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Exploratory Laparoscopy

  • Author: Umashankar K Ballehaninna, MD, MS; Chief Editor: Kurt E Roberts, MD  more...
 
Updated: Jan 29, 2016
 

Background

Exploratory laparoscopy, also termed diagnostic laparoscopy, is a minimally invasive method for the diagnosis of intra-abdominal diseases through direct inspection of intra-abdominal organs. Exploratory laparoscopy also allows tissue biopsy, culture acquisition, and a variety of therapeutic interventions.[1, 2] Laparoscopic ultrasonography (LUS) can also be performed during exploratory laparoscopy to evaluate organs that are not amenable to inspection.

The advent of laparoscopic surgery represents a landmark in surgery that initiated a shift from the era of open abdominal surgery to the minimally invasive surgery revolution.[3, 4] Today, laparoscopy is the most common and preferred method for addressing a number of routine and complex surgical procedures, such as cholecystectomy, appendectomy, splenectomy, adrenalectomy, and others. Whereas the use of laparoscopic techniques has primarily occurred over the last two decades, its development spans three centuries.[5]

The main advantages of diagnostic laparoscopy over traditional open laparotomy are as follows:

  • Reduced morbidity
  • Decreased postoperative pain
  • Shorter hospital stay

Diagnostic laparoscopy is useful for making a definitive clinical diagnosis whenever there is a diagnostic dilemma even after routine diagnostic workup, including patients with nonspecific abdominal pain, hemodynamically stable patients who have sustained blunt/penetrating trauma with suspected intra-abdominal injuries, and critically ill intensive care unit (ICU) patients with suspected intra-abdominal sepsis or pathologies.

Diagnostic laparoscopy is an extremely useful staging tool in patients with intra-abdominal cancers (eg, esophageal, gastric, pancreatic, gallbladder, or bile duct cancer; solitary/resectable liver metastasis; lymphoma). By enabling accurate staging, diagnostic laparoscopy permits patient selection for curative resection or a neoadjuvant chemotherapy while avoiding nontherapeutic laparotomy, which is associated with a delay in initiation of chemotherapy.

This article provides a comprehensive description of the role of exploratory laparoscopy (diagnostic laparoscopy) as an alternative to traditional open exploratory laparotomy in the management of certain intra-abdominal conditions.

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Indications

Acute abdominal pain

Acute abdominal pain is one of the most common indications for an emergency department (ED) visit. In 30-40% of these patients, the etiology of the abdominal pain remains elusive despite laboratory and radiologic investigations. When a diagnosis of persistent acute abdominal pain of less than 7 days' duration remains uncertain after baseline diagnostic and radiologic investigations, this condition is termed nonspecific abdominal pain (NSAP).

Traditionally, these patients have been treated with either an open exploratory laparotomy for conditions the patient was presumed to have or active observation. Unfortunately, these approaches were often associated with prolonged hospital stays, increased numbers of radiologic imaging studies and laparotomies with negative findings, and patient dissatisfaction if the diagnosis could not be established. This scenario is especially prevalent in pregnant women and obese patients, in whom availability or access to imaging studies is limited by the gestational age or the patient’s size.[1, 6]

In this setting, diagnostic laparoscopy is the preferred next step in management because it permits the following:

  • Visualization of the entire abdominal cavity
  • Localization of intra-abdominal pathology
  • Acquisition of peritoneal fluid for cultures or cytology
  • Ability to irrigate the peritoneal cavity to decrease contamination
  • In many cases, specific therapeutic intervention, such as laparoscopic cholecystectomy, appendectomy, or other curative resection

As a result of these capabilities, exploratory laparoscopy results in an improved diagnosis rate, as well as reductions in nontherapeutic laparotomies, number of radiologic studies performed, delayed initiation of treatment, and overall length of hospital stay.[7, 8, 9, 10]

The literature on advantages and efficacy of laparoscopic management for specific intra-abdominal diseases (acute appendicitis, acute cholecystitis, and several others) is vast, and a full survey is beyond the scope of this review.

