Comparison of single incision and multi incision diagnostic laparoscopy on evaluation of diaphragmatic status after left thoracoabdominal penetrating stab wounds.

AIM: Single incision diagnostic laparoscopy (SIDL) may be an alternative procedure to multi-incision diagnostic laparoscopy (MDL) for penetrating thoracoabdominal stab wounds. The purpose of this study is sharing our experience and comparing two techniques for diaphragmatic status.
MATERIALS AND METHODS: Medical records of 102 patients with left thoracoabdominal penetrating stab injuries who admitted to Istanbul School of Medicine, Trauma and Emergency Surgery Clinic between February 2012 and April 2016 were examined. The patients were grouped according to operation technique. Patient records were retrospectively reviewed for data including, age, sex, length of hospital stay, diaphragm injury rate, surgical procedure, operation time and operation time with wound repair, post-operative complications and accompanying injuries.
RESULTS: The most common injury location was the left anterior thoracoabdomen. SIDL was performed on 26 patients. Nine (34.6%) of the 26 patients had a diaphragm injury. Seventy-six patients underwent MDL. Diaphragmatic injury was detected in 20 (26.3%) of 76 patients. The average operation time and post-operative complications were similar; there was no statistically significant difference between MDL and SIDL groups.
CONCLUSION: SIDL can be used as a safe and feasible procedure in the repair of a diaphragm wounds. SIDL may be an alternative method in the diagnosis and treatment of these patients.

INTRODUCTION

In the literature, thoracoabdominal injuries have been described as ‘double jeopardy’ because of the possibility of potential injuries to two anatomic cavities.[1] Visceral injuries (e.g., lung, heart, diaphragm, spleen) may be encountered after trauma. The incidence of diaphragmatic injury is reported between 7% and 48% in the literature.[2] The sensitivity of conventional radiologic methods is low for the evaluation of diaphragmatic injuries.[3] If the diagnosis of diaphragmatic injury is missed, patients may present with diaphragmatic hernia, which has a high long-term mortality rate.[4] The management of asymptomatic patients should be directed towards to diagnosing occult diaphragmatic injuries. Therefore, minimally invasive surgery can be performed both for the diagnosis and treatment of occult diaphragmatic injuries.

In recent years, diagnostic laparoscopy (DL) or thoracoscopy have been performed in many centres for hemodinamically stable patients with penetrating thoracoabdominal wounds.[56] Role of laparoscopy in abdominal trauma is limited. However, it is useful for some indications such as diaphragmatic injuries, hollow viscus lesions and mesenteric lacerations.[7] On the other hand, single incision laparoscopic surgery (SILS) is a modification of laparoscopic surgery that uses laparoscopic instruments but with minor adjustments. It has been used for various abdominal procedures with better cosmetic results, less pain and fewer port site-related complications.[8]

The primary aim of this study was to reveal whether single incision DL (SIDL) may be used as an alternative method to standard multi-incision DL (MDL) in the management of left thoracoabdominal stab wounds.

MATERIALS AND METHODS

Patients

The medical records of 102 patients with left thoracoabdominal penetrating stab injuries who were admitted to Istanbul School of Medicine, Trauma and Emergency Surgery Clinic between February 2012 and January 2016 were retrospectively analysed. All patients had been treated according to the advanced trauma life support protocol, and tetanus prophylaxis was applied to all of them.

Patients who were hemodynamically stable and who had no obvious indications for laparotomy were included in this study. Patients with right thoracoabdominal injuries, gunshot wounds, left thoracoabdominal injuries, but hemodynamically unstable and those who required urgent surgery for accompanying injuries or refused surgery were excluded from the study.

