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PubMed1998

Cytology of peritoneal lavage performed during staging laparoscopy for gastrointestinal malignancies: is it useful?

OBJECTIVE: To evaluate the potential benefit of cytology of the peritoneal lavage obtained during diagnostic laparoscopy for staging gastrointestinal (GI) malignancies. SUMMARY BACKGROUND DATA: Peritoneal lavage is a simple procedure that can be performed during laparotomy for GI tumors. Tumor cells in the lavage fluid are thought to indicate intraperitoneal tumor seeding and to have a negative effect on survival. For this reason, peritoneal lavage is frequently added to diagnostic laparoscopy for staging GI malignancies. METHODS: Patients who underwent peritoneal lavage during laparoscopic staging for GI malignancies between June 1992 and September 1997 were included. Lavage fluids were stained using Giemsa and Papanicolaou methods. Cytology results were correlated with the presence of metastases and tumor ingrowth found during laparoscopy and with survival. RESULTS: Cytology of peritoneal lavage was performed in 449 patients. Tumor cells were found in 28 patients (6%): 8/87 with an esophageal tumor, 2/32 with liver metastases, 11/72 with a proximal bile duct tumor, 7/236 with a periampullary tumor, and none in 7 and 15 patients with a primary liver tumor or pancreatic body or tail tumor, respectively. In 19 of the 28 patients (68%) in whom tumor cells were found, metastatic disease was detected during laparoscopy, and 3 of the 28 patients had a false-positive (n = 1) or a misleading positive (n = 2) lavage result. Therefore, lavage was beneficial in only 6/449 patients (1.3%); in these patients, the lavage result changed the assessment of tumor stage and adequately predicted irresectable disease. Univariate analysis showed a significant survival difference between patients in whom lavage detected tumor cells and those in whom it did not, but multivariate analysis revealed that these survival differences were caused by metastatic or ingrowing disease. CONCLUSION: Cytology of peritoneal lavage with conventional staining should no longer be performed during laparoscopic staging of GI malignancies because it provides an additional benefit in only 1.3% of patients and has limited prognostic value for survival in this group of patients.

Gastrointestinal Neoplasms↗

PubMed2006

Bacteremia after diagnostic conventional laparoscopy and minilaparoscopy: a prospective study in 100 patients.

BACKGROUND/GOALS: Diagnostic laparoscopy under sedoanalgesia is a valuable tool in the work-up of liver diseases and is helpful as a staging procedure. The rate of bacteremia caused by this procedure is unknown, in particular when performed as minilaparoscopy. STUDY: A 100 consecutive patients having undergone diagnostic laparoscopy carried out either conventionally (group I, n=50) or as minilaparoscopy (group II, n=50) were prospectively enrolled in this study. Blood cultures were drawn before and within 5 minutes after the procedure. Risk factors for bacteremia were evaluated. RESULTS: Bacterial growth occurred in 4 blood cultures drawn immediately after laparoscopy. No patient developed fever or other signs of infection in the follow-up. Risk factors predisposing to bacteremia could not be identified. CONCLUSIONS: Conventional diagnostic laparoscopy under sedoanalgesia and minilaparoscopy are associated with a low rate of bacteremia as in diagnostic upper endoscopy.

Adult↗

PubMed1998

Selective application of laparoscopy and fibrin glue in the failure of nonoperative management of blunt hepatic trauma.

