Dr R. K. Mishra

• What is emergency laparoscopy?
• What are the operations possible through emergency laparoscopy?
• What is the benefit of emergency laparoscopy over open procedure?
• How it is done?
• Is their any danger from the telescope inside the body?
• Is there an increased risk of infection?
• What are the benefits of emergency laparoscopy for patients.
• What is the recovery period?
• Is this operation safe in a fat or child patients?
• What are the contraindications of emergency laparoscopy?

What is emergency laparoscopy?

It is the laparoscopic operation which should be performed without any delay in life threatening situations. The gynaecologists were the first to start laparoscopy in the diagnosis and treatment, but since 1990s a lot of general surgeons have started to use this technique in the abdominal urgency, especially: abdominal trauma, acute cholecystitis, acute appendicitis, perforated peptic ulcer or intestinal obstruction. Initially laparoscopy was tried for elective surgery only, but with the advent of new technology many of the emergency surgeries are possible by laparoscopic method. Emergency Laparoscopic treatment of acute abdomen was first proposed by Philippe Mouret in 1990. The diagnostic value of emergency laparoscopy has been proved since the 1950s-1960s, but the emergency therapeutic application of the laparoscopic technique for the surgical treatment is recent.

What are the operations possible through emergency laparoscopy?

• Diagnostic Laparoscopy for Acute Abdominal Pain.
• Laparoscopy for Abdominal Trauma (Blunt and Penetrating) .
• Laparoscopic Management of Intestinal Obstruction.
• Laparoscopic Management of Diverticulitis.
• Laparoscopy for Acute Appendicitis.
• Complicated ovarian cysts.
• Pelvic inflammatory diseases.
• Acute salpingitis.
• Intestinal adhesions.
• Mesenteric adenitis.
• Ectopic pregnancy.
• Endometriosis.
• Complicated Meckel's diverticulum.
• Omental necrosis.
• Intestinal infarction.
• Acute diverticulitis.
• Bedside Laparoscopy in the ICU.
• Laparoscopic Management of Perforated Ulcer.
• Laparoscopy for Intestinal Ischemia.
• Laparoscopic Re-operations for Postoperative Complications.
• Emergency laparoscopic orchidectomy for torsion of intra-abdominal testis.

What are the benefits of emergency laparoscopy?

Acute abdominal emergencies are diagnosed incorrectly or too late in 5 to 20% of cases. The delay in appropriate treatment, improper surgical access route and repeat surgery causes higher morbidity and mortality. Hospital stay and time of recovery are longer, resulting in higher costs for the community. In spite of rising accuracy of non-invasive methods there remain limitations which sometimes cannot be overcome by these investigations. In these condition only useful option is laparoscopy. Recently applicability of diagnostic and therapeutic emergency laparoscopy are highly demanded.

Despite new x-ray techniques, CT scans and ultrasounds, the diagnosis of acute abdomen can be difficult at times. So far the most accurate non-invasive method of diagnosis is ultrasonography but this is not totally reliable. The history and physical examination will generally lead to the correct diagnosis. According to one prospective non-randomised study laparoscopy may prevent unnecessary appendicectomy in 24% of patients with acute abdomen. Laparoscopy reveals a clinical misdiagnosis rate of 8% in male, and 41% in female of reproductive age group. Laparoscopic emergency intervention gives a better evaluation of the peritoneal cavity than that obtained by the standard laparotomy incision. The procedure allows rapid and thorough inspection of the para-colic gutters and the pelvic cavity that is not possible with the open open approach. The emergency laparoscopic approach for patients with acute abdomen improves the diagnostic accuracy and is therefore now a days it is recommended and accepted world wide.

How it is done?

The emergency laparoscopy is done in the same way as elective laparoscopy only difference is that emergency laparoscopy should be done by a specialist laparoscopic surgeon and he should be able to perform laparoscopic surgery, once pathology is diagnosed inside the abdomen. It is just like a police officer who should know to use all types of weapon to fight against a terrorist. If the police officer knows only to use revolver and terrorist have an automatic rifle than you can imagine the situation of poor police officer. Either he will be killed or he will run away to complete his task at some later time. Likewise if the surgeon is not a specialist laparoscopic surgeon than he will diagnose the disease and if he does not know the laparoscopic method to correct that particular disease, he will either convert the case to open, or withdraw his telescope.

Is their any danger from the telescope inside the body?

No, the telescope is used only to see and is not involved with the operation. Operation is done by long cylindrical instruments which is always under the vision of surgeon on monitor.

Is there an increased risk of infection?

No, the small cuts mean that less of the body is exposed to infection. The less post-operative wound infection is one of the advantage of laparoscopic surgery.

What are the benefits of emergency laparoscopy for patients.

1. Accurate diagnosis of the pathology inside the abdomen.
2. Diagnostic and therapeutic surgery is possible at the same time.
3. Less post-operative pain.
4. Faster recovery.
5. Short hospital stay.
6. Less post-operative complications like wound infection, adhesion, hernia, etc.
7. Cost-effective in working group.

What is the recovery period?

The recovery period after emergency laparoscopy depends on the diagnosis of the patient at the time of operation and what the surgeon did to treat the disease. In most of the cases the patient can start drinking liquids soon after coming out of the anaesthesia which is about 4 hours after the operation. They can start eating soon thereafter. The patient is allowed to get off the bed 4 hours after the surgery and walk to the toilet to pass urine. They are usually allowed to go home the next day, can climb stairs and the majority can get back to routine activity in 5 days and back to work in about 10 days.

Is this operation safe in a fat or child patients?

The operation is ideally suited for the fat patient as the thickness of the tummy wall is immaterial when putting in the telescope and instruments. This is in contrast to an open operation where the fatter patient has a deeper and larger cut causing more bleeding, stitches, and pain. The children can also very well tolerate laparoscopic intervention. The instrument used to do laparoscopy in child patients are less in thickness than adult patients. usually 5 mm and some time 3 mm.

What are the contraindications of emergency laparoscopy?

Relative contraindications to emergency laparoscopy is:

• The general anaesthesia and the pneumoperitoneum required as part of the laparoscopic procedure may increase risk in certain patient groups. Most surgeons would not recommend emergency laparoscopy in:
• Patients with cardiac diseases and COPD are not good candidate for emergency laparoscopy
• Patients who have had previous extensive abdominal surgery, emergency laparoscopy may be difficult.
• Those with diminished cardio-pulmonary reserve are also at risk because of the adverse effects of the pneumoperitoneum on the CVS and a longer operative time.
• Those with bleeding disorders or defective haematological values or pre-existing debilitating disease are also not a good candidate for emergency laparoscopy.

Prof. Dr. R. K. Mishra.

Minimal Access Surgeon