腹腔镜技术在外科急腹症中的应用

目的探讨腹腔镜技术在外科急腹症中的应用价值。方法2002年3月～2007年3月,行306例急诊腹腔镜手术探查与相应治疗。术前诊断急性阑尾炎105例,腹痛原因待查34例,急性胆囊炎、胆囊结石64例,消化道穿孔51例,胆总管结石、急性胆管炎5例,肠梗阻33例,有明确外伤史9例,重症急性胰腺炎5例。结果本组306例全部术中明确诊断,腹腔镜手术成功275例,其中阑尾切除术123例,胆囊切除术57例,消化道穿孔修补术48例,22例肠梗阻中行肠粘连松解13例、小肠复位联合斜疝修补4例、腹腔镜辅助下乙状结肠癌根治直肠前吻合4例、小切口小肠肠段切除端端吻合术1例,胆总管切开取石T管引流术3例,右叶肝破裂修补术2例,脾破裂止血3例,重症急性胰腺炎清创冲洗引流术5例,腹腔镜探查12例（肠系膜挫裂伤2例,腹壁刀刺伤伴大网膜挫伤1例,原发性腹膜炎8例,过敏性紫癜腹型1例）;余31例腹腔镜完成困难而中转开腹。306例随访1～18个月,无术中、术后并发症。结论急诊腹腔镜探查术不仅可以对病因不明的急腹症做出准确诊断,且可同时行腹腔镜手术治疗。即使腹腔镜下不能完成的手术,也可以指导及时开腹,以及采取较为合适的手术切口。     

Polyarteritis nodosa and acute abdomen: A role for laparoscopy?

Mesenteric vasculitis secondary to polyarteritis nodosa represents an atypical but potentially life-threatening cause of bowel ischemia and acute abdomen. The patient presented with severe abdominal pain of recent onset, pitting edema of the legs, renal failure and bowel wall thickening suggestive of mesenteric ischemia on CT scan. Early laparoscopy allowed to rule out proximal bowel necrosis and resection was avoided. The patient was successfully managed with corticosteroid therapy and repeated hemodialysis sessions.     

Small Bowel Obstruction during Pregnancy

The authors report the case of a 28-year old pregnant woman with abdominal pain and contractions at 37 weeks of gestation. After labour and delivery, abdominal pain persisted and laparoscopy was performed. A bowel obstruction was diagnosed and surgically corrected. The authors discuss the clinical and therapeutic consequences of bowel obstruction during pregnancy.     

Small bowel obstruction during pregnancy

The authors report the case of a 28-year old pregnant woman with abdominal pain and contractions at 37 weeks of gestation. After labour and delivery, abdominal pain persisted and laparoscopy was performed. A bowel obstruction was diagnosed and surgically corrected. The authors discuss the clinical and therapeutic consequences of bowel obstruction during pregnancy.     

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.     

腹腔镜诊治急慢性腹痛37例分析

目的 :探讨腹腔镜在诊断和治疗不明原因急慢性腹痛中的作用。方法 :回顾分析不明原因急慢性腹痛 37例的临床资料。结果 :急性腹痛 15例中 ,11例行腹腔镜治疗 ,2例未行外科处理 ,2例开腹手术。无误诊及漏诊。治疗患者术后腹痛均明显好转或治愈 ,有效率为 10 0 %。慢性腹痛 2 2例 ,镜下诊断 2 1例 ,其中 1例误诊。 12例行腹腔镜治疗 ,3例行开腹手术 ,6例未进一步手术治疗。 1例腹腔镜下未见异常。手术治疗者近期效果均良好 ,有效率为 93%(14 / 15 )。所有急慢性腹痛患者腹腔镜探查或治疗均无严重并发症。腹腔镜术后 3～ 6d出院。结论 :腹腔镜诊断急慢性腹痛准确率较高 ,腹腔镜治疗减少了患者痛苦 ,缩短了住院时间。腹腔镜应作为外科诊治不明原因急慢性腹痛患者的首选方法。     

Caustic acid burn of the upper gastrointestinal tract

Acute torsion of the small bowel mesentery is a diagnostically challenging cause of acute abdominal pain, which most commonly afflicts pediatric patients with midgut malrotation. We describe a case of mesenteric torsion in an adult patient that had manifested as acute abdominal pain. The patient had a remote history of prior abdominal surgery, presenting on multiple occasions with undiagnosed acute intermittent abdominal pain. Diagnosis of mesenteric torsion was made by contrast enhanced CT and the ailment was successfully treated with laparoscopic surgery without recurrence.     

