The Role of Laparoscopy in Acute Care Surgery

Hakan Yanar MD,Associate Professor of Surgery

Istanbul University, Istanbul Faculty of Medicine, Istanbul, Turkey

ISW, August 28→September 1, 2011,Yokohama, Japon

Role of Emergency Laparoscopy

• Laparoscopy in Non-Trauma AbdominalEmergencies

• Laparoscopy in Trauma

• Diagnostic

• Therapeutic

Diagnostic laparoscopy

• Acute abdominal pain of unknown etiology

• Generalized peritonitis

• Diagnostic laparoscopy after operations orinvasive procedures (po extraordinary pain, post colonoscopy…)

• Sepsis of unknown origin

• Appendicitis and cholecystitis

• Perforated viscus and peritonitis

• Small bowel obstruction due to adhesions

• Drainage of abcess (acute diverticulitis)

• Diagnostic for mesenteric ischemia

• Trauma →Solid organ injury, diaphragmaticinjuries

Therapeutic laparoscopy

Physiologic contraindications

• Cardiac “The heart is the Achilles heel of every laparoscopic operation”

• Pulmonary

• Haemodynamic instability

Technical contraindications

- Lack of working space

- Lack of expertise (surgeon-anesthesia)

- Lack of specialized equipment

Advantages

-Decreased po pain-Less abdominal wall complication-Better visualization -Cosmetically better outcome-Lower intra-operative and post operative complications

-Early return to work-Early mobilization

Warren O, et al. World J Emerg Surg 2006

Basic technical tips and tricks

Triangulation

Working space

Safe entry

Veress needle!!!

Hasson technique

Choice of the right tool

Hemostasis

Laparoscopic suturing

Exploration of small intestine

Douglas pouch exploration

Ectopic pregnacyTubal ruptureOverian cyst torsionSalpingo-oophoritisPyosalpenx

Acute Cholecystitis

- 70 patients randomized to lap vs open

-Median operating time was longer for lap: 90 min (30-155) vs 80 min (range 50-170) in open

-Hospital stay shorter in laparoscopic group (P = 0.011)

-No difference in the rate of post op complications, pain score at discharge , direct costs, sick leave.

Conclusions: open and lap for cholecystitis equivalent

Johansson M. et. al Dig. Surg. 2004

Acute Cholecystitis

- Laparoscopic approach gold standard

- “Get them while they are hot”

(within 72 Hours) J Hunter, Ann Surg

Appendicitis

Sauerland , Cochrane Review 2005

54 randomized studies, total 5000 pts, LA vs OA

- Wound infections were less likely after LA than after OA (OR 0.45; CI 0.35 to 0.58)

- Incidence of intraabdominal abscesses was increased (OR 2.48; CI 1.45 to 4.21).

- Hospital stay was shortened by 1.1 day (CI 0.6 to 1.5)

- Conclusions: Slight advantage for lap

Perforated Peptic Ulcer

• 5 % of abdominal emergencies

• First reports of laparoscopic approach-1990

PUP, two large high quality randomized studycomparing open vs laparoscopy

• Lau WY et al. Ann Surg, 1996 Total hospital stay Time to resume normal diet Reoperation Mortality no benefit

• Siu WT, et al. Ann Surg, 2002 Less po pain Shorter operating time Decrease morbidity and mortality

(1.5% lap vs 5 % open)

Katkhouda N, et al Archives of Surgery 1999Prospective data from 30 lap compared to

matched group of 16 open

Analgesics lap < open ( 3 /9 doses, p=.002)

Length of stay lap < open (3 / 8 days , p=.003)

Return to work lap< open (21 / 30 days, p=.001)

takes longer to perform

Emergency laparoscopy in pregnancy

SAGES : not a contraindication

- Preferably in the 2nd trimester

( some data confirms safety in all trimesters)

- Pneumo pressure low at about 10-12

- Hasson technique

- Fetal monitoring

- Shielding of uterus

Mesenteric ischemia- diagnosis andsecond look

World Journal of Gastroenterology 2007 Jun 28;13(24):3350-053.

Trauma

• Blunt

• Penetrating

Diaphragmatic injurydiagnosis and treatment

Hollow viscus injury-gastric injury

Hallow viscus-transvers colon injury

Conclusion

• For pts with abdominal emergencies, thelaparoscopic approach provides diagnosticaccuracy and therapeutic options,

• Avoids extensive preoperative studies,

• Averts delays in operative intervention,

• Appears to reduce morbidity.

Thank You !