Emergent trauma surgery: a narrative review of laparoscopy, thoracoscopy and robotics

Introduction

Minimally invasive techniques such as “peritoneoscopy” were described in trauma as early as World War II for diagnosing and grading intra-abdominal injuries (1). From the early 1990s to present, there have been several interesting trends: (I) the incidence of therapeutic open laparotomy appears to be decreasing; (II) the use of laparoscopy for trauma had an initial increase in the early 2000s and has since decreased; and (III) the rate of therapeutic laparoscopy has been increasing (2). The cause of these trends is multifactorial and related to improved computed tomography (CT) technology and its increased availability, which allows surgeons to be more selective with who receives an intervention (2). Further, there has been a recognition that serial abdominal exams in penetrating trauma carry high specificity and sensitivity in predicting those who need operative intervention (3). As a result, both the number of laparotomies and total surgical procedures in trauma have decreased (2).

The widespread adoption of laparoscopy in surgical procedures has revolutionized diagnostic capabilities across a broad range of pathologies. In trauma, laparoscopy is useful in diagnosing peritoneal violation and subsequent treatment of injuries (4,5). One meta-analysis of data between 1990 and 2016 found that 9,817 laparoscopies were performed for abdominal trauma, avoiding laparotomy in 67.5% of penetrating trauma patients and 73.8% of patients overall (2). Indeed, laparoscopy has proven useful in the diagnosis and treatment of the stable trauma patient (4-7). Therefore, it is imperative that surgeons know the indications for laparoscopy while formulating a treatment plan for the injured patient.

Previous studies have concluded that laparoscopy is appropriate for both penetrating and blunt abdominal trauma in the hemodynamically stable patient, leading to fewer nontherapeutic laparotomies while allowing for safe, complete, and accurate abdominal exploration (2,4,5). Safety, more specifically, has been measured by missed injuries, reoperation, complications from laparoscopy such as pneumothorax or bowel injury, and deaths during the procedure (8). Chelly et al. retrospectively examined trauma patients who underwent laparoscopy at their institution and found only one complication (pneumothorax) with no missed injuries and no deaths (8). Multiple meta-analyses show that laparoscopy is associated with fewer wound infections, with no difference in mortality or missed injuries, when compared to laparotomy (7,9). Therefore, according to the World Society of Emergency Surgery (WSES), it is safe and feasible to consider a laparoscopic-first method for diagnosis and management of blunt and penetrating trauma (10).

The results of our comprehensive narrative review are organized in two separate parts addressing laparoscopy in acute injuries as well as the evolution of minimally invasive surgery in trauma and the possible application of robotics. The purpose of this review is to review the most current literature for using minimally invasive approaches in trauma and the evidence for and against its use. We focus primarily on the use of laparoscopy in comparison to laparotomy in abdominal trauma, with consideration of patient factors, injury type, and mechanism. This peer-reviewed synopsis has been created in accordance with the Narrative Review reporting checklist (available at https://ales.amegroups.com/article/view/10.21037/ales-23-23/rc).

Methods

A comprehensive literature search was employed using the following search strategy on PubMed: ((“Laparoscopy”[Mesh]) OR (“Hand-Assisted Laparoscopy”[Mesh]) OR (“Robotic Surgical Procedures”[Mesh]) OR (“Thoracoscopy”[Mesh]) OR (“Minimally Invasive Surgical Procedures”[Mesh])) AND (“Trauma Surgery” OR “Emergency Surgery” OR “Trauma”). Filters applied: clinical trial, meta-analysis, randomized controlled trial, systematic review. A total of 1,561 articles were obtained and screened for applicability and excluded orthopedic procedures, endovascular treatments in trauma, urologic procedures, and emergency surgery for appendicitis, cholecystitis, diverticulitis, or hernias. The reason for those exclusions is to distinguish emergent trauma surgery from general and acute care surgery, which sometimes are not differentiated at trauma centers. A total of 22 articles were identified. Additional details of the methodology are shown in Table 1 and Figure 1.

Figure 1 PRISMA flow diagram.

Results

Laparoscopy in acute injuries

Benefits of laparoscopy

Laparoscopy has demonstrated many benefits compared to laparotomy, including reduced postoperative pain, surgical site infections, length of hospital stay, cost, and mortality (7,9,11). Additionally, laparoscopy has been shown to decrease the number of non-therapeutic laparotomies and is associated with fewer wound complications and incisional hernias (6,8,11).

