Urgent Early Laparoscopic Reassessment

George Ferzli MD, FACS

Professor of Surgery

SUNY Downstate

Introduction

• Urgent laparoscopy has two roles :

1)Diagnosis

2) Definitive therapy

Acute AbdomenDiagnostic and Therapeutic Laparoscopy

Authors Patients (n) Definitive diagnosis

Laparoscopic treatment

Conversion to Laparotomy

Agresta F, 2000 365 95.3% 88.2% 6.8%

Henry C, 1998 200 100% 87% 13%

Siragusa G, 1999 61 100% 96.7% 3.3%

Navez B, 1995 255 93% 73% 23%

Cueto F, 1997 107 100% 87.9% 12.1%

Cuesta MA, 1998 65 70% 20%

Salky B, 1998 121 98% 94.4% 17.5%

Laparoscopy for Acute Abdomen in Early Postoperative Period

Author, Year

No. of Patients

(n)

Timing (POD #)

Indication / Diagnosis

Bauer F et al.

19983 1 – 14 Fever, elevated WBC, peritoneal

signs. Tube misplacement or malfunction

Simon P et al. 2000

13 1 – 7 Pain (11), bleeding (2). Acute pancreatitis, SB injury, subhepatic hematoma, minor bile leak (6), unknown (2)

Pecoraro A, Ferzli G et al. 2001

4 1 - 7 Abdominal pain, sepsis. Fibrinous exudate (2), unknown (2)

Indications for Early Laparoscopy

• Sepsis/Peritonitis from perforated viscus, bile leakage, or leaking anastomosis

• Obstruction from adhesions, technical error or intussusception

• Bleeding from splenic trauma during colon resection, liver bed or cystic artery s/p lap chole

• Failure of primary procedure, such as acute herniation s/p lap Nissen causing dysphagia or Lap-band slippage

Perforated Peptic UlcerTechniques

• Simple closure Memon MA et al, Br. Med. J. 86:106-107, 1993

• Omental patchSo JB et al, Surg Endosc, 10:1060-63, 1996

• Fibrin glue Mouret P et al, Br J Surg, 77:1006,1990

• Placement of oxidized cellulose gauzeTate JJT et al, Br J Surg, 80:35, 1993

• Falciform ligament patchMunro WS et al, Ann R Coll Surg, 78:390-1, 1996

• Ligamentum teres patchCastalab G et al, Surg Endosc, 6:677-9, 1995

Perforated Duodenal UlcerLaparoscopic vs. Open Repair

• Decreased perioperative analgesic requirements in laparoscopic group

• No benefit in length of hospital stay, time to resume normal diet or return to normal activity

• Increased operative time and cost

Miserey M et al, Surg Endosc. 10:831-6, 1996So JB et al, Surg Endosc. 10:1060-63, 1996Lau WY et al, Ann Surg. 224: 131-38Lau WY et al, Br J Surg. 82:814-6

Sepsis/Peritonitis

• Anastomotic leak

Sepsis/Peritonitis

• Perforated G-tube

Indications for Early Laparoscopy

• Sepsis/Peritonitis from perforated viscus, bile leakage, or leaking anastomosis

• Obstruction from adhesions, technical error or intussusception

• Bleeding from splenic trauma during colon resection, liver bed or cystic artery s/p lap chole

• Failure of primary procedure, such as acute herniation s/p lap Nissen causing dysphagia or Lap-band slippage

Small Bowel ObstructionDiagnostic and Therapeutic Laparoscopy

Author Total #

Diagnostic laparoscopy

Laparoscopic treatment

Converted to laparotomy

Iatrogenic bowel injury

Navez B, 1998 150 68 31 (46%) 31 (46%) 6 (9%)

Strickland P, 1999 40 40 24 (60%) 13 (32%) 4 (10%)

Agresta F, 2000 136 63 52 (82%) 11 (17.4%) 1 (1.5%)

Suter M, 2000 83 83 47 (57%) 36 (43%) 4 (8%)

Leon EL, 1998 40 40 14 (35%) 26 (65%) 3 (7.5%)

Al-Mulhim A, 2000 19 19 13 (68%) 6 (32%) 0 (0%)

Bailey IS, 1998 139 65 35 (54%) 30 (46%) 1 (1.5%)

Obstruction

• Duplicated small bowel

Obstruction

• Intussusception

Indications for Early Laparoscopy

• Sepsis/Peritonitis from perforated viscus, bile leakage, or leaking anastomosis

