The role of diagnostic laparoscopy for chronic abdominal conditions: an evidence-based review

When you see nothing at all: Outcomes following a negative laparoscopy. A systematic review

BACKGROUND

Persistent pelvic pain (PPP) is a complex and often debilitating condition. While widely accepted to be multifactorial in nature, the precise aetiology of PPP remains elusive. In many cases, women who undergo laparoscopy for PPP will have no visible pathology identified (a 'negative' laparoscopy). Currently, there are no consensus guidelines which outline the recommended management following a negative laparoscopy, and the woman's experiences and outcomes are not widely known.

AIMS

This review aims to identify and summarise the literature surrounding the experiences of women with PPP who have a negative laparoscopy; specifically, their outcomes of pain, quality of life (QoL), satisfaction with care, and their overall management.

MATERIALS AND METHODS

A systematic search of the electronic databases Ovid Medline, PubMed and Embase was performed. Studies in English exploring the outcomes of women with PPP following a negative laparoscopy were included.

RESULTS

Four studies consisting of a total of 200 women were included. Results were inconsistent. Three studies concluded that the majority of women with PPP had persistent pain following a negative laparoscopy. A single study found that pain significantly improved after negative laparoscopy. QoL outcomes varied, with two studies reporting a positive impact and two studies reporting a deleterious impact on QoL following a negative laparoscopy.

CONCLUSIONS

The impact on pain outcomes and QoL following a laparoscopy that does not diagnose pathology remains unknown, and the available evidence is insufficient to guide evidence-based practice. This review highlights a significant gap in our understanding of surgical management for PPP.

An Overview of Postoperative Intraabdominal Adhesions and Their Role on Female Infertility: A Narrative Review

Postoperative intraabdominal adhesions can occur after more than 90% of gynecologic surgeries. They not only cause chronic pelvic pain and small bowel obstruction, but are also one of the main reasons for infertility. Adhesions are not only a burden for the affected patients, but are also a burden for the healthcare system, since the treatment of adhesion-associated complications costs a considerable amount of money. The gold standard for the diagnosis of adhesions is by laparoscopy, although other methods, such as transvaginal hydro-laparoscopy, are being discussed as better alternatives. Ideally, adhesions are avoided inherently, by operating carefully and by using microsurgical principles. If this is not possible, gel barriers have been shown to be successful in reducing postoperative adhesions.

[Laparoscopic totally extraperitoneal repair of strangulated groin hernia]

OBJECTIVE

To study the possibility of totally extraperitoneal repair combined with diagnostic laparoscopy in the treatment of strangulated groin hernias (Laparoscopy-Assisted Totally Extraperitoneal Plasty, LATEP).

MATERIAL AND METHODS

We analyzed the results of laparoscopic totally extraperitoneal hernia repair. The trocar placement technique was modified. There were 38 patients with strangulated groin hernia. The sample included 26 patients with strangulated inguinal hernia, 9 ones with strangulated femoral hernia and 3 patients with recurrent strangulated inguinal hernia.

RESULTS

LATEP was attempted in 38 patients and successful in 37 (97.3%) cases. In 1 (2.6%) patient, correction of small bowel strangulation was failed and conversion to open surgery was required. In 29 patients (76.3%), correction of strangulation was performed after laparoscopy-assisted external manipulations and careful traction from abdominal cavity. In 8 (21%) cases, strangulation spontaneously regressed before laparoscopy. Laparoscopy confirmed viability of strangulated organs in 36 patients. One (2.6%) patient required bowel resection due to small intestine wall necrosis. Later, all patients underwent totally extraperitoneal repair. We were able to prevent the contact of hernia sac fluid with the implant in all cases. At the stage of preperitoneal repair, local damage to peritoneum occurred in 9 patients. Nevertheless, sealing was not required since hernia fluid was previously removed from abdominal cavity. There were no signs of implant infection and hernia recurrence within 6-14 months.

CONCLUSION

Totally extraperitoneal repair combined with diagnostic laparoscopy is possible for strangulated groin hernias.

Negative laparoscopy unveiled

Introduction:

Studies indicate a variable proportion of laparoscopies done for the management of non-acute pelvic pain that do not identify visible pathology and are called negative laparoscopies. Possible explanations have included undetected endometriosis, observer error, and/or neural tissues in the endometrium acting as nociceptive input. The goal was to compare demographic and pain testing measures between women with negative laparoscopies and confirmed endometriosis in a cohort of women presenting with chronic pelvic pain.

Methods:

Women with chronic pelvic pain (n = 255) provided written consent for the study prior to entry. Data were collected at the time of clinic visit and entered contemporaneously into SPSS. Pain sensitization was identified as the presence of cutaneous allodynia. Clinical, pain, and pain sensitization variables were compared using Student’s t-test.

Results:

The frequency of negative laparoscopy was 13.7% (35 cases) and that of confirmed endometriosis was 27.1% (69 cases). There were no differences between women with a negative laparoscopy and women with confirmed endometriosis in clinical, dysmenorrhea, or pain testing measurements.

Conclusion:

The data suggest in the absence of endometriotic tissue in the pelvis, chronic visceral pain may result from a uterine origin and result in a generalized pattern of pain and pain sensitization.

