Bedside Laparoscopy in the Intensive Care Unit

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W23 Bedside Laparoscopy in the Intensive Care Unit

Joseph F. Sucher, S. Rob Todd, Laura J. Moore, Barbara L. Bass

Laparoscopy has proven itself an accurate diagnostic tool in a wide spectrum of clinical scenarios. More recently it has been applied in the evaluation of both trauma and intensive care unit (ICU) patients. This chapter will focus on diagnostic laparoscopy for the critically ill patient in the ICU.

Acute intraabdominal pathologies remain a significant source of morbidity and mortality in the ICU. Etiologies include acalculous cholecystitis, intestinal ischemia, intestinal perforation, peptic ulcer disease complications, pseudomembranous colitis, diverticulitis, and pancreatitis to name a few. Specifically, acalculous cholecystitis has been documented in 1% of surgical ICU patients and 0.5% of critically injured trauma patients. Likewise, intestinal ischemia is a significant risk following aortic procedures.

While the aforementioned occur relatively infrequently, associated morbidity and mortality are significant. If left undiagnosed and/or untreated, intraabdominal sepsis may lead to multiple organ failure (MOF), with mortality rates approaching 100%. The reported mortality rates specific to acalculous cholecystitis and mesenteric ischemia range from 50% to 100%.

A significant contributor to the high morbidity and mortality rates is delay in diagnosis. Such delays are multifactorial and include failure to consider the diagnosis, difficulty in obtaining the diagnosis secondary to patient safety issues, and lack of accuracy of the diagnostic modalities.

Critically ill patients also have numerous other potential sources of sepsis further complicating the picture (e.g., central venous catheter infection, ventilator-associated pneumonia, urinary tract infection, etc.). As such, surgical consultations are often sought in these patients; indications include abdominal pain, abdominal distention, fever of unknown etiology, sepsis of unknown etiology, inexplicable acidosis, enteral intolerance, and others. This often presents a diagnostic dilemma. Diagnostic modalities to assess the abdomen in this critically ill population include the physical examination, laboratory studies, plain radiography, computed tomography (CT) scans, ultrasound, diagnostic peritoneal lavage (DPL), exploratory laparotomy, and increasingly, diagnostic laparoscopy.

image Before Procedure

Indications

• Critical illness with suspicion for intraabdominal pathology with:

• Inability to perform exam (unreliable physical exam findings):

image Altered mental status
image Sedation
image Paralysis

• Inability to transport for diagnostic radiologic imaging:

image Hemodynamic instability
image Pulmonary instability

• Inability to make diagnosis with given information:

image For example, radiologic imaging is equivocal or nondiagnostic
image Other modalities unlikely to provide diagnosis

• For example, DPL unable to diagnose diaphragm injury

Contraindications

• Intraabdominal hypertension
• Open abdomen
• Recent abdominal wound dehiscence
• Previous laparotomy (relative contraindication)

• Recent laparotomy is not an absolute contraindication.

• Hemodynamic instability (relative contraindication)

Equipment

• ICU equipment:

• Monitoring:

image Continuous monitoring:

• Electrocardiogram (ECG)
• SpO2
• Noninvasive blood pressure (NIBP) or arterial line

image If NIBP record at least once every 3 minutes

• End-tidal carbon dioxide (CO2) monitor

image Bispectral index (BIS) monitoring during administration of anesthesia (optional)

• Ventilator:

image Full ventilatory support may or may not be required based on patient condition.
image If patient is not intubated, the team should be fully prepared for endotracheal intubation.

• Laparoscopic equipment:

• Mobile laparoscopic cart with locking brakes and four antistatic rollers

image Optical equipment:

• Laparoscopic camera system
• Laparoscopic light source
• Video monitor
image Only one monitor is necessary.
image Ideally the monitor should be able to tilt, swivel, and pivot on a boom.

image A second monitor can be “slaved” from the main monitor and positioned for the assistant to see.

