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68
3.3 Laparoscopy for the Acute Abdomen
Otherwise the complications are the same as for staging laparoscopy.
Although the risk of gas emboli in cases of vascular injuries
must be considered, this complication is in practice only of
minor significance since patients with such injuries are mostly
not candidates for diagnostic laparoscopy.
Postoperative Complications
The special postoperative complications are discussed elsewhere.
Bibliography
Berci G, Bunkelman D, Michel SL et al. Emergency minilaparoscopy in
abdominal trauma: An update. Amer. J. Surg. 1983; 146:261.
Carnevale N, Baron N, Delaney HM. Peritoneoscopy as an aid in the diagnosis
of abdmoninal trauma: A preliminary report. J. Trauma 1977; 17:634.
Feussner H, Kraemer SJ, Siewert JR. Technik der laparoskopischen Ul-
traschalluntersuchung bei der diagnostischen Laparoskopie. Langenbecks
Arch. Chir. 1994; 379:248.
Gazzaniga AB, Slanton WEW, Bartlett R. Laparoscopy in the diagnosis of
blunt and penetrating injuries to the abdomen. Amer. J. Surg. 1976;
131:315.
Paterson-Brown S, Eckersley JRT, Sim AJW, Dudly HFA. Laparoscopy as an ad-
junct to decision making in the “acute abdomen”. Brit. J. Surg. 1986;
73:1022.
Society of American Gastrointestinal Endoscopic Surgeons. Guidelines for
diagnostic laparoscopy. Surg. Endosc. 1993; 7:367.
3.3 Laparoscopy for the Acute Abdomen
A. Metzger , K. Schönleben, Ch. Klaiber
Rationale
Laparoscopy for the acute abdomen has the potential to be used
either as a diagnostic procedure or as a therapeutic modality.
Urgent laparoscopy has many similarities with exploratory laparotomy, as it allows direct vision of the contents of the
abdominal cavity and may possibly unveil a diagnosis that is
otherwise uncertain by non-invasive diagnostic means (clinical
and radiological). The main advantage over exploratory laparotomy is the lesser degree of surgical trauma. This becomes
especially significant when the laparoscopy demonstrates that
the underlying disease does not require subsequent celiotomy,
or when the patient can be treated completely or partially (i. e.,
“assisted”) by laparoscopic operative techniques.
However, laparoscopy has clear limitations: some areas of the
abdomen, such as the retroperitoneum and the posterior surfaces of the liver and the transverse colon, cannot be accurately
visualized. Digital palpation, a very valuable tool, is not available. Furthermore, the technical peculiarities of the laparoscopy
make it susceptible to missing small injuries of hollow organs.
Due also to technical limitations, laparoscopic management of
profuse bleeding, particularly when it originates from a large
vessel, remains inadequate.
Contraindications
Contraindications for urgent laparoscopy can be divided into
absolute and relative categories. Most importantly, they should
reflect sound surgical judgment, taking into account the underlying disease and the expertise of the surgeon, so that each
patient receives optimal treatment. While the list of conditions
that would challenge a decision to proceed with laparoscopy is
longer in a surgeon’s early experience, it decreases as he or she
becomes more familiar with laparoscopic techniques.
Absolute contraindications for laparoscopy include hemodynamic instability, septic peritonitis, clotting disorders, and poor
respiratory status. The therapy of choice in these conditions is
laparotomy, because laparoscopy, although technically feasible,
may put patients at an unacceptable risk.
Intestinal mechanical obstruction per se is not a contraindication for laparoscopy. Moreover, in cases of obstruction originating from a single adhesion, management by laparoscopy offers
the patient a distinct advantage over laparotomy. However, laparoscopy is contraindicated in patients with massive bowel dilatation. Due to the limited space, laparoscopy carries a high
risk of accidental enterotomy while entering the abdomen or
while handling the instruments.
Similar considerations apply for patients with a previous
Indications
The indications for urgent laparoscopy depend upon the clinical
diagnosis and the therapeutic intent:
1. The diagnosis is unknown despite extensive work-up. Laparaoscopy represents the lesser invasive step before exploratory laparotomy.
2. The diagnosis is suspected (e. g., appendicitis). Laparoscopy
confirms the diagnosis; in addition, laparoscopic treatment
can be definitive.
3. The diagnosis is known (e. g., perforated gastric or duodenal
ulcer). The primary intent is to treat the underlying condition by laparoscopy.
cedures, adhesions may limit the free handling space. Besides,
adhesiolysis may represent an effort not worth the risk of injury
and the prolonged operating time.
Preparing the Patient for an Urgent
Laparoscopy
As with any other surgical procedure, informed consent must be
obtained from the patient prior to the operation. It is imperative
to discuss the primary goal of the laparoscopy (diagnostic and/
or therapeutic), and the factors determining the decision of
whether to conclude laparoscopically or to convert to laparatomy when the diagnosis is made. The patient must also be in-
Instrumentation
69
formed about the risks and complications of either procedure.
In this way, provided that the patient’s condition allows him or
her to make a sound judgment, the patient can be involved in
deciding which option to take.
The necessity of premedication other than that required for anesthesia depends on the underlying disease. In the majority of
patients, some type of prophylaxis against deep venous throm-
bosis will be used. Antibiotics may be required for infectious or
inflammatory conditions.
Placement of a nasogastric tube offers the advantage of emptying the stomach, and thereby reduces the risk of injury and pro-
vides more space for laparoscopic instruments. Insertion of a
Foley catheter into the urinary bladder serves a similar purpose.
It also allows you to monitor minary output.
Anesthesia
Diagnostic laparoscopy can be performed under local anesthesia supplemented by intravenous sedation. This is true for bedside laparoscopy (in the emergency room or the intensive care
unit), especially when using small laparoscopes (2−5 mm).
