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Sat Nov 22 16:30:09 GMT 2008

There is very little if any use for the laparoscopy in the primary
assessment and management of either blunt or penetrating trauma of the
abdomen.

That having been said, let me explain my views: my first research on
this device was in the mid 1970's. This was reported and subsequently
published. This was a needlescope inserted under local anesthesia in the
ED for the assessment of blunt trauma. We found that it took longer, was
more expensive and took longer than diagnostic peritoneal lavage and the
assessment results were the same. Therefore it was not pursued, as a
diagnostic technique. To my knowledge this was the first reported use of
laparoscopy in the care of the trauma patient 

Fast forward 30 years to 2008.  

To assess the abdominal cavity for the need of surgical management one
needs to look for two types of injuries: ongoing hemorrhage and GI tract
injuries. 

1) Gross hemorrhage can be found with a variety of means that are less
costly and with less complication than a laparoscope. DPL is the most
accurate but not necessarily the best for hemorrhage that requires
operative management. It has an over triage factor. DPL identifies the
presence of blood but not the presence of ONGOING hemorrhage. However,
neither CT nor FAST can do this either. 

2) the other needed assessment is injury to the GI tract. In the hands
of most operators, it requires 2-4 hours to run the small bowel and
accurately rule out injury using the laparoscopy. 

Yes, one can assess the presence of abdominal perforation in penetrating
trauma with a laparoscope but the mere presence of peritoneal
penetration does not indicate the need for surgical repair. Nance in
1969 and Shafton in 1974, both demonstrated this, as well as, the
superiority of a standard physical examination and frequent follow-up
examinations as more accurate than other techniques. With the advent of
other technologies FAST, CT or CTA there is still nothing that exceeds
the accuracy that Nance and Shafton described almost 40 years ago. VOMIT
(to use the Mattox phrase). Why put a patient to sleep for a laparotomy
when serial examinations can produce the same outcome without the
complications

The management of hemorrhage and the repair of GI tract injures is far
more difficult with a laparoscope than with an open abdomen

A 30 minute, skin to skin, exploratory laparotomy can do assessment (and
management, if necessary) as quick as, with cheaper costs over all
costs, and less complications than a laparoscopy under general
anesthesia. This is in those cases the physical examination, hard signs
physiological conditions are equivocal. 

Why do a laparoscopy, when the accuracy is not as good and the injuries
cannot be repaired as well, it is not as fast as, and it is probably
more expensive when compared to a laparotomy.

Thus my initial statement-----"There is very little if any use for the
laparoscopy in the primary assessment and management of either blunt or
penetrating trauma of the abdomen"

VATS is different. It can be used for the management of hemorrhage in
most chest injuries. It can be used to identify diaphragmatic
perforation ( and the potential need for a laparotomy). And it is
cheaper in complications, time and money than a thoracotomy

The chest and abdomen are two different cavities, two different types of
problems tow different kinds of complications and two different
outcomes. Do not try to compare these in the same thought process

Norman

Norman McSwain Jr, MD FACS
Trauma Director Charity Hospital
Professor of Surgery
Tulane University School of Medicine
504 988 5111

-----Original Message-----
From: trauma-list-bounces at trauma.org
[mailto:trauma-list-bounces at trauma.org] On Behalf Of rm khattar
Sent: Saturday, November 22, 2008 7:05 AM
To: trauma-list at trauma.org
Subject: Laparoscopy in trauma

Let me refine my question.
1.Role of Diagnostic and therapeutic laparoscopy in blunt and
penetrating abdominal trauma.
2.Role of VATS in thoracic trauma.
R.M.Khattar.
India.

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