Kelly J J, Puyana J C, Callery M P, Yood S M, Sandor A, Litwin D E
Department of Surgery, University of Massachusetts Medical School, Worcester 01605, USA.
Surg Endosc. 2000 Jul;14(7):617-21. doi: 10.1007/s004640010068.
Systemic inflammatory response syndrome (SIRS) and sepsis of unknown origin are common complications of critically ill patients in the ICU. These patients frequently have unreliable clinical exams and are candidates for exploratory laparotomy. Although abdominal CT is commonly used because it is less invasive than laparotomy, it is often unreliable or unobtainable. Bedside laparoscopy is an alternative technique that may be more accurate than CT in selected patients and less invasive than laparotomy.
We performed diagnostic laparoscopy (DL) in a series of ICU patients with SIRS/septic state of unknown origin between May 1997 and June 1998. All patients were unstable and required significant respiratory and hemodynamic support. Laparoscopy was either performed in the ICU at the patient's bedside or in the operating room. CT scan of the abdomen had been performed on most of the patients who were stable enough to transport. Confirmation of diagnosis was obtained either by laparotomy, autopsy, or clinical recovery.
Among the 17 eligible patients, 16 underwent successful DL. Insufflation was impossible in one patient because of high intraabdominal pressure. Bedside evaluations were performed in 14 of the 17 patients. There were no complications from the laparoscopy. Six patients were identified as positive (four intestinal ischemia, two cholecystitis); the other 10 had negative explorations. Follow-up on two patients with negative laparoscopy was incomplete due to denied postmortem. Laparoscopic diagnoses were confirmed in the remaining 14 patients by laparotomy (six cases), postmortem (three cases), or recovery (five cases), with an accuracy of 100%. The overall accuracy of abdominal CT obtained in nine of the 14 patients was 33%.
DL in a select group of critical ICU patients is safe and accurate, whereas CT scan tends to be inaccurate and is often unobtainable due to patient instability. Performing the procedure at the bedside can expedite the diagnosis, eliminate the burden for transfer, and save on anesthesia and operating room charges.
全身炎症反应综合征（SIRS）和不明原因的脓毒症是重症监护病房（ICU）中危重症患者的常见并发症。这些患者的临床检查结果往往不可靠，需要进行剖腹探查。尽管腹部CT因侵入性小于剖腹探查而被广泛应用，但它常常不可靠或无法实施。床旁腹腔镜检查是一种替代技术，在特定患者中可能比CT更准确，且侵入性小于剖腹探查。
我们在1997年5月至1998年6月期间，对一系列患有不明原因SIRS/脓毒症状态的ICU患者进行了诊断性腹腔镜检查（DL）。所有患者病情均不稳定，需要大量呼吸和血流动力学支持。腹腔镜检查在ICU患者床边或手术室进行。大多数病情稳定到足以转运的患者都进行了腹部CT扫描。通过剖腹探查、尸检或临床康复来确诊。
17例符合条件的患者中，16例成功进行了DL。1例患者因腹内压高无法进行气腹。17例患者中有14例进行了床旁评估。腹腔镜检查无并发症发生。6例患者被诊断为阳性（4例肠缺血，2例胆囊炎）；其他10例探查结果为阴性。2例腹腔镜检查阴性的患者因拒绝尸检，随访不完整。其余14例患者的腹腔镜诊断通过剖腹探查（6例）、尸检（3例）或康复（5例）得到证实，准确率为100%。14例患者中有9例进行的腹部CT总体准确率为33%。
对特定的危重症ICU患者进行DL是安全且准确的，而CT扫描往往不准确，且由于患者病情不稳定常常无法实施。在床边进行该操作可加快诊断，消除转运负担，并节省麻醉和手术室费用。
