- Email: [email protected]
Utility of laparoscopy in chronic abdominal pain
Utility of laparoscopy in chronic abdominal pain Raymond P. Onders, MD, and Elizabeth A. Mittendorf, MD, Cleveland, Ohio
Background. Patients with chronic abdominal pain can undergo numerous diagnostic tests with little change in their pain. This study was undertaken to assess the utility of performing diagnostic and therapeutic laparoscopy in patients with chronic abdominal pain for longer than 12 weeks. Methods. All patients undergoing laparoscopy by the primary author were prospectively entered into a database for the 3-year period July 1, 1997 through June 30, 2000. The patients’ demographic data, length of time with pain, number of diagnostic studies performed before surgery, intraoperative findings, interventions, pathology, and long-term follow-up were determined. Results. A total of 70 patients (61 women and 9 men) with an average age of 42 years, underwent diagnostic laparoscopy only for the evaluation and treatment of chronic abdominal pain. The average length of time with pain was 74 weeks (range 12-260) and the average number of studies performed prior to surgical referral was 3.3. Fifty-three (76%) patients had their procedures performed as outpatients, with the remainder admitted for observation status. The average length of operative time was 70 minutes; no cases required conversion to an open procedure and no complications occurred. Findings included adhesions in 39, a hernia in 13, adhesions from the appendix to adjacent structures in 6, appendiceal pathology in 5, endometriosis in 3, and gallbladder pathology in 2. Ten patients had no obvious pathology. At the time of their initial postoperative visit, 90% reported their pain to be gone or improved. After an average follow-up of 129 weeks, 71.4% had long-term pain relief. All patients with recurrence of pain had it within the first 6 months. No patient experienced any long-term complications and all reported satisfaction with their procedure. Conclusions. Laparoscopy has a significant diagnostic and therapeutic role in patients with chronic pain. Therapeutic laparoscopy studies have to follow-up with patients at least 6 months. With aggressive indicated therapeutic laparoscopy, including adhesiolysis, appendectomy, cholecystectomy, or hernia repairs, more than 70% of patients can have improvement in their pain. (Surgery 2003;134:549-54.) From the University Hospitals of Cleveland and Case Western Reserve University School of Medicine, Cleveland, Ohio
CHRONIC ABDOMINAL PAIN can be a diagnostic challenge. These difficult patients are frequently seen by many different physicians and are subjected to a myriad of tests without identifying the etiology of their pain. Surgical consultation often occurs late after other modalities have failed to provide resolution of their symptomatology. Several reports have suggested that laparoscopic evaluation in these patients can establish an etiology and allow for interventions that provide relief from chronic abdominal pain in a majority of patients.1-3 For 4 years prior to this study period, the Presented at the 60th Annual Meeting of the Central Surgical Association, Toronto, Ontario, Canada, March 20-22, 2003. Reprint Requests: Raymond P. Onders, MD, Director of Minimally Invasive Surgery, Department of Surgery, University Hospitals of Cleveland, 11100 Euclid Avenue, Cleveland, Ohio 44106-5047. Ó 2003 Mosby, Inc. All rights reserved. 0039-6060/2003/$30.00 + 0 doi:10.1016/S0039-6060(03)00277-0
senior author had developed a standardized operative protocol for patients with chronic abdominal pain. This study reports on our experience in using this standard protocol when performing diagnostic laparoscopy in this patient population with emphasis on the intraoperative findings, operative interventions, and short- and long-term results.
METHODS A prospective database of patients undergoing laparoscopic procedures performed between July 1997 and July 2000 was analyzed for those patients who underwent procedures for the evaluation of chronic abdominal pain. The recorded data included demographics, length of time the pain had been present, location of the pain, the patient’s abdominal examination, and previous diagnostic studies performed. All patients gave informed consent for the standardized operative goals as outlined in Table I. Procedure time, complications, SURGERY 549
550 Onders and Mittendorf
Table I. Operative goals in laparoscopy for chronic pain d d d d d d
d
d
Hasson technique away from previous incisions Accessory 5 mm trocars placed as indicated Complete adhesiolysis Entire small bowel visualized Appendix removed routinely if pain is on right side Cholecystectomy if abnormally appearing or adhesions present For groin pain, peritoneum is opened to look for small hernias and if present repaired with mesh Extensive irrigation performed at completion of case
intraoperative findings and operative intervention undertaken were also identified. Postoperative data included the length of stay, length of follow-up, and early and late subjective assessment of pain. All patients had long term follow-up by an office visit or telephone questionnaire and were asked to qualify what occurred to their pain: was the pain gone, improved, temporarily relieved then subsequently recurred, no change, or worse. In addition, all patients were questioned about their satisfaction with the procedure.
