and
which can performed laparoscopically, and eventual intracorporeal intracorporeal anastomosis. In case of SB perforations, small
anastomosis, following the same rules of open surgery. (Figs. 1, 4, antimesenteric tears can be primarily repaired by intracorporeal
5, and 20; Videos 4, 9, 17, and 31, Supplemental Digital Content 1, suture. Large defects or shattered/ischemic margins require resection.
http://links.lww.com/TA/B234) (Figs. 1–3; Videos 11, 13, 16, 29, and 30, Supplemental
Digital Content 1, http://links.lww.com/TA/B234)
Small Bowel and Mesenteric Injuries
The treatment of small bowel injuries depends on the ex tent Colonic Traumatic Injuries
of the damage: small-sized perforations with vital margins Colonic serosal tears or full thickness lacerations, if the
can be repaired with double layer suturing, destructive injuries, size is less than 1 cm with viable margins and without significant
or large defects in the mesenteric side must be resected and anas contamination, can be often managed just with a simple laparoscopic
tomosed (intracorporeally or extracorporeally). Mesenteric lacerations repair, but when injuries are destructive and larger lacerations with
may not require any procedure, but if active bleeding is shattered margins are found, resection and anastomosis
found, hemostasis or suturing should be accomplished. Mesenteric (intracorporeal or extracorporeal) or better a stoma diversion
lacerations can be quickly and effectively sealed laparoscopically should be performed. The opportunity of a primary anastomosis
with new hemostatic agents (Floseal, Hemopatch, Tisseel). Small should be evaluated carefully according to patient general conditions,
bowel and mesentery must be carefully explored, by running the- the degree of peritoneal contamination, and the location of
bowel and exploring both bowel sides. Small lacerations with the perforation. Right colonic injuries may be more often amenable
viable margins and minimal contamination can be safely repaired to primary anastomosis in stable and fit patients and when the
primarily. Larger lacerations with shattered or devascularized margins, diagnosis is made early, than left colonic injuries. Laparoscopic
associated with gross contamination or involving the mesenteric Hartmann's resection can be performed in a similar technique
border, or findings of a segment with devascularized bowel, fashion as described elsewhere2 with dissection of the sigmoid
require resection, which with appropriate expertise can be performed mesentery, medial mobilization of the sigmoid colon from the
laparoscopically, and eventual intracorporeal anastomosis, following lateral Toldt's fascia, high rectosigmoid resection with linear
the same rules of open surgery. Abdominal cavity can be altered with endostaplers, cranial mobilization of the resected colonic stump,
open Hasson technique or optical entry in LUQ. and eventually controlling the mesenteric bleeding/completion
Exploration of entire abdomen is performed by run-the-bowel of mesenteric resection with use of endoscopic staplers and vascular
distal-to-proximal, checking both intestinal sides. Small mesen teric reload. The specimen is usually delivered through a mini
defects without underlying ischemia can be repaired to incision in the left flank where the colostomy is also fashioned by


