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Incidental findings at Laparotomy Preoperative evaluation and

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Incidental findings at Laparotomy Preoperative evaluation and Powered By Docstoc
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Incidental findings at Laparotomy Preoperative evaluation and presumptive diagnosis do not always tell the whole story. Despite careful preoperative evaluation, asymptomatic lesions, which escape identification, will be encountered during abdominal exploration for other reasons. This reality is the rationale for a thorough and systematic approach to the evaluation of the abdominal cavity during all procedures. Failure to identify coincidental processes undoubtedly leads to progression of those diseases and potentially to incurability.

Whether a finding is incidental, requiring no additional treatment, or significant, requiring precedence over a planned procedure, will be outlined. Additional operations and/or procedures are often required to diagnose and treat a disease process, that was unanticipated , appropriately. The problems encountered by the surgeon when an unforeseen condition is identified during laparotomy is as follows: 1. Deciding on the most appropriate action. 2. No consent for additional procedures. 3. Existing co-morbidities of the patient. 4. Morbidity of additional procedures. 5. Conservative versus aggressive treatment. 6. Palliative versus curative procedures. Often unexpected finding at the time of laparotomy require additional procedures not anticipated preoperatively. This may require additional consent from the patient or family, if the patient is under general anaesthesia.

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Patients and families may opt for very aggressive treatment algorithms or conservative and palliative treatment. This highlights the need for

communication between the surgeon and patent/family. Co-morbidities of a patient and the morbidity of secondary procedures must be taken into account when deciding the most appropriate course of action. Subjecting patents to additional procedures with significant increases in morbidity should not be taken lightly.

When defining potential treatment algorithms, consideration must be given to patient wishes and potential response to additional procedures. Clearly, what is best for the patient should always guide treatment, but how patients respond to unexpected stomas or extirpation can taint the physician-patient relationship. Finally, the best option for the management of surgical patients come from accurate and complete diagnostic evaluation before surgical intervention. However, surprises still occur.

GASTROINTESTINAL TRACT : A. Neoplasms of the G I tract : . Malignant neoplasms :

Invasive masses of the stomach, small bowel, colon or appendix are encountered occasionally.

Stomach : Accurate staging is essential for patients with adenocarcinoma of the stomach found incidentally.

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Resection

is

recommended

for

early lesions

because

subtotal

gastrectomy carries little additional morbidity and these lesions are potentially curable. More advanced lesions requiring near total or total gastrectomy are best left for a planned second operation, unless the patient’s preoperative symptom complex will clearly benefit from a palliative resection. Small bowel: Invasive small bowel tumours should be resected with adequate margins and a thorough abdominal exploration should be done for purposes of accurate staging. Colorectum : Incidentally found colorectal cancers in asymptomatic patients are likely to be at an early stage. Resection of early lesions carries a 5 year survival rate of up to 88%. Early resection is the only option for potential cure and colectomy with adherence to the principles of colorectal cancer resection is indicated. Whether to do this at the time of laparotomy or as a planned procedure during the same admission is an issue of location and extent of the disease. Patients with pending obstruction or perforation generally require a Hartmann’s resection and end colostomy at the first operation. Generally right sided lesions can be resected with a primary anastomosis in spite of the bowel being unprepared. Transverse, left sided and sigmoid lesions would be best approached after a bowel preparation, which may be done during the same admission. If the surgeon is familiar with the technique of either on table colonic irrigation or intracolonic tube bypass, either could be employed prior to resection and primary anastomosis. This then would obviate the need for a second procedure.

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Most surgeons stage the abdomen clinically in this scenario, obtaining biopsies of extracolonic disease and defer resection to a second procedure. Invasive cancers requiring en bloc resection of adjacent organs require a preoperative bowel preparation and a planned second procedure. (These lesions will be of later stage and patients will have a limited 5 year survival.)

