International Journal of Surgery 44 (2017) 94e98

Contents lists available at ScienceDirect

International Journal of Surgery

journal homepage: www.journal-surgery.net

Original Research

Laparoscopic-assisted approach for penetrating abdominal trauma: A

solution for multiple bowel injuries
Oleh Yevhenovych Matsevych, MD (UA), MMed Surg (SA), FCS (SA) a, b, *,
Modise Zacharia Koto, MBChB, FCS (SA), FACS a, b, Colleen Aldous, PhD b
a
Department of Surgery, Dr George Mukhari Academic Hospital, Sefako Makgatho Health Sciences University, Pretoria, South Africa
b
University of KwaZulu e Natal, Nelson R Mandela (NRMSM) Campus, Durban, South Africa

h i g h l i g h t s

The laparoscopic-assisted approach is safe in management of stable trauma patients.

It can used for management of multiple bowel injuries instead of a conversion.

It is not inferior to entirely laparoscopic therapeutic procedures.

It has benefits of minimally invasive surgery and the versatility of laparotomy.

a r t i c l e i n f o a b s t r a c t

Article history: Background: Therapeutic laparoscopy (TL) for penetrating abdominal trauma (PAT) is controversial
Received 13 March 2017 because the management of multiple bowel injuries is challenging and the conversion rate is high.
Received in revised form However, the laparoscopic-assisted approach (LAA) allows easy management of multiple bowel injuries
2 June 2017
but not investigated in a trauma setting. The aim of this study was to investigate its role in management
Accepted 7 June 2017
Available online 16 June 2017
of multiple bowel injuries and to compare LAA with therapeutic laparoscopy performed fully lapa-
roscopically (FTL).
Methods: All adult patients with PAT managed with TL over four-year period were analyzed. Intra-
operative findings, trauma scoring, grading of bowel injuries, related procedures, outcomes and length of
hospital stay (LOS) were compared between LAA and FTL groups.
Results: Seventy two (53%) patients were in the FTL group and 65 (47%) in the LAA group. The majority of
patients presented with stab wounds. Colonic and small bowel injuries were more common in the LAA
group (19 versus 17 and 47 versus 8, respectively). The higher number of bowel repairs, resections and
anastomosis were performed in the LAA group. The ISS was higher in the FTL group (13 versus 11,
p ¼ 0.02), and the PATI was higher in the LAA group (6 versus 10, p < 0.001). Nine patients in the FTL
group suffered Clavien-Dindo grade 3 complications and 11 patients in the LAA group. There was one
death in each group. No missed injuries were reported. There was no significant difference in LOS be-
tween groups.
Conclusions: The LAA is safe in the management of stable patients with PAT. It can used for management
of multiple bowel injuries instead of a conversion to laparotomy. It provides benefits of minimally
invasive surgery and the speed and versatility of laparotomy. Moreover, the LAA seems not to be inferior
to entirely laparoscopic therapeutic procedures. More studies are needed to compare LAA with FTL and
laparotomy.
© 2017 IJS Publishing Group Ltd. Published by Elsevier Ltd. All rights reserved.

1. Introduction

Diagnostic laparoscopy (DL) is a well-accepted technique in the

* Corresponding author. Department of General Surgery, P.O.Box 231, Medunsa, assessment of patients with penetrating abdominal trauma (PAT).
0204, South Africa. Its sensitivity, specificity and accuracy approaches 100% in recent
E-mail address: info@matsevych.com (O.Y. Matsevych).

