Laparoscopy for hemodynamic stable penetrating abdominal trauma. An exploratory study in a European setting.

Laparoscopy for hemodynamic stable penetrating abdominal trauma. 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An exploratory study in a European setting. Nathja Groth Harpsøe, Lasse Rehné Jensen, Emma Possfelt-Møller, and 3 more This is a preprint; it has not been peer reviewed by a journal. https://doi.org/ 10.21203/rs.3.rs-4001343/v1 This work is licensed under a CC BY 4.0 License Status: Posted Version 1 posted You are reading this latest preprint version Abstract Purpose Trauma laparotomy is the golden standard for the treatment of penetrating abdominal trauma, though laparotomy is associated with a higher complication risk and prolonged length of hospital stay. Therefore, we explored whether laparoscopy in a trauma setting can be a valuable alternative. We analyzed the management of hemodynamic stable patients with penetrating abdominal trauma and assessed the applicability of laparoscopy in order to reduce non-therapeutic laparotomies. Methods We performed a retrospective study of hemodynamic stable patients with a penetrating abdominal trauma who underwent surgery. Data were extracted for a 5-year period from January 2018 to December 2022. Collected data included patient demographics, in-hospital data such as radiological procedures, surgical findings and interventions performed and postoperative outcomes with mortality, complication including reoperation, missed injury and length of stay. Results A total of 127 patients were included. We created three groups: A laparoscopy group; a laparoscopy converted to laparotomy group; and a laparotomy group. The e-FAST and CT scan were significantly more positive in the laparotomy group. Most frequently injured organs were liver, diaphragm, stomach, small bowel and colon, retroperitoneal hematoma and spleen. Therapy with hemostatic procedures on the liver and suture of the diaphragm were frequently performed. In total, 29 patients (28%) had a non-therapeutic laparotomy. Conclusion Our study revealed a very high rate of non-therapeutic laparotomies. Considering the organ injuries and surgical procedures performed they can in experienced hands be handled laparoscopically. Prospective studies are urgently needed to assess the safety and efficacy of laparoscopy in abdominal trauma. penetrating abdominal trauma hemodynamic stable laparoscopy laparotomy retrospective study Background Trauma remains a major cause of morbidity and mortality worldwide. The World Health Organization (WHO) estimates that 8% of all deaths worldwide are due to trauma as a direct cause, including both penetrating and blunt [ 1 ]. In Denmark, nationally around 2,600 patients are admitted to one of the 4 major trauma centers due to trauma each year [ 2 ]. The Trauma Center at Rigshospitalet is one out of 4 major trauma centers in Denmark and serves as a Regional Trauma Center for the Eastern part of Denmark with a population of 2.6 million people. The distinction between penetrating and blunt trauma is important, but both mechanisms may require surgical evaluation. Until now, exploratory laparotomy has been the golden standard procedure to evaluate trauma patients with abdominal trauma when suspecting intraabdominal injuries or when breach of peritoneum was detected at laparoscopy. Previous studies have demonstrated a rate of negative laparotomy of up to 61% [ 3 , 4 ]. A recent report from our institution has reported a 17,3% rate of negative laparotomies when combining both blunt and penetrating trauma in a Scandinavian setting [ 5 ]. Studies have suggested that a very high proportion, and up to 45% of negative laparotomies, can be avoided with the use of laparoscopy for penetrating abdominal trauma [ 3 ]. Laparotomy is known to cause a higher risk of complications such as surgical site infections, medical complications and longer length of stay compared to laparoscopy [ 3 , 6 ]. Over the last decades, laparoscopy has increasingly gained success in elective and emergency surgery but has not yet an established role in trauma surgery. The earliest studies, in the late 1990’s and beginning of the 2000’s, regarding the use of laparoscopy for evaluating trauma patients showed a high rate of missed injuries, especially small bowel lesions [ 7 – 9 ]. More recent studies demonstrate that diagnostic laparoscopy can be used safely with a low rate of missed injuries [ 3 , 6 , 10 , 11 ]. Probably, because the knowledge and experience with laparoscopic procedures has increased significantly over the last decades. Laparoscopy can be used exploratory (to determine whether peritoneum is intact), diagnostic (systematic assessment of intraabdominal injuries) and/or therapeutically (surgical repair of intraabdominal injuries). A successful diagnostic laparoscopy must identify all intraabdominal injuries required for intervention. Injuries must not to be missed as they will delay the time to intervention, and increase morbidity [ 3 , 11 ]. The aim of this study was to analyze the management of hemodynamic stable patients with penetrating abdominal trauma and to assess the potential role of laparoscopy in a manner to reduce the rate of negative and non-therapeutic laparotomies. Methods We performed a retrospective quality assurance study including stable penetrating abdominal trauma patients admitted to the Trauma Center at Rigshospitalet over a 5-year period from January 1st, 2018 to December 31st, 2022. The study was conducted and reported in accordance with the STROBE guidelines. Ethical approval to access patient data for the purpose of quality assurance was obtained. Patient selection We included all patients admitted with a penetrating abdominal trauma to the Trauma Center at Rigshospitalet, both primary admitted patients and those transferred from other hospitals. Patients had to be hemodynamic stable, defined as a pulse > 100 and a systolic blood pressure < 100, as well as planned for surgery, either laparoscopy or laparotomy. Data was obtained from the hospital’s Trauma Registry and the EPIC electronic health record system used within the Capital Region of Denmark. Study variables We extracted data including patient demographics and patient related information: sex, age, mechanism of injury (stab, gunshot etc.), Injury Severity Score (ISS), American Society of Anesthesiologists (ASA) score, Abbreviated Injury Score (AIS) and Charlson Comorbidity Score (CCI). In-hospital data included systolic blood pressure and pulse at arrival, radiological procedures performed and findings, indication for surgery, initiation (laparoscopy or laparotomy), conversion, operative findings, performed therapy and procedures for review the abdomen for injuries and duration of surgery. Postoperative data with mortality, reoperations both performed within the first 30 days and long term, complications according to Clavien-Dindo Score, missed injuries and length of stay (LOS). Our primary outcomes were proportion of non-therapeutic laparotomies, defined as a laparotomy with no injuries or injuries without need of therapy, and missed injuries. Secondary outcomes were mortality, procedure time, LOS, complication with Clavien-Dindo score and reoperation, both within 30 days and long term. Data and statistical analysis Statistical analyses were performed using Microsoft Excel (version 15.29) and IBM SPSS Statistics (version 29.0.1.0 (171)). Dichotomous and categorical data are presented as percentages. Continuous data are presented as means and standard deviation (SD) or medians and interquartile range (IQR, range from the 25th to 75th percentile). Chi-squared test was used to compare proportions and to test for trends. The Mann-Whitney U -test or Fischers exact test was used to compare unpaired groups of continuous data. Univariate analysis identified any statistic differences. Actual P -values were reported. All tests were two-tailed. Differences were considered to be statistically significant at a P < 0.05 level. Data registry All data were collected by NGH and LRJ, and registered in the Research Electronic Data CAPture (RedCap) system (Vanderbilt University, Nashville, TH, USA). Results We identified a total of 252 patients presenting with penetrating abdominal injury within the 5-year study period. Of these, 127 patients met the inclusion criteria; 112 presented with stab wounds, 10 with gunshots and five patients with a trauma mechanism after fall over a penetrating object. This included one patient falling on the bicycle handlebars and four patients after hitting a penetrating object during a fall from heights. We separated the patients into three groups. Group one represented the patients only undergoing laparoscopy (n = 25), group two with patients initiated as laparoscopy but converted to laparotomy (n = 19) and group three counted patients undergoing direct laparotomy (n = 83). Baseline patient characteristics are presented in Table 1 . Table 1 Baseline patient characteristics Laparoscopy n = 25 (20%) Laparoscopy converted n = 19 (15%) Laparotomy n = 83 (65%) P -value Sex male (%) female (%) 23 (92%) 2 (8%) 17 (90%) 2 (10%) 71 (86%) 12 (14%) 0.67 Age in years (IQR) 25.4 (21.1–42.5) 38.7 (26.9–54.9) 26 (20.4– 44) 0.13 CCI , mean (± SD) 0.2 (± 0.5) 0.8 (± 1.1) 0.6 (± 1.6) 0.11 Trauma mechanism Stab Gunshot Falls over penetrating object 23 (92%) 1 (4%) 1 (4%) 19 (100%) 0 (0%) 0 (0%) 70 (84%) 9 (11%) 4 (5%) 0.30 Type of Admission Primary Secondary 22 (88%) 3 (12%) 19 (100%) 0 (0%) 73 (88%) 10 (12%) 0.28 Hemodynamics , mean (± SD) Pulse sBP Shock index 93 (± 19.7) 129 (± 25.1) 0.77 (± 0.37) 99 (± 20.6) 141 (± 17.1) 0.72 (± 0.20) 95 (± 21.2) 131 (± 24.9) 0.76 (± 0.24) 0.63 0.18 0.80 AIS , abdomen, mean (± SD) 0.6 (± 0.58) 1.7 (± 1.03) 2.3 (± 0.96) < 0.001 ISS , mean (± SD) 3.1 (± 3.01) 5.6 (± 4.3) 10.4 (± 7.1) < 0.001 E-FAST (%) Positive Negative Not performed 1 (4%) 22 (88%) 2 (8%) 0 (0%) 18 (95%) 1 (5%) 19 (23%) 52 (63%) 12 (14%) 0.005 0.005 0.45 CT-scan findings (%) Positive Negative Suspicion of peritoneal perf. without intraabdominal lesions Inconclusive Not performed 3 (12%) 17 (68%) 2 (8%) 2 (8%) 1 (4%) 8 (42%) 8 (42%) 2 (11%) 0 (0%) 1 (5%) 61 (73%) 3 (4%) 6 (7%) 0 (0%) 13 (16%) < 0.001 < 0.001 0.89 0.27 0.18 Indications, initiation (%) CT findings Objective signs of peritoneal penetration Trauma mechanism Other * 5 (20%) 0 (0%) 20 (80%) 0 (0) 8 (42%) 0 (0%) 11 (58%) 0 (0%) 68 (82%) 6 (7%) 4 (5%) 5 (6%) < 0.001 0.3 < 0.001 0.51 *Positive eFAST and hemodynamic instability after arrival There was no statistical difference between groups regarding sex, age, CCI, type of admission or pulse and systolic blood pressure at arrival. The