Diagnostic Laparoscopy Case File

Diagnostic Laparoscopy Case File

Eugene C. Toy, MD, Konrad P. Harms, MD, Keith O. Reeves, MD, Cristo Papasakelariou, MD, FACOG

Case 4

A 28-year-old G2P2 woman complains of lower abdominal and pelvic pain for 2 years which seems to be worsening. She states that the pain is exacerbated by menses and is located in the lower abdomen in the midline. She describes it as cramping with radiation to the back. She has tried nonsteroidal anti-inflammatory drugs (NSAIDs) with no relief. She denies gastrointestinal symptoms. The patient denies a history of sexually transmitted infections, and has menses every month. She was on the oral contraceptive agent last year without affecting the pelvic pain. On examination, she is 5 ft 5 in tall and weighs 120 lb (54.43 kg). Her abdomen is without surgical scars. She has mild tenderness of the lower abdominal quadrants with normal bowel sounds. On pelvic examination, the external genitalia appear normal. The cervix and vagina are normal. The uterus is retroverted and fixed and tender. The adnexa are bilaterally tender. There are no nodules or barbs noted. The rectovaginal examination reveals some tenderness of the posterior uterus.

➤ What is your diagnostic plan?

➤ What is your differential diagnosis?

➤ What are options for establishing a gynecologic diagnosis?

ANSWERS TO CASE 4:

Diagnostic Laparoscopy

Summary: A 28-year-old G2P2 woman has chronic pelvic pain, consistent with dysmenorrhea, which is not amenable to medical therapy. The examination shows a retroverted uterus that is fixed.

➤ Diagnostic plan: Assays for gonorrhea, Chlamydia, pregnancy test, and pelvic

ultrasound; consider a pain diary.

➤ Differential diagnosis: Gynecologic conditions: endometriosis, pelvic adhesions, chronic pelvic inflammatory disease (PID), adenomyosis; Urologic: interstitial cystitis; Gastrointestinal: irritable bowel syndrome, diverticulitis; 

Psychological: anxiety disorder, depression, somatization, sexual abuse, marital discord, drug abuse; Neurologic: pudendal neuralgia, vulvodynia; 

 Musculoskeletal: pelvic floor disorder, fibromyalgia.

➤ Establishing a gynecologic diagnosis: Diagnostic laparoscopy. The history, physical examination, and limited tests are the key to determining which etiology is most likely. With a gynecologic likelihood, diagnostic laparoscopy is indicated to help to establish the diagnosis.

ANALYSIS

Objectives

1. Describe the role of diagnostic laparoscopy in gynecological conditions.
2. Describe the major surgical approach in minimizing injuries associated with diagnostic laparoscopy.
3. List the most common complications associated with diagnostic laparoscopy.

Considerations

Chronic pelvic pain is one of the most difficult diagnostic challenges that a gynecologist faces. The history is essential in trying to establish the body system etiology. The pain in this patient has been present for 2 years and is worsening. The factors that lean toward a gynecologic cause include the location of the lower abdomen, worsening with menses, and midline in nature. There is no mention of pain with intercourse, dyspareunia, but this is also very important in the investigation process. After establishing a good idea of the location, character, duration, and radiation of the pain, the physician must look for associated conditions. For instance, if the patient has dysuria or urinary urgency or frequency, then a urinary disorder may be considered. Psychological issues are very common, and the physician should spend time inquiring about depression, anxiety, and the patient’s relationship with her partner. Past history of sexual or physical abuse is also relevant. Gastrointestinal symptoms should be sought such as bloating, constipation and diarrhea, or upper abdominal discomfort. When a reasonable etiology belonging to a nongynecologic system exists, the patient should be referred to the appropriate consultant. When a gynecologic disorder is likely, further testing or imaging and, if needed, diagnostic laparoscopy can help to establish the diagnosis.

APPROACH TO

Diagnostic Laparoscopy

The advantages of laparoscopy are well known when compared to laparotomy. Advantages include faster recovery to normal activities, decreased cost, decreased adhesion formation, smaller incisions and therefore decreased postoperative pain, and shorter operative times (although this may not hold true for some procedures).1 Large meta-analysis published in 2002 comparing laparoscopy to laparotomy for benign gynecologic disease found that the overall risk of minor complications such as fever, urinary tract infection, or wound infection was lower in woman undergoing laparoscopic procedures, but both groups had the same risk for major complication such as pulmonary embolism, major bleeding, fistula formation, or damage to surrounding organs.1 Laparoscopic procedures in gynecology are standard for many conditions, and its widespread use has made the transition to the minimally invasive procedures as standard of care in many respects.

Laparoscopy is the best diagnostic/treatment tool in endometriosis because it allows the gynecologist to assess the extent of the disease and at the same time treat lesions with fulguration and resection. The accuracy of laparoscopic diagnosis depends on location and type of lesion, as well as surgeon experience (see Figure 4–1). Direct biopsies of suspicious lesions are necessary when direct visualization can lead to errors in certain cases.2 Most common anatomical sites where endometriotic implants are located include the ovaries and the posterior cul-de-sac, although it is not uncommon to see them at the broad ligament, uterosacral ligament, posterior uterine wall, fallopian tubes, sigmoid colon, and appendix. Multiple extra-abdominal organs can be affected as well.

