The role of laparoscopy in the diagnosis and treatment of abdominal pain syndromes

BACKGROUND: Diagnostic laparoscopy plays a significant role in the evaluation of acute and chronic abdominal pain in the era of therapeutic laparoscopic surgery. METHODS: We referred to our personal series of laparoscopy for both acute and chronic abdominal pain. This is a retrospective review of data accumulated prospectively between 1979 and the present. RESULTS: In our series, 387 consecutive patients underwent laparoscopy because of abdominal pain. In a group of 121 patients with acute abdominal pain, a definitive diagnosis was made in 119 cases (98%). Two patients needed laparotomy to confirm the diagnosis; both had a disease process that did not require laparotomy to treat. A definitive therapeutic laparoscopic procedure was performed in 53 cases 944%). In 45 patients (38%), a diagnosis was made that did not require therapeutic laparoscopy or laparotomy to treat. In the remaining 21 patients (17.5%), exploratory laparotomy was needed to treat the condition. In a chronic abdominal pain group of 265 patients, the etiology was established laparoscopically in 201 cases (76%). A definitive therapeutic laparoscopic procedure was performed in 128 patients (48%). There was a normal laparoscopic examination in 64 patients (24%). There was one false negative laparoscopy that required laparotomy to treat 1 month later. CONCLUSIONS: Laparoscopy is an accurate modality for the diagnosis of both acute and chronic abdominal pain syndromes. These data support the use of laparoscopy as the primary invasive intervention in patients with acute and chronic abdominal pain.     

Primary epiploic appendagitis: US and CT findings

A retrospective review is presented of seven cases of epiploic appendagitis, with surgical confirmation in one case. The main clinico-analytical data and the US and CT findings are described, as well as the histopathologic features in the sole case that underwent surgical resection. We also calculated the frequency of this entity in patients undergoing emergency abdominal US on clinical suspicion of diverticulitis. In all seven cases the clinico-analytical evidence was nonspecific (localized acute abdominal pain and slight leukocytosis), mimicking in six cases the clinical presentation of sigmoid diverticulitis and in one case that of acute appendicitis. US imaging findings were characteristic: a hyperechoic mass localized under the point of maximum pain, adjacent to the anterior peritoneal wall and fixed during deep breathing. In none of the cases did color Doppler US show flow. CT findings were also typical and showed a mass with a peripheral hyperattenuated rim surrounding an area of fatty attenuation. Overall 7.1 % of patients investigated to exclude sigmoid diverticulitis finally showed findings of primary epiploic appendagitis. Primary epiploic appendagitis thus shows characteristic US and CT findings that allow its diagnosis and follow-up. This entity is much more frequent than previously reported, especially in patients referred for US to exclude sigmoid diverticulitis.     

Outcome after exploratory laparoscopy for unexplained abdominal pain in childhood

BACKGROUND: Abdominal pain in childhood is common yet frustrating when unexplained. OBJECTIVE: To describe the clinical features and outcome of 8 children (6 girls and 2 boys; mean[+/- SD] age, 13 +/- 2 years) with unexplained abdominal pain who underwent exploratory laparoscopy. SETTING: All 8 patients were examined at an academic pediatric gastroenterology center and referred for exploratory laparoscopy because of unexplained abdominal pain. Laparoscopy was offered after family agreement to pursue behavioral management if the pain and disability did not improve. RESULTS: In all 8 children, laparoscopy detected an anomaly at a site corresponding to that of the abdominal pain. Findings were adhesions in 7 children (3 colonic, 2 ileocecal, 1 gastric, and 1 appendiceal) and ovarian torsion in 1 child. At a mean follow-up of 12.6 months, the abdominal pain had completely resolved in 6 children, notably improved in 1 child, and continued unchanged in 1 child. Disability completely resolved in 2 of 3 children. CONCLUSIONS: In children with unexplained abdominal pain that is acute in onset, well described, and suggestive of peritoneal involvement, exploratory laparoscopy (1) successfully ends the cycle of abdominal pain in most cases; and (2) commonly identifies abnormalities, usually adhesions. However, whether laparoscopy, the placebo effect, or both promote the healing process is unclear. Further study is needed to develop criteria for referral for laparoscopic evaluation of unexplained abdominal pain.     