Figure 20. Diagnostic and therapeutic laparoscopy in penetrating abdominal trauma with multiple SW in the upper quadrants,
hemodynamically stable and free air bubbles between the transverse colon and the abdominal wall on CT, no free fluid, and abdominal
examination was still clinically silent. Case description: Hemodynamically stable patient with LUQ and epigastrium stab wounds.
Abdomen was nonperitonitic. The patient was eupnoic, not septic; arterial blood gas was normal; and Focused Assessment Sonography for
TraumaUS was negative. Computed tomography scan done about 70 to 80 minutes from arrival in the emergency department showed visible free
air bubbles close to the transverse colon (red arrow). Early diagnosis usually allows a laparoscopic primary repair of the colon with big bites
seromuscular layers with 3.0 vycril sutures and a possibly second serosal layer. If tissues are devitalized, the edges may need to be freshened up
with cold scissors. Both sides of the bowel must be explored to avoid missing through-and-through injuries.
When the transverse colon is injured, the lesser sac must be explored to find out possible associated injuries of pancreas and stomach.
Laparoscopic suturing skills and a careful inspection of the abdominal cavity are essentials. Technical points: It is preferred to do a primary
repair for a small nondestructive colon injury in a stable patient with minimal localized peritonitis and no sepsis. Minimal debridement and
repaired in double layer intracorporeally. Run the entire small bowel to exclude any other injuries up the Treitz.
Methylene blue via NGT can also be used for double check if any microscopic leak from the stomach (which in this case was looking intact both
anteriorly and posteriorly). Finish with one drain in the lesser sac and another at the base of transverse mesocolon close to the repair.
securing the proximal colonic edges to the fascia/skin. (Figs. 4, 6, and 20; or as a complication of angioembolization but requires a significant
Videos 4, 12, 14, 18, and 31, Supplemental Digital Content 1, http:// hepatobiliary and minimally invasive expertise to be safely per formed
links.lww.com/TA/B234) laparoscopically. (Fig. 19; Videos 5–32, Supplemental Digital Content
1, http://links.lww.com/TA/B234)
Liver
Small liver lacerations with active venous bleeding found Gallbladder and Biliary Tract
during diagnostic or therapeutic laparoscopy for other indications, Gallbladder lacerations or detachments after high-energy
if venous oozing is seen, can be controlled laparoscopically with blunt trauma are rare and can be diagnosed intraoperatively
hemostatic agents or figure-of-eight stitches, but otherwise, they and treated with simultaneous laparoscopic cholecystectomy
do not need to be surgically treated . Arterial hepatic bleeding is (Fig. 19; Videos 5–32, Supplemental Digital Content 1 , http://
usually primarily eligible for angiography and embolization, if links.lww.com/TA/ B234). Most common can be penetrating
available; otherwise, they can be controlled with laparoscopic injuries of the gallbladder after SW in the RUQ, and if the patient
figure-of-eight stitches, but this may better usually need is stable, they can be amenable to laparoscopic diagnosis and
conversion to an open procedure and probing or opening the treatment with a definitive laparoscopic cholecystectomy and
liver fracture for exploring a possible arterial bleeding is never wash out of biliary peritonitis. Common bile duct injuries are
advised laparoscopically. Liver resection may be only indicated very rare, and their diagnosis is usually delayed. Usually, they
as delayed procedure in case of large hepatic necrosis develops afterneed open surgery and referral to a
trauma