Regarding the utility of exploratory laparoscopy for patients with nonspecific abdominal pain, a meta-analysis of four randomized control trials (N=811) comparing exploratory laparoscopy with active observation concluded that early diagnostic laparoscopy was associated with a decreased number of patients’ discharges without a final diagnosis. Length of hospital stay (LOS) and readmission rate were also decreased in the diagnostic laparoscopy group; however, these changes did not reach statistical significance.[11]

Morino et al conducted a randomized study involving 522 patients with nonspecific abdominal pain who underwent either diagnostic laparoscopy (group 1) or observation (group 2).[12] They found that early exploratory laparoscopy decreased the number of radiologic investigations (114 in group 1 vs 554 in group 2) and resulted in fewer patients without a clear diagnosis (4.2% in group 1 vs 34.7% in group 2). Equally notable, overall morbidity was 1.1% in group 1 and 27% in group 2, and LOS was significantly shorter in the former (3.1 vs 7.3 days). Eight patients in group 1 required readmission (46 total readmission days), compared with 58 in group 2 (201 total readmission days).[12]

In a nonrandomized prospective study, Golash et al reported on 1320 consecutive patients with acute abdominal pain who underwent diagnostic laparoscopy within 48 hours of admission.[13] A definitive diagnosis was made in 90% of patients after diagnostic laparoscopy, of which 30% underwent a therapeutic procedure. These authors concluded that diagnostic laparoscopy reduced unnecessary laparotomy and improved diagnostic accuracy in this population.

In summary, diagnostic laparoscopy is ideally suited to patients with nonspecific acute abdominal pain as a means of improving diagnostic accuracy, reducing the numbers of radiologic imaging studies and nontherapeutic laparotomies, and shortening overall LOS.[13, 14]

Trauma

Diagnostic laparoscopy is uniquely useful in the evaluation of hemodynamically stable trauma patients (blunt or penetrating).[15] It can provide accurate diagnosis of intra-abdominal injuries, thereby reducing nontherapeutic laparotomies and associated complications. In some cases, therapeutic procedures can be performed, depending on local expertise and extent of additional injuries.

Indications for diagnostic laparoscopy in trauma patients include a high index of suspicion for intra-abdominal injuries after a negative initial diagnostic workup, patients with penetrating abdominal trauma and a breach of the peritoneum where intra-abdominal organ injury is suspected, and patients with tangential gunshot wounds with unclear intra-peritoneal trajectory.

Diagnostic laparoscopy may also prove useful to evaluate diaphragmatic injury in patients with penetrating trauma to the thoracoabdominal region, and mainly for the creation of a transdiaphragmatic pericardial window to diagnose or relieve hemopericardium/cardiac tamponade.[7, 1, 16]

Diagnostic laparoscopy in trauma patients is typically performed with the patient under general anesthesia; however, ED diagnostic laparoscopy with local anesthesia[17] and intravenous (IV) sedation has been reported. Diagnostic laparoscopy is indicated only in hemodynamically stable patients and those patients without a clear indication for a laparotomy, such as evisceration or aspiration/leakage of bile or bowel contents.

Limitations that undermine the universal application of diagnostic laparoscopy in trauma patients include prolonged operating room (OR) time to set up laparoscopic equipment, which may delay therapeutic intervention and the difficulty associated with clear identification of certain injuries, such as bowel injuries and retroperitoneal injuries.[7]

Intensive care unit patients

Critically ill patients with suspected intra-abdominal pathology pose a uniquely difficult diagnostic problem. Whereas the need to expedite the diagnosis, rule out intra-abdominal pathology, and gain control of the source is pressing, there are inherent risks in transporting ICU patients who are often unstable and require mechanical ventilator or inotropic support to either radiology or the OR.

A bedside diagnostic laparoscopy, which can be performed within the ICU, often with local anesthesia or IV sedation, is ideal for these patients in that it can expedite the diagnosis, enable therapeutic intervention, and avoid the morbidity of open exploration. Note, however, that not all pathologies are readily identifiable with exploratory laparoscopy. Conditions involving the retroperitoneum, including pancreas, perinephric area, and kidneys, may be missed with exploratory laparoscopy.

That said, exploratory laparoscopy has demonstrated excellent accuracy in the diagnosis of more common etiology of ICU-related sepsis, such as ischemic bowel, intra-abdominal abscess, perforated viscus, and acalculous/gangrenous cholecystitis.[7, 1, 18, 19]

The most common indication for diagnostic laparoscopy in an ICU patient is suspected intra-abdominal pathology in a patient with unexplained sepsis. Other indications include the following:

  • Abdominal pain and tenderness in an obtunded or sedated patient without an obvious indication for a therapeutic intervention (eg, free intra-abdominal air, massive gastrointestinal [GI] bleeding, small-bowel obstruction) or unexplainable from other causes (eg, urinary tract infection, pneumonia, or pleuritis)
  • Progressive metabolic acidosis (lactic acidemia) that is not explained by other causes
  • Suspected intra-abdominal hypertension not attributed to small-bowel obstruction/GI bleeding or bowel obstruction; diagnostic laparoscopy is rarely used in this setting, because it may pose an increased risk of bowel injury during port creation, and pneumoperitoneum itself may exacerbate elevated intra-abdominal pressure [1, 3]

Although minimally invasive surgery has expanded extensively in the past two decades, adaptation of this technique in ICU patients, despite multiple indications has been reported in rare case series (N=150). Whereas exploratory laparoscopy in this setting succeeded in decreasing the number of nontherapeutic laparotomies in 36-95% of patients, mortality has remained unchanged (58-100%), probably as a consequence of patients’ underlying critical illnesses.