Tumours with evidence of pending obstruction require either Hartmann’s resection or diversion followed by resection in a second stage. These patients require placement of a stoma with reversal at a later time, if appropriate . Appendix : Several types of invasive appendiceal mass may be encountered unexpectedly. These lesions are rare, occurring in less than 2% of all appendectomies. They usually remain asymptomatic until the patient presents with appendicitis. These lesions vary in aggressiveness and intraoperative frozen sections should be performed for all appendiceal masses: • For uncomplicated mucoceles appendectomy is sufficient with post operative colonoscopy because of their association with colon carcinoma. • Pseudomyxoma peritonei secondary to a benign mucocele necessitates peritoneal lavage with evacuation of all mucous. • Cystadenocarcinoma (diagnosed on frozen section) require right hemicolectomy at the time of laparotomy. Interval right hemicolectomy should be reserved for patients whose frozen

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section is nondiagnostic, but permanent section reveals an invasive cystadenocarcinoma. Either scenario mandates

evaluation of the entire colon in the postoperative period. • Therapy for appendiceal carcinoids is dependant on size. Lesions smaller than 2 cm have minimal malignant potential and are treated adequately with appendectomy. However, if there is

mesoappendiceal involvement or a high mitotic index, a right hemicolectomy is indicated. Carcinoids larger than 2cm require formal right hemicolectomy. Occasionally patients present with a clinical picture and imaging studies consistent with ruptured appendicitis. caecum. At operation some of these

patients are found to have ruptured tumours of either the appendix or This situation mandates formal right hemicolectomy at the Posttime of laparotomy with inta-operative evaluation of the liver.

operative management includes an evaluation for metastatic disease and medical oncology consultation for consideration of adjuvant therapies. .Benign neoplasms of the GI tract : Rarely benign masses or masses with low grade invasive potential are found at laparotomy. These include stromal cell tumours of the stomach or small bowel, colon lesions and carcinoids. These tumours should be resected locally with 2-3cm margins in the stomach and 5cm margins in the small bowel. Appropriate definitive therapy should be delayed until the diagnosis is obtained on a permanent section.

B. Non –neoplastic conditions of the GI tract . Inflammatory bowel disease

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Ulcerative colitis Unsuspected ulcerative colitis found at laparotomy without perforation, abscess or toxic megacolon, may be left in situ with the understanding that medical treatment and eventual elective surgical resection to eliminate long term risk of colorectal cancer is indicated.

Unexpected perforation or abscess necessitates resection of the involved segments with the understanding that the resection of the remaining colon is completed at a later date.

Finding of a toxic megacolon mandates subtotal colectomy. Crohn's disease It is not infrequent to find Crohn’s disease when exploring a patient for abdominal pain (commonly right lower quadrant), obstruction and abdominal sepsis. Resection of the diseased segment with unaffected margins, being careful to maintain as much bowel length as possible, remains the mainstay of treatment. For asymptomatic patients, in the absence of perforation, abscess, pending obstruction or fistula formation, incidentally recognised Crohn’s disease should not be managed medically without resection. Ischaemic bowel The patient with ischaemic bowel can present in a variety of ways. In a patient who is otherwise healthy, the onset of ischaemic bowel may present itself as intestinal angina. Early ischaemic bowel can manifest with pain out of proportion to examination, sepsis of explained origin or sepsis in a patient who is unable to communicate symptoms of pain. Perforation manifested by free air on radiographic examination is a late finding. In the absence of peritonitis or other evidence of bowel

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ischaemia that has progressed to necrosis, urgent angiographic evaluation may be of benefit. Occasionally interventional vascular

techniques, with or without thrombolytic therapy, may be appropriate. Despite the ability to treat early bowel ischaemia, most patients with ischaemic bowel present late, already with necrotic bowel. When

necrotic bowel is identified at the time of laparotomy an attempt should be made to determine the aetiology of the ischaemic insult. The most common aetiology is a throbo-embolic event resulting from an underlying clot or atherosclerotic disease.

The pattern of ischaemia can be patchy or with localised lesion and the treatment will vary depending on the pattern of necrosis. bowel is no longer viable, resection is necessary. When the When bowl is

marginally ischaemic, without patchy areas of necrosis, it is reasonable to observe the intestine to preserve length. As much length as possible should always be preserved, especially when large areas of the bowel have become necrotic. At laparotomy a complete abdominal exploration should first be undertaken to identify all sources of pathology or intra abdominal sepsis. Second, the extent of bowel ischaemia should be carefully measured and documented; this is important for subsequent operations and identifying the length of remaining bowel.

Frankly necrotic bowel demands resection.

In cases of total bowel

ischaemia, involving the small bowel from the ligament of Treitz to the iliocaecal valve, consideration should be given to aborting the resection and having a frank discussion with the patient’s family. In this scenario palliative measures are the most appropriate because loss if the entire small bowel is not compatible with survival.

