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Role ofEmergency Laparoscopy inPediatric Patients
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Fig. 4 A Meckel’s
diverticulum has been
brought through the
umbilical incision along
with the adjacent ileum in
order for a segmental
bowel resection to be
performed
Fig. 5 Laparoscopic
diverticulectomy is
performed for a bleeding
Meckel’s, ensuring
adequate diameter of the
adjacent ileum
325
resection can be accomplished laparoscopically either via segmental small bowel
resection or with a stapled diverticulectomy. If a segmental bowel resection is performed, this can be completed through the umbilical incision as seen in Fig.4. The
laparoscopic diverticulectomy-only approach has been shown to reduce hospital
length of stay and operative time as compared to segmental resection. Complete,
margin-free resection of the gastric mucosa has been demonstrated via diverticulectomy when these are taken at the base with endoscopic stapling devices [31]. When
performing a diverticulectomy, as seen in Fig.5, care needs to be taken to ensure
there is no narrowing of the adjacent small bowel.
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R. B. Laverty and M. E. Gallagher
7 Pyloric Stenosis
Frequently seen in 2–10-week-old infants, pyloric stenosis is another common pediatric diagnosis requiring acute surgical care. This can be fatal if left untreated as
dehydration and malnutrition can occur from this gastric outlet obstructive process.
The surgery itself is not an emergency, but the resuscitation of the child is. A recent
retrospective review of ACS NSQIP data revealed that the management of this process by minimally invasive means has increased in recent years. The authors demonstrated that laparoscopic pyloromyotomy, as compared to open pyloromyotomy,
was associated with a shorter hospital length of stay, decreased rates of surgical site
infection, and overall complications without a difference in rates of reoperation [32].
After diagnosis of pyloric stenosis, close attention should be paid to the patient’s
uid and electrolyte status. Hypokalemia, hypochloremia, and metabolic alkalosis
are common and need to be corrected prior to taking the patient to the operating
room. Access to the abdominal cavity can be typically performed directly through
the umbilicus with a 3 or 5mm port. After insufation, usually only to a set pressure
of 8mmHg, a 3mm nontraumatic bowel grasper or pyloric (Geiger) clamp is placed
laterally in the right upper quadrant through a stab incision, and a third 3mm incision is made in the left upper quadrant. The proximal duodenum or pylorus should
then be grasped gently and retracted to expose the hypertrophic pylorus from under
the edge of the liver. Using Bovie monopolar energy on cutting mode or a pyloromyotomy knife, an incision is then made from the duodenal side of the pylorus to
the stomach carrying it through the serosa and underlying muscle bers while keeping the submucosal layer intact. A bowel grasper or pyloric muscle spreader can
then be used to spread and further separate the pyloric musculature. The two sides
of the divided pyloric muscle should be able to move independently from one
another, and the submucosa should bulge into the myotomy site. Figure6 shows the
laparoscopic view of a hypertrophic pylorus and a completed pyloromyotomy with
bulging submucosa. At the conclusion of the case, a leak test should be performed.
Fig. 6 Laparoscopic view of the hypertrophic pylorus and completed myotomy
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As mentioned above, a systematic review of patient outcomes following pyloromyotomy when performed by different surgical specialties demonstrated improved
overall morbidity when treated by pediatric surgeons or general surgeons with operative volumes of over four cases per year [3]. Acute care general surgeons should be
prepared to handle these types of cases, though, and recognize their limitations
when doing so. This should only be considered if adequate volume per year is
expected, patient has access to a children’s unit, and there is appropriate pediatric
anesthetic and medical care available. The learning curve for laparoscopic pyloromyotomy is believed to be 35 cases, at which time there is a decline in the rate of
incomplete myotomies or mucosal perforations [33]. As with all surgeries that can
be performed laparoscopically or open, a surgeon should do which operation they
are most comfortable with.
327
8 Ovarian Pathology
Ovarian cysts, neoplasms, and torsion can occur in the female pediatric population.
In these patients, prompt diagnosis and treatment of these conditions are of the
utmost importance to minimize complications and risk of infertility. Minimally
invasive approaches are acceptable for each of these diseases.
Treatment options for ovarian cysts include aspiration or resection, fenestration,
unroong, cysto-ovariectomy, and cysto-adnexectomy, the choice of which depends
on the size and character of the cyst, ability to preserve ovarian tissue, and operator
experience [34]. Benign neoplasms should be removed via ovarian-sparing techniques. If a malignant process is suspected, consideration should be given to transfer to a pediatric subspecialist.
