What is the Role of MIS in Pediatric Trauma?
George W. Holcomb, III, M.D., MBASurgeon-in-Chief/Senior Vice-President
Children’s Mercy HospitalKansas City, Missouri
Pediatric MISAppendectomy Inflammatory Bowel Disease
Cholecystectomy Choledochal Cyst
Fundoplication EsophagomyotomySplenectomy AdrenalectomyPyloromyotomy Esophageal AtresiaHirschsprung’s Dz Lung Resection/BiopsyAnorectal Atresia EmpyemaInguinal Hernia Posterior Mediastinal MassDuodenal Atresia Congenital Diaphragmatic HerniaIntussusception Tumor Resection/BiopsyMeckel’s Diverticulum Trauma - ?
MIS TraumaBackground
• Most intra-abdominal (and intra-thoracic) injuries can be managed non-operatively
• Absolute indications for operation: Shock from intra-abdominal bleeding Pneumoperitoneum Contrast extravasation
• Selective indications for operation Thickened bowel loops Mesenteric infiltration Unexplained free fluid Violation peritoneum on local exploration for penetrating trauma
MIS TraumaBackground
• FAST (Focused Abdominal Sonographyfor Trauma) & DPL (Diagnostic Peritoneal Lavage) not as helpful in deciding management in children
• Equivocal findings for an injury are sometimes found on CT scan
When To Use MIS in Trauma• Hemodynamically
stable patient• Blunt trauma Free fluid not from solid
organ injury Persistent abdominal
pain/tenderness
• Penetrating trauma Peritoneal violation?
Algorithm
Gaines BA, et al: The role of laparoscopy in pediatric trauma. Sem Pediatr Surg 19:300-303, 2010
Laparoscopy for Trauma
• Screening: identify one injury, then convert Helps avoid a negative laparotomy Very sensitive: misses only 1% injuries
• Diagnostic: identifies all injuries Should be as effective as other imaging studies Can miss up to 50% of all injuries
• Therapeutic: identifies and treats all injuries
Children’s Hospital Alabama
4836 Trauma Admissions(1997 – 2009)
92 Abdominal Operations
Open – 71 Laparoscopic - 21
Marwan et al: J Trauma 69:761-764, 2010
Children’s Hospital Alabama• 19/21 laparoscopies correctly diagnosed
the injury
• 5/5 therapeutic laparoscopic procedures were successful
• Laparotomy was avoided in 15/21 patients overall and 10/10 with penetrating injuries
Marwan et al: J Trauma 69:761-764, 2010
Pancreatic Trauma• Retrospective Review 2000 - 2012 13 pediatric trauma centers 167 patients
• 95 managed non-operatively• 72 managed operatively
• 57 underwent resection• 15 underwent drainage alone
• Study: Non-operative mgmt (95) vs. operative resection (57)
J Am Coll Surg 218:157-162, 2014
Results
Since 2007, 80% of the pancreatic resections were performed
laparoscopically
J Am Coll Surg 218:157-162, 2014
Conclusions• Laparoscopy can be a useful tool for diagnosis
of a traumatic injury when the diagnosis is not clear
• Some traumatic injuries can be managed entirely laparoscopically or with the use of a small umbilical incision
• Patient must be hemodynamically stable if the laparoscopic approach is utilized
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