Article 1
Trauma laparoscopy and the six w's: Why, where, who, when, what, and how? Di Saverio S, Birindelli A, Podda M, Segalini E, Piccinini A, Coniglio C, Frattini C, Tugnoli G. J Trauma and Acute Care Surg. 2019 Feb;86(2):344-367.
The aim of the article is to explore and discuss the surgical techniques for the minimally invasive approach in hemodynamically stable trauma patients. The article is accompanied by several videos and images showing the surgical procedures that can be performed at level I trauma centers, by highly experienced trauma surgeons with both advanced laparoscopic skills and trauma surgery expertise. These videos by experienced surgeons can help guide and encourage other surgeons to approach these injuries in a similar fashion or even inspire then to share some of their own personal videos and techniques. The article even includes tips and guidance to when to convert to an open procedure. The experience is based on the cases gathered and managed by a single attending surgeon with specific expertise in acute care and trauma and a subspecialty experience in gastrointestinal minimally invasive surgery, within an 8-year period in a major (level III) trauma center in northern Italy.
The article offers a wide review of experiences in trauma patient with use of MIS techniques and is the prelude to more publications by surgeons interested in these technologies. The use of laparoscopy in trauma patients has increasingly been reported both as a diagnostic and a therapeutic tool and may have significant advantages in terms of morbidity and costs, but it requires a careful selection of patients, a collaborating and equipped setting, and, last but not the least, a highly skilled laparoscopic trauma surgeon. In fact, the wrong selection of patients and the missed injuries are the main risks, and these are more likely occur if the surgeon has limited experience.
Amazing review of the experience of the authors at Maggiore Hospital Trauma Centre, Bologna, Italy and later at Cambridge, United Kingdom; and Department of General (M.P.), Emergency and Robotic Surgery, San Francesco Hospital, Nuoro, Italy.
The authors give their current opinion about the benefits and risks of treating patients with minimally invasive techniques. Where, who, when, what, how? Are the questions we have to ask ourselves when challenged with the management of trauma patients and approaching them with these new technologies. It’s a captivating read for all of us interested in MIS and for those eager to learn about new technologies and applications.
Article 2
Trends in the Adoption of Robotic Surgery for Common Surgical Procedures. Sheetz KH, Claflin J, Dimick JB. JAMA Netw Open. 2020 Jan 3;3(1):e1918911.
The article delineates the trend of the new technology of Robotic surgery and its adoption into the therapeutic armamentarium of the surgeon to treat a wide variety of pathologies. Similar to the initial adoption of laparoscopy, this is following an increasing trend that has been accompanied by the learning curve and a decrease in open surgery.
As cited by the authors “Increasing use of robotic surgery for common surgical procedures with limited evidence and unclear clinical benefit is raising concern”. We have encountered these issues previously with the adoption of laparoscopic surgery, which have prompted the creation of new study groups and committees at hospitals and international organizations for the development and adaptation of new technologies into a safe practice. Although there is no delineation about the urgency of the patients, the wide variety of procedures and the high number of patients, make it relevant for surgeons interested in MIS and its application in acute care surgery and eventually in selected stable trauma patients.
The study included 169404 patients at 73 hospitals in Michigan, USA. Population-based data from a manually abstracted statewide clinical registry was used to characterize contemporary trends in the adoption of robotic surgery across a range of general surgical procedures, which now represent the largest market for the technology in the United States. Robotic surgery use increased from 1.8% in 2012 to 15.1% in 2018 (8.4-fold increase. For inguinal hernia repair, the use of robotic surgery increased from 0.7% to 28.8% (41.1-fold change). The study shows how the robotic learning curve is following a similar trend to initial laparoscopic trends and demonstrates a decrease in laparoscopic use at the state of Michigan. After adopting robotic surgery, the use of laparoscopic surgery declined 0.3%. “Robotic surgery has continued to diffuse across a broad range of common surgical procedures. Hospitals that launched robotic surgery programs had a broad and immediate increase in the use of robotic surgery, which was associated with a decrease in traditional laparoscopic minimally invasive surgery”.
This article highlights some of the trends that can be currently experienced in surgery departments with Robotic capabilities and encourages to learn and improve our skills with new technologies for the benefit of both patient and surgeon.
Article 3
Fully therapeutic laparoscopy for penetrating abdominal trauma in stable patients. Cabrera Vargas LF, Pedraza M, Rincon FA, Pulido JA, Mendoza-Zuchini A, Gomez D, Moreno-Villamizar MD, Ferrada P, Lopez P, Di Saverio S. Am J Surg. 2021 Jul 17:S0002-9610(21)00388-3.
The authors did a retrospective study of penetrating abdominal trauma patients with hemodynamic stability who presented to 2 medical centers in Bogota, Colombia between December 2018 and December 2019. All patients underwent diagnostic and fully therapeutic laparoscopic surgical treatment. Chart review included 192 patients with PAT. Only adult stable patients older than 15 years of age were included. Twenty-four patients met selection criteria and underwent initial laparoscopic evaluation with diagnosis and fully therapeutic laparoscopic definitive treatment.
The patients were evaluated by a multidisciplinary group of surgeons with training in laparoscopy and trauma surgery. Both penetrating gunshot wounds and stab wounds were included. Intraoperatively, the therapeutic approach was defined after the initial damage assessment, surgeon's expertise, degree of contamination and general condition of the patient. 24 hemodynamically stable patients underwent diagnostic laparoscopy and fully therapeutic laparoscopy was performed. 15 male patients (62,5%), with an average age of 27,8 years (16–44 years). 21 patients presented anterior abdominal penetrating wounds, 3 thoracoabdominal penetrating injuries. 19 had abdominal stab wounds (79,1%), and 5 patients presented abdominal gunshot wounds (20,9%). Only 1 patient required conversion to open surgery due to active uncontrolled bleeding. No missed injuries. No required intensive care unit (ICU) treatment. No mortality. The average length of hospital stay was 1,3 days, and tolerance to the oral intake food was in the first 24 hours for all patients.
The authors concluded that Full Therapeutic Laparoscopy is a safe and efficient procedure for Penetrating Abdominal Trauma in hemodynamic stable patients and must be part of the trauma surgeon armamentarium to avoid the morbidity of an unnecessary laparotomy in indicated cases. Experience in advanced laparoscopic skills is a determining factor in the patient outcomes.
