Esmeralda Ruspoli: Laparoscopic "capriccio", 1976 (Collage made on a laparoscopic photograph. 20 x 20 cm)

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2 Esmeralda Ruspoli: Laparoscopic "capriccio", 1976 (Collage made on a laparoscopic photograph. 20 x 20 cm)

3 Giorgio Dagnini Laparoscopy and Imaging Techniques Translated by Sara Pearcey With a Foreword by F. ViI ardell With 187 Figures, 145 in Color Springer-Verlag Berlin Heidelberg New York London Paris Tokyo Hong Kong Barcelona

4 Prof. Dr. Giorgio Dagnini Via del Vescovado Padova ISBN-13: e-1sbn-13: DOT: / Library of Congress Cataloging-in-Publication Data. Dagnini. Giorgio. Laparoscopy and imaging techniques / G. Dagnini; translated by Sara Pearcey. p. cm.isbn (U.S.: alk. paper) 1. Laparoscopy. 2. Abdomen - Imaging. I. Title. [DNLM: I. Peritoneoscopy - methods. WI 575 D127LJ RC944.D ' dc20 DNLMIDLC This work is subject to copyright. All rights reservcd. whether the whole or part of the material is concerned. specifically the rights of translation. reprinting. reuse of illustrations. recitation, hroadcasting. reproduction on microfilms or in other ways. and storage in data banks. Duplication of this puhlication or parts thereof is only permitted under the provisions of the German Copyright Law of Septemher in its current version. and a copyright fcc must always he paid. Violations fall under the prosecution act of the German Copyright Law. Springer-Vcrlag Berlin lieidclhcrg 1990 Softcover reprint of the hardcover 1st edition 1990 The usc of registered names. trademarks. etc. in this puhlication docs not imply. even in the absence of a specific statement. that such names arc exempt from the relevant protective laws and regulations and thereforc free for general usc. Product liahility: Thc puhlisher can give no guarantec for information ahout drug dosage and application thereof containcd in this hook. In every individual case the respective user must check its accuracy hy consulting other pharmaceutical literature. Typesetting: Best-set Typesetter Ltd.. Hong Kong 212WUO Printed on acid-free paper

5 Foreword Laparoscopy has been used in Europe since the turn of the century. The interest of gastroenterologists in laparoscopy was greatly expanded in the 1930s by the work of Kalk in Germany and Ruddock in the United States. Since then, laparoscopy has been widely employed all over the world. Opinions concerning the indications of laparoscopy vary a great deal. More than 50 years ago Korbsch, a well-known German gastroenterologist and endoscopist, recommended that "Laparoscopy should be used if the diagnosis cannot be established by other means and there is a good chance of visualizing the lesion"; this is still valid. However, as Professor Dagnini states, the advent of newer imaging techniques have doubtless changed these indications, narrowing them in some areas but expanding them in others. These examination methods have by no means negated the use or value of laparoscopy. We believe, with Professor Dagnini, that laparoscopy should be employed in the diagnosis of obscure abdominal disease if other tests fail to give a definite answer, as is often the case with imaging techniques, when laparotomy, for one reason or another, should be avoided. Gynecologists' wide utilization of laparoscopy to perform surgical procedures is now being matched by abdominal surgeons who are now performing laparoscopic appendectomies and particularly cholecystectomies. In some countries, such as France, the latter are being done in several centers and extensive experience has been accumulated. This magnificent book by Professor Giorgio Dagnini, one of the foremost representatives of laparoscopic techniques in Europe, is timely and courageous. It addresses several important points: (1) the comparison with imaging techniques and the emergence of new indications secondary to imaging discoveries; (2) The progress in technology, such as fine needles for pneumoperitoneum, laparoscopy with flexible instruments, the use of the bio-plug, and echolaparoscopy; (3) Laparoscopy of the pancreas, and biopsy of the pancreas and spleen for the staging of lymphomas, an indication for laparoscopy with which the school of Professor Dagnini has very wide experience. There follows a series of chapters on the traditional indications for laparoscopy, including the diagnosis of ascites, splenomegaly, hepatomegaly, and abdominal masses and the role of combined sonography and laparoscopy in their final assessment. The chapter on liver diseases shows clearly that laparoscopy retains a major role in diagnosis, as imaging methods are usually only able to demonstrate pronounced changes, not early disease. Laparoscopy has an important role in the staging of tumors and also in abdominal emergencies, although in the latter, imaging techniques have narrowed its use. The book is illustrated by many outstanding colour photographs, which are well known to be one of Professor Dagnini's strengths. It presents the current status of laparoscopy objectively and dispassionately: there are large numbers of references in several languages supporting the discussions, and the text is clear and to the point, probably a consequence of the great experience of Professor Dagnini as a teacher and clinician.

