Principles of
common Laparoscopic procedures Laparoscopic cholecystectomy
Laparoscopic cholecystectomy is the treatment
of choice for gallstone disease. The most accepted technique was outlined by
Reddick and Olsen, and has been described extensively in the literature. The
main drawback of the technique is the
Following
introduction of the three working trocars, the operation is carried out using
the surgical principles of open cholecystectomy. Most common bile duct injuries
can be avoided by adhering to the following steps.
1.
Ensure maximum cephalic traction on the gall bladder. This step minimizes
redundancies in the gall bladder infundibulum for better visualisation of
Calot’s triangle (Fig. 70.5).
2.
The gall bladder should be pulled away from the liver by maintaining
lateral and inferior traction on Hartmann’s pouch. This manoeuvre avoids
alignment of the cystic and common bile duct, allowing more precise identification
of both structures.
3.
Dissection should begin high in the neck of the gall bladder and
proceed in a lateral to medial direction. All dissection should be kept close
to the gall bladder until the anatomy is well defined. The cystic duct node is a
good landmark at which to start the dissection. The cystic duct should be the
first spherical structure found in Calot’s triangle when dissecting in a
lateral-to-medial direction.
4.
Hartmann’s pouch should be turned medially for posterolateral
dissection of the gall-bladder serosa. This manoeuvre aids identification of the
junction between the neck of the gall bladder and the cystic duct. Dissection
should proceed along the posterolateral aspect, dividing the serosal attachments
of the neck of the gall bladder to the liver. The narrowing of the gall-bladder
infundibulum into the cystic duct should be clearly defined in all of its
circumference, particularly in the presence of acute inflammation or chronic
scarring (Fig. 70.6).
5. Dissect
the neck of the gall bladder from its hepatic bed. This approach, similar to
that of the anterograde technique of open cholecystectomy, permits clear
visualisation of the neck of the gall bladder as it narrows into the cystic
duct. Identification of the cystic duct—common duct junction is no longer
considered imperative if there is adequate visualisation of the
gall-bladder—cystic duct junction. Extensive dissection in the region of the
common duct may be a source of avoidable morbidity.
6.
A clear view of the cystic duct should be obtained before the application
of clips, which should be placed as close to the gall bladder as possible under
direct vision. When a short cystic duct is present, an endoloop or ligature
around the gall-bladder neck can be used instead of a clip. Diathermy should
never be used to divide the cystic duct or artery.
7.
Operative cholangiography — intraoperative cholangiography is helpful
for definition of the anatomy, detecting the presence of calculi and preventing,
recognising or decreasing the severity of a bile-duct injury. However, a
significant percentage of surgeons does not perform cholangiography unless
indicated. It is left to the surgeon’s discretion to decide upon the use of
cholangiography.
8.
Following division of the cystic duct and artery, dissection should
continue close to the gall-bladder wall and away from the liver hilum. Excessive
use of electrocautery should be avoided in close proximity to the hilar
structures. Bipolar diathermy is safer but less efficient than monopolar
diathermy. Most surgeons use mono-polar diathermy with lower voltage during
dissection. Progressive detachment of the gall bladder is much easier
and
occurs with less bleeding if dissection is carried in the correct plane close to
the gall-bladder wall.
9.
Convert to open cholecystectomy — the surgeon should consider his or
her limitations and be able to determine when the degree of difficulty or
uncertainty necessitates conversion to open cholecystectomy. Conversion should
not be considered as ‘loss of face’ and should be undertaken when
‘progress no longer seems feasible’.
10.
Removal of the dissected gall bladder from the abdominal cavity should be
performed under direct vision from either the umbilical or the epigastric port.
It is not uncommon for extraction to be complicated by a thickened gall-bladder
wall or the presence of multiple large calculi. Enlarging the fascial incision
by a few millimeters at each edge should not be left too late as this manoeuvre
can prevent the spillage of calculi or bile into the abdominal cavity.
Endoscopic retrieval bags can be used to prevent stone spillage if gall-bladder
perforation has occurred (Fig. 70.7). Extending the incision by a small amount
does not appear to increase postoperative pain and, overall, may save time.
Reduction in postoperative shouldertip pain may be achieved if care is taken to
remove any residual fluid or blood and to obtain complete deflation before
closure.
Laparoscopic
inguinal hernia repair
Inguinal hernia is one of the most common
surgical problems seen in general practice, and accounts for 15 per cent of
operating time in a typical district general hospital. Despite the existence of
many well-established traditional hernia repairs, results have been variable
with recurrence rates ranging from 0.2 to 18 per cent. These unsatisfactory
results have led to surgeons developing and seeking new methods of hernia
repair. The main factor contributing to hernia recurrence is the tension
produced after the repair by the suturing together of structures not normally in
apposition. This theory led to the use of mesh to repair the
hernia, making it a ‘tension free’ procedure. