Laparoscopy In Abdominal Emergencies


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Laparoscopy In Abdominal Emergencies

  1. 1. LAPAROSCOPY IN ABDOMINAL EMERGENCIES Dr.Anil Haripriya In the last decade, the laparoscopic procedures have been used extensively in an elective setting for both diagnostic as well as therapeutic purposes. With increasing experience, the General Surgeons at many centers have felt confident enough to undertake evaluation of its role in the management algorithm of various abdominal emergencies, both traumatic as well as non-traumatic. Reasonable body of data has by now accumulated in the literature to be able to take a critical look at the reported experiences and suggest a possible role for this newly emerging diagnostic and therapeutic modality in our setting. The term "abdominal emergencies "includes cases of abdominal trauma as well as various non-traumatic cases like perforated duodenal ulcer, acute appendicitis, intestinal obstruction, acute abdominal pain of unknown etiology and abdominal problems in pregnant patients and ICU patients.
  2. 2. This paper intends to look at the role of laparoscopy in the management of all these conditions individually with a view to provide answers to the following points: · Currently practiced management algorithm and its shortcomings. · Reported experience in the literature. · The feasibility and advisability of it's use in our setup. Laparoscopy in abdominal trauma Due to a significant rise in the number of road traffic accidents and increasing violence, abdominal trauma is emerging as a major cause of abdominal emergencies. The management algorithms are different for blunt and penetrating abdominal trauma. In patients with blunt abdominal trauma, evaluation of the abdomen begins with a detailed clinical examination. Hemodynamically unstable patients and those with obvious abdominal signs are taken up for immediate exploratory laparotomy. However, there are a large number of stable patients where abdominal signs are equivocal. Often, the situation is complicated by associated alcohol or other drug intoxication and head or spinal injury, which alters the abdominal signs. Under these situations, additional tests such as diagnostic peritoneal lavage (DPL), ultrasound (US) and
  3. 3. Computerised Tomography (CT) scan of the abdomen are usually employed. In most surgical centers, DPL performed under local anaesthesia in the emergency room has been the most often used diagnostic modality for blunt abdominal trauma patients. Indications for DPL include head injury, altered mental status (injury, drugs or alcohol), an equivocal abdominal examination, unexplained hypotension or instability of the patient and if a patient with major trauma requires operation and general anaesthesia for another injury like fracture etc. Positive DPL is based on the presence of 50,000 - 100,000 RBCs/ml, WBC >500/ml or presence of bile or fecal material in the lavage fluid. The shortcoming of DPL is that it is a highly sensitive test and in patients operated on the basis of a positive DPL, 13 - 25 % have been reported to have either a negative laparotomy (NL i.e. no injury present) or a non-therapeutic laparotomy (NTL i.e. injury present but does not need treatment) 1-5 . Similarly US and CT scan have also been used in many centers in the recent past. Like DPL, although these tests can tell about the presence or absence of intra-abdominal injury, there continues to be a significant NL/NTL rate despite the use of these modalities. Also, CT scan and US have not been found to be very sensitive in detecting hollow viscus injuries.
  4. 4. Thus with the use of DPL, US and CT scan, although the pickup rate for injuries has gone up very high, there continues to be an irreducible rate of false positivity resulting in NL/NTL. Penetrating abdominal injuries due to stab and gunshot wounds are managed differently. The hemodynamically unstable patients and those with obvious physical signs need immediate exploration. For stable patients with stab injury, most of the institutions follow the policy of local wound exploration for depth of penetration and if the peritoneal breach is present, exploratory laparotomy is performed. With this policy, different series have reported NL/NTL rate of 20 - 50 % 2-4. For gunshot wounds of the abdomen, most institutions follow the policy of mandatory laparotomy, but it has been reported to result in NL/NTL rate ranging from as low as 6 % to as high as 40 % 4,6,7 .Although an NL/NTL is preferable to a missed intra-abdominal injury and delayed treatment with it's disastrous consequences, the morbidity associated with these unnecessary explorations is significant ( 5 - 22 % ) 4,8-12, apart from the pain inflicted on the patient and the cost to the health-care system. Thus it is obvious that in the management algorithm of the
