In today’s modern world of surgery, laparoscopy has major diagnostic as well as therapeutic role in many acute abdominal conditions. Abdominal emergencies have been managed increasingly by laparoscopy, including peritonitis. This study was undertaken to evaluate our institution’s experience with Laparoscopic surgery as a safe and effective treatment for different acute abdominal conditions.
Design: A descriptive prospective study.
Place and Duration of Study:
Ghulam Muhammad Mahar Medical College and Hira Medical Center Sukkur, during a period of last 2 years, from Jan: 2008 to Dec: 2009.
Patients & Methods:
This study included 350 patients undergoing Laparoscopic surgery for different acute abdominal conditions. Clinical data was recorded and routine investigations along with plain X-ray abdomen, ultrasound abdomen and C.T scan were carried out. The procedure performed, and its complications and success rate noted.
Results:
In our department, a prospective study was performed in 350 patients with acute abdomen (with no signs of well-established intestinal obstruction or perforation on plain X-ray and ultrasonography). All the patients underwent diagnostic laparoscopy except those patients who had already diagnosed clinically and on ultrasonography as acute calculus Cholecystitis or appendicitis. Among 350 patients there are 100 (28.57%) males and 250 (71.42%) females. The age of patients ranged from 16 – 70 years. The open conversion rate in case of Laparoscopic cholecystectomy is 2%. Patients with acute calculus cholecystitis, empyema, mucocele, and acute pancreatitis were managed by laparoscopy successfully with minimal complications. Cases other than Laparoscopic cholecystectomy were also done successfully with minimal complications.
Conclusion:
Laparoscopy has gained widespread acceptance in acute abdomen as a diagnostic and therapeutic tool. It is cost effective and safe with less postoperative morbidity.
Keywords: Acute abdomen, Laparoscopy, Liver abscess and trauma.
INTRODUCTION:
The acute abdomen is characterized by the sudden appearance of abdominal complaints that oblige the surgeon to decide promptly whether to operate immediately, to treat conservatively or to observe the patient. In spite of new diagnostic developments, such as ultrasonography and computed tomography (C.T.), it seems that acute abdominal conditions present situations in which a surgeon dares to open an abdomen without a clear diagnosis. With the only exception of haemodynamic instability caused by the abdominal condition, this situation is changing in the surgical community: a proper pre-operative diagnosis can lead to better and more specific surgical treatment and to an improved approach.
In surgical practice, all acute abdominal conditions can be divided into four categories:
local peritonitis, such as acute appendicitis or acute Cholecystitis;
perforation of a hollow organ such as duodenal ulcer or acute diverticulitis;
generalized peritonitis of uncertain aetiology without perforation or intestinal obstruction, such as intestinal ischaemia, acute pancreatitis, peritoneal or pelvic collection followed by PID or primary peritonitis in females; and
intestinal obstruction.
The acute abdomen can be diagnosed by the help of plain radiography, ultrasonography or C.T scan. But these diagnostic tools are not always conclusive. Morever a clear diagnosis, if possible, is important in order to plan right abdominal approach or to avoid an unnecessary Laparotomy. Diagnostic laparoscopy is the only technique which can visualize the abdominal cavity and by establishing an adequate diagnosis, permit the surgeon to plan the proper surgical procedure. Laparoscopy may be used for the treatment of intestinal obstruction. Bands or adhesions and internal hernias may be approached laparoscopically. Conversion remains around 40% with high possibility of enterostomies, recognized or not. With growing experience and strict indications a laparoscopy seems sound practice in work-up of the patients with intestinal obstruction.1 In spite of the accumulating evidence of the benefits and safety of laparoscopic surgery in acute abdomen, little objective evidence exists concerning clinical practice among Pakistani surgeons. The aim of this study was to analyze the current laparoscopic management of patients admitted with acute abdomen and to evaluate our institution’s experience with laparoscopic surgery as a safe and effective treatment of acute abdomen.
