Is Laparoscopy Safe and Effective in Nontraumatic Acute Abdomen?

Abstract

Background and Aims:

Progress in laparoscopic experience has increased the number of laparoscopic procedures performed, even in emergency cases. Herewith, results in a prospective series of 300 patients laparoscopically treated for nontraumatic abdominal emergencies are presented with the intent to prove the safety and feasibility of laparoscopic approach in the treatment of acute abdomen.

Materials and Methods:

From a prospective multicenter study performed between June 2008 and December 2009, the authors collected data on 300 patients with a provisional diagnosis of acute abdomen, laparoscopically treated or who underwent explorative laparoscopy.

Results:

A correct diagnosis was made by means of laparoscopy in all 300 (100%) patients, and therapeutic laparoscopy was successfully performed in 270 (90%) patients. With laparoscopy, it was possible to modify the preoperative diagnosis and the treatment in 17 cases (5.6%). Upon statistical analysis, the conversion rate was correlated to the age of the patients (P<.0001) and to the operative time (P<.0001). The overall postoperative morbidity rate was 8%. Statistical analysis revealed that morbidity is correlated to the age of patients (P<.0001) and to the operative time (P<.0001). The mean hospital stay was 5.4 days.

Conclusions:

Laparoscopy has been shown to play a crucial role in the management of almost every abdominal emergency, offering, compared with the open approach, an initial diagnostic or explorative tool and a valid alternative in the treatment of the cause of acute abdomen with low morbidity and mortality rates.

Introduction

Progress in laparoscopic experience and improvement in technology have led to an increase, over the last two decades, in the number of laparoscopic procedures performed, even in emergency conditions, as a result of the benefit of a minimally invasive technique. Laparoscopy in emergency practice, combined with radiological investigations, offers a useful tool in establishing adequate diagnosis, treating, at the same time, the causative pathology, and thus offering the possibility of an appropriate abdominal approach. Noninvasive diagnostic procedures, in fact, such as radiological studies are not always conclusive, and laparoscopy is the only technique able to establish a diagnosis by direct visualization of the abdominal organs.¹

Laparoscopy is particularly useful, not only in women of reproductive age, as it provides an excellent view of the pelvic organs,^2,3 but also in obese patients in whom open surgery results in a much larger incision and in children to reduce the lifetime incidence of adhesions.^4,5 It may also be useful in the elderly or in critically ill patients to confirm the need for laparotomy when there is diagnostic uncertainty.^6,7

Several authors have demonstrated that laparoscopy in the management of abdominal peritonitis due to upper or lower gastrointestinal perforation and in selected patients for acute small bowel obstruction (SBO) is safe and feasible in terms of early postoperative outcomes; the minimal endoscopic approach is superior to conventional open surgery,^8–10 thus reducing the number of negative laparotomies and avoiding a large abdominal incision by planning the right incision.^11–15

The aim of the present report related to a prospective series of 300 patients laparoscopically treated for nontraumatic abdominal emergencies was to prove the safety and feasibility, as well as the diagnostic accuracy, of laparoscopic approach in acute abdomen.

Materials and Methods

From a prospective multicenter study performed between June 2008 and December 2009, 300 patients were consecutively collected with a provisional diagnosis of acute abdomen, either laparoscopically treated or who underwent explorative laparoscopy, to evaluate the safety and feasibility of laparoscopy in nontraumatic abdominal emergencies at the Departments of Surgery of the Sandro Pertini Hospital, the Vannini Hospital, the San Camillo Hospital, the Santa Maria Goretti Hospital, the Regina Apostolorum Hospital, as well as the Department of Emergency Surgery of the Policlinico Umberto I of Rome.

Inclusion and exclusion criteria used in the trial are listed in Table 1.

Table 1.

Exclusion Criteria

Age >90 years or <10 years

Trauma

Hemodynamic instability

Diverticulitis Hinchey class 3 or 4 at the CT scan

Previous extensive abdominal surgery^a

Massive bowel distension

Previous colorectal/gastric/hepatobiliary/pancreatic surgery; previous abdominal surgery for purulent or feculent peritonitis.

CT, computed tomography.

