Laparoscopy In Abdominal Emergencies

LAPAROSCOPY IN ABDOMINAL EMERGENCIES

Dr.Anil Haripriya
In the last decade, the laparoscopic procedures have been used

extensively in an elective setting for both diagnostic as well as

therapeutic purposes. With increasing experience, the General

Surgeons at many centers have felt confident enough to undertake

evaluation of its role in the management algorithm of various

abdominal emergencies, both traumatic as well as non-traumatic.

Reasonable body of data has by now accumulated in the literature to

be able to take a critical look at the reported experiences and suggest

a possible role for this newly emerging diagnostic and therapeutic

modality in our setting. The term "abdominal emergencies "includes

cases of abdominal trauma as well as various non-traumatic cases

like perforated duodenal ulcer, acute appendicitis, intestinal

obstruction, acute abdominal pain of unknown etiology and abdominal

problems in pregnant patients and ICU patients.

This paper intends to look at the role of laparoscopy in the
management of all these conditions individually with a view to provide
answers to the following points:

· Currently practiced management algorithm and its
shortcomings.

· Reported experience in the literature.

· The feasibility and advisability of it's use in our setup.

Laparoscopy in abdominal trauma

Due to a significant rise in the number of road traffic accidents

and increasing violence, abdominal trauma is emerging as a major

cause of abdominal emergencies. The management algorithms are

different for blunt and penetrating abdominal trauma.

In patients with blunt abdominal trauma, evaluation of the

abdomen begins with a detailed clinical examination.

Hemodynamically unstable patients and those with obvious abdominal

signs are taken up for immediate exploratory laparotomy. However,

there are a large number of stable patients where abdominal signs are

equivocal. Often, the situation is complicated by associated alcohol or

other drug intoxication and head or spinal injury, which alters the

abdominal signs. Under these situations, additional tests such as

diagnostic peritoneal lavage (DPL), ultrasound (US) and

Computerised Tomography (CT) scan of the abdomen are usually

employed. In most surgical centers, DPL performed under local

anaesthesia in the emergency room has been the most often used

diagnostic modality for blunt abdominal trauma patients. Indications

for DPL include head injury, altered mental status (injury, drugs or

alcohol), an equivocal abdominal examination, unexplained

hypotension or instability of the patient and if a patient with major

trauma requires operation and general anaesthesia for another injury

like fracture etc. Positive DPL is based on the presence of 50,000 -

100,000 RBCs/ml, WBC >500/ml or presence of bile or fecal material

in the lavage fluid. The shortcoming of DPL is that it is a highly

sensitive test and in patients operated on the basis of a positive DPL,

13 - 25 % have been reported to have either a negative laparotomy

(NL i.e. no injury present) or a non-therapeutic laparotomy (NTL i.e.

injury present but does not need treatment) 1-5 . Similarly US and CT

scan have also been used in many centers in the recent past. Like

DPL, although these tests can tell about the presence or absence of

intra-abdominal injury, there continues to be a significant NL/NTL rate

despite the use of these modalities. Also, CT scan and US have not

been found to be very sensitive in detecting hollow viscus injuries.

Thus with the use of DPL, US and CT scan, although the pickup rate

for injuries has gone up very high, there continues to be an irreducible

rate of false positivity resulting in NL/NTL.

Penetrating abdominal injuries due to stab and gunshot wounds

are managed differently. The hemodynamically unstable patients and

those with obvious physical signs need immediate exploration. For

stable patients with stab injury, most of the institutions follow the

policy of local wound exploration for depth of penetration and if the

peritoneal breach is present, exploratory laparotomy is performed.

With this policy, different series have reported NL/NTL rate of 20 - 50

% 2-4. For gunshot wounds of the abdomen, most institutions follow the

policy of mandatory laparotomy, but it has been reported to result in

NL/NTL rate ranging from as low as 6 % to as high as 40 %
4,6,7
.Although an NL/NTL is preferable to a missed intra-abdominal

injury and delayed treatment with it's disastrous consequences, the

morbidity associated with these unnecessary explorations is

significant ( 5 - 22 % ) 4,8-12, apart from the pain inflicted on the patient

and the cost to the health-care system.

Thus it is obvious that in the management algorithm of the

abdominal trauma patients, there is need for a better screening

modality which can not only detect injuries with a high degree of

accuracy but can also differentiate between those requiring surgical

treatment and those requiring only conservative treatment.

