Need For Laparotomy Research Articles

Laparoendoscopic Surgical Management of the Abdominal/Transinguinal Undescended Testicle

We report a laparoendoscopic surgical technique to perform a single-stage orchiopexy in a 10-year-old patient with a high intra-abdominal undescended testicle. This approach indicates the technical feasibility of laparoendoscopic orchiopexy and prevents the need for laparotomy. The results are compared with a laparoendoscopic approach in the staged Fowler-Stephens orchiopexy.

Applications of Laser Surgery in Gynecology: Hype or High Tech?

Despite the proliferation of the use of lasers in gynecology, physicians in both private practice and the academic setting remain skeptical about the role of these instruments. The laser has not made it possible to perform surgical procedures that have previously been impossible to carry out in the operating theater. Further, as yet, higher pregnancy rates have not been achieved with any reconstructive procedure using the laser rather than conventional or electrocautery surgery. On the other hand, surgeons such as Daniell reported on the impact of laser in decreasing the need for laparotomy in their practices. For instance, prior to the introduction of the laser, Daniell performed laparotomy on 80% of his patients with endometriosis, pelvic adhesive disease, or tubal disease, whereas currently he performs 80% of these procedures through the laparoscope. However, one could argue that this change simply represents the trend of performing more gynecologic procedures through endoscopes whether a laser is involved or not. Convincing evidence exists that pelviscopy results in savings in terms of morbidity and the cost of surgery. Whether endoscopic surgery can be performed more safely using the laser than with a traditional technique has not been addressed in a formal study. Whether laser surgery produces better pregnancy rates is unresolved. Ninety per cent of all clinical trials involving the laser have been uncontrolled. Those studies that have been controlled, reported by Tulandi, for example, have shown results at least equivalent to those achieved with diathermy, and it is of interest that the pregnancies tended to occur sooner in the laser-treated groups. The laser is at least as effective as electrocautery in the treatment of adhesions and distal tubal disease. Therefore, it is the author's recommendation that all types of lasers be used in conjunction with electrocautery and conventional sharp dissection in the treatment of various forms of pelvic pathology. It is important that surgeons become familiar with all types of lasers, as future devices may be vastly different and prove to be clearly superior in treating the various pelvic pathologies.

Pig‐bel but no pig: enteritis necroticans acquired in Australia

To report a case of enteritis necroticans acquired in Australia, and to review the history, epidemiology, pathogenesis, clinical features, management and prevention of this disease. A 44-year-old diabetic and alcoholic restaurateur of Chinese-Malay origin, who had been living in Australia for over 20 years, was admitted to hospital with bloody diarrhoea which progressed to fulminant toxaemia and circulatory collapse, and ultimately required laparotomy. Typical pathological features and the isolation of Clostridium perfringens type C from faeces confirmed the diagnosis of enteritis necroticans. He was treated initially with ampicillin, gentamicin, metronidazole and chloramphenicol, and later with penicillin and metronidazole, and he required large volumes of intravenously administered fluid and blood for his toxaemic, hypotensive state. Laparotomy was performed as a life-saving procedure. Despite a lengthy convalescence, the patient recovered. Enteritis necroticans is a rare disease in developed countries, however it is likely to be underdiagnosed. Clinicians are encouraged to be on the alert for signs of severity that may indicate the need for laparotomy in a predisposed individual with features of this condition.

Blunt trauma in children: significance of peritoneal fluid.

Seven hundred ninety consecutively seen children who had not undergone peritoneal lavage underwent imaging with computed tomography (CT) after blunt trauma. Collections of peritoneal fluid were prospectively characterized as small (51 children), moderate (32 children), or large (40 children). Associated injuries included hepatic or splenic injury in 74%, isolated renal or pancreatic injury in 5%, isolated pelvic fracture in 5%, isolated hollow viscus injury in 5%, and a combination of the above in 7%. Peritoneal fluid was the only CT abnormality in three children. A significant correlation was found between presence and increasing size of peritoneal fluid collections and clinical signs of hemodynamic instability such as lower trauma score (P = .0008 by analysis of variance), the presence of arterial hypotension (P = .0001 by chi 2 test), and hematocrit less than 30% (0.30) (P = .0001 by chi 2 test). Additionally, the presence and amount of peritoneal fluid correlated with need for laparotomy and with mortality (P = .0001 by chi 2 test for both).

