Single-incision laparoscopic surgery for blunt abdominal trauma: A single-institution experience at a level I trauma centre

Abstract

BACKGROUND

Laparoscopic surgery remains a safe and feasible option for managing traumatic intra-abdominal organ injuries, offering advantages over laparotomy in terms of pain, cosmesis, and postoperative recovery. Single-incision laparoscopic surgery (SILS) is an evolving technique that aims to further reduce the invasiveness of laparoscopy. The authors report seven cases of small bowel injury from blunt trauma treated with SILS.

AIM

To evaluate the feasibility and safety of SILS in hemodynamically stable patients with blunt abdominal trauma.

METHODS

Adult patients with blunt abdominal trauma who presented to a level 1 trauma centre and were diagnosed with small bowel injury were retrospectively reviewed. Patients who had undergone SILS were identified. Clinical data, operative details, and postoperative outcomes were analyzed.

RESULTS

Seven patients were included in this study. Four patients were male, with a median age of 68 years. The most common mechanism of injury was in-car traffic accidents (5 cases). All patients presented with hemodynamic stability and an alert mental status upon arrival. Injured sites included the ileum (3 cases), mesentery (3 cases), and jejunum (2 cases), with no associated solid organ injuries. Surgical procedures consisted of primary repair in 5 cases and resection with anastomosis in 2 cases. No injuries were missed. Postoperative complications included ileus in 2 cases, with no other complications reported. No mortality was observed during the study period.

CONCLUSION

SILS appears feasible and safe in carefully selected hemodynamically stable patients with blunt abdominal trauma, although larger studies are required to confirm its clinical role.

Key Words: Trauma; Blunt abdominal trauma; Laparoscopy; Small bowel injury; Single-incision laparoscopic surgery

Core Tip: This study presents the first case series evaluating single-incision laparoscopic surgery (SILS) for blunt abdominal trauma. In seven hemodynamically stable patients with small-bowel injuries, SILS enabled both diagnostic exploration and therapeutic management without missed injuries, major complications, or mortality. Although limited by its retrospective design and small sample size, SILS may represent a feasible minimally invasive option in carefully selected trauma patients, with the flexibility to convert to conventional multiport laparoscopy when necessary.

INTRODUCTION

Minimally invasive surgery, particularly laparoscopy, has rapidly evolved, expanding its indications from minor emergency procedures such as appendectomy and cholecystectomy to complex, highly difficult operations, including elective oncologic surgery[1-5]. Compared to conventional open surgery, laparoscopy consistently offers multiple advantages, such as shorter postoperative recovery, less pain, reduced rates of selected complications, and improved cosmetic outcomes[2-5]. Consequently, it has become a standard approach for many elective surgical procedures.

Despite its utility in other surgical settings, laparoscopy has limited use in patients with abdominal trauma. Traditionally, laparotomy has been prioritized due to hemodynamic instability, multisystem intra-abdominal injury, and the need for expeditious operative interventions. Specifically, laparotomy remains indispensable for hemoperitoneum resulting from hepatic or splenic injury or when multiple hollow viscus injuries are present[6,7]. In contrast, for hemodynamically stable patients with equivocal intra-abdominal injuries, diagnostic laparotomy provides comprehensive information but is associated with higher morbidity and delayed recovery[8,9]. Therefore, diagnostic laparoscopy has been proposed as an alternative to overcome these limitations. Several studies report that it can reduce negative laparotomies and promote postoperative recovery[10,11].

Previous studies have primarily focused on multiport laparoscopy, and evidence regarding the role and utility of single-incision laparoscopic surgery (SILS) remains limited. Accordingly, this study reports our experience with SILS in hemodynamically stable patients with abdominal trauma at a level I trauma centre, aiming to evaluate its feasibility and appropriateness as a diagnostic and therapeutic modality.

MATERIALS AND METHODS

Patient selection

This study was designed as a retrospective descriptive case series. We retrospectively identified and analyzed patients who presented to the level I trauma centre at Dankook University Hospital between May 2021 and April 2025 and underwent SILS for blunt abdominal trauma. During this period, 87 patients with blunt abdominal trauma underwent laparoscopic exploration. To eliminate inter-surgeon technical bias, patient enrollment was limited to the experience of a single surgeon. Of these, 80 patients underwent conventional multi-port laparoscopic surgery [multi-port laparoscopy (MPL)] performed by other attending trauma surgeons and were therefore excluded. The remaining seven consecutive patients who underwent SILS met the study eligibility criteria and were included in the final analysis.

