Techniques and Procedures

Journal of Intensive Care Medicine

2015, Vol. 30(5) 297-302
Diagnostic Laparoscopy ª The Author(s) 2013
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in the Intensive Care Unit DOI: 10.1177/0885066613492102
jic.sagepub.com

Alla Zemlyak, MD1, B. Todd Heniford, MD, FACS1,

and Ronald F. Sing, DO, FACS, FCCM1

Abstract
Primary and acquired abdominal pathology accounts for a significant proportion of sepsis and SIRS in the ICU population.
Abdominal processes often present a difficult diagnostic dilemma in the truly critically ill patient who, due to hemodynamic
instability or severe acute respiratory distress syndrome (ARDS) requiring high-level ventilatory support, is at significant risk
during transport to radiology department. Furthermore, the accuracy of radiologic studies in the ICU setting is often limited.
Laparoscopy provides a ‘‘minimally invasive’’ definitive modality to diagnose intra-abdominal problems. It may quickly provide the
necessary information to define further management. In selective circumstances, it may actually allow appropriate intervention.
However, the overall mortality of patients who undergo diagnostic laparoscopy in the ICU is high regardless of diagnostic fin-
dingsduring this procedure. Although not a technically difficult procedure, diagnostic laparoscopy does require a certain skill level,
especially when limited time and unfavorable patient physiology are taken into account. The use of diagnostic laparoscopy should
be limited to patients in whom a therapeutic intervention is feasible.

Keywords
diagnostic laparoscopy, ICU, sepsis

Introduction accuracy of CT scan was only 33% in ICU patients who under-
went abdominal CT for SIRS of unknown origin.5 Furthermore,
Despite the tremendous increase in the understanding of sepsis,
it is not always feasible to transport hemodynamically unstable
systemic inflammatory response syndrome (SIRS), and multi-
patients or patients with severe ARDS requiring high levels of
system organ failure, source control is mandatory if the patient
ventilatory support. The US can be brought to the bedside and
is to survive. The abdomen is a common primary source of
thus does not require transporting a patient out of the ICU. The
pathology (eg, peritonitis due to ulcer perforation, diverticuli-
US, however, has diagnostic limitations. A study on the use of
tis, etc) but can also be a secondary source in patients being US in 400 ICU patients published in 2007 found that US is
treated for medical conditions (eg, acalculous cholecystitis and
effective for confirming the diagnosis already established clini-
ischemic bowel). Notably, nonocclusive mesenteric ischemia,
cally but not as a primary diagnostic tool.6 Abdominal US is
which is one of the most common problems in the intensive
mostly useful for detecting fluid collections and evaluating bili-
care unit (ICU) population, although often transient, affects
ary anatomy. However, for acalculous cholecystitis, which
up to 80% of the patients with multiorgan failure.1 Abdominal
commonly affects patients with a prolonged ICU stay, the sen-
processes often present a difficult diagnostic dilemma in the
sitivity of US is quite low. In a study on critically ill patients
truly critically ill patient who, due to hemodynamic instability
with trauma, it had a sensitivity of only 30%.7
or severe acute respiratory distress syndrome (ARDS) requir- Transporting critically ill patients to and from the radiology
ing high-level ventilatory support, is at significant risk during
department for diagnostic testing is associated with significant
transport to radiology department.2,3
risk of adverse events. According to some studies, adverse
Imaging modalities that are often used in the critical care set-
tings include abdominal x-rays, computed tomography (CT)
scan, and ultrasound (US). Abdominal x-rays have a limited 1
Department of Surgery, Carolinas Medical Center, Charlotte, NC, USA
diagnostic value, and the decision to proceed to the operating
room is rarely based on a plain film alone unless it is clearly indi- Received December 16, 2012. Accepted February 5, 2013.
cative of a perforated viscus (ie, pneumoperitoneum). According
Corresponding Author:
to the study of 53 patients admitted to surgical ICU, abdominal Ronald F. Sing, Department of Surgery, Carolinas Medical Center, PO Box
CT had a sensitivity of 48% and a specificity of 64% in that 32861, Charlotte, NC 28232-2861, USA.
patient population.4 Kelly et al showed that the overall Email: ron.sing@carolinashealthcare.org
298
events may complicate up to 70% of the intrahospital trans-
ports, and the majority of these occur during transport for a
CT scan1,2 and involve hypoxia and changes in blood pressure.8
Patients who are at high risk are those on mechanical ventila-
tion, patients with a high injury severity score, and those with
a high therapeutic intervention severity score.1
Laparoscopy provides a ‘‘minimally invasive’’ definitive
modality to diagnose intra-abdominal problems. It may quickly
provide the necessary information to define further manage-
ment. In selective circumstances, it may actually allow appro-
priate intervention. Bedside laparoscopy, although it may
present some technical difficulties, should be considered by
an intensivist, because it does not carry the mortality associated
with nondirected emergency laparotomy in a patient requiring
ICU care up to multiorgan failure.9,10
Who Should Get Laparoscopy?
