Mesenteric ischemia laparoscopic second look
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Acute mesenteric ischemia has a high mortality rate ranging from 40-100% and the mean overall mortality is 74%. Second-look laparotomy was traditionally used to assess intestinal viability after surgery for acute mesenteric ischemia but has disadvantages like duplicating risks of complications and increasing hospital stay. Laparoscopic second-look procedures can minimize these risks with benefits like examining the anastomosis, assessing intestinal viability and motility, and being performed minimally invasively with fewer trocars. The timing of second-look procedures is unclear but they may be done 24-48-72 hours after the initial surgery or thrombolytic treatment.
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Mesenteric ischemia laparoscopic second look
- 1. Hakan Yanar MD Istanbul University Faculty of Medicine, Trauma and Emergency Surgery Service Istanbul, Turkey
- 5. Yanar et al. World Journal of Gastroenterology 2007 Jun 28;13(24):3350-053.
- 13. Low flow state
- 14. Anastomosis viability Terminal ileum duodenum jejenum jejenum
- 15. Before – during - after thrombolytic treatment
- 16. NOMI
- 17. MVT
- 19. Kurtoglu et al.
- 25. Celiac stent
- 27. Second look
- 34. Second look
- 40. Second look
- 42. SMV thrombosis
- 45. World Journal of Gastroenterology 2007 Jun 28;13(24):3350-053.
Notes de l'éditeur
- Mesenteric ischemia is a major cause of mortality in surgery ranging from 40 to 100 % in some series . In a recent systemic and comprehensive review Schoots et al. f ound that the mean overall, in-hospital mortality for AMI is 74% . Although advances in diagnostic imaging, surgical technique have improved outcomes in most surgical diseases over the last several decades, mesenteric ischemia remains a highly morbid condition.
- Mesenteric ischemia occurs when visceral tissues receive inadequate blood flow. This may be a consequence of an arterial embolus or thrombosis, venous thrombosis limiting arterial inflow, and NOMI.
- The disease predominantly affects elderly patients, and they often have serious comorbidities and other systemic illnesses.
- The most common co-morbid diseases are hypertension , AF, and DM in our series.
- During the management of disease considerable number of patients undergoes reoperations for a better assessment of intestinal viability. Although great majority of these second-look operations are “negative explorations,” progressive nature of this devastating disease pushes surgeons to re-explore / reevaulate the abdomen .
- In addition the negative exploration second look laparotomy has many other disadvantages.
- For all these reasons, replacement of second-look laparotomy by laparoscopic intervention for those patients minimizes these risks
- During the second-look laparoscopy, the anastomotic line can often be examined . In a few cases, even if the anastomosis can not be visualized, seeing viable intestine and motility or absence of a necrotic segment or free gastrointestinal content is also enough to terminate the operation and remove the trocar.
- S econd-look intervention can be performed using only a trocar and a telescope without further disturbing the patient by using a minimally invasive technique
- Which patients should undergo laparoscopy
- During the initial operation if low flow state found on the bowel a 10 mm trocar can be insert for further evaluating the abdomen.
- These selected images are from a CT scan of a patient who had acute mesenteric ischemia secondary to a nearly occluded SM V and you see the small bowel thickening here. Laparoscopy will be helpful for evaulating the vaiability of bowel initialy and in suspect case second look should also be done
- Practically, re-operation may be performed within 24 h. However, we prefer to perform the second-look operation within 72 h, which promotes bowel viability and anastomotic healing. We believe this contributes to early detection of leakage and prevent peritonitis.
- In our clinic, our policy is to perform a second look laparoscopy for all patients operated on for AMI. Regardless of the clinical course of patients during the first operation when bowel viability was suspected and a low flow state was detected or bowel resection and anastomosis were performed, we performed a second-look laparoscopy within 72 h following the first operation at the bed side in the ICU or operating room.
- Total occlusion of celiac truncus and near total occlusion of SMA was found on CT Angio. To rule out the bowel ischemia diagnostic laporoscopy was performed.
- After insertion of 10 mm umbilical port using Hasson approach the camera is inserted in the abdomen. A second 5 mm port then inserted lateral to the inferior epigastric vessels. Atraumatic bowel grasper through the this port is used for retract the bowel. Rarely, in the case of a difficult adhesion on the bowel a 5mm port may also have to be inserted. The patient can return Trendelenburg position for reflecting small bowel cranially this allows and help to see the whole bowel. You can see the ischemic area on the distal small bowel and right colon. After elevation of ileocolic pedicule color of appendix was found paled.
- You can see the ischemic area on the distal small bowel and right colon. After elevation of ileocolic pedicule color of appendix was found paled.
- Because of the suspision of bowel ischemia we decided to conventional angiography. Angiography revealed 90% occlusion of celiac truncus with total occlusion.
- To increase the colleteral circulation celiac stent placed.
- Because of the accurately predict which segments of bowel remain viable, patient underwent a second-look operation 48 hours after the initial procedure . Confirmation of viability full bowel from Treitz to rectum should be done during the prosudure.
- Magnified imeges
- In 1996 the (FDA) approved the use of tPA to treat ischemic stroke in the first three hours after the start of symptoms . Than it found place in the treatment of other ischemic lesions.
- Catheter placed into SMA orifis and t PA started. Control angiography showed increased collateral circulation.
- Color of the bowel
- CT Angiography
- CT scan of the patient revealed small bowel thickening in the ileum secondary to a nearly occluded SM V. You can see thickened small bowel loops.
- We performed diagnostic laparoscopy and extensive small bowel thickening was found during the laparoscopic exploration.
- Between January 2000 and November 2005, 71 patients were operated for the treatment of AMI. The indications for a second-look were low flow state, bowel resection and anastomosis or mesenteric thromboembolectomy performed during the first operation. Regardless of the clinical course of patients, the second-look laparoscopic examination was performed 72 h post-operatively at the bed side in the ICU or operating room. In 13 patients, a second-look laparoscopic examination revealed normal bowel viability and were rescued from unnecessary laparotomies but in one patient, intestinal necrosis was detected.
- Laparoscopic second-look procedure has the following advantages: 1. Shorter operative time because of the absence of “opening” and “closing” the abdomen. 2. All you need is a shorter and superficial anesthesia , It can even be performed as a bedside procedure and sometimes without anesthesia. 3. In addition to the second one, it gives you the chance of “third” or even more explorations. 4. Using only a reusable telescope can prevent unnecessary laparotomies in terms of operating room costs. 5. There is no need to give the patient a surgical trauma as a “second insult” to cause MOF .
- Second-look laparoscopy is a minimally invasive, technically simple procedure that is performed for diagnostic as well as therapeutic purposes. L aparoscopic second-look intervention, should be totally replaced second-look laparotomy and must become the routine procedure of choice for every patient who is operated on with the diagnosis of mesenteric ischemia . However, the timing of a second-look procedure is unclear particularly in a patient with anastomosis.