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Chapter12
Thelaparoscopicapproachtoemergency
abdominalsurgery
DannyRosin
Laparoscopy shares many similarities with the emperor’s
newclothes.Ifyoudonotjoininthechoirofpraiseyouare
considered either stupid or unfit for the job. But someone
hastotellthetruth.
RolandAndersson
Generalprinciples
Laparoscopyhaslongagobecomepartofourdailyroutine,andevenif
we still argue about its value in certain procedures, you surely feel
familiar and confident, after getting some training and experience, to
enter the abdomen and use the relevant instruments. So, what is so
specialanddifferent in emergency laparoscopy,comparedtoyour
usuallaparoscopiccholecystectomy?
Well,quitealot…
Diagnosismaybeelusive.
Thepatient’sphysiologymaybederanged.
Abdominalconditionsmaybeunfavorable.
Speedmaybecritical.
Timing is usually inconvenient: experienced staff may be lacking, available staff
may be tired, and you may need to handle unfamiliar situations, with less
assistance.
Soingeneral,bothdecisionmakingandoperatingtechniqueare
morecomplicatedinasurgicalemergency.Evenproceduresyouare
confidentwith (laparoscopiccholecystectomy)may becomeachallenge
—forexample,inacutegangrenouscholecystitis.But,asyouknowfrom
elective surgery, reducing surgical trauma to the abdominal wall is
beneficial,maybeevenmoresoinapatientwithanacuteconditionwho
needs his ‘healing energy’ to overcome the disease itself. The usual
potentialadvantagesoflaparoscopy—lesspain,shorterileus,enhanced
mobilization—arerelevantintheacute setting.On theother hand,the
listabovemakesitobviousthatemergencylaparoscopyisnotawalk
inthepark,andtheriskofcomplicationsisincreased.
So,beforeyoudecidetousethisexcellenttool,youhavetorealizeits
limitations, and even more important — you have to realize YOUR
limitations. Selectivity, dexterity, andclinical judgment mustguide
yourdecisionswhenandiftouselaparoscopy,howtocarryitout
safely,whentoconvert,andwhentoavoiditaltogether.
Potentialadvantages
•
Diagnosis. Despite modern imaging, we still operate on patients
that may surprise us. The use of CT scans has not completely
eliminatedsurgeryforthenon-inflamed appendix.Thefreeairmay
come from perforation of a viscus we did not suspect. The bowel
obstruction in a metastatic patient can be the result of a single
adhesive band. These situations and others can of course be
detectedandtreatedbyalarge,‘formal’laparotomy,butwhatif
we could reduce the price of exploration by limiting the
abdominal wall trauma? Laparoscopic exploration can establish
thediagnosis,anddirectustotherequiredintervention.Andevenif
opensurgeryisrequired—itmaybe doneinamoredirected
way,throughalimitedincisionsitedwherethepathologylies.
•
Surgical trauma. In a patient suffering from an acute abdominal
condition, reducing the additional physiologic burden of a large
abdominal wound is a highly desired objective. Pain, ileus,
immobilization, respiratory dysfunction — are all expected in a
patient with an inflammatoryor obstructive abdominal condition —
whyaddtothatalongincisionwhichcanfurtherstokethefireofthe
SIRS? Reducing tissue trauma contributes to enhanced
recovery.
•
Wound-related problems. In acute conditions, the risk of wound
infection is increased, and so are the chances of wound healing
disorders, wound dehiscence and eventual incisional hernia.
Laparoscopymaypreventtheseconditions,oratleastdiminish
thembyallowingtheuseofsmaller,directedincisions.
Potentialflaws
The significant advantages listed above should be balanced against
many potential difficultiesand risks expected ina patient with an acute
abdomen.Theserelatebothto thegeneral conditionof thepatient,and
the specific conditions found inside the abdomen. The resulting
complications, or even mortality, may be fully preventable by an
openapproachoratimelyconversion. Herearea few drawbacksof
laparoscopy:
•
Hemodynamic stability. Inflating the abdomen with CO2 is well
toleratedbymostpatientsinelective conditions,despitetheknown
effectsonthecardiovascular andrespiratorysystem. Thismay not
be the case in the septic patient, suffering from a distended
abdomenand respiratoryinsufficiency.Thedelicatephysiological
balance,ifstillmaintainedbeforesurgery,maybeeasilylostby
the added insult of increased abdominal pressure and
decreasedperfusion.Infact,anopenabdomenmayactuallybe
requiredaspartofthetreatment…
•
Need for speed. Procrastination is certainly not something a
bleedingpatientneeds.Atraumapatientinshockisnotthecorrect
patientonwhomtopracticeyourhand-eyecoordinationskills.Open
upandstopthebleeding!