• Video recorder (optional)

image Laparoscopic CO2 insufflator system with pressure monitor

• CO2 gas tank with backup tank and wrench tool

image Monopolar electrocautery generator with grounding pad

• Laparoscopic-specific set (sterilized):

image Fiberoptic light cable
image Telescopes:

• 10-mm scope (0- and 30-degree angles)
• 5-mm scope (0- and 30-degree angles)

image CO2 insufflation hose with filter
image Trocars/ports (surgeon specific)

• Entry technique:

image Open (Hasson method)

image 12-mm Hasson port

image Optiview visualizing trocar

image 5-mm clear

image Blind

image Veress needle

• 5- to 12-mm trocar

• Additional ports

image Additional ports dictated by surgeon requirements

image Laparoscopic instruments (minimal necessary)

• Ratcheted atraumatic graspers (×2)
• Non-ratcheted atraumatic graspers (×2)
• Maryland dissector
• Laparoscopic scissors
• Cauterization instrumentation with associated generators

image Monopolar system
image Other 5-mm cauterization systems can be used if necessary, such as:

image Harmonic
image Ligasure
image EnSeal

• Laparoscopic suction-irrigator

• Basic abdominal surgical set:

• Surgical sterile prep system
• Laparotomy towels and drapes
• Laparotomy sponges
• Scalpel (#11 blade and/or #15 blade)
• Suture:

image 0- polyglactin 910 suture on UR-6 needle (×2)
image 4-0 poliglecaprone 25 suture on PS-2 needle (×2)

• Surgical pickups:

image Adson tissue forceps (×2)
image Rat-toothed, heavy forceps (×1)

• Suture scissors

• Dressings

• image-inch Steri-Strips
• Surgical wound covers

image Band-aids or
image 2 × 2 sterile gauze with clear occlusive dressing

image Anatomy

Special considerations for patient selection and the entry technique need to be evaluated. Prior operations may preclude the ability to enter the abdomen safely or may obscure the clinician’s ability to perform complete visual inspection of its contents because of adhesive disease. In these cases, diagnostic laparoscopy may not be successful. Patients with portal hypertension are at increased risk of bleeding due to inadvertent injury of dilated venous collaterals that are not normally present within the abdominal wall. Finally, the inferior epigastric artery is at risk for injury during trocar placement, and careful attention should be paid to avoid its consistent location within the rectus sheath.

image Procedure

• The procedure can be performed safely with the following personnel:

• The surgeon (laparoscopist)
• The intensivist/anesthesiologist for administration of sedation and analgesia, as well as for respiratory and hemodynamic monitoring
• A scrub nurse to assist the surgeon
• An ICU nurse (circulator) to obtain necessary equipment and medications
• A respiratory therapist on standby to assist the intensivist/anesthesiologist

• The patient’s position is neutral and supine.
• Complete prep and drape in standard fashion
• Monitoring should be continuous or at least every 3 minutes and include:

• Blood pressure, pulse rate, respiratory rate, tidal volume and peak inspiratory pressure, oxygen saturation (SpO2), and end-tidal PCO2
• Bispectral index (BIS) monitory is optional.

• Sedation and analgesia provided intravenously

• A narcotic (e.g., fentanyl, morphine)
• A sedative:

image Benzodiazepines (e.g., midazolam, lorazepam)
image Propofol
image A paralytic (e.g., vecuronium, rocuronium, cisatracurium)

• Diagnostic laparoscopy has been done successfully using only local anesthesia and a mild sedative.

image For complex ICU patients with suspected intraabdominal pathology, using local anesthesia would not be optimal.

• Decompression of the stomach with a nasogastric tube (NGT) and the bladder with a Foley catheter is advisable.
• A vertical incision is placed just cephalad or caudad to the umbilicus.

• This can be extended if a formal laparotomy is necessary.

• Open approach:

• Under direct vision, the fascia and peritoneum are opened through the linea alba.
• Stay sutures (0-polyglactin 910) are placed (can be used to close fascia at end of procedure).
• Cannula is inserted, and the two fascial sutures are looped around it in the provided grooves for stabilization.

• Blind techniques can be used if deemed safe and can minimize the incision necessary for peritoneal access.
• CO2 is insufflated slowly to minimize adverse effects on respiratory function and hemodynamics.

• Some advocate lower insufflation pressures (8-12 mm Hg). No studies have been performed comparing different insufflation pressures.