In two large published series, Peris et al[19] and Karasakalides et al[20] reported on ICU patients who underwent diagnostic laparoscopy.

In the series from Peris et al (N=32),[19] bedside diagnostic laparoscopy was performed after an average ICU stay of 8 days, and the mean procedure time was 40 minutes. Diagnostic laparoscopy identified the source of intraabdominal pathology in 15 patients, of whom 13 subsequently underwent a definitive surgery. A diagnosis of cholecystitis was confirmed in seven cases, of which two were treated with open cholecystectomy and five underwent percutaneous cholecystostomy. The authors reported that the time required to perform a diagnostic laparoscopy was less (21.8±7.6 min) than that required for completing a computed tomography (CT) scan when patient transport was included (38.2±6.2 min).

In the series from Karasakalides et al, of the 35 ICU patients in whom bedside diagnostic laparoscopy was performed, 20 (57.1%) avoided a negative laparotomy. The remaining patients were found to have intra-abdominal pathologic condition, such as acalculous cholecystitis, perforated duodenal ulcer, ischemic colitis, or empyema of gallbladder.[20]

Bedside diagnostic laparoscopy may be a practical means of identifying or excluding intra-abdominal pathology in a very ill cohort of the ICU population. It can be performed using local anesthesia with sedation and may permit therapeutic intervention while avoiding the morbidity of a negative laparotomy in patients who are already ill. Large-scale randomized trials are needed for further validation.

Staging of intra-abdominal cancers

A significant percentage of intra-abdominal cancers prove to be inoperable because of metastatic or locally advanced disease despite a preoperative workup suggesting a potentially resectable disease. Historically, these patients would have undergone morbid negative laparotomies with associated complications and the resultant delay in the initiation of adjuvant or palliative chemotherapy. Diagnostic laparoscopy for accurate staging of intra-abdominal malignancies is referred to as staging laparoscopy and is performed as a standard part of the staging workup for an increasing number of cancer subtypes.[1, 21, 22, 23]

Staging laparoscopy is useful in the evaluation of intra-abdominal malignancy in the following aspects:

  • Accurate staging of the tumor
  • Avoidance of nontherapeutic laparotomy in patients with metastatic diseases
  • Means of excluding metastatic disease and obtaining tissue biopsy prior to the initiation of neoadjuvant chemotherapy
  • Means of obtaining tissue for diagnosis (lymphomas) or performing peritoneal lavage cytology to exclude the presence of occult peritoneal metastasis
  • Identification of patients with locally advanced disease (fixed tumor or vascular invasion) when there is no evidence of distant metastasis
  • Selection of appropriate palliative treatment in patients with advanced or metastatic disease
  • Prior to definitive laparotomy after completion of neoadjuvant chemotherapy to assess treatment response or disease progression

Detailed discussion of the utility of staging laparoscopy for individual cancer types is beyond the scope of this article; however, a brief overview is provided below.

Esophageal cancer

Esophageal cancer often presents with locally advanced tumors, as well as lymph node and/or distant metastases, and is associated with an overall poor prognosis. Data suggest that survival may be improved with preoperative chemotherapy and radiation followed by surgical resection. However, as with other GI malignancies, preoperative imaging may suggest resectable disease, though a significant percentage (20-65%) of esophageal cancers are found to be unresectable at the time of exploration.

Diagnostic laparoscopy is particularly valuable in staging esophageal cancer because it helps identify patients who may or may not benefit from preoperative chemotherapy and thus helps avoid avoid laparotomy or thoracotomy with negative findings.

Laparoscopic placement of feeding tubes can also be performed at the same setting as staging laparoscopy, which can improve nutritional status of these patients and prevent the need for additional procedures such as percutaneous endoscopic gastrostomy (PEG), which may be technically difficult.[1, 22]

In esophageal cancer, staging laparoscopy has a reported accuracy of 75-80% in identifying peritoneal metastasis with a staging sensitivity and specificity of 64% and 70% compared to ultrasonography (40-50%) and CT (45-60%). The utility of diagnostic laparoscopy in esophageal cancer is shown to improve with the addition of LUS and video thoracoscopy.[24]

