Role Of Laparoscopy In Diagnosis Biology Essay

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Diagnostic laparoscopy is being practiced for many decades by; physicians and gynaecologists. It is more frequently used in the diagnosis of various surgical disorders for last three decades. Many patients with chronic abdominal pain undergo various diagnostic tests with little or no change in their pain. Diagnostic laparoscopy may help in avoiding unnecessary laparotomy, provide accurate diagnosis and help in planning optimal therapy in these selected patients. Our objectives were to evaluate the role of laparoscopy in the diagnosis of chronic abdominal disorder and its impact on the management of these patients and to study the role of laparoscopy in preventing unnecessary laparotomy in selected medical patient and in patient with advanced abdominal malignancy.

A retrospective study of 70 patients with chronic abdominal disorder admitted in a surgical unit in a government medical college from June 2009 to December 2011 was carried out. Most of these patients were referred by physician and were investigated by the referring physician. Investigations included haematology, biochemistry, radiology, ascitic fluid analysis, endoscopic and imaging studies and the Monteux test. They were referred for elective diagnostic laparoscopy and tissue biopsy. Diagnostic laparoscopy confirmed the diagnosis in all patients suspected of malignancy.(13) There was 80% impact of diagnostic laparoscopy on the management of patients with chronic abdominal disorders in our study. Diagnostic laparoscopy is proven to have a significant diagnostic and therapeutic role in a patient with chronic abdominal disorder, where the diagnosis remained uncertain after the laboratory and non-invasive investigation.

Keywords: Laparoscopy, Diagnostic laparoscopy, Abdominal disorder, Chronic abdominal disorder, Laparoscopy in diagnosis, CAD.

INTRODUCTION

Diagnostic laparoscopy is being practised for almost a century,(1) but it gain the popularity among the general surgeons for last three decades after the first laparoscopic cholecystectomy performed in 1980.many of the time diagnosis remains elusive despite numerous non invasive diagnostic tests like ultrasonography computed tomography and magnetic resonance imaging.(2,3) Currently, diagnostic laparoscopy is getting wide acceptance as an alternative to laparotomy in a selected group of patients with abdominal pathology. Beside the benign intra abdominal disorders, it is very beneficial in patients with intra abdominal malignancy not only in making diagnosis but also in staging and identification of inoperability.(4-9) Thus, unnecessary laparotomy may be avoided in many patients with advance stage intra abdominal malignancy.

Laparoscopy is the most reliable method to detect peritoneal metastasis. In many of these patients, palliative surgery can be undertaken by the same time.(17) This study details the experience of 70 patients who had elective diagnostic laparoscopy for chronic abdominal disorders in whose history clinical examination, laboratory tests and non-invasive, or even invasive, radiological investigations had failed to give accurate diagnosis.

LITERATURE REVIEW

A lot of literature about Diagnostic Laparoscopy (DL) exists. Diagnostic laparoscopy is used in many clinical conditions in recent years. On Medline search there are more than 700 articles related to diagnostic laparoscopy in the last 10 years. They can be categorized as:

Prospective studies

Retrospective studies

Case reports

Review articles

Systemic review, Meta analysis, Randomized controlled trials were selected for further review along with prospective and retrospective studies that included at least 50 patients; studies with smaller samples were reviewed when other available evidence was lacking.

Following categorization can be done to increase the efficiency of the review:

Diagnostic laparoscopy for acute conditions -

Acute abdomen

Trauma

ICU

Diagnostic laparoscopy for chronic conditions -

Abdominal Tuberculosis

Chronic Pelvic Pain and Endometriosis

Liver Disease

Infertility

Others

Staging laparoscopy for cancer -

Oesophageal cancer

Gastric cancer

Pancreatic and peri ampullary cancers

Liver cancer

Biliary tract cancer

Colorectal cancer

Lymphoma

History of Laparoscopy

The earliest recorded references to endoscopy date to ancient times with Hippocrates, in his description there is explanation of rectum examination with a speculum.

In 1585, Aranzi was the first to use a light source for an endoscopic procedure, focusing sunlight through a flask of water and projecting the light into the nasal cavity.

In1706, the term "trocar," was coined in 1706, and is thought to be derived from trochartor troise-quarts, a three-faced instrument consisting of a perforator enclosed in a metal cannula.

In 1806, Philip Bozzini, built an instrument that could be introduced in the human body to visualize the internal organs. He called this instrument "LICHTLEITER".