BACKGROUND: Most blunt hepatic trauma patients can be managed nonoperatively. The current failure rate in adult blunt hepatic trauma is reportedly 0 to 19%. We wished to evaluate the applicability of laparoscopy and fibrin glue as a minimally invasive alternative to laparotomy in these unsuccessfully nonoperative cases. METHODS: All adult patients with blunt hepatic trauma managed nonoperatively at Linkou, Chang Gung Memorial Hospital Medical Center, Taipei, Taiwan, over a 2-year period from July 1, 1994, to June 30, 1996, were eligible for the study. A laparoscopic examination was performed on those who failed conservative care before undertaking an exploratory laparotomy. Fibrin glue was sprayed over the wound surface if ongoing hemorrhage was evident from any liver laceration. The clinical data, operative and laparoscopic findings, operative methods, and outcomes of these patients were studied. RESULTS: Of the 61 patients, 55 patients were successfully treated without operation. Of the six failures (10%) all were liver related. After the introduction of laparoscopy, the nontherapeutic laparotomy rate would have decreased from 100% (6 of 6) to 50% (3 of 6), and with the adjunctive use of fibrin glue, the laparotomy rate went down to 0% (0 of 6). There were no deaths among the six patients receiving laparoscopy and fibrin glues; and only one developed a liver abscess, for a morbidity rate of 17% (1 of 6). CONCLUSIONS: The selective use of laparoscopy and fibrin glue can effectively reduce the nontherapeutic laparotomy rate among blunt hepatic trauma patients who fail nonoperative management.

Adolescent↗

PubMed1996

Benefits and afterthoughts of laparoscopy for the nonpalpable testis.

PURPOSE: Recent reports in the literature indicate that laparoscopy tends to be seen as the most appropriate approach to the nonpalpable testis for diagnosis and therapy. The aim of our study was to evaluate the real benefits of laparoscopy in terms of diagnostic accuracy, safety, costs and validity of the chosen treatment. MATERIALS AND METHODS: We compared anatomical findings and results of the treatment of impalpable testes in 2 pediatric surgical groups, including 47 children treated laparoscopically during a 2 1/2-year period and 296 treated with open surgery (classic orchiopexy) in a 6 1/2-year period. RESULTS: There was no significant difference in the diagnosis of abdominal testes (51 versus 50%), whereas a difference was noted in inguinal (4 versus 15%) and absent testes (45 versus 35%). Differences in treatment were more striking. In the laparoscopic group standard orchiopexy was performed in 62.5% of cases versus 83% in the open group. Conversely the rate of Fowler-Stephens repairs increased from 5.5% of open surgery cases to 37.5% of laparoscopic cases. There have been no serious complications in the laparoscopic procedures. To date 6 of the 9 patients who underwent a staged Fowler-Stephens procedure have undergone complete repair (open second stage). A review of the literature revealed a similar but lower tendency to over perform the Fowler-Stephens operation in laparoscopic cases (34%) versus open surgery (8%). Also, in previous series there was a 29% orchiectomy rate during laparoscopy compared to only 5% in classic open surgery. In Italy under current public health programs overall costs of the laparoscopic approach to the nonpalpable testis become noncompetitive when the procedure is extended from only diagnostic to interventional use due to the need for additional trocars and other special instruments. In contrast, private health insurers provide an additional 30% for laparoscopic cases over the cost of open orchiopexy. CONCLUSIONS: Laparoscopy is definitively accurate in establishing the differential diagnosis of impalpable testis. The number of Fowler-Stephens repairs in the laparoscopic group seems inordinately high, probably due to a lack of definite standards in the proper assessment of the length of the internal spermatic vessel pedicle and the potential scrotal displacement of the testis. This reason may explain the higher number of orchiectomies reported in the literature.

Child↗

PubMed1986

Interval laparoscopy as predictor of response to chemotherapy in ovarian carcinoma.

Fifty-one patients with FIGO stage III and IV ovarian adenocarcinoma underwent six-month interval laparoscopy for assessment of chemotherapy response. Thirty-nine of these patients were followed by a second-look procedure at 12 months or to disease progression if it occurred earlier. A positive interval laparoscopy was predictive of disease in 91% of patients, whereas a negative interval laparoscopy showed absence of disease at second look in only 70.5% of patients. A positive laparoscopic biopsy at six months showed presence of disease at second look procedure in 100% (11 of 11) of patients. It is concluded that either an intensive initial chemotherapy or change in therapy such as intraperitoneal chemotherapy after positive interval laparoscopy is indicated in future studies.

