Formal Laparotomy Research Articles

Temporary colostomy for trauma. A new method to simplify colostomy closure.

A technique for construction of a functional loop colostomy is described for the management of colonic injuries in which complete fecal diversion is not required. The colostomy and mucous fistula are converted into a functional loop colostomy at the initial procedure and exteriorized through a single stoma. Subsequent colostomy closure is simplified. Intraperitoneal colostomy closure can usually be performed by mobilizing the colon at the stoma site without resorting to formal laparotomy.

Hypertrophic pyloric stenosis complicating oesophageal atresia with distal tracheo oesophageal fistula: A case report

A neonate was operated upon for esophageal atresia with distal tracheo oesophageal fistula. He developed mediastinitis due to an anastomotic leak, which led to a fatal outcome. At autopsy, an associated hypertrophic pyloric stenosis was found. This had probably contributed to the development of the leak. The condition had been suspected in the post operative period, but had not been further investigated. A review of the literature shows a high incidence of anomalies associated with tracheoesophageal fistula. In patients of tracheo oesophageal fistula, in whom associated gastro-intestinal anomalies are suspected, contrast radiographic studies to include the pylorus, stomach and duodenum are mandatory. A formal laparotomy and surgical correction must then follow, if required. A high index of suspicion is required so as to avoid complications arising from a delay in complete diagnosis.

Abdominal tuberculosis: still a problem today.

Thirty cases of abdominal tuberculosis were diagnosed over an 18-year period, 26 being in immigrants; the mean age at presentation was 33 years. There were 25 cases of tuberculous peritonitis, two of tuberculous mesenteric lymphadenitis, and one each of gastric tuberculosis, colonic tuberculosis and tuberculous ischiorectal abscess. The presenting symptoms were of vague ill-health and not diagnostic, and the most common findings were of pyrexia, abdominal tenderness and ascites. The most common haematological abnormalities were raised ESR (22 patients) and mild anaemia (15 patients). Most commonly, diagnosis was made by formal laparotomy (19 cases) with biopsy (18 cases); histological examination gave a positive diagnosis in all 18 cases, but bacteriological examination yielded the tubercle bacillus in only 10 (56%). There were 2 deaths in the series, not directly related to the abdominal tuberculosis. In view of its infrequent and vague presentation, care is required to avoid overlooking the diagnosis of abdominal tuberculosis, particularly in the immigrant population.

Balloon catheter dilatation of focal intestinal strictures following necrotizing enterocolitis

Dilatation with a balloon catheter was successfully employed for 9 focal intestinal strictures which occurred in 5 infants following necrotizing enterocolitis. Eight of the 9 strictures were located in defunctionalized colon distal to an enterostomy; no infant had clinical intestinal obstruction. Because the dilatation achieved distal patency, subsequent closure of the enterostomy was accomplished without a formal laparotomy. The balloon dilatation technique may be valuable in the management of focal strictures that are not causing clinical intestinal obstruction.

End-Loop Ileocolostomy for Massive Trauma to the Right Side of the Colon

In patients with severe trauma to the right side of the colon, who might have intraoperative contraindications to primary ileocolostomy, we use a new technique called end-loop ileocolostomy, which allows for complete diversion of the fecal stream with the distinct advantage that it precludes the need for formal laparotomy at the time of subsequent closure. This has been used successfully in eight patients.

Management of the newborn with gastrointestinal anomalies and tracheoesophageal fistula

A standard approach to the otherwise healthy newborn with esophageal atresia and tracheoesophageal fistula has been well established. A significant number of these infants have additional gastrointestinal anomalies that necessitate alteration of the usual operative management. Over 2 1 2 years , nine such newborns have been managed. There were 17 additional gastrointestinal abnormalities, the most frequent being an imperforate anus (5), malrotation (5), and intestinal atresia (4). Management consisted of initial formal laparotomy, thoracotomy, and central line placement. In four infants these procedures were performed at a single sitting. Eight infants survived (89 percent); the single death resulted from intracerebral hemorrhage. Detection of coexisting gastrointestinal anomalies is mandatory in the management of the newborn with esophageal atresia. Standard local gastrostomy and subsequent thoracotomy may delay recognition of these associated anomalies, increase morbidity, and complicate subsequent correction. Preliminary abdominal exploration with correction, diversion, or both followed by thoracotomy, either immediate or staged, is indicated.