However, in most situations both patient and surgeon are better
served with the patient under general anesthesia in the operating room; the high degree of patient cooperation required with
the use of local anesthesia no longer is a limiting factor, examination of the entire abdominal cavity is enhanced by the possi-
bility of multiple repositioning of the operating table, and ther-
apy can be carried out without delay.
Positioning the Patient
The position of the patient depends mainly on the goal of the laparoscopy. Whenever it is unclear if a laparoscopic procedure or
a laparotomy will be carried out, the most flexible position for
all potential procedures at the outset is preferred. In our experience, some upper abdominal organs—gallbladder, diaphragm, and stomach—are best inspected by laparoscopy when
the surgeon stands between the legs of the patient. Therefore, a
modified lithotomy position is used. The patient lies supine
with slightly angled and abducted legs resting on well-padded
supports. The arms are tucked to the body, since otherwise they
may interfere with the operating team, especially when exploration of the pelvis is carried out. Shoulder and side supports
are mounted to allow extreme repositioning (rotation and tilting) of the operating table. The entire abdomen and the inguinal
region are washed and draped.
Position of the Video Monitors
The ideal arrangement to conduct a diagnostic laparoscopy consists of two video monitors. One is located close to the area oc-
cupied by the anesthetist, the other is placed in a caudad posi-
tion. In this way, the surgeon is able to explore the entire abdomen without having to relocate the monitor. When only one
monitor is available, it is preferable to begin the laparoscopy
with the monitor placed on one side of the patient, approximately at the level of the umbilicus. If necessary, relocation to a
more cranial or caudad position may be achieved easily.
Instrumentation
A laparoscope with angled view (25−30°) is the authors‘ preferred choice. Its handling requires a higher degree of training,
but it provides a definitive advantage over a straight-view lens
in that the field of view can be extended simply by rotating the
telescope.
For a complete laparoscopic evaluation of the abdominal organs, the standard laparoscopic instrumentarium should be
supplemented by atraumatic grasping forceps and, most important, by endoscopic bowel clamps (e. g., Babcock type or others),
which are essential to manipulate and thereby examine the entire small bowel and colon thoroughly.
Patient Monitoring
Patients must be monitored carefully during laparoscopy. Deterioration of systemic arterial or airway pressures, oxygen saturation, or end-tidal CO
traabdominal pressure or the presence of a complication.
suggests either an excessive in-
2
Induction of the Pneumoperitoneum
Two techniques are available for induction of the pneumoperitoneum. The closed technique uses a Veress needle, which is
usually inserted in the periumbilical area. When adhesions are
expected, the left upper quadrant, which statistically has the
lowest incidence of adhesions, may be elected as an alternative
puncture site.
With the open technique, a skin incision of approx. 1.5 cm is per-
formed. The fascia is exposed and incised along the length of the
skin incision. A purse string is placed around the fascia opening,
and the peritoneum is opened with scissors. Then, a 10 mm trocar sleeve without trocar is inserted into the abdomen. Insertion of the trocar can sometimes be facilitated by preliminary
introduction of a 10 mm rod, which serves as a guide for the trocar sleeve. After confirmation of the intraperitoneal location of
the trocar, either by direct vision or by introduction of the laparoscope, CO
vented by tying the purse string around the trocar sleeve. The
Hasson trocar, which features a conical device to prevent gas
escape, simplifies this technique to maintain the trocar in position, two stay sutures are placed into the fascia and secured to
the trocar wings. We strongly recommend the open technique;
in experienced hands it is straightforward and much safer than
the Veress needle.
An intraabdominal pressure of 8−10 mm Hg is usually enough
to provide excellent vision and working space. Higher levels
may be necessary in certain situations, but they should not be
used routinely, as depression of cardiac output directly correlates with intraabdominal pressure. The surgeon must monitor
the intraabdominal pressure throughout the procedure. Sudden
increases of pressure usually indicate poor relaxation of the
patient and result in diminished working space and impairment
of vision.
is insufflated into the abdomen. Gas leak is pre-
2
Placement of Trocars
A 10/11 mm trocar is inserted after creation of the pneumoperitoneum to allow introduction of the laparoscope. The preferred
site is the periumbilical region, because this position allows in-
70
3.3 Laparoscopy for the Acute Abdomen
spection of the entire abdominal cavity. In certain instances the
underlying disease may require placement of the laparoscope in
a different position (e. g., the hypochondrium). At least two
further ports are required for a complete evaluation of the
abdominal organs. As a rule, one trocar is inserted laterally in
the mid-clavicular line at the level of the umbilicus, the other on
the opposite side slightly more caudad. Whether to insert 5 mm
or 10−12 mm trocars is a matter of preference, but larger trocars
are more versatile with respect to the choice of instruments,
thus outweighing the disadvantage of larger wounds. Additional ports may be necessary depending on the findings and
the appropriate therapy. Insertion sites should be chosen keeping in mind a potential conversion to laparotomy.
If laparoscopy is performed primarily for a therapeutic purpose
(e. g., appendectomy), the trocar number and insertion sites are
usually chosen according to the established technique (see
corresponding chapters).
Systematic Inspection of the Abdomen
In the majority of cases the differential diagnosis will dictate the
area within the abdomen to be inspected first (e. g., the upper
abdomen in case of a suspected perforated duodenal ulcer).
Upon confirmation of the diagnosis, however, and as with exploratory laparotomy,other accessible organs should also be explored in order to rule out concomitant disease. This is of paramount importance, especially when the decision to proceed laparoscopically can be made safely. The extent of the exploration
beyond the primary form of disease depends greatly on the
findings, but, as a rule, failure to explore the entire abdomen is
an indication for conversion to celiotomy.
