Rationale for the Procedure
Pancreatic adenocarcinoma is diagnosed in just over 30,000 patients every year in the United States and has a dismal prognosis, with an almost identical yearly death rate. Surgery is the only modality that can lead to cure; however, most patients present with inoperable disease. The overall 5-year survival is <5%. Patients with localized disease have a 15% 5-year survival after curative resection. In a disease with such a poor prognosis even after curative resection, it is not only important to identify patients with resectable disease but also to spare patients with incurable disease the morbidity, inconvenience, and expense of an unnecessary operation. Thus, accurate staging of pancreatic adenocarcinoma is of paramount importance. A high quality CT scan of the pancreas is considered the best initial diagnostic modality for this disease. Nevertheless, even after appropriate preoperative imaging, 11-48% of patients are found to have unresectable disease during laparotomy. For this reason, many authors have introduced SL in the treatment algorithm of pancreatic adenocarcinoma patients in an effort to decrease the number of unnecessary laparotomies.
Technique
The feasibility of SL has been demonstrated in multiple studies with success rates ranging from 94-100% (level II, III). Dense adhesions that impair inspection and examination with the ultrasound probe are the main reason for technical failures. Nevertheless, even patients with adhesions can be examined; however, the extent and yield of the examination may be compromised. Conversions to open surgery are uncommon and have been reported to occur in <2% of patients in a large series (level III) [5].
The procedure is usually performed under general anesthesia, and the majority of reports have used 15 mm Hg insufflation pressures. A thorough evaluation of peritoneal surfaces is performed. The suprahepatic and infrahepatic spaces, the surface of the bowel, the lesser sac, the root of the transverse mesocolon and small bowel, the ligament of Treitz, the paracolic gutters, and pelvis are inspected with frequent bed position changes as necessary. In addition to visual inspection, peritoneal washings can be performed, ascitic fluid, if present, sent for cytology, and biopsy specimens of lesions suspected to be malignant obtained. When no metastatic disease is identified on inspection, a detailed laparoscopic ultrasound examination can be employed during which the deep hepatic parenchyma, the portal vein, mesenteric vessels, celiac trunk, hepatic artery, the entire pancreas, and even pathologic periportal and paraaortic nodes can be evaluated and biopsied. The addition of color flow Doppler can further assist in the assessment of vascular patency.
A controversy exists in the literature about the extent of SL for pancreatic adenocarcinoma patients. Advocates of a short duration procedure that is based only on inspection of abdominal organ surfaces argue that the procedure can be performed quickly (usually within 10–20 min), can be done through one port, does not require significant expertise, minimizes the risk of potential complications by the dissection near vascular structures, and has good diagnostic accuracy (level III) [1,2]. On the other hand, advocates of a more extensive procedure that includes opening the lesser sac and assessment of the vessels argue that the diagnostic accuracy of the procedure can be enhanced by detecting metastatic lesions in the lesser sac, vascular invasion by the tumor, or deep hepatic metastasis, often missed by visual inspection alone, and that it can be performed safely without a significant increase in morbidity and within a reasonable time (level II, III) [3-5].
It is very important, therefore, to consider these differences in the SL technique when evaluating reports of the diagnostic yield of this procedure in patients with pancreatic adenocarcinoma.