The Agency for Healthcare Research and Quality current
guidelines state that the indications for diagnostic laparo-
scopy in the ICU settings include unexplained sepsis, SIRS,
multiorgan failure, unexplained metabolic acidosis, abdom-
inal pain with signs of sepsis and without obvious indication
for laparotomy, and increased abdominal distention that is not
a consequence of bowel obstruction. When diagnostic laparo-
scopy is performed in patients with these indications, the yield
of this procedure can be significant as indicated by multiple
retrospective studies. In the largest series, 35 patients from
Greece underwent laparoscopy for the aforementioned indica-
tions. It had positive findings in 43% of the patients.11 Inter-
estingly in this study, the average time to complete diagnostic
laparoscopy at the bedside was shorter than the time to obtain
an abdominal CT scan. In a single-institution study from Italy
performed in 2009, diagnostic laparoscopy was performed in
12 patients with sepsis of unknown origin confirming a diag-
nosis of purulent peritonitis and leading to exploratory lapar-
otomy in 50%.12 In 3 of 6 patients, the source of peritonitis
was identified (2 colonic perforations and 1 ischemic distal
ileum). In the other 6 patients, the abdomen was definitively
excluded as a source of sepsis. In a study of 17 critical care
patients with SIRS of unknown origin, diagnostic laparoscopy
identified abdominal processes in 6 patients with 100% accu-
racy as confirmed by laparotomy, postmortem examination,
or recovery.5
Researchers at Case Western Reserve University examined
a series of 25 critically ill patients with multiorgan failure; 11
had respiratory failure, 5 had renal failure, 2 had congestive
heart failure, and 9 had hyperbilirubinemia/cirrhosis.13 Laparo-
scopy revealed pathology in 12 of 25 patients, leading to a
change in management in 9 (36%) patients. Four of these
underwent earlier abdominal exploration based on the laparo-
scopic findings, and in 5, exploratory laparotomy was avoided
although deemed necessary at first. In a series of 26 patients by
Orlando et al, mesenteric ischemia was suspected in 9 patients
based on refractory lactic acidosis and was confirmed in 3 of 9
patients during laparoscopic examination.14 In a study by
Journal of Intensive Care Medicine 30(5)
Jaramillo et al in 2006, abdominal pain was the primary reason
for diagnostic laparoscopy in 5 of 13 critically ill patients.15 In
these 5 patients, 4 had positive findings (2 with mesenteric
ischemia and 2 with acalculous cholecystitis).
Although limited to retrospective case series, these studies
demonstrate laparoscopy is a sensitive diagnostic modality in
critically ill patients in whom a definitive diagnosis is otherwise
difficult. It avoids nontherapeutic laparotomy and leads to earlier
abdominal exploration in cases where it is necessary, for exam-
ple, prompt source control. Diagnostic laparoscopy does have its
limitations. Presence of abdominal adhesions due to previous
abdominal surgeries may substantially complicate laparoscopy
leading to prolonged operative times, conversion to laparotomy,
bowel injury at the time of surgery, or false negative results due
to incomplete visualization. For example, in a series of 12
patients reported by Walsh et al, 1 patient in whom visualization
was difficult had a prolonged laparoscopy time of 40 minutes,
which resulted in bradycardia and an increase in peak inspiratory
pressure.16 High intra-abdominal pressure may render laparo-
scopy impossible,5 although frequently lower insufflation levels
(around 8-10 mm Hg) can be applied than are typically required
to perform surgery.17 Also, retroperitoneal processes will likely
be missed during laparoscopy and also lead to a false negative
result. In a series of 17 patients who had diagnostic laparoscopy
after major cardiac surgery reported by Hackert et al, 1 patient
with necrotizing pancreatitis had no pathologic findings on
laparoscopic examination.18 However, apart from these few
exceptions, laparoscopy has nearly a 100% diagnostic accuracy,
as reported by many studies.