While ultrasonography is typically used for diagnosis of ovarian torsion, diagnostic laparoscopy may be required in the setting of unclear patient presentations
and/or imaging. Tenets of these operations include ovarian and fertility preservation
and oophorectomy should be avoided if possible. The black-blue appearance of
ovaries in the setting of torsion can be deceptive and does not always indicate irreversible ischemia. Ovarian detorsion should be performed if the diagnosis is conrmed. In the setting of concomitant ovarian pathology, these should also be
addressed in the same operation to prevent recurrence.
9 Conclusion
With further technologic advances and increased evidence of efcacy, the use of
laparoscopy in the pediatric population for surgical emergencies will likely continue
to grow. Appendicitis, inguinal hernias, intussusception, Meckel’s diverticulum,
pyloric stenosis, and select ovarian pathology are examples of surgical problems
that may be managed through minimally invasive means. Surgeons should be aware
of these management options and techniques.
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R. B. Laverty and M. E. Gallagher
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Minimally Invasive Surgery
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forEmergency General Surgery
inElderly
KenjiOkumura, MatthewMcGuirk, andRifatLatifi
1 Introduction
Emergency general surgery (EGS) and emergent trauma surgeries represent a large
proportion of hospital utilization in the United States. It has been reported that 20%
of the inpatient population in 2019 were EGS with an estimated inpatient cost of
$341billion [1]. Scott etal. reported the seven most common EGS procedures to be
partial colectomy, small bowel resection, cholecystectomy, peptic ulcer disease
(PUD), lysis of adhesions, appendectomy, and laparotomy. These seven procedures
accounted for 80% of all EGS procedures [2]. Emergency surgery has been associated with a 1.2–2.4-fold risk for morbidity and mortality, and elderly patients have
been associated with high complications including mortality [2].
The elderly population is rapidly increasing around the world. In the United
States alone in 2015, there were 47.8 million people aged 65 or older, and the population is projected to be more than double to 98 million by 2060 [3]. The number of
patients requiring an operation has outpaced even this expansive growth in the aging
population [4], and it is expected to grow further.
The role of minimally invasive surgery (MIS) has been growing in all surgical
specialties. Whereas surgery has traditionally required large incisions sufcient to
allow the surgeon to introduce his/her hands into the body and to allow sufcient
light to see the structures being operated on, innovations in MIS have allowed the
surgeon to perform complex procedures with small incisions but great visualization.
K. Okumura · M. McGuirk
Department of Surgery, Westchester Medical Center, Valhalla, NY, USA
e-mail: Kenji.Okumura@wmchealth.org; Matthew.McGuirk@wmchealth.org
R. Lati (*)
Department of Surgery, Westchester Medical Center, Valhalla, NY, USA
Department of Surgery, New York Medical College, Valhalla, NY, USA
e-mail: Rifat.Lati@wmchealth.org
© The Author(s), under exclusive license to Springer Nature Switzerland AG 2023
F. Coccolini et al. (eds.), Mini-invasive Approach in Acute Care Surgery,
Hot Topics in Acute Care Surgery and Trauma,
https://doi.org/10.1007/978-3-031-39001-2_24
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The MIS approach in EGS has increased, and the outcomes of a MIS approach have
shown signicant improvement in the EGS [5].
Although there are limitations for MIS in EGS [6], such as hemodynamic instability and severe abdominal distention, the role of MIS in EGS has been well established. In this chapter, we discuss the role of MIS for the elderly in the several
general surgery settings.
K. Okumura et al.
2 Esophagus
Esophageal perforation (Boerhaave’s syndrome) is a rare but life-threatening spontaneous perforation and is associated with signicant morbidity and mortality, especially in the elderly. Historically, thoracotomy has been the mainstay of treatment;
however, it is associated with high morbidity and pain [7–9]. Minimally invasive
surgical approaches have been reported with promising outcomes in terms of morbidity, length of stay, and postoperative pain [8, 9]. However, the management of
Boerhaave’s syndrome remains a signicant challenge. Early diagnosis and prompt
treatment are the keys to manage this challenge successfully. Since the survival rate
is signicantly decreased when diagnostic delay is longer than 24h [10], the best,
most prompt approach needs to be selected. Endoscopic approach has also been
another mainstay of the treatment for esophageal perforation for the selected population [11, 12]. Due to the complexity of this selecting process, Abbas etal. proposed a perforation severity score [13] which correlates with the severity of the
illness. Although the application of a MIS approach is debated in the setting of
patients with early presentation and stable vital signs, MIS seems the promising and
feasible approach [8]. The denite management algorithm to adopt MIS is lacking,
but MIS techniques, particularly the use of robotic approach, would be one of the
great treatment tools for esophageal perforation.