•
Need for space. This is a pre-requisite for safe and successful
laparoscopy.Colonicobstructionwillnot leaveyou enoughworking
space and is almost out of the question for laparoscopy. A thick,
edematousabdominalwall(commonafteraggressiveresuscitation)
withlimitedcompliancewillhardlyletyoucreateaworkingspaceor
will mandate high (and dangerous) insufflation pressures.
Obstructed small bowel may stillleave youenough working space
butwillnotmakeyourlifeeasy…extremecarefulnessandahigh
degree of expertise are needed to avoid catastrophic injuries
like major spillage of obstructed contents — we have seen
mortalityfromthis.
•
Technical limitations. The local conditions found in the acute
abdomen may limit the ability to handle the situation
laparoscopically. Adhesions, tissue edema, bowel distension— all
of these can interfere with the handling, retraction,
manipulation and mobilization needed to complete the
procedurepromptlyandsafely.
•
Missed pathology. The limited palpation, limited access to
retroperitonealstructuresandsometimeslimitedvisibilitymayresult
inmissingtheactualpathology.Conversionisagoodsolutionbut
onlyifthesurgeonrealizesthatsomethingismissing…
Remember:Ihaveneverseenapatientdyingbecausehewasconvertedtoopen;Isaw
themdyingbecausetheywerenotconvertedinatimelymanner.Moshe
Asmallscardoesn’tmatterinthecoffin.Ari
Settingthescene
Laparoscopy is ateam procedure, even more so than open surgery.
YourelyonequipmentandtechnologythatshouldbefamiliartoyourOR
staff,whoshouldhelpyouoperateandtrouble-shootthem.Youalsorely
on good assistance, for holding the camera and additional instruments.
Andyoucertainlyrelyontheanesthetistandhismuscle-relaxingpotions.
Achievingsmoothlaparoscopicproceduresout-of-hours,fornonroutinecases,performedonpatientsinnon-optimalconditions, in
notaneasytask.Thetiredanesthetistandthethirstyscrubnursemay
not be eager to join you in what is conceivedto be a longerand more
difficult procedure. To become an emergency surgerylaparoscopist
youshouldtrainyourORteamtofunctionintheseconditions,and
itstartsbyrealizingthatlaparoscopyispossible,andthatit’sinthe
patient’sbestinteresttohavetheproceduredonelaparoscopically,
evenat2a.m.
Youshouldstartwithsimpleprocedures,likeappendectomyormaybe
cholecystectomyforacutecholecystitisifyoufeelproficientenough,and
makesurethesystemfunctionswell.Onlythencanyouembarkonmore
challenging conditions like duodenal perforation or small bowel
obstruction.Anddon’tbuyallthatisdescribedintheliterature—we
willforgiveyouifyoucontinuetoremovetheshatteredspleenviaa
midlinelaparotomy.
Youshould also make sure you arewellequippedfor completing the
taskinfront of you. Youmayknow how to suture laparoscopically (you
should!) but youneed a suture holder. You mayneed to workin more
thanonequadrantsobetter haveanothermonitorready.Youmayneed
to aspirate infected fluid so make sure your suction is connected and
functioning.Energysources,staplers—thinkaboutyourpossibleneeds
inadvance,whileyouthinkaboutyourimpendingprocedureandplanit,
andmakesureyouhavewhatyouneedtomaketheoperationsafeand
successful—youreleganthandsareimportant butnot enoughon their
own.
Technique
Planningtheprocedure
Thebeautyof emergency surgery is in the surprises it holds for you.
