Diagnostic Laparoscopy in Laparoscopic Surgical Procedure.pdf

Diagnostic Laparoscopy
INTRODUCTION
Diagnostic laparoscopy is a minimally invasive surgical
procedure that allows the visual examination of intra-
abdominal organs in order to detect any pathology. This
procedure allows the direct visual examination of intra-
abdominal organs including large surface areas of the
liver, gallbladder, spleen, peritoneum, pelvic organs, and
retroperitoneum. Biopsies, aspiration, and cultures can be
obtained, and laparoscopic ultrasound (US) may be used.
Diagnostic laparoscopy is safe and well tolerated and
can be performed in an outpatient or inpatient setting
under general anesthesia (Fig. 1A). There may also be
unique circumstances where office based diagnostic
laparoscopy may be considered under local anesthesia.
These circumstances should include only procedures where
complications and the need for therapeutic procedures
through the same access are extremely unlikely. Manipulation
and biopsy of the viscera is possible through additional ports.
Diagnostic laparoscopy is the most commonly performed
gynecological procedure today. Its greatest advantage is that
it has replaced exploratory laparotomy.
Diagnostic laparoscopy was first introduced in 1901,
when Kelling, performed a peritoneoscopy in a dog and was
called ‘‘celioscopy’’
. A Swedish internist named Jacobaeus is
credited with performing the first diagnostic laparoscopy on
human in 1910. He described its application in patients with
ascites and for the early diagnosis of malignant lesions.
In last 10 years, laparoscopy has made a great difference
to the diagnosis of abdominal acute and chronic pain. It
has evolved as an informative and important method of
diagnosing a wide spectrum of both benign and malignant
diseases. Exploratory laparoscopy also allows tissue
biopsy, culture acquisition, and a variety of therapeutic
interventions. Elective diagnostic laparoscopy refers to the
use of the procedure in chronic intra-abdominal disorders.
Emergency diagnostic laparoscopy is performed in patients
presenting with acute abdomen.
INDICATIONS
The indications for diagnostic laparoscopy can be divided
into two main groups.
Nontraumatic and Nongynecological
Acute Abdomen Like
■ Appendicitis
■ Diverticulitis
■ Duodenal perforation
■ Mesenteric adenitis
■ Intestinal adhesion
■ Omental necrosis
■ Intestinal infarction
■ Complicated Meckel’s diverticulum
■ Bedside laparoscopy in the intensive care unit (ICU)
■ Torsion of intra-abdominal testis
Gynecological Abdominal Emergencies Like
■ Ovarian cysts
■ Pelvic inflammatory diseases
■ Acute salpingitis
■ Ectopic pregnancy
■ Endometriosis
■ Perforated uterus due to criminal abortion
■ Salpingitis
One of the important uses for diagnostic laparoscopy
is the investigation of female infertility. Tubal causes of
infertility are found in almost 15% of couples. In these
patients, laparoscopy not only allows tubal patency to be
assessed but also enables other features in the pelvis to be
examined. Most important findings related to infertility are
kinking of the tube, fimbrial damage or ovarian adhesions.
The presence of corpus luteum is considered as good
evidence of current ovulation.
If tubal recanalization surgery is planned, it is a good idea
toperformapreliminarylaparoscopytoassesstheprospectof
successful anastomosis. If the length of remaining tube is less
than2cm,therecanalizationsurgeryshouldnotbeattempted
and in vitro fertilization (IVF) should be recommended.
Ovarian biopsy can also be taken at the time of diagnostic
laparoscopy to diagnose the cause of amenorrhea and
infertility. Although the functional test of ovarian stimulation
by gonadotropin-releasing hormone is more in use, but it
can be still of help if the presence of primordial follicles is in
doubt in primary amenorrhea or premature ovarian failure.
Prof. Dr. R. K. Mishra

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CHAPTER 24: Diagnostic Laparoscopy
Figs. 1A and B: (A) Diagnostic laparoscopy; (B) Local anesthesia can be used for diagnostic laparoscopy.
A B
RELATIVE CONTRAINDICATIONS
Contraindications may include:
■ Hemodynamic instability
■ Mechanical or paralytic ileus
■ Uncorrected coagulopathy
■ Generalized peritonitis
■ Severe cardiopulmonary disease
■ Abdominal wall infection
■ Multiple previous abdominal procedures
■ Late pregnancy
However, the final decision is determined not only by
the clinical condition of patients, but also by the surgeon’s
judgment.
