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Diagnostic Laparoscopy

MK Jadliwala, BL Chitlangia
 
Historical Background

Diagnostic laparoscopy is minimally invasive
surgical procedure for diagnosis of a medical ailment. The procedure allows direct visual examination of the intra-abdominal organs including large surface areas of the liver, gall bladder, spleen, peritoneum, pelvic organs and intestines. Biopsies, aspiration and cultures can be obtained. German surgeon George Kelling was the first person to do laparoscopy using a cystoscope in a dog in 1901. A Swedish internist HC Jacobaeus performed the first diagnostic laparoscopy in human beings in 1910. The credit for safe laparoscopy must go to certain very eminent people namely Janos Veress of Hungary for designing spring loaded needle to create pneumoperitoneum, Prof. Hopkins for the rigid rod lens system and Kurt Semm, a German Gynaecologist, who invented automatic insufflator device capable of monitoring intra-abdominal pressures.

Diagnostic laparoscopy is safe and well tolerated and can be performed under local, regional or general anaesthesia. It should be performed by surgeons trained in laparoscopic techniques and who are able to recognize and treat common complications.

Indications

  1. Ascites : When aetiology of ascites remains elusive, laparoscopy may prove helpful especially when the ascites is secondary to tuberculosis or carcinomatosis.
  2. Abdominal Pain : Laparoscopy can be helpful in diagnosing acalculus cholecystitis, perforated viscus, acute appendicitis, mesenteric ischaemia or other surgical emergencies in patients who are critically ill and have an equivocal clinical examination. The negative laparotomy rate for acute appendicitis can be reduced by 20% to 40% if diagnostic laparoscopy is carried out prior to laparotomy.1-3
  3. Liver Disease : Laparoscopy is indicated for cirrhotic patients when a standard biopsy is inconclusive or not desired (e.g. small liver, large volume ascites). Patients with liver disease are more prone to haemorrhage following biopsy, but at laparoscopy bleeding from the biopsy site can be controlled using electrocoagulation or other techniques. The accuracy of laparoscopic liver biopsy has been estimated to be 90%.4
  4. Intra-abdominal / retroperitoneal masses : Diagnostic laparoscopy can be used to perform directed biopsies and stage intra-abdominal tumours. Conventional preoperative imaging techniques with gastrointestinal malignancies frequently fail to detect small hepatic and peritoneal metastases. Laparoscopy is highly successful in detecting those surface tumour implants that preclude curative surgical resection. Laparoscopic ultrasound can be used to identify the masses. Warshaw and associates5 performed laparoscopy in 72 patients with pancreatic carcinoma who subsequently underwent laparotomy. Peritoneal metastases were accurately detected in 96% of cases. Most implants were small and not detected by CT or MRI scans.
  5. Abdominal Trauma : Laparoscopy for specific problems (i.e. anterior and lateral stab wounds, tangential gunshot wounds) may be helpful in avoiding a full laparotomy. Berci and associates6 recently evaluated the role of diagnostic laparoscopy in 150 patients with abdominal trauma. In 56% of the patients no haemoperitoneum was found and none of these patients required exploratory laparotomy. The presence of large amounts of blood in the peritoneal cavity should be an indication for immediate laparotomy.
  6. Gastrointestinal Bleeding : Patients in whom upper and lower gastrointestinal endoscopies are normal and the source of bleeding is suspected to be in small intestine, diagnostic laparoscopy may be useful in detecting lesions such as Meckelís diverticulum, leiomyoma etc. If no obvious lesion is found, a mini laparotomy and enteroscopy can be done to detect a mucosal lesion.
  7. Miscellaneous Conditions : Abdominal or pelvic pain of unknown origin, acute and chronic abdominal pain in elderly patients, fever of unknown origin and patients with suspected congenital anomalies. Easter and associates7 performed diagnostic laparoscopy in 70 patients with chronic abdominal complaints. Positive findings were found in 47% of the patients, most common finding being intra-abdominal adhesions. Subsequent interventions resulted in positive clinical outcome in 39% of the patients.

Contraindications
Potential contraindications for diagnostic laparoscopy are:

1) Haemodynamic instability
2) Mechanical or paralytic ileus
3) Uncorrected coagulopathy
4) Generalized peritonitis
5) Severe cardiopulmonary disease
6) Abdominal wall infection
7) Multiple previous abdominal procedures
8) Late pregnancy

Technique
Pneumoperitoneum is created by using Veress needle introduced through a small subumbilical incision. The open technique using Hassonís cannula is recommended to create pneumoperitoneum in patients with multiple previous abdominal operations. The abdomen is appropriately insufflated and additional trocars are inserted as necessary. Insufflation pressure should be limited to 10 mm of Hg in a spontaneously breathing patient. Systemic laparoscopic examination of peritoneal surfaces, diaphragm, liver, spleen, gall bladder, small and large intestines, pelvic organs and retroperitoneal tissues and organs is done. Appropriate biopsies, cytology, intraoperative ultrasound, cultures and fluid analysis may be performed.

