Bedside Laparoscopy in the Intensive Care Unit

Published on 22/03/2015 by admin

Filed under Critical Care Medicine

Last modified 22/03/2015

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W23 Bedside Laparoscopy in the Intensive Care Unit

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