  5. 5. abdominal trauma patients, there is need for a better screening modality which can not only detect injuries with a high degree of accuracy but can also differentiate between those requiring surgical treatment and those requiring only conservative treatment. Laparoscopy holds promise not only to allow this, but also offers the additional possibility of therapeutic interventions - thereby avoiding laparotomy altogether in some of those patients who otherwise merited a laparotomy. Laparoscopy can achieve this with minimal morbidity, much reduced pain to the patients and overall reduced cost to the healthcare system. The first report in the English literature about the use of diagnostic laparoscopy in the setting of abdominal trauma was published in 1976, much before the presently used miniature camera and monitor system came into use. Gazzaniga et al 13published a series of 37 trauma patients who underwent emergency diagnostic laparoscopy. NTL were avoided in 10 of 24 patients with blunt trauma. Based on the laparoscopy findings, the remaining 14 patients underwent exploratory laparotomy with only one negative laparotomy (7%). In 13 patients with penetrating injuries, 4 (30%) were spared unnecessary laparotomies, The other 9 (70%) patients underwent
  6. 6. exploratory laparotomy on the basis of suspicious laparoscopic findings. Four(44%) of these were therapeutic and 5 (56%) were nontherapeutic, This high rate of NTL in this pioneering series was possibly because the authors were near the beginning of their learning curve and all these laparoscopies were performed looking through the eye piece of the telescope i.e. without the benefit of magnification, ease of operation and "team involvement" that the currently used camera - monitor system offers. Berci et al (1991)14 reported their retrospective experience with 150 emergency laparoscopies in blunt abdominal trauma patients, performed in the emergency room under local anaesthesia. Based on the laparoscopic findings ,they decided for immediate laparotomy(19%),simple observation(25%) or early discharge (56 %) of these patients..There was only one failure-a patient considered suitable for conservative management on diagnostic laparoscopy(DL)needed a laparotomy.The authors concluded that DL for trauma patients is highly sensitive ,decreases the NTL rate and is safe. Fabian et al( 1993)15 reported a prospective analysis of 182
  7. 7. diagnostic laparoscopies for blunt as well as penetrating abdominal trauma in hemodynamically stable patients with equivocal abdominal signs. There were 99(55%) patients with abdominal stab wounds,66(36%) patients with gunshot wounds and 17 (9%) patients with blunt abdominal trauma. NL/NTL could be avoided in a significant number of patients in all three groups on the basis of laparoscopic findings. The authors concluded that laparoscopy is a safe diagnostic modality for abdominal trauma patients. It is most effective in evaluating patients with equivocal signs after penetrating injuries and offers significant cost savings, especially if performed under local anaesthesia. Salvino et al( 1993 )16 reported on a prospective analysis of 75 patients of blunt as well as penetrating injuries and compared the value of diagnostic peritoneal lavage and diagnostic laparoscopy(DL). They concluded that although DL had no advantage over DPL as a primary assesment tool in the blunt abdominal trauma patients, it's main advantage was in patients with penetrating injuries. Townsend et al (1993)17 studied the efficacy of DL in 15 patients with solid organ injuries documented by CT scans. The DL identified 6
  8. 8. patients who needed urgent laparotomies, 2 with hollow viscus injuries and 4 with continuing haemorrhage. One patient could not undergo complete laparoscopic examination and underwent laparotomy, which was negative. The remaining 8 patients were successfully treated with conservative management on the basis of their laparoscopic findings. The authors concluded that DL allowed for successful nonsurgical management in 100% of their patients and also identified patients in need of urgent laparotomy. ` Ivatury et al (1993)18 performed DL in 100 hemodynamically stable patients with penetrating abdominal injuries and compared them with 407 laparotomies without laparoscopy.The authors concluded that DL helped exclude peritoneal violation, thereby avoiding unnecessary laparotomies. It was specially accurate in detecting haemoperitoneum ,solid organ injuries, diaphragmatic lacerations and retroperitoneal haematomas. The authors remarked that DL has a definite role in the evaluation of penetrating abdominal trauma patients. Sosa et al (1995)10,19 reported their experience with DL in 121 consecutive haemodynamically stable patients with abdominal gunshot wounds. By the conventionally used policy of "mandatory
  9. 9. laparotomy in gunshot wounds"- all patients would have undergone exploratory laparotomy. Instead , all patients underwent DL and 82(68%) were spared unnecessary laparotomies on the basis of laparoscopic findings. The remaining 39(32%) patients underwent exploratory laparotomies,one of which was negative and 3 were nontherapeutic. The authors concluded that DL is extremely useful in patients with gunshot wounds , results in the lowest NL and NTL rate and identifies patients needing urgent laparotomies. Zantut et al (1997)20 reported a retrospective analysis of 510 haemodynamically stable patients of penetrating abdominal injuries (316 stab wounds,194 gun shot wounds) from three large urban trauma centers in Brazil. Laparotomy was avoided in 277 of these patients(54.3%) either because of nonpenetration of peritoneum or insignificant findings on laparoscopy.All were discharged uneventfully after a mean hospital stay of 1.7 days.26 patients had successful therapeutic procedures on laparoscopy ( diaphragmatic repair in 16 patients,cholecystectomy in 1,hepatic repair in 6 and closure of gastrotomy in 3 patients) with uneventful recovery. In the remaining 203 patients, laparotomy was therapeutic in 155.Fifty two patients had NTL for exclusion of bowel injuries or as a mandatory laparotomy for
