Emergency laparoscopic surgery: a hospital's experience]

BACKGROUND AND AIM: The wide diffusion and increasing use of laparoscopic surgery prompts the authors to broaden discussion to its validity and diagnostic-therapeutic use in emergency abdominal surgery. The aim was to evaluate the efficacy of laparoscopic surgery in the light of reports in the international literature and in relation to the situation in our hospital. METHODS: From April 1994 to May 1998, out of 1016 emergency abdominal operations performed at our hospital, 783 (77.5%) used a laparoscopic approach for diagnostic and therapeutic purposes: intestinal occlusion: 26 cases; gastrointestinal ulcer pathology: 15 cases; hepatobiliary pathology: 398 cases; "pelvic" pathology: 305 cases; colic pathology: 39 cases. These represent 24.4% of all laparoscopic procedures carried out during the same period. We preferred to use immediate laparotomic access in patients with the following characteristics: anamnesis of previous surgery for malignant pathologies; anamnesis of more than two major abdominal operations; massive intestinal distension; patients whose general conditions were a contraindication to a laparoscopic approach. RESULTS: The conversion rate was 6.2% (49 cases) with morbidity of 3.4% (25 cases) and a mortality rate of 0.2% (2 cases). A final diagnosis was made in 763 patients (97.4%) with the possibility of treating 719 of them (94.2%), again using a laparoscopic approach. CONCLUSIONS: It is right to regard the laparoscopic approach in emergency abdominal surgery as a feasible and safe model, offering a high potential for diagnosis and therapy if appropriately performed by an expert and well coordinated team. The increased experience of mini-invasive surgery and the improved range of instruments available make the laparoscopic approach a valid alternative to laparotomy, even in the event of emergency abdominal pathologies.     

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.     

Laparoscopy in abdominal emergencies. Indications and limitations

Laparoscopy, which has been well known as a diagnostic procedure for more than a century, has recently established itself as an important therapeutic procedure in several branches of surgery. In the present study the authors report on 221 patients over a 10-year period (1991-2001), admitted to hospital with a diagnosis of acute abdomen or abdominal trauma. All patients were submitted to emergency laparoscopic surgery; 128 patients (57%) presented acute appendicitis, 40 (18%) acute cholecystitis, 13 (6%) occlusive ileus, 10 (5%) adnexal pathologies, 9 (4%) perforation of abdominal viscera, 3 (1.4%) acute diverticulitis, 3 (1.4%) subdiaphragmatic abscesses, 3 (1.4%) intestinal infarction, 2 (0.8%) other diseases and 10 (5%) abdominal trauma. The operation was completed laparoscopically in 192 cases (87%), while conversion to laparotomy proved necessary in 29 cases (13%). The morbidity of the cases completed laparoscopically was 3%, the mortality 0.5%, and the mean hospital stay 4 days. Advantages of laparoscopy (shorter hospital stay, rapid postoperative recovery and faster return to social activities) emerge from the present study and are confirmed by the literature. The possibility of combining a diagnostic procedure with curative therapy suggests that laparoscopy may have an important role in emergency surgery, demonstrating its efficacy also in acute abdominal syndromes. Nevertheless, emergency laparoscopic surgery is still a technically difficult procedure that needs to be performed by an expert surgical team.     

Emergency laparoscopy for acute abdominal conditions: a prospective study

BACKGROUND: Currently, emergency laparoscopic surgery for acute abdominal conditions has become the favored surgical approach; therefore, we investigated the diagnostic accuracy and therapeutic efficacy of laparoscopy in acute abdominal pain in Saudi Arabian patients. PATIENTS AND METHODS: In this prospective study, 176 patients with acute abdominal pain (113 patients with pain localized to the right iliac region [group A] and 63 patients with generalized abdominal pain [group B] underwent emergency laparoscopy between January 2002 and December 2006. We evaluated the initial clinical diagnosis, the laparoscopic diagnosis, and the outcome in these two groups of patients. RESULTS: In group A, a definitive diagnosis was established at laparoscopy in 89% of patients, and it was therapeutic in 81.4% of the patients, and in 9 patients (8%) a conversion to laparotomy was necessary a to manage their condition. In group B, the diagnosis was accurate in 87% of patients, and it was therapeutic in 79.4% of the patients, and in 5 patients (8%) a conversion to laparotomy was necessary. There was no mortality. CONCLUSIONS: The emergency laparoscopy is a diagnostic and therapeutic option in the majority of acute abdominal pain conditions.     

