Elective diagnostic laparoscopy.

Laparoscopy developed as a science at the turn of the century, and many scientists assisted in the evolution of this technique. However, it was many years before the multiple trocar system was developed that allowed internal organs to be moved and biopsies to be obtained. This has led to the development of numerous indications for elective diagnostic laparoscopy. Adequate preparation and attention to instrumentation ensure the safety of this operation. Elective diagnostic laparoscopy is a useful adjunct to many other diagnostic modalities such as, for instance, the assessment of abdominal pain, abdominal masses, fever of unknown origin, and gastrointestinal bleeding. In many other circumstances, such as the assessment of oncology cases, this modality is superior to conventional radiology because biopsy specimens may be obtained. If the procedure is correctly performed, the diagnostic yield is extremely high and the morbidity and mortality are low. The role of this important technique should not be underestimated by today's practicing surgeon.     

Pneumatosis cystoides intestinalis as a complication of celiac disease

Pneumatosis cystoides intestinalis (PCI) is an uncommon but important condition characterized by the presence of gas-filled cysts in the submucosa and subserosa of the gastrointestinal tract. PCI has been associated with several clinical settings. We report a case where PCI developed in a patient with known celiac disease. To our knowledge, this type of coincidence has been described in seven prior cases. Since PCI often results in pneumoperitoneum through rupture of the cysts, it is important to differentiate the benign form of pneumoperitoneum, in which no intervention is indicated, from the life-threatening form with intestinal infarction and/or perforation, in which immediate surgery is mandatory. Differentiating between them can be difficult; this explains the high rate of negative laparotomy, which, in the past, occurred in 27% of cases. By performing diagnostic laparoscopy, we were able to establish the diagnosis of PCI and exclude intestinal perforation or infarction, thus permitting the patient to avoid an unnecessary laparotomy. Although diagnostic laparoscopy is not routinely indicated as a diagnostic tool for the detection of PCI, it proved to be a safe and accurate method to differentiate between the benign form of PCI and the life-threatening form. Whenever this differentiation has to be made, we recommend that diagnostic laparoscopy be performed first rather than primary laparotomy. Herein, the laparoscopic features of PCI are described and the coincidence of PCI with celiac disease is reviewed.     

Pneumoperitoneum without perforation of the gastrointestinal tract

Pneumoperitoneum (PP) is usually the result of perforation of the gastrointestinal (GI) tract with associated peritonitis. However, other rare causes, including spontaneous PP incidental to intrathoracic, intra-abdominal, gynecologic, and miscellaneous other origins not associated with a perforated GI tract have been described in the literature. Six cases of PP without any perforated GI tract are reported. Three patients with generalized peritonitis underwent exploratory laparotomy or laparoscopy when clinical examinations suggested an acute abdomen. At surgical procedure, perforated pyometra, perforated liver abscess and a ruptured necrotic lesion of a liver metastasis were documented in these patients, respectively. We also saw 3 PP patients not associated with peritonitis. Two patients with PP caused by pneumatosis cystoides intestinalis were encountered, 1 was managed conservatively and the other received diagnostic laparoscopy. A patient in whom pneumomediastinum and pneumoretroperitoneum were accompanied by PP caused by an alveolar rupture based on decreased pulmonary compliance due to malnutrition was managed conservatively. The history of the patient and knowledge of the less frequent causes of PP can possibly contribute towards refraining from exploratory laparotomy in the absence of peritonitis.     

Idiopathic intussusception: the role of laparoscopy

BACKGROUND: The use of a barium enema affords both diagnostic confirmation and a chance for nonsurgical complete reduction of the intussusception, which must be proven by adequate reflux of barium into the distal ileum. If this does not occur, it is assumed that the intussusception has not been reduced, and the infant is taken straight to the operating room for laparotomy and surgical treatment. The aim of this study is to limit unnecessary surgical explorations by the diagnostic and the therapeutic policy of laparoscopy with assisted hydrostatic saline reduction under general anesthesia. METHODS: Over a period of 3 years, 90 patients with intussusception were treated. Twenty patients in whom hydrostatic reduction was contraindicated were treated initially by surgery. In the remaining 70 patients, hydrostatic reduction was successful in 50 (71%), and laparoscopy was performed in 20 patients before laparotomy. Hydrostatic saline reduction was used when there was failure of reduction seen by laparoscopy. RESULTS: In 20 patients, laparoscopy showed reduction of intussusception in eight patients (40%), and saline hydrostatic reduction was successful in six patients (30%), with failure of reduction in six patients (30%) necessitating laparotomy. CONCLUSION: The use of laparoscopy for diagnosis of failure of reduction of intussusception and the hydrostatic reduction by saline enema during laparoscopy saved 14 patients from unnecessary laparotomy.     