Inclusion criteria: (1) Presentation to the trauma center within the defined study period; (2) Diagnosis of blunt abdominal trauma; and (3) Hemodynamic stability at admission with clinical indications for laparoscopy, such as hemoperitoneum or generalized peritonitis, and deemed suitable for minimally invasive surgical exploration.

Exclusion criteria: (1) Patients with penetrating abdominal trauma; (2) Patients who underwent conventional MPL performed by other attending trauma surgeons at the same center during the study period; (3) Patients requiring intraoperative conversion to MPL or open laparotomy due to severe intra-abdominal contamination, dense adhesions, or uncontrolled bleeding; and (4) Patients requiring emergency laparotomy due to persistent hypotension or hemorrhagic shock during the initial evaluation or operative planning.

Demographic data, mechanism of injury, laboratory parameters, operative findings, postoperative course, and clinical outcomes were obtained through a comprehensive review of electronic medical records.

Ethics approval and consent to participate

The study was reviewed and approved by the Dankook University Hospital Institutional Review Board (Approval No. 2025-11-008) and conducted in accordance with the Declaration of Helsinki. The need for informed consent was waived due to the retrospective nature of this study.

Data and statistical analysis

The parameters assessed included demographic factors such as age and sex; injury-related variables including mechanism of injury, blunt trauma, past medical history, systolic blood pressure, pulse rate, Glasgow Coma Scale[12], computed tomography findings, injured organs, abdominal Abbreviated Injury Scale[13]; and perioperative outcomes including type of surgery, duration of surgery, estimated blood loss, time of drain removal, time to diet initiation, length of intensive care unit stay, length of hospital stay, rate of missed injuries, complications classified by the Clavien-Dindo system[14], and mortality.

All statistical analyses were performed using the R software environment (version 3.6.1, Comprehensive R Archive Network; http://cran.r-project.org). Given the descriptive nature of this case series and the limited sample size, inferential statistical analyses were not conducted. Instead, all variables were summarized using descriptive statistics only. Quantitative variables were summarized using medians with ranges, while categorical variables were described as n (%).

Treatment outcomes in the present study were descriptively compared with data from our previously published 2021 cohort on conventional MPL[15]. Due to the highly selective patient enrollment in the current series and inherent limitations, including potential selection bias and small sample size, no formal statistical testing was performed, and the comparison was limited to a descriptive presentation of the data.

Procedure detail and postoperative management

Laparoscopic surgery was performed in a standard fashion using a 3-dimensional laparoscopic camera. A vertical incision of approximately 5 cm, including the umbilicus, was made, and pneumoperitoneum was established using a glove port (NELIS^©, Bucheon, South Korea). The operator explored the peritoneal cavity using non-articulating laparoscopic instruments. Solid organs, including the liver, spleen, and omentum, were gently manipulated for careful visual inspection. The small bowel was then systematically examined by tracing it from the ligament of Treitz to the terminal ileum, with both anterior and posterior surfaces inspected after sequential elevation. Finally, the colon was evaluated similarly. Solid organs and the colon were not routinely mobilized or dissected unless injury was suspected. When injuries to the small intestine or mesentery were identified, the glove port was partially removed, and the small intestine was exteriorized for extracorporeal primary repair or resection. The extracorporeal procedure was performed using conventional techniques similar to those employed in standard open laparotomy (Figure 1). The incision was closed in a layer-by-layer fashion. A Jackson-Pratt drain was inserted through the incision and positioned in a dependent area, such as the pelvic cavity, to facilitate adequate drainage. The skin was closed with subcutaneous absorbable sutures, with attention to cosmetic outcomes.

Figure 1 Extracorporeal procedures during single incision laparoscopic surgery. A: Exteriorization of the perforated jejunum through the single-incision port; B: Exteriorization of the injured ileum and mesentery through the single-incision port; C: Extracorporeal primary repair performed through the single-incision port; D: Extracorporeal resection and anastomosis performed through the single-incision port.