腹腔镜技术在非创伤性外科急腹症中的应用

目的探讨腹腔镜技术在非创伤性外科急腹症中的应用价值. 方法回顾分析1999年3月～2002年5月201例腹腔镜急诊手术. 结果本组201例全部术中明确诊断,腹腔镜手术成功190例,其中急性阑尾炎139例,急性胆囊炎21例,上消化道穿孔19例,肠梗阻10例,胆总管结石合并急性胆囊炎1例,成功率94.5%(190/201).余11例中转开腹.结论急诊腹腔镜探查术不仅可以对病因不明的急腹症作出准确诊断,而且90%以上病变可同时进行腹腔镜手术治疗.     

Laparoscopy for abdominal emergencies

Background Emergency laparoscopic exploration can be used to identify the causative pathology of acute abdominal pain. Laparoscopic surgery also allows treatment of many intraabdominal disorders. This report was prepared to describe the effectiveness of laparoscopic surgery compared to laparotomy or nonoperative treatment. Methods A panel of European experts in abdominal and gynecological surgery was assembled and participated in a consensus conference using Delphi methods. The aim was to develop evidence-based recommendations for the most common diseases that may cause acute abdominal pain. Recommendations Laparoscopic surgery was found to be clearly superior for patients with a presumable diagnosis of perforated peptic ulcer, acute cholecystitis, appendicitis, or pelvic inflammatory disease. In the emergency setting, laparoscopy is of unclear or limited value if adhesive bowel obstruction, acute diverticulitis, nonbiliary pancreatitis, hernia incarceration, or mesenteric ischemia are suspected. In stable patients with acute abdominal pain, noninvasive diagnostics should be fully exhausted before considering explorative surgery. However, diagnostic laparoscopy may be useful if no diagnosis can be found by conventional diagnostics. More clinical data are needed on the use of laparoscopy after blunt or penetrating trauma of the abdomen. Conclusions Due to diagnostic and therapeutic advantages, laparoscopic surgery is useful for the majority of conditions underlying acute abdominal pain, but noninvasive diagnostic aids should be exhausted first. Depending on symptom severity, laparoscopy should be advocated if routine diagnostic procedures have failed to yield results. Paper presented at the 13th International Congress of the European Association for Endoscopic Surgery (EAES), Venice, Italy, June 2005 S. Sauerland and E. A. M. Neugebauer are the Conference organizers on behalf of the Scientific Committee of the European Association for Endoscopic Surgery (EAES), c/o EAES Office, P.O. Box 335, 5500 AH Veldhoven, The Netherlands     

Laparoscopic diagnosis and treatment in gynecologic emergencies.

OBJECTIVE: To present an analysis of our experience with 22 consecutive cases of acute abdominal gynecologic emergencies managed with a laparoscopic approach. METHODS: From March 1997 to October 1998, 22 patients with a diagnosis of acute abdominal gynecologic emergencies underwent laparoscopic intervention. A transvaginal ultrasound was performed on all patients preoperatively to supplement the diagnostic workup. Surgical time, complications, and length of hospital stay were evaluated, and the laparoscopic diagnosis was compared with the preoperative diagnosis. RESULTS: The laparoscopic diagnosis was different from the preoperative diagnosis in 31.8% of patients. Of the 22 patients, laparoscopic therapeutic procedures were performed in 18 (81.8%), all satisfactorily, and with no need for conversion to open surgery. No morbidity or mortality occurred. CONCLUSION: Laparoscopy is a safe and effective method for diagnosing and treating gynecologic emergencies.     