A systematic review and meta-analysis of 64 studies, including 9,058 patients with abdominal trauma managed laparoscopically, demonstrated reduced postoperative pain and subsequently decreased the need for narcotic use (6). In multiple meta-analyses comparing laparoscopic management vs. open surgical management in trauma, laparoscopy significantly reduces the risk of wound infection compared to laparotomy (7,9). Laparoscopic management is associated with a lower incidence of postoperative pneumonia and abscesses which significantly reduces hospital length of stay (7,10,12). Additionally, a 2015 meta-analysis by Li and colleagues suggests that in all-cause trauma, undergoing laparoscopy vs. laparotomy has decreased length of stay, operative time, intraoperative blood loss, and intensive care unit (ICU) length of stay (6). These benefits can partly be explained by patient selection, but indicate that there is a large population that can be treated in a minimally invasive fashion.

Regarding economic impact, diagnostic laparoscopy can also reduce hospital costs by reducing non-therapeutic laparotomies and hospital length of stay (11). Reducing ICU length of stay and operative time can also contribute to reduced hospital costs (6). These findings were corroborated by Karateke and colleagues in a prospective study (13). Lastly, an overwhelming amount of evidence has demonstrated a significant reduction in mortality with the use of laparoscopy (2,7). This contradicts a common concern among many surgeons that the inability to control hemorrhage or contamination with minimally invasive techniques would lead to higher mortality.

Indications and contraindications for diagnostic laparoscopy

Given the previously stated benefits, it is important to identify those trauma patients who will be candidates for a minimally invasive approach. Traditionally, the decision to approach a trauma operation with minimally invasive techniques has been made on a case-by-case basis and was dependent on the surgeon’s comfort level with laparoscopy, the injury pattern, and the patient’s hemodynamics.

Several studies illustrate the diagnostic and therapeutic benefits for blunt and penetrating trauma in hemodynamically stable patients (2,4). The successful use of laparoscopy, however, depends on the correct patient selection, as there are no specific criteria for laparoscopy in trauma. Selecting a patient with an isolated injury who is hemodynamically stable will increase the odds of a successful operation. Patients with multiple injuries have decreased odds of successful laparoscopies with potentially increased operative time, bleeding, and missed injuries.

The indications for abdominal exploration with laparoscopy are the same as with laparotomy: known or suspected intra-abdominal injury that is potentially amenable to repair. However, certain injuries, such as those to the diaphragm or those in the deep pelvis, may be better suited for a laparoscopic approach. Contraindications to laparoscopy include hemodynamic instability, shock, traumatic brain injury, surgeon inexperience, lack of available equipment, surgical history suggesting significant adhesive disease, and patients who cannot tolerate pneumoperitoneum from a cardiac or pulmonary standpoint (14). However, an initially hemodynamically unstable patient who responds well to resuscitation may undergo laparoscopy in select instances (14).

For patients with penetrating trauma and positive CT findings, Uranues and colleagues suggest that these stable patients may undergo laparoscopy (5). When there is suspicion for a diaphragmatic injury or laceration, a diagnostic laparoscopy or video-assisted thoracic surgery (VATS) can allow the visualization of the diaphragm to determine if further interventions are necessary, which can be routinely performed through the minimally invasive approach (5). This can be done in a non-urgent fashion if there are no other outstanding indications for urgent abdominal exploration.

For stable patients with blunt trauma, some injuries may be subtle or missed on CT scan, for which laparoscopy may have a role. Kaban and colleagues evaluated patients after blunt trauma who had positive CT findings and found that they were able to perform the necessary procedures laparoscopically, including bowel repair or resection, diaphragmatic repair, and splenectomy (4). They were able to avoid laparotomy in 50% of patients with no missed injuries or reoperations (4). The study also showed reduced hospital length of stay and overall complications compared to patients undergoing laparotomy (4).

Occasionally, there are scenarios where the diagnosis remains uncertain despite CT imaging. In these scenarios, abdominal or thoracic exploration may be indicated or necessary. In these situations, laparoscopy or thoracoscopy is a viable option to minimize morbidity and use a minimally invasive approach to avoid the complications of a laparotomy or even a negative exploration that was performed open.

Diagnostic sensitivity and specificity

The diagnostic laparoscopy is an established procedure in emergency general surgery, which has developed societal guidelines and its skillset is easily transferable to the stable trauma patient (2,15). However, determining the proper subset of patients suitable for this option is key. Presently, ultrasound and CT have great sensitivity and specificity for penetrating and blunt abdominal injuries. Ultrasound may have 83.3% sensitivity and 99% specificity in blunt and penetrating abdominal injuries (5). CT has 97% sensitivity and 98% specificity with peritoneal violation, along with 94% sensitivity and 96% specificity for detecting mesenteric injuries (5). However, both ultrasound and CT imaging have limited diagnostic ability to detect diaphragmatic injuries and occult small bowel injuries, with a sensitivity of approximately 26% (5). Up to 45% of exploratory laparotomies done for suspected diaphragmatic injury and small bowel injury result in non-therapeutic laparotomies (so-called “negative laparotomy”) (5). Thus, there is a growing role for a minimally invasive technique that allows safe abdominal exploration without the increased morbidity from a large laparotomy incision.

