Rationale for the Procedure
Exploratory laparotomies in trauma patients with suspected intra-abdominal injuries are associated with a high negative laparotomy rate and significant procedure-related morbidity. Diagnostic laparoscopy has been proposed for trauma patients to prevent unnecessary exploratory laparotomies with their associated higher morbidity and cost.
Technique
Many studies have documented the feasibility and safety of the procedure in trauma patients (level I-III) [1-25]. The procedure is usually performed under general anesthesia; however, local anesthesia with IV sedation has also been used successfully. The latter, in conjunction with a dedicated mobile cart, facilitates the procedure in the emergency department. A recent study demonstrated the safety and advantages of awake laparoscopy under local anesthesia in the emergency department over standard DL in the operating room (level III) [21]. Many authors have used low insufflation pressures (8-12 mm Hg); however, pressures up to 15 mm Hg have been described without untoward events. Special attention should be given to the possibility of a tension pneumothorax caused by the pneumoperitoneum due to an unsuspected diaphragmatic rupture. The pneumoperitoneum is created usually through a periumbilical incision using a Veress needle or open technique after insertion of a nasogastric tube and a Foley catheter.
In the case of penetrating wounds, air leaks can be controlled with sutures. A 30-degree laparoscope is advantageous, and additional trocars are used for organ manipulations. The peritoneal cavity can be examined systematically taking advantage of patient positioning manipulations. The colon can be mobilized and the lesser sac inspected. Suction/irrigation may be needed for optimal visualization, and methylene blue can be administered IV or via a nasogastric tube to help identify urologic or stomach injuries, respectively. In penetrating injuries, peritoneal violation can be determined.
Indications
• Suspected but unproven intra-abdominal injury after blunt or penetrating trauma
• More specific indications include:
• Suspected intra-abdominal injury despite negative initial workup after blunt trauma
• Abdominal stab wounds with proven or equivocal penetration of fascia
• Abdominal gunshot wounds with doubtful intraperitoneal trajectory
• Diagnosis of diaphragmatic injury from penetrating trauma to the thoracoabdominal area
• Creation of a transdiaphragmatic pericardial window to rule out cardiac injury
Contraindications (Absolute or Relative)
• Hemodynamic instability (defined by most studies as systolic pressure < 90 mm Hg)
• A clear indication for immediate celiotomy such as frank peritonitis, hemorrhagic shock, or evisceration
• Known or obvious intra-abdominal injury
• Posterior penetrating trauma with high likelihood of bowel injury
• Limited laparoscopic expertise
Risks
• Delay to definitive treatment
• Missed injuries with their associated morbidity
• Procedure- and anesthesia-related complications
Benefits
• Reduction in the rate of negative and nontherapeutic laparotomies (with a subsequent decrease in hospitalization, morbidity, and cost after negative laparoscopy)
• Accurate identification of diaphragmatic injury
• Ability to provide therapeutic intervention
Diagnostic Accuracy of the Procedure
The sensitivity, specificity, and diagnostic accuracy of the procedure when used to predict the need for laparotomy are high (75-100%) (level I-III) [1-25]; however, they depend on several factors (see Limitations of the Available Literature). When DL has been used as a screening tool (i.e., early conversion to open exploration with the first encounter of a positive finding like the identification of peritoneal penetration in penetrating trauma or active bleeding/peritoneal fluid in blunt trauma patients), the number of missed injuries is <1% (level II, III) [2-8]. Although early studies cautioned about the low sensitivity and high missed injury rates of the procedure when used to identify specific injuries (level II, III) [9-12], studies published recently consistently report a 0% missed injury rate even when DL is used for reasons other than screening (level I-III) [1-7,14,16-25]. This rate holds true for studies that have used laparoscopy to treat the majority of identified injuries (level II, III) [22,24,25].
Studies of DL for trauma report negative procedures in a median 57% (range, 17-89) of patients, sparing them an unnecessary exploratory laparotomy (level I-III) [1-7, 13-25]. On the other hand, the median percentage of negative exploratory laparotomies after a positive DL (false positive rate) is reported to be around 6% (range, 0-44) (level I-III) [1-7,14,16-25]. While most authors have converted to open exploration after a positive DL, some authors have successfully treated the majority of patients (up to 83%) laparoscopically (level II, III) [22,24,25]. The safety and accuracy of the procedure has also been demonstrated in pediatric trauma patients (level III) [22].
