Translate this page into:
An Observational Study of Incidental Findings During Elective Laparoscopic Procedures
* Corresponding author: Dr. Parveen Kharb, M.S., (General Surgery), Department of Surgery, Ravindra Nath Tagore Medical College, Dilshad Bhawan, Udaipur, Rajasthan, 313001, India. parveenkharb1234@gmail.com
-
Received: ,
Accepted: ,
How to cite this article: Sharma DK, Kharb P, Kothari A, Rao SA. An Observational Study of Incidental Findings During Elective Laparoscopic Procedures. Int J Recent Surg Med Sci. 2025:11(e010). doi: 10.25259/IJRSMS_36_2025
Abstract
Objectives
Advancements in medical imaging have revolutionized preoperative diagnostics, yet surgeons still encounter unexpected findings during surgeries, particularly in laparoscopic procedures. This study aims to analyze the prevalence and nature of incidental findings (IFs) in elective laparoscopic surgeries and correlate these with patient demographics, other clinical factors, and their impact on surgical decision-making and patient management.
Material and Methods
This cross-sectional observational study evaluates IFs in patients undergoing elective laparoscopic procedures at Rabindranath Tagore Medical College (RNTMC), Udaipur, from 1 January 2023 to 31 December 2023.
Results
The study included 81 patients; the male-to-female ratio was 1:2.1. The mean age of the patients was 41.05 5.01 years. A higher prevalence of IFs was observed in females (55%) than in males (50%). Laparoscopic cholecystectomy (72%, n 58) was the most commonly performed procedure, followed by laparoscopic appendectomy (17%, n 14). The most common IFs were adhesions (58%, n 45), followed by ovarian cysts, hernias, and pelvic fluid accumulations.
Conclusion
The incidence of IFs in elective laparoscopic procedures highlights the complexity and unpredictability of surgical practice. This study underscores the need for robust protocols to guide the management of such findings.
Keywords
Adhesions
Elective laparoscopic procedures
Incidental findings
Laparoscopic cholecystectomy
INTRODUCTION
Advancements in medical imaging have revolutionized preoperative diagnostics, yet surgeons still encounter unexpected findings during surgeries, particularly in laparoscopic procedures. These incidental findings (IFs) are defined as unexpected lesions or conditions discovered during an operation that are unrelated to the primary condition for which the patient was being treated. They refer to unexpected abnormalities discovered during diagnostic or therapeutic procedures performed for unrelated reasons.[1,2]
Laparoscopic surgery[3] has become a standard procedure in general surgery, offering benefits like reduced recovery time and minimal postoperative pain. The advent of advanced imaging and diagnostic technologies, coupled with the enhanced visualization offered by laparoscopy, has contributed to a rise in the detection of IFs and can significantly impact clinical outcomes and postoperative management.[4]
The significance of IFs varies, ranging from benign anomalies that require no intervention to pathologies that may necessitate immediate treatment[5] or further investigation. This unpredictability underscores the need for surgeons to be well-prepared to manage such discoveries, balancing the ethical considerations of informed consent, patient anxiety, and the potential implications for patient health. Such discoveries can pose significant challenges, including ethical and legal dilemmas, and may necessitate a change in the surgical approach.[6–8]
This study aimed to analyse the prevalence and nature of IFs in elective laparoscopic surgeries, correlate these with patient demographics and other clinical factors, and their impact on surgical decision-making and patient management.
MATERIAL AND METHODS
This prospective observational study was conducted at Rabindranath Tagore Medical College (RNTMC), Udaipur, from 1 January 2023 to 31 December 2023, following approval from the ethics committee. The study included all patients undergoing elective laparoscopic procedures in the Department of General Surgery, regardless of the underlying pathology. Patients unwilling to provide consent were excluded from the study.
Data were collected using a standardized proforma, including demographic information, relevant clinical history, significant previous diseases, surgical history, preoperative diagnosis, preoperative radiological investigations, procedure being performed, and intra-operative findings, including IFs, duration of surgery, and postoperative outcomes. Patients were positioned supine under general anesthesia, followed by sterile preparation. The surgeries utilized both open and Veress needle techniques for camera port introduction, with pneumoperitoneum maintained at 12-15 mmHg using CO2. A 10-mm 30-degree Karl Storz laparoscope was used for intra-abdominal examination, identifying both primary and incidental pathologies. After the planned procedure, we looked for IFs by changing the patient's position. Liver, para-colic region, pelvic cavity, and sub-diaphragmatic regions were examined.
The statistical analysis involved qualitative and quantitative assessments using tools like the Chi-square test and Student's t-test, with a p-value of <0.05 considered statistically significant. All statistical and analytical processes were done using MS Excel and SPSS version 26.
