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.