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Table of Content - Volume 19 Issue 3 - September 2021
A study of efficacy of diagnostic laparoscopy as an investigative and therapeutic modality in the diagnosis and management of abdominal pathology
Anil S Degaonkar1, Kiran D Ahire2*, Ashish R Chavan3
1Associate professor, 2Junior Resident, 3Assistant professor, Under Department of general surgery, Dr SCGMC Vishnupuri Nanded, Maharashtra, INDIA.
Abstract Background: Diagnostic laparoscopy is a minimally invasive surgery for the diagnosis of a medical ailment. The procedure allows the direct visual examination of intra-abdominal organs including large surface area of the liver, gall bladder, spleen, peritoneum, pelvic organs and retroperitoneum. Aim and objective: To study the efficacy of diagnostic laparoscopy as an investigative and therapeutic modality in the diagnosis and management of patients with abdominal pathology. Methodology: Present study was a Prospective descriptive study carried out on 50 patients with nonspecific abdominal pain where other clinical symptoms and investigations were not conclusive. Data was collected with pre tested questionnaire. Data included demographic data, clinical history, clinical examination findings and reports of investigations. All surgeries were carried out under general anaesthesia. The surgical procedure carried out were depending on the intra operative findings and as per indications which ranged from biopsy from suspicious lesions to adhesiolysis to appendectomy. Results and discussion: out of total 50 patients, 28 patients 56% of the study population was males. 23 patients had history of Right iliac fossa pain. 15 patients 30 % of the patients had a previous history of abdominal surgeries. The most common finding at laparoscopy in our study was subacute intestinal obstruction Adhesive17 patients (34%) followed by appendicitis in 10 cases 14.28 %. 3 cases 6% required conversion to laparotomy. In 47 cases 96% unnecessary laparotomy avoided. Key Word: diagnostic laparoscopy.
INTRODUCTION Diagnostic laparoscopy is a minimally invasive surgical procedure that allows the visual examination of the intra-abdominal organs in order to detect pathology. Diagnostic laparoscopy was first introduced in 1901, when the German surgeon George Kelling performed a Peritoneoscopy in a dog which was called “Celioscopy”. Diagnostic laparoscopy is one of the few investigations available that could be used to determine the exact cause of surgical pathology. 1 Chronic abdominal pain is a common complaint which is difficult to manage by both physician and surgeon. Chronic abdominal pain of unknown origin, abdominal distention, vomiting, constipation, represents a significant problem in surgical patients. Such patients are most difficult to treat without diagnosis. In some cases even series of investigations does not reveal the causes of pathology. Due to improvements in instrumentation and greater experience with diagnostic and therapeutic laparoscopy, the procedure is no longer limited to visualization. All strategies for the management of abdominal pathology underline the need for an interdisciplinary approach to diagnosis and procedure. This requires focussed and intelligent use of efficient diagnostic tools. Diagnostic laparoscopy may be a key to solve the diagnostic dilemma of non-specific abdominal pathology. Furthermore; it allows not only direct inspection of the abdominal cavity, but also surgical intervention if needed. 2 An accurate diagnosis is an important first step to determine the correct treatment for pain resolution. Although laparoscopy is very frequently used by surgeons in a wide spectrum of surgical procedures all over the world, its utility as a diagnostic procedure for abdominal pathology was not favoured initially, either due to lack of data on its effectiveness as a diagnostic modality, lack of training or expertise amongst surgeons, and Lack of awareness among both doctors and patients. 3 Despite new x-ray techniques, or scan, and ultrasound, the diagnosis of pain abdomen can be difficult at times, so far, the cost effective non- invasive method of diagnosis is ultrasound, but that is not reliable as it is operator dependent. Next modality is CT Scan which is costly and not available in all the hospitals. History and physical examination will generally lead to correct diagnosis. Diagnostic laparoscopy when compared to open laparotomy is better in the absence of adhesions where whole of peritoneal cavity can be visualized but in case of retro peritoneal lesions, due to lack of tactile sensations the lesion cannot be palpated which is possible by open laparotomy. 4 The procedure allows rapid and thorough inspection of whole peritoneal cavity and pelvic cavity and paracolic gutter that is not possible with the open approach. Diagnostic Laparoscopy is an emerging tool in diagnosis of abdominal pathology and is therefore nowadays recommended and accepted worldwide. Laparoscopic surgeries are quiet common today than diagnostic laparoscopy , The diseases of peritoneum, pelvis require nothing less than direct visual confirmation of pathology, this world provide the most definitive diagnosis possible , there by specific therapy can be given to patients. The purpose of current study is to determine the efficacy of diagnostic laparoscopy on patient with abdominal pathology. Additionally, a negative laparoscopic examination potentially would avoid the morbidity and unnecessary laparotomy in this group. Hence this study was conducted to see the efficacy of diagnostic laparoscopy as an investigative and therapeutic tool. Aim and objective: To study the efficacy of diagnostic laparoscopy as an investigative and therapeutic modality in the diagnosis and management of patients with abdominal pathology MATERIALAND METHODS Present study was a Prospective descriptive study carried out at a tertiary health care centre over a period of 2 years. Study population was 50 patients with nonspecific abdominal pain where other clinical symptoms and investigations were not conclusive. Inclusion Criteria: 1. Patients with Chronic pain abdomen of uncertain etiology and conditions which are unexplained by other investigation and clinical symptom. 