1. LAPAROSCOPY IN ABDOMINAL EMERGENCIES
Dr.Anil Haripriya
In the last decade, the laparoscopic procedures have been used
extensively in an elective setting for both diagnostic as well as
therapeutic purposes. With increasing experience, the General
Surgeons at many centers have felt confident enough to undertake
evaluation of its role in the management algorithm of various
abdominal emergencies, both traumatic as well as non-traumatic.
Reasonable body of data has by now accumulated in the literature to
be able to take a critical look at the reported experiences and suggest
a possible role for this newly emerging diagnostic and therapeutic
modality in our setting. The term "abdominal emergencies "includes
cases of abdominal trauma as well as various non-traumatic cases
like perforated duodenal ulcer, acute appendicitis, intestinal
obstruction, acute abdominal pain of unknown etiology and abdominal
problems in pregnant patients and ICU patients.

2. This paper intends to look at the role of laparoscopy in the
management of all these conditions individually with a view to provide
answers to the following points:
· Currently practiced management algorithm and its
shortcomings.
· Reported experience in the literature.
· The feasibility and advisability of it's use in our setup.
Laparoscopy in abdominal trauma
Due to a significant rise in the number of road traffic accidents
and increasing violence, abdominal trauma is emerging as a major
cause of abdominal emergencies. The management algorithms are
different for blunt and penetrating abdominal trauma.
In patients with blunt abdominal trauma, evaluation of the
abdomen begins with a detailed clinical examination.
Hemodynamically unstable patients and those with obvious abdominal
signs are taken up for immediate exploratory laparotomy. However,
there are a large number of stable patients where abdominal signs are
equivocal. Often, the situation is complicated by associated alcohol or
other drug intoxication and head or spinal injury, which alters the
abdominal signs. Under these situations, additional tests such as
diagnostic peritoneal lavage (DPL), ultrasound (US) and

3. Computerised Tomography (CT) scan of the abdomen are usually
employed. In most surgical centers, DPL performed under local
anaesthesia in the emergency room has been the most often used
diagnostic modality for blunt abdominal trauma patients. Indications
for DPL include head injury, altered mental status (injury, drugs or
alcohol), an equivocal abdominal examination, unexplained
hypotension or instability of the patient and if a patient with major
trauma requires operation and general anaesthesia for another injury
like fracture etc. Positive DPL is based on the presence of 50,000 -
100,000 RBCs/ml, WBC >500/ml or presence of bile or fecal material
in the lavage fluid. The shortcoming of DPL is that it is a highly
sensitive test and in patients operated on the basis of a positive DPL,
13 - 25 % have been reported to have either a negative laparotomy
(NL i.e. no injury present) or a non-therapeutic laparotomy (NTL i.e.
injury present but does not need treatment) 1-5 . Similarly US and CT
scan have also been used in many centers in the recent past. Like
DPL, although these tests can tell about the presence or absence of
intra-abdominal injury, there continues to be a significant NL/NTL rate
despite the use of these modalities. Also, CT scan and US have not
been found to be very sensitive in detecting hollow viscus injuries.

4. Thus with the use of DPL, US and CT scan, although the pickup rate
for injuries has gone up very high, there continues to be an irreducible
rate of false positivity resulting in NL/NTL.
Penetrating abdominal injuries due to stab and gunshot wounds
are managed differently. The hemodynamically unstable patients and
those with obvious physical signs need immediate exploration. For
stable patients with stab injury, most of the institutions follow the
policy of local wound exploration for depth of penetration and if the
peritoneal breach is present, exploratory laparotomy is performed.
With this policy, different series have reported NL/NTL rate of 20 - 50
% 2-4. For gunshot wounds of the abdomen, most institutions follow the
policy of mandatory laparotomy, but it has been reported to result in
NL/NTL rate ranging from as low as 6 % to as high as 40 %
4,6,7
.Although an NL/NTL is preferable to a missed intra-abdominal
injury and delayed treatment with it's disastrous consequences, the
morbidity associated with these unnecessary explorations is
significant ( 5 - 22 % ) 4,8-12, apart from the pain inflicted on the patient
and the cost to the health-care system.
Thus it is obvious that in the management algorithm of the

