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
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. 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.
DL for Acute Abdominal Pain
Technique
Many studies have documented the feasibility and safety of the procedure using general anesthesia in patients with acute abdominal pain (Level I-III). Severe abdominal distention due to bowel obstruction usually precludes successful deployment of the technique due to inadequate working space. In addition, the presence of multiple adhesions can limit its use. Conversion rates to an open procedure have ranged widely and are usually the result of intra-abdominal adhesions, inability to visualize all structures, technical difficulties, and surgeon inexperience.
For initial access, a cut-down technique and the Veress needle technique have been described. Access-related complications have been reported, and some authors recommend the use of the cut-down technique to prevent untoward events, especially in the case of abdominal distention or prior abdominal operations. Nevertheless, no studies have compared these two access techniques in patients with acute abdominal pain. The periumbilical region is the usual site for initial access; however, previous midline incisions may dictate the use of another "virgin" site. While most studies describe insufflation pressures of 14-15 mm Hg, some authors have used lower levels (8-12 mm Hg) due to concerns of hemodynamic compromise with higher pressures. Nonetheless, no untoward effects of higher pressures have been described, and no comparative studies using different insufflation pressures exist. 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 for free intraperitoneal fluid. Additional (5-mm) trocars may be used at the discretion of the surgeon to optimize exposure or provide therapeutic intervention. The use of laparoscopic ultrasound has not been described in this population.
Indications
- Unexplained acute abdominal pain of less than 7 days duration after initial diagnostic workup
- As an alternative to close observation for patients with nonspecific abdominal pain which is the current practice in the management of these patients
Recommendations
DL is technically feasible and can be applied safely in appropriately selected patients with acute non-specific abdominal pain (Grade B). The procedure should be avoided in patients with hemodynamic instability and may have a limited role in patients with severe abdominal distention or a clear indication for laparotomy (Grade C). The procedure should be considered in patients without a specific diagnosis after appropriate clinical examination and imaging studies (Grade C). Based on the available evidence, an invasive procedure cannot be recommended before other non-invasive diagnostic options have been exhausted.
DL may be superior to observation for nonspecific abdominal pain; however, the available evidence is mixed, making it difficult to provide a firm recommendation. In addition, DL may be preferable to exploratory laparotomy in appropriately selected patients with an indication for operative intervention provided that laparoscopic expertise is available (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 |