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Once the extent of the resection is identified, consideration must be given to the remaining continuity of bowel. Options include primary

anastomosis and in situations of significant necrosis and a contaminated abdomen, it may be necessary to create one or more end enterostomies. During a thrombotic event, anticoagulation of the patient may be indicated. The arterial tree must be examined for evidence of thromboembolism. Emboli most frequently lodge 8-10cm distal to the ligament of Treitz within the initial branches of the superior mesenteric artery and Doppler signals should be obtained along this vessel to the root of the mesentery, ensuring intact perfusion. Emboli, when identified, can be removed by embolectomy or bypassed (aorta-SMA or coeliac SMA bypasses). A re-look should be planned 24 to 48 hours later as nearly 50% of cases will require additional bowel resection.

Mesenteric venous thrombosis can manifest with necrotic bowel and the venous structures are dilated and clot filled. Here the patient must be anticoagulated, the necrotic segments of bowel resected, and a second look laparotomy must be planned. The patient should be evaluated post operatively for hereditary thrombophilic conditions. Patients suffering from non-occlusive mesenteric ischaemia can present at laparotomy with ischaemic bowel as well. This disease arises from a diffuse arterial vasospasm of the mesenteric vasculature resulting in ischaemia. Patients should be anticoagulated, necrotic bowel resected and an angiogram performed as early as possible. Vasodilators can be infused through indwelling arterial catheters to counteract vasospasm. A second look laparotomy must be considered. Also, a careful search for inciting factors should be undertaken (often over aggressive dialysis).

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In general, the finding of ischaemic or necrotic bowel at laparotomy is an ominous sign. Intervention should be undertaken to maintain as much bowel length as possible with the goal being preservation of at least 100cm of small bowel to enable adequate nutrition. If possible the iliocaecal valve should be left intact as well, since this aids in slowing small bowel transit time and thereby improving absorptive potential. In patients who have a substantial portion of small bowel resected, severe diarrhoea can result, making their care very difficult and their quality of life poor. Referral to centres specialising in the care of patients with short-gut syndromes may help avoid some of the long term complications associated with the treatment of this disease. Meckel’s Diverticulum A Meckel’s diverticulum is not infrequently found in the patient with right lower quadrant pain. (Incidence 2%). Resection is recommended in any patient whose diverticulum has established heteroptic mucosa, has fibrous bands to the umbilicus or mesentery that may cause obstruction, is greater than 2cm in length or in patients of less than 40 years of age and of good health. Resection should not be performed if the primary procedure involves the use of prosthetic materials.

Resection should encompass the entire diverticulum along with it’s heterotopic mucosa. This may be accomplished via segmental small bowel resection or diverticulectomy in the diverticulum possessing a long neck.

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In all other situations an incidentally found, asymptomatic Meckel’s diverticulum, should not be removed.

HEPATO-BILIARY AND PANCREAS : A. Neoplastic disease : Liver mass Finding pathologic lesions within the substance of the liver is not uncommon. lesions. However, a certain percentage will be either primary malignant tumours or metastases. The action taken after discovering such a lesion would depend on which type of lesion it is expected to be and what the appropriate therapy for that lesion is. Most of these lesions are benign ; most often haemangiomas, focal nodular hyperplasia, hepatic adenoma and cystic

Gross examination, intra-operative ultrasound are all intra-operative techniques used to characterise the lesion and to provide data that would be useful in later therapy. In most cases resection of the lesion, if indicated, would be deferred to a second operation. On gross examination focal nodular hyperplasia is typically a red-brown firm lesion, whereas hepatic adenomas are typically soft and pale yellow. Haemangiomas are either beefy red in colour or pale if there is a fibrous component.

Ultrasound is useful in examining cystic lesions for septations and also for studying the relationship of suspected malignant lesions to surrounding vascular and biliary structures. Additional lesions within the hepatic parenchyma can easily be identified and characterised. Hepatocellular carcinoma often appears hyperechoic whereas

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metastases can have a varied presentation. Benign lesions often appear as normal liver parenchyma.

In cases where gross and ultrasound examinations are not definitive, a core needle biopsy is easily performed intra-operatively with negligible morbidity to provide a diagnosis on either frozen or permanent section.

’Attention should also be given to examining the loco-regional lymph node basins, particularly the periduodenal, retro-pancreatic and coelic lymph nodes that might harbour metastatic disease.

For

the

non-infectious,

asymptomatic

benign

lesion

expectant

management is generally the rule, with exception of hepatic adenomas greater than 5cm or enlarging on interval imaging.