Diagnostic laparoscopy through the right lower abdominal incision following open appendectomy

BACKGROUND: Diagnostic laparoscopy through the right lower abdominal incision following open appendectomy for suspected acute appendicitis may help in making the correct diagnosis in the absence of pathology of the appendix. METHODS: Fourteen patients with a clinical diagnosis of acute appendicitis underwent diagnostic laparoscopy through the right lower quadrant incision after open appendectomy to exclude further pathology in the case of a noninflamed appendix. RESULTS: In 10 of the 14 patients, laparoscopy helped to correct the diagnosis. In two patients, the etiology of the acute right lower abdominal pain remained unclear. In two others, histological examination showed acute appendicitis despite a normal macroscopic appearance. CONCLUSIONS: Diagnostic laparoscopy through the right lower quadrant incision may help to correct the diagnosis in patients who are operated on for clinically acute appendicitis but in whom no acute appendicitis or other pathological findings are seen.     

Laparoscopy for chronic abdominal pain

BACKGROUND: This purpose of this investigation was to evaluate the utility of laparoscopy in patients with chronic abdominal pain. METHODS: A retrospective review was performed of 34 patients who underwent laparoscopy for chronic abdominal pain. Average patient age was 39 years. The majority were women. Most had undergone abdominal surgery in the past. RESULTS: All procedures were performed laparoscopically. A positive finding was made in 65% of patients. Fifty-six percent of patients underwent adhesiolysis, but 26% required no operative intervention other than laparoscopic exploration. Notably, 73% of patients reported improvement in pain postoperatively, whether or not a positive finding had been made on laparoscopy. CONCLUSIONS: This retrospective study suggests laparoscopy can identify abnormal findings and improve outcome in a majority of selected cases. Recommendations are provided for patient selection. Prior abdominal surgery is not an absolute contraindication to laparoscopic exploration for chronic abdominal pain.     

Pre-peritoneal bisaccular umbilical and subcutaneous abscess after laparoscopic appendectomy

Laparoscopic surgery has gained much interest since its advent the late eighties. A 36-year-old patient underwent laparoscopic appendicectomy via the transumbilical route. She was rehospitalized three times thereafter for subumblical pain. At day +48, an abscess was evacuated at the point of the umbilical trocar insertion. This hour-glass shaped abscess had a preperitoneal and subcutaneous localization, blocked by the epiploic reaction. The infection this patient developed is an unusual clinical finding as pain was localized at a distance. The umbilical site and the preperitoneal subcutaneous nature of the abscess are also unusual. This case emphasizes the gravity of post-operative abscess of the abdominal wall and the necessity for adequate prophylaxy.     

Chronic abdominal pain: role of video-laparoscopic adhesiolysis

Adhesions have been suggested as a possible cause of chronic abdominal pain, but the reports of their etiological role conflict. Lysis of adhesions has been proposed as the therapeutic modality of choice, although the reports of success are controversial. The aim our prospective study was to determine whether laparoscopic adhesiolysis ameliorates chronic abdominal pain in patients with abdominal adhesions. Forty-one patients with chronic abdominal pain lasting for more than 6 months, but with no abnormal findings other than adhesions found at laparoscopy, underwent laparoscopic adhesiolysis. 37 patients (90.2%) were available for follow-up after a median time interval of 18 months (range: 12-41 months). Twenty-two patients (59.4%) were free from abdominal pain and 9 (24.3%) patients reported significant amelioration of their pain. Six (16.2%) patients had no amelioration. In conclusion the laparoscopy is an effective tool for the evaluation of patients with chronic abdominal pain, and laparoscopic adhesiolysis cures of ameliorates chronic abdominal pain in more than 80% of patients.     

The analgesic efficacy of tenoxicam versus placebo in day case laparoscopy: a randomised parallel double-blind trial

The analgesic efficacy and duration of action of tenoxicam, an injectable non-steroidal analgesic with a long elimination half-life, were studied in day case laparoscopy in a double-blind randomised prospective parallel placebo-controlled trial. Tenoxicam 20 mg or saline was given intravenously at induction of anaesthesia in 67 women undergoing day case investigative laparoscopy for infertility or abdominal pain. Outcome measures were time to first analgesia, pain levels at 2, 4 and 24 h plus postoperative analgesic consumption in hospital and at home. The study showed no statistically significant difference in any of these measures between the two groups. Tenoxicam 20 mg intravenously immediately pre-operatively cannot be recommended for day case surgery on the basis of this study.     

Cutaneous blood flow changes and weal induced by intradermal bradykinin following pretreatment with indomethacin and captopril

Ruptured duodenal peptic ulcer is a serious complication of ulcer disease that occurs in approximately 5% of cases and accounts for over 70% of deaths associated with peptic ulcer disease. This case report details the management of a 67-year-old male with a ruptured duodenal peptic ulcer who presented to the emergency room with acute onset of severe abdominal pain. There was no past history of ulcer disease. An abdominal x-ray suggested the presence of free air, and diagnostic laparoscopy was performed. The superior exposure afforded by this minimally invasive technique not only permitted an exact diagnosis to be made, but also afforded a means to expeditiously correct the pathologic defect.     