RESULTS Of 1308 laparoscopic procedures performed, 70 (5%) were for the evaluation of chronic abdominal pain. There were 61 women and 9 men ranging in age from 17 to 78 years old (mean age, 42). The average length of time with pain before surgical referral was 74 weeks (range 12-260), and the average number of studies performed before surgical referral was 3.3 per patient. Commonly performed tests included plain radiographs, ultrasound, computed tomographic scan, upper gastrointestinal studies, barium enema, esophagogastroduodenoscopy, and colonoscopy. No correlation was found between the studies done and the operative findings or operative procedures done. None of the patients had symptoms of partial small bowel obstructions nor were any of the small bowel follow-through studies positive for a delayed transit time, fixed loops of bowels, or evidence of partial obstruction. If the small bowel studies had shown evidence of partial bowel obstruction, the patients would have been excluded from this review since they would have had a known preoperative diagnosis. The average length of operative time was 70 minutes (range 30-180 minutes). All cases were done under general anesthesia. No cases were
Surgery October 2003
Table II. Intraoperative findings Adhesions Hernia Adhesions from the appendix to adjacent structures Abnormal appearing appendix Endometriosis Abnormal appearing gallbladder No pathology
39 13 6 5 3 2 10
converted to open procedures and no complications occurred. Intraoperative findings are summarized in Table II and included adhesions (39), hernia (13), adhesions from the appendix to adjacent structures (6), appendiceal pathology (5), endometriosis (3), gallbladder pathology (2), and no pathology (10). Interventions undertaken are listed in Table III and include adhesiolysis (45), appendectomy (23), hernia repair (13), cholecystectomy (5), ablation with electrocautery or excision of endometriosis (2), and oophorectomy or resection of a fallopian tube (1 each). Five patients had no interventions performed. Fifty-three (76%) patients had their procedures performed as outpatients with the remainder admitted for observation status. At the time of their initial postoperative visit, 63 (90%) patients stated that their pain was gone or improved. After an average follow-up of 129 weeks, 14 patients noted recurrence of their abdominal pain. Thirteen of these patients had adhesions identified at the time of laparoscopy, and all had undergone a complete adhesiolysis. One other patient who noted recurrence of abdominal pain had no pathology identified at the time of laparoscopy and no intervention performed. Two other patients who initially stated that their pain had not gone away subsequently had their pain resolve within 6 months without any other treatment besides the initial laparoscopy. Overall, 50 (71.4%) patients had long-term pain relief. There were no recurrences of pain after the first 6 months. No late complications were identified and 100% of the patients reported satisfaction with their procedure. Patients who still had pain were even satisfied that they had the operative procedure because it allayed their fear of cancer or allowed them to seek other options for control of their pain besides surgery. Three main groups were analyzed separately. The largest group was patients who underwent complete adhesiolysis. In every patient, every adhesion was lysed in the entire abdominal cavity
Surgery Volume 134, Number 4
including adhesions between loops of bowels. In this group, all had an initial improvement in their symptoms, so their early results were 100%. By the 6-month mark there was a recurrence of pain in 13 patients so that the long-term success rate decreased to 71%. There were no further recurrences of pain during subsequent follow-up for the remainder of the study. Overall, 23 patients underwent an appendectomy, and a review of the appendiceal pathology revealed evidence of chronic appendicitis (11), a fecalith (2), endometriosis (2), and the presence of exudates (1). The pathologists did not know the reason for the appendectomy. Seven patients had histologically normal appendices. The macroscopic appearance of the appendix at the time of laparoscopy was unreliable in predicting the histologic findings. In 6 patients with abnormal histology, the appendix was noted to be normal appearing at the time of laparoscopy. Conversely, 3 patients who had abnormal-appearing appendices—1 that was thickened and 2 with adhesions to adjacent structures—had histologically normal appendices. At the time of their initial postoperative visit, 22 (95.6%) patients reported improvement or resolution of their pain. The patient who had been noted to have a normal-appearing appendix at the time of laparoscopy and evidence of exudates histologically noted no change in his symptoms. In the long-term follow-up, 17 (74%) have had resolution of their pain. Of the 16 patients with histologic abnormalities of the appendix, 13 (81%) had long-term resolution of their pain. Of the 7 patients with histologically normal appendices, only 4 (57%) had long-term resolution of their pain. A third group of patients had hernias identified. Eleven patients had inguinal hernias and 2 had ventral hernias. At the time of their initial postoperative visit, 11 of 13 patients had resolution of their pain. In the long term follow-up there was no change; therefore, the overall success rate was 84.6%.
