Rationale for the Procedure
Laparoscopy has been applied by multiple authors in the diagnosis of non-specific acute abdominal pain, which is defined as acute abdominal pain of less than 7 days duration where the diagnosis remains uncertain after baseline examination and diagnostic tests. The rationale for the use of DL in this setting is to prevent treatment delay and its potential for disastrous complications and at the same time to avoid unnecessary laparotomy, which is associated with relatively high morbidity rates (5-22%). Diagnostic laparoscopy offers the potential advantage of visually excluding or confirming the diagnosis of acute intra-abdominal pathology expeditiously without the need for a laparotomy.
A sizable proportion of the literature also refers to the use of DL for suspected appendicitis. Since SAGES has a separate guideline for laparoscopic appendectomy, these articles are excluded from this review.
Technique
Many studies have documented the feasibility and safety of the procedure using general anesthesia in patients with acute abdominal pain (level I-III). Severe abdominal distention due to bowel obstruction usually precludes successful deployment of the technique due to inadequate working space. In addition, the presence of multiple adhesions can limit its use. Conversion rates to an open procedure have ranged widely and are usually the result of intra-abdominal adhesions, inability to visualize all structures, technical difficulties, and surgeon inexperience.
For initial access, a cut-down technique and the Veress needle technique have been described. Access-related complications have been reported, and some authors recommend the use of the cut-down technique to prevent untoward events, especially in the case of abdominal distention or prior abdominal operations. Nevertheless, no studies have compared these two access techniques in patients with acute abdominal pain. The periumbilical region is the usual site for initial access; however, previous midline incisions may dictate the use of another “virgin” site. While most studies describe insufflation pressures of 14-15 mm Hg, some authors have used lower levels (8-12 mm Hg) due to concerns of hemodynamic compromise with higher pressures. Nonetheless, no untoward effects of higher pressures have been described, and no comparative studies using different insufflation pressures exist. An angled scope is used at the periumbilical trocar site for inspection of the intra-abdominal organs, including the surface of the liver, gallbladder, stomach, intestine, pelvic organs, and visible retroperitoneal surfaces along with examination for free intraperitoneal fluid. Additional (5-mm) trocars may be used at the discretion of the surgeon to optimize exposure or provide therapeutic intervention. The use of laparoscopic ultrasound has not been described in this population.
Indications
• Unexplained acute abdominal pain of less than 7 days duration after initial diagnostic workup
• As an alternative to close observation for patients with nonspecific abdominal pain which is the current practice in the management of these patients
Contraindications
• Patients with a clear indication for surgical intervention such as bowel obstruction, perforated viscous (free air), or hemodynamic instability
• Relative contraindications used by some authors include patients with prior intra-abdominal surgeries, patients with chronic pain, morbidly obese patients, pregnant patients, and patients with psychiatric disorders.
Risks
• Delay to definitive treatment with potentially increased morbidity when the study is false negative
• Procedure- and anesthesia-related complications
Benefits
• Reduction in the rate of negative and nontherapeutic laparotomies (with a subsequent decrease in hospitalization, morbidity, and cost after negative laparoscopy)
• Earlier diagnosis and intervention with potentially improved outcomes compared with observation
• Ability to provide therapeutic intervention
Diagnostic Accuracy of the Procedure
Many studies have demonstrated high diagnostic accuracy for the procedure (70-99%, level I-III) [1-13]. In a level I evidence study, the diagnosis was established with early laparoscopy in more patients with non-specific abdominal pain compared with an observation group (81% vs. 36%, respectively; p<0.001) [1]. In contrast, another level I study showed a small non-significant improvement in the diagnostic accuracy for acute lower abdominal pain in women of reproductive age when laparoscopy was compared with observation (85% vs. 79%, respectively; p=n.s.) [2]. In the latter study, the diagnosis was established significantly faster in the laparoscopy group, and laparoscopy aided more accurate diagnostic judgments with clinical significance in 2/5 of the patients. Diagnostic laparoscopy has been demonstrated to change the treatment strategy in 10-58% of patients (level II, III) [3-9]. While CT of the abdomen/pelvis was scarcely used during the preoperative workup in the majority of the reviewed papers, one study demonstrated a higher diagnostic accuracy of DL in the diagnosis of diverticulitis compared with CT of the abdomen or colonic enema (level II) [13].
Procedure-related Complications and Patient Outcomes
The procedure can be performed safely in the majority of patients (level I-III) [1-13]. A 0-24% morbidity and 0-4.6% mortality have been reported (level I-III) [1-12]. The complications reported include pulmonary embolism, prolonged ileus, wound infection or hematoma, intra-abdominal abscess, pneumonia, congestive heart failure, urinary infection, acute herniations at trocar sites, intraoperative injuries to bowel or vascular structures, bladder injuries, fistulas, septic shock, myocardial infarction, and others. Since the procedure has been applied to patients with variable disease acuity and operative risk (from patients with acute abdominal pain to patients with acute abdomen and peritonitis), complications are higher in studies that include sicker patients. The majority of reported deaths have been associated with multiple organ failure secondary to sepsis.
