Laparoscopy: A See- and -treat Modality for Lower Abdominal Pain in Females

INTRODUCTION

In females, lower abdominal pain (LAP) is a very common presenting complaint in both the outpatient and emergency department. It can be acute, subacute, and chronic in nature. Acute LAP is intense and characterized by sudden onset, sharp rise, and short course. To consider a pain as acute pelvic pain, different authors have defined different durations. Some authors have defined it as the pain lasting for less than 7 days¹ while others have defined it as the pain lasting for less than 3 months.² The gynecological causes of acute pelvic pain are pelvic inflammatory disease (PID), ectopic pregnancy, adnexal torsion, ruptured ovarian cyst, and adhesions. Subacute pelvic pain is the pain that does not clearly fit either in acute or chronic category and requires consideration of differential diagnosis for both acute and chronic pain. Chronic pelvic pain is defined as intermittent or constant pain in the lower abdomen or the pelvis of at least 6 months’ duration, not associated with menstruation, intercourse, or pregnancy. It is severe enough to cause functional disability or may require medical or surgical intervention.³ The causes of chronic pelvic pain are chronic PID, endometriosis, and adhesions.⁴

The etiology is of LAP is diverse. It can be reproductive, gastrointestinal, genitourinary, or musculoskeletal. Hence, accurate diagnosis of the underlying cause presents a clinical challenge.^3,4 In many cases, the cause of LAP remains obscure despite thorough examination, lab investigations, and noninvasive imaging like ultrasonography (USG), CT, and MRI. Laparoscopy has been increasingly recognized as a key in solving the diagnostic dilemma. Not only that, treatment may also be provided in the same sitting.⁵ Therefore, the present study was conducted to assess the role of laparoscopy for diagnosis and management of LAP.

MATERIALS AND METHODS

The prospective study was conducted on 84 patients from December 2012 to January 2015 after getting approval from the ethical committee. Women with complaints of LAP—acute, subacute, and chronic—were included in the study. Patients with abdominal trauma, gynecological malignancy, cardiopulmonary disease, and peritonitis were excluded from the study.

A detailed clinical history was taken regarding site, duration, pain, nature, and radiation of pain; aggravating and relieving factors; and associated complaints like dyspareunia, dysmenorrhea, discharge per vaginam, gastrointestinal, and urological complaints. Menstrual history, obstetric history, and past history were also taken.

All women underwent a thorough general, systemic, and gynecological examination. Routine investigations were carried out in all the patients, which included complete hemogram, renal function test, random blood sugar, urine examination, and culture sensitivity, if required. Imaging methods included USG of the abdomen and the pelvis, which was performed in all the patients, and X-ray, CT scan, or MRI whenever necessary. Laparoscopy was performed in all the patients under general anesthesia; the Karl Storz laparoscope (10 mm and 5 mm), both straight viewing 0° and oblique viewing 30°, was used.

The methodical inspection of the upper and lower abdomen was done. All the pathological findings were noted, and if required the operative procedure was also done in the same sitting like taking biopsies, performing adhesiolysis, cyst aspiration, cystectomy, salpingectomy, oophorectomy, etc. All the samples were sent for histopathological examination and the final diagnosis was confirmed. In cases where complication occurred or therapeutic laparoscopy was difficult, the laparoscopic procedure was converted into laparotomy. The gathered data were statistically analyzed. Descriptive statistics that included frequency, mean, percentage, and standard deviation were calculated. The McNemar’s test was used to test the significance of difference for qualitative variables. The Probability value (p value %3C; 0.05) was considered statistically significant.

RESULTS

The mean age of patients in the study was 28.0 ± 6.4 years (age range 15–60 years). The other characteristics of the patients are as shown in Table 1. We categorized the duration of pain as acute (duration of less than 1 week), which was present in 16.7% (n = 14), as subacute (duration of 1 week to 6 months) in 26.2% (n = 22), and as chronic (duration of more than 6 months) in 57.1% (n = 48) of patients. The maximum duration of pain was 36 months and the minimum duration was 24 hours.

Along with LAP, the associated symptoms were dysmenorrhea in 30.9% (n = 26), primary infertility in 22.6% (n = 19), dyspareunia in 15.4% (n = 13), spotting in 14.3% (n = 12), secondary infertility in 9.5% (n = 8), white discharge per vaginam in 7.2% (n = 6), oligomenorrhea in 7.2% (n = 6), and menorrhagia in 5.9% (n = 5) of patients. Per vaginal examination revealed tenderness in the fornix 34.5% (n = 29), adnexal mass 30.9% (n = 26), restricted mobility of the uterus 19.0% (n = 16), fullness in the fornix 15.5% (n = 13), cervical motion tenderness 15.5% (n = 13), retroverted uterus 8.3% (n = 7), and bulky uterus 8.3% (n = 7).

