Are we doing too many non-therapeutic laparotomies in trauma? An analysis of the National Trauma Data Bank

Abstract

Background

Exploratory laparotomy (EL) has been the definitive diagnostic and therapeutic modality for operative abdominal trauma in the US. Recently, many trauma centers have started using diagnostic laparoscopy (DL) in stable trauma patients in an effort to reduce the incidence of non-therapeutic laparotomy (NL). We aim to evaluate the incidence of NL in the trauma population in the US and compare the outcomes between DL and NL.

Methods

Using ICD-9 codes, the National Trauma Data Bank (2010–2015) was queried for patients undergoing any abdominal surgical intervention. Patients were divided into two groups: diagnostic laparoscopy (DL) and exploratory laparotomy (EL). Hemodynamically unstable patients on arrival and patients with abbreviated injury score (AIS) > 3 were excluded. Patients in EL group without any codes for gastrointestinal, diaphragmatic, hepatic, splenic, vascular, or urological procedures were considered to have undergone NL. After excluding patients who were converted to open from the DL group, multivariate regression models were used to analyze the outcomes of DL vs NL group with respect to mortality, length of stay, and complications.

Results

A total of 3197 patients underwent NL vs 1323 patients who underwent DL. Compared to DL group, the NL group were older (mean age: 35 vs. 31, P < 0.01). Rate of penetrating injury was 77% vs 86% for patients in NL vs DL. On multivariate analysis, NL was associated with increased mortality (OR 4.5, 95% CI 2.1–9.7), higher rate of complications (OR 2.2, 95% CI 1.4–3.3), and a longer hospital stay (OR 2.7, 95% CI 2.1–3.5). NL was also associated with higher rates of pneumonia, VTE, ARDS, and cardiac arrest.

Conclusion

With increasing experience in minimally invasive surgery, DL should be a part of the armamentarium of trauma surgeons. This study supports that in well-selected trauma patients DL has favorable outcomes compared to NL. These findings warrant further investigation.

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References

  1. 1.

    Justin V, Fingerhut A, Uranues S (2017) Laparoscopy in blunt abdominal trauma: for whom? When? and Why? Curr Trauma Rep 3:43–50

    Article  Google Scholar 

  2. 2.

    Li Y, Xiang Y, Wu N, Wu L, Yu Z, Zhang M, Wang M, Jiang J, Li Y (2015) A comparison of laparoscopy and laparotomy for the management of abdominal trauma: a systematic review and meta-analysis. World J Surg 39:2862–2871

    Article  Google Scholar 

  3. 3.

    Lee P, Lo C, Wu JM, Lin KL, Lin HF, Ko WJ (2014) Laparoscopy decreases the laparotomy rate in hemodynamically stable patients with blunt abdominal trauma. Surg Innov 21:155–165

    Article  Google Scholar 

  4. 4.

    Shamim AA, Zafar SN, Nizam W, Zeineddin A, Ortega G, FullumTM Tran DD (2018) Laparoscopic splenectomy for trauma. JSLS. https://doi.org/10.4293/JSLS.2018.00050

    Article  PubMed  PubMed Central  Google Scholar 

  5. 5.

    Hajibandeh S, Hajibandeh S, Gumber AO, Wong CS (2016) Laparoscopy versus laparotomy for the management of penetrating abdominal trauma: a systematic review and meta-analysis. Int J Surg. https://doi.org/10.1016/j.ijsu.2016.08.524

    Article  PubMed  Google Scholar 

  6. 6.

    Ertekin C, Yanar H, Taviloglu K, Güloglu R, Alimoglu O (2005) Unnecessary laparotomy by using physical examination and different diagnostic modalities for penetrating abdominal stab wounds. Emerg Med J 22:790–794

    CAS  Article  Google Scholar 

  7. 7.

    Arikan S, Kocakusak A, Yucel AF, Adas G (2005) A prospective comparison of the selective observation and routine exploration methods for penetrating abdominal stab wounds with organ or omentum evisceration. J Trauma 58:526–532

    Article  Google Scholar 

  8. 8.

