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Научни трудове на Съюза на учените в България-Пловдив, серия Г.Медицина, фармация и дентална медицина т. XVIII. ISSN 1311-9427. Научна сесия „Медицина и дентална медицина", 5 - 6 ноември 2015. Scientific works of the Union of Scientists in Bulgaria-Plovdiv, series G. Medicine, Pharmacy and Dental medicine, Vol. XVIII, ISSN 1311-9427 Medicine and Dental medicine Session, 5-6 November 2015.
GUIDELINES AND RECOMMENDATIONS FOR LAPAROSCOPIC TREATMENT OF ACUTE ABDOMEN IN THE FIRST DECADE OF
21ST CENTURY.
B. Sakakushev, B. Atanasov University of Medicine/University Hospital"Saint George", Plovdiv
First Clinic of Surgery
НАСОКИ И ПРЕПОРЪКИ ЗА ЛАПАРОСКОПСКО ЛЕЧЕНИЕ НА ОСТРИЯ ХИРУРГИЧЕН КОРЕМ ПРЕЗ ПЪРВАТА ДЕКАДА НА 21 ВЕК.
Б. Сакакушев, Б. Атанасов..
Медицински Университет/УМБАЛ „Свети Георги" Пловдив Първа Клиника по Хирургия
The development of new instruments and the refinement of established techniques will lead to the expansion of minimally invasive surgery to new areas of interest for general surgeons. However, one must realize - and accept, that minimally invasive surgery only represents a different technique that offers an alternative to open surgery. The indication for surgery are similar for both minimally invasive surgery and open surgery.. .It is important for all general surgeons to keep up with this trend and become an integral part of the revolution in medicine that the advent of minimally surgery has wrought/1/.
Acute appendicitis
The diagnosis of acute appendicitis includes clinical exam, US to , CT in equivocal cases, to reduce negative appendectomy rate (NAR) and missed perforations . Alvarado score (with a cutoff of 4) for diagnosis and for stratification of candidates to CT scan /2/.
Laparoscopic appendectomy/LA/ is gold standard in pre-menopausal women; age > 65 years improved clinical outcomes (in terms of length of stay (LOS), mortality and overall morbidity) compared with OA ; obese (BMI >30) and feasible in men, even if advantages over OA in the latter group are not demonstrated /3,4,5,6/. Complicated appendicitis can be approached laparoscopically by experienced surgeons with significant advantages, comprehending lower overall complications, readmission rate, SBO rate, infections of the surgical and faster recovery/7,8,9/. Higher rates of conversion affect patients with >5 days of symptoms, >20000 WBC count, > 45 years males, ruptured appendicitis on CT scan (10).
Colonic malignant obstruction
Emergency laparoscopic right colectomy for malignant obstruction is rarely reported and not supported by literature/11/.Colonic stenting for obstructing neoplasm offers advantages over emergency surgery in terms of increase in successful primary anastomosis, reduction of stoma creation, infections and overall morbidities. If emergency surgery is proposed through laparotomy, colon stenting is followed by laparoscopy in a minority of cases reported/12,13/.
Iatrogenic perforations
Early recognition of perforation during diagnostic or therapeutic endoscopy allows immediate repair of the defect endoscopically if feasible. For those non recognised immediately
or failed to repair, emergency surgery is mandatory and may be approached laparoscopically. The options include a laparoscopic lavage and drainage, eventual defunctioning stoma, or a segmental resection with or without primary anastomosis/14/.
Inflammatory bowel disease
In the emergency setting, compared to open surgery, laparoscopy offers limited advantages in terms of overall morbidity, in the treatment of both ulcerative colitis and Crohn's disease of the colon.Based on the evidence of case-matched studies with few cases in each series, a limited advantage in terms of overall morbidity may be observed/15/..
Acute diverticulitis
Hinchey I and II, when septic despite medical therapy, are indicated for percutaneous drainage when feasible (16). When successfully performed laparoscopic lavage and drainage does not always necessitate a future elective colonic resection (17,18). Advantages advocated by the supporters of this technique are avoidance of a large laparotomy and derivative procedures, thus, reducing their consequent complications, reduction of postoperative pain and the subsequent use of analgesic, lowering of surgical site infections, potential reduction of the rate of incisional hernias, amelioration in postoperative disability. In all other cases colonic resection is indicated, which may be performed laparoscopically, depending on the general conditions of the patient and on the skill of the operator where primary anastomosis protected by a loop ileostomy seems more effective than Hartmann's procedure in terms of stoma reversal rate (19,20). With no difference in mortality or morbidity, laparoscopic approach resulted a predictor of routine discharge and decreased length of stay, although cost analysis revealed substantial equivalence between groups/21/.
Acute pancreatitis
In moderate biliary pancreatitis, LA must be performed after stabilizing the patient in the same hospitalization/22,23,24 /. In severe pancreatitis При тежкия билиарен панкреатит, LA must be postponed until regress of inflammatory syndrome and clinical recovery /25/.
Besides cases with emergency ERCP, in choleocholithiasis, stones are derived either by preoperative ERCP or during the cholecystectomy /26,27/. Necrectomy in necrotizing pancreatitis with poly-organ insufficiency, without medical treatment response are indicative for step approach by needle aspiration or if needed mini-invasive retroperitoneal debridement. Open surgery follows mini-invasive failure. /28,29/. Abdominal compartment syndrome requires laparostomy.
