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PubMed1999

Diagnostic laparoscopy: an update.

With new technical advances, wider availability, and the recent proliferation of less invasive surgery, the use of diagnostic laparoscopy has expanded far beyond its traditional role in the evaluation of chronic liver disease. Short of open laparotomy, diagnostic laparoscopy is the most accurate modality for staging of intra-abdominal malignancies, and is particularly well-suited for patients who otherwise would not require surgical palliation. In addition to avoiding unnecessary laparotomy in this group, diagnostic laparoscopy has proved valuable in the assessment of abdominal trauma, acute abdomen, and ischemic bowel disease. We briefly review here some of the new developments in the field of diagnostic laparoscopy.

Abdomen, Acute↗

PubMed2003

Staging of abdominal metastases in pancreatic carcinoma by diagnostic laparoscopy and magnetic resonance imaging.

BACKGROUND: Different noninvasive and invasive techniques are available for the detection of abdominal metastases in pancreatic carcinoma. Since small hepatic or peritoneal metastases are a crucial problem which precludes resection, accurate detection is mandatory. We compared laparoscopic staging of abdominal metastases in adenocarcinoma of the pancreas with MRI. METHODS: 55 patients with pancreatic adenocarcinoma had been screened and 49 entered the retrospective study. All patients had undergone MRI of the upper abdomen with concomitant MR-cholangiopancreatography (MRCP) and diagnostic laparoscopy under conscious sedation. Patients without histologic proof of abdominal metastases underwent laparotomy. RESULTS: In 6/10 patients, metastases were correctly detected by laparoscopy, yielding a sensitivity of 60% and a specificity of 92%.MRI predicted metastases in 6/10 patients with 60% sensitivity and 100% specificity. Laparoscopy showed metastases in 3 patients that were missed by MRI, but failed to identify metastases in 3 of 6 patients with metastases on MRI. Though only one patient showed previously undetected metastases during laparotomy, 3 patients with abdominal metastases underwent unnecessary laparotomy due to a lack of histologic proof of malignancy. CONCLUSIONS: Whereas diagnostic laparoscopy is sensitive for the detection of small metastases and offers histologic verification, intrahepatic alterations are not detectable by sole visual inspection.MRI may compensate for this deficiency, but histologic proof of malignancy may be problematic. To date, no definite decision in favor of one of the presented procedures for the staging of abdominal metastases can be given.

Adenocarcinoma↗

PubMed1987

Validity of laparoscopy after abdominal surgery.

The authors carried out a retrospective study to investigate the effect of previous abdominal surgery on the validity of laparoscopy. Laparoscopy was done in 2,000 patients with liver disease, between 1976 and 1985. Of these, 250 (12.5%) had undergone abdominal operations, and all presented with intraperitoneal adhesions. The whole surface of the liver was visible in 45.3%, but only in part in 46.2% of patients with upper abdominal operations (cholecystectomy, gastric surgery). Lower abdominal surgery (appendectomy, gynaecological operations) was associated with complete visibility of the liver in 97.5% of the cases. Laparotomy was followed by the highest incidence of non-visibility of the liver (28.5%). In the other 1,750 patients without abdominal operations, adhesions were detected only in 83 (4.1%) and the liver was entirely observable in 83.1% of these. In conclusion, previous abdominal surgery does not represent an absolute contraindication to laparoscopy, since risks are not as great as one might suppose. Although the view of the liver is sometimes impaired, laparoscopy retains its role in the assessment and therapy of liver disease, and avoids complications related to blind biopsy of the liver.

Abdomen↗

PubMed2000

Diagnosis of nonpalpable testes in childhood: comparison of magnetic resonance imaging and laparoscopy in a prospective study.

In a prospective study, the accuracy of magnetic resonance imaging (MRI) and laparoscopy in the diagnosis of nonpalpable testes was evaluated. Advantages and disadvantages of the two procedures were compared. 29 boys with unilateral nonpalpable testis underwent MRI. When MRI failed to demonstrate a testis, laparoscopy with a 1.9 mm mini-laparoscope was performed. All cases were verified by operative exploration of the inguinal region. MRI demonstrated 10 inguinal and 7 abdominal testes. MRI revealed no testis in 12 boys. The false positive rate was 32%, correct negative findings were confirmed in four patients. When laparoscopy was performed, preservable testis could be demonstrated in 8 of 12 patients (1 abdominal, 7 inguinal) which otherwise were not visible on MRI. The correct positive rate was 100%. We encountered no complications with laparoscopy. In summary, laparoscopic evaluation is recommended as the preferable method in pediatric cases of nonpalpable testes.