Is there additional information from laparoscopic ultrasound in tumor staging?

Accurate preoperative staging of gastrointestinal malignancies is of major importance in the decision for adequate stage-related therapy. There is evidence that laparoscopy in combination with laparoscopic ultrasound is more accurate in the detection of intra-abdominal metastases than conventional preoperative imaging. Staging laparoscopy in combination with laparoscopic ultrasound is a minimally invasive technique that reveals intra-abdominal disseminated tumor spread and local tumor extent. Therefore laparoscopic ultrasound is an ideal adjunct to laparoscopy because this technique may compensate for the lack of tactile feedback with laparoscopic instruments. Color-coded Doppler imaging can be very valuable for the assessment of resectability in patients with pancreatic cancer. Current data confirm that laparoscopic ultrasound is capable of enhancing the accuracy of staging laparoscopy. Compared to standard laparoscopy, a combination of both techniques markedly increases the sensitivity of staging laparoscopy in the determination of unresectable disease. This is of major importance in the assessment of occult liver metastases and lymph node involvement. Laparoscopic ultrasonography improves the diagnostic accuracy compared to conventional imaging techniques and should be considered as integral part of staging laparoscopy.     

Acute hemorrhage from Meckel's diverticulum--Laparotomy or laparoscopy?

Meckel's diverticulum is the most common congenital malformation of the gastrointestinal tract with a potential risk to develop complications such as obstruction, diverticulitis or intussusception. Lower gastrointestinal bleeding due to ulceration of heterotopic gastric tissue of the diverticulum is a known phenomenon in children and young adults. We present two cases of a 15-year-old girl and a 20-year-old man that revealed a massive lower gastrointestinal hemorrhage of unknown origin. In this emergency situation laparotomy was performed in combination with lower endoscopy as rendezvous manouver. In both cases a Meckel's diverticulum with peptic ulceration was the source of hemorrhage, in one case the bleeding was active and visible. After resection of a short small bowel segment and end-to-end anastomosis the postoperative course was uneventful. We prefer in the case of lower gastrointestinal hemorrhage with hemodynamic instability laparotomy with intraoperative endoscopy instead of laparoscopy.     

Laparoskopie beim traumatisierten Abdomen

With increasing experience in minimally invasive surgery, laparoscopy's role in abdominal trauma can be defined exactly. Main exclusion criteria are hemodynamic instability and increased intracranial pressure. A literature review of 1996 to 2006 reveals perforating injury mainly of the left thoracoadominal area as the most important indication for laparoscopy . Its goal is to determine intraperitoneal lesions and integrity of the abdominal wall and diaphragm. Minor injuries of the parenchymatous organs and diaphragm can be successfully repaired laparoscopically. In blunt abdominal trauma, laparoscopy is used as a complementary diagnostic device in case ultrasound and multislice CT show unclear findings and the patient's clinical status requires invasive measures. The clear weakness of laparoscopy in abdominal trauma is its inability to identify reliably hollow viscus perforation and retroperitoneal injury. In this, sensitivity is only 25%. In case of proven lesions of the gastrointestinal tract, conversion to laparotomy is to be considered. Despite the reports on laparoscopic treatment, open repair of hollow organ injuries is still to be recommended.     

