Rationale for the Procedure
A number of reports have described the use of DL in ICU patients. The main argument for the use of DL in ICU patients has been for the diagnosis of suspected intra-abdominal pathology in critically ill patients without the need for transport to the operating room with its potential complications. Furthermore, such an approach allows for the uninterrupted treatment of the ICU patient and may minimize the cost of the intervention.
Technique
Many studies have documented the feasibility of the procedure (levels II, III) [1-10]. The most common reason that the procedure fails is the presence of severe adhesions. Although in the initial reports on DL for ICU patients the procedure was performed in the operating room, most recent studies have applied the procedure exclusively at the bedside. Local anesthesia, sedation, and occasionally paralytics have been used for the procedure at the bedside. Many patients who are breathing spontaneously require intubation before the procedure; however, the procedure has also been applied successfully in nonintubated patients. In most instances, a portable laparoscopic cart, which contains a monitor, video camera, light source, and gas supply, is used. A cut-down technique and the Veress needle technique have been used for initial access without reported untoward events. The periumbilical region is the most used site for initial access; however, concerns about intra-abdominal adhesions may dictate the use of another “virgin” site. Pneumoperitoneum has been kept at lower levels (8-12 mm Hg) by many authors due to concerns of hemodynamic compromise in already compromised patients. Nevertheless, level III evidence exists that 15 mm Hg can be used safely without significant hemodynamic or respiratory compromise with the exception of a well tolerated increase in peak inspiratory pressure. No studies have compared different insufflation pressures in ICU patients. Although most studies have used CO2 for insufflation, the use of N2O has also been described. 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 of free intraperitoneal fluid. Additional (5-mm) trocars are used at the discretion of the surgeon as needed for exposure and for potential therapeutic intervention. The use of laparoscopic ultrasound has not been described in ICU patients. The duration of the procedure is short, ranging between 10 and 70 minutes, with an average duration of about 30 minutes.
Indications
The main indication for DL in the ICU has been unexplained sepsis, systemic inflammatory response syndrome, and multisystem organ failure. In addition, the procedure has been used for abdominal pain or tenderness associated with other signs of sepsis without an obvious indication for laparotomy (i.e., pneumoperitoneum, massive gastrointestinal bleeding, small bowel obstruction), fever and/or leukocytosis in an obtunded or sedated patient not explained by another identifiable problem (such as pneumonia, line sepsis, or urinary sepsis), metabolic acidosis not explained by another process (such as cardiogenic shock), and increased abdominal distention that is not a consequence of bowel obstruction.
Contraindications (Absolute or Relative)
• Patients unable to tolerate pneumoperitoneum or who are so sick that there is no realistic chance of survival even if a “treatable” intra-abdominal process were found
• Patients with an obvious indication for surgical intervention such as a bowel obstruction or perforated viscus
• Patients with an uncorrectable coagulopathy or uncorrectable hypercapnia >50 torr
• Patients with a tense and distended abdomen (i.e., clinically suspected abdominal compartment syndrome)
• Patients with abdominal wall infection (e.g., cellulitis, soft tissue infection, open wounds)
• Patients with extensive previous abdominal surgery with multiple incisional scars or after a laparotomy within the last 30 days
Risks
• Delay in the diagnosis and treatment of patients if the procedure is false negative
• Missed pathology and its associated complications
• Procedure- and anesthesia-related complications
Benefits
• Expeditious diagnosis of suspected intra-abdominal pathology
• Minimization of treatment interruption by not moving the patient outside the ICU
• Avoid the morbidity of open exploration
• Avoid potential risks associated with transportation to the operating room or radiology for diagnostic tests
• Ability to provide therapeutic intervention
Diagnostic Accuracy of the Procedure
The diagnostic accuracy of the procedure is high, ranging between 90 and 100% in the published series (level II, III) [1-10]. The main limitation of the procedure is for the evaluation of retroperitoneal structures with the few false negative reported findings attributed to retroperitoneal processes like pancreatitis [4,9]. Nevertheless, the procedure appears to have excellent accuracy when evaluating for two of the most prevalent diseases in this population, acalculous cholecystitis and ischemic bowel (level II, III) [4,5,7,10]. The procedure has been reported to prevent unnecessary laparotomies in 36-95% of patients (level III) [1,2,5,6]. Its sensitivity has also been demonstrated in patients with suspected abdominal complications after cardiac surgery [4,9].
Diagnostic laparoscopy has been compared with diagnostic peritoneal lavage and found to have superior diagnostic accuracy in critically ill patients (level II) [5]. It has also been found to be superior to computed tomography (CT) or ultrasound of the abdomen (level III) [3,6,7,10].
Procedure-related Complications and Patient Outcomes
The procedure can be performed safely, is well tolerated in ICU patients (level II) [5], and only a few minor complications have been described (bradycardia and increased peak airway pressure that resolved after release of pneumoperitoneum and perforation of a gangrenous gallbladder during manipulation). Overall morbidity has been reported between 0 and 8%, and no mortality directly associated with the procedure has been described [1-10]. Nevertheless, the ICU patient population has very high mortality rates (33-79%) regardless of the findings of DL.
Cost-effectiveness
While it has been implied that DL in the ICU rather than the operating room can yield substantial cost savings, no direct evidence exists.
Limitations of the Available Literature
A few single-center studies of limited quality, which include small patient cohorts, address the role of DL in the ICU population making generalizations difficult and allowing institutional and personal biases to be introduced into the results. There is also a lack of uniformity and detail in the reported selection criteria and noninvasive imaging prior to the procedure. These limitations of the available literature and the high mortality rates of this patient population make it difficult to draw firm conclusions about the impact of the procedure on patient outcomes and its cost-effectiveness. Furthermore, the impact of the surgeon’s laparoscopic expertise on the diagnostic accuracy of the procedure is unknown.
Recommendations
Diagnostic laparoscopy is technically feasible and can be applied safely in appropriated selected ICU patients (grade B). The procedure should be used in critically ill patients when an intra-abdominal catastrophe is suspected but cannot be ruled out by noninvasive means and would otherwise require an exploratory laparotomy (grade C). It should be given strong consideration in ICU patients with suspected acalculous cholecystitis or ischemic bowel, as its accuracy likely exceeds that of noninvasive studies (grade C). On the other hand, it should be kept in mind that the procedure is unlikely to identify retroperitoneal processes. The decision to undertake DL and at which location (bedside or operating room) should be individualized and should be based on the available resources and laparoscopic expertise of the surgeon.
Bibliography
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