LAPAROSCOPIC CHOLECYSTCTOMY
Posted by on Thursday, 7th May 2009
1. What is the function of the Gallbladder?
The gallbladder is a small pear-shaped organ under the liver on the right side of the upper abdomen. It stores bile produced by the liver cells during resting state and squeezes it into the intestine via the bile duct to aid in digestion during a meal.
2. What are Gallstones and how are they detected?
Causes of gallstones formation are multi-factorial, involving bacteria infection of the bile, precipitation of constituents of the bile such as bile salt, calcium, bile pigment and cholesterol. The stones can be hard stones of varying sizes or they can be in the form of soft cholesterol stones or mid-like sludge. Ultrasound scan of the abdomen is the commonest method used in detecting gallstones; it is non-invasive and very accurate. Other methods in detecting gallstones include computerized tomography (CT) scan and oral cholecystography.
3. When do I need an operation to remove the Gallbladder?
Gallstones disease is a common occurrence in the population but majority of people are symptoms free and therefore unaware of their existence. An operation is recommended when the gallstones cause problems such as pain, jaundice (yellowing of skin) or infection. The current standard treatment entails removal of the diseased gallbladder together with gallstones.
4. What is Laparoscopic Cholecystectomy?
Laparoscopic cholecystectomy (removal of the gallbladder via key-hole operation) is conducted under general anesthesia. The procedure is carried out after distending the abdomen cavity with carbon dioxide insufflations to create space for the operation. A 10mm diameter telescope is then place through a small incision at the umbilicus for visualization. The actual operation on the gallbladder is performed with three slim instruments 3-5mm in diameters placed just below the right ribcage. Tiny clips are used to seal the blood vessels around the gallbladder and the cystic duct that connects the gallbladder to the bile duct. The gallbladder and the stones inside will be extracted at completion of operation as in conventional open operation.
5. What are the benefits of Laparoscopic Cholecystectomy?
The benefits include: -
• Less pain
• Shorter hospitalization stay
• Faster recovery and return to work
• Reduce overall hospitalization cost
• Better cosmetic outcome
6. What to prepare for the operation?
You will be review by an anesthesiologist before the operation to ensure that you are healthy and fit for general anesthesia. Routine blood tests, chest X-ray and ECG will be done when necessary.
The operation is generally a straightforward one. You can be admitted on the day of the operation but you need to fast for at least 6-8 hours prior to the operation. You should not have any food or liquid after midnight if your operation is scheduled in the morning. You can have a beverage early in the morning if your operation is scheduled for later in the afternoon.
7. What to expect after the surgery?
When you wake up from the surgery, you will find,
• Bandages on the incisions
• A tube that was inserted in your vein to give you fluids and medications
Post-anesthetic nausea, headache and sore throat are common symptoms experience by many patients. You will be prescribed medications to counter these symptoms. You can take liquid orally after you wake up fully from the general anesthesia and should be able to progress to diet in the evening if you tolerated the liquid well.
Pain from the small laparoscopic wounds is usually well tolerated. Majority of patients required only oral medication for adequate pain relief. Patient control analgesia will be available if you need.
Majority of patients recover from the operation very quickly and are ready to go home after a night rest in the hospital.
8. Are there potential complications associated with the operation?
Laparoscopic cholecystectomy is generally a safe operation and complications are rare, these include -
• Risks of anesthesia
• Wound infection
• Slight numbness around the incision
• Small risk (less than 1%) of Injury to the bile duct.
9. Are there any side effects after operation?
The gallbladder is not an essential digestive organ and its removal does not carry significant long-term side effect. Some patients experience loose stool and bloating with fatty food in the early period after the operation. This usually improves and resolves after a few weeks.
10. Care after discharge
• Care of the wound - dressing of the wound can be removed after couple of days. It is perfectly safe to leave the wound exposed and shower with soap and clean running water.
• Wound infection occurs rarely, this usually presents with discharge from the wound or redness and persistent pain at the wound. When this happens, please contact your surgeon or your family doctor for advice.
