The role of diagnostic laparoscopy for chronic abdominal conditions: an evidence-based review

Background  Diagnostic laparoscopy is minimally invasive surgery for the diagnosis of intraabdominal diseases. The aim of this review is a critical examination of the available literature on the role of laparoscopy for chronic intraabdominal conditions. Methods  A systematic literature search of English-language articles on MEDLINE, the Cochrane database of evidence-based reviews, and the Database of Abstracts of Reviews of Effects was performed for the period 1995–2006. The level of evidence in the identified articles was graded. The search identified and reviewed six main categories that have received attention in the literature: pelvic pain and endometriosis, primary and secondary infertility, nonpalpable testis, and liver disease. Results  The indications, contraindications, risks, benefits, diagnostic accuracy of the procedure, and its associated morbidity are discussed. Conclusions  The limitations of the available literature are highlighted, and evidence-based recommendations for the use of laparoscopy to stage intraabdominal cancers are provided.     

Bedside diagnostic laparoscopy in the intensive care unit: a 13-year experience.

BACKGROUND: Frequently, critically ill patients suffer from intraabdominal pathology, such as sepsis or ischemia, either as a cause of a critical illness or as a complication from another illness requiring an intensive care unit (ICU) admission. These complications are associated with high rates of morbidity and mortality (between 50% to 100%). The diagnosis of these problems can be difficult in these very ill patients because it may require transport of unstable patients to additional departments outside the ICU setting. One option in the diagnosis of these difficult patients is bedside laparoscopy, as it avoids patient transport, is very accurate, and maintains ICU monitoring. METHODS: From 1991 to 2003, 13 patients underwent bedside diagnostic laparoscopy in the ICU to diagnose intraabdominal pathology in critically ill patients. All the procedures were done at the bedside in the ICU with the patient under local anesthesia and intravenous sedation. RESULTS: Mean procedure time was 36 minutes (range, 17 to 55). Mean patient age was 75.5 years (range, 56 to 86). There were 8 males and 5 females. Forty-six percent of the patients were diagnosed with mesenteric necrosis and died within 48 hours with no further testing or procedures. One patient with massive fecal contamination died the same day. Thirty percent of patients had a normal intraabdominal examination; of these, 2 died of unrelated illnesses and 2 survived their nonabdominal illness. Fifteen percent were diagnosed with acute acalculous cholecystitis as a complication of their ICU illness, which resolved satisfactorily. No intraoperative complications occurred with the ICU procedure. CONCLUSION: Bedside diagnostic laparoscopy in the ICU is feasible, safe, and accurate in the assessment of possible intraabdominal problems in properly selected, critically ill patients.     

The role of staging laparoscopy for intraabdominal cancers: an evidence-based review

Diagnostic laparoscopy is minimally invasive surgery for the diagnosis of intraabdominal diseases. The aim of this review is a critical examination of the available literature on the role of laparoscopy for the staging of intraabdominal cancers. A systematic literature search of English-language articles on MEDLINE, the Cochrane database of evidence-based reviews, and the Database of Abstracts of Reviews of Effects was performed for the period 1995–2006. The level of evidence in the identified articles was graded. The search identified and reviewed seven main categories that have received attention in the literature: esophageal cancer, gastric cancer, pancreatic cancer, hepatocellular carcinoma, biliary tract cancer, colorectal cancer, and lymphoma. The indications, contraindications, risks, benefits, diagnostic accuracy of the procedure, and its associated morbidity are discussed. The limitations of the available literature are highlighted, and evidence-based recommendations for the use of laparoscopy to stage intraabdominal cancers are provided.     

Diagnostic laparoscopy in the intensive care patient

Summary Evaluation of a potential acute abdomen in patients who require intensive care for concurrent medical/surgical problems is often difficult due to ambiguities in the physical exam and ancillary diagnostic tests. Between August 1990, and February 1992, 25 ICU patients underwent diagnostic laparoscopy to evaluate a suspected acute intraabdominal process. Thirteen laparoscopies were negative, and 12 were positive. The overall accuracy for laparoscopy was 96% as confirmed by subsequent laparotomy, autopsy, or clinical course. Laparoscopic findings led to a change in management in nine patients (36%), leading to earlier exploration in four patients, and avoidance of laparotomy in five. No significant hemodynamic effects were noted during laparoscopy, and the procedure-related morbidity was low (8.0%).Diagnostic laparoscopy is a safe and accurate guide for managing the ICU patient with a suspected acute surgical abdomen. The use of laparoscopy can help avoid nontherapeutic laparotomy or confirm the need for operative intervention in these complex cases.     