laparotomy group had a significantly higher AIS and ISS. E-FAST was performed in most cases and significantly more often positive in the laparotomy group. There was one positive e-FAST in the laparoscopy group which was due to pneumothorax and therefore not an indication of abdominal injury. In addition, the CT scan had significantly more positive findings indicating intraabdominal injuries in the laparotomy group (n = 61). The CT scan was therefore the predominate factor when choosing to initiate with a laparotomy. The most predominate factor to initiate with laparoscopy was the need to surgically evaluate the patient because of the trauma mechanism and doubt about penetration of the peritoneum. Table 2 shows the intraoperative findings and performed therapy. Table 2 Intraoperative findings and interventions Laparoscopy n = 25 (20%) Laparoscopy converted n = 19 (15%) Laparotomy n = 83 (65%) P -value Findings (%) Intact peritoneum Peritoneal perforation Intraabdominal injuries None Single Multiple 23 (92%) 2 (8%) 24 (96%) 1 (4%) 0 (0%) 0 (0%) 19 (100%) 7 (36%) 6 (32%) 6 (32%) 7 (8%) 76 (92%) 13 (16%) 32 (38%) 38 (46) < 0.001 < 0.001 < 0.001 0.005 < 0.001 Organ injuries (%) Liver Gallblader Spleen Small bowel, serosal Small bowel, perforation Large bowel, serosal Large bowel, perforation Appendix Diaphragm Stomach, serosal Stomach, perforation Duodeum Pancreas Bladder Vessels Omentum Mesentery Retroperitoneal hematoma 1 (4%) 0 (0%) 0 (0%) 0 (0%) 0 (0%) 0 (0%) 0 (0%) 0 (0%) 0 (0%) 0 (0%) 0 (0%) 0 (0%) 0 (0%) 0 (0%) 0 (0%) 0 (0%) 0 (0%) 0 (0%) 3 (16%) 0 (0%) 0 (0%) 1 (5%) 0 (0%) 2 (10%) 3 (16%) 0 (0%) 1 (5%) 0 (0%) 1 (5%) 0 (0%) 0 (0%) 0 (0%) 1 (5%) 4 (21%) 2 (10%) 1 (5%) 22 (26%) 4 (5%) 10 (12%) 5 (6%) 10 (12%) 4 (5%) 6 (7%) 1 (1%) 15 (18%) 6 (7%) 6 (7%) 1 (1%) 4 (5%) 1 (1%) 3 (4%) 2 (2%) 8 (10%) 14 (17%) 0.04 0.78 0.06 0.46 0.06 0.26 0.13 0.77 0.03 0.19 0.38 0.77 0.78 0.77 0.60 0.006 0.30 0.04 Therapy (%) None Suture of stomach Serosal Perforation Suture of small bowel Serosal Perforation Suture of large bowel Serosal Perforation Suture of duodenum Small bowel, resection Large bowel, resection Hemostatic procedure on liver Hemostatic procedure on kidney Hemostatic procedure on pancreas Hemostatic procedure on spleen Splenectomy Suture of diaphragm Cholecystectomy Ligature of bleeding/vessel Procedure on Greater Omentum Procedure at retroperitoneum Appendectomy Suture of the urinary bladder JJ ureteral stent ERCP 25 (100%) NA NA NA NA NA NA NA NA NA NA NA NA NA NA NA NA NA NA NA NA NA NA NA 9 (47%) 0 (0%) 1 (5%) 1 (5%) 0 (0%) 2 (10%) 3 (16%) 0 (0%) 0 (0%) 0 (0%) 2 (10%) 0 (0%) 0 (0%) 0 (0%) 0 (0%) 1 (5%) 0 (0%) 1 (5%) 4 (21%) 0 (0%) 0 (0%) 0 (0%) 0 (0%) 0 (0%) 20 (24%) 5 (6%) 6 (7%) 5 (6%) 4 (5%) 4 (5%) 6 (7%) 1 (1%) 6 (7%) 0 (0%) 14 (17%) 4 (5%) 2 (2%) 6 (7%) 5 (6%) 15 (18%) 4 (5%) 3 (4%) 2 (2%) 1 (1%) 1 (1%) 1 (1%) 1 (1%) 2 (2%) < 0.001 0.51 0.39 0.48 0.78 0.30 0.13 1 0.30 NA 0.06 0.78 1 0.21 0.27 0.04 0.78 0.60 0.006 1 1 1 1 1 Procedures for review (%) None Access to the lesser sac Kocher maneuver Cattell-Braasch maneuver Preparation for Pringles maneuver Mobilization of colon 25 (100%) NA NA NA NA NA 3 (16%) 14 (74%) 6 (32%) 0 (0%) 0 (0%) 1 (5%) 12 (14%) 60 (72%) 41 (49%) 4 (5%) 2 (2%) 20 (24%) < 0.001 < 0.001 < 0.001 0.78 1 0.007 Frequent injuries included damage to the liver (n = 26, 20%), diaphragm (n = 16, 13%), stomach (n = 13, 10%), small and large bowel (n = 16, 13% and n = 15, 12%), retroperitoneal hematoma (n = 15, 12%) and spleen (n = 10, 8%). Injuries to duodenum and pancreas were rare (below 10%). Two patients in the laparoscopic group had a peritoneal breach. One patient had, a liver injury but without the need of intervention. In the other patient, there were no intraabdominal injuries. In the laparotomy group, there were seven patients without breach of peritoneum. In total, there were 20 laparotomies (20%) performed without any intraabdominal findings. The most frequent surgical interventions were hemostatic procedures on the liver (n = 16, 16%) and suture of the diaphragm (n = 16, 16%). The most frequently used procedures to review the abdomen were getting access to the lesser sac (omental bursa) (n = 74, 73%) and Kocher maneuver (n = 47, 46%). There were 15 laparotomies (15%) where no further procedures were performed. Non-expanding retroperitoneal hematoma (n = 10, 8%) and non-bleeding liver lesions (n = 8, 6%) were the most common intraoperative findings where no further therapy was needed. Table 3 provides an overview of the primary and secondary outcomes. Table 3 Primary and secondary outcomes Laparoscopy n = 25 (20%) Laparoscopy converted n = 19 (15%) Laparotomy n = 83 (65%) P -value Negative laparotomies * (%) NA 9 (47%) 20 (24%) 0.04 Missed injuries (%) 0 (0%) 0 (0%) 2 (2%) 0.58 Procedure time in min., mean (± SD) 28.84 (± 15.5) 85.2 (± 31.5) 91.8 (± 43.7) < 0.001 LOS in days, mean (± SD) 1 (± 1.02) 4.1 (± 1.8) 6.8 (± 6.3) < 0.001 Reoperation in the first 30 days (%) 0 (0%) 3 (16%) 7 (8%) 0.15 Long term reoperation (%) 0 (0%) 1 (5%) 4 (5%) 0.51 Clavien Dindo Score (%) Grad 0 Grad I Grad II Grad IIIa Grad IIIb Grad IVa Grad IVb Grad V 24 (96%) 0 (0%) 1 (4%) 0 (0%) 0 (0%) 0 (0%) 0 (0%) 0 (0%) 8 (42%) 5 (26%) 1 (5%) 0 (0%) 5 (14%) 0 (0%) 0 (0%) 0 (0%) 44 (53%) 9 (11%) 11 (13%) 6 (7%) 10 (12%) 2 (2%) 0 (0%) 1 (1%) < 0.001 0.02 0.30 0.19 0.03 0.58 NA 0.77 Mortality (%) 0 (0%) 0 (0%) 1 (1%) 0.77 *laparotomies with no injuries or injuries without need of therapy There were 29 (28%) non-therapeutic laparotomies in the study group. One patient died due to respiratory and cardiac failure after laparotomy. Most complications were graded lesser than Clavien-Dindo IIIb, not requiring general anesthesia. The most common complications were renal failure, pain issues, pneumonia and wound dehiscence. Ten patients underwent an unplanned reoperation within the first 30 days, of which three patients had fascial dehiscence, one paralytic ileus, one gastrointestinal bleeding requiring gastroscopy, one with wound infection, one with hernia in the injury wound containing small bowel, one with the need of a Double-J stent because of a retroperitoneal hematoma compromising the ureter, and two patients because of missed injuries in the laparotomy group. One of the two missed injuries was a patient with additional stomach perforations from multiple stab wounds and the other was a complicated patient with damage to the pancreas and a bile duct with bile leakage. No patients in the laparoscopy group had missed injuries. Procedure time and LOS were statistically significantly longer for laparotomies compared to laparoscopy. In the follow-up period five reoperations were performed in the laparotomy group. Three of those were because of hernias and two were due to adhesive small bowel obstruction. Discussion The current standard practice involves conducting a complete trauma laparotomy, characterized by an incision extending from the xiphoid process to the pubic symphysis. A comprehensive assessment of the abdomen consists of inspection of the hollow viscus organs and the solid organs, performing Kocher maneuver to inspect the duodenum, and create access to the lesser sac for inspection of the posterior stomach site of and the pancreas. Other procedures such as Pringles maneuver, Cattell-Braasch maneuver, and colon mobilization are selectively performed if indicated by suspicion of injuries. Laparoscopy can be useful to establish a minimally invasive overview and initially diagnosis on which further examinations and decisions can be based. Moreover, most surgeons will be able to handle the basic steps of explorative and diagnostic laparoscopy. Our study found a high rate of non-therapeutic laparotomies of 28% in stable patients presenting with penetrating abdominal trauma. Laparotomies performed without any intraabdominal findings were 20%. Internationally, also including high-volume centers, wide incidences of negative laparotomies are reported ranging from 3,9–61% [ 3 – 5 , 10 , 13 , 14 ]. The rate of non-therapeutic laparotomies seems to be higher in patients with stable penetrating abdominal trauma, and laparoscopy could therefore have an important role in reducing the rate of non-therapeutic laparotomies in this specific patient category. Moreover, the group mainly consists of young and healthy individuals, who receive an intervention associated with substantial morbidity. With hemodynamically stable patients, there is ample time to conduct a thorough diagnostic laparoscopy. The decision to initiate with laparotomy is primarily based on assumed penetration of the peritoneum on the CT scan, though we found intact peritoneum in seven patients in the laparotomy group. In all seven instances, the CT scans showed doubtful intraabdominal findings, e.g. only with small amounts of free air which often was located at the point of penetration. The most frequent trauma mechanism is stab wounds and the penetration will lead air along the stab canal. If the lesion stops just before the peritoneum it can be difficult to determine whether the air is located intraabdominal or between the fascia and peritoneum. In the laparoscopy group another seven patients were converted to laparotomy without further findings. These seven patients were all patients with a negative E-FAST and CT scan before surgery. Overall, we have to interpret the findings on CT scans more cautiously and since the patients are hemodynamic stable, these patients can benefit from an initial explorative and diagnostic laparoscopy and likely avoid a laparotomy. The most injured organs are stomach, liver, diaphragm, small bowel and colon, and account for a total of 68% of all injuries. These are all organs where it is feasible to visualize and inspect the injuries by laparoscopy and therefore laparoscopy will in many cases be sufficient to find the needed injuries. In our study 31% of the patients only had a single injury requiring surgical intervention which most surgeons are expected to be able to handle laparoscopically, for example a hemostatic patch on a liver bleed, suturing of a stomach perforation, suturing of a diaphragm lesion, etc. If a laparotomy is needed to handle the injury diagnosed laparoscopically, e.g. in case of a small bowel resection, we can target the incision, and therefore avoid a full trauma laparotomy. Most surgeons trained in laparoscopy will manage to create access to the lesser sac, but Kocher maneuver may be more challenging and may increase the risk of iatrogenic damage to duodenum. If it is required to review the abdomen using more advanced procedures, there will be a substantial probability that the injuries are so severe, that it will not be beneficial to address it laparoscopically. Under any circumstances, it is relevant to consider the trauma mechanism and location to a greater extent, and create a personalized approach for the individual patient. E.g. a single stab wound on the anterior part of the abdomen which has not caused any damage to the nearest organs in front, will unlikely have caused damage to the posterior located organs. Therefore, if there are no visible injuries at the anterior wall of the organ, it should not be indicated to look in the lesser sac or perform a Kocher maneuver. Laparoscopy appears to be an obvious way of identifying intraabdominal injuries after penetrating trauma in the hemodynamic stable patient and may likely lead to a decreased number of non-therapeutic laparotomies. More research is needed to clarify whether diagnostic laparoscopy is safe in the trauma setting and is able to identify all injuries before laparoscopy is going to be implemented as a standard treatment in this patient group. Moreover, a clear definition is required of what a sufficient diagnostic laparoscopy in trauma should consist of. Ultimately, choice of treatment must always depend on the expertise of the individual surgeon. Therefore, we need to train the relevant surgeons to increase expertise and skills. Laparoscopy must be an integrated part in the education to become a trauma surgeon in the future. Limitations The retrospective study design is a limitation and data are only extracted from a single center, thus data are not necessarily comparable with other centers. Due to the limited number of patients included and especially the low number of laparoscopies performed, we cannot draw firm conclusions on the safety of laparoscopy in trauma. Especially, because laparoscopy in this study is only performed in an exploratory manner and not used as either diagnostic or therapeutic. Conclusion In this exploratory study to investigate the potential role of laparoscopy in penetrating hemodynamically stable trauma patients, we identified a very high rate of non-therapeutic laparotomies of 28%. The detected organ injuries and the performed surgical interventions are largely considered to be injuries and procedures that can be handled laparoscopically. Therefore, we conclude that laparoscopy may play an important role in trauma surgery, though further prospective research is necessary to demonstrate both the safety and efficacy of laparoscopy in trauma patients. Future implementation of laparoscopy in trauma may reduce non-therapeutic laparotomies and enhance patient recovery. Declarations Competing interests: The authors have no relevant financial or non-financial interests to declare. Author Contribution NGH, LRJ, EPM and LP designed the study. NGH and LRJ performed the data collection. 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Elliott DC, Rodrigeuz A, Moncure M, Myers RA, Shillinglaw W, Davis F, Goldberg A, Mitchell K, McRitchie D. The accuracy of diagnostic laparoscopy in trauma patients: a prospective, controlled study. Int Surg. 1998;83:294–8. Cocco AM, Bhagvan S, Bouffler C, Hsu J. Diagnostic laparoscopy in penetrating abdominal trauma. ANZ J Surg. https://doi.org/10.1111/ans.15140 . Matsevych OY, Koto MZ, Balabyeki M, Mashego LD, Aldous C. Diagnostic laparoscopy or selective non-operative management for stable patients with penetrating abdominal trauma: What to choose? J Minim Access Surg. https://doi.org/10.4103/jmas.JMAS_72_18 . Kawahara NT, Alster C, Fujimura I, Pogetti RS, Birolini D. Standard Examination System for Laparoscopy in Penetrating Abdominal Trauma. J Trauma. https://doi.org/10.1097/TA.0b013e3181a60593 . Schnüriger B, Lam L, Inaba K, Kobayashi L, Barbarino R, Demetriades D. Negative laparotomy in trauma: are we getting better? Am Surg. 2012;78:1219–23. Hietbrink F, Smeeing D, Karhof S, Jonkers HF, Houwert M, Wessem KV, Simmermacher R, Govaert G, Jong Md B, Id, Leenen L. Outcome of trauma-related emergency laparotomies, in an era of far-reaching specialization. World J Emerg Surg. https://doi.org/10.1186/s13017-019-0257-y . Additional Declarations No competing interests reported. Cite Share Download PDF Status: Posted Version 1 posted You are reading this latest preprint version Research Square lets you share your work early, gain feedback from the community, and start making changes to your manuscript prior to peer review in a journal. As a division of Research Square Company, we’re committed to making research communication faster, fairer, and more useful. We do this by developing innovative software and high quality services for the global research community. Our growing team is made up of researchers and industry professionals working together to solve the most critical problems facing scientific publishing. Also discoverable on Platform About Our Team In Review Editorial Policies Advisory Board Help Center Resources Author Services Accessibility API Access RSS feed Manage Cookie Preferences © Research Square 2026 | ISSN 2693-5015 (online) Privacy Policy Terms of Service Do Not Sell My Personal Information {"props":{"pageProps":{"initialData":{"identity":"rs-4001343","acceptedTermsAndConditions":true,"allowDirectSubmit":true,"archivedVersions":[],"articleType":"Research Article","associatedPublications":[],"authors":[{"id":275954161,"identity":"8679497c-dad9-4d2e-969b-14bde2402058","order_by":0,"name":"Nathja Groth Harpsøe","email":"","orcid":"","institution":"Rigshospitalet","correspondingAuthor":false,"prefix":"","firstName":"Nathja","middleName":"Groth","lastName":"Harpsøe","suffix":""},{"id":275954162,"identity":"444a3022-9b24-46af-a7a2-fd1d1390ca8a","order_by":1,"name":"Lasse Rehné Jensen","email":"","orcid":"","institution":"Rigshospitalet","correspondingAuthor":false,"prefix":"","firstName":"Lasse","middleName":"Rehné","lastName":"Jensen","suffix":""},{"id":275954163,"identity":"a0294d9d-c359-4305-8b3e-40228044ea0d","order_by":2,"name":"Emma Possfelt-Møller","email":"","orcid":"","institution":"Rigshospitalet","correspondingAuthor":false,"prefix":"","firstName":"Emma","middleName":"","lastName":"Possfelt-Møller","suffix":""},{"id":275954164,"identity":"f4b6157f-4cc2-4f1e-90c6-f7a67766f137","order_by":3,"name":"Søren Steemann Rudolph","email":"","orcid":"","institution":"Rigshospitalet","correspondingAuthor":false,"prefix":"","firstName":"Søren","middleName":"Steemann","lastName":"Rudolph","suffix":""},{"id":275954165,"identity":"e8a4be0e-bba2-48f2-8c99-dd641478be1e","order_by":4,"name":"Louise Preisler","email":"","orcid":"","institution":"Rigshospitalet","correspondingAuthor":false,"prefix":"","firstName":"Louise","middleName":"","lastName":"Preisler","suffix":""},{"id":275954166,"identity":"12654b0d-a48b-4ed7-87e0-97901ffd5c18","order_by":5,"name":"Luit Penninga","email":"data:image/png;base64,iVBORw0KGgoAAAANSUhEUgAAAZAAAAAyAQMAAABI0h/eAAAABlBMVEX///8AAABVwtN+AAAACXBIWXMAAA7EAAAOxAGVKw4bAAAA+UlEQVRIiWNgGAWjYBACPgbGBgiLGURUQBggZIBLCxsDY2MDQssZorTArQECxja4jXi0SCS3P2DcYZNnzs57+MXPeffk5N2Zjz0uYLA2xq0lsbGB8UxasWUzX5pl77ZiY8PDbOnGMxjSzfBraTucuOEwj5kB77aExI3NPGbSPAyHbQho+Q/WYvh3TkI9sVoOgLQYP+ZtSEiQZ4Zowe0wnoeNMxLPJINtYZY5lmC4gZktTZrHIB2n9/nZ0x98+LjDLnHD+TPGH9/UJMjL9x8+Js1TYW3YgEsPCCQ2QB0JIg0OgEl86hngkcn8AUTK4zV9FIyCUTAKRiIAANctT9PDn8HyAAAAAElFTkSuQmCC","orcid":"","institution":"Rigshospitalet","correspondingAuthor":true,"prefix":"","firstName":"Luit","middleName":"","lastName":"Penninga","suffix":""}],"badges":[],"createdAt":"2024-02-29 22:19:05","currentVersionCode":1,"declarations":"","doi":"10.21203/rs.3.rs-4001343/v1","doiUrl":"https://doi.org/10.21203/rs.3.rs-4001343/v1","draftVersion":[],"editorialEvents":[],"editorialNote":"","failedWorkflow":false,"files":[{"id":52460209,"identity":"be868540-f881-4c9e-8e78-43974125e0ca","added_by":"auto","created_at":"2024-03-11 22:40:37","extension":"pdf","order_by":0,"title":"","display":"","copyAsset":false,"role":"manuscript-pdf","size":400693,"visible":true,"origin":"","legend":"","description":"","filename":"manuscript.pdf","url":"https://assets-eu.researchsquare.com/files/rs-4001343/v1/4c800f4c-69da-4ec0-a410-d2861f333d83.pdf"}],"financialInterests":"No competing interests reported.","formattedTitle":"Laparoscopy for hemodynamic stable penetrating abdominal trauma. An exploratory study in a European setting.","fulltext":[{"header":"Background","content":"\u003cp\u003eTrauma remains a major cause of morbidity and mortality worldwide. The World Health Organization (WHO) estimates that 8% of all deaths worldwide are due to trauma as a direct cause, including both penetrating and blunt [\u003cspan citationid=\"CR1\" class=\"CitationRef\"\u003e1\u003c/span\u003e]. In Denmark, nationally around 2,600 patients are admitted to one of the 4 major trauma centers due to trauma each year [\u003cspan citationid=\"CR2\" class=\"CitationRef\"\u003e2\u003c/span\u003e]. The Trauma Center at Rigshospitalet is one out of 4 major trauma centers in Denmark and serves as a Regional Trauma Center for the Eastern part of Denmark with a population of 2.6\u0026nbsp;million people.\u003c/p\u003e \u003cp\u003eThe distinction between penetrating and blunt trauma is important, but both mechanisms may require surgical evaluation. Until now, exploratory laparotomy has been the golden standard procedure to evaluate trauma patients with abdominal trauma when suspecting intraabdominal injuries or when breach of peritoneum was detected at laparoscopy. Previous studies have demonstrated a rate of negative laparotomy of up to 61% [\u003cspan citationid=\"CR3\" class=\"CitationRef\"\u003e3\u003c/span\u003e, \u003cspan citationid=\"CR4\" class=\"CitationRef\"\u003e4\u003c/span\u003e]. A recent report from our institution has reported a 17,3% rate of negative laparotomies when combining both blunt and penetrating trauma in a Scandinavian setting [\u003cspan citationid=\"CR5\" class=\"CitationRef\"\u003e5\u003c/span\u003e]. Studies have suggested that a very high proportion, and up to 45% of negative laparotomies, can be avoided with the use of laparoscopy for penetrating abdominal trauma [\u003cspan citationid=\"CR3\" class=\"CitationRef\"\u003e3\u003c/span\u003e].