• Stitches will be removed after a week at the clinic
• Bloated sensation and occasional loose stools will be expected for a few days and up to a few weeks. Avoiding fatty food can help to lessen the problem.
• You should be able to resume normal daily routine at home or desk job at the office by the end of first week. You can do light exercises such as walking and swimming as long as the wound pain is tolerable. Strenuous exercises or lifting heavy objects is not advisable and should be delayed to at least 4-6 weeks later.
11. Are there any dietary restrictions?
Generally no. But preferably avoid fatty and oily food, avoid overeating and have more portions of fresh fruits and vegetables in your diet.
12. Please seek medical attention
If you have the following signs and symptoms, please do not hesitate to get help.
• Fever >38 C
• Severe pain, redness or discharges from at the wound site
• Jaundice (yellowing of skin)
Rate It
Diagnostic Laparoscopy in the ICU
Posted by on Thursday, 7th May 2009
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
1. Gagne, D. J., Malay, M. B., Hogle, N. J., and Fowler, D. L. Bedside Diagnostic Minilaparoscopy in the Intensive Care Patient. Surgery 2002;131(5):491-6.
2. Pecoraro, A. P., Cacchione, R. N., Sayad, P., Williams, M. E., and Ferzli, G. S. The Routine Use of Diagnostic Laparoscopy in the Intensive Care Unit. Surgical Endoscopy 2001;15(7):638-41
3. Kelly, J. J., Puyana, J. C., Callery, M. P., Yood, S. M., Sandor, A., and Litwin, D. E. The Feasibility and Accuracy of Diagnostic Laparoscopy in the Septic ICU Patient. Surgical Endoscopy 2000;14(7):617-21.
4. Orlando R, Crowell KL. Laparoscopy in the critically ill. Surg Endosc 1997; 11(11):1072-4.
5. Walsh, R. M., Popovich, M. J., and Hoadley, J. Bedside Diagnostic Laparoscopy and Peritoneal Lavage in the Intensive Care Unit. Surgical Endoscopy 1998;12(12):1405-9.
6. Brandt CP, Priebe PP, Eckhauser ML. Diagnostic laparoscopy in the intensive care patient. Avoiding the nontherapeutic laparotomy. Surg Endosc. 1993 May-Jun;7(3):168-72
7. Brandt CP, Priebe PP, Jacobs DG. Value of laparoscopy in trauma ICU patients with suspected acute acalculous cholecystitis. Surg Endosc. 1994 May;8(5):361-4; discussion 364-5
8. Jaramillo EJ, Trevino JM, Berghoff KR, Franklin ME Jr.
Bedside diagnostic laparoscopy in the intensive care unit: a 13-year experience. JSLS. 2006 Apr-Jun;10(2):155-9.
9. Hackert T, Kienle P, Weitz J, Werner J, Szabo G, Hagl S, Büchler MW, Schmidt J. Accuracy of diagnostic laparoscopy for early diagnosis of abdominal complications after cardiac surgery. Surg Endosc 2003;17(10):1671-4.
10. Almeida J, Sleeman D, Sosa JL, Puente I, McKenney M, Martin L. Acalculous cholecystitis: the use of diagnostic laparoscopy. J Laparoendosc Surg 1995;5(4):227-31.
Rate It
Diagnostic Laparoscopy Guidelines
Posted by on Thursday, 7th May 2009
Preamble
These diagnostic laparoscopy guidelines are a series of systematically developed statements to assist surgeons’ (and patients’) decisions about the appropriate use of diagnostic laparoscopy (DL) in specific clinical circumstances. The statements included in this guideline are the product of a systematic review of published work on the topic, and the recommendations are explicitly linked to the supporting evidence. The strengths and weaknesses of the available evidence are described and expert opinion sought where the evidence is lacking. This is an update of previous guidelines on this topic (SAGES publication #0012; last revision 2002) as new information has accumulated.