Bedside diagnostic minilaparoscopy in the intensive care patient

BACKGROUND: The diagnosis of acute abdominal conditions in the critically ill patient remains difficult. The goal of this study is to demonstrate the use of bedside minilaparoscopy as a diagnostic aid in the intensive care unit (ICU) in patients with possible intra-abdominal catastrophic condition. METHODS: Between February 1998 and May 1999, intensive care patients with abdominal pain, unexplained acidosis or sepsis, or suspected mesenteric ischemia were eligible for bedside diagnostic minilaparoscopy (3.3-mm laparoscope and instruments). The procedure was performed at bedside in the ICU with the patient under local anesthesia and intravenous sedation. Pneumoperitoneum was established with nitrous oxide (N(2)O) to a pressure of 8 to 10 mm Hg. Hemodynamics and ventilatory parameters were monitored before, during, and after the procedure. RESULTS: Nineteen patients underwent bedside diagnostic minilaparoscopy, including 1 patient who underwent 2 diagnostic laparoscopies. Total procedure time was 9 to 68 minutes (mean, 21 minutes). Three patients were found to have extensive mesenteric ischemia and did not undergo laparotomy. One patient found to have questionably viable bowel at laparoscopy underwent a nontherapeutic formal laparotomy. One patient had a gangrenous gallbladder, and another had a small ischemic segment of bowel; each underwent later open laparotomy and resection. The remaining laparoscopic examinations either showed a nonsurgical cause for the patient's condition or were normal. Nontherapeutic laparotomy was avoided in 19 of 20 patients. One gallbladder perforation occurred during laparoscopy in a patient with a necrotic gallbladder. CONCLUSIONS: Bedside minilaparoscopy can be a safe and accurate method to evaluate critically ill patients in whom the possibility of mesenteric ischemia or other intra-abdominal process is entertained. Nontherapeutic laparotomy can be avoided in many critically ill patients. Bedside diagnostic laparoscopy can be a useful replacement for diagnostic laparotomy in the operating room. It should be included in the diagnostic algorithm in the evaluation of the unstable patient in the ICU with a suspected acute intra-abdominal process.     

Emergency laparoscopy in closed abdominal injuries]

Results of emergency laparoscopies in 240 patients with closed traumas of the abdomen are presented. No injuries were found in 154 patients when performing laparoscopy. By the authors' data the diagnostic informative value of laparoscopy in closed traumas made up 98%. Wide use of laparoscopy allowed to avoid diagnostic laparotomy in doubtful clinical picture of closed abdominal traumas.     

The development and application of wireless capsule endoscopy

The introduction of the Video Capsule Endoscope (VCE) by Given Imaging Ltd. (Yoqneam, Israel) in 2001, and its subsequent approval by the FDA as a first line tool in the detection of abnormalities of the small bowel, is indicative of the rapid acceptance of capsule endoscopy by the practicing gastroenterological community. An extensive clinical trials program consistently revealed a high diagnostic yield of the VCE when compared to other diagnostic modalities of the small intestine. The capsule endoscope contains a miniature color video camera, illumination sources, lens, transmitter/controller, antenna, and a power source. It is small enough to easily swallow (11 x 26 mm), and it is propelled through the gastrointestinal (GI) tract by peristalsis. Its development was enabled by a series of technological breakthroughs that occurred at the close of the 20th century. The VCE is one of the most exciting examples of the recent trend for minimally invasive autonomous medical tools in diagnostic, monitoring, and therapeutic applications. Expanding applications of the VCE to additional parts of the GI tract, adding physiological sensors, and--in the more remote future--addition of therapeutic capabilities will likely occur as this new branch of endoscopy develops.     

Technique and value of staging laparoscopy

Despite significant improvements in preoperative tumor staging due to sophisticated new imaging and interventional techniques, peritoneal tumor spread and occult liver and lymph node metastases are only detected during surgery in some patients. Newer treatment modalities using neoadjuvant regimens are only given if occult tumor spread is excluded. Diagnostic laparoscopy has therefore been introduced to prevent patients with advanced tumor disease from unnecessary laparotomy and as a diagnostic tool in neoadjuvant treatment protocols. Laparoscopic ultrasound represents an important technical improvement in diagnostic laparoscopy. The main indication for diagnostic laparoscopy is therefore exact tumor staging, especially in terms of peritoneal, liver, and lymphatic tumor spread, whereas determination of local tumor resectability is not the main issue. The aim of the current review is to summarize the technique of staging laparoscopy and to discuss its clinical value for a variety of gastrointestinal malignancies.     

