Page 12 - Journal of World Association of Laparoscopic Surgeons

Role of Diagnostic Laparoscopy in Chronic Abdominal Pain with Uncertain Diagnosis

MAterIAls And Methods Assessment of Pain
Study Design The pain was assessed using VAS score ranging from 0 to 10. VAS
The present one-year hospital-based cross-sectional study was was explained to the patient during preoperative visit, considering
zero as no pain and 10 as maximum pain points. The assessment of
conducted from January 2016 to December 2016 at the Department pain was done at enrolment and at postoperative followups, i.e.,
of General Surgery. An approval was obtained from the Institutional day 15, 30, 45, and 60.
Ethical review board, prior to the commencement of the study.
A total of 55 patients with undiagnosed chronic abdominal pain Statistical Analysis
were included in the study. The patients fulfilling selection criteria The data obtained were coded and entered in Microsoft Excel
were informed in detail especially, the procedure of diagnostic spreadsheet. The categorical data were expressed as rates, ratios,
laparoscopy and a written informed consent was obtained. and percentages. Continuous data were expressed as mean ±
Selection Criteria standard deviation. The comparison of mean pain scores at different

Patients aged ≥18 years with a history of chronic abdominal pain follow-ups was done using one-way ANOVA test. p ≤ 0.05 at 95%
confidence interval was considered as statistically significant.
from ≥8 weeks and undiagnosed despite biochemical and other
radiological investigations such as USG/CT/MRI were included in
the study. However, the patients diagnosed with chronic abdominal results
pain, discontinued follow-up, pregnant women, and those not fit The mean age of the patients was 37.67 ± 14.45 years with striking
for general anesthesia were exempted. female preponderance (64.45%; Table 1). Majority of the patients
(38.18%) were in the age group of 18–30 years. Most of the patients
Data Collection were married (84.55%) and were graduates (54.55%). Fever was
Demographic data (including age and gender) were noted. Patients the clinical feature observed in most of the patients (41.82%).
were interviewed for the medical and surgical history along A history of lower segment cesarean section was observed in
with presenting complaints. Symptoms such as fever, diarrhea, 5.45% patients. Tenderness over the lower abdomen was noted in
constipation, burning, and micturition were recorded. The patients 45.45% patients, while 43.6% patients had generalized tenderness
were subjected to clinical examination and details about severity (Table 1). The characteristics of the pain in the study population are
of pain based on visual analog scale (VAS) score, duration of pain, given in Table 2. Most of the patients (65.45%) had a duration of
site of pain, and nature of pain were noted. These findings were pain between 8 and 12 weeks. The mean duration of pain observed
recorded on a predesigned and pretested proforma. Investigations in patients was 10.80 ± 2.78 weeks. Most of the patients reported
including hemoglobin, total leucocyte counts, direct count, random generalized (49.09%), intermediate (32.73%), and progressive type
blood sugar, platelet count, liver function test, urine routine and of pain (65.45%).
microscopy, serum creatinine, and radiological investigations such The clinical and biochemical profile of the study population
as USG, CT, and MRI were also performed. is shown in Table 3. Blood urea levels (24.51 ± 10.23 mg/dL) of
the patients with chronic abdominal pain was slightly high, while
Intervention the remaining clinical and biochemical parameters were within the
After the evaluation of preoperative investigations and fitness for standard limits.
anesthesia, the selected patients were subjected to diagnostic USG, CT, surgical findings, and the type of surgery performed
laparoscopy, either by the open or closed technique by a single in patients is summarized in Table 4. USG and CT findings were
surgeon, under general anesthesia. Patients were kept nil by normal in 76.36% and 20% of the patients, respectively. The most
mouth for 12 hours prior to surgery. Initial port placement was common surgical finding was adhesions (30.91%) followed by an
done at umbilical point by open technique (Figs 1A and B). In cases inflamed appendix (29.09%). The most common surgical procedure
with scars and previous history of surgery, initial port placement performed was adhesiolysis (30.91%) followed by appendectomy
was done at Palmer’s point, by open technique. Additional ports (29.09%).
were inserted as required (Fig. 1C). The abdominal cavity was Postoperative pain scores in the patients during the followup
examined to the possible extent in each case. Interventions such period is given in Table 5. On day 15, 47.27% patients had moderate
as adhesiolysis, appendectomy, peritoneal biopsy, lymph node pain and 14.55% patients had no pain. The pain was absent in
biopsy, or aspiration of any peritoneal fluid were carried out at 54.55%, 80%, and 89.09% patients on days 30, 40, and 60. The mean
the discretion of the operating surgeon. Starting from the pelvis, VAS score gradually reduced from 3.05 ± 1.88 on day 15 to 1.22 ±
the uterus, ovary, uterine adnexa in females, rectum and sigmoid 1.54 on day 30, 0.47 ± 1.02 on day 45, and 0.25 ± 0.78 on day 60.
colon, ileocecal region, cecum, appendix, ascending colon, This reduction was statistically significant (p < 0.001).

transverse colon, stomach, duodenum, gallbladder, liver, spleen,
and descending colon were serially visualized and examined.
The patient was then turned in reverse Trendelenburg position dIscussIon
for examination of the upper abdomen. With the help of bowel Chronic abdominal pain is a persistent problem that requires
grasping forceps, the whole length of small bowel could be walked immediate investigation and management. Hence, the study aimed
over for direct visualization and examination. The final diagnosis to evaluate the role of laparoscopy as an investigative modality in
was established based on the reports of biopsy examination. the diagnosis and management of patients with chronic abdominal
Following the procedure, patients received appropriate treatment pain.
based on the findings of the laparoscopy. The general anesthesia Male-to-female ratio in this study was 1:1.89. This suggests that
protocol remained same for all patients, and they were followed chronic abdominal pain is widely prevalent among females, which
up for assessment of pain. could be explained by the number of gynecological procedures

10 World Journal of Laparoscopic Surgery, Volume 12 Issue 1 (January–April 2019)