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

2013 APSA Mtg.

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

J Am Coll Surg 218:157-162, 2014

Results

*excluding venous accessJ 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

MIS and TraumaPancreatic Resection

MIS and Trauma Diaphragmatic Hernia Repair

MIS and Trauma Diaphragmatic Hernia Repair

MIS and Trauma Possible Bowel Injury

MIS and Trauma Possible Bowel Injury

MIS and Trauma Penetrating Injury

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

QUESTIONS