In 1853, Antoine Jean Desormeaux, a French surgeon first introduced the "Lichtleiter" of Bozzini to a patient. For many surgeons he is considered as the "Father of Endoscopy".

In 1867, Desormeaux, used an open tube to examine the genitourinary tract, combining alcohol and turpentine with a flame in order to generate a brighter, more condensable beam of light.

In 1901, The first experimental laparoscopy was performed in Berlin in 1901 by German surgeon Georg Kelling.

In 1910, H.C. Jacobaeus of Stockholm published a discussion of the inspection of the peritoneal, pleural and pericardial cavity.

In 1920, Zollikofer of Switzerland discovered the benefit of CO2 gas to use for insufflation, rather than filtered atmospheric air or nitrogen.

In 1934, John C. Ruddock, an American surgeon described laparoscopy as a good diagnostic method, many times, superior than laparotomy.

In 1938, Janos Veress of Hungary developed a specially designed spring-loaded needle. He used veress needle for the induction of pneumothorax.

In 1939, Heinz Kalk published his experience of 2000 liver biopsies performed using local anaesthesia without mortality.

In 1944, Raoul Palmer, of Paris performed gynaecological examinations using laparoscopy.

In 1966, Kurt Semm introduced an automatic insufflation device capable of monitoring intra-abdominal pressures.

In 1973, Gaylord D. Alexander developed techniques of safe local and general anaesthesia suitable for laparoscopy.

In 1977, first Laparoscopic assisted appendicectomy was performed by Dekok. Appendix was exteriorized and ligated outside.

In 1978, Hasson introduced an alternative method of trocar placement. He proposed a blunt mini-laparotomy which permits direct visualization of trocar entrance into the peritoneal cavity.

In 1983, Semm, a German gynaecologist, performed the first laparoscopic appendicectomy.

In 1985, the first documented laparoscopic cholecystectomy was performed by Erich Milhe in Germany in 1985.

In 1987, Phillipe Mouret, has got the credit to perform the first laparoscopic cholecystectomy in Lyons, France using video technique.

In 1990, Bailey and Zucker in USA popularized laparoscopic anterior highly selective vagotomy combined with posterior truncal vagotomy.

In 1996, first live telecast of laparoscopic surgery performed remotely via the Internet. (Robotic Telesurgery).

B. Decadt, L. Sumsman et al. (1999) from U.K. conducted a Randomized clinical trial of early laparoscopy in the management of non specific abdominal pain.

MATERIALS AND METHODS

Prospective and retrospective study was taken in a single surgical unit in a government medical college.This study was done in 70 patients with chronic abdominal disorder who were referred to us diagnosis was elusive in these patients despite numerous non invasive tests from June 2009 to Dec 2011 for epidemiology, clinical presentation, laboratory tests, imaging investigations, indications and findings in diagnostic laparoscopy as well as biopsy results.

Prior to laparoscopy, all the patients were investigated completely by the referring physicians. These investigations includes complete blood count ,coagulation profile ESR, serum electrolytes, creatinine and liver function tests, Monteux test, and ultrasound (US) and computerized (CT) scans of the abdomen. Magnetic resonance (MR) scan was employed selectively, where indicated. Upper GI endoscopy, colonoscopy and barium meal and follow through were done in selected patients. Ascitic fluid analysis for biochemistry and cytology was performed in patients with clinical ascites. Where the accurate diagnosis could not be made despite all relevant investigations, diagnostic laparoscopy was requested for defining the pathology and obtaining tissue biopsy.

Diagnostic laparoscopy was done electively under general anaesthesia after preoperative anaesthetic check-up. The two ports technique was used routinely employing 10 mm sub umbilical port for telescope and 5 mm port for probing, diathermy and biopsy in the relevant abdominal quadrant. An additional 5mm port was inserted only if necessary. No urinary catheter was used. The whole peritoneal cavity, including the pelvis, was thoroughly examined routinely. Multiple biopsies were obtained from the suspected pathology and sent for frozen section in order to confirm the adequacy of the sample.

The impact of the procedure was considered positive if the laparoscopy revealed pathology, which may be responsible for the patient's symptoms.

Limitations of the Study

Main limitation of our study is unavailability of high resolution ultrasound probe in our set up. Diagnostic accuracy of the procedure can be further enhanced by use of laparoscopic ultrasonography. Laparoscopic ultrasound easily detect intra parenchymal lesion other peri ampullary lesion missed on conventional laparoscopy.(24,25)

Other limitation of the study is unavailability of DNA PCR for patient suspected to have tuberculosis. Literature related to such studies in similar set up is less available. To draw more significant conclusion more similar studies and prospective studies are needed and more patient should be included in study. There is also a need of placebos controlled study in which patients are randomized in to laparoscopy and conservatively treated group with the measurement of quality of life.

