Bedside laparoscopy to diagnose intrabdominal pathology in the ICU

Introduction

The aim of the study was to evaluate the accuracy of bedside diagnostic laparoscopy (BDL) in critically ill patients (CIP) suspected to suffer from intrabdominal pathology compared with operative laparotomy or diagnostic imaging (CT scan) and to verify the safety of the procedure. In fact, a delay in the diagnosis of intrabdominal pathology could worsen the morbidity and mortality in these patients. In ICU patients treated with prolonged parenteral nutrition, mechanical ventilation and high-dose opioid analgesics, acalculous cholecystitis (AC) is a severe complication [1]. Clinical evaluation of the abdomen is difficult as deep sedation often masks symptoms, and physical examination is inconclusive so they are potentially eligible for exploratory laparoscopy after abdominal CT. Furthermore, performing CT is often impossible because of the difficulty in safely transporting CIP.

Methods

From January 2006 to November 2007 a BDL was performed in 24 CIP to confirm the clinical diagnosis of AC. Every day, liver function tests are collected and abdominal ultrasonography is performed when the suspicion of AC is high. Elevated liver function tests and ultrasonography signs such as gallbladder distension or wall thickening (>3–4 mm) with or without pericholecystic fluid were the more significant findings of suspected AC and were considered admission criteria in the study. Twenty-four patients met the criteria. Ten were trauma victims, three were post-cardiac surgical patients, and 11 had sepsis of unknown origin. Fifteen were hypotensive and required haemodynamic support. BDL was performed with the Visiport. The pneumoperitoneum was created with a 10–15 mmHg CO₂ pressure. The mean procedure time was 40 minutes.

Results

The procedure was done a mean 8 days (range 5–15 days) after ICU admission. In two patients the BDL was positive for gangrenous colecystitis (both after cardiac surgery) requiring laparoscopic cholecystectomies in the operating room. Purulent peritonitis was found in five patients with sepsis of unknown origin but microbiological tests on ascites resulted negative in all cases. The other BDLs resulted negative for intrabdominal pathology.

Conclusion

BDL seems to represent an alternative and effective technique that might be more accurate than a CT scan and less invasive than laparotomy to obtain a diagnostic evaluation of intrabdominal pathology in ICU patients.