Choice of Anesthesia
Diagnostic laparoscopy can be performed under local
anesthesia. Sedation with diazepam and pethidine can
be used to make patient unaware of procedure because
unpleasant sensation of stretching of peritoneum due to
pneumoperitoneumcannotbeabolishedbylocalanesthesia.
Local anesthetic 4% Xylocaine can be injected
subcutaneously over inferior crease of umbilicus (Fig. 1B).
Epidural anesthesia is not preferred by many anesthetists
because to anesthetize the entire peritoneum, a high block is
necessary which would interfere with intercostal nerves and
respiration will be affected. General anesthesia with good
muscle relaxation is ideal in laparoscopic surgery.
LAPAROSCOPIC ANATOMY
Diagnosticlaparoscopymaybehelpfulformanyundiagnosed
surgical problems and therefore knowledge of laparoscopic
anatomy of the whole abdomen is necessary. However,
most common indications of diagnostic laparoscopy are
gynecological and especially related to infertility.
From anterior to posterior, following important tubular
structures are found crossing the brim of true pelvis: The
round ligament of the uterus, the infundibulopelvic ligament,
whichcontainsthegonadalvessels,andtheureter.Theovaries
and fallopian tube are found between the round ligament and
the infundibulopelvic ligament (Figs. 2A and B).
The fallopian tubes arise from the superior portion of
the uterus just above the attachment points of the round
ligament. Laparoscopically, the round ligaments overhang
the fallopian tube because of uterine manipulation and can
be easily mistaken for them. The fallopian tubes towards
their lateral end encircle the ovaries partially with their
fimbriated ends.
If the uterus is deviated to the contralateral side with
the help of uterine manipulator infundibulopelvic ligament
is spread out and a pelvic side wall triangle is created. The
base of this triangle is the round ligament, the medial side
is the infundibulopelvic ligament, and the lateral side is the
external iliac artery. The apex of this triangle is the point at
which the infundibulopelvic ligament crosses the external
iliac artery (Fig. 3A).
Patient Position
The anesthetized patient is placed on the operating table
with the legs straight or lithotomy position if patient is
female. The lithotomy position will allow the gynecologists
and assistant to work simultaneously and uterine
manipulation is simultaneously possible. The thighs must
not be flexed onto the abdominal wall and should be as they
generally are in the full lithotomy position used for other
open surgical gynecological procedures. The operating
table is tilted head-up or head-down by approximately 15°
depending on the main area of examination. Compression
bandage may be used on leg during the operation to prevent
thromboembolism, especially if patient is in lithotomy
position.
Position of the Surgical Team
Before starting diagnostic laparoscopy a best guess is made
about the quadrant in which pathology is likely to be found.
The surgeon should stand opposite to this quadrant to allow
direct view into this quadrant. If the pathology is more
likely in pelvic cavity the surgeon stands on left side of the
patient (Fig. 3B). The first assistant, whose main task is to
position the video camera, is also on the patient’s left side.

324 SECTION 2: Laparoscopic General Surgical Procedures
Figs. 2A and B: (A) Anatomy of normal female pelvis; (B) Laparoscopic anatomy of normal female pelvis: (1) Uterus; (2) Round ligament;
(3) Utero-ovarian ligament (proper ovarian ligament); (4) Uterosacral ligament; (5) Ovary; (6) Suspensory ligament of the ovary; (7) Ureter.
A
B
The instrument trolley is placed on the patient’s left, allowing
the scrub nurse to assist with placing the appropriate
instruments in the operating ports. Television monitors are
positioned on either side of the top end of the operating
table at a suitable height for surgeon, anesthetists, as well as
assistant to see the procedure.
Port Position
Generally one optical port in umbilicus and one 5 mm port
in left iliac fossa are required (Fig. 4A). Some gynecologists
prefer to put their second port in suprapubic region in
midline (Fig. 4B). In our opinion, left iliac fossa port is better
because it gives elevation angle of 30° and manipulation
angle of 60°, which is ergonomically better. With suprapubic
port elevation angle of instrument and tubal structure is
90° and hence lifting up of ovary and tube may be difficult
without grasping it.
During diagnostic laparoscopy it is advisable that both
telescope and probing instrument is held by surgeon himself
as he knows better what he wants to see and where he wants
to concentrate more and also which structure he wants to
see in magnified close-up view. At the time of diagnostic
laparoscopy surgeon should try to be very gentle with the
tubal structures and bowel so that adhesions will not form
and stricture of tube shall not occur.