Laparoscopic treatment of acute mesenteric torsion

Acute torsion of the small bowel mesentery is a diagnostically challenging cause of acute abdominal pain, which most commonly afflicts pediatric patients with midgut malrotation. We describe a case of mesenteric torsion in an adult patient that had manifested as acute abdominal pain. The patient had a remote history of prior abdominal surgery, presenting on multiple occasions with undiagnosed acute intermittent abdominal pain. Diagnosis of mesenteric torsion was made by contrast enhanced CT and the ailment was successfully treated with laparoscopic surgery without recurrence.     

Resection and double ileostomy as an alternative approach for superior mesenteric venous thrombosis in poor risk patients: a case report.

An 85-year-old male with a sudden onset of abdominal pain was operated on under the suspicion of intestinal ischemia and was later diagnosed as acute superior mesenteric venous thrombosis (SMVT). The patient was successfully treated by resecting the entire involved bowel and performing a double ileostomy. These procedures are considered to be the preferred method of choice for improving survival in poor risk patients.     

Resection and double ileostomy as an alternative approach for superior mesenteric venous thrombosis in poor risk patients: A case report

An 85-year-old male with a sudden onset of abdominal pain was operated on under the suspicion of intestinal ischemia and was later diagnosed as acute superior mesenteric venous thrombosis (SMVT). The patient was successfully treated by resecting the entire involved bowel and performing a double ileostomy. These procedures are considered to be the prefered method of choice for improving survival in poor risk patients.     

Mesenterialarterienverschluss als seltene Komplikation bei Thrombangiitis obliterans

Mesenteric artery occlusions are rare complications of Thrombangiitis obliterans (Buerger's disease). We report on a 30-year old male with Thrombangiitis obliterans and mesenteric occlusion as a complication of this disease. Because of unclear abdominal pain, laparoscopy was performed which showed small bowel infarction and reduced liver perfusion. After small bowel resection and a second examination, ischemia of the intestinum continued. Angiography was performed, which showed central occlusion of the celiac trunk and the superior mesenteric artery. Relaparotomy with the embolectomy of the superior mesenteric artery, venous bypass from the sup.mes.art. to the hepatic arteries and repeated small bowel resection was performed. The patient recovered completely and was discharged from hospital after 3 weeks. After a further admission to the hospital 3 weeks later with abdominal pain caused by acute occlusion of the right colonic artery and severe ischemia of the right hemicolon, a right hemicolectomy was performed.Now, one year after the last hospital admission, the patient shows no sign of having any abdominal problems.     

Small bowel perforation caused by a sharp bone: laparoscopic diagnosis and treatment

Small bowel perforation caused by sharp or pointed foreign bodies rarely is diagnosed preoperatively because clinical symptoms usually are nonspecific and can mimic other surgical conditions such as appendicitis and cecal diverticulitis. We report the case of a 57-year-old man who underwent diagnostic laparoscopy for abdominal pain of unknown etiology. Swelling and erythema were noted in a segment of small bowel in the right lower abdomen. A tiny sharp-pointed object was found penetrating the inflamed portion of the bowel. This foreign body was removed and the perforation immediately repaired under laparoscopic guidance. The postoperative course was uneventful. We believe that in cases of lower abdominal pain with peritoneal irritation, laparoscopy can provide not only a wide field of examination to localize intraabdominal pathology, but in some instances it can aid in case management.     

Laparoscopically assisted treatment of acute abdomen in systemic lupus erythematosus

The incidence of abdominal pain in patients with systemic lupus erythematosus (SLE) is very high. Most patients do not require surgical treatment (serositis). Some cases such as appendicitis, perforated ulcer, cholecystitis or, rarely, intestinal infarction are surgical. Differential diagnosis is difficult, partly because noninvasive examinations do not provide enough evidence to rule out a diagnosis. On the other hand, in patients with SLE who have acute abdomen, it is dangerous to delay surgery by attempting conservative therapy. In fact, a better survival rate has been associated with early laparotomy. We report a case of acute abdomen in a patient affected by SLE, in which the diagnostic problem was solved by means of laparoscopy and the treatment was laparoscopically assisted. A 45-year-old woman with a 25-year history of SLE was admitted with abdominal pain and fever. Her physical examination revealed a painful right iliac fossa with rebound tenderness. Her WBC count was normal. Abdominal x-ray, ultrasonography, paracentesis, and peritoneal lavage did not provide a diagnosis. A diagnostic laparoscopy was performed, showing segmentary small bowel necrosis. The incision of the umbilical port site was enlarged to allow a small laparatomy, and a small bowel resection was performed. The histopathologic finding was "leucocytoclasic vasculitis, with infarction of the intestinal wall." The patient recovered uneventfully. In conclusion, this case report shows that emergency diagnostic laparoscopy is feasible and useful for acute abdomen in SLE. Currently, this diagnostic possibility could be considered the technique of choice in these cases, partly because, when necessary, it also can allow for mini-invasive treatment therapy.     