• Obstruction from adhesions, technical error or intussusception

• Bleeding from splenic trauma during colon resection, liver bed or cystic artery s/p lap chole

• Failure of primary procedure, such as acute herniation s/p lap Nissen causing dysphagia or Lap-band slippage

Abdominal TraumaDiagnostic Laparoscopy (DL)

Authors / year

# of patients

Neg. DL,

n (%)

Pos. DL, n (%)

Unnecessary lap. n (%)

Comments

Berci et al, 1991

150 84 (56) 66 (44) 0 Retrospective study. Blunt trauma only. 25% had min to mod hemo- peritoneum, Rx close observation

Brandt et al, 1994

21 3 (14) 18 (86) 9 (43) Prospective study. 10 blunt and 11 penetrating traumas. Hard to see splenic, mesenteric and retroperitoneal injuries

Fabian et al, 1993

182 97 (53) 85 (47) 26 (30) Prospective study. Blunt and penetrating trauma. High cost.

Gazzaniga et al, 1976

37 14 (38) 23 (62) 6 (26) Retrospective study. DL using eyepiece (no camera and monitor)

Ivatury et al, 1993

100 43 (43) 57 (57) 20 (37) Prospective study. Penetrating trauma only. 7 missed injuries in 54 pts. who had laparotomy based on DL.

Abdominal TraumaDiagnostic Laparoscopy (DL)

Authors / year

# of patients

Neg. DL,

n (%)

Pos. DL, n (%)

Unnecessary lap. n (%)

Comments

Livingston et al, 1992

39 7 (18) 32 (82) 4 (13) Prospective study. Blunt and penetrating trauma. Difficulty in running bowel, seeing spleen and evacuating hematomas.

Rossi et al, 1993

32 11 (34) 21 (66) 11 (34) Prospective study. 19% significant injuries missed on DL

Salvino et al, 1993

75 42 (56) 33 (44) 2 (20) Prospective study. DL vs. DPL. Blunt and penetrating trauma. DL improved care in 8% cases. No better than DPL in blunt trauma.

Sosa et al, 1995

121 79 (65) 42 (35) 7 (18) Prospective study for abdominal GSW. Very sensitive and specific. Reduces unnecessary laparotomy, morbidity and hospital stay

Townsend et al, 1993

15 0 15 (100) 0 Prospective study. CT prior to DL.

Bleeding

• Iatrogenic splenic injury

Indications for Early Laparoscopy

• Sepsis/Peritonitis from perforated viscus, bile leakage, or leaking anastomosis

• Obstruction from adhesions, technical error or intussusception

• Bleeding from splenic trauma during colon resection, liver bed or cystic artery s/p lap chole

• Failure of primary procedure, such as acute herniation s/p lap Nissen causing dysphagia or Lap-band slippage

Failure of Primary Procedure

• Reoperation for Gastrojej obstruction s/p Gastric Bypass

Failure of Primary Procedure

• Distal pancreatectomy after cystjejunostomy

Contraindications to Reoperative Laparoscopy

• Inability to tolerate general anesthesia• Uncorrectable coagulapathy• Conditions better approached via another

body cavity (thoracic approach for esophageal procedure)

• Frozen abdomen• Many prior laparoscopic failures• Medico-legal

Bedside Laparoscopyperformed under local anesthesia

• 12 bedside laparoscopies were performed in 11 patients over one year in ICU of one hospital

• Indications for diagnostic laparoscopy were to evaluate intraabdominal processes that may be responsible for the patient’s condition

• 6 laparoscopies corrected the radiographic diagnosis thus avoiding 6 nontherapeutic laparotomies

• One laparoscopy was both diagnostic and therapeutic- loop ileostomy was created in a patient with urosepsis secondary to a colovesical fistula

Pecoraro et al. Surg Endo. 2001: 15; 638-641

Contraindications to Reoperative Laparoscopy

• Inability to tolerate general anesthesia• Uncorrectable coagulapathy• Conditions better approached via another

body cavity (thoracic approach for esophageal procedure)

• Frozen abdomen• Many prior laparoscopic failures• Medico-legal

Medico-legal

• CBD injury

Conclusion

• Urgent early laparoscopy is feasible

• It has two roles: (1) diagnosis and (2) therapy

Conclusion

• Urgent early laparoscopy must be performed by an experienced laparoscopist

• Be prepared for conversion to an open procedure

• Have a low threshold for conversion