Viewing of lateral pelvic organs is helped by the
manipulation of mobile structure with a second port
introduced through the left iliac fossa port. Many
gynecologists introduce the second port in suprapubic
region but the elevation angle of the instrument is 90° and
the mobilization of organs is difficult.
A three-port approach should be used if there is any
difficulty in manipulation with two ports, especially in case
of extensive adhesions.

325
Figs. 3A and B: (A) Anatomy of adnexa; (B) Position of surgical team for diagnostic laparoscopy in female.
A B
Figs. 4A and B: Port position for diagnostic laparoscopy.
A B
■ 10 mm umbilical (optical)
■ 5 mm suprapubic
■ 5 mm right hypochondrium
A 30° telescope is employed in most instances, as
this facilitates easier inspection of the deeper peritoneal
cavity and abdominal organs. The secondary ports are
inserted under laparoscopic vision. The selected site on
the abdominal wall is identified by finger indentation of the
parietal peritoneum.
The optimum incision for optical port is in the
subumbilical region. The open technique for trocar
insertion is recommended if patient presents with severe
abdominal distension. Nitrous oxide is preferably used if
diagnostic laparoscopy is performed in local anesthesia
because nitrous oxide has its own analgesic effect. Carbon
dioxide (CO2) is the preferred gas if diagnostic laparoscopy
is performed under general anesthesia. Insufflation
should be very slow and with care taken not to exceed
12.0 mm Hg.
Operative Procedure
The first step in diagnostic laparoscopy is thorough
exploration, just as during exploratory laparotomy. A
systematic approach to exploration is essential to ensure that
nothing is missed.
Systemic Plan of Inspection in Mid Abdomen
Positioning is the primary means of displacing the bowel
and exposing peritoneal surfaces. In women with a deep
pelvis, the bowel should be displaced gently into the upper
abdomen, using a blunt probe or closed blunt grasping
instrument to avoid laceration of the bowel or mesentery. An
additional port with a blunt tipped instrument may be used,
if required. Occasionally, fan retractor can be used to retract
full sigmoid colon. This instrument can be inserted through
a 5 mm trocar cannula and fanned out in the abdomen to
retract the bowel. Some common findings are shown in
Figures 5 to 11.

Fig. 5: Hepatic carcinoma.
Figs. 6A and B: (A) Hemangioma; (B) Carcinomatosis.
A B
Inspection of Pelvis
Patient should be again positioned in steep Trendelenburg’s
position.
After assessing the genital organs, the gynecologist may
wish to view areas outside the pelvis. This should be done by
tilting the table head up or laterally to examine the paracolic
or subdiaphragmatic spaces. Systematic plan of inspection
of pelvis is shown in (Figs. 9A to C).
ROLE OF LAPAROSCOPY IN ASCITES
Although the determination of the etiology of ascites is
usually straight forward by history, physical examination,
and analysis of ascitic fluid, the diagnosis of tuberculous
or carcinomatous ascites may be elusive. In such cases,
laparoscopy with biopsy is highly accurate. Peritoneal
mesothelioma is frequently missed on ascitic fluid by
cytology and by blind biopsy. This entity is readily diagnosed
by laparoscopy with peritoneal biopsy. Laparoscopy may be
useful in the evaluation of hepatic malignancy (both primary
or metastatic). About 80–90% of these lesions are present on
the hepatic surface and up to two-thirds of the liver surface
may be inspected by laparoscopy. When surgical resection is
a therapeutic option, laparoscopy may reveal small (1 cm or
less) metastatic lesions, peritoneal metastases, or cirrhosis,
which represent contraindications to this plan of resection
and are frequently missed on computed tomography (CT),
magnetic resonance (MRI), and US. The use of laparoscopic
US allows detection of deeper lesions and vascular
infiltration.
In a study on the role of laparoscopy in the diagnosis and
differential diagnosis of ascites, it was found that out of 2,500
patients who underwent laparoscopy, 30.89% had ascites;
of which, liver cirrhosis underlays it in 57.78%, peritoneal
carcinosis in 26.29%, primary and metastatic carcinoma in
12.95%, and tuberculous peritonitis in 1.42%, more rarely
other diseases. Liver cirrhosis, malignant tumors, and
the other hepatic affections with concomitant ascites in
their course can certainly be diagnosed laparoscopically.