• Angled scope is preferred for improved visualization.
• If procedure performed for trauma patient, inspection of diaphragm should be first step (to reduce risk of tension pneumothorax if diaphragm injury)
• Quick inspection around the abdominal cavity for any obvious signs of peritonitis. If found, terminate procedure and prepare for formal therapeutic operation.
• Additional 5-mm ports can be placed under direct vision as necessary.
• Complete the inspection as you would with formal exploration, in organized fashion, including all abdominal and pelvic viscera in addition to peritoneal surfaces.

image After Procedure

Postprocedure Care

• Continuous monitoring with ECG, SpO2 and NIBP as long as patient condition warrants
• Maintain NGT to suction and Foley to gravity.
• Check arterial blood gas (ABG) for acidosis and hypoxemia.

• Optimize ventilation and oxygenation.

• If laparoscopy was nondiagnostic, the surgeon should be prepared to perform laparotomy, either at bedside if patient condition warrants or in operating room if patient is stable for transport.

Complications

• Common:

• Increased intraabdominal pressure which may result in:

image Oliguria
image Increased peak airway pressures and resistance

• Decreased functional residual capacity and lung compliance
• Increased difficulty with ventilation and/or oxygenation

image Hypotension due to:

• Decreased venous return and/or increased systemic vascular resistance (afterload)

• Hypercarbia with associated metabolic acidosis:

image Results from increased pulmonary dead-space and peritoneal absorption of insufflated CO2
image Usually transient
image Can be corrected through increasing minute ventilation

• Infrequent:

• Intestinal injury due to:

image Trocar insertion
image Manipulation of bowel or intestinal adhesiolysis
image Use of electrocautery

• Vascular injury due to:

image Trocar insertion
image Manipulation of mesentery

• Bladder injury due to:

image Trocar insertion

• Deep venous thrombosis:

image Associated with prolonged procedures coupled with prolonged impaired venous blood return and perioperative hypercoagulability

• Serious, rare complications:

• Gas embolization from CO2 pneumoperitoneum into venous system, manifested by:

image Sudden hemodynamic collapse with precipitous drop in end-tidal CO2 (not specific)

• Positioning patient in steep Trendelenburg and rolled to the left may put gas embolism away from pulmonary outflow tract and restore blood flow out of the right heart.

• Tension pneumothorax due to CO2 tracking through gaps in the diaphragm into the pleural space
• Acute volume overload and pulmonary edema:

image Can result after release of pneumoperitoneum
image Large amounts of intravenous fluids infused during procedure to maintain hemodynamic status

• Elevated intracranial pressure (ICP):

• Hypercarbia can result in cerebral vasodilation, with concomitant potential for increased ICP.
• Intraabdominal hypertension can impede venous flow from the periphery and increases cerebrospinal fluid pressure.

• Despite the significant advantages of laparoscopy, it is not without its disadvantages. The most concerning are potential detrimental physiological effects, specifically to the cardiovascular and pulmonary systems. Experimental animal models demonstrate hemodynamic compromise in septic animals undergoing laparoscopy, usually secondary to the associated hypercarbia and acidosis. Others document temporary myocardial insufficiency, with decreases in cardiac output up to 80% after only 20 minutes of CO2 insufflation. However, many studies report no hemodynamic alterations during laparoscopy. Means of avoiding such outcomes include slow CO2 insufflation, lower intraabdominal pressures, using alternative gases for insufflation (e.g., nitrous oxide), and ultimately, desufflation if necessary.

image Outcomes and Evidence

• Bedside laparoscopy in the ICU is safe and effective in diagnosing intraabdominal pathology in critically ill patients.
• Gagné et al. performed 20 bedside laparoscopic procedures on 19 patients, with mean time of 21 minutes; 18 of 19 patients avoided nontherapeutic laparotomy as a result.
• Pecoraro et al.—4 of the 11 patients had recent laparotomies. In 6 of the 11 patients studied, the use of bedside laparoscopy avoided nontherapeutic open laparotomy.
• Kelly et al.—17 cases, 16 completed. No complications, with 100% accuracy among the 16 completed procedures. Abdominal CT in 9 patients was accurate in only 33%.
• Hackert et al.—17 patients studied, revealing a 94% sensitivity for bedside laparoscopy.
• Peris et al.—largest (retrospective) study to date, with 32 patients, mean time of 40 minutes, and no complications; 15 (46.9%) of the patients had a pathologic finding necessitating intervention; 6 patients with sepsis, who had prior negative diagnostic peritoneal lavages, were found to have peritonitis on diagnostic laparoscopy.

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