Authors: Wail Alqatta
Categories: Case Report, Penetrating trauma, Emergency surgery, Laparoscopy, Thoracoscopy, Gastric injury, Hepatic injury, Pulmonary injury
Source: International Journal of Emergency Medicine
Authors: Wail Alqatta
Penetrating thoracic and abdominal trauma presents a diagnostic and therapeutic challenge in the emergency department (ED). Traditionally managed with open laparotomy or thoracotomy, advances in minimally invasive surgery (MIS) have enabled safe, effective, and rapid diagnosis and intervention. We present a case series of four patients with penetrating gastric, hepatic, and pulmonary injuries successfully managed using MIS, highlighting its role in emergency care.
Four hemodynamically stable patients presented to the ED with penetrating abdominal or thoracic (1) Stab wound to Diagnostic laparoscopy revealed a 1 cm anterior gastric body perforation, repaired laparoscopically. The patient recovered uneventfully and remained asymptomatic at 3-year follow-up. (2) Gunshot to upper Laparoscopic wedge resection of a gastric cardia perforation was performed. Recovery was uneventful, with 1-year follow-up showing no complications. (3) Gunshot to right upper abdomen with hepatic Laparoscopic hemostasis and bullet extraction under fluoroscopy were successfully performed. Four-year follow-up was uneventful. (4) Gunshot to left upper Video-assisted thoracoscopic left upper lobe segmentectomy and bullet extraction were carried out. Five-year follow-up revealed preserved pulmonary function and no complications.
Early identification and triage in the ED, combined with MIS, enabled rapid diagnosis and definitive treatment while minimizing morbidity. Laparoscopy and thoracoscopy provide excellent visualization, reduce unnecessary open procedures, and shorten hospital stays.
MIS is a safe, effective, and feasible approach for selected hemodynamically stable penetrating thoracic and abdominal injuries in the ED. Careful patient selection and surgical expertise are essential for optimizing outcomes.
Abdominal trauma remains a major cause of morbidity and mortality worldwide, with penetrating injuries accounting for a substantial proportion of cases [1, 2]. The abdomen is involved in approximately 9–15% of all trauma presentations [3]. Penetrating thoracic or abdominal trauma poses unique diagnostic and therapeutic challenges due to the potential involvement of multiple intra-abdominal and thoracic organs, including the diaphragm, liver, spleen, stomach, small bowel, and colon [4]. Missed injuries, particularly of the diaphragm, hollow viscera, or retroperitoneal structures, can lead to severe complications, prolonged hospitalization, and increased mortality [5, 6].
Exploratory laparotomy or thoracotomy has long been considered the standard approach for managing such injuries [1, 2]. However, routine open exploration can result in substantial morbidity and a considerable rate of non-therapeutic procedures, highlighting the need for more selective and less invasive management strategies [7, 8].
Minimally invasive surgery (MIS), including diagnostic laparoscopy (DL) and video-assisted thoracic surgery (VATS), has emerged as an effective alternative in hemodynamically stable trauma patients [6, 9]. DL enables direct visualization of the peritoneal cavity, allowing accurate detection of peritoneal violation, diaphragmatic defects, and hollow viscus injuries [6]. Several studies have shown that DL significantly reduces unnecessary laparotomies in penetrating trauma [10–12]. Similarly, VATS enables targeted management of thoracic injuries, such as retained hemothorax, with lower morbidity than open thoracotomy, while MIS as a whole provides further benefits, including reduced complications and faster postoperative recovery [9, 11, 13]. Collectively, MIS reduces postoperative complications, hospital stay, and resource utilization, which is particularly relevant in the emergency care setting.
Despite these advantages, the adoption of MIS in trauma remains limited by technical demands, equipment availability, and variation in surgeon expertise [14, 15]. Early experiences were associated with high missed-injury rates [16, 17], but recent evidence demonstrates that standardized protocols and experienced surgical teams have markedly improved diagnostic accuracy and safety [18–20].
Current literature on MIS in trauma largely consists of retrospective studies and isolated case reports, with limited data on long-term outcomes in penetrating thoracic or abdominal injuries [9, 11]. Additional clinical evidence is therefore required to confirm its safety, feasibility, and long-term efficacy.
This case series aims to present the emergency management of four hemodynamically stable patients with penetrating thoracic or abdominal trauma using minimally invasive techniques. By emphasizing early ED assessment, rapid imaging, and definitive MIS intervention, we provide practical insights into the feasibility, safety, and outcomes of this approach in contemporary emergency care. This series is reported according to the PROCESS 2025 guidelines [21].