Malignant lesions are generally resected if the criteria for resection for that specific lesion are met. This is mostly carried out at a second, planned operation. Performing a resection, without patient consent and a more thorough oncologic evaluation would be unwise in most instances. However, wedging out a small exophytic single lesion on the surface of the liver, for diagnostic purposes, would not be unreasonable. Gallbladder mass Gallbladder carcinoma is rare and an incidental finding in 0.30 to 2.3% of all cholecystectomies. A suspicious gallbladder mass found during lapraroscopic cholestectomy should be biopsied for frozen sections. The gallbladder should be removed using extraction bags to prevent seeding. The decision to subject the patient to an extensive dissection and liver resection is determined by the stage of the tumour.

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More advanced lesions (T2NOMO, T2N1M0 or T3N1MO) should

be

converted to an open procedure and have shown improved survival benefit with cholecystectomy and resection of the tumour bed with regional lymphadenectomy. Pancreas mass Unless large, pancreatic masses are unlikely to be discovered during routine abdominal exploration. Possible etiologies include pancreatitis with or without pseudocyst and serous cystic neoplasms. The remaining causes represent either primary pancreatic malignancies (eg. Ductal carcinomas, neuroendocrine tumours) lesions with malignant potential (eg mucinous cystadenomas) or rarely, metastatic disease. These lesions are typically identified with preoperative abdominal imaging in symptomatic patients or discovered as “incidentalomas” during imaging for other conditions. Since many of these tumours could be

asymptomatic, particularly the more unusual pancreatic tumours, it is possible that they would first be encountered during laparotomy for other reasons.

When an unexpected mass in the pancreas is found, efforts should be made to characterise the lesion by using techniques similar to those used for incidental hepatic lesions. Gross examination and intraoperative ultrasound are useful tools to assess the relationship of the mass to vascular structures and the pancreatic duct and examination of the loco-regional lymph node should be completed. Ultrasound examination accurately identifies cystic lesions and allows for sampling of the fluid for culture, as well as enzyme and tumour marker analysis(CEA, CA 19-9).

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Most malignant lesions of the pancreas are treated with resection given that the mass meets criteria for resectability.

Pancreatic lymphoma and metastatic disease to the pancreas are examples of lesions which may not be primarily treated with surgery. Performing a core needle biopsy at the time of the initial operation has many potential benefits, including ruling out benign disease and establishing a tissue diagnosis in those with unresectable disease, which can be used to direct other neoadjuvant or adjuvant therapies.

Pancreatic resection carries significant morbidity and mortality and should only be undertaken after complete evaluation and discussion with the patient and family members.

Available data should be gathered intraoperatively to allow for clinical diagnosis and nonpathalogical staging. Exceptions to this approach would be cases with tumours that are clearly unresectable and with impending gastric or biliary obstruction. It is not unreasonable to perform palliative measures at the time of diagnosis in patients with end state disease. B. Non-neoplastic disease :

Cirrhosis When cirrhosis is encountered unexpectedly during surgery, the surgeon must carefully reassess the need for the planned operation and consider carefully the patient’s history and any available preoperative data. It has been documented in many studies that patients with cirrhosis have much higher morbidity and mortality with anaesthesia and surgery then healthy controls.

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Patients without ascites or a history of encephalopathy and normal preoperative liver function tests, are likely to tolerate lesser operations with only mildly increased morbidity and equivalent mortality when compared with healthy subjects.

Patients with ascites, encephalopathy and abnormal liver function tests are likely to have significantly increased morbidity and mortality. Often with induction of anaesthesia alone.

Unless the planned procedure is a mandatory one, it should be deferred and a liver biopsy should be taken for pathologic diagnosis. Biliary conditions Incidental cholelithiasis found during laparotomy in the absence of biliary symptoms generally does not require cholecystectomy. The literature suggests that certain subgroups of patients are at increased risk of gallstone related complications and some authors recommend concomitant cholecystectomy in these patients. These include resection of cholerectal cancers requiring postoperative adjuvant chemotherapy, splenectomy for sickle cell disease, patients undergoing Roux-en-Y gastric bypass (as part of bariatric surgery). * Colorectal Cancer Resection: Either therapeutic option is acceptable and appropriately based on the current literature. * Roux-en-Y gastric bypass: practised. There is no consensus about the

appropriate treatment and incidental cholecystectomy is not routinely

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* Splenectomy for sickle cell anaemia: Prophylactic cholecystectomy is generally recommended during splenectomy procedure because of the high incidence of pigment gallstone formation and biliary complications in the patient. Acute cholecystitis Unanticipated acute cholecystitis found at laparotomy, generally mandates cholecystectomy. ERCP). Intraoperative cholangiogram may be necessary because of the lack of properative evaluation (LFT, U/S,