RESULTS
A total of 81 patients were enrolled in the study after considering the eligibility criteria, and the following results were obtained.
Demographics and incidental findings
Among the patients studied (n=81), there were 26 males (32%) and 55 females (68%) (1:2.1). A higher prevalence of IFs was observed in females (n=30, 55%) compared with males (n=13, 50%). The most common IFs were adhesions, followed by ovarian cysts, hernias, and pelvic fluid accumulations.
Age distribution and incidental findings
Patients ranged from 14 to 92 years of age with a mean age of 41.05±5.01years. The incidence of IFs was the highest among patients aged 51-60 years (77%), indicating a correlation between age and the likelihood of IFs [Table 1].
| Incidental findings | Age in years | P-value | |
|---|---|---|---|
| Up to 45 | More than 45 | ||
| Adhesion | 19 | 15 | >0.05 |
| Ovarian cyst | 2 | 1 | |
| Hernia | 1 | 1 | |
| Pelvic cavity fluid | 1 | 1 | |
| Mirizzi (type 1) syndrome | 1 | 0 | 0.02 |
| Bowel edema | 0 | 1 | 0.01 |
| Liver cirrhosis | 0 | 1 | 0.03 |
Paired t-test was used using SPSS 16 applications. P-value <0.05 is significant.
Symptomatology and incidental findings
The majority of patients presented with abdominal pain (94%), predominantly in the right upper quadrant (70%). Other symptoms included vomiting (21%), nausea, and anterior abdominal wall swelling (5%). The primary diagnoses for which laparoscopic procedures were commonly done were cholelithiasis (72%, n=58), followed by appendicitis (17%, n=14) [Table 2].
| Symptoms | No. of patients | No. patients with Incidental Findings | Incidental Findings | Frequency | No. of pts without IF | P-value |
|---|---|---|---|---|---|---|
| Pain abdomen | 76 | 38(50%) | Adhesion | 29 | 38(50%) | 0.34 |
| Ovarian cyst | 3 | 0.04 | ||||
| Hernia | 2 | 0.003 | ||||
| Pelvic fluid | 2 | 0.001 | ||||
| Liver cirrhosis | 1 | 0.001 | ||||
| Nausea | 4 | 2(50%) | Adhesion | 2 | 2(50%) | 0.03 |
| Vomiting | 17 | 6(35%) | Adhesion | 2 | 11(65%) | 0.28 |
| Anterior abdominal wall swelling | 4 | 3(75%) | Bowel edema | 1 | 1(25%) | 0.16 |
| Adhesion | 2 | 0.09 | ||||
| Primary diagnosis | ||||||
| Cholelithiasis | 58 | 28(48%) | Adhesion | 25 | 30(52%) | 0.034 |
| Hernia | 1 | 0.445 | ||||
| Mirizzi syndrome | 1 | 0.445 | ||||
| Liver cirrhosis | 1 | 0.445 | ||||
| Acute appendicitis | 14 | 8(57%) | Adhesion | 6(43%) | 0.451 | |
| Hernia | 1 | 0.29 | ||||
| Ovarian cyst | 1 | 0.29 | ||||
| Inguinal hernia | 3 | 2(66%) | Adhesion | 1 | 1(33%) | 0.43 |
| Bowel edema | 1 | 0.43 | ||||
| Gall Bladder polyp | 2 | 2(100%) | Adhesion | 0 | 0.001 | |
| Lump abdomen | 1 | 1(100%) | Ovarian Cyst | 1 | 0 | 0.001 |
| Acute abdomen | 1 | 1(100%) | Ovarian Cyst | 1 | 0 | 0.001 |
| Chronic pain abdomen | 1 | 1(100%) | Fluid in pelvic cavity | 1 | 0 | 0.001 |
| Carcinoma pyriform fossa | 1 | 0(0%) | 0 | 1(100%) | 0.321 | |
*p-value was calculated using paired t-test; A value of p<0.05 was considered significant; IF: Incidental findings.
Common incidental findings in the study
Adhesions were the most common IF (n=45, 55%). Other notable findings included ovarian cysts, liver pathology, and pelvic fluid. Adhesions were most commonly present in the peri-colonic region (n=21, 47%) [Table 3].
| Incidental findings | Number (n) | Percentage (%) |
|---|---|---|
| No incidental finding | 34 | 42 |
| Adhesions | 45 | 55 |
| Ovarian cysts | 3 | 3 |
| Liver pathology | 3 | 3 |
| Pelvic cavity fluid | 2 | 2 |
Correlation of previous surgical history and incidental findings
In the present study, 60% patients with previous surgical history had IFs (p-value − 0.001), which were statistically significant. Additionally, 51% patients have IFs in the absence of surgical history (p-value − 0.004), which was statistically significant [Table 4].
| Previous surgical history | Number of pts | Number of pt with IF | Percentage (%) | P-value |
|---|---|---|---|---|
| Present | 22 | 13 | 60 | 0.001 |
| Absent | 59 | 30 | 51 | 0.004 |
| Total | 81 | 43 | 53 | 0.002 |
*p-value was calculated using paired t-test; A value of p<0.05 was considered significant; IF: Incidental findings.
