Gonchar, Bogush, and Pryymak: Methods of Diagnostic Laparoscopy



Problem statement and analysis of the recent research

Diagnostic laparoscopy is the final stage of logical reasoning of a surgeon. The use of a laparoscope for diagnosing the pathology of the abdominal cavity is a reliable and low traumatic method, which has been increasingly used over recent decades. At the same time, its application may result in the development of complications being associated with these techniques: damage to the abdominal cavity caused by a Veress needle can cause peritonitis and bleeding; the application of carboperitonium can cause the external respiration dysfunction, cardiovascular disorders [1, 2].

All of the above-mentioned requires the development of new methods of sparing diagnostic laparoscopy, especially to be used in people with severe concomitant disease on the background of which it is difficult to verify the abdominal pathology.

The objective of the research was to develop a low traumatic method of diagnostic laparoscopy to be used in patients with the abdominal pathology and severe comorbidity.

Materials and methods

A retrospective analysis of 1,414 patients who were treated at the surgical department of Ivano-Frankivsk Central Clinical Hospital during 2013 – 2015 was made. All patients were laparoscopically operated on for various abdominal pathologies. The age of patients ranged from 18 to 84 years. There were 57.9% of women and 42.1% of men. In 41.82% of patients at the age over 60 years comorbidity such as cardiac arrhythmia, bundle branch block, past heart attack and stroke, congenital heart defect, chronic bronchitis, pulmonary emphysema, liver cirrhosis was found. They were consulted by subspecialists who prescribed corrective therapy.

In 18 cases, these patients underwent diagnostic laparoscopy under local anaesthesia using the method developed in our clinic, which was as follows: the first thing to do was the determination of patients’ susceptibility to an anaesthetic: procaine, longocain. In some cases, especially in the presence of hypertension, patients received epidural or spinal anaesthesia. Additionally, on the left and right of the navel, at a distance of 5 cm local anaesthesia was applied to numb the skin, subcutaneous fat, muscles and aponeurosis. In these points 2 forceps were placed and the assistant raised up the anterior abdominal wall (laparolifting). A 1-mm incision of the skin and aponeurosis was made along the lower edge of the navel; then, a 10-mm trocar was inserted without abdominal insufflation with carbon dioxide. The laparoscope was inserted and abdominal organs were inspected. Further tactics depend on the diagnosed disease: when it required further surgery patient was given anaesthesia and the necessary operation was performed after the application of carboperitonium and the insertion of additional tools.

If it was impossible to make the diagnosis using the laparoscope only additional devices were inserted. In extreme cases, if it was impossible to conduct adequate inspection of the abdominal organs - on the background of laparolifting carbon dioxide the amount of which did not exceed 5-7 mm Hg was injected into the abdominal cavity.

If the abdominal pathology was not found the laparoscope and instruments were removed from the abdomen and the trocar sites were closed.

Results and Discussion

This method of diagnostic laparoscopy under local anaesthesia using laparolifting was applied to 18 patients with severe concomitant disease and symptoms of peritonitis of unknown etiology. 3 patients developed pronounced ascites; therefore, first of all, a fluid aspiration with subsequent inspection of the abdominal cavity was performed.

The results of diagnostics were as follows: 2 patients were diagnosed with ascites-peritonitis and surgery ended with abdominal drainage using silicone drainage tube. Acute calculous cholecystitis was detected in 1 patient – the application of carboperitonium, laparoscopic cholecystectomy. Acute appendicitis was diagnosed in 3 patients - the application of carboperitonium, laparoscopic appendectomy. In 4 patients edematous form of acute pancreatitis was found - drainage of the omental bursa and abdominal cavity. 2 patients were diagnosed with ovarian cancer - taking a biopsy. In 1 patient necrosis in uterine fibromatous nodes was detected - the application of carboperitonium, laparoscopic removal of the node. 2 patients were diagnosed with omental necrosis - the application of carboperitonium, laparoscopic removal of the omentum. In 3 patients surgical pathology was not found.

All patients were discharged home in a satisfactory condition.

Conclusions

  • Diagnostic laparoscopy under local anaesthesia may be used to make a diagnosis in surgical patients with severe concomitant cardiopulmonary pathology.

  • The use of laparolifting under local anesthesia for diagnostic laparoscopy should be short (3-5 min) and performed by an experienced surgeon.

  • The proposed method of diagnosing the abdominal pathology does not cause any load on the cardiopulmonary system.

  • Diagnostic laparoscopy under local anesthesia requires further study and improvement.

References

1 

RO Sabadyshyn, VO Ryzhkovskyy. Surgical treatment of patients with acute calculous cholecystitis and concomitant functional cardiovascular pathology. Shpytalna khirurhiia. 2004;1:24-27.

2 

VI Lupaltsov, VV Melnikov. Optimization of the method of cholecystectomy in patients with work-related respiratory diseases. Klinichna khirurhiia. 2014;8:29-31.



Copyright (c) 2017 M G Gonchar, A Ye Bogush, L D Pryymak

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