Diagnosis of hepatocellular carcinoma by needle puncture--aspiration and cytological test. The experience in Cameroon

Acute appendicitis is believed to be one of the commonest causes of the acute abdomen in tropical Africa. Negative appendicectomy rates are usually above 20%, which is now considered unacceptably high because of increased risk to patients and the availability of diagnostic facilities to aid clinical decision-making. Our negative appendicectomy rate over a 4-year retrospective period was 29.7% in males, and 47% in females. These reduced to 11% and 10%, respectively, after the introduction of laparoscopy for doubtful cases of acute abdominal pain.     

Isolated torsion of the fallopian tube. A case report

BACKGROUND: While torsion of the adnexa is relatively common, isolated torsion of the fallopian tube alone remains a rare occurrence. Diagnosis and surgical intervention are often delayed. CASE: A 38-year-old woman presented with acute lower right abdominal pain initially managed as renal colic. She returned to the emergency department three days later. After surgical consultation, a computed tomography scan and ultrasound showed a cystic pelvic mass with normal ovarian flow studies. Ultimately, the gynecology team performed laparoscopy with the suspicion of intermittent adnexal torsion. A 6 x 8-cm, twisted, dusky purple right fallopian tube was noted. A laparoscopic salpingectomy was performed. CONCLUSION: In the differential diagnosis of acute lower abdominal pain, isolated torsion of the fallopian tube should be considered. A timely diagnosis and surgical intervention may allow preservation of the tube. Even when irreversible damage has occurred, laparoscopic management is recommended.     

Outcome of nonspecific right iliac fossa pain syndromes

One-third of all cases of abdominal pain and a quarter of cases of right iliac fossa pain urgently admitted to hospital leave hospital with no precise diagnosis. Based on a series of 400 patients hospitalised for right iliac fossa pain, comprising 107 cases with no identified aetiology, this prospective study was designed to assess the medium-term outcome of these patients, with or without surgical exploration. 67 cases were reviewed at five years. No major diagnosis was missed. Over this 5-year period, 30 patients (45%) experienced another episode of abdominal pain. Among the third of patients (21 cases, 31%) reviewed for another episode of right iliac fossa pain, 7 were readmitted to hospital, with 5 operations, for histologically confirmed acute appendicitis in 3 cases (5% of the series). The patient and his attending physician must be informed of the nonspecific diagnosis established during the first hospitalisation. There is no significant evidence to suggest a psychological component in the recurrent nature of the pain. Cancer must be formally excluded in patients over the age of 50. When surgical exploration is performed, nowadays by laparoscopy, appendicectomy is recommended. This procedure does not decrease the risk of recurrent pain, but confirms the real absence of histopathological abnormality and decreases the number of subsequent hospitalisations.     

Pelvic abscess after ultrasound-guided aspiration of endometrioma: a case report

A 31-year-old female with four years of infertility due to endometriosis and severe pelvic adhesions underwent transvaginal ultrasound-guided aspiration of an ovarian endometrioma before ovulation induction for in vitro fertilization (IVF) and embryo transfer. Seven days following the aspiration, the patient developed acute abdominal pain; diagnostic laparoscopy was performed at a local medical center, revealing a right tubo-ovarian abscess. Exploratory laparotomy ensued and right salpingo-oophorectomy was performed. A combination regimen of three antibiotics was administered and the patient was transferred to the intensive care unit of the Cathay General Hospital two days after surgery for further care. Her postoperative condition was uneventful and she recovered quickly. The patient then continued with further IVF treatment.     

Ovarian abscess following puncture of an endometrioma during ultrasound-guided oocyte retrieval

A 34-year-old white female patient with 11 years of primary infertility due to endometriosis underwent ultrasound-guided oocyte retrieval for in-vitro fertilization. A right ovarian endometrioma was aspirated during oocyte retrieval. Two weeks after follicular aspiration, the patient developed acute abdominal pain and operative laparoscopy revealed a ruptured right ovarian abscess. She responded to laparoscopic drainage and intravenous antibiotics. The patient conceived during that cycle and has a single ongoing pregnancy.     

Successful laparoscopic management of primary abdominal pregnancy

Overall, approximately 1% of ectopic pregnancies are abdominal pregnancies, which can be life-threatening even when surgical intervention with laparotomy is performed. We present a case in which abdominal pregnancy was successfully managed by operative laparoscopy. A 25 year old Japanese woman presented 6 weeks after her last menstruation with elevated basal body temperature, lower abdominal pain, and light vaginal bleeding. The urinary human chorionic gonadotrophin (HCG) concentration was 2137 IU/I, and laparoscopic findings (i.e. the implantation site was the posterior serosa of the uterus with normal adnexae) established a diagnosis of primary abdominal pregnancy. The gestational product was completely removed by laparoscopic surgery with no uncontrollable loss of blood. The urinary concentration of HCG declined rapidly and the patient made an uneventful recovery. Operative laparoscopy is a safe alternative for the management of appropriately selected patients with early abdominal pregnancy.     