Disclaimer
Clinical practice guidelines are intended to indicate the best available approach to medical conditions as established by systematic review of available data and expert opinion. The approach suggested may not be the only acceptable approach given the complexity of the health care environment. These guidelines are intended to be flexible, as the surgeon must always choose the approach best suited to the patient and variables in existence at the time of the decision. These guidelines are applicable to all physicians who are appropriately credentialed and address the clinical situation in question, regardless of specialty.
Guidelines are developed under the auspices of SAGES and the guidelines committee and approved by the Board of Governors. The recommendations of each guideline undergo multidisciplinary review and are considered valid at the time of production based on the data available. Recent developments in medical research and practice pertinent to each guideline will be reviewed, and guidelines will be updated on a periodic basis.
Clinical Application
Diagnostic laparoscopy is minimally invasive surgery for the diagnosis of intra-abdominal diseases. The procedure enables the direct inspection of large surface areas of intra-abdominal organs and facilitates obtaining biopsy specimens, cultures, and aspiration. Laparoscopic ultrasound can be used to evaluate deep organ parts that are not amenable to inspection. Diagnostic laparoscopy not only facilitates the diagnosis of intra-abdominal disease but also makes therapeutic intervention possible.
Literature Review Methods
A large body of literature about DL exists. The many clinical situations where DL has been applied, adds complexity to the analysis of the literature. Our systematic literature search of MEDLINE for the period 1995-2005, limited to English language articles, identified 663 relevant reports. The search strategy is shown in Figure 1 at the end of this document. Using the same strategy, we searched the Cochrane database of evidence-based reviews and the Database of Abstracts of Reviews of Effects (DARE), which identified an additional 54 articles. Thus, a total of 717 abstracts were reviewed by three committee members (DS, WR, LC) and divided into the following categories:
a) Randomized studies, metaanalyses, and systematic reviews
b) Prospective studies
c) Retrospective studies
d) Case reports
e) Review articles
Randomized controlled trials, metaanalyses, and systematic reviews were selected for further review along with prospective and retrospective studies that included at least 50 patients; studies with smaller samples were reviewed when other available evidence was lacking. The most recent reviews were also included. All case reports, old reviews, and smaller studies were excluded. According to these exclusion criteria, 169 articles were reviewed by the three committee members (DS, WR, LC).
To maximize the efficiency of the review, the articles were divided in the following subject categories:
1) Staging laparoscopy for cancer
a) Esophageal cancer
b) Gastric cancer
c) Pancreatic and periampullary cancers
d) Liver cancer
e) Biliary tract cancer
f) Colorectal cancer
g) Lymphoma
2) Diagnostic laparoscopy for acute conditions
a) Acute abdomen
b) Trauma
c) ICU
3) Diagnostic laparoscopy for chronic conditions
a) Chronic pelvic pain and endometriosis
b) Liver disease (including cirrhosis)
c) Infertility
d) Cryptorchidism
e) Other
4) Other (general reviews, complications, etc.)
The reviewers graded the level of evidence of each article and manually searched the bibliographies for additional articles that may have been missed by our search. Any additional relevant articles (n=33) were included in the review and grading. A total of 140 graded articles relevant to this guideline were included in this review. Based on the reviewer grading of all articles, we devised the recommendations included in these guidelines.
Levels of Evidence
Level I - Evidence from properly conducted randomized, controlled trials
Level II - Evidence from controlled trials without randomization Cohort or case-control studies Multiple time series dramatic uncontrolled experiments
Level III - Descriptive case series, opinions of expert panels
General Recommendations
Diagnostic laparoscopy is a safe and well tolerated procedure that can be performed in an inpatient or outpatient setting under general or occasionally local anesthesia with IV sedation in carefully selected patients. Diagnostic laparoscopy should be performed by physicians trained in laparoscopic techniques who can recognize and treat common complications and can perform additional therapeutic procedures when indicated. During the procedure, the patient should be continuously monitored, and resuscitation capability must be immediately available. Laparoscopy must be performed using sterile technique along with meticulous disinfection of the laparoscopic equipment. Overnight observation may be appropriate in some outpatients. There are unique circumstances when office-based DL may be considered. Office-based DL should only be undertaken when complications and the need for therapeutic procedures through the same access are highly unlikely.