http://dx.doi.org/10.1016/j.ijsu.2017.06.040
1743-9191/© 2017 IJS Publishing Group Ltd. Published by Elsevier Ltd. All rights reserved.
 O.Y. Matsevych et al. / International Journal of Surgery 44 (2017) 94e98
studies [1]. However, when therapeutic procedures are required,
most surgeons will proceed to laparotomy. Although, therapeutic
laparoscopy (TL) is reported by many authors, it is still controver-
sial. The rate of TL is reported as low as 13.8% by some authors and
as high as 83% by others [1,2]. The conversion rate varies between
centers from 37.3% to 7% [3e5]. The main reason for the reluctance
to apply laparoscopy in PAT is the difficulties in the management of
multiple hollow viscus injuries. Laparotomy is considered to be a
preferred approach in case of multiple bowel injuries by many
surgeons [6]. This was challenged by Koto and colleagues and they
described a laparoscopic-assisted approach (LAA) in trauma pa-
tients with multiple bowel injuries as a transitional step before
conversion. In their initial experience, no patient needed conver-
sion to laparotomy [7].
The LAA may be a minimally invasive solution for a management
of multiple bowel injuries in patients with PAT. The aim of this
study was to investigate its role in the management of multiple
bowel injuries and to compare LAA with therapeutic laparoscopy
performed fully laparoscopically (FTL).
2. Methods
All adult patients with PAT managed with TL from January 2012
to December 2015 were included in the study. The data were
extracted from a prospectively collected database. The patients
converted to laparotomy and with missing records were excluded
from the study. Patients whose therapeutic procedures were per-
formed entirely laparoscopically were included in the FTL group
and the patients treated with assisted approach were included in
the LAA group.
TL was defined as performing therapeutic procedures (other
than blood suctioning, observation or hemostatic agent applica-
tion) for the management of intraabdominal injuries. FTL was
considered when all therapeutic procedures were performed
intracorporeally through the laparoscopic ports. LAA was defined as
any therapeutic procedures performed extracorporeally through
the assisted access, usually 4e8 cm incision of the abdominal wall.
Fig. 1. Study diagram.
95
The procedure followed the standard steps as described by Koto
and colleagues [7]. Incision of equal or more than 8.1 cm was
considered as a conversion to laparotomy.
The mechanism and location of injuries, intraoperative findings,
grading of small bowel and colonic injuries, associated therapeutic
procedures, trauma scoring, length of hospital stay (LOS) and sig-
nificant complications were analyzed and compared between
groups. The Injury Severity Score (ISS), and the Penetrating
Abdominal Trauma Index (PATI) were calculated. In order to
describe and compare the severity of intraabdominal injuries the
New Injury Severity Score (NISS) was modified to abdominal NISS
(aNISS) and was calculated within abdominal region of Abbreviated
Injury Regions. Significant complications (Clavien-Dindo (CD)
grades 3e5) were recorded and investigated [8]. Wound sepsis was
defined as any infection above the aponeurosis that require
drainage or debridement. Any collections below the aponeurosis
were classified as intraabdominal.
Mean values were compared using the two-sample t-test. Me-
dian values were compared by the nonparametric Wilcoxon rank-
sum test. Associations in two-way contingency tables were tested
by the Fisher exact test.
The study was approved by the Research Ethics Committee.
3. Results
Over the period of four years 283 patients with PAT were
managed laparoscopically. Thirty-three patients were converted to
laparotomy and were excluded from the study. Out of 250 patients
completed laparoscopically, 113 (45%) patients met criteria for DL
and were excluded. A total of 137 (55%) patients underwent TL and
were analyzed. All therapeutic procedures were completed entirely
laparoscopically in 72 (53%) patients, LAA was utilized in 65 (47%)
patients (Fig. 1). Mean age and gender distribution was similar in
two groups (Table 1).
The majority of patients in both groups presented with stab
wounds. The most common location of injuries was the lower chest
in the FTL group and anterior abdominal wall in the LAA group
96 O.Y. Matsevych et al. / International Journal of Surgery 44 (2017) 94e98

Table 1 Table 3
Therapeutic laparoscopy: patient data. The grade of bowel injuries and performed procedures.

Variables Fully therapeutic Laparoscopic-assisted p-value Bowel injuries and FTL LAA Total p-value
laparoscopy (FTL) Approach (LAA) procedures