We recommend a systematic, step-by-step exploration of all
abdominal quadrants. Cooperation from the anesthesist is required in this operative phase, since he or she plays a major role
by repositioning the patient as the surgeon proceeds with the
various exploratory maneuvers.
Step 1: If any turbid, purulent, or bloody fluid is found, aspiration is usually the first task to accomplish. A large amount of
fluid may be an indication to proceed with open exploration.
Otherwise, samples are taken for bacteriological and/or cytological examination. Irrigation with warm Ringer’s solution follows to avoid further contamination and to enhance visualization. In some instances, several liters of irrigation fluid may be
required to achieve a clear operative field. Complete aspiration
of the irrigated fluid is facilitated by rotating and tilting the
operating table.
Step 2: The reverse Trendelenburg position allows inspection of
the anterior aspect of the liver, diaphragm, anterior aspect of
the stomach, and first portion of the duodenum. With the help
of an atraumatic instrument, the liver is elevated to expose its
underfaces, the gallbladder, the caudate lobe, and the porta hepatis. Exploration of the entire convexity of the spleen is difficult when the laparoscope has been inserted at the umbilicus,
but can be achieved to some extent in the maximal right lateral
position. If the spleen is the main target of exploration, insertion
of the laparoscope subcostally in the midclavicular or anterior
axillary line is preferred (see chapter 6.1). Exploration of the
pancreas and of the posterior aspect of the stomach requires
opening the gastrocolic omentum. This is best achieved in an
avascular portion and is greatly facilitated by elevating and putting the stomach and the transverse colon under tension.
Step 3: The Trendelenburg position facilitates inspection of the
pelvic organs down to the space of Douglas. Especially in
women, complete exploration of the genitoururinary organs requires maximal tilting of the operating table. In this way the
small bowel is kept out of the pelvis by gravity. By rotating the
table to the left, the cecum and the appendix can be inspected.
To display the ascending colon up to the hepatic flexure, the
greater omentum is moved and held into the upper abdomen
with an atraumatic grasper. Rotation of the table to the right allows inspection of the sigmoid and descending colon. Exploration of the posterior aspects of both the ascending and descending colon requires incision of their peritoneal attachments
and reflection of the colon to the midline.
Step 4: Neutral position: Examination of the entire small bowel
is probably the most difficult and time-consuming part of a diagnostic laparoscopy. In our experience, it is usually easier to
run the bowel retrograde starting at the ileocecal junction
which can be readily identified. This is best accomplished by
holding the laparoscope in a fixed position and by bringing into
view successively segments of bowel with the aid of two endoscopic bowel graspers. To visualize the proximal bowel up to the
ligament of Treitz, the patient is placed again in the reverse
Trendelenburg position and rotated to the right. Elevation of the
root of the mesentery facilitates this step, but to accomplish this
maneuver, insertion of an additional instrument may be required.
At this point, all laparoscopically accessible organs have been
inspected. Again, it is important to keep in mind that the evaluation of retroperitoneal structures is only possible by indirect
means; presence of retroperitoneal swelling may indicate an
ongoing inflammatory disease. If profuse hemorrhage has occurred, both swelling and a hematoma may be noticed by translucency.
Due to the limited resolution of the video picture, appreciation
of color for assessment of perfusion may be somewhat misleading if it is only observed through the monitor. Therefore, taking
down the video camera and looking directly through the laparoscope may be a valuable step in some instances.
Therapeutic Choices
The decision as to which treatment to pursue upon completion
of the diagnostic laparoscopy (nonoperative treatment, laparoscopic or laparoscopic-assisted procedure, or laparotomy) depends on two factors: the diagnosis, and the laparoscopic expertise of the surgeon.
If no pathological findings have been discovered, the surgeon
faces the difficult decision of either concluding the laparoscopy
and further observing the patient, or converting to laparotomy.
We feel that a low threshold for conversion is of paramount importance, but recognize that certain situations may well justify
a cautiously nonoperative approach. Equivocal findings demand
for conversion to laparotomy. Some diagnoses (e. g., Fitz-Curtis
lymphadenitis, enteritis) deserve nonoperative treatment and
therefore do not represent a major decision problem. Whenever
the diagnosis requires operative treatment, the magnitude of
the findings and the laparoscopic skills of the surgeon should
determine which approach to select. While an appendicitis or a
perforated anterior duodenal ulcer can be managed by laparoscopy, the more difficult laparoscopic resection of the sigmoid
colon in the presence of a perforated diverticulum may not be
the best of choices. Even for the experienced laparoscopic surgeon capable of performing such a procedure, the possible
advantages of an endoscopic approach may not be worth the
overall effort in terms of operating time, personnel, and costs.
Indications
71
An intermediate technique between laparoscopic treatment
and laparotomy is the laparoscopically-assisted approach. With
this method, diagnosis is made by laparoscopy, which also indicates the best location for a conventional open incision. The actual procedure (e. g., small bowel resection) takes place outside
the abdomen with conventional techniques. Since retrieval of
the target organ is facilitated by laparoscopy, the incision can be
made much smaller than that required for an exploratory laparotomy.
Complications
Laparoscopy-related complications include injuries to either
blood vessels or the intraabdominal organs; these occur during
insertion or manipulation of the Veress needle, the trocars, and
3.4 Laparoscopy for Peritonitis
E. Löhde, E. Kraas
the instruments, or are caused directly by the insufflation of CO
(e. g., shock, gas embolism, tension pneumothorax). While injuries can usually be avoided by a careful technique—such as
open induction of pneumoperitoneum, insertion of trocars
under direct vision, and atraumatic handling of the intraabdominal organs—the complications related to the pneumoperitoneum are difficult to predict and should be watched for carefully.