Laparoscopy holds promise not only to allow this, but also offers

the additional possibility of therapeutic interventions - thereby

avoiding laparotomy altogether in some of those patients who

otherwise merited a laparotomy. Laparoscopy can achieve this with

minimal morbidity, much reduced pain to the patients and overall

reduced cost to the healthcare system.

The first report in the English literature about the use of

diagnostic laparoscopy in the setting of abdominal trauma was

published in 1976, much before the presently used miniature camera

and monitor system came into use. Gazzaniga et al 13published a

series of 37 trauma patients who underwent emergency diagnostic

laparoscopy. NTL were avoided in 10 of 24 patients with blunt

trauma. Based on the laparoscopy findings, the remaining 14 patients

underwent exploratory laparotomy with only one negative laparotomy

(7%). In 13 patients with penetrating injuries, 4 (30%) were spared

unnecessary laparotomies, The other 9 (70%) patients underwent

exploratory laparotomy on the basis of suspicious laparoscopic

findings. Four(44%) of these were therapeutic and 5 (56%) were

nontherapeutic, This high rate of NTL in this pioneering series was

possibly because the authors were near the beginning of their

learning curve and all these laparoscopies were performed looking

through the eye piece of the telescope i.e. without the benefit of

magnification, ease of operation and "team involvement" that the

currently used camera - monitor system offers.

Berci et al (1991)14 reported their retrospective experience with

150 emergency laparoscopies in blunt abdominal trauma patients,

performed in the emergency room under local anaesthesia. Based on

the laparoscopic findings ,they decided for immediate

laparotomy(19%),simple observation(25%) or early discharge (56 %)

of these patients..There was only one failure-a patient considered

suitable for conservative management on diagnostic

laparoscopy(DL)needed a laparotomy.The authors concluded that DL

for trauma patients is highly sensitive ,decreases the NTL rate and is

safe.

Fabian et al( 1993)15 reported a prospective analysis of 182

diagnostic laparoscopies for blunt as well as penetrating abdominal

trauma in hemodynamically stable patients with equivocal abdominal

signs. There were 99(55%) patients with abdominal stab

wounds,66(36%) patients with gunshot wounds and 17 (9%) patients

with blunt abdominal trauma. NL/NTL could be avoided in a significant

number of patients in all three groups on the basis of laparoscopic

findings. The authors concluded that laparoscopy is a safe diagnostic

modality for abdominal trauma patients. It is most effective in

evaluating patients with equivocal signs after penetrating injuries and

offers significant cost savings, especially if performed under local

anaesthesia.

Salvino et al( 1993 )16 reported on a prospective analysis of 75

patients of blunt as well as penetrating injuries and compared the

value of diagnostic peritoneal lavage and diagnostic laparoscopy(DL).

They concluded that although DL had no advantage over DPL as a

primary assesment tool in the blunt abdominal trauma patients, it's

main advantage was in patients with penetrating injuries.

Townsend et al (1993)17 studied the efficacy of DL in 15 patients

with solid organ injuries documented by CT scans. The DL identified 6

patients who needed urgent laparotomies, 2 with hollow viscus

injuries and 4 with continuing haemorrhage. One patient could not

undergo complete laparoscopic examination and underwent

laparotomy, which was negative. The remaining 8 patients were

successfully treated with conservative management on the basis of

their laparoscopic findings. The authors concluded that DL allowed

for successful nonsurgical management in 100% of their patients and

also identified patients in need of urgent laparotomy. `

Ivatury et al (1993)18 performed DL in 100

hemodynamically stable patients with penetrating abdominal injuries

and compared them with 407 laparotomies without laparoscopy.The

authors concluded that DL helped exclude peritoneal violation,

thereby avoiding unnecessary laparotomies. It was specially accurate

in detecting haemoperitoneum ,solid organ injuries, diaphragmatic

lacerations and retroperitoneal haematomas. The authors remarked

that DL has a definite role in the evaluation of penetrating abdominal

trauma patients.

Sosa et al (1995)10,19 reported their experience with DL in 121

consecutive haemodynamically stable patients with abdominal

gunshot wounds. By the conventionally used policy of "mandatory

laparotomy in gunshot wounds"- all patients would have undergone

exploratory laparotomy. Instead , all patients underwent DL and

82(68%) were spared unnecessary laparotomies on the basis of

laparoscopic findings. The remaining 39(32%) patients underwent

exploratory laparotomies,one of which was negative and 3 were

nontherapeutic. The authors concluded that DL is extremely useful in

patients with gunshot wounds , results in the lowest NL and NTL rate

and identifies patients needing urgent laparotomies.