Laparoscopy with oriented biopsy of peritoneum and liver is
ofdecisiveimportanceindifferentiatingperitonealcarcinosis
from tuberculosis. In peritoneal carcinosis the diagnosis
(as based in clinical and laboratory findings) coincided
perfectly with the laparoscopic and histologic one in 24.5%,
and partially in 45.5%. In 30% there was no congruence at
all. Laparoscopy and the test methods associated with it
contributedtotheaccuratediagnosisofperitonealcarcinosis
in 75.5% of the patients. Ovarian carcinoma (20.9%) and
cancerofthestomach(16.3%)underlayperitonealcarcinosis
most frequently, other diseases were by far more seldom.
Diagnostic peritoneoscopies were performed in
226 patients with ascites. Satisfactory examination was
possible in 220 patients. Clinical diagnosis was confirmed
at peritoneoscopy in 82.7% of patients. Peritoneoscopic
examination corrected the clinical diagnosis in 13.7%, was
inconclusive in 2.6% and was incorrect in 0.8% of cases.

327
Figs. 7A and B: Endometriosis.
A
B
It was 100% diagnostic in malignant peritonitis and 89.5%
in patients with tuberculous peritonitis. Pseudomyxoma
peritonei and mesothelioma were suspected in one patient
each at peritoneoscopy and was confirmed histologically.
The utility of routine ascitic fluid examination was reviewed
in all patients. The ascitic fluid was transudative in 81.9%,
exudative in 8.6% and indeterminate in 9.5% of patients
with cirrhosis of liver. Patients with tuberculous peritonitis
had exudative, transudative and indeterminate ascites in
71.8%, 3.2%, and 25%, respectively. The ascites in patients
with malignant peritonitis was either exudative (80%) or
indeterminate (20%). There was considerable overlap in the
nature of ascites present in the three groups of patients. We
therefore conclude that peritoneoscopy is the most valuable
investigation in the diagnosis of ascites, particularly in
exudative and indeterminate types.
The Value of Laparoscopic Diagnosis of
Tuberculosis
The laparoscopic and pathological diagnosis of 43 patients
who underwent abdominal laparoscopy for various
indications are presented here. Major indications for the
laparoscopy included hepatomegaly in 32 patients, ascites
in 28, and pyrexia of unknown origin (PUO) in 18 patients.
A combination of two or more of these indications was a
more common feature. The most frequently encountered
laparoscopic diagnoses were tuberculosis and chronic liver
disease (16 patients each), followed by cancer (9 patients).
However, on pathological examination of peritoneal or liver
biopsy tissue and on follow-up, tuberculosis was confirmed
in 12 patients, chronic liver disease in 14 patients, and
hepatocellular carcinoma in 11 patients. No complications
were encountered during the laparoscopy. Our findings
indicate that abdominal laparoscopy is a safe, quick, and
inexpensive diagnostic tool, particularly when appropriate
and adequate tissue is taken for pathological examination.
In such instances, laparoscopy would save an unnecessary
laparotomy, especially where tuberculosis and cancer are
considered in the differential diagnosis.
Due to its high accuracy, some suggest polymerase
chain reaction (PCR) before laparoscopy. In the light of
our accumulated experience, we would suggest that PCR of

Figs. 8A to H: Ectopic pregnancy.
A B
C
F
D
G
E
H
ascetic fluid obtained by US-guided fine-needle aspiration
is now the investigation of choice for patients with the
described clinical and radiological presentations and should
at least be attempted before surgical intervention. If the
result is negative, diagnostic laparoscopy or, if this is not
feasible, laparotomy needs to be performed.
Role of Laparoscopy in Carcinoma Assessment
A pretherapeutic staging system to design operative or
neoadjuvant treatments in gastric cancer is needed.
Laparoscopy can be done even under local anesthesia as it is
a sensitive predictor of peritoneal recurrence.
Staging laparoscopy with peritoneal lavage cytology
is a safe, effective tool in patients with locally advanced
gastric cancer, especially in patients receiving neoadjuvant
chemotherapy. The ability of minimally invasive surgeons
and endoscopists to diagnose and palliate unresectable
pancreatic cancer is likely to continue to improve and these
techniqueswillplayanincreasinglyimportantroleinthecare
of patients with pancreatic cancer. Likewise, the accuracy
of radiological imaging techniques to detect unresectable
disease will also continue to advance and further decrease
the incidence of nontherapeutic laparotomies. It is valuable
and has many therapeutic uses as in staging of tumor,
catheter placement in nephrogenic ascites.
