Laparoscopy: A Comprehensive Approach for Diagnosis and Treatment of Abdominal Pain

*Maula K¹, Rahman MM², Khan MEH³, Hasan MN⁴, Ahmed MN⁵

Laparoscopy is a minimally invasive technique for visualization of the peritoneal cavity without creating large abdominal incisions. It has changed the treatment of abdominal pain in both emergency and elective settings. Many patients undergo exploration according to the conventional investigation; many are treated conservatively and discharged. However, in most cases, patients return with a recurrence or more definitive symptoms of pathology. Laparoscopy is now a well-known and accurate way to make a final diagnosis and avoid delays in making a diagnosis. Objective of the study was to evaluate the role of laparoscopy in diagnosis and treatment of abdominal pain where clinical symptoms and routine investigations are inconclusive. It was a prospective, cross-sectional study and the duration of the study was 6 months, from March 2016 to August 2016. All the patients who underwent laparoscopy for the diagnosis of abdominal pain were chosen using the purposive sampling technique. They were then investigated in accordance with the eligibility criteria, and 30 patients with abdominal pain that couldn’t be diagnosed by clinical examination, routine investigations, and who consented to laparoscopy were included in this study. All data for the study were collected using a predesigned pro forma. After collecting the data, it is compiled, edited, and analyzed. After laparoscopy, 93.0% (28) of cases had a definitive diagnosis, while 6.67% (2) of cases had no obvious pathology. At the time of diagnosis, 66.67% (20) of patients underwent laparoscopic surgery and in 3.33% (1) of cases, they required conversion to laparotomy to treat the condition. Laparoscopic biopsy was taken in 16.67% (4) cases. In 3.33% (1) of the cases, a complication was observed related to laparoscopic port infection. The average hospital stay was 3.73 days and the average operation time was 65 minutes. Abdominal pain can be accurately, quickly and efficiently managed with laparoscopy. This procedure decreases the number of avoidable laparotomies while also improving diagnostic accuracy. Thus, physicians should consider diagnostic laparoscopy as the first invasive test for people with the unknown abdominal pain.

[Mymensingh Med J 2025 Jan; 34 (1): 250-255]

Key words: Laparoscopy, Comprehensive Approach, Abdominal pain, Diagnosis, Treatment

Introduction

L

aparoscopy is a well-known surgical procedure that allows the surgeon to insert a fibre optic telescope known as a laparoscope into the abdominal cavity via small incisions for better vision and surgical intervention¹. It is used to diagnose and manage a wide range of conditions that develop inside the abdomen as well as the pelvis². In the past few years, the role of laparoscopy in surgery has increased continuously, not only for the management of acute abdominal pain but also has a significant role in the management of chronic abdominal pain and in trauma settings³. Abdominal pain is a frequently occurring symptom that brings a patient to a surgeon⁴. It can refer to a variety of illnesses, starting from benign to life-threatening surgical emergencies⁵. It often causes diagnostic difficulties for a surgeon⁶. The clinical examination does not always provide a diagnosis, especially when features are exacerbated by high BMI. In those cases where blood tests can be conclusive, however, they usually just suggest the existence of inflammation⁷.

1. *Dr Kulsum Maula, Clinical Fellow in General Surgery, Colchester General Hospital, East Suffolk and North Essex NHS foundation trust, Colchester, Essex, CO4 5JL, GBR; E-mail: [email protected]

2. Dr Md Mustafizur Rahman, Professor and Head, Department of Surgery, Shaheed Suhrawardy Medical College Hospital, Dhaka, Bangladesh

3. Dr Mohammad Emrul Hasan Khan, Associate Professor, Department of Surgery, Dhaka Medical Collage Hospital, Dhaka, Bangladesh

4. Dr Md Nazmul Hasan, Critical Care Medicine, Labaid Specialized Hospital, Dhaka, Bangladesh

5. Dr Md Nadim Ahmed, Senior Consultant, Department of Surgery, Shaheed Suhrawardy Medical College Hospital, Dhaka, Bangladesh

250

*for correspondence

Radiology could help with the diagnosis. However, both radiology and ultrasound can give inconclusive results. Despite diagnostic developments, it seems that an acute abdominal condition presents a situation in which a surgeon dares to open an abdomen without a clear diagnosis. According to research from high-income countries, abdominal pain is reported in the emergency department at a rate of 7.0-10.0%⁸. These cases can place a strain on hospitals and physicians; particularly those with abdominal pains who have no diagnosis after examination and baseline investigations. Even after using all diagnostic tools, some cases remain perplexing. In these scenarios, one option is to keep the patient in the hospital and examine them regularly⁹. The statistical validity of this technique was determined to be between 68.0 and 92.0%^10,11,12. This technique may put the patient at risk of developing further complications. However, if proactive measures are taken, laparotomy may be performed^13,14. In these circumstances, laparoscopy is a great choice that allows the surgeon to see the peritoneal cavity in the right way and, by an expert hand; it has great therapeutic value with minimal scarring. Since the emergence of minimally invasive procedures, laparoscopy has become a feasible alternative for diagnosing abdominal conditions of unknown aetiology¹⁵. It has changed the way of managing various surgical illnesses and is now approved as the best choice for the diagnosis and treatment of numerous diseases^16,17. Laparoscopy improves the management of abdominal pain by not only providing immediate diagnosis and treatment but also reducing the length of hospital stay, decreasing postoperative pain and an earlier return to work^18,19.

