In the obese patient, an OptiView^© or similar trocar is recommended for use if available. The trocar should be placed lateral to the umbilicus but still within the rectus. Place the trocar with a 0° scope and then change to a 30° scope.

If hemoperitoneum is seen, evacuate the blood and examine the abdomen completely if the patient remains hemodynamically stable. The blood may be from a small liver or spleen injury or from the abdominal wall, all of which can be managed laparoscopically.

Patients with penetrating trauma to the anterior abdominal wall can present a challenge in management as up to 45 % of hemodynamically stable patients may not have suffered peritoneal penetration. Diagnostic laparoscopy in this circumstance provides a clear benefit as a minimally invasive means of evaluating for peritoneal penetration.

Local wound exploration with subsequent diagnostic peritoneal lavage (DPL) if peritoneal penetration is found has been used in combination for evaluation of bowel or solid organ injury. However, DPL can have false positives secondary to blood from insignificant liver or splenic injuries as well as bleeding from the anterior abdominal wall. Selective non-operative management has been used as a treatment strategy as a means of decreasing the rate of negative exploratory laparotomies. However, concern exists over the delay in diagnosis of an injury as the management is based on subjective physical exam findings. In this circumstance, diagnostic laparoscopy provides abdominal exploration in a minimally invasive fashion as well as information regarding the extent of injury. Hospital length of stay and cost are higher for patients managed nonoperatively versus those who undergo negative diagnostic laparoscopy. If diagnostic laparoscopy is completely negative, considerations for discharge of the patient from the PACU avoid unnecessary hospitalization.

It has long been the accepted standard that all abdominal gunshot wounds (GSW) must be evaluated by laparotomy. However, with the use of focused assessment with sonography for trauma (FAST) scans as well as improvement in computed tomography (CT) imaging and the increasing utilization of diagnostic laparoscopy, this standard is being challenged. Zantut et al. reported that 58 % (113 of 194) of stable patients with gunshot wounds who were evaluated with laparoscopy were discharged home with confidence after a brief hospital stay without the need for laparotomy.

The risk of diaphragmatic injury exists with penetrating trauma in the thoracoabdominal region. Several studies have shown that penetration in the thoracoabdominal region has an 18–35 % incidence of diaphragmatic injury. A stab wound below the nipple, from the xiphoid around to the scapula that traverses the ribs has a chance of causing a diaphragmatic injury. Laparoscopy is particularly useful in making this diagnosis. Spann et al. found that 31 % of patients with a hemo- or pneumothorax on chest x-ray had a diaphragmatic injury later identified with laparoscopy. Multiple studies have found that laparoscopy is safe and effective not only for diagnosis but also for treatment of such an injury. Laparoscopic repair of a diaphragmatic injury is the most commonly reported therapeutic laparoscopic intervention (Fig. 18.3).

When repairing a diaphragmatic injury laparoscopically, you should use a braided permanent suture. However, large traumatic diaphragmatic injuries adjacent to or including the esophageal hiatus are best approached via laparotomy.

The current consensus in regard to rectal injuries is that intraperitoneal injuries are repaired primarily. Extraperitoneal injuries are also repaired primarily if minimal dissection is needed or if the injury is exposed during dissection to examine and repair other injuries. The feasibility of laparoscopic fecal diversion as a means of managing an isolated extraperitoneal GSW injury has been documented. With laparoscopy, you are able to rule out other injuries and perform mobilization of the colon, allowing for creation of a loop sigmoid colostomy. Presacral drainage is also able to be established laparoscopically. The urinary tract is also evaluated to exclude injury.

Several series demonstrate the utility of laparoscopy for definitive repair. One small series documents 26 of 28 patients undergoing successful repair of intra-abdominal injury following penetrating trauma. Repairs included closure of gastrostomies, repair of liver lacerations, cholecystectomy, and repair of diaphragmatic injuries. Another small series in children demonstrates successful repair of bowel injury secondary to trauma. When small bowel injuries are identified, all of the following are able to be performed laparoscopically: primary repair and stapled resections with side-to-side anastomosis as done in laparoscopic bariatric surgery. For liver and spleen injuries, laparoscopy allows for evacuation of blood and establishment of hemostasis with electrocautery, argon beam, and/or hemostatic agents. Drains should only be left in place for large injuries. Gallbladder injuries can be treated with cholecystectomies performed in a standard fashion. Bladder injuries can be repaired with a laparoscopic suturing device. However, the inside of the bladder must be fully examined with the laparoscope or cystoscope prior to closure.