Gallstone Ileus and Gallbladder-Enteric Fistula Patients with gallstone ileus are often explored for bowel obstruction. A large calculus can be identified anywhere in the gastrointestinal tract, but most often in the jejunum or ileum with the stone being unable to pass through the iliocaecal valve. Enterotomy with extraction of the obstructing stone and closure has been the traditional treatment, but resection of the involved segment is not inappropriate, especially if extraction will narrow the bowel lumen. The underlying biliary enteric fistula should be considered at the primary operation.

Most advocate takedown and repair of the cholecysto-enteric or choldedocho-enteric fistula during initial exploration. This may be in the form of cholecystectomy with common bile duct exploration and repair over a T-tube or Roux-en-Y choledocho-jejunostomy. This approach

assumes that the patient is of appropriate age and medical condition to undergo a more involved procedure and is clinically stable. Simple relief

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of the bowel obstruction with delivery of the gallstone without concurrent repair of the fistula has a recurrence rate of 4-7%, but may be acceptable for the elderly, debilitated or the unstable patient. PERITONEUM : Carcinomatosis In abdominal carcinomatosis, found incidentally, definitive therapy is rarely an option. Attempts to localize and definitively diagnose tumours, offering appropriate palliation, is often the best option. If the reason for laparotomy is unrelated to a neoplasctic process, the decision algorithm quickly becomes complex. A suggested approach is as follows: • Acute processes (eg, acute cholecystitis, acute appendicitis,) must be dealt with primarily. • Attempts to obtain a tissue diagnosis should be paramount. • The abdomen should be thoroughly explored in search of the primary source of the neoplasm. • Any finding posing an immediate danger eg. Isolated small bowel metastasis with impending obstruction, and if an additional procedure would not add significant morbidity to the procedure, then resection or excision is warranted.

If the source is not found or cannot be confirmed at the time of laparotomy, eg metastatic melanoma or bronchus carcinoma then closure and complete evaluation as directed by the permanent section obtained by pathology should be pursued. When the etiology is evident, good communication with the family is essential. It is most appropriate to consult with waiting spouses or family

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at the time of surgery about unexpected findings and appropriate course of action.

Carcinomatosis is most commonly encountered with certain gastrointestinal tumours, including • Pancreatic cancer, • Gastric cancer, • Mesotheliomas and • Ovarian tumours. Pancreatic neoplasm resulting in carcinomatosis do not require definitive resection. Palliation via hepaticojejunostomy with or without gastrojejunostomy is most appropriate in this setting and should be discussed with the family. Gastric carcinoma may be palliated with total or subtotal gastrectomy in patients with significant dysphagia. The extent of preoperative

symptoms may guide the need for a palliative procedure with the consent of the family. Mesotheliomas do not require resection. Definitive diagnosis with biopsy is essential to guide postoperative chemotherapy.

Ovarian cancers found unexpectedly are unique in their evaluation. An intraoperative consultation from a gynaecologic oncologist is most appropriate. In their absence a staging laparotomy is indicated. This includes washing of each quadrant of the abdominal cavity for cytology, following this biopsies should be taken from the diaphragm bilaterally, 4 quadrant peritoneal biopsies, biopsy of pelvic peritoneum and the omentum. The para-aortic lymph nodes should also be examined. These maneuvres will provide accurate pathological staging on which

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subsequent therapy can be based. A total abdominal hysterectomy with bilateral salpingo-oophorectomy would be in order for postmenopausal women, definitive resection must be delayed to first counsel the patient, but a staging procedure should be performed. Several other gastrointestinal tumours may infrequently result in carcinomatosis : A primary colorectal tumour should be resected at the time of exploration, after consultation with the family.This may necessitate colostomy or ileostomy in the face of an unprepared bowel. Oesophageal, biliary, gallbladder, hepatic or retroperitoneal cancers resulting in carcinomatosis, may require palliation at the time of laparotomy. Placement of an enteral access, cholecystectomy to avoid obstruction of the gallbladder, bowel resection to avoid bowel obstruction or gastrointestinal bypass may circumvent imminent complications in patients with these tumours.