Efficacy of routine laparoscopy for the acute abdomen

Background: Laparoscopic surgery of selected acute abdominal conditions has been shown to be highly effective. Therefore, we investigated the diagnostic accuracy and therapeutic efficacy of routine laparoscopic surgery for the acute abdomen. Methods: After appropriate investigations, patients with acute abdomen, with or without a specific diagnosis, were offered the options of either laparoscopic or open surgery. Postoperatively, we analyzed the outcome measures of diagnostic accuracy, complications, and operating time of laparoscopy. The hospital stays for our patients were compared to case-matched controls. Results: The accuracy of laparoscopic diagnosis is the same as laparotomy. The 62% of our patients who were managed totally laparoscopically required shorter hospitalization than the case-matched controls treated by open operation. Morbidity was not increased by laparoscopy in patients who required conversion to open operation. The additional cost of laparoscopy appeared modest. Conclusions: Routine laparoscopy for the acute abdomen is safe and accurate. Patients eligible for laparoscopic treatment also require less hospitalization time. Received: 3 April 1997/Accepted: 9 June 1997     

Diagnostic laparoscopy in patients with an acute abdomen of uncertain etiology

Background: There are acute abdominal conditions in which it is difficult to establish an indicative diagnosis before laparotomy. A diagnosis is important in planning the right abdominal incision or to avoid an unnecessary laparotomy. Diagnostic noninvasive procedures such as X-ray studies do not always appear conclusive. Diagnostic laparoscopy is the only technique which can visualize the abdomen and, by establishing an adequate diagnosis, permits the surgeon to plan the right abdominal approach. Methods: In a prospective study, 65 patients with a generalized acute abdomen (no intestinal obstruction or perforation) underwent a diagnostic laparoscopy under general anesthesia previous to the planned median laparotomy. Results: In 46 patients (70%) diagnostic laparoscopy permitted the establishment of an adequate diagnosis, whereas in seven patients (10%) no cause for the acute abdomen could be found and an explorative laparotomy was avoided. In another 12 patients (20%) insufficient information was obtained during laparoscopy and an explorative laparotomy was performed. Conclusions: A conclusive diagnosis was established in 53 patients. This information led to a change in the surgical approach in 38 patients (e.g., limited, well-placed approach, laparoscopically, or avoidance of an unnecessary laparotomy). Diagnostic laparoscopy in this category of patients is a useful technique with important therapeutic consequences. Received: 5 May 1997/Accepted: 18 September 1997     

Early laparoscopy as a routine procedure in the management of acute abdominal pain: a review of 1,320 patients

Background Acute abdominal pain is a common cause for presentation to the emergency room and hospital admission. Many of these patients will undergo exploration for suspected appendicitis, but in 20–35% of cases a normal appendix is found. Because of the limited access provided by the gridiron incision, a definitive diagnosis may not be found. Other patients may be treated conservatively and discharged, only to return with recurrent pain or more definitive symptoms of pathology. In patients with acute abdominal pain, early laparoscopy is an accurate means of both making a definitive diagnosis and avoiding a delay in the diagnosis.Methods We performed a retrospective analysis of 1,320 consecutive patients with acute abdominal pain over a 62-month period. All patients underwent diagnostic laparoscopy within 48 h of admission. We evaluated the initial clinical diagnosis, the laparoscopic diagnosis, and the subsequent outcome in this group of patients. Individuals with abdominal trauma were excluded from the study, and all patients were >12 years of age.Results A definitive diagnosis was made in 90% of patients after diagnostic laparoscopy. Laparoscopy changed the clinical diagnosis in 30% of cases. (83%) of patients underwent a laparoscopic operation for management of their condition at the time of diagnosis. In 92 patients (7%), conversion to laparotomy was required to manage their condition. Peritonitis was present in 180 patients; of 110 of them had appendicitis. Twelve patients developed complications related to the diagnostic laparoscopy or the laparoscopic operation, and there was one postoperative death due to a perforated gastric malignancy. Mean operating time was 30 min (range, 17–90)Conclusion Early diagnostic laparoscopy and treatment results in the accurate, prompt, and efficient management of acute abdominal pain. This technique reduces the rate of unnecessary laparotomy and right iliac fossa gridiron incisions and increases the diagnostic accuracy in these patients. This treatment method is feasible where facilities are available to accommodate the workload and there are practitioners with the requisite expertise.     

