In Brief

Article Outline

• Copyright

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 exemplifies the shortcomings of current medical knowledge and diagnostic modalities, and 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. Data regarding appropriate treatment and surgical management is sparse on this issue.

Unexpected findings at laparotomy or laparoscopy challenge a surgeon’s judgment, knowledge base, and experience. Few published data are available in the literature and are limited to case reports and reviews based on “experience” and the most prevalent “opinions” of the surgical community. 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 appropriately that was unanticipated at the time of surgical exploration. The surgeon is faced with not only “what to do” at the time of laparotomy/laparoscopy, but a number of issues that may need to be addressed in the immediate postoperative period. These are not limited to, but include, patient consent, comorbidities of the patient, morbidity of additional procedures, conversion to an open procedure, postoperative recovery, communication with the patient/family at the time of operation, conservative versus aggressive treatment, and palliation versus curative procedures.

Often unexpected findings at the time of laparotomy/laparoscopy require additional procedures unanticipated preoperatively. This may require additional consent from the patient or family if the patient is under general anesthesia. A comprehensive approach to consent preoperatively may account for additional findings, but often, family must be approached to direct surgical treatment and options. 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 patient/family.

Comorbidities of a patient and the morbidity of secondary procedures must be taken into account when deciding the most appropriate course of action. Subjecting patients to additional procedures with significant increases in morbidity and mortality should not be taken lightly. Part of this consideration may be the need to subject patients to additional procedures and general anesthetics. Is it best to proceed under the same anesthesia or retreat and assure a patient’s cardiac status will tolerate an unexpected procedure? Generally the same decision-making process a surgeon uses to arrive at a treatment plan for the initial operation must be utilized to reassess the need for the original operation in the face of new findings. The risk/benefit ratio of adding additional procedures to the initial one, or possibly altering the planned course of action, must be reviewed in this situation and a new course of action chosen. This adjustment must usually be made based largely on the experience of the surgeon combined with the few published data available on these subjects.

In the “minimally invasive period” of surgical evolution these decisions have begun to be addressed. For example, conversion from laparoscopic cholecystectomy to open is inherent in our preoperative consent. More profound conversions (eg, conversion from laparoscopic cholecystectomy to a Whipple procedure for a malignant biliary stricture found at the time of intraoperative cholangiogram) are not routinely addressed. Given the low morbidity of laparoscopic explorations versus pancreaticoduodenectomy, the decision to convert or proceed becomes significant.

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 options for the management of surgical patients come from accurate and complete diagnostic evaluation before surgical intervention. However, surprises still occur. Additionally, the specific diagnosis is not necessarily made before appropriate interventions in some cases (eg, free intra-abdominal air on plain radiography). Despite preoperative evaluation, elective operations can yield surprises, too, so competent surgeons must be able to deal with these situations appropriately.