Laparoscopy in gastrointestinal emergency

Summary BACKGROUND: Laparoscopy is an established component of modern visceral surgery. To one extent or another, it is used for operations on virtually all abdominal organs, depending on the specialization and expertise of the respective department. In spite of its extensive use, there are no clear guidelines for the application of laparoscopy in acute situations. The reports in the literature do not at present suffice for the formulation of such guidelines. METHODS: This survey covers the role of laparoscopy in seven different types of emergency abdominal surgery. We carefully evaluated the relevant literature on the use of laparoscopy in emergency abdominal surgery. RESULTS: Many relevant works are case reports or uncontrolled series that are only concerned with feasibility. Further, comparative studies often have poor selection criteria and so cannot provide a reliable answer to the question as to whether laparoscopic technique should be used in gastrointestinal emergencies. Our experience shows that laparoscopy is also suitable for acute abdominal situations. CONCLUSIONS: Laparoscopy can be successfully applied for all seven indications considered here. Patient safety and efficacy depend on the experience and manual dexterity of the laparoscopic surgeon. It should be borne in mind that in emergency settings, it is important to recognize in time the need to convert to open surgery     

Small bowel volvulus resulting from a congenital band treated laparoscopically

Laparoscopy has gained widespread acceptance in the setting of acute abdominal pain. We report the case of a patient with acute abdominal pain in the right lower quadrant that proved to be due to a fish bone perforation of the ileum at laparoscopy. The fish bone was retrieved and the perforation closed laparoscopically. Laparoscopy is a powerful diagnostic and therapeutic tool and should be used routinely in patients with acute abdominal affections.     

Laparoscopy for diagnosis and treatment of acute abdominal pain

PURPOSE: To evaluate the role of laparoscopy in the diagnosis and treatment of unexplained acute abdominal pain. PATIENTS AND METHODS: Fifty-six patients with acute abdominal pain (41 women, 15 men; median age 27) who attended our hospital between July 1996 and July 1999 and in whom a definite diagnosis could not be made by conventional methods underwent diagnostic laparoscopy. RESULTS: The laparoscopic procedure was performed under general anesthesia in 43 patients and local anesthesia in 13 patients. The median duration of laparoscopy was 16 minutes. The sensitivity and specificity of diagnostic laparoscopy were found to be 98% and 96%, respectively. The most frequent diagnosis was acute appendicitis (38%). Laparoscopic treatment of the surgical pathology was possible in 36 patients; in seven patients, conversion to laparotomy was necessary. The median postoperative hospital stay was 1 day in the diagnostic laparoscopy group. The median treatment cost was lower in the diagnostic laparoscopy group than in the therapeutic laparoscopy or laparotomy groups. There was no mortality or morbidity in the laparoscopy groups. CONCLUSIONS: Laparoscopy is an effective method for the diagnosis and treatment of surgical pathologies in patients in whom the diagnosis cannot be made with physical examination and noninvasive methods.     

Laparoscopy in abdominal trauma]

Laparoscopy is very useful in penetrating abdominal trauma, in particular to exclude intraabdominal lesions in stab wounds. In blunt abdominal trauma laparoscopy is not the first choice of diagnostic means though it warrants comparable good results to CTscan and ultrasound. Invasiveness, high costs, and time consuming procedure require a critical and specific application making it suitable especially in unclear clinical situations and equivocal diagnostic findings. Without doubt laparoscopy is only useful in hemodynamically stable patients and is of secondary value in polytraumatized patients. In the future it has to be thought about laparoscopy in local anesthesia and in bedside procedure e.g. on the intensive care unit. Laparoscopy should be regarded as an integral part of diagnostic spectrum in blunt abdominal trauma.     