Failure to recognize a condition which requires operative treatment may be the most harmful complication of emergency laparoscopy. Therefore, whenever laparoscopy is used for the purpose of limiting invasiveness, its potential advantages have to
be weighed against its potential risks. If surgeons recognize
these factors, laparoscopy will prove to be a most valuable tool
in the diagnostic and therapeutic management of the acute abdomen.
2
Goals and Methods
At present, there is a definite role for laparoscopy in the presence of peritonitis. Laparoscopy expands the spectrum of sur-
gical options and allows for a flexible therapeutic intervention.
Laparoscopy helps to establish a prompt and reliable diagnosis.
It can enable the surgeon to ascertain the cause and extent of
the peritonitis and gives important information for deciding on
the operative strategy. Diagnostic laparoscopy helps the sur-
geon to identify patients with findings that allow curative laparoscopically-guided or -assisted therapy, thus sparing them a
conventional procedure.
Indications
The use of laparoscopy for peritonitis is not fully established yet.
Essential requirements of this method include an extensive experience in the conventional operative treatment of peritonitis,
a high degree of proficiency in laparoscopic surgical techniques,
a laparoscopically experienced operating team, and close
cooperation with the anesthesiologist.
Exploratory laparoscopy is indicated in patients with clinical
signs of peritonitis of uncertain etiology (Fig. 3.4.1). It allows the
surgeon to avoid time-consuming diagnostic procedures and
leads rapidly to the definitive diagnosis. Usually it will be
possible to evaluate the condition of the whole peritoneal cavity. Laparoscopy can localize the primary focus of peritonitis,
determine the type, extent, and duration of the underlying con-
ditions, and possibly provide other additional information.
Patients in their postoperative course can also benefit from
these opportunities. In the presence of an unclear postoperative
abdominal situation, laparoscopy can provide valuable informa-
tion about complications (such as suture failure, early adhesions, bowel ischemia, acalculous cholecystitis etc.) early and
without significant patient trauma. This makes it possible to
redress the situation laparoscopically or perform a repeat la-
parotomy more quickly and precisely if indicated, or to avoid laparotomy if findings do not warrant it.
On the basis of laparoscopic findings, the surgeon can decide
between the following types of management:
쐌 laparoscopy as a simple diagnostic procedure or additionally
combined with an intraperitoneal lavage (primary peritonitis, pseudoperitonitis, purulent adnexitis, enteritis, colitis,
etc.),
쐌 definitive laparoscopically guided on assisted operation,
쐌 laparotomy is indicated.
The indication to perform definitive laparoscopic surgery is
made during exploratory laparoscopy. The surgeon assesses the
possibility of laparoscopic management on the basis of local in-
Clinical peritonitis
Genesis unclear Genesis confirmed
Patient suitable for laparoscopic
operation?
Yes No
Exploratory laparoscopy
Laparoscopic
operation
Abb. 3.4.1 Indications for exploratory laparoscopy for peritonitis.
Conventional
operationif necessary
72
3.4 Laparoscopy for Peritonitis
Step-by-Step-Procedure
Using a gastric ulcer as an example, proceed as follows:
1. Explore the peritoneal cavity, establish the diagnosis, and localize the perforation site.
2. Assess the extent, duration, severity, and particular details of
the peritoneal involvement.
3. Determine the appropriate procedure, laparoscopy or la-
parotomy.
4. Place required working trocars.
5. Take specimen for laboratory examination and bacterial culture and antibiotic sensitivities; remove the exudate.
6. Treat the primary lesion. Place a single or double row of inter-
rupted sutures (using extracorporeal or intracorporeal knot-
tying techniques). If desired an excision of the lesion can be
performed. The greater omentum may be fixed over the per-
foration site with interrupted sutures.
7. Avoid bleeding being deleterious for peritonitis healing.
8. Copiously irrigate the peritoneal cavity until the irrigation
fluid is clear. Thoroughly irrigate all compartments, changing
the patient’s position accordingly.
9. Place drains through the existing trocar incisions. Initiate
postoperative tidal lavage if necessary.
10. Feel free to perform a “second-look” laparoscopy in cases of
slow recovery.
traabdominal findings. With the definite limitations of laparo-
scopic procedures in mind, he or she has to decide if the pri-
mary goals of peritonitis therapy can be achieved safely: “blocking the source of infection” (Kirschner, 1926), removing the exudate, and cleaning the abdominal cavity. This decision also re-
quires taking into consideration all known preoperative data
such as the patient’s general condition, age, estimated immune
state, kidney function, peritonitis score, etc. (Beger, 1993; Knaus
et al., 1985).
Note: The success and risk of the laparoscopic operation depend
on the surgeon making the right decision. The specific danger of
laparoscopic intervention lies in incorrectly assessing in-
traoperative findings and exceeding the limitations of the
method. If any difficulties are encountered or there is any doubt,
conversion to an open procedure is indicated.
Specific indications include:
쐌 as a general rule, only early peritonitis,
쐌 localized peritonitis from complicated appendicitis,
쐌 localized peritonitis from acute ulcerating cholecystitis or
empyema,
쐌 localized and generalized (chemical) peritonitis from per-
foration of an anterior gastroduodenal ulcer,
쐌 iatrogenic colon perforation following colonoscopy,
쐌 peritonitis in reaction to bowel obstruction due to in-
traabdominal adhesions,
쐌 bilious peritonitis as a postoperative complication after la-
paroscopic cholecystectomy.
Contraindications
Absolute contraindications include:
쐌 duration of peritonitis exceeding 12−18 hours,
쐌 generalized bacterial peritonitis,
쐌 failure of one or more organs,
쐌 anesthetic contraindications,
쐌 limited laparoscopic experience on the part of the surgeon.
