الفهرس 
ACUTE ABDOMEN
Incarcerated herniaOnly 14 pages are availabe for public view
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Abstract
T
he majority of emergency admissions to surgical wards are patients complaining of abdominal pain. Gynecological emergencies remain a common cause of admission to general surgical wards being as high as 13% in some series.
Acute abdomen remains a difficult challenge to all medical practitioners. It should be emphasized that a well conducted history and a proper physical examination are important components of the evaluation of the patient with an acute abdomen. Laboratory and radiological investigations may confirm or exclude diagnostic possibilities that are being considered based on a proper history and physical examination. These tests should in no way replace any part of the history or physical examination. Confirmatory laboratory tests or radiographic studies are not mandatory to secure a diagnosis. They should only be ordered when they may directly influence patient care.
Ultrasonography often serves as the first study in evaluating the patient with abdominal or pelvic pain,it is sensitive and accurate in many abdominal conditions like ovarian cysts, ectopic gestation and adnexal torsion. It can detect acute appendicitis and other abdominal conditions. However, in cases like early appendicitis, pelvic adhesions, early intestinal ischemia and minimal pelvic fluid collection, transcutaneous ultrasound scanning does not seem to be the method of choice, CT has its powerful diagnostic modality for imaging the surgical abdomen, and plain film radiography can provide useful information in gastrointestinal perforation and obstruction, for which they should be the initial imaging study. The choice of imaging technology must take into account the cost, the likelihood that clinical benefit will be gained, the possibility of therapeutic gain, and the institutional experience with the chosen technology.
The ability to improve surgical decision-making in the acute abdomen using diagnostic laparoscopy is now established. When the decision to operate is uncertain, laparoscopy not only identifies those patients who do not require laparotomy, but also reveals those who need surgery which might otherwise have been delayed.
In fact laparoscopy has many advantages over all other diagnostic methods since it allows direct vision inside the pelvis and the abdomen in general. Early intestinal ischemia is diagnosed laparoscopically by the dusky appearance, absence of peristalsis, lack of serosal shine, edematous wall and / or haemorrhagic fluid in the pelvis or gutter and early intervention may prevent the disaster of mesenteric infarction to continue undiagnosed.
Another advantage of laparoscopy is that it can allow a biopsy to be taken from an early lesion.
Not only does laparoscopy prevent an unnecessary laparotomy but it can also be a minimally invasive way in so many surgeries like appendectomy, resection of an ovarian cyst, salpingectomy, adhesiolysis for intestinal bands or tubal adhesions as well as many other operations. In frequent occasions emergency laparoscopy exhibited a high degree of efficiency and safety.
Laparoscopic surgery means less direct contact between the surgeon and the patient and consequently less risk that the surgeon will acquire a virus infection from the patient or vice versa.
In patient terms, laparoscopic surgery has the advantages of avoiding large open wounds or incisions and thus of decreasing blood loss, pain and discomfort. Patients have fewer unwanted effects from analgesia because less analgesia is required.
Disadvantages of laparoscopy include that it is an invasive way of diagnosis and reported complications vary from 0.3 to 5%. However the reported complications of unnecessary laparotomy exceed this figure and the cost of delayed intervention can be a disaster. In addition laparoscopy is both costy and time consuming and requires a special training. These problems will be solved with time where new instruments and techniques are advised and with more popularization of this new modality.
Images from three-dimensional structures are transmitted via the laparoscope onto a two-dimensional screen, making it difficult to judge depth and reducing the perceptual cues for identification of anatomical structures. An added difficulty is that the visual field is smaller than with open surgery, and the necessity to work with screen images demands special mental as well as physical skills.Against this must be set the advantage that objects are magnified and with current digital cameras the resolution is very high; areas that would be difficult to inspect in an open procedure are now readily displayed).
Does laparoscopic surgery spell the end of the open surgeon? Clearly the answer is no: the skills of open surgery will remain indispensable.
However, a number of unanswered questions remain such as: who should perform emergency laparoscopic procedures? What should the selection criteria be? What are the cost implications?