Laparoscopic Articles from Laparoscopy Hospital

Dr Christopher Ekwunife
Dept of Surgery,
Federal Medical Centre, Owerri
Nigeria

Abstract

Background:

Intestinal perforation from typhoid fever presents with challenges for the surgeon in developing countries. Laparoscopic surgery may be an option to improve outcome in the management of the disease.

Methods:

A search of Medline, EMBASE, High Wire Press from January 1998 to July 2008 for publications on typhoid perforation with special attention to the use of laparoscopy in diagnosis and management.

Results:

We could only access two publications on laparoscopic surgery for typhoid perforation, which were all from India. Twenty six(26) patients were treated without any mortality. Port site infection is the only significant complication. Review of cases managed with conventional open surgery show higher complication rates.

Conclusion:

Laparoscopy surgery should be considered as an option of treatment for haemodynamically stable patients who have typhoid intestinal perforation even in the presence of peritonitis

Key words:

Typhoid perforation, ileal perforation, laparoscopy

INTRODUCTION

Typhoid intestinal perforation is still a major health problem in the developing world with its attendant high morbidity and mortality 3-8 . Early surgery has become the accepted mode of treatment and this has improved survival in the patients. Surgeons have adduced several modalities of operations to improve outcome 13,14,22 . It is apparent though that mortality is still significant in those patients that present early to the hospital. However laparoscopy is becoming the preferred surgical approach to different pathologies due to the possibility of accurately diagnosing and treating them at the same time. It has become possible to carry out even complicated bowel surgeries with laparoscopic techniques. These are unquestionably advantageous to the patient in terms of decreased incidence of wound infections, shorter length of hospital stay and improved survival. However some authorities still consider peritonitis a contraindication to laparoscopic surgery because of the theoretical risk of enhanced bacteraemia and endotoxaemia by pneumoperitoneum 15 . The purpose of this study is to search the literature for minimally invasive approaches to the management of ileal typhoid perforation, and see how it compares to open surgery.

MATERIALS AND METHODS

We searched the Medline, EMBASE and High Wire Press using the terms ‘typhoid perforation laparoscopy’, ‘typhoid perforation’, enteric fever perforation’, ‘intestinal perforation laparoscopy’ to identify studies reporting cases of typhoid perforation and its management. On account of the few reports of laparoscopic management of typhoid perforation, we have to limit our search to the period January 1998 till July 2008. Data extracted from these studies include country of origin, type of operation done, postoperative complications including mortalities and duration of hospital stay.

RESULTS

In the period under review there were 110 citations for typhoid perforation. There are only two papers on laparoscopic surgery for typhoid perforation, and they are all from the Indian subcontinent. There is no randomized clinical trial or comparative studies between open and laparoscopic surgery for typhoid perforation. A total of 41 publications reporting on open surgical management of typhoid perforation were also retrieved and studied. Nine of these met our selection criteria for the purpose of this review.

In the laparoscopic arm of the study a total of 26 patients were operated on without any mortality. Sinha R et al reported 2(10%) cases of wound infection and duration of patients’ stay to be 7-10days while Ramachandra’s patients stayed 6 days on the average. The duration of surgery ranges from 45-92minutes in Sinha’s series and a single layer intracorpooreal closure of the perforation with 3-0 polydioxanone was done. Ramachandra used 2-0 silk. Duration of perforation prior to surgery ranges from 3-5 days.

Table 1
Outcome of laparoscopic repair of Typhoid perforation

The result of the cases managed conventionally from different parts of the world is as given in Table 2. Wound infection is a very common complication of open surgery and mortality can range from 6-34%. Average duration of patients’ stay in the hospital was mentioned in 3 publications giving a combined average of 23.6 days

DISCUSSION

The management of thyroid perforation is still presenting challenges to the surgeon despite improvement in patient survival 10 . This disease condition affects predominantly the low socio economic class and some of the variables that determine the outcome are not within the interventional reach of the surgeon. These include poverty, poor sanitation and delay in seeking medical attention. However different approaches to the surgery of typhoid perforation have been described and these have impacted positively on the disease outcome 13,22 . There is yet a lot of ground to cover as a result of the unacceptably high post operative morbidity and mortality. Laparoscopic surgery has been proven to beneficial in other intestinal perforative conditions e.g. perforated duodenal ulcer and traumatic small bowel injuries 9,15 . It could have a place in the treatment of the patient with typhoid perforation.

Abdominal emergencies quite often pose diagnostic challenge to the surgeon. Accurate diagnosis is essential in the face of different pathologies giving similar clinical features so that appropriate therapies will be planned or unnecessary laparotomy avoided 11 . A negative laparotomy rate of 4.8% has been reported in one series 5 . Many patients with wit acute suppurative peritonitis do not have an obvious perforation,but rather an inflammatory and necrotic zone with oedema and abscess formation. Therefore they can be safely treated with drainage near the pathology zone with a large peritoneal lavage and antibiotic therapy. Diagnostic procedures are expensive and not readily available in the developing world. From these studies there is no evidence of a firm pre operative diagnosis. Laparoscopy is the only minimally invasive technique that provides the platform for adequate diagnosis, appropriate treatment and/or the best abdominal approach 11 .

Laparoscopic surgery for typhoid perforation is quite uncommonly done as shown by the only 2 publications on the procedure. And it may be unfair to compare these results with open surgery; the sample size is quite small and there may have been selection bias for haemodynamically stable patients. It can thus be argued that this cannot be applicable to the majority of patients with severe peritonitis because of the risk of exacerbation of septicaemia. However studies in CO2-insufflated septic animal models demonstrate survival advantage via interleukin-10-mediated downregulation of TNF-alpha 16 .

It has been observed that the least traumatic but effective surgical procedure that could seal the perforations and keep the peritoneum clean gave the best results 6,7,11 . Laparoscopy is advantageous because of the better quality of peritoneal washing and easy cleaning in the abdominal recesses as well as minimal destruction of the abdominal wall. Open surgery has a high rate of wound dehiscence and intra abdominal abscess formation 4,19,20 . This is not the case with the patients who underwent laparoscopy, port site infection being the commonly reported morbidity 1,2 . Significantly there was no mortality in the laparoscopy group. This could be attributed to patient selection. However the surgeon can always convert in difficult cases. Even these converted cases(intention-to-treat laparoscopically) are likely to have a better outcome compared to the patient who had a planned open operation. This has been demonstrated in complicated appendicitis 23 .

Single layer closure was used during laparoscopic surgery which has also shown to be effective in enteric perforation 22 . Shorter duration of hospital stay is a well known benefit of laparoscopy 1,2 ,and this can significantly reduce the cost of patient management. Duration of surgery could also be shortened in expert hands 2 .

CONCLUSION

Laparoscopic surgery has a promising place in the management of thyroid perforation and every effort should be made to offer it to patients who will benefit from it.

REFRENCES