Medical Journal Of BabylonVol 10 No 1 2013 مجلة

medical journal of babylon-vol. 10- no. 1 -2013 مجلة بابل الطبية- المجلد العاشر- العدد الاول- 2013 our laparoscopic experience in managemen

Medical Journal of Babylon-Vol. 10- No. 1 -2013 مجلة بابل الطبية-
المجلد العاشر- العدد الاول- 2013
Our Laparoscopic Experience in Management of Chronic Abdominal Pain: A
Cross-sectional Study
Mahmoud M. Al-Mukhtar
Surgery Dept., Collegeof Medicine, University of Babylon, Hilla,
Babylon, Iraq.
Email :[email protected]
Curved Up Ribbon 2
Abstract
Background:Laparoscopic and endoscopic surgery are currently worldwide
surgical procedures. Laparoscopic surgery in particularis a minimal
invasive surgery. The rapid evolution of laparoscopic surgical
subspeciality have introduced it into a wide range of clinical
applications regarding diagnosis and/or therapy of remarkable spectrum
of diseases. Laparoscopy, in optimal circumstances , enables excellent
visualization of the abdominal cavity. Accordingly, it has been
practiced in this study to assess and/or treat cases of chronic
abdominal pain.
Objectives :This study tries to evaluate the significance of adopting
laparoscopy in the management of patients with chronic abdominal pain
in Al-Hilla General Teaching Hospital.
Methods :This is a cross-sectional case series study that had assessed
(49) patients of an average age of (35)years complaining of chronic
abdominal pain for the period 01/09/2008-01/09/2011. Postoperative
follow-up was conducted for (12) months. All cases of known
intra-abdominal malignancies were excluded from this study. All data
were collected using a formed questionnaire by the worker and
information were filled by the worker single handly.
Results :Thirty-four patients ( 69 %) of the study group had previous
abdominal or pelvic surgery. Thirty-five patients (71 %) showed
intra-abdominal adhesions. Thirty-one patients (63 %) had underwent
laparoscopic adhesiolysis while the remaining four cases had their
adhesions kept undisturbed as they were considered to be
insignificant. Three patients (6.1%) exhibited mesenteric
lymphadenopathy which was discovered to be secondary to chronic upper
respiratory tract infections. Two cases (4%) of unilaterl left-sided
inguinal hernias were disclosed. One case (2%) of abnormally looking
appendix was detected and managed by laparoscopic appendectomy. Eight
Patients (16.3 %) showed complete normality on laparoscopy.
Conclusion :With standard laparoscopic equipements , techniques and
postoperative care laparoscopy is a safe, useful and more informative
invasive investigation to evaluate and/or resolve the problem of
chronic abdominal pain.
Keywords :Laparoscopy ,Chronic Abdominal pain , Babylon
تجربتنا مع التنظير البطني في تدبير حالات الألم البطني المزمن دراسة
مقطعية
الخلاصة
خلفية البحث: أن الجراحة بأستخدام النواظير الداخلية ومن ضمنها ناظور
الجوف البطني يعتبر من الممارسات الجراحية الحديثة و المعاصرة و قد سبب
التقدم السريع في تقنياتها الى جعلها تخصص جراحي بحد ذاته ومنتشراعالميا
و تم أدخاله الى العديد من التطبيقات السريرية لغرض تشخيص و/ أو علاج طيف
كبير من الامراض . يعتبر تنظير الجوف البطني عند أجرائه حسب الضوابط
القياسية أجراءا سليما و مفيدا. ومن هذا المنظور أستخدمنا تقنية التنظير
البطني لدراسة و تقييم بعض من حالات الألم البطني المزمن.
الأهداف: تهدف هذه الدراسة الى تقييم المنفعة من أستخدام و تبني أجراء
تنظير الجوف البطني في تدبير و معالجة حالات المرضى الذين يشكون من الألم
البطني المزمن .
الطريقة :هذه دراسة مقطعية لسلسلة من حالات الألم البطني المزمن حيث تمت
دراسة و تقييم (49) مريض و بمعدل عمري (35) سنة على مدى ثلاث سنوات . تمت
متابعة هؤلاء المرضى لمدة (12) شهرا بعد أجراء فحص تنظير الجوف البطني.
تـم أستثناء كل الحالات المشخصة مسبقا كحالة سرطان البطن من هذه الدراسة
.