Relative contraindications can arise from a number of details involving not only the nature and severity of the clinical picture,
but also considerations specific to the surgical staff. Lack of
sufficient laparoscopic experience on the part of the assistant
holding the camera or the operating room nurse, or a limited
range of available equipment and instrumentation are seemingly minor considerations that can cause devastating problems
as the operation progresses.
Surgical Risks and Patient Information
Laparoscopic surgery involves specific risks that are largely absent in open procedures, such as unnoticed injuries to hollow
viscera or bleeding from trocar ports. However, complications
such as wound infection or burst abdomen are rarely or never
seen after laparoscopic procedures.
Laparoscopy in peritonitis involves the specific risk of the surgeon incorrectly assessing the intraabdominal situation due to
the inherently limited sensory perception (lack of touch and
spatial orientation, and distorted color perception). The limited
exploration of the abdomen permitted by the procedure may
cause the surgeon to overlook findings and misjudge the extent
of the peritonitis. This specific risk of laparoscopy requires extensive experience on the part of the surgeon.
The significant advantages of successful laparoscopic management (reduced pain, minor surgical trauma, rapid convalescence, good cosmetic results, etc.) are of primary interest to the
patient. He or she must know that in case of doubt, the surgeon
will always convert to an open procedure to reduce risks. Since
this decision is made intraoperatively, the patient must always
be informed about both operative procedures and their inherent risks.
The majority of patients accept conversion without reservation. This makes it easier for the surgeon to reach this decision, and helps to avoid unnecessary risks and situations in
which the surgeon may exceed the limits of the laparoscopic
method.
Special Preparations
The patient is prepared as for laparotomy (placement of an in-
dwelling urinary catheter, placement of a nasogastric tube in
applicable cases, infusion therapy, etc.). The definite operative
method is determined intraoperatively during exploratory laparoscopy. The surgeon must always consider the possibility of
conversion to an open procedure, which must be done promptly
without any further preparations.
Patient Positioning
The patient is positioned supine with the legs together (or apart
and place d in supports) and both arms extended. Lateral sup-
Complications
73
ports on both sides and shoulder blocks (if necessary) are re-
quired to permit safely inclining the patient in any direction so
that the surgeon can visualize all four quadrants of the abdo-
men including the pouch of Douglas.
Anesthesia
General anesthesia is standard. In laparoscopy for peritonitis,
the surgeon must pay special attention to specific anesthetic
problem areas.
The increase in intraabdominal pressure combined with extreme patient positioning leads to a decrease in the ventilation
of the basal segments of the lungs. Progressive worsening of the
ventilation/perfusion ratio can require an enormous increase in
respiration pressure, which may reach values exceeding
30 mm Hg. This entails a risk of pulmonary barotrauma. Circu-
latory fluctuations due to the relative lack of volume and in-
creased peripheral resistance can cause serious anesthesiological problems.
Tissue absorption of CO
the blood, producing respiratory acidosis. This is exacerbated by
the metabolic acidosis due to peritonitis. The patient must
“breathe off” the absorbed carbon dioxide with increased ventilation. Thus, the respiratory minute volume can exceed 20 liters
and requires sufficient lung function and compliance.
The surgeon must be familiar with these problems. In close
cooperation with the anesthesiologist, the surgeon can help immensely by using lower abdominal CO
operative technique.
increases the concentration of CO2in
2
pressures and swift
2
Trocar Placement
The trocars are placed according to the expected operative site.
In most cases, the pneumoperitoneum is established and the laparoscope/camera trocar placed near the umbilicus through a
small longitudinal incision, if a median laparotomy could be-
come necessary. Depending on the location of the findings, the
remaining trocars are placed along an imaginary arc around the
operative site.
If the periumbilical approach is unsuitable, the Veress needle
can be safely inserted inferior to the left costal arch. A 10-mm
trocar is then placed in the midline in the epigastric region to
permit placing the umbilical trocar under laparoscopic visualization.
If establishing the pneumoperitoneum with the Veress needle
represents too great a risk (for example in patients with pre-
vious operations, adhesions, or ileus), open trocar placement is
indicated (see chapter 2.2).
Continuous Postoperative Lavage
Continuous lavage is an established procedure after laparoscopic operation for peritonitis. After completion of intraopera-
tive irrigation, two or three Robinson catheters are placed (in
subhepatic and subphrenic positions on both sides for a per-
forated gastric ulcer) for in-flow and one or two out-flow drains
are placed in the pouch of Douglas and in a paracolic position.
The irrigation of the abdominal cavity may be continued with a
lavage (continuous or better as a tidal lavage at three-hour intervals) with 24 liters of Ringer’s solution per day for three days.
Despite its success rate, this method cannot replace the sur-
geon’s decision to convert to an open procedure in cases requiring open management.
Complications
Intraoperative Complications
Failure to visualize all compartments and limited exposure of
the operative site can result in dangerous complications such as
persistence of the peritonitis or development of intraabdominal
abscesses. The surgeon must recognize these limitations of laparoscopy and convert to an open procedure if necessary.
Postoperative Complications
If postoperative complications occur, repeat laparoscopy permits one to obtain intraabdominal findings quickly and easily as
well as to assess the success of treatment. The operative site
may be inspected, proper placement of drains verified, and the
abdomen irrigated again. The surgeon must always consider
and decide intraoperatively whether laparotomy is indicated for
further treatment of peritonitis. In case of doubt, laparotomy is
indicated.
Evaluation of the experience of individual surgical centers has
shown that patients critically selected according to these criteria can benefit from laparoscopic surgery. The greatly reduced
intraabdominal trauma and shortened convalescence period
are factors that should not be discounted (Eypasch et al., 1993;
Mutter et al., 1994; Geis et al., 1995).