Adolescent↗

PubMed2001

Minilaparoscopy versus conventional laparoscopy in the diagnosis of hepatic diseases.

BACKGROUND: Minilaparoscopy (ML) is being used increasingly in the diagnosis of liver disease. This is a prospective study of the accuracy and safety of ML compared with conventional laparoscopy (CL) in the diagnostic workup of liver disease. METHODS: One hundred four patients with suspected liver disease were randomized either to undergo CL (n = 50) or ML (n = 54). CL was performed with a standard Storz laparoscope (Ø 11 mm, Storz GmbH, Tuttlingen, Germany) according to accepted guidelines. For ML a 1.9-mm small-diameter optical telescope was used (Richard Wolf GmbH, Knittlingen, Germany). In all cases, an attempt was made to obtain a liver biopsy specimen. RESULTS: Laparoscopy could successfully be performed in 100 of 104 (96%) patients with simultaneous procurement of biopsy specimens of the liver. In 4 cases, postoperative adhesions prevented sufficient inspection of the liver and in another patient the technique was switched from CL to ML for the same reason. Minor self-limiting bleeding at the biopsy site was observed in 20% of CL and 15% of ML examinations. One patient in each group required surgery for uncontrollable bleeding from the biopsy site. The patients' subjective perception of the examination was comparable in both groups. Compared with CL, ML could be performed in a significantly shorter time (27 vs. 22 min, p < 0.05). Liver cirrhosis diagnosed during laparoscopy was histologically confirmed in 77%, independent of the method of examination. Cirrhosis was diagnosed by histology in 1 of 14 (7%) and 1 of 21 (5%) patients without macroscopic signs of cirrhosis. CONCLUSIONS: Laparoscopy with a small diameter telescope in the workup of liver disease is comparable in terms of results to CL. Possible advantages of ML are a shorter examination time and a subjective impression of lower degree of invasiveness.

Adult↗

PubMed1998

Diagnostic laparoscopy in 1043 patients with suspected acute appendicitis.

OBJECTIVE: To evaluate the efficacy of diagnostic laparoscopy in patients with suspected acute appendicitis, the number of complications associated with the laparoscopic technique, and the effect of leaving a macroscopically normal-looking appendix in place. DESIGN: Three prospective protocols. SETTING: Three departments of surgery, one in Norway and two in Sweden. SUBJECTS: 1043 patients aged 15 years or over. INTERVENTIONS: Diagnostic laparoscopy in patients with signs and symptoms of acute appendicitis who were to be operated on. MAIN OUTCOME MEASURES: Morbidity, mortality, and histological appearance of removed appendices, and outcome whether or not the patient was operated on. RESULTS: 819 patients had appendectomies (61% laparoscopically and 39% by conversion to open operation) with a total complication rate of 10%. In 211 patients a diagnostic laparoscopy was done as a single procedure. There were 181 women in this group and 86 of them had gynaecological disorders. The complication rate was 2% among these 211 patients and after a follow up of two years no patients had been readmitted for appendicectomy. 13 patients were subjected to other open procedures. The overall mortality was 0.4%. CONCLUSION: Diagnostic laparoscopy is safe and can be recommended in patients with suspected acute appendicitis, particularly in women. A macroscopically normal-looking appendix can be left in place.

Acute Disease↗

PubMed1999

Value of diagnostic laparoscopy in fertile women with suspected appendicitis.

