Acute abdomen and role of laparoscopy

1. Acute abdomen and role of laparoscopy Dr. Girish Juneja Head of Surgery Department Al Noor Hospital Airport Road, Abu Dhabi

3. Acute Abdomen Undiagnosed pain that arises suddenly and is usually less than 48 hours

4. 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.

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

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

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

8. Data sheets Sufficient evidence to support the routine use of data sheets

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

12. Acute Abdomen Assessment Obtain clinical history Generate tentative differential diagnosis Perform physical examination Perform basic investigative studies Generate working diagnosis

13. Working diagnosis Patient requires immediate laparotomy Patient has suspected surgical abdomen Diagnosis is uncertain Patient has suspected nonsurgical abdomen

14. 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.

15. 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

16. 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

17. 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

23. Frequency of Specific DiagnosesOMGE Study

24. 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.

25. 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

26. Post Op Incision for Abdominal Trauma

27. 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

28. 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.

29. RIF & Supra-Pubic Pain Left Ovarian Cyst

30. RIF & Central Abdominal Pain Infarcted Omentum

31. RIF Pain Infarcted Anterior Abdominal Wall Fat

32. RIF Pain Endometriosis

33. Intestinal Obstruction from Adhesion Band due to Appendicitis, Laparoscopic Adhesiolysis

34. Peritonitis: Gangrenous Appendix with Pus in the Pelvic Space

35. Undiagnosed Ectopic Pregnancy presenting as severe RHC Pain and Peritonitis

36. 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

37. Laparoscopy allows more appropriate placement of Incision following Diagnosis. Avoid double or extended incision due to unexpected diagnosis

38. Laparoscopic Appendicectomy: Pregnant Patient

39. Obstructed Hernia : Assessment of Bowel Viability & Laparoscopic Repair

40. Laparoscopic Repair of PDU

41. EMERGENCY LAPAROSCOPIC PROCEDURES: Conversion • After Diagnosis • Inexperienced to deal with problem • Safer outcome with open Surgery • Gangrene • Ruptured / Bulky Tumour • Hemorrhage

42. 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