Percutaneous Endoscopic Stomas

Percutaneous endoscopic gastrostomy was introduced in 1980 as a method for the creation of a feeding gastrostomy without the need for laparotomy or general anesthesia. The technique originally described, the pull method, involves puncturing the apposed gastric and abdominal walls under endoscopic control. A suture is then passed from the exterior into the gastric lumen and grasped with a snare. The suture is pulled out of the mouth, affixed to the end of a gastrostomy tube, and then pulled back down into the stomach. The gastrostomy tube is thus pulled into the stomach, and its end exits the abdominal wall. Modifications of this technique have included pushing the gastrostomy tube over a guidewire (the push method) and direct puncture of the stomach under endoscopic control with an introducer and outer peel-away sheath. All of these methods have been used with good results. Complications have included infection of the abdominal wall and intraperitoneal leakage. These may be minimized by attention to detail. The indications for the method have been expanded to include gastric decompression, administration of unpalatable medications in children, and creation of a conduit for bile replacement. Careful judgment in patient selection is crucial if good results are to obtained. This technique also introduces the concept of percutaneous endoscopic fixation of a loop of bowel to the abdominal wall. This concept may be employed in other areas of the gastrointestinal tract.

Laparoscopic Removal of Translocated Intrauterine Contraceptive Devices

Data is presented regarding 20 translocated intrauterine contraceptive devices (IUCD). Successful laparoscopic removal was made in 13 (65%) cases though all these devices were Copper 'T' 200 model which tend to produce dense adhesions. Only when the IUCD was suspected to be partially or fully in the gut lumen or thick adhesions were present, or the device was not visualised, was laparotomy performed. Hence it is advocated that laparoscopy should be performed as a routine in patients with suspected translocated IUCD, as it obviates the need for laparotomy and thus decreases the duration of the hospital stay as well as preventing morbidity associated with laparotomy.

Standardised management of PID in a developing country.

During a 15 month period, 464 patients admitted to hospital with pelvic inflammatory disease (PID) were classified according to Monif's staging and treated following strict guidelines. Stage II, PID with peritoneal reaction, was treated with intravenous antibiotics. Stage III, PID with tubo-ovarian mass, was drained by posterior colpotomy when indicated or treated with triple antibiotics when high abdominal masses were present. Stage IV, ruptured tubo-ovarian abscess, was always surgically treated. Mortality was almost limited to patients with stage IV PID, 15% (3/20) of whom died. Morbidity included the need for laparotomy (in 1.6% (6/368) of stage II, 59.3% (45/76) of stage III, and 100% of 20 stage IV patients) and draining pus (in 6.6% (5/76) of stage III cases and 50% (10/20) of stage IV patients). This study also shows that unspecialised hospital staff are able to use Monif's staging correctly, and that acceptable results can be obtained with the limited resources that are available in most developing countries.

Diagnostic laparoscopy

This report examines the value of laparoscopy as a diagnostic aid to one general surgeon. Seventy-seven consecutive patients who underwent this procedure are reported. In 31 patients, laparoscopy was performed for assessment of the cause of acute abdominal pain. Diagnosis was achieved in 28 patients (90 percent) and laparotomy was avoided in 17 (55 percent). Assessment of chronic abdominal pain in 11 patients yielded a diagnostic accuracy in 9 (82 percent) and laparotomy was avoided in 7 (64 percent). In 11 patients with abdominal trauma, diagnostic accuracy was 91 percent (10 of 11 patients) and laparotomy was not required in 6 (54 percent). In 21 patients with intraabdominal malignancy, 14 (67 percent) were accurately assessed, and in 8 (38 percent) formal exploration was spared. Three patients with obscure causes of ascites and jaundice were all accurately assessed without need for laparotomy. Based on our data, we believe the reports in the literature are reproducible by any abdominal surgeon who uses laparoscopy as a diagnostic aid in their practice.