Antineoplastic Combined Chemotherapy Protocols↗

PubMed2000

Ureteral injury during laparoscopy-assisted anterior lumbar fusion.

STUDY DESIGN: A case report of ureteral injury as a complication incurred during a laparoscopy-assisted lumbar fusion. OBJECTIVE: To alert orthopedic surgeons to this injury, which may occur during such surgery. SUMMARY OF BACKGROUND DATA: Laparoscopy-assisted lumbar fusion is a minimally invasive surgical technique to accomplish lumbar fusion with excellent patient satisfaction, reduced hospital stay, and decreased rehabilitative time. METHOD AND RESULTS: A case report is presented detailing ureteral injury as a complication of laparoscopy-assisted lumbar fusion and the subsequent treatment of the injury. CONCLUSION: Laparoscopy-assisted lumbar fusion is a new, less invasive technique with excellent patient satisfaction; however, ureteral injury may occur, and the surgeon should keep this in mind if a postoperative fluid collection occurs in the pelvis.

Adult↗

PubMed2005

Urological laparoscopy: basic physiological considerations and immunological consequences.

PURPOSE: The applications of laparoscopy to urological surgery continue to grow at a steady pace. A complete understanding of the physiological and immunological changes associated with pneumoperitoneum is required. We reviewed the physiology of laparoscopy with regard to the major organ systems and summarize the effects of pneumoperitoneum on immune function. MATERIALS AND METHODS: Articles published in the scientific literature from 1990 to 2004 with relevance to laparoscopic physiology and the immune response to pneumoperitoneum were reviewed using PubMed. RESULTS: Pneumoperitoneum induces predictable pulmonary and renal responses. The cardiovascular and hemodynamic responses are phasic and dynamic in nature, and only generalizations regarding cardiac function can be made. Renal parenchymal and venous compression during pneumoperitoneum are the etiology of oliguria during laparoscopy. The effects are reversible and cause no adverse effects on renal function. There is a general trend toward systemic immune preservation and peritoneal immune depression during insufflation based laparoscopy. Attenuated peritoneal immunity has been demonstrated most consistently by altered macrophage function. CONCLUSIONS: Physiological changes incurred as a result of pneumoperitoneum have minimal adverse effects in healthy individuals undergoing laparoscopic surgery. Interest has grown in the impaired peritoneal immune response to CO2 pneumoperitoneum. Altered intraperitoneal immunity may represent a new avenue for the development of adjuvant therapies for minimally invasive treatments of urological malignancies and for the prevention of port site metastasis. Further elucidation and investigation into the immunological responses to pneumoperitoneum during urological laparoscopic procedures is called for.

Animals↗

PubMed2006

Acute nonspecific abdominal pain: A randomized, controlled trial comparing early laparoscopy versus clinical observation.

