The Role of the Laparoscope in theThe Role of the Laparoscope in the Acute Setting Acute Setting

Mr John GriffithMr John Griffith

Bradford Royal InfirmaryBradford Royal Infirmary

Why ?Why ?

No difference from elective surgeryNo difference from elective surgery

The reduction of the extent of the The reduction of the extent of the abdominal wound is associated with abdominal wound is associated with significant advantagessignificant advantages– Less pain Less pain – Fewer wound infectionsFewer wound infections– Shorter hospital stayShorter hospital stay

Why?Why?DiagnosisDiagnosis

The laparoscope may be used to make an The laparoscope may be used to make an accurate diagnosis accurate diagnosis

Facilitates thorough lavage and Facilitates thorough lavage and localisation of pathologylocalisation of pathology

We now have enhanced image systems We now have enhanced image systems and instruments and instruments

Which pathologies?Which pathologies?

Right iliac fossa pain / appendicitisRight iliac fossa pain / appendicitis

Acute cholecystitisAcute cholecystitis

Perforated Viscus (DU)Perforated Viscus (DU)

DiverticulitisDiverticulitis

Intestinal obstructionIntestinal obstruction

Malignant large bowel obstructionMalignant large bowel obstruction

Acute AppendicitisAcute Appendicitis

Little benefit in performing a laparoscopic Little benefit in performing a laparoscopic approach in young men and childrenapproach in young men and children

Ideal in obese individuals or in patients in Ideal in obese individuals or in patients in whom the diagnosis may be in doubt whom the diagnosis may be in doubt (elderly and females)(elderly and females)Reduction in wound complications and Reduction in wound complications and hospital stayhospital stay

Varela JE Am J Surg 196Varela JE Am J Surg 196

Changing the way we workChanging the way we workMaw a et alMaw a et al

Compared two groups of patients open vs Compared two groups of patients open vs laparoscopic appendicectomylaparoscopic appendicectomy

3:1 preponderance of females in the 3:1 preponderance of females in the laparoscopic group (1.2:1 open)laparoscopic group (1.2:1 open)

13% normal appendix in the open group13% normal appendix in the open group

53% normal appendix in the lap group53% normal appendix in the lap group

16% had an alternative diagnosis16% had an alternative diagnosis

Laparoscopy for RIF painLaparoscopy for RIF painTechnical tipsTechnical tips

Supra umbilical optical portSupra umbilical optical port

Monitor Rt thighMonitor Rt thigh

5mm LIF port 5mm LIF port

Suction with a “trap”Suction with a “trap”

Proceeding to appendicectomy – 5mm Proceeding to appendicectomy – 5mm supra-pubic portsupra-pubic port

Acute CholecystitisAcute Cholecystitis

Safe procedureSafe procedure

Not can it be done but should it be done Not can it be done but should it be done acutely in all cases?acutely in all cases?

Cost benefit of this policy remains unclearCost benefit of this policy remains unclearMacafee DA BJS 2009 1031-40Macafee DA BJS 2009 1031-40

Lavage for post op bile leakLavage for post op bile leak

Perforated Viscus:Perforated Viscus:Peritonitis with free intra abdominal airPeritonitis with free intra abdominal air

Further imaging is unlikely to change Further imaging is unlikely to change management – surgerymanagement – surgery

Laparoscopy usually allows accurate Laparoscopy usually allows accurate localisation of the pathology and lavagelocalisation of the pathology and lavage

30 degree scope and large bore suction 30 degree scope and large bore suction with rapid infusion with rapid infusion

Laparoscopic repair of Perforated DULaparoscopic repair of Perforated DU

Review of 56 papersReview of 56 papers

Laparoscopic repair of a perforated peptic ulcer Laparoscopic repair of a perforated peptic ulcer is associated with reduction in M&M, pain and is associated with reduction in M&M, pain and hospital stayhospital stay

12% conversion rate (diameter of perforation)12% conversion rate (diameter of perforation)

Increased risk of persistent leak Increased risk of persistent leak

Maybe contraindicated in those with symptoms Maybe contraindicated in those with symptoms over 24hrsover 24hrs

