The laparoscopic approach in abdominal emergencies: has the attitude changed?

Background Laparoscopy has been practiced more and more in the management of abdominal emergencies. The aim of the present work was to illustrate retrospectively the results of a case-control 5-year experience of laparoscopic versus open surgery for abdominal emergencies carried out at our institution, especially with regard to whether our attitude toward use of this procedure has changed as compared with the beginning of our laparoscopic emergency experience (1991–2002). Materials and Methods From January 2002 to January 2007 a total of 670 patients underwent emergent and/or urgent laparoscopy (small bowel obstruction, 17; gastroduodenal ulcer disease, 16; biliary disease, 118; pelvic disease and non-specific abdominal pain (NSAP), 512; colonic perforations, 7) at the hands of a surgical team trained in laparoscopy Results The conversion rate was 0.15%. Major complications ranged as high as 1.9% with no postoperative mortality. A definitive diagnosis was accomplished in 98.3% of the cases, and all such patients were treated successfully by laparoscopy. Conclusions We believe that laparoscopy is not an alternative to physical examination/good clinical judgment or to conventional noninvasive diagnostic methods in treating the patient with symptoms of an acute abdomen. However it must be considered an effective option in treating patients in whom these methods fail and as a challenging alternative to open surgery in the management algorithm for abdominal emergencies.     

Emergency laparoscopyrid=""

BACKGROUND: By now, laparoscopic surgery has achieved widespread acceptance among surgeons and, generally speaking, by the public. Therefore, we set out to evaluate whether this technique is a feasible method of treating patients with abdominal emergencies, traumatic or not. To assess the routine use of emergency laparoscopy in a community hospital setting, we undertook a retrospective analysis of an unrandomized experience (presence or absence of a surgeon with laparoscopic experience). METHODS: Between January 1993 and October 1998, 575 emergency abdominal surgical procedures were done in our department. In all, 365 (63.4%) were diagnostic and operative laparoscopy procedures (acute small bowel obstruction: 23 cases; hernia disease: one case; gastroduodenal ulcer disease: 15 cases; biliary system disease: 89 cases; pelvic disease: 237 cases). These cases represent almost 56% of all laparoscopic procedures done during the same period at our institution. Laparoscopy was not performed in patients with a history of a previous abdominal approach to malignant disease, a history of more than two major abdominal surgeries, or massive bowel distension; nor was it used in patients whose general conditions contraindicate this approach. RESULTS: The conversion rate was 6.8%. The morbidity and mortality rates were, respectively, 4.1% and 0.8%. A definitive diagnosis was provided in 95.3% of cases, with the possibility to treat 88.2% of them by laparoscopy. CONCLUSIONS: We consider the laparoscopic approach in patients with abdominal emergencies to be feasible and safe in experienced hands. It provides diagnostic accuracy as well as therapeutic capabilities. Sparing patients laparotomy reduces postoperative pain, improves recovery of GI function, reduces hospitalization, cuts health care costs, and improves cosmetic results. This approach promises to play a significant role in emergency abdominal situations and will certainly become increasingly important in today's health care environment.     

Laparoscopic management of surgical complications after a recent laparotomy

Background The use of laparoscopy in the scarred abdomen is now well established. However, recent laparotomy and the presence of a fresh abdominal wound usually preclude laparoscopic intervention. Thus, early postlaparotomy complications, which mandate surgical interventions, are usually treated by a second laparotomy. We report our experience with the use of laparoscopy for the treatment of postoperative complications, after open abdominal procedures.Methods Fourteen patients were operated for a variety of conditions, and postoperative complications, such as bowel obstruction, intraabdominal infection, or anastomotic insufficiency, were handled laparoscopically.Results Eleven patients recovered from the acute condition. One patient died from sepsis, one retroperitoneal abscess was missed and later drained percutaneously, and one conversion to open surgery was necessary because of adhesions and lack of working space.Conclusions We conclude that a recent laparotomy is not a contraindication for laparoscopic management of acute abdominal conditions. Postlaparotomy complications can be successfully treated by laparoscopy. Avoiding the reopening of the abdominal wound and a second laparotomy may reduce the additional surgical trauma, and thus result in easier recovery.     

