Laparoscopy as a diagnostic tool

Dr (Col) K. M Harikrishnan

Consultant General & Laparoscopic Surgeon

Medical Director, KIMS Oman Hospital, Muscat

Introduction: In recent years, medical diagnostics has reached dizzying heights in terms of both range and accuracy. It is important to realize, however, that clinical assessment is still the foremost tool in arriving at a diagnosis when a patient presents to a doctor’s office. A thorough history and clinical examination still form the cornerstone of medical diagnostics. This does not however take away from the advances made in radiological imaging such as CT and MRI scanning. These have revolutionalised the assessment of a patient presenting, say, with acute abdomen. In the final analysis, though, seeing is believing, and a laparotomy has been the final port of call for making a diagnosis in difficult and perplexing situations when a patient has an acute intra abdominal problem. An exploratory laparotomy, however, entails a major procedure, and in up to 12-15% cases may prove to be unproductive. Enter, diagnostic laparoscopy as a minimally invasive tool in the management of acute abdominal conditions.

Indications: The most important indication for considering a diagnostic laparoscopy may be said to be as a forerunner to a therapeutic procedure. If this therapeutic procedure can also be carried out laparoscopically, the patient derives the full advantage of using laparoscopy as a diagnostic tool in the first instance. Nevertheless, a diagnostic laparoscopy leading to a full laparotomy as a means of sorting out an intra abdominal problem should not be considered a contra indication for its use as a diagnostic procedure.

Diagnostic laparoscopy has been evaluated  for its usefulness in:

1.       Acute abdomen: Patients presenting with symptoms and signs suggestive of acute abdominal conditions like perforated  viscus, acute inflammation (such a acute cholecystitis) or intestinal obstruction have been traditionally managed by exploratory laparotomy. In recent times, there has been increasing evidence for the use of diagnostic laparoscopy as an alternative . In many instances, such as duodenal perforation, acute cholecystitis, or intra-abdominal abscess, the surgeon can easily proceed to a therapeutic procedure such as  suturing the peroforated duodenum, cholecystectomy or drainage of abscess collection. Laparoscopy is especially useful when there is radiological evidence of perforated viscus, but the involved region is not clear. For instance, in obese persons with free air under the diaphragm, it may be clinically impossible to distinguish between perforated duodenal ulcer and perforated divericutis. IN such a situation, a diagnostic laporoscopy can help settle the issue, as well as offer a repair – for a duodenal perforation. If a perforated divericutis is discovered, a much smaller incision may then suffice to exteriorize the affected segment of the bowel. In acute intestinal obstruction, the role of laparoscopy is still controversial. However, if the obstruction is found to be the result of bands or postoperative adhesions, diagnostic laparoscopy can offer a much less invasive treatment option as well.

2.       Abdominal trauma: When a patient with abdominal trauma has a positive peritoneal lavage or evidence of intra-abdominal fluid collection on CT scanning, diagnostic laparoscopy can be very useful. Identification of the involved viscus such as the spleen can allow completion of the definitive treatment as well, since laparoscopi splenectomy is eminently feasible. It should be noted, however, that diagnostic laparoscopy should only be considered in those trauma patients who are haemodynamically stable or those who respond rapidly to resuscitation. In unstable patients,  and where major vessel injury is suspected, a formal laparotomy is still the best way forward.

3.       Abdominal pain of unclear aetiology: Diagnostic laparoscopy has a definitive role in patients with acute  or chronic debilitating abdominal pain where the diagnosis is unclear despite adequate imaging. Further management of such patients will depend on the findings at laparoscopy. It is important to  note that in 10-15% cases laparoscopy may fail to yield significant diagnostic information.

4.       Suspected appendicitis: Perhaps this is the most well established indication for laparoscopy as an initial diagnostic procedure. In children, young adults and women, especially, this could spare the need for a full laparotomy. If the appendix is found to be normal, a thorough inspection of the rest of the bowel, especially to look for a Meckel’s diverticulum is mandatory. If no cause is found, the decision on whether to remove the normal looking appendix is a difficult one. This aspect should be discussed with the patient or their relatives prior to laparoscopy.