6 VI Foreword All laparoscopists and also gastroenterologists and surgeons should read this book. It will be an invaluable source of references, and will be helpful in many ways to the beginner as well as to the seasoned endoscopist. This superb monograph is a joy to read and a great achievement. Professor Francisco Vilardell President, World Organisation of Gastroenterology (OMGE)

7 Preface Since laparoscopy has become a less frequent topic of discussion, it might seem anachronistic to write a book on it. Far from this being the case, however, a review such as this is the natural outcome of the revolution in the diagnosis of abdominal diseases brought about by the increasingly wide spread use of imaging techniques. We are all aware of the extraordinary diagnostic potential of the "new" noninvasive techniques, and it is therefore logical to ask ourselves why the "old" laparoscope, which is invasive and more risky, should still be even considered. In recent years, people have sometimes asked me in an ironic tone whether I still believe in laparoscopy and continue to perform it. The question gives me the unpleasant sensation of being a "has been." I can only give a decent answer to it after, on the one hand, considering the state of the art of laparoscopy with respect to new technical and methodological advances and, on the other, ascertaining systematically whether sonography or other noninvasive techniques can really replace laparoscopy in all cases. The aim of this book is to answer these question along two lines. The first part describes the most recent developments, progress that has greatly enhanced the efficacy and reduced the risks of laparoscopy. The second part deals with the complex issue of the present indications for this technique. We have used echography and laparoscopy in combination for several years, with the same operator performing both techniques. This qualifies us to make an impartial assessment of them. Now, when faced with a particular diagnostic problem we can directly evaluate and compare the advantages, potential, gaps, and drawbacks of each technique and then consider the clues in order to work out the quickest and most advantageous way of reaching a satisfactory diagnosis in a given case. We have greatly modified and updated the entire protocol for the indications for laparoscopy. Some have been abandoned in favor of sonography while others must still be considered valid. Lastly, new indications have emerged. This book is based on direct observation from my own experience, and it follows the scheme of teaching in daily practice. I did not intend to write a treatise, but preferred to deal with the innovations made in laparoscopy since these innovations are the window of opportunity for laparoscopy itself. Because of this, most references are to works published from 1980 onwards. This book has, of course, been written for laparoscopists and sonographists. But it is, above all, for clinicians, internal physicians, surgeons, gastroenterologists, and oncologists. I trust that it provides them with a clear picture of the value of laparoscopy and that it helps them decide if and when it is opportune to use this glorious technique to resolve a particular diagnostic problem. Giorgio Dagnini

8 Contents Introduction... 1 I Progress in Laparoscopy New Instruments Fine Needles for Pneumoperitoneum Veress Needle Fine Needle Conclusions Laparoscopy with Flexible Instruments Fiberscope Used as a Laparoscope Rigid Laparoscope with a Mobile Head Conclusions Bio-Plug Instrument and Technique Results Conclusions Integration of Laparoscopy with Sonography Echolaparoscopy Instruments Technique Results Clinical Applications Practical Value Conclusions Sonography for Laparoscopy Sonography Before Pneumoperitoneum Sonography After Pneumoperitoneum Sonography After Laparoscopy Conclusions Technical Innovations Laparoscopic Exploration of the Pancreas Technique Interpretation of Laparoscopic Findings Present Value Conclusions Operative Laparoscopy Technique Lysis of Adhesions for Diagnostic Purposes

9 x Contents Lysis of Algogenic Adhesions Puncturing and Drainage of Cystic Formations Puncturing and Drainage of Abscesses Endoscopic Operations for Laparoscopic Accidents Conclusions Laparoscopy in Patients with Possible Endoabdominal Adhesions Risks Results Conclusions Laparoscopic Biopsy Biopsy of Peritoneum, Mesentery, and Omentum Liver Biopsy Pancreas Biopsy Splenic Biopsy Disinfection of Instruments Current Precautions and Disinfection Procedures Conclusions II Present Uses of Laparoscopy Traditional Indications for Laparoscopy Ascites Present Indications for Laparoscopy False Ascites Conclusions Hepatomegaly False Hepatomegaly Conclusions Splenomegaly Present Indications for Laparoscopy Main Laparoscopic Findings Conclusions Abdominal Masses Present Indications for Laparoscopy Conclusions Jaundice Present Indications for Laparoscopy Main Laparoscopic Findings Conclusions Abdominal Pain Present Indications for Laparoscopy Main Laparoscopic Findings Conclusions Fever Present Indications for Laparoscopy Main Laparoscopic Findings Conclusions Liver Diseases Diffuse Noncirrhotic Liver Diseases Alcoholic Liver Disease

10 Contents XI Chronic Hepatitis Conclusions Cirrhosis of the Liver Main Laparoscopic Findings Etiological Diagnosis Liver Biopsy Laparoscopic Classification Cirrhosis and Liver Tumors Present Indications for Laparoscopy Conclusions Focal Liver Lesions Present Indications for Laparoscopy Conclusions Portal Hypertension Main Laparoscopic Findings Present Indications for Laparoscopy Conclusions Laparoscopy in Oncology Staging of Malignant Tumors Follow-up and Restaging Systemic Tumors: Malignant Lymphomas Imaging Techniques Progress in Oncological Laparoscopy Present Indications for Laparoscopy Primary Extraabdominal Tumors Breast Cancer Esophageal Carcinoma Lung Tumors Melanoblastoma Primary Endoabdominal Tumors Stomach Carcinoma Intestinal Tumors Pancreatic Tumors Liver Carcinoma Ovarian Carcinoma Conclusions Emergency Laparoscopy Present Indications for Laparoscopy Acute Spontaneous Abdomen Abdominal Trauma Conclusions Subject Index The reference list appear at the end of each chapter