Zantut et al (1997)20 reported a retrospective analysis of 510

haemodynamically stable patients of penetrating abdominal injuries

(316 stab wounds,194 gun shot wounds) from three large urban

trauma centers in Brazil. Laparotomy was avoided in 277 of these

patients(54.3%) either because of nonpenetration of peritoneum or

insignificant findings on laparoscopy.All were discharged uneventfully

after a mean hospital stay of 1.7 days.26 patients had successful

therapeutic procedures on laparoscopy ( diaphragmatic repair in 16

patients,cholecystectomy in 1,hepatic repair in 6 and closure of

gastrotomy in 3 patients) with uneventful recovery. In the remaining

203 patients, laparotomy was therapeutic in 155.Fifty two patients had

NTL for exclusion of bowel injuries or as a mandatory laparotomy for

penetrating gunshot wounds(19.7%). The overall incidence of NTL

was 10.2% . Complications were minimal and minor.The authors

concluded that DL has an important diagnostic role in stable patients

with penetrating abdominal trauma. In carefully selected patients,

therapeutic laparoscopy is practical, feasible and offers all the

advantages of minimally invasive surgery.

Hallfeldt et al (1998)21 have reported on DL in abdominal stab

wounds and concluded that DL offers an important diagnostic tool in

excluding peritoneal penetration, lowering the rate of unnecessary

laparotomies, with therapeutic laparscopy also being possible in

selected cases.

Marks et al (1997)22 performed cost effectiveness analysis of

DL Vs laparotomy in the evaluation of penetrating abdominal trauma

and concluded that total cost and length of stay were significantly

lower in patients who underwent DL as compared to laparotomy.

Numerous other reports 16,23-27 have also suggested that DL is

an important modality in evaluating trauma patients with suspected

abdominal injuries. These studies confirm that DL for trauma patients

is a safe modality that has the potential to decrease both NL as well

as NTL. It's greatest value is in patients with uncertain diagnosis even

after other diagnostic tests like DPL, US, and CT scan. There have

been suggestions that it may in fact be used as a primary diagnostic

tool, bypassing these conventional modalities 7.

Although doubts have been raised about the accuracy of DL in

detecting hollow viscus injuries, retroperitoneal injuries such as to the

pancreas and evaluation of spleen, others have suggested that with

the use of angled lenses, proper patient positioning and appropiate

manipulation of the operating table, an experienced laparoscopic

surgeon can appraise both the spleen and the bowel without difficulty
7
. However, it must be re-emphasised that laparoscopy should not be

performed in hemodynamically unstable patients and in those where

the diagnosis of a significant intra-abdominal injury requiring

exploratory laparotomy is obvious.

Laparoscpy for non traumatic abdominal emergencies

Acute appendicitis

Acute appendicitis is a common condition. Low threshold for

surgery based on clinical suspicion alone results in a significant

negative laparotomy rate especially in young women. On the other

hand delayed operation may result in perforation peritonitis with

serious consequences. DL in patients with suspected acute

appendicitis not only decreases the risk of appendicular perforations

but also reduces the number of negative laparotomies. It provides us

a tool not only to confirm or rule out appendicitis, but also offers the

possibility of inspecting other organs simultaneously to determine the

real cause of patient's symptoms 7. The two important group of

patients with suspected acute appendicitis who benefit most from DL

are the premenopausal women (in whom the differential diagnosis

with gynecological conditions is often difficult )and obese individual ,in

whom a large laparotomy incision is required to perform conventional

appendicectomy or to allow thorough inspection of the abdominal

contents 28. At laparoscopy, if the diagnosis of acute appendicitis is

confirmed, DL can be converted to therapuetic laparoscopy. The

indications for laparoscopic appendectomy 7,28-29 for patients

undergoing DL are (a)acute appendicitis confirmed, (b) large

appendicolith, (c) recurring condition such as crohn's disease or

endometriosis, (d) a normal examination as it may represent very

early appendicitis which is not grossly visible. Also ,it eliminates future

confusion should the similar pain recur in the patient. Ongoing

radiotherapy and an immunosuppresed patients are absolute

contraindication for laparoscopic appendectomy 7, whereas relative

contraindications include previous abdominal surgery, coagulopathy,

portal hypertension, appendicular abcess and pregnancy 7. In patients

with appendicular abcess, DL should be avoided as

pneumoperitoneum may disrupt the abcess cavity resulting in

contamination of the peritoneal cavity and septicemia. Patients with

acute appendicitis who have been managed conservatively, may be

considered candidates for laparoscopic interval appendectomy usually

after 6 weeks.