Gastric cancer

Clinical trials have reported improved survival among gastric cancer patients with tumors (T3-T4N1) who received neoadjuvant chemotherapy prior to definitive surgical resection.[25] In those trials, gastric cancer patients with locally advanced tumor or with lymph node metastases derived survival benefit; however, in the presence of unresectable disease or disseminated metastases, 5-year survival remains poor (<20%). It is thus imperative to identify gastric cancer patients who may benefit from neoadjuvant chemotherapy and those with advanced or metastatic tumors who are not candidates for therapeutic laparotomy.[26]

Several investigators reported that diagnostic laparoscopy has an accuracy of 89-100% for staging, identifies occult metastasis or unresectable disease, and avoids nontherapeutic laparotomy in 13-57% of gastric patients despite a negative preoperative imaging workup.[27, 28] Diagnostic laparoscopy has a uniquely high sensitivity (90-96%) for identifying metastasis to liver, peritoneum, and lymph nodes as compared with either ultrasonography (23-37%) or CT (28-52%). As in pancreatic cancer, diagnostic laparoscopy combined with LUS further improved identification of liver metastasis, and peritoneal lavage cytology enhanced identification of occult peritoneal metastasis by 10-15%.[28]

Pancreatic adenocarcinoma

Despite advances in preoperative imaging (including CT, endoscopic ultrasonography [EUS], magnetic resonance imaging [MRI], and positron emission tomography [PET]), 15-40% of patients with pancreatic cancer whose tumors are deemed resectable are found to have unresectable tumors because of local tumor extension or presence of metastasis. Large tumor size, pancreatic adenocarcinoma as opposed to periampullary cancer or duodenal cancer, body and tail location, and preoperative CA 19-9 serum levels higher than 150 U/mL are associated with a finding of metastatic cancer at the time of staging laparoscopy.[29]

The median sensitivity (range), specificity, and accuracy of diagnostic laparoscopy in identifying imaging-occult, unresectable pancreatic adenocarcinoma are 94% (93-100%), 88% (80-100%), and 89% (87-98%) respectively. Laparotomy with negative findings can be avoided in 4-36% of patients, but not in all cases; 5-7% of patients believed to be resectable on the basis of diagnostic laparoscopy findings are found to have unresectable tumors at the time of open exploration, typically attributable to occult vascular invasion, fixed tumors, or presence of lymph node metastasis.[29]

When diagnostic laparoscopy is combined with LUS, the diagnostic accuracy of the procedure increases by 12-14%; however, few surgeons and centers have the skills and equipment to interpret LUS images. Peritoneal lavage cytology can further improve the identification of occult metastasis in 7-15% of patients; however, time constraints may hinder identification, and expert cytopathologists may not be available.[30]

Primary liver tumors

Staging laparoscopy is indicated in patients with primary liver tumors when preoperative imaging suggests likely resectable disease and an adequate hepatic reserve. Although the incidence of peritoneal metastases is uncommon in these patients, diagnostic laparoscopy combined with LUS permits assessment of the entire hepatic parenchyma and allows identification of the size, location, and number of liver tumors as well as potential vascular invasion.

Diagnostic laparoscopy combined with LUS has a sensitivity of 63-67% for identifying unresectable disease in patients with liver cancer and a nontherapeutic laparotomy avoidance rate of 25-40%. Diagnostic laparoscopy with LUS has a sensitivity of 96-100% for lesions larger than 2 cm compared with a sensitivity of 35-40% for triphasic CT. However, diagnostic laparoscopy can also yield false-negative results in 5-15% of primary liver tumors.[20, 21, 22]

Biliary tract tumors

Staging laparoscopy is indicated for nearly all patients with gallbladder cancer, hilar cholangiocarcinoma, or extrahepatic bile duct tumors without evidence of unresectability or metastatic disease on preoperative imaging. The increased availability of EUS may limit the yield of diagnostic laparoscopy to those with T2 or T3 cholangiocarcinoma; most patients with T1 cancers are resectable. Diagnostic laparoscopy has diagnostic accuracies of 48-60% and 53-60% for identifying unresectable disease in patients with gallbladder cancer and cholangiocarcinoma, respectively.[20, 21, 22]  The addition of LUS may enhance the overall yield and accuracy of diagnostic laparoscopy in this setting.[31]

Colorectal cancer

Patients with primary colorectal cancer but without evidence of systemic metastases seldom benefit from diagnostic laparoscopy, primarily because of its low yield in identifying occult or subclinical metastasis but also because most patients undergo a colectomy (laparoscopic or open) with curative intent or as palliation for bleeding, obstruction, or perforation.

However, when colorectal cancer presents with isolated liver metastases without evidence of extrahepatic disease, diagnostic laparoscopy with intraoperative ultrasonography can be extremely useful for the identification of the number and location of hepatic metastases as well as to rule out peritoneal or extrahepatic disease. When a staging laparoscopy is performed for this indication, a nontherapeutic laparotomy can be avoided in 25-45% of patients.