Our experience of liver Epithelioid Hemangioendothelioma: from a misdiagnosis to liver transplantation with long term follow-up

Malignant Hepatic Epithelioid hemangioendothelioma (HEHE) is an uncommon vascular tumor of intermediate malignant potential. HEHE is a rare tumor and it is difficult to diagnose for surgeons, hepatologists, radiologists and pathologists. So, misdiagnosis with a delay of the treatment is not uncommon. We describe a case of a young woman with a diagnosis of HEHE made 6 years after the first evidence of liver mass with a very long term follow-up after surgical treatment. She had two diagnoses of Hepatocellurar carcinoma (HCC) and a diagnosis of Cholangiocarcinoma after three different fine needle biopsies. After clinical observation, a new laparoscopic core biopsy was performed. In a first time approach, considering clinical and radiological patterns, a diagnosis of Budd-Chiari Syndrome was finally made. For that the patient underwent an orthotopicliver transplantation (OLTx). The surgical sample histological analysis allowed a definitive diagnosis of HEHE. At last, at follow up 7 years after three OLTx the patient is still alive and in good health with no evidence of recurrence.

Gynaecological pathology in women with Fowler's syndrome

OBJECTIVES

To assess the prevalence of gynaecological pathologies in women with Fowler's syndrome (FS) which is characterised by chronic urinary retention (CUR) secondary to failure of urethral sphincter to relax and allow normal voiding.

STUDY DESIGN

This was a case control study conducted at a tertiary referral centre specialised in managing women with FS. There were 41 patients with FS in the study group with CUR without mechanical obstruction of the urethra or neurological problem. All patients had raised maximum urethral closure pressure on urethral pressure profile, high urethral sphincter volume on ultrasound and complex repetitive discharges on eletromyography of the urethral sphincter. Normal voiding was established in these women after treatment with sacral neuromodulation. Fifty women without voiding dysfunction acted as control group. Data was obtained by using standard questionnaire for both the groups. Information was collected regarding gynaecological pathologies such as endometriosis, polycystic ovarian syndrome, menstrual abnormalities, ovarian cysts and subfertility and also regarding previous pregnancies. Analysis was performed using SPSS software from IBM Corporation.

RESULTS

At least one gynaecological pathology was present in 33 (80%) patients with FS compared to 16 (32%) women from control group (P<0.001). This included a higher incidence of endometriosis (29% versus 6%, P=0.003), PCOS (24% versus 8%, P=0.041) and subfertility (34% versus 8%, P=0.003). The incidence of menstrual abnormalities and ovarian cysts was similar in both groups (P>0.05).

CONCLUSION

Subfertility was more prevalent in women with FS in our study. Though the prevalence of different pathologies was higher in the FS group compared to the control group, it remained similar to that found in the normal female population in the published literature. Thus, it is not possible to state whether FS is caused by a hormonally based disorder. It took patients many years before they could get right diagnosis and treatment for FS. Early investigation of chronic urinary retention and referral to specialists for appropriate treatment in this small group of women can result in better health and improvement in their quality of life.

Laparoscopic liver biopsy in the diagnosis of hepatic epithelioid hemangioendothelioma: A case report

Hepatic epithelioid hemangioendothelioma (HEH) is a rare vascular tumor of the liver, and its definitive diagnosis is completely dependent on histopathological verification. In the present study, we report the case of a patient whose percutaneous liver biopsy failed to reveal a diagnosis of HEH, twice, and who was ultimately diagnosed by laparoscopic liver biopsy. The patient was a 42-year-old female with mild right upper quadrant discomfort. Ultrasonography and magnetic resonance imaging showed multiple mass lesions scattered throughout the liver, but no evidence of extrahepatic diseases. The initial laboratory tests included liver function tests and tumor markers were within normal limits. Subsequently, two, ultrasound (US)-guided liver biopsies from the liver lesion were performed using an 18-gauge needle, and both of these showed massive hepatocellular necrosis. To obtain adequate tissue samples for histological examination, the patient underwent laparoscopic liver biopsy. The overall immunohistochemical findings supported the diagnosis of HEH. In the present case, two, US-guided percutaneous liver biopsies failed to diagnose HEH, and laparoscopic liver biopsy was safely performed to obtained adequate specimens for analysis. Although this method is not the preferred technique and has certain disadvantages, it is considered to be a useful and minimally invasive approach for liver lesions when other less-invasive diagnostic modalities fail or are difficult to be performed.

Legal disputes over duties to disclose treatment risks to patients: a review of negligence claims and complaints in Australia

David Studdert and colleagues identified disputes over informed consent among malpractice claims and serious health care complaints in Australia and provide an analysis of disagreements between patients and doctors over whether particular clinical risks should have been disclosed before treatment.

Adhesion prevention and reduction: current status and future recommendations of a multinational interdisciplinary consensus conference

Adhesions can be found after virtually every abdominopelvic operation performed through standard laparotomy as well as by laparoscopic approaches. Adhesions can be completely asymptomatic or can cause significant morbidity and mortality including strangulation, obstruction, and necrosis of bowel loops and/or infertility and organ injury during repeat abdominal surgery. Perhaps because of the multifactorial nature of adhesion development, prevention has been very limited. Three anti-adhesion products are commercially available, none of which has been universally accepted as a panacea. Part of the obstacles with adhesion management is the lack of an objective clinically relevant classification to allow their study. Because a single band can cause a life-threatening bowel obstruction, whereas extensive dense intra-abdominal adhesions may be asymptomatic, neither the mere presence or absence of adhesions nor their extent if present is totally adequate endpoints. Adhesions are a major health care burden, and their reduction is a significant unmet need in surgical therapeutics facing all surgeons. Of all the parameters assessing adhesions currently available, the authors believe that adhesion incidence (presence or absence) is the most relevant endpoint with a direct clinical implication. The authors endorse the development of a validated, clinically relevant scale to assess intra-abdominal adhesions. Given the present limitation of objective assessment of adhesions and prediction of their clinical effect, the authors also advocate, when appropriate, the use of one of the Food and Drug Administration-approved adhesion barriers. Further research is required to develop safe and effective anti-adhesion methods as well as better assessment tools for their efficacy.