The selective management of penetrating wounds of the back.

Fifty patients with penetrating wounds of the back were prospectively evaluated and managed selectively on the basis of physical examination. Despite the theoretic problems of evaluating the retroperitoneum, physical examination was found to be a reliable method of determining the need for laparotomy. Every patient who had a significant injury had evidence for this on initial physical examination and no patient judged to have a normal examination required laparotomy. The negative laparotomy rate was 4% and no patients died as a result of delayed surgical intervention. Careful physical examination and surgical judgment allow for safe management of penetrating back wounds.

Selective Conservatism in Abdominal Stab Wounds

An analysis of 186 consecutive patients with anterior abdominal stab wounds in a 2-year period was carried out to assess the efficacy of serial physical examination as the determining factor for the need for laparotomy. Of 106 patients managed by clinical evaluation, the incidence of negative laparotomy was 0.9% and three patients (2.7%) had an "unnecessary" celiotomy. There were no missed injuries or delayed detection of intraperitoneal visceral trauma. The incidence of negative laparotomy among patients subjected to wound exploration +/- peritoneal lavage (n = 41) was 2.4%, and 39 patients had mandatory laparotomy for evisceration, with a negative celiotomy rate of 20.5%. Our experience supports serial physical examination as a highly effective method of "selective conservatism" of anterior abdominal stab wounds. Mandatory laparotomy for evisceration needs further clarification.

The role of computed tomography in blunt abdominal trauma in children.

This study was performed in order to test the hypothesis that abdominal computed tomography (CT) can assist in the decision to perform laparotomy in children following blunt trauma to the abdomen. Three hundred forty children with blunt abdominal trauma underwent evaluation with CT. Abdominal injuries were detected in 84 children (25%). These included: 75 injuries to solid viscera in 60 patients (30 splenic, 29 hepatic, 13 renal, and three pancreatic); four injuries to hollow viscera (three small bowel transections, and one rupture of the urinary bladder); and 23 skeletal injuries (21 fractures of the pelvis, and two lumbar spine subluxations). Injury to solid viscera was categorized as minor in 32 (43%), moderate in 18 (24%), or severe in 25 (33%) according to an assessment of the percentage of parenchyma involved. Hemoperitoneum was detected in 42 patients, and characterized as small in 18 (43%), moderate in nine (21%), and large in 15 (36%). CT was useful in establishing the location and extent of injuries, and in detecting the presence of blood or air in the peritoneal cavity. However, the extent of injury to solid viscera detected on CT did not correlate with the need for laparotomy. Of 46 moderate to severe anatomic injuries of the liver, spleen or kidney, only five (9%) required surgical intervention because of persistent bleeding or infection. Although laparotomy occurred more frequently in the presence of a large hemoperitoneum, only 6/24 (25%) with moderate to large hemoperitoneum required surgical exploration. This analysis confirms the usefulness of CT for detection of location and extent of injury in pediatric blunt abdominal trauma.(ABSTRACT TRUNCATED AT 250 WORDS)

Nonsurgical management of unruptured ectopic pregnancy: an extended clinical trial

Unruptured tubal pregnancies diagnosed at laparoscopy were treated with either methotrexate/citrovorum factor (MTX/CF) (n = 21) or observation (n = 5). Entry criteria required that the ectopic pregnancy be visualized, less than or equal to 3 cm in diameter, with intact serosa and no active bleeding. Treatment selection was based upon preoperative levels of beta-human chorionic gonadotropin (beta-hCG), with MTX/CF given to subjects exhibiting a plateaued or rising pattern and observation alone given to those with falling levels. Twenty-five of 26 ectopic pregnancies resolved without need of laparotomy. Two subjects received blood transfusions and one required a second operation for intra-abdominal bleeding. In both cases, fetal cardiac activity was noted pretreatment on ultrasound. The authors conclude the following: (1) MTX/CF may be safely used to treat selected unruptured ectopic pregnancy; (2) many ectopic pregnancies resolve spontaneously; and (3) ectopic pregnancies that form fetal elements, as evidenced on ultrasound, should not be managed medically.

