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THE ROLE OF DIAGNOSTIC AND THERAPEUTIC LAPAROSCOPYIN ACUTE ABDOMEN

Nandkishor P Potdar

Laparoscopic Surgeon and Therapeutic Endoscopist, Consultant Surgeon, Kothari Hospital/Motiben Dalvi, Bombay Hospital and Medical Research Centre.

Laparoscopy the "BUZZ WORD" of the 90ís is all set to embrace the new Millennium with enthusiasm and gusto and if my prediction is right 70-80% of all elective and emergency abdominal procedures will be done by this revolutionary method of surgery in the coming decades. Surgeons all round the world and for time immemorial have two important traits.

  1. Curiosity for the unknown.
  2. Sense of adventure.

It is this curiosity which made surgeons, of the whole of the last century and better half of the 20th Century, devise instruments which will fit in each and every normal orifice, "JUST TO GET A GLIMPSE INSIDE".

As if this was not enough they then started creating artificial holes, and started observing internal structures of the body from a different perspective. Thus dawned an era of laparoscopy surgery with Philip Moriet performing the 1st laparoscopic cholecystectomy in 1989 in France. The whole world was swept with a wave and surgeons were performing laparoscopic operations and acquiring tremendous skill and experience.

But still the sense of adventure was haunting the surgeons, so they decided to enter the tiger country of acute abdominal catastrophes. The skills and experience of elective laparoscopic surgery were applied to diagnose, as well as treat, therapeutically abdominal emergencies with good result. So, from 1902 when Kelling performed the 1st diagnostic peritoneoscopy (DP) in a dog and Jacobeus who was credited for performing the first operation on humans, we have come a long way.

Calk and Brital in 1928 published the 1st series and then this branch remained dormant until the 1980ís, when it was done exclusively by gynaecologists.

The universal acceptance of laparoscopy was due to four factors

  1. Advances of technology with the introduction of compact, high definition, solid state video system, which allowed a team approach.
  2. Popularity of laparoscopic cholecystectomy which is now the gold standard for treating gallstone disease.
  3. Enthusiasm for keyhole surgery shared by both surgeons and lay people.
  4. Companies seeing the potential and entering the market aggressively.

The purpose of this article is to analyse and support the theory of minimal access surgery to diagnose and treat abdominal emergencies.

UPPER ABDOMEN
Fig 1:

 

LOWER ABDOMEN
Fig 2:

Current Practice, in a General Surgical Unit

After going through a variety of causes of acute abdomen given above and careful assessment of patients there is still a significant percentage of patients who are misdiagnosed and thus leading to increase in morbidity and mortality.

This article is a sincere attempt to prove scientifically and on the basis of clinical data that laparoscopy may be an answer, to these challenging clinical conditions.

Laparoscopy for Abdominal pain

Gone are the days when diagnostic laparotomies were performed for abdominal pain. Despite all modern investigations a number of conditions were still missed out leading to a delay in the surgical treatment which may be vital for the patients survival. Diagnostic laparoscopy will offer a quick diagnoses as well as lower morbidity and mortality. Sugerbaker et al gave a diagnostic accuracy of 96% and completion of procedure in 20 minutes.

In a combine analysis of 23 series comprising 200,000 procedures, Diagnostic laparoscopies was shown to be a safe procedure with acceptable low morbidity and mortality.

Laparoscopy in Trauma Patients (Blunt and Penetrating)

Trauma patients with equivocal signs are always a dilemma, more so when patients are victims of "Urban violence, car accidents, intoxication by alcohol, spinal cord injury and/or head injury. Commonly used diagnostic peritoneal lavage (DPL) has a sensitivity of > 95% and specificity of 83%. The rate of unnecessary laparotomy is still very high with a morbidity of 20% and mortality of 6%. If DL is combined with DPL then the sensitivity can be increased up to 100% and specificity up to 90%.

Series of 10 diaphragmatic ruptures in a London Hospital diagnosed by CT and contrast Radiology, Laparoscopy findings revealed:Rupture with herniation ó- 6 cases leading to Laparotomy.Rupture without herniation ó 2 cases.No Abnormality - 2 cases.

Conclusion : Four patients were spared unnecessary laparotomy.

Diagnostic laparoscopy is extremely useful in patients with equivocal signs and haemo dynamically stable. It is slowly replacing the old belief that, all penetrating abdominal wounds whether stab or gunshot should be explored. Also in cases of sub capsular tears of liver or spleen or minor tears in mesentery or omental injury can now be completely conserved saving the number of non therapeutic laparotomies (NTL).