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3.5 Comments on Laparoscopy for the Acute Abdomen
3.5 Comments on Laparoscopy for the Acute Abdomen
M.−E. Arregui
Chapter 3.3 gives a good overview of the indications and contraindications to laparoscopic exploration for the “acute abdomen.” The technique described by the authors is thorough and
complete.
There are generally three types of patients to consider. Those
who have a rigid abdomen with free air, those who have peri-
toneal signs and no free air, and those who have a bowel obstruction. A fourth category may be trauma which is not considered in this chapter.
In those patients with free air, the most common cause is a per-
forated peptic ulcer which is very treatable by the laparoscopic
approach. Extensive peritoneal lavage can be carried out fol-
lowed by a Graham patch closure of the perforation. The second
most common organ to have a perforation would be the colon.
For the most part, this is due to perforated diverticulitis or per-
foration proximal to an obstructing tumor. This is more difficult
to manage laparoscopically. A laparoscopic approach, however,
gives an excellent exposure. If tumor is present, evaluation for
distant metastasis is easily performed. Partial mobilization of
the bowel may allow a more optimally placed incision for resec-
tion. If the colon or a perforated ulcer is not the culprit, it is im-
perative to run the entire small bowel as described by the
authors. The source of a free perforation will rarely ever be
missed by the laparoscopic approach. If open operation is re-
quired, an optimally placed incision will enhance the recovery
of the patient. As a rule, I usually perform a laparoscopic ex-
ploration in most patients who have free intraperitoneal air.
Patients without pneumoperitoneum but with signs of peri-
tonitis are greatly benefited by the laparoscopic approach. The
visual inspection offered by the laparoscope is optimally util-
ized. Acute cholecystitis, appendicitis, pelvic inflammatory dis-
eases, pancreatitis, and ischemic bowel are the most common
diagnoses. Operative or nonoperative treatment is determined
by the laparoscopic inspection. The authors express the opinion
that a limited retroperitoneal inspection can be performed by
laparoscopy. High-quality, B-mode laparoscopic ultrasound
units are currently available which will provide a visual window
into solid organs such as the liver, pancreas, and spleen and
some fluid-filled organs such as the gallbladder, bile ducts, and
vascular structures. If ischemic bowel is encountered, the ultrasound can be used to detect vascular thrombus or stenosis. Dop-
pler and color Doppler can provide insight into the perfusion of
the organs. Because of air in the hollow viscera, ultrasound is
not very useful for evaluating the intestines. In the critically ill
patient, we have found laparoscopy quite useful to rule out in-
traabdominal sepsis. This has allowed us to avoid unnecessary
laparotomies in these very ill patients who are often quite unstable and on ventilators. We have even done some limited ex-
plorations in the intensive care unit.
In patients with bowel obstruction, the decision to perform laparoscopic exploration is more difficult. The primary decision is
the urgency of the operation. If ischemia is suspected, operation
must be performed immediately. If the abdomen is not overly
distended, then a laparoscopic attempt should be made. We
prefer to use a Verress needle inserted at an alternate location
away from the umbilicus. Small bowel distension is usually
greatest in the lower abdomen so I usually place the needle just
subcostally at about the mid-clavicualr line either in the right
upper quadrant or the left upper quadrant. After insufflation to
15 mm Hg, we insert a 5 mm trocar followed by a 5 mm
30 degree angle laparoscope. This allows preliminary inspection and adhesiolysis to clear an area for optimal placement of
the 10 mm trocar and the larger laparoscope. We keep available
both a zero degree and a 45 degree angle of view scope. Of ten a
single adhesive band is encountered as the culprit. If this can be
found, it is lysed. Because the distended bowel is friable and can
be easily perforated, great care is taken to avoid injury. If there is
an obvious site of obstruction that has been released, no attempt is made to free up the entire small bowel. In patients who
do not require urgent intervention, we prefer to place a nasogastric tube to decompress the intestines. This sometimes helps
and allows the surgeon more room to perform a more thorough
laparoscopic examination and, if indicated, a more complete adhesiolysis. If the abdomen remains very distended and tympanic in spite of general anesthesia and nasogastric decompression, then an open approach is preferred to a Verress needle
placement. Often patients have had previous midline incisions
near the umbilicus which makes this approach difficult as most
of the adhesions will be encountered in this area. With very distended bowel, exploration must be very limited and extremely
cautious. If an easily remedied source is not immediately encountered, the surgeon should proceed to open operation.
As a rule, little is lost, other than time and inconvenience for the
surgeon and operating room staff, when laparoscopic exploration is first carried out for the ”acute abdomen”. If the surgeon
has limited laparoscopic skills, the diagnostic aspects of laparoscopic exploration will allow him to identify the problem and
plan the open approach optimally. A well placed incision will
enhance the exposure for the surgeon and reduce the abdominal wall trauma for the patient. If the surgeon has more advanced skills, he will be able to carry out therapeutic laparoscopic procedures. Ultimately, most patients will benefit from
this benign intervention.
3.6 Diagnostic Laparoscopy for Tumors
H. Feussner
Anesthesia
75
Objectives and Methods
The objectives of diagnostic laparoscopy for malignant diseases
are typing and staging.
In such cases, diagnostic laparoscopy is usually a complemen-
tary procedure. It is employed when tumor manifestation and
extent of the disease cannot be evaluated with sufficient accuracy by imaging methods. As a result of the high standards of
non-invasive diagnostic methods available today, laparoscopic
exploration for malignant diseases is used mostly selectively at
present. However, diagnostic laparoscopy has attained signifi-
cance for the staging of gastrointestinal tumors when multimodal therapeutic regimens are used.