Rate It
Laparoscopy for Non-palpable Testicle
Posted by on Thursday, 7th May 2009
Rationale for the Procedure and/or General Comments
Laparoscopy has been used since 1976 for the evaluation of the non-palpable testis in pediatric patients. The rationale for the procedure has been to decrease the morbidity of open standard surgical exploration for the non-palpable testicle. Furthermore, therapeutic interventions such as orchiopexy and orchiectomy are also feasible using this technique.
Technique
In the operating room under general anesthesia, a second manual palpation is performed to check for testes in the inguinal canal or scrotum. If none is found, the patient is prepped and draped in the usual manner. The primary port is inserted in the periumbilical region. A 5-mm port is placed in the contralateral lower abdominal quadrant for manipulation. A second port can be used for laparoscopic clipping and division of testicular vessels where necessary for the first part of the two-part staged Fowler-Stevens orchiopexy. During this part of the procedure, the testicle is identified and its relation to the spermatic vessels and internal inguinal ring ascertained. A testicle that is normal size for the patient’s age should be salvaged, whereas a testicle that is non-viable should be removed. If no testicle is identified on laparoscopy and blind ending spermatic vessels are seen, the testicle has atrophied and the procedure is terminated. If no testicle is identified, no spermatic vessels are seen, and only the vas deferens is seen going into the inguinal canal, the laparoscopic dissection must continue higher in the retroperitoneum in search of the undescended testicle. The second stage of the procedure is usually performed approximately 6 months later through a high groin incision mobilizing the testicle into the scrotum.
Indications
• Identification of a non-palpable testis on physical exam
Contraindications
• Inability to tolerate the procedure
• Dense abdominal adhesions that may preclude safe access and/or dissection
Risks
• Procedure- and anesthesia-related complications
Benefits
• Decreased morbidity, less pain, and earlier recovery compared with open exploration
Diagnostic Accuracy of the Procedure
Diagnostic laparoscopy identifies the location of a nonpalpable testis with 99-100% accuracy (level III) [1-5]. The procedure reliably demonstrates whether the testicle is present intra-abdominally or whether the vas and the vessels enter the internal inguinal ring. When laparoscopy is applied only for diagnosis, it can still prevent unnecessary abdominal explorations in 13-18% of patients (level III) [1,3]. Inguinal exploration alone may identify up to 34% of testicles and obviate laparoscopy; however, no good predictors exist III) [3]. Laparoscopy by a skilled laparoscopist enables therapeutic intervention (orchidopexy or orchiectomy), minimizes the need for open explorations, and preserves the benefits of the minimally invasive approach. Importantly, physical examination under anesthesia prior to laparoscopy may identify up to 18% of nonpalpable testicles in the groin (level III) [3]. There are little data comparing laparoscopic and open exploration.
Procedure-related Complications and Patient Outcomes
Procedure-related complications have been described to occur in 0-3.2% of patients, the most severe being a bowel injury.
Laparoscopic-assisted orchidopexy has been associated with 0-2.2% testicular atrophy and 97% success rates. This compares favorably with the one-stage Fowler-Stephens orchidopexy (with a 22% atrophy and 74% success rate) and the two-stage Fowler-Stephens orchidopexy (with a 10% atrophy and 88% success rate) (level III) [4,5]. It has been hypothesized that laparoscopic orchidopexy may decrease the rate of testicular atrophy by preserving the vascular supply as it can be performed usually in one stage.
Cost-effectiveness
There are no available data on the cost-effectiveness of the procedure.
Limitations of the Available Literature
The quality of the available literature for laparoscopy in the management of non-palpable testis is limited to level III evidence. No studies compare the open and laparoscopic approach with regard to patient morbidity, and there is inconsistency in the use of preoperative localization studies before laparoscopy. These limitations make strong recommendations difficult.
Recommendations
Patients undergoing DL for nonpalpable testis should have physical examination of the groin under anesthesia before the procedure is started as this approach will identify up to 18% of testicles and obviate the need for the procedure (grade A). Diagnostic laparoscopy should be part of the treatment algorithm of patients with nonpalpable testis as it is likely to improve patient outcomes; however, further higher quality study is needed. (grade C).