Indications
• As a staging procedure for pancreatic adenocarcinoma
• For detection of imaging occult metastatic disease or unsuspected locally advanced disease in patients with resectable disease based on preoperative imaging prior to laparotomy
• For assessment prior to administration of neo-adjuvant chemoradiation
• For selection of palliative treatments in patients with locally advanced disease without evidence of metastatic disease on preoperative imaging
Contraindications (Absolute or Relative)
• Known metastatic disease
• Inability to tolerate pneumoperitoneum or general anesthesia
• Multiple adhesions/prior operations
Risks
• False negative studies that lead to unnecessary exploratory laparotomies and unnecessary cost
• Procedure-related complications
Benefits
• Avoidance of unnecessary exploratory laparotomy with its associated higher morbidity and cost in patients with metastatic disease
• Appropriate selection of patients with true locally advanced disease and exclusion of patients with CT-occult metastatic disease from further unnecessary treatment (chemotherapy or chemoradiation) with its associated morbidity and cost
• Minimizes the delay of primary treatment (chemotherapy or chemoradiation) in the subset of patients whose disease is unresectable by avoiding laparotomy and its associated longer convalescence period
Diagnostic Accuracy of the Procedure
The reported median (range) sensitivity, specificity, and accuracy of SL in detecting imaging-occult, unresectable pancreatic adenocarcinoma in the literature is 94% (range, 93-100%), 88% (range, 80-100%), and 89% (range, 87-98%), respectively (level II, III) [2-23]. However, the procedure misses 6% (range, 5-25) of patients whose disease is identified as unresectable during an ensuing laparotomy (level II-III) [2-23]. Overall, in 4-36% of patients, an unnecessary laparotomy can be avoided (level II-III) [2-23].
A number of studies have also evaluated the added benefit of laparoscopic ultrasound at the time of laparoscopic staging indicating that the diagnostic accuracy of the procedure can be improved by 12-14% (level II-III) [3-8,19-22]. In addition, peritoneal washings have been reported to augment the yield of the procedure. Reports on the sensitivity of peritoneal washings have ranged widely (25-100%) [2,17,24-26]. The highest sensitivity for peritoneal cytology has been reported in patients with a disrupted ventral pancreatic margin (when peripancreatic fatty tissue cannot be differentiated from the tumor by helical CT scan) (level III) [26]. In addition, locally advanced pancreatic cancers have a higher incidence of positive cytology (level III) [12,17,27]. Importantly, studies have reported a 7-14% incidence of positive peritoneal washings in the absence of other findings of metastatic disease during preoperative imaging and SL (level III) [2,17]. This incidence seems to be lower in studies that include a variety of periampullary tumors (level II) [14].
The diagnostic yield of the procedure also depends on the histology, stage of disease, tumor size, and location. There is convincing evidence that the yield of SL is significantly higher in patients with pancreatic cancer compared with other types of periampullary tumors (level III) [11,12,16,23]. Furthermore, SL appears to have a higher yield in patients with locally advanced cancer compared with patients with localized disease. Identification of metastatic disease by SL in patients with locally advanced disease by high quality imaging studies has been reported in 34-37% of cases, which compares favorably with the identification rates of metastatic disease in patients with localized disease (level III) [1,27,28].
Tumors of the pancreas body and tail are associated with a higher chance for unsuspected metastasis found at laparoscopy (level III) [2,17]. Larger tumors appear to be associated with a higher incidence of imaging occult metastatic disease (level III) [12,23,29,30]. Although the tumor size at which the risk of occult M1 disease justifies the added time and cost of laparoscopy is currently unknown, some studies have suggested that tumors > 3 cm are more likely to be associated with metastatic disease at exploration (level III) [29,30]. Moreover, a Ca 19-9 level <150 has been associated with a lower chance for metastatic disease and consequently a lower yield for SL (level III) [31].
Procedure-related Complications and Patient Outcomes
Procedure-related morbidity has been reported to range 0 and 4% (level II, III) [1-30]. Most complications are minor and consist of wound infections, bleeding at port sites, or skin emphysema. Nevertheless, complications such as myocardial infarction, pulmonary embolism, and intestinal or vascular injury during the procedure have been described. The majority of the literature reports mortality rates of 0% (level II, III) [1-30]; however, at least one death has been reported due to a missed colonic injury during the procedure. Although studies comparing open and laparoscopic staging are scarce, the morbidity and mortality rates reported in the literature compare favorably to reports of negative exploratory laparotomies. No studies compare a short-duration inspection-only SL with a more extended procedure.
