Effect on negative laparoscopy rate in chronic pelvic pain patients using patient assisted laparoscopy.

L A Demco, LA Demco
JSLS : Journal of the Society of Laparoendoscopic Surgeons · 1999 · vol. 1(4) , pp. 319–21 · PMID:9876695 · PMC3016755 · W2418091439
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⚙ AI-generated summary by claude@2026-06, 2026-06-10 ⓘ

Patient Assisted Laparoscopy identified an abdominal cause for pelvic pain in 97% of patients, significantly reducing the negative laparoscopy rate compared to traditional methods.

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This paper evaluated Patient Assisted Laparoscopy (PAL) as a diagnostic approach for 100 women with chronic pelvic pain who had negative ultrasound/CT (and MRI when ordered) and, if previously performed, negative laparoscopy under general anesthesia. PAL was performed while patients were conscious, using trocar insertion under local anesthesia, intra-peritoneal carbon dioxide insufflation, and tactile mapping of pain where laparoscopic findings were only diagnosed when the patient confirmed that palpation reproduced her presenting symptoms; 12 patients were excluded for technique failure, gas reaction, inability to visualize due to adhesions, or intolerance. Among 88 assessable patients, 61 had biopsy-confirmed endometriosis and only 2 had a totally negative PAL, reducing the negative laparoscopy rate to less than 3% versus a cited 35% under general anesthesia; the stated limitation is that PAL depended on patient tolerance and adequate technique/visualization. Relevance to endometriosis: endometriosis was the predominant confirmed diagnosis in this PAL cohort (61/88, 69%), with findings and diagnosis explicitly tied to patient-reproduced pain during laparoscopy, though the paper’s main focus is assessing PAL’s effect on negative laparoscopy rate in chronic pelvic pain.

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Abstract

OBJECTIVE: To determine the value of Patient Assisted Laparoscopy (PAL) in the diagnosis of pelvic pain. METHODS: One hundred patients with pelvic pain were assessed by the procedure of Patient Assisted Laparoscopy to determine the cause of chronic pelvic pain. RESULTS: Of the 100 patients with pelvic pain, 12 patients were not assessed due to technique failure, which included reaction to the carbon dioxide gas, inadequate visualization due to abdominal adhesions or failure to enter peritoneum. Of the remaining 88 patients, 61 had endometriosis; 16 had adhesions not associated with endometriosis; five had hernias; one had occult bowel cancer; one pseudo-stone from previous cholecystectomy; one had pain as a result of staples used at hysterectomy and one patient had chronic Crohn's disease. Two patients had no demonstrated interabdominal cause for their symptoms. CONCLUSION: In contrast to the well published rate of 35% negative laparoscopy in those patients with pelvic pain when examined under general anesthetic, Patient Assisted Laparoscopy decreased the negative laparoscopy rate to less than 3%. This methodology was also of benefit in giving the patient a better understanding of the cause of her pain and the need for therapy.
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Results

Of the 100 patients entered into the study, twelve patients were eliminated. The reasons for elimination included retroperitoneal insufflation of gas; reaction to the intraperitoneal gas (i.e., shoulder tip pain); or the inability to visualize due to adhesions ( Table 2 ). Of the 88 remaining patients ( Table 3 ), 6l (69%) had endometriosis confirmed by biopsy; 16 (18%) had adhesions from previous operations or disease other than endometriosis. Five patients (5%) had a direct or indirect hernia. The remaining 6% patients had unusual diagnosis, including a cancer of the sigmoid colon, chronic disease of the terminal ileum, a staple impinging the serosa of the ureter and a pseudostone from spillage of the contents of the gallbladder at time of cholecystectomy. Cause for PAL failure. Diagnosis at time of PAL. Only two patients had a totally negative PAL. Further investigations revealed that one of the remaining patients had a myofascial cause for her pain as described by Slocumb. 5 The remaining patient had no discernible cause for the pain she was experiencing.

