Gonchar, Bogush, Marushchak, and Bogush: Laparoscopy in Elective and Emergency Surgery



Problem statement and analysis of the recent research

Traditional elective and emergency surgery is increasingly taking a back seat to minimally invasive surgical interventions covering almost all the abdominal organs [1, 2, 3, 4]. The widespread use of laparoscopic surgery is due to its apparent advantage over laparotomy surgery - primarily due to minimizing the injury of the abdomen and rapid rehabilitation of patients. At the same time, the introduction of advanced minimally invasive innovations as well as new approaches to surgical tactics has changed the technique of their application, namely, during appendectomy stump of the appendix is not immersed; perforated gastric ulcer and duodenal ulcer, in most cases, are not cut out but are closed with a single-row suture; acute pancreatitis is usually limited by sanitation and drainage of the abdominal cavity and omental sac. At the same time, the introduction of laparoscopic techniques allows the surgeon to be more confident in the positive result of surgery in patients with severe concomitant diseases. The increase in the number and range of laparoscopic procedures within a short period of their use is accompanied by an increase in the number of complications when applying these techniques [1, 3, 4]. It requires further consideration, analysis and adequate correction in order to reduce the negative impact as well as to contribute to wider use of these sparing techniques in both elective and emergency surgery.

The objective of the research was to study the prospects of using minimally invasive procedures in elective and emergency surgery.

Materials and methods

6,950 patients were operated on at the surgical department of Ivano-Frankivsk Central Clinical Hospital during 2013 – 2015; 3,045 out of them underwent abdominal surgery. In 1,455 cases minimally invasive surgical techniques were used (Table 1). 744 patients underwent elective laparoscopy, and 63.05% of patients underwent an emergency laparoscopic operation. The age of patients ranged from 18 to 84 years. There were 1,820 female patients while male constituted 42.1%.

Results and Discussion

Table 1

Range of laparoscopic procedures

No Pathology Type of surgery Number Complications
1. Acute appendicitis Laparoscopic appendectomy 398 Bleeding (2) – re-laparoscopy, arrest of hemorrhage
2. Perforated ulcer Laparoscopic suture of a perforated ulcer 18
3. Acute cholecystitis Laparoscopic cholecystectomy 213 Bile leakage (1) - stopped without any intervention
4. Acute biliary pancreatitis Laparoscopic cholecystectomy with abdominal drainage 169
5. Ovarian apoplexy, ruptured cyst Laparoscopic sanitation and drainage, arrest of hemorrhage, cystectomy 83 Perforation of the small intestine by the Veress needle (1) - laparotomy, suture of the intestine; re-laparoscopy (1), arrest of hemorrhage
6. Mesenteric thrombosis Experimental laparoscopy 4
7. Omental torsion and necrosis Laparoscopic resection of the greater omentum 7
8 Fat necrosis of epiploic appendages Laparoscopic removal of necrotic epiploic appendage 8
9 Mesadenitis Laparoscopic lymph node biopsy 7
10. Intestinal colic Diagnostic laparoscopy
11. Carcinomatosis Laparoscopic biopsy 11
12. Colon cancer Laparoscopic right hemicolectomy with ileotransversostomy 8
13. Sigmoid colon cancer Laparoscopic resection of visible sigmoid colon and end-to-end anastomosis 8
14. Adhesive peritoneal disease Laparoscopic separation of adhesions 11
15. Chronic appendicitis Laparoscopic appendectomy 2
16. Gallbladder polyps Laparoscopic cholecystectomy 2
17. Сholelithiasis, chronic calculous cholecystitis Laparoscopic cholecystectomy 459 Pneumatisation of the retroperitoneal space (1)- laparotomy, surgical revision
18. Hiatal hernia Laparoscopic anterior cruroraphy 3
19. Hepatic cyst Laparoscopic removal of hepatic cyst 18
20. Chronic pancreatitis, pancreatic cyst Laparoscopic drainage 4
21. Bile leakage Re-laparoscopy, sanitation and drainage 1
22. Foreign body in the abdomen Laparoscopic removal of foreign body 3
23. Trauma Laparoscopic arrest of hemorrhage, sanitation and drainage 3
24. Abdominal abscess Disclosure of abscess, sanitation and drainage 2
26. Laparoscopy with conversion in various pathologies 92
27. Usage of the laparoscope 1,455