Dialysis Catheter and Laparoscopy
Regarding complications of dialysis catheter insertion,
Tiong reported many surgical, early and late complications
of dialysis catheter of open Tenckhoff catheter insertion
under local anesthesia in a single institution. A review
was carried out on 164 insertions in 139 patients over a
3-year period. Tenckhoff catheter insertion for continuous
ambulatory peritoneal dialysis (CAPD) is a procedure
associated with significant surgical morbidity. Patients with
diabetes mellitus, glomerulonephritis, and ongoing sepsis
are at greater risk of early complications, and hence, must
have their conditions stabilized or treated before surgery.
In addition, prolonged surgical time and patients with
previous abdominal surgery are at increased risk. The rate
of complications may be improved by early consideration of
patients with poor tolerance of local anesthetic for surgery or

329
Fig. 10: Bicornuate uterus. Fig. 11: Polycystic ovary.
Figs. 9A to C: Systematic plan of inspection of pelvis.
A B
C
with previous abdominal surgery for laparoscopic insertion
under general anesthesia. To prevent late complications
dominated by CAPD peritonitis, patient’s nutritional status
and care of the catheter should both be optimized.
Open insertion of peritoneal dialysis (PD) catheters is
the standard surgical technique, but it is associated with
a relatively high incidence of catheter outflow obstruction
and dialysis leak. Omental wrapping is the most common
cause of mechanical problem; laparoscopic omental fixation
technique is of higher value, in addition laparoscopic surgery
also enabled diagnosis of intra-abdominal pathologies and
treatment of the accompanying surgical problems during the
same operation.
Port-site Metastasis
The risk of port-site metastases in those undergoing
laparoscopy for gynecologic malignancy was highest in
those with ascites in a study of 82 patients. The study
participants underwent 87 procedures that involved 330
trocar sites. The overall risk of port-site metastases per
procedure was 2.3%, and per port site was 2.4%, Dr Nimesh
Nagarsheth, at an international congress sponsored by the
Society of Laparoendoscopic Surgeons reported 39 patients
with endometrial cancer, 29 with ovarian cancer, and 14 with
cervical cancer. About 20 of those were treated for recurrent
cancer, and 10 of them had ascites. They were followed for
an average of 361 days. Port-site metastases occurred in two

patients. The first developed metastases at five sites, and was
diagnosed 13 days after second-look laparoscopy for stage
IIIB ovarian cancer. The second had metastases at three sites,
and was diagnosed 46 days after second-look laparoscopy
for stage IIIC primary peritoneal cancer. Both patients had
ascites.
Laparoscopy and Ascites
Laparoscopy in ascites is a safe and cost-effective diagnostic
modality and its rules extended the diagnostic procedure
often providing definitive diagnosis in unexplained cause of
ascites.
In such instances, laparoscopy would save an
unnecessary laparotomy; especially where tuberculosis and
cancer are considered in the differential diagnosis.
DISCUSSION
Theusualsiteofinsertionofthetrocar/cannulafordiagnostic
laparoscopy is below or to the side of the umbilicus.
This position may require to be altered in the presence of
abdominal scars. The use of a 30° forward oblique telescope
is preferable for viewing the surface architecture of organs.
By rotation of the telescope, different angles of inspection
can be achieved.
The first important step after access to the abdomen
has been gained, is to check for damage caused by trocar
insertion. A second 5 mm port is then inserted under vision
in an appropriate quadrant to take in a palpating rod.
A systematic examination of the abdomen must be
performed just as in laparotomy. We begin at the left lobe of
theliverbutanyschemecanbeusedaslongasitisconsistent.
Next, check around the falciform ligament to the right lobe
of liver, gallbladder, and hiatus. After checking the stomach,
move onto the cecum and appendix and check the terminal
ileum. Follow the colon round to the sigmoid colon, and
then check the pelvis. Surgeon should be conversant with
sampling and biopsy techniques, and the use of position and
manipulation to aid vision.
At the time of diagnostic laparoscopy all the abdominal
organs are inspected for any gross anatomical abnormalities.
