Ruolo della laparoscopia nei traumi addominali Dr Micaela Piccoli UO complessa di Chirurgia generale e d’urgenza Dipartimento di Chirurgia, Dir. G Melotti N.O.C.S.A.E, Baggiovara Master di II livello Chirurgia Mini-invasiva d’urgenza e moderne applicazioni tecnologiche

Laparoscopy in trauma Conservative   Risk of missed injuries Intestinal Diaphragm Laparotomy   Mortality: 0 – 5 %   Morbidity: 20 %   Bowel obstruction: 3%   Unnecessary: up to 70 %

Laparoscopy in trauma Conservative   Risk of missed injuries Intestinal Diaphragm Laparotomy   Mortality: 0 – 5 %   Morbidity: 20 %   Bowel obstruction: 3%   Unnecessary: up to 70 % LAPAROSCOPY

Laparoscopy in trauma Selman Uranüs. Laparoscopy in Abdominal Trauma. Eur J Trauma Emerg Surg 2010;36:19–24

Laparoscopia diagnostica nel trauma   Efficace e sicura (Livello I-III) in pazienti selezionati (B) ‏   Possibile da eseguire anche in Pronto Soccorso in anestesia locale (Livello III) ‏   8-12mmHg. Attenzione allo pnx iperteso da lesione misconosciuta del diaframma National Guideline Clearinghouse Update SAGES guidelines 2002

Laparoscopia diagnostica nel trauma   Indicazioni in stabilità emodinamica (C) : Sospetta lesione intraddominale nonostante un iniziale workup negativo, nei traumi chiusi Trauma aperto da arma bianca con penetrazione fasciale Trauma aperto da arma da fuoco con sospetta traiettoria intraddominale Lesione diaframmatica da trauma penetrante nell’area toraco-addominale Creazione di una finestra pericardica transdiaframmatica per verificare una lesione cardiaca National Guideline Clearinghouse Update SAGES guidelines 2002  Accurato monitoraggio postoperatorio per una precoce diagnosi di lesioni non identificate durante la laparoscopia  Laparoscopia operativa in centri con elevata esperienza (C)

Laparoscopia terapeutica nel trauma   Riparazione definitiva della lesione: Riparazione di lesioni diaframmatiche Riparazione di lesioni gastro-intestinali Resezioni pancreatiche Riparazione di lesioni vescicali Emostasi epatiche. Washout del sangue e/o controllo della bliostasi Splenectomie/emostasi spleniche Current Surgery 2004  Aspirazione dell’emoperitoneo: Riduce la degenza ospedaliera Diminuisce la risposta infiammatoria Autotrasfusione con dimunizione del n. di trasfusioni  Colostomia

Laparoscopy in trauma   Blunt trauma: sensitivity of 100%, specificity of 91%, and accuracy of 96%   Penetrating trauma: sensitivity of 80– 100%, specificity of 38–86%, and accuracy of 54–89%   Missed injuries with screening laparoscopy were 0.4%   Laparoscopy-related complications were 1.3%   Prevent laparotomy in 63% Villavicencio. Analysis of Laparoscopy in Trauma. J Am Coll Surg 1999;189:11–20

Traumi addominali (161 casi) dal 06/01/06 al 01/09/11 approccio laparoscopico 42 casi (26%) Blunt 39 Stab 2 Gunshot

Results   Missed injuries 2/42 (4,7%): 1 intestinal injury (reoperated) 1 bleeding (reoperated)   Laparotomies prevented : 24/42 (57 %)

Selman Uranüs. Laparoscopy in Abdominal Trauma. Eur J Trauma Emerg Surg 2010;36:19–24

Villavicencio. Analysis of Laparoscopy in Trauma. J Am Coll Surg 1999;189:11–20

Therapeutic laparoscopy: 13 pts, 17 procedures TreatmentNumber Bilistasis1 Cholecystectomy1 Liver hemostasis3 Spleen hemostasis1 Hemostasis meso3 Intestinal suture3 Diaphragm suture1 Uterin hemostasis1 Splenectomy2 Bladder suture 1

TAC ADDOME 23/02/2008 Trauma chiuso addominale (contrasto con portiere, durante una partita di calcio), pz. di sesso maschile, anni 17, stabile. TAC ADDOME 23/02/2008 Rottura centrale del parenchima epatico con interessamento del IV, V e VI segmento; in quest’ultimo lacerazione capsulare. Sottile raccolta liquida sottocapsulare (la capsula mostra intensa impregnazione contrastografica) di 8mm di spessore max; discreta quantità di liquido (ematico) in sede periepatica, perisplenica, nelle docce parietocoliche e nello scavo pelvico.