Andyet,trytominimizesurprisesand beready.If youplantotacklean
incarcerated hernia laparoscopically — think about the possible
scenarios and how you will handle them: what will you do if you find
necroticbowel?Ifyougoinforsmallbowelobstruction,trytoidentifythe
locationoftheobstructioninthepre-op CTscan:thiswillhelpyouplan
thetrocarplacementforyourscopeandinstruments,andthelocationof
themonitorataconvenientspotinfrontofyou.
Gettingin
Wearenotheretosolvetheeternaldebate—VeressorHasson?You
mayhaveyour ownpreferencesforelectivesurgery,andit’sfineby us.
Butwe expect youtobefamiliar with bothtechniques,because in
emergency conditions selectivity is the key,and the closed, blind
entry may bemore dangerousin certain conditions.For example,
with bowel obstruction — both the distended bowel and the
adhesionsfrom previous operations mandate thatyou choosethe
openentrytoavoidinadvertentbowelinjury.
Choosingthecamera
Asyouhaveprobablyrealizedbynow,a30°scopewillincreaseyour
field of view and your overall versatility, and is recommended as a
standard.Itmaybeevenmorevaluableinemergencyoperations,where
theneed‘tolookbehind’,duetoadhesionsorboweldistension,iseven
morepronounced.Providedyouhaveagoodopticalsystemwithagood
light source, a 5mm scope may allow you to easily move the camera
between different trocars, providing different viewing angles. A second
monitor on the other side of the table may be a good adjunct for this
condition.Butifyoudon’t have a high-quality 5mm optical system, and
especially when you know you are going to work in a single quadrant
(appendectomy,cholecystectomy), don’tcompromise,and getthebest
viewing conditions you can, using a 10mm scope. This will keep
your illumination maximal, even in harsh conditions like blood
poolinginyourfield.
Placingtheworkingtrocars
Youshouldhaveageneralworkingplan,toachieveyoursurgicaltask
in hand. Some of the surgical emergencies are ‘straightforward’, and
have a standard scheme: laparoscopic cholecystectomy or
appendectomy are usually done the same way (with some minor
variations), and are limited to one abdominal quadrant. Bowel
obstruction, on the other hand, can have its ‘transition point’ in an
unexpected abdominal location. Analyzing the CT scan and
understanding where the obstruction point is, even approximately, will
helpyoutoplanthetrocars’locationinthemosteffectiveway( Figure
12.1).
Figure12.1.Surgeon:“Ihadtoinsertafewmoretrocars for exposure.” Assistant: “But
Sir,SILSwouldhavebeenmoreminimallyinvasive...”
Tissuehandling
Dealing with swollen, edematous and inflamed tissues, or
obstructed,distendedbowel,isasurgicalchallenge,requiringboth
delicacyandfirmnessintheexactamounts.Holdingtoodelicatelyor
tooaggressively—youcanripsoftenedtissue.Manipulatingadistended
bowel—youcanperforateit.Dissectinganinflamedtissuetoomuch—
youcanproduceexcessivebleeding.Muchexperienceisneeded,buta
few rules and tips can help you sail more safely through stormy
emergencywatersuntilyougainthatexperience:
•
‘Bigbites’arelesslikelytoteardelicatetissuesyouneedtohold.
•
Suctiontipisawonderfultoolfordissectinginflamedtissues.
•
Blunt dissection will help you to follow the anatomical planes,
especiallywhenseparatingrelativelyfreshadhesions.
•
Collapsed,post-obstructionbowel loops are the best place to start
whenyoulookfortheobstructionpoint.
•
When ‘running’ the bowel, holding the mesentery just below the
bowel and not the bowel itself may reduce the risk of inadvertent
bowelinjury.
Procedures
Choosing which emergency procedure to attempt laparoscopically is
notalwayssimple.Someproceduresarewithintheconsensus—a‘hot’
gallbladder will rarely be approached initially by open surgery.In other
conditions — like in abdominal trauma — some will rarely attempt
laparoscopy. In most cases the final decision will be a complex
consideration of multiple factors, but if the necessary conditions
(equipment, experience) are met, we still have to ask ourselves: is it
worthwhile? What do we gain from laparoscopy and what do we risk?
The best emergency procedures, listed below, to accomplish
laparoscopically, are those with a large ‘delta’ — denoting a
significantdifferenceandthusalargeadvantage/disadvantageratio
comparedtoopensurgery.