AIMS: To evaluate, in a prospective, randomized, single-institution trial, the role of early laparoscopy in the management of nonspecific abdominal pain (NSAP) in young women. PATIENTS AND METHODS: Women aging from 13 to 45 years, admitted for NSAP at the emergency department, were included in the study. Exclusion criteria were pregnancy, previous appendectomy, contraindications to laparoscopy, diagnosis of malignancy, or chronic disease. NSAP was defined as an abdominal pain in right iliac or hypogastric area lasting more than 6 hours and less than 8 days, without fever, leukocytosis, or obvious peritoneal signs and uncertain diagnosis after physical examination and baseline investigations including abdominal sonography. Patients were randomly assigned to early (<12 hours from admission) laparoscopy group (LAP) or to clinical observation group (OBS). After discharge a follow-up was carried out. RESULTS: From January 2001 to February 2004, 508 female patients without previous abdominal surgery were evaluated in admitting area for acute right iliac or hypogastric abdominal pain, in 373 patients diagnosis was established for obvious signs or with baseline investigations. Of the remaining 135 patients, 31 were excluded from study for various reasons, 53 patients were randomly assigned to LAP and 51 to OBS. Groups were similar for age, mean BMI, white blood cell count, and duration of pain. During hospitalization diagnosis was established in 83.4% of the LAP and in 45.1% of OBS (P < 0.05). Twenty patients of OBS (39.2%) were operated during observation because of worsening of symptoms or appearance of peritoneal sign. Diagnoses in LAP were appendicitis in 16 patients (30.1%), pelvic inflammatory disease in 7 (13.2%), carcinoid in 1 (1.9%), other in 18 (33.9%), no diagnosis in 11 (20.7%); diagnoses in OBS were appendicitis in 3 patients (5.8%), pelvic inflammatory disease in 8 (15.6%), other in 12 (23.5%), and no diagnosis in 28 (54.9%). Mean length of hospital stay was 3.7 +/- 0.8 days in LAP and 4.7 +/- 2.4 days in OBS (P < 0.05); no differences were found regarding mortality, morbidity, radiation dose, and analgesia. Mean follow-up time was 29.3 months (range, 12-60 months) for LAP and 30.6 months for OBS (range, 12-60 months). After 3 months from discharge, 20% of patients in LAP and 52% in OBS had recurrent abdominal pain (P < 0.05); after 12 months, 16% in LAP and 25% in OBS (P = not significant). Six patients in OBS required readmission for surgery. CONCLUSIONS: Compared with active clinical observation, early laparoscopy did not show a clear benefit in women with NSAP. A higher number of diagnosis and a shorter hospital stay in the LAP group did not led to a significant reduction in symptoms recurrences at 1 year.

Abdominal Pain↗

PubMed2004

Patient information following emergency laparoscopy for right iliac fossa pain.

Laparoscopy is increasingly used as a diagnostic and therapeutic tool in the management of emergency surgical admissions. Laparoscopic scars give little clue to the operation performed. Hence, the future assessment of patients re-admitted with abdominal pain, often needs to rely on the patient's own account of the operation performed. This study attempted to evaluate the quality of communication between surgeons and patients regarding the results of their laparoscopy and how much information was retained by the patients on discharge. Seventy-seven patients were identified from computerised medical records. A detailed case note review was undertaken looking at operative findings, procedure performed, and documentation of surgeon-to-patient communication. A questionnaire was posted to patients asking their opinion regarding the quality of communication from surgeons. The questionnaire asked specific questions regarding the patient's understanding of the operation performed and its findings. Overall communication between surgeons and patients was good. However, a small proportion of patients were unsure of their diagnosis and what therapeutic procedure had been performed following laparoscopy. This included one patient (out of 28 who had undergone laparoscopic appendectomy) who was unsure if their appendix had been removed. Two from 12 patients diagnosed with pelvic pathology at laparoscopy who were unclear of their diagnosis and two patients with histologically normal appendices who thought their appendices had been inflamed at removal. Greater effort must be made to inform patients of their laparoscopic findings and any therapeutic procedure performed. We recommend the use of written information leaflets to be sent to the patient's home address to ensure that all patients are fully aware of their laparoscopic findings. For any future emergency admission, the patient's knowledge of any previous surgery and whether their appendix is in situ is of considerable diagnostic value to the assessing clinician. More effort must be made to enable patients to retain such necessary information.

Abdominal Pain↗

PubMed2005

Inflammatory response of interleukin-1beta and interleukin-6 in septic rats undergoing laparotomy and laparoscopy.