Diagnostic laparoscopy for the acute abdomen and trauma

Background: We set out to investigate the potential benefits of routine diagnostic laparoscopy (DL) in cases of acute abdomen. Methods: A prospective study of 120 DL in acute abdominal cases was performed in comparison with 310 similar acute abdominal cases treated without DL. The diagnostic accuracy, hospital stay, therapeutic delay, and convalescence time were then evaluated. Results: DL established the indications for intervention in 96% of cases, yielded a diagnosis in 90%, and changed the treatment in 14%. The sensitivity achieved was 99.3%, specificity was 83.3%, and accuracy was 88.6%. There were two false positives, one false negative, and three results insufficient to make a diagnosis. Morbidity was one (0.8%), and mortality was one (0.8%). Seventy-nine patients (66%) were managed by laparoscopy and 24 by open interventions. The hospital stay in DL groups was shorter (median, 5 days vs 6 days in controls, p < 0.0003), as was the effective treatment time (median, 5 days vs 6 days, p<0.0012). The convalescence time was also shorter in DL groups (median, 14 days vs 14 days, p<0.04). Therapeutic delay occurred in 16% of the control group cases, doubling the morbidity rate, increasing mortality by 50%, and prolonging hospital stay (median, 9 days vs 6 days, p>0.3 (NS). Conclusions: DL in the acute abdomen is a safe and accurate procedure that enables laparoscopic interventions and helps avoid nontherapeutic surgery. DL and appropriate treatment reduces hospital stay, therapeutic delay, and convalescence time. Received: 14 July 1999/Accepted: 20 November 1999/Online publication: 22 August 2000     

Value of laparoscopy in trauma ICU patients with suspected acute acalculous cholecystitis

Patients who require prolonged intensive care following traumatic injuries are at risk for developing acute acalculous cholecystitis (AAC). The diagnosis of AAC is often difficult to establish, resulting in increased morbidity and mortality in this critically ill population. We reasoned that diagnostic laparoscopy might provide a more accurate and timely method of diagnosis. Laparoscopy was performed in nine trauma ICU patients with suspected AAC. Four procedures were considered positive and five were negative. There were no false-positive or false-negative laparoscopic exams, and no procedure-related morbidity occurred. Comparison of multiple clinical, laboratory, and radiologic findings showed that only laparoscopy accurately distinguished between those patients with AAC and those without AAC. We conclude that diagnostic laparoscopy is safe and definitive in trauma ICU patients with suspected AAC and should be performed prior to proceeding with laparotomy.Presented at the annual meeting of the Society of American Gastrointestinal Endoscopic Surgeons (SAGES), Phoenix, Arizona, USA, 2 April 1993     

Accuracy of diagnostic laparoscopy for early diagnosis of abdominal complications after cardiac surgery