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PATIENTS AND METHODS:
This is a descriptive prospective study. This study includes 350 cases undergoing laparoscopic surgery for acute abdominal conditions at Ghulam Muhammad Mehar Medical College, and Hira Medical Centre Sukkur, during a period of last two years (Jan, 2008 to Dec, 2009). In our department, the patients were admitted in emergency with acute abdomen (with no signs of well-established intestinal obstruction or perforation on plain X-ray and ultrasonography). The patients underwent diagnostic laparoscopy after initial resuscitation and investigations, except those patients who had already diagnosed clinically and on ultrasonography as acute calculus Cholecystitis or appendicitis. The patients of acute abdomen with haemodynamically unstable condition were excluded from the study. Clinical data was recorded and routine investigations along with plain X-ray abdomen, ultrasound abdomen and C.T scan were carried out. Nature of the procedure was explained and consent for open conversion was also taken. All clinical data, investigations, operative findings and post-operative complications were recorded. The data was compiled and results drawn. Operations were carried out under general anaesthesia with antibiotic prophylaxis of cefotaxime (Claforan) 2 grams daily for initial 2 to 3 days.
RESULTS:
Among 350 patients there are 100 (28.57%) males and 250 (71.42%) females. The age of patients ranged from 16 – 70 years. Out of these 350 cases, majority are of Laparoscopic cholecystectomy for acute gall bladder disease i.e. 200 (57.14%), Laparoscopic appendicectomy 65 (18.57%), Ruptured / leaking liver abscess 10 (2.85%), Ruptured ovarian cysts 4 (1.14%), Ruptured ectopic pregnancy 10 (2.85%), Splenic abscess 2 (0.57%), Abdominal or Pelvic abscesses 20 (5.71%), Blunt abdominal trauma (grade-I to III liver injury and omental bleed) 20 (5.71%), Perforated peptic ulcer 4 (1.14%), Perforated diverticulitis 1 (0.28%), intestinal obstruction 4 (1.14%), and negative diagnostic laparoscopy 10 (2.85%).
Table I: Acute abdominal conditions managed laparoscopically are as under:
Acute abdominal conditions
No: of patients
%
Acute gall bladder disease
200
57.14
Appendicitis
65
18.57
Ruptured Liver abscess
10
2.85
Splenic abscess
2
0.57
Abdominal/ pelvic abscess
20
5.71
Blunt abdominal trauma
20
5.71
Ruptured ectopic pregnancy
10
2.85
Ruptured Ovarian Cysts
4
1.14
Perforated peptic ulcer
4
1.14
Perforated diverticulitis
1
0.28
Intestinal obstruction
4
1.14
Displaced Copper-T
1
0.28
1. Acute gallbladder disease is a common surgical emergency. In the pre-laparoscopic era, standard management of acute Cholecystitis involved treatment with intravenous fluids and antibiotics followed by delayed open cholecystectomy. Nowadays early laparoscopic cholecystectomy is the treatment of choice. Laparoscopic Cholecystectomy was done for acute gallbladder disease in about 200 patients, like acute calculus Cholecystitis (103), acute calculus Cholecystitis with acute pancreatitis (21), empyma gall bladder (62), gangrenous gall bladder (08), and perforatd gallbladder (06) with open cnversion of only 4 cases and minimal complications.
Table II:Different conditions for acute gallbladder disease managed laparoscopically:
Conditions of acute gallbladder disease
No: of patients
%
Management/ Outcome
Acute calculus cholecystitis
103
51.5%
Managed successfully.
Acute calculus cholecystitis with acute pancreatitis
21
10.5%
No complications
Empyema / mucocele
62
31%
Recovered fully
Gangrenous gallbladder
8
4%
Uneventful recovery
Perforated gallbladder
6
3%
Table III: Results of Laparoscopic Cholecystectomies for Acute Gallbladder Disease:
Difficulties / Complications
No. of patients
Percentage
Reasons / management
Open conversion
04
2%
Fibrosed gallbladder with cholecystoduodenal fistula.