Diagnosis of acute abdomen was clinically made at the end of a preoperative work-up, including physical examination, biochemical investigations such as blood count, reactive C protein urea creatinine, electrolytes, coagulation, amylase, and lipase, as well as radiological investigations such as abdominal X-ray, abdominal ultrasound (US), and computed tomography when clinically indicated.

The initial, or preoperative, clinical diagnosis, any change in diagnosis, operative details and diagnosis, operating time, intraoperative and postoperative complications, reasons for conversion to open surgery, length of hospital stay, postoperative outcomes, and operative/postoperative mortality were evaluated and entered into the database for analysis.

The laparoscopic approach was performed by well-trained surgeons.

Laparoscopy was performed in all patients within 48 hours of admission. The procedure was carried out under general anesthesia in the supine position. Exploration of the peritoneal cavity was performed after introduction of the optic system through an umbilical port. Additional ports were inserted according to the nature of the disease. After diagnosis had been established, either patients were laparoscopically managed or they underwent conversion to an open procedure.

Drains were introduced at the end of the operation using the port position. Nasogastric and urinary catheters were selectively used.

Ethical approval was obtained from the ethics committee of each hospital institution prior to the treatment and each patient signed an informed consent to the procedure.

Statistical analyses were performed using MedCalc for Windows, version 10.2.0.0 (MedCalc Software, MariaKerke, Belgium). Differences in distribution were calculated using the chi-square test, Fisher's exact test, or Student's t-test, depending upon the number of cases in each subgroup or depending on data distribution. Statistical significance remained conventionally defined as P<.05 in all other cases.

Results

Of the 300 patients enrolled in this study, 186 were female and 114 male. Mean age was 43 years (range: 10–89). Mean body weight was 70 kg (range: 25–173 kg). All patients had presented at the emergency room with abdominal pain as the main symptom; abdominal pain was localized in the lower quadrants of the abdomen in 184 (61% of the cases) and in the upper quadrants in 116 (39% of the cases). In 74% of cases, patients presented with fever, in 67% with nausea and vomiting, and in 31% with modifications in bowel movements.

The preoperative diagnoses are outlined in Table 2.

Table 2.

Preoperative and Postoperative Diagnoses (Number)

	Preoperative diagnosis	Postoperative diagnosis
Acute appendicitis	87	108
Cholecystitis	96	96
Small bowel obstruction	16	16
Nontraumatic hemoperitoneum	5	7
Pelvic inflammatory disease	7	27
Acute diverticulitis	9	12
Duodenal perforated ulcer	6	5
Gastric perforated ulcer	5	6
Endoscopic perforation	4	4
Acute abdomen of uncertain origin	65	Ovarian cyst rupture, 12
		Ovarian torsion, 5
		Corpus luteal cyst rupture, 2

Overall, 21 patients (7% of cases) had undergone previous abdominal surgery.

Diagnostic or explorative laparoscopy was performed in 65 patients (21.6%), when the preoperative diagnosis was uncertain or dubious. In 39% of these cases, patients were females of reproductive age with a history of abdominal pain localized in the lower abdominal quadrants.

Laparoscopy led to a correct diagnosis in all 300 (100%) patients, with a diagnostic accuracy rate of 100%, and therapeutic laparoscopy was successfully performed in 270 (90%) patients.

Laparoscopy allowed preoperative diagnosis and the strategy to be modified in 17 cases (5.6%). Of these cases, 12 (70%) were females of child-bearing age with a preoperative diagnosis of acute appendicitis and a final diagnosis of a gynecologic disorder. In all these cases, unnecessary laparotomy was avoided.

The type of intervention performed is listed in Table 3. Mean operative time was 83.8 minutes (range: 20–300 minutes).

Table 3.

Type of Surgery Performed (Number)

Surgical procedure	No.
Appendectomy	108
Cholecystectomy	96
Adhesiolysis	19
Ovarian cystectomy	16
Salpingectomy	9
Peritoneal toilet (lavage and drainage)	8
Duodenorraphy	6
Left colectomy	6
Bowel resection	4
Ovariectomy	3
Sigmoidectomy	2
Gastrorraphy	2
Right colectomy	1
Ileo-cecal resection	1
Distal gastric resection	1
Other	18

Conversion from laparoscopy to open surgery was necessary in 30 patients (10%), because of adherences (40% of cases), local inflammation (40% of cases), and bowel distention (20% of cases). By statistical analysis, the conversion rate was found to be correlated to the age of patients (P<.0001) and to the operative time (P<.0001; Table 4).

