The Use of Minilaparoscopy for Conscious
Pain Mapping
James C. Rosser, MD, FACS, Matthew Goodwin, MD, Nick H. Gabriel, DO,
and Lloyd Saberski, MD
Conscious pain mapping via minilaparoscopy is a technique
designed to localize the source of abdominal pain by taking
advantage of the best monitor for pain—the patient. The areas of
concern are examined laparoscopically in a lightly sedated pa-
tient. The patient then directs the physician to the area of
concern. Careful in vivo examination often reveals pathologic
conditions that are not recognized by other means. When the
source of pain has been identified,subsequent treatment steps
are often clear. When the pain source is localized to a nerve,such
as the genitofemoral nerve,a cryoanesthetic block can be placed
on the nerve with direct visualization. If conscious pain mapping
assessment is correct,placement of the cryoanesthetic block
should render the patient’s pain improved. Cryoanesthesia pro-
vides a reversible,nondestructive nerve block. This allows for
assessment of blockade well beyond the placebo period and
may have an effect on central nervous system wind-up.
Copyright
©
2001 by W.B. Saunders Company
P
ain is the most common symptom that brings patients in for
a medical evaluation. The International Association for the
Studyof Pain has described it as “an unpleasant sensoryand
emotional experience associated with either actual or potential
tissue damage, or described in terms of such damage.”
1
When
faced with a patient who is complaining of chronic pain, the
physician should establish goals of management.
First, the cause of the pain should be discovered, if at all
possible. This is often verydifficult because there is often no
easilyrecognized single responsible cause. The verynature of
pain is quite subjective, and histories of the patients are at times
inconsistent with physical findings. There has been no truly
effective wayto obtain absolutelyconsistent data to help guide
the clinician to the correct diagnosis. Trigger point identifica-
tion, local blocks, and percutaneous ablations are just a few of
the standard maneuvers that are used. The glaring shortcom-
ing, however, is that the potential anatomic sources of the pain
cannot be exposed and isolated with absolute certainty. With
volume-based block establishment, localization attempts may
not be precise because of the exposure of multiple structures to
the anesthetic. Open techniques usuallyrequire the patient to
be asleep. This eliminates patient assistance in the identifica-
tion of the pain-eliciting culprit. The abilityto obtain reliable,
patient-assisted data with precise identification of specific po-
tential anatomic foci is the diagnostic high ground.
Second, once the cause of the pain has been identified, an
aggressive treatment plan should be undertaken to eliminate or
control the problem. For example, a proper medical regimen
should be used for a diagnosis of sarcoidosis that has been
causing right upper quadrant pain secondaryto diffuse liver
involvement. The excision of an intermittentlyobstructive
band of adhesions involving the small bowel can be the keyto
the elimination of chronic abdominal pain. Tighter serum glu-
cose control can help to control intermittent acute abdominal
pain.
Lastly, if the cause of the pain cannot be identified, then the
clinician must treat the pain itself. Treatment of the pain can be
drug therapy, such as physical and cognitive therapy, or surgi-
cal. The main goal is to improve the patient’s qualityof life,
therebyfacilitating the patient’s normal day-to-dayfunctions
and interactions. To accomplish this goal, a veryfine distinc-
tion must be established between drug treatment for manage-
ment of the chronic pain condition and drug treatment for
psychosocial disease. A desperate, anxious, and drug-addicted
patient decreases the odds of achieving effective relief and func-
tionality.
Today, there is opportunity to establish the correct diagnosis
veryearlyin the care plan. Saberski and others have shown that
conscious, patient-assisted spinal endoscopywith visual in-
spection of anatomyvia miniature endoscopes can be very
effective in identifying disease.
2
The use of minilaparoscopic
equipment with video guidance can allow the surgeon to ma-
neuver within the abdominal cavitywhile the patient is awake.
This is the world of minilaparoscopywithout general anesthe-
sia, as well as conscious pain mapping, offering the possibility
of taking a patient on a fantastic voyage within their abdomen
and pelvic regions to document the source of acute and chronic
pain syndromes. Appendicitis, diverticulitis, chronic low-grade
intestinal obstruction, and hepatic disease are just a few of the
elusive diagnoses that can be made. If a peripheral nerve (in
particular, the genital and femoral branch of the genital-femoral
nerve, femoral and lateral femoral cutaneous nerve) is identi-
fied as the culprit, cryoablation can be undertaken with pin-
point accuracyto increase the success rate of this modality.
Laparoscopywas initiallya procedure performed under local
anesthesia. The first documented use of laparoscopyon a hu-
man was reported byHans Jacobaeus of Sweden in 1910.
George Kelling, who first performed laparascopyon dogs and
cadavers starting in 1901, later argued he had been the first, but
he did not publish a report. Jacobaeus’ procedure was per-
formed under local anesthesia.
3
Laparoscopic tubal steriliza-
tion has been performed most often under local anesthesia, and
From the Yale New Haven Hospital,New Haven,CT.
Address reprint requests to Lloyd R. Saberski,MD,Medical Staff
Attending,Yale New Haven Hospital,60 Temple St,Suite 4D,New
Haven,CT 06510.
Copyright © 2001 by W.B. Saunders Company
1084-208X/01/0504-0004$35.00/0
doi:10.1053/trap.2001.26220
Techniques in Regional Anesthesia and Pain Management, Vol 5,No 4 (October),2001: pp 152-156
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