Acute pelvic inflammatory disease as a rare cause of acute small bowel obstruction

Introduction: Small bowel obstruction (SBO) is a common presentation to emergency abdominal surgery. The most frequent causes of SBO are congenital, postoperative adhesions, abdominal wall hernia, internal hernia and malignancy.

Patients: A 27-year-old woman was hospitalized because of acute abdominal pain, blockage of gases and stools associated with vomiting. Abdominal computed tomography showed an acute small bowel obstruction without any obvious etiology. In view of important abdominal pain and the lack of clear diagnosis, an explorative laparoscopy was performed. Diagnostic of pelvic inflammatory disease was established and was comforted by positive PCR for Chlamydia Trachomatis.

Results: Acute small bowel obstruction resulting from acute pelvic inflammatory disease, emerging early after infection, without any clinical or X-ray obvious signs was not described in the literature yet. This infrequent acute SBO etiology but must be searched especially when there is no other evident cause of obstruction in female patients. Early laparoscopy is mostly advised when there are some worrying clinical or CT scan signs.     

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.     

Laparoscopy in the management of children with chronic recurrent abdominal pain.

BACKGROUND AND OBJECTIVES: The purpose of the present study was to evaluate the results of diagnostic laparoscopy in children with chronic recurrent abdominal pain. PATIENTS AND METHODS: Thirteen children with chronic recurrent abdominal pain were subjected to diagnostic laparoscopy. Ages varied from 10 to 17 years. There were six males and seven females. Abdominal pain was present from 3 weeks to 12 months (mean, 2 months). Extensive laboratory and imaging studies did not contribute to the diagnosis. In all patients, the pain was disabling and severe enough to warrant repeated visits to the pediatrician, emergency room visits, or hospital admissions, as well as absence from school. RESULTS: All children recovered uneventfully. Laparoscopic findings that identified the cause of abdominal pain were obtained in 12 of 13 patients. Laparoscopic appendectomy was done in all patients. There were no operative complications. One child presented three months later with incomplete small bowel obstruction, which resolved with conservative management. There were no other postoperative complications. Follow-up varied from six months to three years. Abdominal pain resolved in ten patients. One patient presented eight months later with biliary dyskinesia. She improved following laparoscopic cholecystectomy and later on sphincterotomy, but her pain has not yet completely resolved. One patient presented six months later with abdominal pain secondary to intestinal adhesions. Her pain completely resolved after laparoscopic lysis of adhesions. A third patient who developed lower abdominal pain six months after laparoscopy improved with conservative management and antibiotics for pelvic inflammatory disease. CONCLUSIONS: Diagnostic laparoscopy is a valuable procedure in the management of children with chronic recurrent abdominal pain. In the present study, laparoscopic examination revealed the cause of abdominal pain in most patients, and this pain resolved in most cases. Based on our experience, we recommend diagnostic laparoscopy early in the course of debilitating chronic recurrent abdominal pain in children. Appendectomy should be done when no other significant cause of abdominal pain has been identified, even if the appendix looks normal.     

Laparoscopic management of a primary small bowel volvulus: a case report

Primary small bowel volvulus in adults is a very rare condition, and it is defined as torsion of all or a large segment of the small intestine and its mesentery in the absence of any preexisting etiologic factors. Proper management of the patients suffering from a strangulated obstruction depends on making an early and accurate diagnosis. Timely treatment is crucial to prevent gangrene. A 49-year-old man who had a history of previous abdominal surgery was admitted to our hospital with complaints of acute abdominal pain. Simple abdominal x-ray showed multiple dilated loops of small intestine in the mid-abdomen. Enhanced abdominal computed tomography showed the distended small bowel loops and longitudinal tapering of the collapsed bowel loops. We carried out diagnostic laparoscopy to confirm the cause of suspected mechanical ileus. It revealed strangulation of the small bowel at the terminal ileum due to clockwise torsion of the bowel loop. There were no adhesions or congenital anomalies in the peritoneal cavity. The torsional segment was spontaneously reduced with minimal handling, and the strangulated portion was resected. The patient was discharged from hospital on postoperative day 6. Primary small bowel volvulus in adults is a very rare malady; if the diagnosis is uncertain, then diagnostic laparoscopy is a valuable tool for making the definitive diagnosis and administering prompt treatment.     

