Indications for diagnostic laparoscopy can be divided into three broad groups. Gynecologic conditions include infertility, endometriosis, primary amenorrhea, pelvic pain in the female, and to rule out appendicitis in women with pelvic pain. In an effort to accurately diagnose or stage cancer, patients with gastric, esophageal, or pancreatic cancer may undergo diagnostic laparoscopy to stage the disease and determine resectability or direct further treatment. In patients with intra-abdominal lymphadenopathy, in whom lymphoma is a possibility, diagnostic laparoscopy is indicated to biopsy a representative lymph node to make the diagnosis. Benign conditions represent the third group that may benefit from diagnostic laparoscopy. Patients (typically those who have undergone previous abdominal procedures) with chronic abdominal pain and intermittent partial small bowel obstructions may benefit from diagnostic laparoscopy and adhesiolysis. Patients with symptoms suggestive of an inguinal hernia but who lack a clear inguinal hernia on physical examination may benefit from diagnostic laparoscopy. These patients may then be repaired laparoscopically. In patients with a unilateral inguinal hernia, laparoscopy can diagnose an inguinal hernia on the contralateral side to rule out a contralateral hernia. The laparoscopic incisions cause less pain, and there is a faster return to normal activities or work in the event that no therapeutic maneuvers are undertaken.
The patient must be optimized prior to undergoing an operative procedure. Respiratory function should be optimized with cessation of smoking and appropriate pulmonary function evaluation if indicated. A discussion with the patient should occur preoperatively because the findings at diagnostic laparoscopy may dictate further surgery, and consent should be obtained for these potential additional procedures prior to undergoing anesthesia. In the event the diagnostic laparoscopy is for adhesiolysis after previous abdominal procedures, the preceding operative note should be reviewed.
A general anesthetic with an endotracheal tube is required. The patient should be relaxed or chemically paralyzed with paralytics to facilitate relaxation of the abdominal wall and visualization with insufflation.
The patient is placed in a supine position with a pillow placed to produce mild flexion of the hips and knees. This helps to relax the abdominal wall. If visualization of the upper abdomen is required (e.g., for gastric, esophageal, or pancreatic cancer), the arms should be left “out” at 90 degrees. Video screens should be placed at the head of the bed just over the patient’s shoulders for viewing by the surgeon on the contralateral side (FIGURE 1). Patients undergoing laparoscopy of the pelvis should have their arms tucked at their side to facilitate the position of the surgeon to view the video screen(s) placed at the foot of the bed (FIGURE 2).
The patient is given perioperative antibiotics. An orogastric tube is passed for gastric decompression. For pelvic laparoscopy, a Foley catheter ...