For surgical ergonomics, the patient was placed in the supine position under general anesthesia. The operating surgeon and camera assistant stood on the right or left side of the patient, depending on the suspected site of injury, following the standard positioning used in conventional MPL. A transumbilical vertical incision was made to accommodate the single-incision port platform. Systematic exploration of the abdominal cavity was performed sequentially from the solid organs to the hollow viscus, utilizing the same principles as standard laparoscopic exploration.

The drain was removed when bowel function had adequately recovered, and the daily drainage volume was less than 100 mL. After discharge, patients were followed up in the outpatient clinic approximately 4 weeks postoperatively. In the absence of specific symptoms or concerns, only a physical examination was performed, without routine radiologic imaging. Thereafter, patients were advised to visit the emergency department if any discomfort or complications developed, and no scheduled routine follow-up visits were arranged.

RESULTS

The baseline characteristics of the patients are summarized in Table 1. Seven patients underwent SILS. Of these seven patients, four (57%) were male, with a median age of 68 years. The most common mechanism of injury was in-car traffic accidents (5 cases, 71%), followed by one case each of bicycle collisions and other blunt impacts. Hemoperitoneum was identified on computed tomography in 4 patients (57%), while the remaining three patients were diagnosed with pneumoperitoneum. These findings led to the decision for emergency surgery.

Table 1 Baseline characteristics of the patients.

Variable	n = 7
Age (year)	68 (26-76)
Male	4 (57)
Mechanism of injury
In-car traffic accident	5 (71)
Bicycle traffic accident	1 (14)
Collision	1 (14)
Blunt trauma	7 (100)
Past medical history
Thyroid cancer	1 (14)
Cerebrovascular disease	1 (14)
Diabetes mellitus	1 (14)
Asthma	1 (14)
Systolic blood pressure (mmHg)	133 (97-156)
Pulse rate, per min	83 (55-97)
Glasgow coma scale	15 (15-15)
Computed tomography
Hemoperitoneum	4 (57)
Pneumoperitoneum	3 (43)

Data are presented as n (%) or median (range) due to small sample size.

The median interval from emergency department arrival to operating room entry was 101 minutes (range 51-1030 minutes). For five patients, transfer to the operating room was completed within 4 hours. A prolonged interval (17 hours and 10 minutes) was observed in one patient who required extended serial clinical observation and diagnostic evaluation; however, no missed injuries or clinical deterioration were observed in this patient.

Intraoperative findings revealed injuries to the ileum in 3 cases, the mesentery in three cases, and the jejunum in 2 cases. Although seven patients were included, a total of eight small-bowel injuries were identified because one patient had multiple perforations involving both the jejunum and ileum. The patients had a median abdominal Abbreviated Injury Scale score of 3 and a median Injury Severity Score of 10. Primary repair of the small intestine was performed in 5 patients (71%), whereas resection with anastomosis was required in the remaining 2 patients (29%). The median time to drain removal was 6 days. The median lengths of stay in the intensive care unit and hospital were 2 days and 17 days, respectively. No injuries to other intra-abdominal organs were identified. Postoperative ileus developed in two patients, but no complications of Clavien-Dindo classification grade III or higher were observed. The patients recovered well after surgery and were discharged in a stable condition. At outpatient follow-up, the wounds showed no complications (Figure 2). No postoperative mortality was observed. The treatment outcomes are summarized in Table 2 and are presented alongside data from our previously reported MPL cohort for descriptive comparison only.

Figure 2 Umbilical incision scar at the 4-week postoperative outpatient follow-up.

Table 2 Summarised results of treatment.

Variable	SILS (n = 7)	MPL (n = 19)
Injured organs
Ileum	3 (43)	4 (21)
Mesentery	3 (43)	0
Jejunum	2 (29)	8 (42)
Duodenum	0	1 (5)
Urinary bladder	0	2 (11)
Solid organ	0	0
Abdomen Abbreviated Injury Score	3 (3-4)	3 (2-3)
Injury Severity Score	10 (9-21)	13 (7-20)
Surgery
Primary repair	5 (71)	13 (68)
Resection and anastomosis	2 (29)	6 (32)
Duration of surgery (minute)	95 (80-126)	155 (110-181)
Estimated blood loss (mL)	200 (10-1000)	100 (40-300)
Time of drain removal (day)	6 (5-14)	4 (1-6)
Length of intensive care unit	2 (2-3)	2 (2-5)
Length of hospital stay	17 (6-25)	11 (8-21)
Time of diet start (day)	4 (3-6)	3 (3-5)
Rate of missed injury	0	0
Complications (Clavien-Dindo grade II)
Postoperative ileus	2 (29)	0
Postoperative bleeding	0	1 (5)
Intraabdominal abscess	0	1 (5)
Acute respiratory distress syndrome	0	1 (5)
Mortality	0	0