Complications
Complications may occur during creation of the pneumoperitoneum, trocar insertion or the diagnostic examination. These include cardiac arrhythmias, haemodynamic 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 insufflated gas.

Conclusion
Diagnostic laparoscopy is useful for patients in whom the diagnosis or extent of the disease is unclear or abdominal findings and investigations are equivocal. It can be performed safely in expediting diagnosis and treatment.

References

  1. Leap LL, Ramenofsky ML. Laparoscopy for questionable appendicitis: Can it reduce the negative appendectomy rate? Ann Surg 1980; 191: 410-3.
  2. Deutsch AA, Zelikovsky A, Reiss R. Laparoscopy in the prevention of unnecessary appendicectomies: A prospective study. Br J Surg 1982; 69 : 336-7.
  3. Paterson-Brown S. Laparoscopy as an adjunct to decision making in the acute abdomen. Br J Surg 1986; 73 : 1022-4.
  4. Jeffers L, Speigelman G, Reddy KR, et al. Laparoscopically directed fine needle aspiration for the diagnosis of hepatocellular carcinoma: A safe and accurate technique. Gastrointest Endosc 1988; 34 : 235-7.
  5. Warshaw AL, Zhou-Yun G, Wittenberg J, et al. Preoperative staging and assessment of respectability of pancreatic carcinoma. Arch Surg 1990; 125 : 230-3.
  6. Berci G, Sackier JM, Paz-Partlow M. Emergency laparoscopy. Am J Surg 1991; 161 : 332-5.
  7. Easter DW, Cushieri A, Nathanson IK, Lavelle-Jones M. The utility of diagnostic laparoscopy for abdominal disorders : Audit of 120 patients. Arch Surg 1992; 127: 379-83.
  8. Society of American Gastrointestinal Endoscopic Surgeons (SAGES). SAGES guidelines for diagnostic laparoscopy. Los Angeles (CA): Society of American Gastrointestinal Endoscopic Surgeons (SAGES); 2002.

 

UPPER GASTROINTESTINAL ALARMS : THE 2-WEEK RULE

The age of the patient at presentation is often used as a reason for referral for endoscopy.

Uncomplicated dyspepsia is not a reason for urgent endoscopy. Uncomplicated dyspepsia was defined as any patient above 55 years of age with onset of dyspepsia within the past year or continued symptoms since the onset of dyspepsia.

The three most common were dysphagia in 34%, weight loss in 29%, and vomiting in 28% of patients. In logistic regression three factors significantly predicted cancer : age over 55 years, odds ratio 9.5 (95% Cl 3.8-23.9); dysphagia, 3.1 (1.8-5.2); and weight loss 2.6 (1.5-4.4).

On the basis of these data, new criteria were formulated by Kapoor and colleagues for the 2-week endoscopy rule. These dyspepsia patients over 55 years of age with any alarm feature.

The results of Kapoor and colleagues’ study have high face validity. Dysphagia is also a common symptom in gastro-oesophageal reflux disease. The dysphagia resolved in 83% of patients after a 4-week treatment with a proton-pump inhibitor. Studies need to be done to see whether it is possible to reliably distinguish between trivial and more serious dysphagia.

I agree with Kapoor and colleagues’ conclusion that it is reasonable to use age over 55 years with any alarm symptom, progressive dysphagia (especially for solids), and weight loss as reasons for prompt endoscopy. I therefore concur that the criteria they suggest for the 2-week rule be adopted. But there still should be some room for clinical judgement. Occasionally, I get a referral from a primary-care colleague which basically states that he or she would feel better if they knew the patient had a normal endoscopy. I always accommodate those requests and do an endoscopy in such patients swiftly.

Sander V Van Zanten, Lancet, 2005; 365 : 2163-4.


CRP SHOULD NOT GUIDE ANTIBIOTIC PRESCRIPTION IN PNEUMONIA

Testing for C reactive protein (CRP) is neither sensitive nor specific enough to be used to guide antibiotic prescription in patients with pneumonia. In a systematic review, van der Meer and colleagues included all studies that compared C reactive protein testing with a chest radiograph or a microbiology work-up as a reference test. The authors conclude that with sensitivities ranging from 8% to 99% and specificities from 27% to 99%, testing for C reactive protein is neither sensitive enough to rule out nor sufficiently specific to rule in bacterial aetiology of lower respiratory tract infection.

BMJ, 2005; 331 : 26.

Honorary Consultant General Surgeons, Bombay Hospital, Mumbai.
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