Patients 72 (53%) 65 (47%) Colon injuries 17 (47%) 19 (53%) 36 (100%) <0.001

Grade 2 10 7 17 0.31
Age 29 (15e53) 32 (12e74) Grade 3 7 12 19
Male 60 (83%) 58 (89%) Mobilized (no injuries) 1 1 2 1.00
Female 12 (17%) 7 (11%) Repair 9 12 21 0.73
Resection/anastomosis 0 5 5 0.05
Stab 52 (72%) 40 (61%) 0.20 Stoma 8 2 12 0.03
GSW 20 (28%) 25 (39%)
Small Bowel injuries 8 (15%) 47 (85%) 55 (100%) <0.001
sBP 123 (95e156) 129 (83e198) 0.13 Grade 1 0 2 2
Ps 95 (65e133) 86 (58e140) 0.002 Grade 2 5 7 12
Hb 13.0 (7.8e17) 13.5 (8.3e18.3) 0.29 Grade 3 3 34 37 0.09
pH 7.35 (7.12e7.5) 7.35 (7.10e7.45) 0.94 Grade 4 0 3 3
Lactate 2.6 (0.6e21) 2.4 (0.6e6.2) 0.71 Grade 5 0 1 1
BE 3.6 (0- (11)) 3.4 (0.6-(-9.2)) 0.75 Repair 8 29 36 0.04
Resection/anastomosis 0 18 18 0.04

ISS 13 (4e24) 11 (4e22) 0.02 FTL, Full therapeutic laparoscopy; LAA, Laparoscopic-assisted approach.
aNISS 13 (4e27) 13 (4e27) 0.78
PATI 6 (0e24) 10 (2e28) <0.001
Table 4
No complication 62 (86.1%) 53 (81.5%) Therapeutic laparoscopy: organ evisceration and involvement of other regions.
CD 3 9 (12.5%) 11 (17%) 0.74
CD 4 0 0 Fully therapeutic Laparoscopic-assisted Total
CD 5 1 (1.4%) 1 (1.5%) laparoscopy (FTL) approach (LAA)

Organ evisceration 11 (31%) 25 (69%) 36 (100%)

LOS 8.8 (2e128) 8.6 (1e45) 0.89 Pneumohaemothorax 36 (85.7%) 6 (14.3%) 42 (100%)
LOS (without 6.2 (2e15) 6.3 (1e20) 0.89 Orthopaedic injuries 2 (50%) 2 (50%) 4 (100%)
complications)