As with other GI cancers, diagnostic laparoscopy with LUS has a higher sensitivity and specificity of 98-99% to identify occult hepatic metastasis and to evaluate the portahepatic and celiac lymph nodes.[20, 21, 22]

Lymphoma

Hodgkin lymphoma, or Hodgkin disease, originates in one nodal region/group and spreads to contiguous nodal regions in a typically stepwise manner. The prognosis and treatment of Hodgkin disease is determined based on the extent of the disease, involvement of extra nodal lymphatic sites, and presence of constitutional symptoms. Hodgkin disease was typically staged by exploratory laparotomy and biopsy of liver and enlarged lymph nodes followed by splenectomy; however, this procedure is associated with significant morbidity.

With improved radiologic imaging and image-guided biopsy procedures, an open operation for staging lymphomas has become mostly obsolete. However, a needle biopsy is associated with high false-negative rates, and architectural classification of lymphomas cannot be interpreted from tissue obtained on a needle biopsy. The goals of the staging workup for Hodgkin disease are to determine the presence of intradiaphragmatic disease and the presence or absence of splenic and liver involvement. This information is especially relevant in patients with clinical stage I and II Hodgkin disease, in that 25-40% of these patients will be upstaged as a result of this information.[32]

Laparoscopic staging of Hodgkin disease typically consists of splenectomy, wedge biopsy of the liver, and three core-needle liver biopsies. Lymph node biopsies from the left and right para-aortic and iliac nodes and from the celiac, portahepatic, and mesenteric regions may also be obtained with all operative sites marked by metallic clips to aid localization during subsequent radiation therapy. LUS may also have a role if hepatic lesions are suspected. Oophoropexy behind the uterus may also be performed to protect it from radiation injury. In addition, laparoscopy may also have a role in assessing treatment response or when a recurrence is suspected.

Unlike Hodgkin disease, non-Hodgkin lymphoma (NHL) does not spread in a predictable or contiguous fashion. These patients may present with prominent retroperitoneal lymphadenopathy and/or hypersplenism but without peripheral lymphadenopathy, thus requiring laparoscopic biopsy for diagnosis or splenectomy in case of hypersplenism.

Diagnostic laparoscopy in patients with Hodgkin disease and NHL provides tissue for diagnosis, aids in accurate staging, and prevents the morbidity of unnecessary laparotomy. Compared with percutaneous biopsy, laparoscopy biopsy has superior sensitivity (87% vs 100%), specificity (93% vs 100%), and accuracy (33% vs 83%).[33]

Diagnostic laparoscopy for chronic conditions

Diagnostic laparoscopy may be performed for the following chronic conditions.

Liver diseases

Diagnostic laparoscopy is frequently used to evaluate or obtain biopsy in patients with abnormal liver function test results (liver diseases) after nondiagnostic findings from radiologic investigations. It is particularly useful in patients with liver cirrhosis for establishing histopathologic confirmation, grading severity of illness, and evaluating and performing biopsy on lesions that are difficult to access percutaneously. Other indications include diffuse liver diseases (related to HIV or hepatitis virus, hepatomegaly of unknown etiology, or portal hypertension) and liver masses (to rule out metastatic cancer, hepatoma, or benign masses).

Exploratory laparoscopy is associated with a 91% success rate for obtaining the correct diagnosis in patients who require laparoscopic liver biopsy and has a sensitivity and specificity of 100% and 97%, respectively. LUS can further improve the accuracy of diagnostic laparoscopy.[1, 34]

Nonpalpable testis (cryptorchidism)

In pediatric patients with nonpalpable testicles, diagnostic laparoscopy offers a minimally invasive alternative to open surgical exploration for locating testicles. Diagnostic laparoscopy is indicated when findings from initial inguinoscrotal exploration are nondiagnostic.

In reported series, diagnostic laparoscopy permitted localization of the nonpalpable testis with 99-100% accuracy, and nontherapeutic laparotomy was avoided in 15-30% of patients. Laparoscopic examination also provides information essential for therapeutic planning, including length and point of entry of the vas deferens, presence of malignant transformation, and status of opposite testis (if undescended). If necessary, therapeutic intervention (orchidectomy or orchidopexy[35] ) can be performed laparoscopically in the same setting.[34]

Chronic pelvic pain and infertility

Chronic pelvic pain, defined as pelvic pain lasting more than 6 months, is a complex disorder with multiple underlying etiologies that range from endometriosis and adhesions to pelvic inflammatory disease (PID). Diagnostic laparoscopy permits direct visualization of pelvic structures, allowing identification of common etiologies, including endometriosis, adhesions, and ovarian cysts. In published reports, diagnostic laparoscopy has a sensitivity of 78-84% for identifying endometriosis directly; pelvic peritoneal biopsy and peritoneal lavage can further improve the diagnostic yield by 20-25%. Diagnostic laparoscopy is a similarly highly accurate method for evaluating women with PID and has a diagnostic accuracy of 78-92%.[1, 34, 36]