Bertleff MJ et al Surg Endosc 2009Bertleff MJ et al Surg Endosc 2009

Diverticulitis: Diverticulitis: The Cork experienceThe Cork experience

100 patients: Hinchey II 25, III 67, IV 8100 patients: Hinchey II 25, III 67, IV 8

92 managed with laparoscopic lavage and 92 managed with laparoscopic lavage and drainage : 3 dieddrainage : 3 died

2 failed to settle one of whom had a 2 failed to settle one of whom had a Hartmann’sHartmann’s

Of 88 patients only 2 were readmitted Of 88 patients only 2 were readmitted (median fup 36 months)(median fup 36 months)

Winter DC BJS 2008Winter DC BJS 2008

Diverticulitis:Diverticulitis:Champault G DCR 2009Champault G DCR 2009

Emergency lavage vs resection and Emergency lavage vs resection and defunctioning stoma (35 patients)defunctioning stoma (35 patients)

Length of stay: 8 vs 17 daysLength of stay: 8 vs 17 days

71% of the lavage group underwent 71% of the lavage group underwent laparoscopic resection and all the laparoscopic resection and all the defunctioning stomas were closeddefunctioning stomas were closed

Total length of stay 14 vs 23 days with Total length of stay 14 vs 23 days with less morbidity less morbidity

Intestinal ObstructionIntestinal Obstruction

Small bowel obstructionSmall bowel obstruction

Large bowel obsttructionLarge bowel obsttruction

Small bowel obstruction:Small bowel obstruction:19 studies 1994-200519 studies 1994-2005

Laparoscopy was attempted in 1061 casesLaparoscopy was attempted in 1061 cases83% adhesive obstruction 83% adhesive obstruction – 45 recognised enterotomies45 recognised enterotomies

33% conversion rate 33% conversion rate – Dense adhesions 28%Dense adhesions 28%– Bowel resection 23%Bowel resection 23%– Iatrogenic injury 10%Iatrogenic injury 10%

9 missed enterotomies9 missed enterotomiesGhoseheh et al Surg Endosc 2007Ghoseheh et al Surg Endosc 2007

What predicts success?What predicts success?

If obstruction is due to a single band If obstruction is due to a single band

Radiology : definite cut ofRadiology : definite cut of

Previous surgery : gynae, laparoscopic vs Previous surgery : gynae, laparoscopic vs midlinemidline

Successful in diagnosing the site Successful in diagnosing the site

Cost NeutralCost NeutralWexner et al Surg Endosc 2007Wexner et al Surg Endosc 2007

Malignant Large Bowel obstructionMalignant Large Bowel obstructionStenting to bridge to surgeryStenting to bridge to surgery

Several none randomised studies Several none randomised studies

It would appear safe It would appear safe

The presence of the stent does not The presence of the stent does not preclude a laparoscopic resectionpreclude a laparoscopic resection

Park IJ J Gast Surg 2009Park IJ J Gast Surg 2009

CRESTCREST

PositioningPositioning

Gel none slip cover and or a Bean bag Gel none slip cover and or a Bean bag supportsupport

Use incopads to retain the armsUse incopads to retain the arms

Two monitors are preferable but not Two monitors are preferable but not essentialessential

TrainingTraining

The introduction of a laparoscopic The introduction of a laparoscopic approach to the emergency theatre has approach to the emergency theatre has some problemssome problems

Procedures take longerProcedures take longer

Upward shift in training exposureUpward shift in training exposureHedrick T Am J Surg 2009Hedrick T Am J Surg 2009

Is the laparoscope creating a new Is the laparoscope creating a new problem?problem?

Reduction in adhesionsReduction in adhesions

Increase in internal hernias after Increase in internal hernias after laparoscopic morbid obesity surgerylaparoscopic morbid obesity surgery

Volvulus around ileostomy sitesVolvulus around ileostomy sites

ConclusionConclusion

Many acute patients can experience the Many acute patients can experience the benefits of a laparoscopic approach benefits of a laparoscopic approach

THE WOUNDTHE WOUND

The approach develops surgeons and The approach develops surgeons and theatre nurses skillstheatre nurses skills

HoweverHowever

It takes longer and there is probably an It takes longer and there is probably an upward shift in training exposureupward shift in training exposure