RESULTS, ANALYSIS AND DISCUSSION

Results and Analysis

In the present study 70 patients with suspected chronic abdominal disorder are studied from June 2009 to December 2011.Incidence of patient with chronic abdominal pain was 2.2% during this duration. Out of 70 patients with chronic abdominal disorder 37 were male and 33 were female. Maximum patients belong to 5th decade of life followed by 3rd decade and fourth decade.53% patients were above the 40 years of age. And 27% were above 50 years of age. The age range was 15-80 years. (see Table 1).

Table 1: Age and Sex Incidence

Age Group

Male

Female

Total

0-10 yrs.

0

0

0

11-20 yrs.

3

3

6

21-30 yrs.

4

10

14

31-40 yrs.

8

5

13

41-50 yrs.

10

8

18

51-60 yrs.

7

3

10

>60

5

4

09

TOTAL

37

33

70

Mean age for all 70 patients was 43 ± 2.3 years.5 patients were presented with acute presentation and rest were presented with chronic presentation. Patient with acute presentation were having history of similar pain at least 2 times in last 3 months. All the patients were having pain of at least 12 weeks duration. Pains in abdomen of less than 12-week duration were not included in our study. (see Table 2)

Table 2: Mode of Presentation (n=70)

Presentation

No. of Cases

Acute presentation

05

Chronic presentation

65

According to Table 3, presenting features of the patients were pain(n=52), loss of weight(n=24), anorexia(n=20), distension of abdomen(n=17), vomiting(n=14), fever(n=8) and diarrhoea(n=3). Main physical findings were tenderness(n=35), lump in abdomen(n=15), doughy abdomen(n=19) and free fluid (n=9). (see Table 4).

Table 3: Presenting Complaints (n=70)

Characteristic

No of Patients

Distension of Abdomen

17

Pain in abdomen

52

Loss of Weight

24

Anorexia

20

Fever

8

Vomiting

14

Diarrhea

03

Table 4: Physical Signs

Characteristics

No of Patients

Tenderness

35

Lump in abdomen

15

Doughy Abdomen

19

Free Fluids

05

Monteux test was positive in 16 patients out of 24 patients later diagnosed to have tuberculosis. Plain x-ray ultrasonography and CT scan was done in all 70 cases. X-ray was positive only in two cases, ultrasonography was positive in 23 cases ct was positive in 42 cases. Here positivity means some abnormality suggestive of pathology, but they cannot form the basis of diagnosis.mri was done in one case with hepatic malignancy and was positive.

These all patient were subjected to elective laparoscopy under general anaesthesia. Laparoscopic findings were peritoneal/omental tubercles(n=22), followed by ascites(n=20), liver tubercle(n=9), mesenteric lymphadenopathy(n=4), inflamed appendix(n=5), salpingitis(n=4), small bowel band(n=2), diverticulosis(n=2) and hemangioma liver(n=1).

No abdominal pathology was detected on laparoscopy in 14 patients (see Table 5). Ascitic fluid analysis suggestive of exudative fluid in 20 patients and tansudative fluid in 8 patients. Malignant cell were detected in ascetic fluid of two cases (see Table 6).

Table 5: Laparoscopic Finding (n=70)

Characteristic

No of Patients

Peritoneal /Omental tubercles**

22

Ascites

20

Liver tubercles

9

Inflammed Appendix

05

Salpingitis

04

Lymphadenopathy

04

Nodular Liver

02

Colitis

02

Diverticulosis

02

Small Bowel Band

02

No Abdominal Pathology

11

.

**Many patients with peritoneal tubercles also have liver tubercles and ascites.

Table 6: Ascitic Fluid Analyses

Characteristic

No of Patients

Exudative (Protien >3 gm/dl)

20

Transudate (Protein (>3G/Dl)

08

Malignant cells

02

Biopsied tissues for histopathological examination were lymph node, peritoneal / omental tissue/ liver tissue, gut wall .Lymph node biopsy (n=4) suggestive of granuloma with giant cell in 02 cases, tubercles with caseation in 1 case and 1 case with non specific changes. Peritoneal/omental/liver deposits biopsy were performed in 28 cases, granuloma with giant cell found in 12 cases, feature consistent with malignancy in 6,tubercle with caseation in 8 and non specific changes in 2 cases. Gut wall biopsy was done in 08 patient, 06 cases having feature suggestive of malignancy, one was having tubercle with caseation one was having no specific finding.(see Table 7)