Overview: Four hemodynamically stable patients presented to the emergency department (ED) with penetrating thoracic or abdominal trauma. Rapid triage, early imaging (FAST and contrast-enhanced CT), and prompt surgical consultation enabled minimally invasive management in all cases. Patients requiring emergency open laparotomy or thoracotomy due to hemodynamic instability were excluded. Diaphragmatic injuries were excluded preoperatively by careful review of CT imaging and confirmed intraoperatively through systematic laparoscopic or thoracoscopic inspection. Clinical presentation, imaging findings, operative details including operative time and blood loss, and postoperative outcomes were systematically documented, with follow-up conducted via routine outpatient visits. AAST injury grades are specified where applicable. All procedures were completed without conversion to open surgery or intraoperative complications.
A 38-year-old male presented six hours after a stab wound to the epigastrium. He was hemodynamically stable with localized epigastric pain. Examination revealed a penetrating wound with subcutaneous emphysema, mild oozing, and localized tenderness with signs of peritonitis. Laboratory tests showed leukocytosis (WBC 13,000/µL) and elevated CRP (123 mg/dL). FAST was positive for free fluid, and CT revealed pneumoperitoneum and a suspected 1 cm anterior gastric perforation with mild intraperitoneal fluid (AAST grade II gastric injury).
The patient underwent diagnostic laparoscopy using a three-port technique (10 mm infraumbilical camera, 5 mm right hypochondrium, 10 mm left hypochondrium). Operative time was 90 min, estimated blood loss 50 mL. Intraoperatively, ~ 300 mL peritoneal fluid with fibrin deposits and perigastric contamination was noted. A 1 cm anterior gastric body perforation was repaired laparoscopically with single-layer interrupted non-absorbable Ethibond sutures (Figs. 1 and 2), followed by peritoneal lavage and placement of subhepatic and pelvic drains.
Postoperatively, broad-spectrum antibiotics were administered. Recovery was uneventful with no complications; oral intake resumed on POD3, drains removed sequentially, and discharge on POD6. At nearly three-year follow-up, the patient remained asymptomatic and expressed high satisfaction with the minimally invasive management.
Fig. 1Intraoperative laparoscopic view of a 1 cm anterior gastric body perforation, showing fibrin and gastric content contamination
Fig. 2Laparoscopic intracorporeal repair of the gastric perforation using single-layer interrupted non-absorbable Ethibond sutures
A 28-year-old male presented one hour after a gunshot wound to the upper abdomen. He was hemodynamically stable (GCS 15) with localized upper abdominal tenderness and peritonitis. The entry wound was in the left paravertebral region, and the exit wound on the left epigastrium. Laboratory tests were normal. FAST revealed mild intraperitoneal fluid, and CT showed a bullet tract with pneumohemoperitoneum, gastric wall thickening, and a suspected defect at the gastric cardia; no other visceral or vascular injuries were noted. Chest CT was unremarkable (AAST grade III gastric injury). Diaphragmatic injury was excluded on CT and confirmed intraoperatively during laparoscopy.
Diagnostic laparoscopy was performed using a three-port technique (10 mm infraumbilical camera, 5 mm right hypochondrium, 10 mm left hypochondrium). Operative time was 125 min, estimated blood loss 75 mL. Exploration revealed a full-thickness gastric perforation at the greater curvature of the cardia with devitalized tissue (Fig. 3). A laparoscopic wedge resection using a 60 mm linear stapler excised the injured segment and closed the defect (Fig. 4). Hemostasis was achieved, and two drains were placed in the perigastric and pelvic regions.
Postoperatively, the patient received broad-spectrum antibiotics. Recovery was uneventful with no complications; enteral feeding started on POD4, drains removed sequentially, and discharge on POD7. At one-year follow-up, he remained asymptomatic, with no complications, and expressed high satisfaction with the minimally invasive management.
Fig. 3Intraoperative laparoscopic view of a full-thickness gastric perforation at the greater curvature of the cardia with surrounding devitalized tissue
Fig. 4Laparoscopic wedge resection of the gastric cardia perforation using a 60 mm linear stapler, achieving complete excision of the devitalized tissue
A 42-year-old male presented two hours after a gunshot wound to the right upper abdomen. He was hemodynamically stable with localized right hypochondrial pain. Examination showed tenderness without generalized peritonitis. Labs revealed hemoglobin 11.8 g/dL, WBC 15,400/µL, and markedly elevated liver enzymes (GPT 865 U/L, GOT 644 U/L). Ultrasound and contrast-enhanced CT demonstrated perihepatic fluid, a right hepatic lobe laceration, and a bullet lodged in segment VI, with no major vascular injury or other intra-abdominal trauma (AAST grade III liver injury). No diaphragmatic injury was noted on CT, and the diaphragm was systematically inspected laparoscopically.
