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Official Journal of the American Society of Abdominal Surgeons, Inc.
This article originally appeared in the Winter 2012 / Spring 2013 issue of the Journal.
Treatment Options of Laparoscopic Complications
Dr. Faris Dawood Alaswad, M.D., M.B.CH.B.,
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Aims: To evaluate the best methods of management of laparoscopic complications.
Patients and Methodology: This is a prospective study done in NMC Specialty Hospital, Dubai, UAE between January 2006 and December 2011. We performed a retrospective review of 32 patients who underwent laparoscopy for complications of previous surgery over a 3-year period.
Results: A 32 patients underwent laparoscopy for complication during the study period including 24 laparoscopies,7 laparotomies, and 1 endoscopic procedure. The median delay between operations was 3 days. In 9 (28.1%)patients, laparoscopy did not find intra-abdominal pathology. The conversion to open surgery was necessary in 5 (14.1%) patients. Seven patients underwent more than 1 re-laparoscopy. No cases of misdiagnosis were observed. Morbidity was 12.5%. There was no laparoscopy-related death.
Main Conclusions: Laparoscopy is an effective tool for the management of postoperative complications after open and laparoscopic surgery. It avoids diagnostic delay and unnecessary laparotomy.
Complications after abdominal surgery, including bile leak,intra-abdominal bleeding, anastigmatic leak, intraabdominal abscess, small bowel obstruction, bowel necrosis,inadvertent bowel injury, and hollow viscous perforation,may necessitate reoperation and can be associated with significant morbidity and mortality. Re-laparotomy is considered beneficial in patients developing intraperitonealsepsis after abdominal procedures. Abdominal re-exploration by laparotomy is associated with an increased risk of abdominal infection, pain, ileus, wound complications, and prolonged admission.
The growth in the popularity of minimal access surgery has coincided with its use in different fields of surgery. Laparoscopic treatment is accepted for many emergency surgical conditions. Planned second-look laparoscopy is used to determine bowel viability in the treatment of acute mesenteric ischemia. The management of complications after laparoscopic cholecystectomy has been performed by repeated laparoscopy. Few reports of the successful use of laparoscopy for the diagnosis and treatment of surgical complications after initial laparoscopic and open abdominal surgery have been published. After the initial experience with laparoscopic treatment of complications after operations or invasive procedures, laparoscopy was adopted as the preferred procedure in the management of patients with suspected complications after open and laparoscopic surgery in our facility. This study report sour experience in the use of laparoscopy for management of postoperative complications.
Background to the Topic: A study sought to determine the role of laparoscopy in the management of suspected postoperative complications.
PATIENTS AND METHODS
A retrospective analysis of 32 patients who required laparoscopy for postoperative complications between January 2006 and December 2011 was performed. Patients were identified by a search of the operating room database.Data was collected from hospital charts and operative reports. Demographic and clinical variables included, age,sex, type of primary surgery and its complications, indications for repeated operations, time between surgeries,length, diagnostic accuracy, and therapeutic possibilities of laparoscopy, conversions, complications and mortality rate. Laparoscopy was carried out in each patient as soon as possible after a complication was suspected. A number of patients underwent preoperative abdominal or chest plain film ultrasonography, or computed tomography scan. Patient selection and indication for laparoscopy were decided by an available experienced surgeon and team.Only selected patients who underwent primary open surgery were managed laparoscopically. Re-laparoscopy was offered based on clinical judgment. Patients after previous laparotomy who had obvious anastomotic leak, peritonitis, and septic shock were explored secondly by open re-laparotomy.
Thirty two patients underwent laparoscopy for suspected complications of previous surgery. Patients data are presented in table 1, 26 (80%) patients underwent laparoscopy during the first 76 hours after initial surgery. Abdominal plain film was performed in 5 patients with suspected early postoperative small bowel obstruction .A chest x-ray was done to recognize suspected intraabdominal free air. An abdominal computed tomography scan was negative in 4 patients. The type of initial surgeriesis presented in table 2. The majority of the cases (23)indicated that re-laparoscopy was after cholecystectomy. Seven patients had bile leaks: 5 infected hematomas, 2 subhepatic abscesses, and 1 small bowel perforation were identified by laparoscopic re-exploration. One patient with bile leak closure and small bowel resection.
