Delayed laparoscopic peritoneal washout in non-operative management of blunt abdominal trauma: a scoping review

Study selection

A total of 910 potentially relevant articles were identified. Duplicates were removed, which left 907 articles that met the inclusion criteria for title and abstract screening. Following the title and abstract screening, 694 articles were excluded, leaving 213 full-text articles to be reviewed. An additional 187 articles were excluded upon full-text review. Two additional articles were identified by hand through searching bibliographies of included studies, leaving a total of 28 included studies. Inter-rater agreement for inclusion criteria, as measured by Fleiss’ kappa was 0.91 (95% CI 0.819 to 1). Exclusion criteria included: laparoscopy solely used for diagnostic purposes (n = 33), no blunt abdominal trauma (n = 1), laparoscopy before trial of NOM (n = 39), surgical intervention during laparoscopy (n = 17), or no therapeutic laparoscopy following NOM (n = 74).

Study characteristics

Included research had a variety of study designs including one randomized clinical trial [10], ten observational cohort studies [2, 4, 5, 11,12,13,14,15,16,17], seven case reports [3, 18,19,20,21,22,23], six review articles [6, 24,25,26,27,28], two management guidelines [29, 30], and one textbook chapter [31]. The single clinical trial was only published in abstract format. They were published in eleven countries with a majority being from the USA and France. Language of original text was predominantly English (88.5%) with two articles in French and one article in Portuguese. Dates of publication ranged from 1993 to 2019 with the great majority being published after 1999.

Patient demographics

In total, the included papers reported on 108 patients who underwent DLPW after initial non-operative management of blunt abdominal trauma. Of those for which it was reported, 68.9% were male (Table 1). Average reported age was 31.6 years with a range from 11 to 61.

Table 1 Patient demographics from included studiesTypes of trauma

All included patients suffered a blunt trauma mechanism. Motor vehicle collisions (MVCs), including motorbike accidents, accounted for most (68.4%) of the mechanisms followed by falls (15.8%), horse kicks (10.5%), and falling objects (5.3%). No cause was explicitly reported for 82.1% of patients meeting inclusion criteria; all of these included patients sustained known blunt abdominal trauma however, demographics were often grouped together with patients receiving immediate laparoscopy. Of those for which it was reported, organs injured included liver (95.2%), small bowel (3.2%), and pancreas (1.6%). Organ injury was unspecified in 40.6% of patients (Table 2).

Table 2 Trauma descriptorsPre-operative course

Non-operative management (NOM) for patient injuries consisted of observation for 86.5% and angiography with or without embolization for 12.7% of patients (Table 3). One patient (1%) presented to medical services in a delayed fashion. Indications for NOM was unknown for 3.8% of patients. All patients underwent an initial CT scan of the abdomen and pelvis. Following the initial assessment and admission, 35.8% of patients underwent repeat imaging or invasive investigations prior to laparoscopy, which included computerized axial tomography (CT), ultrasonography, endoscopic retrograde cholangiopancreatography (ERCP), and hepatobiliary imiodiactic acid (HIDA) scan in 27.4%, 4.7%, 1.9%, and 1.9% of patients, respectively. Additionally, 13.2% of patients received transfusion pre-laparoscopy, and those patients required on average 4.1 units of red blood cells (RBC) assuming 1 unit of RBC was 300 mL where volume was reported instead of units [32].

Table 3 Description of pre-operative course including management, investigations, and interventionsOperative intervention

On average, operative intervention occurred on day 5 with a range of 2–35 days (Table 4). Reported indications for DLPW included sepsis/SIRS criteria (65%), imaging findings (54%), hemodynamic instability (23%), bloodwork results (20%), abdominal pain/peritonitis (15%), experimental arm in RCT (13%), pulmonary dysfunction (4%), intra-abdominal hypertension (4%), abdominal distension (4%), suspected infection collection (3%), ileus (2%), abdominal compartment syndrome (1%), decreased urine output (1%), and poor oral intake (1%). Percentages add up to more than 100% as authors often listed more than one reason for the decision to operate. The type of fluid identified at the time of OR was most often blood (55.9%), followed by bile (48.4%), blood and/or bile (23.7%), infected collection (3.2%), and lastly chyle (1.1%). The type of fluid was not reported for thirteen patients.

Table 4 Description of operative course including indications and findingsHealth related outcomes

Average hospital length of stay (LOS) was 14 days with a range of 11–43 days (Table 5). Post-operative interventions included surgical drains, ERCP with stenting, and IR drainage in 19.8%, 4.7%, and 3.8%, of patients, respectively, with patients commonly requiring more than one intervention. The single RCT reported an improvement in LOS from 8.93 days (± 2.89) in the control group to 5.69 days (± 1.887) in the DLPW group. No statistical test for significance of this difference was reported.

Table 5 Post-operative patient outcomes and interventions

Of those for which it was reported, 97% of patients had no complications or deaths. Two patients (2%) developed liver abscesses and one patient (1%) developed a partial thrombosis of the IVC. For those reported, there were no patients that failed laparoscopy requiring a second operation. Post-operative complications were not reported in six patients.

Secondary sources

All nine secondary sources (six review articles, two management guidelines, and one textbook chapter) meeting inclusion criteria commented favorably on the use of DLPW in blunt abdominal trauma patients managed non-operatively [2, 6, 14, 25,26,27,28,29, 31]. Hepatic injury-associated bile peritonitis was the most commonly recommended indication for the procedure, with multiple sources citing resolution of systemic inflammatory response syndrome (SIRS) features including tachycardia and fever, as well as ileus and respiratory failure following washout. In the event that biliperitoneum was confirmed, ERCP was commonly advised as a follow-up for evaluation and intervention of possible ongoing bile leak. Other recommended indications for DLPW included retained hemoperitoneum, hepatic collections, and decompression of abdominal compartment syndrome with a large fluid component. When indicated, most sources preferred delayed laparoscopic washout 2–5 days after initial trauma.

Quality of evidence

The mean score on the Newcastle–Ottawa Scale across the 10 comparative studies was 6.9 (0.3), with an average of 3.9 stars allocated for the selection domain, 0 for the comparability domain, and 3 for the outcome domain. According to the AHRQ standards, this corresponds with poor quality of evidence. All ten studies received 0 stars in the comparability domain, thus meeting the criteria for poor quality of evidence.

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