1. What is the role of laparoscopy?

2.  Trauma results in more deaths among children older than 1 year of age than all other causes combined.  Abdominal trauma accounts for 8-10% of all trauma admissions to pediatric hospitals.  Abdominal injuries from trauma are the direct cause of death in 10% of cases.  85% of abdominal trauma is due to blunt force with the remaining 15% due to penetrating injuries.  Gunshot wounds are the most common cause of penetrating injuries in the pediatric age group and represent the leading cause of death in black males aged 15-24 years.

3. CC: Abdominal puncture wound secondary to a fall on glass HPI : AN is a 3 yo M, previously health, who fell from his parents bed, knocked over and shattered a mason jar. He subsequently fell on the glass shards resulting in 2 abdominal lacerations, one of which had protrusion of tissue. He was hemodynamically stable Per his mother patient hit his head and immediately started crying. Mom denies loss of consciousness. Patient was brought to the ED at SCH and general surgery was consulted to evaluate the penetrating abdominal wound.

4. PMHx: Normal birth hx, growth and development WNL, No hx of surgeries or hospitalizations FHx: No sick contacts Meds: None SHx: Lives at home with parents and brother. Attends preschool

5. Physical Exam: VS: T 36.8 HR 110 BP 101/79 RR 24 O2 Sat 98% on RA Gen: WDWN Male in mild distress HEENT: NCAT, EOMI, PERL, neck supple CV: RRR no m/r/g Pulm: CBTA Abdomen: Soft, NTND. 2 lacerations 1 in the supraumbilical region left of midline with omental protrusion. 2 nd in RUQ with no frank blood or discharge

6.  Hemodynamic instability  Emergent laparotomy  Hemodynamically stable  Blunt Trauma  CT  DPL  US/FAST Exam  Diagnostic Laparotomy  Laparoscopy  Penatrating Trauma  Wound Exploration  CT  US  DPL  Diagnostic Laparotomy  Laparoscopy

7.  Prospective study 19 months ending Oct 31, 1992  182 patients included in the study underwent diagnostic laparoscopy (DL)  Blunt injury: +DPL or liver/spleen injury on CTA  Penetrating: stab wounds anterior or lateral to abdomen and GSW A Prospective Analysis of Diagnostic Laparoscopy in Trauma

8.  97 (53%) patients who underwent DL had no peritoneal penetration or significant injury requiring subsequent laparotomy  No intraabdominal complications or missed injuries in these patients  85 (47%) underwent laparotomy  59 (70%) therapeutic laparotomy  13 (15%) negative laparotomy

9. BLUNTPENETRATING  Diaphragm injury  Free fluid analysis THERAPUTIC  Diaphragm repair  Irrigation & Evacuation of blood/bile  Placement of closed suction drainage  Case reports of GI injury repair, pancreatic resection, bladder repair  Peritoneal penetration  Diaphragm injury  Pericardial Injury  Bowel injury Goettler CE, Bard MR, Toschlog EA. 2004 Current Surgery

11. Diagnostic and therapeutic laparoscopy in pediatric abdominal trauma  Retrospective review study  Jan 1, 2000- Dec 31, 2004  Benedum Trauma Program admissions of hemodynamically stable blunt or penetrating abdominal injuries  Therapy was surgeon preference driven  113 children:  81 emergent laparotomy  32 diagnostic laparoscopy

12. Diagnostic Laparoscopic Group (n = 32)  72% (23) + Laparoscopy  28% (9) – Laparoscopy  19% (6) Laparoscopic repair of injury  56% (17) Avoided laparotomy

16.  Small sample size  Surgeon preference  Confounding factors

17. Laparoscopic Repair of Traumatic Bowel Injury in Children  Retrospective review of 5 years (1998-2003)  LeBonheur Children’s Medical Center & Vanderbilt University Children’s Hospital  Strict inclusion criteria  Hemodynamically stable patients w/intestinal injury after isolated focal energy transfer to the abdomen  50 patients (40 blunt, 10 penetrating)  36 Laparotomy  8 Laparoscopic repair  6 Laparoscopic assisted  Surgeon preference

20.  Shorter return to bowel function  Decreased hospital stay  No complications  Increased OR time “Appropriate for hemodynamically stable patients who sustain focal abdominal trauma..”

21. The Role of Laparoscopy in Pediatric Trauma CT gold standard for evaluation of hemodynamically stable blunt force trauma patients  Difficult to asses intestine, pancreas, mesentery, and diaphragm on CT  Non-diagnostic signs:  Bowel wall thickening  Free intraperitoneal fluid w/o evidence of solid organ injury  Mesenteric stranding  FAST exam low sensitivity and specificity in children.  Laparoscopy in place of laparotomy for both diagnostic and therapeutic purposes to avoid the complications associated with formal laparotomy

22. AH was taken to the OR for an diagnostic laparoscopy where he was found to have peritoneal invasion without subsequent injury to spleen, liver, gallbladder, colon, small bowel, or pancreas or evidence of a retroperitoneal hematoma He was admitted for observation overnight and was discharged home the following day.

23.  Laparoscopy is appropriate in hemodynamically stable children with blunt or penetrating abdominal injuries when:  Imagining is indeterminate  Concern for diaphragm, pancreas, intestine, and/or mesentery injury  r/o peritoneal penetration  Prevents unnecessary exploratory laparotomy  Increased hospital stay length  High degree of morbidity  Increased risk of infection and other complications  Laparoscopy is surgeon dependent  More studies are needed with higher power to determine the overall impact on the use of laparoscopy over laparotomy

24. Brooks, A., Simpson, J.: Blunt and penetrating abdominal trauma. Surgery, 27:6 266-271, (2009) Coley, BD., et al.: Focused Abdominal Sonography for Trauma (FAST) in Childern with Blunt Abdominal Trauma. Journal of Trauma, 48:5 902-906, (2000) Fabian, TC., et al.: A Prospective Analysis of Diagnostic Laparoscopy in Trauma. Annals of Surgery, 217:5 557-565 (1993) Feliz, A., et al.: Diagnostic and therapeutic laparoscopy in pediatric abdominal trauma. Journal of Pediatric Surgery, 41 72-77 (2006) Furnival, RA., Controversies in Pediatric Thoracic and Abdominal Trauma. Pediatric Thoracic and Abdominal Trauma. 48-56, (2001) Gaines, BA., Rutkosi, JD.: The role of laparoscoy in pediatric trauma. Seminars in Pediatric Surgery. 19, 300-303 (2010) Goettler CE., Bard, MR., Toschlog, EA.: Laparoscopy in Trauma. Current Surgery, 61:6 554- 559 (2004) Marwan, A., et al.: Use of Laparoscopy in the Management of Pediatric Abdominal Trauma. Journal of Trauma, 69:4 (2010)

25. Rossi, P., Mullins, D., Thal, E.: Role of Laparoscopy in the Evaluation of Abdominal Trauma. American Journal of Surgery, 166 707-711 (1993) Smith, RS., et al.: Therapeutic Laparoscopy in Trauma. American Journal of Surgery, 170 632- 637 (1995) Streck, CJ., et al.: Laparoscopic repair of traumatic bowel injury in children. Journal of Pediatric Surgery, 41, 1864-1869 (2006) Taylor GA., et al.: The Role of Computed Tomography in Blunt Abdominal Trauma in Children. Journal of Trauma, 28:12 1660-1664 (1988)