3 Stomach andPeptic Ulcer Disease
The incidence and prevalence of peptic ulcer disease (PUD) in developed countries,
including in the United States, have declined over the years, which also shows a
decrease in hospitalization and mortality related to PUD [14]. Even through the
evolution of the medical treatment for PUD, surgery is the gold standard treatment
for perforated PUD for elderly population. Patients requiring surgery for PUD tend
to be elderly with associated comorbidities [15]. Emergency surgery for perforated
PUD has been shown to have a mortality of 6–30% [16]; however, the elderly has a
higher mortality. In the emergent setting, the procedure of choice for perforated
PUD is determined based on the general patient’s condition and location of perforation. Simple patch closure (Graham patch repair) [17] of the perforation should be
considered in the setting of shock, delayed presentation, and signicant medical
comorbidities, especially in the elderly. MIS approaches have been widely used in
the setting of perforated duodenal ulcer [18]. The outcome of MIS showed
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signicant decrease to the length of hospital stay, wound infection, and decreased
incisional hernias [19]. Compared to open procedures, laparoscopic repair of perforated PUD has a longer operating time; however, it is found to have similar postoperative results to the open approach [20–22]. Some authors warn to use a MIS
approach for ages over 70 and more than 24h of symptoms, both of which lead to
high morbidity and mortality [23]. When the perforation of PUD is located in the
stomach, a biopsy to rule out malignancy should be performed, and the surgeon
should consider converting to laparotomy in the situations when hemodynamic
instability, a large ulcer (more than 20 mm), or a perforation located at posterior
wall are present [24, 25]. Currently, the literature regarding the robotic surgery
approach for PUD is lacking; however, robotic surgery would be a good treatment
option for PUD due to the ergonomics of robotic surgery.
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4 Hepato-Pancreato-Biliary System
Pyogenic liver abscess is a rare but life-threating disease. Historically, the treatment
of choice for pyogenic liver abscess has been an open surgical approach, although
with the advancement of minimally invasive therapy such as image-guided percutaneous needle aspiration or catheter drainage and the availability of broad-spectrum
antibiotics, patients with pyogenic liver abscess rarely require surgical interventions
[26]. Surgical drainage is indicated for abscess of biliary origin; intra-abdominal
collections secondary to surgery, or in cases where percutaneous drainage is contraindicated or expected to fail due to the presence of multi-loculated abscess; biliary
communication; elevated urea; and creatinine and total bilirubin levels [27, 28]. In
these cases, a minimally invasive approach such as a laparoscopic or robotic
approach would be a reasonable option as alternative to conventional open surgery,
but further studies must be conducted to support the assumption.
Over the years, laparoscopic cholecystectomy has become the standard approach
for cholecystectomy. Historically, laparoscopic cholecystectomy was limited for
elective settings due to increasing the risk of common bile duct injury and other
morbidities. However, currently, laparoscopic cholecystectomy is one of the most
common MIS procedures, even in the acute setting [29]. The outcomes of MIS
include decreased pain, recovery time, morbidity, and mortality when compared to
open cholecystectomy. Despite these benets, the surgical community has been
reluctant to implement the laparoscopic approach in elderly patients [30]. With
advanced surgical techniques and improvement of perioperative management, early
cholecystectomy is safe for the elderly [31]. Others have suggested a delayed cholecystectomy for severely ill elderly patients [31, 32]. We submit to early rather than
late cholecystectomy in the elderly.