Infertility is one common indication in which diagnostic laparoscopy plays an important role. Diagnostic laparoscopy is often combined with hysterosalpingography to evaluate patency of fallopian tubes, during which a therapeutic intervention can also be undertaken. Diagnostic laparoscopy has a yield of 21-68% for identifying the cause of infertility.[34]

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Contraindications

Patient selection for diagnostic laparoscopy with identification of relative or absolute contraindications is vital to a successful outcome of laparoscopic procedure. In addition to a detailed history and meticulous physical examination, special effort should be made to identify prior history of abdominal surgery, intra-abdominal abscess, perforated appendicitis, or the presence of intra-peritoneal mesh for ventral hernia; these conditions may be associated with substantial adhesions. Laboratory studies, electrocardiography (ECG), and chest radiography should be performed according to the same criteria relevant to any surgical procedure necessitating general anesthesia.[34]

Patients with history of severe chronic obstructive pulmonary disease (COPD) may require additional studies, such as arterial blood gases and pulmonary function tests. Helium gas may be considered as an alternative insufflant. Severe cardiac dysrhythmias should be evaluated and treated; hypercarbia and the resulting acidosis may have adverse effects on the myocardium by accentuating ischemia.

Absolute contraindications for exploratory laparoscopy include the following:

  • Known or obvious indication for therapeutic intervention, such as perforation, peritonitis, known intra-abdominal injury, complications of previous surgery, shock, evisceration, or abdominal wall dehiscence
  • Acute intestinal obstruction associated with a massive (>4 cm) bowel dilatation, which may obscure the laparoscopic view and increase the likelihood of bowel injury
  • Uncorrected coagulopathy
  • A tense or distended abdomen (with suspected intra-abdominal compartment syndrome)
  • Trauma with hemodynamic instability or a clear indication of bowel injuries, such as presence of bile or evisceration

Relative contraindications for diagnostic laparoscopy include the following:

  • ICU patients who are too ill to tolerate pneumoperitoneum, potential hypercarbia, or general anesthesia
  • Presence of anterior abdominal wall infection (cellulitis or soft-tissue infection)
  • Recent laparotomy (within 4-6 weeks) or extensive adhesions secondary to previous abdominal surgery
  • Aortoiliac aneurysmal disease (may be associated with increased risk of vascular rupture)
  • Pregnancy (may be associated with injury to gravid uterus or fetal distress)
  • Cardiopulmonary compromise
  • Morbid obesity
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Technical Considerations

Complication prevention

Complications associated with laparoscopic surgery can be classified as those related to anesthesia and those associated with creation of the pneumoperitoneum/insertion of the trocars and may include the following:

  • Anesthesia-related complications
  • Extra-peritoneal gas insufflation
  • Injury to intra-abdominal structures
  • Bladder injury
  • Pneumothorax/pneumomediastinum
  • Gas embolism
  • Bowel injury
  • Port-site recurrence

Anesthesia-related complications

Although diagnostic laparoscopy is associated with same risk of complications seen with general anesthesia in any open procedure, certain factors related to diagnostic laparoscopy may predispose patients to specific anesthesia complications.

Reduced oxygenation and hypercarbia may happen during diagnostic laparoscopy as a consequence of elevated intra-abdominal pressure. Use of a steep Trendelenburg position may limit excursion of the diaphragm. The absorption of carbon dioxide (CO2) used to create pneumoperitoneum can lead to hypercarbia and elevated endotracheal tube carbon dioxide levels.

An improvement in oxygenation and relief of hypercarbia can be achieved by positive-pressure ventilation, increasing the ventilation rate, and reducing laparoscopic insufflation pressure and the flow of carbon dioxide.[37]

Extra-peritoneal gas insufflation

In closed technique, a blunt-tipped Veress needle is introduced into the peritoneal cavity after skin incision while the anterior abdominal wall is elevated. Sometimes, the tip of the Veress needle may be situated in the preperitoneal space. Insufflation of CO2 in this situation leads to extraperitoneal emphysema evidenced by crepitus, artificially elevated abdominal pressure reading, and failure to visualize peritoneal structures, whereas a typical spider-web pattern of preperitoneal fascia is seen upon introduction of the laparoscope. On recognition, stopping CO2 insufflation, removal, and reintroduction of the Veress needle should be performed.

