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  SAGES Society of American Gastrointestinal and Endoscopic Surgeonshttp://www.sagescms.org Guidelines for Diagnostic Laparoscopy Preamble These diagnostic laparoscopy guidelines are a series of systematically developed statements toassist surgeons’ (and patients’) decisions about the appropriate use of diagnostic laparoscopy(DL) in specific clinical circumstances. The statements included in this guideline are the productof a systematic review of published work on the topic, and the recommendations are explicitlylinked to the supporting evidence. The strengths and weaknesses of the available evidence aredescribed and expert opinion sought where the evidence is lacking. This is an update ofprevious guidelines on this topic (SAGES publication #0012; last revision 2002) as newinformation has accumulated. Disclaimer Clinical practice guidelines are intended to indicate the best available approach to medicalconditions as established by a systematic review of available data and expert opinion. Theapproach suggested may not necessarily be the only acceptable approach given the complexityof the healthcare environment. These guidelines are intended to be flexible, as the surgeonmust always choose the approach best suited to the patient and to the variables at the momentof decision. These guidelines are applicable to all physicians who are appropriately credentialedregardless of specialty and address the clinical situation in question.These guidelines are developed under the auspices of SAGES, the guidelines committee andapproved by the Board of Governors. The recommendations of each guideline undergomultidisciplinary review and are considered valid at the time of production based on the dataavailable. New developments in medical research and practice pertinent to each guideline arereviewed, and guidelines will be periodically updated. Clinical Application Diagnostic laparoscopy is minimally invasive surgery for the diagnosis of intra-abdominaldiseases. The procedure enables the direct inspection of large surface areas of intra-abdominalorgans and facilitates obtaining biopsy specimens, cultures, and aspiration. Laparoscopicultrasound can be used to evaluate deep organ parts that are not amenable to inspection.Diagnostic laparoscopy not only facilitates the diagnosis of intra-abdominal disease but alsomakes therapeutic intervention possible. Literature Review Methods A large body of literature about DL exists. The many clinical situations where DL has beenapplied, adds complexity to the analysis of the literature. Our systematic literature search ofMEDLINE for the period 1995-2005, limited to English language articles, identified 663 relevantreports. The search strategy is shown in Figure 1  at the end of this document. Using the same  1 / 8  SAGES Society of American Gastrointestinal and Endoscopic Surgeonshttp://www.sagescms.org strategy, we searched the Cochrane database of evidence-based reviews and the Database ofAbstracts of Reviews of Effects (DARE), which identified an additional 54 articles. Thus, a totalof 717 abstracts were reviewed by three committee members (DS, WR, LC) and divided into thefollowing categories:1.Randomized studies, metaanalyses, and systematic reviews2.Prospective studies3.Retrospective studies4.Case reports5.Review articlesRandomized controlled trials, metaanalyses, and systematic reviews were selected for furtherreview along with prospective and retrospective studies that included at least 50 patients;studies with smaller samples were reviewed when other available evidence was lacking. Themost recent reviews were also included. All case reports, old reviews, and smaller studies wereexcluded. According to these exclusion criteria, 169 articles were reviewed by the threecommittee members (DS, WR, LC).To maximize the efficiency of the review, the articles were divided in the following subjectcategories:1.Staging laparoscopy for cancer1.Esophageal cancer2.Gastric cancer3.Pancreatic and periampullary cancers4.Liver cancer5.Biliary tract cancer6.Colorectal cancer7.Lymphoma2.Diagnostic laparoscopy for acute conditions1.Acute abdomen2.Trauma3.ICU3.Diagnostic laparoscopy for chronic conditions1.Chronic pelvic pain and endometriosis2.Liver disease (including cirrhosis)3.Infertility4.Cryptorchidism5.Other4.Other (general reviews, complications, etc.)The reviewers graded the level of evidence of each article and manually searched thebibliographies for additional articles that may have been missed by our search. Any additionalrelevant articles (n=33) were included in the review and grading. A total of 140 graded articlesrelevant to this guideline were included in this review. Based on the reviewer grading of allarticles, we devised the recommendations included in these guidelines.  