{"paper_id":"23863707-b1cd-44c3-9270-c87353b16204","body_text":"Acute pelvic pain (APP) presentations are non-\nspecific.1,2 As demonstrated in Table 1, they can be \nattributed to gynaecological, gastrointestinal, urolog-\nical, and other pathologies giving rise to a diagnostic \ndilemma.\n2 It has been postulated that direct visuali-\nsation of the pelvic cavity via a laparoscopic ap-\nproach could reduce the incidence of this diagnostic \nerror.\n1 A systematic review performed by Gaitán et \nal. reviewed 12 studies including 1,020 participants; \n4 of the 12 trials investigated laparoscopic diagnosis \nof APP compared with a conservative approach to \ndemonstrate a significant difference in diagnostic ac-\ncuracy (83% vs 45%) with a preference for la-\nparoscopy.\n1  \nA conservative approach of hospitalisation and \nactive clinical observation is the most widely used \nmanagement protocol at present in women presenting \nwith APP, with a predictive value estimated between \n68% and 92%.\n1,2 With regards to bimanual assess-\nment, 75% of presentations with a normal bimanual \nexamination will show abnormal findings at la-\nparoscopy compared with 11% of presentations with \nan abnormal bimanual examination resulting in nor-\nmal laparoscopy.\n4 Transvaginal ultrasound commonly \nutilised as the initial diagnostic modality proves ben-\neficial for small masses and when pelvic examination \nis abnormal, but has a significantly low predictive \nvalue (51%) when ultrasound findings are normal.\n1,4  \nLaparoscopy offers a diagnostic and therapeutic \nmodality to APP.1 It is a minimally invasive approach \nproviding direct visualisation of the pelvic and ab-\ndominal cavities.\n3,5 In women with atraumatic APP, \nlaparoscopy has confirmed a diagnosis in 70% of pre-\nsentations, clarified the diagnosis in 29% and pro-\nvided a definitive diagnosis in 99% of cases.\n4 \nTherefore, laparoscopy proves invaluable in undif-\nferentiated APP; it is conclusive, safe, and cost ef-\nfective.\n1 Most importantly, it reduces pitfalls in \ndiagnosis, enables earlier management, and improves \nprognosis.\n4 Although this approach is somewhat in-\nvasive, it is offset by the ability to treat the condition \nsimultaneously via the use of diathermy or excision.\n5 \nIn addition, severe complications are rare, at a rate of \n2 in 1,000 patients; these include bowel perforation, \nport site herniation, haemorrhage, infection, damage \nto neighbouring structures, adhesion formation, and \nJCOG. 2023;33(1):43-5\n43\nLaparoscopic Surgery in the Evaluation of Acute Pelvic Pain \n     Dinushi DE ALWISa,     Pavitra NANAYAKKARAb \naMonash Health, Clayton, Victoria, Australia \nbEpworth Hospital, Richmond, Victoria, Australia\nABS TRACT Acute pelvic pain (APP) is non-specific with a 5% to 10% prevalence of visits per annum to emergency. The multiple organ \nsystems within the pelvis, result in diagnostic error, with an estimated 45% of pre-menopausal women misdiagnosed. Unfortunately, diagnostic \naccuracy cannot always be ascertained with physical examination or imaging; however, direct visualisation of the pelvic cavity via laparo-\nscopic surgery provides a more conclusive diagnostic approach. This letter aims to explore the various aetiologies of APP in wo men and the \ncurrent modalities utilised in the diagnostic pathway. The primary aim of this letter is to propose laparoscopic surgery as a p ossible diagnos-\ntic modality to evaluate APP in women. \n \nKeywords: Pelvic pain; acute; non-specific lower abdominal pain; diagnostic laparoscopy; laparoscopic surgery\nDOI: 10.5336/jcog.2022-92762\nCorrespondence: Dinushi DE ALWIS \nMonash Health, Clayton, Victoria, Australia \nE-mail: dinushi.dealwis@monashhealth.org  \nPeer review under responsibility of Journal of Clinical Obstetrics & Gynecology.  \nRe ce i ved: 04 Aug 2022          Ac cep ted: 24 Jan 2023          Available online: 27 Jan 2023  \n2619-9467 / Copyright © 2023 by Türkiye Klinikleri. This is an open \naccess article under the CC BY-NC-ND license (http://creativecommons.org/licenses/by-nc-nd/4.0/).\nTurkiye Klinikleri Journal of Internal Medicine \nJournal of Clinical Obstetrics & Gynecology\nSCIENTIFIC LETTER\n\n44\nfailure.1,4,5 Cost and recovery time relating to surgery \nmay deter some patients from a laparoscopic ap-\nproach to their treatment.\n1,5  \nA prospective algorithm to evaluate APP with \nthe inclusion of laparoscopy in the diagnostic path-\nway is depicted in \nFigure 1. Nevertheless, the advent \nof laparoscopy provides a minimally invasive, accu-\nrate approach to overcome the diagnostic challenge \nposed by APP. Further research is undoubtedly ne-\ncessitated prior to its introduction to the diagnostic \nprotocol for APP. \nSource of Finance \nDuring this study, no financial or spiritual support was received \nneither from any pharmaceutical company that has a direct con-\nnection with the research subject, nor from a company that pro-\nvides or produces medical instruments and materials which may \nnegatively affect the evaluation process of this study. \nConflict of Interest \nNo conflicts of interest between the authors and / or family mem-\nbers of the scientific and medical committee members or members \nof the potential conflicts of interest, counseling, expertise, working \nconditions, share holding and similar situations in any firm. \nAuthorship Contributions \nIdea/Concept: Pavitra Nanayakkara; Design: Dinushi De Alwis; \nControl/Supervision: Pavitra Nanayakkara; Data Collection \nand/or Processing: Dinushi De Alwis; Analysis and/or Interpre-\ntation: Dinushi De Alwis; Literature Review: Dinushi De Alwis; \nWriting the Article: Dinushi De Alwis; Critical Review: Pavitra \nNanayakkara, Dinushi De Alwis; References and Fundings: Di-\nnushi De Alwis; Materials: Dinushi De Alwis.\nDinushi DE ALWIS et al. JCOG. 2023;33(1):43-5\n44\nGynaecological \nNon-pregnancy related Pregnancy related  \n● Pelvic inflammatory disease ● Ectopic pregnancy  \n● Tubo-ovarian abscess ● Miscarriage \n● Endometriosis ● Endometritis \n● Adenomyosis ● Uterine fibroid degeneration   \n● Pelvic adhesions ● Ovarian torsion   \n● Uterine fibroid degeneration  ● Pelvic vein thrombosis  \n● Ovarian cyst rupture ● Placental abruption  \n● Ovarian torsion  \n● Mittelschmerz  \n● Primary dysmenorrhea  \n● Imperforate hymen  \n● Transverse vaginal septum \n● Congenital pelvic malformations  \n● Carcinoid   \nNon-gynaecological \nGastrointestinal Urological Other  \n● Appendicitis ● Cystitis ● Dissecting aortic aneurysm  \n● Bowel obstruction ● Pyelonephritis ● Somatization disorder  \n● Diverticulitis ● Urolithiasis ● Myofascial pain  \n● Inguinal hernia ● Narcotic seeking  \n● Irritable bowel syndrome ● Domestic abuse  \n● Inflammatory bowel disease \nTABLE 1:  Aetiological classification of APP.1-5\nAPP: Acute pelvic pain.\nFIGURE 1: Algorithm for a prospective approach to APP.1-5  \nAPP: Acute pelvic pain.\n\n454545\nDinushi DE ALWIS et al. JCOG. 2023;33(1):43-5\n45\n1. Gaitán H, Angel E, Sánchez J, Gómez I, Sánchez L, Agudelo C. La-\nparoscopic diagnosis of acute lower abdominal pain in women of repro-\nductive age. Int J Gynaecol Obstet. 2002;76(2):149-58. \n[Crossref]  \n[PubMed]  \n2. Kruszka PS, Kruszka SJ. Evaluation of acute pelvic pain in women. Am \nFam Physician. 2010;82(2):141-7. [Link]  \n3. Mikkelsen AL, Felding C. Laparoscopy and ultrasound examination in \nwomen with acute pelvic pain. Gynecol Obstet Invest. 1990;30(3):162-\n4. [Crossref]  [PubMed]  \n4. Murphy A, Fliegner J. Diagnostic laparoscopy: role in management  \nof acute pelvic pain. Med J Aust. 1981;1(11):571-3. [Crossref]   \n[PubMed]   \n5. Laborda E, Clarke A, Carpenter T. The threshold for laparoscopy for \npelvic pain. Obstet Gynecol. 2010;12:7-12. [Crossref] \n REFERENCES","source_license":"CC0","license_restricted":false}