Conclusions

Since pain is a symptom that cannot be visualized, but only experienced, it would be reasonable to expect that there would be an advantage to having the patient demonstrate where the pain was located, as well as its physical parameters. Patient assistance during the laparoscopy has several advantages: 1) Patient is able to show the surgeon (and, more importantly, herself) the cause of her pain; 2) Laparoscopic findings can be demonstrated to the patient as the cause of her pain; 3) Treatment can be determined and explained to the patient; 4) The patient can be shown potential complications of therapy; 5) The patient can confirm the result of therapy, i.e., release of adhesions result in resolution of pain; 6) The negative laparoscopic rate can be reduced from 35% to less than 3%. 1) Patient is able to show the surgeon (and, more importantly, herself) the cause of her pain; 2) Laparoscopic findings can be demonstrated to the patient as the cause of her pain; 3) Treatment can be determined and explained to the patient; 4) The patient can be shown potential complications of therapy; 5) The patient can confirm the result of therapy, i.e., release of adhesions result in resolution of pain; 6) The negative laparoscopic rate can be reduced from 35% to less than 3%. In contrast to the published rate of a 35% negative laparoscopy when the client is under general anaesthetic, Patient Assisted Laparoscopy (PAL) decreases the negative laparoscopy rate to less than 3%. This methodology also gives the patient a better understanding of the cause of her pain and the need for therapy.

Introduction

Patients presenting with chronic pelvic pain, defined as non-menstrual pain in the pelvic area for longer than three (3) to six (6) months, have often been investigated without significant objective findings to explain the pain. These cases account for 10% of visits to the gynecologist. 1 As a last resort, laparoscopy under general anaesthetic has been offered. In these instances, a diagnosis based on visual inspection by the surgeon, without confirmation by the patient, has been established in 70% of patients ( Table 1 ). 2 , 3 Thirty percent of these cases, however, have a negative laparoscopy as defined by no visible pathology. Howard 4 has characterized these patients as 1) nothing wrong; 2) pain is in her head and patient is referred to a psychiatrist; 3) a neurolytic procedure, such as uterine nerve transection or presacral neurectomy is recommended; 4) the only thing left to do is a hysterectomy; 5) nothing can be done and the woman must learn to live with the pain. Laparoscopic findings in women with CPP, 1981 - 1994. Many patients viewed these conclusions as unacceptable as they were never given the opportunity to "show the doctor" exactly where the pain was. To answer this need to "show the doctor" the site of her pain, a technique of performing laparoscopy while the patient was fully conscious was developed. This procedure is referred to as Patient Assisted Laparoscopy (PAL).

Materials|Methods

One hundred patients entered the study with a diagnosis of pelvic pain. All tests including ultrasound, CT, and, if ordered, MRI were negative. If performed, previous laparoscopy under general anaesthesia revealed no cause of the pain. All patients underwent Patient Assisted Laparoscopy. This procedure entailed the following: Emla cream was placed to the planned subumbilical and suprapubic trocar sites two hours prior to surgery. One percent (1%) Xylocaine was infiltrated with a 25-gauge needle to produce a field block of the abdominal muscles and peritoneum in the proposed path of the trocar. A 4 mm Storz trocar and laparoscope were inserted subumbilically and a second 3 mm trocar and probe suprapubically. A maximum of 600 cc carbon dioxide gas was instilled into the peritoneal cavity. A Storz twin video system was used to record patient response so that the responses could be correlated to findings at laparoscopy. The probe was used in a tactile manner to map the area of pain. No Medazolm was used, and small boluses of fentynal were given only upon patient's request. Normal peritoneum was first palpated to establish a control. Other areas were palpated and compared to the control. A diagnosis was not established unless the patient confirmed that the pain produced by palpation reproduced her presenting symptoms.

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Condition tags

chronic_pelvic_painendometriosis

MeSH descriptors

Laparoscopy Patient Participation Pelvic Pain Female Humans Laparoscopy Pain Measurement Pelvic Pain Pelvic Pain

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