Abdominal cavity is inspected for excess of fluids. Samples
aretakeniffreefluidispresentforlaboratorytests(chemistry,
cytology or bacteriology). Peritoneal lavage and adhesiolysis
mayneedtobeperformedtoimprovevisualizationoforgans.
Atthetimeofperitoneallavage,whenfluidissuckedfromthe
cul-de-sac, it is important to keep all the holes of the suction-
irrigator beneath the level of the fluid to avoid removing
pneumoperitoneum. If the suction-irrigator is positioned
improperly, the CO2 gas will be removed undesirably.
However, with high-flow insufflators, pneumoperitoneum is
rarely lost and quickly restored.
When performing a diagnostic laparoscopy to confirm
appendicitis, a-5 mm port is placed in the left iliac fossa to
facilitate manipulation. The patient is placed head down
and rotated to the left to displace the small bowel from
the pelvis and allow the uterus and ovaries to be checked.
This, however, should be limited to avoid contamination of
subphrenic spaces, if this is not already present.
Ending of the Operation
During diagnostic laparoscopy, surgeon can perform
therapeutic laparoscopy if indicated when having a prior
consent or can be obtained from patient’s relative.
At the end of surgery, abdomen should be re-examined
for any possible bowel injury or hemorrhage. The entire
accessory instrument and then port is removed. The
telescope should be removed leaving gas valve of umbilical
port open to let out all the gas. Once the complete gas is
out, for removing primary cannula, telescope or any blunt
instrument should be introduced again and cannula should
bepulledoverthatinstrumenttopreventpullingofomentum
or bowel. Wound should be closed with suture. Vicryl should
be used for rectus and unabsorbable intradermal or stapler
for skin. Only 10 mm port wound is necessary to repair.
Adhesive sterile dressing over the wound should be applied.
Patient may be discharged on the same day after
operation if everything goes well. The patient may have slight
pain initially but usually resolves. Diagnostic laparoscopy is
a useful method for reducing hospital stay, complications,
and return to normal activity if carried on in proper manner.
Laparoscopy for Abdominal Trauma
Trauma is the leading cause of death between 1 and 44
years. In all age groups, it is surpassed only by cancer and
atherosclerosis in mortality. The evaluation and treatment
of abdominal injuries are critical components in the
management of severely injured trauma patients. Because
missed intra-abdominal injuries are a frequent cause of
preventable trauma deaths, a high index of suspicion is
warranted. Multiple factors, including the mechanism of
injury, the body region injured, the patient’s hemodynamic
and neurological status, associated injuries, and institutional
resources influence the diagnostic approach and the
outcome of abdominal injuries.
Laparoscopy was first used for a trauma patient in 1956 by
Lamy, who observed two cases of splenic injury. Since then,
Gazzaniga noted that laparoscopy is useful for determining
the need for laparotomy. In 1991, Berci reported that he
had reduced the number of nontherapeutic laparotomies
performed for hemoperitoneum by 25% through the use of
laparoscopy in 150 patients with blunt abdominal trauma.
Data show that laparoscopy is a useful modality
for evaluating and managing hemodynamically stable
trauma patients with penetrating injuries. Increased use of
laparoscopy in select patients with penetrating abdominal
trauma will decrease the rate of negative and nontherapeutic

331
laparotomies, thus lowering morbidity, decreasing length of
hospitalization, and provide for more efficient utilization
of available resources. As technology and expertise among
surgeons continues to improve, more standard therapeutic
interventions may be done laparoscopically in the future.
Mandatory surgical exploration for gunshot wounds to the
abdomen has been a surgical dictum for the greater part of
this century. Although nonoperative management of blunt
solid organ injuries and low-energy penetrating injuries
such as stab wounds is well established, the same is not
true for gunshot wounds. The vast majority of patients who
sustain a gunshot injury to the abdomen require immediate
laparotomy to control bleeding and contain contamination.
Nonoperative treatment of patients with a gunshot injury
is gaining acceptance in only a highly selected subset of
hemodynamically stable adult patients without peritonitis.
Although the physical examination remains the cornerstone
in the evaluation of patients with gunshot injury, other
techniques such as CT, diagnostic peritoneal lavage (DPL),
and diagnostic laparoscopy allows accurate diagnosis of an
intra-abdominal injury. The ability to exclude internal organ
injury nonoperatively avoids the potential complications of
unnecessary laparotomy. Clinical data to support selective
nonoperative management of certain gunshot injuries
to the abdomen are accumulating, but the approach has
risks and requires careful collaborative management by
emergency physicians and surgeons experienced in the
care of penetrating injury. Sosa reported 121 consecutive
abdominal gunshot wounds managed with laparoscopy.
