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Laparoscopic treatment of gastric and duodenal perforation in children after blunt abdominal trauma
Injury, Int. J. Care Injured 43 (2012) 1442–1444
Contents lists available at ScienceDirect
Injury journal homepage: www.elsevier.com/locate/injury
Laparoscopic treatment of gastric and duodenal perforation in children after blunt abdominal trauma S.H.A.J. Tytgat *, S. Zwaveling, W.L.M. Kramer, D.C. van der Zee Department of Paediatric Surgery, KE.04.140.5, Wilhelmina Children’s Hospital, University Medical Center Utrecht, P.O. Box 85090, 3508 AB Utrecht, The Netherlands
A R T I C L E I N F O
A B S T R A C T
Article history: Accepted 1 November 2010
Minimal invasive surgery has not yet gained wide acceptation for the care of patients that sustained an abdominal trauma. We describe the complete laparoscopic surgical treatment of two patients after a single blunt abdominal trauma. One patient sustained a handle bar injury and presented with a gastric perforation. The other sustained a duodenal rupture by falling on a sharp edge of a table. The patients were assessed and treated laparoscopically. The perforations were identified and closed. Both patients had an uneventful postoperative recovery. Therapeutic laparoscopic treatment of patients with upper gastrointestinal perforation is feasible. We would recommend this approach to experienced laparoscopic surgeons in hemodynamically stable patients. ß 2010 Elsevier Ltd. All rights reserved.
Keywords: Abdominal Trauma Laparoscopy Gastric perforation Duodenal perforation
Introduction Diagnostic laparoscopy in patients with abdominal trauma is not only increasingly applied in adults, but also in children.5,2 In penetrating abdominal trauma, the integrity of the peritoneum can be accurately established via this technique. Furthermore, in both penetrating and blunt abdominal trauma, intraperitoneal organ injury or perforation may be diagnosed. When damaged structures are found usually conversion to a laparotomy is advocated.14 In this paper we describe the complete laparoscopic surgical treatment of two children that sustained a single blunt abdominal trauma. One patient suffered from a gastric perforation while the other had a duodenal rupture. Patient 1 A nine-year-old boy with no medical history sustained a mountain bike handle bar injury. Two hours after the accident he presented with complaints of worsening abdominal pain at a nearby first aid department. The patient had some bruising around the umbilicus and manifested tenderness of the upper abdomen. He was hemodynamically stable. Extra intestinal air and free intraperitoneal fluid was seen on an abdominal CT scan. No injury to any solid organs was found. He was referred to our department and was operated 7 h after the injury. Under general anaesthesia and broad spectrum intravenous antibiotic coverage, laparoscopic inspection of the abdomen was
* Corresponding author. Tel.: +31 887554004. E-mail address: [email protected] (S.H.A.J. Tytgat). 0020–1383/$ – see front matter ß 2010 Elsevier Ltd. All rights reserved. doi:10.1016/j.injury.2010.11.002
started. For this purpose we used a three port technique; one 5 mm port was placed in the umbilicus for the camera and two 5 mm ports for instrumentation were introduced, one on each side of the abdomen. A diffuse peritonitis with contamination of gastric content was seen, with hematoma and debris around a 6 cm tear of the greater curvature of the stomach. This lesion was closed laparoscopically with six interrupted 4.0 Vicryl1 sutures after local rinsing. Patency of the gastric wall was tested by submerging the suture line under saline solution, while insufflating the stomach via a nasogastric tube. The whole abdomen was subsequently lavaged laparoscopically with two litres of warm saline solution. Postoperatively the patient remained in the intensive care unit overnight. Parental nutrition was started via a central venous line. On the second post-operative day gastric feeding was introduced. Full feeding was possible on day four. There were no postoperative complications. Abdominal cultures, taken during laparoscopy, remained negative. Antibiotics were stopped on the fourth postoperative day. Five days following surgery the patient was discharged in good clinical condition. His further recovery went uneventful. Patient 2 A ten-year-old boy had lost his balance while standing on a triangular table at school and, as a result of falling on one of the corners, he sustained a blunt injury above the level of the umbilicus. One hour later he arrived at our emergency department. Upon examination some painful bruises were seen above the level of the umbilicus. He was hemodynamically stable. A CT scan of the abdomen showed signs of a perforation of the duodenum with extraluminal retroperitoneal air bubbles in this region (Fig. 1). The
S.H.A.J. Tytgat et al. / Injury, Int. J. Care Injured 43 (2012) 1442–1444
1443
Fig. 1. CT-scan of a patient with a duodenal rupture, after blunt abdominal trauma. Arrows indicate extraluminal retroperitoneal air adjacent to the duodenum and under the liver. Fig. 3. Laparoscopic closure of the duodenal defect with a running suture.