Procedure-related Complications and Patient Outcomes
Procedure-related complications occur in up to 11% of patients and are usually minor (level I-III) [1-25]. A 1999 review of 37 studies, which included more than 1,900 patients demonstrated a procedure-related complication rate of 1% [9]. Recent studies report a median of 0 (range, 0-10%) morbidity and 0% mortality (level I-III) [1-7,14,16-25]. Intraoperative complications can occur during creation of the pneumoperitoneum, trocar insertion, or during the diagnostic examination. These complications include tension pneumothorax caused by unrecognized injuries to the diaphragm, perforation of a hollow viscus, laceration of a solid organ, vascular injury (usually trocar injury of an epigastric artery or lacerated omental vessels), and subcutaneous or extraperitoneal dissection by the insufflation gas. Port site infections may occur during the postoperative course.
Negative DL is associated with shorter postoperative hospital stays compared with negative exploratory laparotomy (2-3 days vs. 4-5 days, respectively) (level II, III) [2,4-9,14,16-20,22-25]. Although a few studies have even demonstrated shorter stays after therapeutic laparoscopy compared with open (level III) [22,24,25], the only level I study available demonstrated a statistically significant shorter hospital stay after DL (5.1 vs. 5.7 days) [1]. In a very recent study, awake laparoscopy in the emergency department under local anesthesia resulted in discharge of patients from the hospital faster compared with DL in the operating room (7 vs. 18 hours, respectively; p<0.001) (level III) [21].
Comparative studies also suggest lower morbidity rates after negative DL compared with negative exploratory laparotomy (level II, III) [5,19,21], whereas other studies have shown similar outcomes (level I-III) [1,7].
Cost-effectiveness
A number of reports have demonstrated higher costs (up to two times higher) after negative exploratory laparotomy compared with negative DL (levels II, III) [6,14,17] as a direct consequence of shorter hospital stays. Nevertheless, a level I study did not demonstrate cost differences when an intention-to-treat analysis was used to compare a DL-treated group with that of an exploratory laparotomy-treated group [1]. Recently a level III study reported cost savings of $2,000 per patient when awake laparoscopy under local anesthesia was used in the emergency department compared with DL in the operating room [21].
Limitations of the Available Literature
The available literature has limited quality (only one small, level I study exists) and is very inhomogeneous, making generalizations and conclusions difficult. Study populations have been variable (blunt, penetrating, or mixed), and some studies have focused only on patients with suspected diaphragmatic injuries or blunt bowel injuries. Moreover, the indication for conversion to exploratory laparotomy has also been inconsistent. Most studies use peritoneal penetration or bleeding and free peritoneal fluid as an immediate reason for conversion, whereas others have converted only after specific injuries have been identified, and others have converted only when laparoscopic repair was impossible. The impact of laparoscopic expertise on the diagnostic accuracy of the procedure has not been assessed. Since the sensitivity, specificity, accuracy, and number of missed injuries can be substantially influenced by most of these factors, it is difficult to provide firm recommendations on the role of DL in trauma patients.
Recommendations
Diagnostic laparoscopy is technically feasible and can be applied safely in appropriately selected trauma patients (grade B). The procedure has been shown to effectively decrease the rate of negative laparotomies and minimize patient morbidity. It should be considered in hemodynamically stable blunt trauma patients with suspected intra-abdominal injury and equivocal findings on imaging studies or even in patients with negative studies but a high clinical likelihood for intra-abdominal injury (grade C). It may be particularly useful and should be considered in patients with penetrating trauma of the abdomen with documented or equivocal penetration of the anterior fascia (grade C). It should be used in patients with suspected diaphragmatic injury, as imaging occult injury rates are significant, and DL offers the best diagnostic accuracy (grade C). Patients should be followed cautiously postoperatively for the early identification of missed injuries. Therapeutic intervention can be provided safely when laparoscopic expertise is available (grade C). To optimize results, the procedure should be incorporated in institutional diagnostic and treatment algorithms for trauma patients.