Is laparoscopic surgery applicable to complicated colonic diverticular disease?

Background: Expanding upon our experience with laparoscopic surgery for colonic benign and malignant processes and for bowel obstruction, we have reviewed our experience with minimal access laparoscopic surgery for complicated diverticular disease. We propose an approach of surgical care incorporating diagnostic laparoscopy in those not responding to medical therapy alone. Methods: Our study includes data from two different surgical teams working in separate hospital-and-patient environments. Our theory that laparoscopy could be widely applicable to this complex disease process is borne out by experience in both locations. One hundred forty-eight patients were managed by laparoscopic or laparoscopically assisted methods with 18 patients requiring drainage only without resection. Results: Our management of 148 of 164 patients (90%) by laparoscopic approach was successful, with a very acceptable morbidity of 5% in the elective cases and decreased ileus (20% of open vs 7% laparoscopic) in acute complicated cases. Elective resections required hospitalization of 4–5 days, demonstrating the benefits of incorporating laparoscopy in the care of these cases, particularly when compared to standard open procedures requiring 8 days' hospitalization. Conclusions: We believe complications of diverticular disease including abscess, perforation, fistula, and bleeding can potentially be managed in this way by minimal access procedures, decreasing postoperative wound problems, decreasing length of hospitalization and overall morbidity, and improving patient care.     

The direct trocar technique: an alternative approach to abdominal entry for laparoscopy.

OBJECTIVE: The direct trocar technique is an alternative to Veress needle insertion and open laparoscopy for accessing the abdominal cavity for operative laparoscopy. We review our approach to abdominal entry in 1385 laparoscopies performed between September 1993 and June 2000 by our group at Stanford University Hospital, a tertiary Medical Center. METHODS: We performed a retrospective chart review of 1385 patients who underwent operative laparoscopy during the study years. The mode of abdominal entry, patient demographics, and complications were reviewed. RESULTS: The transumbilical direct trocar entry method was used in 1223 patients. In 133 patients, the Veress needle insertion technique was used. Open laparoscopy was used in 22 patients. Three (0.21%) major complicadons occurred: 1 enterotomy, 1 omental herniation, and 1 bowel hemiation. One complication was related to primary access (0.072%) in a patient who had an open laparoscopy. She sustained an enterotomy during placement of the primary trocar. The bowel was repaired laparoscopically. No trocar-related injuries occurred among the 1223 patients in whom the direct trocar entry technique was used. One patient had an omental herniation and required a repeat laparoscopy on postoperative day 2. The second patient had a repeat laparoscopy on the 12th postoperative day to repair a bowel herniation. None of our patients required a laparotomy. No vascular injuries occurred. CONCLUSION: Based on our experience, the direct trocar technique is a safe approach to abdominal entry for laparoscopic surgery.     

The rationale of laparoscopic treatment in acute appendiceal disease

Notwithstanding its widely perceived advantages, laparoscopic appendectomy has not yet met with universal acceptance. The aim of the present work was to illustrate retrospectively the results of a case-control study of laparoscopic vs open appendectomy carried out at our institution. From Jan. 1993 to Dec. 1999 a total of 457 patients (M:F = 210:247; mean age 25.2 +/- 15 years) underwent emergency and/or urgent appendectomy. Among them, 254 (55.5%) were operated on laparoscopically, while 203 (44.5%) were treated by conventional surgery The choice of technique depended upon the availability or otherwise of a team expert in minimally invasive surgery. The laparoscopic technique conversion rate was 3.9% and was mainly due to the presence of dense intraabdominal adhesions. The major intraoperative complication rates were 0.39% and 0% in the laparoscopic and laparotomy groups, respectively (P = ns). Major postoperative complications occurred in 2 and 1%, respectively (P = ns). The postoperative mortality rates were 0.4% and 0.5% in the laparoscopy and laparotomy groups, respectively (P = ns). The reoperation rate was 1.1% in the laparoscopic group as against 0% in the open surgery group (P = ns). Minor postoperative complications were observed in 0.8% and 7.5% of patients in the laparoscopy and open surgery groups, respectively (P = 0.001) and consisted mainly of wound infections. Resumption of bowel function was significantly more rapid and the hospital stay significantly shorter in the laparoscopically treated patients. The greater diagnostic accuracy of laparoscopy allowed concurrent diseases to be diagnosed in 9% of laparoscopically treated patients with histologically proven appendicitis as against 1.5% of those treated by conventional surgery (P = 0.001). Similarly, among those patients with no evidence of gross and/or microscopic appendicitis, concurrent diseases were detected in 58.4% of the laparoscopic cases as against only 6% of the laparotomy cases (P = 0.0001). Despite the limitations of a retrospective investigation, on the basis of our experience we believe that laparoscopic appendectomy is as safe and effective as conventional surgery, presents a higher degree of diagnostic accuracy and makes for less trauma and a more rapid postoperative recovery. Such features make its use mandatory in female patients of child-bearing age referred for urgent abdominal and/or pelvic surgery.     

