Introduction

Diagnostic laparoscopy is used in endoscopic surgery for the diagnosis of intra-abdominal pathologies. This technique has the capability for directly visualizing intra-abdominal organs with the opportunity for gathering tissue biopsy, fluid aspiration, and tissue cultures. This procedure has the capability to aid other possible interventional alternatives.

There are several situations in which the role of diagnostic laparoscopy (DL) is useful in reducing the number of unnecessary laparotomies. Staging laparoscopy can be done for intra-abdominal cancer. Its application in the acute abdominal condition is also common. There is also DL for chronic conditions, such as infection, pelvic pain, cirrhosis, and cryptorchidism.

Instruments

  • 12 mm trocar

  • 5 mm trocar × 2.

  • 30° laparoscope

  • Atraumatic bowel graspers × 2.

General Technique for Diagnostic Laparoscopy

Under general anesthesia, a 10 mm umbilical incision is made for insertion of the Hasson’s trocar with stay sutures to secure that trocar. A pneumoperitoneum at 12 mm Hg on medium flow (10–15 L/min) is created. The 30° telescope is then inserted through the 12 mm trocar and an initial exploration of the abdominal cavity is performed. Port placement of the working trocars will now depend on the location of the pathology. The general rule is to apply the technique of triangulating the working ports in relation to the camera and the suspected pathology. A minimum of two trocars is advised, but additional trocars are deemed appropriate if needed. The size of the working trocars is variable depending on the instruments that you will use. Two 5 mm trocars would be sufficient to fit most instruments, being liberal to changing to a 10 mm working trocar as the need arises.

If a known pathology is suspected, for example, acute appendicitis. Upon insertion of the camera, a limited diagnostic laparoscopy is done around the abdominal cavity before focusing on the right lower quadrant. One working trocar is placed initially at the left lower quadrant for a bowel grasper to assist in exposing the appendix. Upon confirmation of acute appendicitis, the next working trocar can be placed on area of your preference as long as proper triangulation of the instruments in relation to the pathology is observed. If another pathology is to be suspected (and not appendicitis), then a formal diagnostic laparoscopy can commence.

For the above example, in performing a formal diagnostic laparoscopy, a second working trocar is placed at the right lower quadrant and the patient is placed in a reverse Trendelenburg position. Inspection of the right upper quadrant by visualizing the liver and the subdiaphragmatic area is done, going down to the subhepatic area to where the gallbladder and the extrahepatic biliary tree are located. The left upper quadrant is visualized by inspecting the anterior wall of the stomach, gastroesophageal junction, and splenic area. The patient is then placed in the Trendelenburg position to examine the pelvic area. Bowels are moved cephalad in order to visualize the posterior wall of the urinary bladder, sigmoid, and rectum, in addition to the uterus, ovaries, and fallopian tubes in females. Once the patient is returned to the supine position, the bowels are now inspected from the duodenum down to the sigmoid using both bowel graspers to run the bowels. If needed, the greater sac of the stomach is opened to visualize the pancreas retroperitoneally.

Specimen collection can be accomplished in various ways. For pedunculated nodules on the peritoneum or abdominal organs, a sharp dissection of the nodules can be achieved, followed by appropriate hemostasis (Fig. 1). For evacuation and examination of fluids like ascites and puss, needle aspiration instruments connected to syringes can be done.

Fig. 1
Two images of nodules on abdominal tissues were taken during diagnostic laparoscopy and biopsy.

(a) Intra-abdominal milliary tuberculosis during diagnostic laparoscopy with (b) biopsy

Full size image