specialized hepato-bilio-pancreatic unit for definitive surgery. attachments (splenocolic, splenophrenic, and splenorenal
The laparoscopic treatment of a biliary leak should be considered only after a ligaments) with aid of the hook and monopolar energy to get
failed attempt or unavailable endoscopic retrograde cholangio-pancreatography enough mobilization and medial rotation. Once freed from the
or percutaneous biliary stenting and consists of a biliary laparoscopic suturing/ ligaments, the spleen is thus bluntly suspended with aid of the
clipping or positioning of a biliary transcystic or T-tube drain in the common suction tube, and a modified hanging spleen technique can be
bile duct Often, gallbladder necrosis leading to gangrene/perforation may occur applied to lift the spleen up, to avoid further parenchymal trauma
as a consequence of heavy angioembolization of the main branches of the and capsular tears, which may worsen intraoperative back flow
hepatic artery during initial NOM of severe, high-grade liver injuries with bleeding from the injured splenic parenchyma, to expose and
multiple blushes diffuse in different hepatic segments (Video 32, Supplemental safely access the splenic hilum. The hilum is clamped and
Digital Content 1, http://links.lww.com/TA/B234). controlled with a vascular-cartridge flexible endostapler. The
short gastric vessels are stapled and divided with a separate
load, and the splenectomy is quickly completed. After gradual
stapling and division of the splenic hilar vessels and short gastric
Pancreas vessels, which were easily achieved, thanks to the flexible arm
The AAST Grades I and II pancreatic injury can be non- of the endostapler, the splenectomy is quickly completed. Care
operatively managed, but if found during diagnostic laparoscopy, ful exploration of the left diaphragm, splenic colonic flexure, and
hemostasis and drain placement can be performed with a mini gastric greater curvature to exclude associated injuries is
mally invasive procedure. The treatment of Grade III pancreatic recommended. After irrigation, hemostasis of the splenic bed
injuries depends on the location of the ductal tear along the must be verified and eventually completed with aid of bipolar
organ: traumas of the pancreatic head are preferably just drained, energy and topical hemostatic agents, and corrugated drains are
while those of the tail can be treated with a distal pancreatectomy inserted in LUQ and Douglas pouch.
(“suck the head and eat the tail ”) and usually not suitable for The specimen is retrieved in an endobag, completely
laparoscopic procedures. Grades IV and V pancreatic injuries morcellated and extracted through the umbilical access, using a
are usually modynamically unstable and cannot be treated laparoscopically. wound protector.
However, laparoscopy can be useful to control eventual In the case of splenic abscess after AE and large purulent
postoperative low output fistulas. (Videos 5 and 6, Supplemental collections around the abscessualized spleen, we advise the
Digital Content 1, http://links.lww.com/TA/B234) following technique:
Patient's position should always be supine, because in
Splenectomy case of sudden occurring of intraoperative bleeding/hemodynamic
In splenic injuries, supine position and legs closed with instability, a rapid conversion to laparotomy is necessary.
surgeon standing on the right side of the patient is preferred, Umbilical access is gained with open Hasson technique and
given the risk of a rapid conversion to laparotomy in case of sud three or four more trocars are inserted in the epigastrium, LUQ,
den hemodynamic instability or unexpected and uncontrollable and right flank as necessary (see trocar position in Figs. 11G,
bleeding and also given the frequent association with complex 12D, 13F, 14D, 15F, 16F, 17H). Inflammatory adhesions between
orthopedic or pelvic injuries and the risks associated with spleen, omentum, and colon are divided bluntly using suction
standing between legs spread apart. To achieve a better exposure tube, the safest way to get avascular plane. Perisplenic purulent
of the left upper quadrant, if possible and in the absence of collections are entered bluntly and drained. Capsular tears can
scapular or vertebral fractures or severe left thoracic trauma, a be trolled with bipolar coagualtion and gauze packing. Spleen is
pillow under the hemi thorax or left scapula can be useful. Some freed dividing its ligaments using monopolar hook and blunt dis
surgeons may prefer standing between open legs to better section, achieving mobilization of inferior pole (after division of
access the left upper quadrant, but this is contraindicated in case splenocolic ligament), followed by medial rotation (splenorenal
of blunt trauma with concomitant lower spinal, pelvic, and/or ligament). Spleen is suspended upwards using endoretractor,
inferior extremities or thopedic fractures. After securing the and splenic hilum is exposed and divided by endostapler.
patient to the table with belts, a moderate left-side up tilt and anti- Short-gastric vessels are stapled; splenectomy is completed,
Trendelenburg position can be achieved. (Figs. 11–17; Videos 1, following mobilization of the superior pole (after division of
2, and 21–28, Supplemental Digital Content 1, http://links.lww.com/TA/B234) splenodiaphragmatic attachments and short-gastric vessels).
Trocars are positioned in the umbilicus with open Hasson Spleen is morcellated and extracted within an endobag through
access technique, two in the left flank and a fourth in the umbilical port.
epigastrium. All these ports can easily be connected in case of
conversion to open. Minimal evacuation of the splenic blood clot Bladder
is performed to avoid “popping out” the clot and eventually cause Bladder lacerations with intraperitoneal leak, most
a sudden copious arterial bleeding. Inflammatory adhesions frequently found after blunt abdominal traumas and seat belts
between spleen, omentum and colon, if present, can be divided causing a blow out of the full bladder, can be effectively repaired
bluntly using suction tube, which is the safest way to get relatively by laparoscopic interrupted absorbable suturing with a single or
avascular and safe plans of dissection in the presence of severe double layer repair of heavy reabsorbable sutures. Laparoscopic
inflammation. suturing and knotting skills are essential. Best position of trocars
The inferior polar vessels can be identified and clipped is umbilical port for the camera and two more trocars in the RLQ
separately or stapled altogether with splenic hilum. The spleen and LLQ for an adequate triangulation and smooth laparoscopic
is rapidly mobilized, dividing the inferior, posterior, and lateral suturing. Foley catheter is left for few days until a postoperative