The role of laparoscopy in the management of pelvic pain in women of reproductive age

OBJECTIVE: To review the diagnostic and therapeutic roles of laparoscopy in women of reproductive age with acute and chronic pelvic pain. DATA IDENTIFICATION: Studies relating to the use of laparoscopy in women with acute and chronic pelvic pain were identified through the literature and MEDLINE searches. CONCLUSION(S): Laparoscopy has an important place in the management of conditions that cause acute pelvic pain in women of reproductive age, including ectopic pregnancy, pelvic inflammatory disease, tubo-ovarian abscess, and adnexal torsion. The procedure frequently facilitates the diagnosis and provides the necessary access for surgical treatment. Prompt diagnosis and effective management prevent complications and help preserve fertility. The role of laparoscopy in women with chronic pelvic pain is more controversial and limited, but abnormal laparoscopic findings are detected in approximately 60% of those who have undergone a multidisciplinary investigation and received a tentative clinical diagnosis. The access provided by laparoscopy permits the effective surgical treatment of many of the conditions encountered, including endometriosis, pelvic adhesions, ovarian lesions, and symptomatic uterine retroversion.     

Spigelian hernia with Crohn''s appendicitis

We present a case report of a young man found to have Crohn's appendicitis in an incarcerated spigelian hernia, initially diagnosed via laparoscopy. We have found two published cases of incarcerated appendicitis in spigelian hernias; however, only one of them also showed histologic evidence of Crohn's disease, and neither was discovered during laparoscopy. Therefore, we submit this rare case presentation and discuss the advantages of laparoscopy as an aid in diagnosing the cause of chronic abdominal pain.     

Abdominal pain in women attending a genitourinary medicine clinic: who has PID?

Eighty-one women who presented to a genitourinary medicine clinic with mild to moderate acute or chronic abdominal pain were studied in order to compare the clinical features of those who had pelvic inflammatory disease (PID) and those who did not. The diagnosis was made by laparoscopy, and PID was detected in 14%, adhesions in 11% and endometriosis in 16%. Women with PID were clinically indistinguishable from women with other diagnoses or no obvious cause.     

A giant follicular cyst of the ovary in a newborn infant

The purpose of this study was to evaluate the accuracy of clinical diagnosis of acute pelvic inflammatory disease (PID). Data were obtained on 176 consecutive women admitted to St. Elizabeth Hospital Medical Center with a clinical diagnosis of PID. All underwent diagnostic laparoscopy. PID was established laparoscopically in 134 (76.1%) of the patients. Statistical tests for significant associations between PID and each of 21 clinical indicators of the disease were conducted using the chi 2 and Mann-Whitney tests. Stepwise logistic regression was performed on those variables whose univariate tests of significant association with PID resulted in P values < 0.20. An optimal set of PID indicators consisted of adnexal tenderness, lower abdominal pain of < one week's duration and an elevated white blood cell count. Use of these indicators resulted in a test with an estimated sensitivity and specificity of 86.6% and 45.7%, respectively. Estimated predictive values for positive and negative test results were 0.84 and 0.52, respectively. These results confirm the fact that laparoscopy is the definitive diagnostic modality in PID.     

Right-sided diverticulitis: new diagnostic and therapeutic aspects

Because of its rarity in the Western World, diverticulitis of the ascending colon is often not taken into account in the differential diagnosis of abdominal pain in the right lower quadrant or is misdiagnosed as appendicitis. Of five patients who were treated for right-side diverticulitis in our hospital between April 1995 and April 1996, one underwent right hemicolectomy and one laparoscopic diverticulectomy. In three cases we succeeded with antibiotics alone. In three cases the diagnosis was made on the basis of CT-scan, prompted by peridiverticular changes. In one case the diagnosis was made at laparoscopy and confirmed by CT. In one case diagnosis and therapy were carried out only by laparoscopy. From the moment of diagnosis the average stay in hospital was twelve days and no complications occurred. During an average follow-up time of twelve months, all patients remained free of pain. On the basis of the case reports and a literature review we discuss the diagnostic value of CT and laparoscopy as well as the benefit of conservative therapy, which to us--in contrast to other authors--seems appropriate at least for the first bout of uncomplicated diverticulitis.