Laparoscopy as an adjunct to decision making in the ‘acute abdomen’

Abstract

When patients are admitted to hospital with acute abdominal pain, clinicians, irrespective of a specific diagnosis, intuitively select three diagnostic classes: operation definitely required (Group A); operation definitely not required (Group B); need for operation uncertain (Group C). The last is followed either by a precautionary laparotomy or a variable period of observation/investigation. We have studied prospectively the influence of laparoscopy on the distribution between these classes and particularly on outcome in group C. One hundred and twenty-five consecutive patients with abdominal pain severe enough for emergency admission have been classified by one of two admitting surgeons (SHO/registrar), who also expressed in group C a view on how they would proceed--operation or observation. Group C were then laparoscoped. The procedure confirmed a provisional view that laparotomy was needed in 11 of 15 patients. In the 'observation' sub-group the provisional decision was confirmed in 14 of 16 and early discharge followed in most. Six inappropriate decisions were thus avoided. Seven management decisions in group A and 4 in group B proved incorrect (11/94: 12 per cent). The majority were potentially recognizable by laparoscopy. Though relatively high rates of successful decision making are achieved with conventional clinical techniques, they can be further improved by laparoscopy. This procedure is particularly applicable in the management of patients with acute abdominal pain without a definite diagnosis, or when appendicitis is regarded as an established diagnosis.

Dilemma of Acute Appendicitis

“…Purulent fluid tracking down the right paracolic gutter may also suggest acute cholecystitis. If clinical diagnosis is equivocal despite investigations, it is best to begin with a low midline incision which could be extended if there is evidence of a perforated peptic ulcer [2,23].…”

“…Minor frequent episodes of right iliac fossa pain "the grumbling appendix" can be caused by thread worms in the appendix or by some conditions other than the appendix. Chronic pain with evidence of organic disease (weight loss, elevated ESR) is usually due to Crohn's disease at any age, caecal carcinoma in the elderly or lymphoma or tuberculosis in endemic areas [2,22,23]. Pain without signs or abnormal investigations is likely to be due to irritable bowel syndrome, but small bowel studies are still warranted if pain persists, to exclude more unusual causes [3].…”

Appendektomie 1997 – Offen oder geschlossen?

“…In mehreren Untersuchungen werden jedoch die diagnostischen Mö glichkeiten der Laparoskopie allgemein herausgestellt und als Vorteil bewertet. Dies bedarf an sich keiner weiteren Diskussion und deckt sich mit einer Fü lle von Literaturangaben [8,26,29,30,44,46].…”

Der unklare Unterbauchschmerz – Stellenwert der Laparoskopie „If in doubt, carry it out“

“…[2,4,6]. Die Wertigkeit der Laparoskopie in der Diagnostik des unklaren Unterbauchschmerzes ist inzwischen von verschiedenen Arbeitsgruppen untersucht worden [12,13,15,16,19,20]. Die diagnostische Genauigkeit wird zwischen 79 und 97 % angegeben [4,12,13].…”