Surgery Lecture - 12 Endoscopy

Endoscopy ranks as one of the most important technical advances in medicine of the last few decades. Not only has it added a new precision to gastrointestinal and pancreaticobiliary diagnosis, particularly when used in conjunction with cytology or biopsy, but it has also been one of the earliest tools, along with interventional radiological techniques, in the advances of minimally invasive therapy.

There are two types of endoscopy

Rigid -Proctoscope -Sigmoidoscope -Thoracoscopy -Cystoscope -Laparoscopy -Athroscopy

Flexible -Esofagogastroscopy -Duodenoscopy -Colonoscopy -Sigmoscopy -Bronchscopy

The modern flexible endoscope has the following features: Light source – in the handle with a fibreoptic bundle for the transmission of light to the area under investigation. Viewing system – Photons impacting on this are converted into a digital video signal which can then be viewed on a screen. The video image can easily be stored for use in teaching and can be enhanced by electronic processing. Control and manipulative elements which are still mechanical and allow the tip to be defected and instruments such as snares, stents, biopsy forceps, balloons and baskets to be passed along a working channel.

Preparing patient for examination The patient must have an empty stomach; nothing by mouth for 6 h beforehand is usually sufficient. Pharyngeal anesthesia to blunt the gag reflex is achieved with benzocaine or lidocaine. The patient is also given intravenous sedation and is monitored during the procedure with blood pressure determinations, pulse oximetry and electrocardiography.

Procedure: Most endoscopists place the patient on his or her left side. Doctor hold the instrument in the left hand and alternately manipulate the scope controls and shaft with the right hand. After placing a bite block between the patient’s teeth, the endoscope is inserted into his or her mouth. The tongue is followed down to its base where the upper larynx can be seen.

Procedure: The oesophagus is best entered under vision. The scope is guided posterior to the arytenoid cartilages, where the view becomes obscured by the contracted cricopharyngeus muscle. While maintaining gentle pressure against the muscle with the scope, the patient is asked to swallow.

Procedure: This maneuver allows ready passage of the instrument into the upper esophagus. If not, one should back up into the posterior pharynx, suction out any saliva with the scope, and try once more after the patient catches his breath. Keeping the gut lumen in the center of the field of view the operator advances the scope distally with deflection of the tip and twisting of the shaft as necessary.

INDICATIONS. Diagnostic esophagogastroduodenoscopy is especially valuable for evaluating upper gastrointestinal tumors, strictures, ulcers, varices, and mucosal changes such as esophagitis and gastritis. It is less useful for judging functional or motility disorders or extraluminal lesions.

The major indications for diagnostic upper gastrointestinal endoscopy are: (1) persistent upper abdominal pain or distress, especially if it is associated with symptoms or signs suggestive of serious disease (anorexia, weight loss, anemia); (2)persistent symptoms of gastro-esophageal reflux despite treatment; (3)swallowing difficulties; (4)persistent vomiting of unknown cause; (5)surveillance for upper gastrointestinal malignancy in high-risk patients; (6)evaluation of upper gastrointestinal bleeding of unexplained iron deficiency anemia; (7)evaluation of ulcers, strictures, and tumors found by a barium meal examination

Indications for therapeutic esophagogastroduodenoscopy are: (1)cauterization of injection of bleeding peptic ulcers (and occasionally vascular malformations); (2)injection sclerosis of esophageal varices that have bled; (3)removal of foreign bodies or bezoars; (4)removal of gastric polyps; (5)dilatation of esophageal strictures; (6)palliative treatment of malignant upper gastrointestinal obstruction by dilatation, laser fulguration, or intubation; (7)placement of gastrostomy tubes.

Contraindications to esophagogastroduodenoscopy Endoscope should be avoided if there is a possibility of a perforated viscus. If the stomach is not empty, little useful inspection is possible, and the risk of vomiting and aspiration pneumonia is great. A poor airway contraindicates upper gastrointestinal endoscopy. Respiratory arrest may result if there is a marginal passage (for example, pharyngeal tumor) combined with intravenous sedation, as well as partial occlusion and edema induced by the endoscope. Endoscope surgery should not be carried out if the patient is anticoagulated or has a coagulopathy.