Arteriografia selettiva tripode celiaco ed epatica 23/02/2008 L’angiografia selettiva dell’arteria epatica evidenzia sanguinamento attivo di un ramo periferico per il V segmento

Arteriografia selettiva tripode celiaco ed epatica 23/02/2008 L’angiografia selettiva dell’arteria epatica evidenzia sanguinamento attivo di un ramo periferico per il V segmento

Arteriografia selettiva tripode celiaco ed epatica 23/02/2008 Dopo embolizzazione con spongostan, buona devascolarizzazione del vaso sanguinante.

Arteriografia selettiva tripode celiaco ed epatica 23/02/2008 Dopo embolizzazione con spongostan, buona devascolarizzazione del vaso sanguinante.

TAC ADDOME 24/02/2008 In adiacenza al focolaio di frattura epatica, si rileva la presenza di materiale iperdenso, con alcune bolle aeree contestuali, senza segni di sanguinamento attivo. Aumento del versamento libero endoaadominale

Arteriografia selettiva epatica 23/02/2008 Non evidenza di focolai attivi di sanguinamento

Arteriografia splenica 23/02/2008 Non evidenza di focolai attivi di sanguinamento

Traumi addominali: trattamento chirurgico Ruolo della laparoscopia BILIOSTASI

RAFFIA DIGIUNALE

Traumi addominali: trattamento chirurgico Ruolo della laparoscopia SUTURADIAFRAMMATICA

Società Italiana Chirurgia Endoscopica e nuove tecnologie (SICE) Società Italiana di Chirurgia (SIC) Associazione Chirurghi Ospedalieri Italiani (ACOI) Società Italiana Chirurgia d'Urgenza e Trauma (SICUT) Società Italiana Chirurghi dell’Ospedalità Privata (SICOP) The Consensus has been held under the Auspices of the EAES.

Topics Acute cholecystitis Acute pancreatitis Acute appendicitis Gynecologic disorders Non-Specific Abdominal Pain Perforated Gastroduodenal ulcer Acute diverticulitis Small bowel obstruction Incarcerated hernias Ventral hernias Abdominal Trauma – V. Mandalà Mesenteric ischemia

In stable penetrating trauma of the abdomen, laparoscopy may be particularly useful in patients with documented or equivocal penetration of the anterior fascia.(GoR B) Laparoscopy should be considered in hemodynamically stable blunt trauma patients with suspected intra-abdominal injury and equivocal findings on imaging studies or even in patients with negative studies but with a high clinical likelihood for intra- abdominal injury (“unclear abdomen”) to exclude relevant injury (GoR C) To optimize results, the procedure should be incorporated in institutional diagnostic and treatment algorithms for trauma patients (GoR D). Vincenzo Mandalà ABDOMINAL TRAUMA

Diagnostic laparoscopy It is indicated in hemodynamically stable patients with suspect intra-abdominal lesions and equivocal findings on imaging studies, and when non-operative management is not indicated (suspect hollow viscus injuries with peritonitis, potential diaphragmatic lesion). The procedure decreases the rate of negative laparotomies and minimizes patients morbidity. (Diagnostic accuracy about 75%). (EL 2b) Leppäniemi A, Haapiainen R. (2003) Diagnostic laparoscopy in abdominal stab wounds: a prospective, randomized study. J Trauma Oct;55(4): National Guideline Clearinghouse. Diagnostic Laparoscopy for trauma. Guideline Summary NGC – 6829(NCG Status: Update information was verified by the guideline developer on March 9, 2009) Choi YB., Lim KS. (2003) Therapeutic laparoscopy for abdominal trauma. Surg Endosc 17: 421–427

ABDOMINAL TRAUMA Diagnostic laparoscopy The procedure is usually performed under general anesthesia; however, local anesthesia with I.V. sedation has also been used successfully in the emergency department (“awake laparoscopy”) (EL 4) Weinberg JA, Magnotti LJ, Edwards NM, Claridge JA, Minard G, Fabian TC, Croce MA. (2007) "Awake" laparoscopy for the evaluation of equivocal penetrating abdominal wounds”. Injury Jan 38(1):60-4 Suction/irrigation may be needed for optimal visualization, and methylene blue can be administered to help identify gastrointestinal injuries. In penetrating injuries, peritoneal violation can be determined (EL4). Stefanidis D, Richardson W S, Lily C, Earle D B., Fanelli R D (2009) The role of diagnostic laparoscopy for acute abdominal conditions: an evidence-based review. Surg Endosc 23:16–23.