With regard to oncologic safety, initial concerns for more port-site recurrences after laparoscopic procedures in cancer patients have not been substantiated. Multiple studies report a 0-2% incidence of port-site recurrences after SL, which is similar to the incidence after open explorations of cancer patients (level III) [8,23,32]. In one comparative study of 235 patients who had undergone exploratory laparotomy or SL, laparoscopy was not associated with increased port-site recurrences or peritoneal disease progression (level III) [32]. Furthermore, there is evidence from the Surveillance Epidemiology and End Results (SEER) database suggesting no survival differences between pancreatic cancer patients who underwent a laparoscopic procedure compared with an open surgery (level II) [33].
Hospital length of stay after SL has been reported to range from 1 to 4 days [23]. Level III evidence suggests that the hospital stay is shorter after laparoscopic staging compared with open staging in pancreatic cancer patients [10].
In patients with locally advanced disease, SL has been reported to be superior to exploratory laparotomy, as it decreases length of hospital stay, increases the number of patients who receive chemotherapy, and shortens the time to initiation of such treatment (level III) [18,32].
Cost-effectiveness
Although high quality evidence on the cost effectiveness of SL is lacking, the literature suggests that SL is more cost-effective than open exploration when it is the only procedure required (i.e., in patients with unsuspected metastatic disease identified during SL) (level II) [34]. This is a consequence of decreased patient length of stays. On the other hand, the cost-effectiveness of SL when applied in the diagnostic algorithm of all pancreatic cancer patients appears to be linked directly to the yield of the procedure in identifying patients with imaging occult disease. In a cost utility analysis of the most effective management strategy for pancreatic cancer patients, at least a 30% yield was needed for SL to be more cost-effective than open exploration (level III) [35].
Literature Controversies
The main controversy regarding SL is whether it should be used routinely or selectively in patients with pancreatic adenocarcinoma deemed resectable on preoperative imaging. Proponents for the routine use of SL cite the high incidence of imaging occult metastatic disease found during laparoscopic examination of the abdominal cavity that leads to avoidance of unnecessary operations and thus benefits patients [3,20,27]. Proponents for the selective use of SL argue that when high quality imaging is used, only a small percentage of patients benefit from SL, and under these circumstances the procedure is not cost-effective [12,14]. As discussed in the technique section, there is also a controversy about whether to perform a limited or extended procedure.
Limitations of the Available Literature
The quality of the available studies on SL for patients with pancreas cancer is limited; no level I evidence exists. Furthermore, population-based data are very limited, as the majority of studies are single institution reports from highly specialized centers, making generalizations difficult and allowing institutional and personal biases to be introduced into the results.
In addition, reported data are not uniform across studies, making their analysis difficult. A number of studies assess the role of laparoscopy indirectly without having ever performed a single laparoscopic staging procedure (referred to as ‘phantom’ studies by some authors) and assume that only visible metastatic disease would have been detected at the time of laparoscopy, ignoring the value of laparoscopic ultrasound and cytology. Other studies do not clearly report the quality of preoperative imaging, the criteria used to define resectability, and the number of R0 resections. Importantly, studies often evaluate inhomogeneous patient samples, including patients with localized and locally advanced pancreatic cancers, with periampullary and other non-pancreatic cancers or even with benign disease and do not report results separately. Moreover, the information on the cost-effectiveness of the procedure is limited, and there are no studies that assess the quality of life of patients undergoing SL compared with patients undergoing open exploration.
Recommendations
Staging laparoscopy can be performed safely in patients with pancreatic adenocarcinoma (grade B). The procedure should be considered after high quality imaging studies have excluded metastatic disease in appropriately selected patients with either localized or locally advanced pancreatic adenocarcinoma (grade C). The use of laparoscopic ultrasound and peritoneal washings is encouraged, since they may improve the diagnostic accuracy of the procedure (grade C). Based on the available evidence, selective rather than routine use of the procedure may be better justified and more cost-effective (grade C). Patient selection may be based on the available evidence that suggests that the diagnostic accuracy of SL may be higher in patients with larger tumors, tumors of the neck, body, and tail or with clinical, laboratory (such as higher levels of Ca 19-9), or imaging findings suggestive of more advanced disease (grade C). Nevertheless, the effectiveness of such selection criteria needs to be verified by additional prospective studies.
