It was a pleasure to read such a neat and clearly presented paper. As a result of my knowledge in the field of trauma, obtained at Hospital de Urgencias de Córdoba, I venture to make the following contributions. I agree that diagnostic laparoscopy is a useful screening tool for patients with abdominal trauma and avoids a significant number of unnecessary exploratory laparotomies. As the authors have pointed out, this is an attractive and interesting practice in any trauma center with residents in training, since abdominal exploration and treatment of diaphragmatic, gastric or intestinal injuries through laparoscopy represent an intermediate level of complexity. The evaluation and management of abdominal trauma have undergone significant changes in recent decades. Diagnostic methods in this type of lesions have evolved with the development of new concepts and technological advances achieved over the past twenty years. Therefore, it is important to define some parameters to indicate laparoscopy in patients with abdominal trauma.

Laparoscopy has certainly lost some validity and usefulness in our environment for the diagnosis of traumatic intra-abdominal injuries, whether on elective or emergency basis, due to the technological progress of the latest computed tomography devices with image reconstruction techniques, also considering that laparoscopy is an invasive practice not free from complications. Nevertheless, it is still a great complement available nowadays. Rapid and accurate determination of peritoneal penetration and identification of the need for surgery is a priority to reduce morbidity and mortality in patients with penetrating abdominal trauma.

In this setting, laparoscopy may have a major impact on the rate of negative or non-therapeutic laparotomies. In our experience, diagnostic laparoscopy was indicated more commonly in open abdominal trauma than in blunt trauma, which coincides with most publications on the subject. The importance of a stable hemodynamic status has been highlighted by all authors to indicate laparoscopy in patients with penetrating trauma. Although the use of laparoscopy has proved to be safe, rapid and highly sensitive for the evaluation of penetrating trauma with the advantages of laparoscopy over open surgery (lower rate of surgical site infection and respiratory tract infection, better pain control and shorter length of hospital stay) as was analyzed in this work, it is still controversial in the literature for blunt abdominal trauma. Nevertheless, we consider it very useful in our hospital. Patients with blunt abdominal trauma and non-conclusive diagnostic tests for organ injury are a clear indication for diagnostic laparoscopy. In some cases, the results are negative but laparotomy is avoided and, very often, a slight hemoperitoneum caused by a mesenteric tear, sometimes associated with bowel ischemia, is demonstrated and repaired by laparoscopy. Moreover, the patients who could benefit most from the laparoscopic approach in blunt trauma would be those with suspected hollow viscus injury, suspected diaphragmatic injury, failure after conservative management, or those with isolated free fluid and clinical impairment.

With the possibility of other therapeutic modalities, as angioembolization, or the advances in imaging tests that have increased their diagnostic accuracy, conservative management is the strategy of choice in blunt trauma. Nonoperative management (NOM) of blunt abdominal trauma is mandatory and has become increasingly common in hemodynamically stable patients without injuries with surgical indications. There are known complications of NOM due to undrained intra-abdominal fluid, including bleeding and biliary leak that require delayed operation, more commonly in liver lesions. Thus, laparoscopy can be considered as part of the overall management plan instead of failure of NOM. Laparoscopy is beneficial in blunt abdominal trauma patients following NOM with improvement in symptoms, systemic inflammatory response syndrome features, and a possible reduction in hospital length of stay.

Laparoscopy still plays a minor role in trauma patients, although it should be considered useful for diagnosis and treatment in selected cases. It is also widely used for the diagnosis of peritoneal injury in penetrating abdominal trauma in hemodynamically stable patients, for evaluating and repairing the diaphragmatic injuries in left thoracoabdominal trauma, or for exploring equivocal findings in CT scans. Diagnostic laparoscopy in trauma patients should be performed by surgeons with experience in the management of polytrauma patients and in laparoscopic surgery.