Impact of diagnostic laparoscopy on the management of gastric cancer: prospective study of 120 consecutive patients with primary gastric adenocarcinoma

BACKGROUND: Peritoneal seeding or liver metastases found at laparotomy usually preclude curative treatment in patients with gastric adenocarcinoma. Such exploratory laparotomies may be avoided by diagnostic laparoscopy. However, routine diagnostic laparoscopy does not benefit those patients who proceed to laparotomy after negative laparoscopy. The aim of this study was to evaluate prospectively the selective use of laparoscopy in uncertain situations. METHODS: One hundred and twenty consecutive patients with primary gastric adenocarcinoma were studied prospectively. Diagnostic laparoscopy was performed in patients with clinical T4 tumours or suspected metastases, unless laparotomy was required for symptomatic disease. RESULTS: Ninety-six of 120 patients were selected for immediate laparotomy with curative intent (n = 81) or for palliation (n = 15). In two of the 81 patients gastrectomy was abandoned because of unexpected peritoneal carcinomatosis. Fifteen patients underwent diagnostic laparoscopy, which identified intra-abdominal metastases in six; the other nine patients proceeded to laparotomy, which revealed peritoneal metastases not detected at laparoscopy in four patients. The remaining nine patients had overt metastases and were referred for systemic chemotherapy without abdominal exploration. CONCLUSION: Diagnostic laparoscopy in selected patients effectively limits the number of unnecessary invasive staging procedures. Routine use of diagnostic laparoscopy in all patients with gastric adenocarcinoma is not warranted.     

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.     

Influence of laparoscopy on postoperative recurrence and survival in patients with ruptured hepatocellular carcinoma undergoing hepatic resection

BACKGROUND: Use of laparoscopy in patients with gastrointestinal cancer has been associated with port-site and peritoneal tumour metastases. The effect of laparoscopy on tumour recurrence and long-term survival in patients undergoing resection of ruptured hepatocellular carcinoma (HCC) remains unknown. METHODS: Between June 1994 and December 2001, 59 patients with ruptured HCC underwent surgical exploration with a view to hepatic resection. Laparoscopy with laparoscopic ultrasonography was performed in 33 patients; the other 26 patients underwent exploratory laparotomy without laparoscopy. Perioperative and long-term outcomes were compared between the two groups. RESULTS: Exploratory laparotomy was avoided in 12 of 13 patients with irresectable HCC who had a laparoscopy. The hospital stay of these 12 patients was significantly shorter than that of eight patients found to have irresectable HCC at exploratory laparotomy (median 11 versus 15 days; P = 0.043). Twenty patients had a laparoscopy followed by open resection of HCC, whereas 18 patients underwent laparotomy and resection without laparoscopy. There were no significant differences in disease-free (16 versus 19 per cent; P = 0.525) and overall (32 versus 48 per cent; P = 0.176) survival at 3 years between the two groups. The tumour recurrence pattern was similar between the two groups, and there were no port-site or wound metastases. CONCLUSION: Use of diagnostic laparoscopy in patients with ruptured HCC helps avoid unnecessary exploratory laparotomy. The present data suggest that laparoscopy does not have an adverse effect on tumour recurrence or survival in patients who undergo resection.     

Endoscopic diagnostics and treatment of submucous tumors of the upper gastrointestinal tract

The endoscopic ultrasonography (EUS) is considered to be the leading method of diagnostic of the submucous gastrointestinal tumors. Results of diagnostics and treatment of submucous tumors of the upper gastrointestinal tract in 38 patients were analyzed. EUS was performed in 37 (97,4%) of patients, which allowed to detect the origin, size and localization of the tumor. The differential diagnostic algorithm was suggested together with certain indications for various surgical treatment modalities. Thereby, endoscopic ablation is reasonable when the tumor invades not deeper than muscle plate of mucosa or the submucose layer. Laparoscopic full-layer resection of the organ wall is necessary when the tumor invades the muscle layer. Larger tumors or those of any size, but with preoperative signs of high malignancy must be eradicated through laparotomy, meeting all principles of oncology.     