Data are presented as n (%) or median (range) for the single-incision laparoscopic surgery group, and as n (%) or median (interquartile range) for the multi-port laparoscopy group. SILS: Single-incision laparoscopic surgery; MPL: Multi-port laparoscopy.

DISCUSSION

To our knowledge, this was the first study to investigate the feasibility of SILS in patients with blunt abdominal trauma. With appropriate patient selection, the procedure was performed safely without major postoperative complications or missed injuries, and the perioperative outcomes were favorable. Although robotic surgery (RS) has attracted considerable attention, its limited availability and high cost remain barriers in many settings. In this context, the cost-effectiveness of laparoscopy remains an advantage, and our findings support its applicability in trauma care.

In the present series, our team performed diagnostic exploration using SILS and subsequently exteriorized the injured small bowel through a single incision for extracorporeal management. While operative difficulty and efficiency are influenced by the surgeon’s level of laparoscopic expertise, it is generally acknowledged that laparoscopic procedures require greater technical demands and longer operative times than open laparotomies[3]. From this perspective, the ability to exteriorize and manage bowel injuries through a single incision may be regarded as a practical advantage of SILS over conventional MPL.

Conversely, SILS also offers procedural flexibility. When necessary, an additional working port can be introduced through a separate incision, effectively converting the procedure into MPL. Considering that one of the inherent limitations of SILS is its potential for instrument and camera crowding due to the shared access point, such convertibility underscores the versatility and adaptability of SILS[16]. Specifically, in a trauma scenario, coaxial interference between the laparoscope and working instruments can hinder a meticulous, comprehensive exploration of the entire abdominal cavity, particularly when dealing with anatomically challenging angles. In such situations, standard MPL provides a definite technical advantage over SILS. Therefore, to safely maximize the potential advantages of SILS, the operator must always be prepared to add working ports whenever technical difficulties arise. Furthermore, the procedure should ideally be performed by surgeons who are already sufficiently experienced with MPL. Although evidence regarding the learning curve in trauma surgery remains limited, several studies in non-trauma settings have reported that the number of cases required to achieve procedural proficiency varies according to the type of operation, ranging from approximately 30 cases for appendectomy to up to 36 cases for colorectal resection[17,18]. Therefore, once the learning curve for conventional MPL has reached a stable phase—typically after at least 30 cases—it may be reasonable to cautiously introduce SILS into clinical practice.

The 2023 WSES Cesena consensus recommends a laparoscopy-first strategy for hemodynamically stable trauma patients, particularly for evaluating diaphragmatic, jejunal, or mesenteric injuries resulting from blunt trauma[10]. A 2025 meta-analysis further reported that this approach reduced infectious and pulmonary complications, hospital stay, and operative time, with rates of missed injury and mortality comparable to those of open surgery[19]. In our series, despite the small sample size, we observed no delayed diagnoses or missed injuries during follow-up. Morbidity was limited to manageable Clavien-Dindo grade II events, and no deaths occurred. Our team has previously demonstrated the feasibility and clinical utility of multi-port laparoscopic surgery in hemodynamically stable patients with both blunt and penetrating abdominal trauma[15]. In that prior study, postoperative complications, including bleeding and pleural effusion, occurred in 5 of 19 patients (26.3%) who underwent therapeutic laparoscopic surgery, with no mortalities. Although a direct comparison is challenging due to differences in patient populations and small sample sizes, the overall complication rates appear comparable between the two approaches. Taken together, these findings suggest that, for surgeons proficient in laparoscopy, SILS may be a judicious option when small-bowel injury is suspected after blunt trauma. However, given our limited sample size, we are extremely cautious about generalizing the absence of missed injuries in this cohort. To rigorously validate the diagnostic safety and definitive efficacy of SILS in abdominal trauma, further large-scale prospective studies are warranted, which our trauma team is actively planning.

