Der Stellenwert der Laparoskopie beim akuten Abdomen und Abdominaltrauma

Zusammenfassung

Ziel der Untersuchung war es, den Stellenwert der Laparoskopie im Versorgungsablauf des Bauchverletzten und beim akuten Abdomen zu bestimmen. Für die Beurteilung des Stellenwertes der Laparoskopie beim Abdominaltrauma wurde das Krankengut der Chirurgischen Klinik des Carl-Thiem-Klinikums Cottbus aus den Jahren 1998 bis 2002 retrospektiv analysiert. In diesem Zeitraum wurden 104 Patienten wegen eines Bauchtraumas operativ versorgt, davon 33 (31,7 %) primär laparoskopiert. In 18 Fällen wurde der abdominelle Eingriff ohne Konversion laparoskopisch beendet, bei 10 Patienten dabei intraabdominelle Verletzungen laparoskopisch versorgt. Die Rate der so genannten „negativen” Laparotomien lag bei 7,7 %. Beim akuten Abdomen besteht die wichtigste Indikation zur diagnostischen Laparoskopie in der Abklärung unklarer rechtsseitiger Unterbauchbeschwerden. Aber auch in Einzelindikationen (mesenteriale Durchblutungsstörungen, Perforationen, Meckelsches Divertikel, gynäkologische Erkrankungen, Peritonitis unklarer Genese, Dünndarmileus) stellt die diagnostische Laparoskopie ein wichtiges diagnostisches Instrument mit therapeutischer Option dar. Anhand der Daten einer Multizenterstudie mit 1703 diagnostischen Laparoskopien bei Verdacht auf Appendizitis wird der Stellenwert der diagnostischen Laparoskopie im Rahmen der Appendizitisbehandlung dargestellt. Gute Einzelindikationen werden in Falldarstellungen und Literaturanalysen erörtert. Damit sollte die Laparoskopie unserer Meinung nach einen festen Platz im diagnostischen und gegebenenfalls therapeutischen Prozedere beim Bauchtrauma und akuten Abdomen einnehmen.

Abstract

The importance of laparoscopy in the management of acute abdomen and blunt abdominal trauma should be evaluated. Therefore we retrospectively analysed all patients with blunt abdominal trauma treated in the Department of Surgery at the Carl-Thiem-Hospital Cottbus between 1998 and 2002. Within this period a total number of 104 patients with blunt abdominal trauma underwent operative treatment, 33 (31,7 %) of them had primary laparoscopy. Of the 18 cases where laparoscopic operation could be completed without conversion to exploratory laparotomy, 10 patients had intra-abdominal injuries and underwent sufficient laparoscopic treatment. The percentage of so called „negative” exploratory laparotomies within this study was 7,7 %. Diagnostic laparoscopy in patients with unclear right hand side lower abdominal pain is the most important indication in acute abdomen. In special cases (mesenteric ischemia, perforations, Meckel's diverticulum, gynecopathies, peritonitis of unknown origin, small bowel obstruction) laparoscopy is an usefull diagnostic tool with a therapeutic option. The value of diagnostic laparoscopy is demonstrated by means of the data of a multicenter trial with 1703 diagnostic laparoscopies under suspicion of acute appendicitis. Special indications are discussed on the basis of case studies and the literature. Our analysis suggests that laparoscopy should become firmly established in the diagnostic management and, if indicated, in the treatment of acute abdomen and blunt abdominal trauma as well.

Schlüsselwörter

Akutes Abdomen - Bauchtrauma - diagnostische Laparoskopie - laparoskopische Therapie

Key words

Acute abdomen - blunt abdominal trauma - diagnostic laparoscopy - laparoscopic treatment