Thus it is clear that laparoscopy is safe and effective procedure

for establishing the diagnosis of acute appendicitis as well as removal

of the appendix. The best indication for DL in patients with suspected

appendicitis are premenopausal women (where the rate of negative

laparotomies is quite high) and very obese patients in whom a

laparotomy will require a relatively large incision.

Perforated duodenal ulcer

Patients with perforated duodenal ulcer require early recognition

and prompt treatment. It has a reported mortality of 0-10%. With delay

in treatment ,the mortality may go up to as high as 90% 7. A number of

reports in the literature 30-34 have shown the feasibility of diagnosing

and treating acutely perforated duodenal ulcers by laparoscopy. DL

can determine the type of fluid present in the peritoneal cavity and can

accurately locate the site of perforation in the majority of cases.

Following confirmation of diagnosis by DL, therapeutic maneuver i.e.

closure of the ulcer perforation can also be performed, if the surgeon

has advanced laparoscopic suturing and knotting skills. In one of the

earliest reports on laparoscopic management of perforated duodenal

ulcer, Memon and Brow32 showed that this procedure is technically

feasible if performed within 6 hours of perforation. However, in cases

with significant delay in diagnosis, laparoscopic repair may be difficult

and hazardous because of the edematous and friable duodenal wall
7,35,36
.

Laparoscopic repair of a perforated duodenal ulcer can be

achieved by simple closure 32, omental patch, use of fibrin glue 34,

placement of oxidised cellulose sponge 37, falciform ligament patch 38

or ligamentum teres patch39 . Most of the reports are in the form of

small, isolated case reports. Four recent papers 30,31,33,40 have

compared laparotomy and laparoscopy for treatment of perforated

duodenal ulcer. These studies have shown no benefits of laparoscopy

in terms of the length of hospital stay, time to resume normal diet,

visual analog pain score in the first 24 hours or early return to normal

activity, although the analgesic requirement in the postoperative

period was less in the laparoscopy group. Additionally the operating

time in the laparoscopy group was much longer. Others 7 ,however

have reported favorable experience especially in selected patients.

Thus it is obvious from the currently available literature that DL can

provide an accurate diagnosis in patients with perforated peptic ulcer

and can be used safely for the treatment as well in early cases.

However, till date none of the reports has shown any clearly

documented benefit of this procedure over conventional laparotomy.

Small bowel obstruction

Development of gangrene is one of the most feared

complications of small bowel obstruction (SBO). Patients with

complete SBO are at a much higher risk of developing this

complication, and need prompt surgical treatment whereas those with

a partial obstruction may resolve with conservative treatment. DL can

be helpful in distinguishing complete from a partial SBO 7. However,

during DL in SBO ,great care needs to be exercised to avoid injury to

the bowel during initial port placement as well as during manipulation

of the bowel. For initial port placement, open technique is

recommended and only atraumatic instruments should be used for

bowel handling. At DL , if we find single adhesive band, it is safe to

divide it laparoscopically to complete the procedure. However, in case

multiple or broad based adhesions involving multiple bowel loops are

discovered, laparoscopic adhesiolysis is technically demanding and

dangerous and it is safer to open the abdomen 7.

Duh 41 identified certain subset of patients of SBO who are likely

to benefit from laparoscopic management. These are patients with

mild abdominal distension allowing adequate room for visualization,

proximal obstruction, partial obstruction, single band obstruction and

obstruction which readily improves with nasogastric suction. Patients

with advanced, complete and /or distal obstruction are not candidates

for laparoscopic treatment. Patients with large bowel obstruction,

matted adhesions, carcinomatosis and those who do not respond to

conservative management (i.e. nasogastric suction) are also not

candidates for DL and should be managed by laparotomy. Several

authors 42-44 in the recent past have reported successful outcome

using DL in the "selected" patients as mentioned above. It has been

pointed out repeatedly that "careful patient selection" is the key to

successful outcome with DL in SBO patients 7,44.

Thus from the currently available data it is obvious that DL may

have a role in establishing an early diagnosis for patients with SBO. In

a selected subset of patients, laparoscopic adhesiolysis is also

possible. It has been suggested that in such patients, the long term

effects of successful adhesiolysis on the reformation of adhesions will

be favorable as compared to the laparotomy 7. However, long term

follow-up studies on larger number of patients are needed to justify

this statement.

pregnant patients with abdominal pain

Use of DL for evaluation of pregnant patients with acute

abdominal pain is an area of intense controversy. Whereas increasing

number of reports in the literature have attested to the safety of DL in

pregnancy if the pressure is kept low 28,45,46, others 47 have reported

increased incidence of fetal death in these patients as compared to

laparotomy. With the present state of knowledge ,it is prudent to

consider pregnancy a relative contraindication to DL until enough

clinical and laboratory data are available which indicate unequivocally

that no risk to the foetus exists 48.