OBJECTIVE: To assess the value of diagnostic laparoscopy in women of child-bearing age with suspected appendicitis. DESIGN: Prospective, non-randomised study. SETTING: University hospital, Sweden. SUBJECTS: 94 women aged between 15 and 40 years with suspected appendicitis. INTERVENTION: Diagnostic laparoscopy. If necessary, the appendix was removed either laparoscopically or by open operation. The outcomes were compared with those during 1994, during which all appendicectomies were done through a laparotomy. MAIN OUTCOME MEASURES: Rates of unnecessary appendicectomy, operating time, and length of hospital stay. RESULTS: 77 had diagnostic laparoscopy, and 17 primary open appendicectomy. 73 appendixes were removed; 53 open and 20 laparoscopically. 12 appendicectomies (13%) were unnecessary compared with 27/80 (34%) during the year 1994. The duration of the open operation was significantly shorter (mean (SD) 35 (14) minutes) than the laparoscopic one (78 (18) minutes) (p<0.001), and there were no differences in duration of postoperative hospital stay. No patients developed complications. CONCLUSIONS: Diagnostic laparoscopy is safe and helpful in suspected cases of appendicitis and could substantially reduce the rate of unnecessary appendicectomies. However, the data suggest that laparoscopic appendicectomy offers no advantages over primary open appendicectomy in terms of postoperative course.

Adolescent↗

PubMed1999

Value of diagnostic laparoscopy in tuberculous peritonitis.

OBJECTIVE: To assess the safety and efficacy of diagnostic laparoscopy in patients with tuberculous peritonitis. DESIGN: Retrospective clinical study. SETTING: University hospital, Turkey. SUBJECTS: 8 patients (2 women, 6 men; mean age 26 years) who presented with tuberculous peritonitis between January 1994 and January 1996. INTERVENTION: Laparoscopy under local anaesthesia with sedation (the 4 who presented with ascites) and laparotomy (the 4 who presented with an acute abdomen). MAIN OUTCOME MEASURES: Clinical and laboratory findings, biochemical and microbiological analysis of ascites, histopathological examination of specimens, morbidity, and mortality. RESULTS: 4 patients presented with ascites, and 4 with adhesions. Ascites; adhesions between liver and diaphragm, liver and intestines, and intestines and the abdominal wall; miliary nodes on the peritoneal surface; and inflamed haemorrhagic areas on the peritoneum could all be seen at laparoscopy. One of the 8 patients who underwent laparotomy developed a spontaneous enterocutaneous fistula during the early postoperative period. Two of eight patients died, one of an early enterocutaneous fistula and the other of cor pulmonale 3 1/2 months later. The remaining 6 patients survived without complications after antituberculous medical treatment. CONCLUSIONS: Laparoscopy is a safe and accurate method of diagnosis of tuberculous peritonitis.

Adolescent↗

PubMed2002

Laparoscopy for definite localization and simultaneous treatment of ectopic ureter draining a dysplastic kidney in children.

BACKGROUND AND PURPOSE: Single-system ectopic ureter draining a dysplastic kidney is a rare urologic abnormality. In this study, we evaluated our own experience using laparoscopy for the simultaneous identification and removal of such ureterorenal units. PATIENTS AND METHODS: Between February 1999 and August 2001, four girls with a mean age of 11 years presented with urinary incontinence. After imaging studies including CT scan, MRI, or both were done, all the patients underwent laparoscopy for definitive localization and simultaneous treatment. RESULTS: In all cases, ultrasonography and intravenous urography combined to reveal a single normal kidney. Even the CT scan could not identify the dysplastic kidney or ectopic ureter in three children. Laparoscopy was performed transperitoneally in all four patients, and a small dysplastic kidney was identified. Discovery of the kidney was not difficult because we initially identified the ureter crossing over the iliac vessels. Laparoscopic nephroureterectomy was successful in all patients with a mean operative time of 102 minutes. There was no significant intraoperative or postoperative complication, and the mean postoperative hospital stay was 2.5 days. All patients have remained completely dry without any problems after surgery. CONCLUSIONS: For patients having a clinical suspicion of ectopic ureter draining a dysplastic kidney, laparoscopy may represent an alternative modality for simultaneous diagnosis and treatment.

Adolescent↗

PubMed2002

Laparoscopy-assisted orchidopexy: an ideal treatment for children with intra-abdominal testes.

