1. The Role of the Laparoscope in the Acute Setting Mr John Griffith Bradford Royal Infirmary

2. Why ? No difference from elective surgery The reduction of the extent of the abdominal wound is associated with significant advantages –Less pain –Fewer wound infections –Shorter hospital stay

3. Why? Diagnosis The laparoscope may be used to make an accurate diagnosis Facilitates thorough lavage and localisation of pathology We now have enhanced image systems and instruments

4. Which pathologies? Right iliac fossa pain / appendicitis Acute cholecystitis Perforated Viscus (DU) Diverticulitis Intestinal obstruction Malignant large bowel obstruction

5. Acute Appendicitis Little benefit in performing a laparoscopic approach in young men and children Ideal in obese individuals or in patients in whom the diagnosis may be in doubt (elderly and females) Reduction in wound complications and hospital stay Varela JE Am J Surg 196

6. Changing the way we work Maw a et al Compared two groups of patients open vs laparoscopic appendicectomy 3:1 preponderance of females in the laparoscopic group (1.2:1 open) 13% normal appendix in the open group 53% normal appendix in the lap group 16% had an alternative diagnosis

7. Laparoscopy for RIF pain Technical tips Supra umbilical optical port Monitor Rt thigh 5mm LIF port Suction with a “trap” Proceeding to appendicectomy – 5mm supra-pubic port

8. Acute Cholecystitis Safe procedure Not can it be done but should it be done acutely in all cases? Cost benefit of this policy remains unclear Macafee DA BJS 2009 1031-40 Lavage for post op bile leak

9. Perforated Viscus: Peritonitis with free intra abdominal air Further imaging is unlikely to change management – surgery Laparoscopy usually allows accurate localisation of the pathology and lavage 30 degree scope and large bore suction with rapid infusion

10. Laparoscopic repair of Perforated DU Review of 56 papers Laparoscopic repair of a perforated peptic ulcer is associated with reduction in M&M, pain and hospital stay 12% conversion rate (diameter of perforation) Increased risk of persistent leak Maybe contraindicated in those with symptoms over 24hrs Bertleff MJ et al Surg Endosc 2009

11. Diverticulitis: The Cork experience 100 patients: Hinchey II 25, III 67, IV 8 92 managed with laparoscopic lavage and drainage : 3 died 2 failed to settle one of whom had a Hartmann’s Of 88 patients only 2 were readmitted (median fup 36 months) Winter DC BJS 2008

12. Diverticulitis: Champault G DCR 2009 Emergency lavage vs resection and defunctioning stoma (35 patients) Length of stay: 8 vs 17 days 71% of the lavage group underwent laparoscopic resection and all the defunctioning stomas were closed Total length of stay 14 vs 23 days with less morbidity

13. Intestinal Obstruction Small bowel obstruction Large bowel obsttruction

14. Small bowel obstruction: 19 studies 1994-2005 Laparoscopy was attempted in 1061 cases 83% adhesive obstruction –45 recognised enterotomies 33% conversion rate –Dense adhesions 28% –Bowel resection 23% –Iatrogenic injury 10% 9 missed enterotomies 9 missed enterotomies Ghoseheh et al Surg Endosc 2007

15. What predicts success? If obstruction is due to a single band Radiology : definite cut of Previous surgery : gynae, laparoscopic vs midline Successful in diagnosing the site Cost Neutral Wexner et al Surg Endosc 2007

16. Malignant Large Bowel obstruction Stenting to bridge to surgery Several none randomised studies It would appear safe The presence of the stent does not preclude a laparoscopic resection Park IJ J Gast Surg 2009 CREST

18. Positioning Gel none slip cover and or a Bean bag support Use incopads to retain the arms Two monitors are preferable but not essential

21. Training The introduction of a laparoscopic approach to the emergency theatre has some problems Procedures take longer Upward shift in training exposure Hedrick T Am J Surg 2009

22. Is the laparoscope creating a new problem? Reduction in adhesions Increase in internal hernias after laparoscopic morbid obesity surgery Volvulus around ileostomy sites

23. Conclusion Many acute patients can experience the benefits of a laparoscopic approach THE WOUND THE WOUND The approach develops surgeons and theatre nurses skills However However It takes longer and there is probably an upward shift in training exposure