In our experience, diagnostic laparoscopy has the highest
yield in critically ill patients with abdominal pain, tenderness,
or distention in the setting of a worsening clinical course. Our
major predictor of converting to exploratory laparotomy under
these circumstances is the presence of significant bowel dilata-
tion. Intestinal distention significantly decreases the visualiza-
tion and increases the risk of visceral injury during laparoscopy.
Laparoscopic Physiology and Techniques
When a decision to proceed with diagnostic laparoscopy on a
critically ill patient is made, a few physiologic and technical
aspects need to be considered. Bedside laparoscopy is preferred
if possible, since it avoids the risks associated with transporting
a critically ill patient. Inhaled anesthetics are not necessarily
excluded from the ICU, but performing laparoscopy under
local anesthesia with intravenous sedation is feasible as evi-
denced by many studies.11,14,17,19 The transumbilical technique
is most commonly used to enter the abdomen unless the patient
has had prior midline surgery involving the umbilicus. In that
setting, access can be obtained by open technique (our
approach) at either upper quadrant at the tip of the 11th rib. The
approach needs to be individualized to the needs of the patient
and the comfort and technical expertise of the operating
surgeon. Some concerns have been expressed in the literature
regarding the cardiopulmonary effects of pneumoperitoneum
and systemic CO2 absorption in ICU patients whose physiology
Zemlyak et al
Figure 1. Laparoscopic view of gangrenous segment of small bowel.
is already compromised by their disease.20 Carbon dioxide
pneumoperitoneum increases arterial CO2 and peripheral vas-
cular resistance and can cause acidemia. Intra-abdominal pres-
sure leads to increased central venous pressure and decreased
urine output.21 However, it appears from multiple retrospective
studies that diagnostic laparoscopy is overall a very safe proce-
dure even in critically ill patients. None of the studies reported
significant hemodynamic complications associated with its use.
In most of the studies, diagnostic laparoscopy was performed at
the bedside under either general or local anesthesia with intra-
venous sedation. No advantages are apparent from either
approach. In all but 2 series, an anesthesiologist was present
at the bedside during the procedure. Two studies reported the
use of local anesthesia with intravenous sedation without help
from a certified anesthesiologist with no complications.11,17
Open or Veress needle technique was used in all the series
depending on surgeon’s preference. One author reported suc-
cessful use of the mini-laparoscopy technique (3.3 mm ports).17
Brandt et al reported 1 case of omental bleeding associated with
trocar placement, which did not affect the patient’s outcome.13
Gallbladder perforation was also reported during laparoscopic
manipulation as well as ascitic leak from a trocar site, but none
of these complications affected the overall outcome of the
patients.17 One series reported the use of N2O as an insufflating
gas as opposed to more traditional CO2 due to fear of inducing
hypercarbia and acidosis in patients with limited physiologic
reserve.17 CO2 pneumoperitoneum can cause acidosis and
some electrolyte changes more so than insufflation with
N2O.22 However, in most of the studies, CO2 was safely used
without significant physiologic derangements. Most authors
tried to achieve laparoscopic diagnosis with the lowest intra-
abdominal pressure that was feasible; the lowest being 8 and
the highest 15 mm Hg. Limiting insufflating pressure and
laparoscopy time leads to better tolerance of the procedure
by critically ill patients.23,24 In our experience, diagnostic abil-
ity of laparoscopic exploration is not compromised by lower
intra-abdominal pressures (8-10 mm Hg). We have not seen
any significant problems associated with CO2 insufflation, and
most patients tolerate laparoscopy very well, especially when
lower insufflation pressures are utilized.
299
Figure 2. Laparoscopic view of gangrenous cholecystitis.
What Are We Diagnosing?
Pathologic findings that are diagnosed on laparoscopy will
depend on whether the abdominal process was the original
cause of ICU admission, or it was diagnosed during ICU stay.