Injury to intra-abdominal structures

Introduction of the Veress needle to create a pneumoperitoneum involves blind insertion of the needle into abdominal cavity. Thus, it may be associated with injury to peritoneal structures. Depending on the location of the port, the structures that have been previously reported to be injured include the following:

  • Stomach, liver and/or spleen (epigastric ports)
  • Small intestine, colon, and/or omentum (ports in the umbilical region)
  • Bladder (pelvic ports; see below)

In addition, the abdominal wall and major intra-abdominal vessels including the abdominal aorta, iliac arteries, and/or inferior vena cava (IVC), may also be injured.

To reduce incidence of unintentional organ injuries, it is important to avoid previously scarred regions that can be associated with underlying dense adhesions. Insertion of the Veress needle should be done in a controlled fashion and the tip of the needle should be directed towards the pelvis.

Certain conditions may predispose patients to injury by the Veress needle, including distention of the GI tract (bowel obstruction) or adhesions of bowel to the anterior abdominal wall. After insertion, the needle should be aspirated and its contents carefully examined; the presence of bile, feculent material, and/or bright red blood suggests a misplaced needle tip.

Bladder injury

Injury to the urinary bladder may happen during initial insertion of the trocar or during blunt and sharp dissection (with laparoscopic scissors) of suprapubic preperitoneal space. The reported incidence of bladder injury is 0.02-8%, most often following a gynecologic or pelvic surgery.

The first sign of trocar injury to the bladder is visualization of the bulb of a Foley catheter or evidence of pneumaturia or hematuria. The diagnosis of bladder injury can also be confirmed by retrograde instillation of blue dye diluted with saline, which allows rapid identification of cystostomy site. Certain preexisting conditions that may predispose patients to bladder injury include bladder or pelvic anomalies or pathologic conditions, such as prior pelvic or bladder surgery, endometriosis, malignant infiltration, bladder diverticula, or previous radiation.

Postoperatively, if the bladder injury was missed, the patient may develop oliguria and urinary ascites; this may be accompanied by hyponatremia and, rarely, hyperkalemia with mild elevation of serum creatinine as a result of peritoneal absorption of urine. Patients who have been discharged from the hospital because of the minor nature of their laparoscopic procedure may present later with lower abdominal discomfort, abdominal swelling, and fever.

After intraoperative identification of bladder injury, depending on the surgeon's expertise, laparoscopic or open repair should be performed in two layers, as follows:

  • Approximation of the mucosal edges with absorbable suture (with care taken not to expose the sutures to the bladder lumen)
  • Continuous or interrupted repair of the seromuscular layer

Cystostomy may also be closed by using a laparoscopic stapler or preformed suture loops to encircle and secure the cystostomy. When the bladder injury is diagnosed postoperatively, the nature of bladder drainage (whether extraperitoneal or intraperitoneal) should be assessed. An extraperitoneal bladder injury may be treated through simple placement of an indwelling Foley catheter. Intraperitoneal drainage is an indication for subsequent laparoscopic or open repair. To prevent bladder injury, preoperative placement of a Foley catheter is useful.

Pneumothorax/pneumomediastinum

CO2 may extend from a correctly induced pneumoperitoneum into the mediastinum along congenital defects or along the great vessels and create pneumomediastinum or pneumothorax. Extensive pneumothorax can lead to tension pneumothorax, which manifests as hypoxia, elevated airway pressure, and difficulty in ventilating with a decrease in oxygen tension (PO2) and an increase in carbon dioxide tension (PCO2).

The pneumomediastinum may cause cardiac embarrassment in the form of reduced venous return, hypotension, and cardiac arrhythmias and is associated with loss of dullness to percussion over the precordium. In this event, CO2 insufflation should be stopped, and the remaining gas must be evacuated. After adequate resuscitation, the procedure can be contemplated.[38]

Gas embolism

An unrecognized incorrect intravascular placement of Veress needle and insufflation of CO2 may result in gas embolism or even death. Gas embolism manifests as acute cardiovascular collapse and is associated with cardiac dysrhythmias, tachycardia, cyanosis, and pulmonary edema. The diagnosis of gas embolism is usually recognized when the anesthesiologist notices an acute drop in oxygen saturation and an abrupt increase in end-tidal CO2 and is often associated with a “millwheel” murmur in the precordial area. Treatment of gas embolism includes immediate cessation of CO2 insufflation and decompression of pneumoperitoneum.

The patient should be turned into left lateral decubitus position (ie, right side up) to help gas accumulation in the right ventricular apex so as to prevent right ventricular outflow obstruction and further gas embolism. The patient should be hyperventilated with 100% oxygen; if the symptoms persist, a central venous catheter should be inserted with the tip into the right heart, and aspiration of the gas should be performed, though the efficacy of this approach is unproven.[39]

Bowel injury

Injury to a hollow viscus may arise from creation of pneumoperitoneum, insertion of trocars, mechanical injury with laparoscopic instruments, or electrocauterization. Previous surgery and adhesions increase the likelihood of bowel injury, which may range in severity from superficial damage of the serosa to complete penetration into the lumen.