Table 7: Histopathologica Examination

Biopsied Tissue

No. of Patient

Granuloma with Giant Cells

Features Consistent with Malignancy

Tubercles with Caseation

Non Specific

Lymph node

04

02

00

01

01

Peritoneal tissue/Omentum/liver tissue

22

12

06

08

02

Gut wall

08

00

06

00

02

Final laparoscopic diagnosis was based on classical finding (i.e. peritoneal/omental tubercle, liver tubercle, ascites, and adhesion), histopathology and ascetic fluid analysis. With the aid of laparoscopy, 43 cases were diagnosed to have benign disease. This group includes tuberculosis(n=24), sub acute appendicitis (n=5), mesenteric lymphadenitis(n=4), pelvic inflammatory disease(n=4), benign liver disease(n=3), small bowel band(n=2), diverticulosis(n=2), colitis(n=2). All the patients with inflamed appendix were subjected to appendicectomy, later appendicitis was confirmed in all cases on histopathology. Three out of four patients with mesenteric lymphadenitis were confirmed tubercular after histopathology reports. Patients with pelvic inflammatory disease and colitis were treated with antibiotics. In patients with small bowel band, band was relieved laparoscopically. One out of three patients with benign liver disease was diagnosed hemangioma. No biopsy was taken in this case; two cases were diagnosed as cirrhosis of liver.

Table 8: Final Diagnosis of the Patients (n=70)

Benign Diseases

43

Tuberculosis

24

Sub-Acute Appendicitis

05

Pelvic Inflammatory Disease

04

Benign Live Disease

03

Small Bowel Band

02

Diverticulosis

02

Colitis

02

NonSpecific Lymphadenitis

01

Malignant Disease*

13

Gastric Malignancy

07

Esophageal Malignancy

02

Pancreatic Malignancy

02

Hepatocellular carcinoma

01

Lymphoma

01

No Abdominal Pathology

14

*Laparoscopy done for staging purposes.

Malignancy was confirmed in 13(18.57%). In these cases laparoscopy was done for staging purpose. 6 out of 7 patient with gastric malignancy were having ascites and peritoneal carcinomatosis, thus with the help of lapa roscopy unnecessary laparotomy was avoided in these cases. One case with gastric malignanay was found to have resectable disease. This case was converted to laparotomy and D2 gastrectomy was done. A laparoscopic gastrectomy with D2 dissection is performed in limited number of institution.(28-29) However, few reports of laparoscopic gastrectomy for advance gastric cancer are available.(30,31) Other malignancy diagnosed were hepatocellular carcinoma (n=1), oesophageal carcinoma (n=2), pancreatic carcinoma (n=2) and lymphoma (n=1). Peritoneal seedling was detected in both patient with pancreatic malignancy and one patient with hepatocellular malignancy. Biopsy was taken in these patients. Both patient with pancreatic malignancy were having obstructive jaundice, these patients were subjected to laparoscopic surgery to relieve jaundice, thus avoids the complication of stent placement. Patient with lymphoma was diagnosed by CT scan as a large peritoneal mass; laparoscopy confirms the presence of mass. In addition, multiple tumour deposits were noted in liver surface. Biopsy was taken, result reveals lymphoma of B cell origin. In both the patient with oesophageal malignancy, no intraabdominal disease was detected on laparoscopy. Both the patients were subjected to oesophagectomy.

DISCUSSION

There are many retrospective studies on the diagnostic use of laparoscopy in surgical practice. Our study confirmed the previously reported experiences.(2,3,5-10,12-15) Furthermore, influence of laparoscopy in the management of patient with chronic abdominal disorder was confirmed. With the aid of laparoscopy incidence of diagnosis to be missed is low, but this can be reduced further with the use of laparoscopic ultrasound, which allows the detection of intraparenchymal lesion of solid viscera, not detected on visual inspection.