2 / 8  SAGES Society of American Gastrointestinal and Endoscopic Surgeonshttp://www.sagescms.org Levels of Evidence Level I - Evidence from properly conducted randomized, controlled trialsLevel II - Evidence from controlled trials without randomization Cohort or case-control studiesMultiple time series dramatic uncontrolled experimentsLevel III - Descriptive case series, opinions of expert panels General Recommendations Diagnostic laparoscopy is a safe and well tolerated procedure that can be performed in aninpatient or outpatient setting under general or occasionally local anesthesia with IV sedation incarefully selected patients. Diagnostic laparoscopy should be performed by physicians trained inlaparoscopic techniques who can recognize and treat common complications and can performadditional therapeutic procedures when indicated. During the procedure, the patient should becontinuously monitored, and resuscitation capability must be immediately available.Laparoscopy must be performed using sterile technique along with meticulous disinfection of thelaparoscopic equipment. Overnight observation may be appropriate in some outpatients. Thereare unique circumstances when office-based DL may be considered. Office-based DL shouldonly be undertaken when complications and the need for therapeutic procedures through thesame access are highly unlikely. 1) Diagnostic Laparoscopy in the ICU Rationale for the Procedure A number of reports have described the use of DL in ICU patients. The main argument for theuse of DL in ICU patients has been for the diagnosis of suspected intra-abdominal pathology incritically ill patients without the need for transport to the operating room with its potentialcomplications. Furthermore, such an approach allows for the uninterrupted treatment of the ICUpatient and may minimize the cost of the intervention. Technique Many studies have documented the feasibility of the procedure (levels II, III) [1-10] . The mostcommon reason that the procedure fails is the presence of severe adhesions. Although in theinitial reports on DL for ICU patients the procedure was performed in the operating room, mostrecent studies have applied the procedure exclusively at the bedside. Local anesthesia,sedation, and occasionally paralytics have been used for the procedure at the bedside. Manypatients who are breathing spontaneously require intubation before the procedure; however, theprocedure has also been applied successfully in nonintubated patients. In most instances, aportable laparoscopic cart, which contains a monitor, video camera, light source, and gassupply, is used. A cut-down technique and the Veress needle technique have been used forinitial access without reported untoward events. The periumbilical region is the most used sitefor initial access; however, concerns about intra-abdominal adhesions may dictate the use ofanother “virgin” site. Pneumoperitoneum has been kept at lower levels (8-12 mm Hg) by many  3 / 8  SAGES Society of American Gastrointestinal and Endoscopic Surgeonshttp://www.sagescms.org authors due to concerns of hemodynamic compromise in already compromised patients.Nevertheless, level III evidence exists that 15 mm Hg can be used safely without significanthemodynamic or respiratory compromise with the exception of a well tolerated increase in peakinspiratory pressure. No studies have compared different insufflation pressures in ICU patients.Although most studies have used CO 2  for insufflation, the use of N 2 O has also been described.An angled scope is used at the periumbilical trocar site for inspection of the intra-abdominalorgans, including the surface of the liver, gallbladder, stomach, intestine, pelvic organs, andvisible retroperitoneal surfaces along with examination of free intraperitoneal fluid. Additional(5-mm) trocars are used at the discretion of the surgeon as needed for exposure and forpotential therapeutic intervention. The use of laparoscopic ultrasound has not been described inICU patients. The duration of the procedure is short, ranging between 10 and 70 minutes, withan average duration of about 30 minutes. Indications The main indication for DL in the ICU has been unexplained sepsis, systemic inflammatoryresponse syndrome, and multisystem organ failure. In addition, the procedure has been usedfor abdominal pain or tenderness associated with other signs of sepsis without an obviousindication for laparotomy (i.e., pneumoperitoneum, massive gastrointestinal bleeding, smallbowel obstruction), fever and/or leukocytosis in an obtunded or sedated patient not explained byanother identifiable problem (such as pneumonia, line sepsis, or urinary sepsis), metabolicacidosis not explained by another process (such as cardiogenic shock), and increasedabdominal distention that is not a consequence of bowel obstruction. Contraindications (Absolute or Relative) Patients unable to tolerate pneumoperitoneum or who are so sick that there is norealistic chance of survival even if a “treatable” intra-abdominal process were foundPatients with an obvious indication for surgical intervention such as a bowel obstructionor perforated viscusPatients with an uncorrectable coagulopathy or uncorrectable hypercapnia >50 torrPatients with a tense and distended abdomen (i.e., clinically suspected abdominalcompartment syndrome)Patients with abdominal wall infection (e.g., cellulitis, soft tissue infection, open wounds)Patients with extensive previous abdominal surgery with multiple incisional scars or aftera laparotomy within the last 30 days Risks Delay in the diagnosis and treatment of patients if the procedure is false negativeMissed pathology and its associated complicationsProcedure- and anesthesia-related complications Benefits  4 / 8
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