Thick adhesions
CBD injury with small rent, managed by T-tube.
Mirrze syndrome
Avulsion of cystic duct
6
3%
Four managed by suturing/ligation
Two by clipping with no complication
Avulsion of cystic artery
10
5%
Managed by clipping / diathermy
Bleeding from liver bed
36
18%
Managed by diathermy, sponge stone, Argon beam spray.
Difficult dissection at callot’s triangle
100
50%
Done by blunt and sharp dissection successfully with no complications
Spillage of bile and stones during procedure
53
26.5%
Managed intraoperatively by picking up stones and irrigation/ suction. No late complications noted.
Post-op biliary collection
4
2%
One case U/S guided drainage.
Two cases managed conservatively.
In one case, open drainage done.
Infra umbilical port infection
12
6%
Managed by application of pyodine
Port site serous discharge
25
12.5%
Managed by application of pyodine.
Retained CBD stones
2
1%
By ERCP retrieval of stones.
Gut / solid visceral injury
0
0%
–
Post-op abdominal pain
35
17.5%
Managed by analgesics.
Post-op jaundice
3
1.5%
Two were because of retained CBD stones and one because of medical cause (hepatitis).
2. Laparoscopic appendicectomies were done in 65 patients successfully but in two cases, patients developed prolonged paralytic ileus for upto 3 days. Five cases were converted into open because of thick adhesions of appendix with caecal wall and difficulty in dissection. No complications of faecal fistula, slippage of ligature or mesoappendix bleeding were found. No post-op collection or any other complications noted.
3. Ruptured liver abscesses drained laparoscopically in 10 patients with success. Only one patient developed further collection and generalized peritonitis for which laparotomy and drainage was done on 5th postoperative day.
4. Ruptured ovarian cysts in 4 patients causing acute abdomen were excised laparoscopically with no post operative complications.
5. Ruptured ectopic pregnancies were managed in 10 hemodynamically stable patients successfully. No post-operative complication was found.
6. In two cases of splenic abscess, drainage was done laparoscopically with no complications and preservation of spleen.
7. Abdominal or Pelvic abscesses in 20 patients followed by acute pancreatitis, intestinal tuberculosis, PID or primary peritonitis in female patients were drained and peritoneal toilet done. Patients recovered completely.
8. In 20 cases of Blunt abdominal trauma with hemodynamically stable patients, diagnostic laparoscopy and Laparoscopic drainage of blood (of about 1 – 1.5 litters) done. Grade-I to III liver injuries, splenic injury grade-I and omental/ mesenteric bleeding were managed successfully. Open conversion was done in three patients with associated jejunal perforation, one patient with ileal perforation and one with uncontrolled bleeding from mesentry.
9. Laparoscopic removal of displaced copper-T in one young female patient of about 35 years was done. Patient recovered completely.
10. In four patients with perforated peptic ulcer, laparoscopic omentopexy was done. Patients recovered completely with no complications.
11. Four patients with Intestinal obstruction were managed laparoscopically. The recovery of patients was uneventful.
DISCUSSION:
In today’s modern world of surgery, laparoscopy has major diagnostic as well as therapeutic role in many acute abdominal conditions. Diagnostic laparoscopy should be performed in all patients with signs of a generalized acute abdomen in whom no clear cause is suspected after clinical, radiological, and laboratory investigation. A correct diagnosis will dictate the right surgical approach2. Laparoscopic surgery is superior and beneficial to open surgery. Open surgery may result in increased post-operative pain, delayed mobility, prolonged hospital stay, adhesion formation and incisional hernia.3 On the contrary, after Laparoscopic surgery patient returns to home and work early.