Colonoscopy in children

The flexible 65 cm endoscope, while introduced for use in the diagnosis of colonic disease in adults, has proven valuable for diagnosis and treatment in children. The diameter of the American Cystoscope Company's instrument makes it ideal for children. The spectrum of colonic disease in children parallels that in adults. Although carcinoma is rare, polypoid disease, colitis, enterocolitis and lymphoid hyperplasia are sufficiently common to warrant consideration of colonoscopy. The present study, while small, suggests the usefulness of this procedure. With the use of the easily maneuvered, short instrument, a surgeon experienced in colonoscopy can reduce the need for laparotomy in many children.

Surgical Management of Unruptured Ectopic Pregnancy

There is an increasing frequency of early diagnosis of unruptured tubal ectopic pregnancy. This is due primarily to better diagnostic testing, such as the use of ultrasound and radioimmunoassay for the beta-subunit of human chorionic gonadotropin. The more stable conditions of the patients at the time of surgery caused us to reconsider the need for laparotomy in these cases. Therefore, an attempt was made to definitively treat 18 patients with ectopic pregnancy utilizing laparoscopic techniques. Eighteen patients had signs, symptoms, and diagnostic test results suggestive of unruptured ectopic pregnancy. Laparoscopy was employed to confirm the diagnosis. If the tubal swelling was less than 3 cm in diameter, a linear salpingostomy was carried out on the antimesenteric side of the fallopian tube, utilizing a cutting current. The contents were expressed and removed through a second puncture site. Vigorous lavage was used to cleanse the abdomen, and bleeding was controlled with electrocautery. All tubes which were operated upon were patent at the time of postoperative hysterosalpingography. Fifty per cent of those patients actively trying to conceive have achieved pregnancy. There were not repeat ectopic pregnancies or abortions. There were no immediate or long-term postoperative complications. This method represents an alternative to the treatment of unruptured tubal ectopic pregnancies in early gestation.

The evolution of abdominal stab wound management.

The results of the selective management of 300 abdominal stab wound victims have been reviewed for a 5-year period. Initially the need for laparotomy was evaluated by sinography, later physical examination, and most recently by local wound exploration combined with peritoneal lavage. The use of sinography resulted in an unnecessary laparotomy rate of 38%. Exploration based upon physical findings eventuated in 36% unnecessary laparotomies, of which 79% were negative, 17% morbidity, and no mortality. Local wound exploration followed by peritoneal lavage when peritoneal violation was suspected resulted in 8% unnecessary laparotomies of which half were negative, 9% morbidity, and no mortality. Based on this experience we have adopted the following approach to abdominal stab wounds. Patients with unexplained blood loss or overt signs of visceral injury undergo prompt exploration. In all other cass with intact peritoneum are discharged from the Emergency Department. If peritoneal violation is evident peri toneal lavage is performed. If the lavage is positive laparotomy is undertaken, and if negative the patient is hospitalized for an additional 24 hours of observation.

Polycystic liver and other hepatic masses mimicking gall-bladder disease

Hepatic and biliary tract diseases can both present as pain or mass in the right upper quadrant of the abdomen. Occasionally, hepatic masses impress the gall-bladder, simulating gall-bladder disease both symptomatically and radiographically. Ultrasonography and computed tomography (CT) imaging have facilitated the preoperative differentiation between hepatic and biliary tract disease and, further, between cysts (polycystic liver disease) and solid tumours. We wish to report a patient with hepatic masses and review similar reports to illustrate that when filling defects are noted in the gallbladder on the cholecystogram, hepatic disease can then be differentiated from biliary tract disease without the need for laparotomy. A 45-year-old hypertensive woman was admitted to our hospital because of a six-month history of an enlarging abdominal mass and a sensation of pressure and fullness. She had no associated pain, jaundice, nausea, vomiting, or change in bowel habits.

