Definitions of the levels of evidence (I, II, III) and grades of the recommendations (A, B, C) are provided at the end of the "Major Recommendations" field.
General Recommendations for Diagnostic Laparoscopy (DL)
Diagnostic laparoscopy is a safe and well tolerated procedure that can be performed in an inpatient or outpatient setting under general or occasionally local anesthesia with intravenous 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.
DL in the Intensive Care Unit (ICU)
Technique
Many studies have documented the feasibility of the procedure (Levels II, III). The most common reason that the procedure fails is the presence of severe adhesions. Although in the initial reports on DL for ICU patients the procedure was performed in the operating room, most recent studies have applied the procedure exclusively at the bedside. Local anesthesia, sedation, and occasionally paralytics have been used for the procedure at the bedside. Many patients who are breathing spontaneously require intubation before the procedure; however, the procedure has also been applied successfully in nonintubated patients. In most instances, a portable laparoscopic cart, which contains a monitor, video camera, light source, and gas supply, is used. A cut-down technique and the Veress needle technique have been used for initial access without reported untoward events. The periumbilical region is the most used site for initial access; however, concerns about intra-abdominal adhesions may dictate the use of another "virgin" site. Pneumoperitoneum has been kept at lower levels (8-12 mm Hg) by many authors due to concerns of hemodynamic compromise in already compromised patients. Nevertheless, level III evidence exists that 15 mm Hg can be used safely without significant hemodynamic or respiratory compromise with the exception of a well tolerated increase in peak inspiratory pressure. No studies have compared different insufflation pressures in ICU patients. Although most studies have used CO2 for insufflation, the use of N2O has also been described. An angled scope is used at the periumbilical trocar site for inspection of the intra-abdominal organs, including the surface of the liver, gallbladder, stomach, intestine, pelvic organs, and visible retroperitoneal surfaces along with examination of free intraperitoneal fluid. Additional (5-mm) trocars are used at the discretion of the surgeon as needed for exposure and for potential therapeutic intervention. The use of laparoscopic ultrasound has not been described in ICU patients. The duration of the procedure is short, ranging between 10 and 70 minutes, with an average duration of about 30 minutes.
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.
Recommendations
Diagnostic laparoscopy is technically feasible and can be applied safely in appropriated selected ICU patients (Grade B). The procedure should be used in critically ill patients when an intra-abdominal catastrophe is suspected but cannot be ruled out by noninvasive means and would otherwise require an exploratory laparotomy (Grade C). It should be given strong consideration in ICU patients with suspected acalculous cholecystitis or ischemic bowel, as its accuracy likely exceeds that of noninvasive studies (Grade C). On the other hand, it should be kept in mind that the procedure is unlikely to identify retroperitoneal processes. The decision to undertake DL and at which location (bedside or operating room) should be individualized and should be based on the available resources and laparoscopic expertise of the surgeon.
For details of the rationale for the procedure and its diagnostic accuracy, see the original guideline document.
Definitions:
Levels of Evidence
| Level I |
Evidence from properly conducted randomized, controlled trials |
| Level II |
Evidence from controlled trials without randomization
Or
Cohort of case-control studies
Or
Multiple time series, dramatic uncontrolled experiments
|
| Level III |
Descriptive case series, opinions of expert panels |
Scale Used for Recommendation Grading
| Grade A |
Based on high-level (level I or II), well-performed studies with uniform interpretation and conclusions by the expert panel |
| Grade B |
Based on high-level, well-performed studies with varying interpretation and conclusions by the expert panel |
| Grade C |
Based on lower-level evidence (level II or less) with inconsistent findings and/or varying interpretations or conclusions by the expert panel |