Methods

It was a prospective, cross-sectional study conducted in the Surgery Department of Shaheed Suhrawardy Medical College and Hospital, a tertiary care hospital in Dhaka, Bangladesh during the period from March 2016 to August 2016. Purposive sampling was used to select 30 participants for this investigation. This study included both male and female patients with abdominal pain who could not be diagnosed by clinical examination or routine investigations and consented to laparoscopy. Exclusion criteria were patients with uncontrolled coagulopathy, hemodynamically unstable patients, patients who underwent previous multiple abdominal surgeries, USG-proven cholecystitis, high amylase, lipase-proven pancreatitis, and had serious cardiopulmonary risk factors, patients with obvious features of Peritonitis, acute intestinal obstruction and the patient who refused laparoscopy and all patients under 14 years old. Immediately following initial inclusion, patients were interviewed in person for data collection. The data was collected with the patients’ or legal guardians' permission. Then they were inspected for particular features that were noted on a data collection form. After that the patient’s demographic variables (age, sex and BMI), as well as the main clinical variables and investigations, were recorded in the datasheet. After collecting data were compiled edited and analyzed. P value was calculated by Chi square test. In acute cases, we performed laparoscopy within 48 hours of admission, and in chronic cases, it was delayed but within 7 days. We evaluate the laparoscopic diagnosis, procedures that were performed, and the subsequent outcomes of these patients. Follow-up was done for every patient in the follow-up clinic after 6 weeks of laparoscopy.

Results

Among 30 patients, the highest 12(40.0%) belonged to the age group 21-30 years, which was subsequently followed by 6(20.0%) in the age group <20 years. The average age ±SD was 32.18±13.05 years shown in Table I.

Table I: Distribution of patients according to age (n=30)

Age range (years)	n (%)
<20	06 (20.00)
21-30	12 (40.00)
31-40	05 (16.67)
41-50	04 (13.33)
>50	03 (10.00)

Figure 1: Distribution of patients according to Gender

Figure 1 showed that among 30 patients, 67.0% (20) were female and 33.0% (10) were male. The female-to-male ratio was 2:1.

Table II: Distribution of patients according to BMI (n=30)

BMI	n (%)
<18.5	05 (16.67)
18.5-24.9	09 (30.00)
25-29.9	12 (40.00)
30-39.9	04 (13.33)

Table II showed distribution based on BMI groups of the patients that the highest 12 (40%) patients belonged to a BMI range of 25-29.9. In addition, 9 (30%), 5 (16.67%), and 4 (13.33%) belonged to BMI 18.5-24.9, 30-39.9 and <18.5 respectively.

Figure 2: Distribution of patients according to nature of pain

Figure 2 showed out of 30 patients, 60.0% (18) presented with acute abdominal pain and the rest of 40.0% (12) presented with chronic abdominal pain.

Table III showed that among 30 patients, the highest 13 (43.33%) presented with RIF pain, followed by 11 (36.67%) with chronic abdominal pain, 2 (6.67%) with acute lower abdominal pain, and diffuse abdominal pain following blunt abdominal trauma. Besides, in 1 (3.33%) of the cases, they showed acute right upper quadrant pain, and chronic left upper quadrant pain with fever, respectively.

Table III: Distribution of patients according main symptoms (n=30)

Complaints	Number of patients (n)	Percentage (%)
RIF pain	13	43.33
Right upper quadrant pain	01	03.33
Lower abdominal pain	02	06.67
Diffuse abdominal pain following blunt abdominal trauma	02	06.67
Chronic left upper quadrant pain	01	03.33
Chronic diffuse abdominal pain	11	36.67

Table IV showed that among 30 patients, the highest 8(26.67%) were diagnosed as having appendicular pathology, followed by 5(16.67%) bowel adhesion, 2(6.67%) mesenteric tear, and pelvic inflammatory disease. All were treated laparoscopically. Besides, 4(13.33%) cases showed an enlarged mesenteric lymph node where lymph node biopsy was taken laparoscopically. In addition, 2(6.67%) showed retrograde menstruation. One (3.33%) case had a right-sided twisted ovary, endometriosis, concealed gallbladder perforation, a splenic mass, and a mesenteric cyst. Most of them were managed laparoscopically except for the splenic mass that required conversion into a laparotomy, and endometriosis was referred to gynaecology. In 2(6.67%) of these cases, no obvious pathology was found.