Fig. 2. Laparoscopic view of a ruptured duodenum. The perforation is expanded using a suction device. The duodenal mucosa can be seen through the perforation (arrow).
pancreas was not damaged. Subsequently, under broad spectrum intravenous antibiotic coverage, a diagnostic laparoscopy was performed. We used the same port positions as described in the previous case with one additional port in the right flank for exposure of the retroperitoneum. The entire abdomen was inspected. Some bile stained fluid was detected in the upper quadrants, but no lesions were discovered. The hepatic flexure of the colon was mobilized to the left side. The duodenum including its dorsal aspect was approached and mobilised via a full Kocher manoeuvre. A 4 cm long rupture of the duodenal wall with bile leakage was detected (Fig. 2). The lesion was closed with a continuous 4.0 Vicryl1 suture (Fig. 3). Subsequently, the abdomen was intensively lavaged with two litres of warm saline solution. Postoperative parenteral nutrition was started via a central venous line. The patient recovered quickly. The nasogastric tube was removed one day after the operation. Complete oral feeding could be commenced three days postoperatively. The further recovery was uneventful and five days following surgery the patient was discharged from the hospital. Discussion In this paper we describe two young patients who sustained upper gastrointestinal injury after blunt abdominal trauma. In
both patients we were able to diagnose and manage their injury laparoscopically. Both hemodynamically stable patients had evidence of intestinal injury without solid organ injury. According to the guidelines for diagnostic laparoscopy, published by the Society of American Gastrointestinal and Endoscopic Surgeons, diagnostic laparoscopy is contraindicated when there is obvious intra-abdominal injury or peritonitis.14 Despite these recommendations, a growing number of publications have appeared in recent years, describing diagnostic and sometimes therapeutic laparoscopy in abdominal trauma patients.4,6,7,9,10,12,15 The studies are summarized in Table 1. Obviously prevention of a negative laparotomy, with its associated morbidity and complications up to 41%,13 is increasingly considered a major advantage of laparoscopy. In total 206 patients are described in four paediatric and three adult series. In 17% to 62% of the patients a laparotomy could be avoided. The laparoscopy was therapeutic in 12% to 57% of the patients. In 204 of the 206 patients no diagnoses were missed by laparoscopy. The remaining two patients had a delayed operation at two and three weeks after the abdominal trauma. Their procedure was converted to a laparotomy as the exact site of the intestinal perforation could not be identified.9 To our knowledge, this is the first publication, describing the successful laparoscopic treatment of a duodenal rupture. According to the mentioned guidelines,14 a retroperitoneal injury is a contraindication for laparoscopic investigation. In other series, patients with suspected duodenal injury are excluded from the laparoscopic group.15 Routinely full Kocherisation of the duodenum was performed to exclude further injury. As the patient had only sustained a single trauma, and because signs of any concomitant pancreatic injury on the CT scan or in the blood
Table 1 Studies that describe the diagnostic and therapeutic role of laparoscopy in abdominal trauma. The first four studies are paediatric series. The latter three are adult series. Study
Year
Patients
Avoidance laparotomy
Therapeutic
Injury missed
McKinley12 Feliz6 Streck15 Marwan9 Choi4 Mathonnet10 Kaban7
2002 2006 2006 2010 2003 2003 2008
1 32 14 21 78 42 18
1 17 (56%) n.a. 13 (62%) 13 (17%) 15 (35,7%) 9 (50%)
1 6 8 5 43 5 3
0 0 0 2 0 0 0
(19%) (57%) (25%) (55%) (12%) (17%)
1444
S.H.A.J. Tytgat et al. / Injury, Int. J. Care Injured 43 (2012) 1442–1444
chemistry analysis were absent, no further exploration of the pancreas was indicated. Extensive laparoscopic expertise is mandatory, to be able to treat patients with upper intestinal perforations.2 The closure of bruised intestinal tears requires sufficient skills in intracorporeal laparoscopic suturing. In our department laparoscopic suturing is daily practice. As an additional control we inflated the suture line submerged in saline. Localising the perforation and ruling out other injuries requires experience in surgical exploration of the anatomical area of interest. Nowadays, in our hospital over 80% of the abdominal interventions are performed laparoscopically.16 Over the years we have come to find laparoscopic exploration of the upper gastrointestinal tract useful in many paediatric surgical conditions, such as in duodenal atresia and intestinal malrotation. Based on the skills required, we would recommend this approach only to experienced laparoscopic surgeons. Also the laparoscopic approach should be restricted to hemodynamically stable patients. Conversion to open surgery should be considered at every step of the procedure. In both our patients we found obvious abdominal contamination as the perforation already existed for several hours. We rinsed the abdomen with warm saline solution. Cultures taken from the abdomen after prophylactic intravenous antimicrobial therapy remained negative. Sheer laparoscopic cleaning of the abdomen in purulent peritonitis is feasible as shown in multiple series of gastric or colorectal perforation.1,3,8,11 Therefore we believe that finding a perforation during laparoscopy is not an absolute indication to convert to laparotomy, provided that the lesion can be managed adequately. With increasing incorporation of endoscopic surgery into general practice, we believe that in the future there will be a solid place for the laparoscopic approach to diagnosis and repair of traumatic visceral injury.2,6 It may be particularly beneficial for hemodynamically stable patients that sustained a focal abdominal trauma. We expect that this approach will lead to a decline in nontherapeutic laparotomies, and its associated complications. To further determine how laparoscopy can contribute to the diagnosis and treatment of trauma patients, more studies with larger case series are still needed.
