INTRODUCTION: Early diagnosis and treatment of intraabdominal illness is a challenge in the ICU patient and any delay may have devastating consequences. The aim of this study is to study the role of laparoscopy as a therapeutic tool in the ICU. There are a few studies in the literature describing laparoscopy as a diagnostic tool, but there is only one study describing a single case where laparoscopy was used as a therapeutic tool. We describe our experience with the use of bedside laparoscopy as a therapeutic tool in ICU patients with intraabdominal illness.
METHODS AND PROCEDURES: During a 24 month period, 13 patients (mean age 69 years), intubated and mechanically ventilated, underwent a therapeutic laparoscopy procedure in the ICU. In these patients diagnostic laparoscopy was performed initially and was subsequently converted to a therapeutic laparoscopic procedure at the bedside. Hemodynamic parameters (central venous pressure [CVP], mean arterial pressure [MAP]), ABGs, and respiratory parameters were monitored throughout the entire laparoscopic procedure. These patients were heavily sedated and required hemodynamic support. The ASA, APACHE, and SOFA were documented on the day of the procedure.
RESULTS: Of the 13 patients who underwent a therapeutic laparoscopy procedure at the bedside, 8 patients had gallbladder related disease (5 acalculous cholecystitis, 2 empyema, 1 gangrene of the fundus). Six of these patients went on to have a therapeutic procedure at the bedside in the ICU (5 patients had a laparoscopic cholecystectomy and 1 patient a laparoscopic cholecystostomy). Of the remaining 5 patients, 2 patient was found to have a cirrhotic liver with intraabdominal ascites and drains were placed. Periappendyceal inflammation (Plastron) was found in one patient and the abdomen was irrigated and drains placed. Bile leakage from the cystic stump was found in another patient who was admitted after a cumbersome cholecystectomy, clips were applied, drains placed, and the abdomen irrigated. The last patient was found to have murky fluid intraabdominally and on further inspection, a perforation of the antrum was noted. The perforation was sutured with an omental patch and the abdomen copiously irrigated. Of all the parameters recorded during this study only the central venous pressure during laparoscopy was higher and this was statistically significant (p < 0.05). Five patients in this study succumbed despite intensive medical therapy. Post mortem exam was performed in 3 patients; in the remaining 2 patients, post mortem was unobtainable because of lack of consent from the relatives. The clinical course and post mortem exam suggested that the cause of death was unrelated to any intraabdominal process or the laparoscopic procedure.
CONCLUSIONS: The present study shows that the laparoscopy in the ICU has potential as a therapeutic tool. The complications that were observed during laparoscopy were of minor importance and did not influence the morbidity and mortality. We believe that laparoscopy is an accurate and time efficient bedside therapeutic tool that can be performed safely in certain critically ill patients who are too ill and unstable to be transported to the operating room. A greater effort should be made to incorporate laparoscopy as a therapeutic tool in the ICU.
Program Number: P427