Table 4.

Correlation Between Conversion of Laparoscopic Approach and Age, Sex, Weight, and Operative Time

	P
Age (years)
<54
>55	<.0001
Sex
Male
Female	.23
Weight (BMI)
<24.9
>25	.18
Operative time (minutes)
<70
>71	<.0001

BMI, body mass index.

The overall postoperative morbidity rate was 8% (25 patients). Respiratory complications (3% of cases, 9 patients) were the main postoperative complications; superficial surgical site infection was encountered in 2% (6 patients), deep abdominal collection in 1.6% (5 patients), postoperative pancreatitis in 1 patient, gastrointestinal bleeding in 2 patients), pseudomembranous colitis in 1 patient, and duodenal stenosis in 1 patient who underwent duodenorraphy for duodenal peptic perforated ulcer, developing a postoperative fibrotic duodenal stenosis treated with a open Heineke-Mikulicz duodenoplasty.

Statistical analysis revealed that morbidity was correlated to age of the patients (P<.0001) and to the operative time (P<.0001; (Table 5). The mean hospital stay was 5.4 days (range: 2–53).

Table 5.

Correlation Between Morbidity and Age, Sex, Weight, Operative and Time

	P
Age (years)
<54
>55	<.0001
Sex
Male
Female	.46
Weight (BMI)
<24.9
>25	.11
Operative time (minutes)
<70
>71	<.0001

The postoperative mortality rate was 1% (3 patients with severe postoperative respiratory complications).

The two main surgical procedures (appendectomy and cholecystectomy) were separately analyzed.

Appendectomy was performed in 108 patients (63 female, 45 male; mean age: 29 years). Of the 63 females, 60 (95%) were women of child-bearing age, and of the 45 males, 38 (84%) were overweight (body mass index >25.1).

The mean operative time was 58 minutes. Morbidity rate was 5.5% because of six postoperative complications (five superficial surgical site infections and one deep abdominal collection). Statistical analysis confirmed that morbidity was not correlated to the sex or age of the patients or to operative time.

No cases of mortality were observed. In 2 cases (1.8%), laparoscopy was converted to the open approach because of local inflammation. Mean hospital stay was 4 days.

Cholecystectomy was performed in 96 patients (42 male, 54 female; mean age: 57 years). The mean operative time was 97 minutes. Overall, eight postoperative complications (8.3%) occurred: three respiratory complications, two gastrointestinal bleeding, one deep abdominal collection, one postoperative pancreatitis, and one pseudomembranous colitis. In 13 cases (13.5%), laparoscopy was converted to the open approach because of local inflammation. Statistical analysis revealed that morbidity was correlated with age of the patients and to an operative time >90 minutes (P<.02), and it was not related to the conversion approach (P=.3).

No cases of mortality occurred. Mean hospital stay was 5.1 days.

Discussion

The role of laparoscopy has considerably increased over the last two decades, as a result of improved expertise on the part of the surgeon, more experience in laparoscopic technology, and a better knowledge of the possibilities of this technique. Initially employed in elective abdominal benign disease, laparoscopy is now successfully employed not only in the oncologic field but also, more frequently, in abdominal emergencies. There is still some concern regarding laparoscopic treatment for abdominal emergencies on account of the longer operative time, uncertain postoperative effectiveness, leakage, high rate of need for reoperation, as well as intra-abdominal abscess.

These disadvantages of laparoscopic treatment may likely be attributed, for example, to less experience of surgeons and bad prognostic factors of patients.^10,16,17 At present, reports in the literature, consensus conferences, and surgical workshops have led to better standardization of the correct indications of the laparoscopic approach in abdominal emergencies.