GSW, gunshot wounds; sBP, systolic blood pressure; Ps, pulse; Hb, hemoglobin; BE,
base deficit; ISS, the Injury Severity Score; aNISS, the abdominal New Injury Severity Table 5
Score; PATI, the Penetrating Abdominal Trauma Index; CD, Clavien-Dindo grade; Therapeutic laparoscopy: morbidity and mortality.
LOS, length of hospital stay.
Variables Fully therapeutic Laparoscopic-assisted p-value
laparoscopy (FTL) Approach (LAA)
Table 2 Patients 72 (53%) 65 (47%)
Location of injuries. No complication 62 (86.1%) 53 (81.5%)
Fully therapeutic Laparoscopic-assisted Total CD 3 9 (12.5%) 11 (17%) 0.74
laparoscopy (FTL) approach (LAA) CD 4 0 0
CD 5 (mortality) 1 (1.4%) 1 (1.5%)
Anterior 23 (31.9%) 59 (90.8%) 82 (59.9%) Complications
Back 3 (4.2%) 1 (1.5%) 4 (2.9%) Clotted haemothorax 5 (6.9%) 1 (1.5%) 0.37
Flank 7 (9.7%) 2 (3.1%) 9 (6.6%) Iatrogenic injury 1 (1.4%) 0 1.00
Lower Chest 38 (52.8%) 3 (4.6%) 41 (29.9%) (delayed gall bladder
Pelvis 1 (1.4%) 0 (0.0%) 1 (0.7%) perforation)
Total 72 (100%) 65 (100%) 137 (100%) Suture line leak 3 (4.2%) 0 0.25
Colon 2
Stomach 1
ECF (colon) 0 2 (3%) 0.22
(Table 2). The grades of and procedures performed for colonic and Wound sepsis 1 (1.4%) 5 (7.7%) 0.10
small bowel injuries are listed in Table 3. The other injured organs Intraabdominal 0 3 (4.6%) 0.10
were the diaphragm, stomach, gall bladder, mesentery, urinary haematoma/serous
collections
bladder, kidney, pancreas, inferior vena cava, retroperitoneum
(haematoma), and therapeutic procedures ranged from observation CD, Clavien-Dindo grade; ECF, enterocutaneous fistula.
and drainage to repair and organ removal. Eleven patients had or-
gan evisceration in the FTL group and 25 patients in the LAA group.
Pneumohaemothorax was present in 36 patients in the FTL group was managed with laparotomy; he developed fatal pulmonary
and only in six patients in the LAA group. Two patients in each embolism on postoperative day five. Another patient suddenly died
group had associated orthopaedic injuries (Table 4). There was no on postoperative day 29 after exacerbation of preexisting non-
statistical difference between groups for initial systolic blood hodgkin lymphoma. Five patients in the FTL group and one pa-
pressure, hemoglobin, pH, lactate level and base deficit. The initial tient in the LAA group had clotted haemothorax. Three patients
pulse was higher in the FTL group (95 versus 86, p ¼ 0.002). The ISS were managed with thoracotomy and two patients with thoraco-
was higher in the FTL group (13 versus 11, p ¼ 0.02). The aNISS was scopy. Three suture line leaks were recorded in the FTL group. One
the same in both groups but the PATI was significantly higher in the colonic leak was managed with laparoscopy and colostomy, and
LAA group (10 versus 6, p < 0.001). second required laparotomy. The gastric suture line leak was
Nine (12.5%) patients in the FTL group suffered CD 3 complica- repaired laparoscopically. In the LAA group, two colonic enter-
tions and 11 (17%) patients in the LAA group, p ¼ 0.74 (Table 5). ocutaneous fistulae (ECF) were reported; one patient was managed
There was one death in each group. One patient in the LAA group conservatively and the second required laparotomy. One patient in
had intraluminal bleeding from the stapler-line of anastomosis and the FTL group and five patients in the LAA group developed wound
 O.Y. Matsevych et al. / International Journal of Surgery 44 (2017) 94e98
sepsis and were managed with drainage and debridement. One
iatrogenic injury to the gall bladder was recorded in the FTL group.
It presented as delayed leak and was managed with laparoscopy
and cholecystectomy. No fascial dehiscence and no missed injuries
were reported. There was no significant difference in LOS between
groups. The LOS in patients without complications did not differ
between groups (Table 1).
4. Discussion
DL for PAT is well accepted and practiced by many surgeons in
the world. The accuracy of DL in detecting bowel injuries is re-
ported to be up to 100% [1]. In contrast, the computed tomography
scan has an accuracy of 75.3% for identifying bowel injuries [9]. The
TL is still controversial and its role in trauma patients has being
debated for many years [1]. The main reason for the reluctance to
