13Working diagnosis Patient requires immediate laparotomy Patient has suspected surgical abdomenDiagnosis is uncertainPatient has suspected nonsurgical abdomen
14Patient requires immediate laparotomy Ruptured abdominal aortic or visceral aneurysmRuptured ectopic pregnancySplenic ruptureMajor blunt or penetrating abdominal trauma and hemoperitoneum from various causes.Hemodynamic instability is the essential indication.
15Patient has suspected surgical abdomen Patient requires urgent laparotomy or laparoscopyHospitalization and observationPatient requires early laparotomy or laparoscopyPatient is candidate for elective laparotomy or laparoscopyDiagnosis is uncertain, or patient has suspected nonsurgical abdomen
16Diagnosis is uncertain Patient should be hospitalized and observedPatient can be evaluated in outpatient settingPatient has suspected surgical abdomenDiagnosis is uncertain, or patient has suspected nonsurgical abdomen
17Patient has suspected nonsurgical abdomen Patient should be hospitalized and observedProvide narcotic analgesia as appropriate. Observe patient carefully, and reevaluate condition periodically. Consider additional investigative studies.Diagnosis is uncertain, or patient has suspected surgical abdomenDiagnosis is NonsurgicalReevaluate patient as appropriateRefer patient for medical management
23Frequency of Specific Diagnoses OMGE Study DiagnosisFrequency (% of Patients)Age < 50 Yr(N = 6, 317)Age > 50 Yr(N = 2, 406)Nonspecific Abdominal Pain39.515.7Appendicitis32.015.2Cholecystitis6.320.9Obstruction2.512.3Pancreatitis1.67.3Diverticular disease<0.15.5Cancer4.1Hernia3.1Vascular disease2.3
24The Role of EMERGENCY LAPAROSCOPY Diagnosis has been the most important roleEven when pre-operative diagnosis is certain, peritoneal assessment in the acute situation is important to assess the situation and avoid a missed diagnosis.Therapeutic procedures are done once the diagnosis is established.Convert to open surgery when indicated.
25Benefits1. Accurate diagnosis of the pathology inside the abdomen Diagnosis and therapeutic surgery is possible at the same time Less post op. pain Faster recovery and short hosp. Stay less post op. complications like wound infection,Hernia etc Cost effective in working group In Case of conversion more suitable and better place incision
27Benefits contd…Acute abdominal emergencies are diagnosed incorrectly or too late in 5-20% of cases. This leads to1. Delay in appropriate treatment2. Improper surgical access route3. Repeat surgeryThis causes higher morbidity and mortality, longer hospital stay and recovery time which leads to higher cost for the community
28Laparocopy hasBetter evaluation of the peritoneal cavity then that obtained by the standard laparotomy incision.It allows rapid and thorough inspection of the paracolic gutters and the pelvic cavity better than open approach.
33Intestinal Obstruction from Adhesion Band due to Appendicitis, Laparoscopic Adhesiolysis
34Peritonitis: Gangrenous Appendix with Pus in the Pelvic Space
35Undiagnosed Ectopic Pregnancy presenting as severe RHC Pain and Peritonitis
36EMERGENCY THERAPEUTIC LAPAROSCOPY Indications for Therapeutic Laparoscopy; requires trained LaparoscopistAcute CholecystitisAppendicectomy in High Risk PatientAdhesiolysis with Intestinal ObstructionPerforated Peptic UlcerOther GIT PerforationSecond Look e.g. for Bowel viabilityDrainage of abscess collections
37Laparoscopy allows more appropriate placement of Incision following Diagnosis. Avoid double or extended incision due to unexpected diagnosis
41EMERGENCY LAPAROSCOPIC PROCEDURES: Conversion After DiagnosisInexperienced to deal with problemSafer outcome with open SurgeryGangreneRuptured / Bulky TumourHemorrhage
42EMERGENCY LAPAROSCOPIC PROCEDURES: Conversion After attempt at Therapeutic LaparoscopyDifficult Tissue Planes with increased risk of injuryLack of Visibility to perform safe surgeryComplications e.g. uncontrolled bleeding