Laparoscopic Treatment of the Acute Abdomen
Abe Fingerhut
Mousa Khoursheed
I. Introduction
Minimal access techniques (including percutaneous, interventional radiology techniques) are used often in the emergency situation. Employed for emergency diagnostic and therapeutic procedures as early as 1991, laparoscopy now has gained a well-defined and often validated position in the armamentarium of management of acute abdominal diseases.
As the accuracy of imaging techniques has improved over the last few years, the need for laparoscopy as an isolated diagnostic tool without any indication for laparoscopic therapy has diminished. A wide array of laparoscopic therapeutic options is available; many well adapted to emergency surgery.
II. Definitions
Definitions vary for “acute abdomen,” “acute abdominal pain,” “acute care surgery,” “emergency,” or “urgent surgery.”
The acute abdomen is defined as any acute intra-abdominal condition of abrupt onset, usually associated with pain due to inflammation, perforation, obstruction, infarction, or rupture of abdominal organs, and usually requiring emergency surgical intervention.
Acute abdominal pain is defined as any medium or severe abdominal pain of less than 7 days duration.
Acute care can be defined as:
Medical treatment for individuals with short-term illnesses or health problems (National Caregivers Library)
Comprehensive patient management from emergency room arrival to hospital discharge and seamless 24/7 services
The distinction between emergency surgery (immediate life-saving operation, usually within 1 hour, with simultaneous resuscitation) and urgent surgery (operation performed as soon as possible after resuscitation, usually within 24 hours) is semantic as best, as the two terms have been used interchangeably in the literature. Most of the literature speaks of emergency surgery as any operation taking place during the acute phase of disease; ideally, as quickly as possible after stabilization.
Emergency admission, defined as an “unpredictable admission at short notice because of clinical need” by the NHS Data Model and Dictionary, accounts for 35% of total admissions on general surgical units; 9.7% of all emergency surgical admissions were for abdominal pain.
III. Operation Room and Ergonomic Considerations
As for any laparoscopic procedure, the ergonomic and technical aspects of minimal access surgery in emergency surgery are important issues and directly affect outcomes.
Patient
Positioned supine (dorsal decubitus) for most operations
One arm in abduction if need be for anesthesiology purposes
If not, both arms tucked alongside patient
Legs spread apart
Prepped and draped so that any unexpected findings or the need to convert to open surgery can be managed without delay
Insertion of a bladder catheter is a wise precaution
Surgeon position
Stands between the legs (“French position”)
Or on the side opposite the target organ
With possibility of moving around to gain access to all four quadrants of the abdomen as required
Operating room
The surgeon, scrub, and circulating nurses share the responsibility of:
Appropriate laparoscopic instruments and equipment setup, adapted to the envisioned procedure
Laparotomy instruments and equipment ready for use
Vascular surgery instruments and equipment within easy and rapid reach in case of bleeding
Monitor and screen position
Flat screen placed at 15 degrees below the eye level
Or at the gaze-down level (height at the level of the surgeon’s elbows)
Monitors should be mobile and moved according to the site of the pathology to keep the alignment necessary for optimal ergonomic conditions
Trocar setup
Should allow full and unrestricted exploration of the abdominal cavity, irrespective of the location of the underlying pathology
Initial trocar layout depends on preoperative clinical findings and diagnostic probabilities:
for acute abdominal pain predominating in the right lower quadrant, plan complete exploration of the pelvis and the genital organs as well as the appendix
In case of intestinal dilation (intestinal obstruction or ileus secondary to peritonitis or abscess), stay lateral to view the middle of the abdomen
Avoid previous scars (incisions or drainage sites)
Additional trocars can be added as needed
Unless prior abdominal surgery suggests otherwise, the first trocar can be inserted near the umbilicus
At least one trocar is necessary to manipulate, palpate, or move viscera for exploration
Insertion
We recommend the open approach for creation of pneumoperitoneum and insertion of the first trocar
If incidental enterotomy occurs, repair immediately
Laparoscope
The choice between the smaller 5 mm laparoscope should be weighed against the better lighting and view associated with the 10 mm scope
Both a 0-degree and a 30-degree (or greater) scope should be available
Essential instrumentation
Several 5, 10, and 12 mm ports
Atraumatic grasping forceps and clamps
Right-angle forceps
Titanium and absorbable clips
Two or more needle holders
An energy-driven (ultrasonic or bipolar) coagulation device
Traditional laparoscopic scissors
Powerful suction–irrigation device
Swabs
Umbilical tapes, rubber drains, tourniquets
Clamps and bulldog vascular clamps
Plastic bags for specimen extraction
As appropriate, never hesitate to change the optical device and manipulation instruments from one port to another, or to insert another trocar, to be able to view the entire field and maintain optimal ergonomic conditions
The peritoneal cavity is entered and explored in its entirety.
The cause of the acute abdomen is obvious (perforated appendix, ulcer, or sigmoid diverticulitis): Treat (see later, as appropriate).
The cause is not obvious.
Note the area of maximal inflammation, concentration of pus, or blood, as in the case of ruptured ectopic pregnancy.
