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 Hepatocellular Carcinoma
Technique
The patient is placed in the supine position, and pneumoperitoneum is established. A 30-degree laparoscope through an umbilical port is recommended for optimal visualization of the entire liver. Additional ports can be placed in the right anterior axillary line and epigastric area as needed. A standard laparoscopic ultrasound probe is used to systematically examine the entire liver identifying all lesions suspected to be malignant. Ultrasound-guided core biopsy should be used for suspicious lesions that are unresectable or preclude curative resection. Biopsy of resectable lesions need not be performed.
Indications
Patients with primary hepatic tumors who are candidates for curative resection based on preoperative identification of size and location of disease with adequate hepatic reserve.
Recommendations
SL with laparoscopic ultrasound can be performed safely in patients with primary hepatic tumors (Grade B). Patients with primary hepatic cancers that appear resectable on preoperative imaging may benefit from SL with laparoscopic ultrasound to evaluate extent, location, and size of disease (Grade C). Selection criteria that may increase the yield and cost-effectiveness of the procedure are not currently available.
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 |