  10. 10. penetrating gunshot wounds(19.7%). The overall incidence of NTL was 10.2% . Complications were minimal and minor.The authors concluded that DL has an important diagnostic role in stable patients with penetrating abdominal trauma. In carefully selected patients, therapeutic laparoscopy is practical, feasible and offers all the advantages of minimally invasive surgery. Hallfeldt et al (1998)21 have reported on DL in abdominal stab wounds and concluded that DL offers an important diagnostic tool in excluding peritoneal penetration, lowering the rate of unnecessary laparotomies, with therapeutic laparscopy also being possible in selected cases. Marks et al (1997)22 performed cost effectiveness analysis of DL Vs laparotomy in the evaluation of penetrating abdominal trauma and concluded that total cost and length of stay were significantly lower in patients who underwent DL as compared to laparotomy. Numerous other reports 16,23-27 have also suggested that DL is an important modality in evaluating trauma patients with suspected abdominal injuries. These studies confirm that DL for trauma patients is a safe modality that has the potential to decrease both NL as well
  11. 11. as NTL. It's greatest value is in patients with uncertain diagnosis even after other diagnostic tests like DPL, US, and CT scan. There have been suggestions that it may in fact be used as a primary diagnostic tool, bypassing these conventional modalities 7. Although doubts have been raised about the accuracy of DL in detecting hollow viscus injuries, retroperitoneal injuries such as to the pancreas and evaluation of spleen, others have suggested that with the use of angled lenses, proper patient positioning and appropiate manipulation of the operating table, an experienced laparoscopic surgeon can appraise both the spleen and the bowel without difficulty 7 . However, it must be re-emphasised that laparoscopy should not be performed in hemodynamically unstable patients and in those where the diagnosis of a significant intra-abdominal injury requiring exploratory laparotomy is obvious. Laparoscpy for non traumatic abdominal emergencies Acute appendicitis Acute appendicitis is a common condition. Low threshold for surgery based on clinical suspicion alone results in a significant
  12. 12. negative laparotomy rate especially in young women. On the other hand delayed operation may result in perforation peritonitis with serious consequences. DL in patients with suspected acute appendicitis not only decreases the risk of appendicular perforations but also reduces the number of negative laparotomies. It provides us a tool not only to confirm or rule out appendicitis, but also offers the possibility of inspecting other organs simultaneously to determine the real cause of patient's symptoms 7. The two important group of patients with suspected acute appendicitis who benefit most from DL are the premenopausal women (in whom the differential diagnosis with gynecological conditions is often difficult )and obese individual ,in whom a large laparotomy incision is required to perform conventional appendicectomy or to allow thorough inspection of the abdominal contents 28. At laparoscopy, if the diagnosis of acute appendicitis is confirmed, DL can be converted to therapuetic laparoscopy. The indications for laparoscopic appendectomy 7,28-29 for patients undergoing DL are (a)acute appendicitis confirmed, (b) large appendicolith, (c) recurring condition such as crohn's disease or endometriosis, (d) a normal examination as it may represent very early appendicitis which is not grossly visible. Also ,it eliminates future
  13. 13. confusion should the similar pain recur in the patient. Ongoing radiotherapy and an immunosuppresed patients are absolute contraindication for laparoscopic appendectomy 7, whereas relative contraindications include previous abdominal surgery, coagulopathy, portal hypertension, appendicular abcess and pregnancy 7. In patients with appendicular abcess, DL should be avoided as pneumoperitoneum may disrupt the abcess cavity resulting in contamination of the peritoneal cavity and septicemia. Patients with acute appendicitis who have been managed conservatively, may be considered candidates for laparoscopic interval appendectomy usually after 6 weeks. Thus it is clear that laparoscopy is safe and effective procedure for establishing the diagnosis of acute appendicitis as well as removal of the appendix. The best indication for DL in patients with suspected appendicitis are premenopausal women (where the rate of negative laparotomies is quite high) and very obese patients in whom a laparotomy will require a relatively large incision. Perforated duodenal ulcer Patients with perforated duodenal ulcer require early recognition