Bibliography
1. Leppaniemi A, Haapiainen R Diagnostic laparoscopy in abdominal stab wounds: a prospective, randomized study. J Trauma 2003; 55(4):636-45.
2. Ahmed, N., Whelan, J., Brownlee, J., Chari, V., and Chung, R. The Contribution of Laparoscopy in Evaluation of Penetrating Abdominal Wounds. Journal of the American College of Surgeons 2005;201(2):213-6.
3. Mitsuhide, K., Junichi, S., Atsushi, N., Masakazu, D., Shinobu, H., Tomohisa, E., and Hiroshi, Y. Computed Tomographic Scanning and Selective Laparoscopy in the Diagnosis of Blunt Bowel Injury: a Prospective Study. Journal of Trauma-Injury Infection & Critical Care 2005;58(4):696-701.
4. Cherry, R. A., Eachempati, S. R., Hydo, L. J., and Barie, P. S. The Role of Laparoscopy in Penetrating Abdominal Stab Wounds. Surgical Laparoscopy, Endoscopy & Percutaneous Techniques 2005;15(1):14-7.
5. Miles, E. J., Dunn, E., Howard, D., and Mangram, A. The Role of Laparoscopy in Penetrating Abdominal Trauma. Journal of the Society of Laparoendoscopic Surgeons 2004;8(4):304-9.
6. Taner, A. S., Topgul, K., Kucukel, F., Demir, A., and Sari, S. Diagnostic Laparoscopy Decreases the Rate of Unnecessary Laparotomies and Reduces Hospital Costs in Trauma Patients. Journal of Laparoendoscopic & Advanced Surgical Techniques 2001;Part A. 11(4):207-11.
7. Simon, R. J., Rabin, J., and Kuhls, D. Impact of Increased Use of Laparoscopy on Negative Laparotomy Rates After Penetrating Trauma. Journal of Trauma-Injury Infection & Critical Care 2002;53(2):297-302.
8. Murray, J. A., Demetriades, D., Asensio, J. A., Cornwell, E. E., III, Velmahos, G. C., Belzberg, H., and Berne, T. V. Occult Injuries to the Diaphragm: Prospective Evaluation of Laparoscopy in Penetrating Injuries to the Left Lower Chest. Journal of the American College of Surgeons 1998;187(6):626-30.
9. Villavicencio, R. T. and Aucar, J. A. Analysis of Laparoscopy in Trauma. [Review] [62 Refs]. Journal of the American College of Surgeons 1999;189(1):11-20
10. Rossi P, Mullins D, Thal E. Role of laparoscopy in the evaluation of abdominal trauma. Am J Surg 1993;166:707–711.
11. Ortega AE, Tang E, Froes ET, et al. Laparoscopic evaluation of penetrating thoracoabdominal traumatic injuries. Surg Endosc 1996;10:19–22.
12. Brandt CP, Priebe PP, Jacobs DG. Potential of laparoscopy to reduce nontherapeutic trauma laparotomies. Am Surg 1994;60: 416–420.
13. Mathonnet, M., Peyrou, P., Gainant, A., Bouvier, S., and Cubertafond, P. Role of Laparoscopy in Blunt Perforations of the Small Bowel. Surgical Endoscopy 2003;17(4):641-5.
14. DeMaria, E. J., Dalton, J. M., Gore, D. C., Kellum, J. M., and Sugerman, H. J. Complementary Roles of Laparoscopic Abdominal Exploration and Diagnostic Peritoneal Lavage for Evaluating Abdominal Stab Wounds: a Prospective Study. Journal of Laparoendoscopic & Advanced Surgical Techniques 2000;Part A. 10(3):131-6.
15. Elliott, D. C., Rodriguez, A., Moncure, M., Myers, R. A., Shillinglaw, W., Davis, F., Goldberg, A., Mitchell, K., and McRitchie, D. The Accuracy of Diagnostic Laparoscopy in Trauma Patients: a Prospective, Controlled Study. International Surgery 1998;83(4):294-8.