cystogram is obtained. (Fig. 10; Video 13, Supplemental Digital 4. Parajuli P, Kumar S, Gupta A, Bansal VK, Sagar S, Mishra B, Singhal M,
Kumar A, Gamangatti S, Gupta B, et al. Role of laparoscopy in patients with
Content 1, http://links.lww.com/TA/B234).
abdominal trauma at level-I trauma center. Surg Laparosc Endosc Percutan
Tech. 2018;28(1):20–25.
Vascular Injuries 5. Hajibandeh S, Hajibandeh S, Gumber AO, Wong CS. laparoscopy versus
Minor vascular injuries (eg, mesenteric injuries) can be laparotomy for the management of penetrating abdominal trauma: a systemic
laparoscopically treated with diathermic coagulation, hemostatics, review and meta-analysis. Int J Surg. 2016;34:127–136.
hemoclips, or suturing. Before attempting a laparoscopic 6. Cirocchi R, Birindelli A, Inaba K, Mandrioli M, Piccinini A, Tabola R,
treatment of arterial bleeding, we suggest to always keep in mind Carlini L, Tugnoli G, Di Saverio S. Laparoscopy for trauma and the changes
in its use from 1990 to 2016: a current systematic review and meta-analysis.
the chance of better treating this type of injuries with angio Surg Laparosc Endosc Percutan Tech. 2018;28(1):1–12.
embolization if available and eventually consider a laparoscopic 7. Mandrioli M, Inaba K, Piccinini A, Biscardi A, Sartelli M, Agresta F,
approach only if this first option fails, or for mesenterial bleeding Catena F, Cirocchi R, Jovine E, Tugnoli G, Di Saverio S. Advances in
and if the patient remains perfectly hemodynamically stable. laparoscopy for acute care surgery and trauma. World J Gastroenterol. 2016;
Large vessels injuries are usually associated with hemodynamic 22(2):668–680.
instability, and there is no role at all for laparoscopy in such 8. Sammour T, Kahokehr A, Chan S, Booth RJ, Hill AG. The humoral response
after laparoscopic versus open colorectal surgery: a meta-analysis. J Surg
patients. (Figs. 3–6; Videos 10, 13, and 30, Supplemental Digital
Res. 2010;164(1):28–37.
Content 1, http://links.lww.com/TA/B234).
9. Krog AH, Sahba M, Pettersen EM, Sandven I, Thorsby PM,
Jørgensen JJ, Sundhagen JO, Kazmi SS. Comparison of the acute phase
CONCLUSIONS response after laparoscopic versus open aortobifemoral bypass
surgery: a substudy of a randomized controlled trial. Vasc Health Risk
Manag. 2016;12:371–378.
The use of laparoscopy in trauma patients is increasingly
10. Dreizin D, Bergquist PJ, Taner AT, Bodanapally UK, Tirada N, Munera F.
been reported both as a diagnostic and a therapeutic tool and
Evolving concepts in MDCT diagnosis of penetrating diaphragmatic injury.
may have significant advantages in terms of morbidity and costs, Emerg Radiol. 2015;22(2):149–156.
but it requires a careful selection of patients, a collaborating and 11. Matsushima K, Mangel PS, Schaefer EW, Frankel HL. Blunt Hollow Viscus
equipped setting, and, last but not the least, a highly skilled lap and mesenteric injury: still underrecognized. World J Surg. 2013;37(4):
aroscopic trauma surgeon. In fact, the wrong selection of patients 759–765.
and the missed injuries are the main risks, and these are 12. Lin HF, Chen YD, Lin KL, Wu MC, Wu CY, Chen SC. Laparoscopy de
more likely to occur if the surgeon has limited experience. creases the laparotomy rate for hemodynamically stable patients with blunt
hollow viscus and mesenteric injuries. Am J Surg. 2015;210(2):326–333.
AUTHORSHIP 13. Stefanidis D, Richardson WS, Chang L, Earle DB, Fanelli RD. The role of
diagnostic laparoscopy for acute abdominal conditions: an evidence-based
