Year : 2006 | Volume
: 12 | Issue : 1 | Page : 27--30
The impact of elective diagnostic laparoscopy in chronic abominal disorders
Mohammed Hamad Al-Akeely
Department of Surgery, 37 College of Medicine, P.O. Box 2925, Riyadh 11461, Saudi Arabia
Mohammed Hamad Al-Akeely
Department of Surgery, 37 College of Medicine, P.O. Box 2925, Riyadh 11461
Objectives: Diagnostic laparoscopy has become an integral part of general surgical procedures with the recent advancements in laparoscopic technology. Since surgeons are more oriented in viewing and dissection of different intra-abdominal areas and are proficient in the definitive management of complications in the procedures, diagnostic laparoscopy may be better off in the hands of surgeons. Laparoscopy has proved to be an important tool in final minimally invasive exploration for selected medical patients with chronic abdominal disorders, the diagnosis of which remains uncertain despite employing the requisite laboratory and non-invasive imaging investigations. This retrospective study was done to evaluate the accuracy of elective diagnostic laparoscopy in patients with chronic abdominal disorders and its impact on the management of these patients.
Methods: The records of 35 patients, admitted to Riyadh Medical Complex with chronic abdominal disorders and referred to the author by physicians for elective diagnostic laparoscopy from 1999 through 2004, were evaluated for the accuracy and impact of this procedure in the further management of these patients. All 35 patients were investigated by the referring physician. Investigations included hematology, biochemistry, radiology, ascitic fluid analysis, endoscopic and imaging studies and the Mantoux test. These investigations suggested abdominal tuberculosis in 22 patients and intra-abdominal malignancy in 13 patients. They were referred for elective diagnostic laparoscopy and tissue biopsy.
Results: Diagnostic laparoscopy confirmed the diagnosis in all patients suspected of malignancy. In patients with suspected abdominal tuberculosis, the laparoscopic diagnosis and biopsy revealed tuberculosis (16 patients), liver cirrhosis (2 patients), Crohn«SQ»s disease (1 patient), and metastatic carcinoma of terminal ileum (1 patient). In 2 patients the procedure did not reveal any specific pathology. The accuracy of the preoperative investigations for those suspected to have abdominal tuberculosis was 71 %. There was 100% impact of diagnostic laparoscopy on the management of all 35 patients since, in the 2 patients with negative laparoscopy, at least tuberculosis and malignancy were excluded.
Conclusion: Diagnostic laparoscopy in the hands of surgeons proved to have an impact as an investigation technique, where the diagnosis remained uncertain after the laboratory and non-invasive investigations, of selected medical patients with chronic abdominal disorders. It is a minimally invasive procedure which has a high percentage of accuracy in diagnosis and impact in the further management of selected patients.
|How to cite this article:|
Al-Akeely MH. The impact of elective diagnostic laparoscopy in chronic abominal disorders.Saudi J Gastroenterol 2006;12:27-30
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Al-Akeely MH. The impact of elective diagnostic laparoscopy in chronic abominal disorders. Saudi J Gastroenterol [serial online] 2006 [cited 2020 Feb 21 ];12:27-30
Available from: http://www.saudijgastro.com/text.asp?2006/12/1/27/27741
The history of diagnostic laparoscopy goes back over 100 years. Gynecologists and physicians were very active in this field in terms of viewing female pelvic organs and liver respectively, in hepatic disease. Until 30 years ago, and despite the efforts of investigators in this field, diagnostic laparoscopy was not taken up by surgeons except in a few centers, mainly in Europe.  Ruddock, an American surgeon, reported 500 cases of diagnostic laparoscopy in 1930. (2] General surgeons became more interested in the field of diagnostic laparoscopy in the early 1980s after the advent of laparoscopic cholecystectomy.  Currently, diagnostic laparoscopy is getting wide acceptance as an alternative to laparotomy. This is primarily due to the growing experience and familiarity with laparoscopic surgery improvement in instrumentation as well as a high percentage of negative laparotomies.  Physicians and surgeons might have to face patients in whom the diagnosis remains uncertain despite utilizing all available laboratory and non-invasive diagnostic modalities. Diagnostic laparoscopy may help in avoiding unnecessary laparotomy, provide accurate diagnosis and help in planning the optimal therapy in these selected patients. This study details the experience of 35 patients who had elective diagnostic laparoscopy for chronic abdominal disorders in whose history clinical examination, laboratory tests and non-invasive, or even invasive, radiological investigations had failed to give accurate diagnosis.
Patients & Methods
The records of the 35 patients who were referred for elective diagnostic laparoscopy to the department of general surgery at Riyadh Medical Complex from 1999 through 2004 were reviewed retrospectively for demography, clinical presentation, laboratory tests, imaging investigations, indications and findings in diagnostic laparoscopy as well as biopsy results.