Diagnostic laparoscopy was performed using a three-port technique (10 mm infraumbilical camera, 5 mm lower right hypochondrium, 10 mm epigastrium). Exploration revealed a small deep laceration in segment VI with low-grade bleeding (Fig. 5). Operative time was 95 min, estimated blood loss 60 mL, and there were no intraoperative complications or conversion. Given the patient’s hemodynamic stability and the risk of delayed complications such as abscess formation, hematoma, or bile leak, laparoscopic bullet extraction was performed using intraoperative C-arm fluoroscopy to precisely localize the embedded bullet (Figs. 6 and 7). Hemostasis was achieved with monopolar coagulation, peritoneal lavage performed, and a subhepatic drain placed.
Postoperative recovery was uneventful; oral intake resumed on POD2, and the drain was removed before discharge on POD5. Follow-up imaging confirmed healing without bile leak, abscess, or hematoma. At 4-year follow-up, the patient remained asymptomatic and satisfied with the minimally invasive approach.
Fig. 5Intraoperative laparoscopic view of a small deep laceration in segment VI of the right hepatic lobe with low-grade bleeding
Fig. 6Laparoscopic localization of the embedded bullet in the right hepatic lobe using intraoperative C-arm fluoroscopy
Fig. 7Post-extraction laparoscopic view showing successful removal of the bullet from the right hepatic lobe
A 30-year-old male presented one hour after a penetrating gunshot wound to the left upper chest. He was hemodynamically stable but hypoxic (SpO₂ 72%) with acute dyspnea and left-sided chest pain. Examination revealed decreased breath sounds on the left, extensive subcutaneous emphysema, and a retained bullet in the left parascapular region. Labs showed hemoglobin 12.3 g/dL; other parameters were normal. Chest CT revealed a large left hemopneumothorax, left upper lobe laceration with intraparenchymal hematoma, and the retained bullet; no major vascular injury was identified (AAST grade III lung injury). No diaphragmatic injury was identified on imaging, and the diaphragm was carefully inspected thoracoscopically.
Given the patient’s clinical stability and absence of tension pneumothorax, video-assisted thoracoscopic surgery (VATS) was chosen for definitive management. Rapid triage and efficient preoperative preparation enabled timely intervention without prior chest tube placement. Intraoperative findings included a mild active bleeding from a cranial left upper lobe laceration (Fig. 8). Operative time was 130 min, estimated blood loss 80 mL, with no intraoperative complications or conversion. Thoracoscopic segmentectomy was performed using multiple 60 mm linear staplers to remove devitalized tissue and achieve hemostasis (Fig. 9). A 36 F chest tube was placed, and the bullet was extracted via a small parascapular incision. The wound was irrigated and closed primarily.
The patient was extubated postoperatively and monitored in the ICU. Recovery was uneventful; the chest tube was removed, and he was discharged on POD8. At 5-year follow-up, he remained asymptomatic with preserved lung function and expressed satisfaction with the minimally invasive thoracoscopic approach.
Fig. 8Thoracoscopic view of low-grade bleeding and parenchymal laceration involving the cranial part of the left upper lobe
Fig. 9Thoracoscopic left upper lobe segmentectomy using multiple 60 mm linear staplers to resect devitalized lung tissue and achieve hemostasis
Table 1 summarizes the key clinical characteristics, interventions, and outcomes for each patient.
Table 1Summary of clinical Characteristics, Interventions, and outcomes of patientsCaseAge/SexMechanism & Site of InjuryClinical PresentationImaging FindingsIntraoperative FindingsProcedure/InterventionPostoperative Course & Follow-up138/MStab wound, epigastriumHemodynamically stable, localized epigastric pain, mild peritonitisFAST: free fluid; CT: pneumoperitoneum, gastric perforation1 cm anterior gastric body perforation, perigastric contamination, no other injuriesLaparoscopic repair with intracorporeal single-layer non-absorbable sutures, peritoneal lavage, drainsUneventful recovery, oral intake POD3, discharged POD6; 3-year follow-up: no complications228/MGunshot, upper abdomenHemodynamically stable, upper abdominal tenderness, localized peritonitisFAST: mild fluid; CT: bullet tract, pneumohemoperitoneum, gastric cardia defectFull-thickness gastric perforation at greater curvature of cardia with devitalized tissueLaparoscopic gastric wedge resection using 60 mm linear stapler, drainsUneventful recovery, enteral feeding POD4, discharged POD7; 1-year follow-up: asymptomatic, no complications342/MGunshot, right upper abdomenHemodynamically stable, right hypochondrial painUS: perihepatic fluid, liver laceration; CT: bullet in segment VI, perihepatic hematomaSmall deep laceration in right hepatic lobe, low-grade bleeding, bullet embeddedLaparoscopic bullet extraction under C-arm guidance, hemostasis, subhepatic drainUneventful recovery, oral intake POD2, discharged POD5; 4-year follow-up: asymptomatic, no hepatic complications430/MGunshot, left upper chestHemodynamically stable, O₂ sat 72%, dyspnea, left-sided chest painCT: left hemopneumothorax, left upper lobe laceration, subcutaneous bulletLow-grade bleeding, devitalized lung parenchyma in cranial left upper lobeThoracoscopic left upper lobe segmentectomy using multiple 60 mm staplers, bullet extraction, chest tubeUneventful recovery, extubated postop, chest tube removed before discharge; discharged POD8; 5-year follow-up: asymptomatic, preserved lung function
The management of penetrating thoracic and abdominal trauma has traditionally relied on exploratory laparotomy or thoracotomy, which, although effective, are associated with significant morbidity and prolonged hospitalization, especially in non-therapeutic cases [7, 8]. In recent years, minimally invasive surgery (MIS), encompassing diagnostic laparoscopy (DL) and video-assisted thoracic surgery (VATS), has emerged as a safe and effective alternative in selected hemodynamically stable patients [9, 22]. DL allows precise evaluation of peritoneal and diaphragmatic injuries, while VATS enables targeted management of thoracic lesions such as retained hemothorax, both with substantially less morbidity than open approaches [19, 23].