DISCUSSION This study adds to the growing experience that has identified diagnostic laparoscopy as a safe, effective tool in the management of patients with chronic abdominal pain. The main difference in our study compared to others is that our length of follow-up is considerably longer. We also addressed multiple pathologic reasons for chronic abdominal pain so that appropriate procedures, such as adhe-
Onders and Mittendorf 551
Table III. Surgical interventions Adhesiolysis Appendectomy Hernia repair Cholecystectomy Ablation of endometriosis Oophorectomy Resection of fallopian tube No intervention
45 23 13 5 2 1 1 5
siolysis, hernia repair, appendectomy, cholecystectomy, or ablation of endometriosis, were performed. In our study, 60 (85.7%) patients had pathologic findings identified at the time of laparoscopy. This is slightly higher then the rate of 76% reported by Salky et al3 or the rate of 65% reported by Klingensmith and colleagues.1 Sixty-five (92.8%) patients in our study had a definitive therapeutic procedure performed. We attribute the discrepancy between the number of pathologic findings and the number of therapeutic procedures performed to our practice of performing appendectomy in patients with chronic right lower quadrant pain regardless of the appearance of their appendix at the time of laparoscopy. We have found that histologically, a majority of these appendices are abnormal and that patients’ symptomatology improved. In a study by Fayez et al,4 records of patients with chronic lower abdominal pain undergoing appendectomy were reviewed. Ninety-two percent of their patients’ appendices had abnormal histologic findings and 95% of patients had resolution of their pain.4 This is slightly higher than our long-term success rate of 74%. Our most common finding at the time of laparoscopy was adhesive disease, present in 64% of our patients. This is comparable to the study by Klingensmith et al1 in which 58% of patients were found to have adhesions. In 45 patients who underwent complete laparoscopic adhesiolysis, the initial success rate of 100% decreased to our long-term rate of improvement of 71% after adhesiolysis. We suspect that recurrent pain could be caused by recurrent adhesive disease, de novo adhesion formation, or, as was suggested by Bremers et al,5 the wearing off of a placebo effect. The placebo effect is also supported by the results reported by Klingensmith and colleagues1 who identified that 73% of patients had postoperative improvement in their pain, regardless of whether a positive finding had been made at laparoscopy. In our study, 3 out of 5 patients with no operative intervention had improvement in their pain.