It is generally accepted that greater inflammatory response is observed after laparotomy than laparoscopy in animal models. However, in a previous study, we reported there are no significant differences in the systemic response of tumor necrosis factor (TNF)-alpha between the laparotomy and laparoscopy groups in a rat model of endotoxic shock. The present study extends this investigation to the inflammatory response of 2 additional proinflammatory mediators, interleukin (IL)-1beta and IL-6, in septic rats after laparotomy and laparoscopy in the same animal model. Rats received lipopolysaccharide (LPS) intraperitoneally and underwent laparotomy (n = 5), laparoscopy (n = 5), or no surgical intervention (n = 5). A control group received anesthesia only (n = 5). Serum IL-1beta and IL-6 levels were significantly higher at 2, 4, and 8 hours after LPS injection and were equally suppressed in the laparotomy and laparoscopic groups (P < 0.05). Liver IL-1beta mRNA and protein levels were significantly inhibited at 2, 4, and 8 hours in the laparotomy and laparoscopic groups. Liver IL-6 mRNA (2 and 4 hours) and protein (4 hours) levels were also suppressed significantly in both the laparotomy and laparoscopic groups (P < 0.05). There were no significant differences in hepatic levels of mRNA and protein of IL-beta and IL-6 in both the laparotomy and laparoscopic groups. These results extend our previous finding demonstrating the suppression of TNF-alpha in both the laparotomy and laparoscopic groups. The behavior of the markers used in our study demonstrated that the inflammatory response does not differ between laparotomy and laparoscopic surgery in our rat model of endotoxic shock.

Animals↗

PubMed2005

Laparoscopy-assisted surgical management of obscure gastrointestinal bleeding secondary to Meckel's diverticulum in a pediatric patient: case report and review of literature.

Despite advances in endoscopy and imaging, acute gastrointestinal (GI) bleeding of obscure origin in children presents a challenge to pediatric gastroenterologist. Bleeding Meckel's diverticulum (MD) commonly presents with acute episode of lower GI bleeding. A conventional diagnostic algorithm includes endoscopy, technetium 99m pertechnetate scintigraphy, angiography, and exploratory laparotomy. The advent of minimal access surgery prompts the use of laparoscopy for children with obscure GI bleeding. Laparoscopy assists in the diagnosis and can offer definitive treatment of patients with MD. Herein, we report a case of pediatric GI bleeding of obscure origin associated with MD that was successfully diagnosed and managed via laparoscopy. This article updates the current management for pediatric patients with obscure GI bleeding and the role of laparoscopy in the management of MD.

Child↗

PubMed2006

The effect of laparoscopy on the IGF system in patients diagnosed with acute cholecystitis.

OBJECTIVE: IGFs and IGF binding proteins in the circulation are subject to modulation by a number of catabolic states including inflammation, trauma and surgery. We sought to determine the impact of laparoscopy on the IGF system in patients diagnosed with acute cholecystitis. DESIGN: The components of the IGF system, cortisol, glucose and insulin concentration in both the serum and urine of patients were compared to those from a healthy group of subjects. An additional comparison was made between pre- and post-laparoscopically assisted patients. PATIENTS: Thirty patients diagnosed with acute cholecystitis and 81 matched controls were included in the study. MEASUREMENTS: Radioimmunoassays were used to determine the IGF-I, IGF-II, insulin and cortisol concentrations. The concentration of IGFBP-3 was measured using an immunoradiometric assay. The GOD-PAP method was used to determine the glucose concentration. Gel filtration chromatography was performed to calculate the IGF binary/ternary complex ratio. The amount of sialic acid in IGFBP-3 was determined by affinity chromatography. The presence of IGFBPs in serum was determined by both immunoblotting and ligandblotting. RESULTS: The concentrations of circulating IGF-I, IGF-II and IGFBP-3 were significantly reduced in pre-operative patients compared to healthy subjects. No further reductions were observed post-laparoscopy. Immunoblotting and ligandblotting demonstrated a decreased amount of IGFBP-3 in both pre- and post-operative patients compared to healthy subjects. Increased levels of IGFBP-2 and IGFBP-1 were observed in pre-operative patients compared to healthy subjects, but laparoscopy did not cause further elevation. No alteration in the IGF binary/ternary complex ratio was witnessed between any of the study groups. A significant increase in the sialic acid content of IGFBP-3 was seen in both patient groups when compared to healthy subjects. The level of urinary cortisol was significantly increased in post-operative patients, whereas the urinary IGF-I concentration was decreased compared to healthy subjects. CONCLUSIONS: Our results indicate that acute cholecystitis causes several significant changes in the circulating IGF system. Laparoscopy, however, does not aggravate such changes, but elevates urinary cortisol.