Table IV: Distribution of patients according to laparoscopic diagnosis and procedure was performed (n=30)

Laparoscopic diagnosis	Procedure performed	Number of patients (n)	Percentage (%)	p value
Appendicular pathology	Appendicectomy	8	26.67	<0.05
Retrograde menstruation	Nil	2	6.67
Twisted ovary on right side	Oophorectomy on right side	1	3.33
Endometriosis	Nil (referred to gynae)	1	3.33
Concealed Gall bladder perforation	cholecystectomy	1	3.33
Splenic mass	Laparotomy & splenectomy	1	3.33
Mesenteric cyst	Excision of cyst	1	3.33
Mesenteric tear	Mesenteric vascular repair	2	6.67
Bowel adhesion	Adhesiolysis	5	16.67
Enlarged mesenteric lymph node	Lymph node biopsy	4	13.33
Pelvic inflammatory disease	Laparoscopic washout	2	6.67
No pathology	Nil	2	6.67

Discussion

Abdominal pain is one of the most common and frequent presentations in surgery. According to a review of the scientific literature, laparoscopy has a lot of advantages that make it an effective treatment for abdominal pain. More than 90.0% accuracy has been recorded in several investigations^20,21. Some studies were unable to achieve such a high level of reliability. Ninety three percent of patients in our study had a precise diagnosis. Gender distribution showed that out of 30 patients, 67.0% were female and 33.0% were male. That is supported by Lippert Vet, showing females with lower abdominal pain and consistent appendicitis symptoms have additional diagnostic challenges²². Among the 30 patients, 40.0% were obese. That can be considered one of the significant causes of negative ultrasonology results for patients with appendicitis²³. Before laparoscopy, we used to investigate patients routinely. Neutrophilic leukocytosis was found in 40.0% (12) of the cases. Ultrasound scan only considered for young female with acute abdominal pain and all chronic abdominal pain. In most of the cases, USG was inconclusive except 3.33% (1) splenic abscess and cyst in RIF respectively. The plane x-ray abdomen was normal in all cases except 10.0% (3), which had a dilated bowel. CT scan was not considered in this study due to young age group and less availability. In this study, 60.0% (18) of patients presented with acute abdominal pain and 40.0% (12) of patients presented with chronic abdominal pain. The diagnostic success rate for acute abdominal pain is 94.44% (17) while the success rate for chronic abdominal pain is 91.66% (11). In 6.67% (2) of the cases, there was no obvious pathology, and those were treated conservatively. All of these figures coincide with the laparoscopic study of A Kumar et al.²⁴. Laparoscopy is not a new technique for diagnosing and treating abdominal pain. It has been proven in several studies that it improves surgical decision-making, especially when the indication of surgery is not clear¹³. The most frequent pathology detected in this study is appendicular pathology, in 26.67% of the cases (8). They were all managed by laparoscopic appendicectomy and complete pain relief was found at the follow-up visit. Abdominal adhesion was the second most common cause of abdominal pain with an incidence of 16.67% (5), which is supported by Di Lorenzo and colleagues who reported an incidence of 18.6%²⁵. In 13.33% (4) of the cases, a laparoscopic biopsy was taken for an enlarged mesenteric lymph node, and histopathology confirmed abdominal tuberculosis. Thus, anti- tubercular regimens were given to those patients. The incidence is higher than that of Western studies. This reflects the higher incidence of tuberculosis in developing countries²⁴. Besides, 6.67% (2 cases) of patients with abdominal pain had pelvic inflammatory disease, mesenteric vascular tear and retrograde menstruation, respectively. In 3.33% of cases, endometriosis, twisted ovary on the right side, concealed gall bladder perforation and mesenteric cyst were discovered. All the above cases were managed laparoscopically, except the retrograde menstruation and endometriosis which were referred to gynae. In this study, 3.33% of patients undergoing laparoscopy were converted to laparotomy. In their study, Waclawiczek et al. found a conversion rate of 2.7% and a recent Indian study discovered that laparotomy can be avoided in 96.0% of identical cases^26,27. The laparoscopic approach is usually associated with reduced postoperative pain, a prompt return of bowel function, and a more rapid return to normal activity. When compared to active observation, laparoscopy has a major benefit in terms of hospital stay. In this study, the mean hospital stay was 3.73 days, which is virtually identical to the 3.7 days in Gaiten's randomized controlled experiment²⁸. The overall frequency of major complications in laparoscopic surgery is 1.93% and minor complications are 4.29%²⁹. In this study, 3.33% (1) cases of complications related to port infection were observed, which is also supported by Fuentes MN and Romero MTA et al.²⁹. In our country, many patients presenting with abdominal pain remains undiagnosed until exploratory laparotomy. Although diagnostic methods such as CT scanning have advanced significantly nowadays, a large number of patients are still being treated without confirmation of diagnosis. In these and many others, laparoscopy acts as a blessing not only diagnosis of the disease but also for an excellent therapeutic value.

Conclusion

This study explores the role of laparoscopy in the diagnosis and treatment of both acute and chronic abdominal pain. Thus, it can be concluded that laparoscopy is a feasible, effective, and safe modality for abdominal pain with unknown aetiology in limited resources. Thus, a surgeon should consider laparoscopy as the first invasive test for a patient with undiagnosed abdominal pain. Multi-centred research work with large sample size and availability of resources can help to make the study more accurate and authentic.

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