552 Onders and Mittendorf
These results, as well as those of others, support the performance of laparoscopic adhesiolysis in patients with prior abdominal surgery and chronic abdominal pain.6-10 In contrast, other authors suggest that adhesiolysis should only be performed in patients with evidence of obstruction.11 They suggest that adhesions explain pain only if they are causing an obstruction. In contrast, we believe that adhesions may limit bowel mobility enough to cause pain without causing an obstruction. Mueller et al7 also suggest that abdominal adhesions cause pain by limiting the movement or distensibility of bowel, and in a prospective evaluation of laparoscopic adhesiolysis in patients with chronic abdominal pain, they reported improvement or resolution of symptoms in more than 80%. When adhesions are identified as the likely etiology of chronic pain, we advocate a complete adhesiolysis. We use atraumatic graspers and sharp dissection to do this safely. Cautery is rarely used and the harmonic scalpel is used only for thick vascular adhesions. With this technique, we have not experienced any intraoperative complications. The benefits of performing adhesiolysis laparoscopically with regard to the development of further adhesive disease has been documented. Studies in both animal models and clinical studies have shown that the rate of adhesion formation after laparoscopic surgery, including laparoscopic adhesiolysis, is less then after open surgery.12-14 One other often unrecognized source of chronic pain is a hernia. Inguinal, femoral, sciatic, and obturator hernias can all explain chronic abdominal pain and can be identified and addressed laparoscopically.15 In our series, 13 patients were found to have hernias. We believe it is frequently difficult to identify small painful hernias on physical examination and that laparoscopy can provide excellent visualization of the abdominal and pelvic walls to assess for hernia in patients in whom other workup has failed to identify an etiology. In summary, this study has shown that diagnostic laparoscopy is an effective approach in the management of patients with chronic abdominal pain. Responsible pathology can usually be identified and appropriate intervention undertaken. In patients with a prior history of intra-abdominal surgery, adhesive disease is a likely finding and complete adhesiolysis is effective in providing longterm relief in more than 70% of patients. Chronic right lower quadrant pain often can be attributed to appendiceal pathology even when the appendix appears grossly normal, and consideration should be given to performance of appendectomy. Other
Surgery October 2003
etiologies of pain, such as hernias or endometriosis, may be identified and addressed laparoscopically. When assessing results, it is important to have long-term follow-up because pain can recur up to 6 months after surgery.
REFERENCES 1. Klingensmith ME, Soybel DI, Brooks DC. Laparoscopy for chronic abdominal pain. Surg Endosc 1996;10:1085-7. 2. Salky B. Diagnostic laparoscopy. Surg Laparosc Endosc 1993;3:132-4. 3. Salky BA, Edye MB. The role of laparoscopy in the diagnosis and treatment of abdominal pain syndromes. Surg Endosc 1998;12:911-4. 4. Fayez JA, Toy NJ, Flanagan TM. The appendix as the cause of chronic lower abdominal pain. Am J Obstet Gynecol 1995;172:122-3. 5. Bremers AJ, Ringers J, Vijn A, Janss RAJ, Bemelman WA. Laparoscopic adhesiolysis for chronic abdominal pain: an objective assessment. J Laparoendosc Adv Surg Tech A 2000;10:199-202. 6. Freys SM, Fuchs KH, Heimbucher J, Thiede A. Laparoscopic adhesiolysis. Surg Endosc 1994;8:1202-7. 7. Mueller MD, Tschudi J, Herrmann U, Klaiber C. An evaluation of laparoscopic adhesiolysis in patients with chronic abdominal pain. Surg Endosc 1995;9:802-4. 8. Malik E, Berg C, Meyhofer-Malik A, Haider S, Rossmanith WG. Subjective evaluation of the therapeutic value of laparoscopic adhesiolysis. Surg Endosc 2000;14:79-81. 9. Carbajo Caballero MA, Martin del Olmo JC, Blanco JI, Martin F, Toledano C Cuesta M. Therapeutic value of laparoscopic adhesiolysis. Surg Endosc 2001;15:102. 10. Nezhat FR, Crystal RA, Nezhat CH, Nezhat CR. Laparoscopic adhesiolysis and relief of chronic pelvic pain. JSLS 2000;4:281-5. 11. Ikard RW. There is no current indication for laparoscopic adhesiolysis to treat abdominal pain. South Med J 1992;85: 939-40. 12. Poymeneas G, Theodosopoulos T, Stamatiadis A, Kourias E. A comparative study of postoperative adhesion formation after laparoscopic vs open cholecystectomy. Surg Endosc 2001;15:41-3. 13. Tittel A, Treutner KH, Titkova S, Ottinger A, Schumpelick V. New adhesion formation after laparoscopic and conventional adhesiolysis. Surg Endosc 2001;15:44-6. 14. Schippers E, Tittel A, Ottinger A, Schumpelick V. Laparoscopy versus laparotomy: comparison of adhesion formation after bowel resection in a canine model. Dig Surg 1998;15: 148-52. 15. Kavic MS. Chronic pelvic pain, hernias and the general surgeon. JSLS 1999;3:89-90.
DISCUSSION Dr Michael S. Nussbaum (Cincinnati, Ohio). This is certainly a careful study of a group of challenging patients. Your study demonstrated that laparoscopy is a safe and effective diagnostic tool for the evaluation of such patients, with approximately a 70% chance of providing long-term relief of their pain. I have several comments and questions for you.