5. abdominal trauma patients, there is need for a better screening
modality which can not only detect injuries with a high degree of
accuracy but can also differentiate between those requiring surgical
treatment and those requiring only conservative treatment.
Laparoscopy holds promise not only to allow this, but also offers
the additional possibility of therapeutic interventions - thereby
avoiding laparotomy altogether in some of those patients who
otherwise merited a laparotomy. Laparoscopy can achieve this with
minimal morbidity, much reduced pain to the patients and overall
reduced cost to the healthcare system.
The first report in the English literature about the use of
diagnostic laparoscopy in the setting of abdominal trauma was
published in 1976, much before the presently used miniature camera
and monitor system came into use. Gazzaniga et al 13published a
series of 37 trauma patients who underwent emergency diagnostic
laparoscopy. NTL were avoided in 10 of 24 patients with blunt
trauma. Based on the laparoscopy findings, the remaining 14 patients
underwent exploratory laparotomy with only one negative laparotomy
(7%). In 13 patients with penetrating injuries, 4 (30%) were spared
unnecessary laparotomies, The other 9 (70%) patients underwent

6. exploratory laparotomy on the basis of suspicious laparoscopic
findings. Four(44%) of these were therapeutic and 5 (56%) were
nontherapeutic, This high rate of NTL in this pioneering series was
possibly because the authors were near the beginning of their
learning curve and all these laparoscopies were performed looking
through the eye piece of the telescope i.e. without the benefit of
magnification, ease of operation and "team involvement" that the
currently used camera - monitor system offers.
Berci et al (1991)14 reported their retrospective experience with
150 emergency laparoscopies in blunt abdominal trauma patients,
performed in the emergency room under local anaesthesia. Based on
the laparoscopic findings ,they decided for immediate
laparotomy(19%),simple observation(25%) or early discharge (56 %)
of these patients..There was only one failure-a patient considered
suitable for conservative management on diagnostic
laparoscopy(DL)needed a laparotomy.The authors concluded that DL
for trauma patients is highly sensitive ,decreases the NTL rate and is
safe.
Fabian et al( 1993)15 reported a prospective analysis of 182

7. diagnostic laparoscopies for blunt as well as penetrating abdominal
trauma in hemodynamically stable patients with equivocal abdominal
signs. There were 99(55%) patients with abdominal stab
wounds,66(36%) patients with gunshot wounds and 17 (9%) patients
with blunt abdominal trauma. NL/NTL could be avoided in a significant
number of patients in all three groups on the basis of laparoscopic
findings. The authors concluded that laparoscopy is a safe diagnostic
modality for abdominal trauma patients. It is most effective in
evaluating patients with equivocal signs after penetrating injuries and
offers significant cost savings, especially if performed under local
anaesthesia.
Salvino et al( 1993 )16 reported on a prospective analysis of 75
patients of blunt as well as penetrating injuries and compared the
value of diagnostic peritoneal lavage and diagnostic laparoscopy(DL).
They concluded that although DL had no advantage over DPL as a
primary assesment tool in the blunt abdominal trauma patients, it's
main advantage was in patients with penetrating injuries.
Townsend et al (1993)17 studied the efficacy of DL in 15 patients
with solid organ injuries documented by CT scans. The DL identified 6

8. patients who needed urgent laparotomies, 2 with hollow viscus
injuries and 4 with continuing haemorrhage. One patient could not
undergo complete laparoscopic examination and underwent
laparotomy, which was negative. The remaining 8 patients were
successfully treated with conservative management on the basis of
their laparoscopic findings. The authors concluded that DL allowed
for successful nonsurgical management in 100% of their patients and
also identified patients in need of urgent laparotomy. `
Ivatury et al (1993)18 performed DL in 100
hemodynamically stable patients with penetrating abdominal injuries
and compared them with 407 laparotomies without laparoscopy.The
authors concluded that DL helped exclude peritoneal violation,
thereby avoiding unnecessary laparotomies. It was specially accurate
in detecting haemoperitoneum ,solid organ injuries, diaphragmatic
lacerations and retroperitoneal haematomas. The authors remarked
that DL has a definite role in the evaluation of penetrating abdominal
trauma patients.
Sosa et al (1995)10,19 reported their experience with DL in 121
consecutive haemodynamically stable patients with abdominal
gunshot wounds. By the conventionally used policy of "mandatory