Emergency medicine considerations include rapid triage, early imaging, and identification of candidates suitable for MIS. Contraindications to laparoscopy include hemodynamic instability, shock, traumatic brain injury, surgeon inexperience, lack of available equipment, surgical history suggesting significant adhesive disease, and patients who cannot tolerate pneumoperitoneum from a cardiac or pulmonary standpoint. However, an initially hemodynamically unstable patient who responds well to resuscitation may undergo laparoscopy in select cases [24].
MIS offers several well-established advantages. Enhanced visualization improves detection and management of complex injuries, including those of the diaphragm and deep pelvis [11, 19, 22]. Reduced surgical trauma results into lower postoperative pain, decreased wound and pulmonary complications, shorter ICU and hospital stays, and faster recovery [25–27]. Moreover, multiple studies have shown that MIS markedly reduces unnecessary laparotomies, avoiding 50–77% of non-therapeutic explorations and their associated morbidity [28, 29]. Therapeutic procedures such as bowel or diaphragmatic repair, splenectomy, and control of mesenteric or abdominal wall bleeding can also be safely performed laparoscopically, extending the role of MIS beyond diagnosis alone [11, 19].
Comparative studies indicate that MIS achieves diagnostic accuracy equivalent to open surgery while significantly lowering morbidity [11, 22, 27]. Traditional open procedures remain associated with higher complication rates, longer hospitalization, and increased risk of wound infection, particularly in non-therapeutic settings [7, 8]. Early thoracoscopic intervention similarly demonstrates favorable outcomes, with VATS achieving up to 87% success in evacuating retained hemothorax and conversion rates near 11% [9, 30]. Collectively, these findings support selective adoption of MIS in emergency trauma care for appropriately chosen patients.
Optimal outcomes depend on careful patient selection. Hemodynamically stable patients without ongoing bleeding are the best candidates, while those with uncontrolled hemorrhage or severe traumatic brain injury remain unsuitable due to the physiologic demands of pneumoperitoneum and longer operative times [20, 31]. Although laparoscopy was initially employed primarily for diagnostic purposes, such as excluding peritoneal violation or occult diaphragmatic injury [32, 33], it is now increasingly applied for both blunt and penetrating trauma when expertise and resources permit [34, 35].
Surgeon experience and institutional readiness are key determinants of success [5, 10, 11]. Early reports of missed injuries and high conversion rates reflected limited training, inadequate equipment, and absence of standardized exploration protocols [16, 17]. With advances in instrumentation, imaging, and structured operative strategies, missed-injury rates have fallen to below 1% [5, 10, 11]. Effective multidisciplinary coordination and operating room preparedness further enhance safety in emergency trauma settings [36–38].
This case series demonstrates that MIS can be safely and effectively integrated into emergency trauma management for hemodynamically stable patients, with favorable outcomes, reduced morbidity, and excellent long-term recovery. Limitations include the small sample size, non-comparative design, and resource-dependent applicability. Nonetheless, the cases provide practical guidance for ED decision-making and early intervention using MIS.
Minimally invasive surgical techniques, including diagnostic laparoscopy and video-assisted thoracic surgery, are safe and effective options for hemodynamically stable patients with penetrating thoracic or abdominal trauma in the emergency setting. These approaches provide rapid diagnosis, definitive therapeutic management, reduced morbidity, avoidance of unnecessary open procedures, shorter hospital stays, and faster recovery compared with traditional open surgery.
Successful implementation requires careful patient selection, early and efficient ED triage, timely imaging, surgical expertise, and institutional readiness. By minimizing non-therapeutic laparotomies/thoracotomies and reducing postoperative complications, MIS represents a valuable and practical approach in emergency trauma care, with durable long-term outcomes in appropriately chosen stable patients.