RAJIV GANDHI UNIVERSITY OF HEALTH SCIENCES
BANGALORE, KARNATAKA
SYNOPSIS FOR REGISTRATION OF
SUBJECT FOR DISSERTATION
TITLE OF THE TOPIC“ROLE OF DIAGNOSTIC LAPAROSCOPY IN NONSPECIFIC ABDOMINAL PAIN.”
by
DR. HINA.A.KHAN
P.G M.S GENERAL SURGERY,
AL-AMEEN MEDICAL COLLEGE,
BIJAPUR
PROFORMA FOR REGISTRATION OF SUBJECT FOR DISSERTATION
1 / Name of the candidate and Address (in block letters) / DR. HINA A. KHANPRESENT - c/o Dr.Imtiyaz Kotwal,opposite reliance
tower,quereshi colony,athani road bijapur,Karnataka
BIJAPUR – 586102
PERMANENT – GP-93 LAKE PEARL SPRING COLONY, GODARMAU, AIRPORT ROAD, BHOPAL, MADHYA PRADESH
PIN CODE – 462010
2 / Name of the Institution / AL-AMEEN MEDICAL COLLEGE,
BIJAPUR
3 / Course of study and Subject / M.S. GENERAL SURGERY
4 / Date of admission to course / 30th MAY-2013
5 / Title of the topic / “ROLE OF DIAGNOSTIC LAPAROSCOPY IN
NONSPECIFIC ABDOMINAL PAIN”
6 / Brief resume of the intended work
6.1 Need for the study / Annexure – I
6.2 Review of literature / Annexure – II
6.3 Objectives of the Study / Annexure – III
7 / Material and Methods
7.1 Source of Data
7.2 Study Design
7.3 Duration of the study
7.4 Sample Size
7.5 Study Population
7.6 Inclusion Criteria
7.7 Exclusion Criteria / Annexure – IV
8. / Method of collection of data (including sampling procedure, if any) / Annexure – V
9. / Does the Study require any investigations
or interventions to be conducted on patients or
other humans or animals? If so, please describe briefly. / Annexure – VI
10 / Has ethical Clearance been obtained from
your institution in case of 9.
Sample informed consent form / Yes (Certificate has been enclosed herewith)
11 / List of References / Annexure – VII
12 / Signature of the Candidate
13 / Remarks of the Guide / Inspite of good clinical examination and all
available investigations diagnosis of chronic
abdominal pain cannot be made many a times.
Diagnostic Laparoscopy provides us with good view
of whole peritoneal cavity thereby clinching
diagnosis. Hence this study is taken up to evaluate
the role of Diagnostic Laparoscopy in nonspecific
abdominal pain.
14 / Name and Designation of
( in block letters )
14.1 Guide / DR. SAJID AHMED MUDHOL
M.S (GENERAL SURGERY)
PROFESSOR AND H.O.D
DEPARTMENT OF SURGERY
AL-AMEEN MEDICAL COLLEGE, BIJAPUR
14.2 Signature
14.3 Co – Guide / DR.S.P.GARAG
MS (GENERAL SURGERY)
ASSISTANT PROFESSOR
DEPARTMENT OF SURGERY
AL-AMEEN MEDICAL COLLEGE, BIJAPUR
14.4 Signature
14.5 Head of the Department / DR. SAJID AHMED MUDHOL
M.S (GENERAL SURGERY)
PROFESSOR AND H.O.D
DEPARTMENT OF SURGERY
AL-AMEEN MEDICAL COLLEGE HOSPITAL, BIJAPUR
14.6 Signature
15 / 15.1 Remarks of the Chairman and Dean
15.2 Signature
ANNEXURE – I
BRIEF RESUME OF THE INTENDED WORK
6.1 NEED FOR THE STUDY
Chronic abdominal pain of unknown origin represents a significant problem in surgical patients. Patients with chronic abdominal pain presents as more difficult diagnostic dilemma. In somecases even battery of investigations does not reveal the causes of pain. Due to improvements in instrumentation and greater experience with diagnostic and therapeutic laparoscopy, the procedure is no longer limited to visualization.
All strategies for the management of pain abdomen underline the need for an inter disciplinary approach to diagnosis and procedure. This requires focussed and intelligent use of efficient diagnostic tools. Diagnostic laparoscopy may be a key to solve the diagnostic dilemma of non-specific pain abdomen. Furthermore; it allows not only direct inspection of the abdominal cavity, but also surgical intervention if needed1.
Diagnostic laparoscopy is a minimally invasive surgical procedure that allows the visual examination of the intra-abdominal organs in order to detect pathology. Diagnostic laparoscopy was first introduced in 1901, when the German surgeon George Kelling performed a Peritoneoscopy in a dog which was called “Celioscopy”. Diagnostic laparoscopy is one of the few investigations available that could be used to determine the exact cause of chronic abdominal pain.
An accurate diagnosis is an important first step to determine the correct treatment for pain resolution. Although laparoscopy is very frequently used by surgeons in a wide spectrum of surgical procedures all over the world, its utility as a diagnostic procedure for chronic abdominal pain was not favoured initially, either due to lack of data on its effectiveness as a diagnostic modality, lack of training or expertise amongst surgeons, and/or lack of awareness among both doctors and patients2.