Bibliography
1. Luque-de Leon, E., Tsiotos, G. G., Balsiger, B., Barnwell, J., Burgart, L. J., and Sarr, M. G. Staging Laparoscopy for Pancreatic Cancer Should Be Used to Select the Best Means of Palliation and Not Only to Maximize the Resectability Rate. Journal of Gastrointestinal Surgery 1999;3(2):111-7.
2. Jimenez, R. E., Warshaw, A. L., Rattner, D. W., Willett, C. G., McGrath, D., and Fernandez-Del Castillo, C. Impact of Laparoscopic Staging in the Treatment of Pancreatic Cancer. Archives of Surgery 2000;135(4):409-14.
3. Schachter, P. P., Avni, Y., Shimonov, M., Gvirtz, G., Rosen, A., and Czerniak, A. The Impact of Laparoscopy and Laparoscopic Ultrasonography on the Management of Pancreatic Cancer. Archives of Surgery 2000;135(11):1303-7.
4. Minnard, E. A., Conlon, K. C., Hoos, A., Dougherty, E. C., Hann, L. E., and Brennan, M. F. Laparoscopic Ultrasound Enhances Standard Laparoscopy in the Staging of Pancreatic Cancer. Annals of Surgery 1998;228(2):182-7.
5. Hunerbein, M., Rau, B., Hohenberger, P., and Schlag, P. M. The Role of Staging Laparoscopy for Multimodal Therapy of Gastrointestinal Cancer. Surgical Endoscopy 1998;12(7):921-5.
6. Durup Scheel-Hincke, J., Mortensen, M. B., Qvist, N., and Hovendal, C. P. TNM Staging and Assessment of Resectability of Pancreatic Cancer by Laparoscopic Ultrasonography. Surgical Endoscopy 1999;13(10):967-71.
7. Doran HE, Bosonnet L, Connor S et al. Laparoscopy and laparoscopic ultrasound in the evaluation of pancreatic and periampullary tumours. Dig Surg 2004; 21: 305–313.
8. Pietrabissa, A., Caramella, D., Di Candio, G., Carobbi, A., Boggi, U., Rossi, G., and Mosca, F. Laparoscopy and Laparoscopic Ultrasonography for Staging Pancreatic Cancer: Critical Appraisal. World Journal of Surgery 1999;23(10):998-1002
9. Awad, S. S., Colletti, L., Mulholland, M., Knol, J., Rothman, E. D., Scheiman, J., and Eckhauser, F. E. Multimodality Staging Optimizes Resectability in Patients With Pancreatic and Ampullary Cancer. American Surgeon 1997;63(7):634-8.
10. Conlon, K. C., Dougherty, E., Klimstra, D. S., Coit, D. G., Turnbull, A. D., and Brennan, M. F. The Value of Minimal Access Surgery in the Staging of Patients With Potentially Resectable Peripancreatic Malignancy. Annals of Surgery 1996;223(2):134-40
11. Vollmer CM, Drebin JA, Middleton WD et al. Utility of staging laparoscopy in subsets of peripancreatic and biliary malignancies. Ann Surg 2002; 235: 1–7.
12. Pisters, P. W., Lee, J. E., Vauthey, J. N., Charnsangavej, C., and Evans, D. B. Laparoscopy in the Staging of Pancreatic Cancer. [Review] [45 Refs]. British Journal of Surgery 2001;88(3):325-37.