Peritonitis: laparoscopic approach

Background  

Laparoscopy has became as the preferred surgical approach to a number of different diseases because it allows a correct diagnosis and treatment at the same time. In abdominal emergencies, both components of treatment – exploration to identify the causative pathology and performance of an appropriate operation – can often be accomplished via laparoscopy. There is still a debate of peritonitis as a contraindication to this kind of approach. Aim of the present work is to illustrate retrospectively the results of a case-control experience of laparoscopic vs. open surgery for abdominal peritonitis emergencies carried out at our institution.     

Laparoscopic augmentation cystoplasty. Surgical technique

Laparoscopic enterocystoplasty is technically feasible and successfully emulates the established principles of open enterocystoplasty while minimizing operative morbidity. As is true in open surgery, various bowel segments can be fashioned and anastomosed to the bladder laparoscopically. The increased costs associated with laparoscopy and with minimally invasive surgery in general have been a significant disadvantage; however, a previous report on the costs of laparoscopic procedures concluded that increased surgical experience reduces the surgical time and length of hospital stay, thereby decreasing costs. Furthermore, the increased use of reusable instruments results in considerable economic benefits. Implementation of appropriate cost-saving strategies ultimately will result in decreased expenses associated with laparoscopy. Although laparoscopic enterocystoplasty is currently a lengthy procedure lasting twice as long as open surgery, further technical modifications and increasing experience will continue to reduce the surgical time involved. For patients with complex comorbid illness who desire the improved quality of life associated with traditional augmentation cystoplasty, the reduced morbidity observed in the authors' series of patients undergoing a laparoscopic procedure makes this approach an attractive option to consider. The authors' initial experience suggests that laparoscopic enterocystoplasty has the potential to become a viable alternative to open enterocystoplasty.     

Re-laparoscopy in the diagnosis and treatment of postoperative complications following laparoscopic colorectal surgery

BackgroundLaparoscopic colorectal surgery has increasingly become the standard of care in the management of both benign and malignant colorectal disease. We herein describe our experience with laparoscopy in the management of complications following laparoscopic colorectal surgery.MethodsBetween November 2010 and July 2012, data were prospectively collected for all patients requiring surgical intervention for colorectal cancer. This was performed by a full-time colorectal cancer data manager.ResultsA total of 203 patients had surgery for colorectal cancer during this period, 154 (75.9%) of which were performed laparoscopically and 49 (24.1%) performed by open surgery. Ten patients (4.9%) underwent surgery for complications of which 7 were following laparoscopic surgery. Two of these 7 patients had an exploratory laparotomy due to abdominal distension and haemodynamic instability. Laparoscopic surgical intervention was successful in diagnosing and treating the remaining 5 patients. Three of these patients developed small bowel obstruction which was managed by re-laparoscopy while in 2 patients there was a significant suspicion of an anastomotic leakage despite appropriate diagnostic imaging which was out ruled at laparoscopy.ConclusionsLaparoscopy can frequently be used to diagnose and treat complications following laparoscopic colorectal surgery. This is another benefit associated with laparoscopic colorectal surgery which is rarely described and allows the benefits associated with the laparoscopic approach to be maintained.     