SDS performed all the procedures. SDS and CC developed the indications and review. Surg Endosc. 2009;23(1):16–23.
selection criteria. AB helped in drafting the article. EN and 14. O'Malley E, Boyle E, O'Callaghan A, Coffey JC, Walsh SR. Role of
AP helped in editing the videos. MP, CF, and GT revised critically laparoscopic copy in penetrating abdominal trauma: a systematic review. World J Surg.
the final article. AB, ES, CF, and AP assisted in OR the attending sur geon SDS 2013;37(1):113–122.
15. Powell BS, Magnotti LJ, Schroeppel TJ, Finnell CW, Savage SA, Fischer PE,
ACKNOWLEDGMENTS Fabian TC, Croce MA. Diagnostic laparoscopy for the evaluation of occult
diaphragmatic injury following penetrating thoracoabdominal trauma.
SDS and GT, senior Trauma Surgeons at Maggiore Hospital Trauma injury. 2008;39(5):530–534.
Center, would like to acknowledge the mastery and common sense of 16. Miles EJ, Dunn E, Howard D, Mangram A. The role of laparoscopy in pen
their common master Dr Franco Baldoni MD PhD, who was inspirational treating abdominal trauma. JSLS. 2004;8(4):304–309.
for being well performing open trauma surgeons, which is an essential
17. Friese RS, Colon CE, Gentilello LM. Laparoscopy is sufficient to exclude
prerequisite before SDS could start embarking on challenging and pio neering
occult diaphragm injury after penetrating abdominal trauma. J Trauma. 2005;
advanced procedures of laparoscopic trauma surgery. SDS
58(4):789–792.
would also thankfully acknowledge Dr Andrea Biscardi MD for being an assistant
surgeon in theater and contributing to the development of Trauma 18. Ahmed N, Whelan J, Brownlee J, Chari V, Chung R. The contribution of
Laparoscopy in the Maggiore Hospital of Bologna. laparoscopy in evaluation of penetrating abdominal wounds. J Am Coll Surg.
2005;201(2):213–216.
DISCLOSURE 19. Berg RJ, Inaba K, Okoye O, Pasley J, Teixeira PG, Esparza M,
The authors declare no conflicts of interest. Demetriades D. The contemporary management of penetrating splenic in
Ethical approval: All procedures performed in studies involving human jury. injury. 2014;45(9):1394–1400.
participants were in accordance with the ethical standards of the institutional and/ 20. Mjoli M, Oosthuizen G, Clarke D, Madiba T. Laparoscopy in the diagnosis
or national research committee and with the 1964 Declaration and repair of diaphragmatic injuries in left-sided penetrating thora
of Helsinki and its later amendments or comparable ethical standards. coabdominal trauma: laparoscopy in trauma. Surg Endosc. 2015;29(3):
Informed consent: Informed consent was obtained from all individual participants 747–752.
included in the study. 21. Kawahara NT, Alster C, Fujimura I, Poggetti RS, Birolini D. Standard
examination system for laparoscopy in penetrating abdominal trauma. J Trauma.
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Trauma laparoscopy and the six w's: Why, where,

in dangerous and long-lasting laparoscopic procedures (how).

Copyright © 2019 Wolters Kluwer Health, Inc. All rights reserved.

J Trauma Acute Care Surg

The correct selection of candidates is extremely important

Potential Risks of Laparoscopy The

© 2018 Wolters Kluwer Health, Inc. All rights reserved. 3. 4. 5

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J Trauma Acute Care Surg

TABLE 2. ATLS Classification of Hemorrhagic Shock

Blood loss, mL <750 750–1500 1500–2000 >2000

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J Trauma Acute Care Surg