Early experience with endoscopic percutaneous gastrostomy.

We performed endoscopic percutaneous gastrostomy (EPG) on 22 patients. All procedures were performed using local anesthesia with intravenous diazepam sedation. Formal laparotomy was not required. The mean patient age was 58 years (range, 21 to 83 years). Indications for EPG placement included neurologic disorders in 17 patients, head and neck tumors in four patients, and esophageal disease in one patient. The mean operative time for EPG was 27.5 minutes, with a range of 11 to 60 minutes. Two major complications, a gastrocolic fistula and an intraperitoneal gastric leak, occurred early in the series. The technique has been modified with no similar complications. Pneumoperitoneum after EPG was demonstrated in eight patients without sequelae. Ileus following EPG was not observed in any patient, and enteral feedings were uniformly resumed 48 hours after tube placement. Our early experience with EPG suggests that this technique is a safe, cost-effective, and time-saving alternative to traditional gastrostomy tube placement.

Repair of Parastomal Hernia by Translocation of the Stoma Without Laparotomy

Relocation of the ileal conduit stoma in cases of large peristomal hernia is simple and effective, and can be accomplished safely without formal laparotomy. Four difficult cases have been managed successfully in this manner. The technique also is applicable for other intransigent stomal problems.

Periileostomy fistulae in Crohn's disease.

Fifteen of 214 patients with an ileostomy constructed during the course of Crohn's disease developed periileostomy fistulae. In each case this was the consequence of recurrent ileal disease. The incidence was higher in female patients as well as those with a prior history of either intraabdominal abscess or any type of fistula. Periileostomy fistulae are frequently multiple. In addition to the clinical features of recurrent disease, periileostomy fistulae cause additional symptoms that are particularly distressing. These result from the proximity of the fistula to the stoma and the difficulty of maintaining the seal of an appliance. All periileostomy fistulae require resection and reconstruction of the stoma. Superficial fistulae with relatively smooth skin around the stoma may be reconstructed using the original stoma site; but deep fistulae with severe peristomal excoriation, induration and inflammation require transposition to a different quadrant. This may, in suitable cases, be carried out by direct stoma-to-stoma transposition, without formal laparotomy. The quality of life following successful reconstruction of the stoma is excellent, even though some patients will develop additional recurrent disease. To date none of these patients have developed another periileostomy fistula.

Emergency laparoscopy in patients with multiple trauma (author's transl)

In 83 patients with multiple trauma emergency laparoscopy spared the patient a formal laparotomy in 46%. 95% of the laparoscopies gave unequivocal clinical information. Emergency laparoscopy is less invasive and of special value in patients with multiple trauma and poor general condition.

The use of peritoneoscopy in the diagnosis and treatment of complications of ventriculoperitoneal shunts in children

Abdominal complications of ventriculoperitoneal shunts used for hydrocephalus have been diagnosed and treated by peritoneoscopy in six instances. In four children, lost catheters were retrieved, and in two cases malfunction was treated. This technique was curative in each instance, thus avoiding total shunt replacement and formal laparotomy.