13. Kwon, A. H., Inui, H., and Kamiyama, Y. Preoperative Laparoscopic Examination Using Surgical Manipulation and Ultrasonography for Pancreatic Lesions. Endoscopy 2002;34(6):464-8
14. Nieveen van Dijkum, E. J., Romijn, M. G., Terwee, C. B., de Wit, L. T., van der Meulen, J. H., Lameris, H. S., Rauws, E. A., Obertop, H., van Eyck, C. H., Bossuyt, P. M., and Gouma, D. J. Laparoscopic Staging and Subsequent Palliation in Patients With Peripancreatic Carcinoma. Annals of Surgery 2003;237(1):66-73.
15. Friess, H., Kleeff, J., Silva, J. C., Sadowski, C., Baer, H. U., and Buchler, M. W. The Role of Diagnostic Laparoscopy in Pancreatic and Periampullary Malignancies. Journal of the American College of Surgeons 1998;186(6):675-82.
16. Barreiro, C. J., Lillemoe, K. D., Koniaris, L. G., Sohn, T. A., Yeo, C. J., Coleman, J., Fishman, E. K., and Cameron, J. L. Diagnostic Laparoscopy for Periampullary and Pancreatic Cancer: What Is the True Benefit? Journal of Gastrointestinal Surgery 2002;6(1):75-81.
17. Liu RC, Traverso LW. Diagnostic laparoscopy improves staging of pancreatic cancer deemed locally unresectable by computed tomography. Surg Endosc. 2005;19(5):638-42.
18. Holzman MD, Reintgen KL, Tyler DS, Pappas TN. The role of laparoscopy in the management of suspected pancreatic and periampullary malignancies. J Gastrointest Surg. 1997;1(3):236-43.
19. Tilleman, E. H., de Castro, S. M., Busch, O. R., Bemelman, W. A., van Gulik, T. M., Obertop, H., and Gouma, D. J. Diagnostic Laparoscopy and Laparoscopic Ultrasound for Staging of Patients With Malignant Proximal Bile Duct Obstruction. Journal of Gastrointestinal Surgery 2002;6(3):426-30.
20. John, T. G., Wright, A., Allan, P. L., Redhead, D. N., Paterson-Brown, S., Carter, D. C., and Garden, O. J. Laparoscopy With Laparoscopic Ultrasonography in the TNM Staging of Pancreatic Carcinoma. World Journal of Surgery 1999;23(9):870-81.
21. Callery, M. P., Strasberg, S. M., Doherty, G. M., Soper, N. J., and Norton, J. A. Staging Laparoscopy With Laparoscopic Ultrasonography: Optimizing Resectability in Hepatobiliary and Pancreatic Malignancy. Journal of the American College of Surgeons 1997;185(1):33-9.
22. Bemelman, W. A., de Wit, L. T., van Delden, O. M., Smits, N. J., Obertop, H., Rauws, E. J., and Gouma, D. J. Diagnostic Laparoscopy Combined With Laparoscopic Ultrasonography in Staging of Cancer of the Pancreatic Head Region.[See Comment]. British Journal of Surgery 1995;82(6):820-4.
23. Stefanidis D, Grove KD, Schwesinger WH, Thomas CR Jr. The current role of staging laparoscopy for adenocarcinoma of the pancreas: a review. Ann Oncol. 2006 Feb;17(2):189-99.
24. Fernandez-del Castillo, C. L. and Warshaw, A. L. Pancreatic Cancer. Laparoscopic Staging and Peritoneal Cytology. Surgical Oncology Clinics of North America 1998;7(1):135-42.
25. Fernandez-Del Castillo, C., Rattner, D. W., and Warshaw, A. L. Further Experience With Laparoscopy and Peritoneal Cytology in the Staging of Pancreatic Cancer. British Journal of Surgery 1995;82(8):1127-9.
26. Schmidt J, Fraunhofer S, Fleisch M, Zirngibl H. Is peritoneal cytology a predictor of unresectability in pancreatic carcinoma? Hepatogastroenterology 2004; 51: 1827–1831.