About 79 (65%) had negative laparoscopy, and these patients
were managed without laparotomy. Another 7.2% avoided
nontherapeutic laparotomy.
It is very important to determine the presence, location,
and severity of intra-abdominal injury to decide the surgical
intervention; and to thoroughly evaluate intra-abdominal
organs for associated injuries in the trauma patient. For stab
wounds, serial physical examination is supplemented by
local wound exploration, DPL, abdominal US, abdominal
CT, MRI, and in some cases, angiography to maximize the
value of surgical intervention and to reduce negative and
nontherapeutic laparotomy. Despite having many positive
qualities, these diagnostic methods have some drawbacks.
DPL is an invasive but sensitive procedure; it may result in
nontherapeutic laparotomy with its attendant morbidity.
The use of CT is limited to the hemodynamically stable
patient. There has been increasing interest in the use of
abdominal US because it is portable, noninvasive, rapid, and
easily repeatable. However, it is less accurate for diagnosis of
diaphragmatic and hollow viscera injury. With experience in
laparoscopic cholecystectomy and the advent of improved
and readily accessible laparoscopic equipment and
devices, laparoscopic surgery became widespread for intra-
abdominal operations, setting the stage for renewed interest
in its applications for the diagnosis of traumatic abdominal
injuries and examination of their therapeutic potential.
In the evaluation and management of the abdominal
injury, current diagnostic methods have a defined
sensitivity, specificity, and accuracy, but none of these
represents a gold standard. Thus, abdominal exploration by
laparotomy should not be discarded as a worthy diagnostic
and therapeutic procedure for patients with equivocal and
unreliable findings. It is associated with complication rates
as high as 40% including a 10–40% negative laparotomy rate,
a 20% morbidity rate, a 0–5% mortality rate, and a 3% long-
term risk of bowel obstruction secondary to adhesions.
Laparoscopy has been reported infrequently as a
therapeutic tool in selected trauma patients. Examples of
therapeutic laparoscopy include repair of diaphragmatic
lacerations with sutures, staples, or prosthetic mesh;
suturing of gastrointestinal perforations; hemostasis of
low-grade liver and splenic lacerations; resection of small
bowel and colon; cholecystectomy; splenectomy; and distal
pancreatectomy. Autotransfusion of collected blood from
the hemoperitoneum is another potential application.
Fabian in a large study of 182 trauma patients reported
one suture repair of diaphragmatic injury. Successful
laparoscopic repair of small bowel, colon, and rectal injuries,
and laparoscopic repair of a small gastric stab wound using
hernia stapler have been reported recently. For the repair
of solid visceral injuries, there are three methods that merit
investigation: (1) The totally laparoscopic procedure, (2) the
laparoscopically assisted procedure, and (3) hand-assisted
laparoscopic surgery (HALS). The argon beam coagulator,
fibrin glue, topical hemostatic agent, and absorbable mesh
may be beneficial for hepatic and splenic lacerations.
Laparoscopic repair of bowel injuries can be performed
using suture or staples. Primary suture repair of a small
bowel injury would be amenable by a totally laparoscopic
procedure. Using a porcine model, Pietrafitta and Soperet
described a technique for an intraperitoneal functional end-
to-end anastomosis of the small intestine. Milsom and Bohm
modified these techniques and reported that their technique
for intracorporeal intestinal anastomosis has been proven
safe in dozens of animal and human procedures, but that it
had some drawbacks. It requires a long operating time and
needs two or three 30 mm endogastrointestinal anastomosis
(GIAs) and a skin incision for specimen retrieval. Recently,
animal research has assessed the potential for hand-assisted
laparoscopic exploration to detect traumatic injuries. Asbun
reported that hand-assisted laparoscopic exploration is
more accurate than laparoscopic exploration alone in
detecting injuries (63% vs. 38%), but that it still resulted in an
unacceptable rate of missed injuries.
