Urgent Early Laparoscopic Reassessment
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Urgent Early Laparoscopic Reassessment

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Urgent Early Laparoscopic Reassessment Presentation Transcript

  • 1. Urgent Early Laparoscopic Reassessment George Ferzli MD, FACS Professor of Surgery SUNY Downstate
  • 2. Introduction
    • Urgent laparoscopy has two roles :
    • 1)Diagnosis
    • 2) Definitive therapy
  • 3. Acute Abdomen Diagnostic and Therapeutic Laparoscopy 17.5% 94.4% 98% 121 Salky B, 1998 20% 70% 65 Cuesta MA, 1998 12.1% 87.9% 100% 107 Cueto F, 1997 23% 73% 93% 255 Navez B, 1995 3.3% 96.7% 100% 61 Siragusa G, 1999 13% 87% 100% 200 Henry C, 1998 6.8% 88.2% 95.3% 365 Agresta F, 2000 Conversion to Laparotomy Laparoscopic treatment Definitive diagnosis Patients (n) Authors
  • 4. Laparoscopy for Acute Abdomen in Early Postoperative Period Abdominal pain, sepsis. Fibrinous exudate (2), unknown (2) 1 - 7 4 Pecoraro A, Ferzli G et al. 2001 Pain (11), bleeding (2). Acute pancreatitis, SB injury, subhepatic hematoma, minor bile leak (6), unknown (2) 1 – 7 13 Simon P et al. 2000 Fever, elevated WBC, peritoneal signs. Tube misplacement or malfunction 1 – 14 3 Bauer F et al. 1998 Indication / Diagnosis Timing (POD #) No. of Patients (n) Author, Year
  • 5. Indications for Early Laparoscopy
    • Sepsis/Peritonitis from perforated viscus, bile leakage, or leaking anastomosis
    • Obstruction from adhesions, technical error or intussusception
    • Bleeding from splenic trauma during colon resection, liver bed or cystic artery s/p lap chole
    • Failure of primary procedure, such as acute herniation s/p lap Nissen causing dysphagia or Lap-band slippage
  • 6. Perforated Peptic Ulcer Techniques
    • Simple closure
    • Memon MA et al, Br. Med. J. 86:106-107, 1993
    • Omental patch
    • So JB et al, Surg Endosc, 10:1060-63, 1996
    • Fibrin glue
    • Mouret P et al, Br J Surg, 77:1006,1990
    • Placement of oxidized cellulose gauze
    • Tate JJT et al, Br J Surg, 80:35, 1993
    • Falciform ligament patch
    • Munro WS et al, Ann R Coll Surg, 78:390-1, 1996
    • Ligamentum teres patch
    • Castalab G et al, Surg Endosc, 6:677-9, 1995
  • 7. Perforated Duodenal Ulcer Laparoscopic vs. Open Repair
    • Decreased perioperative analgesic requirements in laparoscopic group
    • No benefit in length of hospital stay, time to resume normal diet or return to normal activity
    • Increased operative time and cost
    Miserey M et al, Surg Endosc. 10:831-6, 1996 So JB et al, Surg Endosc. 10:1060-63, 1996 Lau WY et al, Ann Surg. 224: 131-38 Lau WY et al, Br J Surg. 82:814-6
  • 8. Sepsis/Peritonitis
    • Anastomotic leak
  • 9. Sepsis/Peritonitis
    • Perforated G-tube
  • 10. Indications for Early Laparoscopy
    • Sepsis/Peritonitis from perforated viscus, bile leakage, or leaking anastomosis
    • Obstruction from adhesions, technical error or intussusception
    • Bleeding from splenic trauma during colon resection, liver bed or cystic artery s/p lap chole
    • Failure of primary procedure, such as acute herniation s/p lap Nissen causing dysphagia or Lap-band slippage
  • 11. Small Bowel Obstruction Diagnostic and Therapeutic Laparoscopy 1 (1.5%) 30 (46%) 35 (54%) 65 139 Bailey IS, 1998 0 (0%) 6 (32%) 13 (68%) 19 19 Al-Mulhim A, 2000 3 (7.5%) 26 (65%) 14 (35%) 40 40 Leon EL, 1998 4 (8%) 36 (43%) 47 (57%) 83 83 Suter M, 2000 1 (1.5%) 11 (17.4%) 52 (82%) 63 136 Agresta F, 2000 4 (10%) 13 (32%) 24 (60%) 40 40 Strickland P, 1999 6 (9%) 31 (46%) 31 (46%) 68 150 Navez B, 1998 Iatrogenic bowel injury Converted to laparotomy Laparoscopic treatment Diagnostic laparoscopy Total # Author
  • 12. Obstruction
    • Duplicated small bowel
  • 13. Obstruction
    • Intussusception
  • 14. Indications for Early Laparoscopy
    • Sepsis/Peritonitis from perforated viscus, bile leakage, or leaking anastomosis
    • Obstruction from adhesions, technical error or intussusception
    • Bleeding from splenic trauma during colon resection, liver bed or cystic artery s/p lap chole