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28. Shoup, M., Winston, C., Brennan, M. F., Bassman, D., and Conlon, K. C. Is There a Role for Staging Laparoscopy in Patients With Locally Advanced, Unresectable Pancreatic Adenocarcinoma? Journal of Gastrointestinal Surgery 2004;8(8):1068-71.
29. Yoshida T, Matsumoto T, Morii Y et al. Staging with helical computed tomography and laparoscopy in pancreatic head cancer. Hepatogastroenterology 2002; 49:1428–1431.
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Rationale for the Procedure
Exploratory laparotomies in trauma patients with suspected intra-abdominal injuries are associated with a high negative laparotomy rate and significant procedure-related morbidity. Diagnostic laparoscopy has been proposed for trauma patients to prevent unnecessary exploratory laparotomies with their associated higher morbidity and cost.
Technique
Many studies have documented the feasibility and safety of the procedure in trauma patients (level I-III) [1-25]. The procedure is usually performed under general anesthesia; however, local anesthesia with IV sedation has also been used successfully. The latter, in conjunction with a dedicated mobile cart, facilitates the procedure in the emergency department. A recent study demonstrated the safety and advantages of awake laparoscopy under local anesthesia in the emergency department over standard DL in the operating room (level III) [21]. Many authors have used low insufflation pressures (8-12 mm Hg); however, pressures up to 15 mm Hg have been described without untoward events. Special attention should be given to the possibility of a tension pneumothorax caused by the pneumoperitoneum due to an unsuspected diaphragmatic rupture. The pneumoperitoneum is created usually through a periumbilical incision using a Veress needle or open technique after insertion of a nasogastric tube and a Foley catheter.
In the case of penetrating wounds, air leaks can be controlled with sutures. A 30-degree laparoscope is advantageous, and additional trocars are used for organ manipulations. The peritoneal cavity can be examined systematically taking advantage of patient positioning manipulations. The colon can be mobilized and the lesser sac inspected. Suction/irrigation may be needed for optimal visualization, and methylene blue can be administered IV or via a nasogastric tube to help identify urologic or stomach injuries, respectively. In penetrating injuries, peritoneal violation can be determined.
Indications
• Suspected but unproven intra-abdominal injury after blunt or penetrating trauma
• More specific indications include:
• Suspected intra-abdominal injury despite negative initial workup after blunt trauma
• Abdominal stab wounds with proven or equivocal penetration of fascia
• Abdominal gunshot wounds with doubtful intraperitoneal trajectory
• Diagnosis of diaphragmatic injury from penetrating trauma to the thoracoabdominal area
• Creation of a transdiaphragmatic pericardial window to rule out cardiac injury
Contraindications (Absolute or Relative)
• Hemodynamic instability (defined by most studies as systolic pressure < 90 mm Hg)
• A clear indication for immediate celiotomy such as frank peritonitis, hemorrhagic shock, or evisceration
• Known or obvious intra-abdominal injury
• Posterior penetrating trauma with high likelihood of bowel injury
• Limited laparoscopic expertise
Risks
• Delay to definitive treatment
• Missed injuries with their associated morbidity
• 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)
• Accurate identification of diaphragmatic injury
• Ability to provide therapeutic intervention
Diagnostic Accuracy of the Procedure
The sensitivity, specificity, and diagnostic accuracy of the procedure when used to predict the need for laparotomy are high (75-100%) (level I-III) [1-25]; however, they depend on several factors (see Limitations of the Available Literature). When DL has been used as a screening tool (i.e., early conversion to open exploration with the first encounter of a positive finding like the identification of peritoneal penetration in penetrating trauma or active bleeding/peritoneal fluid in blunt trauma patients), the number of missed injuries is <1% (level II, III) [2-8]. Although early studies cautioned about the low sensitivity and high missed injury rates of the procedure when used to identify specific injuries (level II, III) [9-12], studies published recently consistently report a 0% missed injury rate even when DL is used for reasons other than screening (level I-III) [1-7,14,16-25]. This rate holds true for studies that have used laparoscopy to treat the majority of identified injuries (level II, III) [22,24,25].