Laparoscopic appendectomy. State of the art

The authors present the results of a fact-finding survey on the state of the art of laparoscopic appendectomy in North-Eastern Italy. Over the period from 1991 to 2000 a total of 10,451 laparoscopic procedures were performed. Despite the extensive and increasing use of minimally invasive surgery, only 58% of the surgeons surveyed adopt laparoscopy in the management of suspected acute appendiceal disease. Thirty-six percent of surgeons indicate laparoscopy for all patients, while 60% reserve laparoscopic appendectomy for female patients. Forty-seven point one percent of procedures are performed in an emergency setting (within 6 hours of admission to hospital). The mean conversion rate is 4.9% and is mainly due to the aftermath of inflammation. Major intraoperative complications are of the order of 0.08%, while major postoperative morbidity is 0.6%. Wound infections are reported in 2% of patients. The mean hospital stay is 3 days. The majority of surgeons remove the appendix even in the absence of macroscopic inflammation and convert the procedure in the presence of suspected neoplastic disease found incidentally at surgery. The high diagnostic potential of the laparoscopic approach may well explain the infrequent use of preoperative imaging techniques.     

Die laparoskopische Therapie des Adhäsionsbauchs

INTRODUCTION: About 90 % of the patients have abdominal surgery develop adhesions afterward. Studies analyzing complications and follow-up even in emergency cases are rare. METHODS: Intra- and postoperative findings and complications and follow-up were analyzed in a prospective trial between January 1994 and June 1998. RESULTS: We performed laparoscopic procedures in 56 patients with complaints of obstructing adhesive bands or adhesions. Ninety-six percent of the patients have had abdominal surgery; 51.8 % were treated as emergency cases with acute pain, 48.2 % with chronic abdominal pain. Intraoperatively, 37.5 % of the patients showed single adhesive bands; 62.5 % showed adhesions. Mean operation time was 60 min, conversion rate: 5.4 %. Complications were recorded according to the "Cologne classification": class I: 78.6 %, class II: 8.9 %, class III: 1.8 %, class IV: 10.8 %, class V: 0 %. The postoperative hospital stay was 6 days on average. CONCLUSION: Our study suggests that laparoscopic adhesiolysis can be done safely in emergency cases and in patients with extensive adhesions as well.     

Laparoscopic diagnosis and treatment of nontraumatic acute abdominal pain in women

PURPOSE: We reviewed the records of 77 women treated for nontraumatic acute abdomen by the principal author between June 1991 and June 1996. All patients presented to either the surgeon's office or the emergency room at Northwest Hospital, which is an urban community hospital in North Seattle. Our objectives in the study were to determine the effectiveness of diagnostic laparoscopy for nontraumatic acute abdomen and the percentage of cases managed using laparoscopic technique exclusively. PATIENTS AND METHODS: The mean patient age was 36.5 (range 12-65) years. The majority of these women (92%) were premenopausal. Seventy-two (93.5%) were Caucasian, and the remaining 5 (6.5%) were Asian. Thirty-eight of the women (49%) had undergone at least one prior pelvic or abdominal operation, and 28 (36%) had undergone more than one. The principal author performed preoperative clinical evaluations, then diagnostic laparoscopy for all 77 patients. RESULTS: Laparoscopy provided a definitive diagnosis in 76 of the 77 cases. In 70% of the cases (54 of 77) the preoperative diagnosis was confirmed by diagnostic laparoscopy, and in 29% (22 of 77), the diagnosis was confirmed, yet augmented or clarified, by diagnostic laparoscopy. In the remaining case, diagnostic laparoscopy ruled out any acute etiology. Ninety-five percent of the patients (72 of 76) were treated exclusively by laparoscopy (70 cases) or a laparoscopy-assisted procedure (2 cases). Four patients (5%) required conversion to laparotomy. The remaining patient required no therapeutic surgery. Mortality was 0 and morbidity 4%. CONCLUSION: A high proportion of women presenting with acute abdominal pain can be managed using a laparoscopic technique exclusively.     