BACKGROUND: In the early postoperative period after major cardiac surgery using extracorporal circulation, abdominal complications can have serious consequences with a mortality rate of up to 70%. Early diagnosis and the timely institution of therapy are the most important factors to improve the outcome; however, clinical evaluation of the abdomen is difficult in these patients. Diagnostic laparoscopy is a minimally invasive procedure with low procedure-associated morbidity, even in critically ill patients. The aims of our study were to investigate the safety of laparoscopy in critically ill patients suspected to have intraabdominal pathology following cardiac surgery and to evaluate the accuracy of diagnostic laparoscopy compared to laparotomy in this setting. METHODS: A total of 17 patients were included (13 male, four female, age 52-80 years) in the early (3-30 days) postoperative period after cardiac surgery using extracorporal circulation (10 ACVB, four valve replacement, one aorto-coronary-venous-bypass (ACVB)+ valve replacement, two cardiac transplantation). Clinical and laboratory findings included distended abdomen (17 of 17), elevated white blood cells (12 of 17), elevated C-reactive protein (CRP) (13 of 17), and elevated lactate levels (11 of 17). The decision to perform laparotomy was taken in all patients on the basis of their clinical condition. Diagnostic laparoscopy was always performed immediately before laparotomy. The laparoscopic findings were then compared to the laparotomy findings. RESULTS: In one patient, laparoscopy showed no abnormal findings, this was confirmed on laparotomy. Five patients were found to have massive distension of the large bowel without ischemia on both laparoscopy and laparotomy. Colonic ischemia of the right hemicolon was found laparoscopically in six patients, which was confirmed in all cases by open resection and histological workup. Three patients suffered from acute cholecystitis, which was correctly diagnosed by laparoscopy in all cases. In one patient, laparoscopy revealed fibrinous peritonitis without other findings. Open exploration failed to identify the cause of the peritonitis in this patient. Laparoscopy showed no pathological findings in one patient, but laparotomy then revealed necrotizing pancreatitis confined to the lesser sac. There was one laparoscopy-associated intraoperative complication (6%) in this series. CONCLUSIONS: Diagnostic laparoscopy is a minimally invasive procedure that can be performed at low intraoperative risk in critically ill patients and has a high sensitivity (94%) for the correct diagnosis of intraabdominal complications after major cardiac surgery. These results suggest that bedside laparoscopy should be considered for all patients with equivocal abdominal symptoms in this setting.     

The effect of previous abdominal surgery on urological laparoscopy

PURPOSE: Abdominal surgery causes adhesions that may render subsequent laparoscopic access and dissection problematic. We determined the effect of previous surgery on the operative outcome in a large series of patients undergoing urological laparoscopy. MATERIALS AND METHODS: The records of 700 consecutive laparoscopic procedures performed at a single institution from 1995 to 2001 were reviewed. Patient gender, American Society of Anesthesiologists (ASA) patient classification, surgical history, operative time, estimated blood loss, transfusion rate, rate of conversion to an open procedure, complication rate and hospital stay were assessed in each patient. Patients were categorized by anatomical site of previous surgeries and the type of laparoscopic procedure performed. Statistical analysis was performed with 1-way ANOVA, and the chi-square, Fisher exact and Kruskal-Wallis tests. RESULTS: Of the 700 patients 366 (52%) had never undergone surgery, 105 (15%) had a history of abdominal surgery at the same anatomical region and 229 (33%) had a history of abdominal surgery at a different region. Overall previous abdominal surgery of any type was associated with female gender, higher ASA classification, increased age and an increased rate of perioperative transfusion (p = 0.0001). A history of surgery at the same site was associated with increased operative time (p = 0.03) and increased hospital stay (p = 0.02). Differences in operative blood loss (p = 0.3), and the complication (p = 0.11) and conversion (p = 0.08) rates in patients with and without a history of surgery did not attain significance. Outcomes analysis of individual types of surgery showed similar results except for renal biopsy. In these cases previous surgery was not associated with increased age, ASA score or transfusion rate. CONCLUSIONS: Of all patients presenting to a single center for urological laparoscopy 48% had a history of abdominal surgery. Overall compared with patients with no history of surgery those with such a history tended to be older, predominantly female and at significantly higher operative risk. Patients with a history of surgery who underwent nephrectomy or pyeloplasty were also more likely to have received blood transfusion perioperatively, which was probably related to their increased age and higher degree of medical co-morbidity. There were no significant differences in operative blood loss, rate of conversion to open procedure or rate of operative complications. Therefore, previous abdominal surgery does not appear to affect adversely the performance of subsequent urological laparoscopy.     

腹腔镜在急腹症中的应用

目的 探讨腹腔镜技术在急腹症中的临床应用价值。方法 回顾性分析1995年10月。2005年12月，应用腹腔镜技术为118例急腹症患者实施腹腔镜手术治疗的临床资料。结果 手术及病理检查诊断证实，腹腔镜手术成功114例，中转开腹手术4例，无手术并发症。结论 腹腔镜技术在急腹症中的应用具有独特优点，既可以明确诊断又可同时进行治疗，治疗效果可靠，值得临床进一步推广应用。     