Background. Patients with chronic abdominal pain can undergo numerous diagnostic tests with little change in their pain. This study was undertaken to assess the utility of performing diagnostic and therapeutic laparoscopy in patients with chronic abdominal pain for longer than 12 weeks. Methods. All patients undergoing laparoscopy by the primary author were prospectively entered into a database for the 3-year period July 1, 1997 through June 30, 2000. The patients’ demographic data, length of time with pain, number of diagnostic studies performed before surgery, intraoperative findings, interventions, pathology, and long-term follow-up were determined. Results. A total of 70 patients (61 women and 9 men) with an average age of 42 years, underwent diagnostic laparoscopy only for the evaluation and treatment of chronic abdominal pain. The average length of time with pain was 74 weeks (range 12-260) and the average number of studies performed prior to surgical referral was 3.3. Fifty-three (76%) patients had their procedures performed as outpatients, with the remainder admitted for observation status. The average length of operative time was 70 minutes; no cases required conversion to an open procedure and no complications occurred. Findings included adhesions in 39, a hernia in 13, adhesions from the appendix to adjacent structures in 6, appendiceal pathology in 5, endometriosis in 3, and gallbladder pathology in 2. Ten patients had no obvious pathology. At the time of their initial postoperative visit, 90% reported their pain to be gone or improved. After an average follow-up of 129 weeks, 71.4% had long-term pain relief. All patients with recurrence of pain had it within the first 6 months. No patient experienced any long-term complications and all reported satisfaction with their procedure. Conclusions. Laparoscopy has a significant diagnostic and therapeutic role in patients with chronic pain. Therapeutic laparoscopy studies have to follow-up with patients at least 6 months. With aggressive indicated therapeutic laparoscopy, including adhesiolysis, appendectomy, cholecystectomy, or hernia repairs, more than 70% of patients can have improvement in their pain. (Surgery 2003;134:549-54.) From the University Hospitals of Cleveland and Case Western Reserve University School of Medicine, Cleveland, Ohio
CHRONIC ABDOMINAL PAIN can be a diagnostic challenge. These difficult patients are frequently seen by many different physicians and are subjected to a myriad of tests without identifying the etiology of their pain. Surgical consultation often occurs late after other modalities have failed to provide resolution of their symptomatology. Several reports have suggested that laparoscopic evaluation in these patients can establish an etiology and allow for interventions that provide relief from chronic abdominal pain in a majority of patients.1-3 For 4 years prior to this study period, the Presented at the 60th Annual Meeting of the Central Surgical Association, Toronto, Ontario, Canada, March 20-22, 2003. Reprint Requests: Raymond P. Onders, MD, Director of Minimally Invasive Surgery, Department of Surgery, University Hospitals of Cleveland, 11100 Euclid Avenue, Cleveland, Ohio 44106-5047. Ó 2003 Mosby, Inc. All rights reserved. 0039-6060/2003/$30.00 + 0 doi:10.1016/S0039-6060(03)00277-0
senior author had developed a standardized operative protocol for patients with chronic abdominal pain. This study reports on our experience in using this standard protocol when performing diagnostic laparoscopy in this patient population with emphasis on the intraoperative findings, operative interventions, and short- and long-term results.
METHODS A prospective database of patients undergoing laparoscopic procedures performed between July 1997 and July 2000 was analyzed for those patients who underwent procedures for the evaluation of chronic abdominal pain. The recorded data included demographics, length of time the pain had been present, location of the pain, the patient’s abdominal examination, and previous diagnostic studies performed. All patients gave informed consent for the standardized operative goals as outlined in Table I. Procedure time, complications, SURGERY 549
550 Onders and Mittendorf
Table I. Operative goals in laparoscopy for chronic pain d d d d d d
d
d
Hasson technique away from previous incisions Accessory 5 mm trocars placed as indicated Complete adhesiolysis Entire small bowel visualized Appendix removed routinely if pain is on right side Cholecystectomy if abnormally appearing or adhesions present For groin pain, peritoneum is opened to look for small hernias and if present repaired with mesh Extensive irrigation performed at completion of case
intraoperative findings and operative intervention undertaken were also identified. Postoperative data included the length of stay, length of follow-up, and early and late subjective assessment of pain. All patients had long term follow-up by an office visit or telephone questionnaire and were asked to qualify what occurred to their pain: was the pain gone, improved, temporarily relieved then subsequently recurred, no change, or worse. In addition, all patients were questioned about their satisfaction with the procedure.