ABDOMINAL TRAUMA Therapeuthic laparoscopy In a highly selected group of patients therapeutic laparoscopy should be performed only by surgeons skilled in advanced mini-invasive surgery (EL3a). Smith RS, Fry WR, Morabito DJ, Koehler RH, Organ CH Jr (1995) Therapeutic laparoscopy in trauma. Am J Surg 170:632–637 Matthews BD, Bui H, Harold KL, Kercher KW, Adrales G, ParkA, Sing RF, Heniford BT (2003) Laparoscopic repair of traumatic diaphragmatic injuries. Surg Endosc. 17: 254–258 Smith CH, Novick TL, Jacobs DG, Thomason MH (2000) Laparoscopic repair of a ruptured diaphragm secondary to blunt trauma. Surg Endosc 14: 501– 502 Zantut LF, Ivatury RR, Smith RS, Kawahara NT, Porter JM, Fry WR, Poggetti R, Birolini D, Organ CH Jr(1997) Diagnostic and therapeutic laparoscopy for penetrating abdominal trauma: a multicenter experience. J Trauma 42: 825–831. Mathonnet M, Peyrou P, Gainant A, Bouvier S, Cubertafond P (2003) Role of laparoscopy in blunt perforations of the small bowel. Surg Endosc 17: 641– 645 Warren O, Kinross J, Paraskeva P,Darzi A (2006) Emergency laparoscopy – current best practice. World Journal of Emergency Surgery, 1:24 Laparoscopy allows to manage hemoperitoneum, diaphragmatic, mesentery and hollow viscus injuries and avoid non-therapeutic laparotomy. Diaphragmatic laceration and perforating stab wounds of the gastrointestinal tract can be sewn or stapled safely when laparoscopic expertise is available (EL 4)

ABDOMINAL TRAUMA Complications - Costs PROCEDURE-RELATED COMPLICATIONS (11%):  Tension pneumothorax in patients with diaphragmatic injury from positive-pressure pneumoperitoneum  Gas embolism in patients with intraabdominal venous injuries;  Metabolic and hemodynamic changes caused by trans-peritoneal absorption of carbon dioxide (especially in liver lacerations) such as acidosis, cardiac suppression, atelectasis, subcutaneous emphysema and increased intracranial pressure. Fabian TC, Croce MA, Stewart RM, Pritchard F.E., Minard G, Kudsk KA (1993) A prospective analysis of diagnostic laparoscopy in trauma. Ann Surg 217: 557–565 Chen RJ, Fang JF, Lin BC, Hsu YB, Kao JL, Kao YC, Chen MF (1998) Selective application of laparoscopy and fibrin glue in the failure of nonoperative management of blunt hepatic trauma. J Trauma 44: 691–695 [i]

ABDOMINAL TRAUMA Complications - Costs [i] COST ANALYSIS:  A retrospective study of total hospital costs of exploratory laparotomy vs diagnostic laparoscopy in 37 patients with penetrating abdominal trauma: Laparoscopy is 1136 Euro cheaper than exploratory laparotomy) Marks JM, Youngelman DF, Berk T (1997) Cost analysis of diagnostic laparoscopy vs laparotomy in the evaluation of penetrating abdominal trauma. Surg Endosc 11: 272–2  A prospective, randomized study of 43 patients with abdominal stab wounds: No difference between the two strategies in the total hospital costs (EL 4) Leppäniemi A, Haapiainen R. (2003) Diagnostic laparoscopy in abdominal stab wounds: a prospective, randomized study. J Trauma Oct;55(4):

The usefulness of videothoracoscopy in the setting of chest trauma is the possibility to remove intrathoracic foreign bodies expeditiously in a less invasive way than thoracotomy. Videothoracoscopy in Chest Trauma In conclusion, videothoracoscopy is a safe, accurate, and useful diagnostic and therapeutic tool in the acute management of selected patients with penetrating chest trauma and no indication for emergent thoracotomy or sternotomy.

Videothoracoscopy in Chest Trauma It is also useful in the acute or delayed management of patients with blunt trauma for removal of clotted hemothorax, for treatment of thoracic empyema, for treatment of persistent pneumothorax, for treatment of recurrent or continued chylothorax, and for diagnosis of diaphragmatic injuries. However, we do not recommend use of videothoracoscopy in the setting of suspected cardiac or pericardial injury.

Videothoracoscopy in Chest Trauma