Bedside diagnostic minilaparoscopy in the intensive care patient

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.

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.

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.

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.