Richtlinien der Society of American Gastrointestinal Endoscopic Surgeons (SAGES) zur diagnostischen Laparoskopie |
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1. Diagnostic Laparoscopy PREAMBLEThis is one of a series of statements discussing the utilization of laparoscopy in common clinical situations. This guideline was prepared by the Standards of Practice Committee of the Society of American Gastrointestinal Endoscopic Surgeons. Previous guidelines on this topic (SAGES Publication #0012) were written in 1991. Since that time, new information has been released that requires an update of this information and recommendations. In preparing this update, a literature search was performed, and additional references obtained from the bibliographies of the identified articles and from the recommendations of expert consultants. As little data exists from well-designed prospective trials, emphasis was given to the results from large series and reports from recognized experts. Revision of this guideline may be necessary as new data appear. Clinical consideration may justify a course of action at a variance from these recommendations. Clinical ApplicationDiagnostic laparoscopy is a procedure which allows the direct visual examination of intra abdominal organs including large surface areas of the liver, gallbladder, spleen, peritoneum, and pelvic organs.1,2 Directed biopsies can be obtained and may be more accurate than CT-guided aspiration biopsies. Laparoscopy allows a surgeon to diagnose and obtain information about dissemination of disease and to diagnose patients with equivocal abdominal findings.3,4 Since surgical procedures performed via laparoscopic access carry risks above and beyond that of diagnostic laparoscopy alone, they are addressed under separate guidelines. Diagnostic laparoscopy is safe and well tolerated and can be performed in an outpatient or inpatient setting under local or general anesthesia.5 During the procedure, the patient should be continuously monitored6 and resuscitation capability must be immediately available. Laparoscopy must be performed using sterile technique along with a high level disinfection of the laparoscopic equipment. Overnight observation may be appropriate in some outpatients. Indications
ContraindicationsContraindications may include a known ruptured diaphragm, hemodynamic instability, an uncooperative patient, mechanical or paralytic ileus, uncorrected coagulopathy, generalized peritonitis, severe cardiopulmonary disease, large hiatal hernia, abdominal wall infection, multiple previous abdominal procedures, and pregnancy.14,15 However, the final decision is determined not only by the clinical conditions, but also by the surgeon’s judgement. TechniqueInstruments used in diagnostic laparoscopy should include but are not limited to a laparoscope, trocar, grasping, biopsy, and retracting instruments as needed. Most instruments will range in size from 2-10 mm in diameter. Personnel should include the laparoscopist and a trained assistant to monitor blood pressure, pulse, respiratory rate, oxygen saturation, EKG and level of sedation. Many patients having diagnostic laparoscopy can be done under local anesthesia with intravenous sedation as necessary. When general anesthesia is necessary, a trained anesthetist or anesthesiologist should be present. Initial entry into the abdomen can be obtained by the Veress needle or cut down technique. The abdomen is appropriately insufflated and additional trocars inserted as needed. Insufflation pressure should be limited to 10 mm Hg in a spontaneously breathing patient. Routine laparoscopic examination of the abdomen may include evaluation of peritoneal surfaces, diaphragm, liver, spleen, gallbladder, stomach, small intestine, colon, pelvic organs, and retroperitoneal tissues and organs. Appropriate biopsies, cytology, cultures and fluid analysis may be performed as necessary and / or other imaging modalities may be useful. ComplicationsComplications may occur during creation of the pneumoperitoneum, trocar insertion, or during the diagnostic exam. These complications include but are not limited to, 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 of the insufflation gas. Wound infection or leakage of ascites may occur postoperatively. Failure to accurately diagnose the extent of intra-abdominal pathology is another potential complication. ConclusionDiagnostic laparoscopy is useful for patients in whom the diagnosis or extent of the disease is unclear or the abdominal findings are equivocal. It can be performed safely in an inpatient or outpatient setting, potentially expediting diagnosis and treatment. References
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