Transabdominal ultrasound was performed in all the patients. The collection in the pouch of Douglas was found in maximum number of cases 34.5% (n = 29), followed by other abnormalities as shown in Table 2. After history, examination, and ultrasound, a provisional diagnosis was established in only 75% (n = 63) of patients. In rest of 25% (n = 21), the diagnosis was in dilemma. Most common cause was PID in 19.0% (n = 16) followed by other causes (Table 3).

All the 84 patients underwent laparoscopy for confirmation. After which diagnosis was established in 94.1% (n = 79) of patients. In 5.9% (n = 5) of patients, diagnosis of pain could not be established as no pelvic pathology was observed on laparoscopy. The most cause of LAP after laparoscopy was PID present in 20.2% (n = 17) of patients (Table 4).

The second most common diagnosis was endometriosis present in 17.9% (n = 15) of cases. Ectopic pregnancy was present in 15.5% (n = 13) of cases. Ovarian cyst was found in 15.5% (n = 13) of cases. About 7.1% (n = 6) of females were diagnosed as cases of genital TB. Out of which, one case was of genital TB with fibroid. polycystic ovarian disease (PCOD) was found in 4.8% (n = 4) of cases. Intra-abdominal adhesions formed secondary to past history of abdominal surgery without any gynecological problem were found in 5.9% (n = 5) of cases. Myoma was found in 2.4% (n = 2) of cases. There were two (2.4%) cases of misplaced intrauterine contraceptive device (IUCD) where the IUCDs were found in the Pouch of Douglas (POD). One patient (1.2%) was diagnosed as the didelphys uterus with obstructed hemivagina with hematometra, hematocolpos, and hematosalpinx. There was one (1.2%) case of pelvic abscess where thick pus with adhesion was present.

Correlation was done between the provisional diagnosis, made on the basis of clinical examination and abdominal ultrasound, with the final diagnosis made after laparoscopy and histopathology (Table 5). There were 73.8% (n = 62) cases where the cause of LAP was diagnosed both by clinical examination with USG and by laparoscopy. In 20.2% (n = 17) of cases, no abnormality was detected on clinical examination and USG; diagnosis was in dilemma. Only after laparoscopy, the cause of LAP was established. There were 7.1% (n = 6) cases of genital TB, 5.9% (n = 5) cases of endometriosis, 5.9% (n = 5) cases of intra-abdominal adhesions, and 1.2% (n = 1) cases of PID. There was one case (1.2%) of chronic cervicitis where no abnormality was found on either laparoscopy or ultrasound. It was found on clinical examination. No abnormality was detected in 4.8% (n = 4) cases either on clinical examination, USG, or laparoscopy. On applying the McNemar’s test, the p value was less than 0.05, which shows laparoscopy is statistically significant for the diagnosis of LAP. So, when history, examination, noninvasive investigations, and laparoscopy are combined the diagnosis rate is increased. Not only that, the patients are treated in the same sitting when the pathology was noted.

Diagnostic as well as therapeutic laparoscopy was performed in 82.1% (n = 69) of women. Adhesiolysis was done in 41.7% (n = 35), followed by other procedures given in Table 6. In 8.3% (n = 7) cases, the laparoscopy was converted into laparotomy and treatment was provided in the same sitting. No major intraoperative, postoperative, or anesthetic complications were encountered.

DISCUSSION

Lower abdominal pain represents a significant problem in female patients. It is a common problem faced not only by the gynecologists but by all practicing physicians. For the correct diagnosis of lower abdominal pathology, even a battery of investigations may not reveal exact cause of pain. In the present study, on the basis of history, examination, and ultrasound a provisional diagnosis could be reached only in 75% (n = 63) of the cases and rest of the 25% (n = 21) cases did not revealed any abnormality, which is similar to the study conducted by Morino et al., who diagnosed 73.4% of patients on the basis of basic investigations and abdominal USG.⁶

Although laparoscopy is an invasive modality, it allows the surgeon to survey the entire abdomen through a small puncture, better than any other investigative modalities. It can be considered as the first-line interventional investigation for LAP. In the present study after laparoscopy, pathology was found in 94.1% (n = 79) of cases and no abnormality was noted in remaining 5.9% (n = 5) of patients. Thus, laparoscopy increases the chances of diagnosing the cause of LAP. This shows that laparoscopy is a very good diagnostic tool for the LAP. Our finding is quite similar to Arya and Gaur, Bareeq and Dayna, Ali et al., and Baria, who also reported pathology on laparoscopy in 90, 98, 93.3 and 90% of cases, respectively.^7–10 Moussa et al., Kang et al., and Morino also found abnormality in nearly same frequency, 78.6, 79.2, and 80%, respectively.^6,11,12