Bibliography
1. Lima M, Bertozzi M, Ruggeri G, Domini M, Libri M, Pelusi G, Landuzzi V, Messina P. The nonpalpable testis: an experience of 132 consecutive videolaparoscopic explorations in 6 years. Pediatr Med Chir, 2002 Jan-Feb;24(1):37- 40.
2. Baillie CT, Fearns G, Kitteringham L, Turnock RR. Management of the impalpable testis: the role of laparoscopy. Arch Dis Child, 1998; 79:419-422.
3. Cisek, Lars J, Peters, Craig A.; Atala, Anthony, Bauer, Stuart B, Diamond, David A.; Retik, Alan B. Current findings in diagnostic laparoscopic evaluation of the nonpalpable testis. J Urol. 1998 Sep;160(3 Pt 2):1145-9; discussion 1150.
4. Merguerian PA, Mevorach RA, Shortliffe LD, Cendrn M. Laparoscopy for the evaluation and management of the nonpalpable testicle. Urology. 1998 May;51(5A Suppl):3-6.
5. Baker LA, Docimo SG Surer I, Peters C, Cisek L, Diamond DA, Caldamone A, Koyle M, Strand W, Moore R, Mevorach R, Brady J, Jordan G, Erhard M, Franco I. A multi-institutional analysis of laparoscopic orchidopexy. B J U Int. 2001 apr;87(6):484-9.
Rate It
Diagnostic Laparoscopy for Pelvic Pain and Endometriosis
Posted by on Thursday, 7th May 2009
Rationale for the Procedure
Chronic pelvic pain is typically defined as pelvic pain lasting more than 6 months and is a complex disorder with multiple etiologies. It affects many women and can severely impair their quality of life and lead to frequent visits to gynecologists. The etiology of chronic pelvic pain is frequently obscure despite the use of many diagnostic tests. Diagnostic laparoscopy is an excellent tool for direct visualization of the pelvis and may help identify the etiology of the patients’ pain. The procedure facilitates therapeutic intervention and may help ameliorate the morbidity of an open exploration.
Technique
The procedure can be employed under general anesthesia or conscious sedation. The latter approach must be used with the technique of conscious pain mapping during which the patient can respond to intraperitoneal manipulations that may identify the source of pain. Smaller trocars and lower pneumoperitoneum pressures should be used with this technique to decrease the operative pain [2,3].
The patient is placed in the lithotomy position. The initial access site is usually peri-umbilical. Additional trocars can be placed in the left lower or right lower quadrant [1]. A manipulator can be placed on the cervix and a rectal probe can be used if necessary for further retraction; these instruments are usually not used during conscious sedation.
During the procedure, identified adhesions are divided, and lesions suspected to be endometriosis should be biopsied and classified. In the absence of visible endometriosis lesions, random biopsies may demonstrate endometriosis in 30% of patients with typical symptoms. Free peritoneal fluid should be sampled and examined for the presence of endometriosis. Endometriosis lesions can then be fulgurated or removed.
Indications
• Chronic pelvic pain of unknown etiology after appropriate noninvasive workup
Contraindications
• Procedure intolerance
• Known dense pelvic adhesions that may make an accurate evaluation of pelvic pathology impossible or may impede safe abdominal access
Risks
• Procedure- or anesthesia-related complications
Benefits
• Potential identification of the source of the chronic pelvic pain
• Possibility for immediate therapeutic intervention
• Potential improvement in the patient’s quality of life
Diagnostic Accuracy of the Procedure
Diagnostic laparoscopy has been demonstrated to identify endometriosis, adhesions, or other abnormalities of the appendix and ovaries as the source of chronic pelvic pain [3].