\u003c/p\u003e \u003cp\u003eLaparotomy is known to cause a higher risk of complications such as surgical site infections, medical complications and longer length of stay compared to laparoscopy [\u003cspan citationid=\"CR3\" class=\"CitationRef\"\u003e3\u003c/span\u003e, \u003cspan citationid=\"CR6\" class=\"CitationRef\"\u003e6\u003c/span\u003e]. Over the last decades, laparoscopy has increasingly gained success in elective and emergency surgery but has not yet an established role in trauma surgery. The earliest studies, in the late 1990\u0026rsquo;s and beginning of the 2000\u0026rsquo;s, regarding the use of laparoscopy for evaluating trauma patients showed a high rate of missed injuries, especially small bowel lesions [\u003cspan additionalcitationids=\"CR8\" citationid=\"CR7\" class=\"CitationRef\"\u003e7\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR9\" class=\"CitationRef\"\u003e9\u003c/span\u003e]. More recent studies demonstrate that diagnostic laparoscopy can be used safely with a low rate of missed injuries [\u003cspan citationid=\"CR3\" class=\"CitationRef\"\u003e3\u003c/span\u003e, \u003cspan citationid=\"CR6\" class=\"CitationRef\"\u003e6\u003c/span\u003e, \u003cspan citationid=\"CR10\" class=\"CitationRef\"\u003e10\u003c/span\u003e, \u003cspan citationid=\"CR11\" class=\"CitationRef\"\u003e11\u003c/span\u003e]. Probably, because the knowledge and experience with laparoscopic procedures has increased significantly over the last decades.\u003c/p\u003e \u003cp\u003eLaparoscopy can be used exploratory (to determine whether peritoneum is intact), diagnostic (systematic assessment of intraabdominal injuries) and/or therapeutically (surgical repair of intraabdominal injuries). A successful diagnostic laparoscopy must identify all intraabdominal injuries required for intervention. Injuries must not to be missed as they will delay the time to intervention, and increase morbidity [\u003cspan citationid=\"CR3\" class=\"CitationRef\"\u003e3\u003c/span\u003e, \u003cspan citationid=\"CR11\" class=\"CitationRef\"\u003e11\u003c/span\u003e].\u003c/p\u003e \u003cp\u003eThe aim of this study was to analyze the management of hemodynamic stable patients with penetrating abdominal trauma and to assess the potential role of laparoscopy in a manner to reduce the rate of negative and non-therapeutic laparotomies.\u003c/p\u003e"},{"header":"Methods","content":"\u003cp\u003eWe performed a retrospective quality assurance study including stable penetrating abdominal trauma patients admitted to the Trauma Center at Rigshospitalet over a 5-year period from January 1st, 2018 to December 31st, 2022. The study was conducted and reported in accordance with the STROBE guidelines. Ethical approval to access patient data for the purpose of quality assurance was obtained.\u003c/p\u003e \u003cdiv id=\"Sec3\" class=\"Section2\"\u003e \u003ch2\u003ePatient selection\u003c/h2\u003e \u003cp\u003eWe included all patients admitted with a penetrating abdominal trauma to the Trauma Center at Rigshospitalet, both primary admitted patients and those transferred from other hospitals. Patients had to be hemodynamic stable, defined as a pulse\u0026thinsp;\u0026gt;\u0026thinsp;100 and a systolic blood pressure\u0026thinsp;\u0026lt;\u0026thinsp;100, as well as planned for surgery, either laparoscopy or laparotomy.\u003c/p\u003e \u003cp\u003eData was obtained from the hospital\u0026rsquo;s Trauma Registry and the EPIC electronic health record system used within the Capital Region of Denmark.\u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec4\" class=\"Section2\"\u003e \u003ch2\u003eStudy variables\u003c/h2\u003e \u003cp\u003eWe extracted data including patient demographics and patient related information: sex, age, mechanism of injury (stab, gunshot etc.), Injury Severity Score (ISS), American Society of Anesthesiologists (ASA) score, Abbreviated Injury Score (AIS) and Charlson Comorbidity Score (CCI).\u003c/p\u003e \u003cp\u003eIn-hospital data included systolic blood pressure and pulse at arrival, radiological procedures performed and findings, indication for surgery, initiation (laparoscopy or laparotomy), conversion, operative findings, performed therapy and procedures for review the abdomen for injuries and duration of surgery.\u003c/p\u003e \u003cp\u003ePostoperative data with mortality, reoperations both performed within the first 30 days and long term, complications according to Clavien-Dindo Score, missed injuries and length of stay (LOS).\u003c/p\u003e \u003cp\u003eOur primary outcomes were proportion of non-therapeutic laparotomies, defined as a laparotomy with no injuries or injuries without need of therapy, and missed injuries. Secondary outcomes were mortality, procedure time, LOS, complication with Clavien-Dindo score and reoperation, both within 30 days and long term.\u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec5\" class=\"Section2\"\u003e \u003ch2\u003eData and statistical analysis\u003c/h2\u003e \u003cp\u003eStatistical analyses were performed using Microsoft Excel (version 15.29) and IBM SPSS Statistics (version 29.0.1.0 (171)).\u003c/p\u003e \u003cp\u003eDichotomous and categorical data are presented as percentages. Continuous data are presented as means and standard deviation (SD) or medians and interquartile range (IQR, range from the 25th to 75th percentile). Chi-squared test was used to compare proportions and to test for trends. The Mann-Whitney \u003cem\u003eU\u003c/em\u003e-test or Fischers exact test was used to compare unpaired groups of continuous data. Univariate analysis identified any statistic differences. Actual \u003cem\u003eP\u003c/em\u003e-values were reported. All tests were two-tailed. Differences were considered to be statistically significant at a \u003cem\u003eP\u003c/em\u003e\u0026thinsp;\u0026lt;\u0026thinsp;0.05 level.\u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec6\" class=\"Section2\"\u003e \u003ch2\u003eData registry\u003c/h2\u003e \u003cp\u003eAll data were collected by NGH and LRJ, and registered in the Research Electronic Data CAPture (RedCap) system (Vanderbilt University, Nashville, TH, USA).\u003c/p\u003e \u003c/div\u003e"},{"header":"Results","content":"\u003cp\u003eWe identified a total of 252 patients presenting with penetrating abdominal injury within the 5-year study period. Of these, 127 patients met the inclusion criteria; 112 presented with stab wounds, 10 with gunshots and five patients with a trauma mechanism after fall over a penetrating object. This included one patient falling on the bicycle handlebars and four patients after hitting a penetrating object during a fall from heights.\u003c/p\u003e \u003cp\u003eWe separated the patients into three groups. Group one represented the patients only undergoing laparoscopy (n\u0026thinsp;=\u0026thinsp;25), group two with patients initiated as laparoscopy but converted to laparotomy (n\u0026thinsp;=\u0026thinsp;19) and group three counted patients undergoing direct laparotomy (n\u0026thinsp;=\u0026thinsp;83). Baseline patient characteristics are presented in Table \u003cspan refid=\"Tab1\" class=\"InternalRef\"\u003e1\u003c/span\u003e.\u003c/p\u003e \u003cp\u003e \u003cdiv class=\"gridtable\"\u003e\u003ctable float=\"Yes\" id=\"Tab1\" border=\"1\"\u003e \u003ccaption language=\"En\"\u003e \u003cdiv class=\"CaptionNumber\"\u003eTable 1\u003c/div\u003e \u003cdiv class=\"CaptionContent\"\u003e \u003cp\u003eBaseline patient characteristics\u003c/p\u003e \u003c/div\u003e \u003c/caption\u003e \u003ccolgroup cols=\"5\"\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c1\" colnum=\"1\"\u003e\u003c/div\u003e \u003cdiv align=\"char\" char=\".\" class=\"colspec\" colname=\"c2\" colnum=\"2\"\u003e\u003c/div\u003e \u003cdiv align=\"char\" char=\".\" class=\"colspec\" colname=\"c3\" colnum=\"3\"\u003e\u003c/div\u003e \u003cdiv align=\"char\" char=\".\" class=\"colspec\" colname=\"c4\" colnum=\"4\"\u003e\u003c/div\u003e \u003cdiv align=\"char\" char=\".\" class=\"colspec\" colname=\"c5\" colnum=\"5\"\u003e\u003c/div\u003e \u003cthead\u003e \u003ctr\u003e \u003cth align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/th\u003e \u003cth align=\"left\" colname=\"c2\"\u003e \u003cp\u003eLaparoscopy\u003c/p\u003e \u003cp\u003e\u003cem\u003en\u003c/em\u003e\u0026thinsp;=\u0026thinsp;25 (20%)\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c3\"\u003e \u003cp\u003eLaparoscopy converted\u003c/p\u003e \u003cp\u003e\u003cem\u003en\u003c/em\u003e\u0026thinsp;=\u0026thinsp;19 (15%)\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c4\"\u003e \u003cp\u003eLaparotomy\u003c/p\u003e \u003cp\u003e\u003cem\u003en\u003c/em\u003e\u0026thinsp;=\u0026thinsp;83 (65%)\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c5\"\u003e \u003cp\u003e\u003cem\u003eP\u003c/em\u003e-value\u003c/p\u003e \u003c/th\u003e \u003c/tr\u003e \u003c/thead\u003e \u003ctbody\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003eSex\u003c/b\u003e\u003c/p\u003e \u003cp\u003emale (%)\u003c/p\u003e \u003cp\u003efemale (%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e23 (92%)\u003c/p\u003e \u003cp\u003e2 (8%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e17 (90%)\u003c/p\u003e \u003cp\u003e2 (10%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e71 (86%)\u003c/p\u003e \u003cp\u003e12 (14%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e0.67\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003eAge\u003c/b\u003e in years (IQR)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e25.4 (21.1\u0026ndash;42.5)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e38.7 (26.9\u0026ndash;54.9)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e26 (20.4\u0026ndash; 44)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e \u003cp\u003e0.13\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003eCCI\u003c/b\u003e, mean (\u0026plusmn;\u0026thinsp;SD)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e0.2 (\u0026plusmn;\u0026thinsp;0.5)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e0.8 (\u0026plusmn;\u0026thinsp;1.1)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e0.6 (\u0026plusmn;\u0026thinsp;1.6)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e \u003cp\u003e0.11\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003eTrauma mechanism\u003c/b\u003e\u003c/p\u003e \u003cp\u003eStab\u003c/p\u003e \u003cp\u003eGunshot\u003c/p\u003e \u003cp\u003eFalls over penetrating object\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e23 (92%)\u003c/p\u003e \u003cp\u003e1 (4%)\u003c/p\u003e \u003cp\u003e1 (4%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e19 (100%)\u003c/p\u003e \u003cp\u003e0 (0%)\u003c/p\u003e \u003cp\u003e0 (0%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e70 (84%)\u003c/p\u003e \u003cp\u003e9 (11%)\u003c/p\u003e \u003cp\u003e4 (5%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e0.30\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003eType of Admission\u003c/b\u003e\u003c/p\u003e \u003cp\u003ePrimary\u003c/p\u003e \u003cp\u003eSecondary\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e22 (88%)\u003c/p\u003e \u003cp\u003e3 (12%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e19 (100%)\u003c/p\u003e \u003cp\u003e0 (0%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e73 (88%)\u003c/p\u003e \u003cp\u003e10 (12%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e0.28\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003eHemodynamics\u003c/b\u003e, mean (\u0026plusmn;\u0026thinsp;SD)\u003c/p\u003e \u003cp\u003ePulse\u003c/p\u003e \u003cp\u003esBP\u003c/p\u003e \u003cp\u003eShock index\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e93 (\u0026plusmn;\u0026thinsp;19.7)\u003c/p\u003e \u003cp\u003e129 (\u0026plusmn;\u0026thinsp;25.1)\u003c/p\u003e \u003cp\u003e0.77 (\u0026plusmn;\u0026thinsp;0.37)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e99 (\u0026plusmn;\u0026thinsp;20.6)\u003c/p\u003e \u003cp\u003e141 (\u0026plusmn;\u0026thinsp;17.1)\u003c/p\u003e \u003cp\u003e0.72 (\u0026plusmn;\u0026thinsp;0.20)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e95 (\u0026plusmn;\u0026thinsp;21.2)\u003c/p\u003e \u003cp\u003e131 (\u0026plusmn;\u0026thinsp;24.9)\u003c/p\u003e \u003cp\u003e0.76 (\u0026plusmn;\u0026thinsp;0.24)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e0.63\u003c/p\u003e \u003cp\u003e0.18\u003c/p\u003e \u003cp\u003e0.80\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003eAIS\u003c/b\u003e, abdomen, mean (\u0026plusmn;\u0026thinsp;SD)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e0.6 (\u0026plusmn;\u0026thinsp;0.58)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e1.7 (\u0026plusmn;\u0026thinsp;1.03)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e2.3 (\u0026plusmn;\u0026thinsp;0.96)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e \u003cp\u003e\u003cb\u003e\u0026lt;\u0026thinsp;0.001\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003eISS\u003c/b\u003e, mean (\u0026plusmn;\u0026thinsp;SD)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e3.1 (\u0026plusmn;\u0026thinsp;3.01)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e5.6 (\u0026plusmn;\u0026thinsp;4.3)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e10.4 (\u0026plusmn;\u0026thinsp;7.1)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e \u003cp\u003e\u003cb\u003e\u0026lt;\u0026thinsp;0.001\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003eE-FAST\u003c/b\u003e (%)\u003c/p\u003e \u003cp\u003ePositive\u003c/p\u003e \u003cp\u003eNegative\u003c/p\u003e \u003cp\u003eNot performed\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e1 (4%)\u003c/p\u003e \u003cp\u003e22 (88%)\u003c/p\u003e \u003cp\u003e2 (8%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e0 (0%)\u003c/p\u003e \u003cp\u003e18 (95%)\u003c/p\u003e \u003cp\u003e1 (5%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e19 (23%)\u003c/p\u003e \u003cp\u003e52 (63%)\u003c/p\u003e \u003cp\u003e12 (14%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e\u003cb\u003e0.005\u003c/b\u003e\u003c/p\u003e \u003cp\u003e\u003cb\u003e0.005\u003c/b\u003e\u003c/p\u003e \u003cp\u003e0.45\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003eCT-scan findings\u003c/b\u003e (%)\u003c/p\u003e \u003cp\u003ePositive\u003c/p\u003e \u003cp\u003eNegative\u003c/p\u003e \u003cp\u003eSuspicion of peritoneal perf.\u003c/p\u003e \u003cp\u003ewithout intraabdominal lesions\u003c/p\u003e \u003cp\u003eInconclusive\u003c/p\u003e \u003cp\u003eNot performed\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e3 (12%)\u003c/p\u003e \u003cp\u003e17 (68%)\u003c/p\u003e \u003cp\u003e2 (8%)\u003c/p\u003e \u003cp\u003e2 (8%)\u003c/p\u003e \u003cp\u003e1 (4%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e8 (42%)\u003c/p\u003e \u003cp\u003e8 (42%)\u003c/p\u003e \u003cp\u003e2 (11%)\u003c/p\u003e \u003cp\u003e0 (0%)\u003c/p\u003e \u003cp\u003e1 (5%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e61 (73%)\u003c/p\u003e \u003cp\u003e3 (4%)\u003c/p\u003e \u003cp\u003e6 (7%)\u003c/p\u003e \u003cp\u003e0 (0%)\u003c/p\u003e \u003cp\u003e13 (16%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e\u003cb\u003e\u0026lt;\u0026thinsp;0.001\u003c/b\u003e\u003c/p\u003e \u003cp\u003e\u003cb\u003e\u0026lt;\u0026thinsp;0.001\u003c/b\u003e\u003c/p\u003e \u003cp\u003e0.89\u003c/p\u003e \u003cp\u003e0.27\u003c/p\u003e \u003cp\u003e0.18\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003eIndications, initiation\u003c/b\u003e (%)\u003c/p\u003e \u003cp\u003eCT findings\u003c/p\u003e \u003cp\u003eObjective signs of peritoneal penetration\u003c/p\u003e \u003cp\u003eTrauma mechanism\u003c/p\u003e \u003cp\u003eOther *\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e5 (20%)\u003c/p\u003e \u003cp\u003e0 (0%)\u003c/p\u003e \u003cp\u003e20 (80%)\u003c/p\u003e \u003cp\u003e0 (0)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e8 (42%)\u003c/p\u003e \u003cp\u003e0 (0%)\u003c/p\u003e \u003cp\u003e11 (58%)\u003c/p\u003e \u003cp\u003e0 (0%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e68 (82%)\u003c/p\u003e \u003cp\u003e6 (7%)\u003c/p\u003e \u003cp\u003e4 (5%)\u003c/p\u003e \u003cp\u003e5 (6%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e\u003cb\u003e\u0026lt;\u0026thinsp;0.001\u003c/b\u003e\u003c/p\u003e \u003cp\u003e0.3\u003c/p\u003e \u003cp\u003e\u003cb\u003e\u0026lt;\u0026thinsp;0.001\u003c/b\u003e\u003c/p\u003e \u003cp\u003e0.51\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003c/tbody\u003e \u003c/colgroup\u003e \u003ctfoot\u003e \u003ctr\u003e\u003ctd colspan=\"5\"\u003e*Positive eFAST and hemodynamic instability after arrival\u003c/td\u003e\u003c/tr\u003e \u003c/tfoot\u003e \u003c/table\u003e\u003c/div\u003e \u003c/p\u003e \u003cp\u003eThere was no statistical difference between groups regarding sex, age, CCI, type of admission or pulse and systolic blood pressure at arrival. The laparotomy group had a significantly higher AIS and ISS. E-FAST was performed in most cases and significantly more often positive in the laparotomy group. There was one positive e-FAST in the laparoscopy group which was due to pneumothorax and therefore not an indication of abdominal injury. In addition, the CT scan had significantly more positive findings indicating intraabdominal injuries in the laparotomy group (n\u0026thinsp;=\u0026thinsp;61). The CT scan was therefore the predominate factor when choosing to initiate with a laparotomy. The most predominate factor to initiate with laparoscopy was the need to surgically evaluate the patient because of the trauma mechanism and doubt about penetration of the peritoneum.\u003c/p\u003e \u003cp\u003eTable\u0026nbsp;\u003cspan refid=\"Tab2\" class=\"InternalRef\"\u003e2\u003c/span\u003e shows the intraoperative findings and performed therapy.\u003c/p\u003e \u003cp\u003e \u003cdiv class=\"gridtable\"\u003e\u003ctable float=\"Yes\" id=\"Tab2\" border=\"1\"\u003e \u003ccaption language=\"En\"\u003e \u003cdiv class=\"CaptionNumber\"\u003eTable 2\u003c/div\u003e \u003cdiv class=\"CaptionContent\"\u003e \u003cp\u003eIntraoperative findings and interventions\u003c/p\u003e \u003c/div\u003e \u003c/caption\u003e \u003ccolgroup cols=\"5\"\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c1\" colnum=\"1\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c2\" colnum=\"2\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c3\" colnum=\"3\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c4\" colnum=\"4\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c5\" colnum=\"5\"\u003e\u003c/div\u003e \u003cthead\u003e \u003ctr\u003e \u003cth align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/th\u003e \u003cth align=\"left\" colname=\"c2\"\u003e \u003cp\u003eLaparoscopy\u003c/p\u003e \u003cp\u003e\u003cem\u003en\u003c/em\u003e\u0026thinsp;=\u0026thinsp;25 (20%)\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c3\"\u003e \u003cp\u003eLaparoscopy converted\u003c/p\u003e \u003cp\u003e\u003cem\u003en\u003c/em\u003e\u0026thinsp;=\u0026thinsp;19 (15%)\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c4\"\u003e \u003cp\u003eLaparotomy\u003c/p\u003e \u003cp\u003e\u003cem\u003en\u003c/em\u003e\u0026thinsp;=\u0026thinsp;83 (65%)\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c5\"\u003e \u003cp\u003e\u003cem\u003eP\u003c/em\u003e-value\u003c/p\u003e \u003c/th\u003e \u003c/tr\u003e \u003c/thead\u003e \u003ctbody\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003eFindings\u003c/b\u003e (%)\u003c/p\u003e \u003cp\u003eIntact peritoneum\u003c/p\u003e \u003cp\u003ePeritoneal perforation\u003c/p\u003e \u003cp\u003eIntraabdominal injuries\u003c/p\u003e \u003cp\u003eNone\u003c/p\u003e \u003cp\u003eSingle\u003c/p\u003e \u003cp\u003eMultiple\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e23 (92%)\u003c/p\u003e \u003cp\u003e2 (8%)\u003c/p\u003e \u003cp\u003e24 (96%)\u003c/p\u003e \u003cp\u003e1 (4%)\u003c/p\u003e \u003cp\u003e0 (0%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e0 (0%)\u003c/p\u003e \u003cp\u003e19 (100%)\u003c/p\u003e \u003cp\u003e7 (36%)\u003c/p\u003e \u003cp\u003e6 (32%)\u003c/p\u003e \u003cp\u003e6 (32%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e7 (8%)\u003c/p\u003e \u003cp\u003e76 (92%)\u003c/p\u003e \u003cp\u003e13 (16%)\u003c/p\u003e \u003cp\u003e32 (38%)\u003c/p\u003e \u003cp\u003e38 (46)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e\u003cb\u003e\u0026lt;\u0026thinsp;0.001\u003c/b\u003e\u003c/p\u003e \u003cp\u003e\u003cb\u003e\u0026lt;\u0026thinsp;0.001\u003c/b\u003e\u003c/p\u003e \u003cp\u003e\u003cb\u003e\u0026lt;\u0026thinsp;0.001\u003c/b\u003e\u003c/p\u003e \u003cp\u003e\u003cb\u003e0.005\u003c/b\u003e\u003c/p\u003e \u003cp\u003e\u003cb\u003e\u0026lt;\u0026thinsp;0.001\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003eOrgan injuries\u003c/b\u003e (%)\u003c/p\u003e \u003cp\u003eLiver\u003c/p\u003e \u003cp\u003eGallblader\u003c/p\u003e \u003cp\u003eSpleen\u003c/p\u003e \u003cp\u003eSmall bowel, serosal\u003c/p\u003e \u003cp\u003eSmall bowel, perforation\u003c/p\u003e \u003cp\u003eLarge bowel, serosal\u003c/p\u003e \u003cp\u003eLarge bowel, perforation\u003c/p\u003e \u003cp\u003eAppendix\u003c/p\u003e \u003cp\u003eDiaphragm\u003c/p\u003e \u003cp\u003eStomach, serosal\u003c/p\u003e \u003cp\u003eStomach, perforation\u003c/p\u003e \u003cp\u003eDuodeum\u003c/p\u003e \u003cp\u003ePancreas\u003c/p\u003e \u003cp\u003eBladder\u003c/p\u003e \u003cp\u003eVessels\u003c/p\u003e \u003cp\u003eOmentum\u003c/p\u003e \u003cp\u003eMesentery\u003c/p\u003e \u003cp\u003eRetroperitoneal hematoma\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e1 (4%)\u003c/p\u003e \u003cp\u003e0 (0%)\u003c/p\u003e \u003cp\u003e0 (0%)\u003c/p\u003e \u003cp\u003e0 (0%)\u003c/p\u003e \u003cp\u003e0 (0%)\u003c/p\u003e \u003cp\u003e0 (0%)\u003c/p\u003e \u003cp\u003e0 (0%)\u003c/p\u003e \u003cp\u003e0 (0%)\u003c/p\u003e \u003cp\u003e0 (0%)\u003c/p\u003e \u003cp\u003e0 (0%)\u003c/p\u003e \u003cp\u003e0 (0%)\u003c/p\u003e \u003cp\u003e0 (0%)\u003c/p\u003e \u003cp\u003e0 (0%)\u003c/p\u003e \u003cp\u003e0 (0%)\u003c/p\u003e \u003cp\u003e0 (0%)\u003c/p\u003e \u003cp\u003e0 (0%)\u003c/p\u003e \u003cp\u003e0 (0%)\u003c/p\u003e \u003cp\u003e0 (0%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e3 (16%)\u003c/p\u003e \u003cp\u003e0 (0%)\u003c/p\u003e \u003cp\u003e0 (0%)\u003c/p\u003e \u003cp\u003e1 (5%)\u003c/p\u003e \u003cp\u003e0 (0%)\u003c/p\u003e \u003cp\u003e2 (10%)\u003c/p\u003e \u003cp\u003e3 (16%)\u003c/p\u003e \u003cp\u003e0 (0%)\u003c/p\u003e \u003cp\u003e1 (5%)\u003c/p\u003e \u003cp\u003e0 (0%)\u003c/p\u003e \u003cp\u003e1 (5%)\u003c/p\u003e \u003cp\u003e0 (0%)\u003c/p\u003e \u003cp\u003e0 (0%)\u003c/p\u003e \u003cp\u003e0 (0%)\u003c/p\u003e \u003cp\u003e1 (5%)\u003c/p\u003e \u003cp\u003e4 (21%)\u003c/p\u003e \u003cp\u003e2 (10%)\u003c/p\u003e \u003cp\u003e1 (5%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e22 (26%)\u003c/p\u003e \u003cp\u003e4 (5%)\u003c/p\u003e \u003cp\u003e10 (12%)\u003c/p\u003e \u003cp\u003e5 (6%)\u003c/p\u003e \u003cp\u003e10 (12%)\u003c/p\u003e \u003cp\u003e4 (5%)\u003c/p\u003e \u003cp\u003e6 (7%)\u003c/p\u003e \u003cp\u003e1 (1%)\u003c/p\u003e \u003cp\u003e15 (18%)\u003c/p\u003e \u003cp\u003e6 (7%)\u003c/p\u003e \u003cp\u003e6 (7%)\u003c/p\u003e \u003cp\u003e1 (1%)\u003c/p\u003e \u003cp\u003e4 (5%)\u003c/p\u003e \u003cp\u003e1 (1%)\u003c/p\u003e \u003cp\u003e3 (4%)\u003c/p\u003e \u003cp\u003e2 (2%)\u003c/p\u003e \u003cp\u003e8 (10%)\u003c/p\u003e \u003cp\u003e14 (17%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e\u003cb\u003e0.04\u003c/b\u003e\u003c/p\u003e \u003cp\u003e0.78\u003c/p\u003e \u003cp\u003e0.06\u003c/p\u003e \u003cp\u003e0.46\u003c/p\u003e \u003cp\u003e0.06\u003c/p\u003e \u003cp\u003e0.26\u003c/p\u003e \u003cp\u003e0.13\u003c/p\u003e \u003cp\u003e0.77\u003c/p\u003e \u003cp\u003e\u003cb\u003e0.03\u003c/b\u003e\u003c/p\u003e \u003cp\u003e0.19\u003c/p\u003e \u003cp\u003e0.38\u003c/p\u003e \u003cp\u003e0.77\u003c/p\u003e \u003cp\u003e0.78\u003c/p\u003e \u003cp\u003e0.77\u003c/p\u003e \u003cp\u003e0.60\u003c/p\u003e \u003cp\u003e\u003cb\u003e0.006\u003c/b\u003e\u003c/p\u003e \u003cp\u003e0.30\u003c/p\u003e \u003cp\u003e\u003cb\u003e0.04\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003eTherapy\u003c/b\u003e (%)\u003c/p\u003e \u003cp\u003eNone\u003c/p\u003e \u003cp\u003eSuture of stomach\u003c/p\u003e \u003cp\u003eSerosal\u003c/p\u003e \u003cp\u003ePerforation\u003c/p\u003e \u003cp\u003eSuture of small bowel\u003c/p\u003e \u003cp\u003eSerosal\u003c/p\u003e \u003cp\u003ePerforation\u003c/p\u003e \u003cp\u003eSuture of large bowel\u003c/p\u003e \u003cp\u003eSerosal\u003c/p\u003e \u003cp\u003ePerforation\u003c/p\u003e \u003cp\u003eSuture of duodenum\u003c/p\u003e \u003cp\u003eSmall bowel, resection\u003c/p\u003e \u003cp\u003eLarge bowel, resection\u003c/p\u003e \u003cp\u003eHemostatic procedure on liver\u003c/p\u003e \u003cp\u003eHemostatic procedure on kidney\u003c/p\u003e \u003cp\u003eHemostatic procedure on pancreas\u003c/p\u003e \u003cp\u003eHemostatic procedure on spleen\u003c/p\u003e \u003cp\u003eSplenectomy\u003c/p\u003e \u003cp\u003eSuture of diaphragm\u003c/p\u003e \u003cp\u003eCholecystectomy\u003c/p\u003e \u003cp\u003eLigature of bleeding/vessel\u003c/p\u003e \u003cp\u003eProcedure on Greater Omentum\u003c/p\u003e \u003cp\u003eProcedure at retroperitoneum\u003c/p\u003e \u003cp\u003eAppendectomy\u003c/p\u003e \u003cp\u003eSuture of the urinary bladder\u003c/p\u003e \u003cp\u003eJJ ureteral stent\u003c/p\u003e \u003cp\u003eERCP\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e25 (100%)\u003c/p\u003e \u003cp\u003eNA\u003c/p\u003e \u003cp\u003eNA\u003c/p\u003e \u003cp\u003eNA\u003c/p\u003e \u003cp\u003eNA\u003c/p\u003e \u003cp\u003eNA\u003c/p\u003e \u003cp\u003eNA\u003c/p\u003e \u003cp\u003eNA\u003c/p\u003e \u003cp\u003eNA\u003c/p\u003e \u003cp\u003eNA\u003c/p\u003e \u003cp\u003eNA\u003c/p\u003e \u003cp\u003eNA\u003c/p\u003e \u003cp\u003eNA\u003c/p\u003e \u003cp\u003eNA\u003c/p\u003e \u003cp\u003eNA\u003c/p\u003e \u003cp\u003eNA\u003c/p\u003e \u003cp\u003eNA\u003c/p\u003e \u003cp\u003eNA\u003c/p\u003e \u003cp\u003eNA\u003c/p\u003e \u003cp\u003eNA\u003c/p\u003e \u003cp\u003eNA\u003c/p\u003e \u003cp\u003eNA\u003c/p\u003e \u003cp\u003eNA\u003c/p\u003e \u003cp\u003eNA\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e9 (47%)\u003c/p\u003e \u003cp\u003e0 (0%)\u003c/p\u003e \u003cp\u003e1 (5%)\u003c/p\u003e \u003cp\u003e1 (5%)\u003c/p\u003e \u003cp\u003e0 (0%)\u003c/p\u003e \u003cp\u003e2 (10%)\u003c/p\u003e \u003cp\u003e3 (16%)\u003c/p\u003e \u003cp\u003e0 (0%)\u003c/p\u003e \u003cp\u003e0 (0%)\u003c/p\u003e \u003cp\u003e0 (0%)\u003c/p\u003e \u003cp\u003e2 (10%)\u003c/p\u003e \u003cp\u003e0 (0%)\u003c/p\u003e \u003cp\u003e0 (0%)\u003c/p\u003e \u003cp\u003e0 (0%)\u003c/p\u003e \u003cp\u003e0 (0%)\u003c/p\u003e \u003cp\u003e1 (5%)\u003c/p\u003e \u003cp\u003e0 (0%)\u003c/p\u003e \u003cp\u003e1 (5%)\u003c/p\u003e \u003cp\u003e4 (21%)\u003c/p\u003e \u003cp\u003e0 (0%)\u003c/p\u003e \u003cp\u003e0 (0%)\u003c/p\u003e \u003cp\u003e0 (0%)\u003c/p\u003e \u003cp\u003e0 (0%)\u003c/p\u003e \u003cp\u003e0 (0%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e20 (24%)\u003c/p\u003e \u003cp\u003e5 (6%)\u003c/p\u003e \u003cp\u003e6 (7%)\u003c/p\u003e \u003cp\u003e5 (6%)\u003c/p\u003e \u003cp\u003e4 (5%)\u003c/p\u003e \u003cp\u003e4 (5%)\u003c/p\u003e \u003cp\u003e6 (7%)\u003c/p\u003e \u003cp\u003e1 (1%)\u003c/p\u003e \u003cp\u003e6 (7%)\u003c/p\u003e \u003cp\u003e0 (0%)\u003c/p\u003e \u003cp\u003e14 (17%)\u003c/p\u003e \u003cp\u003e4 (5%)\u003c/p\u003e \u003cp\u003e2 (2%)\u003c/p\u003e \u003cp\u003e6 (7%)\u003c/p\u003e \u003cp\u003e5 (6%)\u003c/p\u003e \u003cp\u003e15 (18%)\u003c/p\u003e \u003cp\u003e4 (5%)\u003c/p\u003e \u003cp\u003e3 (4%)\u003c/p\u003e \u003cp\u003e2 (2%)\u003c/p\u003e \u003cp\u003e1 (1%)\u003c/p\u003e \u003cp\u003e1 (1%)\u003c/p\u003e \u003cp\u003e1 (1%)\u003c/p\u003e \u003cp\u003e1 (1%)\u003c/p\u003e \u003cp\u003e2 (2%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e\u003cb\u003e\u0026lt;\u0026thinsp;0.001\u003c/b\u003e\u003c/p\u003e \u003cp\u003e0.51\u003c/p\u003e \u003cp\u003e0.39\u003c/p\u003e \u003cp\u003e0.48\u003c/p\u003e \u003cp\u003e0.78\u003c/p\u003e \u003cp\u003e0.30\u003c/p\u003e \u003cp\u003e0.13\u003c/p\u003e \u003cp\u003e1\u003c/p\u003e \u003cp\u003e0.30\u003c/p\u003e \u003cp\u003eNA\u003c/p\u003e \u003cp\u003e0.06\u003c/p\u003e \u003cp\u003e0.78\u003c/p\u003e \u003cp\u003e1\u003c/p\u003e \u003cp\u003e0.21\u003c/p\u003e \u003cp\u003e0.27\u003c/p\u003e \u003cp\u003e\u003cb\u003e0.04\u003c/b\u003e\u003c/p\u003e \u003cp\u003e0.78\u003c/p\u003e \u003cp\u003e0.60\u003c/p\u003e \u003cp\u003e\u003cb\u003e0.006\u003c/b\u003e\u003c/p\u003e \u003cp\u003e1\u003c/p\u003e \u003cp\u003e1\u003c/p\u003e \u003cp\u003e1\u003c/p\u003e \u003cp\u003e1\u003c/p\u003e \u003cp\u003e1\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003eProcedures for review\u003c/b\u003e (%)\u003c/p\u003e \u003cp\u003eNone\u003c/p\u003e \u003cp\u003eAccess to the lesser sac\u003c/p\u003e \u003cp\u003eKocher maneuver\u003c/p\u003e \u003cp\u003eCattell-Braasch maneuver\u003c/p\u003e \u003cp\u003ePreparation for Pringles maneuver\u003c/p\u003e \u003cp\u003eMobilization of colon\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e25 (100%)\u003c/p\u003e \u003cp\u003eNA\u003c/p\u003e \u003cp\u003eNA\u003c/p\u003e \u003cp\u003eNA\u003c/p\u003e \u003cp\u003eNA\u003c/p\u003e \u003cp\u003eNA\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e3 (16%)\u003c/p\u003e \u003cp\u003e14 (74%)\u003c/p\u003e \u003cp\u003e6 (32%)\u003c/p\u003e \u003cp\u003e0 (0%)\u003c/p\u003e \u003cp\u003e0 (0%)\u003c/p\u003e \u003cp\u003e1 (5%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e12 (14%)\u003c/p\u003e \u003cp\u003e60 (72%)\u003c/p\u003e \u003cp\u003e41 (49%)\u003c/p\u003e \u003cp\u003e4 (5%)\u003c/p\u003e \u003cp\u003e2 (2%)\u003c/p\u003e \u003cp\u003e20 (24%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e\u003cb\u003e\u0026lt;\u0026thinsp;0.001\u003c/b\u003e\u003c/p\u003e \u003cp\u003e\u003cb\u003e\u0026lt;\u0026thinsp;0.001\u003c/b\u003e\u003c/p\u003e \u003cp\u003e\u003cb\u003e\u0026lt;\u0026thinsp;0.001\u003c/b\u003e\u003c/p\u003e \u003cp\u003e0.78\u003c/p\u003e \u003cp\u003e1\u003c/p\u003e \u003cp\u003e\u003cb\u003e0.007\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003c/tbody\u003e \u003c/colgroup\u003e \u003c/table\u003e\u003c/div\u003e \u003c/p\u003e \u003cp\u003eFrequent injuries included damage to the liver (n\u0026thinsp;=\u0026thinsp;26, 20%), diaphragm (n\u0026thinsp;=\u0026thinsp;16, 13%), stomach (n\u0026thinsp;=\u0026thinsp;13, 10%), small and large bowel (n\u0026thinsp;=\u0026thinsp;16, 13% and n\u0026thinsp;=\u0026thinsp;15, 12%), retroperitoneal hematoma (n\u0026thinsp;=\u0026thinsp;15, 12%) and spleen (n\u0026thinsp;=\u0026thinsp;10, 8%). Injuries to duodenum and pancreas were rare (below 10%). Two patients in the laparoscopic group had a peritoneal breach. One patient had, a liver injury but without the need of intervention. In the other patient, there were no intraabdominal injuries. In the laparotomy group, there were seven patients without breach of peritoneum. In total, there were 20 laparotomies (20%) performed without any intraabdominal findings.\u003c/p\u003e \u003cp\u003eThe most frequent surgical interventions were hemostatic procedures on the liver (n\u0026thinsp;=\u0026thinsp;16, 16%) and suture of the diaphragm (n\u0026thinsp;=\u0026thinsp;16, 16%). The most frequently used procedures to review the abdomen were getting access to the lesser sac (omental bursa) (n\u0026thinsp;=\u0026thinsp;74, 73%) and Kocher maneuver (n\u0026thinsp;=\u0026thinsp;47, 46%). There were 15 laparotomies (15%) where no further procedures were performed. Non-expanding retroperitoneal hematoma (n\u0026thinsp;=\u0026thinsp;10, 8%) and non-bleeding liver lesions (n\u0026thinsp;=\u0026thinsp;8, 6%) were the most common intraoperative findings where no further therapy was needed.\u003c/p\u003e \u003cp\u003eTable\u0026nbsp;\u003cspan refid=\"Tab3\" class=\"InternalRef\"\u003e3\u003c/span\u003e provides an overview of the primary and secondary outcomes.\u003c/p\u003e \u003cp\u003e \u003cdiv class=\"gridtable\"\u003e\u003ctable float=\"Yes\" id=\"Tab3\" border=\"1\"\u003e \u003ccaption language=\"En\"\u003e \u003cdiv class=\"CaptionNumber\"\u003eTable 3\u003c/div\u003e \u003cdiv class=\"CaptionContent\"\u003e \u003cp\u003ePrimary and secondary outcomes\u003c/p\u003e \u003c/div\u003e \u003c/caption\u003e \u003ccolgroup cols=\"5\"\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c1\" colnum=\"1\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c2\" colnum=\"2\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c3\" colnum=\"3\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c4\" colnum=\"4\"\u003e\u003c/div\u003e \u003cdiv align=\"char\" char=\".