Background

Stable patients with thoracoabdominal penetrating injuries represent a difficult and challenging management dilemma. Laparoscopy and thoracoscopy have now emerged as the most reliable and efficient diagnostic modality. Despite improvements in the technical expertise and laparoscopic capabilities amongst trauma surgeons, open laparotomy for repair of these injuries is still commonly practiced, even for mere evidence of peritoneal violation or a hemoperitoneum.

Methods: We present a series of 50 hemodynamically stable patients treated over 2,5 year period using a unique approach of combined laparoscopic, and when necessary, open repair of injuries resulting from gunshot or stab wounds. Injuries include those involving the diaphragm, liver, stomach, intercostal vessels, anterior abdominal wall with resultant hernias, mesenteric vessels, and retroperitoneal hematomas.

Technique

Open or Verress needle technique is used to create the pneumoperitoneum. Additional 5 or 10 mm ports are placed appropriately to enable thorough examination of the peritoneum, small bowel and other abdominal viscera. Based on the location and degree of injury, open or laparoscopic repair can be performed Hemoperitoneum resulting from a liver, spleen, or mesenteric laceration, or an intercostal hematoma can be identified, evacuated and treated accordingly. A diaphragmatic injury is repaired via an open approach, performed through the existing thoracic stab or tangential gunshot wound. For the more anterior injuries resulting from bleeding intercostal vessels, laparoscopic endosuturing is used.

Results

Using this approach, all of our patients were discharged on postoperative day one, or after removal of the chest tube without any complications. We use laparoscopic exploration as our first choice in the management of stable penetrating injuries to the thoracoabdominal and flank area in patients without an obvious indication for laparotomy. There were no missed injuries. One iatrogenic small bowel injury was caused while entering the abdomen using the open technique.

Conclusion

Laparoscopic exploration of hemodynamically stable patients is an optimal diagnostic and therapeutic option. The mare fact that the peritoneum has been penetrated is not an indication for a laparotomy. Repair of the injury can be performed either laparoscopically in its entirety, via the open technique or a combination of both. We suggest that this technique be incorporated into the armamentarium of modern trauma surgeons.