Core Topics in General & Emergency Surgery: Companion to Specialist Surgical Practice (26 page)
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Authors: Simon Paterson-Brown MBBS MPhil MS FRCS
With the increased use of CT in the investigation of the acute abdomen it was only a matter of time before attention turned to the role of MRI, which is not associated with the radiation exposure of CT. MRI can undoubtedly differentiate an acutely inflamed appendix from a normal one
105
and therefore is useful in pregnant patients, where the diagnosis of acute appendicitis can be difficult.
106
However, a review of academic centres in North America reported that radiologists still preferred CT to MRI in the second and third trimester to investigate acute abdominal pain.
107
Laparoscopy is now an integral part of the emergency surgeon's armamentarium, for both diagnosis and treatment of acute abdominal conditions. Laparoscopy significantly improves surgical decision-making when used as a diagnostic tool,
108
particularly when the need for operation is uncertain.
56
With the increasing use of laparoscopic appendicectomy (see
Chapter 9
), most patients with suspected appendicitis can now undergo diagnostic laparoscopy followed by laparoscopic appendicectomy if the diagnosis of acute appendicitis is confirmed (
Fig. 5.15
). Even if a policy of laparoscopic appendicectomy is not followed, all females with suspected acute appendicitis should still undergo diagnostic laparoscopy because the diagnostic error is more than twice that of males,
109
usually due to underlying gynaecological conditions (
Figs 5.16
and
5.17
). When used as a diagnostic tool in patients admitted to hospital with suspected acute non-specific abdominal pain, some of whom of course subsequently turn out to have a surgical cause, early laparoscopy versus observation has been shown to be of benefit. Two randomised studies
110,
111
have demonstrated that the associated improved diagnostic accuracy in the patients undergoing laparoscopy converts to a reduced hospital stay, and in one of the studies
110
an improved quality of life (assessed 6 weeks after discharge from hospital).
Figure 5.15
Laparoscopy showing an acutely inflamed appendix with pelvic peritonitis.
Figure 5.16
Laparoscopic view of a torsion of the right fallopian tube with ischaemia of the distal tube and ovary.
Figure 5.17
Laparoscopic view of a haemorrhagic ovarian cyst.
The decision on what to do if a normal appendix is seen at laparoscopy is discussed in detail in
Chapter 9
, and there are differing arguments for and against its removal. What is essential is that the patient must be clearly told the diagnosis made at laparoscopy and the procedure performed. It has been shown that around 27% of patients undergoing laparoscopy for acute abdominal pain could either not remember what had happened or their recall was incorrect.
112
This included knowledge as to whether the appendix had been removed or not.
It is clear that there is now overwhelming evidence in support of the use of diagnostic laparoscopy in the management of patients with acute abdominal pain in whom the need for surgery is uncertain and particularly women with suspected appendicitis.
108,
110,
111
Key points
The art of good management of patients with acute abdominal pain lies in an accurate history, careful examination and logical decision-making, taking into account results from all appropriate and available investigations.
Regular reassessment of patients is an essential part of this process and facilities should be provided so that emergency patients are kept in an area of the hospital where regular review is facilitated.
The ability to provide adequate emergency surgical care, with careful observation, reassessment and early access to the operating theatre, is best provided by dedicated emergency surgical teams without elective commitments.
Swift access to investigations and an emergency theatre is an essential requisite for the appropriate management of patients with acute abdominal pain.
Although emergency subspecialisation has great attractions for the overall care of the emergency patient with complex problems, this area of development will depend very much on local resources, requirements and workload.
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