Laparoscopic appendectomy: why it should be done.

OBJECTIVE: Notwithstanding its widely perceived advantages, laparoscopic appendectomy has not yet met with universal acceptance. The aim of the present work is to illustrate retrospectively the results of a case-control experience with laparoscopic versus open appendectomy carried out at our institution. METHODS: Between January 1993 and November 2000, 555 patients (M:F = 210:345; mean age 25.2 +/- 15 years) underwent emergency or urgent appendectomy, or both. Of them, 322 (52%) were operated on laparoscopically, and 233 (48%) were treated via conventional surgery, according to the presence of a well-trained surgical team. RESULTS: The laparoscopic group conversion rate was 3.1% (10/322) and was mainly due to the presence of dense intraabdominal adhesions. Major intraoperative complications ranged as high as 0.3% (1/322) and 0%, respectively, in the laparoscopic and conventional groups (P=ns). Major postoperative complications were 1.6% (5/312) vs 0.8% (2/243), respectively (P=ns). Postoperative mortality was 0.3% (1/312) and 0.4% (1/243) in the laparoscopic and conventional subsets of patients. Reinterventions were 0.9% (3/322) in the laparoscopic patients versus nil in the open group (P=ns). Minor postoperative complications were observed in 0.6% (2/312) and 6.5% (16/243) of patients, respectively, in the laparoscopy and open surgery groups, and consisted mainly of wound infections (P=0.001). Flatus passage and hospitalization were significantly more rapid among the laparoscopic patients. The greater diagnostic accuracy of laparoscopy allowed the diagnosis of concurrent diseases in 12% (30/254) versus 1.5% (3/199) of patients with histology proven appendicitis treated via laparoscopy versus laparotomy (P<0.01). Similarly, among those patients without gross or microscopic evidence of appendicitis, or both gross and microscopic evidence, concurrent diseases were detected in 57.3% (39/68) of laparoscopic patients versus 8.8% (3/34) in the conventional ones (P<0.01). CONCLUSION: Even if limited by its retrospective nature, the present experience shows that laparoscopic appendectomy is as safe and effective as conventional surgery, has a higher diagnostic yield, causes less trauma, and offers a more rapid postoperative recovery. Such features make laparoscopy a challenging alternative to laparotomy in premenopausal women referred for urgent abdominal or pelvic surgery, or both.     

Indications and limits of laparoscopic treatment for diverticular disease of the colon: personal experience

The aim of the study was to evaluate the role of laparoscopic surgery in diverticular disease of the colon, in the experience of a specialized centre. Sixty-seven patients were observed from November 2004 to March 2006 at the Robert Koch Krankenhaus of Gehrden (Hannover) with a diagnosis of acute diverticulitis, chronic diverticulitis and/or complications and submitted to elective or emergency surgery. The mean operating time was 171.5 minutes for the laparoscopic approach, and 142.7 minutes for open surgery. Return to normal bowel function occurred after 3.7 days for laparoscopy, as against 4.4 days for open surgery. Mean hospital stay was 9.8 days for the laparoscopic approach and 16.3 days for open surgery. Morbidity was 18.6% (8 cases) in the laparoscopic group and 25% (6 cases) in the open group. Mortality was 0%. Re-operation was necessary in 5 cases in the laparoscopic group (11.6%) and in 4 cases (16.6%) in the open group. Laparoscopy is an important innovation in the surgical treatment of diverticular disease. This approach should be assessed in relation to patient characteristics, medical history and clinical presentation. The advantages of laparoscopy are shorter postoperative hospital stay, less postoperative pain, earlier discharge, better cosmetic result, less blood loss and less peritoneal contamination. In the advanced stages of disease open surgery still remains very important.     

Laparoscopy in intra-abdominal infection. Its diagnostic value and therapeutic possibilities

In 550 patients with the clinical features of acute abdomen a surgical laparoscopy was performed. In 121 cases there was found an unspecific reason of the acute abdominal disease that did not require surgical therapy. In 349 cases a regional peritonitis was found, 80 times a diffuse peritonitis. The diagnostic validity of laparoscopy was 96% as compared to 42% for sonography. The laparoscopic access resulted in a complication rate of 0.2%. In 239 cases (43%) the disease could be managed laparoscopically, 190 cases (35%) required open surgery.     