Besides diagnosis, laparoscopy can also help in the management of both acute, subacute, and chronic LAP. Therapeutic intervention like adhesiolysis, fulguration of endometriotic lesions, cystectomy, and salpingectomy can be done at the same sitting, thus avoiding unnecessary laparotomy. Therefore, it can be considered as a “see and treat” modality. In the present study, therapeutic laparoscopy was performed in 82.1% of woman. Moussa, Arya and Gaur, Bareeq and Dayna, Baria, and Kumar et al. also have performed therapeutic laparoscopy in the same sitting in 64.3, 75.5, 78, 90, and 69% patients, respectively.^7,8,10,12,13

Sometimes, though no abnormality is detected on laparoscopy, it helps in giving reassurance to the patients and removes the psychological concern, which is associated with chronic pelvic pain. If laparoscopic exploration is not sufficient, the surgeon should not hesitate to convert into laparotomy. In the present study, 8.3% (n = 7) cases were converted to the open procedure for therapeutic intervention. Studies like Arya and Gaur, Bareeq and Dayna, and Teamma also converted laparoscopy into therapeutic laparotomy in 13.5, 2, and 6.4% cases, respectively.^7,8,14 The reasons behind the conversion in their studies were early experience, extensive adhesions, bowel resection, and technical fault.

CONCLUSION

Laparoscopy can be considered as a diagnostic and therapeutic tool in acute, subacute, and chronic LAP. It can also be considered as the first-line minimally invasive investigation for undiagnosed LAP.

REFERENCES

1. Rapkin AJ, Howe CN. Pelvic pain and dysmenorrhea. In Berek and Novak’s Gynecology Berek JS Lippincott Williams and Wilkins; 2011. pp. 506–540.

2. Karnath BM, Breitkopf DM. Acute and chronic pelvic pain in women. Hosp Physician 2007;0:41–48.

3. %3E;RCOG 2012. Royal College of Obstetricians and Gynaecologists. The Initial Management of Chronic Pelvic Pain; Green–top Guideline No. 41, May 2012.

4. Howard FM. Chronic pelvic pain. Am College Obstet and Gynecolog 2003;101(3):594–611. DOI: 10.1097/00006250-200303000-00029.

5. Porpora MG, Gomel V. The role of laparoscopy in the management of pelvic pain in women of reproductive age. Fertil Steril 1997;68(5):765–779. DOI: 10.1016/s0015-0282(97)00192-1.

6. Morino M, Pellegrino L, Castagna E, et al. Acute nonspecific abdominal pain a randomized, controlled trial comparing early laparoscopy versus clinical observation. Annals Surg 2006;244(6):881–888. DOI: 10.1097/01.sla.0000246886.80424.ad.

7. Arya PK, Gaur KJBS. Laparoscopy: a tool in diagnosis of lower abdominal pain. Indian J Surg 2004;66:216–220.

8. Al-Bareeq R, Dayna KB. Diagnostic laparoscopy in acute abdominal pain: 5-year retrospective series. Bahrain Med Bull 2007;29:1–5.

9. Ali SAS, Moosa FA, Sultan N, et al. Role of diagnostic laparoscopy in recurrent vague abdominal pain. J Surg Pakistan (International) 2013;18(2):74–77.

10. Baria KAK. Role of laparoscopy in diagnosis and management of chronic abdominal pain. Indian J Sci Res 2013;4(1):65–68.

11. Kang S-B, Chung HH, Lee H-P, et al. Impact of diagnostic laparoscopy on the management of chronic pelvic pain. Surg Endosc 2007;21(6):916–919. DOI: 10.1007/s00464-006-9047-1.

12. Moussa GI, Mahfouz AE. Role of laparoscopy in management of unexplained chronic abdominal pain. Egyptian J Surg 2004;23(1):22–29.

13. Kumar A, Sarwar MY, Pandey NK. Role of diagnostic laparoscopy in nonspecific chronic abdominal pain: experience of 100 cases. J Evol Med Dent Sci 2013;2(48):9361–9366. DOI: 10.14260/jemds/1622.

14. Teamma MS. Evaluation of laparoscopy in the management of abdominal emergencies. J Arab Soc Med Res 2013;8:19–25.