Laparoscopy in Three Cases of Unusual Abdominal Emergencies: Report and Literature Review
Corresponding Author: Balram Goyal, Department of Gastrointestinal Surgery, Command Hospital (SC) Pune, Pune, Maharashtra, India, Phone: +91 9599386202, e-mail: firstname.lastname@example.org
How to cite this article: Goyal B, Jakhmola CK, Remanidevi SBN, et al. Laparoscopy in Three Cases of Unusual Abdominal Emergencies: Report and Literature Review. World J Lap Surg 2023;16(1):43–46.
Source of support: Nil
Conflict of interest: None
Patient consent statement: The author(s) have obtained written informed consent from the patients (for case 1, 2 and 3) for publication of the case report details and related images.
Received on: 27 May 2023; Accepted on: 26 July 2023; Published on: 05 September 2023
Common abdominal emergencies like acute appendicitis, acute pancreatitis, hollow viscus perforation, and diverticulitis are being managed with laparoscopy.
We here present three cases of unusual abdominal emergencies which were managed successfully by laparoscopy at a tertiary care center.
These cases are of anaphylactic shock due to hepatic hydatid cyst with free peritoneal rupture, upper GI bleeds due to early gastric volvulus in a patient with a posttraumatic left-sided diaphragmatic hernia and the last case was a patient of blunt abdominal trauma with splenic laceration with hypotension. The postoperative course was very satisfying and possibly laparotomy was avoided in all cases.
We reviewed the literature on the role of laparoscopy in acute abdominal conditions.
Keywords: Acute abdomen, Blunt and penetrating trauma, Laparoscopy in emergency, Ruptured hydatid, Splenic laceration.
With expanding surgical experience and skills application of laparoscopy in the emergency setting has proved its role.1 This approach allows both the evaluation in case of a diagnostic dilemma as well as the accomplishment of procedure in a wide variety of abdominal surgeries, such as acute appendicitis, blunt and penetrating trauma, perforated peptic ulcer disease, and a variety of conditions that seem set to expand further.2–4 Initially, laparoscopy was limited to elective surgery, however with accumulated surgical experience and skills over the past decades the application of laparoscopy into the emergency setting has stepped in. It also has a significant impact on the reduction of wound complications, postoperative pain, hospital stay and overall costs, and high patient satisfaction.5 Our aim is to present three cases of relatively uncommon abdominal emergencies managed with a laparoscopic approach with a positive outcome.
Case 1: Anaphylactic Shock
A 40-year-old male presented with sudden onset epigastric pain associated with profuse sweating, giddiness, and brief loss of consciousness of 3 hours duration. There was no history of fever, chills, and seizure.
On examination, he was drowsy his vital parameters were as pulse rate 110/minute, BP 84/58 mm Hg, RR 22/minute, and was afebrile. Systemic examination was essential within normal limits except for having urticarial rashes all over the body.
He was started on inotropic support, injection of hydrocortisone 100-mg stat, and intravenous (i.v.) fluids.
On further evaluation by contrast-enhanced computed tomography (CECT) abdomen was found to have a liver cystic lesion in segment IV/V of the liver with an impression of ruptured hydatid cyst (Fig. 1).
With this, he was referred to our center and was taken up for emergency diagnostic laparoscopy and found to have around 300 mL peritoneal clear fluid with ruptured hydatid cyst right lobe of the liver (segment IVB with 3 cm × 3 cm rent) (Fig. 2).
He underwent deroofing of the cyst and peritoneal lavage with normal saline and placement of two drains 28 Fr size. Cyst wall submitted to histopathological examination and which confirmed hydatid in nature. In postoperative period, he recovered well and was started on tab albendazole 400 mg twice a day for 6 months, and on follow-up at 3 and 6 months was asymptomatic.
Case 2: Hematemesis with Left Diaphragmatic Hernia
A 41-year-old male had a history of a road traffic accident 10 years back which was without any immediate clinical consequences as he remained asymptomatic till now. He now presented with acute onset pain epigastrium with three episodes of hematemesis of 1-day duration. He presented outside our hospital and was resuscitated with iv fluids and two units of packed red blood cells. His CECT chest and abdomen revealed features of a left diaphragmatic hernia with stomach herniating into chest – volvulus (Fig. 3).
He presented to our center and on arrival, his vitals parameters were within normal limits, on systemic examination he had reduced breath sounds on the left side, and the rest of the systemic examination was essentially normal.