Acute abdomen in women of child-bearing age, for example, gives rise to a particular problem in the diagnosis of acute lower abdominal pain. Gynecological conditions may present with signs and symptoms that are often indistinguishable from acute appendicitis,¹⁸ and laparoscopic assessment has been shown to reduce the frequency with which normal appendices were removed in women with a clinical diagnosis of acute appendicitis. The negative appendectomy rate is described ranging between 15% and 32% in patients submitted to conventional open surgery for lower quadrant abdominal pain,^13,19 and the postoperative complication rate of a negative appendectomy is still 6%.²⁰

In our series, 39% of the diagnostic laparoscopies were performed in women of child-bearing age with a history of abdominal pain in the lower quadrants of the abdomen, and of the 71 cases of female patients with a preoperative diagnosis of acute appendicitis, 12 (17%) had a definitive diagnosis of pelvic inflammatory disease or endometriosis following diagnostic laparoscopy and were not submitted to appendectomy.

Laparoscopy should not be performed to substitute other less invasive diagnostic techniques such as US because of the risks associated with a general anesthetic and laparoscopic port placement. However, in certain groups of patients, such as fertile women, the possibility to diagnose other pathological conditions, such as endometriosis, makes it an appropriate, indispensable approach.²¹ If used on a wider scale, the number of normal appendices removed would be reduced and other important diagnoses could be made, resulting in better timing of appropriate therapy.¹⁹

In patients with acute cholecystitis, optimal timing for laparoscopy, as recommended by several authors, plays a crucial role. A surgical laparoscopic procedure performed within 48–72 hours after the onset of symptoms reduces morbidity and mortality when compared with delayed surgery.^11,22 In our series, the conversion rate was 13.5% with a morbidity rate of 8.3%, considering that 50% of patients with complication were ≥80 years.

Hence, selection criteria could optimize the use of laparoscopy in the event of acute abdominal emergency and identify patients suitable for laparoscopy and who would benefit from laparoscopic surgery.

Selection criteria are necessary, as demonstrated by Siu et al.,²³ in treating acute abdomen due to perforated peptic ulcers. The authors considered as exclusion criteria, for laparoscopic repair, the presence of a juxta-pyloric gastric ulcer, an ulcer >10 mm in diameter, and technical difficulties. Recent meta-analyses of comparative studies described a reduction in postoperative complication rates following emergency laparoscopic surgery, which may be explained by scrupulous patient selection and increased experience.^24,25

The advantage of the laparoscopic approach is not only cosmetic, but also decreased surgical trauma, which reduces frequent wound infections as well as the resulting laparotomic hernias. Moreover, with a reduction in trauma, recovery of the patient is improved.¹

Laparoscopy offers direct visualization of the affected organ, indicating the best surgical approach to treat the disease, selecting the best place for the laparotomic incision when laparoscopic treatment is difficult or not indicated, and thus avoiding uncomfortable or extensive abdominal incision; and, finally, in other cases it will contribute to avoiding laparotomy, as, for instance, in the case of extensive mesenteric ischemia with necrosis.¹

Laparoscopy has been found to be safe and effective, as demonstrated by several authors,^14,15 in SBO, especially in selected patients with a single adhesion responsible for the occlusion. In these cases, the laparoscopic approach results in lower morbidity rate, faster return to normal diet, and shorter hospital stay.

In our series, we treated 19 patients with SBO, with a conversion rate of 33% and complication rate of 5% (1 patient with a respiratory complication who died because of respiratory failure).

Ghosheh and Salameh,¹⁴ in a review of the literature, reported a success rate of 66% for laparoscopy in the treatment of SBO with a morbidity rate of 15.5% and a mortality rate of 1.5%. Early recurrence (defined as recurrence within 30 days of surgery) was reported in 2.1%.

Kirshtein et al. observed that a significant number of patients with SBO laparoscopically managed require conversion; however, conversion frequently consisted in a small abdominal incision to perform a segmental ileal resection.¹⁵

In conclusion, laparoscopy, with correct selection of patients, optimal timing, and appropriate experience of the surgeon, plays a crucial role in the management of almost every nontraumatic abdominal emergency, offering an initial diagnostic or explorative tool and guaranteeing both a low morbidity and mortality rate, compared with the open approach.

Footnotes

Disclosure Statement

The authors declare that no conflicts of interest exist. The authors certify that they have no commercial associations that might pose a conflict of interest in connection with the submitted article.

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