腹腔镜在急腹症中的应用

目的:探讨腹腔镜在急腹症中的应用价值。方法:回顾分析146例急腹症的临床资料及手术选择。结果:146例急腹症中134例在腹腔镜下完成诊断和治疗,占92.5%。结论:腹腔镜技术在诊断及治疗急腹症中具有安全、可靠、微创的特点,在鉴别诊断中尤有价值。     

Pediatric trauma-associated acute respiratory distress syndrome: Incidence,risk factors,and outcomes

Background/PurposeAcute Respiratory Distress Syndrome (ARDS) results in significant morbidity and mortality in pediatric trauma victims. The objective of this study was to determine risk factors and outcomes specifically related to pediatric trauma-associated ARDS (PT-ARDS).MethodsA retrospective cohort (2007–2014) of children ≤ 18 years old from the American College of Surgeons National Trauma Data Bank (NTDB) was used to analyze incidence, risk factors, and outcomes related to PT-ARDS.ResultsPT-ARDS was identified in 0.5% (2660/488,381) of the analysis cohort, with an associated mortality of 18.6% (494/2660). Mortality in patients with PT-ARDS most commonly occurred in the first week after injury. Risk factors associated with the development of PTARDS included nonaccidental trauma, near drowning, severe injury (AIS ≥ 3) to the head or chest, pneumonia, sepsis, thoracotomy, laparotomy, transfusion, and total parenteral nutrition use. After adjustment for age, injury complexity, injury mechanism, and physiologic variables, PT-ARDS was found to be independently associated with higher mortality (adjusted OR 1.33, 95% CI 1.18–1.51, p < 0.001).ConclusionsPT-ARDS is a rare complication in pediatric trauma patients, but is associated with substantial mortality within 7 days of injury. Recognition and initiation of lung-protective measures early in the postinjury course may represent the best opportunity to change outcomes.Level of EvidenceLevel 3 — Epidemiologic.     

Introducing diagnostic laparoscopy for patients with suspected acute appendicitis

Background: The diagnostic accuracy in patients with suspected acute appendicitis varies from 60% to 90% depending on age and gender. The aim of this study was to evaluate the use of diagnostic laparoscopy for diagnostic purposes in patients with suspected acute appendicitis to prevent unnecessary laparotomy and to leave a macroscopically normal appendix in place. Methods: For this study, 500 consecutive patients with suspected acute appendicitis admitted between January 1994 and October 1996 were included prospectively in a surgical training program set to provide diagnostic laparoscopy on a 24-h-a-day basis. Primary open operation was performed when no laparoscopically trained surgeon was available. Short-term outcome measurements were recorded, and a retrospective long-term follow-up evaluation was performed. Results: We succeeded in performing a diagnostic laparoscopy in 376 patients and a primary open operation in 124 patients. The overall appendicitis rate was 78%. A diagnostic laparoscopy alone was performed in 66 patients (56 of which were fertile women), with a median operating time of 36 min and a complication rate of 0%. The overall complication rate was 8.0%. During a median follow-up period of 19 months one patient returned on a later occasion with appendicitis. At completion of the study, 85% of the surgeons were skilled in diagnostic laparoscopy. Conclusions: Substantial education effort is needed to introduce diagnostic laparoscopy on a 24-h-a-day basis. Diagnostic laparoscopy has a high rate of accuracy, short operating time, and low associated morbidity, and prevents unnecessary laparotomy. It is possible to leave a macroscopically normal-appearing appendix in place. Received: 12 March 200/Accepted: 23 May 2000/Online publication: 9 August 2000     

Diagnostic laparoscopy

Diagnostic laparoscopy began in a surgical unit in a developing country in 1972. The developers of this technique aimed to hasten diagnosis, reduce patient distress, and improve bed utilization in an overcrowded teaching hospital wherein simple investigations such as x-rays took weeks to materialize. Over a period of 18 years reaching to 1990, 3,200 diagnostic laparoscopies were performed on adults under local anesthesia with no mortality, a complication rate of 0.09%, an 84% diagnosis rate, and 74% undergoing histologic biopsies targeting a wide spectrum of pathology. The equipment cost spread out over the 3,200 patients works out to 30 rupees ($0.60) per patient. With the availability of noninvasive diagnostic aids such as ultrasound, computed tomography, and magnetic resonance imaging used US, CT, MRI under the control of target biopsy, the role of diagnostic laparoscopy has altered. Since 1990, clinicians have had the sophistication of the video camera and the pneumoperitoneum insufflator. Diagnostic laparoscopy is used for the evaluation of liver and peritoneal pathology, abdominal tuberculosis, malignancy, acute abdomen, and abdominal trauma. It often is a prelude to laparoscopic treatment of the underlying pathology, specifically in cases of acute appendicitis.     

