Richtlinien der Society of American Gastrointestinal Endoscopic Surgeons (SAGES) zur diagnostischen Laparoskopie



1. Diagnostic Laparoscopy


This is one of a series of statements discussing the utilization of laparoscopy in common clinical situations. This guideline was prepared by the Standards of Practice Committee of the Society of American Gastrointestinal Endoscopic Surgeons. Previous guidelines on this topic (SAGES Publication #0012) were written in 1991. Since that time, new information has been released that requires an update of this information and recommendations. In preparing this update, a literature search was performed, and additional references obtained from the bibliographies of the identified articles and from the recommendations of expert consultants. As little data exists from well-designed prospective trials, emphasis was given to the results from large series and reports from recognized experts. Revision of this guideline may be necessary as new data appear. Clinical consideration may justify a course of action at a variance from these recommendations.

Clinical Application

Diagnostic laparoscopy is a procedure which allows the direct visual examination of intra abdominal organs including large surface areas of the liver, gallbladder, spleen, peritoneum, and pelvic organs.1,2 Directed biopsies can be obtained and may be more accurate than CT-guided aspiration biopsies. Laparoscopy allows a surgeon to diagnose and obtain information about dissemination of disease and to diagnose patients with equivocal abdominal findings.3,4 Since surgical procedures performed via laparoscopic access carry risks above and beyond that of diagnostic laparoscopy alone, they are addressed under separate guidelines.

Diagnostic laparoscopy is safe and well tolerated and can be performed in an outpatient or inpatient setting under local or general anesthesia.5 During the procedure, the patient should be continuously monitored6 and resuscitation capability must be immediately available. Laparoscopy must be performed using sterile technique along with a high level disinfection of the laparoscopic equipment. Overnight observation may be appropriate in some outpatients.


  • Liver tumors: Evaluation of suspected hepatic malignancies, either primary or secondary, may be enhanced with laparoscopy,7,8 since 80-90% of lesions are on the liver surface and two-thirds of the liver surface can be inspected. Laparoscopically-guided biopsy is particularly helpful when hepatic neoplasm is suspected and blind percutaneous biopsy is negative. When surgical resection is a therapeutic option, laparoscopy may reveal small (less than 2 cm) satellite lesions which might not be detected using other modalities.
  • Staging: Laparoscopy can be helpful in detection and staging of lymphoma, pancreatic,9 gastric or esophageal cancer,10 as well as in second look operations after chemotherapeutic regimens.
  • Liver disease: Laparoscopy is indicated for cirrhotic patients when a standard biopsy is inconclusive or not desired (e.g., small liver, large volume ascites).11 Patients with liver disease are more prone to hemorrhage following biopsy, but at laparoscopy, bleeding from the biopsy site can be controlled using electrocoagulation or other techniques.
  • Ascites: When the etiology of ascites remains elusive, laparoscopy may prove helpful, especially when the ascites are secondary to tuberculosis or carcinomatosis.
  • Critical Illness: Laparoscopy can be helpful in diagnosing acalculous cholecystitis, perforated viscus, or other surgical emergencies in patients who are critically ill and have an equivocal abdominal exam.
  • Abdominal Trauma: Laparoscopy for specific problems (i.e., anterior and lateral stab wounds, tangential gunshot wounds) may be helpful in avoiding a full laparotomy. Laparoscopy for blunt abdominal trauma is currently debated.12,13
  • Miscellaneous Conditions: Other indications where laparoscopy may be helpful include a palpable abdominal mass, abdominal or pelvic pain of unknown origin, acute and chronic abdominal pain in the elderly patient, fever of unknown origin, and in patients with possible appendicitis.


Contraindications may include a known ruptured diaphragm, hemodynamic instability, an uncooperative patient, mechanical or paralytic ileus, uncorrected coagulopathy, generalized peritonitis, severe cardiopulmonary disease, large hiatal hernia, abdominal wall infection, multiple previous abdominal procedures, and pregnancy.14,15 However, the final decision is determined not only by the clinical conditions, but also by the surgeon’s judgement.


Instruments used in diagnostic laparoscopy should include but are not limited to a laparoscope, trocar, grasping, biopsy, and retracting instruments as needed. Most instruments will range in size from 2-10 mm in diameter. Personnel should include the laparoscopist and a trained assistant to monitor blood pressure, pulse, respiratory rate, oxygen saturation, EKG and level of sedation. Many patients having diagnostic laparoscopy can be done under local anesthesia with intravenous sedation as necessary. When general anesthesia is necessary, a trained anesthetist or anesthesiologist should be present.

Initial entry into the abdomen can be obtained by the Veress needle or cut down technique. The abdomen is appropriately insufflated and additional trocars inserted as needed. Insufflation pressure should be limited to 10 mm Hg in a spontaneously breathing patient.

Routine laparoscopic examination of the abdomen may include evaluation of peritoneal surfaces, diaphragm, liver, spleen, gallbladder, stomach, small intestine, colon, pelvic organs, and retroperitoneal tissues and organs. Appropriate biopsies, cytology, cultures and fluid analysis may be performed as necessary and / or other imaging modalities may be useful.


Complications may occur during creation of the pneumoperitoneum, trocar insertion, or during the diagnostic exam. These complications include but are not limited to, cardiac arrhythmias, hemodynamic instability due to decreased venous return, bleeding, bile leak, perforation of a hollow viscus, laceration of a solid organ, vascular injury, gas embolism, and subcutaneous or extraperitoneal dissection of the insufflation gas. Wound infection or leakage of ascites may occur postoperatively. Failure to accurately diagnose the extent of intra-abdominal pathology is another potential complication.


Diagnostic laparoscopy is useful for patients in whom the diagnosis or extent of the disease is unclear or the abdominal findings are equivocal. It can be performed safely in an inpatient or outpatient setting, potentially expediting diagnosis and treatment.


  1. Boyce HW. Laparoscopy. In: Schiff L, Schiff ER (eds.), Diseases of the Liver. Philadelphia: JB Lippincott 1982; 333-348.
  2. Berci G, Cuschieri A. Practical Laparoscopy. London: Bailliere Tindall, 1986.
  3. Mansi C, Savarino V., Picciotta A, et al. Comparison between laparoscopy, ultrasonography and computed tomography in widespread and localized liver disease. Gastrointestinal Endoscopy. 1982; 28:83.
  4. Gandolfi L, Rossi A, Leo P, et al. Indications for laparoscopy before and after the introduction of ultrasonography. Gastrointestinal Endoscopy. 1985; 31:1.
  5. Sleeman D, Sosa JL, Almeida J, et al. Bedside laparoscopy in critically ill patients. Critical Care Medicine. 1995; 21 (2 suppl.):A237.
  6. Monitoring of Patients Undergoing Gastrointestinal Endoscopic Procedures. Guidelines for Clinical Applications. American Society for Gastrointestinal Endoscopy, 1989.
  7. Coupland G, Townsend D, Martin C. Peritoneoscopy - Use in assessment of intra abdominal malignancy. Surgery. 1981; 89:645-649.
  8. Brady PG, Goldschmidt S, Chappel G, et al.