    Schnüriger B, Lam L, Inaba K, Kobayashi L, Barbarino R, Demetriades D (2012) Negative laparotomy in trauma: are we getting better? Am Surg 78:1219–1223

    PubMed  Google Scholar 

  9. 9.

    Lin HF, Chen YD, Lin KL, Wu MC, Wu CY, Chen SC (2015) Laparoscopy decreases the laparotomy rate for hemodynamically stable patients with blunt hollow viscus and mesenteric injuries. Am J Surg 210:326–333

    Article  Google Scholar 

  10. 10.

    Matsevych OY, Koto MZ, Aldous C (2018) Trauma laparoscopy: a prospect of skills training (cohort study). Int J Surg 55:117–123

    CAS  Article  Google Scholar 

  11. 11.

    Lim KH, Chung BS, Kim JY, Kim SS (2015) Laparoscopic surgery in abdominal trauma: a single center review of a 7-year experience. World J Emerg Surg. https://doi.org/10.1186/s13017-015-0007-8

    Article  PubMed  PubMed Central  Google Scholar 

  12. 12.

    Chestovich PJ, Browder TD, Morrissey SL, Fraser DR, Ingalls NK, Fildes JJ (2015) Minimally invasive is maximally effective: diagnostic and therapeutic laparoscopy for penetrating abdominal injuries. J Trauma Acute Care Surg 78:1076–1085

    Article  Google Scholar 

  13. 13.

    Marks JM, Youngelman DF, Berk T (1997) Cost analysis of diagnostic laparoscopy vs laparotomy in the evaluation of penetrating abdominal trauma. Surg Endosc 11:272–276

    CAS  Article  Google Scholar 

  14. 14.

    O’Malley E, Boyle E, O’Callaghan A, Coffey JC, Walsh SR (2013) Role of laparoscopy in penetrating abdominal trauma: a systematic review. World J Surg 37:113–122

    Article  Google Scholar 

  15. 15.

    DeMaria EJ, Dalton JM, Gore DC, Kellum JM, Sugerman HJ (2000) Complementary roles of laparoscopic abdominal exploration and diagnostic peritoneal lavage for evaluating abdominal stab wounds: a prospective study. J Laparoendosc Adv Surg Tech A 10:131–136

    CAS  Article  Google Scholar 

  16. 16.

    Miles EJ, Dunn E, Howard D, Mangram A (2004) The role of laparoscopy in penetrating abdominal trauma. JSLS 8:304–309

    PubMed  PubMed Central  Google Scholar 

  17. 17.

    Short AR (1925) The uses of coelioscopy. Br Med J 2:254–255

    CAS  Article  Google Scholar 

  18. 18.

    Villavicencio RT, Aucar JA (1999) Analysis of laparoscopy in trauma. J Am Coll Surg 189:11–20

    CAS  Article  Google Scholar 

  19. 19.

    Kawahara NT, Alster C, Fujimura I, Poggetti RS, Birolini D (2009) Standard examination system for laparoscopy in penetrating abdominal trauma. J Trauma 67:589–595

    Article  Google Scholar 

  20. 20.

    Matsevych O, Koto M, Balabyeki M, Aldous C (2018) Trauma laparoscopy: when to start and when to convert? Surg Endosc 32:1344–1352

    Article  Google Scholar 

  21. 21.

    Koto MZ, Matsevych OY, Aldous C (2018) Diagnostic laparoscopy for trauma: how not to miss injuries. J Laparoendosc Adv Surg Tech A 28:506–513

    Article  Google Scholar 

  22. 22.

    - Bloom BA, Gibbons RC (2019). Focused assessment with sonography for trauma (FAST). https://www.ncbi.nlm.nih.gov/books/NBK470479/. Accessed 1 Apr 2019

  23. 23.