Additional procedures following the planned procedure due to the IFs
Seven patients underwent additional procedures following the planned procedure, and out of these, four underwent adhesiolysis, which obscured the site of the intended planned procedure and port placement. Adhesions were dissected with the harmonic scalpel close to the abdominal wall to avoid injury to the bowel loop. In two patients, ovarian cystectomy and biopsy for ovarian cysts were done because of suspected malignancy. In one patient, ovarian drilling was done for an ovarian cyst (suspected polycystic ovarian syncrome) [Table 5].
| Planned procedure | Additional procedure done | Number of pts | Incidental findings |
|---|---|---|---|
| Appendectomy | Ovarian drilling | 1 | Ovarian cyst |
| Appendectomy | Ovarian cystectomy | 2 | Ovarian cyst |
| Cholecystectomy | Adhesiolysis | 4 | Adhesions |
DISCUSSION
General surgery is the largest specialty in surgery, as it involves the surgery of the abdomen more commonly, and it is prone to the discovery of more IFs.
Our study reports that 53% of patients had IFs, in which female patients had more IFs compared to males. Female patients (68%, n=55) involved in the study were also more compared with males (32%, n=26), with a male-to-female ratio 1:2.1. This pattern is similar to previous studies,[2,9] which reported a higher proportion of female patients undergoing laparoscopic surgeries. Similar results were found for IFs in these studies,[2,9] in which a higher incidence of IFs was reported in female patients compared to male patients. This is probably due to a higher number of female patients undergoing laparoscopic surgery, especially laparoscopic cholecystectomy, in the study comparative to male patients.
In our study, IFs were most prevalent in the sixth decade of life (77%). This is somewhat later than reported in another study,[9] in which IFs were more common in the third and fourth decades. The higher incidence of IFs among elderly patients in our study could be attributed to the increased propensity for disease development with advancing age, emphasizing the need for thorough preoperative evaluations in older populations.
No correlation was found between the presence of IFs and specific symptoms, an observation that suggests symptomatology may not be a reliable predictor of IFs.
In our study, the most common indication of the laparoscopic procedure was cholelithiasis (72%, n=58), followed by appendicitis (17%, n=14) and inguinal hernia (4%, n=3). This is similar to a previous study[2] in which a similar pattern of primary diagnosis was reported. Cholelithiasis is the most common indicator of laparoscopic elective surgery in northern India, where this study was conducted, explaining the pattern of incidence of primary diagnosis.
Adhesions were the most common IFs (55%, n=45), followed by liver pathology and ovarian cysts (3%, n=3 each), and hernia and pelvic fluid (2%, n=2 each). Female patinets having adhesions as incidental findings were predominant in our study. Females might have higher incidence of adhesions because of obstetric and gynaecological conditions that occur during their lifetime like pregnancy related interventions and pelvic inflammatory diseases. They are also at a higher risk for cholecystitis.
Some studies[9,10] have reported abdominal tuberculosis, peritoneal bands, adhesions, and ovarian cysts as the most common IFs. This has been attributed to tuberculosis being a major health problem in developing countries, where these studies were conducted, explaining these IFs. Another study[2] reported Polycystic Ovary Syndrome (PCO) and appendicitis as the most common IFs with 1.1% incidence (6 out of 534) of all IFs in all indicated abdominal surgeries, highlighting regional and methodological differences in IF prevalence. One[11] study reported ovarian cysts and abdominal tuberculosis as the most common IFs. In this study, 4% of patients had ovarian cysts, and tuberculosis was the next IF. In another study,[12] the frequency of incidental gallbladder carcinoma was 4% following cholecystectomy for symptomatic gallstones.
In our study, seven patients underwent additional procedures apart from the planned procedure, and out of these, four patients underwent lysis of adhesions that obscured the site of the intended planned procedure and port placement. In two patients, ovarian cystectomy and biopsy were done. In one patient, ovarian drilling was done. These additional procedures required extra operating time but were crucial for addressing the IFs and improving patient outcomes. The efficient management of IFs without requiring additional ports or significant changes in patient positioning demonstrates the adaptability of laparoscopic techniques in handling unexpected findings.
