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Diagnostic laparoscopy

Article  in  Surgical Endoscopy · February 2004

DOI: 10.1007/s00464-002-8872-0 · Source: PubMed

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Tehemton E Udwadia
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 Review article
Surg Endosc (2004) 18: 6–10
DOI: 10.1007/s00464-002-8872-0
Ó Springer-Verlag New York Inc. 2003
Diagnostic laparoscopy
A 30-year overview
T. E. Udwadia
Department of Minimal Access Surgery P.D., Hinduja National Hospital and Research Centre, and the Department of Surgery,
B.D. Petit Parsee General Hospital, Breach Candy Hospital, Mumbai, India
Received: 20 March 2003/Accepted: 15 April 2003/Online publication: 10 September 2003
Abstract. Diagnostic laparoscopy began in a surgical
unit in a developing country in 1972. The developers of
this technique aimed to hasten diagnosis, reduce patient
distress, and improve bed utilization in an overcrowded
teaching hospital wherein simple investigations such as
x-rays took weeks to materialize. Over a period of 18
years reaching to 1990, 3,200 diagnostic laparoscopies
were performed on adults under local anesthesia with no
mortality, a complication rate of 0.09%, an 84% diag-
nosis rate, and 74% undergoing histologic biopsies tar-
geting a wide spectrum of pathology. The equipment
cost spread out over the 3,200 patients works out to 30
rupees ($0.60) per patient. With the availability of
noninvasive diagnostic aids such as ultrasound, com-
puted tomography, and magnetic resonance imaging
used US, CT, MRI under the control of target biopsy,
the role of diagnostic laparoscopy has altered. Since
1990, clinicians have had the sophistication of the video
camera and the pneumoperitoneum insufflator. Diag-
nostic laparoscopy is used for the evaluation of liver and
peritoneal pathology, abdominal tuberculosis, malig-
nancy, acute abdomen, and abdominal trauma. It often
is a prelude to laparoscopic treatment of the underlying
pathology, specifically in cases of acute appendicitis.
Key words: Diagnostic laparoscopy — Cost effective
— Developing countries — Malignancy — Tubercu-
losis — Acute pain — Trauma
The axiom ‘‘truth is change’’ applies very aptly to
medicine. In the 30 years since we started using diag-
nostic laparoscopy (DL), there has been appreciable
change in the technique, the instrumentation and the
indications of DL. In 1972, noninvasive diagnostic
methods were nonexistent in most parts of the Indian
Correspondence to: T. E. Udwadia
subcontinent. Diagnostic laparoscopy, performed by
direct eye vision, was of great value in the surgical
service of our hospital to ensure prompt and early di-
agnosis and to help improve bed turnover. Currently,
with the availability of noninvasive methods such as
ultrasound, computed tomography (CT) scan and
magnetic resonance imaging (MRI) not only in large
cities, but also in many towns of the developing world,
the impact of laparoscopy as a diagnostic method is
considerably reduced. However, whereas DL has re-
duced indications in some disease processes, new areas
have opened in which DL can play a significant role.
Currently, DL has relevance for the staging and man-
agement of abdominal malignancy, for abdominal tu-
berculosis, for abdominal trauma, and for the acute
abdomen. It must be stressed that laparoscopy is subject
to all the risks, complications, and accidents inherent to
any invasive procedure, and that a high positive diag-
nosis rate would be irrelevant and meaningless if the
safety of the patient were to be compromised.
Materials and methods
Over the years, by trial and error, a technique of DL [13] has been
standardized that ensures the three essential criteria we set for
ourselves:
1. A high margin of safety and freedom from complications
(primum non nocere).
2. A high diagnostic yield.
3. Cost effectiveness for a developing country.
We began DL in 1972 with the double-puncture Storz instrument using
a 7-mm 30° telescope and a 5-mm trocar for the second puncture. We
prefer the double-puncture instrument for the following reasons:
1. The narrower 7-mm cannula of the double-puncture instrument
has a shorter trocar, making injury to intraabdominal structures
during introduction less likely.
2. Ascites leak, omental prolapse, and incisional or Richter’s her-
nia are unlikely after the use of the narrower cannula.