apply laparoscopy in PAT is the difficulties in the management of
multiple hollow viscus injuries. Laparotomy is considered to be a
preferred approach in case of multiple bowel injuries by many
surgeons [6]. This approach was challenged by Koto and colleagues
by utilizing LAA to manage multiple bowel injuries extracorporeally
[7]. In their early experience, 23 patients avoided laparotomy and
were successfully managed with LAA [4]. In our study, the assisted
incision was sufficient enough to manage all bowel injuries in 65
patients and there was no need for conversion. Choi and Lim re-
ported the successful management of 20 patients with 3e4 cm
assisted incision [2]. A study from Taiwan reported the feasibility of
resection and anastomosis of the small bowel through the assisted
3e5 cm incision in one patient [10]. The LAA can be viewed as a
transitional step before conversion to laparotomy. This approach
may also be considered in the event a novice surgeon may lack the
dexterity with intracorporeal suturing.
The LAA was tested in experimental setting of gunshot wounds
with multiple small bowel injuries in a porcine model. Multiple
injuries were managed with the LAA and outcomes were compared
with laparotomy and showed a significant reduction in the length
of incision (5.27 cm versus 15.73 cm) as well as an average recovery
period for bowel function. There were no missed injuries and the
therapeutic time was not statistically different [11].
Many surgeons consider organ evisceration as a contraindica-
tion to laparoscopy [12]. Organ evisceration is associated with
symptomatic hernia and significant intraabdominal injuries in
these patients. The incidence of intraabdominal injuries requiring
therapeutic procedures is reported to be greater than 65% [12,13].
However, a recent study showed that DL and TL are feasible and
safe in stable patients with evisceration [13]. In that study, 25 pa-
tients with organ evisceration needed therapeutic procedures and
16 (64%) of them were managed with the LAA technique. In our
study, 25 patients with evisceration were managed with LAA.
Traumatic injury to the abdominal wall may be extended to 4e8 cm
and be used as an assisted access.
In the FTL group, the ISS score was significantly higher because
the associated haemopneumothorax was present in 36 patients, as
opposed to only six patients in the LAA group. Although the aNISS
was the same in both groups, the PATI was significantly higher in
LAA group confirming the presence of complex bowel injuries.
More colonic and small bowel injuries were managed with LAA, 66
(73%) versus 25 (27%) in the FTL group, p < 0.001. The grade of
injuries was also higher in the LAA group, although, this difference
did not reach statistical significance. Therefore, significantly more
bowel repair and resections with anastomosis were performed in
the LAA group (Table 3).
Morbidity and mortality after traumatic bowel injuries managed
by laparotomy are relatively high. The highest morbidity of 21.6%
and mortality of 3.6% were reported after traumatic colonic injury
97
[14]. In this study, overall morbidity of 12.5% was in the FTL group
and the 17% in the LAA group and mortality of 1.4% and 1.5%
respectively. The rate of suture line leak was 4.2% in the FTL group
and the rate of ECF was 3% in the LAA group. Only one gastric repair
was leaking, the others were related to colonic reconstruction. In
review by Greer and colleagues, the rate of anastomotic leak after
primary reconstruction of traumatic colonic injuries ranged from
0.3 to 27% [15]. The rate of colonic ECF is reported to be as high as
13.5% in trauma patients after laparotomy [14]. Although, the leak
rate in this study falls within the reported range, more studies are
needed to clarify if the LAA can decrease the incidence of leak. In
terms of bowel resection and anastomosis, the LAA technique
shouldn't be different from laparotomy as all procedures on the
bowel are performed extracorporeally. Fascial dehiscence of 10.8%
is reported in patients managed with laparotomy [14]. Whereas in
this study, there was no fascial dehiscence in the FTL or LAA groups.
Despite the presence of more complex injuries and the more
complicated therapeutic procedures in the LAA group, the