In patients with clinical suspicion of endometriosis, DL has been shown to confirm the diagnosis in 78-84% of patients (level III) [4,6]. Random peritoneal biopsies and peritoneal fluid cytology have been shown to improve the diagnosis of endometriosis by 20% (level III) [4,8]. In addition, up to 22% of patients with findings of endometriosis during DL have had previous nondiagnostic laparoscopy (level III) [4]. The diagnosis of endometriosis is more likely when multiple complex pigmented lesions are observed during DL [1].
For pelvic inflammatory disease, the visual accuracy of DL alone was found to be 78% (sensitivity 27% and specificity 92%) (level III) [5]. In the same study, the diagnostic accuracy of the procedure was significantly higher for more experienced laparoscopists. Pain mapping identified a direct source for the pain in 80% of patients with adhesions but was inconsistent in patients with endometriosis [3].
Procedure-related Complications and Patient Outcomes
Procedure-related complications include bowel injuries, bleeding, urologic injuries, vaginal cuff wounds, peritonitis, and pelvic pain. In a large multicenter French study (n=30,000), diagnostic and therapeutic laparoscopy were found to be associated with a 3.3 per 100.000 mortality and a 4.6 per 1,000 morbidity risk (level II) [7]. Complications requiring conversion to laparotomy occurred in 3.2 per 1,000 patients. The risk of complications was related to the complexity of surgery and the experience of the laparoscopist. One in four intraoperative complications were missed during the procedure.
For laparoscopic pain mapping, under conscious sedation, one study showed 48 of 50 women had improvement (level II) [3].
Cost effectiveness
There are no available data on the cost effectiveness of DL for chronic pelvic pain.
Limitations of the Available Literature
The quality of the available literature is limited, as almost all of the available studies are retrospective studies from single institutions. Furthermore, there is a paucity of data on long-term outcomes and little data on cost-effectiveness and quality of life. These shortcomings limit our ability to provide firm recommendations.
Recommendations
Diagnostic laparoscopy can be safely applied in the diagnosis of chronic pelvic pain (grade B). The procedure may identify the etiology of chronic pelvic pain in a proportion of patients, and its diagnostic accuracy may be improved by the technique of conscious pain mapping (grade B). Nevertheless, the existing evidence does not allow firm recommendations, and further research is needed to establish the value of DL for chronic pelvic pain (grade B).
Bibliography
1. Ueki M, Saeki M, Tsurunaga T, Ueda M, Ushiroyama N, Sugimoto O. Visual Findings and Histologic Diagnosis of Pelvic Endometriosis Under Laparoscopy and Laparotomy. Int J Fertil. 1995;40(5):248-253
2. Demco L. Mapping the Source and Character of Pain due to Endometriosis by Patient-Assisted Laparoscopy. J Am Assoc Gynecol Laparosc. 1998; 5(3):241-245.
3. Almeida Jr O, Val-Gallas J. Conscious Pain Mapping. J Am Assoc Gynecol Laparosc. 1997 Nov; 4(5):587-590.
4. Wood C, Kuhn R, Tsaltas J. Laparoscopic Diagnosis of Endometriosis. Obstet Gynecol. 2002; 42:3:277.
5. Molander P, Finne P, Sjoberg J, Sellors J, Paavonen J. Observer Agreement With Laparoscopic Diagnosis of Pelvis Inflammatory Disease Using Photographs. Obstet Gynecol., 2003 May;101(5 Pt 1):875-80
6. Mettler L, Schollmeyer T, Lehmann-Willenbrock, Schuppler U, Schmutzler A, Shukla D, Zavala A, Lewin A. Accuracy of Laparoscopic Diagnosis of Endometriosisg. JSLS, 2003 Jan-Mar;7(1):15-8.
7. Chapron C, Querleu D, Bruhat M, Madelenat P, Fernandez H, Pierre F, Dubuisson J. Surgical Complications of Diagnostic and Operative Gynaecological Laparoscopy. Human Reproduction. 1998 13(4):867-872.
8. Stowell S, Wiley C, Perez-Reyes N, Powers C. Cytological Diagnosis of Peritoneal Fluids. Acta Cytol 1997; 41:817-822.
Rate It
Why we are No. 1 › 
Category (
Views ( 13379 ) | User Rating