3. The second puncture is made safely under laparoscopic vision
and can be suitably sited, depending on the intraabdominal
pathology, as seen through the peritoneoscope.
4. The double puncture gives a three-dimensional view, providing
a better sense of depth and distance; permits the use of both
hands; and greatly increases the versatility of translaparoscopic
procedures, [5] as well as their safety.
Movement and palpation of organs with a probe, biopsies under
vision, suction–coagulation of bleeding areas, aspiration of cysts and
abscesses, and severence of adhesions, all performed through the
double-puncture instrument make it eminently suitable for surgical
practice and an ideal teaching method for laparoscopic surgery.
Since 1990, we use the 5-mm 30° Storz telescope and a 5- or 3-mm
trocar for the second-puncture.
Diagnostic laparoscopy can be performed with the patient under
general anesthesia and with the use of relaxants and intubation. Local
anesthesia is far safer, faster, more suitable for general surgery and
high risk cases. It has been used in more than 3,200 consecutive adult
elective laparoscopies. Intravenous diazepam is used for sedation only
if required. With increasing experience, the need for sedation has de-
creased, ensuring earlier ambulation and discharge. Patient tolerance
has made it impossible to achieve or maintain an intraabdominal
pressure exceeding 6 to 8 mmHg in a conscious patient under local
anaesthesia. The average procedure time is 12 min. All these factors
have obviated the incidence of pulmonary embolism. In children and in
the acute abdomen, the procedure is performed with the patient under
general anesthesia. An anesthetist with complete anesthesia equipment
is available during every laparoscopy session.
Pneumoperitoneum
The skin and subcutaneous tissue are infiltrated with 2% lignocaine at
the left McBurney point. Through a 2-mm stab incision, the Veress
needle, with its point guarded by a blunt spring-loaded hollow obtu-
rator, is directed at a right angle in relation to the abdominal wall. No
attempt is made to tent up the abdominal wall or to insert the needle
obliquely. Continuing firm pressure is maintained on the needle while
the patient is asked to cough. The momentary contraction of the
muscle permits the spring-loaded needle to click smoothly and audibly
into the peritoneal cavity. The preperitoneal tissue is not infiltrated
with local anaesthesia because infiltration there would begin a strip-
ping off of the peritoneum, making it difficult for the Veress needle to
puncture the peritoneum cleanly.
A prerequisite to safe laparoscopy is a proper and adequate
pneumoperitoneum. Placement of the Veress needle tip correctly in the
free peritoneal cavity must be very carefully confirmed. The following
indications establish that the tip of the Veress needle is in the free
peritoneal cavity:
1. injection of saline without resistance and inability to aspirate
any return.
2. ‘‘hanging drop’’ placed on the needle hub sucked in with res-
piration.
3. palpation of the first gush of gas bubbling in peritoneum over
the needle tip when pneumoperitoneum is began.
4. percussion confirmation of a generalized pneumoperitoneum
when pneumoperitoneum is being established.
Complications of incorrect needle tip placement are not remote or
hypothetical, necessitating careful confirmation of needle tip place-
ment in the free peritoneal cavity before creation of the pneumoperi-
toneum. Subcutaneous, omental, retroperitoneal, or mediastinal
emphysema and perforation or distension of a hollow viscus, bleeding,
or gas embolism all could occur as a result of a malpositioned tip of the
pneumoperitoneum needle. Currently, many refined gadgets are
available for creating a pneumoperitoneum by insufflating carbon di-
oxide or nitrous oxide at a controlled rate. From 1972 to 1990, we have
used a sigmoidoscope pump and instilled atmospheric air to create
pneumoperitoneum in more than 3,200 consecutive adult cases without
any complications. We insufflate the air gradually, building up the
intraabdominal pressure slowly. Continuous percussion of the abdo-
men ensures that a generalized pneumoperitoneum has been created.
We carefully monitor the pulse, blood pressure, respiration, and the