The accuracy and the impact of the procedure on the outcome were evaluated. Prior to laparoscopy, all the patients were investigated completely by the referring physicians. Various investigations included blood count, ESR, electrolytes, urea and liver function tests, The Mantoux test, and ultrasound (US) and computerized (CT) scans of the abdomen. Magnetic resonance (MR) scan was employed selectively, where indicated. Upper GI endoscopy, colonoscopy and barium meal and follow through were done in selected patients. Ascitic fluid analysis for biochemistry and cytology was performed in patients with clinical ascites. Where the accurate diagnosis could not be made despite all relevant investigations, diagnostic laparoscopy was requested for defining the pathology and obtaining tissue biopsy. No interventional radiology was available during the period under review.
Diagnostic laparoscopy was done electively under general anesthesia after preoperative anesthetic check-up. The two ports technique was used routinely employing 10 mm sub umbilical port for telescope and 5 mm port for probing, diathermy and biopsy in the relevant abdominal quadrant. An additional 5mm port was inserted only if necessary. No urinary catheter was used. A nasogastric tube was inserted during the procedure if the stomach was distended. The whole peritoneal cavity, including the pelvis, was thoroughly examined routinely. Multiple biopsies were obtained from the suspected pathology and sent for frozen section in order to confirm the adequacy of the sample.
The impact of the procedure was considered positive if the laparoscopy revealed a pathology which may be responsible for the patient's symptoms, or when the suspected pathology was excluded.
There were 11 (31%) male and 24 (69%) female patients. The age range was 14 to 90 years (mean 45 years). Twenty nine (85%) patients were more than 60 years of age. The clinical presentation of these patients included ascites in 25 patients (71%), weight loss in 19 patients (54%), abdominal pain in 18 patients (51%), anorexia in 16 patients (48%), fever in 11 patients (31%), cough in 11 patients (31%), night sweats in 6 patients (17%) and diarrhea in 4 patients (11%). The suspected preoperative diagnosis was tuberculosis in 22 patients (63%) and intra-abdominal malignancy in 13 patients (37%). Elective laparoscopy was able to establish diagnosis in 33 patients (94%) and excluded abdominal pathology in the 2 remaining patients (6%). The laparoscopic findings included ascites in 28 patients (80%), peritoneal or mental nodules in 22 patients (63%), liver nodules in 14 patients (40%), mesenteric lymph adenopathy in 3 patients (9%) and right iliac fossa (RIF) mass in 2 patients (6%). Biopsy and frozen section were done on all visible lesions. In 2 patients laparoscopy did not reveal any pathology. The liver was biopsied in these patients and revealed normal liver tissue. The mean operating time for diagnostic laparoscopy in 33 patients was 34 (+ 9.3) minutes (the 2 patients in whom the procedure was converted to formal laparotomy for definitive treatment were excluded). No patient required blood transfusion. [Table 1] summarizes the final histology on tissue samples obtained in all cases. Intra-abdominal tuberculosis and malignancy comprised the two largest groups of patients in this study. A comparison of the clinical characteristics between these two groups is presented in [Table 2]. The procedure was converted to formal laparotomy in 2 patients who had terminal ileal mass with proximal bowel loops distension. Both patients underwent right hemicolectomy. Final histology results showed Crohn's disease in one patient and adenocarcinoma in the other patient. There were no procedure-related complications.
Although laparoscopy was first described at the turn of last century, many years lapsed before evolution of instrumentation and experience allowed internal organs to be adequately viewed and biopsies to be obtained.  General surgeons were slow in adopting laparoscopy as a diagnostic technique. With the advent of laparoscopic cholecystectomy, general surgeons became more interested in other uses of laparoscopy, including its diagnostic applications.  Laparoscopy which is done by gastroenterologists differ substantially from that done by surgeons in terms of invasiveness and extent of dissection in the procedure. Gastroenterologists mainly focus on the detection of liver disease and peritoneal metastases which does not require extensive dissection of both the lesser sac and retroperitoneum with which they are not familiar.  Some patients with chronic abdominal complaints constitute a difficult group in terms of the diagnosis. The search for pathology in these patients usually entails a series of laboratory and non-invasive, or even invasive, tests and procedures.  Surgeons are sometimes consulted when a battery of relevant investigations fail to reveal the diagnosis or when a tissue diagnosis is deemed necessary for initiation of a specific therapy. , In such cases, laparoscopy provides an effective diagnostic tool avoiding a formal exploratory laparotomy. It minimizes the surgical trauma, particularly in chronically ill patients with chronic abdominal disorders, resulting in a better outcome and making a short stay possible. 
Intra-abdominal tuberculosis and malignancy remained the most common ailment in the present study.