النتائج :بينت هذه الدراسة أن (34) مريض (69%) في هذه المجموعة لديهم
تأريخ مرضي سابق لجراحة فتح البطن أو الحوض . تبين وجود التصاقات صفاقية
في (35) مريض (71%) و تم أجراء فتح الألتصاقات في (31) مريض (63%) منهم
فيما لم يجرى اي تداخل في الاربعة الباقيين . كما وجدنا (3) مرضى (6.1%)
يعانون من التهاب العقد اللمفاوية المساريقية الذي تبين فيما بعد أنه كان
نتيجة لألتهابات المجاري التنفسية العلياالمستتر وتم أكتشاف حالتين لوجود
فتق مغبني أيسر (4%) . وجدنا حالة واحدة لمريض يعاني من وجود زائدة دودية
غير طبيعية (2%) . كان فحص التظير البطني طبيعيا في (8) مرضى (16.3%) .
الأستنتاج :في حالة توفر الأدوات و التقنيات القياسية لأجراء عملية تنظير
الجوف البطني مع توفر عناية قياسية لما بعد العملية فأن التنظير البطني
يعتبر فحصا أمينا و مفيدا في تشخيص و علاج حالات الألم البطني المزمن.
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Introduction
It is well known that the clinical complaint of chronic abdominal pain
is a troublesome dilemma confronting both the medical and surgical
care professionals[1]. These patients presenting with chronic
abdominal pain of unsettled aetiology commonly have been suffering for
long periods which may rank to years in some cases [1 -2]. Also they
have been examined by many experts and have been submitted to a lot of
diagnostic investigations but, regretfully , no precise aetiology of
their problem could be elicited. At current surgical practice with the
rapid introduction and developments in laparoscopic technology,
laparoscopy can provide a remarkable and extensive view of the
abdominal cavity. Thus, laparoscopy can be expected to be a useful
tool to obtain a better and superior information than that obtained
using non-invasive investigations. This study tries to evaluate the
role of diagnostic and therapeutic laparoscopic abilities in the
management of patients with chronic abdominal pain.
Patients and Methods
We reviewed in this study (49) patients with chronic abdominal pain of
undiagnosed aetiology for the period 01/09/2009–01/09/2011 whom have
been submitted to diagnostic laparoscopy. The patients group constited
of (38) females and (11) males with an average age of(35) years (17-76
years). General anaesthesia and standard postoperative care have been
adopted. All cases of diagnosed intra-abdominal malignancies have been
excluded from the study. Abdominal pain persisting for more than (4)
months have been considered to be a chronic one [2]. The average
duration of chronic abdominal pain in our study was (4) years (4-13
years). We investigated the patients subjective experience of their
abdominal pain in two stages :prelaparoscopical and postlaparoscopical
intervention. The laparoscopy have been performed according to
conventional standard techniques and instruments. In those patients
with history of previous laparotomy for abdominal or pelvic surgery in
whom abdominal adhesions were expected there have been some
modification in the creation of pneumoperitoneum .This modification
consisted of inserting the Veres needle in a scarless area of the
abdominal wall. This was commonly in the left subcostal region in an
attempt to creat a safe pneumoperitoneum ( Plummer's procedure). After
creation of a satisfactory pneumoperitoneuma (10) mm trocar was
introduced to be the telescopic port. This gave us an initial general
view of the peritoneal cavity and the presence and sites of any
intra-abdominal adhesions. After good assessment of the
intra-abdominal adhesions the sites of other presumed ports sites have
been determined accordingly. Obtaining a good view of the peritoneal
cavity was so essential to examine and record any suspected
abnormalities. Any intra-abdominal adhesions were considered to be
non-pathological /insignificant if they have been assessed to have no
preventive/restrictive effect on movements of organs and/or its
distension [3-4]. Adhesiolysis have been perfomed using scissors or
laparoscopic hook cautery in coagulation and/or cutting mode. All
adhesions have been delt with as close as possible to the abdominal
wall.