The most common indications for abdominal re-exploration were extraordinary abdominal pain and peritonitis (table 3). Finding during laparoscopy included bile leak. Intraabdominal hematoma, abscess, and free fluid; tears of colon, stomach, and small bowel: anastigmatic leak: adhesions small bowel and stomach necrosis identified during surgery mesh detachment from the abdominal wall: and small bowel obstruction (table 4). There were no findings during re-laparoscopy in 9 (28.1%) patients. 4 of 11 patients (35%) who had negative re-exploration were after cholecystectomy, and the rest had other types of primary surgery. No cases of misdiagnosis were observed. Procedure was completed laparoscopically in 86% of cases. The closure of 4 bile leaks, suturing of 4 gastric tears, release of 3 small bowel obstructions. In other patients the drainage of abscesses and hematomas, and abdominal larvae were performed during re-laparoscopy. Conversion to open surgery was needed for small bowel resection; stoma creation and suture of tears of stomach, colon and small bowel (table 5). Most of these were performed under laparoscopic guidance and formal laparotomy was avoided.3, 4
Surgery outcome is presented in table 6. Seven patients underwent more than 1 additional planned re-laparoscopy, 2 for the control of viability of stomach and small bowel after resection, 3 for sepsis source control, and 2 for additional peritoneal lavage. Mild bile leak, intrahepatic hematoma, upper gastrointestinal bleeding, and intraabdominal collection were managed non-operatively after laparoscopy. One patient required removal of the gastric band because of band infection with acute cholecystitis. Small bowel fistula and abscess, burst abdomen, and small bowel necrosis occurred after conversion and required additional open surgery. Overall, these complications were not directly associated with laparoscopy.
No re-laparoscopy related mortality was observed. A 96- year-old patient died from respiratory failure. Necrosis of the whole small bowel was the cause of death in another patient. Continuous uncontrolled bile leak from the gallbladder bed in a patient with adenocarcinoma of the gallbladder and multi organ failure led to death in another patient. Sepsis was irreversible in patients with congenital immunodeficiency, end stage renal failure, late diagnosis of small bowel perforation, and small bowel perforation, and small bowel necrosis followed by resection.3, 4
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Type of Primary Surgery
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Re-exploration for complications of abdominal surgery is required in 1.7% of patients. The presence of marked abdominal pain, tenderness, guarding, or early wound infectionmay be suspect for postoperative complication.1, 2 Usually,these patients were undergoing surgical re-explorations(re-laparotomy for diagnosis and treatment of complications).Laparoscopy was found to be clearly superior for patients with resemble diagnosis of perforated peptic ulcer, acute cholecystitis,appendicitis, or pelvic inflammatory disease. The successful use of laparoscopy has been described for the treatment of complications of open and laparoscopic surgery.3, 4
Postoperative abdominal pain presents a difficult diagnosticchallenge.5 Severe postoperative pain was an indication for exploration in 28.1% (9) of the patients in our series. Of these intraabdominal pathology was found in 18 cases(56%). Usually pain after laparoscopic surgery is localized at the place of surgery and port wounds.6 Extraordinary and out of proportion postoperative pain is one of the signs ofcomplications.7 Small amount of bile, blood, or stomach and bowel content below the bowel loops may be an innocent irritant for the peritoneum, and guarding will not appear in these cases shortly after surgery.8
Findings at Diagnostic
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Nonspecific signs may delay the diagnosis and treatment of early postoperative complications.9, 10 The European association for endoscopic surgery recommended first exhausting noninvasive diagnostic aids in patients with acute abdominal pain, and, depending on symptom severity, the use of laparoscopy if routine diagnostic procedures have failed to yield results.1, 3 However, abdominal imaging such as a computed tomography scan and ultrasonography, contributed relevant information in roughly 50% of case with postsurgical intra-abdominal sepsis.2, 5 Laparoscopy provides a superior overview of the abdominal cavity with reported diagnostic accuracy between 93% and 100%.8, 9 It is associated with less operative trauma anted lower systemic stress response than a laparoscopy should be expanded and postoperative abdominal inspection performed earlier so as to enable earlier intervention and improve outcome for these patients.3, 4