Quality-of-life outcomes with laparoscopic vs open cholecystectomy

Background: The purpose of this article is to describe our experience using laparoscopy in the management of emergent and acute abdominal conditions. Methods: Between March 1997 and November 2001, 277 consecutive minimally invasive procedures were performed for various nontrauma surgical emergencies. The indications for operation were nonspecific abdominal pain in 129 cases (46%), peritonitis in 64 cases (23%), small bowel obstruction in 52 cases (19%), complications after previous surgery or invasive procedures in 24 cases (9%), and sepsis of unknown origin in 8 cases (3%). Results: Laparoscopy obtained a correct diagnosis in 98.6% of the cases. In 207 patients (75%), the procedure was completed laparoscopically. An additional 35 patients (12.5%) required a target incision. The remaining 35 patients (12.5%) underwent formal laparotomy. The morbidity rate was 5.8%. No laparoscopy-related mortality was observed. Conclusions: For patients with abdominal emergencies, the laparoscopic approach provides diagnostic accuracy and therapeutic options, avoids extensive preoperative studies, averts delays in operative intervention, and appears to reduce morbidity. Preliminary results presented at the 9th European Association for Endoscopic Surgery (E.A.E.S.) Annual Congress, Maastricht the Netherlands, 13–16 June 2001     

Management of rectal prolapse: the role of laparoscopic approaches

Rectal prolapse is a lifestyle-altering disability which has been treated with over 100 surgical options. The specific goals of surgical management of full thickness rectal prolapse are to minimize the operative risk in this typically elderly population, eradicate the external prolapse of the rectum, improve continence, improve bowel function, and reduce the risk of recurrence. The theoretical advantages of a laparoscopic approach are to couple reductions in surgical morbidity and good post-operative outcome. Studies which compare the same laparoscopic and open surgical approach for rectal prolapse have demonstrated that laparoscopy confers benefits related to postoperative pain, length of hospital stay, and return of bowel function. Virtually every type of open transabdominal surgical approach to rectal prolapse has been laparoscopically accomplished. Current laparoscopic surgical techniques include suture rectopexy, stapled rectopexy, posterior mesh rectopexy with artificial material, and resection of the sigmoid colon with colorectal anastomosis, with or without rectopexy. The growing body of literature supports the concept that laparoscopic surgical techniques can safely provide the benefits of low recurrence rates and improved functional outcome for patients with full thickness rectal prolapse.     

Laparoscopic and open surgical nephrectomy for xanthogranulomatous pyelonephritis

BACKGROUND AND PURPOSE: Xanthogranulomatous pyelonephritis (XGP) is a severe, chronic renal-parenchymal infection. Nephrectomy is the treatment of choice. Because of the renal and perirenal inflammatory changes that commonly accompany XGP, the laparoscopic approach is difficult. We compared our experience with laparoscopic and open surgical nephrectomy for XGP. PATIENTS AND METHODS: A retrospective chart review of all adult nephrectomy specimens with the pathologic diagnosis of XGP between January 1997 and May 2003 was performed. Preoperative presentation, operative details, and postoperative recovery and complications were included in the data collection. RESULTS: Three patients approached laparoscopically and eight patients approached with open surgery were found to have XGP on pathologic analysis. The disease was suspected preoperatively in all patients. Among the laparoscopically treated patients, there was 1 (33%) who suffered major complications; this was the only patient who required conversion to open surgery. Among the open-surgical group, there were 2 (22%) major and 3 (33%) minor complications. Postoperative hospitalization was longer in the open-surgical group (mean 13.7 v 4.7 days), and when the case of open conversion was excluded, narcotic use was less in the laparoscopy group. CONCLUSIONS: The treatment of some XGP cases with laparoscopic nephrectomy is a possible, albeit challenging, option. The incidences of intraoperative and postoperative complications were roughly equivalent in the laparoscopic and open-surgery patients in our study. If completed, laparoscopy appears to be associated with decreased postoperative morbidity. However, this may represent selection bias, and larger, prospective studies may better define the suspected benefit.     