Port site metastasis after diagnostic laparoscopy for upper gastrointestinal tract malignancies: an uncommon entity

Background The role of laparoscopy for diagnosing, staging, and treating intra-abdominal malignancies is increasing. This study was designed to examine the incidence of port site metastasis and open incision site metastasis for upper gastrointestinal tract (GI) malignancies. Methods From a prospective database maintained by the Department of Surgery, patients undergoing laparoscopy for upper GI malignancies were identified. Clinical outcomes and recurrences were noted. Results Between January 1993 and January 2001, 1965 laparoscopic procedures were identified. After those patients lost to follow-up were excluded, 1650 procedures were performed in 1548 patients. Port site implantation for all laparoscopies occurred in 13 (.79%) of 1650, with a median time to recurrence of 8.2 months. After laparotomy, open incision site recurrence occurred in 9 (.86%) of 1040 (not significant). Among the patients resected, there were 5 (.60%) of 830 port site recurrences and 7 (.84%) of 830 open incision site recurrences. At the time of diagnosis of recurrence, all of the patients with port site and five of seven with open site implantation had distant or local disease, or both, as well. Conclusions Port site implantation after diagnostic laparoscopy for upper GI malignancy is uncommon, does not seem to be different from open incision site recurrence, and occurs in the setting of advanced disease. Therefore, the risk of port site recurrence cannot be used as an argument against laparoscopy in upper GI malignancy. Presented at the 55th Annual Meeting of the Society of Surgical Oncology, Denver, CO, March 15, 2002.     

Laparoscopy as diagnostic-therapeutic method in abdominal traumatism in the pediatric age

The management of blunt abdominal traumatism with a moderate amount of free peritoneal fluid and without solid organ injury as well as the one of minimal penetrating trauma is controversial. We present three cases of blunt abdominal trauma and two of penetrating trauma that underwent diagnostic laparoscopy in our department. We found a small bowel perforation in one of the cases of blunt trauma that was repaired by externalization of the jejuna loop by one of the ports. In the other two cases we found intestinal and mesenteric contusions and free fluid that were treated by peritoneal drainage. One of the cases of penetrating trauma presented omentum evisceration with no other injuries and the second presented a gastric perforation that needed reconversion to laparotomy. In our experience and according to literature, laparoscopy should be taken into account as a diagnostic procedure and sometimes also therapeutic in selected cases of both blunt and penetrating abdominal trauma in pediatric population.     

Laparoscopy of a traumatic rupture of a dysontogenetic splenic cyst. A case report

The role of laparoscopy in the stepped approach to the diagnosis and treatment of blunt abdominal trauma has not yet been fully elucidated. Despite the use of a variety of imaging modalities, it can still be difficult to make a proper evaluation in cases where there are questionable abdominal injuries. In particular, when there is a discrepancy between a bland clinical picture and the results of diagnostic imaging procedures, laparoscopy should be given preference over laparotomy, provided the patient's circulatory situation is stable. Herein we describe a case in which laparoscopy allowed the detection and treatment of a traumatic rupture of a dysontogenetic splenic cyst that had mimicked a rupture of the spleen on both the ultrasound (US) and computed tomography (CT) images.     

Use of laparoscopy in evaluation and treatment of penetrating and blunt abdominal injuries

Use of laparoscopy in penetrating trauma has been well established; however, its application in blunt trauma is evolving. The authors hypothesized that laparoscopy is safe and feasible as a diagnostic and therapeutic modality in both the patients with penetrating and blunt trauma. Trauma registry data and medical records of consecutive patients who underwent laparoscopy for abdominal trauma were reviewed. Over a 4-year period, 43 patients (18 blunt trauma / 25 penetrating trauma) underwent a diagnostic laparoscopy. Conversion to laparotomy occurred in 9 (50%) blunt trauma and 9 (36%) penetrating trauma patients. Diagnostic laparoscopy was negative in 33% of blunt trauma and 52% of penetrating trauma patients. Sensitivity/specificity of laparoscopy in patients with blunt and penetrating trauma was 92%/100% and 90%/100%, respectively. Overall, laparotomy was avoided in 25 (58%) patients. Use of laparoscopy in selected patients with blunt and penetrating abdominal trauma is safe, minimizes nontherapeutic laparotomies, and allows for minimal invasive management of selected intra-abdominal injuries.