Laparoscopic management of acute abdominal emergencies

Use of minimally invasive approaches to acute abdominal surgical emergencies has increased in recent decades. Uptake has been slower than for elective surgery, however, with concerns regarding inadvertent injury and operative time being most frequently cited. Laparoscopy for abdominal pain has shown to be safe and is a useful diagnostic procedure in the context of unexplained abdominal pain. Minimally invasive surgery has also been shown to be the approach of choice in appendicitis and cholecystitis. Laparoscopy has shown to be useful in trauma patients and may obviate the need for laparotomy. Management of perforated peptic ulcers has shown to be feasible and safe, with some uncertainty as to the superiority over an open approach. The management of perforated diverticulitis has been the subject of much debate, with significant risk possibly associated with minimally invasive lavage. Small bowel obstruction may also be managed using laparoscopy but the potential for inadvertent injury remains. While useful and certainly yielding benefits in terms of postoperative recovery when performed without incident, the decision to proceed minimally invasively in many acute abdominal emergencies must be taken by clinicians and surgical teams with suitable experience and expertise.     

The laparoscopic approach in abdominal emergencies: a single-center 10-year experience.

INTRODUCTION: Laparoscopy has rapidly emerged as the preferred surgical approach to a number of different diseases because it allows for a correct diagnosis and proper treatment. In abdominal emergencies, both components of treatment--exploration and surgery--can be accomplished via laparoscopy. The aim of the present work is to illustrate retrospectively the results of a case-control experience with laparoscopic versus open surgery for abdominal emergencies performed at our institution. METHODS: From January 1992 to January 2002, 935 patients (mean age, 42.3+/-17.2 years) underwent emergent or urgent surgery, or both. Of these, 602 (64.3%) were operated on laparoscopically (small bowel obstruction, 28; gastroduodenal ulcer disease, 25; biliary disease, 165; pelvic disease, 370 cases; colonic perforations, 14) based on the availability of a surgical team trained in laparoscopy. Patients with a history of malignancy, more than 2 previous major abdominal surgeries, or massive bowel distension were not treated laparoscopically. Peritonitis was not deemed a contraindication to laparoscopy. RESULTS: The conversion rate was 5.8% and was mainly due to the presence of dense intraabdominal adhesions. Major complications ranged as high as 2.1% with a postoperative mortality of 0.6%. A definitive diagnosis was accomplished in 96.3% of cases, and 94.1% of these patients were treated successfully with laparoscopy. CONCLUSIONS: Even if limited by its retrospective nature, the present experience shows that the laparoscopic approach to abdominal emergencies is as safe and effective as conventional surgery, has a higher diagnostic yield, and results in less trauma and a more rapid postoperative recovery. Such features make laparoscopy an attractive 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 acute abdominal emergencies

Use of minimally invasive approaches to acute abdominal surgical emergencies has increased in recent decades. Uptake has been slower than for elective surgery, however, with concerns regarding inadvertent injury and operative time being most frequently cited. Laparoscopy for abdominal pain has shown to be safe and is a useful diagnostic procedure in the context of unexplained abdominal pain. Minimally invasive surgery has also been shown to be the approach of choice in appendicitis and cholecystitis. Laparoscopy has shown to be useful in trauma patients and may obviate the need for laparotomy. Management of perforated peptic ulcers has shown to be feasible and safe, with some uncertainty as to the superiority over an open approach. The management of perforated diverticulitis has been the subject of much debate, with significant risk possibly associated with minimally invasive lavage. Small bowel obstruction may also be managed using laparoscopy but the potential for inadvertent injury remains. While useful and certainly yielding benefits in terms of postoperative recovery when performed without incident, the decision to proceed minimally invasively in many acute abdominal emergencies must be taken by clinicians and surgical teams with suitable experience and expertise.     

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.     

Diagnostic and therapeutic laparoscopy for stab wounds of the anterior abdomen

BACKGROUND: At present, laparoscopy is used mainly as a diagnostic tool in patients with abdominal stab wounds. PATIENTS AND METHODS: Thirty-two hemodynamically stable patients with isolated stab wounds of the anterior abdomen, thought to be penetrating, were prospectively selected to undergo treatment via a laparoscopic approach. When possible, parenchymal wounds were coagulated or sealed, and wounds to the intestines were sutured or stapled. RESULTS: The results of laparoscopy were negative in 6 (18.8%) of the cases: nonpenetrating wounds in 4 cases and nonsignificant organ injury in 2 cases. A hemoperitoneum was identified in 13 (40.6%) of the cases, and significant organ injuries in 26 (81.3%) of the cases: stomach, 2; small bowel, 5; colon, 2; pancreas, 1; vascular injuries, 4; liver, 5; mesentery, 9. Laparoscopy was therapeutic in 20 (62.3%) of the cases. Conversion to open surgery was required in 6 (18.8%) of the cases. No injuries were missed, and no mortality occurred. Postoperative complications developed in 2 (6.2%) of the cases. The mean hospital stay was 4 days, with no late complications. CONCLUSIONS: Laparoscopy can avoid a number of unnecessary laparotomies and can treat most of the lesions found in hemodynamically stable patients with anterior abdominal stab wounds.     

