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Diagnostic Laparoscopy

Definition

Diagnostic laparoscopy is a procedure that allows a health care provider to look directly at the contents of a patient's abdomen or pelvis, including the fallopian tubes, ovaries, uterus, small bowel, large bowel, appendix, liver, and gallbladder.

The purpose of this examination is to actually see if a problem exists that has not been found with noninvasive tests. Inflammation of the gallbladder (cholecystitis), appendix (appendicitis), pelvic organs (pelvic inflammatory disease), or tumors of the ovaries may be diagnosed laparoscopically.

Additionally, the provider may wish to exclude abdominal trauma following an accident by using laparoscopy rather than a large abdominal incision.

Major procedures to treat cancer, such as surgery to remove an organ, may begin with laparoscopy to exclude the presence of additional tumors (metastatic disease), which would change the course of treatment.

How the test is performed

The procedure is usually done in the hospital or outpatient surgical center under general anesthesia (while the patient is unconscious and pain-free). However, this procedure may also be done using local anesthesia, which merely numbs the area affected by the surgery and allows the patient to stay awake.

A small incision is made below the navel, a needle is inserted into the incision, and carbon dioxide gas is injected to elevate the abdominal wall, creating a larger space to work in. This allows for easier viewing and manipulation of the organs. A tube called a trocar is inserted through the incision, which allows passage of a tiny video camera into the abdomen.

The laparoscope is then inserted so that the organs of the pelvis and abdomen can be examined. Additional small incisions may be made for instruments that allow the surgeon to move organs for a clearer view.

In the case of gynecologic laparoscopy, dye may be injected through the cervical canal to make the fallopian tubes easier to view.

Following the examination, the laparoscope is removed, the incisions are closed, and bandages are applied.

How to prepare for the test

Do not consume any food or fluid for 8 hours before the test. You must sign a consent form.

Infants and children:

The preparation you can provide for this test depends on your child's age, previous experiences, and level of trust.

How the test will feel

If you are under general anesthesia, you will feel no pain during the procedure, although the incisions may throb and be slightly painful afterward. A pain reliever may be given by your physician.

With local anesthesia, you may feel a prick and a burning sensation when the local anesthetic is given. Pain may occur at the incision site. The laparoscope may cause pressure, but there should be no pain during the procedure. Afterward, the incision site may throb for several hours and may be slightly painful. A pain reliever may be given by your physician.

Additionally, you may experience shoulder pain for a few days, because the carbon dioxide can irritate the diaphragm, which shares some of the same nerves as the shoulder. You may also experience an increased urge to urinate, since the gas can put pressure on the bladder.

Why the test is performed

The examination helps identify the cause of pain in the abdomen and pelvic area. It may detect the following conditions:

Endometriosis (tissues normally found in the uterus growing in other areas)
Ectopic pregnancy (in which the fertilized egg develops outside of the uterus),
Pelvic inflammatory disease (an inflammation in the pelvic cavity)
Cancer
Cholecystitis
Appendicitis

Normal Values

There is no blood in the abdomen, no hernias, no intestinal obstruction, and no cancer in any visible organs. The uterus, fallopian tubes, and ovaries are of normal size, shape, and color. The liver is normal.

What abnormal results mean

The procedure may detect the following:

Ovarian cysts
Abnormal union of body surfaces (such as adhesions following prior surgery)
Endometriosis
Uterine fibroids
Tumors
Pelvic inflammatory disease
Appendicitis
Cholecystitis
Metastatic cancer
Signs of trauma

What the risks are

There is a risk of puncturing an organ, which could cause leakage of intestinal contents, or bleeding into the abdominal cavity. These complications may result in the conversion of laparoscopy to open surgery (laparotomy).

There is also some risk of infection. However, antibiotics are usually given as a precaution.

Update Date: 7/14/2004

Updated by: Norman S. Kato, MD, Surgeon with the Cardiac Care Medical Group, Encino, CA. Review provided by VeriMed Healthcare Network.

