Diagnostic laparoscopy

Significance of laparoscopy in the management of chronic pelvic pain

OBJECTIVE

Chronic pelvic pain is a complex disease and is far more common than generally recognized.

STUDY DESIGN

Between 1 January 1979 and 31 December 2002 authors had performed 11,681 laparoscopic interventions. Among them, 1061 operations (9.08%) were done because of chronic pelvic pain.

RESULTS

In 29.5% of these cases no anatomical abnormality was found. Analysis of data of laparoscopic operations performed from 1989 to 1990 and from 1998 to 1999 revealed that complaints dated back for a significantly longer period of time in patients presenting no obvious sign of pelvic anatomical anomaly when compared with those who had positive findings. In patients with positive pelvic findings laparotomy had previously been performed in a significantly higher number. When no apparent pelvic pathology was found medical history was also negative for ectopic pregnancy. Similarly, there were only three cases of previous adnexal operations. However, among patients with positive findings, medical history revealed 19 prior cases of ectopic pregnancy, 49 cases of previous adnexal operations, 82 appendectomy, and 26 cholecystectomy (p<0.01). Among patients with positive pelvic findings, diagnostic laparoscopy was immediately completed by adequate surgical treatment in the same session in more than two-third of cases. Most frequently this included adhesiolysis, ovarian cystectomy, uterosacral nerve ablation, electrocoagulation of areas of endometriosis, and ventrosuspension of the retroflected uterus.

CONCLUSION

Based on our retrospective data analysis we believe that laparoscopy is an essential method for the diagnosis and management of chronic pelvic pain.

Laparoscopy in the management of pelvic pain in Calabar, Nigeria

During the study period (July 1988 to June 1993), 707 laparoscopies were performed in the maternity annex of the University of Calabar Teaching Hospital. Fifty-eight (8.2%) were for pelvic pain. Some of the cases of pelvic pain were laparoscoped only after failure of other investigative procedures and medical treatment. In 45 (77.6%) definitive diagnoses were made and 37 of these became asymptomatic after definitive treatment following the laparoscopy. Of the 12 (20.69%) with no detectable abnormalities, four became asymptomatic with explanation and reassurance. All the patients with unruptured and the two with ruptured ectopic pregnancy were managed without the need for blood transfusion. Most of the diagnostic laparoscopies were performed on a day-case basis. A complication rate of 1.7% was recorded. A more liberal use of the procedure in the investigation of pelvic pain in women is advocated.

Laparoscopy in the management of women with chronic pelvic pain

A review of 232 women who had diagnostic laparoscopy for chronic pelvic pain was undertaken. Diagnostic error in the preoperative pelvic examination in the series varied from 21% to 61%; of 135 patients who had normal pelvic examination findings preoperatively, 82 (61%) were found to have pelvic pathology on diagnostic laparoscopy, whereas 21 of 97 women (21.6%) who had abnormal pelvic examination, had normal findings on laparoscopy. The overall incidence of pelvic pathology in the series was found to be 69%. Our results suggest that there is poor correlation between findings of pelvic examination and the existence of pelvic disease. Laparoscopy has a definite place in the evaluation of patients with chronic pelvic pain and certainly justifies its increasing use in their management.

Laparoscopic diagnosis of acute pelvic inflammatory disease

At Ngwelezana Hospital, 103 patients admitted from the outpatient clinic with a diagnosis of pelvic infection were laparoscoped and in only 63 was the diagnosis confirmed. A disturbingly high incidence of ectopic pregnancy (8 patients) was found.

Laparoscopic findings in patients with pelvic pain

We have reviewed 1,194 charts of consecutive patients who had a diagnostic laparoscopy for pelvic pain from January 1, 1972, to December 31, 1980, at the Deaconess Division of the Buffalo General Hospital. A total of 749 of these patients had normal pelvic examinations prior to the diagnostic laparoscopy; 479 (63%) had abnormal findings on diagnostic laparoscopy. Of the 445 patients with abnormal pelvic examinations, 78 (17.5%) had normal findings on diagnostic laparoscopy. The laparoscopic findings and ovarian pathology are reviewed. These results are substantiated by other reports in the literature and certainly justify the increasing use of the laparoscope as a diagnostic tool in the gynecologist's armamentarium.

Differential diagnosis of acute pelvic inflammatory disease

Laparoscopic investigations have shown that clinical symptoms and signs in cases of acute pelvic inflammatory disease (acute salpingitis) show considerable variation and seem to a great extent to be nonspecific. Diagnosis based on clinical criteria alone is, therefore, unacceptably unreliable. Different intrapelvic disorders and acute infections limited to the lower genital tract (LGTI) represent substantial differential diagnostic problems. The routine use of laparoscopy is currently the best method for solving these problems but its broader application is restricted by several factors. Determination of specific genital isoamylases obtained at vaginal puncture of the cul-de-sac seems to represent a promising and specific laboratory test for differentiating between acute PID and LGTI that simulates acute PID.