Accordingly, it is always important to inspect the bowel at the axis of insertion of the primary trocar and cannula to ensure that it has not been damaged. If the cannula remains within the bowel, the injury will be obvious by the recognition of mucosal folds. A through-and-through injury may be missed and may only be evidenced by the sight of fecal soiling, a fecal smell when the pneumoperitoneum is released, or the subsequent development of peritonitis.

Management of bowel injury depends on the skill of the surgeon. The traditional treatment is to perform laparotomy and suture the bowel in two layers. A skilled laparoscopic surgeon may perform the repair by means of laparoscopic suturing. The defect should be closed in two layers in such a way as to avoid stricture formation; this should be followed by a copious peritoneal irrigation, and a drain should be inserted into the abdomen. Appropriate antibiotic therapy should be instituted.

Port-site recurrence

Although laparoscopic staging of intra-abdominal cancers is a safe technique associated with a low (1-2%) rate of major morbidity (eg, hemorrhage, visceral perforation, or intra-abdominal infection), there was an initial concern of higher rates of port-site recurrence following staging laparoscopy. Dobronte et al first reported a case of port-site tumor recurrence 2 weeks after laparoscopy in a patient with malignant ascites.[40] Thereafter, multiple authors have expressed concern regarding the potential risk of disseminating disease at the time of pneumoperitoneum.

A number of hypotheses have been suggested to explain port-site implantation, including tumor seeding associated with carbon dioxide pneumoperitoneum in animal studies, tissue manipulation, direct wound contamination, poor surgical technique, or immunologic effects such as changes in host immune responses. However, with improved expertise and use of an impervious barrier bag for organ retrieval, there has been no documentation of increased port-site recurrence following staging laparoscopy as compared with open exploration.

Pearlstone et al, based at MD Anderson Cancer Center, reported results of diagnostic laparoscopy in 533 patients with intra-abdominal cancer (nongynecologic), of whom 339 had upper GI malignancies. The authors reported port-site recurrences in four patients (0.88%), three of whom had advanced disease at the time of initial laparoscopy.[41]

A similar study from Memorial Sloan-Kettering Cancer Center reported on 1650 diagnostic laparoscopic procedures performed among 1548 patients with upper GI malignancies, in whom a total of 4299 trocars were inserted. After a median follow-up of 18 months, port-site recurrence was noted in 13 patients (0.8%). An open operation was performed in 1040 patients, of whom nine (0.9%) developed a wound recurrence.[42]

This latter figure is similar to the 0.8-1% incisional recurrence rate noted in open laparotomies for cancer. The authors concluded that laparoscopic staging appeared safe from an oncologic standpoint because port-site implantation is uncommon, differs little from open surgical incision recurrence, and likely reflects the underlying biologic behavior of the disease rather than the type of surgery.

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Contributor Information and Disclosures
Author

Umashankar K Ballehaninna, MD, MS Resident Physician, Department of General Surgery, Maimonides Medical Center

Disclosure: Nothing to disclose.

Coauthor(s)

Ronald S Chamberlain, MD Chairman, Surgeon-in-Chief, Department of Surgery, Director, Gastrointestinal Care Center, Medical Student Clerkship Director, Medical Executive Committee Member, St Barnabas Medical Center; Associate Professor of Surgery, New York College of Osteopathic Medicine; Associate Professor of Surgery, University of Medicine and Dentistry of New Jersey-New Jersey Medical School

Ronald S Chamberlain, MD is a member of the following medical societies: Alpha Omega Alpha, American Association for the Study of Liver Diseases, American College of Surgeons, American Medical Association, Phi Beta Kappa, Society for Surgery of the Alimentary Tract, Society of Surgical Oncology

Disclosure: Received honoraria from Wyeth for speaking and teaching; Received honoraria from Pfizer for speaking and teaching; Received honoraria from Sanofi Aventis for speaking and teaching.

Chief Editor

Kurt E Roberts, MD Assistant Professor, Section of Surgical Gastroenterology, Department of Surgery, Director, Surgical Endoscopy, Associate Director, Surgical Skills and Simulation Center and Surgical Clerkship, Yale University School of Medicine

Kurt E Roberts, MD is a member of the following medical societies: American College of Surgeons, Society of American Gastrointestinal and Endoscopic Surgeons, Society of Laparoendoscopic Surgeons

Disclosure: Nothing to disclose.

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