7
patient’s subjective discomfort. The method we first used because of
financial necessity we used until 1990 by choice. Under local anes-
thesia, the conscious patient’s tolerance of abdominal distension and
pressure combined with careful clinical monitoring makes overinflation
very unlikely.
The purpose of creating the pneumoperitoneum is twofold: to
ensure that the main trocar puncture can be performed with safety in
an air cushion that separates the anterior abdominal wall from the
abdominal viscera and to provide a medium in which examination of
the peritoneal viscera can be performed.
The infraumbilical midline, the left subcostal region, the (right)
McBurney point, and various other sites have been recommended for
entry of the pneumoperitoneum needle. Unless there is a strong reason
to contraindicate the use of the left McBurney point, such as scars or a
grossly enlarged spleen, we routinely use the left McBurney point for
introduction of the pneumoperitoneum needle for the following reasons:
It is seldom the site of varices or surgical scars.
While the pneumoperitoneum is being created, the Veress needle
can be used as a probe to ensure that there are no adhesions in the
infraumbilical midline at the site of the main trocar entry, and to gauge
the depth and safety of the air cushion before trocar insertion. Our
technique of using the Veress needle as a probe is, we think, one of the
most important factors responsible for our low complication rate. We
have had no perforation since we evolved this method after a trocar
perforation of the ileum in our first 100 cases.
The second puncture trocar can be inserted at the same site, after
removal of the Veress needle, under vision for all upper abdominal
pathology, permitting right-hand translaparoscopic procedures.
Main trocar insertion
Only after an adequate pneumoperitoneum air cushion has been created
is the main trocar inserted. Unless there is strong reason to do otherwise
(e.g., grossly enlarged liver, adhesions detected by the Veress needle, or
hernia), the observation trocar cannula is invariably inserted in the
infraumbilical midline. The subcutaneous and preperitoneal tissues are
infiltrated with 2% lignocaine. At the moment the main trocar is in-
serted, the fact is clearly brought home that laparoscopy is an invasive
procedure. A transverse incision 1 cm below the umbilicus is made with
a pointed knife in the skin and subcutaneous tissue. The incision is made
slightly longer than the diameter of the trocar to ensure that skin fric-
tion does not further add to the ‘‘give’’ of the abdominal wall. The
direction of entry is always caudad, in the midline toward the pelvis,
ensuring that the trocar enters the abdominal cavity caudally to the
bifurcation of the major vessels and in the area where maximum air
cushion is present. The safe entry of the trocar is confirmed by the hiss
of the escaping pneumoperitoneum. The trocar is removed, leaving the
trocar sheath in the peritoneal cavity. If the volume of the pneumo-
peritoneum is causing discomfort, the valve of the trocar sheath is
opened to permit escape of gas and ensure patient comfort during ex-
amination. Any gas lost during examination is constantly replaced.
Perforation of the stomach, bowel, and bladder, as well as vascular and
solid viscus injury by the trocar all have been reported. Although ab-
dominal vessels have been damaged, the most dreaded complication is
major vessel injury, particularly injury to the aorta or common iliac
vessels. This highlights the importance of careful, controlled, correct
direction of the trocar tip during introduction.
Visual examination
Visual examination begins as soon as the telescope enters the sheath so
that the entry of the telescope into the peritoneal cavity is under vision.
The abdomen is examined in a systematic and sequential manner,
beginning with the falciform ligament, which is the key anatomic
landmark. If documentation by laparoscopic photography is required,
the 7-mm laparoscope is replaced by the 11-mm telescope with its
greatly increased light transmitting capacity.
The second puncture
When the liver or gallbladder needs to be visualized, when adhesions,
omentum, or bowel obscure view, or when pathology (for biopsy must
8