Results
According to this study the most common findings were intra-abdominal
adhesions. It have been detected in (35) patients (71 %) out of the
whole group. Adhesiolysis was performed for (31) patients out of these
(35) patients while the remaining (4) patients have been offered no
any interference and adhesions were kept undisturbed as they had been
judged to be insignificant. Mesenteric lymphadenopathy have been
discovered in (3) patients which had been shown latter to be secondary
to a latent chronic upper respiratory tract infections. Two patients
got a unilateral inguinal hernia : both on the left side although they
were not evident on clinical examination. In one patient the appendix
showed features of abnormal looking and have been considered to be a
case of appendicitis for which laparoscopical appendectomy was
performed. Of the whole (49) patients (8) patients (16.3 %) showed no
any abnormality on laparoscopy. These eight patients together with the
(4) patients considered to have insignificant intra-abdominal
adhesions constituted a group of (12) patients which have been
designated as the diagnostic laparoscopy group.
Table (1) demonstrates laparoscopic findingsin this study. In cases of
diagnostic laparoscopy the average operating time was (33)minutes
(25-48min) while the average operating time was (49) minutes
(32-83min) for the cases of therapeutic laparoscopy in which
adhesiolysis was performed. The average inpatient hospital stay was
(3) days (1-6 days).
Aveagetime required to regain home and/or work activity was (6)days
(3-10 days). The postoperative outcome was assessed after a (12)months
follow-upperoidusing a standard questionnaire with the data being
filled by the worker. All patients in this study did an uneventual
postoperative course. We could keep contact with only (47) patients
(95.9 %) out of the whole group for follow-up. Of the (31) patients
who underwentlaparoscopicaladhesiolysis only (29) could be contacted
for follow-up and assessment. Of these (29) patients only (25)patients
had reported complete resolution of their complaint or at least
experienced a remarkable relieve. The remainingfour patients had
reported no detectable change or improvement of their problem
postlaparoscopicaladhes-iolysis. The two patients with left sided
inguinal hernias have been managed with laparoscopic hernioplasty and
both of them had reported complete resolution of their abdominal pain.
Regarding the one patient with abnormally looking appendix, on
follow-up he reported that his pain had been disappeared completely
postlaparoscopic appendectomy.
Regarding the diagnostic laparoscopy group which consisted of (12)
patients , only (10) patients of them could be contacted for
follow-up. Out of these (10) patients four patients reported no
improvement postlaparoscopy while (6)patients reported considerable
relieve of their complaints after they had been informed of being
completely normal : this may ruminate the suggestion that their
abdominal pain may be of a psychogenic origin.
This study revealed that an overall (34) patients out of (49) patients
of patients complaining of chronic abdominal pain (=69.3%) had
reported resolution or improvement of their complaints following
laparoscopical examination with or without therapeutic intervention.
Discussion
It is easy to recognize that patients with chronic abdominal pain
constitute a category which may be problematic to medical/surgical
care professionals. Reviewing the literature showed that only a few
reports had indicated the significance of diagnostic laparoscopy in
the management of chronic abdominal pain complaint. Nevertheless,
these reports do suggest that diagnostic laparoscopy should be
implicated in the management of patients with chronic abdominal pain
especially if they have had underwent previous abdominal and/or pelvic
surgery or pelvic inflammatory disease in their medical history [5-6].
Experimental laparoscopic surgery on animals proved that this type of
surgery is uncommonly associated with postoperative adhesion formation
[7-8]. From the point of view of clinical surgery, Nezhat et al. had
reported that laparoscopic adhesiolysiswas so effective in reduction
of peritoneal adhesions and was associated with a low recurrence rate
of postoperative adhesions [9]. Smith et al. in their study showed
that all patients with chronic abdominal pain of undiagnosed aetiology
had intra-abdominal adhesion as the only abnormal finding during
diagnostic laparoscopy and that laparoscopic adhesiolysis was so
beneficial in (82%) of their patient group after a period of (10)
months follow-up [10]. Dellinger et al. also reported a good or
beneficial postoperative outcome in (80%)of their patients group
following laparoscopic adhesiolysis [11]. It can be well realized from
gyneacological point of view that formation of adhesions is a well
known aetiology of infertility and chronic pelvic pain. Williams el
al. reported that a constant pelvic pain in the same location for a
minimum of (6) months is usually associated with organic disease most
oftenly pelvic adhesions or pelvic endometriosis. Their study also
incriminated adhesions, particularly those that can limit the bowel
movements and/or organs distention, as the most likely aetiology to
cause pain than adhesions in other sites. Pain due to adhesions is
well correlated with local peritoneal tension. Increase in the
parietal peritoneal tension is the mainstay in pain experience as
parietal peritoneum is of high somatic innervation [12].
