Definitions of the grades of the recommendations (A, B, C) and the levels of evidence (I, II, III) are provided at the end of the "Major Recommendations" field.
General Recommendations for Diagnostic Laparoscopy
Diagnostic laparoscopy (DL) 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. DL 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.
DL Liver Diseases
Technique
Preoperatively coagulopathy should be corrected to the extent possible. The procedure is usually performed under general anesthesia; however, conscious sedation has also been described. The first trocar is usually placed in the periumbilical area paying attention to avoid potential varices. The position of other trocars is based on the liver lesions under evaluation or potential biopsy sites. A wedge biopsy can be taken with a cupped forceps through a 10-mm trocar at the umbilicus with a second 5-mm trocar below the liver edge to accommodate the camera. The same trocar can then be used to coagulate the biopsy site. For liver exploration, two 5-mm trocars in addition to the umbilical trocar may be used for tissue manipulation. Percutaneous needle biopsy specimens may be obtained under direct visualization and to confirm hemostasis. Hemostasis may be obtained with direct compression or coagulation. Laparoscopic ultrasound may be used to identify discrete liver lesions, confirm appropriate biopsy method, and avoid venous structures. The procedure is feasible in at least 98% of high risk patients, and biopsies are possible in 93-95% of patients (Level III). Ninety-seven percent of laparoscopic liver biopsies are an adequate size for diagnostic histological evaluation (Level III).
Indications
- Evaluation of liver diseases after nondiagnostic radiologic examination
- Grading of severity of illness particularly in cases of cirrhosis
- Biopsy in patients with coagulopathy or for lesions difficult to access percutaneously
- Staging of hepatoma (?)
Recommendations
DL can be performed safely in patients with liver disease (Grade B). It should be considered for the diagnosis or the grading of liver disease when other less invasive modalities fail to provide a diagnosis or are associated with a high bleeding risk in coagulopathic patients (Grade C). DL may be safer than percutaneous biopsy in patients with coagulopathy; however, further study is needed to confirm this.
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 |