In a study by Pecoraro et al performed in ICU patients who
were admitted with the suspicion of an abdominal process,
some of the diagnoses included tumors, colovesical fistula,
postoperative abscess, and perforated duodenal ulcer.19 In a
study by Peris et al of 6 patients admitted to ICU with abdom-
inal sepsis, 2 had colonic perforations and 1 had ischemia of the
distal ileum, with 3 others having purulent peritonitis without
an obvious cause.12 By far, the most common diagnoses
discovered during laparoscopy performed in ICU patients with
prolonged stay and admitted with diagnosis other than abdom-
inal sepsis are small or large bowel ischemia (Figure 1), acal-
culous cholecystitis/gangrenous gallbladder (Figure 2), and
liver cirrhosis. Other findings include colonic perforations, sig-
moid diverticulitis, and peritonitis without an identifiable
cause.16 The yield of diagnostic laparoscopy is highest in critical
care patients who have undergone major cardiac surgery. Hack-
ert et al identified 17 ICU patients with cardiac disease who
underwent laparoscopy based on the findings of abdominal dis-
tention, leukocytosis, and acidosis. Laparoscopy was positive in
15, with 1 negative finding being a false negative.18 In this
series, 5 patients had massive colonic distention, 6 had colonic
ischemia, 3 had cholecystitis, and 1 had peritonitis without an
identifiable pathology. The number of positive laparoscopies is
somewhat lower in the literature for general surgical patients,
patients with trauma, and medical ICU patients. In a study on
surgical ICU patients, laparoscopy was positive in 15 of 26
patients, with 10 patients having acalculous cholecystitis.14 In
an Italian study of 32 ICU patients, there were 14 patients with
trauma, 12 patients with sepsis of unknown origin, and 6 patients
with cardiac surgery who underwent diagnostic laparoscopy.
Among the patients with trauma, laparoscopy was positive in
3 of 14 patients revealing acalculous cholecystitis in all patients.
With regard to patients after cardiac surgery, laparoscopy was
positive in all the 6 cases (4 had gangrenous cholecystitis and
2 had extensive bowel ischemia). In a study by Walsh et al, diag-
nostic laparoscopy was performed in 12 patients from the
300
medical ICU (admitted for cardiac or pulmonary failure or septic
shock) for whom surgical consultation was requested. The study
showed positive findings in 5 patients; 2 patients had mesenteric
ischemia, 1 had sigmoid diverticulitis, 1 thickened terminal
ileum, and 1 nonpurulent peritonitis.16 Liver cirrhosis was the
only abnormal finding during laparoscopy in several patients
in a series by Orlando, Gagne, and Bender,14,17,25 and it was the
ultimate cause of the patients’ death.
Alternatives to Diagnostic Laparoscopy
Diagnostic peritoneal lavage (DPL) is another minimally inva-
sive procedure that can be performed at the bedside and under
local anesthesia. Walsh et al16 compared the use of DPL and
diagnostic laparoscopy in 12 critical care patients. In this study,
positive DPL was defined as white blood cell >200 cells/mm3.
Based on these criteria, DPL was 100% sensitive in predicting
which patients needed laparotomy, but specificity was only
about 85%. Laparoscopy was more specific and overall more
accurate in predicting the need for abdominal exploration.
Another advantage of laparoscopy is a potential for therapeutic
intervention without converting to an open operation. We have
not seen any advantages in using DPL over low-pressure
laparoscopy, since the latter can provide more information and
is generally well tolerated.
Bedside abdominal US is another diagnostic modality that
can be used for an evaluation of a critically ill patient. It has
been shown by some studies to be more accurate for detecting
pneumoperitoneum than a plain radiograph.26,27 The US is also
a very sensitive test for the detection of free abdominal fluid.
Although the trauma literature suggests a high correlation
between the presence of free fluid and surgical pathology,28,29
critically ill patients often have small amounts of ascites that
are readily detectable with US but do not need surgical inter-
vention. The US has reported to be unreliable in the diagnosis
of acalculous cholecystitis.7 It is also not a useful tool in diag-
nosing intestinal ischemia, and thus its applicability for diag-
nosing intra-abdominal pathology in the ICU population is
rather limited. In our experience, the value of bedside US in
evaluating abdominal pathology is very limited. Clinical
suspicion should prompt abdominal exploration regardless of
sonographic findings.
With the advent of natural orifice transluminal endoscopic
surgery (NOTES), there is yet another modality that could poten-
tially be used as a diagnostic modality in the ICU. Two animal
studies used transgastric exploration as a diagnostic modality
in pigs. One study found that a transgastric endoscope can be
used to perform complete abdominal exploration.30 Another
study found that although NOTES was 100% specific for detec-
tion of intra-abdominal pathology, it was less sensitive than
laparoscopy (63.1% vs 77.4%).31 The NOTES has a potential
to become another diagnostic maneuver for the ICU patients
in whom regular laparoscopy is difficult to perform for various
reasons, but perforation of the stomach to perform such an exam-
ination can lead to its own set of significant complications.
