Acute abdomen and role of laparoscopy

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Acute abdomen and role of laparoscopy

• Dr. Girish Juneja
• Head of Surgery Department
• Al Noor Hospital
• Airport Road, Abu Dhabi

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Acute Abdomen

• Undiagnosed pain that arises suddenly and is
  usually less than 48 hours

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Primary goal

• Management of patients with acute
• abdominal pain is to determine whether operative
  intervention is necessary and
• if, so, when the operation should be
• performed.

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• Most (at least two thirds) of the patients who
  present with acute abdominal pain have disorders
  for which surgical intervention is not required.

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• Clinical evaluation
• Tentative differential diagnosis
• Basic investigative studies
• Working diagnosis
• Acute abdominal crisis
• Suspected surgical abdomen
• Uncertain diagnosis
• Suspected nonsurgical abdomen

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Clinical evaluation

• History
• Use of standardized history and physical forms,
  with or without aid of diagnostic computer
  programs, has been recommended.

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Data sheets

• Sufficient evidence to support the routine use of
  data sheets

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Pattern recognition

• At least one third of patients with acute
  abdominal pain exhibit atypical features that
  render pattern recognition unreliable.

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Acute Abdomen Assessment
Obtain clinical history
Generate tentative differential diagnosis
Perform physical examination
Perform basic investigative studies
Generate working diagnosis
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Working diagnosis
Patient requires immediate laparotomy
Patient has suspected surgical abdomen
Diagnosis is uncertain
Patient has suspected nonsurgical abdomen
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Patient requires immediate laparotomy

• Ruptured abdominal aortic or visceral aneurysm
• Ruptured ectopic pregnancy
• Splenic rupture
• Major blunt or penetrating abdominal trauma and
  hemoperitoneum from various causes.
• Hemodynamic instability is the essential
  indication.

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Patient has suspected surgical abdomen
Patient requires urgent laparotomy or laparoscopy
Hospitalization and observation
Patient requires early laparotomy or laparoscopy
Patient is candidate for elective laparotomy or
laparoscopy
Diagnosis is uncertain, or patient has suspected
nonsurgical abdomen
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Diagnosis is uncertain
Patient should be hospitalized and observed
Patient can be evaluated in outpatient setting
Diagnosis is uncertain, or patient has suspected
nonsurgical abdomen
Patient has suspected surgical abdomen
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Patient has suspected nonsurgical abdomen
Patient should be hospitalized and observed
Provide narcotic analgesia as appropriate.
Observe patient carefully, and reevaluate
condition periodically. Consider additional
investigative studies.
Diagnosis is uncertain, or patient has suspected
surgical abdomen
Diagnosis is Nonsurgical
Refer patient for medical management
Reevaluate patient as appropriate
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Frequency of Specific DiagnosesOMGE Study
Diagnosis Frequency ( of Patients) Frequency ( of Patients)
Diagnosis Age lt 50 Yr (N 6, 317) Age gt 50 Yr (N 2, 406)
Nonspecific Abdominal Pain 39.5 15.7
Appendicitis 32.0 15.2
Cholecystitis 6.3 20.9
Obstruction 2.5 12.3
Pancreatitis 1.6 7.3
Diverticular disease lt0.1 5.5
Cancer lt0.1 4.1
Hernia lt0.1 3.1
Vascular disease lt0.1 2.3
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The Role of EMERGENCY LAPAROSCOPY

• Diagnosis has been the most important role
• Even when pre-operative diagnosis is certain,
  peritoneal assessment in the acute situation is
  important to assess the situation and avoid a
  missed diagnosis.
• Therapeutic procedures are done once the
  diagnosis is established.
• Convert to open surgery when indicated.

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Benefits
1. Accurate diagnosis of the pathology inside
the abdomen. 2.
Diagnosis and therapeutic surgery is possible at
the same time
3. Less post
op. pain
4. Faster recovery and short hosp. Stay
5. less post
op. complications like wound infection,Hernia
etc.
6. Cost effective in
working group
7. In Case of conversion more
suitable and better place incision
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Post Op Incision for Abdominal Trauma
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Benefits contd Acute abdominal emergencies are
diagnosed incorrectly or too late in 5-20 of
cases. This leads to 1.      Delay in
appropriate treatment 2.      Improper surgical
access route 3.      Repeat surgery This causes
higher morbidity and mortality, longer hospital
stay and recovery time which leads to higher cost
for the community
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Laparocopy has Better evaluation of the
peritoneal cavity then that obtained by the
standard laparotomy incision. It allows rapid
and thorough inspection of the paracolic
gutters and the pelvic cavity better than open
approach.
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RIF Supra-Pubic Pain Left Ovarian Cyst
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RIF Central Abdominal Pain Infarcted Omentum
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RIF Pain Infarcted Anterior Abdominal Wall Fat
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RIF Pain Endometriosis
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Intestinal Obstruction from Adhesion Band due to
Appendicitis, Laparoscopic Adhesiolysis
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Peritonitis Gangrenous Appendix with Pus in the
Pelvic Space
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Undiagnosed Ectopic Pregnancy presenting as
severe RHC Pain and Peritonitis
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EMERGENCY THERAPEUTIC LAPAROSCOPY

• Indications for Therapeutic Laparoscopy requires
  trained Laparoscopist
• Acute Cholecystitis
• Appendicectomy in High Risk Patient
• Adhesiolysis with Intestinal Obstruction
• Perforated Peptic Ulcer
• Other GIT Perforation
• Second Look e.g. for Bowel viability
• Drainage of abscess collections

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Laparoscopy allows more appropriate placement of
Incision following Diagnosis. Avoid double or
extended incision due to unexpected diagnosis
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Laparoscopic Appendicectomy Pregnant Patient
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Obstructed Hernia Assessment of Bowel Viability
Laparoscopic Repair
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Laparoscopic Repair of PDU
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EMERGENCY LAPAROSCOPIC PROCEDURES Conversion

• After Diagnosis
• Inexperienced to deal with problem
• Safer outcome with open Surgery
• Gangrene
• Ruptured / Bulky Tumour
• Hemorrhage

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EMERGENCY LAPAROSCOPIC PROCEDURES Conversion

• After attempt at Therapeutic Laparoscopy
• Difficult Tissue Planes with increased risk of
  injury
• Lack of Visibility to perform safe surgery
• Complications e.g. uncontrolled bleeding

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