Literatur

• 1 Andersen B R, Kallehave F L, Andersen H K. Antibiotics versus placebo for prevention of postoperative infection after appendicectomy (Cochrane Review).  Cochrane Database Syst Rev. 2001;  2 CD001439
• 2 Berci G, Dunkelman D, Michel S L, Sanders G, Wahlstrom E, Morgenstern L. Emergency minilaparoscopy in abdominal trauma. An update.  Am J Surg. 1983;  146 (2) 261-265
• 3 Berci G. Elective and emergent laparoscopy.  World J Surg. 1993;  17 (1) 8-15
• 4 Bergamaschi R, Marvik R, Johnsen G, Thoresen J E, Ystgaard B, Myrvold H E. Open vs laparoscopic repair of perforated peptic ulcer.  Surg Endosc. 1999;  13 679-682
• 5 Block E F, Singh I, Thompson E. Utility and cost-savings of diagnostic laparoscopy in low-probability gunshot wounds of the abdomen.  J La State Med Soc. 1998;  150 (5) 232-234
• 6 Bloechle C, Emmermann A, Strate T, Scheurlen U J, Schneider C, Achilles E, Wolf M, Mack D, Zornig C, Broelsch C E. Laparoscopic vs open repair of gastric perforation and abdominal lavage of associated peritonitis in pigs.  Surg Endosc. 1998;  12 218
• 7          Bloechle C, Emmermann A, Treu H, Achilles E, Mack D, Zornig C, Broelsch C E. Effect of a pneumoperitoneum on the extent and severity of peritonitis induced by gastric ulcer perforation in the rat.  Surg Endosc. 1995;  9 898-901
• 8 Bloechle C, Emmermann A, Zornig C. Effect of carbon dioxide pneumoperitoneum on bacteraemia and endotoxaemia in an animal model of peritonitis.  Br J Surg. 1995;  82 1702-1703
• 9 Brandt C P, Priebe P P, Jacobs D G. Potential of laparoscopy to reduce non-therapeutic trauma laparotomies.  Am Surg. 1994;  60 (6) 416-420
• 10 Brefort J L, Samama G, Le Roux Y, Damamme A. Contribution of laparoscopy in the management of abdominal stab wounds.  Ann Chir. 1997;  51 (7) 697-702
• 11 Cuschieri A, Hennessy T P, Stephens R B, Berci G. Diagnosis of significant abdominal trauma after road traffic accidents: preliminary results of a multicentre clinical trial comparing minilaparoscopy with peritoneal lavage.  Ann R Coll Surg Engl. 1988;  70 (3) 153-155
• 12 Decat B, Sussman L, Lewis M P, Secker A, Cohen L, Rogers C, Patel A, Rhodes M. Randomized clinical trial of early laparoscopy in the management of acute non-specific abdominal pain.  Br J Surg. 1999;  86 1383-1386
• 13 Ditmars M L, Bongard F. Laparoscopy for triage of penetrating trauma: the decision to explore.  J Laparoendosc Surg. 1996;  6 (5) 285-291
• 14 Elliott D C, Rodriguez A, Moncure M, Myers R A, Shillinlaw W, Davis F, Goldberg A, Mitchell K, McRitchie D. The accuracy of diagnostic laparoscopy in trauma patients: a prospective, controlled study.  Int Surg. 1998;  83 (4) 294-298
• 15 Franklin M E, Dorman J P, Jacobs M, Plasencia G. Is laparoscopic surgery applicable to complicated colonic diverticular disease?.  Surg Endosc. 1997;  11 1021-1025
• 16 Gazzaniga A B, Stanton W W, Bartlett R H. Laparoscopy in the diagnosis of blunt and penetrating injuries to the abdomen.  Am J Surg. 1976;  131 (3) 315-318
• 17 Goh P MY, Kum C-K K, Chia Y-W, Ti T K. Laparoscopic repair of perforation of the colon during colonoscopy.  Gastrointestinal Endoscopy. 1994;  40 396-397
• 18 Guth A A, Pachter H L. Laparoscopy for penetrating thoracoabdominal trauma: pitfalls and promises.  J Soc Laparoendosc Surg. 1998;  2 (2) 123-127
• 19 Hallfeldt K K, Trupka A W, Erhard J, Waldner H, Schweiberer L. Emergency laparoscopy for abdominal stab wounds.  Surg Endosc. 1998;  12 (7) 907-910
• 20 Johnson S R, Luchette F A. The role of laparoscopy in the acute abdomen and trauma.  Semin Laparosc Surg. 1996;  3 (3) 168-177
• 21 Kim Y S, Kim Y, Cho O K, Koh B H, Rhim H, Park D W, Park C K. Sonography for right lower quadrant pain.  J Clin Ultrasound. 2001;  29 157-185
• 22 Koch A, Zippel R, Marusch F, Schmidt U, Gastinger I, Lippert H. Prospective multicenter study of antibiotic prophylaxis in operative treatment of appendicitis.  Dig Surg (Switzerland). 2000;  17 (4) 370-378
• 23 Korabelnikov A I. Peace-time penetrating abdominal wounds with injuries of the small intestine.  Khirurgiia (Mosk). 1990;  9 50-53
• 24 Lee F Y, Leung K L, Lai P B, Lau J W. Selection of patients for laparoscopic repair of perforated peptic ulcer.  Br J Surg. 2001;  88 133-136
• 25 Leppaniemi A K, Elliott D C. The role of laparoscopy in blunt abdominal trauma.  Ann Med. 1996;  28 (6) 483-489