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.     

The role of laparoscopy in the diagnosis and treatment of abdominal pain syndromes

Background: Diagnostic laparoscopy plays a significant role in the evaluation of acute and chronic abdominal pain in the era of therapeutic laparoscopic surgery. Methods: We referred to our personal series of laparoscopy for both acute and chronic abdominal pain. This is a retrospective review of data accumulated prospectively between 1979 and the present. Results: In our series, 387 consecutive patients underwent laparoscopy because of abdominal pain. In a group of 121 patients with acute abdominal pain, a definitive diagnosis was made in 119 cases (98%). Two patients needed laparotomy to confirm the diagnosis; both had a disease process that did not require laparotomy to treat. A definitive therapeutic laparoscopic procedure was performed in 53 cases 944%). In 45 patients (38%), a diagnosis was made that did not require therapeutic laparoscopy or laparotomy to treat. In the remaining 21 patients (17.5%), exploratory laparotomy was needed to treat the condition. In a chronic abdominal pain group of 265 patients, the etiology was established laparoscopically in 201 cases (76%). A definitive therapeutic laparoscopic procedure was performed in 128 patients (48%). There was a normal laparoscopic examination in 64 patients (24%). There was one false negative laparoscopy that required laparotomy to treat 1 month later. Conclusions: Laparoscopy is an accurate modality for the diagnosis of both acute and chronic abdominal pain syndromes. These data support the use of laparoscopy as the primary invasive intervention in patients with acute and chronic abdominal pain. Received: 24 March 1997/Accepted: 4 September 1997     

Laparoscopy in diagnosis and management of Meckel's diverticulum

OBJECTIVE: The aim of this paper is to demonstrate that laparoscopy can successfully diagnose otherwise elusive Meckel's diverticuli and at the same time offer a therapeutic access for successful resection. MATERIALS AND METHODS: Two patients with anemia of unknown cause and a further patient with acute small bowel obstruction underwent diagnostic laparoscopy. A Meckel's diverticulum was identified in each case and successfully resected through a minilaparotomy. RESULTS: All three patients were successfully investigated and treated with laparoscopy with no morbidity or mortality. CONCLUSION: Laparoscopy is a safe and effective surgical modality for diagnosis of atypically presenting Meckel's diverticulum and has a therapeutic role that results in an excellent cosmetic result.     

Laparoscopy in penetrating abdominal injuries]

An experience with treatment of 138 patients with penetrating punctured-incised wounds of the abdominal cavity has shown advantages of laparoscopy in diagnostics of the character of injuries of internals. Laparoscopy used in cases with difficult diagnosis allowed to give up operative interventions in 53.8% of patients. High diagnostic value and relative safety of laparoscopy make it possible to widely use this method in wounds of the abdomen.     

Laparoscopy in the diagnosis and treatment algorithm for an acute surgical diseases and trauma of abdomen

Laparoscopy was performed in 1977 patients in an acute surgical diseases and the abdominal cavity (AC) injuries, the curative one--in 895. In patients with clinical signs of the AC organs acute disease or trauma it is possible the four-variants diagnostic and curative program application: radial methods of investigation and laparocentesis--for diagnosis, laparoscopy and laparotomy--for diagnosis and treatment. The laparoscopy application is indicated even if the "acute abdomen" clinical features presence are confirmed the radial diagnosis and laparocentesis result. If necessary the diagnostical laparoscopy is transformed into curative procedure, which is used with the miniinvasive access application, resulting in low operative risk.     

Intramesosigmoid hernia: a rare type of congenital internal hernia

Intestinal obstruction from congenital internal hernias is a rare and often unsuspected problem. We report the case of a 66-year-old male with a rare type of congenital internal hernia causing bowel obstruction. He underwent successful laparoscopy-assisted surgical repair without bowel resection. Symptomatic congenital internal hernias usually present with intermittent or acute small-bowel obstruction without any history of previous abdominal surgery. Laparoscopy or hand-assisted laparoscopy can be useful tools for locating the region of pathology and enable minimally invasive surgical treatment.     

