the role of laparoscopy in acute care surgery
TRANSCRIPT
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The Role of Laparoscopy in Acute Care Surgery
Hakan Yanar MD,Associate Professor of Surgery
Istanbul University, Istanbul Faculty of Medicine, Istanbul, Turkey
ISW, August 28→September 1, 2011,Yokohama, Japon
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Role of Emergency Laparoscopy
• Laparoscopy in Non-Trauma AbdominalEmergencies
• Laparoscopy in Trauma
• Diagnostic
• Therapeutic
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Diagnostic laparoscopy
• Acute abdominal pain of unknown etiology
• Generalized peritonitis
• Diagnostic laparoscopy after operations orinvasive procedures (po extraordinary pain, post colonoscopy…)
• Sepsis of unknown origin
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• Appendicitis and cholecystitis
• Perforated viscus and peritonitis
• Small bowel obstruction due to adhesions
• Drainage of abcess (acute diverticulitis)
• Diagnostic for mesenteric ischemia
• Trauma →Solid organ injury, diaphragmaticinjuries
Therapeutic laparoscopy
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Physiologic contraindications
• Cardiac “The heart is the Achilles heel of every laparoscopic operation”
• Pulmonary
• Haemodynamic instability
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Technical contraindications
- Lack of working space
- Lack of expertise (surgeon-anesthesia)
- Lack of specialized equipment
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Advantages
-Decreased po pain-Less abdominal wall complication-Better visualization -Cosmetically better outcome-Lower intra-operative and post operative complications
-Early return to work-Early mobilization
Warren O, et al. World J Emerg Surg 2006
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Basic technical tips and tricks
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Triangulation
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Working space
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Safe entry
Veress needle!!!
Hasson technique
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Choice of the right tool
Hemostasis
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Laparoscopic suturing
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Exploration of small intestine
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Douglas pouch exploration
Ectopic pregnacyTubal ruptureOverian cyst torsionSalpingo-oophoritisPyosalpenx
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Acute Cholecystitis
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- 70 patients randomized to lap vs open
-Median operating time was longer for lap: 90 min (30-155) vs 80 min (range 50-170) in open
-Hospital stay shorter in laparoscopic group (P = 0.011)
-No difference in the rate of post op complications, pain score at discharge , direct costs, sick leave.
Conclusions: open and lap for cholecystitis equivalent
Johansson M. et. al Dig. Surg. 2004
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Acute Cholecystitis
- Laparoscopic approach gold standard
- “Get them while they are hot”
(within 72 Hours) J Hunter, Ann Surg
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Appendicitis
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Sauerland , Cochrane Review 2005
54 randomized studies, total 5000 pts, LA vs OA
- Wound infections were less likely after LA than after OA (OR 0.45; CI 0.35 to 0.58)
- Incidence of intraabdominal abscesses was increased (OR 2.48; CI 1.45 to 4.21).
- Hospital stay was shortened by 1.1 day (CI 0.6 to 1.5)
- Conclusions: Slight advantage for lap
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Perforated Peptic Ulcer
• 5 % of abdominal emergencies
• First reports of laparoscopic approach-1990
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PUP, two large high quality randomized studycomparing open vs laparoscopy
• Lau WY et al. Ann Surg, 1996 Total hospital stay Time to resume normal diet Reoperation Mortality no benefit
• Siu WT, et al. Ann Surg, 2002 Less po pain Shorter operating time Decrease morbidity and mortality
(1.5% lap vs 5 % open)
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Katkhouda N, et al Archives of Surgery 1999Prospective data from 30 lap compared to
matched group of 16 open
Analgesics lap < open ( 3 /9 doses, p=.002)
Length of stay lap < open (3 / 8 days , p=.003)
Return to work lap< open (21 / 30 days, p=.001)
takes longer to perform
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Emergency laparoscopy in pregnancy
SAGES : not a contraindication
- Preferably in the 2nd trimester
( some data confirms safety in all trimesters)
- Pneumo pressure low at about 10-12
- Hasson technique
- Fetal monitoring
- Shielding of uterus
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Mesenteric ischemia- diagnosis andsecond look
World Journal of Gastroenterology 2007 Jun 28;13(24):3350-053.
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Trauma
• Blunt
• Penetrating
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Diaphragmatic injurydiagnosis and treatment
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Hollow viscus injury-gastric injury
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Hallow viscus-transvers colon injury
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Conclusion
• For pts with abdominal emergencies, thelaparoscopic approach provides diagnosticaccuracy and therapeutic options,
• Avoids extensive preoperative studies,
• Averts delays in operative intervention,
• Appears to reduce morbidity.
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Thank You !