BACKGROUND AND PURPOSE: The investigation of a child with a nonpalpable testis is probably the most frequent indication for laparoscopy in pediatric patients. The objective of this study was to evaluate the results and advantages of laparoscopy-assisted orchidopexy performed without dividing the spermatic vessels. PATIENTS AND METHODS: During a 3-year period, 85 boys with nonpalpable testes (NPT) (91 testes overall) underwent laparoscopic diagnostic exploration. Twenty-five patients (27.4%) showed an intra-abdominal testis (IAT): 24 underwent a laparoscopy-assisted orchidopexy (LAO) without sectioning of the spermatic vessels, and one, whose inner spermatic vessels were not adequately long for LAO without tension, underwent a two-step Fowler-Stephens (FS) procedure. The technique consists of dissection and mobilization of the inner spermatic vessels and the vas deferens from the posterior peritoneum, sectioning of the gubernaculum attachments, and bringing down of the testis into the scrotum through the internal inguinal ring, if open, or through a neo-inguinal ring created medial to the epigastric vessels. RESULTS: Surgery lasted between 40 and 80 minutes (median 60 minutes). All the testes were brought down into the scrotum. There was only 1 (4%) intraoperative complication, which occurred in the second patient operated on with this procedure. He experienced an iatrogenic rupture of the spermatic vessels secondary to excessive traction. CONCLUSION: Laparoscopic orchidopexy is the logical extension of diagnostic laparoscopy for the evaluation of NPT. Concerning the technique, we believe that LAO with intact spermatic vessels could be considered the treatment of choice in the patient with IAT, as it does not affect normal testicular vascularization. Alternatively, in the case of very high IAT (more than 3 cm from IIR), an FS procedure may be considered.

Child↗

PubMed2001

Bedside laparoscopy in the ICU: report of four cases.

BACKGROUND: Patients in the intensive care unit (ICU) may suffer from life-threatening abdominal pathologies, which may necessitate a surgical intervention. Diagnosis may be difficult, as deep sedation and analgesia often mask symptoms, and physical examination is unreliable. Imaging studies are not accurate enough, and exploratory laparotomy carries significant morbidity and mortality rates in this patient population. The unstable patient is difficult to mobilize to the imaging department or to the operating room. Bedside laparoscopy may overcome these difficulties. PATIENTS AND METHODS: We describe our initial experience with the use of bedside laparoscopy in critical patients with suspected abdominal pathology. The procedure was performed in four patients over a 4-month period and completed in all four. RESULTS: The findings were: turbid fluid consistent with viscus perforation in a patient with unexplained sepsis after cardiac surgery, sterile hemorrhagic fluid in a patient with malignancy and thrombotic thrombocytopenia purpura, a retroperitoneal mass from which biopsies were taken in a patient with sudden respiratory failure, and abdominal abscess in a patient after bowel resection for mesenteric embolism. None of these patients had a laparotomy after the laparoscopy. Patients 1 and 4 died a few hours after the procedure from sepsis, and patients 2 and 3 died several days later. CONCLUSION: Bedside laparoscopy in the ICU is feasible, informative, and accurate. It has a role in diagnosing abdominal pathologies and planning further treatment. It may avert a nontherapeutic laparotomy. Unfortunately, the prognosis in these patients is poor. Earlier use of this diagnostic modality may improve patient outcome.

Abdominal Abscess↗

PubMed2001

Diagnostic laparoscopy decreases the rate of unnecessary laparotomies and reduces hospital costs in trauma patients.

BACKGROUND AND PURPOSE: The use of laparoscopy for the treatment of various surgical diseases has been well described, and recently, it has gained popularity in the evaluation of abdominal trauma patients. The value of diagnostic laparoscopy (DL) in avoiding unnecessary laparotomies and its effects on hospital costs was evaluated in a prospective clinical trial. PATIENTS AND METHODS: In a 48-month period, 99 hemodynamically stable abdominal trauma patients (28 blunt and 71 penetrating injuries) among 428 patients admitted with abdominal trauma in whom the decision for surgical exploration was made were accepted for the study and underwent DL prior to laparotomy. RESULTS: The DL was negative in 60.7% of the patients with blunt abdominal trauma (BAT) and in 62.0% of the patients with penetrating abdominal trauma (PAT). Laparoscopy-positive patients (Group 1) underwent immediate laparotomy, whereas on DL-negative patients (Group 2), no laparotomies were performed. Hospitalization times and hospital costs of the two groups were recorded and compared. The difference between the hospitalization times of Group 1 and Group 2 was statistically significant (P < 0.001). The use of DL reduced the rate of unnecessary laparotomies from 60.7% to 0 in BAT and from 78.9% to 16.9% in PAT. The mean hospitalization time was 2.75 +/- 1.20 days in patients with negative DL, whereas it was 7.4 +/- 2.20 days and 5.2 +/- 1.42 days in DL-positive patients undergoing a therapeutic and nontherapeutic laparotomy, respectively. When the hospital costs of the Group 1 patients were compared with those of Group 2 patients, there was a 4.07-fold increase in patients undergoing therapeutic laparotomy and a 1.78-fold increase in patients undergoing nontherapeutic laparotomy. CONCLUSION: Diagnostic laparoscopy might be used in selected patients to exclude significant intra-abdominal injuries.