Table 1. Range of applications for diagnostic laparoscopy Table 2. Clinical presentation in 3,200 cases of diagnostic laparoscopy
from 1972 to 1994a
Clinical presentation
Elective Disease process Clinical presentation Cases

Hepatomegaly Malignancy / cirrhosis / abscess Hepatomegaly 898

Ascites Tuberculosis / cirrhosis / malignancy Splenomegaly (±hepatomegaly) 138
Jaundice Cirrhosis / ca pancreas / gallstone disease Ascites 599
Abdominal mass} Abdominal mass 370
Chronic abdominal pain} Various Jaundice 287
Undiagnosed fever} Chronic abdominal pain 261
Emergency Acute abdomen 192
Abdominal trauma} Various Fever 151
Acute abdomen} Miscellaneous 304
Total 3,200
a
The most common disease processes were malignancy, tuberculosis,
be performed) is detected, it is necessary to insert the second trocar. In cirrhosis. The highest diagnostic yield was in hepatomegaly (90%), the
our experience with DL, approximately 85% of cases require a second lowest in chronic pain and fever
puncture. The second puncture usually is made at the left McBurney
point for upper or middle abdominal pathology and at the right
McBurney point for lower abdominal pathology (in which case the
surgeon stands to the left of the patient). The Veress needle skin in- Table 3. Complications
cision is enlarged to permit entry of the 3- mm or 5-mm trocar, and the
second puncture is made under laparoscopic guidance after infiltration Cases (n)
of the prepreperitoneum at the selected puncture site with 2% ligno-
caine to ensure a painless penetration. Through the second cannula, Perforation (ileum) 1
various endoscopic procedures can be performed. Translaparoscopic Respiratory arrest after intravenous diazepam 1
procedures greatly augment the versatility and diagnostic potential of Wound infection 7
laparoscopy. They also increase the risks and complications. Bleeding, Surgical emphysema 12
perforation, and biliary leak can occur after biopsy, severing adhesions Pain over 24 h 9
and other translaparoscopic procedures. Translaparoscopic diathermy Mortality 0
carries the added risk of delayed perforation caused by injury to the Total 30
bowel.

Exit megaly. Findings have shown laparoscopy to be of

At the end of the laparoscopic procedure, it is necessary to ensure that
there is no intraperitoneal or retroperitoneal bleeding, and to remove
all the gas from the peritoneal cavity. Thereafter, the cannula is
withdrawn slowly by the assistant. The peritoneum and sheath, tightly
gripped by the cannula, are pulled up. They can be grasped and su-
tured, a necessary step in cases with ascites and whenever the 11-mm
cannula is used to avoid omental prolapse or herniation. The two skin
incisions are sutured. These two sutures, performed with the patient
under local anesthesia, complete a histologically established diagnosis
of abdominal pathology. Although DL is safe, it should not be taken
lightly as ‘‘easy.’’ A sticker on our instrument box says, ‘‘There is no
easy laparoscopy until it is over.’’
Results
special value in the diagnosis of unusual amoebic liver
abscess presentation [14].
Vargas et al. [17], in a summary of 1,794 cases over a
5-year period, found that DL gave a correct diagnosis in
98% of chronic liver disease cases, 91% of persistently
abnormal liver function test cases, and 85% of primary
or secondary liver malignancy cases. Stahel et al. [9],
working in rural Tanzania, found that only clinical
examination concurred with the final diagnosis in 40%
of cases, clinical and laboratory investigation in 46%
of cases, and the addition of DL without biopsy in 71% of
cases, whereas laparoscopy with biopsy yielded positive
results in more than 90% of cases.