Beru et al published a retrospective study of 150 DL in victims of blunt abdominal trauma (BAT) performed in emergency room or ICU.

Their management decisions - immediate laparotomy (19%), simple observation (25%) and early discharges (56%) correlated very well with DL findings. He thus demonstrated that DL has high sensitivity and decreases NTL rates significantly.

A prospective analysis of 182 DL recently published.

99 (55%) patients has stab wounds.

66 (36%) patients had gunshot wounds.

17 (9%) patients has blunt trauma.

DL reduced NTL in all groups significantly also high cost of open operations and hospitalisation was saved.

Therefore to summarise advantages of DL in trauma cases.

Laparascopy in ICU patients/critically ill

ICU patients developed high rate of complications apart from the primary condition. For example:

  1. Acalculus/Calculus cholecystitis.
  2. Large bowel perforation.
  3. Duodenal and gastric perforations (e.g. stress ulcers)
  4. Intestinal ischaemia (embolus or low flow)
  5. Pancreatitis (due to biliary sludge)
  6. Intra abdominal haemorrhage.

It is extremely difficult to diagnose above mentioned complications in a patient who is already in MOF (multiple organ failure). There are no symptoms and signs which can be elucidated as patients are on ventilation or gravely ill and delay in surgical treatment may lead to increase in morbidity and mortality.

Beru et al published data of DL in 25% ICU patients for various conditions. DL was done under GA in all patients in OT except 1 patient in 12 patients.

Positive results were obtained, as follows:

6 - intestinal ischaemia

4 - gangrenous cholecystitis

1 - perforated caecum

1 - ruptured spleen

13 patients had a negative DL and were spared unnecessary NTL.

8 of the latter 13 recovered

5 died - 1 died of cardiac failure and 4 had PM which revealed

3 without intra abdominal sepsis

1 had pericolic abscess without bowel perforations.

In summary advantages of DL in ICU patients are:

  1. Avoid transportation of gravely ill patients.
  2. Rapid establishment of the correct diagnosis.
  3. Avoidance of unnecessary ancillory tests such as CT, lavages etc.

Disadvantages

    1. Expensive
    2. Operator experience essential.
    3. Low sensitivity in intestinal or retro peritoneal disease.

Laparoscopy in HIV positive patients with acute abdomen

Advantages of DL in HIV positive patients are:

  1. Correct diagnosis achieved with least surgical trauma.
  2. Institution of timely and effective treatment
  3. Reduction of risks of transmission of virus to theatre personnelís due to small incision and less contact with patients body fluids.

Disadvantages

  1. Contamination of operating room by decompression of the pneumoperitoneum, which propels debris, peritoneal fluid and blood.
  2. Inhalation of HIV DNA as these are seen in laser plumes (this modality should be avoided).
  3. Costly due to the use of disposable instruments to avoid HIV transmission.

Role of Laparoscopy in Gynaecological Emergencies

13% of acute abdominal emergencies are of gynaecological origin series of 49 patients from Oxford 45 had successful DL + TL (therapeutic laparoscopy) 24 out of 25 had successful treatment of ectopic pregnancy by TL. 14 out of 15 patients of ovarian cysts had successful TL. Mean hospital stay was 1.9 days.

Laparoscopy is useful in the early recognition of pelvic inflammatory disease and Fitz Hughes Curtis syndrome (Perihepatitis associated with PID)

Energetic and early treatment of above condition prevents liver failure and infertility.

Role of Laparoscopy in Suspected Acute Appendicitis

Commonest abdominal emergency all round the world is acute appendicitis.

An early DL in suspected acute appendicitis reduces the risk of appendiceal perforation, improves diagnostic accuracy and reduces the number of negative laparotomies. It helps the surgeon to rule out concomitant problems but two important groups of patients where it is immensely useful is

  1. Pre menopausal women when it is difficult to rule out gynaecological conditions.
  2. Obese patients in whom large incisions may be required to remove the appendix.

Large single-center series of laparoscopic appendectomy

 

Authors

Year

Patients (n)

Negative Appendectomy Rate (%)

Complication Rate (%)

Bouillot et al [10]

1995

283

16

1.5

el Ghoneimi et al [22]

1994

1379

7

1.5

Jain et al [46]

1995

75

11

4

Nowazaradan et al [71]

1993

100

14

18

Pier et al [76]

1991

639

14

3

Pier et al [77]

1993

933

12

2

Shiffino et al [83]

1993

154

0.6

5

Vargas et al [99]

1994

201

2.5

8

The table above definitely confirms the low negative appendectomy rates and complication rates.