Indications
Diagnostic laparoscopy for malignancy is indicated when clini-
cal, laboratory, or diagnostic imaging studies provide inconclu-
sive results or are unable to stage the tumor.
Diagnostic laparoscopy is indicated in the following situations:
쐌 Staging of stomach, esophagus, pancreas carcinomas,
쐌 Clarification of uncertain hepatic lesions,
쐌 Diagnosis of ascites of cryptogenic origin.
In particular, tumor spread beyond the walls (T3/T4), lymph
node status, and the question of distant metastases can be eval-
uated by laparoscopy.
Contraindications
Special Preparations
In addition to the standard preparations for anesthesia and
surgery, administer an oral laxative to the patient on the afternoon of the day before surgery. The evening meal should consist
only of light nonflatulent foods, and the patient should not be
fed again until after surgery. On the day of surgery, the patient is
shaved from the symphysis to the nipples. The patient then
empties bladder and bowel, and takes a thorough shower. Introduce a gastric tube immediately before inducing anesthesia. In
the absence of complications, it may be removed again after extubation.
After inducing anesthesia, insert a urinary catheter for the duration of the procedure to empty the bladder completely.
Disinfect the skin of the periumbilical area as for laparotomy.
Perioperative antibiotic prophylaxis is not necessary.
Anesthesia
General anesthesia will be required in most cases. In special situations (i. e., examination of abdominal penetrating wounds or
laparoscopic biopsy), local anesthesia and light sedation will be
sufficient. Infiltrate a 3-cm round area of the abdomen with a 1−
2% Novocain solution (10−30 mL), taking care to extend the anesthetized area as far as the parietal peritoneum. Sedate the
patient before inserting the Veress needle to insufflate the abdomen (i. e., with 3−15 mg of Dormicum IV), because alert
patients do not tolerate insufflation well.
Note: Extensive exploration of the abdominal cavity is only
possible under general anesthesia.
Diagnostic laparoscopy is contraindicated in the presence of:
쐌 Severe cardiopulmonary decompensation which precludes
establishing a pneumoperitoneum,
쐌 Known hemorrhagic diathesis,
쐌 Extensive intraabdominal adhesions.
Surgical Risks and Informing the Patient
Diagnostic laparoscopy is a comparatively safe procedure with
only 0.05% mortality and a complication rate of 1−5%. In addition to informing the patient of the general risks involved in any
abdominal procedure (thrombosis, embolism, impaired wound
healing), the surgeon should specifically mention the possibility
of:
쐌 Vascular and intestinal injury,
쐌 Injury of parenchymal organs,
쐌 Biliary fistulas (specifically after puncturing the liver),
쐌 Gas embolism,
쐌 Subcutaneous emphysema,
쐌 Unsatisfactory cosmetic results,
쐌 Spread of tumor cells.
The patient should always be informed that additional pro-
cedures may be required (i. e., removal of a biopsy specimen,
lysis of adhesions, conversion to open laparotomy, colectomy
including stoma).
Positioning
Since diagnostic laparoscopy often requires changing the
patient’s position, use foot and shoulder cushions to facilitate
intraoperativerepositioning. Induce anesthesia with the patient
supine on a flat table. At the beginning of the procedure, raise
the head and thorax 30° higher than the lower extremities
(reverse Trendelburg position). Examine the lower abdomen
with the patient inclined in the opposite direction (Trendelburg
position).
When performing diagnostic laparoscopy to examine processes
located primarily in the upper abdomen, place the monitor level
with the patient’s left shoulder with the surgeon standing on
the patient’s right (see chapter 3.2). The lower abdomen may
also be examined from this position. If the procedure requires
extensive dissection of the lower abdomen, change the position
of the monitor accordingly.
Trocar Placement
The number and location of trocars depend on the indication
and the expected findings (see chapter 3.2). The trocar for the
laparoscope is generally inserted through a periumbilical port.
Five trocar ports are required for extended diagnostic laparoscopy for staging tumors.
76
3.7 Staging of Neoplastic Disease with Ultrasound
Complications
Intraoperative Complications
Bleeding is the most frequent intraoperative complication. This
can occur when resecting lymph nodes, when opening the
gastrocolic ligament, or during aspiration biopsy.
Corrective action: Coagulate the bleeding laparoscopically by
applying staples or hemostatic techniques and materials. If hemostasis cannot be achieved laparoscopically, immediate conversion to laparotomy is indicated.
Puncture of a hollow organ is a rare but serious intraoperative
complication.
Corrective action: Some punctures can be sutured laparoscopically, but most require conversion to laparotomy. If in doubt,
conversion is indicated.
Postoperative Complications
Immediate Postoperative Complications: Localized postoperative
bleeding from the trocar ports or aspirated biopsy areas may
occcur. In rarer cases following aspiration biopsy of the liver,
bleeding or biliary fistulas may occur. Very rarely, bleeding and
impaired wound healing may occur.
Corrective action: If bleeding or biliary fistulas occur, repeat laparoscopy or conventional open laparotomy is indicated.
Late complications
The question of whether diagnostic laparoscopy can promote
the spread of tumor cells or induce metastases in the wound
channel in the presence of malignant tumor has not yet been
clearly resolved.
In about 4% of all cases, even extended diagnostic laparoscopy
cannot sufficiently clarify the diagnosis. In these cases, as in
the presence of laparoscopic complications, conversion to an
open procedure is indicated. For this reason, the operating
team must always be prepared for laparotomy. After conversion, the staging laparotomy is performed according to the
usual principles.
