The acute abdomen in the critically ill patient

Bedside diagnostic laparoscopy for critically ill patients: a retrospective study of 62 patients

BACKGROUND

Bedside diagnostic laparoscopy has an important role of diagnosing acute abdomen in critically ill patients hospitalized in the intensive care unit (ICU). Delayed diagnosis of intraabdominal pathology increases the morbidity and mortality rates for these patients, whose clinical signs often are absent due to analgesic medication and sedation.

METHODS

In this retrospective study performed from January 2007 to December 2009, 62 consecutive ICU patients whose blood test results showed them to be hemodynamically unstable underwent bedside diagnostic laparoscopy. The inclusion criteria specified clinically suspected acute cholecystitis, unknown sepsis, acidosis with a high level of lactate, elevated lab tests (white blood cell count, bilirubin, lactic dehydrogenase, creatine phosphokinase, gamma glutamyl transferase [γGT]), and acute anemia with suspected intraabdominal bleeding. The major contraindications to bedside diagnostic laparoscopy were coagulopathy, endocranic hypertension, and heart failure. Patients with a clear indication for an open surgical procedure were excluded from the study.

RESULTS

Of the 62 patients who underwent bedside diagnostic laparoscopy, 43 (69.3%) had positive findings and 29 (46.7%) had acute acalculous cholecystitis. The mean operation time was 38 min, and no procedure-related deaths occurred. The procedure was performed for postsurgery patients, especially after cardiac operations, and for trauma or septic patients. Respiratory and hemodynamic parameters were monitored before, during, and after the procedure.

CONCLUSIONS

As a minimally invasive procedure, bedside diagnostic laparoscopy can be performed in the ICU for hemodynamically unstable patients. It is safe procedure with high diagnostic accuracy for acute intraabdominal conditions that avoids negative laparotomies for unstable patients. The bedside diagnostic laparoscopy procedure is not performed widely, and prospective studies are needed to better evaluate outcome and advantages for critically ill patients.

Bedside diagnostic minilaparoscopy in the intensive care patient

BACKGROUND

The diagnosis of acute abdominal conditions in the critically ill patient remains difficult. The goal of this study is to demonstrate the use of bedside minilaparoscopy as a diagnostic aid in the intensive care unit (ICU) in patients with possible intra-abdominal catastrophic condition.

METHODS

Between February 1998 and May 1999, intensive care patients with abdominal pain, unexplained acidosis or sepsis, or suspected mesenteric ischemia were eligible for bedside diagnostic minilaparoscopy (3.3-mm laparoscope and instruments). The procedure was performed at bedside in the ICU with the patient under local anesthesia and intravenous sedation. Pneumoperitoneum was established with nitrous oxide (N(2)O) to a pressure of 8 to 10 mm Hg. Hemodynamics and ventilatory parameters were monitored before, during, and after the procedure.

RESULTS

Nineteen patients underwent bedside diagnostic minilaparoscopy, including 1 patient who underwent 2 diagnostic laparoscopies. Total procedure time was 9 to 68 minutes (mean, 21 minutes). Three patients were found to have extensive mesenteric ischemia and did not undergo laparotomy. One patient found to have questionably viable bowel at laparoscopy underwent a nontherapeutic formal laparotomy. One patient had a gangrenous gallbladder, and another had a small ischemic segment of bowel; each underwent later open laparotomy and resection. The remaining laparoscopic examinations either showed a nonsurgical cause for the patient's condition or were normal. Nontherapeutic laparotomy was avoided in 19 of 20 patients. One gallbladder perforation occurred during laparoscopy in a patient with a necrotic gallbladder.

CONCLUSIONS

Bedside minilaparoscopy can be a safe and accurate method to evaluate critically ill patients in whom the possibility of mesenteric ischemia or other intra-abdominal process is entertained. Nontherapeutic laparotomy can be avoided in many critically ill patients. Bedside diagnostic laparoscopy can be a useful replacement for diagnostic laparotomy in the operating room. It should be included in the diagnostic algorithm in the evaluation of the unstable patient in the ICU with a suspected acute intra-abdominal process.