This presents an important role for laparoscopy to aid in the diagnosis of these injuries, where current imaging technologies are less effective, and to replace laparotomy for evaluation of an injury. As imaging becomes more sensitive and accurate, therapeutic laparotomy rates have decreased with an increase in the number of therapeutic laparoscopies (2). This not only shows safety and efficacy for laparoscopy but also strengthens the evidence and benefit of laparoscopy in trauma.

The goal of exploration is to identify injuries and then apply appropriate surgical management as needed. With high sensitivity and specificity rates, laparoscopy is an ideal tool to replace the exploratory laparotomy in the right setting (4,5,7,9,16). The most striking example of laparoscopy being an effective alternative is in identifying diaphragmatic injuries in thoracoabdominal penetrating injuries. Up to 45% of exploratory laparotomies done for suspected diaphragmatic injury and small bowel injury result in non-therapeutic laparotomies (so-called “negative laparotomy”), whereas laparoscopy is effective in identifying these injuries (5).

Overall, there is a growing role for a minimally invasive technique that allows safe abdominal exploration without the increased morbidity from a large laparotomy incision (2,4-7,9,10,16,17).

Perceived challenges to successfully using laparoscopy

Missed injuries are a concern when managing trauma patients of all mechanisms, and can lead to significant morbidity and mortality. Due to the concern of limited exploration compared to open exploration, missed injuries are traditionally believed to be of more concern in laparoscopy. Laparoscopy removes the tactile ability of exposure with one’s hands and the ability to visualize injuries directly. Difficult locations such as the retroperitoneum, the hepatorenal fossa, lesions deep within the pelvis, and the right lateral liver sector (i.e., segments VI and VII) are particularly challenging to visualize and explore laparoscopically (17). An early meta-analysis in 2013 did demonstrate significant missed injuries, 83 missed in a total of 2,569 pooled patients, which were identified on subsequent laparotomy (18). However, many of these studies were retrospective or simple audits of early surgeon experiences. Several recent studies have demonstrated a low rate of missed injuries of less than 1% when utilizing laparoscopy in abdominal trauma, demonstrating safety in the use of laparoscopy (19,20). Further, multiple meta-analyses have demonstrated no difference in missed injuries when compared to open surgery (7,9,17).

Optimizing exposure and exploration, placement of the laparoscopic ports is a crucial factor that can significantly impact both the success and ease of an operation. It is also important for a surgeon’s ergonomics. The ideal position of trocars in trauma ultimately depends on the location of the injury. In general, triangulation of laparoscopic ports should be achieved toward the area of concern (21). When the site of injury is unknown, a 5-sided dice-like position could be used with 5-mm ports in each quadrant, along with a periumbilical camera. Not all quadrants need to have ports placed and each port can be upsized if needed for advanced instruments, such as staplers, or if suturing needs to be performed. The use of advanced instruments, such as laparoscopic staplers, vessel sealing devices, and suturing devices, has also allowed for the successful completion of operations that otherwise would have required laparotomy.

Specifically looking at a 2020 systematic review by Beltzer and colleagues, the missed injury rate for both penetrating and blunt abdominal trauma in laparoscopy was low at approximately 1.4% (17). They also found in their review that 29% of all trauma laparoscopy cases were converted to open, and about 60% of all trauma laparoscopy was therapeutic (17). Thus, even though a procedure is started laparoscopically, it does not preclude conversion to open surgery when suspicious for an injury or need for more effective exposure. Laparoscopy can potentially protect patients from the morbidity of open incisions but can easily be converted to open surgery as needed to prevent missed injuries. As a result, it is a great option for those with low injury suspicion.

Further supporting the use of laparoscopy, a meta-analysis by Li and colleagues suggests that the pooled incidence of missed injuries is 1% in laparoscopy (6). A meta-analysis by Hajibandeh and colleagues found that in 3,362 patients with penetrating abdominal trauma, only two missed injuries in the laparoscopy group and one missed injury in the laparotomy group were noted (7). Additionally, there was no significant difference in the reduction of mortality. Given the low rate of missed injury, combined with the ability to perform a therapeutic operation, the data appears to support the use of laparoscopy in both blunt and penetrating trauma when clinically indicated and in stable patients who can tolerate the hemodynamics of laparoscopic surgery (7).

