Acute abdomen and role Acute abdomen and role of laparoscopyof laparoscopy

Dr. Girish JunejaDr. Girish JunejaHead of Surgery DepartmentHead of Surgery Department

Al Noor HospitalAl Noor HospitalAirport Road, Abu DhabiAirport Road, Abu Dhabi

Acute AbdomenAcute Abdomen

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

Primary goalPrimary goal

Management of patients with acute Management of patients with acute

abdominal pain is to determine whether abdominal pain is to determine whether operative intervention is necessary and operative intervention is necessary and

if, so, when the operation should be if, so, when the operation should be

performed.performed.

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

Clinical evaluationClinical evaluation Tentative differential diagnosis Tentative differential diagnosis Basic investigative studiesBasic investigative studies Working diagnosisWorking diagnosis Acute abdominal crisisAcute abdominal crisis Suspected surgical abdomenSuspected surgical abdomen Uncertain diagnosisUncertain diagnosis Suspected nonsurgical abdomenSuspected nonsurgical abdomen

Clinical evaluationClinical evaluation

HistoryHistoryUse of standardized history and physical Use of standardized history and physical

forms, with or without aid of diagnostic forms, with or without aid of diagnostic computer programs, has been computer programs, has been recommended.recommended.

Data sheetsData sheets

Sufficient evidence to support the Sufficient evidence to support the routine use of data sheets routine use of data sheets

Pattern recognitionPattern recognition

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

Acute Abdomen Acute Abdomen Assessment Assessment

Obtain clinical history Generate tentative differential diagnosis

Generate working diagnosis

Perform physical examinationPerform basic investigative studies

Working diagnosis

Patient requires immediate laparotomy

Patient has suspected surgical abdomen

Diagnosis is uncertain

Patient has suspected nonsurgical abdomen

Patient requires immediate laparotomy

Ruptured abdominal aortic or visceral aneurysmRuptured ectopic pregnancy Splenic ruptureMajor blunt or penetrating abdominal trauma and hemoperitoneum from various causes.Hemodynamic instability is the essential indication.

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

Diagnosis is uncertain

Patient should be hospitalized and observed

Patient can be evaluated in outpatient setting

Patient has suspected surgical abdomen

Diagnosis is uncertain, or patient has suspected nonsurgical abdomen

Patient has suspected nonsurgical abdomen

Diagnosis is uncertain, or patient has suspected surgical abdomen

Diagnosis is Nonsurgical

Patient should be hospitalized and observed

Reevaluate patient as appropriate Refer patient for medical management

Provide narcotic analgesia as appropriate. Observe patient carefully, and reevaluate condition periodically. Consider additional investigative studies.

Frequency of Specific DiagnosesFrequency of Specific DiagnosesOMGE StudyOMGE Study

DiagnosisDiagnosis

Frequency (% of Patients)Frequency (% of Patients)

Age < 50 YrAge < 50 Yr(N = 6, 317)(N = 6, 317)

Age > 50 YrAge > 50 Yr(N = 2, 406)(N = 2, 406)

Nonspecific Abdominal PainNonspecific Abdominal Pain 39.539.5 15.715.7

AppendicitisAppendicitis 32.032.0 15.215.2

CholecystitisCholecystitis 6.36.3 20.920.9

ObstructionObstruction 2.52.5 12.312.3

PancreatitisPancreatitis 1.61.6 7.37.3

Diverticular diseaseDiverticular disease <0.1<0.1 5.55.5

CancerCancer <0.1<0.1 4.14.1

HerniaHernia <0.1<0.1 3.13.1

Vascular diseaseVascular disease <0.1<0.1 2.32.3

The Role of The Role of EMERGENCY LAPAROSCOPYEMERGENCY LAPAROSCOPY

Diagnosis has been the most important roleDiagnosis has been the most important role Even when pre-operative diagnosis is certain, Even when pre-operative diagnosis is certain,

peritoneal assessment in the acute situation is peritoneal assessment in the acute situation is important to assess the situation and avoid a missed important to assess the situation and avoid a missed diagnosis.diagnosis.

Therapeutic procedures are done once the diagnosis Therapeutic procedures are done once the diagnosis is established.is established.

Convert to open surgery when indicated.Convert to open surgery when indicated.

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

Benefits

Post Op Incision for Abdominal TraumaPost Op Incision for Abdominal Trauma

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

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.

RIF & Supra-Pubic Pain RIF & Supra-Pubic Pain Left Ovarian CystLeft Ovarian Cyst

RIF & Central Abdominal Pain RIF & Central Abdominal Pain Infarcted OmentumInfarcted Omentum

RIF Pain RIF Pain Infarcted Anterior Abdominal Wall FatInfarcted Anterior Abdominal Wall Fat

RIF Pain RIF Pain EndometriosisEndometriosis

Intestinal Obstruction from Adhesion Band due Intestinal Obstruction from Adhesion Band due to Appendicitis, Laparoscopic Adhesiolysisto Appendicitis, Laparoscopic Adhesiolysis

Peritonitis: Gangrenous Appendix with Pus in the Peritonitis: Gangrenous Appendix with Pus in the Pelvic SpacePelvic Space

Undiagnosed Ectopic Pregnancy presenting as Undiagnosed Ectopic Pregnancy presenting as severe RHC Pain and Peritonitissevere RHC Pain and Peritonitis

EMERGENCY THERAPEUTIC EMERGENCY THERAPEUTIC LAPAROSCOPYLAPAROSCOPY

Indications for Therapeutic Laparoscopy; requires trained Indications for Therapeutic Laparoscopy; requires trained LaparoscopistLaparoscopist• Acute CholecystitisAcute Cholecystitis• Appendicectomy in High Risk PatientAppendicectomy in High Risk Patient• Adhesiolysis with Intestinal ObstructionAdhesiolysis with Intestinal Obstruction• Perforated Peptic UlcerPerforated Peptic Ulcer• Other GIT PerforationOther GIT Perforation• Second Look e.g. for Bowel viabilitySecond Look e.g. for Bowel viability• Drainage of abscess collectionsDrainage of abscess collections

Laparoscopy allows more appropriate placement of Laparoscopy allows more appropriate placement of Incision following Diagnosis. Avoid double or Incision following Diagnosis. Avoid double or

extended incision due to unexpected diagnosisextended incision due to unexpected diagnosis

Laparoscopic Appendicectomy: Laparoscopic Appendicectomy: Pregnant PatientPregnant Patient

Obstructed Hernia : Assessment of Bowel Obstructed Hernia : Assessment of Bowel Viability & Laparoscopic RepairViability & Laparoscopic Repair

Laparoscopic Repair of PDU Laparoscopic Repair of PDU

EMERGENCY LAPAROSCOPIC EMERGENCY LAPAROSCOPIC PROCEDURES: Conversion PROCEDURES: Conversion

After DiagnosisAfter Diagnosis• Inexperienced to deal with problem Inexperienced to deal with problem • Safer outcome with open SurgerySafer outcome with open Surgery

GangreneGangrene Ruptured / Bulky TumourRuptured / Bulky Tumour HemorrhageHemorrhage

EMERGENCY LAPAROSCOPIC EMERGENCY LAPAROSCOPIC PROCEDURES: ConversionPROCEDURES: Conversion

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