9. laparotomy in gunshot wounds"- all patients would have undergone
exploratory laparotomy. Instead , all patients underwent DL and
82(68%) were spared unnecessary laparotomies on the basis of
laparoscopic findings. The remaining 39(32%) patients underwent
exploratory laparotomies,one of which was negative and 3 were
nontherapeutic. The authors concluded that DL is extremely useful in
patients with gunshot wounds , results in the lowest NL and NTL rate
and identifies patients needing urgent laparotomies.
Zantut et al (1997)20 reported a retrospective analysis of 510
haemodynamically stable patients of penetrating abdominal injuries
(316 stab wounds,194 gun shot wounds) from three large urban
trauma centers in Brazil. Laparotomy was avoided in 277 of these
patients(54.3%) either because of nonpenetration of peritoneum or
insignificant findings on laparoscopy.All were discharged uneventfully
after a mean hospital stay of 1.7 days.26 patients had successful
therapeutic procedures on laparoscopy ( diaphragmatic repair in 16
patients,cholecystectomy in 1,hepatic repair in 6 and closure of
gastrotomy in 3 patients) with uneventful recovery. In the remaining
203 patients, laparotomy was therapeutic in 155.Fifty two patients had
NTL for exclusion of bowel injuries or as a mandatory laparotomy for

10. penetrating gunshot wounds(19.7%). The overall incidence of NTL
was 10.2% . Complications were minimal and minor.The authors
concluded that DL has an important diagnostic role in stable patients
with penetrating abdominal trauma. In carefully selected patients,
therapeutic laparoscopy is practical, feasible and offers all the
advantages of minimally invasive surgery.
Hallfeldt et al (1998)21 have reported on DL in abdominal stab
wounds and concluded that DL offers an important diagnostic tool in
excluding peritoneal penetration, lowering the rate of unnecessary
laparotomies, with therapeutic laparscopy also being possible in
selected cases.
Marks et al (1997)22 performed cost effectiveness analysis of
DL Vs laparotomy in the evaluation of penetrating abdominal trauma
and concluded that total cost and length of stay were significantly
lower in patients who underwent DL as compared to laparotomy.
Numerous other reports 16,23-27 have also suggested that DL is
an important modality in evaluating trauma patients with suspected
abdominal injuries. These studies confirm that DL for trauma patients
is a safe modality that has the potential to decrease both NL as well

11. as NTL. It's greatest value is in patients with uncertain diagnosis even
after other diagnostic tests like DPL, US, and CT scan. There have
been suggestions that it may in fact be used as a primary diagnostic
tool, bypassing these conventional modalities 7.
Although doubts have been raised about the accuracy of DL in
detecting hollow viscus injuries, retroperitoneal injuries such as to the
pancreas and evaluation of spleen, others have suggested that with
the use of angled lenses, proper patient positioning and appropiate
manipulation of the operating table, an experienced laparoscopic
surgeon can appraise both the spleen and the bowel without difficulty
7
. However, it must be re-emphasised that laparoscopy should not be
performed in hemodynamically unstable patients and in those where
the diagnosis of a significant intra-abdominal injury requiring
exploratory laparotomy is obvious.
Laparoscpy for non traumatic abdominal emergencies
Acute appendicitis
Acute appendicitis is a common condition. Low threshold for
surgery based on clinical suspicion alone results in a significant

12. negative laparotomy rate especially in young women. On the other
hand delayed operation may result in perforation peritonitis with
serious consequences. DL in patients with suspected acute
appendicitis not only decreases the risk of appendicular perforations
but also reduces the number of negative laparotomies. It provides us
a tool not only to confirm or rule out appendicitis, but also offers the
possibility of inspecting other organs simultaneously to determine the
real cause of patient's symptoms 7. The two important group of
patients with suspected acute appendicitis who benefit most from DL
are the premenopausal women (in whom the differential diagnosis
with gynecological conditions is often difficult )and obese individual ,in
whom a large laparotomy incision is required to perform conventional
appendicectomy or to allow thorough inspection of the abdominal
contents 28. At laparoscopy, if the diagnosis of acute appendicitis is
confirmed, DL can be converted to therapuetic laparoscopy. The
indications for laparoscopic appendectomy 7,28-29 for patients
undergoing DL are (a)acute appendicitis confirmed, (b) large
appendicolith, (c) recurring condition such as crohn's disease or
endometriosis, (d) a normal examination as it may represent very
early appendicitis which is not grossly visible. Also ,it eliminates future

13. confusion should the similar pain recur in the patient. Ongoing
radiotherapy and an immunosuppresed patients are absolute
contraindication for laparoscopic appendectomy 7, whereas relative
contraindications include previous abdominal surgery, coagulopathy,
portal hypertension, appendicular abcess and pregnancy 7. In patients
with appendicular abcess, DL should be avoided as
pneumoperitoneum may disrupt the abcess cavity resulting in
contamination of the peritoneal cavity and septicemia. Patients with
acute appendicitis who have been managed conservatively, may be
considered candidates for laparoscopic interval appendectomy usually
after 6 weeks.
Thus it is clear that laparoscopy is safe and effective procedure
for establishing the diagnosis of acute appendicitis as well as removal
of the appendix. The best indication for DL in patients with suspected
appendicitis are premenopausal women (where the rate of negative
laparotomies is quite high) and very obese patients in whom a
laparotomy will require a relatively large incision.
Perforated duodenal ulcer
Patients with perforated duodenal ulcer require early recognition