Abdominal Injuries↗

PubMed2003

Therapeutic laparoscopy for blunt abdominal trauma with bowel injuries.

In the setting of abdominal trauma, laparoscopy is used mainly for diagnosis, and its role in definitive operative repair is still debated. We report the case of a 50-year-old woman who underwent diagnostic and therapeutic laparoscopy after being subjected to blunt abdominal trauma in a traffic accident. Multiple injuries to the small bowel and colon were repaired laparoscopically with a favorable outcome. Surgeons with experience in advanced laparoscopy and trauma care can use laparoscopy in the diagnosis and treatment of selected patients with blunt abdominal trauma.

Abdominal Injuries↗

PubMed2003

Diagnostic and therapeutic laparoscopy for stab wounds of the anterior abdomen.

BACKGROUND: At present, laparoscopy is used mainly as a diagnostic tool in patients with abdominal stab wounds. PATIENTS AND METHODS: Thirty-two hemodynamically stable patients with isolated stab wounds of the anterior abdomen, thought to be penetrating, were prospectively selected to undergo treatment via a laparoscopic approach. When possible, parenchymal wounds were coagulated or sealed, and wounds to the intestines were sutured or stapled. RESULTS: The results of laparoscopy were negative in 6 (18.8%) of the cases: nonpenetrating wounds in 4 cases and nonsignificant organ injury in 2 cases. A hemoperitoneum was identified in 13 (40.6%) of the cases, and significant organ injuries in 26 (81.3%) of the cases: stomach, 2; small bowel, 5; colon, 2; pancreas, 1; vascular injuries, 4; liver, 5; mesentery, 9. Laparoscopy was therapeutic in 20 (62.3%) of the cases. Conversion to open surgery was required in 6 (18.8%) of the cases. No injuries were missed, and no mortality occurred. Postoperative complications developed in 2 (6.2%) of the cases. The mean hospital stay was 4 days, with no late complications. CONCLUSIONS: Laparoscopy can avoid a number of unnecessary laparotomies and can treat most of the lesions found in hemodynamically stable patients with anterior abdominal stab wounds.

Abdominal Injuries↗

PubMed1996

Is laparoscopy a worthy method to treat varicocele? Comparison between 160 cases of two-port laparoscopic and 120 cases of open inguinal spermatic vein ligation.

Because it is still a puzzling debate whether ligation of a unilateral varicose spermatic vein is worth performing by laparoscopy, even with the two-port technique, we conducted a study in which 280 patients with palpable left varicoceles were treated with spermatic vein ligation either by open surgery (120 patients) or by laparoscopy (160 patients). The inclusion criteria were the same for each group, and the two groups were homogeneous in preoperative clinical features and patient characteristics. The clinical outcomes were compared 6 months after surgery, and the costs of each treatment were analyzed. The procedures showed the same effectiveness and intraoperative safety. Open surgery scored a shorter operating time, whereas hospitalization was significantly shorter in the laparoscopic group. Postoperative complications occurred more frequently in the open surgery than in the laparoscopic group (7.5% and 0.6%, respectively). Of the patients treated, 197 were eligible for seminal analysis: 82 and 115 in the open surgery and laparoscopic groups, respectively. Significant improvement in seminal analysis was recorded in both groups, whereas no difference was found between the groups. Laparoscopy costs about 60% more than open surgery. It can thus be concluded that laparoscopy is not a worthy method to treat unilateral varicocele.

Adolescent↗

PubMedDate not supplied

Laparoscopy-assisted transperitoneal percutaneous nephrolithotomy for renal caliceal diverticular calculi.