    - Sudakoff GS, Rosen MP, Rybicki FJ, Blake MA, Cash, BD, Desjardins B, Greene FL, Hindman NM, Oliva IB, Weiss C, Yaghmai V (2012). American College of Radiology ACR Appropriateness Criteria: Blunt Abdominal Trauma. https://acsearch.acr.org/docs/69409/Narrative/. Accessed 1 Apr 2019

  24. 24.

    Lin HF, Chen YD, Chen SC (2018) Value of diagnostic and therapeutic laparoscopy for patients with blunt abdominal trauma: a 10-year medical center experience. PLoS ONE. https://doi.org/10.1371/journal.pone.0193379

    Article  PubMed  PubMed Central  Google Scholar 

  25. 25.

    Koto MZ, Matsevych OY, Mosai F, Patel S, Aldous C, Balabyeki M (2018) Laparoscopy for blunt abdominal trauma: a challenging endeavor. Scand J Surg. https://doi.org/10.1177/1457496918816927

    Article  PubMed  Google Scholar 

  26. 26.

    Navsaria PH, Berli JU, Edu S, Nicol AJ (2007) Non-operative management of abdominal stab wounds–an analysis of 186 patients. S Afr J Surg 45(128–30):132

    Google Scholar 

  27. 27.

    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

    CAS  Article  Google Scholar 

  28. 28.

    Cocco AM, Bhagvan S, Bouffler C, Hsu J (2019) Diagnostic laparoscopy in penetrating abdominal trauma. ANZ J Surg. https://doi.org/10.1111/ans.15140

    Article  PubMed  Google Scholar 

  29. 29.

    Coleman L, Gilna G, Portenier D, Auyang E, Khan U, Grabo D, Wilson A, Szoka N (2018) Trauma laparoscopy from 1925 to 2017: publication history and study demographics of an evolving modality. J Trauma Acute Care Surg 84:664–669

    Article  Google Scholar 

  30. 30.

    Uranues S, Popa DE, Diaconescu B, Schrittwieser R (2018) Laparoscopy in penetrating abdominal trauma. World J Surg 39:1381–1388

    Article  Google Scholar 

  31. 31.

    Guth AA, Pachter HL (1998) Laparoscopy for penetrating thoracoabdominal trauma: pitfalls and promises. JSLS 2:123–127

    CAS  PubMed  PubMed Central  Google Scholar 

  32. 32.

    Zafar SN, Onwugbufor MT, Hughes K, Greene WR, Cornwell EE 3rd, Fullum TM, Tran DD (2015) Laparoscopic surgery for trauma: the realm of therapeutic management. Am J Surg. 209:627–632

    Article  Google Scholar 

  33. 33.

    Koto ZM, Mosai F, Matsevych OY (2017) The use of laparoscopy in managing penetrating thoracoabdominal injuries in Africa: 83 cases reviewed. World J Emerg Surg. https://doi.org/10.1186/s13017-017-0137-2

    Article  PubMed  PubMed Central  Google Scholar 

  34. 34.

    Guidelines for diagnostic laparoscopy (2010). https://www.sages.org/publications/guidelines/guidelines-for-diagnostic-laparoscopy/. Accessed 12 June 2019

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Correspondence to Adeel A. Shamim.

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Adeel A. Shamim, Suhail Zeineddin, Ahmad Zeineddin, Olubode A. Olufajo, Gregory O. Mathelier, Edward E. Cornwell III, Terrence Fullum and Daniel Tran have no conflicts of interest or financial ties to disclose.

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Shamim, A.A., Zeineddin, S., Zeineddin, A. et al. Are we doing too many non-therapeutic laparotomies in trauma? An analysis of the National Trauma Data Bank. Surg Endosc 34, 4072–4078 (2020). https://doi.org/10.1007/s00464-019-07169-z

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Keywords

  • Non-therapeutic laparotomy
  • Diagnostic laparoscopy
  • Trauma
  • Exploratory laparotomy
  • Minimally invasive surgery