诊断性腹腔镜手术在急腹症诊治中的应用

诊断性腹腔镜手术是用于诊断腹腔内疾病的一种微创方法。（1）可以直接观察腹腔各脏器表面的改变;（2）获取活检标本、抽吸腹腔积液及进行细菌培养;（3）借助腔镜超声行腹腔脏器的进一步探查;（4）必要时可行腹腔镜下治疗。急症情况下诊断性腹腔镜手术主要用于急性非特异性腹痛、外伤以及重症病人的腹痛。     

腹腔镜在外科急腹症诊治中的应用

目的:探讨腹腔镜技术在外科急腹症中的诊断与治疗价值。方法:回顾性分析了20例腹腔镜外科急腹症探查及疗效。结果:20例经腹腔镜探查全部明确诊断,17例免除开腹手术,所有病例均恢复顺利,无术后并发症及死亡。结论:急诊腹腔镜探查可以提高急腹症的确诊率,降低阴性剖腹探查率。     

Bedside diagnostic laparoscopy and peritoneal lavage in the intensive care unit

Background: Early diagnosis and treatment of intra-abdominal pathology in critically ill intensive care unit (ICU) patients remains a clinical challenge. The objective of this study is to assess the feasibility of portable, bedside diagnostic laparoscopy (DL) in the ICU for patients suspected of intra-abdominal pathology, and to contrast its accuracy with diagnostic peritoneal lavage (DPL). Methods: All adult ICU patients for whom a general surgery consultation was requested were eligible. Patients with a recent laparotomy or obvious peritonitis were excluded. All procedures were performed in the ICU. Results: Over a consecutive 16-month period, 12 patients underwent DPL/DL. Ages ranged from 28 to 88 (mean, 72) years. Causative findings were disclosed by DL in five patients, (42%) including intestinal ischemia in two. Perforated diverticulitis, thickened terminal ileum, and nonpurulent peritonitis were found in one patient each. All patients with findings by DL had a positive DPL (WBC > 200 cells/mm³), and one negative laparoscopy was positive by lavage. The average length of time to perform DPL was 14 min, and to complete DL 19 min. One patient underwent laparotomy based on DPL/DL and survived along with three others with negative DPL/DL. Eight patients died (67%), four from their surgically untreated intra-abdominal pathology. One patient sustained a procedure-related complication of bradycardia and high ventilatory airway pressures. Peak airway pressures increased an average of 8 mmHg and were significantly higher (p < 0.001) than pre-DL pressures without any significant change in end-tidal CO₂ or pCO₂. There were no statistically significant hemodynamic changes based on mean arterial pressure (MAP), central venous pressure (CVP), or pulmonary artery diastolic pressure (PADP). Conclusions: Bedside laparoscopy can be performed rapidly and safely in the ICU. In predicting the need for laparotomy, DL was more accurate than DPL. Received: 18 July 1995/Accepted: 19 December 1995     

Outcomes of abdominal surgery in patients receiving mechanical ventilation for more than 48 hours

Background

Abdominal surgery in critically ill patients has high mortality, contributing to high US healthcare costs. This study sought to identify specific predictors of mortality in this population.

Methods

Using the National Surgical Quality Improvement Program database 2006 to 2012, we identified 4,901 patients who were intubated for more than 48 hours before undergoing common abdominal procedures. Mortality and predictors of mortality were determined using chi-square and/or regression analysis.

Results

Overall 30-day mortality was 44.2% with increasing mortality for additional procedures performed. Ventilated patients with the following preoperative risk factors were 2 to 3 times as likely to die within 30 days of surgery: age greater than 65-years old, coma, preoperative international normalized ratio greater than 3.0, esophageal varices, and disseminated cancer.

Conclusions

Mortality is significant in ventilated patients who undergo abdominal surgery and is especially high with advanced age, disseminated cancer, and complications of liver disease. Physicians should carefully discuss this with patients and/or family and consider palliative options when appropriate.