Laparoscopic management of intra-abdominal infections: Systematic review of the literature

AIM: To investigate the role of laparoscopy in diagnosis and treatment of intra abdominal infections.METHODS: A systematic review of the literature was performed including studies where intra abdominal infections were treated laparoscopically.RESULTS: Early laparoscopic approaches have become the standard surgical technique for treating acute cholecystitis. The laparoscopic appendectomy has been demonstrated to be superior to open surgery in acute appendicitis. In the event of diverticulitis, laparoscopic resections have proven to be safe and effective procedures for experienced laparoscopic surgeons and may be performed without adversely affecting morbidity and mortality rates. However laparoscopic resection has not been accepted by the medical community as the primary treatment of choice. In high-risk patients, laparoscopic approach may be used for exploration or peritoneal lavage and drainage. The successful laparoscopic repair of perforated peptic ulcers for experienced surgeons, is demonstrated to be safe and effective. Regarding small bowel perforations, comparative studies contrasting open and laparoscopic surgeries have not yet been conducted. Successful laparoscopic resections addressing iatrogenic colonic perforation have been reported despite a lack of literature-based evidence supporting such procedures. In post-operative infections, laparoscopic approaches may be useful in preventing diagnostic delay and controlling the source.CONCLUSION: Laparoscopy has a good diagnostic accuracy and enables to better identify the causative pathology; laparoscopy may be recommended for the treatment of many intra-abdominal infections.     

Current indications for laparoscopic adrenalectomy in the era of minimally invasive surgery

The aim of this study was to clarify the current indications for laparoscopic adrenalectomy, reviewing both our own experience and the literature data. Since January 2000, 22 patients have undergone adrenalectomy in our department: 17 (77.3%) with the laparoscopic approach and 5 (22.7%) with the traditional one. The indications for laparoscopy were: 6 Cushing's adenomas, 4 aldosterone-producing adenomas, 4 non-functional adenomas, 2 pituitary-dependent bilateral adrenocortical hyperplasias and 1 metachronous adrenal metastasis. The conversion rate to laparotomy was 11.7%. The indications for the open approach were: tumours greater than 7 cm and previous abdominal surgery. The mean size of laparoscopic specimens was smaller than those removed by the open procedure (3.9 cm versus 6.7 cm). The mean postoperative hospital stay in the laparoscopic group was 4.9 days as compared to 10.2 days in the open group. Morbidity was encountered in 2/17 laparoscopically treated patients (11.7%) and in 2/5 patients in the open group. In our early experience, laparoscopic adrenalectomy has been the procedure of choice for removing unilateral or bilateral tumours measuring less than 7 cm in diameter. Nevertheless, apart from diameter cut-off, on the basis of evidence from the literature, an invasive carcinoma is currently considered the only absolute contraindication to laparoscopy.     

Does nasogastric tube decompression get used less often with laparoscopic and hand-assisted compared with open colectomy?

Introduction

Laparoscopic surgery is associated with well-known benefits, one of which is earlier return of bowel function. Since the laparoscopic approach to colon resections was introduced in the early 1990s, it has become the standard of care. Hand-assisted laparoscopic surgery (HALS) is a surgical approach in which dissection is facilitated by the surgeon’s hand within the abdominal cavity during laparoscopy. The purpose of this study was to compare the incidence of postoperative ileus and the need for nasogastric tube (NGT) decompression in patients undergoing elective colon resections.

Methods and procedures

Following institutional review board approval, we performed a retrospective review of a prospectively collected database. Included were patients who underwent elective left-sided large bowel resections between 2009 and 2012. Exclusion criteria were urgent operation, stoma creation, ASA IV classification, NGT left in place at the end of surgery, and postoperative anastomotic leakage. Patients were divided into three groups: laparoscopic surgery, HALS, and open surgery. We evaluated the incidence of postoperative ileus and the use of nasogastric decompression in each group.

