Duration of the Procedure
The duration of a laparoscopy is variable; it is generally possible to carry out a complete examination in about ten minutes, a consideration of capital importance, when one knows how important it is, in a bush hospital, not to waste time, to arrive at the most precise diagnosis possible and the necessary therapeutic conclusion. Pre-medication is not essential, but sedatives in moderate doses have proven useful. The patient is able to return to his bed by his own means.
For a large number of reasons use of simulators is a prudent choice like Laparoscopic Needle Driver.
Laparoscopy found very many detractors who opposed laparotomy to it. The disadvantage of laparoscopy is that it does not allow any palpation, but we will bring to its credits:
Systematic Exploration
It must do whatever the suspected condition and the point of entry of the laparoscope.
1. If the quantity of air introduced has been sufficient, the view that we have of the viscera is remarkable.
2. The laparoscope first holds vertically and, pivoting on its axis, allows a general view of the abdomen.
3. Examination of the parietal peritoneum (appearance, blood circulation, granulations, adhesions),
4. Right hypochondrium, liver and gallbladder. After examination on a horizontal table, the table is straightens, feet down and possibly in a lateral inclination left.
5. Left hypochondrium, spleen, great curvature of the stomach, etc. Table straightened, patient's feet down, right lateral inclination.
6. Returning the table to the horizontal, inspection of the intestinal loops
7. Table of Trendelenburg, inspection of the small basin; the view is generally remarkable.
Right iliac fossa, Trendelenburg table and left lateral inclination
Methods of Laparoscopy
The exploration being done, remove the laparoscope, open the valve, the air will come out through the cannula. We used to inject into the peritoneum, systematically, using an intrauterine injection cannula, a solution of 1 million units of penicillin and 1g of streptomycin. One or two staples place at the skin.
· No shock;
· Has only very rare contraindications (compartmentalized peritoneal tuberculosis seemed to us to be the only one we encountered);
· It does under local anesthesia;
· It allows a vision that only an autopsy incision can
· Would put to have;
It is often sufficient for diagnosis (90% of cases), does not contraindicate a laparotomy (10% of cases) and, if it indicates the need for a curative intervention, it will have defined the characteristics of operability largely.
Purulent peritonitis and septate tuberculosis constitute a contraindication to laparoscopy, the risks of adhesion at the level of the puncture are too students.
Let us now review the cases where this mode of investigation seemed to us to be of the greatest interest. -
Laparoscopic Exploration
The hepatic region has always been the ideal place for laparoscopic exploration and on this subject, many books and articles writes; let us note, however, a few specific points.
Ascites of unknown origin is a definite indication for laparoscopy, especially in places without a suitable laboratory; Local anesthesia carries out at the point of insertion of the laparoscope trocar (instead of air when the piston withdraws, peritoneal fluid withdraws and anesthesia will carries out, by successive withdrawals, of the different planes.)
The emptying of the ascites make through the cannula of the laparoscope and the pneumoperitoneum installs through the same route. The review process is unremarkable. The depth of field of the laparoscope extending from infinity to a few millimeters, it is, in a way, possible to look at the surface with a magnifying glass if one approaches it close enough. As it is a matter of examining the surface of an organ, essentially descriptive determinants must addresses, a bit like in dermatology. However, we must not be frightened for all that: the criteria for cirrhosis, cardiac liver, metastatic liver, etc. Are enough evocative.
Use of Photo-Laparoscopy
The ideal way to make this method effective is to combine photolaparoscopy and biopsy puncture under laparoscopic control, but we are here at laparoscopy simple.
Permit us to dwell on a particular aspect of the liver seen with the laparoscope; it is that of its sequelae. When the abscess is recent, when no curvature is yet palpable, the laparoscope will reveal a hyperaemia and reddish zone whose color contrasts with the rest of the organ. Most often, this aspect superimposes with generally darker circular spots, and a process of more or less whitish capsulitis regional. At the beginning, this capsulitis gives images intertwined with the hyperaemia zone and will give, in very close laparoscopic view, an image evoking a mosaic.
In the next stage, the arch forms distinctly (and may, of course, not be palpable if it is below the costal grill), the capsulitis intensifies as a white thickening extending to the surface. Here, two possibilities: either the abscess heals under the influence of therapy or only a vast retractile whitish scar (either stellate or ribbon-like) will remain; or else, the abscess continues to evolve and a hepatodiaphragmatic adherence forms which will be permanent. These hepatodiaphragmatic adhesions finds in a certain number of epigastric pains whose origin was, until then, unknown. This is a permanent painful sequela of amoebiasis hepatic.
Results
We have, several times occasion to observe livers that, because of an adherence of this kind, showed only their concave face, and stuck together by the whole surface of their diaphragm.
The interest of puncture of single or multiple abscess, under laparoscopic control and their setting in culture, if it s. acts of pyogenic germs, is evident, the causes of abscess of madness being multiple.
The gall residue quite easily observed. Cholecystitis is very rare in these regions and we observed only one case, presenting from adhesions multiple with the neighboring organs.
Conclusion
From the examination of the stomach, we removed little information, but it has been described in the literature, ( Kalk) , the interest of observing peristaltic waves and their possible interest in a place of induration (neo or ulcus). This sighting must be part of the exam systematic.
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