RESULTS Of 1308 laparoscopic procedures performed, 70 (5%) were for the evaluation of chronic abdominal pain. There were 61 women and 9 men ranging in age from 17 to 78 years old (mean age, 42). The average length of time with pain before surgical referral was 74 weeks (range 12-260), and the average number of studies performed before surgical referral was 3.3 per patient. Commonly performed tests included plain radiographs, ultrasound, computed tomographic scan, upper gastrointestinal studies, barium enema, esophagogastroduodenoscopy, and colonoscopy. No correlation was found between the studies done and the operative findings or operative procedures done. None of the patients had symptoms of partial small bowel obstructions nor were any of the small bowel follow-through studies positive for a delayed transit time, fixed loops of bowels, or evidence of partial obstruction. If the small bowel studies had shown evidence of partial bowel obstruction, the patients would have been excluded from this review since they would have had a known preoperative diagnosis. The average length of operative time was 70 minutes (range 30-180 minutes). All cases were done under general anesthesia. No cases were
Surgery October 2003
Table II. Intraoperative findings Adhesions Hernia Adhesions from the appendix to adjacent structures Abnormal appearing appendix Endometriosis Abnormal appearing gallbladder No pathology
39 13 6 5 3 2 10
converted to open procedures and no complications occurred. Intraoperative findings are summarized in Table II and included adhesions (39), hernia (13), adhesions from the appendix to adjacent structures (6), appendiceal pathology (5), endometriosis (3), gallbladder pathology (2), and no pathology (10). Interventions undertaken are listed in Table III and include adhesiolysis (45), appendectomy (23), hernia repair (13), cholecystectomy (5), ablation with electrocautery or excision of endometriosis (2), and oophorectomy or resection of a fallopian tube (1 each). Five patients had no interventions performed. Fifty-three (76%) patients had their procedures performed as outpatients with the remainder admitted for observation status. At the time of their initial postoperative visit, 63 (90%) patients stated that their pain was gone or improved. After an average follow-up of 129 weeks, 14 patients noted recurrence of their abdominal pain. Thirteen of these patients had adhesions identified at the time of laparoscopy, and all had undergone a complete adhesiolysis. One other patient who noted recurrence of abdominal pain had no pathology identified at the time of laparoscopy and no intervention performed. Two other patients who initially stated that their pain had not gone away subsequently had their pain resolve within 6 months without any other treatment besides the initial laparoscopy. Overall, 50 (71.4%) patients had long-term pain relief. There were no recurrences of pain after the first 6 months. No late complications were identified and 100% of the patients reported satisfaction with their procedure. Patients who still had pain were even satisfied that they had the operative procedure because it allayed their fear of cancer or allowed them to seek other options for control of their pain besides surgery. Three main groups were analyzed separately. The largest group was patients who underwent complete adhesiolysis. In every patient, every adhesion was lysed in the entire abdominal cavity
Surgery Volume 134, Number 4
including adhesions between loops of bowels. In this group, all had an initial improvement in their symptoms, so their early results were 100%. By the 6-month mark there was a recurrence of pain in 13 patients so that the long-term success rate decreased to 71%. There were no further recurrences of pain during subsequent follow-up for the remainder of the study. Overall, 23 patients underwent an appendectomy, and a review of the appendiceal pathology revealed evidence of chronic appendicitis (11), a fecalith (2), endometriosis (2), and the presence of exudates (1). The pathologists did not know the reason for the appendectomy. Seven patients had histologically normal appendices. The macroscopic appearance of the appendix at the time of laparoscopy was unreliable in predicting the histologic findings. In 6 patients with abnormal histology, the appendix was noted to be normal appearing at the time of laparoscopy. Conversely, 3 patients who had abnormal-appearing appendices—1 that was thickened and 2 with adhesions to adjacent structures—had histologically normal appendices. At the time of their initial postoperative visit, 22 (95.6%) patients reported improvement or resolution of their pain. The patient who had been noted to have a normal-appearing appendix at the time of laparoscopy and evidence of exudates histologically noted no change in his symptoms. In the long-term follow-up, 17 (74%) have had resolution of their pain. Of the 16 patients with histologic abnormalities of the appendix, 13 (81%) had long-term resolution of their pain. Of the 7 patients with histologically normal appendices, only 4 (57%) had long-term resolution of their pain. A third group of patients had hernias identified. Eleven patients had inguinal hernias and 2 had ventral hernias. At the time of their initial postoperative visit, 11 of 13 patients had resolution of their pain. In the long term follow-up there was no change; therefore, the overall success rate was 84.6%.