Here are only a few ‘laparoscopic’ comments for each of these
procedures,asacomprehensivediscussionofthemisgiveninthe
relevantchapters.
Laparoscopiccholecystectomy
Depending on your local practice, acutely inflamed gallbladders may
be either operated upon or treated conservatively. But while open
surgery for acute cholecystitis was once the bread and butter of
surgicalresidents,laparoscopicsurgery for this conditionis quite
demanding,requiringthepresenceofanexperiencedlaparoscopist,
andfamiliaritywithseveralmaneuversthatwill makesaferemoval
ofthegallbladderpossible:
•
Graspingadistendedgallbladderisdifficult.Aspiratingthebile(you
canusetheVeressneedleforthis)willmakegraspingpossible.
•
Blunt dissection, using the suction tip, is especially rewarding in
edematous,inflamedtissues.
•
Anatomy may be obscure in inflamed conditions — don’t take
shortcuts;insistonobtainingthe‘criticalviewofsafety’.
•
If you can’t delineate the anatomy — consider alternative
approaches, like retrograde cholecystectomy or subtotal
cholecystectomy. Opening the gallbladder justabove Hartmann’s
pouch, carefully evacuating thestones into a pre-placed collection
bag,andlookingdownintothegallbladder outletmayassistyouin
delineationoftheanatomy,andunderstandingwherethecysticduct
hides.Ifstillunclear—makesureyouhaveclearedthestonesand
thensuturethe cystic duct from within, or close Hartmann’spouch
with sutures or an Endoloop®. If these maneuvers seem
‘impossible’,youcansimplyleaveadrainandbailout!
•
Don’tforgettheoptionofconversion!‘Remembering’thatoption
inhindsightafter thepatienthassufferedaCBD injuryorafteryou
havebeensued,isnottoohelpful.
•
Readmuchmoreaboutitin Chapter20.
Laparoscopicappendectomy
The‘delta’mentionedabove,comparedtoopenappendectomy,isnot
toobig,andthereforethedebateregardingwhichapproachispreferable
isnotover.Bethatasitmay,inpracticewehaveseenamajorincrease
in the rate of laparoscopic appendectomy, so it’s here to stay. Its
advantagesaremorepronouncedinobesepatients,infemales,and
whereimagingmodalitiesarelessavailable.
Wewillnotdwellheretoomuchonthetechnique(see Chapter23),
andthe trocararrangement isreally notthat important—usewhatyou
weretaughttodoandwhatyoufeelcomfortablewith.Butifyouwantto
decrease the most quoted disadvantage — postoperative pelvic
collection — you probably have to be careful while handling the
inflamedappendix,andavoidoverzealousirrigation.
Perforationsandperitonitis
Youmaynotwanttotakeanelderly,unstable,septicpatientandpump
hisabdomenwithCO2(anyway youbetter resuscitateand stabilizehim
beforehecrashesunderanesthesia), butin manycases laparoscopyis
usefulindealingwithperitonitis.Ifyoualreadyhaveadiagnosis,likea
perforatedpepticulcer,allyouneedisperitonealtoiletandafewsutures
tocompletetheGrahampatch, andlaparoscopy isideal: itwill certainly
reducethewoundinfectionriskandotherincision-relatedproblems.Just
makesureyourlaparoscopicsuturingskillsarewellpracticed.
If the diagnosis is not known — laparoscopy may be a perfect
diagnostictool, once you decidethatthe patient needs surgery.Evenif
conversion is needed — it may be done through a directed, limited
incision. The small bowel perforation, due to a fish-bone, may be
exteriorized and repaired (or resected), without a major midline
laparotomy.Perforateddiverticulitiscanalsobehandledlaparoscopically,
especially if you like (and trust) the modern ‘lavage and drainage’
approach for Hinchey 3 cases (non-fecal peritonitis). If resection is
needed, probably with a Hartmann’s procedure, and you have
laparoscopic colectomy skills, they can be of use now. Otherwise, a
conversion through a lower midline laparotomy will usuallysuffice. But
again—theseproceduresarefortheexperts—youneedtopolish
your elective advanced laparoscopic skills before venturing into
suchpotentialminefields.
Smallbowelobstruction
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