Role of laparoscopy in the management of visceral injuries following abdominal stab wounds

BACKGROUND: Laparoscopy offers several advantages in the treatment of abdominal stab wounds. In this paper, we report our experience during 2004, where hemodynamically stable patients with stab wounds were managed laparoscopically. PATIENTS AND METHODS: Between January and December 2004, 8 hemodynamically stable patients (7 men, 1 woman) underwent laparoscopy for anterior abdominal stab wounds. Median age was 28.5 years (range, 17-55). All patients underwent an abdominal computed tomography (CT) prior to the laparoscopy. RESULTS: Exploration of the wound under aseptic conditions, carried out as a part of the physical examination, confirmed peritoneal penetration in 7 of the 8 cases. Abdominal CT revealed positive findings in 7 (87.5%) cases. Laparoscopy was performed after a median time of 60 minutes (range 30-90). Laparoscopic exploration evidenced peritoneal penetration in 100% of the cases and visceral lesions in 87.5% of the cases. All visceral injuries were managed laparoscopically. Median operative time was 135 minutes (range, 45-200). Operative mortality was 0% and early morbidity was 12.5%. Median hospital stay was 5 days (range, 1-11). After a median follow-up of 12 months (range, 1-28), 1 patient complained of persistent chest pain and a ventral hernia at the site of the abdominal stab wound was diagnosed in another patient. CONCLUSIONS: Laparoscopy should be included in management algorithms in patients with anterior abdominal stab wounds who are hemodynamically stable. In addition to its diagnostic ability, this study demonstrates that laparoscopy can be an effective management modality with minimal morbidity and no mortality.     

Diagnostic of non-palpable testis in children: laparoscopy or magnetic resonance imaging?

Summary Laparoscopy and magnetic resonance imaging (MRI) are competetive tools in the diagnostic of non-palpable testis. Advantages and disadvantages of this methods will be demonstrate. 29 boys investigated for this indication with MRI. In case MRI failed to locate the testis laparoscopy was performed with a new miniaturized set of pediatric instruments (1.9 mm optic). The aim of laparoscopy was the identification of the spermatic duct and vessels and their topographic relation to the internal inguinal ring. All findings were verified by open surgical procedures. MRI revealed 10 inguinal and 7 abdominal testis. There was no false positive finding. In 12 boys MRI showed no testis. 4 cases were correct negative, 8 cases were false negative (32 %). In these 8 MRI-negative patients laparoscopy revealed 7 inguinal and 1 abdominal testis. The optical quality of the mini-telescope was sufficient for a 100 % correct diagnosis. Laparoscopy related complications did not occur. Laparoscopy proved to be a powerful low risk diagnostic method in non- palpable testis with high senitivity and specifity (100 % correct positive, 0 % false negative). Therefore lapraroscopy is recommended as primary diagnostic access for this indication. In the same anesthesia a optimal therapy is possible. Nevertheless a positive MRI-finding locates the testis reliably, whereas a negative finding always needs further exploration because testis might have been missed.      

Relaparoscopy in the management of acute abdomen due to localized ischemic bowel: a novel technique--case report

Diagnostic and therapeutic laparoscopy for acute abdomen has been widely reported in the literature. Diagnostic laparoscopy has an accuracy of 99.08% and 1% morbidity. The usefulness of relaparoscopy in acute abdomen has also been reported. We describe a patient with acute abdominal pain who underwent diagnostic laparoscopy. Ischemic segment of small bowel was found and it was decided not to resect but to go in for a second look 48h later. Relaparoscopy revealed the ischemic segment to regain vascularity, so nothing further was done. The patient recovered well and was discharged on the 6th postoperative day. Laparotomy was avoided both the times, thus sparing the patient of morbidity and prolonged hospital stay. Other advantages are lower risk of incisional hernias, less postoperative pain and early return to normal activity. Laparoscopy and relaparoscopy certainly has a definite role in the management of acute abdomen, at least diagnostic if not therapeutic.