Despite new x-ray techniques, or scan, and ultrasound, the diagnosis of pain abdomen can be difficult at times ,so far, the cost effective non-invasive method of diagnosis is ultrasound, but that is not reliable as it is operator dependent. Next modality is CT Scan which is costly and not available in all the hospitals. History and physical examination will generally lead to correct diagnosis. Diagnostic laparoscopy when compared to open laparotomy is better in the absence of adhesions where whole of peritoneal cavity can be visualized but in case of retro peritoneal lesions, due to lack of tactile sensations the lesion cannot be palpated which is possible by open laparotomy3. The procedure allows rapid and thorough inspection of whole peritoneal cavity and pelvic cavity and paracolic gutter that is not possible with the open approach. Diagnostic Laparoscopy is an emerging tool in diagnosis of chronic nonspecific abdominal pain and is therefore nowadays recommended and accepted worldwide4.
The purpose of current study is to determine the efficacy of diagnostic laparoscopy on patient with chronic abdominal pain. Additionally, a negative laparoscopic examination potentially would avoid the morbidity and unnecessary laparotomy in this group. Hence this study is taken up.
ANNEXURE – II
6.2 REVIEW OF LITERATURE
Laparoscopy has embraced the new millennium where in most of elective and emergency surgeries are done laparoscopically then the open laparotomies. Surgeons all around the world and for time immemorial have two important traits:
1. Curiosity for the unknown.
2. Sense of adventure.
It is this curiosity which made surgeons, of the whole of last century to devise instruments which will fit in each and every normal orifice, “just to get a glimpse inside”. As if this was not enough they then started creating artificial holes, and started observing internal structures of the body from a different perspective. Thus dawned an era of laparoscopic surgery with Philip Moriet , performing the first laparoscopic cholecystectomy in 1989, in France. The whole world was swept with a wave and surgeons were performing laparoscopic operations and acquiring tremendous skill and experience.
Later the use of laparoscopy was extended even for emergencies and abdominal trauma. The skills and experience of elective laparoscopic surgery were applied to diagnose, as well as treat, abdominal emergencies with good result. So, from 1901 when Kelling performed the first diagnostic peritonioscopy in a dog and Jacobeus who was credited for performing the first operation on humans, we have come a long way.
Calk and Brital, in 1928, published the first series and then this branch remained dormant until the 1980s, when it was done exclusively by gynaecologists.
The universal acceptance of laparoscopy was due to four factors:-
1. Advances of technology with the introduction of compact, high definition, solid state video system, which allows a team approach.
2. Popularity of laparoscopic cholecystectomy which is now the gold standard for treating gall stones disease.
3. Enthusiasm for key hole surgery shared by both surgeons and lay people.
4. Companies seeing the potential and entering the market aggressively.
Diagnostic laparoscopy is a minimally invasive surgery for the diagnosis of a medical ailment. The procedure allows the direct visual examination of intra-abdominal organs including large surface area of the liver, gall bladder, spleen, peritoneum, pelvic organs and retroperitoneum5.
Biopsies, aspiration and cultures can be obtained and laparoscopic ultra sound may be used. Laparoscopy allows a surgeon to diagnose and obtain information about dissemination of disease and to diagnose patients with abdominal findings6.
Despite sophisticated methodology to image abdominal content, establishment of a diagnosis prior to image difficult for several conditions. Unnecessary laparotomy is painful, increases hospital stay, increases hospital costs and is associated with a morbidity of 5% to 22%.
The use of diagnostic laparoscopy in trauma patients is increasing but is restricted to haemodynamicaly stable patients.
Hannu Paajanen, Kristiina Julkunen and Hedi Waris7. : Prospective study non randomised study of 72 patient (60 women and 12 men) with chronic pain abdomen, Diagnostic laparoscopy was performed. Finding included intrabdominal adhesions in 61, gynecologic disorders in 4, chronic appendicitis in 1 and no abnormalities in 6 patients. In the long term follow up, chronic abdominal pain was totally healed in 33% , diminished in 46% and unchanged in 21% of the patient. A total of 65 patient (90%) reported that the surgery had been beneficial for their intractable pain.
Prafull K. Arya and K.J.B.S Gaur8 : Prospective study of 49 patients who underwent Laparoscopy for chronic abdominal pain. Finding included (including Histopathology) abdominal tuberculosis in 14, appendicitis in 13, postoperative adhesions in 4 , Jejunal Diverticulitis in 1, genito–urinary tuberculosis in 5, endometriosis in 2, Fibroid uterus in 2, pelvic inflammatory disease in 3 and no organic cause in 5. Present study shows a diagnostic rate of 90% in patients with lower abdominal pain. Therapeutic laparoscopy has a role in many of these patients.