• 26 Leppaniemi A K, Voutilainen P E, Haapiainen R K. Indications for early mandatory laparotomy in abdominal stab wounds.  Br J Surg. 1999;  86 (1) 76-80
• 27 Lippert H, Koch A, Marusch F, Wolff S t, Gastinger I. Offene versus laparoskopische Appendektomie.  Chirurg. 2002;  73 791-798
• 28 Marks J M, Youngelman D F, Berk T. Cost analysis of diagnostic laparoscopy versus laparotomy in the evaluation of penetrating abdominal trauma.  Surg Endos. 1997;  11 (3) 272-276
• 29 Marusch F, Allecke K, Gastinger I. [Value of ultrasound in diagnosis of appendicitis. Results of the East German Multicenter Study. East German Working Group „Outcome Assessment and Quality Assurance in Surgery” of the CAQ of the German Society of Surgery].  Zentralbl Chir. 1998;  123 (Suppl 4) 29-31
• 30 Memon M A, Fitzgibbons R J. The role of minimal access surgery in the acute abdomen.  Surg Clin North Am. 1997;  77 1333-1353
• 31 Nast-Kolb D, Gtrupka A, Buchholtz S. Abdominaltrauma.  Unfallchirurg. 1998;  101 82-91
• 32 Navez B, Tassetti V, Scohy J J, Mutter D, Guiot P, Evrard S, Marescaux J. Laparoscopic management of acute peritonitis.  Br J Surg. 1998;  85 32-36
• 33 Niebuhr H, Nahrstedt U, Born O. [Routine ultrasound in diagnosis of acute appendicitis].  Zentralbl Chir. 1998;  123 (Suppl 4) 6-28
• 34 Ortega A E, Tang E, Froes E T, Asensio J A, Katkhouda N, Demetriades D. Laparoscopic evaluation of penetrating thoracoabdominal traumatic injuries.  Surg Endosc. 1996;  10 (1) 19-22
• 35 Perri S G, Altilia F, Pietrangeli F, Dalla Torre A, Gabbrielli F, Amendolara M, Nicita A, Nardi M, Lotti R, Citone G. Laparoscopy in abdominal emergencies. Indications and limitations.  Chir Ital. 2002;  54 165-178
• 36 Porter J M, Ivatury R R. The role of laparoscopy in the management of penetrating trauma.  Semin Laparosc Surg. 1996;  3 (3) 156-167
• 37 Richter H A, Thoma E, Lebrecht K, Franke A, Wagner D. Die laparoskopische Therapie des perforierten peptischen Ulcus ventriculi und duodeni.  Min Invas Chir. 1994;  3 3-6
• 38 Sabra J, Roh M, Paez X, Cronan J. Use of sonography in diagnosing acute appendicitis: comparison of a teaching hospital and a community hospital.  Acad Radiol. 1996;  3 438-441
• 39 Schlinkert R T, Rasmussen T E. Laparoscopic repair of colonoscopic perforations of the colon.  J of Laparoendoscopic Surgery. 1994;  4 51-54
• 40 Simon R J, Rabin J, Kuhls D. Impact of increased use of laparoscopy on negative laparotomy rates after penetrating trauma.  J Trauma. 2002;  53 (2) 297-302
• 41 Siu W T, Leong H T, Law B K, Chau C H, Li A C, Fung K H, Tai Y P, Li M K. Laparoscopic repair for perforated peptic ulcer: a randomized controlled trial.  Ann Surg. 2002;  235 313-319
• 42 Sosa J L, Arrillaga A, Puente I, Sleeman D, Ginzburg E, Martin L. Laparoscopy in 121 consecutive patients with abdominal gunshot wounds.  J Trauma. 1995;  39 (3) 501-504
• 43 Sosa J L, Baker M, Puente I, Sims D, Sleeman D, Ginzburg E, Martin L. Negative laparotomy in abdominal gunshot wounds: potential impact of laparoscopy.  J Trauma. 1995;  38 (2) 194-197
• 44 Waclawiczek H W, Sungler P, Boeckl O. Bedside laparoscopy (BSL) for postoperative follow-up of mesenteric infarct and diffuse peritonitis.  Langenbecks Arch Chir Suppl Kongressbd (Germany). 1997;  114 708-710
• 45 Weiner R, Wagner D. Laparoskopische Drainage eines Leberabszesses.  Min Invas Chir. 1995;  4 126-128
• 46 Weiner R, Ziegler B, Wagner D, Görge B. Intermittierende Bed Side Laparoskopie über ein temporäres Laparoskopie-Stoma nach Mesenterialinfarkt.  Min Invas Chir. 1996;  5 87-90
• 47 Wustner M, Horst F, Neufang T, Becker H. [Effect of ultrasonic diagnosis and incidence of appendectomy and laparoscopy].  Langenbecks Arch Chir Suppl Kongressbd. 1998;  115 1117-1119
• 48 Zantut L F, Ivatury R R, Smith R S, Kawahara N T, Porter J M, Fry W R, Poggetti R, Birolini D, Organ C H. Diagnostic and therapeutic laparoscopy for penetrating abdominal trauma: a multicenter experience.  J Trauma. 1997;  42 (5) 825-829
• 49 Zoller W G, Kellner H, Schwerk W B. [Value of ultrasound in diagnosis of acute appendicitis].  Bildgebung. 1996;  63 78-82
• 50 Zippel R, Meyer L, Koch A, Marusch F, Gastinger I. Laparoscopic treatment of iatrogenic perforations of the colon.  Zentralbl Chir.. 2002;  127 (4) 307-309