  14. 14. and prompt treatment. It has a reported mortality of 0-10%. With delay in treatment ,the mortality may go up to as high as 90% 7. A number of reports in the literature 30-34 have shown the feasibility of diagnosing and treating acutely perforated duodenal ulcers by laparoscopy. DL can determine the type of fluid present in the peritoneal cavity and can accurately locate the site of perforation in the majority of cases. Following confirmation of diagnosis by DL, therapeutic maneuver i.e. closure of the ulcer perforation can also be performed, if the surgeon has advanced laparoscopic suturing and knotting skills. In one of the earliest reports on laparoscopic management of perforated duodenal ulcer, Memon and Brow32 showed that this procedure is technically feasible if performed within 6 hours of perforation. However, in cases with significant delay in diagnosis, laparoscopic repair may be difficult and hazardous because of the edematous and friable duodenal wall 7,35,36 . Laparoscopic repair of a perforated duodenal ulcer can be achieved by simple closure 32, omental patch, use of fibrin glue 34, placement of oxidised cellulose sponge 37, falciform ligament patch 38 or ligamentum teres patch39 . Most of the reports are in the form of small, isolated case reports. Four recent papers 30,31,33,40 have
  15. 15. compared laparotomy and laparoscopy for treatment of perforated duodenal ulcer. These studies have shown no benefits of laparoscopy in terms of the length of hospital stay, time to resume normal diet, visual analog pain score in the first 24 hours or early return to normal activity, although the analgesic requirement in the postoperative period was less in the laparoscopy group. Additionally the operating time in the laparoscopy group was much longer. Others 7 ,however have reported favorable experience especially in selected patients. Thus it is obvious from the currently available literature that DL can provide an accurate diagnosis in patients with perforated peptic ulcer and can be used safely for the treatment as well in early cases. However, till date none of the reports has shown any clearly documented benefit of this procedure over conventional laparotomy. Small bowel obstruction Development of gangrene is one of the most feared complications of small bowel obstruction (SBO). Patients with complete SBO are at a much higher risk of developing this complication, and need prompt surgical treatment whereas those with a partial obstruction may resolve with conservative treatment. DL can
  16. 16. be helpful in distinguishing complete from a partial SBO 7. However, during DL in SBO ,great care needs to be exercised to avoid injury to the bowel during initial port placement as well as during manipulation of the bowel. For initial port placement, open technique is recommended and only atraumatic instruments should be used for bowel handling. At DL , if we find single adhesive band, it is safe to divide it laparoscopically to complete the procedure. However, in case multiple or broad based adhesions involving multiple bowel loops are discovered, laparoscopic adhesiolysis is technically demanding and dangerous and it is safer to open the abdomen 7. Duh 41 identified certain subset of patients of SBO who are likely to benefit from laparoscopic management. These are patients with mild abdominal distension allowing adequate room for visualization, proximal obstruction, partial obstruction, single band obstruction and obstruction which readily improves with nasogastric suction. Patients with advanced, complete and /or distal obstruction are not candidates for laparoscopic treatment. Patients with large bowel obstruction, matted adhesions, carcinomatosis and those who do not respond to conservative management (i.e. nasogastric suction) are also not candidates for DL and should be managed by laparotomy. Several
  17. 17. authors 42-44 in the recent past have reported successful outcome using DL in the "selected" patients as mentioned above. It has been pointed out repeatedly that "careful patient selection" is the key to successful outcome with DL in SBO patients 7,44. Thus from the currently available data it is obvious that DL may have a role in establishing an early diagnosis for patients with SBO. In a selected subset of patients, laparoscopic adhesiolysis is also possible. It has been suggested that in such patients, the long term effects of successful adhesiolysis on the reformation of adhesions will be favorable as compared to the laparotomy 7. However, long term follow-up studies on larger number of patients are needed to justify this statement. pregnant patients with abdominal pain Use of DL for evaluation of pregnant patients with acute abdominal pain is an area of intense controversy. Whereas increasing number of reports in the literature have attested to the safety of DL in pregnancy if the pressure is kept low 28,45,46, others 47 have reported increased incidence of fetal death in these patients as compared to laparotomy. With the present state of knowledge ,it is prudent to