Studies of DL for trauma report negative procedures in a median 57% (range, 17-89) of patients, sparing them an unnecessary exploratory laparotomy (level I-III) [1-7, 13-25]. On the other hand, the median percentage of negative exploratory laparotomies after a positive DL (false positive rate) is reported to be around 6% (range, 0-44) (level I-III) [1-7,14,16-25]. While most authors have converted to open exploration after a positive DL, some authors have successfully treated the majority of patients (up to 83%) laparoscopically (level II, III) [22,24,25]. The safety and accuracy of the procedure has also been demonstrated in pediatric trauma patients (level III) [22].
Procedure-related Complications and Patient Outcomes
Procedure-related complications occur in up to 11% of patients and are usually minor (level I-III) [1-25]. A 1999 review of 37 studies, which included more than 1,900 patients demonstrated a procedure-related complication rate of 1% [9]. Recent studies report a median of 0 (range, 0-10%) morbidity and 0% mortality (level I-III) [1-7,14,16-25]. Intraoperative complications can occur during creation of the pneumoperitoneum, trocar insertion, or during the diagnostic examination. These complications include tension pneumothorax caused by unrecognized injuries to the diaphragm, perforation of a hollow viscus, laceration of a solid organ, vascular injury (usually trocar injury of an epigastric artery or lacerated omental vessels), and subcutaneous or extraperitoneal dissection by the insufflation gas. Port site infections may occur during the postoperative course.
Negative DL is associated with shorter postoperative hospital stays compared with negative exploratory laparotomy (2-3 days vs. 4-5 days, respectively) (level II, III) [2,4-9,14,16-20,22-25]. Although a few studies have even demonstrated shorter stays after therapeutic laparoscopy compared with open (level III) [22,24,25], the only level I study available demonstrated a statistically significant shorter hospital stay after DL (5.1 vs. 5.7 days) [1]. In a very recent study, awake laparoscopy in the emergency department under local anesthesia resulted in discharge of patients from the hospital faster compared with DL in the operating room (7 vs. 18 hours, respectively; p<0.001) (level III) [21].
Comparative studies also suggest lower morbidity rates after negative DL compared with negative exploratory laparotomy (level II, III) [5,19,21], whereas other studies have shown similar outcomes (level I-III) [1,7].
Cost-effectiveness
A number of reports have demonstrated higher costs (up to two times higher) after negative exploratory laparotomy compared with negative DL (levels II, III) [6,14,17] as a direct consequence of shorter hospital stays. Nevertheless, a level I study did not demonstrate cost differences when an intention-to-treat analysis was used to compare a DL-treated group with that of an exploratory laparotomy-treated group [1]. Recently a level III study reported cost savings of $2,000 per patient when awake laparoscopy under local anesthesia was used in the emergency department compared with DL in the operating room [21].
Limitations of the Available Literature
The available literature has limited quality (only one small, level I study exists) and is very inhomogeneous, making generalizations and conclusions difficult. Study populations have been variable (blunt, penetrating, or mixed), and some studies have focused only on patients with suspected diaphragmatic injuries or blunt bowel injuries. Moreover, the indication for conversion to exploratory laparotomy has also been inconsistent. Most studies use peritoneal penetration or bleeding and free peritoneal fluid as an immediate reason for conversion, whereas others have converted only after specific injuries have been identified, and others have converted only when laparoscopic repair was impossible. The impact of laparoscopic expertise on the diagnostic accuracy of the procedure has not been assessed. Since the sensitivity, specificity, accuracy, and number of missed injuries can be substantially influenced by most of these factors, it is difficult to provide firm recommendations on the role of DL in trauma patients.
