Definitions of the levels of evidence (I, II, III) and the grades of the recommendations (A, B, C) are provided at the end of the "Major Recommendations" field.
General Recommendations for Diagnostic Laparoscopy
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. Overnight observation may be appropriate in some outpatients.
Staging Laparoscopy (SL) for Lymphoma
Technique
Patients are commonly placed at a 45-degree angle, left decubitus position. A laparoscopic hand-assisted technique is often used, especially when splenectomy is planned. The steps of SL are similar to the traditional open procedure:
- Inspection for gross abnormalities
- Core liver biopsy of each hepatic lobe and wedge biopsy of left lateral liver segment
- Laparoscopic ultrasound to search for hepatic lesions
- Splenectomy with removal of organ intact
- Lymph node sampling of the following areas: iliac, celiac, portal, mesenteric, and peri-aortic
- Lymph node excision of abnormal nodes identified on preoperative testing with application of clips at those excision areas
- Oophoropexy posterior to the uterus
Indications
- Tissue diagnosis and biopsy of intra-abdominal lymphadenopathy in the absence of peripheral lymphadenopathy, especially for non-Hodgkin's lymphoma cases and when core needle biopsy has been non-diagnostic
- Accurate staging in Hodgkin's lymphoma when staging affects decisions for appropriate treatment or prognosis
- Restaging after treatment or when recurrence is suspected
Recommendations
SL in lymphoproliferative disorders is safe and effective (Grade B). The best indication for SL in lymphoproliferative disorders may be for obtaining tissue diagnosis for non-Hodgkin lymphoma when core needle biopsy is non-diagnostic and for primary staging or even restaging in Hodgkin's lymphoma when accurate staging affects decisions for appropriate treatment and prognosis or when splenectomy is required (Grade C).
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 |