The discovery of IFs during abdominal surgery presents several challenges and considerations, e.g., diagnostic evaluation, management decisions, ethical and psychological considerations, and healthcare costs. IFs necessitate further diagnostic workup, including imaging studies, biopsy, or histopathological examination, to determine their nature and clinical significance. This additional evaluation can delay the primary surgical intervention and extend the patient's hospital stay. The management of IFs depends on their nature and potential impact on the patient's health. Benign lesions may require regular monitoring, while malignant or potentially harmful findings necessitate immediate intervention. The decision-making process must be individualized, taking into account the patient's overall health, preferences, and prognosis. IFs can have significant psychological impacts on patients, causing anxiety and stress. Ethical considerations also arise regarding the disclosure and management of these findings, emphasizing the need for clear communication and shared decision-making between the healthcare provider and the patient. These findings can lead to increased healthcare costs due to additional diagnostic tests, extended hospital stays, and potentially more complex surgical procedures. Healthcare systems must balance the benefits of identifying and treating these findings with the associated economic burden.
This study's limitations include its focus on elective laparoscopic procedures for benign diseases, excluding malignant conditions that may present with occult metastasis as IFs. The study was conducted in a single tertiary care centre with a limited regional scope, somewhat limiting the generalizability of the findings. Moreover, it is difficult to evaluate the usefulness of extensive search for IFs in patients undergoing elective laparoscopic surgery because the impact on symptoms like pain or progression of incidentally detected disease can be evaluated over a long-time follow-up. Future multicentre studies are recommended to validate and expand upon our results
CONCLUSION
The incidence of IFs in elective laparoscopic procedures highlights the complexity and unpredictability of surgical practice. The discovery of IFs poses several challenges, including the potential need for additional surgical interventions not covered by the initial patient consent. Surgeons must navigate these situations carefully, balancing the immediate clinical needs against ethical and legal considerations. This study underscores the need for robust protocols to guide the management of such findings. These protocols should include guidelines for intra-operative communication, consent processes, and postoperative management strategies to ensure patient safety for better outcomes and legal compliance.
Acknowledgement
Special thanks to Prof. B.R. Ranhwah for his expertise in statistics and helping me computing results. We also thank Dr. Apoorva for her help in our research work.
Ethical approval
The research/study approved by the Institutional Review Board at Ravindra Nath Tagore Medical College, Udaipur, number RNT/ACAD/IEC/2023/691, dated 8th August, 2023.
Declaration of patient consent
The authors certify that they have obtained all appropriate patient consent.
Financial support and sponsorship
Nil.
Conflicts of interest
There are no conflicts of interest.
Use of artificial intelligence (AI)-assisted technology for manuscript preparation
The authors confirm that there was no use of artificial intelligence (AI)-assisted technology for assisting in the writing or editing of the manuscript and no images were manipulated using AI.
References
- The Dilemma of Incidental Findings in Abdominal Surgery: A Cross-sectional Study. Ann Med Surg (Lond). 2022;81:104470.
- [CrossRef] [PubMed] [PubMed Central] [Google Scholar]
- Applications of Laparoscopy in General Surgery. Surg Gynaecol Obstet. 1976;143:829-34.
- [Google Scholar]
- Intraoperative Management of Renal Allograft Venous-calyceal Fistula and Incidental Renal Cell Carcinoma During Renal Transplantation: A Case Report. Transplant Proc. 2013;45:3421-3.
- [CrossRef] [PubMed] [Google Scholar]
- Legal Ethical Dilemmas in Incidental Findings During Surgery: Review Article. Int J Surg (London, England). 2020;75:107-13.
- [Google Scholar]
- The Legal Pitfalls of the Surgeon. Postgrad Med J. 1933;9:223-34.
- [CrossRef] [PubMed] [Google Scholar]
- Commentary on ‘Legal Ethical Dilemmas in Incidental Findings During Surgery’. Int J Surg. 2020;76:49-50.
- [CrossRef] [PubMed] [Google Scholar]
- Frequency of Incidental Findings on Diagnostic Laparoscopy in Patients Undergoing Elective Laparoscopic Cholecystectomy. JPRI. ;2021:227-31.
- [CrossRef] [Google Scholar]
- The Role of Laparoscopy in Diagnosis of Abdominal Tuberculosis. Int Surg J. ;2016:1557-63.
- [CrossRef] [Google Scholar]
- Parity and Risk of Ovarian Cysts: Cross-sectional Evidence from the Dongfeng-Tongji Cohort Study. J Huazhong Univ Sci Technolog Med Sci. 2016;36:767-71.
- [CrossRef] [PubMed] [Google Scholar]
- Frequency of Carcinoma Gallbladder in Cases of Cholelithiasis Undergoing Cholecystectomy at Tertiary Care Hospital. Rawal Med J. 2012;37:406-8.
- [Google Scholar]