Complications Complications due to diagnostic esophagogastroduodenoscopy are uncommon. Aspiration pneumonia may occur because of the combination of pharyngeal anaesthesia and instrumentation, especially in obtunded patients, or if there is active upper gastrointestinal bleeding. Although adverse cardiorespiratory events are rare, they may occur if the patient is frail or if sedation is excessive. Perforation and bleeding are infrequent unless endoscopic surgery is done. As is the case for colonoscopy, drug reactions, vasovagal reflex, bacteraemia, and superficial phlebitis are other less serious potential problems.

Erosion of stomach

Ulcers of stomach

Ulcers of cardiac part of stomach

Bleeding

Tumor of stomach

Varices of esophagus.

Laparoscopy The peritoneal cavity of a dog was examined in 1902 by Kelling, using air insufflation and the insertion of a cystoscope through the abdominal wall. The first clinical use was described in 1912 by Jacobaeus, although it was a further decade before a purpose-built scope was in use by Kalk (1929) and the era of modern-day laparoscopy (peritoneoscopy) began.

PROCEDURE (DIAGNOSTIC LAPAROSCOPY) The patient is positioned supine on the operating table. A general anaesthetic with muscle relaxation is usually preferred, but it is possible to use local anaesthetic and sedation with intravenous benzodiazepines. The Verres needle is introduced via a stab incision. This is usually subumbilical in position, but the presence of scars may influence the precise location. The needle contains a springloaded blunt probe, and compression of the spring against the skin retracts the probe to expose the needle. Damage to intra-abdominal viscera can be minimized by holding up the anterior abdominal wall with one hand while inserting the needle with the other

PROCEDURE (DIAGNOSTIC LAPAROSCOPY) When the needle has passed through the abdominal wall the resistance falls and the spring pushes forwards the probe covering the needle. Free flow of normal saline solution through the needle confirms that the linea alba and peritoneum have been punctured. The abdomen is then insufflated with carbon dioxide, using approximately 2 to 3 litres for an adult. During insufflation, the intra-abdominal pressure should not exceed 15 mmHg. The Verres needle is then withdrawn and the incision is enlarged to accommodate the laparoscope trocar, which is pushed down and back into the pelvis. The end- or side-view telescope is then inserted and laparoscopy commenced. Biopsy forceps and a palpating probe can be used in other, suitably placed stab incisions through the anterior abdominal wall. This allows the peritoneal contents to be inspected. Throughout the procedure, carbon dioxide is continually insufflated at low pressure.

CONTRAINDICATIONS There are few absolute contraindications to the procedure, but certain conditions should alert the surgeon to potential problems. Multiple scars make introduction of the scope hazardous, and adhesions from repeated abdominal procedures may hinder the view within the peritoneum. Abdominal wall sepsis may introduce intraperitoneal infection. The procedure is not tolerated well in patients with severe pulmonary or cardiac problems, due to the intra-abdominal distension. Bleeding diatheses may result in body wall or intraperitoneal bleeding.

COMPLICATIONS To minimize complications, laparoscopy is a procedure best performed by surgeons experienced in the technique, in an operating theatre equipped with the facilities to proceed to a laparotomy if necessary. Minor complications include abdominal wall bruising, subcutaneous emphysema, the development of a wound infection/hernia, and postoperative shoulder pain. Other complications are related to accidental visceral damage and bleeding from vessel injury. These problems should be noted at the time of laparoscopy and dealt with by prompt laparotomy if necessary. Mortality rates of 0.03 to 0.1 per cent are reported.

INDICATIONS In patients with localized peritonism, diagnostic laparoscopy is most commonly used in the management of patients with acute right iliac fossa pain. With the aid of a palpating probe inserted through the anterior abdominal wall of the right iliac fossa, the surrounding ileum and omentum may be manipulated away in order to see the appendix. In the case of a retrocaecal or retroileal appendix, it may be impossible to visualize the target organ, but other signs of acute inflammation may be noted. Alternatively, other causes of right iliac fossa pain may be apparent, and, if these require surgery, an appropriate incision can be made.

INDICATIONS The role of diagnostic laparoscopy in the management of the patient with abdominal trauma is in conjunction with imaging techniques (CT and ultrasound scanning) and peritoneal lavage. The relative importance of each is not established clearly, although aggressive use of laparoscopy in this clinical situation may reduce the number of unnecessary laparotomies performed for minimal or moderate haemoperitoneum. The procedure can be performed in the accident and emergency department under local anaesthesia with intravenous sedation.

Inflammation of appendix

Uterus with myomas node

Abdominal pregnancy

Inflammation of ovary (ovaritis)

Inflammation of gallbladder

Metastasis of stomach cancer