Hand-assisted laparoscopic surgery allows for the
application of minimally invasive surgical techniques to
complex intra-abdominal operations, particularly when

specimenremovalisrequired.Therationaleforthisapproach
is that the hand offers the surgeon some advantage in terms
of tactile feedback, exposure, retraction, and orientation,
enabling the surgeon to perform with greater safety and
efficiency. Most trauma surgeons consider omental
herniation through an anterior abdominal stab wound an
indication for laparotomy because frequently there are
significant intra-abdominal injuries. As an alternative
to laparotomy, the herniated omentum was evaluated
and managed, with laparoscopy performed through the
abdominal stab wound or using it for accessory trocar. If
there are no significant injuries, the wound can be managed
without further treatment. Depending on the surgeon’s
preference, therapeutic laparoscopy can be continued.
The complications of laparoscopy for trauma include not
only the usual complications of anesthesia and laparoscopy,
but also some that are unique to the trauma patient. Fabian
independently reported the development of tension
pneumothorax in patients with diaphragmatic injury
from positive-pressure pneumoperitoneum. If suspected,
induction of pneumoperitoneum is stopped and an
immediate needle thoracocentesis is performed, followed
by a tube thoracostomy, if needed. However, routine
prophylactic tube thoracostomy is not indicated. The risks
of gas embolism in patients with intra-abdominal venous
injuries, especially liver lacerations, are another problem.
Among 133 laparoscopic examinations of trauma, Smith did
encounter this complication in two patients with injuries of
the inferior vena cava tamponaded by clot.
This potential problem of laparoscopy has stimulated
interest in ‘‘gasless’’ laparoscopy based on expansion of
the peritoneal cavity by mechanical retractors. In addition
to averting the risks of tension pneumothorax and gas
embolism, it facilitates the use of conventional instruments
such as hemostats, needles, sutures, and electrocautery,
resulting in significant cost savings. The major disadvantage
of gasless laparoscopy, however, is the excessive cost of the
powered mechanical arm and the poor exposure in the lateral
gutters. Less expensive apparatus to lift the abdominal wall is
expected in times to come. The transperitoneal absorption of
CO2 may cause metabolic and hemodynamic changes such
as acidosis, cardiac suppression, atelectasis, subcutaneous
emphysema, and increased intracranial pressure, resulting
in more profound consequences for the trauma patient.
Joseph demonstrated that CO2 pneumoperitoneum causes
significantly increased intracranial pressure in a porcine
model of head injury.
The results of this study led them to recommend the
avoidance of CO2 pneumoperitoneum for the evaluation
of patients with head injuries. Undoubtedly, gasless
laparoscopy could replace CO2 pneumoperitoneum in these
cases. Missed intra-abdominal injuries are among the most
frequent causes of potentially preventable trauma deaths.
The evaluation and management of abdominal trauma is
dependent on multiple factors, including mechanism of
injury, location of injury, hemodynamic status of the patient,
neurological status of the patient, associated injuries, and
institutional resources. Therefore careful selection, high
index of suspicion, and a low threshold for laparotomy will
provide the patient the benefits of minimal invasive surgery
and reducing the rates and morbidity of unnecessary
laparotomy.
The diagnostic laparoscopy of various organs is shown in
Figures 12 to 17.
Complications
Complications may occur during access, trocar insertion, or
the diagnostic manipulation of viscera. These complications
include, cardiac arrhythmias, hemodynamic instability due
to decreased venous return, bleeding, bile leak, perforation
of a hollow viscus, laceration of a solid organ, vascular
injury, gas embolism, and subcutaneous or extraperitoneal
dissection due to the insufflation gas. If proper sterilization
Fig. 12: Fibroid. Fig. 13: Adhesion of appendix.

333
Fig. 14: Acute appendicitis. Fig. 15: Diverticulum.
Fig. 16: Impalpable testes. Fig. 17: Perforation of small bowel.
are equivocal. It can be performed safely in an inpatient or
outpatient setting, potentially expediting diagnosis, and
treatment. This laparoscopic procedure helps to achieve
the final diagnosis without any significant complication
and less operative time, it can be safely concluded that
diagnostic laparoscopy is a safe, quick, and effective adjunct
to nonsurgical diagnostic modalities, for establishing a
conclusive diagnosis, but whether it will replace imaging
studies as a primary modality for diagnosis needs more
evidence.
of instrument is not done then wound infection or leakage
of ascites may occur postoperatively. Failure to accurately
diagnose the extent of intra-abdominal pathology is another
potential complication for which patient may have to go for
resurgery.
CONCLUSION
Diagnostic laparoscopy is one of the very important
methods of investigation for patients in whom the diagnosis
or extent of the disease is unclear or the abdominal findings

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