Perforated Peptic Ulcer
Up to today, there is no unanimous agreement about which group of patients might benefit from a laparoscopic approach of PPU. Several studies suggest that Boey's shock score on admission, ASA III-V (severe comorbidities), and duration of symptomatology, are the most reliable parameters for selecting patientsq while other principles of selection are: MPI, age >70 years, APACHE II and surgeon's skill in miniinvasive surgery/30/. There is is growing evidence that high risk surgical patients can benefit from a period of resuscitation ("damage control") before surgical intervention to minimize the insult on physiology and get early control on sepsis/31/. NOM management should be carefully considered in selected patients, knowing that evidence is weak for its efficacy and risk may be high if disease symptoms does not resolve/32/.The choice of perforation closure technique depends on lesion characteristics: if margins are edematous, friable,and/or difficult to mobilize, repair can be limited to an omental patch, eventually associated with one or more sealant devices; when the margins can be easily brought together, without tension, direct suturing can be sufficient with or without omentoplasty/33,34/. A recent Danish study demostred that laparoscopy was associated with lower risk of reoperation than laparotomy or a converted procedure. However, the quality is limited because there was a risk of bias, including confounding by indication/35/. Recent reports confirm a decrease in the incidence of complications (abdominal wall complications, prolonged postoperative ileus, pulmonary infection, and mortality rate) with laparoscopic surgery compared to open surgery. The operative times are longer for laparoscopy however, progressive and constant reduction of operative times 108
over the past 10 years has been seen, probably due to an improvement in the surgeon's skill, better technology, and better organization of the surgical teams. The hospital stay has been shown to be more favorable for the laparoscopic approach compared to traditional surgery in Siu et al. but not in Lau and Bertleff et al. The meta-analysis of Sanabria (updated in 2012) and Stravos (2013) conclude that laparoscopic surgery could be the first therapeutic after considering other variables such as surgeon's experience, costs and availability/36/.Variables that measure the experience of surgeons with laparoscopic repair must be introduced and assessed. One of the advantages of laparoscopic surgery is less postoperative pain (LE 1a), but earlier data about pain (within 24 h postoperatively) did not show any difference, probably because of peritoneal inflammation.On the other hand, a greater incidence of intra-abdominal fluid collection (due mostly to leakage at the suture site) has been reported. However, none of these differences are statistically significant.
Adhesive small bowel obstruction
Laparoscopic treatment of adhesive small bowel obstruction can be successfully and safely accomplished. Selection of patients and preoperative planning is the key for a safe and successful laparoscopic surgery for ASBO. When feasible, laparoscopic adhesiolisis is associated with a quicker functional recovery and a reduced LOS, with at least similar morbidity and mortality than open surgery/37/. The use of laparoscopy in the setting of ASBO as a diagnostic tool only is not advised. No differences between Oxford GL 2009 and 2011No subtantial new data from recent literature
Gynecological disorders
The 2010 recommendations state that when gynecologic disorders like adnnexial torsion, ecotopic pregnancy, endometriosis ,PID follicular bleeding are the suspected cause of abdominal pain, diagnostic laparoscopy (DL) should follow conventional diagnostic investigations, especially US and if needed, a laparoscopic treatment of the disease should be performed . Close cooperation with the gynecologist is strongly recommended. Both recommendations are confirmed.
Nonspecific acute abdominal pain
NSAP is defined as acute abdominal pain that lasts less than 7 days and for which the diagnosis remains uncertain after baseline examination and diagnostic tests and not requiring urgent procedure. Laparoscopy is feasable also in high risk patients(morbidity 0-8% mortality 0% ), because it improves % diagnosis, reduces hospital stay and reduces % laparotomies and rate of postoperative adhesions/38/.
AMI / ACUTE MESENTERIC ISCHEMIA /
The gold standard for the diagnosis according with the consensus statement of SICE and latest literature articles is multidetector CT Angiography (CTA) with sensibility of 93.3% and specificity of 95.9%/39/.Laparotomy could be useful to confirm cases of AMI without signs of SMA (superior mesenteric artery) occlusion at CTA /40/.In AMI when there aren't conditions for rapid CTA performing or when a previous CTA had been not conclusive laparoscopy can reduce the number of unnecessary laparotomies overall in elderly critically ill patients. Literature underlines that the first treatment of AMI is bowel revascularization (The second step is the reassessment of bowel viability. If possible the time of 20 or 30 minutes after revascularization should be spent before decision making about bowel /41/.If no vascular surgeon is available, resection of obvious necrotic bowel should be performed and after the abdomen closure the patient should be transported to a vascular surgical center .
PENETRATING ABDOMINAL TRAUMA
In stable penetrating abdominal trauma laparoscopy may be useful in patients with documented or equivocal penetration of the anterior fascia. Stable blunt trauma patients with suspected Intraabdominal injury and equivocal findings on imaging studies or even in patients with negative studies, but with high clinical likehood for intraabdominal injury*unclear abdomen* to exclude relevant injury. The use of laparoscopy in selected trauma patients, especially after penetrating abdominal trauma, is associated with decreased negative laparotomy rate, decreased
109
morbidity, shortened hospital stay and increased cost-effectiveness. The use of laparoscopy for trauma should be attempted only after a proper laparoscopic learning curve skills, by surgeons with appropriate both open and laparoscopic surgical skills. Laparoscopy has an highly effective diagnostic value and potential therapeutic value for diaphragmatic injuries repair, in patients sustaining left upper quadrant thoraco-abdominal injuries. After penetrating abdominal trauma laparoscopy may have diagnostic and eventually therapeutic purpose in hemodynamically stable patients with documented or suspected peritoneal penetration. Laparoscopy should be considered in hemodynamically stable blunt trauma patients with suspected intra-abdominal hollow viscus injuries on imaging and peritoneal findings or in patients with negative imaging but with high clinical suspicion of intra-abdominal hollow viscus injury (''unclear abdomen'').
These guidelines have been developed to help surgeons with their decisions in the very difficult situation of emergency surgery... a need to discuss and share experience, using the same language.
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