Laparoscopy revealed no findings in 28% of patients. All patients were discharged uneventfully 1 day later. This result compared with the 30% negative re-laparoscopy and 14% negative re-laparotomy rates. An attempt to recognize postoperative complications earlier leads to those true-negative results
We completed 86% of the procedures in our series by laparoscopy. Therapeutic capabilities of laparoscopy include intra-operative cholangiography for demonstration of biliary tree anatomy and exclusion or diagnosis of bile leak or retained stone,2, 6 closure of cystic duct leak, suturing of stomach and bowel tear, adhesiolysis, repair of mesh detachment, drainage of abscess, biloma, hematoma and free abdominal fluid, and irrigation of the abdomen. Most of the converted procedures were performed under laparoscopic guidance through enlarged port sites. Laparoscopic small bowel resection is possible; however, this prolonged the surgery time, and there was no difference between intra and extracorporeal anastomosis, excluding cost.3, 7
The risk of applying laparoscopy to emergency patients,especially after previous abdominal surgery, includes procedure-associated complications including veress needle and trocar injuries and iatrogenic tears of a distended and inflamed bowel wall.1, 9 The reported diagnostic laparoscopy-related complication rate varied between 1%and 9%. With increased experience by the surgeon, this approaches zero. On the other hand, morbidity is higher(4%-14%) after therapeutic laparoscopy in peritonitis and re-laparoscopy for complications (7%-23%). These complications were associated with peritonitis and inflammation and were not related to laparoscopic technique. The mortality rate is related to the proportion of elderly patients, delay in presentation or treatment, and control of peritonitis source.7, 10 Reported postoperative mortality inpatients with peritonitis-treated laparoscopically ranged from 0.8% to 7%. This compared with the high mortality rate (9%-43%) in patients who underwent re-laparotomy for postoperative intra-abdominal sepsis.1
Repeated re-laparoscopy was performed in 4 (11%)patients. Cueto et al reported about 7% re-laparoscopies in patients with peritonitis. The cause for reparation usually was a second look for bowel viability or sepsis source control.For causative treatment of intra-abdominal sepsis,we provided planned re-laparoscopy 24 to 48 hours after the last surgery. However a policy of on-demand surgery is still acceptable.
Laparoscopy is an effective tool for the management of postoperative complications after open and laparoscopic surgery. It is feasible, safe, and avoids diagnostic delay and unnecessary laparotomy.
1. Sauerland S, Agresta F, Bergamaschi R, et al. Laparoscopy for abdominal emergencies: evidence-based guidelines of the European association for Endoscopic surgery. Surg Endosc. 2006;20:14-29.
2. Slutzki S, Halpern Z, Negri M, et al. the laparoscopic second look for ischemic bowel disease. Surg Endosc. 1996;10:729-31.
3. Krishtein B, Roy- Shapira A, Lantsberg L, et al. the use of laparoscopy in abdominal emergencies. Surg Endosc. 2003;17:1118-24.
4. Navez B, Tassetti V, Scohy JJ, et al. Laparoscopic management of acute peritonitis. Br J Surg. 1998;85:32-6
5. Orlando R 3rd, Crowell KL. Laparoscopy in the critically ill. Surg Endosc. 1997;11:1072-4
6. Chung RS DJ < Diaz JJ, Chari V. efficacy of routine laparoscopy for the acute abdomen. Surg Endosc. 1998;12:219-22.
7. Agresta F MI, Coluci G, Bedine N. emergency laparoscopy; a community hospital experience. Surg Endosc. 2000;14:484
8. Rosin D, Zmora O, Khaikin M, et al. Laparoscopic management of surgical complications after a recent laparotomy. Surg Endosc. 2004;18:994-6
9. Koperna T, Schulz F Relaparotomy in peritonitis; prognosis and treatment of patient with persisting intraabdominal infection. World J Surg. 2000;24:32-7
10. Sanna A, Adani GL, Anania G, Donini A. The role of laparoscopy in patients with suspected peritonitis; experience of a single institution. J Laparoendosc. Adv Surg Tech. A 2003;13:17-9
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