Benefits and hazards of laparotomy for medical patients

Spleen laceration, a rare complication of laparoscopy

A 31-year-old woman had secondary infertility of 4 years' duration. Hysterosalpingography revealed bilateral distal tubal occlusion with bilateral hydrosalpinx-like appearance. At laparoscopy, both oviducts were occluded with marked hydropic change. Salpingoplasty was performed to correct bilateral hydrosalpinges and reform the fimbriated tubal ends. The procedure was performed uneventfully by an experienced surgeon in 45 minutes. Nine hours after the operation an emergency exploratory laparotomy was performed due to massive intraabdominal bleeding. The cause was a small tear, 3 cm long and 1 cm deep, with active bleeding in the inferior splenic tail. The laceration was repaired successfully with 1-0 chromic suture. The etiology of splenic laceration during laparoscopic surgery is uncertain. Many complications of laparoscopy are physiologic, and this one might have occurred while establishing pneumoperitoneum. Distortion and stretching of small vascular adhesions of the spleen with the abdominal wall also may have played a role. Gynecologists must be aware of the physiologic insult to patients during laparoscopy.

Laparoscopy in the management of patients with cancer of the gastric cardia and oesophagus

The role of laparoscopy in determining suitability for resection was prospectively evaluated in 244 patients with cancer of the gastric cardia and oesophagus. Laparoscopy enabled detection of inoperable disease in 92 patients (38 per cent), several of whom had more than one contraindication to surgery. Hepatic metastases (n = 75, 31 per cent), extensive peritoneal (n = 25, 10 per cent) or lymph node involvement (n = 5, 2 per cent) and direct invasion of the liver or colon (n = 5, 2 per cent) were considered contraindications to surgery. Laparoscopy was poorly tolerated in a further 11 (5 per cent) patients, who were not considered suitable for resection. Extra-abdominal metastatic disease was detected in 17 patients who appeared normal at laparoscopy, and a further six patients refused surgery. The remaining 118 patients underwent laparotomy with a view to resection which was successful in 85 (72 per cent). Laparoscopy thus prevented ill-advised laparotomy in 103 patients (42 per cent), either because of extensive intra-abdominal disease or poor tolerance to anaesthesia. Laparoscopy may be a valuable investigation when used to assess the feasibility of resection.

Laparoscopy or scanning in oesophageal and gastric carcinoma?

A prospective study was undertaken of the accuracy in diagnosing intra-abdominal metastatic disease of the liver by scintigraphy, ultrasound scanning and laparoscopy. The effect of laparoscopy on management was also studied. Fifty patients were studied: 23 oesophageal carcinoma, 14 gastric carcinoma and 13 with suspected intra-abdominal metastatic spread. Accuracy was determined by laparoscopic biopsy, laparotomy and autopsy. The accuracy was 72 per cent for scintigraphy, 75 per cent for ultrasound and 96 per cent for laparoscopy (with 10 per cent failed ultrasound due to intra-abdominal gas). There was no morbidity or mortality associated with laparoscopy, with one failure due to adhesions. Thirteen patients without hepatic metastases had nodal and/or peritoneal spread diagnosed only by laparoscopy. Laparotomy was avoided in 58 per cent, and 74 per cent died in the 18 month follow-up period. Laparoscopy can obviate the need for laparotomy in inoperable cases of oesophageal carcinoma and allow better planning for potentially curable surgery. In gastric carcinoma the value of laparoscopy is doubtful as a high percentage require at least palliative surgery.

Complications of diagnostic laparoscopy in Dallas: a 7-year prospective study

The complication rate for diagnostic laparoscopy reported in the literature is very low (1.07%, 0.3%, and 0.03% for minor and major complications, and deaths, respectively). A prospective study of the complications of diagnostic laparoscopy by 17 gastroenterologists in the Dallas-Fort Worth metropolitan area is reported. In 603 laparoscopies performed during a 7-year period, there were 31 (5.1%) minor complications and 14 (2.3%) major complications requiring surgery or transfusion. These rates are five- and sevenfold higher (p less than 0.01) than are reported in retrospective series in the literature. There were three (0.49%) deaths in this series. It is concluded that retrospective studies have underestimated the complication rate of laparoscopy. However, despite the higher complication rate found in this prospective study, laparoscopy appears to be as safe or safer than other methods of establishing a tissue diagnosis under direct vision in intraabdominal diseases.

Laparoscopy in general surgery

The results of diagnostic laparoscopy under general anaesthetic in 81 general surgical patients have been reviewed. A tissue diagnosis was achieved in 25 of 42 patients (60 per cent) suspected to have widespread intra-abdominal malignancy with minimal preoperative investigation. Extensive investigation, excluding only computerized tomography, failed to achieve a diagnosis in 25 patients with an intra-abdominal mass. Subsequent laparoscopy allowed diagnosis of 22 of these patients (92 per cent). Severe persistent and unexplained abdominal pain in 14 patients was diagnosed at laparoscopy in only one patient (7 per cent) and the procedure did not influence the subsequent course of events in the remainder. There was no mortality and the morbidity (4.9 per cent) compares well with that of laparotomy in similar patients. Laparoscopy failed in 5 patients (6.2 per cent) due to the presence of dense intraperitoneal adhesions.

Fever of unknown origin: the value of abdominal exploration

The decision to perform exploratory laparatomy in search of the cause of prolonged fever should not be made hastily. The operation is not benign, and before the patient is subjected to it, a meticulous medical evaluation should be made. A number of recently developed diagnostic techniques are invaluable aids to the physician challenged by this diagnostic dilemma.

Abdominal exploration as a diagnostic procedure

Diagnostic laparotomies performed during a five and a half year period in a 400-bed hospital were reviewed. Positive findings on physical examination, laboratory results, or x-ray findings were given one point each, making possible a range of points extending from zero to three for each patient. The number of positive laparotomies (those truly diagnostic) increased in a "linear" fashion with the point rating of each patient. No patients with a zero score had a laparotomy that was diagnostic, whereas 97 per cent of those with a score of three had positive laparotomy.