The patients were divided into three groups based on the injured left thoracoabdominal stab wounds:

Anterior left thoracoabdominal injury: Injuries located anterior to the axillary line (below the nipple in front left superior quadrant of the abdomen)

Lateral left thoracoabdominal injury: Left thoracoabdominal injuries between the anterior axillary line and posterior axillary line (below the sixth intercostal space, left superior quadrant of the abdomen)

Posterior left thoracoabdominal injury: Injuries located posterior to the posterior axillary line (the eighth intercostal space at the back, left superior quadrant of the abdomen).[9]

Evaluation methods and diagnostic techniques

Physical examination leucocyte counting: Patients with suspected simultaneous intra-abdominal organ injuries were followed up with leucocyte counting and serial physical examinations every 4 h

SIDL = Group A: This was used in the left thoracoabdominal injuries as an alternative to DL to exclude the possibility of diaphragmatic injury

MDL = Group B: DL was performed in the left thoracoabdominal stab wound injuries to exclude the possibility of diaphragmatic injury when laparotomy was not indicated.

After the first examination, all skin wounds were primarily sutured. Haemodynamic parameters were controlled by monitorisation and stable patients were followed up for 24–48 h. Patients with intra-abdominal solid organs injury were followed up conservatively and underwent surgery between the 4th and 5th days of hospitalisation. Operations were performed at the end of the follow-up period. MDL or SIDL were used according to the surgeon's preference. Recently, we have mostly used SIDL rather than MDL. A single incision port was used in the suprainfraumbilical or intraumblical position for surgery. A 10-mm or 5-mm camera was used for the exploration with two 5-mm laparoscopic devices. If SIDL failed, the operation was completed using additional ports [Figure 1a and b]. Patients who had a negative DL were discharged 1 day later; those who were positive for diaphragmatic/organ injury or hernia were discharged after they tolerated oral intake. In the follow-up period, patients were asked if they are satisfied about their incision scars cosmetically. Patients who did not come for control were reached by phone.

Figure 1

Port position in single incision diagnostic laparoscopy (a), additional port positioning in single incision diagnostic laparoscopy (b)

Patient records were retrospectively reviewed for data including age, sex, length of hospital stay, rate of diaphragm injury, operative procedure, operation time and operation time with wound repair, post-operative complications and accompanying injuries (e.g., haemothorax [HX], pneumothorax [PX] and solid organ injuries).

Statistical analyses

Demographic properties, trauma location, physical examination findings, diagnostic study results, treatment plans, duration of operation, hospitalisation and complications were recorded on a database. The MDL and SIDL findings were compared using the Chi-square test. All statistical analyses were performed using SPSS statistical package version 21.0 (SPSS Inc., Chicago, IL, USA). A P < 0.05 was considered statistically significant.

RESULTS

Six of the patients were female and the rest were male (female/male = 6/96). The average of patients' age was 27.9 years (range, 12–61 years). Distribution of patients according to group, age, gender, stab locations and accompanying injuries was given in Table 1.

Table 1

Distribution of patient age, gender and accompanying injuries according to surgery type

When evaluating injuries, common injury localisation of the both groups was anterior left thoracoabdominal region. Distribution of patients according to group, stab wound locations and diagnosis of PX, HX and solid organ injuries detected in initial assessment was given in Table 2.

Table 2

Distribution of stab locations, and diagnosis of pneumothorax, haemothorax and solid organ injuries detected in initial assessment

SIDL was performed on 26 patients. Nine (34.6%) out of 26 patients had diaphragm injury. SIDL procedure was enough to repair the diaphragm in 7 (77.7%) of these 9 patients. Rest one patient who had a diaphragmatic tear behind the spleen and another one with colonic injury were treated using an additional 5 mm port [Figure 1a and b]. Three trocars were used in the Group B (n = 76). Diaphragmatic injury was detected in 20 (26.3%) patients in the Group B, which repaired laparoscopically. One patient who had partial ischaemic omentum was resected with MDL. In both groups, the procedures were not required conversion to an open procedure. Post-operative there was no missed injury for all cases.

The means of operation and hospitalisation time were similar, and there was no statistically significant difference between two groups. Distribution of the patients according to group, diaphragma injury, operation time and hospitalisation was given in Table 3.