morbidity and LOS were not statistically different.
In the current literature, there is no comparison of fully lapa-
roscopic procedures with LAA in trauma setting. From our experi-
ence, we can suggest that the LAA is not inferior to FTL. More
studies are needed to confirm its role in the management of PAT. To
our knowledge, there are no published studies comparing LAA with
laparotomy. However, in elective colorectal surgery, the LAA was
not inferior to laparotomy and was associated with a statistically
significant smaller incision length (6 cm versus 18 cm), a shorter
hospital stay, and decreased analgesics requirement [16].
The choice of approach still remains the clinical decision of
operating surgeon and depends on a case complexity and avail-
ability of appropriate expertise and equipment. However, the LAA
will be preferable in cases with multiple and more severe bowel
injuries, where a limited expertise in intracorporeal suturing is
available or an extensive intracorporeal repair will significantly
prolong the operation. The FTL is reserved for management of
isolated bowel and other intraabdominal organs injuries.
Our study has several limitations. First, the data were analyzed
retrospectively. Second, this study represented a heterogenic pop-
ulation, because no exclusions were made based on the type and
severity of injuries, and complexities of performed procedures.
Therefore, the interpretation of statistical analysis should take this
into account. Third, the results may be reproducible only in in-
stitutions with comparable expertise in laparoscopic surgery.
Finally, there were no clinical criteria stipulating a point for
discharge of patients, therefore, the LOS was not accurate and the
discharge was often unnecessarily delayed owing to logistics
(transport issues and the absence of some specialized services in
the patients' area of residence).
5. Conclusions
The LAA is a workable and safe technique in the management of
stable patients with PAT. It is mainly used for the management of
multiple bowel injuries instead of a conversion to laparotomy. It
provides the benefits of minimally invasive surgery and the speed
and versatility of laparotomy. Moreover, the LAA seems not to be
inferior to entirely laparoscopic therapeutic procedures. More
studies are needed to compare LAA with FTL and laparotomy.
Conflicts of interest
None.
98 O.Y. Matsevych et al. / International Journal of Surgery 44 (2017) 94e98
Sources of funding
This research did not receive any specific grant from funding
agencies in the public, commercial, or not-for-profit sectors.
Ethical approval
The study was approved by the Sefako Makgatho University
Research Ethics Committee, Pretoria, South Africa.
SMUREC/M/32/2016: IR.
Unique identifying number (UIN)
Research Registry UIN: researchregistry2267.
Author contribution
O. Matsevych participated in the study conception and design,
literature search, data collection, data analysis, data interpretation,
manuscript preparation, and revision of the manuscript.
M. Koto participated in the study conception and design, data
interpretation, critical review and revision of the manuscript,
mentoring throughout the manuscript preparation.
C. Aldous participated data interpretation, critical review and
revision of the manuscript.
Guarantor
Dr OY Matsevych.
References
[1] E. O'Malley, E. Boyle, A. O'Callaghan, J.C. Coffey, S.R. Walsh, Role of laparoscopy
in penetrating abdominal trauma: a systematic review, World J. Surg. 37
(2013) 113e122, http://dx.doi.org/10.1007/s00268-012-1790-y.
[2] Y.B. Choi, K.S. Lim, Therapeutic laparoscopy for abdominal trauma, Surg.
Endosc. Other Interv. Tech. 17 (2003) 421e427, http://dx.doi.org/10.1007/
s00464-002-8808-8.
[3] M.S. Khubutiya, P.A. Yartsev, A.A. Guliaev, V.D. Levitsky, M.A. Tlibekova, Lap-
aroscopy in blunt and penetrating abdominal trauma, Surg. Laparosc. Endosc.
Percutan. Tech. 23 (2013) 507e512, http://dx.doi.org/10.1097/
SLE.0b013e3182937c37.
[4] M.Z. Koto, O.Y. Matsevych, S.R. Motilall, The role of laparoscopy in penetrating
abdominal trauma: our initial experience, J. Laparoendosc. Adv. Surg. Tech. 25
(2015) 730e736, http://dx.doi.org/10.1089/lap.2015.0042.
[5] S. Hajibandeh, S. Hajibandeh, A.O. Gumber, C.S. Wong, H.C. Shih, Y.S. Wen,