ICU patients with abdominal pain

Intensive care unit patients are at an increased risk of developing a

number of acute intra-abdominal pathologies such as cholecystitis,

duodenal or gastric perforation, intestinal ischaemia, pancreatitis,

bowel obstruction and intra-abdominal haemorrhage. Presence of

multi-organ patholgy, equivocal abdominal signs and difficulty in

shifting these sick patients for conventional diagnostic modalities like

CT scan make accurate diagnosis difficult in these patients. In some

patients this delay in diagnosis may lead to either a delay in the

institution of appropriate surgical care or an unwarranted, non-

therapeutic laparotomy. This has prompted surgeons to evaluate the

role of DL in these critically ill patients. Several authors 49-51 have

reported their experience in the recent past in accurately diagnosing

the intra-abdominal pathology requiring surgical care, at the same

time excluding those who did not require surgical intervention. The

advantages of DL in these ICU patients include avoiding

transportation of the critically ill, often ventilator dependant patients(as

DL can be performed at the bedside in the ICU), rapid establishment

of correct diagnosis and avoidance of unnecessary ancillary tests.

However it is an invasive test that carries a small but definite morbidity

and has low sensitivity for intestinal or retroperitoneal diseases.

Nonetheless, DL is emerging as an important development in the

management of abdominal problems in critically ill ICU patients and

may become the first investigation of choice in future.

Suggestions

From above discussion it is obvious that in the last 10 years the

role of DL has been evaluated in the management of all types of

abdominal emergencies.Whereas the "feasibility "of performing it

safely and getting meaningful information has been proved beyond

doubt in most of the situations, the "advisability" (i.e. advantage over

conventional laparotomy) remains to be proved beyond doubt for most

of the causes of abdominal emergencies.This issue can only be

settled satisfactorily by well designed randomized trials recruiting

enough number of patients and by long term follow-up studies of

these patients.However, as per the currently available literature,

following guidelines can be followed:

Which patients should have DL ?

Only those patients with abdominal emergencies ( traumatic as well

as non-traumatic )who are hemodynamically stable and where the

diagnosis is still in doubt after a detailed clinical examination and

conventional investigations, should have DL.Hemodynamically

unstable patients and patients where a diagnosis requiring surgical

treatment is obvious, should not be taken up for DL. Although some

authors have suggested DL as the first investigation after clinical

examination i.e. in place of conventional investigations like DPL,US

and CT scan, under the present state of knowledge, I would

recommend it only as a part of a clinical trial and NOT for every

patient. These principles apply to all the causes of abdominal

emergencies discussed in the previous sections.

Who should perform DL for abdominal emergencies ?

It is obvious that DL in patients with abdominal emergencies is

technically very demanding and needs high degree of laparoscopic

skills on the part of the Surgeon to give the required , accurate

information.Therefore , it should only be performed by Surgeons who

have sufficient experience in elective laparoscopy for diagnostic as

well as therapeutic purposes.Any Surgeon who is in the learning

curve of his laparoscopy career should not attempt DL in abdominal

emergencies. Availability of laparoscopic suturing and knotting skills

is "desirable " as it will make therapeutic maneuvers possible in some

of the patients, avoiding laparotomy altogether. This will obviously

make laparoscopy more cost effective .

DL in abdominal emergencies should only be undertaken at

centers where the equipment and the instruments are available round

the clock and 'preferably' two surgeons with experience in

laparoscopy are available whenever a patient is taken up for

emergency DL.Needless to say that the 'Surgeon 'and the 'Center '

MUST be experienced and geared to handle any 'emergency' that

may arise during the performance of DL in abdominal emergency

cases.

Summary

Application of laparoscopy in the management of patients with

abdominal emergencies is an exciting , new development of this

decade which has opened tremendous possibilities for the future.

However, with the present state of knowledge, this new tool needs to

be used selectively:

* Only in patients who stand to benefit most from it as mentioned
in the previous sections,

* Only by the Surgeons who are well experienced in laparoscopic
surgery, and

* Only at the centers which have the requisite infra-structure.

It is also important that the data be recorded in an objective and

unbiased manner and reported accurately so that meaningful

conclusions could be drawn and definite guidelines could be laid down

for its more widespread use in the future.

Laparoscopy In Abdominal Emergencies

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