Basic elements for any gynecologic laparoscopic procedure start with positioning the patient in dorsal lithotomy with padded candy cane–type stirrups or Allen stirrups; knees and legs should be in a resting nonflexed position in order to avoid nerve injury. Entry into the peritoneal cavity can be by open or closed technique, although no major differences have been found in the avoidance of major complications among laparoscopic entry techniques.3

Figure 4–1. Right endometrioma noted, with right ovary significantly larger than the left ovary. (Courtesy of Dr.Cristo Papasakelariou.)

Different locations can be used for both techniques, although the periumbilical area is the most widely used. Other locations utilized are the transfundal area, posterior cul-de-sac, left upper quadrant, and the lateral border of the rectus muscle at either left or right McBurney point.

The abdominal cavity is then insufflated with CO2 (typically with 2-4 L), and insufflation is confirmed once the liver dullness disappears and overall expansion of the abdominal wall appears symmetrical in all quadrants. The entry pressure should not be higher than 10 mm Hg; if in doubt of correct

placement, a 10-mL open syringe with saline may be utilized to test for proper placement of the Veress needle. The saline should evacuate the syringe in the peritoneal cavity by gravity if properly placed. Multiple devices have been designed to be used in laparoscopic gynecologic procedures, including graspers, scissors, cutting and coagulating tools, tools for intra- and extracorporeal suturing techniques, and, lately, high-quality sealing and coagulation devices such as the argon beam coagulator (ABC), the LigaSure (Valleylab, Colorado, USA), the harmonic scalpel, and stapler devices.

Removal of tissue from the pelvic cavity can be achieved by morcellation technique and/or retrieval bags. Many companies have developed these tools for such occasions. Potential complications with laparoscopic procedures include bowel injury, vascular injuries, urinary tract injury (bladder or ureteral injuries), nerve damage, hematomas, postoperative incisional hernias, and gas embolism. But almost half of these complications are related to the initial entry to the peritoneal cavity.4,5

Comprehension Questions

Match the single best diagnosis (A-F) with the clinical scenario (4.1-4.4).

A. Endometriosis

B. Vaginismus

C. Pelvic inflammatory disease

D. Interstitial cystitis

E. Diverticulitis

F. Hydrosalpinx

4.1 A 35-year-old woman with cyclic pelvic pain related to menses has tried multiple medications, including birth control pills, without success. Occasionally, she experiences rectal bleeding with bloating, and bimanual examination reveals a fixed retroverted uterus.

4.2 A 26-year-old nulligravida woman with pelvic pain mainly on the left side states she has had some malodorous vaginal discharge for the previous 2 days, which she has not had before. She has multiple sexual partners, states she is very careful, and is taking oral contraceptives. Urine pregnancy test is negative.

4.3 A 28-year-old woman with infertility, despite two rounds of treatment with clomiphene citrate, has been unsuccessful in attempts at pregnancy. Otherwise asymptomatic, she has a history of Chlamydia 5 years prior.

4.4 A 57-year-old woman presents with left lower quadrant pain and fever; at physical examination, rebound tenderness was noticed. She has a history of ovarian cysts and a surgery for torsion of a left necrotic ovary.

ANSWERS

4.1 A. Cyclic pain associated with rectal bleeding and a fixed uterus should lead one toward the diagnosis of endometriosis.

4.2 C. A nulliparous woman with multiple sexual partners and unprotected intercourse associated with pelvic pain is very suggestive of pelvic inflammatory disease. Other possibilities would include the presence of a hydrosalpinx, although this condition is not usually associated with malodorous vaginal discharge.

4.3 F. Hydrosalpinx would be the best explanation for this reproductive age woman after two rounds of ovulation induction drugs. Hydrosalpinx is almost always bilateral in the presence of infertility.

4.4 E. Diverticulitis is the most likely diagnosis, given that the patient had previously had a left salpingo-oophorectomy and was experiencing left lower quadrant pain and fever.

Clinical Pearls

See Table 1-2 for definition of level of evidence and strength of recommendation

➤ Overall risk of minor complications is lower in woman undergoing operative laparoscopic procedures when compared to laparotomy; however, major complication risks are the same in both groups (Level B).

➤ The diagnosis of endometriosis is by direct visualization, but confirmatory biopsy of lesions is recommended in cases of suspicious lesions (Level B).

➤ No major differences have been found in major complications among laparoscopic entry techniques (Level A).

➤ Roughly half of the complications related to laparoscopic procedures are related to initial entry into peritoneal cavity (Level B).

REFERENCES

1. Chapron C, Fauconnier A, Goffinet F, et al. Laparoscopic surgery is not inherently dangerous presenting with benign gynaecologic pathology. Result of a meta-analysis. Hum Reprod. 2002;17:1334. 

2. Wykes CB, Clark TJ, Khan KS. Accuracy of laparoscopy in the diagnosis of endometriosis: a systematic quantitative review. BJOG. 2004;111:1204. 

3. Ahmad G, Duffy JM, Phillips K, Watson A. Laparoscopic entry techniques. Cochrane Database Syst Rev. 2008;16:CD006583. 

4. Jansen FW, Kolkman W, Bakkum EA, de Kroon CD, Trimbos-Kemper TC, Trimbos JB. Complications of laparoscopy: an inquiry about closed- versus open-entry technique. Am J Obstet Gynecol. 2004;190:634. 

5. Shirk GJ, Johns A, Redwine DB. Complications of laparoscopic surgery: how to avoid them and how to repair them. J Minim Invasive Gynecol. 2006;13:352.

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