Table 3

Distribution of the patients according to group, diaphragma injury, operation time and hospitalisation time

Port site infection was improved in one of Group A and two of Group B patients. Atelectasia was observed in six patients. No further lung or abdominal complications were seen. Patients who underwent MDL or SIDL were discharged within 24 h post-operatively if there are no other additional complications or organ injuries. The duration of hospital stay was longer due to solid organ and accompanying injury. All umblical incision scars were healed with satisfactory results in the Group A [Figure 2]. Cosmetic satisfaction was not significantly different between the two groups post-operatively. Port site infection was improved in one of SIDL and two of MDL patients. Limitations of our article are that there was no pain scale for comparison of groups.

Figure 2

Repair of diaphragm with single incision diagnostic laparoscopy (a), umblical incision of single incision diagnostic laparoscopy port (b)

DISCUSSION

Hemodynamically unstable patients who are exposed to penetrating left thoracoabdominal injury require urgent surgical intervention. Follow-up with conservative therapy preferred in clinically stable patients who have no urgent laparotomy indication.[1011] Development of new concepts and advancing technologies induced an evolution for diagnostic and operative techniques in intra-abdominal and diaphragm injuries in last decades.

Diaphragmatic injury caused by penetrating left thoracoabdominal injury may be asymptomatic initially but can cause intrathoracic herniation which becomes symptomatic if diagnosis and treatment is delayed. Treatment becomes more complicated with higher mortality and morbidity rates if diaphragm herniation develops.[51213] Consequently, it is essential to identify and assess these injuries in the early stages.[512]

Surgical procedures are the most effective manner for the evaluation of patients with left thoracoabdominal injury. During surgery, diaphragmatic injuries can be easily displayed and concurrently can be treated. Various methods are used to assess diaphragm injuries. Nowadays, one of the widely preferred methods is DL, which is a minimally invasive procedure.[1415] According to the literature, the diaphragmatic injury rate in left-sided penetrating thoracoabdominal trauma was 40%.[16] Diaphragmatic injury was detected in 29 (28.4%) of our 102 patients, and all were repaired laparoscopically.

SILS has been found safe and applicable in the treatment of intra-abdominal diseases.[1718] The current literature shows comparable results between SILS and multiport laparoscopic surgery in aspects of operation time, intraoperative complications and readmission rates.[1920] Diaphragm injury was detected in 9 of our 26 patients, who were underwent SIDL; and SIDL was sufficient to repair injuries in 7 of these 9 patients. The mean operation time was similar, and there was no statistically significant difference between the MDL and SIDL groups in our study.

SILS has not been widely used even though it has many proven favourable sides. SILS demands extra time, cost and skill, also it is ergonomically more difficult, which are inhibiting reasons widespread use of this method.[2122] Technical and ergonomic challenges may be handled better with time when surgeons gain experience, and new operation instruments are being developed to assist learning the technique better.[2223] We had to use an additional 5 mm port on two patients, one who had a diaphragmatic tear behind the spleen and another one with colonic injury, because of these disadvantages. On the other hand, all of our operations were terminated with minimally invasive surgery.

Several studies have proven that SILS offers substantially shorter hospitalisation period than the multiport technique.[1824] SILS also has positive sides such as the cosmetic benefit of a single incision, post-operative less pain and lower incidence of port site complications.[181923] In our study, there was no significant difference between two groups in terms of hospitalisation periods. Hospitalisation duration may be longer depending on accompanying organ injury and pre-operative conservative observation time. Patients were discharged within 24 h both in MDL and SIDL groups. Port site infection was improved in one of SIDL and two of MDL patients. Cosmetic satisfaction was not significantly different between the two groups post-operatively. Limitations of our article are that there was no pain scale for comparison of groups.

CONCLUSION

SIDL and MDL are highly specific and sensitive in the evaluation of diaphragmatic tears. SIDL is a useful diagnostic and operative procedure in cases of penetrating injuries to the lower chest, thoracoabdominal region and flank. Therefore, SIDL should be considered as the procedure of choice for the diagnosis and treatment of left thoracoabdominal stab wounds.

Financial Support and Sponsorship

Nil.

Conflicts of Interest

There are no conflicts of interest.