16. Zantut, L. F., Ivatury, R. R., Smith, R. S., Kawahara, N. T., Porter, J. M., Fry, W. R., Poggetti, R., Birolini, D., and Organ, C. H., Jr. Diagnostic and Therapeutic Laparoscopy for Penetrating Abdominal Trauma: a Multicenter Experience. Journal of Trauma-Injury Infection & Critical Care 1997;42(5):825-9.
17. Marks, J. M., Youngelman, D. F., and Berk, T. Cost Analysis of Diagnostic Laparoscopy Vs Laparotomy in the Evaluation of Penetrating Abdominal Trauma. Surgical Endoscopy 1997;11(3):272-6.
18. Smith, R. S., Fry, W. R., Morabito, D. J., Koehler, R. H., and Organ, C. H., Jr. Therapeutic Laparoscopy in Trauma. American Journal of Surgery 1995;170(6):632-6.
19. Sosa, J. L., Arrillaga, A., Puente, I., Sleeman, D., Ginzburg, E., and Martin, L. Laparoscopy in 121 Consecutive Patients With Abdominal Gunshot Wounds. Journal of Trauma-Injury Infection & Critical Care 1995;39(3):501-4.
20. Hallfeldt, K. K., Trupka, A. W., Erhard, J., Waldner, H., and Schweiberer, L. Emergency Laparoscopy for Abdominal Stab Wounds. Surgical Endoscopy 1998;12(7):907-10..
21. Weinberg JA, Magnotti LJ, Edwards NM, Claridge JA, Minard G, Fabian TC, Croce MA. "Awake" laparoscopy for the evaluation of equivocal penetrating abdominal wounds. Injury. 2007;38(1):60-4.
22. Feliz A, Shultz B, McKenna C, Gaines BA. Diagnostic and therapeutic laparoscopy in pediatric abdominal trauma. J Pediatr Surg. 2006;41(1):72-7.
23. McQuay N, Britt LD. Laparoscopy in the evaluation of penetrating thoracoabdominal trauma. Am Surg. 2003;69(9):788-91.
24. Fabiani P, Iannelli A, Mazza D, Bartels AM, Venissac N, Baqué P, Gugenheim J. Diagnostic and therapeutic laparoscopy for stab wounds of the anterior abdomen. J Laparoendosc Adv Surg Tech A. 2003 Oct;13(5):309-12.
25. Chol YB, Lim KS.Therapeutic laparoscopy for abdominal trauma. Surg Endosc 2003;17(3):421-7

1. What is Minimally Invasive Surgery?
Minimally Invasive Surgery, some people refer to this simply as MIS, is a broad term for any procedure performed with small incisions (or sometimes no incisions at all).
Laparoscopic Surgery refers to MIS in the abdominal cavity. A telescope and long, fine caliber instruments are inserted into the abdomen to see and perform the surgery. The incisions used are 5 to 10 mm in size. These incisions heal quickly after surgery, resulting in small "keyhole" scars. Sometimes, even finer instruments are used (2 to 3 mm) in what we call Needloscopic Surgery. This results in "pinhole" scars that are hardly discernable.
The same technique is called Thoracoscopic Surgery when used in the thoracic cavity (to approach the esophagus, for example) or Endoscopic Surgery when used elsewhere (for example in the neck for Endoscopic Thyroid Surgery).
2. Can my operation be done using Laparoscopic Surgery?
Almost any conventional operation can be done laparoscopically. This can something simple, like the removal or a gallbladder or appendix, to something very complex, like the resection of the stomach for cancer. Some of the complicated operations can be technically demanding, and a good outcome depends on the skill and experience of the surgeon. In general, we believe that, under our hands, the laparoscopic options gives a better result. Occasionally however, laparoscopic surgery is contraindicated in certain patients, and some operations may be too difficult to offer any substantial benefit over conventional open surgery.
3. What are the contraindications to Laparoscopic Surgery?
The only absolute contraindications are an unstable patient (for example, someone who is bleeding actively from trauma) or a patient who is unfit for general anaesthesia (since GS is always required for laparoscopy). In certain patients, the contraindications are relative and have to be evaluated individually. These patients include those who have severe heart or lung disease, have previous abdominal surgery, bowel obstruction or bleeding problems.