  18. 18. consider pregnancy a relative contraindication to DL until enough clinical and laboratory data are available which indicate unequivocally that no risk to the foetus exists 48. ICU patients with abdominal pain Intensive care unit patients are at an increased risk of developing a number of acute intra-abdominal pathologies such as cholecystitis, duodenal or gastric perforation, intestinal ischaemia, pancreatitis, bowel obstruction and intra-abdominal haemorrhage. Presence of multi-organ patholgy, equivocal abdominal signs and difficulty in shifting these sick patients for conventional diagnostic modalities like CT scan make accurate diagnosis difficult in these patients. In some patients this delay in diagnosis may lead to either a delay in the institution of appropriate surgical care or an unwarranted, non- therapeutic laparotomy. This has prompted surgeons to evaluate the role of DL in these critically ill patients. Several authors 49-51 have reported their experience in the recent past in accurately diagnosing the intra-abdominal pathology requiring surgical care, at the same time excluding those who did not require surgical intervention. The advantages of DL in these ICU patients include avoiding
  19. 19. transportation of the critically ill, often ventilator dependant patients(as DL can be performed at the bedside in the ICU), rapid establishment of correct diagnosis and avoidance of unnecessary ancillary tests. However it is an invasive test that carries a small but definite morbidity and has low sensitivity for intestinal or retroperitoneal diseases. Nonetheless, DL is emerging as an important development in the management of abdominal problems in critically ill ICU patients and may become the first investigation of choice in future. Suggestions From above discussion it is obvious that in the last 10 years the role of DL has been evaluated in the management of all types of abdominal emergencies.Whereas the "feasibility "of performing it safely and getting meaningful information has been proved beyond doubt in most of the situations, the "advisability" (i.e. advantage over conventional laparotomy) remains to be proved beyond doubt for most of the causes of abdominal emergencies.This issue can only be settled satisfactorily by well designed randomized trials recruiting enough number of patients and by long term follow-up studies of these patients.However, as per the currently available literature,
  20. 20. following guidelines can be followed: Which patients should have DL ? Only those patients with abdominal emergencies ( traumatic as well as non-traumatic )who are hemodynamically stable and where the diagnosis is still in doubt after a detailed clinical examination and conventional investigations, should have DL.Hemodynamically unstable patients and patients where a diagnosis requiring surgical treatment is obvious, should not be taken up for DL. Although some authors have suggested DL as the first investigation after clinical examination i.e. in place of conventional investigations like DPL,US and CT scan, under the present state of knowledge, I would recommend it only as a part of a clinical trial and NOT for every patient. These principles apply to all the causes of abdominal emergencies discussed in the previous sections. Who should perform DL for abdominal emergencies ? It is obvious that DL in patients with abdominal emergencies is technically very demanding and needs high degree of laparoscopic skills on the part of the Surgeon to give the required , accurate
  21. 21. information.Therefore , it should only be performed by Surgeons who have sufficient experience in elective laparoscopy for diagnostic as well as therapeutic purposes.Any Surgeon who is in the learning curve of his laparoscopy career should not attempt DL in abdominal emergencies. Availability of laparoscopic suturing and knotting skills is "desirable " as it will make therapeutic maneuvers possible in some of the patients, avoiding laparotomy altogether. This will obviously make laparoscopy more cost effective . DL in abdominal emergencies should only be undertaken at centers where the equipment and the instruments are available round the clock and 'preferably' two surgeons with experience in laparoscopy are available whenever a patient is taken up for emergency DL.Needless to say that the 'Surgeon 'and the 'Center ' MUST be experienced and geared to handle any 'emergency' that may arise during the performance of DL in abdominal emergency cases. Summary Application of laparoscopy in the management of patients with abdominal emergencies is an exciting , new development of this
  22. 22. decade which has opened tremendous possibilities for the future. However, with the present state of knowledge, this new tool needs to be used selectively: * Only in patients who stand to benefit most from it as mentioned in the previous sections, * Only by the Surgeons who are well experienced in laparoscopic surgery, and * Only at the centers which have the requisite infra-structure. It is also important that the data be recorded in an objective and unbiased manner and reported accurately so that meaningful conclusions could be drawn and definite guidelines could be laid down for its more widespread use in the future.