Onders RP, Mittendorf EA9. Performed diagnostic laparoscopy for the evaluation and treatment of chronic abdominal pain in 70 patients. Findings included adhesions in 39, hernia in 13, adhesions from the appendix to adjacent structure in appendiceal pathology in 5, endometriosis in 3 and gallbladder pathology in 2. Ten patients had no obvious pathology. Laparoscopy has a significant diagnostic and therapeutic role in patients with chronic pain. With aggressive indicated therapeutic laparoscopy including adhesiolysis, appendectomy, cholecystectomy, or hernia repairs, more than 70% of patients can have improvement in their pain.
Lavonius M, et al10 - Performed exploratory laparoscopy in patients with chronic abdominal pain. Forty-six patients underwent diagnostic laparoscopy for abdominal pain of unknown origin during 1992-1996. An organic disease was found in 68% of the laparoscopies. Adhesions were found in 29 patients, inguinal hernia in 2 patients, and abnormal mesenteric lymph nodes in 1 patient. Adhesiolysis was carried out in 24 patients. Seventy-seven percent of patients who had undergone adhesiolysis considered the result good or beneficial. Sixty percent of all patients reported a beneficial outcome after laparoscopy. This retrospective study suggests that laparoscopy is a safe and useful procedure in the diagnosis and treatment of chronic abdominal pain.
Miller K, Mayer E, Moritz E11 - Performed 66 laparoscopic treatments on 59 patients. Laparoscopy provided diagnosis in 53 of 59 patients (89.8%). All 66 attempted laparoscopic procedures were completed successfully, no conversion to laparotomy was necessary, and no postoperative complication occurred. Five out of 59 patients (8.5%) revealed no improvement of pain postoperatively, and 6 out of 56 (10.7%) still suffer from pain at the time of the follow-up. The pain assessment and disability score was statistically significant postoperatively and at the time of the follow-up in relation to the preoperative score.
ANNEXURE – III
6.3 AIMS AND OBJECTIVES:
Laparoscopy has definitely reduced the rate of negative non therapeutic laparotomies in undiagnosed abdominal pain. Once diagnosis is established in Diagnostic Laparoscopy, It also helps in proper therapeutic management of patients. All the common painful abdominal conditions such as chronic appendicitis, gynaecological condition can be diagnosed laparoscopically and treated effectively
by therapeutic laparoscopy.
The study concentrates on the fact that undiagnosed abdominal pathology is an important cause of morbidity and the changes in the patient’s quality of life and longevity, that can be improved or restored to normalcy by Diagnostic Laparoscopy and effective postoperative care.
This study is intended to determine:
1. The role of Laparoscopy in diagnosis and management of nonspecific pain abdomen where other clinical symptoms and investigations are not conclusive.
2. The role of Laparoscopy to know exact pathology.
3. The ability to avoid unnecessary non-thereupatic Laparotomies.
4. The various clinical presentations in nonspecific abdominal pain.
5. Benefits and Complications of Diagnostic Laparoscopy.
6. Outcome of the study.
ANNEXURE – IV
MATERIAL AND METHODS
7.1 SOURCE OF DATA
Clinical material for present study comprises the patients with nonspecific abdominal pain where other clinical symptoms and investigations are not conclusive, attending the Out Patient Department and admitted to Al Ameen Medical College Hospital, willing for diagnostic laparoscopy.
7.2 Study Design: Prospective descriptive study.
7.3 Duration Of Study: 1 and 1/2 years.
7.4 Sample Size: A total of 50 patients, who fulfill the inclusion and exclusion criteria from Al Ameen Medical College Hospital Bijapur, will be included in the study.
7.5 Study Population: Patients admitted to surgery ward of Al Ameen Medical College Hospital.
7.6 Inclusion Criteria:
· Chronic pain abdomen of uncertain etiology and conditions which are unexplained by other investigation and clinical symptom.
· Age group of 15-50 years.
· Both sexes are included.
7.7 Exclusion Criteria:
· Inability to tolerate pneumoperitoneum or general anaesthesia.
· Uncorrect coagulopathy.
· Generalised peritonitis.
· Haemodynamic instability.
· Mechanical or paralytic ileus.
· Acute pain abdomen.
ANNEXURE V
8. METHOD OF COLLECTION OF DATA:
TOPIC: “ROLE OF DIAGNOSTIC LAPAROSCOPY IN NON SPECIFIC ABDOMINAL PAIN”
GUIDE: DR. SAJID AHMED MUDHOL
M.S. (GENERAL SURGERY)
PROFESSOR AND H.O.D
DEPARTMENT OF GENERAL SURGERY
CANDIDATE: DR. HINA.A.KHAN
PROFORMA
Sl No. Opd/ Ipd No.
Name DOA
Age DOD
Sex Occupation
Address
Presenting symptoms:
· Abdominal pain:
Onset
Duration
Continuous or Intermittent
Intensity – Increased / Decreased / Same
Site
Type
Radiation / Shifting / Migration
Aggravating and Relieving factors
· Abdominal distension
Onset
Generalised / Local
Increasing / Decreasing / Same
· Vomiiting / Nausea
Frequency
Type
Content
Haematemesis
· Jaundice
· Bowel symptoms
Constipation / Loose motion / Malaena