Conflict of interest statement None of the authors has any conflict of interest regarding the data published in this paper. None of the authors has any financial interest in publishing the paper.
References 1. Alamili M, Go¨genur I, Rosenberg J. Acute complicated diverticulitis managed by laparoscopic lavage. Dis Colon Rectum 2009;52:1345–9. 2. Ball CG, Karmali S, Rajani RR. Laparoscopy in trauma: an evolution in progress. Injury 2009;40:7–10. 3. Bertleff MJ, Lange JF. Laparoscopic correction of perforated peptic ulcer: first choice? A review of literature. Surg Endosc 2010;24:1231–9. 4. Chol YB, Lim KS. Therapeutic laparoscopy for abdominal trauma. Surg Endosc 2003;17:421–7. 5. Degiannis E, Bowley DM, Smith MD. Minimally invasive surgery in trauma: technology looking for an application. Injury 2004;35:474–8. 6. Feliz A, Shultz B, McKenna C, Gaines BA. Diagnostic and therapeutic laparoscopy in pediatric abdominal trauma. J Pediatr Surg 2006;41:72–7. 7. Kaban GK, Novitsky YW, Perugini RA, Haveran L, Czerniach D, Kelly JJ, Litwin DE. Use of laparoscopy in evaluation and treatment of penetrating and blunt abdominal injuries. Surg Innov 2008;15:26–31. 8. Karoui M, Champault A, Pautrat K, Valleur P, Cherqui D, Champault G. Laparoscopic peritoneal lavage or primary anastomosis with defunctioning stoma for Hinchey 3 complicated diverticulitis: results of a comparative study. Dis Colon Rectum 2009;52:609–15. 9. Marwan A, Harmon CM, Georgeson KE, Smith GF, Muensterer OJ. Use of laparoscopy in the management of pediatric abdominal trauma. J Trauma 2010 [Epub ahead of print]. 10. Mathonnet M, Peyrou P, Gainant A, Bouvier S, Cubertafond P. Role of laparoscopy in blunt perforations of the small bowel. Surg Endosc 2003;4:641–5. 11. Mattei P, Alonso M, Justinich C. Laparoscopic repair of colon perforation after colonoscopy in children: report of 2 cases and review of the literature. J Ped Surg 2005;40:1651–3. 12. McKinley AJ, Mahomed AA. Laparoscopy in a case of pediatric blunt abdominal trauma. Surg Endosc 2002;16:358. 13. Renz BM, Feliciano DV. Unnecessary laparotomies for trauma: a prospective study of morbidity. J Trauma 1995;38:350–6. 14. SAGES (Society of American Gastrointestinal and Endoscopic Surgeons). Guidelines for diagnostic laparoscopy-diagnostic laparoscopy for trauma. SAGES publication # 0012 11/2007. http://www.sages.org/publication/id/12/. 15. Streck CJ, Lobe TE, Pietsch JB, Lovvorn 3rd HN.. Laparoscopic repair of traumatic bowel injury in children. J Pediatr Surg 2006;41:1864–9. 16. te Velde EA, Bax NM, Tytgat SH, de Jong JR, Travassos DV, Kramer WL, van der Zee DC. Minimally invasive pediatric surgery: increasing implementation in daily practice and resident’s training. Surg Endosc 2008;22:163–6.