This study detected an intra-abdominal pathology in (41out of 49= 83.6
%) of all the patients who have been subjected to diagnostic
laparoscopy which is well comparable with other publihed studies [13].
Thirty-four patients out of (49) patients =(69.3 %), who had underwent
laparoscopy for different intra-abdominal lesions,had reported good
postoperative results which also agrees well with other reports. Adams
et al. had reviewed records of (79) patients who have had laparoscopic
appendectomies for chronic lower abdominal pain. Ninety percent of
these patients reported excellent postappendectomy results.
Histopathological study of all appendectomies showed abnormalities in
(94%). The appendices appeared to be abnormal at laparoscopy in the
all cases reviewed. At the same time no other abdominal/pelvic
abnormalities could be detected [14].
In this study all the appendices were of normal looking during
diagnostic laparoscopic examination apart from one case which had
underwent appendectomy that had been followed by complete resolution
of pain .In view of the study by Adams et al., it may be recommended
to practice laparoscopic appendectomy in all patients with chronic
right lower quadrant abdominal pain even if the appendix showed no
gross abnormalities on laparoscopic inspection.
Conclusion
According to the results obtained from this study we can cite that
diagnostic laparoscopywith or without therapeutic intervention is a
safe and rewarding minimally invasive investigation which can be
adopted in the management of patients with chronic abdominal pain.
Also we can conclude that laparoscopic adhesiolysis can help many
cases of patients with chronic abdominal pain.
References
1. Sogal BD, Brooks IM, George SM, et al . An evaluation of chronic
abdominal pain . Br Med J 2007;201:124-7.
2. Salky TS, Filmar VG, MetzegerFK . Chronic abdominal pain : the
diagnosis and management. Am J Pain 2007:36:702-7.
3. Mounty ZS, Neil TS, Tohn WP et al. Postoperative adhesive
peritoneal disease. J SurgEndosc 2009;22;801-4.
4. Flangton NR, Tog BS, Vigar DG, et al. Diagnostic Laparoscopy. Eur J
Laparosc 2009;37:905-9.
5. Seifer AG, Frank FE, Gomel SW .An evaluation of laparoscopy role in
diagnosis of chronic abdominal pain. J Am CollSurg 2008;69:303-309.
6. Chan Rs, Anglers SI, Thomas VW, et al. Diagnostic role of
laparoscopy in chronic abdominal pain. SurgEndosc 2009;33:119-26.
7. Rogers EM, Keiln JS, Black SK, et al. Operative laparoscopy versus
open abdominal surgery : a comparatative study of postoperative
adhesions formations in the rat modle. FertilSteril 2008;59:377-83.
8. Nixon RD, Stewart BK, Hugh KA, et al. A comparatative study of
postoperative adhesions following laparoscopic laser surgery versus
laparotomy in the rabbit modle.ObstGyneac 2007;89:488-93.
9. Nezhat AD, Roland SK, Collin MT, et al. Adhesions reformation after
laparoscopical reproductive surgery. SurgEndosc2010 ;41:678-82.
10. Symon DD, Rocklin BR, Nilson JD, et al. A study of laparoscopical
role in adhesiolysis. Surg.Laparosc. Endosc 2009;23:1238-43.
11. Dellinger MR, Cloudy TV, Kelly OE, et al. A study of
laparoscopical role in adhesiolysis in patients with chronic abdominal
pain. Am J Surg 2008;89:462-9.
12.Wialliams CA, Canady SN, Longer BN, et al. Assessment of patients
with chronic pelvic pain. Am J ObstGyn 2009;91:891-7.
13. Luaciano MK, Robbin FG, Sachs DB, et al. Outcome of laparscopical
intervention in management of patients with chronic abdominal pain.
SurgEndosc 2008;20:201-7.
14.Adams WD, Norman HJ, Dorthy AP, et al. Appendix as the cause of
chronic lower abdominal pain. Am J ObstetGynecol 2005;81:443-51.
Table1 showing laparoscopic findings
Laparoscopical Findings
Number
Percentage
Significant Adhesions
31
( 63.2 %)
Insignificant Adhesions
4
( 8.1 %)
Mesenteric Lymphadenpathy
3
( 6.1 %)
Inguinal Hernias
2
( 4 %)
Abnormally Looking Appendices
1
( 2 %)
No Abnormality Detected
8
( 16.3 %)
Total
49
( 100 %)
178