Definition Acute Abdomen.
Peritonitico acute abdomen, remains a major cause of morbidity and mortality, is often of unknown etiology and is frequently associated with acute abdominal or pelvic cavity. . The value of laparoscopy in patients with acute abdomen, is known from the 50's, although it has been in recent years, when the surgeon, used as a diagnostic method and most of the time therapeutic.
Indications for laparoscopic exploration.
Open or closed abdominal trauma.
The alleged abdominal injury, will be investigated with clinical examination, CT and sometimes abdominal puncture washing. In these patients, laparoscopy can prevent 20% of laparotomies in white, that would not be avoidable with all diagnostic tests.
In the nontraumatic acute abdomen.
Laparoscopy provides a fast and effective diagnosis, avoiding, as in the previous case, unnecessary laparotomies, which can reach 25%, and shortening the time of surgical decision, vital for a significant number of patients.
Evaluation algorithm of acute abdomen:
Clinical evaluation of patient.
Analytical test conventional and image.
Hemodynamic stabilization, analytical and biochemistry.
Exploration laparoscopic diagnosis and most of the time, therapeutic.
If necessary, conversion to conventional surgery.
For the latter option, the location and size of the incision is determined in view of the results of laparoscopic exploration, which we call, Laparotomy-assisted laparoscopy.
The indications for emergency laparoscopy are the same as for the needle - wash:
Loss of consciousness by brain trauma, poisoning or drug ingestion.
Closed abdominal trauma or abdominal stab injury.
Unexplained hypotension in polytraumatized.
Signs doubtful clinical examination of the patient.
Acute abdomen laparoscopic surgery
The pneumoperitoneum is performed with the Verres needle abdominal tap, with the same technique as in elective laparoscopy in the paraumbilical region with the open technique or trocar Hansson. The existence of disposable laparoscopic material (two 3 mm trocars, a puncture needle and a lens of 2 mm), allows the realization of this technique in the ICU or the emergency room. Laparoscopy can be done in 15-30 minutes under local anesthesia and light intravenous sedation.
Position the patient.
Supine with legs apart and supported on legs, so that the surgeon is positioned between them if the suspected pathology is in the upper abdomen, and horizontalizado antitrendelemburg lightweight, with the surgeon on the left side of the patient, the pathology located in the lower abdomen and pelvic cavity.
Tubular injury digestive.Find accumulation of yellow-green liquid in the gutter right parieto-colic the existence of this sign is itself indicative of surgical treatment by open or laparoscopic, if you have experience in this surgery. In some cases the injury is discovered perforativa directly, but we can find indirect signs:
Existence of a mass in a given area of the abdomen covered with omentum.
Adhesion edematous fibrin plates or hyperemia of the small bowel loops examination of the abdominal cavity, can be mobilized with careful maneuvering bowel loops and omentum with laparoscopic instruments. More difficult will be the discovery of lesions located in the retroperitoneum perforativas (third duodenal portion) and pancreatic injuries, but luckily these injuries are less common.
Laparoscopic surgery of perforated peptic ulcer, shortens the hospital stay, less morbidity and more patient comfort. The surgical technique must be the same as in conventional surgery. Definitive surgery must predominate over simple suture of the perforation, but this is only possible when you have experience in laparoscopic surgery.
It is important for laparoscopic exploration, the degree of distension of the abdomen, in very advanced cases of occlusion, manipulation and management of dilated bowel loops, difficult to locate the lesion responsible for the clinical picture.
The best results are obtained when adhesions exist only in a "taenia" iatrogenic bowel perforation, can occur when there are multiple adhesions in the cavity (peritoneal and interasas) and the handles are very relaxed, with some degree of ischemia.
Jam for colon malignant disease.
Can be resolved by laparoscopic surgery, a procedure or a Hartmann colostomy decompression, can be completed laparoscopically. The current trend is primary resection by open or laparoscopic surgery.
Fecal contamination without perforated diverticulitis.
Can be treated, after exploratory laparoscopy with: suction-washing the abdominal cavity, drainage and antibiotic coverage. Where there is fecal contamination, shall be required conversion to conventional surgery
The benefit in laparoscopic appendectomy, is beyond doubt, being higher in younger women, where you can avoid 30% of unnecessary operations, using laparoscopic methods. It is also very effective in obese patients, where it will be necessary, major abdominal incisions to perform the operation, and in situations ectopic appendix.
Despite being higher conversion rates, which cholecystectomy for cholelithiasis and slightly higher operating time. The embodiment of this technique requires experience to design the identification strategy pedicle bladder, most often by inflammatory adhesions coated. Peroperative cholangiography is recommended, we must be ready at any time to conversion, if the laparoscopic procedure offers no security.
Solid organ injury.
The laparoscopic exploration discover an accumulation of blood located mainly in the left upper quadrant and left colic gutter parieto-will require the removal of the omentum splenic cell to access this area and discover the potential injury to the spleen.
We can also find a minimal hemoperitoneum superficial injury in the form of decapsulation of the spleen, which together with hemodynamic stability allows us not to do emergency surgery, you can choose from an evolutionary monitoring of the patient within hours, in the other cases, particularly with significant hemoperitoneum and laceration of the spleen, the indication of splenectomy is not expected.
Laparoscopic exploration is indicated in cases of hemodynamic stability and the existence of a severe hemoperitoneum require immediate surgical decision, but in some cases of superficial lesions of the liver, laparoscopic exploration is helpful in the initial assessment in some cases this lesion appears at the falciform ligament or at the top or bottom surfaces of both lobes, aided by laparoscopic instruments that can be displayed and discover. Compression or coagulation of the same, can solve the problem, persistent bleeding after a reasonable time require laparotomy exploration.
There is no indication of laparoscopic exploration abdominal injuries by firearms, where the indication for exploratory laparotomy should not be delayed.
In cases of stab injuries, if any indication for exploratory laparoscopy, suturing the wound in the skin allows the realization of the pneumoperitoneum, the differential diagnosis between non-penetrating or penetrating wound in the abdominal cavity is easily done. The exploration of the abdominal cavity when the wound is penetrating) can be performed with a laparoscopic probe that allows raising or mobilization of the bowel loops, looking for bleeding or any signs.