Thus, the largest number of elective surgical interventions is necessary in chronic calculous cholecystitis (459), which is 15.07%. In urgent surgery it is acute appendicitis - 13.6%. The second disease by the number of emergency surgical interventions is acute cholecystitis - 6.9% (213). Acute pancreatitis accounts for 4.9% (149) of emergency surgery cases. Other pathology occurs in1 to 18 cases. It should be noted that in 92 (3.02%) cases laparoscopy ended up requiring conversion. In 42 cases diagnostic laparoscopy was performed; then, biopsy was taken or abdominal drainage was performed.

It should be noted that over recent years in perforated gastric and duodenal ulcer as well as in acute appendicitis and cholecystitis laparoscopic techniques being less traumatic have been applied due to significantly faster and easier rehabilitation period compared to laparotomy.

When performing 3,045 laparoscopic surgeries there were 6 complications, namely, 3 cases of bleeding from a trocar site; 1 bile leakage which stopped without any intervention; 1 perforation of the small intestine by the Veress needle - laparotomy, suture of the intestine; 1 pneumatisation of the retroperitoneal space -laparotomy, surgical revision. All patients were discharged to outpatient treatment in a satisfactory condition

Patients who underwent laparoscopic surgery stood up, walked, drank, and ate liquid food the next day after surgery.

On the basis of the research and analysis of our material we can propose specific indications for using laparoscopic technology in elective, and especially, in emergency surgery. Currently, laparoscopic surgery covers almost all abdominal organs - from chronic calculous cholecystitis to pancreatic duodenal resection. As for urgent surgery, there are some limitations, such as: severe forms of diffuse peritonitis or acute intestinal obstruction requiring intestinal intubation and programmed re-laparotomy; severe concomitant cardiopulmonary pathology, in which the increase of intra-abdominal pressure can lead to morbid complications; pronounced adhesive process after multiple laparotomies, especially when the bowels are soldered to the anterior abdominal wall and soldered together by rough commissures; congenital anomalies of the internal organs, especially in the hepatobiliary system; and finally, the lack of highly skilled surgeon who has experience in laparoscopic surgery.

Thus, laparoscopic technologies must be applied with specific indications for their use, which will significantly reduce the number of conversions and postoperative complications.

It should be noted that the conversion does not indicate an insufficient qualifications of the surgeon. It must be considered as a stage of comprehensive surgery. The main thing is to convert to laparotomy timely in order to avoid fatal consequences.

Conclusions

The use of laparoscopic procedures in emergency surgery is primarily the final stage of the diagnosis and verification of the pathology with subsequent adequate surgery.

To avoid complications during laparoscopic surgery they should be used strictly according to the indications.

Conversion must be performed timely and considered as a stage of comprehensive intervention.

Low injury rates and highly functional results of laparoscopic techniques predict their perspective quantitative increase in elective and emergency surgery and, at the same time, require an improvement of individual technique of surgeons as well as the development of new minimally invasive techniques.

Modern laparoscopic surgery along with the accumulation of the experience including a deep and thorough study of long-term results, over the course of time, will allow us to develop clear indications for using minimally invasive and traditional surgery.

References

1 

E Ann, C Falor. Early laparoscopic cholecystectomy for mild gallstone pancreatitis: time for a paradigm shift. Arch Surg. 2012;11:1031-1035. doi:10.1001/archsurg.2012.1473.

2 

T Chun. Treatment of severe acute pancreatitis through retroperitoneal laparoscopic drainage. Front Med. 2011;5:302-305. doi:10.1007/s11684-011-0145-7.

3 

J Mittu, B Mathew. Laparoscopic necrosectomy in acute necrotizing pancreatitis: Our experience. J Minim Acces Surg. 2014;10:168-191. doi:10.4103/0972-9941.134875.

4 

SA Kasumyan, AA Prybitkyn, AYu Nekrasov. Laparoscopic technologies in diagnostics and treatment in emergency surgery. Endoskopicheskaya khirurgiya. 2014;1:181-183.



Copyright (c) 2017 M G Gonchar, A Ye Bogush, N M Marushchak, N A Bogush

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