The peritoneal cavity of a dog was examined in 1902 by Kelling, using air insufflation and the insertion of a cystoscope through the abdominal wall. The first clinical use was described in 1912 by Jacobaeus, although it was a further decade before a purpose-built scope was in use by Kalk (1929) and the era of modern-day laparoscopy (peritoneoscopy) began.

The patient is positioned supine on the operating table. A general anaesthetic with muscle relaxation is usually preferred, but it is possible to use local anaesthetic and sedation with intravenous benzodiazepines. The Verres needle is introduced via a stab incision. This is usually subumbilical in position, but the presence of scars may influence the precise location. The needle contains a spring-loaded blunt probe, and compression of the spring against the skin retracts the probe to expose the needle. Damage to intra-abdominal viscera can be minimized by holding up the anterior abdominal wall with one hand while inserting the needle with the other. When the needle has passed through the abdominal wall the resistance falls and the spring pushes forwards the probe covering the needle. Free flow of normal saline solution through the needle confirms that the linea alba and peritoneum have been punctured. The abdomen is then insufflated with carbon dioxide, using approximately 2 to 3 litres for an adult. During insufflation, the intra-abdominal pressure should not exceed 15 mmHg. The Verres needle is then withdrawn and the incision is enlarged to accommodate the laparoscope trocar, which is pushed down and back into the pelvis. The end- or side-view telescope is then inserted and laparoscopy commenced. Biopsy forceps and a palpating probe can be used in other, suitably placed stab incisions through the anterior abdominal wall. This allows the peritoneal contents to be inspected. Throughout the procedure, carbon dioxide is continually insufflated at low pressure.

There are few absolute contraindications to the procedure, but certain conditions should alert the surgeon to potential problems. Multiple scars make introduction of the scope hazardous, and adhesions from repeated abdominal procedures may hinder the view within the peritoneum. Abdominal wall sepsis may introduce intraperitoneal infection. The procedure is not tolerated well in patients with severe pulmonary or cardiac problems, due to the intra-abdominal distension. Bleeding diatheses may result in body wall or intraperitoneal bleeding.

To minimize complications, laparoscopy is a procedure best performed by surgeons experienced in the technique, in an operating theatre equipped with the facilities to proceed to a laparotomy if necessary. Minor complications include abdominal wall bruising, subcutaneous emphysema, the development of a wound infection/hernia, and postoperative shoulder pain. Other complications are related to accidental visceral damage and bleeding from vessel injury. These problems should be noted at the time of laparoscopy and dealt with by prompt laparotomy if necessary. Mortality rates of 0.03 to 0.1 per cent are reported.

In patients with localized peritonism, diagnostic laparoscopy is most commonly used in the management of patients with acute right iliac fossa pain, in an attempt to reduce the incidence of ‘negative’ surgical explorations for acute appendicitis, especially in young women. With the aid of a palpating probe inserted through the anterior abdominal wall of the right iliac fossa, the surrounding ileum and omentum may be manipulated away in order to see the appendix. In the case of a retrocaecal or retroileal appendix, it may be impossible to visualize the target organ, but other signs of acute inflammation may be noted. Alternatively, other causes of right iliac fossa pain may be apparent, and, if these require surgery, an appropriate incision can be made.

The role of diagnostic laparoscopy in the management of the patient with abdominal trauma is in conjunction with imaging techniques (CT and ultrasound scanning) and peritoneal lavage. The relative importance of each is not established clearly, although aggressive use of laparoscopy in this clinical situation may reduce the number of unnecessary laparotomies performed for minimal or moderate haemoperitoneum. The procedure can be performed in the accident and emergency department under local anaesthesia with intravenous sedation, and has been facilitated by the development of a ‘mini’ (5 mm) laparoscope.

In the management of patients with undiagnosed abdominal pain, opinion is divided as to the benefits of laparoscopy. The role of laparoscopy is better established in the investigation of women with chronic pelvic pain, and is frequently performed by gynaecologists.

In children with impalpable testes, laparoscopy can be used to visualize the internal ring and the testicular vessels. These are followed to locate the testis, which may then be classified as being abdominal, pelvic, canalicular (the lower pole entering the orifice of the internal ring), or absent. The laparoscopic findings may then influence the site of a subsequent incision or obviate the need for an exploration.

Other indications for elective laparoscopy in benign disease include the diagnosis of various liver conditions (by direct visualization with or without biopsy), and tuberculous peritonitis.

Laparoscopy is commonly used in the management of intra-abdominal malignancy. As a staging investigation, laparoscopy is a more sensitive and accurate means of detecting small liver metastases and peritoneal seedlings compared with CT and ultrasound scanning. Biopsy may be performed using a Menghini needle under direct vision, which minimizes the risk of inadvertent visceral trauma, and increases the positive histological yield compared with a ‘blind’ percutaneous biopsy. Draining lymph nodes may also be seen and biopsied to exclude malignant involvement. The knowledge obtained by such procedures may avoid an unnecessary laparotomy if a palliative operation is not indicated.

An increasing number of surgical operations are now feasible via the laparoscope (see Fig. 1 1408). These are described, as appropriate, in the relevant chapters.