4. What about pregnant patients?
In general, we try to not to do elective surgery during pregnancy. In those cases where we must, we try to delay the operation until the second trimester, or until fetal viability, or till after delivery. If surgery is absolutely essential, laparoscopic surgery is as safe as open surgery, and even offers certain advantages. However, great care has to be taken with surgery and anaesthesia as the dangers are real: about 12% risk of miscarriage in the first trimester, 5 to 8% risk or preterm labour in the second trimester and 30% risk of preterm labour in the third trimester.
5. What are the benefits of Laparoscopic Surgery?
Since only "keyhole" incisions are used, the post operative functional recovery is rapid. Most patients are discharged from hospital faster and return to work earlier. There is less wound pain and the cosmetic outcome is excellent. In the long term, there are fewer problems with post-surgery bowel adhesions. There is also recent evidence to suggest that the reduced disturbance to the immune system during laparoscopy results in better survival after cancer resection when compared to open surgery. This is because the minimal insults allow the body to fight off circulating cancer cells more effectively.
6. Are there any disadvantages of Laparoscopic Surgery?
Laparoscopic surgery is technically more difficult than conventional open surgery. Moreover, as some of these procedures have only evolved in the last few years, not all surgeons are trained to perform them. Surgeon related errors can occur. Finally, laparoscopic surgery often takes longer to perform and may cost more in terms of equipment used - although this is not always so!

Nowadays fast lifestyle is taking toll on everybody's health . The sleeping hours , diet , timing of meals , exercise , habbits , westernisation have altered everything . It have altered the health system likewise .
Ayurveda science firmly believes that any disease of any system starts with the alteration if Agni which is the digetive power . All the 3 doshas Vata , Pitta & Kapha should remain in balance to have perfect digestion . Any imbalance in this will create problems in digestion & then in other body systems .
Practically it is seen in many cases . When we clear the digetive tract from the ombalances , most health problems decrease . It is like a surprise for the person too .But this is practical experience .
Junk foods doesn't have any specific nutritive value . They just have the taste , nothing else . have anyone heard any doc have adviced to eat junk foods for any therapy ? Why ? As everybody knows the answer but deny to accept it . The Junk Food Free world should be a reality for the well being of the mankind .

Your hernia is suitable for repair by laparoscopic (keyhole) surgery. The operation is essentially
the same as when performed by conventional methods. In other words it will involve
placing a piece of nylon mesh material over the weak area in your groin. The main difference
between the two operations is the way in which this is done. The operation is done under a
general anaesthetic.
With laparoscopic hernia repair the nylon mesh patch is placed over the weak area from the
inside of the abdomen rather than by making a cut over the hernia itself. The operation involves
making 3 very small cuts in the abdomen. One cut of 1 cm in length is made just under
the umbilicus (tummy button) and the other two (each 0.5 cm in length) on either side. One of
the cuts is used to introduce a telescope with a camera on the end so that the surgeon can see
to operate on a television monitor. The other cuts are needed to introduce instruments into the
abdomen.
What are the advantages of laparoscopic hernia repair?
Patients having laparoscopic surgery generally recover faster and experience less discomfort
than those undergoing conventional surgery. Most patients with a hernia are suitable for this
technique. There are particular advantages for patients who have hernias on both sides of the
abdomen as both can be repaired through the same 3 small cuts. The other group of patients
for whom laparoscopic hernia repair is recommended are those who have had a hernia repair
in the past which has failed.
Are there any disadvantages?
Laparoscopic hernia repair is a more major procedure than conventional hernia repair because
it involves entering the abdomen. However because the cuts are so small recovery is generally
faster. There is a slight risk of damaging bowel or blood vessels within the abdomen and
if this were to occur it might mean a more major operation to repair the damage.
Because laparoscopic hernia repair is relatively new we do not as yet know exactly what the
long term results will be. With conventional surgery the risk of recurrence (return) of the hernia
is about 1 in 200. Laparoscopic hernia repair is basically the same operation as conventional
hernia repair. Thus we expect the results to be similar but until the operation has been
performed for many years we cannot be sure of this.
Post operative care
After your operation you should be able to resume normal activities as soon as it is comfort avoided for a few days. The cuts in your abdomen will be closed by either staples or stitches. These will need
to be removed approximately 7 days after your operation. You may resume work as soon as you comfort allows.
