Page 17 - Journal of Laparoscopic Surgery

WJOLS

Diagnostic Laparoscopy as an Effective Tool in Evaluation of Intra-abdominal Malignancies
• Reduced in-patient stay permitting patient selection thin-section CT, spiral CT, Multidetector CT. CT is accu-
for curative resection or a neoadjuvant chemotherapy rate in assessing abdominal malignancy, But there are
This review article provides a comprehensive descrip- certain limitations: 9
tion of the role of diagnostic laparoscopy in the evaluation • It has a limited role in the assessment of local vascu-
of patients of abdominal malignancies. lar invasion, and there is difficulty in distinguishing
whether the tumor is touching vascular structures
Historical Perspective or invading them, e.g., portal vein and superior mes-
enteric artery involvement in pancreatic carcinoma.
Over the past decade, the use of laparoscopy has • It is relatively non-specific for predicting resectability.
expanded into virtually every surgical discipline, with • Tumors less than 1 cm in diameter are difficult to detect,
surgical oncology being no exception. Much of the early thereby reducing the efficacy in detection of perito-
work of Jacobaeus in 1910 focused on the diagnosis of neal metastatic deposits, small liver metastasis, and
malignant diseases. 6
peritoneal micrometastasis
• It cannot distinguish between reactive lymphade-
Setup and Equipment
nopathy and malignant deposits.
As with any surgical procedure, an appropriate setup • Lastly, due to faulty techniques and human error.
of the operating room is critical for an efficient, safe and There are definite concerns about the potential for
effective laparoscopy. For most procedures, the patient a false positive diagnosis of unresectability resulting
is placed supine on the operating table with the surgeon in a repudiation of surgery or a false positive diagnosis
positioned on the right side. The camera operator stands of resectability resulting in an unnecessary trip to the
on the opposite side of the patient, with monitors placed operating room. These limitations can be potentially
above the operative field. overcome by incorporating other imaging modalities,
A basic set of equipment is necessary for safe and especially diagnostic laparoscopy with laparoscopic
effective laparoscopy. The basic tray consists of scissors, ultrasonography and biopsy.
a grasper, and a dissector. Reusable ports are also used
as well as suction irrigation device. Since electrocautery Magnetic Resonance Imaging
is used during the procedure, all instruments are insu- Abdominal MRI is rapidly evolving but currently pro-
lated to the tip. 7 vides essentially the same information as CT scan.
Laparoscopic telescopes are either forward viewing Its limitations involve image artifacts from respira-
°
°
(0 ) or oblique (30 ). Oblique views are essential to visu- tion, aortic pulsation, bowel peristalsis and lack of ideal
alize relatively inaccessible regions of the abdomen. The contrast material for the gut lumen. Recent advances have
telescope has an eyepiece at the proximal end, serves as improved abdominal imaging with MRI, but it has not
the site of attachment for the camera. replaced high-quality CT scanning. 10
Veress needle is used to gain access to the peritoneal
cavity. The ability to obtain tissue safely for pathological Laparoscopic Ultrasonography
evaluation is important. Both cup and grasping forceps
are effective instruments, achieving an adequate speci- Laparoscopic ultrasound (LUS) probes offer a possible
men. Cup forceps help in reduction of the amount of solution allowing the surgeon to perform laparoscopic
tumor spillage by maintaining the entire specimen diagnostic procedures with the use of ultrasound, thereby
within the jaws of the forceps. As the prevalence of improving the accuracy of predicting resectability up to
11,12
minimal-access surgery for staging purposes increases, as high as 98% in some studies.
new equipment and techniques continue to emerge,
laparoscopic ultrasound and ultrasound-guided biopsy Staging of Intra-abdominal Cancers
being essential examples. 7,8 Staging laparoscopy is useful in the evaluation of intra-
abdominal malignancy in the following aspects: 4,13-15
LIMITATIONS IN DETECTING METASTATIC • Precise staging of the tumor
DISEASE BY CT AND MRI • Avoidance of unmerited, non-therapeutic laparotomy
in patients with metastatic diseases
Computed Tomography
• For exclusion of metastatic disease and extraction of
The CT scan has undergone a revolutionary evolution tissue biopsy antecedent to the initiation of neoadju-
over the last twenty years with new developments that vant chemotherapy
have improved data acquisition, processing, and image • For procuring tissue for diagnosis (lymphomas) or
handling. Conventional CT has been replaced by dynamic peritoneal lavage fluid for cytology to exclude the
World Journal of Laparoscopic Surgery, May-August 2018;11(2):68-75 69