Laparoscopic surgery
Introduction to laparoscopic surgery
Laparoscopic surgery is a minimal-access surgical technique that involves insufflation of the abdominal cavity with carbon dioxide to allow diagnosis and treatment of intra-abdominal pathologies. The first published laparoscopic procedure in humans dates back to 1910 and is credited to Hans Christian Jacobaeus (Stockholm, Sweden). Since that initial procedure, laparoscopic surgery encountered many controversies before being accepted as a safe alternative to traditional open techniques. The introduction of gas insufflation, improvement of optics, and development of laparoscopic instruments have been key to the modernization of the technique.
There are specific issues regarding laparoscopic surgery that should be considered at disclosure. The specific complications relating to each procedure are discussed in the relevant section. The aim of this chapter is to provide an overview of the issues relating to laparoscopy in general.
Explaining laparoscopic surgery to patients
Laparoscopic surgery can be described to patients as ‘keyhole surgery’, as this is a term that most patients are familiar with. It is also important to break down the steps of an operation. For general surgical laparoscopy this would include:
• This procedure is performed under general anaesthesia
• Once asleep, a small cut is usually made in the region of the belly button (umbilicus)
• A small plastic sheath is inserted into the abdomen and gas is pumped into the abdominal cavity. (The gas used is carbon dioxide because it is highly soluble and rapidly excreted by the body)
• The gas pumped into the abdomen elevates the front of your abdominal wall away from internal organs. This creates the necessary space for us to obtain good views and perform the operation
• Further small incisions of 5–10mm are made through in which we place further plastic sheaths. Through these plastic sheaths, we insert our instruments
• Most often two further incisions are made, however, this number can vary depending on the pathology identified and the intended operation. The location of these incisions depends on the indications for the procedure and also the pathology identified
Conversion to an open procedure is often wrongly included as a risk when patients are being consented for a laparoscopic operation. This is not a risk and should be included as part of the standard operation (i.e. laparoscopic procedure ± conversion to open). The percentage rate of conversion depends on the procedure being undertaken and the experience of the surgeon performing the operation. The important point to emphasize to the patient is that if the operation cannot be safely completed laparoscopically, it will be necessary to convert to open. When consenting, one should also demonstrate the potential incision sites for the open version of the same operation to the patient. This ensures that the patient is fully informed prior to the procedure and aware of the possible outcomes.
Advantages of laparoscopic surgery
Laparoscopic surgery is considered the gold standard technique for cholecystectomy and fundoplication.1,2 Laparoscopic appendicectomy is considered the gold standard technique for resection of the appendix in women of childbearing age.3 It is advocated, but not currently considered the gold standard for male patients, obese patients, and elderly patients. There have been mixed results reported with laparoscopic appendicectomy in pregnant women and the technique should be used with caution in this cohort of patients. Laparoscopic colorectal surgery is an evolving technique and the oncological safety profile cannot be proven as conclusive long-term data do not yet exist.4
References
1.
Bittner R. The standard of laparoscopic cholecystectomy. Langenbecks Arch
Surg 2004;389:157–63.
Find This Resource
2. Salminen PT, Hiekkanen HI, Rantala AP, et al.
Comparison of long-term outcome of laparoscopic and conventional nissen
fundoplication: a prospective randomized study with an 11-year follow-up. Ann
Surg 2007;246:201–6.
Find This Resource
3. Vettoretto N, Agresta F. A brief review of
laparoscopic appendectomy: the issues and the evidence. Tech Coloproctol
2011;15:1–6.
Find This Resource
4. Künzli BM, Friess H, Shrikhande SV.
Is laparoscopic colorectal cancer surgery equal to open surgery? An evidence based
perspective. World J Gastrointest Surg 2010;2(4):101–8.
Find This Resource
5.
Le Blanc-Louvry I, Coquerel A, Koning E, et al. Operative stress response is
reduced after laparoscopic compared to open cholecystectomy: the relationship with
postoperative pain and ileus. Dig Dis Sci 2000;45:1703–13.
Find This Resource
6. Raymond TM, Kumar S, Dastur JK, et al. Case
controlled study of the hospital stay and return to full activity following
laparoscopic and open colorectal surgery before and after the introduction of an
enhanced recovery programme. Colorectal Dis
2010;12(10):1001–6.
Find This Resource
Complications of laparoscopic surgery
General complications
Complications of laparoscopic surgery are primarily related to the surgery or due to the secondary effects of the pneumoperitoneum. Potential risks/complications include:
• Infection
• Bleeding/haematoma
• Thromboembolism
• Adhesion formation
• Port site hernia formation
• Basal atelectasis/pneumonia
• Damage to surrounding structures/Iatrogenic injury
• Solid organ damage
• Small bowel/colon
• Major vascular injury
• Bile duct injuries
• Bladder
The injuries can occur during trocar insertion (increased risk with Veress needle), due to electrocautery conductivity or as a result of technical failure. Such injuries can go unrecognized at the time of laparoscopy, and therefore a high index of clinical suspicion is necessary in postoperatively unwell patients.
(Complications related to specific procedures are listed under the relevant chapters.)
Complications due to pneumoperitoneum
When absorbed, the systemic effects of carbon dioxide, the gas used for insufflation of the abdomen, include:
• Increase in PaCO2
• Increase in respiratory rate
• Myocardial instability/cardiac dysrhythmia
• Decrease in pH
Abdominal compartment syndrome is a rare, serious complication as a result of intra-abdominal hypertension. It is most commonly due to prolonged carbon dioxide insufflation, and if it is unrecognized, it can lead to severe organ dysfunction.
New techniques in laparoscopic surgery
Description
Laparoscopic surgery techniques continue to evolve and operating through a single trans-umbilical incision is gaining prominence. The single port technique is most commonly known as single incision laparoscopic surgery (SILSTM) or laparoendoscopic single site (LESS) surgery. To date, operations performed via the single port technique include:
• Appendicectomy
• Cholecystectomy
• Nephrectomy
• Colonic resection
• Antireflux surgery
• Bariatric—gastric band placement and gastric bypass
• Inguinal hernia repair
Single port surgery is technically more demanding than traditional laparoscopic surgery and is currently practised by experts in certain centres on select patients. The single port technology has also led to innovation with regards to instruments (e.g. curved/reticulating versions) and camera systems (e.g. flexible). The main demonstrable advantage of single port surgery is that the end cosmetic result is (virtually) scarless. However, given the technique is relatively new, there is no level I evidence proving its efficacy/superiority to traditional laparoscopic surgery. However, it is important to monitor further developments and it remains to be seen whether SILSTM and LESS are adopted in mainstream surgical practice.