As with a conventional
repair it is sensible to avoid strenuous physical activity or heavy lifting for 3-4 weeks. Light exercise can
be resumed within a few days.
What can go wrong?
Bruising may be noticed either beneath the scars or in the groin area. It may extend into the scrotum or
the penis. This will gradually settle within 2-3 weeks. Occasionally a lump may be felt in the groin
within the first 2-3 weeks. This is caused by a haematoma (collection of blood) near the operation site. It
may be very like the original hernia but it will disappear over a few weeks. Occasionally, if large, it may
need to be drained with a needle. This will be done at your follow up outpatient visit.
Occasionally patients notice numbness or discomfort in the groin area or down the outside of the thigh.
This is much less common than after a conventional hernia repair and will settle over the course of a few
weeks.
Questions patients often ask
Is keyhole surgery safe?
Laparoscopic surgery is now well established and many hundreds of thousands of keyhole operations
have been carried out worldwide. Laparoscopic hernia surgery has been established since the late 1980’s.
What if you find a second unexpected hernia on the other side?
One of the advantages of this technique is it allows the surgeon to view both sides of the groin. In about
30% of patients a second hernia will be detected. It makes sense to repair this at the same time as it will
prevent the need for a second operation in the future.
Is Laparoscopic hernia surgery recommended?
The National Institute for Clinical Excellence (NICE) is an organization set up to examine the evidence
behind new techniques and drugs. Guidelines on Laparoscopic hernia repair were produced in July 2004
and details can be found on the NICE website at www.nice.org.uk. The main recommendations are:
1.1 Laparoscopic surgery is recommended as one of the treatment options for the repair of inguinal hernia.
1.2 To enable patients to choose between open and laparoscopic surgery (either by the transabdominal preperitoneal [TAPP] or by
the totally extraperitoneal [TEP] procedure), they should be fully informed of all of the risks (for example, immediate serious
complications, postoperative pain/numbness and long-term recurrence rates) and benefits associated with each of the three
procedures. In particular, the following points should be considered in discussions between the patient and the surgeon:
the individual's suitability for general anaesthesia
the nature of the presenting hernia (that is, primary repair, recurrent hernia or bilateral hernia)
the suitability of the particular hernia for a laparoscopic or an open approach
the experience of the surgeon in the three techniques.
1.3 Laparoscopic surgery for inguinal hernia repair by TAPP or TEP should only be performed by appropriately trained
surgeons who regularly carry out the procedure.

INCONTINENCE :
Fecal incontinence is the inability to control bowel movements, causing stool (feces) to leak unexpectedly from the rectum. Also called bowel incontinence, fecal incontinence can range from occasional stool leakage while passing gas to complete loss of bowel control.
Common causes of fecal incontinence include constipation, diarrhea, and muscle or nerve damage. The condition may be associated with aging and childbirth. Fecal incontinence can cause people to stay at home and withdraw from social events because an embarrassing accident. An estimated 5.5 million Americans, more commonly older people and women, suffer from fecal incontinence.
Surgical Repair of the Anal Sphincter
In patients who have significant fecal incontinence with damage to the muscles but not to the nerves of the anal sphincter, surgery may be the best option. Surgical options include:
* A sphincteroplasty to repair the damaged or weakened anal sphincter
* Surgical repair of rectal prolapse, rectocele or hemorrhoids
* A colostomy to divert the stool into a special bag (used only as a last resort)
* ANAL BAND : The unique ARTIFICIAL ANAL SPHINCTER :
INDICATED IN:
1.Permanent Colostomy after cancer surgery
2.Permanent Colostomy after accident surgery
3.Incontinence after sphincter damage due to accident or surgery or childbirth

SAY NO TO COLOSTOMY
Can Bowel Incontinence Be Prevented?
Since fecal incontinence in women is often caused by anal muscle or nerve damage that occurred during childbirth, prevention is not always possible. However, if the use of forceps can be avoided during childbirth, the period of labour not prolonged and the baby not delivered too rapidly, injury to the pelvic muscles and nerves can be avoided.
Also, chronic constipation may result in incontinence. Getting sufficient water, fiber and exercise can be effective in treating constipation .