BACKGROUND AND PURPOSE: There are a variety of options for the management of symptomatic calculi in caliceal diverticula, each with utility in particular situations. Herein, we describe a laparoscopy-assisted transperitoneal percutaneous nephrolithotomy (PCNL) technique to address the unusual combination of an anterior caliceal diverticulum together with multiple branched calculi having segments both within and proximal to the diverticulum. TECHNIQUE: With the patient in a modified lithotomy position, standard transperitoneal laparoscopy was performed utilizing three 10-mm trocars. After mobilization of the colon medially, the cystic diverticulum was opened. An additional 12-mm trocar was placed to allow transperitoneal PCNL within the diverticulum. Rigid nephroscopy, holmium laser lithotripsy, and stone extraction were performed, including laser enlargement of the diverticular neck and removal of the stone burden proximal to the neck. A double-pigtail ureteral stent and Jackson-Pratt drain were placed. RESULTS: This procedure was successful in the only patient in whom it has been used to date. As far as we know, this is the first report of laparoscopy-assisted transperitoneal PCNL for the management of caliceal diverticular calculi. CONCLUSION: Laparoscopy-assisted transperitoneal PCNL is a safe and effective alternative for the management of symptomatic stones in anterior cystic caliceal diverticula with a narrow neck and complex branched calculi.

Diverticulum↗

PubMed1990

Laser laparoscopy versus laparotomy in the treatment of infertility patients with severe endometriosis.

The best pregnancy rates reported in the literature for infertility patients with severe pelvic endometriosis (stage IV) have been attributed to surgical management. In the last few years, improved endoscopic instruments have allowed gynecologists to treat difficult conditions with the CO 2 laser via laparoscopy, with good results. To assess the usefulness of the CO 2 laser via laparoscopy in treating severe pelvic endometriosis, two groups of patients were studied. Thirteen patients were treated by laparotomy (group I) and 11 patients by laparoscopy (group II). Seven achieved pregnancy in group I (53.8%), and pregnancy occurred in 6 patients in group II (54.5%). This study suggests that the management of severe pelvic endometriosis in infertility patients via laparoscopy seems to yield similar pregnancy rates to those treated with laparotomy, with the advantages of faster recovery and fewer hospitalization days for those undergoing laparoscopic surgery.

Adult↗

PubMed1995

Comparative study of laparoscopy vs. laparotomy for adnexal surgery: efficacy, safety, and cyst rupture.

Operative laparoscopy is becoming routine in gynecologic surgery. This study was designed to compare the safety and efficacy of laparoscopy and laparotomy for ovarian cystectomy and adnexectomy. The medical records of 32 patients who underwent operative laparoscopy for adnexal masses (group L) were reviewed and compared with those of 32 patients who underwent surgical laparotomy (group S) for similar indications. All patients sustained either an ovarian cystectomy or adnexectomy. The group were matched for age, weight, and history of previous laparotomy. Median operating time for group L was 90 min and for group S was 85 min. Blood loss was significantly less in group L (33.4 +/- 22 mL) than in group S (84.6 +/- 22.2 mL), p < 0.0001. There were two intraoperative complications in group L and one in group S. Significantly less patients in group L had postoperative fevers (16%) as compared with those in group S (69%), p < 0.0001. There was a higher incidence of cyst rupture when cystectomy was performed in patients from group L (7 of 21) as compared with patients from group S (2 of 17). No such difference in cyst rupture was noted when an adnexectomy was affected in group L (1 of 11) and group S (1 of 15). Patients in group L remained in the hospital a shorter time period, 1.5 +/- 0.8 days, than patients in group S, 4.7 +/- 0.9 days, p < 0.0001. Patients in group L required a shorter postoperative recovery time before resuming normal activities, 9.1 +/- 6.6 days, than patients in group L, 27.5 +/- 9.2 days, p < 0.0001. Similarly, patients in group L required less time to become pain free, 10.1 +/- 7.4 days, than patients in group L, 17.7 +/- 6.1 days, p < 0.0005. This study demonstrates a statistically significant decrease in postoperative morbidity and faster recovery in patients undergoing laparoscopy for adnexal surgery as compared with patients undergoing laparotomy for the same procedure. When cystectomy is performed via the laparoscope, there is a higher incidence of cyst rupture than with laparotomy.

Adnexa Uteri↗