Adult↗

PubMed2003

Multiport staging laparoscopy in esophageal and cardiac carcinoma.

Between February 1993 and September 2000, 320 patients with esophageal cancer were referred to our oesophagogastric unit. One hundred and thirty-three consecutive patients with histologically proven carcinoma of the esophagus were assessed with a view to resection using multiport staging laparoscopy. Multiport staging laparoscopy was performed as a short stay/day case procedure in 133 patients with esophageal and oesophagogastric junctional carcinoma. Multiple ports were used to inspect the liver, omentum, peritoneal surfaces, coeliac/left gastric lymph nodes and obtain biopsies and cytology. Satisfactory assessment was possible in 127 cases (95%). Laparoscopy detected incurable disease in 31 patients (24%), some of whom had more than one contraindication to surgery, including hepatic metastases (n = 10), peritoneal metastases (n = 12) and malignant small volume ascites (n = 5). Lymph node metastases were confirmed histologically by biopsy at laparoscopy in 26 patients (fixed nodes, n = 14; mobile nodes, n = 12). Sensitivity for the detection of liver and peritoneal metastases was 100%, and lymph node metastases were 83%. Specificity for detection of hepatic metastases was 99%, 100% for peritoneal metastases and 82% for lymph node metastases. Ninety-nine patients proceeded to definitive surgery and only two were unresectable. Multiport laparoscopic assessment of metastases in patients with esophageal carcinoma avoids unnecessary surgery and allows for more efficient use of theatre and intensive care time.

Adult↗

PubMed1981

Laparoscopy in the diagnosis of acute lower abdominal pain.

Laparoscopy was performed on twenty-seven hospital inpatients presenting with acute lower abdominal pain. Nineteen of the twenty-seven were admitted with a provisional diagnosis of appendicitis. Following laparoscopy, nine patients underwent appendicectomy, and a further three underwent laparotomy. Fifteen patients had a laparoscopy as the sole procedure, and all were discharged from hospital without need for further surgery. Of those patients in the operative group, five had their proposed incisions modified as the result of the laparoscopic findings. The only complications attributable to laparoscopy was one small wound haematoma.

Abdomen↗

PubMed2006

Role of laparoscopy in blunt liver trauma.

Although much has been written about the role of laparoscopy in the acute setting for victims of blunt and penetrating trauma, little has been published on delayed laparoscopy relating specifically to complications of conservative management of liver trauma. There has been a shift towards managing liver trauma conservatively, with haemodynamic instability being the key indication for emergency laparotomy, rather than computed tomography findings. However, as a side-effect of more liver injuries being treated non-operatively, bile leak from a disrupted biliary tree presenting later in admission has appeared as a new problem to manage. We describe in this article three cases that have been managed by laparoscopy and drainage alone, outlining the advantages of this technique and defining a new role for delayed laparoscopy in blunt liver trauma.

Adult↗

PubMed1994

Diagnostic laparoscopy and liver disease: experience of 200 cases.

BACKGROUND: Laparoscopy is an old technique that is frequently used by gastroenterologists in America and Germany. With modern equipment it is now possible to perform this technique under local anaesthesia. AIM: To evaluate the usefulness and safety of laparoscopic liver biopsy. METHODS: Liver biopsy was routinely performed by laparoscopy under local anaesthetic and sedation. A standard 5 mm laparoscope was used and a pneumoperitoneum induced with nitrous oxide. RESULTS: Two hundred consecutive patients were laparoscoped and underwent liver biopsy. In five patients the liver could not be visualised due to adhesions. Two patients had bleeds related to the procedure. Twenty-five patients had malignancy diagnosed by guided biopsy. Eight of these had been missed by ultrasound prior to laparoscopy. Cirrhosis was diagnosed laparoscopically in 72 patients. Histology was unable to confirm this diagnosis in four patients. CONCLUSION: Laparoscopy can be performed safely and comfortably on patients with local anaesthetic and sedation. The visualisation of the liver can add valuable information to liver biopsy.