2. Patients with Age group of >15 years. Exclusion Criteria: 1. Patients with Inability to tolerate pneumoperitoneum or general anaesthesia. 2. Patients with Uncorrected coagulopathy. 3. Patients with Generalised peritonitis. 4. Patients with Haemodynamic instability. 5. Patients with Mechanical or paralytic ileus.6. Patients with Acute pain abdomen. Study was approved by ethical committee of the institute. A valid written consent was taken from the patients after explaining study to them. Data was collected with pre tested questionnaire. Data included demographic data, clinical history, clinical examination findings and reports of investigations. A detailed history was taken from the patients as per the proforma. Through clinical examination was done. The recorded data included particulars of the patient, duration of illness, site of abdominal pain, other associated symptoms such as vomiting or fever, per abdomen findings past history of surgical explorations, investigations. Subsequently the intra operative findings, therapeutic/ diagnostic intervention done, complications during the intra and post operative period and the relief from the pain were recorded. All surgeries were carried out under general anaesthesia. All patients had a Ryle‟s tube inserted and bladder catheterized prior to anaesthesia. Pneumoperitoneum was created using Hasson‟s technique. A 10mm umbilical camera port was inserted and two lateral 5mm ports depending on the organ of interest and the suspected pathology. The sites of port insertion varied depending on the presence or absence of previous abdominal surgery scars. Diagnostic laparoscopy of the abdomen was carried out carefully inspecting the entire visceral contents of the abdomen for any pathology. Starting from the liver, the gall bladder, anterior surface of the stomach, large intestine, entire length of small intestine with particular emphasis on appendix and terminal ileum, anterior surfaces of the retroperitoneal organs, uterus, fallopian tubes and ovaries and peritoneal surface. Adhesions between the bowel loops or to the anterior abdominal wall was also looked for. The surgical procedure carried out were depending on the intra operative findings and as per indications which ranged from biopsy from suspicious lesions to adhesiolysis to appendectomy. All the ports were closed using absorbable suture materials at the end of the procedure. Data was analysed with appropriate statistical tests.
RESULTS In our study, maximum patients were from the age group of 15-30 years (36%) followed by 31-45 years (28%). 20% of the patients were from the age group of 46-60 years and 14% were from 61-75 years. Patients from the age group 76-90 years were 2%. (table1) Out of 50 cases, 28 cases (56%) were male and 22 cases (44%) cases were female. Total 50 cases were studied out of which 23 cases (46) % had Right iliac fossa pain while 13 cases (26 %) had diffuse abdominal pain, 7 cases (14%) had epigastric pain. In our study, we found 36% cases were having fever. Out of total 50 cases, 15 (30%) had past history of surgery. 50 cases studied out of which 23 cases (46 %) cases having RIF tenderness, 13 cases (26 %) cases having diffuse tenderness, 7 cases (14 %) cases having epigastrium tenderness, (umbilicus, Rt hypochondrium and hypogastrium tenderness in 4 % cases) in left hypondrium in 2 % cases .out of total 50 cases, 26 (52 %) cases had history of abdominal guarding, 58 % cases shows localised guarding and 42 % shows diffuse guarding. Fig 1 shows 50 cases were studied out of which 17 (34 %) cases diagnosed as subacute intestinal obstruction, 10 (20 %) cases diagnosed as appendicitis, 8 (16 %) as abdominal kochs which started on AKT after diagnosis, 5 cases of Ca stomach, 2 cases each of Haemoperitonium and sealed off intestinal perforation peritonitis, Rt. ovarian cyst, 1 case of mesenteric cyst, 1 case of mesenteric lymphadenopathy, 1 cases of diaphragmatic hernia, and 1 case of ca colon. Out of 50 cases were operated out of which 17(34 %) cases undergo laparoscopic adhenolysis, 8 (16 %) cases laparoscopic appendicectomy, 2 (4 %) cases laparoscopic adhenolysis with appendicectomy, in 12 (24 %) cases biopsy with ascitic fluid analysis done, in 2 cases laparoscopic Rt. ovarian cyst excision, in 1 laparoscopic mesenteric cyst excision, and 4 (8%) cases does not require any inetervention (out of this 3 patients required exploratory laparotomy). 50 cases were studied out of which only 3 (6 %) cases require conversion laparoscopy to laparotomy, in 47 (94%) cases unnecessary laparotomy avoided. In our study, 10 (20 %) had post operative complications, 8 (16 %) cases had post laparoscopy fever which is managed by antibiotics and 2 (4 %) cases had port site infection.
