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 Colorectal Cancer
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. A standard laparoscopic ultrasound probe is often used to systematically examine the entire liver, identifying all lesions suspected to be malignant. The ultrasound examination should also include the porta hepatitis and celiac lymph nodes. Ultrasound-guided biopsy of peritoneal, lymph node, and unsuspected liver lesions should be obtained.
Indications
Patients with resectable liver metastases from colorectal cancer but with no evidence of extrahepatic disease on non-invasive imaging.
Recommendations
SL can be performed safely in patients with hepatic metastasis of colorectal cancer (Grade B). Patients who are candidates for liver resection for isolated colorectal hepatic metastases may benefit from SL with laparoscopic ultrasound. Patients who are the most likely to benefit from this procedure are those who have more than two poor outcome factors as described by the Clinical Risk Score (discussed previously) (Grade B). To decrease cost and minimize treatment delay, the procedure should be followed by laparotomy and resection with curative intent when SL is negative for metastatic disease (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 |