GYNAECOLOGICAL CONDITIONS : Ovarian Torsion: Ovarian torsion is occasionally found at exploration for peritonitis or appendicitis. The usual treatment is oophorectomy. However, if the

ovary appears viable after detorsion, it is reasonable to attempt ovarian salvage. Fixation of the ovary has been described to reduce the risk of reoccurrence; particularly desirable in young women.

Ovarian and uterine masses: Solid masses are sometimes identified within the tubes or ovaries. First an ectopic pregnancy must be ruled out. Ideally beta-HCG levels would

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diagnose pregnancy, in women of childbearing age, preoperatively. Excluding this, a solid mass would be viewed with suspicion. Simple salpingo-oophorectomy may provide a tissue diagnosis, however, this is rarely adequate treatment. Bilateral salpingo-oophorectomy may be In women of considered in elderly patients at the time of surgery.

childbearing age definitive therapy should be deferred until findings can be discussed with the patient. In cases of malignant potential a complete evaluation of the abdominal cavity should be done (as for ovarian cancer – mentioned above).

When an enlarged uterus is found at laparotomy, care must be taken to identify the aetiology. excluded. An unsuspected uterine pregnancy must be In cases where a complete pregnancy screening had not

been undertaken, or may be inconclusive, an intraoperative ultrasound can help identify the contents of an enlarged uterus. modified to protect the foetus: - elective procedures should be deferred - urgent or emergency procedures should be completed with the knowledge that the needs of 2 patients must be addressed. Specific pathology should be identified at the time of laparotomy. Definitive therapy can usually be deferred until an appropriate specialist can be consulted for appropriate care. Ovarian cysts Cystic enlargement of the ovary is commonly seen in women of childbearing age – these cysts are typically functional in nature, but can be responsible for abdominal pain (even acute onset abdominal pain). If a previously

undiagnosed pregnancy is found, the anaesthetic and surgery should be

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Large heterogeneous cysts or cysts appearing in post menopausal women are suspicious of malignancy. In premenopausal patients with large cysts, simple cystectomy may be appropriate treatment.

Cystectomy is not indicated for incidentally discovered, asymptomatic cysts, unless they are larger than 5-6 cm in size. Large complex cysts require tissue evaluation and may need further therapy. Hysterectomy or partial oophorectomy can usually be accomplished and rarely should more extensive resection be undertaken without clear indication. For large or complex cysts staging maneuvres for ovarian cancer should be performed.

In postmenopausal women, in whom there is a suspicion of malignancy, all cystic lesions should be treated with oophorectomy, regardless of size. There are no significant problems associated with resection of a single ovary and unilateral oophorectomy can usually be accomplished during the course of another operation, without significantly adding to the risk or length of the operation. Staging maneuvres for ovarian cancer should be completed as well.

Although definitive therapy for ovarian cancer includes bilateral salpingooophorectomy and total abdominal hysterectomy, it is difficult to recommend hysterectomy in most situations without prior discussion with the patient.