Journal of Intensive Care Medicine 30(5)
Outcomes of the Patients Who Underwent
Diagnostic Laparoscopy
The overall mortality of patients who undergo diagnostic laparo-
scopy in the ICU is high regardless of diagnostic findings during
this procedure according to most of the studies that report sur-
vival data. In a series of 35 patients by Karasakalides et al, the
overall mortality was 60%.11 In a small series by Rosin et al,
mortality in 4 patients who had bedside laparoscopy was
100%.32 Gagne et al reported that of 19 patients who underwent
bedside laparoscopy, only 4 patients (all with negative findings)
survived, and none of the patients with positive findings were
rescued.17 Among 7 patients who had diagnostic laparoscopy
reported by Bender and Talamini, 2 patients underwent explora-
tory laparotomy for gangrenous colon and both survived, but
both were young (36 and 46 years old).25 In a series by Jaramillo
et al, 4 (30%) patients survived their ICU stay, but only 2 were
helped by diagnostic laparoscopy (both with acalculous chole-
cystitis).15 In the study reported by Walsh et al of 12 patients,
4 (33%) survived but only 1 survival was due to diagnostic
laparoscopy that showed limited ischemia of the segment of ter-
minal ileum.16 Global mesenteric ischemia in all series as well as
in our own experience was universally fatal as was liver cirrho-
sis. Thus, based on the limited data that are available from small
retrospective studies, we observe that although diagnostic
laparoscopy is helpful in clinical decision making and helps
avoid unnecessary laparotomy in certain cases, survival of these
patients is infrequently affected by diagnostic findings. Patients
who benefit most from diagnostic laparoscopy are younger
patients with good physiologic reserve. However, diagnostic
laparoscopy may play a significant role in deciding to withdraw
support when uncorrectable issues are found.
Diagnostic Laparoscopy for Acalculous
Cholecystitis
When laparoscopy is performed to rule out acalculous cholecys-
titis, given that the patient does not have an otherwise fatal con-
dition, the outcomes are better than with other indications for
laparoscopy. Patients with trauma with prolonged ICU stay often
develop this abdominal complication, which, when untreated,
carries high mortality. Almeida et al studied 10 ICU patients,
9 of who were patients with trauma.33 All underwent diagnostic
laparoscopy for fever, abdominal tenderness, and/or elevated
liver function tests. Gangrenous cholecystitis was found in 2
patients, and both were treated with laparoscopic cholecystect-
omy. In a study by Brandt et al, laparoscopy was performed in
9 patients with trauma suspected to have acute acalculous chole-
cystitis and was positive in 4.34 No complications were encoun-
tered, and laparoscopy reliably diagnosed gallbladder disease. In
a series by Peris et al, acalculous cholecystitis was laparoscopi-
cally diagnosed in 3 of the 14 patients with trauma, and all were
successfully treated with percutaneous gallbladder drainage.12 In
all these studies, laparoscopy was used to diagnose a potentially
curable disease in patients without major medical comorbidities,
and the results were therefore favorable.
Zemlyak et al
Conclusions
Primary and acquired abdominal pathology accounts for a signif-
icant proportion of sepsis and SIRS in the ICU population, and the
diagnosis of it using laboratory and imaging studies is often diffi-
cult. Laparoscopy provides a sensitive modality to diagnose
abdominal pathology in critical care patients, especially those with
significant intrahospital transport risks. Bedside laparoscopy can
facilitate management decisions, avoiding unnecessary transport
for CT scans, exposure to intravenous contrast, exploratory lapar-
otomy, and it allows intervention when appropriate. It is extremely
accurate compared with other imaging modalities for diagnosing
acute intra-abdominal processes, whether primary or secondary,
and importantly, avoids transport to the CT scanner in patients
at high risk of complications during intrahospital transport.
Furthermore, it may be less time consuming and more cost effec-
tive than CT scan.11 Although not a technically difficult procedure,
diagnostic laparoscopy does require a certain skill level, especially
when limited time and unfavorable patient physiology are taken
into account. The use of diagnostic laparoscopy should be limited
to patients in whom a therapeutic intervention is feasible.
Declaration of Conflicting Interests
The author(s) declared no potential conflicts of interest with respect to
the research, authorship, and/or publication of this article.
Funding
The author(s) received no financial support for the research, author-
ship, and/or publication of this article.
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