Abdominal tuberculosis sometimes closely mimics malignancy in clinical presentation. Laboratory and radiological investigations can only suggest, but not confirm, the diagnosis. , The clinical presentation of all patients showed similarity in both groups [Table 2]. Ascites, loss of appetite, loss of weight and abdominal pain were among the common features of tuberculosis and malignancy. Ascitic fluid analysis has been reported to have poor diagnostic yield. , Ascitic fluid was excudative in most of the patients and the cytology was positive for malignancy in only one patient from the malignancy group in this study. Although the Mantoux test is considered important in patients with suspected tuberculosis, it is reported to be positive in 30-78% of tuberculous patients.  In the present study 12 out of 16 patients (75%) with abdominal tuberculosis had a positive The Mantoux test. The final histological diagnosis in these patients revealed that diagnostic laparoscopy confirmed the diagnosis in all 13 patients with suspected intra-abdominal malignancy (100% accuracy). Diagnostic laparoscopy in the present study was able to establish diagnosis in 33 patients (94%), and excluded suspected pathology in the remaining two patients. So the procedure had a positive impact on the management in all studied patients. The incidence of tuberculous peritonitis in hospitalized patients in Saudi Arabia has been reported to be 3%. , Laparoscopic findings in tuberculous abdomen are omental, peritoneal and/or liver nodules with or without ascites.  Similar findings may be found in intra-abdominal malignancy. Laparoscopy and biopsy are accurate in differentiating this potentially treatable disease from potentially fatal malignancies. Negative laparoscopic exploration in patients suspected to have malignancy can be regarded a 'useful outcome', as this provides reassurance to patient and physician and avoids the performance of further expensive diagnostic tests.  Laparoscopy can be used safely to provide tissue samples in suspected cases of lymphoma. 
It should be considered when percutaneous biopsy is either technically not possible or inadequate to make therapeutic decisions. Non-invasive imaging may misjudge the stage of lymphoma, while laparoscopy can correctly identify the stages of abdominal lymphoma.  In the present study there were three patients of lymphoma suspected preoperatively by CT scan which were technically difficult for image-guided biopsies preoperatively.
Diagnostic laparoscopy and biopsy established the diagnosis in all these cases.
Diagnostic laparoscopy has an additional advantage of providing a definitive treatment in cases with unsuspected lesions. One of our patients, suspected of having abdominal tuberculosis, was found to have a mass lesion in the terminal ileum and another patient had a tumor in the terminal ileum. Both patients had proximal distended bowl loops and both underwent open right hemicolectomy. The biopsy established the diagnosis of Crohn's disease in one patient and adenocarcinoma in the other.
Despite its invasive nature, diagnostic laparoscopy has a reasonable safety record. Bowel perforation and hemorrhage are reported as examples of possible serious complications.  Careful technique can avoid these complications.
Laparoscopy is a safe diagnostic modality. It is useful to establish diagnosis or exclusion of suspected abdominal pathology whenever chronic abdominal complaints remain undiagnosed.
It also provides an opportunity for definitive treatment by laparoscopy or open surgery in unsuspected lesions.
|1||Sackier JM, Berci G, Paz-Partlow M. Elective diagnostic laparoscopy. Am J Surg 1991; 161: 326-330.|
|2||Ruddock JC. Peritoneoscopy: a critical clinical review. Surg Clin North Am 1957; 37: 1249-1260. |
|3||Cuschieri A. The spectrum of laparoscopic surgery. World J Surg 1992;16:1089-1097.|
|4||Schrenk P, Woisetschlager R, Wayand WU, Rieger R, Sulzbacher H. Diagnostic laparoscopy: a survey of 92 patients. Am J Surg1994; 168: 348-351.|
|5||Boyd Jr. WP, Nord HJ. Diagnostic laparoscopy. Endoscopy 2000; 32: 153-158.|
|6||Schneider ARJ, Eickhoff A, Arnold JC, Reimann JF. Diagnostic laparoscopy. Endoscopy 2001; 33: 55-59.|
|7||Easter DW, Cuschieri A, Nathanson LK, Lavelle-Jones M. The utility of diagnostic laparoscopy for abdominal disorders: audit of 120 patients. Arch Surg 1992; 127: 379-383.|
|8||Luo K, Li JS, Li LT, Wang KH, Shun JM. Operative stress and energy metabolism after laparoscopic cholecystectomy compared to open surgery. World J Gastroenterol 2003; 9: 845-850.|
|9||Hossain J, Al-Aska AK, Al Mofleh I. Laparoscopy in tuberculous peritonitis. J R Soc Med 1992; 85: 89-91.|
|10||Lal N, Soto-Wright V. Peritoneal tuberculosis colon diagnostic options. Infact Dis Obstet Gynecol 1999; 7: 244-247.|
|11||Roskos M, Popp MB. Laparoscopic diagnosis and management of malignant ascites. Surg Laparosc Endosc Percutan Tech 1999; 9: 365-368.|
|12||Froude JRL, Kingston M. Extrapulmonary tuberculosis in Saudi Arabia. A review of 162 cases. King Faisal Specialist Hospital Med J 1982; 2: 85-90.|
|13||Yasway MI, Karawi MAL, Mohammed AE. Alimentary tract tuberculosis. A continuing challenge to gastroeneterologists. Report of 55 cases. J Gastroenterol Hepatol 1987; 2: 137-147.|
|14||Mann GB, Conlon KC, LaQagalia M, Dougherty E, Moskowitz CH, Zelenetz AD. Emerging role of laparoscopy in the diagnosis of lymphoma. J Clin Oncol 1998; 16: 1909-1915.|