Ahmad Mirza, Ian Welch. The University Hospital of South Manchester, Manchester, UK
In emergency surgical practice the use of diagnostic laparoscopy has increased significantly . It helps in both the diagnostic and therapeutic management of surgical conditions avoiding the use of laparotomy. The aim of our study was to identify the use of diagnostic laparoscopy and the subsequent management of acute surgical abdominal conditions and their outcome at our institute.
We collected data over six years from 2008 to 2014 of patients undergoing diagnostic laparoscopy. The study included all patients undergoing diagnostic laparoscopy when the initial imaging both ultrasound abdomen and pelvis and computerised tomography scans were negative. The study also included patients who may or may not have elevated inflammatory markers (raised white cell count and C-reactive protein). We collected data for pre-operative (demographic details, laboratory investigations and radiological imaging), operative (laparoscopic and conversion to open, operative details) and post-operative course (histological report, inpatient stay, recovery and post-operative follow-up).
The study identified 182 patients who underwent diagnostic laparoscopic. The female (N=123, 68%) to male (n=59, 32%) ratio was 2.2. The median age was 49 years (range 7 to 79 years). 86 (47%) patients had positive diagnostic laparoscopies which identified significant intra-abdominal pathology (acute appendicitis = 53, ovarian cyst rupture = 17, ovarian torsion = 7, endometriosis = 4, bowel adhesions = 5). 8 (4%) patients required conversion to laparotomy due to the extent of intra-abdominal pathology. The median inpatient hospital stay was 2 days (range 1 to 36 days). 96 (53%) diagnostic laparoscopies were inconclusive and failed to identify any abdominal pathology and these patients were subsequently discharged. 27 (15%) of patients with negative diagnostic laparoscopies were readmitted with ongoing symptoms of abdominal pain over a median follow-up period of 6 months (range 1 to 13 months). Only 5 (3%) of these patients who were readmitted with abdominal pain were found to have an abdominal pathology and underwent a laparoscopic operation (n=3 appendicitis, n=2 ovarian cysts). The overall complication rate was 11 % (lower respiratory tract infections 4%, wound infections 5% and urine infection 2%).
Diagnostic laparoscopic surgery can be safely performed in patients who still have abdominal signs and symptoms despite all negative laboratory and imaging investigations. Though these patients require careful selection as represented from our series that nearly half the patients had negative diagnostic laparoscopy. Diagnostic laparoscopy in acute surgical emergency has significant role to play in situations when both inital laboratory and radiological investigations are negative.