T.J. Ko, J.K. Wu, C.H. Su, C.H. Lee, C. Ertekin, H. Yanar, K. Taviloglu, R. Guloglu,
O. Alimoglu, S. Arikan, A. Kocakusak, A.F. Yucel, G. Adas, D. Petras, J. Lavora,
A.S. Taner, K. Topgul, F. Kucukel, A. Demir, S. Sari, J.A. Pinedo-Onofre,
L. Guevara-Torres, J.M. Sanchez-Aguilar, A.K. Leppaniemi, P.E. Voutilainen,
R.K. Haapiainen, R.P. Gonzales, B. Turk, M.E. Falimirski, M.R. Holevar,
E. O'Malley, E. Boyle, A. O'Callaghan, J.C. Coffey, S.R. Walsh, N.T. Kawahara,
C. Alster, I. Fujimura, R.S. Poggetti, D. Birolini, Y. Li, Y. Xiang, N. Wu, L. Wu,
Z. Yu, M. Zhang, E. Al, A. Birindelli, S. Di Saverio, F. Agresta, M. Mandrioli,
G. Tugnoli, P.J. Chestovich, T.D. Browder, S.L. Morrissey, D.R. Fraser,
€
N.K. Ingalls, J.J. Fildes, F. Karateke, M. Ozdog €
an, S. Ozyazıcı, K. Daş, E. Menekşe,
Y.C. Gülnerman, E. Al, H.F. Lin, J.M. Wu, C.C. Tu, H.A. Chen, H.C. Shih,
M. Cherkasov, V. Sitnikov, B. Sarkisysn, O. Degtirev, M. Turbin, A. Yakuba,
E.J. Miles, E. Dunn, D. Howard, A. Mangram, A. Leppaniemi, R. Happianen,
E.J. DeMaria, J.M. Dalton, D.C. Gore, J.M. Kellum, H.J. Sugerman, D. Mutter,
M. Nord, M. Vix, S. Evrard, J. Marescaux, J.M. Marks, D.F. Youngelman, T. Berk,
L.F. Zantut, R.R. Ivatury, R.S. Smith, N.T. Kawahara, J.M. Porter, W.R. Fry, E. Al,
R.S. Smith, W.R. Fry, D.J. Morabito, R.H. Koehler, C.H. Organ, V.J. Henderson,
C.H. Organ, R.S. Smith, S.R. Petersen, G.F. Sheldon, R.T. Villavicencio, J.A. Aucar,
K.H. Lim, B.S. Chung, J.Y. Kim, S.S. Kim, M.S. Khubutiya, Laparoscopy versus
laparotomy for the management of penetrating abdominal trauma: a sys-
tematic review and meta-analysis, Int. J. Surg. 34 (2016) 127e136, http://
dx.doi.org/10.1016/j.ijsu.2016.08.524.
[6] Y.B.A. El-Bendary, J. Al-Adawi, H. Al-Qadhi, The use of laparoscopy in the
management of trauma patients: brief review, Sultan Qaboos Univ. Med. J. 16
(2016) e9e14, http://dx.doi.org/10.18295/squmj.2016.16.01.003.
[7] M.Z. Koto, O.Y. Matsevych, C. Aldous, Laparoscopic-assisted approach for
penetrating abdominal trauma: an underutilized technique, J. Laparoendosc.
Adv. Surg. Tech. A 0 (2016), http://dx.doi.org/10.1089/lap.2016.0368 lap.2016.
0368.
[8] P.A. Clavien, J. Barkun, M.L. de Oliveira, J.N. Vauthey, D. Dindo, R.D. Schulick,
E. de Santiban ~ es, J. Pekolj, K. Slankamenac, C. Bassi, R. Graf, R. Vonlanthen,
R. Padbury, J.L. Cameron, M. Makuuchi, The clavien-dindo classification of
surgical complications, Ann. Surg. 250 (2009) 187e196, http://dx.doi.org/
10.1097/SLA.0b013e3181b13ca2.
[9] B.A. Landry, M.N. Patlas, S. Faidi, A. Coates, S. Nicolaou, Are we missing trau-
matic bowel and mesenteric injuries? Can. Assoc. Radiol. J. 67 (2016)
420e425, http://dx.doi.org/10.1016/j.carj.2015.11.006.
[10] H.F. Lin, J.M. Wu, C.C. Tu, H.A. Chen, H.C. Shih, Value of diagnostic and ther-
apeutic laparoscopy for abdominal stab wounds, World J. Surg. 34 (2010)
1653e1662, http://dx.doi.org/10.1007/s00268-010-0485-5.
[11] C.H. Liao, I.M. Kuo, C.Y. Fu, C.C. Chen, S.J. Yang, C.H. Ouyang, S.Y. Wang,
S.W. Chen, Y.P. Hsu, S.C. Kang, Gasless laparoscopic assisted surgery for
abdominal trauma, Injury 45 (2014) 850e854, http://dx.doi.org/10.1016/
j.injury.2013.10.041.
[12] W.L. Biffl, A. Leppaniemi, Management guidelines for penetrating abdominal
trauma, World J. Surg. 39 (2015) 1373e1380, http://dx.doi.org/10.1007/
s00268-014-2793-7.
[13] O.Y. Matsevych, M.Z. Koto, S.R. Motilall, N. Kumar, The role of laparoscopy in
management of stable patients with penetrating abdominal trauma and organ
evisceration, J. Trauma Acute Care Surg. 81 (2016) 307e311, http://dx.doi.org/
10.1097/TA.0000000000001064.
[14] E. Fouda, S. Emile, H. Elfeki, M. Youssef, A. Ghanem, A.A. Fikry, A. Elshobaky,
W. Omar, W. Khafagy, M. Morshed, Indications for and outcome of primary
repair compared with faecal diversion in the management of traumatic colon
injury, Colorectal Dis. 18 (2016) O283eO291, http://dx.doi.org/10.1111/
codi.13421.
[15] L.T. Greer, S.M. Gillern, A.E. Vertrees, Evolving colon injury management: a
review, Am. Surg. 79 (2013) 119e127, http://dx.doi.org/10.1111/codi.13421.
[16] T. Clinical, S. Outcomes Therapy, S. Group, A comparison of laparoscopically
assisted and open colectomy for colon cancer, N. Engl. J. Med. 350 (2004)
2050e2059, http://dx.doi.org/10.1056/NEJMoa032651.