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REFERENCES

1. Breaux JR, BRINGAZE w. Chappuis C. Cohn I Jr. Adenocarcinoma of the stomach: a review of 35 years and 1,710 cases. World J Surg 1990: 14-580-6 2. Shui MH, Perotti M< Brennan MF. Adenocarcinoma of the stomach: a multivariate analysis of clinical, pathological and treatment factors. Hepatogastroenterology 1989; 36:7-12. 3. Gilbertson V. colon cancer screening: the Minnesota experience. Gastrointest Endosc 1980;2631s-2s. 4. Hertz RE, Deddish MR, Day E. Value of periodic examinations in detecting cancer to the rectum and colon. Postgrad Med 1960;27:2904. 5. Sanfellippo PM, Beahrs OH. Factors in the prognosis of adenocarcinoma of the colon and rectum. Arch surg 1972;104:401-46. 6. Radcliffe AG, Dudley HA. Intraoperative antegrade irrigation of the large intestine. Surg Gynecol Onstet 1983;156:721-3 7. Ravo B, Ger R. Intracolonic bypass by an intraluminal tube: an experimental study. Dis Colon Rectum 1984;27:360-5. 8. Bucher P, Mathe Z, Demirag A, Morel P. Appendix tumours in the era of laparoscopic appendectomy. Surg Endosc 2004;18:1063-6. 9. Connor SJ, Hanna, GP, Frizell FA. Appendiceal tumours: retrospective clinicopathologic analysis of appendiceal tumours from 7,970 appendectomies. Dis Colon Rectum 1998;42:75-80. 10. Lyss AP. Appendiceal malignancies. Semin Oncol 1988;15:129-37. 11. Higa E, Rosai J, Pizzimbono CA. Mucosal hyperplasia, mucinous cystadenoma and mucinous cystadenocarcinoma of the appendix: a re-evaluation of appendiceal mucocele. Cancer 1973;32:1525-41. 12. Qizilbash AH. Mucoceles of the appendix: their relationship to hyperplastic polyps, mucinous cystadenomas and cystadenocarcinomas. Arch Pathol Lab Med 1975;99:548-55. 13. Syracuse DC..Zin KH, Price JB, Wiedel PD, Mesa-Tejada R. Carcinoid tumours of the appendix Mesoappendeal extension and nodal metastases. Ann Surg 1979;190:58-63. 14. Goede AC, Caplin ME, Winslet MC. Carcinoid tumour of the appendix Br J Surg 2003;90:13172200. Uber die Divertikel am Darm Kanal. Arch die Physiol 1809;9:421-53. 15. Meckel JF. Uber die Divertikel am Darm Kanal. Arch die Physiol 1809;9:421-53 16. Leijonmarck CE, Bonman-Sandelin K, Frisell J, Raf L. Meckel’s diverticulum in the adult. Br J Surg 1986;73:146-49. 17. Soltero MJ, B ill, SH. The natural history of Meckel’s diverticulum and its relationship to incidental removal: a study of 202 cases of diseased Meckel’s diverticulum found in King County, Washington, over a fifteen year period. Am J Surg 1976; 132:168-173. 18. Soteriou MC. Williams LF Jr. Unexpected findings in gastrointestinal tract surgery. Surg Clihn Norm Am 1991;71:1283-306. 19. Kloltz S, Vetring T, Rotker J, Schmidt C. Scheld HH, Schmid C. Diagnosis and treatment of nonconclusive mesenteric ischaemia after open heart surgery. Ann Thoir Surg 2001;72:1583-6. 20. Stoppa RE: The treatment of complicated groin and incisional hernias. World J Surg 18=989;13:545-54. 21. Hesseling VJ. Luijendijk RW, de Wilt JH, Heide R, Jeekel J. An evaluation of risk factors in incisional hernia recurrence. Surg Gynecol Obstet 1993;176:228-34. 22. Luijendijk RW, Hop WC, van den Tol MP, de Lange DC, Braaksma MM, IJzermans JN et al. A comparison of suture repair with mesh repair for incisional hernia. N Engl J Med 2000;343:392-8. 23. Leber GE, Grb JI< Alexander AI, Reed WP. Long-term complications associated with prosthetic repair of incisional hernias. Arch Surg 1998:133:37-82. 24. Ramirez OM, Tuas E, Dellon AL. “Components separation” method for closure of abdominal-wall defects: an anatomic and clinical study. Plast Reconstr Surg 1990;86:519. 25 Saulis AS, Dumanian GA. Periumbilical rectus abdominis perforator preservation significantly reduces superficial wound complications in “separation of parts” hernia repairs. Plast Reconstr. Surg 2002; 109:2275-80. 26, Adedeji OA, Bailey CA, Varma JS. Porcine dermal collagen graft in abdominal wall reconstruction. Br J Plast Surg 2002;55:85-6. 27. Franklin ME Jr, Gonzalez JJ Jr, Glass JL. Use of porcine small intestinal submuscosa as a prosthetic device for laparoscopic repair of hernias in contaminated fields: 2-year follow-up. Hernia 2004;8:186-9. 28. Eid GM, MATTAR sg, Hamad G. Cottam Dr. Lord JL, Watson A, et al. Repair of ventral hernias in morbidity obese patients undergoing laparoscopic gastric bypass should not be deferred. Surg Endosc 2004;18:207-10.

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Inflammatory bowel disease Ulcerative colitis Unsuspected ulcerative colitis found at laparotomy without perforation, abscess or toxic megacolon, may be left in situ with the understanding that medical treatment and eventual elective surgical resection to eliminate long term risk of colorectal cancer is indicated.

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Unexpected perforation or abscess necessitates resection of the involved segments with the understanding that the resection of the remaining colon is completed at a later date. Finding of a toxic megacolon mandates subtotal colectomy.