Diagnostic laparoscopy has been associated with shorter hospital stays, especially when it is the only procedure performed (level I-III) [2,3,8,11]. Converted procedures have similar hospital stays compared with open procedures. One level I evidence study reported similar hospital stays between an early laparoscopy group and an observation group with nonspecific abdominal pain (2 days for both groups), similar morbidity (24% vs. 31%, respectively; p=n.s.), and similar readmission rates at a median of 21 months follow-up (29% vs. 33%, respectively; p=n.s.) [1]. This study, however, documented higher well-being scores in patients treated with early laparoscopy at 6 weeks follow-up compared with the observation group. Another level I evidence study that randomized patients into similar groups, also failed to show morbidity differences but demonstrated a shorter hospital stay for the laparoscopically-treated group (1.3 days vs. 2.3 days for the observation group; p<0.01) [2]. The reoperation rate was reported to be 7.4% in one study (for drainage of intra-abdominal abscesses, continued sepsis, or pancreatic debridement (level III) [7].
Cost-effectiveness
No evidence exists on the cost-effectiveness of DL for non-specific acute abdominal pain.
Limitations of the Available Literature
The results of the analyzed literature are difficult to combine, as there is a lack of homogeneity. Reports range from the evaluation of women of reproductive age with acute pelvic pain to patients with suspected diverticulitis and to patients with an acute abdomen and peritonitis. The diagnostic accuracy of the procedure can be substantially different depending on the examined population. It is also unknown how experience with the procedure impacts its diagnostic accuracy. Given today’s reality, one important limitation of many of the available studies is the lack of preoperative, high quality imaging studies (like spiral CT scan of the abdomen and pelvis), which may have provided the diagnosis without the need for an invasive procedure.
Recommendations
Diagnostic laparoscopy is technically feasible and can be applied safely in appropriately selected patients with acute non-specific abdominal pain (grade B). The procedure should be avoided in patients with hemodynamic instability and may have a limited role in patients with severe abdominal distention or a clear indication for laparotomy (grade C). The procedure should be considered in patients without a specific diagnosis after appropriate clinical examination and imaging studies (grade C). Based on the available evidence, an invasive procedure cannot be recommended before other non-invasive diagnostic options have been exhausted.
Diagnostic laparoscopy may be superior to observation for nonspecific abdominal pain; however, the available evidence is mixed, making it difficult to provide a firm recommendation. In addition, DL may be preferable to exploratory laparotomy in appropriately selected patients with an indication for operative intervention provided that laparoscopic expertise is available (grade C).
Bibliography
1. Decadt B, Sussman L, Lewis MP, Secker A, Cohen L, Rogers C, Patel A, Rhodes M Randomized clinical trial of early laparoscopy in the management of acute non-specific abdominal pain. Br J Surg 1999; 86(11):1383-6.
2. Gaitan H, Angel E, Sanchez J, Gomez I, Sanchez L, Agudelo C. Laparoscopic diagnosis of acute lower abdominal pain in women of reproductive age. Int J Gyn Obstr 2002; 76(2):149-58.
3. Majewski, W. Diagnostic Laparoscopy for the Acute Abdomen and Trauma. Surgical Endoscopy 2000;14(10):930-7.
4. Ou, C. S. and Rowbotham, R. Laparoscopic Diagnosis and Treatment of Nontraumatic Acute Abdominal Pain in Women. Journal of Laparoendoscopic & Advanced Surgical Techniques 2000;Part A. 10(1):41-5.
5. Fahel, E., Amaral, P. C., Filho, E. M., Ettinger, J. E., Souza, E. L., Fortes, M. F., Alcantara, R. S., Regis, A. B., Neto, M. P., Sousa, M. M., Fogagnoli, W. G., Cunha, A. G., Castro, M. M., and Santana, P. A., Jr. Non-Traumatic Acute Abdomen: Videolaparoscopic Approach. Journal of the Society of Laparoendoscopic Surgeons 1999;3(3):187-92.
6. Cuesta, M. A., Eijsbouts, Q. A., Gordijn, R. V., Borgstein, P. J., and de Jong, D. Diagnostic Laparoscopy in Patients With an Acute Abdomen of Uncertain Etiology. Surgical Endoscopy 1998;12(7):915-7
7. Cueto, J., Diaz, O., Garteiz, D., Rodriguez, M., and Weber, A. The Efficacy of Laparoscopic Surgery in the Diagnosis and Treatment of Peritonitis. Experience With 107 Cases in Mexico City. Surgical Endoscopy 1997;11(4):366-70.
8. Navez, B., d'Udekem, Y., Cambier, E., Richir, C., de Pierpont, B., and Guiot, P. Laparoscopy for Management of Nontraumatic Acute Abdomen. World Journal of Surgery 1995;19(3):382-6.
9. Golash V, Willson PD. Early laparoscopy as a routine procedure in the management of acute abdominal pain: a review of 1,320 patients. Surg Endosc 2005;19(7):882-5.
10. Sanna A, Adani GL, Anania G, Donini A. The role of laparoscopy in patients with suspected peritonitis: experience of a single institution. J Laparoendosc Adv Surg Tech A. 2003;13(1):17-9.
11. Sozuer, E. M., Bedirli, A., Ulusal, M., Kayhan, E., and Yilmaz, Z. Laparoscopy for Diagnosis and Treatment of Acute Abdominal Pain. Journal of Laparoendoscopic & Advanced Surgical Techniques 2000;Part A. 10(4):203-7.
12. Poulin, E. C., Schlachta, C. M., and Mamazza, J. Early Laparoscopy to Help Diagnose Acute Non-Specific Abdominal Pain. Lancet 3-11-2000;355(9207):861-3.
13. Stefansson, T., Nyman, R., Nilsson, S., Ekbom, A., and Pahlman, L. Diverticulitis of the Sigmoid Colon. A Comparison of CT, Colonic Enema and Laparoscopy. Acta Radiologica 1997;38(2):313-9