Contents lists available at ScienceDirect
Injury journal homepage: www.elsevier.com/locate/injury
Laparoscopic treatment of gastric and duodenal perforation in children after blunt abdominal trauma S.H.A.J. Tytgat *, S. Zwaveling, W.L.M. Kramer, D.C. van der Zee Department of Paediatric Surgery, KE.04.140.5, Wilhelmina Children’s Hospital, University Medical Center Utrecht, P.O. Box 85090, 3508 AB Utrecht, The Netherlands
A R T I C L E I N F O
A B S T R A C T
Article history: Accepted 1 November 2010
Minimal invasive surgery has not yet gained wide acceptation for the care of patients that sustained an abdominal trauma. We describe the complete laparoscopic surgical treatment of two patients after a single blunt abdominal trauma. One patient sustained a handle bar injury and presented with a gastric perforation. The other sustained a duodenal rupture by falling on a sharp edge of a table. The patients were assessed and treated laparoscopically. The perforations were identified and closed. Both patients had an uneventful postoperative recovery. Therapeutic laparoscopic treatment of patients with upper gastrointestinal perforation is feasible. We would recommend this approach to experienced laparoscopic surgeons in hemodynamically stable patients. ß 2010 Elsevier Ltd. All rights reserved.
Keywords: Abdominal Trauma Laparoscopy Gastric perforation Duodenal perforation
Introduction Diagnostic laparoscopy in patients with abdominal trauma is not only increasingly applied in adults, but also in children.5,2 In penetrating abdominal trauma, the integrity of the peritoneum can be accurately established via this technique. Furthermore, in both penetrating and blunt abdominal trauma, intraperitoneal organ injury or perforation may be diagnosed. When damaged structures are found usually conversion to a laparotomy is advocated.14 In this paper we describe the complete laparoscopic surgical treatment of two children that sustained a single blunt abdominal trauma. One patient suffered from a gastric perforation while the other had a duodenal rupture. Patient 1 A nine-year-old boy with no medical history sustained a mountain bike handle bar injury. Two hours after the accident he presented with complaints of worsening abdominal pain at a nearby first aid department. The patient had some bruising around the umbilicus and manifested tenderness of the upper abdomen. He was hemodynamically stable. Extra intestinal air and free intraperitoneal fluid was seen on an abdominal CT scan. No injury to any solid organs was found. He was referred to our department and was operated 7 h after the injury. Under general anaesthesia and broad spectrum intravenous antibiotic coverage, laparoscopic inspection of the abdomen was
* Corresponding author. Tel.: +31 887554004. E-mail address: [email protected] (S.H.A.J. Tytgat). 0020–1383/$ – see front matter ß 2010 Elsevier Ltd. All rights reserved. doi:10.1016/j.injury.2010.11.002
started. For this purpose we used a three port technique; one 5 mm port was placed in the umbilicus for the camera and two 5 mm ports for instrumentation were introduced, one on each side of the abdomen. A diffuse peritonitis with contamination of gastric content was seen, with hematoma and debris around a 6 cm tear of the greater curvature of the stomach. This lesion was closed laparoscopically with six interrupted 4.0 Vicryl1 sutures after local rinsing. Patency of the gastric wall was tested by submerging the suture line under saline solution, while insufflating the stomach via a nasogastric tube. The whole abdomen was subsequently lavaged laparoscopically with two litres of warm saline solution. Postoperatively the patient remained in the intensive care unit overnight. Parental nutrition was started via a central venous line. On the second post-operative day gastric feeding was introduced. Full feeding was possible on day four. There were no postoperative complications. Abdominal cultures, taken during laparoscopy, remained negative. Antibiotics were stopped on the fourth postoperative day. Five days following surgery the patient was discharged in good clinical condition. His further recovery went uneventful. Patient 2 A ten-year-old boy had lost his balance while standing on a triangular table at school and, as a result of falling on one of the corners, he sustained a blunt injury above the level of the umbilicus. One hour later he arrived at our emergency department. Upon examination some painful bruises were seen above the level of the umbilicus. He was hemodynamically stable. A CT scan of the abdomen showed signs of a perforation of the duodenum with extraluminal retroperitoneal air bubbles in this region (Fig. 1). The
S.H.A.J. Tytgat et al. / Injury, Int. J. Care Injured 43 (2012) 1442–1444
1443
Fig. 1. CT-scan of a patient with a duodenal rupture, after blunt abdominal trauma. Arrows indicate extraluminal retroperitoneal air adjacent to the duodenum and under the liver. Fig. 3. Laparoscopic closure of the duodenal defect with a running suture.