    • Failure of primary procedure, such as acute herniation s/p lap Nissen causing dysphagia or Lap-band slippage
  • 15. Abdominal Trauma Diagnostic Laparoscopy (DL) Prospective study. Penetrating trauma only. 7 missed injuries in 54 pts. who had laparotomy based on DL. 20 (37) 57 (57) 43 (43) 100 Ivatury et al, 1993 Retrospective study. DL using eyepiece (no camera and monitor) 6 (26) 23 (62) 14 (38) 37 Gazzaniga et al, 1976 Prospective study. Blunt and penetrating trauma. High cost. 26 (30) 85 (47) 97 (53) 182 Fabian et al, 1993 Prospective study. 10 blunt and 11 penetrating traumas. Hard to see splenic, mesenteric and retroperitoneal injuries 9 (43) 18 (86) 3 (14) 21 Brandt et al, 1994 Retrospective study. Blunt trauma only. 25% had min to mod hemo- peritoneum, Rx close observation 0 66 (44) 84 (56) 150 Berci et al, 1991 Comments Unnecessary lap. n (%) Pos. DL, n (%) Neg. DL, n (%) # of patients Authors / year
  • 16. Abdominal Trauma Diagnostic Laparoscopy (DL) Prospective study. CT prior to DL. 0 15 (100) 0 15 Townsend et al, 1993 Prospective study for abdominal GSW. Very sensitive and specific. Reduces unnecessary laparotomy, morbidity and hospital stay 7 (18) 42 (35) 79 (65) 121 Sosa et al, 1995 Prospective study. DL vs. DPL. Blunt and penetrating trauma. DL improved care in 8% cases. No better than DPL in blunt trauma. 2 (20) 33 (44) 42 (56) 75 Salvino et al, 1993 Prospective study. 19% significant injuries missed on DL 11 (34) 21 (66) 11 (34) 32 Rossi et al, 1993 Prospective study. Blunt and penetrating trauma. Difficulty in running bowel, seeing spleen and evacuating hematomas. 4 (13) 32 (82) 7 (18) 39 Livingston et al, 1992 Comments Unnecessary lap. n (%) Pos. DL, n (%) Neg. DL, n (%) # of patients Authors / year
  • 17. Bleeding
    • Iatrogenic splenic injury
  • 18. Indications for Early Laparoscopy
    • Sepsis/Peritonitis from perforated viscus, bile leakage, or leaking anastomosis
    • Obstruction from adhesions, technical error or intussusception
    • Bleeding from splenic trauma during colon resection, liver bed or cystic artery s/p lap chole
    • Failure of primary procedure, such as acute herniation s/p lap Nissen causing dysphagia or Lap-band slippage
  • 19. Failure of Primary Procedure
    • Reoperation for Gastrojej obstruction s/p Gastric Bypass
  • 20. Failure of Primary Procedure
    • Distal pancreatectomy after cystjejunostomy
  • 21. Contraindications to Reoperative Laparoscopy
    • Inability to tolerate general anesthesia
    • Uncorrectable coagulapathy
    • Conditions better approached via another body cavity (thoracic approach for esophageal procedure)
    • Frozen abdomen
    • Many prior laparoscopic failures
    • Medico-legal
  • 22. Bedside Laparoscopy performed under local anesthesia
    • 12 bedside laparoscopies were performed in 11 patients over one year in ICU of one hospital
    • Indications for diagnostic laparoscopy were to evaluate intraabdominal processes that may be responsible for the patient’s condition
    • 6 laparoscopies corrected the radiographic diagnosis thus avoiding 6 nontherapeutic laparotomies
    • One laparoscopy was both diagnostic and therapeutic
    • - loop ileostomy was created in a patient with urosepsis secondary to a colovesical fistula
    • Pecoraro et al. Surg Endo. 2001: 15; 638-641
  • 23. Contraindications to Reoperative Laparoscopy
    • Inability to tolerate general anesthesia
    • Uncorrectable coagulapathy
    • Conditions better approached via another body cavity (thoracic approach for esophageal procedure)
    • Frozen abdomen
    • Many prior laparoscopic failures
    • Medico-legal
  • 24. Medico-legal
    • CBD injury
  • 25. Conclusion
    • Urgent early laparoscopy is feasible
    • It has two roles: (1) diagnosis and (2) therapy
  • 26. Conclusion
    • Urgent early laparoscopy must be performed by an experienced laparoscopist
    • Be prepared for conversion to an open procedure
    • Have a low threshold for conversion