Diagnostic yield of laparoscopy in the patient with chronic abdominal disorder is around 70%-75% as per previous studies.(16-17) The data obtained in the patient with chronic abdominal disorder support a policy of early laparoscopy in a preference to multiple expensive investigations before the patient is subjected to laparoscopy. In our study diagnostic yield of laparoscopy is around 80%. In our study most common diagnosis among the patients with chronic abdominal disorder is tuberculosis (n=24). Incidence of tuberculosis in our hospital is around 3.7%. Incidence of patient with chronic abdominal disorder is 2.2% in our hospital. Tuberculosis is still a very common disease in this region despite the various campaigns by the government of India to eliminate this disease. Incidence of abdominal tuberculosis in our hospital is 1.4%. Laparoscopic finding in these patients were ascites peritoneal tubercle, liver tubercle, bowel stricture and bowel adhesion. All these patients were subjected to anti tubercular treatment for at least 6-month duration.

Many of the female patient with childbearing age group with tub ovarian abnormality often present with right lower abdominal pain simulating appendicitis. A subset of these patients with acute abdominal pain who were subjected to unnecessary appendicectomy suffer complication which may lead to infertility.(18) Thus, with the aid of laparoscopy unnecessary surgery can be avoided in such patients .All these patients were further treated with antibiotics and anti inflammatory drugs, symptoms were completely relieved in 3 of 4 patients and one patient got the relief from pain partially.

In our study there were 5 patients with sub acute appendicitis, all these patients underwent appendicectomy, later the diagnosis was confirmed on histopathological examination. In all these cases pain was found relived after two week follow up.

In present study, ileal band was diagnosed in two cases which were released laparoscopically. Symptoms of these patients were found relieved in both cases post operatively. Diverticulosis was diagnosed in two cases, but no inflammation was detected over diverticula in any of these cases. No treatment was given in these patients. Colitis was diagnosed in two patients, both these patients underwent antibiotic treatment and both the patient were significantly relieved from pain on 6 week follow up.75% of the patient with mesenteric lymphadenitis were relieved from pain after completion of anti tubercular treatment. In the sub group of patients with benign liver disease one was found to have hemangioma, two were having cirrhosis of liver. Nothing was done in these patients.

Laparoscopy allows the better inspection of both diffuse and focal liver disease. Diagnostic yield of laparoscopic biopsy was higher than the percutaneous biopsy.(4,19,20) Benign liver disease, i.e. cirrhosis can be missed in 20% of the cases by percutaneous biopsy technique as per various randomized trials.(4) Diagnostic yield of laparoscopic guided biopsy was significantly higher for both diffuse and focal liver disease.(20)

There is lack of imaging and laboratory test that can evaluate with sufficient accuracy, the resectebility of intra abdominal tumours.(21) Several studies have reported the advantage and reliability of laparoscopy in the detection of advanced inoperable disease.(5-11) In our study 6 out of 7 patient with gastric malignancy, both the cases of pancreatic malignancy, case with lymphoma and hepatic malignancy found un resectable on laparoscopy. Thus, unnecessary laparotomy was avoided in these patients with the aid of laparoscopy.

Many pancreatic lesions are difficult to be detected by computed tomography. Intra parenchymal lesions are usually missed on imaging if significant dilatation of pancreatic duct is absent.(26-27) Repeat CT scan at a certain interval causes undue anxiety both to patient as well as treating physician. These patient usually underwent to a diagnostic laparotomy.(6-11,22,23) Further accuracy can be enhanced by the use of laparoscopic ultrasound. Usually all the cases with pancreatic lesion are easily diagnosed on endoscopic retrograde cholangio pancreaticography, but this cannot provide relevant information on staging and resectebility of the disease. Small size peritoneal tubercles of carcinomatus peritonei are missed on computed tomography, but are easily visualized on laparoscopy.(32)

In our study no abdominal finding was detected in 14 patients. In all these patients tuberculosis, malignancy and other obvious lesions are excluded. Furthermore with the aid of high frequency ultrasound probe, diagnostic yield of laparoscopy can be increased.

CONCLUSION

Laparoscopy has significant role in the diagnosis of patient with chronic abdominal disorder. There is significant role of laparoscopy in planning the treatment in such patients. Laparoscopy alleviates the symptoms in more than 80% of the patient with chronic abdominal disorder. Definite advantage of this procedure is that un necessary laparotomy can be avoided in the patients with inoperable intra abdominal malignancy and certain medical diseases. Similarly unnecessary appendicectomy and it's possible complication can be avoided in a female of child bearing age group with tubo ovarian lesion ,presenting with right iliac fossa pain simulating appendicitis .Various therapeutic procedure can be easily done by laparoscopy in same sitting i.e. appendicectomy, adhesiolysis, band release ,palliative surgery for reliving obstructive jaundice in unresectable pancreatic malignancy.

Scope for Further Research

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