\" class=\"colspec\" colname=\"c5\" colnum=\"5\"\u003e\u003c/div\u003e \u003cthead\u003e \u003ctr\u003e \u003cth align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/th\u003e \u003cth align=\"left\" colname=\"c2\"\u003e \u003cp\u003eLaparoscopy\u003c/p\u003e \u003cp\u003en\u0026thinsp;=\u0026thinsp;25 (20%)\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c3\"\u003e \u003cp\u003eLaparoscopy converted\u003c/p\u003e \u003cp\u003en\u0026thinsp;=\u0026thinsp;19 (15%)\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c4\"\u003e \u003cp\u003eLaparotomy\u003c/p\u003e \u003cp\u003en\u0026thinsp;=\u0026thinsp;83 (65%)\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c5\"\u003e \u003cp\u003e\u003cem\u003eP\u003c/em\u003e-value\u003c/p\u003e \u003c/th\u003e \u003c/tr\u003e \u003c/thead\u003e \u003ctbody\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003eNegative laparotomies\u003c/b\u003e* (%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eNA\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e9 (47%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e20 (24%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e \u003cp\u003e\u003cb\u003e0.04\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003eMissed injuries\u003c/b\u003e (%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e0 (0%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e0 (0%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e2 (2%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e \u003cp\u003e0.58\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003eProcedure time\u003c/b\u003e in min., mean (\u0026plusmn;\u0026thinsp;SD)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e28.84 (\u0026plusmn;\u0026thinsp;15.5)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e85.2 (\u0026plusmn;\u0026thinsp;31.5)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e91.8 (\u0026plusmn;\u0026thinsp;43.7)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e \u003cp\u003e\u003cb\u003e\u0026lt;\u0026thinsp;0.001\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003eLOS\u003c/b\u003e in days, mean (\u0026plusmn;\u0026thinsp;SD)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e1 (\u0026plusmn;\u0026thinsp;1.02)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e4.1 (\u0026plusmn;\u0026thinsp;1.8)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e6.8 (\u0026plusmn;\u0026thinsp;6.3)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e \u003cp\u003e\u003cb\u003e\u0026lt;\u0026thinsp;0.001\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003eReoperation in the first 30 days\u003c/b\u003e (%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e0 (0%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e3 (16%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e7 (8%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e \u003cp\u003e0.15\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003eLong term reoperation\u003c/b\u003e (%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e0 (0%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e1 (5%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e4 (5%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e \u003cp\u003e0.51\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003eClavien Dindo Score\u003c/b\u003e (%)\u003c/p\u003e \u003cp\u003eGrad 0\u003c/p\u003e \u003cp\u003eGrad I\u003c/p\u003e \u003cp\u003eGrad II\u003c/p\u003e \u003cp\u003eGrad IIIa\u003c/p\u003e \u003cp\u003eGrad IIIb\u003c/p\u003e \u003cp\u003eGrad IVa\u003c/p\u003e \u003cp\u003eGrad IVb\u003c/p\u003e \u003cp\u003eGrad V\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e24 (96%)\u003c/p\u003e \u003cp\u003e0 (0%)\u003c/p\u003e \u003cp\u003e1 (4%)\u003c/p\u003e \u003cp\u003e0 (0%)\u003c/p\u003e \u003cp\u003e0 (0%)\u003c/p\u003e \u003cp\u003e0 (0%)\u003c/p\u003e \u003cp\u003e0 (0%)\u003c/p\u003e \u003cp\u003e0 (0%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e8 (42%)\u003c/p\u003e \u003cp\u003e5 (26%)\u003c/p\u003e \u003cp\u003e1 (5%)\u003c/p\u003e \u003cp\u003e0 (0%)\u003c/p\u003e \u003cp\u003e5 (14%)\u003c/p\u003e \u003cp\u003e0 (0%)\u003c/p\u003e \u003cp\u003e0 (0%)\u003c/p\u003e \u003cp\u003e0 (0%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e44 (53%)\u003c/p\u003e \u003cp\u003e9 (11%)\u003c/p\u003e \u003cp\u003e11 (13%)\u003c/p\u003e \u003cp\u003e6 (7%)\u003c/p\u003e \u003cp\u003e10 (12%)\u003c/p\u003e \u003cp\u003e2 (2%)\u003c/p\u003e \u003cp\u003e0 (0%)\u003c/p\u003e \u003cp\u003e1 (1%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e\u003cb\u003e\u0026lt;\u0026thinsp;0.001\u003c/b\u003e\u003c/p\u003e \u003cp\u003e\u003cb\u003e0.02\u003c/b\u003e\u003c/p\u003e \u003cp\u003e0.30\u003c/p\u003e \u003cp\u003e0.19\u003c/p\u003e \u003cp\u003e\u003cb\u003e0.03\u003c/b\u003e\u003c/p\u003e \u003cp\u003e0.58\u003c/p\u003e \u003cp\u003eNA\u003c/p\u003e \u003cp\u003e0.77\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003eMortality\u003c/b\u003e (%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e0 (0%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e0 (0%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e1 (1%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e \u003cp\u003e0.77\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003c/tbody\u003e \u003c/colgroup\u003e \u003c/table\u003e\u003c/div\u003e \u003c/p\u003e \u003cp\u003e*laparotomies with no injuries or injuries without need of therapy\u003c/p\u003e \u003cp\u003eThere were 29 (28%) non-therapeutic laparotomies in the study group. One patient died due to respiratory and cardiac failure after laparotomy. Most complications were graded lesser than Clavien-Dindo IIIb, not requiring general anesthesia. The most common complications were renal failure, pain issues, pneumonia and wound dehiscence. Ten patients underwent an unplanned reoperation within the first 30 days, of which three patients had fascial dehiscence, one paralytic ileus, one gastrointestinal bleeding requiring gastroscopy, one with wound infection, one with hernia in the injury wound containing small bowel, one with the need of a Double-J stent because of a retroperitoneal hematoma compromising the ureter, and two patients because of missed injuries in the laparotomy group. One of the two missed injuries was a patient with additional stomach perforations from multiple stab wounds and the other was a complicated patient with damage to the pancreas and a bile duct with bile leakage. No patients in the laparoscopy group had missed injuries. Procedure time and LOS were statistically significantly longer for laparotomies compared to laparoscopy. In the follow-up period five reoperations were performed in the laparotomy group. Three of those were because of hernias and two were due to adhesive small bowel obstruction.\u003c/p\u003e"},{"header":"Discussion","content":"\u003cp\u003eThe current standard practice involves conducting a complete trauma laparotomy, characterized by an incision extending from the xiphoid process to the pubic symphysis. A comprehensive assessment of the abdomen consists of inspection of the hollow viscus organs and the solid organs, performing Kocher maneuver to inspect the duodenum, and create access to the lesser sac for inspection of the posterior stomach site of and the pancreas. Other procedures such as Pringles maneuver, Cattell-Braasch maneuver, and colon mobilization are selectively performed if indicated by suspicion of injuries. Laparoscopy can be useful to establish a minimally invasive overview and initially diagnosis on which further examinations and decisions can be based. Moreover, most surgeons will be able to handle the basic steps of explorative and diagnostic laparoscopy.\u003c/p\u003e \u003cp\u003eOur study found a high rate of non-therapeutic laparotomies of 28% in stable patients presenting with penetrating abdominal trauma. Laparotomies performed without any intraabdominal findings were 20%. Internationally, also including high-volume centers, wide incidences of negative laparotomies are reported ranging from 3,9\u0026ndash;61% [\u003cspan additionalcitationids=\"CR4\" citationid=\"CR3\" class=\"CitationRef\"\u003e3\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR5\" class=\"CitationRef\"\u003e5\u003c/span\u003e, \u003cspan citationid=\"CR10\" class=\"CitationRef\"\u003e10\u003c/span\u003e, \u003cspan citationid=\"CR13\" class=\"CitationRef\"\u003e13\u003c/span\u003e, \u003cspan citationid=\"CR14\" class=\"CitationRef\"\u003e14\u003c/span\u003e]. The rate of non-therapeutic laparotomies seems to be higher in patients with stable penetrating abdominal trauma, and laparoscopy could therefore have an important role in reducing the rate of non-therapeutic laparotomies in this specific patient category. Moreover, the group mainly consists of young and healthy individuals, who receive an intervention associated with substantial morbidity.\u003c/p\u003e \u003cp\u003eWith hemodynamically stable patients, there is ample time to conduct a thorough diagnostic laparoscopy.\u003c/p\u003e \u003cp\u003eThe decision to initiate with laparotomy is primarily based on assumed penetration of the peritoneum on the CT scan, though we found intact peritoneum in seven patients in the laparotomy group. In all seven instances, the CT scans showed doubtful intraabdominal findings, e.g. only with small amounts of free air which often was located at the point of penetration. The most frequent trauma mechanism is stab wounds and the penetration will lead air along the stab canal. If the lesion stops just before the peritoneum it can be difficult to determine whether the air is located intraabdominal or between the fascia and peritoneum. In the laparoscopy group another seven patients were converted to laparotomy without further findings. These seven patients were all patients with a negative E-FAST and CT scan before surgery. Overall, we have to interpret the findings on CT scans more cautiously and since the patients are hemodynamic stable, these patients can benefit from an initial explorative and diagnostic laparoscopy and likely avoid a laparotomy.\u003c/p\u003e \u003cp\u003eThe most injured organs are stomach, liver, diaphragm, small bowel and colon, and account for a total of 68% of all injuries. These are all organs where it is feasible to visualize and inspect the injuries by laparoscopy and therefore laparoscopy will in many cases be sufficient to find the needed injuries. In our study 31% of the patients only had a single injury requiring surgical intervention which most surgeons are expected to be able to handle laparoscopically, for example a hemostatic patch on a liver bleed, suturing of a stomach perforation, suturing of a diaphragm lesion, etc. If a laparotomy is needed to handle the injury diagnosed laparoscopically, e.g. in case of a small bowel resection, we can target the incision, and therefore avoid a full trauma laparotomy.