The prevalence of hospitalizations for acute pancreatitis has increased signicantly in the United States since the prevalence of gallstone-related disorders and
metabolic syndrome increased [33, 34]. The incidence of acute pancreatitis has
increased, and the incidence of pancreatic cyst/pseudocyst has also increased in the
elderly. A minimally invasive “step-up” approach was proposed in 2006 for the
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K. Okumura et al.
management of severe/necrotizing pancreatitis [35]. The initial treatment of necrotizing pancreatitis is conservative, and once peripancreatic necrosis becomes
infected, mortality increases signicantly [36]. Open necrosectomy was performed
as treatment; however, it was associated with high mortality and morbidity [37]. The
“step-up” approach consists of less invasive approaches such as percutaneous catheter drainage, endoscopic transgastric procedures, and minimally invasive necrosectomy. These procedures were started as initial treatment instead of laparotomy/
necrosectomy for infected necrotizing pancreatitis (Fig. 1) [35]. The PANTERstudy was conducted in the randomized setting to investigate the usefulness of this
“step-up” approach; the PANTER trial conveyed the benets in the randomized
setting [38], and it has now been widely accepted [39]. With this minimally invasive
“step-up” approach and improvement of critical care, the outcomes of necrotizing
pancreatitis have been improving recently.
5 Small Bowel Obstruction andHernias
Small bowel obstruction (SBO) continues to be a signicant cause of morbidity and
mortality in the United States. The most common causes of intestinal obstruction in
developed countries are adhesions, which continue to increase as the number of
surgical procedures and population of elderly increase [40, 41]. SBO in the elderly
is challenging. Sakari etal. reported about half of patients with small bowel obstruction are elderly with comorbidities which predispose to postoperative complications
and mortality [42]. MIS has been associated with less formation of adhesions and
reduced the event of SBO [43]. While the postoperative outcomes of MIS for SBO
showed better outcomes regarding the length of stay and complications, the MIS
approach is challenging, especially in the setting of SBO.SBO causes dilated small
bowel, which associates with the risk of bowel injury during initial access and limits
the working space for surgeons. However, previous laparotomy causes adhesions,
Fig. 1 Step-up approach vs. traditional approach to the management of necrotizing pancreatitis
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and the MIS approach is not universally applied, but it is benecial to perform MIS
on the elderly.
Incarcerated hernia is also a surgical emergency, and the incidence of developing
a hernia increases with aging [44, 45]. In the elective setting, MIS is prevalent and
shows better outcomes regarding postoperative pain, incidence of postoperative
complications, and length of hospital stay. In emergent situations, the open approach
is still common and standard; however, some patients would benet from a laparoscopic approach, especially in simple lysis of adhesions. Pei etal. has shown that a
laparoscopic approach for SBO increased 1.6% per year and 28.7% in 2013 [46].
MIS is applied more and more in developed countries, especially in semi-elective
settings. In emergent situations, the MIS approach can also be applied; however, if
the chance of bowel necrosis requiring small bowel resection is high, the open
approach is recommended since the laparoscopic approach requires mesh repair.
The usage of synthetic mesh for emergent setting requiring bowel resection is controversial [47, 48], and biologic mesh has been supported as alternative choice for
hernia repair [49, 50]. We use non-cross-linked acellular porcine dermal matrix
(Strattice™) in all patients with contaminated elds requiring small bowel resection
[51, 52]. We reported that elderly patients undergoing complex abdominal wall hernia repair with biologic mesh experienced similar outcomes to non-elderly patients
when using propensity matching [52].
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6 Appendicitis inElderly
The incidence of acute appendicitis decreases in the elderly population, and the
epidemiology and the outcomes of acute appendicitis in the elderly differ greatly
from the non-elderly population [53]. In general, the risk of morbidity and mortality
with appendicitis in the elderly is greater than in the younger population. Elderly
patients tend to be associated with high comorbidities and experience complicated
appendicitis with perforation. In a meta-analysis done in 2018, Jaschinski et al.
studied the differences between laparoscopic and open appendectomy. Laparoscopic
appendectomy has lower postoperative pain and less wound infections [54, 55],
shorter length of stay, and a shorter time until they were able to return to normal
activities. Initially, the disadvantage of laparoscopic appendectomy was reported to
be a higher association of intra-abdominal abscesses [54, 56, 57]. However, after the
last few decades, the outcomes became similar, and current evidence shows that
there are no differences between open and laparoscopic appendectomy in intraabdominal abscess [54, 55].
Delayed diagnosis of appendicitis is common in elderly, and this is associated
with higher perforation and intra-abdominal abscess. Managing elderly with perforated appendicitis and intra-abdominal abscesses is challenging, although patients
who undergo laparoscopic appendectomy have a shorter length of stay and less
complications than patients who underwent open appendectomies [58]. The rate of
laparoscopic surgery for perforated appendicitis has been increasing [59]. Though
the laparoscopic approach is both safe and effective, there is still controversy
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