14. and prompt treatment. It has a reported mortality of 0-10%. With delay
in treatment ,the mortality may go up to as high as 90% 7. A number of
reports in the literature 30-34 have shown the feasibility of diagnosing
and treating acutely perforated duodenal ulcers by laparoscopy. DL
can determine the type of fluid present in the peritoneal cavity and can
accurately locate the site of perforation in the majority of cases.
Following confirmation of diagnosis by DL, therapeutic maneuver i.e.
closure of the ulcer perforation can also be performed, if the surgeon
has advanced laparoscopic suturing and knotting skills. In one of the
earliest reports on laparoscopic management of perforated duodenal
ulcer, Memon and Brow32 showed that this procedure is technically
feasible if performed within 6 hours of perforation. However, in cases
with significant delay in diagnosis, laparoscopic repair may be difficult
and hazardous because of the edematous and friable duodenal wall
7,35,36
.
Laparoscopic repair of a perforated duodenal ulcer can be
achieved by simple closure 32, omental patch, use of fibrin glue 34,
placement of oxidised cellulose sponge 37, falciform ligament patch 38
or ligamentum teres patch39 . Most of the reports are in the form of
small, isolated case reports. Four recent papers 30,31,33,40 have

15. compared laparotomy and laparoscopy for treatment of perforated
duodenal ulcer. These studies have shown no benefits of laparoscopy
in terms of the length of hospital stay, time to resume normal diet,
visual analog pain score in the first 24 hours or early return to normal
activity, although the analgesic requirement in the postoperative
period was less in the laparoscopy group. Additionally the operating
time in the laparoscopy group was much longer. Others 7 ,however
have reported favorable experience especially in selected patients.
Thus it is obvious from the currently available literature that DL can
provide an accurate diagnosis in patients with perforated peptic ulcer
and can be used safely for the treatment as well in early cases.
However, till date none of the reports has shown any clearly
documented benefit of this procedure over conventional laparotomy.
Small bowel obstruction
Development of gangrene is one of the most feared
complications of small bowel obstruction (SBO). Patients with
complete SBO are at a much higher risk of developing this
complication, and need prompt surgical treatment whereas those with
a partial obstruction may resolve with conservative treatment. DL can

16. be helpful in distinguishing complete from a partial SBO 7. However,
during DL in SBO ,great care needs to be exercised to avoid injury to
the bowel during initial port placement as well as during manipulation
of the bowel. For initial port placement, open technique is
recommended and only atraumatic instruments should be used for
bowel handling. At DL , if we find single adhesive band, it is safe to
divide it laparoscopically to complete the procedure. However, in case
multiple or broad based adhesions involving multiple bowel loops are
discovered, laparoscopic adhesiolysis is technically demanding and
dangerous and it is safer to open the abdomen 7.
Duh 41 identified certain subset of patients of SBO who are likely
to benefit from laparoscopic management. These are patients with
mild abdominal distension allowing adequate room for visualization,
proximal obstruction, partial obstruction, single band obstruction and
obstruction which readily improves with nasogastric suction. Patients
with advanced, complete and /or distal obstruction are not candidates
for laparoscopic treatment. Patients with large bowel obstruction,
matted adhesions, carcinomatosis and those who do not respond to
conservative management (i.e. nasogastric suction) are also not
candidates for DL and should be managed by laparotomy. Several

17. authors 42-44 in the recent past have reported successful outcome
using DL in the "selected" patients as mentioned above. It has been
pointed out repeatedly that "careful patient selection" is the key to
successful outcome with DL in SBO patients 7,44.
Thus from the currently available data it is obvious that DL may
have a role in establishing an early diagnosis for patients with SBO. In
a selected subset of patients, laparoscopic adhesiolysis is also
possible. It has been suggested that in such patients, the long term
effects of successful adhesiolysis on the reformation of adhesions will
be favorable as compared to the laparotomy 7. However, long term
follow-up studies on larger number of patients are needed to justify
this statement.
pregnant patients with abdominal pain
Use of DL for evaluation of pregnant patients with acute
abdominal pain is an area of intense controversy. Whereas increasing
number of reports in the literature have attested to the safety of DL in
pregnancy if the pressure is kept low 28,45,46, others 47 have reported
increased incidence of fetal death in these patients as compared to
laparotomy. With the present state of knowledge ,it is prudent to