Crohn's disease It is not infrequent to find Crohn’s disease when exploring a patient for abdominal pain (commonly right lower quadrant), obstruction and abdominal sepsis. Resection of the diseased segment with unaffected margins, being careful to maintain as much bowel length as possible, remains the mainstay of treatment. For asymptomatic patients, in the absence of perforation, abscess, pending obstruction or fistula formation, incidentally recognised Crohn’s disease should not be managed medically without resection. Ischaemic bowel The patient with ischaemic bowel can present in a variety of ways. In a patient who is otherwise healthy, the onset of ischaemic bowel may present itself as intestinal angina. Early ischaemic bowel can manifest with pain out of proportion to examination, sepsis of explained origin or sepsis in a patient who is unable to communicate symptoms of pain. Perforation manifested by free air on radiographic examination is a late finding. In the absence of peritonitis or other evidence of bowel Occasionally interventional vascular ischaemia that has progressed to necrosis, urgent angiographic evaluation may be of benefit.

techniques, with or without thrombolytic therapy, may be appropriate.

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Despite the ability to treat early bowel ischaemia, most patients with ischaemic bowel present late, already with necrotic bowel. When

necrotic bowel is identified at the time of laparotomy an attempt should be made to determine the aetiology of the ischaemic insult. The most common aetiology is a throbo-embolic event resulting from an underlying clot or atherosclerotic disease.

The pattern of ischaemia can be patchy or with localised lesion and the treatment will vary depending on the pattern of necrosis. bowel is no longer viable, resection is necessary. When the When bowl is

marginally ischaemic, without patchy areas of necrosis, it is reasonable to observe the intestine to preserve length. As much length as possible should always be preserved, especially when large areas of the bowel have become necrotic. At laparotomy a complete abdominal exploration should first be undertaken to identify all sources of pathology or intra abdominal sepsis. Second, the extent of bowel ischaemia should be carefully measured and documented; this is important for subsequent operations and identifying the length of remaining bowel.

Frankly necrotic bowel demands resection.

In cases of total bowel

ischaemia, involving the small bowel from the ligament of Treitz to the iliocaecal valve, consideration should be given to aborting the resection and having a frank discussion with the patient’s family. In this scenario palliative measures are the most appropriate because loss if the entire small bowel is not compatible with survival. Once the extent of the resection is identified, consideration must be given to the remaining continuity of bowel. Options include primary

anastomosis and in situations of significant necrosis and a contaminated abdomen, it may be necessary to create one or more end enterostomies.

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During a thrombotic event, anticoagulation of the patient may be indicated. The arterial tree must be examined for evidence of thromboembolism. Emboli most frequently lodge 8-10cm distal to the ligament of Treitz within the initial branches of the superior mesenteric artery and Doppler signals should be obtained along this vessel to the root of the mesentery, ensuring intact perfusion. Emboli, when identified, can be removed by embolectomy or bypassed (aorta-SMA or coeliac SMA bypasses). A re-look should be planned 24 to 48 hours later as nearly 50% of cases will require additional bowel resection.

Mesenteric venous thrombosis can manifest with necrotic bowel and the venous structures are dilated and clot filled. Here the patient must be anticoagulated, the necrotic segments of bowel resected, and a second look laparotomy must be planned. The patient should be evaluated post operatively for hereditary thrombophilic conditions. Patients suffering from non-occlusive mesenteric ischaemia can present at laparotomy with ischaemic bowel as well. This disease arises from a diffuse arterial vasospasm of the mesenteric vasculature resulting in ischaemia. Patients should be anticoagulated, necrotic bowel resected and an angiogram performed as early as possible. Vasodilators can be infused through indwelling arterial catheters to counteract vasospasm. A second look laparotomy must be considered. Also, a careful search for inciting factors should be undertaken (often over aggressive dialysis). In general, the finding of ischaemic or necrotic bowel at laparotomy is an ominous sign. Intervention should be undertaken to maintain as much bowel length as possible with the goal being preservation of at least 100cm of small bowel to enable adequate nutrition. If possible the

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iliocaecal valve should be left intact as well, since this aids in slowing small bowel transit time and thereby improving absorptive potential. In patients who have a substantial portion of small bowel resected, severe diarrhoea can result, making their care very difficult and their quality of life poor. Referral to centres specialising in the care of patients with short-gut syndromes may help avoid some of the long term complications associated with the treatment of this disease.


				
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Description: Incidental findings at Laparotomy Preoperative evaluation and