Laparoscopic appendectomy. Our experience

The advantages and applications of the videolaparoscopic technique (VL) versus open surgery in the treatment of acute and complicated appendicitis are not well defined. Our study examined 150 patients, 67 males and 83 females. They underwent surgery for acute appendicitis in emergency. The choice between open or laparoscopic tecnique was due to patient's clinical conditions and surgeon's experience. Two of these patients had no infiammatory process. Eleven patients were affected by gynaecological diseases. The last 137 patients underwent surgery for acute appendicitis and the diagnosis was confirmed. Among them, 35 (25%) were affected by a complicated appendicitis with diffuse or clearly defined peritonitis. In 134 patients the surgery was completed laparoscopically. The conversion rate was 2%. Morbility rate was 3%, due to intra abdominal abscesses secondary to acute complicated appendicitis. The mean operative time was 76 min and the mean hospital stay was 4.8 days. The death rate was 0%. In our experience, laparoscopic appendectomy has significant advantages over traditional open surgery in both acute and complicated appendicitis, especially in young women. In this way, we can diagnose pelvic disease that could be characterized by the same symptoms of acute appendicitis, then we suggest laparoscopic appendectomy even just to complete the diagnostic iter. Laparoscopy is useful in terms of convalescence, postoperative pain, hospital stay, aesthetic outcome and an easier exploration of the peritoneal cavity.     

Emergency laparoscopy.

Unnecessary abdominal explorations in severely injured patients can be reduced by employing emergent or urgent laparoscopy in blunt abdominal trauma and the obscured, acute abdominal cases. In 150 blunt abdominal trauma cases, a mini-laparoscopy was used in the emergency room or the intensive care unit without major complications. In 56%, the findings were negative. In 19%, the laparoscopic findings were corroborated by surgery. In 25%, a minimal to moderate hemoperitoneum was found and the laparoscopic impression dictated close observation. Unnecessary exploration was avoided except in one case. In the elderly high-risk patient with a poor history, abdominal examination can be noninformative. Laparoscopy can detect acute appendicitis or organ perforation. In the young female, appendicitis can be differentiated from pelvic inflammatory disease. Laparoscopy is more accurate and gives a larger latitude for decision-making than lavage. It can also be useful in the obscured problematic abdominal case.     

普外科腹腔镜手术中转开腹原因的探讨

目的探讨普外科腹腔镜手术中转开腹的原因及其防治.方法回顾分析1999年6月-2005年12月间7574例接受普外科腹腔镜手术病例中83例中转开腹的原因.结果本组中转开腹率为1.10%(83/7574),主要原因为严重的腹腔粘连和大出血,分别为55.4%(46/83)和26.5%(22/83).另有恶性病变,病灶体积过大,器官损伤及暴露困难等.中转开腹率,有腹部手术史者20%(21/105),明显高于无腹部手术史者0.83%(62/7469),差异显著(P＜0.05).结论腹腔镜胰腺、肝、脾手术、有腹部手术史、严重出血和是腹腔粘连是中转开腹重要原因,术前应严格掌握腹腔镜手术指征,腹腔镜手术困难有可能导致严重并发症时应果断中转开腹手术.     

Laparoscopy in traumatic abdominal emergencies

Over the past few years the laparoscopic technique has changed most of the concepts of traditional surgery and is today the standard approach in elective surgery for many pathologies requiring surgery. Unfortunately the same cannot be said for emergency surgery, though much progress has been made in this field, too. The Authors examine the most important abdominal diseases that can be diagnosed and, possibly, treated by the laparoscopic approach in the emergency setting, concluding that laparoscopic management of such conditions is a feasible proposition in many cases. Technological improvements and the development of new, more versatile surgical instruments will undoubtedly contribute to the increasingly widespread use of the laparoscopic approach also in emergency procedures.     

Urgent laparoscopic surgeries in children of the first year of life

One hundred and ninety-two urgent laparoscopic operations in 179 infants (including 31 newborn infants) were performed. Indications for surgery were intestinal obstruction (108 children), acute diseases of abdominal organs (61), and gynecological diseases (10). The rate of conversion in 3 groups was 10.9, 4.6% and 0, respectively. In all the cases conversion was performed due to technical difficulties, there were no intrasurgical complications, diagnostic value of the method reached 100%. Combined laparoscopic surgeries were performed in 25.1% cases. Intestinal invagination was the most frequent cause of laparoscopy. Comparative analysis of open (28) and laparoscopic (85) desinvagination demonstrated the advantages of the latter one both during and after surgery. Laparoscopy is the useful method for diagnosis and treatment of acute abdominal disease requiring urgent surgery in infants.     

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.     

