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 Biliary Tract Tumors
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 abdominal cavity. Additional ports can be placed in the right anterior axillary line and epigastric area as needed. Careful and thorough inspection of the peritoneum, pelvis, liver surfaces, porta hepatitis, gastrohepatic ligament, and omentum should be made. A standard laparoscopic ultrasound probe may improve the yield of finding lesions in the liver and lymph node metastasis in the porta and celiac nodal areas. Biopsy specimens of peritoneal metastases, nodes suspected to be malignant, or hepatic lesions should be obtained to determine the extent of disease.
Indications
- Known or suspected gallbladder cancer without evidence of unresectable or metastatic disease
- Stage T2 or T3 hilar cholangiocarcinoma without evidence of unresectable or metastatic disease determined by preoperative imaging
Recommendations
SL can be performed safely in patients with cancers of the biliary tract and gallbladder (Grade B). SL may be used for suspected gallbladder cancers that are believed to be resectable by preoperative, high quality imaging studies (Grade B). Patients with biliary tract cancers may also benefit from SL through the identification of imaging occult disease in the peritoneum, lymph nodes, or the liver itself (Grade B); the benefit of the procedure may be maximized in patients with locally advanced cholangiocarcinoma (stage T2 and T3), as the yield of the procedure in this patient population is higher (Grade B). Laparoscopic ultrasound may improve the yield of the procedure; however, additional data are needed regarding this (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 |