Congenital band of the vitelline artery remnant as a cause of chronic lower abdominal pain in an adult: Case report

INTRODUCTIONIntraabdominal bands of the vitelline vessel remnant are the rarest form of congenital mesodiverticluar bands which may or may not be associated with Meckel's diverticulum. In the majority of cases they cause an acute abdominal disease such as intestinal obstruction, especially in children.PRESENTATION OF CASEWe report a case of a 64 year old gentleman who experienced recurrent episodes of abdominal distension and bloating over two years. Computed tomography of his abdomen, colonoscopy, and barium follow through were all normal. Diagnostic laparoscopy revealed a single band adhesion stretching between the distal ileal mesentery and the anterior abdominal wall near the umbilicus.DISCUSSIONCongenital vascular bands are established causes of acute intestinal obstruction especially in children but are relatively uncommon. Their role in chronic abdominal pain is rare and diagnosis is difficult preoperatively. Pain in the patient was most likely due to recurrent partial twisting and untwisting of the bowel around the band.CONCLUSIONThis case not only highlights an unusual cause of chronic abdominal pain, but also the effectiveness of laparoscopy as a diagnostic tool in such patients.     

Cecal splenosis mimicking gastrointestinal stroma tumor. Case report and review of the literature

IntroductionAbdominal splenosis is a rare condition where autotransplanted ectopic spleen tissue is found in the abdominal cavity after spleen injury or splenectomy. While abdominal splenosis is mostly described as asymptomatic, bowel splenosis can present with abdominal pain, obstipation or gastrointestinal (GI) bleeding. Scarce information on bowel splenosis exists and high index of suspicion is needed for diagnosis. We present the case of a patient with abdominal pain and a cecal mass mimicking gastrointestinal stroma tumor (GIST) found to have bowel splenosis after laparoscopic resection.Presentation of caseA 45-year-old female was evaluated for a 6-month history of abdominal pain in right-lower quadrant. She had past medical history of blunt abdominal trauma and splenectomy 35 years before symptoms. An abdominal contrast-enhanced computed tomography (CT) reported a 4.2 × 4.6 × 4.6 cm solid mass located in the antimesenteric border of the cecum, with calcifications and arterial enhancement. Colonoscopy found no epithelial lesions. A diagnostic laparoscopy was done, and resection of the mass achieved. Transoperative histopathological diagnosis revealed ectopic spleen tissue.DiscussionIt is difficult to know whether abdominal pain in bowel splenosis is actually triggered by splenosis itself or by an unrelated cause, making diagnosis incidental. There are no particular imaging findings suggestive of splenosis, and surgical resection is often done under uncertain diagnosis.ConclusionBowel splenosis could present as abdominal pain variable time after spleen injury or splenectomy. Clinical features and imaging characteristics are nonspecific and similar to those of GIST. Most cases of splenosis are diagnosed after surgery.     

Diagnostic laparoscopy for chronic abdominal pain after gastric bypass.

BACKGROUND: To evaluate, in an observational study, the utility of diagnostic laparoscopy as a tool to evaluate patients with abdominal pain of unknown etiology after gastric bypass surgery. METHODS: A retrospective analysis was performed of data from patients who had undergone laparoscopy for diagnosis or treatment of abdominal pain. This study included 13 patients with negative preoperative radiographic and/or endoscopic findings. RESULTS: A total of 13 patients who had undergone Roux-en-Y gastric bypass underwent diagnostic laparoscopy for abdominal pain. The findings included internal hernia (4), adhesions (3), ventral hernia (2), partial small bowel obstruction (1), and chronic cholecystitis (1). There were 2 negative laparoscopies, while a diagnosis was made in 85%. After an average follow-up of 3.2 months, 7 of 11 patients had unresolved abdominal pain and 4 patients experienced pain resolution (2 patients were lost to follow-up). CONCLUSION: The results from this small retrospective study suggest that significant pathologic findings can be identified in most patients who have negative preoperative evaluation findings; however, the efficacy of diagnostic laparoscopy to eliminate pain in this patient population requires additional study. Despite the potential complications, we believe that diagnostic laparoscopy has a role in the diagnosis and treatment of chronic abdominal pain after gastric bypass.