The value of DL in clinical surgery is summarized in Abdominal tuberculosis

Table 1, our experience in Table 2, and our complica-
tions in Table 3.
Discussion
DL and the liver
The laparoscope is of great value for precise identifica-
tion of liver pathology [17]. Whereas cirrhosis and ma-
lignancy constituted the major cause of hepatomegaly in
our series, an appreciable number of hepatomegalies
were caused by abscesses, hydatid cysts, Riedl’s lobe,
polycystic disease, tuberculoma, and diffuse hepato-
Abdominal tuberculosis is a master of disguise. Zhang et
al. [20] found that the rate of accurate clinical diagnostic
was only 39.6%. Furthermore, a clinical misdiagnosis of
abdominal tuberculosis was determined for many pa-
tients. These authors believe that laparoscopy provides
the only way to confirm or disprove the diagnosis of
abdominal tuberculosis. Over the past 25 years, we have
observed a change in the presentation and pathology of
abdominal tuberculosis. More than 40% of all abdomi-
nal tuberculosis cases do not involve the alimentary
tract and may present in a bizarre manner [12]. Radio-
logic examination is of no diagnostic aid in these cases,
and ultimately, the diagnosis is based on exploration or
laparoscopy [7, 18, 20]. A large proportion of these

cases, if left untreated, would result in adhesions and
secondary bowel involvement with obstruction, making
surgery necessary [11]. Laparoscopy also is of value in
cases of bowel tuberculosis because the small bowel can
be visualized, adhesions and tubercles seen, dilated
bowel identified, and strictures evaluated.
Malignancy
In view of the frequency with which tumors of the gas-
trointestinal tract and ovaries metastasize or invade
adjacent viscera, laparoscopy can help with staging,
enabling clinicians to avoid unnecessary laparotomy in
many cases. It is useful for tumors of the liver, gall-
bladder, stomach, large intestine, ovary, and pancreas
[6]. A point not readily appreciated by the surgeon is
that with the help of the fore-oblique lens, alteration of
the pneumoperitoneum volume and the patient’s posi-
tion, and use of the probe, more than 75% of the liver
surface is visible at laparoscopy which is much more
than that seen during open surgery. The most vital role
of laparoscopy in malignancy is avoidance of unneces-
sary surgery in disseminated disease to the liver, bowel,
peritoneum, omentum, and lymph nodes.
Emergency laparoscopy
The examination is always performed by an experienced
laparoscopist with the patient with the patient under
general anesthesia and with full operation theater
preparation so operative laparoscopy or formal lapar-
otomy can be performed as indicated.
Abdominal trauma
A prerequisite for the use of DL in the management of
abdominal trauma is that the patient must be hemody-
namically stable. In the emergency setting, this is eval-
uated according to clinical criteria based on pulse, blood
pressure, urine output, volume depletion, and toxemia.
In almost every case, DL can establish whether the in-
jury has penetrated the peritoneum, both in the case of
stab wounds and in the case of tangential gunshot
wounds. If the peritoneum is penetrated, DL can es-
tablish the site and nature of the injury. Zantut et al. [19]
reported 510 cases (316 stab and 194 gunshot cases), of
penetrating injuries subject to DL. In 277 (54%) cases,
the patient was discharged within 48 h because DL
showed no peritoneum penetration. Laparoscopy has
a role to play in both penetrating and blunt trauma.
Superficial liver lacerations constitute more than 50%
of all liver injuries and stop bleeding spontaneously,
requiring no treatment. Even in the face of a ‘‘blood
tap’’ on paracentesis, if laparoscopy shows no active
liver bleeding and no other organ injury, unnecessary
surgery can be avoided [3]. Diagnostic laparoscopy
greatly improves quality of patient care and reduces cost
with no significant complications.
9
Acute abdomen
Diagnostic laparoscopy is assuming an increasingly
important role in the management of the acute abdo-
men. Acute abdominal pain constitutes one of the most
common surgical emergencies. The main value of DL is
in lower abdominal and pelvic pain among female
patients, especially during their reproductive years, to
exclude gynecologic causes or to confirm acute appen-
dicitis [4, 8]. In such cases, the diagnostic procedure
continues as therapeutic laparoscopic surgery if indi-