Robotic surgery and trauma

As robotic surgery begins to take a foothold in emergency general surgery, the natural evolution in trauma surgery will be the implementation of robotics into the surgeon’s armamentarium. However, as with any new technology, there will be risks and criticisms of early adopters as the indications to dock the robot are created.

In 2024, there is a paucity of published papers on the use of robotics in trauma surgery. Most are case reports, case series and retrospective studies. However, in 2021, the WSES published a position paper on the use of robotics in emergency surgery (12). Although not specific to trauma, the authors of this chapter feel that the concepts of emergency general surgery can be applied to trauma. In the WSES position statement, robotic approaches can also be safe and feasible for acute care surgery, assuming that (I) the patient is hemodynamically stable; (II) the resources are available to use the robot; and (III) the surgeon is comfortable with a robotic approach (12). However, there are clearly practical limitations to doing so, including cost, availability of support staff, operative length, and lack of haptic feedback on current robotic platforms (12). The majority of data related to the robot in this setting is limited to case reports and acute care surgical management.

One case report by Kim and colleagues at Rutgers in 2020 described a traumatic right-sided diaphragmatic robotically repaired trans-thoracically greater than 48 hours after the incident with a good outcome (22). Further, Kim and colleagues at St. Johns Hospital in Springfield, Il described in 2017 at SAGES a successful robotic spleen-preserving distal pancreatectomy for a blunt abdominal trauma causing a grade III pancreatic injury with transection (23). Despite these presentations in 2017 there have been no described prospective observational studies or randomized studies to characterize the use of robotics in trauma. Robotic surgery can have a future in trauma in stable patients who do not require emergent surgery, and its use can be especially valuable for difficult surgical areas to maneuver with traditional laparoscopy, including the diaphragm and retroperitoneum (22). However, in summation, further data is required to clarify the role of robotics in trauma surgery.

As robotic surgery continues to evolve and expand its indications, it would be expected to naturally follow many of the indications of laparoscopy. However, moving the surgeon away from the bedside will be a hurdle that most need to overcome. Success will be defined by patient selection and bedside assistance. Efficiency will be vital as well, requiring operating rooms and nurses to be familiar with the robot and minimize docking times. As the technology and surgeon experience grow in robotics, well-designed studies will be required to compare robotics to both laparoscopy and open surgery in trauma.

Conclusions

Laparoscopy plays a valuable role in the management of the trauma patient by offering a minimally invasive approach that can facilitate accurate diagnosis and treatment while minimizing surgical trauma and complications. Careful patient selection is vital, and hemodynamic stability is critical when deciding to undergo a minimally invasive approach. A surgeon must be aware of the pitfalls of laparoscopy in trauma, and be prepared to convert to an open operation when indicated. Future advances in technology such as robotics, will continue to provide new techniques and options in emergency general surgery and trauma in the future.

Acknowledgments

None.

Footnote

Provenance and Peer Review: This article was commissioned by editorial office, Annals of Laparoscopic and Endoscopic Surgery for the series “Latest MIS Approaches and Data”. The article has undergone external peer review.

Reporting Checklist: The authors have completed the Narrative Review reporting checklist. Available at https://ales.amegroups.com/article/view/10.21037/ales-23-23/rc

Peer Review File: Available at https://ales.amegroups.com/article/view/10.21037/ales-23-23/prf

Funding: None.

Conflicts of Interest: All authors have completed the ICMJE uniform disclosure form (available at https://ales.amegroups.com/article/view/10.21037/ales-23-23/coif). The series “Latest MIS Approaches and Data” was commissioned by the editorial office without any funding or sponsorship. G.F. served as the unpaid Guest Editor of the series and serves as an unpaid editorial board member of Annals of Laparoscopic and Endoscopic Surgery from April 2023 to March 2027. The authors have no other conflicts of interest to declare.

Ethical Statement: The authors are accountable for all aspects of the work in ensuring that questions related to the accuracy or integrity of any part of the work are appropriately investigated and resolved.

Open Access Statement: This is an Open Access article distributed in accordance with the Creative Commons Attribution-NonCommercial-NoDerivs 4.0 International License (CC BY-NC-ND 4.0), which permits the non-commercial replication and distribution of the article with the strict proviso that no changes or edits are made and the original work is properly cited (including links to both the formal publication through the relevant DOI and the license). See: https://creativecommons.org/licenses/by-nc-nd/4.0/.

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