Rationale for the Procedure
Chronic pelvic pain is typically defined as pelvic pain lasting more than 6 months and is a complex disorder with multiple etiologies. It affects many women and can severely impair their quality of life and lead to frequent visits to gynecologists. The etiology of chronic pelvic pain is frequently obscure despite the use of many diagnostic tests. Diagnostic laparoscopy is an excellent tool for direct visualization of the pelvis and may help identify the etiology of the patients� pain. The procedure facilitates therapeutic intervention and may help ameliorate the morbidity of an open exploration.
Technique
The procedure can be employed under general anesthesia or conscious sedation. The latter approach must be used with the technique of conscious pain mapping during which the patient can respond to intraperitoneal manipulations that may identify the source of pain. Smaller trocars and lower pneumoperitoneum pressures should be used with this technique to decrease the operative pain [2,3].
The patient is placed in the lithotomy position. The initial access site is usually peri-umbilical. Additional trocars can be placed in the left lower or right lower quadrant [1]. A manipulator can be placed on the cervix and a rectal probe can be used if necessary for further retraction; these instruments are usually not used during conscious sedation.
During the procedure, identified adhesions are divided, and lesions suspected to be endometriosis should be biopsied and classified. In the absence of visible endometriosis lesions, random biopsies may demonstrate endometriosis in 30% of patients with typical symptoms. Free peritoneal fluid should be sampled and examined for the presence of endometriosis. Endometriosis lesions can then be fulgurated or removed.
Indications
� Chronic pelvic pain of unknown etiology after appropriate noninvasive workup
Contraindications
� Procedure intolerance
� Known dense pelvic adhesions that may make an accurate evaluation of pelvic pathology impossible or may impede safe abdominal access
Risks
� Procedure- or anesthesia-related complications
Benefits
� Potential identification of the source of the chronic pelvic pain
� Possibility for immediate therapeutic intervention
� Potential improvement in the patient�s quality of life
Diagnostic Accuracy of the Procedure
Diagnostic laparoscopy has been demonstrated to identify endometriosis, adhesions, or other abnormalities of the appendix and ovaries as the source of chronic pelvic pain [3].
In patients with clinical suspicion of endometriosis, DL has been shown to confirm the diagnosis in 78-84% of patients (level III) [4,6]. Random peritoneal biopsies and peritoneal fluid cytology have been shown to improve the diagnosis of endometriosis by 20% (level III) [4,8]. In addition, up to 22% of patients with findings of endometriosis during DL have had previous nondiagnostic laparoscopy (level III) [4]. The diagnosis of endometriosis is more likely when multiple complex pigmented lesions are observed during DL [1].
For pelvic inflammatory disease, the visual accuracy of DL alone was found to be 78% (sensitivity 27% and specificity 92%) (level III) [5]. In the same study, the diagnostic accuracy of the procedure was significantly higher for more experienced laparoscopists. Pain mapping identified a direct source for the pain in 80% of patients with adhesions but was inconsistent in patients with endometriosis [3].
Procedure-related Complications and Patient Outcomes
Procedure-related complications include bowel injuries, bleeding, urologic injuries, vaginal cuff wounds, peritonitis, and pelvic pain. In a large multicenter French study (n=30,000), diagnostic and therapeutic laparoscopy were found to be associated with a 3.3 per 100.000 mortality and a 4.6 per 1,000 morbidity risk (level II) [7]. Complications requiring conversion to laparotomy occurred in 3.2 per 1,000 patients. The risk of complications was related to the complexity of surgery and the experience of the laparoscopist. One in four intraoperative complications were missed during the procedure.
For laparoscopic pain mapping, under conscious sedation, one study showed 48 of 50 women had improvement (level II) [3].
Cost effectiveness
There are no available data on the cost effectiveness of DL for chronic pelvic pain.
Limitations of the Available Literature
The quality of the available literature is limited, as almost all of the available studies are retrospective studies from single institutions. Furthermore, there is a paucity of data on long-term outcomes and little data on cost-effectiveness and quality of life. These shortcomings limit our ability to provide firm recommendations.
Recommendations
Diagnostic laparoscopy can be safely applied in the diagnosis of chronic pelvic pain (grade B). The procedure may identify the etiology of chronic pelvic pain in a proportion of patients, and its diagnostic accuracy may be improved by the technique of conscious pain mapping (grade B). Nevertheless, the existing evidence does not allow firm recommendations, and further research is needed to establish the value of DL for chronic pelvic pain (grade B).
Bibliography
1. Ueki M, Saeki M, Tsurunaga T, Ueda M, Ushiroyama N, Sugimoto O. Visual Findings and Histologic Diagnosis of Pelvic Endometriosis Under Laparoscopy and Laparotomy. Int J Fertil. 1995;40(5):248-253
2. Demco L. Mapping the Source and Character of Pain due to Endometriosis by Patient-Assisted Laparoscopy. J Am Assoc Gynecol Laparosc. 1998; 5(3):241-245.
3. Almeida Jr O, Val-Gallas J. Conscious Pain Mapping. J Am Assoc Gynecol Laparosc. 1997 Nov; 4(5):587-590.
4. Wood C, Kuhn R, Tsaltas J. Laparoscopic Diagnosis of Endometriosis. Obstet Gynecol. 2002; 42:3:277.
5. Molander P, Finne P, Sjoberg J, Sellors J, Paavonen J. Observer Agreement With Laparoscopic Diagnosis of Pelvis Inflammatory Disease Using Photographs. Obstet Gynecol., 2003 May;101(5 Pt 1):875-80
6. Mettler L, Schollmeyer T, Lehmann-Willenbrock, Schuppler U, Schmutzler A, Shukla D, Zavala A, Lewin A. Accuracy of Laparoscopic Diagnosis of Endometriosisg. JSLS, 2003 Jan-Mar;7(1):15-8.
7. Chapron C, Querleu D, Bruhat M, Madelenat P, Fernandez H, Pierre F, Dubuisson J. Surgical Complications of Diagnostic and Operative Gynaecological Laparoscopy. Human Reproduction. 1998 13(4):867-872.
8. Stowell S, Wiley C, Perez-Reyes N, Powers C. Cytological Diagnosis of Peritoneal Fluids. Acta Cytol 1997; 41:817-822.