Fig. 2. Laparoscopic view of a ruptured duodenum. The perforation is expanded using a suction device. The duodenal mucosa can be seen through the perforation (arrow).
pancreas was not damaged. Subsequently, under broad spectrum intravenous antibiotic coverage, a diagnostic laparoscopy was performed. We used the same port positions as described in the previous case with one additional port in the right flank for exposure of the retroperitoneum. The entire abdomen was inspected. Some bile stained fluid was detected in the upper quadrants, but no lesions were discovered. The hepatic flexure of the colon was mobilized to the left side. The duodenum including its dorsal aspect was approached and mobilised via a full Kocher manoeuvre. A 4 cm long rupture of the duodenal wall with bile leakage was detected (Fig. 2). The lesion was closed with a continuous 4.0 Vicryl1 suture (Fig. 3). Subsequently, the abdomen was intensively lavaged with two litres of warm saline solution. Postoperative parenteral nutrition was started via a central venous line. The patient recovered quickly. The nasogastric tube was removed one day after the operation. Complete oral feeding could be commenced three days postoperatively. The further recovery was uneventful and five days following surgery the patient was discharged from the hospital. Discussion In this paper we describe two young patients who sustained upper gastrointestinal injury after blunt abdominal trauma. In
both patients we were able to diagnose and manage their injury laparoscopically. Both hemodynamically stable patients had evidence of intestinal injury without solid organ injury. According to the guidelines for diagnostic laparoscopy, published by the Society of American Gastrointestinal and Endoscopic Surgeons, diagnostic laparoscopy is contraindicated when there is obvious intra-abdominal injury or peritonitis.14 Despite these recommendations, a growing number of publications have appeared in recent years, describing diagnostic and sometimes therapeutic laparoscopy in abdominal trauma patients.4,6,7,9,10,12,15 The studies are summarized in Table 1. Obviously prevention of a negative laparotomy, with its associated morbidity and complications up to 41%,13 is increasingly considered a major advantage of laparoscopy. In total 206 patients are described in four paediatric and three adult series. In 17% to 62% of the patients a laparotomy could be avoided. The laparoscopy was therapeutic in 12% to 57% of the patients. In 204 of the 206 patients no diagnoses were missed by laparoscopy. The remaining two patients had a delayed operation at two and three weeks after the abdominal trauma. Their procedure was converted to a laparotomy as the exact site of the intestinal perforation could not be identified.9 To our knowledge, this is the first publication, describing the successful laparoscopic treatment of a duodenal rupture. According to the mentioned guidelines,14 a retroperitoneal injury is a contraindication for laparoscopic investigation. In other series, patients with suspected duodenal injury are excluded from the laparoscopic group.15 Routinely full Kocherisation of the duodenum was performed to exclude further injury. As the patient had only sustained a single trauma, and because signs of any concomitant pancreatic injury on the CT scan or in the blood
Table 1 Studies that describe the diagnostic and therapeutic role of laparoscopy in abdominal trauma. The first four studies are paediatric series. The latter three are adult series. Study
Year
Patients
Avoidance laparotomy
Therapeutic
Injury missed
McKinley12 Feliz6 Streck15 Marwan9 Choi4 Mathonnet10 Kaban7
2002 2006 2006 2010 2003 2003 2008
1 32 14 21 78 42 18
1 17 (56%) n.a. 13 (62%) 13 (17%) 15 (35,7%) 9 (50%)
1 6 8 5 43 5 3
0 0 0 2 0 0 0
(19%) (57%) (25%) (55%) (12%) (17%)
1444
S.H.A.J. Tytgat et al. / Injury, Int. J. Care Injured 43 (2012) 1442–1444
chemistry analysis were absent, no further exploration of the pancreas was indicated. Extensive laparoscopic expertise is mandatory, to be able to treat patients with upper intestinal perforations.2 The closure of bruised intestinal tears requires sufficient skills in intracorporeal laparoscopic suturing. In our department laparoscopic suturing is daily practice. As an additional control we inflated the suture line submerged in saline. Localising the perforation and ruling out other injuries requires experience in surgical exploration of the anatomical area of interest. Nowadays, in our hospital over 80% of the abdominal interventions are performed laparoscopically.16 Over the years we have come to find laparoscopic exploration of the upper gastrointestinal tract useful in many paediatric surgical conditions, such as in duodenal atresia and intestinal malrotation. Based on the skills required, we would recommend this approach only to experienced laparoscopic surgeons. Also the laparoscopic approach should be restricted to hemodynamically stable patients. Conversion to open surgery should be considered at every step of the procedure. In both our patients we found obvious abdominal contamination as the perforation already existed for several hours. We rinsed the abdomen with warm saline solution. Cultures taken from the abdomen after prophylactic intravenous antimicrobial therapy remained negative. Sheer laparoscopic cleaning of the abdomen in purulent peritonitis is feasible as shown in multiple series of gastric or colorectal perforation.1,3,8,11 Therefore we believe that finding a perforation during laparoscopy is not an absolute indication to convert to laparotomy, provided that the lesion can be managed adequately. With increasing incorporation of endoscopic surgery into general practice, we believe that in the future there will be a solid place for the laparoscopic approach to diagnosis and repair of traumatic visceral injury.2,6 It may be particularly beneficial for hemodynamically stable patients that sustained a focal abdominal trauma. We expect that this approach will lead to a decline in nontherapeutic laparotomies, and its associated complications. To further determine how laparoscopy can contribute to the diagnosis and treatment of trauma patients, more studies with larger case series are still needed.