We took him for emergency laparoscopy and intraoperative findings were a large left diaphragmatic hernia with stomach as content (Fig. 4A). Gastric viability was preserved and underwent reduction of content, mesh repair of defect with the placement of left side 28 Fr intercostal drainage (ICD) (Fig. 4B).
He recovered well, started orally on the second postoperative day, and was discharged on postoperative day 5.
Case 3: Blunt Abdominal Trauma with Splenic Laceration
A 24-year-old male presented with a history of blunt injury abdomen following a road traffic accident in the emergency department.
On examination, he was anxious, with hypotension (BP 90/60 mm Hg) and the pulse rate was 120 per minute. Resuscitation started as per standard protocol and bedside ultrasound revealed a large hemoperitoneum with a splenic laceration. His blood pressure (BP) was persistently low and was taken for emergency laparoscopy and intraoperative findings were splenic laceration (Fig. 5A) and hemoperitoneum (about 1-L blood) (Fig. 5B).
Bleeding was controlled laparoscopically, and peritoneal wash was given with normal saline. He recovered well and was discharged after 2 weeks of observation (Fig. 6).
He recovered well in postoperative period and was discharged from the hospital after 2 weeks.
Laparoscopic surgery has grown its age as more and more elective and emergency abdominal surgeries are being performed with the advantage of less postoperative pain, faster recovery, and early return to work. With increasing experience and skills horizon also expanded to unusual conditions apart from acute appendicitis, hollow viscus perforation, and obstruction.
Over the last three decades, a number of studies have reported its role in diagnosis with accuracy rates of between 86–100%,6–8 and with accumulated surgical experience and skills a large number of patients managed exclusively with a laparoscopic approach.9,10 Its role has come a big way in selected patients with penetrating abdominal trauma who are hemodynamically stable as in a large number of cases, there is no peritoneal breach, and the need for emergency laparotomy is safely negated on the basis of laparoscopic findings.11–13 In literature, most of the studies on the role of laparoscopy are for common emergencies such as acute appendicitis, hollow viscus perforation, and acute diverticulitis.
Our first case, who presented with anaphylactic shock, was subsequently diagnosed with a case of ruptured hepatic hydatid cyst was safely managed by emergency approach. In the second case, laparoscopy has helped to assess the viability of the gastric wall and subsequent reduction and repair of diaphragmatic rent. In the last patient of blunt abdominal trauma, splenic laceration was safely managed by avoiding the need for laparotomy and with splenic preservation.
To conclude with available expertise and skills a myriad of abdominal emergencies can be managed successfully with a laparoscopic approach with minimal postoperative morbidities and high patient satisfaction as the benefits of laparoscopy in the emergency setting are compatible with those of elective surgery (less requirement of pain killer, shorter hospital stay, less abdominal wall complications, and early return to work). Laparoscopy is only a means of surgical approach and should not alter the procedure itself. Conversion to open should not be considered a failure but a technical option whenever required. It is emphasized that role of a laparoscopic approach is only valid where experienced and sufficient expertise in minimal-access surgery available.
Balram Goyal https://orcid.org/0000-0001-7037-8445
2. Valla JS, Limonne B, Valla V, et al. Laparoscopic appendectomy in children: Report of 465 cases. Surg Laparosc Endosc 1991;1(3):166–172. PMID: 1669397.
4. Kirshtein B, Bayme M, Mayer T, et al. Laparoscopic treatment of gastroduodenal perforations: Comparison with conventional surgery. Surg Endosc 2005;19(11):1487–1490. DOI: 10.1007/s00464-004-2237-9.
6. Golash V, Willson PD. Early laparoscopy as a routine procedure in the management of acute abdominal pain: A review of 1,320 patients. Surg Endosc 2005;19(7):882–885. DOI: 10.1007/s00464-004-8866-1.
7. Reiertsen O, Rosseland AR, Hoivik B, et al. Laparoscopy in patients admitted for acute abdominal pain. Acta Chir Scand 1985;151(6):521–524. PMID: 2936052.
8. Majewski WD. Long-term outcome, adhesions, and quality of life after laparoscopic and open surgical therapies for acute abdomen: Follow-up of a prospective trial. Surg Endosc 2005;19(1):81–90. DOI: 10.1007/s00464-003-9333-0.
11. Guth AA, Pachter HL. Laparoscopy for penetrating thoracoabdominal trauma: Pitfalls and promises. JSLS 1998;2(2):123–127. PMID: 9876725.
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