Friday, 2 November 2012

Diagnostic abdominal laparoscopy is contraindicated in which of the following patients?

Option A. A patient with rebound tenderness following a tangential gunshot wound to the abdomen
Option B. A stable patient with a stab wound to the lower chest wall
Option C. A patient with a mass in the head of the pancreas
Option D. A young female with pelvic pain and fever
Option E. An elderly patient in the intensive care unit suspected of having intestinal ischemia

The answer is a. The indications for diagnostic laparoscopic exploration are increasing rapidly as the tools and techniques for such intervention improve. In the stable trauma patient with a tangential gunshot wound or with a stab wound to the lower chest wall or abdomen, laparoscopy may show no actual peritoneal penetration and might make a laparotomy unnecessary. If the peritoneum or diaphragm is injured, subsequent laparotomy and exploration are generally indicated to exclude other possible injuries and to facilitate repair of the diaphragm. All unstable patients or those with signs of peritoneal irritation (e.g., rebound tenderness) should undergo prompt celiotomy Laparoscopic staging of malignancies allows improved preoperative assessment of the resectability of intraabdominal malignancies. The procedure has proved particularly useful in cases with pancreatic carcinoma. Laparoscopic evaluations may expedite differentiation of competing etiologies of right lower quadrant pain; this would allow appendectomy for appendicitis or appropriate therapy such as intravenous antibiotics for pelvic inflammatory disease and preempt celiotomy. In critically ill patients, the development of low flow or embolic ischemic insults to the bowel can be fatal if not recognized and treated early. Many such patients are already being ventilated in intensive care units; in this setting, bedside laparoscopy can ascertain the need for early exploration for bowel revascularization or resection.


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