18. consider pregnancy a relative contraindication to DL until enough
clinical and laboratory data are available which indicate unequivocally
that no risk to the foetus exists 48.
ICU patients with abdominal pain
Intensive care unit patients are at an increased risk of developing a
number of acute intra-abdominal pathologies such as cholecystitis,
duodenal or gastric perforation, intestinal ischaemia, pancreatitis,
bowel obstruction and intra-abdominal haemorrhage. Presence of
multi-organ patholgy, equivocal abdominal signs and difficulty in
shifting these sick patients for conventional diagnostic modalities like
CT scan make accurate diagnosis difficult in these patients. In some
patients this delay in diagnosis may lead to either a delay in the
institution of appropriate surgical care or an unwarranted, non-
therapeutic laparotomy. This has prompted surgeons to evaluate the
role of DL in these critically ill patients. Several authors 49-51 have
reported their experience in the recent past in accurately diagnosing
the intra-abdominal pathology requiring surgical care, at the same
time excluding those who did not require surgical intervention. The
advantages of DL in these ICU patients include avoiding

19. transportation of the critically ill, often ventilator dependant patients(as
DL can be performed at the bedside in the ICU), rapid establishment
of correct diagnosis and avoidance of unnecessary ancillary tests.
However it is an invasive test that carries a small but definite morbidity
and has low sensitivity for intestinal or retroperitoneal diseases.
Nonetheless, DL is emerging as an important development in the
management of abdominal problems in critically ill ICU patients and
may become the first investigation of choice in future.
Suggestions
From above discussion it is obvious that in the last 10 years the
role of DL has been evaluated in the management of all types of
abdominal emergencies.Whereas the "feasibility "of performing it
safely and getting meaningful information has been proved beyond
doubt in most of the situations, the "advisability" (i.e. advantage over
conventional laparotomy) remains to be proved beyond doubt for most
of the causes of abdominal emergencies.This issue can only be
settled satisfactorily by well designed randomized trials recruiting
enough number of patients and by long term follow-up studies of
these patients.However, as per the currently available literature,

20. following guidelines can be followed:
Which patients should have DL ?
Only those patients with abdominal emergencies ( traumatic as well
as non-traumatic )who are hemodynamically stable and where the
diagnosis is still in doubt after a detailed clinical examination and
conventional investigations, should have DL.Hemodynamically
unstable patients and patients where a diagnosis requiring surgical
treatment is obvious, should not be taken up for DL. Although some
authors have suggested DL as the first investigation after clinical
examination i.e. in place of conventional investigations like DPL,US
and CT scan, under the present state of knowledge, I would
recommend it only as a part of a clinical trial and NOT for every
patient. These principles apply to all the causes of abdominal
emergencies discussed in the previous sections.
Who should perform DL for abdominal emergencies ?
It is obvious that DL in patients with abdominal emergencies is
technically very demanding and needs high degree of laparoscopic
skills on the part of the Surgeon to give the required , accurate

21. information.Therefore , it should only be performed by Surgeons who
have sufficient experience in elective laparoscopy for diagnostic as
well as therapeutic purposes.Any Surgeon who is in the learning
curve of his laparoscopy career should not attempt DL in abdominal
emergencies. Availability of laparoscopic suturing and knotting skills
is "desirable " as it will make therapeutic maneuvers possible in some
of the patients, avoiding laparotomy altogether. This will obviously
make laparoscopy more cost effective .
DL in abdominal emergencies should only be undertaken at
centers where the equipment and the instruments are available round
the clock and 'preferably' two surgeons with experience in
laparoscopy are available whenever a patient is taken up for
emergency DL.Needless to say that the 'Surgeon 'and the 'Center '
MUST be experienced and geared to handle any 'emergency' that
may arise during the performance of DL in abdominal emergency
cases.
Summary
Application of laparoscopy in the management of patients with
abdominal emergencies is an exciting , new development of this

22. decade which has opened tremendous possibilities for the future.
However, with the present state of knowledge, this new tool needs to
be used selectively:
* Only in patients who stand to benefit most from it as mentioned
in the previous sections,
* Only by the Surgeons who are well experienced in laparoscopic
surgery, and
* Only at the centers which have the requisite infra-structure.
It is also important that the data be recorded in an objective and
unbiased manner and reported accurately so that meaningful
conclusions could be drawn and definite guidelines could be laid down
for its more widespread use in the future.