Spontaneous perforation and closure of the small intestine in association with childhood leukemia

BuDOMINAL C O M P L I C A T I O N S of leukemia in childhood are relatively ncommon. Kuffer et al? encountered intraabdominal complications in 13 of 259 children with leukemia (5~). These complications included intraabdominal abscesses in nine patients (appendiceal, liver, and renal abscesses), intestinal obstruction in two patients, pancreatitis in one, and gallstones in one. Prolla and Kirsner, 2 in a review of autopsy findings in 148 cases of leukemia in children and adults, found necrotic lesions in 8 of 75 evaluable patients (11%) and bacterial peritonitis in 10 of the 148 cases (7%). The bacterial peritonitis was due to ruptured appendicitis in three cases, rupture of the large intestine in three cases, rupture of liver abscesses in two cases, and perforation of agranulocytic abscesses of the terminal ileum in two cases. Prolla and Kirsner stated that these complications tended to be fatal because of the poor condition of the patients. When possible, it is desirable to avoid major or extensive abdominal surgery in the leukemic child. This report is of an unusual instance in which a formal laparotomy was avoided in a leukemic child with roentgen evidence of free air in the peritoneal cavity at a time when the findings on physical examination suggested spontaneous closure of the perforation and the absence of ongoing peritonitis. The patient, a 5-yr-old Oriental female with a 33-mo history of acute lymphocytic leukemia with treatment, was admitted to the UCLA-Harbor General Hospital with a 3-day complaint of abdominal pain, fever, and anorexia. The symptoms had appeared to diminish in severity 1 day prior to admission to the hospital. Intraabdominal testes had been removed in the first week of life because of male pseudohermaphrodit ism. Karotype analysis at birth and at the time of the onset of leukemia had revealed 46 chromosomes and an XY karotype. She had experienced six complete or partial relapses of her leukemic state and had been given one or more of the following chemotherapeutic agents: prednisone, methotrexate, vincristine, 6-mercaptopurine, cyclophosphamide, l-asparaginase, and cytosine arabinoside. Her antileukemia therapy for the sixth relapse had been started 4 wk prior to the onset of her abdominal symptoms and consisted of prednisone 10 mg three times daily and vincristine 1 mg i.v. once a week. On admission to the hospital, her white blood count was 6100 with 80% granulocytes, 18% lymphocytes, and 2% monocytes. A bone marrow aspiration

Rupture fo the intestine in patients with hernia.

Two cases of perforation of the small intestine associated with minor abdominal trauma and right inguinal hernia are presented along with a review of 104 cases in the literature, The condition is treacherous because this minimal injury can produce catastrophic intraabdominal perforation. The most reliable signs and symptoms are abdominal pain associated with guarding and rigidity. Laboratory data may only show leukocytosis and signs of dehydration. Early operation, using a formal laparotomy, is imperative. Systemic antibiotics are recommended.

Savings through the direct approach to jaundice

The clinical and fiscal hospital records of sixty consecutive patients who underwent minilaparotomy for jaundice were analyzed for end results and cost effectiveness. The procedure offers diagnostic combinations of open transhepatic cholangiography, liver biopsy, omentoportography, bile analysis, and portal manometry using local anesthesia in the x-ray special procedure room. Hospital charges were $95.00. The average savings that could have been achieved if the procedure had been carried out as soon as indicated was $984.00. Anatomic diagnosis was made in 97 per cent of the patients. Minilaparotomy obviated formal laparotomy under general anesthesia in 48 per cent of these patients. There were no increased costs due to morbidity and no deaths.

The evolution of an ideal surgical incision for pyloric stenosis.

EARLY in the surgical history of congenital pyloric stenosis, the operative approach was involved and often complicated. The infants who were brought to surgery were seriously depleted and many weeks past the age that the diagnosis is made today. Formal laparotomy was the standard procedure through a generous paramedian incision (Fig 1,<i>A</i>).¹Because of the debility of the tiny patient and the less sophisticated replacement therapy, wound dehiscence, evisceration, and death occurred all too frequently. To this distressing clinical problem, Robertson²brought a fresh look when he conceived the right-upper-quadrant, musclesplitting incision. This surgical incision was a counterpart in the upper abdomen of the McBurney incision in the right lower quadrant (Fig 1,<i>B</i>). Recognizing wound healing as a major cause of death in these desperately ill infants, Robertson demonstrated that if the lateral abdominal musculature were split in fiber direction, the external and internal oblique muscles