Diagnostic Laparoscopy

Diagnostic laparoscopy (DL) is a safe and well tolerated procedure that can be performed in an inpatient or outpatient setting under general or occasionally local anesthesia with IV sedation in carefully selected patients. Diagnostic laparoscopy should be performed by physicians trained in laparoscopic techniques who can recognize and treat common complications and can perform additional therapeutic procedures when indicated. During the procedure, the patient should be continuously monitored, and resuscitation capability must be immediately available. Laparoscopy must be performed using sterile technique along with meticulous disinfection of the laparoscopic equipment. Overnight observation may be appropriate in some outpatients. There are unique circumstances when office-based DL may be considered. Office-based DL should only be undertaken when complications and the need for therapeutic procedures through the same access are highly unlikely.

Indications

The main indication for DL in the ICU has been unexplained sepsis, systemic inflammatory response syndrome, and multisystem organ failure. In addition, the procedure has been used for abdominal pain or tenderness associated with other signs of sepsis without an obvious indication for laparotomy (i.e., pneumoperitoneum, massive gastrointestinal bleeding, small bowel obstruction), fever and/or leukocytosis in an obtunded or sedated patient not explained by another identifiable problem (such as pneumonia, line sepsis, or urinary sepsis), metabolic acidosis not explained by another process (such as cardiogenic shock), and increased abdominal distention that is not a consequence of bowel obstruction.

Contraindications

  • Patients unable to tolerate pneumoperitoneum or who are so sick that there is no realistic chance of survival even if a treatable intra-abdominal process were found
  • Patients with an obvious indication for surgical intervention such as a bowel obstruction or perforated viscus
  • Patients with an uncorrectable coagulopathy or uncorrectable hypercapnia >50 torr
  • Patients with a tense and distended abdomen (i.e., clinically suspected abdominal compartment syndrome)
  • Patients with abdominal wall infection (e.g., cellulitis, soft tissue infection, open wounds)
  • Patients with extensive previous abdominal surgery with multiple incisional scars or after a laparotomy within the last 30 days

Risks

  • Delay in the diagnosis and treatment of patients if the procedure is false negative
  • Missed pathology and its associated complications
  • Procedure- and anesthesia-related complications

Benefits

  • Expeditious diagnosis of suspected intra-abdominal pathology
  • Minimization of treatment interruption by not moving the patient outside the ICU
  • Avoid the morbidity of open exploration
  • Avoid potential risks associated with transportation to the operating room or radiology for diagnostic tests
  • Ability to provide therapeutic intervention