Routine, systematic, and complete exploration is mandatory (check list highly recommended)
IV. Indications According to Disease
Peritonitis
Classical goals include source control, reduction of bacterial contamination, and prevention of persistent or recurrent infection
Source control can be accomplished laparoscopically in most cases (closure, resection)
Reduction of bacterial contamination
Use high pressure irrigation and suction devices.
Although lavage with saline has never been formally demonstrated in patients receiving adequate, systemic antibacterial therapy, adequate peritoneal irrigation is probably more important than the method of closure.
All gross purulent exudates, fecal debris, food particles as well as intraperitoneal lavage must be aspirated.
Addition of:
Antibiotics to the lavage solution of little benefit
Antiseptics, same remark and may even be detrimental
Ideal volume for lavage in peritonitis is not known:
Between 4 and 30 L recommended in the literature
Abdominal drainage as needed
Prevention of recurrence depends on the cause
Does not always require a radical solution (e.g., perforated diverticular disease)
The advantages of laparoscopic treatment of peritonitis, irrespective of the origin, include:
The possibility of full exploration of the abdominal cavity with minimal parietal insult, avoiding long incisions which carry a high rate of surgical site postoperative infection and incisional hernia
Most causes of peritonitis (perforated duodenal ulcer, perforated appendicitis, perforation in diverticular disease, postoperative leakage after index laparoscopic operations) can also be treated laparoscopically
If needed, stoma formation may be accomplished laparoscopically
Precaution: Maintain pneumoperitoneum pressures between 8 and 12 mm Hg, not higher
Acute appendicitis
Still a topic of much debate
Although readily feasible
Routine laparoscopic appendectomy costs are disproportionate to advantages
Main indication: Acute appendicitis (including perforated appendicitis, abscess, and peritonitis) that would normally require large incisions
Prevention of residual post-laparoscopic appendectomy abscess, reported to be higher in the literature for laparoscopic appendectomy, must be avoided
Complete abdominal exploration
Adequate lavage
Complete aspiration
Drains generally not required
Major advantages of the laparoscopic approach:
In the overweight or obese patient
In ectopic location of appendix
In fertile female when all other diagnostic methods are inconclusive
Debate as to how to best close the appendicular stump during laparoscopic appendectomy
Loop closure best
Staples
May reduce operative time and superficial wound (but not deep organ space surgical site) infections in difficult stump closure (when loop closure seems difficult or inappropriate [stump necrosis] or need for speed)
But should not be used routinely because of higher costs
Reversed conversion advocated by some (including this author):
Start with 10 to 12 mm horizontal incision in right iliac fossa (to perform appendectomy with classical laparotomy instruments)
Convert to laparoscopy through the 10 to 12 mm incision (called “reversed conversion”) if difficulty arises (ectopic appendix or perforated appendicitis with localized or generalized peritonitis) rather than to extend the incision or revert to a midline incision
Acute pelvic problems in the female
Ectopic pregnancy
Ideal setting for emergency laparoscopic surgery
Possible in the hemodynamically stable patient
Heparinized saline may be used in cases of large hematoma
Requires clinical experience and skills (intracorporeal suturing and knotting techniques), as well as specific equipment (vacuum, special suction probe) if the tubes are to be spared
Adnexal torsion
Readily treated laparoscopically
Perforated gastroduodenal ulcer
Particularly amenable to laparoscopic repair in the hemodynamically normal patient
Especially in patients without Boey risk factors (see Chapter 51)
Main advantages
Less postoperative pain
Less surgical site morbidity (no need for long incisions, or to extend the initial incision)
Treatment of choice: Closure of the perforation (more extensive operations are uncommonly needed in the era of adequate and effective medical treatment of Helicobacter pylori infection)
Definite need for adequate surgical skills and especially intracorporeal suturing techniques for closure, may be reinforced with fibrin glue, absorbable mesh, or omentoplasty
Closure may be accomplished with fibrin glue, omentum alone
A hybrid NOTES procedure consists of drawing the omentum through the perforation by means of an endoluminal endoscope
Two possible exceptions to simple closure
Those rare patients who are H. pylori negative
Or who cannot stop taking NSAID
Particular attention should be paid to the quality of closure to keep the reoperation rate low (reported to be higher with laparoscopic closure than with open repair when results of the controlled trials comparing the two approaches were analyzed together)
Laparoscopic treatment may be difficult/dangerous in patients:
With Boey risk factors
Ulcer diameter greater than
10 mm (risk factor for conversion)
Larger than 20 mm perforation (12% failure rate if simple suture techniques are employed)
The same therapeutic principles apply for gastric ulcer perforation: In this setting, however, a biopsy must be obtained to exclude carcinoma
Acute cholecystitis
Operative treatment of acute cholecystitis is cholecystectomy
However, cholecystectomy for acute cholecystitis can be challenging
Inflamed, thickened but fragile gallbladder wall
Adhesions of adjacent organs
Distorted anatomy
Main biliary ducts are at risk
Risk of common bile duct injury increased two- to five-foldRelated posts:
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