5.       Acute abdomen in an intensive care unit patient: In patients under intensive care, such as in cardiothoracic and renal wards, acute abdomen is a common cause for seeking surgical advice. In such patients with excessive morbidity, diagnostic laparoscopy spares them the need for a formal laparotomy with its attendant physiological effects, and is known to alter the clinical management in up to 50% of patients.

Procedure: As mentioned above, diagnostic laparoscopy should be carried out with the intention of extending it to a definitive procedure. Hence the set up should be as for a standard cholecystectomy or appendicectomy. Especially when used in trauma patients, adequate irrigation and suction facilities should be ensured. All arrangements for conversion to a formal laparotomy should be at hand. Since many such cases may have medicolegal implications, recording of the entire process is mandatory. The potential benefits, shortcomings, and possible complications, should be explained to the patient and their relatives, and an informed consent taken.

Limitations: In about 10-15% cases, diagnostic laparoscopy may fail to be of any help. Reported rates of conversion to formal laparotomy vary from 5- 45 %. In the presence of severe bowel distension, visualization of all areas of the abdomen may be difficult. Previous abdominal surgery, scarring, dense intra abdominal adhesions, may all limit the amount of information gained by laparoscopy. 

Complications: The potential dangers of the procedure are similar to laparoscopy in general. Bleeding, perforation of bowel or other solid viscera, undue raise in intra abdominal pressure with its consequences, and induced haemodynamic changes are all possible in the peri-operative period. Late complications such as infection, port site hernia and so on may also occur, especially in  compromised patients.

Current status: Diagnostic laparoscopy should be considered in every instance where the procedure can be used to complete the treatment of cause of acute abdomen. It should be resorted to in units well versed with such procedures, by experienced personnel.

Summary: Diagnostic laparoscopy is the latest addition to the surgeon’s armamentarium in making an accurate diagnosis when a patient presents with acute abdomen. Used judiciously, it can allow the surgeon to complete the therapeutic procedure through the same minimally interventional method, sparing the patient the need for a formal laparotomy.

References:

Isenhour JL, Marx J. Advances in abdominal trauma. Emerg Med Clin North Am. 2007 Aug;25(3):713-33

Vons C. Laparoscopy with a diagnostic aim in abdominal emergencies. Chirurgie. 1999 Apr;124(2):182-6.

Memon MA, Fitztgibbons RJ Jr. The role of minimal access surgery in the acute abdomen. Surg Clin North Am. 1997 Dec;77(6):1333-53.

Author

Dr (Col) K. M Harikrishnan

Consultant General & Laparoscopic Surgeon

Medical Director, KIMS Oman Hospital, Muscat

MBBS, MS (General Surgery), DNB. FAIS, FICS, FACS
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Brief Profile :

Dr K. M. Harikrishnan is a Consultant General Surgeon and an accomplished Laparoscopic surgeon with special interest in Gastrointestinal and Laparoscopic Surgery. He has over 25 years of experience as a surgeon and has obtained MBBS degree from Maulana Azad Medcial College, Delhi where he was awarded the University Medal for Surgery at graduation. He later served in the Indian Army for over two decades, during which he acquired a Master of Surgery degree from Armed Forces Medical College in Pune, India. Trained at All India Institute of Medical Sciences in complex Gastrointestinal Surgical procedures, he was the first surgeon from the Indian Army to be trained in Laparoscopic Surgery, and set up the department for key-hole surgery at the Armed Forces Hospital at Calcutta and Pune. He undertook specialized training in this new field of surgery on visiting scholarships to the UK and France. Later, he went to the UK where he has been working as a Consultant General and Laparoscopic Surgeon till recently. He is a Fellow of the American College of Surgeons since the last 14 years, and was one of the Founder Fellows of the Association of Surgeons of India. He is an accomplished teacher for undergraduate and postgraduate medical education from Cardiff University, UK.

Dr Harikrishnan has published extensively in reputed medical journals and has presented many erudite and award winning papers in various national and international conferences. He has organized many training worshops and CMEs as well. His special areas of interest include the use of minimally invasive surgery in gallbladder disease, appendicitis, and hernia – some of the commonest problems faced by the medical profession. He is also an expert in the management of peri anal conditions like haemorrhoids (piles).