Fine-needle Aspiration Biopsy in Ampullary and Pancreatic Carcinoma

Cytological verification of the angiographic, sonographic, and/or intraoperative diagnosis of pancreatic or ampullary carcinoma may be achieved by fine-needle aspiration biopsy (FNAB). Fifteen biopsies were done in 13 patients, 12 of whom were thought to have pancreatic carcinoma clinically. The FNAB specimen confirmed this in 11 of them. Also, one equivocal (suspicious), two false-negative, and no false-positive results were recorded. Complications were not seen. In addition, four patients with ampullary carcinoma had pancreatoduodenectomy on the basis of FNAB specimens. Since this method is more accurate and is safer and simpler than the traditional wedge or core biopsy of suspected pancreatic or ampullary tumors, and since it may eliminate the need for laparotomy in selected cases, we consider it the preferred method for immediate diagnosis of these neoplasms.

Results of endoscopic papillotomy: a collective experience from nine endoscopic centers in West Germany.

AbstractThis is a report of 1,403 patients who underwent endoscopic papillotomy (EPT) in 9 endoscopic centers in West Germany from 1973 up to April 1, 1977. The main indication for EPT was stones in the bile ducts causing obstructive jaundice. In 79.5% of the patients, a previous surgical operation on the bile ducts had been done, and in 20.5%, the gallbladder was still present. Other indications for EPT were benign and malignant stenosis of the duodenal papilla, and cholangitis in the blind sack syndrome associated with an existing choledochoduodenostomy. The complication rate of EPT was 7.3%. The main complications were pancreatitis, cholangitis, hemorrhage, and perforation. Incarceration of stones or instruments was rare. Most complications could be treated conservatively. The mortality rate at 1.5% was low, and less than that of transduodenal papillotomy. Late complications that occur after transduodenal papillotomy were not found and should not occur after EPT. EPT eliminates the need for laparotomy and represents an alternative for the aged patient in poor general condition.

Diagnostic tests and Hodgkin's disease: a standardized approach to their evaluation.

We have analyzed a series of 124 young men with Hodgkin's Disease in an attempt to clarify the role of non-invasive tests in the staging evaluation. Data are presented in a way which permits comparison between series and application of the data to decision-making models. Analysis of the data shows our patients to have had primarily limited (stage I and II) disease. In our hands certain tests were quite accurate in predicting the absence of abdominal disease (lymphangiography, hepatic scintigraphy) as determined by laparotomy, but no study appeared to eliminate the need for laparotomy in this group. Data from several other large series are also presented in the same format. The data demonstrate a large variability between institutions in the predictive value of a positive lymphangiogram. Other studies, such as splenic scintigrams, appear to have more consistent predictive values. We encourage further use of this type of data presentation.

Traumatic lesions of the duodenum

Injuries of the duodenum are relatively uncommon on account of the organ's size and position. Since most of it is retroperitoneal, lesions involving it give rise to such subtle physical and radiological signs that the diagnosis is often overlooked in the early phase after injury. Twenty-six cases of duodenal injury are reviewed, 18 of which were due to penetrating wounds and the remaining 8 to blunt trauma. Anterior penetrating wounds were usually associated with other intraperitoneal lesions which caused more obvious physical signs and thus drew attention to the necessity for exploration. On the other hand, both blunt trauma and posterior stab wounds frequently caused isolated retroperitoneal duodenal lesions where the diagnosis was not evident on admission, but in which the insidious and progressive development of symptoms and signs drew attention to the need for laparotomy. Early repair combined with drainage of the retroperitoneal space resulted in a good result in 23 of 26 cases, 4 of whom, however, developed a temporary lateral duodenal fistula. Two of the 3 deaths were in patients who presented late and had associated pancreatic injuries while the third was due to an abdominal vascular injury.