cated. Surgeons in developing countries see a need to
improve diagnosis and decision making for patients with
an acute abdomen to avoid unnecessary laparotomy.
Without the benefit of diagnostic aids such as CT scans
and high-resolution ultrasonography, the rate of un-
necessary laparotomy often is unacceptably high [10].
The laparoscopy usually is available in a developing
country (thanks largely to its constant use for tubal
ligation), and its use easily acquired.
Diagnostic laparoscopy has value in the diagnosis
and management of ischemic bowel diseases. After
surgery, we position a plastic trocar in the region of the
anastomosis to permit a ‘‘second look’’ at the bedside
after 2 or 3 days to ensure viability of the bowel.
A difficult diagnostic enigma is an acute abdomen in
patients who require intensive care for concurrent
medical problems. Diagnostic laparoscopy, particularly
using the 3-mm laparoscope with the patient under local
anesthesia and sedation is safe and a vital diagnostic
asset. It has value in confirming or excluding the diag-
nosis of acalculus cholecystitis, particularly in the in-
tensive care unit setting [1]. We are increasingly using
the 3.2-mm laparoscope for DL in abdominal trauma
and the acute abdomen because it increases safety with
no appreciable reduction in the diagnostic yield. La-
paroscopy in abdominal trauma and the acute abdomen
should be performed by an experienced laparoscopist
when the likely benefit will outweigh any risk. The main
objective is to avoid unnecessary surgery or to expedite
and plan surgery if indicated [2].
Diagnostic laparoscopy in developing countries
Diagnostic laparoscopy has its most important and ul-
timate application in the developing world. Less than
20% of the population in the developing world has ac-
cess to imaging devices such as ultrasound, CT scan,
MRI, or Doppler. By a happy paradox, vast areas of the
developing world have access to the laparoscope, thanks
largely to the use of this instrument in widespread family
planning campaigns in almost every developing country.
The equipment–cost ratio of laparoscopy/ultrasonog-
raphy/CT scan/MRI is 1:500:2500:4500. In an under-
developed community, most imaging devices are
available in large institutions and large cities, and the
laparoscope has a distinct added diagnostic impact in
developing countries [16]. The laparoscope has no
maintenance or recurring expenditure, needs no addi-
tional staff or floor space, and can be used safely
wherever electricity is available. We have used the same
 10
Table 4. Diagnostic laparoscopy for 3,200 patients under local anes-
thesia (1972–1990)
No mortality
0.09% Morbidity
Histologic diagnosis
Visual diagnosis
Positive diagnosis
Table 5. Equipment cost of diagnostic laparoscopy
Rupees
Equipment cost 37,000 (1972)
Repairs, replacement 57,000
Total 94,000
Used from 1972 to 1990 for 3,200 cases
Equipment cost per case Rs. 30.30 [50/- = $1/-]
a
The apparent disparity between the cost of equipment and the cost of
repairs, for example, results largely from the falling value of the rupee
over 30 years
instrument for more than 3,200 cases in a surgical unit
[15]. This often appears ‘‘remarkable’’ or ‘‘unbelievable’’
to workers in the developed world. However, they would
realize that fiberoptic bundles do not darken with use,
but with misuse if
1. their income is limited and they pay a large pro-
portion of their own annual income to purchase
the equipment, as in our case
2. the equipment is used only for welfare patients and
hence generates no revenue for the surgeon, as in
our case
3. they realize they cannot afford to buy new equip-
ment, as in our case
4. after every procedure the surgeon cleanses and
dries the equipment himself, as in our case.
Being underprivileged has distinct advantages. We have
prototyped a model that uses sunlight as the light
source. Besides being cost effective, laparoscopy has the
great advantage of providing a final histologic diagnosis
on target biopsy, with no element of shadow, image, or
conjecture. (Table 4). In developing countries with large
populations and an immense patient load, the initial cost
of the equipment, repairs, and the like is more than
compensated by the fact that the same equipment is used
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for a large volume of patients, making it entirely cost
effective in the long run (Table 5).
%
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