Recommendations
Diagnostic laparoscopy is technically feasible and can be applied safely in appropriately selected trauma patients (grade B). The procedure has been shown to effectively decrease the rate of negative laparotomies and minimize patient morbidity. It should be considered in hemodynamically stable blunt trauma patients with suspected intra-abdominal injury and equivocal findings on imaging studies or even in patients with negative studies but a high clinical likelihood for intra-abdominal injury (grade C). It may be particularly useful and should be considered in patients with penetrating trauma of the abdomen with documented or equivocal penetration of the anterior fascia (grade C). It should be used in patients with suspected diaphragmatic injury, as imaging occult injury rates are significant, and DL offers the best diagnostic accuracy (grade C). Patients should be followed cautiously postoperatively for the early identification of missed injuries. Therapeutic intervention can be provided safely when laparoscopic expertise is available (grade C). To optimize results, the procedure should be incorporated in institutional diagnostic and treatment algorithms for trauma patients.
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1. What is Minimally Invasive Surgery?
Minimally Invasive Surgery, some people refer to this simply as MIS, is a broad term for any procedure performed with small incisions (or sometimes no incisions at all).
Laparoscopic Surgery refers to MIS in the abdominal cavity. A telescope and long, fine caliber instruments are inserted into the abdomen to see and perform the surgery. The incisions used are 5 to 10 mm in size. These incisions heal quickly after surgery, resulting in small "keyhole" scars. Sometimes, even finer instruments are used (2 to 3 mm) in what we call Needloscopic Surgery. This results in "pinhole" scars that are hardly discernable.
The same technique is called Thoracoscopic Surgery when used in the thoracic cavity (to approach the esophagus, for example) or Endoscopic Surgery when used elsewhere (for example in the neck for Endoscopic Thyroid Surgery).
2. Can my operation be done using Laparoscopic Surgery?
Almost any conventional operation can be done laparoscopically. This can something simple, like the removal or a gallbladder or appendix, to something very complex, like the resection of the stomach for cancer. Some of the complicated operations can be technically demanding, and a good outcome depends on the skill and experience of the surgeon. In general, we believe that, under our hands, the laparoscopic options gives a better result. Occasionally however, laparoscopic surgery is contraindicated in certain patients, and some operations may be too difficult to offer any substantial benefit over conventional open surgery.
3. What are the contraindications to Laparoscopic Surgery?
The only absolute contraindications are an unstable patient (for example, someone who is bleeding actively from trauma) or a patient who is unfit for general anaesthesia (since GS is always required for laparoscopy). In certain patients, the contraindications are relative and have to be evaluated individually. These patients include those who have severe heart or lung disease, have previous abdominal surgery, bowel obstruction or bleeding problems.
4. What about pregnant patients?
In general, we try to not to do elective surgery during pregnancy. In those cases where we must, we try to delay the operation until the second trimester, or until fetal viability, or till after delivery. If surgery is absolutely essential, laparoscopic surgery is as safe as open surgery, and even offers certain advantages. However, great care has to be taken with surgery and anaesthesia as the dangers are real: about 12% risk of miscarriage in the first trimester, 5 to 8% risk or preterm labour in the second trimester and 30% risk of preterm labour in the third trimester.
5. What are the benefits of Laparoscopic Surgery?
Since only "keyhole" incisions are used, the post operative functional recovery is rapid. Most patients are discharged from hospital faster and return to work earlier. There is less wound pain and the cosmetic outcome is excellent. In the long term, there are fewer problems with post-surgery bowel adhesions. There is also recent evidence to suggest that the reduced disturbance to the immune system during laparoscopy results in better survival after cancer resection when compared to open surgery. This is because the minimal insults allow the body to fight off circulating cancer cells more effectively.
6. Are there any disadvantages of Laparoscopic Surgery?
Laparoscopic surgery is technically more difficult than conventional open surgery. Moreover, as some of these procedures have only evolved in the last few years, not all surgeons are trained to perform them. Surgeon related errors can occur. Finally, laparoscopic surgery often takes longer to perform and may cost more in terms of equipment used - although this is not always so!