EP.FRI.554 How long do patients wait for emergency laparoscopy? A local audit of service

Aim Anecdotal experience suggested patients undergoing diagnostic laparoscopy for appendicitis faced long pre-operative waiting periods. This project was undertaken to quantify the situation and determine how long patients were waiting for surgery. National guidelines recommend patients can reasonably wait 6-18 hours for surgery, as per NCEPOD classification of intervention (appendicitis considered to fall under urgent 2b category). Method A retrospective audit of 39 patients listed for diagnostic laparoscopy or appendicectomy during November 2019 was performed. Clinical notes and electronic records were reviewed to determine the timeline of clinical decision making and patient’s arrival in theatre. Operative and histopathology findings were also noted. Results The majority of patients (61%) underwent surgery within 18 hours of a documented decision to operate. Average wait was 17.5 hrs (mean). Longest wait was 41 hours (excluding isolated outlier). Documentation of decision to operate was noted to be poor (undocumented in 5 cases) and in some cases the patient was booked before a documented decision to operate. Variation between the operative and histopathological diagnosis of appendicitis was apparent. Conclusions The findings are re-assuring that once the decision was made to operate most patients had surgery within 18 hours. However, there is still room for improvement with regards to timeliness and documentation. The discrepancy between operative and histological findings highlight the challenge of diagnosing appendicitis accurately.

The Emergency Hospital Bucharest to the Forefront of the Emergency Laparoscopic Surgery Development

The use of laparoscopy in traumatic and non-traumatic abdominal surgical emergencies is unanimously accepted due to the well-known advantages of minimally invasive surgery. In the period 1961-1966 in the Clinical Emergency Hospital of Bucharest (CEHB) the first diagnostic laparoscopes were performed in the acute surgical abdomen, respectively in the obstructive jaundice by dr. Gh.Popovici, respectively dr.C.Petrescu.In the modern era, the first laparoscopic cholecystectomy was performed in 4 dec. 1993 by A.E.N.In 1994 the first laparoscopic appendectomies, gynecological emergencies, exploration in traumatic abdominal contusion, followed by perforated ulcer (1995), intestinal occlusion (1997), were performed. In the specialized literature, out of the 42 emergency laparoscopy articles published in the journal “Chirurgia” (1994-2019), 16 (38,08%) belonged to the CEHB team, 11 of AEN. In 2004 the original monograph "Laparoscopic Emergency Surgery" appeared. Specialized chapters are added in different volumes of surgical pathology. At the Romanian Assocation of Endoscopic Surgery Congress (RAES) of 2008, the international participation course “Laparoscopy in the acute abdomen” was organized. Since 2013, annual trauma workshops (DSTC ™) and non-traumatic abdominal emergencies have been organized with international participation by CEHB, the surgery clinic, and the UMFCarol Davila Department of Anatomy. CEHB surgeons presented papers at EAES,EATES and ESTES congresses. Of the 1699 laparoscopic operations performed in the clinic in 2018, accounting for 31.27% of the total operations, 493 (29.01%) were in emergency. The SCUB surgeons have had and have a major contribution in preparing the residents, implementing and developing emergency laparoscopy within the miniminvasive therapy, the therapy of the future.

Spontaneously conceived 17-week heterotopic pregnancy: a challenging and unusual diagnosis

A 37-year-old woman, gravida 2 para 1, arrived in our emergency clinic at 16 2/7 weeks of a spontaneously conceived pregnancy for abdominal pain. She was on oral antibiotics for 2 days to treat a suspected urinary tract infection with no improvement. Blood tests, abdominal ultrasound and intrauterine fetus were all normal. She left our emergency unit with laxatives. Four days later, she returned to our clinic with severe abdominal pain. We repeated abdominal and foetal ultrasonography and identified a left para-uterine 7×5 cm mass. As adnexal torsion was suspected, we performed an emergency laparoscopy. At laparoscopy, we found a left haematosalpinx and realised a left salpingectomy. Histology confirmed the presence of a heterotopic pregnancy (HP). This case illustrates the importance of exploring the adnexa in a gravid woman presenting with abdominal pain in the first and early second trimesters. Although rare, excluding a HP may prevent a life-threatening haemorrhage.

Laparoscopy-Assisted Repair for Intersigmoid Hernia

Intersigmoid hernia is a rare clinical entity. Only 6 cases of laparoscopic repair for intersigmoid hernia have been reported since 1977. We herein report such a case, which was successfully diagnosed preoperatively and treated with laparoscopic repair. A 50-year-old man with a chief complaint of abdominal pain and vomiting was admitted for the treatment of small bowel obstruction. The patient had no history of abdominal surgery. Computed tomography showed a dilated small bowel and a closed loop of small bowel dorsal to the sigmoid colon and the sigmoid mesocolon. With a diagnosis of an incarcerated internal hernia, the patient underwent emergency laparoscopy-assisted surgery. Laparoscopy showed that the ileum had herniated into the intersigmoid fossa, and therefore the patient was diagnosed with an intersigmoid hernia. Because bowel ischemia was not observed, we reduced the incarcerated small bowel, and the hernial defect was widely opened. After operation, the patient developed ileus and was treated with transnasal ileus tube. Thereafter, the patient made a satisfactory recovery and was discharged on postoperative day 21. The patient is in good general condition without ileus 42 months postoperatively.

Unruptured ovarian ectopic gestation: a rare clinical scenario

Ovarian pregnancy is a rare event, with the incidence ranging from 1 in 2000 to 1 in 60 000 deliveries and accounts for 3% of all ectopic pregnancies. The first case of ovarian pregnancy was published by Saint Monnisey. Authors report a case of a 23-year-old patient with severe lower abdominal pain following five weeks of amenorrhea diagnosed as tubal ectopic pregnancy on ultrasonography. The patient was taken up for emergency laparoscopy and unexpected finding of ovarian pregnancy was established. Early diagnosis and prompt treatment go a long way to prevent serious outcomes and to ensure favourable future reproductive potential.