SAGES GUIDELINES FOR DIAGNOSTIC LAPAROSCOPY

Preamble

This is one of a series of statements discussing the utilization of laparoscopy in common clinical situations. This guideline was prepared by the Standards of Practice Committee of the Society of American Gastrointestinal Endoscopic Surgeons. Previous guidelines on this topic (SAGES Publication #0012) were written in 1991. Since that time, new information has been released that requires an update of this information and recommendations. In preparing this update, a literature search was performed, and additional references obtained from the bibliographies of the identified articles and from the recommendations of expert consultants. As little data exists from well-designed prospective trials, emphasis was given to the results from large series and reports from recognized experts. Revision of this guideline may be necessary as new data appear. Clinical consideration may justify a course of action at a variance from these recommendations.

Clinical Application

Diagnostic laparoscopy is minimally invasive surgery for the diagnosis of a medical ailment. The procedure allows the direct visual examination of intra abdominal organs including large surface areas of the liver, gallbladder, spleen, peritoneum, pelvic organs and retroperitoneum.1,2 Biopsies, aspiration and cultures can be obtained and laparoscopic ultrasound may be used. Laparoscopy allows a surgeon to diagnose and obtain information about dissemination of disease and to diagnose patients with abdominal findings.3,4

Diagnostic laparoscopy is safe and well tolerated and can be performed in an outpatient or inpatient setting under general anesthesia.5 There may be unique circumstances where local anesthetic may be used. Diagnostic laparoscopy should be performed by physicians trained in laparoscopic techniques and who are able to recognize and treat common complications. The physician should also be able to perform additional therapeutic procedures when indicated. During the procedure, the patient should be continuously monitored6 and resuscitation capability must be immediately available. Laparoscopy must be performed using sterile technique along with a high level disinfection of the laparoscopic equipment. Overnight observation may be appropriate in some outpatients. There may also be unique circumstances where office based diagnostic laparoscopy may be considered. These circumstances should include only procedures where complications and the need for therapeutic procedures through the same access are extremely unlikely.

Indications

Intra-abdominal/retroperitoneal masses: diagnostic laparoscopy can be used to perform directed biopsies and stage intrabominal tumors7,8. Laparoscopic ultrasound can be of use to identify masses.

Liver disease: Laparoscopy is indicated for cirrhotic patients when a standard biopsy is inconclusive or not desired (e.g., small liver, large volume ascites).9 Patients with liver disease are more prone to hemorrhage following biopsy, but at laparoscopy, bleeding from the biopsy site can be controlled using electrocoagulation or other techniques.

Ascites: When the etiology of ascites remains elusive, laparoscopy may prove helpful, especially when the ascites are secondary to tuberculosis or carcinomatosis.

Abdominal pain or acute abdomen: Laparoscopy can be helpful in diagnosing acalculous cholecystitis, perforated viscus, acute appendicitis, mesenteric ischemia or other surgical emergencies in patients who are critically ill and have an equivocal abdominal exam.

Abdominal Trauma: Laparoscopy for specific problems (i.e., anterior and lateral stab wounds, tangential gunshot wounds) may be helpful in avoiding a full laparotomy.

Laparoscopy for blunt abdominal trauma is currently debated.10,11

Miscellaneous Conditions: Other indications where laparoscopy may be helpful include a palpable abdominal mass, abdominal or pelvic pain of unknown origin, acute and chronic abdominal pain in the elderly patient, fever of unknown origin, and in patients with suspected congenital abnormalities.

Contraindications

Contraindications may include hemodynamic instability, mechanical or paralytic ileus, uncorrected coagulopathy, generalized peritonitis, severe cardiopulmonary disease, abdominal wall infection, multiple previous abdominal procedures, and late pregnancy.12,13 However, the final decision is determined not only by the clinical conditions, but also by the surgeon's judgement.

Technique

Instruments used in diagnostic laparoscopy should include but are not limited to a laparoscope, trocar, grasping, biopsy, and retracting instruments as needed. Most instruments range in size from 2-10 mm in diameter. Personnel should include the laparoscopist and a trained assistant to monitor blood pressure, pulse, respiratory rate, oxygen saturation, EKG and level of sedation. Some patients requiring diagnostic laparoscopy can have the procedure performed under local anesthesia with intravenous sedation as necessary. When general anesthesia is necessary, a trained anesthetist or anesthesiologist should be present.