With recent technological advances, the scope of RS has been steadily expanding, offering advantages such as high-definition imaging systems and articulated robotic arms[20,21]. However, a substantial proportion of patients with trauma belong to socioeconomically disadvantaged groups, for whom the high cost of treatment may pose a major barrier. Notably, low socioeconomic status has been associated with reduced access to hospital care, higher mortality, and unfavorable trauma outcomes[22]. According to data from our institution, the out-of-pocket cost of robotic small bowel resection is more than five times higher than that of standard laparoscopic resection. For example, the procedural cost of cholecystectomy is approximately 700 USD for laparoscopic surgery compared with approximately 3500 USD for RS, although these figures may vary across institutions. If comparable clinical outcomes are achieved, these considerations suggest that laparoscopy is an important and cost-effective treatment option for patients with trauma. Furthermore, when comparing SILS to conventional MPL within the laparoscopic domain, the institutional cost difference is marginal or nearly cost-neutral under the current South Korean healthcare system, as the cost of a single-incision port platform is highly comparable to the total cost of multiple disposable trocars. Given this minimal cost discrepancy, SILS may serve as a viable alternative for select patients with blunt abdominal trauma, as it may offer improved cosmetic satisfaction without imposing substantial additional financial burden compared with conventional MPL.

Regardless of whether robotic or conventional laparoscopy is used, SILS tends to result in greater cosmetic satisfaction than multiport approaches. Comparative studies of SILS vs conventional MPL cholecystectomy have demonstrated superior body image scores and higher patient satisfaction with the single-port technique[23,24]. Similarly, studies in emergency surgery, such as randomized trials of single-incision laparoscopic appendectomy, have reported higher cosmetic satisfaction compared with conventional laparoscopy[25]. In our series, cosmetic benefit was not prioritized over surgical safety; nevertheless, most patients reported favorable cosmetic outcomes. Further prospective studies are needed to evaluate patient-reported satisfaction in trauma populations.

Several reports have noted an increased risk of incisional hernia with single-port access[26]. Although no hernias were observed in our series, careful surveillance is warranted as the number of cases and the length of follow-up increase. Patients were evaluated at approximately 4 weeks after discharge with physical examination alone, and no routine long-term follow-up visits were scheduled thereafter. During this 4-week follow-up, all patients were thoroughly educated about the potential risk and symptoms of an incisional hernia and instructed to return to the outpatient clinic immediately if any abnormalities were suspected; to date, no patient has returned with hernia-related complications. Nevertheless, we acknowledge that this short follow-up duration may have limited our ability to detect potential long-term issues such as late-onset incisional hernia or subclinical complications. Prompted by this limitation, our trauma center recently updated its clinical protocol to mandate a minimum of 6 months of long-term follow-up for all patients undergoing SILS, ensuring more rigorous surveillance of late postoperative complications.

This study had several limitations. First, as a single-center, small-scale retrospective study, the generalizability of our findings is limited. Larger multicenter studies comparing this approach with open surgery, MPL, and RS are warranted. The authors' team also plans to undertake prospective studies with expanded inclusion criteria, including penetrating injuries, to further explore the feasibility and clinical role of SILS. Second, trauma patients are inherently heterogeneous. Although the procedures were safely completed in a small number of hemodynamically stable patients, increasing case volumes may reveal scenarios in which conversion to open surgery is required after laparoscopic access reveals major injuries, potentially introducing treatment delays. Third, postoperative follow-up was limited. Delayed postoperative complications, such as incisional hernia, may have been underreported in this study. Finally, outcomes are likely influenced by surgeon experience; for surgeons less familiar with laparoscopy, adequate training and sufficient experience with open and multiport laparoscopic procedures are recommended before attempting SILS in trauma patients.

CONCLUSION

SILS appears to be a feasible and safe minimally invasive approach in hemodynamically stable and appropriately selected patients with blunt abdominal trauma. In our experience, the technique allowed both intracorporeal exploration and extracorporeal management of injured bowel through a single incision and could be converted to conventional MPL when additional access was required. Given the small sample size and the descriptive nature of this case series, these findings should be interpreted with caution. Further larger-scale studies are warranted to better evaluate the safety, applicability, and clinical role of SILS in trauma surgery.