Table 1: Distribution of patients of abdominal pathology according to age
Table 2: Distribution of patients of abdominal pathology according to site of pain
Table 3: Distribution of patients of abdominal pathology according to site of tenderness
Figure 1: Distribution of patients of abdominal pathology according to diagnostic laparoscopy diagnosis
Table 4: Distribution of patients of abdominal pathology according to laproscopic procedure
Figure 2: Distribution of cases according conversion rate into laparotomy
DISCUSSION During medical practice in spite of lots of investigation, no pathological condition is found in abdomen, this is common problem facing practising surgeons, In this condition diagnostic laparoscopy helps direct visualisation of abdominal organs and definitive surgery can be done laparoscopically if required , unnecessary laparotomy is avoided. In this study there were 28 males and 22 female patients in the study. Most common age group involved in this study is 15 to 30 yrs. In a study involving 34 patients by Klingensmith et al., the majority were women (85%). The most common average age group involved in this study is (21-35 years). 5 All the above studies show that the female sex was more commonly affected abdominal pathology contrast to our study male patient affected more, and the average age at presentation in our study is same in most of the study. In this study 50 cases were studied out of which 23 cases (46 %) had Right iliac fossa pain while 13 cases (26%) had diffuse abdominal pain, 7 cases (14%) had epigastric pain, from this finding it can be said that more localised the pain greater the probability to have an organic basis for it, and unlikely for it to be merely functional. This has not been described in literature. In our study of 50 patients, 15 patients had previous history of abdominal surgery. In a study by Klingensmith et al. involving 34 patients, most of the patients had previous history of abdominal surgery. 5 In this study 50 cases were studied out of which 17 (34%) cases diagnosed as subacute intestinal obstruction , 10 (20%) caeses diagnosed as appendicitis , 8 (16%) as abdominal kochs which started on AKT after diagnosis ,5 cases of Ca stomach , 2 cases each of Haemoperitonium and sealed off intestinal perforation peritonitis , Rt ovarian cyst , 1 case of mesenteric cyst , 1 case of mesenteric lymphadenopathy , 1 cases of diaphragmatic hernia, and 1 case of ca colon. Adhesion was found in 17 cases and underwent laparoscopic adhenolysis, and had relief of symptoms and most of patients discharge on 2 or 3rd day. Lavonius M et al. in their study of laparoscopy for chronic abdominal pain in 46 patients reported post operative adhesions in 63% of cases. 6 In a study by Klingensmith et al. involving 34 patients, 56% of them underwent adhesiolysis.5 In a study by Vafa Shayani et al. involving 18 cases, laparoscopic adhesiolysis resulted in a 77.8% cure rate from chronic abdominal pain. 7 In a study by Dunker S et al. laparoscopic adhesiolysis resulted in a positive outcome in more than 50% of patients.8 10 cases 20 % of patients in our study were diagnosed to have appendicitis. This is still justifiable because it makes the diagnosis of appendicitis less likely if the patient complains of similar pain in the future. Laparoscopy is a useful technique for the diagnosis and treatment of abdominal pain even if the appendix is normal on inspection. 9 In a study by Onders RP and Mittendorf EA18 involving 70 patients, appendiceal pathology was detected in 7.14% of cases. 10 In our study, 8 cases diagnosed as abdominal kochs lymphnode node biosy ascitic fluid for analysis taken and after confirmation AKT started in these patients. 2 cases diagnosed as haemoperitonium, with liver laceration they had history of abdominal trauma 15 days back, only laparoscopic aspiration of intrabdominal fluid done after diagnostic laparoscopy and unnecessary laparotomy avoided in these patients. 2 cases of Peforation peritonitis with sealed of intestinal perforation diagnosed on diagnostic laparoscopy, aspiration of abdominal contents done with higher antibiotics patients managed conservatively. 5 patients diagnosed as ca stomach out of which one is opearable so laparotomy followed by Distal gastrectomy with gastrojejunostomy done and 4 cases are at non operable state after biosy they send for chemoradiotherapy. Out of 50 cases were operated out of which 17 (34%) cases undergo laparoscopic adhenolysis , 8 (16%) cases laparoscopic appendicectomy, 2 (4%) cases laparoscopic adhenolysis with appendicectomy , in 12 (24%) cases biopsy with ascitic fluid analysis done , in 2 cases laparoscopic Rt ovarian cyst excision , in 1 laparoscopic mesenteric cyst excision, and 4 (8%) cases does not require any inetervention ( out of this 3 patients required exploratory laparotomy, 1 case of ca stomach distal gastrectomy and gastrojejunostomy done, 1 case diagnosed as ca colon, Rt hemicolectomy done , 1 case diagnosed as diaphragmatic hernia In which diaphragmatic hernia, mesh repair done ), This shows that how tremendously useful laparoscopy could be in avoiding an open surgery in most of cases. In this study 50 cases were studied out of which only 3(6%) cases require conversion laparoscopy to laparotomy, in 47(94%) cases unnecessary laparotomy avoided, patient is also satisfied with minimum damage. The high laparotomy avoidance rate and specificity for certain pathologies was mainly achieved by optimal visualisation of the whole abdomen and pelvic by the method of minimal invasive surgery. This method is generally accepted as being less traumatic than open surgery, since chance of adhesion formation are less likely and significant complication of wound infection can be avoided.
CONCLUSION Laparoscopy has an effective diagnostic accuracy and therapeutic efficacy in the management of patients who present to us with abdominal complaints.
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