急性结石性胆囊炎行急诊与延期腹腔镜胆囊切除术的疗效分析(附74例报告)

目的:探讨急性结石性胆囊炎急诊行腹腔镜胆囊切除术(laparoscopic cholecystectomy,LC)的利弊。方法:回顾分析2015年3月至2016年3月为74例急性结石性胆囊炎患者行LC的临床资料。根据手术时机分为急诊组(12 h,n=37)与延期组(12 h～1周,n=37)。结果:66例成功施行LC,8例中转开腹。急诊组术后发生肺部感染2例、切口感染1例,其中1例肺心病患者术后肺部感染较重,住院时间长,费用较高。延期组术后肺部感染1例、切口感染1例。两组患者术后并发症发生率差异无统计学意义(P0.05)。急诊组术前住院时间、术前费用、腹腔粘连、中转开腹、术中出血量、手术时间、总住院时间及住院总费用均少于延期组(P0.05)。结论:急性结石性胆囊炎行急诊LC虽然可降低费用,缩短住院时间、手术时间,减少术中出血量,但手术风险较大。可选一般情况较好、不能耐受急性胆囊炎症状、急诊手术愿望强烈的患者酌情行急诊LC。     

腹腔镜诊治急腹症临床分析

目的探讨腹腔镜对急腹症的诊断与治疗价值。方法对236例急腹症患者采用腹腔镜进行诊断与治疗,回顾性分析手术时间、术中出血量、术后下床活动时间、术后进食时间、术后住院天数、术后并发症及切口愈合情况等。结果术前确诊率为69.92%(165/236),腹腔镜手术确诊率为100%(236/236),后者显著高于前者。腹腔镜手术成功率为90.25%(213/236),手术时间为(45.1±8.3)min,术中出血量为(79.3±28.2)mL,术后下床活动时间为(21.2±4.7)h,进食时间为(1.8±0.6)d,住院天数为(5.8±1.9)d。切口愈合情况良好,无大出血及腹腔积液,未发生与腹腔镜手术相关的并发症及不良反应,无手术死亡病例。23例患者中转开腹手术,全部患者均痊愈出院。结论腹腔镜手术在急腹症的诊疗中具有诊断价值高、手术时间短、出血少、术后恢复快及并发症少等优点,临床可针对具体情况合理选择使用腹腔镜手术治疗急腹症。     

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.     

Early laparoscopy as a routine procedure in the management of acute abdominal pain: a review of 1,320 patients

Background Acute abdominal pain is a common cause for presentation to the emergency room and hospital admission. Many of these patients will undergo exploration for suspected appendicitis, but in 20–35% of cases a normal appendix is found. Because of the limited access provided by the gridiron incision, a definitive diagnosis may not be found. Other patients may be treated conservatively and discharged, only to return with recurrent pain or more definitive symptoms of pathology. In patients with acute abdominal pain, early laparoscopy is an accurate means of both making a definitive diagnosis and avoiding a delay in the diagnosis.Methods We performed a retrospective analysis of 1,320 consecutive patients with acute abdominal pain over a 62-month period. All patients underwent diagnostic laparoscopy within 48 h of admission. We evaluated the initial clinical diagnosis, the laparoscopic diagnosis, and the subsequent outcome in this group of patients. Individuals with abdominal trauma were excluded from the study, and all patients were >12 years of age.Results A definitive diagnosis was made in 90% of patients after diagnostic laparoscopy. Laparoscopy changed the clinical diagnosis in 30% of cases. (83%) of patients underwent a laparoscopic operation for management of their condition at the time of diagnosis. In 92 patients (7%), conversion to laparotomy was required to manage their condition. Peritonitis was present in 180 patients; of 110 of them had appendicitis. Twelve patients developed complications related to the diagnostic laparoscopy or the laparoscopic operation, and there was one postoperative death due to a perforated gastric malignancy. Mean operating time was 30 min (range, 17–90)Conclusion Early diagnostic laparoscopy and treatment results in the accurate, prompt, and efficient management of acute abdominal pain. This technique reduces the rate of unnecessary laparotomy and right iliac fossa gridiron incisions and increases the diagnostic accuracy in these patients. This treatment method is feasible where facilities are available to accommodate the workload and there are practitioners with the requisite expertise.