Biopsy↗

PubMed1995

Laparoscopy in 100 consecutive patients with 128 impalpable testes.

OBJECTIVE: To investigate the value of laparoscopy in boys with impalpable testes, to carry out a histological examination of testicular biopsies or orchidectomy specimens, and to present a clinical description of boys with impalpable testes. PATIENTS AND METHODS: One hundred consecutive patients underwent laparoscopy for 128 impalpable testes. They ranged in age from 2.7 to 19.3 years (median 10.8). Histological examination was performed on 39 testicular biopsies, nine primarily orchidectomized testes and 13 tissue samples from the end of blind-ending vessels and vasa deferentia. Any additional diagnoses to that of impalpable testes were recorded. RESULTS: There were no complications associated with laparoscopy and the procedure clarified the situation in all patients. In 50% of patients either blind-ending cord structures above the internal inguinal ring or intra-abdominal testes were identified; in the remainder, cord structures could be seen passing through the ring, indicating an intracanalicular testis. The impalpable testis was absent in 77% of patients with a contralateral scrotal testis. A seminoma was found in one 18.6-year-old patient with bilateral cryptorchidism. No intratubular germ cell neoplasia (carcinoma in situ) was found. Germ cell hypoplasia or aplasia was demonstrated in 95% of patients with testicular parenchyma. Additional diagnoses were made in 49% of patients with bilaterally undescended testes (one or both of which were impalpable). CONCLUSION: We recommend laparoscopy as a safe procedure which leads to a diagnosis in patients with impalpable testes; the advent of laparoscopic procedures makes definitive treatment possible in about 50% of such patients. Open procedures will be indicated only to ascertain the quality and treatment of intracanalicular testes.

Adolescent↗

PubMed2000

Can diagnostic laparoscopy be avoided in routine investigation for infertility?

OBJECTIVE: To determine whether routine testing for serum Chlamydia trachomatis antibodies, considered in combination with a woman's clinical features, may avoid the need for diagnostic laparoscopy in routine investigation for infertility. DESIGN: Retrospective case notes analysis. SETTING: Secondary level care infertility clinic. POPULATION: Eighty women who had undergone both laparoscopy and serum Chlamydia trachomatis antibody testing. METHODS: Ascertainment of any history of suspected pelvic inflammatory disease, pelvic pain, cervical intraepithelial neoplasia, pelvic surgery or appendicectomy; any abnormality on clinical pelvic examination; the findings at laparoscopy; the result of serum Chlamydia trachomatis antibody testing by enzyme-linked immunosorbent assay (ELISA) screening with microimmunofluorescence (MIF) confirmatory diagnostic testing. The usefulness of clinical features, the serum Chlamydia trachomatis antibody test and these two variables combined in the detection of tubal disease and pelvic pathology of relevance to infertility were measured statistically. MAIN OUTCOME MEASURES: Specificity, sensitivity, positive predictive value, negative predictive value and likelihood ratio for each of the tests. RESULTS: The combination of any positive clinical feature with a positive test for serum Chlamydia trachomatis antibodies detects tubal disease with sensitivity 92%, specificity 70%, positive predictive value 72%, negative predictive value 91% and likelihood ratio 3 x 1; it detects bilateral tubal obstruction with sensitivity 84%, specificity 51%, positive predictive value 35%, negative predictive value 91% and likelihood ratio 1 x 7; it detects pelvic pathology relevant to infertility with sensitivity 76%, specificity 71%, positive predictive value 80%, negative predictive value 65% and likelihood ratio 2 x 6. The negative predictive value for pelvic pathology from the use of clinical features in addition to the chlamydia antibody test is not significantly higher than that from the chlamydia antibody test alone (53%). CONCLUSIONS: A policy of selective laparoscopy in routine investigation for infertility, based on the result of the test for serum Chlamydia trachomatis antibodies and a woman's clinical features, is not supported.

Adult↗