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May07
Diagnostic Laparoscopy Guidelines
Preamble
These diagnostic laparoscopy guidelines are a series of systematically developed statements to assist surgeons’ (and patients’) decisions about the appropriate use of diagnostic laparoscopy (DL) in specific clinical circumstances. The statements included in this guideline are the product of a systematic review of published work on the topic, and the recommendations are explicitly linked to the supporting evidence. The strengths and weaknesses of the available evidence are described and expert opinion sought where the evidence is lacking. This is an update of previous guidelines on this topic (SAGES publication #0012; last revision 2002) as new information has accumulated.
Disclaimer
Clinical practice guidelines are intended to indicate the best available approach to medical conditions as established by systematic review of available data and expert opinion. The approach suggested may not be the only acceptable approach given the complexity of the health care environment. These guidelines are intended to be flexible, as the surgeon must always choose the approach best suited to the patient and variables in existence at the time of the decision. These guidelines are applicable to all physicians who are appropriately credentialed and address the clinical situation in question, regardless of specialty.
Guidelines are developed under the auspices of SAGES and the guidelines committee and approved by the Board of Governors. The recommendations of each guideline undergo multidisciplinary review and are considered valid at the time of production based on the data available. Recent developments in medical research and practice pertinent to each guideline will be reviewed, and guidelines will be updated on a periodic basis.
Clinical Application
Diagnostic laparoscopy is minimally invasive surgery for the diagnosis of intra-abdominal diseases. The procedure enables the direct inspection of large surface areas of intra-abdominal organs and facilitates obtaining biopsy specimens, cultures, and aspiration. Laparoscopic ultrasound can be used to evaluate deep organ parts that are not amenable to inspection. Diagnostic laparoscopy not only facilitates the diagnosis of intra-abdominal disease but also makes therapeutic intervention possible.
Literature Review Methods
A large body of literature about DL exists. The many clinical situations where DL has been applied, adds complexity to the analysis of the literature. Our systematic literature search of MEDLINE for the period 1995-2005, limited to English language articles, identified 663 relevant reports. The search strategy is shown in Figure 1 at the end of this document. Using the same strategy, we searched the Cochrane database of evidence-based reviews and the Database of Abstracts of Reviews of Effects (DARE), which identified an additional 54 articles. Thus, a total of 717 abstracts were reviewed by three committee members (DS, WR, LC) and divided into the following categories:
a) Randomized studies, metaanalyses, and systematic reviews
b) Prospective studies
c) Retrospective studies
d) Case reports
e) Review articles
Randomized controlled trials, metaanalyses, and systematic reviews 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. The most recent reviews were also included. All case reports, old reviews, and smaller studies were excluded. According to these exclusion criteria, 169 articles were reviewed by the three committee members (DS, WR, LC).
To maximize the efficiency of the review, the articles were divided in the following subject categories:
1) Staging laparoscopy for cancer
a) Esophageal cancer
b) Gastric cancer
c) Pancreatic and periampullary cancers
d) Liver cancer
e) Biliary tract cancer
f) Colorectal cancer
g) Lymphoma
2) Diagnostic laparoscopy for acute conditions
a) Acute abdomen
b) Trauma
c) ICU
3) Diagnostic laparoscopy for chronic conditions
a) Chronic pelvic pain and endometriosis
b) Liver disease (including cirrhosis)
c) Infertility
d) Cryptorchidism
e) Other
4) Other (general reviews, complications, etc.)
The reviewers graded the level of evidence of each article and manually searched the bibliographies for additional articles that may have been missed by our search. Any additional relevant articles (n=33) were included in the review and grading. A total of 140 graded articles relevant to this guideline were included in this review. Based on the reviewer grading of all articles, we devised the recommendations included in these guidelines.
Levels of Evidence
Level I - Evidence from properly conducted randomized, controlled trials
Level II - Evidence from controlled trials without randomization Cohort or case-control studies Multiple time series dramatic uncontrolled experiments
Level III - Descriptive case series, opinions of expert panels
General Recommendations
Diagnostic laparoscopy is a safe and well tolerated procedure that can be performed in an inpatient or outpatient setting under general or occasionally local anesthesia with IV sedation in carefully selected patients. Diagnostic laparoscopy should be performed by physicians trained in laparoscopic techniques who can recognize and treat common complications and can perform additional therapeutic procedures when indicated. During the procedure, the patient should be continuously monitored, and resuscitation capability must be immediately available. Laparoscopy must be performed using sterile technique along with meticulous disinfection of the laparoscopic equipment. Overnight observation may be appropriate in some outpatients. There are unique circumstances when office-based DL may be considered. Office-based DL should only be undertaken when complications and the need for therapeutic procedures through the same access are highly unlikely.


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