Initial entry into the abdomen can be obtained by the Veress needle or cut down technique. The abdomen is appropriately insufflated and additional trocars inserted as needed. Insufflation pressure should be limited to 10 mm Hg in a spontaneously breathing patient. Routine laparoscopic examination of the abdomen may include evaluation of peritoneal surfaces, diaphragm, liver, spleen, gallbladder, stomach, small intestine, colon, pelvic organs, and retroperitoneal tissues and organs. Appropriate biopsies, cytology, intraoperative ultrasound, cultures and fluid analysis may be performed as necessary and / or other imaging modalities may be useful.

Complications

Complications may occur during creation of the pneumoperitoneum, trocar insertion, or during the diagnostic exam. These complications include but are not limited to, cardiac arrhythmias, hemodynamic instability due to decreased venous return, bleeding, bile leak, perforation of a hollow viscus, laceration of a solid organ, vascular injury, gas embolism, and subcutaneous or extraperitoneal dissection of the insufflation gas. Wound infection or leakage of ascites may occur postoperatively. Failure to accurately diagnose the extent of intra-abdominal pathology is another potential complication.

Conclusion

Diagnostic laparoscopy is useful for patients in whom the diagnosis or extent of the disease is unclear or the abdominal findings are equivocal. It can be performed safely in an inpatient or outpatient setting, potentially expediting diagnosis and treatment.

References

Boyce HW. Laparoscopy. In: Schiff L, Schiff ER (eds.), Diseases of the Liver. Philadelphia: JB Lippincott 1982; 333-348.
Berci G, Cuschieri A. Practical Laparoscopy. London: Bailliere Tindall, 1986.
Mansi C, Savarino V., Picciotta A, et al. Comparison between laparoscopy, ultrasonography and computed tomography in widespread and localized liver disease. Gastrointestinal Endoscopy. 1982; 28:83.
Gandolfi L, Rossi A, Leo P, et al. Indications for laparoscopy before and after the introduction of ultrasonography. Gastrointestinal Endoscopy. 1985; 31:1.
Sleeman D, Sosa JL, Almeida J, et al. Bedside laparoscopy in critically ill patients. Critical Care Medicine. 1995; 21 (2 suppl.):A237.
Monitoring of Patients Undergoing Gastrointestinal Endoscopic Procedures. Guidelines for Clinical Applications. American Society for Gastrointestinal Endoscopy, 1989.
Coupland G, Townsend D, Martin C. Peritoneoscopy - Use in assessment of intra abdominal malignancy. Surgery. 1981; 89:645-649.
Bogen GL, Manino AT, Scott-Conner C. Laparoscopy for staging and palliation of gastrointestinal malignancy. Surgical Clinics of North America. 1996; 76(3):557-569.
Brugera J, Rodas P, Rodas J. A comparison of accuracy of peritoneoscopy and liver biopsy in the diagnosis of cirrhosis. Gut. 1974; 15:799.
Poole GV, Thomas KR, Hauser CJ. Laparoscopy in trauma. Surgical Clinics of North America. 1996; 76(3):547-556.
Ivatury RR, Simon RJ, Stahl WM. A critical evaluation of laparoscopy in penetrating abdominal trauma. Journal of Trauma. 1993; 34(6):823-828.
Halpern NB. Laparoscopic cholecystectomy in pregnancy: A review of published experiences and clinical considerations, Seminars in Laparoscopic Surgery, 5(2), June, 1998.
Gurbuz AT, Peetz ME. The Acute Abdomen in the Pregnant Patient. Is there a role for Laparoscopy? Surgical Endoscopy. 1997; 11(2): 98-102.
For further information regarding privileges for laparoscopic general surgery, please consult SAGES guidelines (1997) for GRANTING OF PRIVILEGES FOR LAPAROSCOPIC GENERAL SURGERY.

This statement was reviewed by the Board of Governors of the Society of American Gastrointestinal Endoscopic Surgeons (SAGES), March 2002. It was prepared by the SAGES Committee on Standards of Practice with the assistance of previous documents written by the Standards of Practice Committee of the American Society for Gastrointestinal Endoscopy.

Request for reprints should be sent to:

Society of American Gastrointestinal Endoscopic Surgeons
11300 West Olympic Blvd., Suite 600
Los Angeles, CA 90064
(310) 437-0544FAX: (310) 437-0585
E-mail: sagesweb@sages.org

This is a revision of SAGES publication #0012 originally printed 10/91 & 4/98