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Laparoscopy in acute abdominal conditions is a useful technique with important therapeutic consequences and in some cases laparoscopy will help to avoid an unnecessary laparotomy. Information from diagnostic laparoscopy led to a change in the surgical approach, e.g. limited, well-placed approach, laparoscopic surgery, or avoidance of an unnecessary laparotomy. The advantage of laparoscopy is not only cosmetic but also the decrease in operative trauma, which will also reduce frequent wound infections as well as the resulting incisional hernias.1
In this study, total number of cases is 350, but majority of these cases are Laparoscopic cholecystectomy for acute gallbladder disease, which were performed successfully with minimal complications. The cases of gallstones with acute cholecystitis, acute pancreatitis, mucocele, empyema and gangrenous gallbladder were performed laparoscopically with success. More recently, there has been a move towards performing Laparoscopic cholecystectomy in the acute setting to shorten both operative time as well as length of hospitalisation. In this sub-group of patients in which Laparoscopic cholecystectomy was done successfully within 48 – 72 hours of onset of symptoms, only one case was converted into open because of thick adhesions of omentum all around the gallbladder and difficulty in adhesiolysis.
The open conversion rate 2% in this series is better in comparison to 6.9%.4 In one of the local series it was found 12.73% in acute cholecystitis, in others 2%, 6% and 14%.5 The conversion rate of elective laparoscopic cholecystectomy was significantly lower than that of emergency laparoscopic cholecystectomy at first admission or readmission (8.3 versus 11.5 %; P < 0.001)6
Typical mishaps of laparoscopic surgery are reviewed according to the literature. Set-up of the pneumoperitoneum (morbidity upto 0.2%) bleeding from trocar sites and vascular injury (mortality upto 0.2%), biliary leaks and bile duct injuries (0.2% – 0.8%) are the main complications.7 In this study, only 1 case of common bile duct injury was reported (0.5%) which was managed by open conversion and T-tube placement.
Intraoperative non-biliary injuries (duodenal perforation, diaphragmatic injury, small bowel injury, portal vein injury, liver laceration) during Laparoscopic cholecystectomy occur as frequently as biliary injuries and can be life-threatening and difficult to manage.8 In this study it is zero may be because of that all trocar cannula were inserted under direct vision by using Hassan’s technique instead of veress needle.
Laparoscopic inspection of abdominal cavity enables the surgeon to diagnose acute appendicitis accurately. Moreover, it has been showed that leaving an appendix that appears normal during laparoscopic inspection is safe.9 If a normal appendix is left in situ during diagnostic laparoscopy, the number of unnecessary appendicectomies will decrease, particularly in fertile women (17-45%) and establish the correct diagnosis to allow prompt and appropriate treatment. In this study appendicectomy was done in 65 (18.57%) patients with suppurative appendix and abscess in 25 patients (38.46 %) while normal appendix was found in 7 (10.76 %) fertile female patients. The diagnosis of PID/ primary peritonitis was confirmed in these 7 patients on diagnostic laparoscopy. Sauerland et al.10 looked at the diagnostic and therapeutic effects of laparoscopic and conventional ‘open’ surgery and concluded that diagnostic laparoscopy reduced the risk of a negative appendicectomy especially in fertile women and laparoscopic appendicectomy is generallty recommended in patients with suspected appendicitis unless laparoscopy itself is contra-indicated or not feasible. Young female, obese, and employed patients seem to benefit especially from laparoscopic appendicectomy.
This study also included therapeutic laparoscopy for other acute abdominal conditions like ruptured liver abscess, splenic abscess, abdominal/ pelvic abscesses, removal of displaced copper T and blunt abdominal trauma successfully with less postoperative morbidity, a faster recovery and safety, with no conversion or intraoperative complications. Recovery after Laparoscopic surgery is generally fast.11
Laparoscopy was first used for evaluation of acute abdominal pain in pregnancy in 1980 by gynaecologists. The most commonly reported laparoscopic procedure done during pregnancy is laparoscopic cholecystectomy.12 Other procedures performed are for appendicitis, bowel obstruction, in adnexal mass, for ovarian torsion, ovarian cystectomy and ectopic pregnancy.13 In this study laparoscopic cholecystectomy was done in 12 (6%) pregnant patients in first and second trimester with acute calculus Cholecystitis, laparoscopic cystectomy was done in 4 (1.14%) patients with ruptured ovarian cysts(1 with torsion), and 10(2.85%) patients of ruptured eptopic pregnancy were managed laparoscopically with success and no complications.