Bibliography
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Feussner H, Kraemer SJ, Siewert JR. Technik der laparoskopischen Ul-
traschalluntersuchung bei der diagnostischen Laparoskopie. Langenbecks
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Gazzaniga AB, Slanton WEW, Bartlett R. Laparoscopy in the diagnosis of
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3.7 Staging of Neoplastic Disease with Ultrasound
M. Birth, H.−F. W eiser
Goals and Methods
Therapeutic procedures in treating malignancies depend on
staging, particularly resectability and curability of the tumor. To
improve the preoperative staging, diagnostic laparoscopy is
evaluated at present. Additionally, laparoscopic ultrasound can
largely compensate for the loss of tactile sensation and threedimensional visualization inherent to laparoscopy. In this setting, the primary role of laparoscopic ultrasound is to determine
the local growth of the tumor as well as the extent of lymphnode and abdominal metastases with a high degree of sensitivity and specificity. Ultrasound also permits differentiation of
solid tumors from cysts, and can be used to guide biopsies.
Indications
쐌 Staging of gastrointestinal tumors and Hodgkin’s or non-
Hodgkin’s lymphomas.
쐌 Planned minimally invasive tumor resection.
In curative laparoscopic tumor resections, before beginning dissection, the local extent of the tumor should be diagnosed by laparoscopic ultrasound; the surgeon should search for preoperatively unsuspected lymphatic and hepatic metastases.
Contraindications
There are currently no known contraindications to ultrasound.
However, laparoscopically discovered intraperitoneal tumor
dissemination will render subsequent ultrasound superfluous.
Extensive intraabdominal adhesions and morbid obesity can
render the ultrasound study technically impossible.
Surgical Risks and Patient Information
The ultrasound examination is performed during diagnostic laparoscopy. The mandatory discussion of general preoperative
risks, in which the surgeon must mention the possibility of extending the procedure (for example to perform an ultrasound-
guided biopsy), will suffice (see chapters 3.2 and 3.6). Mechanical injuries to intraabdominal organs caused by the ultrasound
probe should be mentioned as specific complications.
Special Preparations and Required
Equipment
The procedure requires the usual preoperative and anesthetic
preparations for diagnostic laparoscopy. Foods that may cause
flatulence and intraluminal endoscopy should be avoided prior
to the ultrasound study. If indicated, the patient should be given
anti-flatulent medication twelve hours prior to the operation.
Laparoscopic ultrasound tumor staging involves sophisticated
techniques and requires the physician to be thoroughly familiar
with the ultrasound morphology of the entire abdomen. The
physician must be proficient in open intraoperative ultrasound
techniques also. The following ultrasound equipment is re-
quired.
쐌 Real-time, B-mode ultrasound unit, with color Doppler op-
tion if desired.
쐌 Flexible-tip ultrasound probes at least 40 cm in length with a
diameter not exceeding 10 mm (for insertion through standard trocars (Fig. 3.7.1). The flexible tip is required for a comprehensive examination; flexible ultrasound endoscopes
may be used as an alternative.
쐌 Linear or convex arrays that provide sound frequencies of 5
and 7.5−10 MHz.
쐌 Electronic split-screen imaging feature for simultaneous vis-
ualization of the position of the probe and the ultrasound
image on one monitor.
쐌 Thermal printer or, preferably, video recorder for docu-
menting findings.
Anesthesia
General anesthesia.
Patient Positioning
As in diagnostic laparoscopy, patient positioning must permit
optimal access and examination of the individual organs.
Patient positioning will vary depending on the localization of
the primary tumor (from Trendelenburg to reverse Trendelen-
burg position), and intraoperative repositioning requiring
special preparations such as foot and shoulder supports may be
necessary (see Fig. 3.7.2 and chapter 3.2).
Trocar Placement
A trocar inserted below the umbilicus or a left lateral trocar is
required. Depending on findings, inserting the probe through
other trocars may improve ultrasound visualization in certain
cases (Figs. 3.7.3 and 3.7.4).
Patient Positioning
Fig. 3.7.1 Staging of neoplastic disease with ultrasound. Ultrasound
probe with flexible tip and biopsy channel. Only flexible-tip ultrasound
probes or ultrasound endoscopes permit positioning in hard-to-reach
areas (such as the posterior sections of the diaphragmatic surface of the
liver and the periaortic region) while simultaneously ensuring the necessary tissue contact. Ultrasound endoscopes offer complete freedom of
movement in every plane, a biopsy channel, and an additional optical system. However, the units currently available may only be inserted through
a 15-mm trocar. An additional problem with flexible endoscopic ultrasound units is that systematic examination of solid organs and topographic and anatomic identification of ultrasound findings involve a more
complicated procedure than that required by rigid probes only equipped
with flexible tips.
77
Step-by-Step Procedure
I Technical Preparations
Prepare the ultrasound unit and connect the ultrasound probe.
II Intraoperative Ultrasound
1. Introduce the ultrasound probe through the trocar placed
below the umbilicus.
2. Place the tip of the probe on the right hepatic convexity in a
posterosuperior position.
3. Using a frequency of 5 MHz, continuously scan the liver in a
craniocaudal view with mediolateral sweeps of the transducer,
gradually moving the probe one transducer width at a time.
4. If visualization is incomplete, position the tip of the probe on
the visceral surface and scan the liver in a caudocranial direction.
5. Reintroduce the probe through the left lateral trocar and place
the transducer on the left hepatic convexity.
6. The rest of the examination procedure including patient positioning and trocar placement must be adapted to the equipment used and the organ being examined (see Figs. 3.7.4
through 3.7.8).
Ultrasound Technique
The organ in question, the selected ultrasound probe, and the
sound frequency will determine the examination procedure
and respective positions of the ultrasound probe. The technique
described in the following section applies to the use of a rigid
probe with a flexible tip using sound frequencies of 5 and
7.5 MHz.
Complications
See chapter 5.1.