Conflict of interest statement None of the authors has any conflict of interest regarding the data published in this paper. None of the authors has any financial interest in publishing the paper.
References 1. Alamili M, Go¨genur I, Rosenberg J. Acute complicated diverticulitis managed by laparoscopic lavage. Dis Colon Rectum 2009;52:1345–9. 2. Ball CG, Karmali S, Rajani RR. Laparoscopy in trauma: an evolution in progress. Injury 2009;40:7–10. 3. Bertleff MJ, Lange JF. Laparoscopic correction of perforated peptic ulcer: first choice? A review of literature. Surg Endosc 2010;24:1231–9. 4. Chol YB, Lim KS. Therapeutic laparoscopy for abdominal trauma. Surg Endosc 2003;17:421–7. 5. Degiannis E, Bowley DM, Smith MD. Minimally invasive surgery in trauma: technology looking for an application. Injury 2004;35:474–8. 6. Feliz A, Shultz B, McKenna C, Gaines BA. Diagnostic and therapeutic laparoscopy in pediatric abdominal trauma. J Pediatr Surg 2006;41:72–7. 7. Kaban GK, Novitsky YW, Perugini RA, Haveran L, Czerniach D, Kelly JJ, Litwin DE. Use of laparoscopy in evaluation and treatment of penetrating and blunt abdominal injuries. Surg Innov 2008;15:26–31. 8. Karoui M, Champault A, Pautrat K, Valleur P, Cherqui D, Champault G. Laparoscopic peritoneal lavage or primary anastomosis with defunctioning stoma for Hinchey 3 complicated diverticulitis: results of a comparative study. Dis Colon Rectum 2009;52:609–15. 9. Marwan A, Harmon CM, Georgeson KE, Smith GF, Muensterer OJ. Use of laparoscopy in the management of pediatric abdominal trauma. J Trauma 2010 [Epub ahead of print]. 10. Mathonnet M, Peyrou P, Gainant A, Bouvier S, Cubertafond P. Role of laparoscopy in blunt perforations of the small bowel. Surg Endosc 2003;4:641–5. 11. Mattei P, Alonso M, Justinich C. Laparoscopic repair of colon perforation after colonoscopy in children: report of 2 cases and review of the literature. J Ped Surg 2005;40:1651–3. 12. McKinley AJ, Mahomed AA. Laparoscopy in a case of pediatric blunt abdominal trauma. Surg Endosc 2002;16:358. 13. Renz BM, Feliciano DV. Unnecessary laparotomies for trauma: a prospective study of morbidity. J Trauma 1995;38:350–6. 14. SAGES (Society of American Gastrointestinal and Endoscopic Surgeons). Guidelines for diagnostic laparoscopy-diagnostic laparoscopy for trauma. SAGES publication # 0012 11/2007. http://www.sages.org/publication/id/12/. 15. Streck CJ, Lobe TE, Pietsch JB, Lovvorn 3rd HN.. Laparoscopic repair of traumatic bowel injury in children. J Pediatr Surg 2006;41:1864–9. 16. te Velde EA, Bax NM, Tytgat SH, de Jong JR, Travassos DV, Kramer WL, van der Zee DC. Minimally invasive pediatric surgery: increasing implementation in daily practice and resident’s training. Surg Endosc 2008;22:163–6.