Results

A total of 243 patients were included in this study; 73 patients underwent open surgery, 89 patients underwent HALS, and 81 patients underwent laparoscopic surgery. The proportion of patients who needed postoperative nasogastric decompression was significantly reduced in patients undergoing laparoscopic surgery (3.7 %) or HALS (4.5 %) compared with those who underwent open resection (17.8 %). The time from surgery to first flatus and first bowel movement, the time to tolerate solid diet, and the total length of postoperative hospital stay also were all significantly reduced in the laparoscopic and HALS groups compared with the open surgery group. There were no significant differences in any of these measures between the laparoscopic group and the hand-assisted group.

Conclusions

Like laparoscopy, HALS is associated with less postoperative ileus and necessitates less NGT decompression than does open surgery.     

Therapeutic laparoscopy for abdominal trauma

Background: Instead of open laparotomy, laparoscopy can be used safely and effectively for the diagnosis and treatment of traumatic abdominal injuries. Methods: Between February 1998 and January 2002, 78 hemodynamically stable patients (49 males and 29 females) with suspicious abdominal injuries underwent diagnostic or therapeutic laparoscopy. The patients ranged in age from 15 to 79 years (median, 40.9 years). Of these patients, 52 were evaluated for blunt trauma and 26 had sustained a stab wound. Preoperative evaluation with enhanced abdominal computed tomography (CT) showed some significant injuries in all cases. All of the laparoscopic procedures were performed in the operating room with the patient under general anesthesia. Pneumoperitoneum was established using an open Hasson technique at the umbilicus, and a forward-viewing laparoscope (30°) was inserted. Two additional 5- or 10- and 12-mm trocars were placed in the right and left lateral quadrants for manipulation, retraction, aspiration–irrigation, coagulation, and the like. The abdominal cavity was systemically examined, the hemoperitoneum aspirated, and the lesion causing the bleeding or spillage located. Results: On the basis of the laparoscopic findings, diagnostic laparoscopy was enough for 13 patients, and therapeutic laparoscopy was performed in 65 patients (83%) for gastric wall repair [8], small bowel repair [15], small bowel resection–anastomosis [19], ligation of bleeders in the mesentery and omentum [8], sigmoid colon repair [4], Hartmann's procedure [5] cholecystectomy [2], distal pancreatectomy [2], and splenectomy [2]. Totally laparoscopic procedures were performed in 43 patients, laparoscopically assisted procedures in 20 patients, and hand-assisted laparoscopic surgery in 2 patients. No significant abdominal injuries were missed as a result of laparoscopy, and no conversion to exploratory laparotomy was noted. The mean operation time was 142 min, and the mean hospital stay was 9.8 days. There were three cases of postoperative complications (1 wound infection, 1 paralytic ileus, and 1 atelectasis), but no missed injuries and no mortality. Conclusions: The short-term results from this study suggest that laparoscopy is a safe, feasible, effective procedure for the evaluation and treatment of hemodynamically stable patients with abdominal trauma, and that it can reduce the number of nontherapeutic laparotomies performed.     

Laparoscopic management of acute small bowel obstruction

BACKGROUND: Conventional surgical management of acute small bowel obstruction involves laparotomy. The laparoscopic approach has not been favoured due to the presumed increased risk of bowel injury. METHODS: A retrospective review of our experience of laparoscopic management of acute small bowel obstruction was undertaken. Nine patients were identified from 1997 to 2003. The aetiology of obstruction was identified laparoscopically in all cases. Eight cases were caused by bands or local adhesions and one patient had a bezoar. RESULTS: Laparoscopic treatment was successful in 78% of patients including one laparoscopy-assisted procedure. Conversion to laparotomy was performed in two patients, one due to difficult adhesiolysis and one due to iatrogenic bowel injury during adhesiolysis. The mean operating time was 74 minutes. There were no postoperative complications and the mean length of hospital stay was 4.3 days. CONCLUSION: This small series demonstrates that laparoscopy can serve as a good diagnostic tool as well as treatment of acute small bowel obstruction. In an appropriately selected patient, laparoscopic management of small bowel obstruction is a feasible therapeutic approach and appears to convey the benefits of a short postoperative hospital stay, reduced postoperative complications and possibly reduced subsequent adhesion formation.