DISCUSSION This study adds to the growing experience that has identified diagnostic laparoscopy as a safe, effective tool in the management of patients with chronic abdominal pain. The main difference in our study compared to others is that our length of follow-up is considerably longer. We also addressed multiple pathologic reasons for chronic abdominal pain so that appropriate procedures, such as adhe-
Onders and Mittendorf 551
Table III. Surgical interventions Adhesiolysis Appendectomy Hernia repair Cholecystectomy Ablation of endometriosis Oophorectomy Resection of fallopian tube No intervention
45 23 13 5 2 1 1 5
siolysis, hernia repair, appendectomy, cholecystectomy, or ablation of endometriosis, were performed. In our study, 60 (85.7%) patients had pathologic findings identified at the time of laparoscopy. This is slightly higher then the rate of 76% reported by Salky et al3 or the rate of 65% reported by Klingensmith and colleagues.1 Sixty-five (92.8%) patients in our study had a definitive therapeutic procedure performed. We attribute the discrepancy between the number of pathologic findings and the number of therapeutic procedures performed to our practice of performing appendectomy in patients with chronic right lower quadrant pain regardless of the appearance of their appendix at the time of laparoscopy. We have found that histologically, a majority of these appendices are abnormal and that patients’ symptomatology improved. In a study by Fayez et al,4 records of patients with chronic lower abdominal pain undergoing appendectomy were reviewed. Ninety-two percent of their patients’ appendices had abnormal histologic findings and 95% of patients had resolution of their pain.4 This is slightly higher than our long-term success rate of 74%. Our most common finding at the time of laparoscopy was adhesive disease, present in 64% of our patients. This is comparable to the study by Klingensmith et al1 in which 58% of patients were found to have adhesions. In 45 patients who underwent complete laparoscopic adhesiolysis, the initial success rate of 100% decreased to our long-term rate of improvement of 71% after adhesiolysis. We suspect that recurrent pain could be caused by recurrent adhesive disease, de novo adhesion formation, or, as was suggested by Bremers et al,5 the wearing off of a placebo effect. The placebo effect is also supported by the results reported by Klingensmith and colleagues1 who identified that 73% of patients had postoperative improvement in their pain, regardless of whether a positive finding had been made at laparoscopy. In our study, 3 out of 5 patients with no operative intervention had improvement in their pain.
552 Onders and Mittendorf
These results, as well as those of others, support the performance of laparoscopic adhesiolysis in patients with prior abdominal surgery and chronic abdominal pain.6-10 In contrast, other authors suggest that adhesiolysis should only be performed in patients with evidence of obstruction.11 They suggest that adhesions explain pain only if they are causing an obstruction. In contrast, we believe that adhesions may limit bowel mobility enough to cause pain without causing an obstruction. Mueller et al7 also suggest that abdominal adhesions cause pain by limiting the movement or distensibility of bowel, and in a prospective evaluation of laparoscopic adhesiolysis in patients with chronic abdominal pain, they reported improvement or resolution of symptoms in more than 80%. When adhesions are identified as the likely etiology of chronic pain, we advocate a complete adhesiolysis. We use atraumatic graspers and sharp dissection to do this safely. Cautery is rarely used and the harmonic scalpel is used only for thick vascular adhesions. With this technique, we have not experienced any intraoperative complications. The benefits of performing adhesiolysis laparoscopically with regard to the development of further adhesive disease has been documented. Studies in both animal models and clinical studies have shown that the rate of adhesion formation after laparoscopic surgery, including laparoscopic adhesiolysis, is less then after open surgery.12-14 One other often unrecognized source of chronic pain is a hernia. Inguinal, femoral, sciatic, and obturator hernias can all explain chronic abdominal pain and can be identified and addressed laparoscopically.15 In our series, 13 patients were found to have hernias. We believe it is frequently difficult to identify small painful hernias on physical examination and that laparoscopy can provide excellent visualization of the abdominal and pelvic walls to assess for hernia in patients in whom other workup has failed to identify an etiology. In summary, this study has shown that diagnostic laparoscopy is an effective approach in the management of patients with chronic abdominal pain. Responsible pathology can usually be identified and appropriate intervention undertaken. In patients with a prior history of intra-abdominal surgery, adhesive disease is a likely finding and complete adhesiolysis is effective in providing longterm relief in more than 70% of patients. Chronic right lower quadrant pain often can be attributed to appendiceal pathology even when the appendix appears grossly normal, and consideration should be given to performance of appendectomy. Other
Surgery October 2003
etiologies of pain, such as hernias or endometriosis, may be identified and addressed laparoscopically. When assessing results, it is important to have long-term follow-up because pain can recur up to 6 months after surgery.