\u003c/p\u003e \u003cp\u003eMost surgeons trained in laparoscopy will manage to create access to the lesser sac, but Kocher maneuver may be more challenging and may increase the risk of iatrogenic damage to duodenum. If it is required to review the abdomen using more advanced procedures, there will be a substantial probability that the injuries are so severe, that it will not be beneficial to address it laparoscopically. Under any circumstances, it is relevant to consider the trauma mechanism and location to a greater extent, and create a personalized approach for the individual patient. E.g. a single stab wound on the anterior part of the abdomen which has not caused any damage to the nearest organs in front, will unlikely have caused damage to the posterior located organs. Therefore, if there are no visible injuries at the anterior wall of the organ, it should not be indicated to look in the lesser sac or perform a Kocher maneuver.\u003c/p\u003e \u003cp\u003eLaparoscopy appears to be an obvious way of identifying intraabdominal injuries after penetrating trauma in the hemodynamic stable patient and may likely lead to a decreased number of non-therapeutic laparotomies. More research is needed to clarify whether diagnostic laparoscopy is safe in the trauma setting and is able to identify all injuries before laparoscopy is going to be implemented as a standard treatment in this patient group. Moreover, a clear definition is required of what a sufficient diagnostic laparoscopy in trauma should consist of. Ultimately, choice of treatment must always depend on the expertise of the individual surgeon. Therefore, we need to train the relevant surgeons to increase expertise and skills. Laparoscopy must be an integrated part in the education to become a trauma surgeon in the future.\u003c/p\u003e\n\u003ch3\u003eLimitations\u003c/h3\u003e\n\u003cp\u003eThe retrospective study design is a limitation and data are only extracted from a single center, thus data are not necessarily comparable with other centers. Due to the limited number of patients included and especially the low number of laparoscopies performed, we cannot draw firm conclusions on the safety of laparoscopy in trauma. Especially, because laparoscopy in this study is only performed in an exploratory manner and not used as either diagnostic or therapeutic.\u003c/p\u003e"},{"header":"Conclusion","content":"\u003cp\u003eIn this exploratory study to investigate the potential role of laparoscopy in penetrating hemodynamically stable trauma patients, we identified a very high rate of non-therapeutic laparotomies of 28%. The detected organ injuries and the performed surgical interventions are largely considered to be injuries and procedures that can be handled laparoscopically. Therefore, we conclude that laparoscopy may play an important role in trauma surgery, though further prospective research is necessary to demonstrate both the safety and efficacy of laparoscopy in trauma patients. Future implementation of laparoscopy in trauma may reduce non-therapeutic laparotomies and enhance patient recovery.\u003c/p\u003e"},{"header":"Declarations","content":"\u003cp\u003e \u003cstrong\u003eCompeting interests:\u003c/strong\u003e \u003cp\u003eThe authors have no relevant financial or non-financial interests to declare.\u003c/p\u003e \u003c/p\u003e\u003ch2\u003eAuthor Contribution\u003c/h2\u003e\u003cp\u003eNGH, LRJ, EPM and LP designed the study. NGH and LRJ performed the data collection. Primarily NGH performed the statistical analysis of the data with assistance from LRJ. NGH drafted the manuscript. All authors contributed to the interpretation of the data and writing the manuscript as well as all authors revised the manuscript and approved it in the final form.\u003c/p\u003e"},{"header":"References","content":"\u003col\u003e\u003cli\u003e\u003cspan\u003eWorld Health Organization. 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ANZ J Surg. \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003ehttps://doi.org/10.1111/ans.15140\u003c/span\u003e\u003cspan address=\"10.1111/ans.15140\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eMatsevych OY, Koto MZ, Balabyeki M, Mashego LD, Aldous C. Diagnostic laparoscopy or selective non-operative management for stable patients with penetrating abdominal trauma: What to choose? J Minim Access Surg. \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003ehttps://doi.org/10.4103/jmas.JMAS_72_18\u003c/span\u003e\u003cspan address=\"10.4103/jmas.JMAS_72_18\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eKawahara NT, Alster C, Fujimura I, Pogetti RS, Birolini D. Standard Examination System for Laparoscopy in Penetrating Abdominal Trauma. J Trauma. \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003ehttps://doi.org/10.1097/TA.0b013e3181a60593\u003c/span\u003e\u003cspan address=\"10.1097/TA.0b013e3181a60593\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eSchn\u0026uuml;riger B, Lam L, Inaba K, Kobayashi L, Barbarino R, Demetriades D. Negative laparotomy in trauma: are we getting better? Am Surg. 2012;78:1219\u0026ndash;23.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eHietbrink F, Smeeing D, Karhof S, Jonkers HF, Houwert M, Wessem KV, Simmermacher R, Govaert G, Jong Md B, Id, Leenen L. Outcome of trauma-related emergency laparotomies, in an era of far-reaching specialization. World J Emerg Surg. \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003ehttps://doi.org/10.1186/s13017-019-0257-y\u003c/span\u003e\u003cspan address=\"10.1186/s13017-019-0257-y\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e.\u003c/span\u003e\u003c/li\u003e\u003c/ol\u003e"}],"fulltextSource":"","fullText":"","funders":[],"hasAdminPriorityOnWorkflow":false,"hasManuscriptDocX":true,"hasOptedInToPreprint":true,"hasPassedJournalQc":"","hasAnyPriority":false,"hideJournal":true,"highlight":"","institution":"","isAcceptedByJournal":false,"isAuthorSuppliedPdf":false,"isDeskRejected":"","isHiddenFromSearch":false,"isInQc":false,"isInWorkflow":false,"isPdf":false,"isPdfUpToDate":true,"isWithdrawnOrRetracted":false,"journal":{"display":true,"email":"[email protected]","identity":"researchsquare","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":true,"externalIdentity":"","sideBox":"","snPcode":"","submissionUrl":"/submission","title":"Research Square","twitterHandle":"researchsquare","acdcEnabled":true,"dfaEnabled":false,"editorialSystem":"","reportingPortfolio":"","inReviewEnabled":false,"inReviewRevisionsEnabled":true},"keywords":"penetrating abdominal trauma, hemodynamic stable, laparoscopy, laparotomy, retrospective study","lastPublishedDoi":"10.21203/rs.3.rs-4001343/v1","lastPublishedDoiUrl":"https://doi.org/10.21203/rs.3.rs-4001343/v1","license":{"name":"CC BY 4.0","url":"https://creativecommons.org/licenses/by/4.0/"},"manuscriptAbstract":"\u003ch2\u003ePurpose\u003c/h2\u003e \u003cp\u003eTrauma laparotomy is the golden standard for the treatment of penetrating abdominal trauma, though laparotomy is associated with a higher complication risk and prolonged length of hospital stay. Therefore, we explored whether laparoscopy in a trauma setting can be a valuable alternative. We analyzed the management of hemodynamic stable patients with penetrating abdominal trauma and assessed the applicability of laparoscopy in order to reduce non-therapeutic laparotomies.\u003c/p\u003e\u003ch2\u003eMethods\u003c/h2\u003e \u003cp\u003eWe performed a retrospective study of hemodynamic stable patients with a penetrating abdominal trauma who underwent surgery. Data were extracted for a 5-year period from January 2018 to December 2022. Collected data included patient demographics, in-hospital data such as radiological procedures, surgical findings and interventions performed and postoperative outcomes with mortality, complication including reoperation, missed injury and length of stay.\u003c/p\u003e\u003ch2\u003eResults\u003c/h2\u003e \u003cp\u003eA total of 127 patients were included. We created three groups: A laparoscopy group; a laparoscopy converted to laparotomy group; and a laparotomy group. The e-FAST and CT scan were significantly more positive in the laparotomy group. Most frequently injured organs were liver, diaphragm, stomach, small bowel and colon, retroperitoneal hematoma and spleen. Therapy with hemostatic procedures on the liver and suture of the diaphragm were frequently performed. In total, 29 patients (28%) had a non-therapeutic laparotomy.\u003c/p\u003e\u003ch2\u003eConclusion\u003c/h2\u003e \u003cp\u003eOur study revealed a very high rate of non-therapeutic laparotomies. Considering the organ injuries and surgical procedures performed they can in experienced hands be handled laparoscopically. Prospective studies are urgently needed to assess the safety and efficacy of laparoscopy in abdominal trauma.\u003c/p\u003e","manuscriptTitle":"Laparoscopy for hemodynamic stable penetrating abdominal trauma. An exploratory study in a European setting.","msid":"","msnumber":"","nonDraftVersions":[{"code":1,"date":"2024-03-06 10:46:24","doi":"10.21203/rs.3.rs-4001343/v1","editorialEvents":[{"type":"communityComments","content":0}],"status":"published","journal":{"display":true,"email":"[email protected]","identity":"researchsquare","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":true,"externalIdentity":"","sideBox":"","snPcode":"","submissionUrl":"/submission","title":"Research Square","twitterHandle":"researchsquare","acdcEnabled":true,"dfaEnabled":false,"editorialSystem":"","reportingPortfolio":"","inReviewEnabled":false,"inReviewRevisionsEnabled":true}}],"origin":"","ownerIdentity":"158079a9-cde5-4369-a156-6d8355302d14","owner":[],"postedDate":"March 6th, 2024","published":true,"recentEditorialEvents":[],"rejectedJournal":[],"revision":"","amendment":"","status":"posted","subjectAreas":[],"tags":[],"updatedAt":"2024-03-11T22:32:30+00:00","versionOfRecord":[],"versionCreatedAt":"2024-03-06 10:46:24","video":"","vorDoi":"","vorDoiUrl":"","workflowStages":[]},"version":"v1","identity":"rs-4001343","journalConfig":"researchsquare"},"__N_SSP":true},"page":"/article/[identity]/[[...version]]","query":{"redirect":"/article/rs-4001343","identity":"rs-4001343","version":["v1"]},"buildId":"qtupq5eGEP_6zYnWcrvyt","isFallback":false,"isExperimentalCompile":false,"dynamicIds":[84888],"gssp":true,"scriptLoader":[]}