Laparoscopy has gained widespread acceptance in surgical practice as a diagnostic and therapeutic tool. Abdominal emergencies have been managed increasingly by laparoscopy, including peritonitis.14-18 In generalized peritonitis, it is difficult to establish the correct diagnosis before laparotomy. A diagnosis is important in planning the right abdominal incision or to avoid an unnecessary laparotomy. Diagnostic laparoscopy will differentiate the type of perforation and guide the surgical treatment. Only haemodynamically stable patients are candidates for laparoscopic approach while haemodynamic instability is a contra-indication for laparoscopy.
The meta-analysis performed by Lau19 in 2004 of 13 studies suggests that laparoscopic repair of perforated peptic ulcer confers superior short-term benefits in terms of postoperative pain and wound morbidity. This approach is as safe and effective as open repair.19 The review performed recently by Lunevicius et al.,20 of 15 well-performed studies, concluded that laparoscopic repair seems better than open repair for low risk patients. In our study only 4 patients with perforated peptic ulcer were managed laparoscopically with no intraabdominal collection and open conversion. The hospital stay was 5 days. Thus Laparoscopic closure of perforated peptic ulcer, in experienced hands, confers superior short-term benefits in terms of postoperative pain and wound morbidity.1
In this study, diagnostic laparoscopy was done for an undiagnosed case of perforated diverticulitis, presented with acute abdomen. Peritoneal lavage was done laparoscopically for faecal contamination and cause was detected out, then loop sigmoid colostomy was made. The current standard approach for perforated diverticulitis is open surgery. A high morbidity and mortality are associated with this open approach in case of faecal peritonitis. Using the laparoscopic lavage, Myers et al21 reported a prospective multi-institutional study on the role of laparoscopic surgery in 100 patients with perforated diverticulitis of sigmoid colon with morbidity and mortality of 4% and 3 % respectively. Laparoscopic lavage and drainage in the acute management of perforated acute diverticulitis is a promising alternative to more radical procedures, including the Hartmann’s procedure.1
Laparoscopic reintervention after primary Laparoscopic surgery can be initiated as an early diagnostic tool to confirm the anastomotic leakage or to explore other causative pathology if patients do not improve as expected.22 Laparoscopic approach might be beneficial in the surgical management of intra-abdominal sepsis and result in fewer postoperative septic complications.23 Another important advantage of Laparoscopic intervention in such septic conditions of peritonitis are low mortality rate and minimal wound infection, early dehiscence and incisional hernia.21
The laparoscopy is also an effective procedure for the treatment of acute small bowel obstruction with acceptable risk of morbidity and early recurrence, but conversion rates of 30 to 40 % should be expected.1 In our study only four patients with small bowel obstruction were managed laparoscopically with success and no complications. Ghosheh et al.24 performed an extended search in the literature (Medline Database) using the keywords laparscopy and bowel obstruction. Their conclusion was that laparoscopy is an effective procedure for the treatment of acute small bowel obstruction with acceptable risk of morbidity and early reccurence.24 In the European Association for Endoscopic Surgery consensus statement on laparoscopy for absominal emergencies, Sauerland et al.25 give an evidence-based guideline on this subject.
CONCLUSION
Laparoscopic surgery now-a-days is superior and beneficial to conventional open surgery in majority of acute abdominal conditions. It is cost effective and safe, with less postoperative morbidity associated with less postoperative pain, short hospital stay, fast recovery, early mobilization, early return to diet and work and cosmetically with very small scar. But careful selection of patients, the knowledge of typical procedure related complications and their best treatment and the proper skill and training of surgeon about laparoscopy are the key points for a safe and successful Laparoscopic surgery.
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