REFERENCES 1. Klingensmith ME, Soybel DI, Brooks DC. Laparoscopy for chronic abdominal pain. Surg Endosc 1996;10:1085-7. 2. Salky B. Diagnostic laparoscopy. Surg Laparosc Endosc 1993;3:132-4. 3. Salky BA, Edye MB. The role of laparoscopy in the diagnosis and treatment of abdominal pain syndromes. Surg Endosc 1998;12:911-4. 4. Fayez JA, Toy NJ, Flanagan TM. The appendix as the cause of chronic lower abdominal pain. Am J Obstet Gynecol 1995;172:122-3. 5. Bremers AJ, Ringers J, Vijn A, Janss RAJ, Bemelman WA. Laparoscopic adhesiolysis for chronic abdominal pain: an objective assessment. J Laparoendosc Adv Surg Tech A 2000;10:199-202. 6. Freys SM, Fuchs KH, Heimbucher J, Thiede A. Laparoscopic adhesiolysis. Surg Endosc 1994;8:1202-7. 7. Mueller MD, Tschudi J, Herrmann U, Klaiber C. An evaluation of laparoscopic adhesiolysis in patients with chronic abdominal pain. Surg Endosc 1995;9:802-4. 8. Malik E, Berg C, Meyhofer-Malik A, Haider S, Rossmanith WG. Subjective evaluation of the therapeutic value of laparoscopic adhesiolysis. Surg Endosc 2000;14:79-81. 9. Carbajo Caballero MA, Martin del Olmo JC, Blanco JI, Martin F, Toledano C Cuesta M. Therapeutic value of laparoscopic adhesiolysis. Surg Endosc 2001;15:102. 10. Nezhat FR, Crystal RA, Nezhat CH, Nezhat CR. Laparoscopic adhesiolysis and relief of chronic pelvic pain. JSLS 2000;4:281-5. 11. Ikard RW. There is no current indication for laparoscopic adhesiolysis to treat abdominal pain. South Med J 1992;85: 939-40. 12. Poymeneas G, Theodosopoulos T, Stamatiadis A, Kourias E. A comparative study of postoperative adhesion formation after laparoscopic vs open cholecystectomy. Surg Endosc 2001;15:41-3. 13. Tittel A, Treutner KH, Titkova S, Ottinger A, Schumpelick V. New adhesion formation after laparoscopic and conventional adhesiolysis. Surg Endosc 2001;15:44-6. 14. Schippers E, Tittel A, Ottinger A, Schumpelick V. Laparoscopy versus laparotomy: comparison of adhesion formation after bowel resection in a canine model. Dig Surg 1998;15: 148-52. 15. Kavic MS. Chronic pelvic pain, hernias and the general surgeon. JSLS 1999;3:89-90.
DISCUSSION Dr Michael S. Nussbaum (Cincinnati, Ohio). This is certainly a careful study of a group of challenging patients. Your study demonstrated that laparoscopy is a safe and effective diagnostic tool for the evaluation of such patients, with approximately a 70% chance of providing long-term relief of their pain. I have several comments and questions for you.