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Three Part Question

In [a patient with an anterior abdominal stab wound] does [laparoscopy] reliably detect [intra-abdominal injury including peritoneal or hollow viscus perforation].

Clinical Scenario

A 35-year-old male presents to the Emergency Department with an anterior abdominal stab wound (AASW). He is haemodynamically stable; you are unsure what the best method of investigation is to detect any significant intra-abdominal injury including hollow viscus perforation.

Search Strategy

NICE Healthcare Databases (1985-2016) including: AMED, PubMED, BNI, EMBASE, HBE, HMIC, Medline, PsycINFO, CINAHL.
Search terms included (anterior abdominal stab).ti,ab OR (abdominal stab investigations).ti,ab.

Search Outcome

81 papers found of which 16 were duplicates, 61 were irrelevant and 1 of insufficient quality for inclusion. 3 papers were relevant and of sufficient quality and are included in this BET. Relevant papers are shown in the table below.

Relevant Paper(s)

Author, date and country	Patient group	Study type (level of evidence)	Outcomes	Key results	Study Weaknesses
O’Malley E, Boyle E, O’Callaghan A, Coffey JC, Walsh SR. 2013 Ireland	51 studies included for analysis, total of 2569 patients who underwent diagnostic laparoscopy. All trauma patients who had experienced stab, gunshot or shotgun wounds causing penetrating injuries were included.	Systematic review	Diagnostic performance of laparoscopy at detecting injury		Majority of studies were retrospective (n=38). Overall analysis did not separate mechanism of injuries therefore not specific to AASW, however individual studies could be reviewed. Acknowledges wide range of surgeon factors including experience reported in studies.
			Sensitivity	66.7-100%
			Specificity	33-100%
			Spared non-therapeutic laparotomy	51.8%
			Missed injuries	3%
				23 of the studies, including 4 of the most recent studies, reported sensitivity, specificity and accuracy of 100%.
Sumislawski JJ, Zarzaur BL, Paulus EM, et al. 2013 United States	158 AASW patients were assessed using a local algorithm, 70 underwent diagnostic laparoscopy (DL) following a positive local wound exploration. Results were compared to the Western Trauma Association (WTA) algorithm of serial abdominal examinations (SAE).	Retrospective cohort study	Subsequent non-therapeutic laparotomy (LAP) rate	DL algorithm (28%) versus SAE-based algorithm (43%), (p=0.18).	Small study group. No acknowledgement of limitations of the study in discussion. Both serial abdominal examination (SAE) and DL are safe and offer similar therapeutic laparotomy rates.
			Successful discharge home	DL algorithm (33%) versus SAE-based algorithm (18%), p=0.01).
Shah M, Galante JM, Scherer LA, Utter GH. 2014 United States	358 patients with AASW, 163 underwent screening laparoscopy. If penetration of parietal peritoneum is found on laparoscopy then conversion to laparotomy takes place. 86 patients had indication for immediate laparotomy.	Retrospective case series study	Peritoneal penetration located on laparascopic screening predicting an injury requiring treatmentPeritoneal penetration located on laparascopic screening predicting an injury requiring treatment		Investigators not blinded to treatment or outcomes. ‘Injuries requiring treatment’ outcome can be influenced by clinician documentation. Verification bias as patients with laparoscopy not requiring laparotomy did not undergo a post operative assessment and therefore may have presented to other healthcare facilities with delayed or missed injuries. Modest selection bias as not all patients underwent laparoscopic evaluation.
			Sensitivity	100% (95% CI 88-100%)
			Specificity	63% (95% CI 54-71%)
			Positive Predictive Value (PPV)	38% (95% CI 27-50%)
			Negative Predictive Value (NPV)	100% (95% CI 95-100%)

Comment(s)

Evidence for the use of laparoscopy is limited due to the lack of high quality and prospective studies. The advantages of using laparoscopy surgery is a high rate of sensitivity, 23 studies from O’Malley et al. reported sensitivity rates of 100% for the detection of peritoneal perforation, and the ability for therapeutic procedures to be undertaken. Laparoscopic surgery appears to have particular advantages in diaphragmatic injuries. The systematic review by O’Malley et al. has a comprehensive coverage of papers with abdominal stab wounds. Whilst difficult to pull out specifics relating to anterior abdominal stab wounds (AASW) alone it provides an important review of papers that would not necessarily be located from an AASW literature search. It therefore has advantages as a method for capturing papers that are predominantly related to gunshot wounds but additionally report AASW data. Comparison of laparoscopy compared to serial clinical examinations and CT (including CT tractography) using a prospective or randomised controlled trial methodology would be the logically next step for research in this area to provide a definitive answer for the management of AASW. All papers commented on surgeon factors including experience, speciality and hospital organisational factors relating to trauma on-calls. O’Malley et al. specifically commented on the learning curve for laparoscopic surgery being longer than for open surgery and how papers controlled for surgeon experience making it difficult to assess standardisation of laparoscopic technique.

Editor Comment

Trauma

Clinical Bottom Line

It appears that laparoscopy has screening, diagnostic and therapeutic roles in the treatment of AASW in a haemodynamically stable patient but higher quality studies and data is required for its recommendation. In addition to patient factors, surgeon and organisational factors have to be taken into consideration if laparoscopy is used in a protocol.

References

1. O’Malley E, Boyle E, O’Callaghan A, Coffey JC, Walsh SR. Role of laparoscopy in penetrating abdominal trauma: a systematic review World Journal of Surgery 2013. 37:113–122
2. Sumislawski JJ, Zarzaur BL, Paulus EM, et al. Diagnostic laparoscopy after anterior abdominal stab wounds: Worth another look? Journal of Trauma and Acute Care Surgery 2013 Dec 1;75(6):1013-8
3. Shah M, Galante JM, Scherer LA, Utter GH The utility of laparoscopic evaluation of the parietal peritoneum in the management of anterior abdominal stab wounds Injury 2014 Jan 31;45(1):128-33