Bedside Laparoscopy in the Intensive Care Unit

Published on 22/03/2015 by admin

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Last modified 22/03/2015

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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
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