Indications of Laparoscopic Appendectomy are:

  1. Undiagnosed lower quadrant pain in younger females in the reproductive age.
  2. Equivocal signs, obese patients.
  3. Presence of appendicular faecolith which is related to higher incidence of acute appendicitis.
  4. Removal of normal appendix as at times patient may have endo luminal or mucosal appendicitis also it eliminates confusion of diagnosis in possible future attacks.

Absolute contraindications

  1. Ongoing radiation therapy.
  2. Immuno suppressed patients.

Relative Contraindications

  1. Previous abdominal surgery
  2. Blood disorders
  3. Severe portal hypertension
  4. Appendix abscess
  5. Pregnancy

Advantages of Laparoscopic Appendicitis

  1. Accurate localisation of appendix and any other pathology.
  2. Irrigation and drainage of the peritoneal cavity.
  3. Easier dissection of adherant bowel.
  4. Easier in obese patients.
  5. Rapid return in intestinal functions.
  6. Probable reduction in post operative adhesion.
  7. Good cosmetic effect.
  8. Shorter hospital stay, reduces wound infections lesser use of post operative analgesics.

Complications

Usual complications related to any laparoscopic procedure such as unusual vessel injury, port site hernia and as recently noted, slightly increased rate of intra abdominal sepsis (dissemination of debris by pneumoperitonium).

Specific complications is fifth day syndrome when a patient develops symptoms and signs of acute peritonitis due to spreading fascitis and not due to peritonitis, this condition is treated conservatively with antibiotics.

Laparoscopy in patients with Perforated Peptic Ulcers

Early diagnosis and treatment of perforated peptic ulcer within 6 hours of the incident can reduce mortality from 90% to about 10%. DL is much more sensitive than CT as it can determine the type of fluid along with food debris and can accurately localise the site of perforation. Perforations are closed by simple suture, omental patch, fibrinous glue, falciform ligament patch or ligamentum teres patch.

The trend is towards sutureless closure or ligamentous patches. Larger delays, beyond 6 hours, makes closure difficult and hazardous due to inflammatory changes and phlegmon.

Main disadvantage is increased operating time and recent studies have not shown to decrease length of hospital stay, resumption of normal diet, reduction of pain in the first 24 hours, or early return to normal activities. Prospective random trials are needed to clarify these factors.

Laparoscopy and Small Bowel Obstruction (SBO)

Early SBO, with minimal peritonitis, single band adhesions, without obvious gangrenous changes in the bowel can be managed by therapeutic laparoscopy.

The other criteria for selection are:

  1. Proximal obstruction.
  2. A partial obstruction.
  3. Obstruction partially responding to nasogastric suction.

Freys et al managed 58 patients with chronic SBO by adhesiolysis to relieve abdominal pain. Following TL 45% had completed remission, 35% had substantive improvement and 20% had persistent pain. It was concluded that the patients who benefited most were ones with localised pain and localised adhesions related to the area of most severe pain. Careful selection of patients is very important.

Laparoscopy and Diverticular disease

DL is very useful in diagnosing severity of diverticular disease so that management decision can be taken whether to conserve or proceed to surgery. Abscesses can be drained under direct vision. Few studies have shown that the postoperative stay and pain is much reduced following TL. Further studies are in progress and management strategies will be further clarified.

CONCLUSION

Laparoscopy has definitely reduced the rate of negative non-therapeutic laparoscopies in undiagnosed abdominal pain. Once diagnosis is established DL helps in proper therapeutic management of patients. All the common acute abdominal conditions such as acute appendicitis SBO, perforation, gynaecological conditions can be treated effectively by TL due to increase in skills of the surgeons and technological advancement.

However a few questions need to be answered, such as who should perform emergency laparoscopic procedures? What should be the selection criteria? Cost implications? Has TL a better outcome? Randomised control trials in future will answer a lot of these questions. It is important that all newer technologies should be evaluated in an unbiased manner, under strict protocol so that objective data can be obtained to devise guidelines for safe and effective use of new devises.

Finally, I would like to end this article by a very prudent saying by Sir Robert Hutchinson.

From inability to leave well alone
From too much zeal for what is new
And contempt for what is old
.From putting knowledge before wisdom
Science before art cleverness before common sense
From treating patients as cases, and
From making the cure of a disease moreGrievous than itís endurance.
Good lord, deliver us.



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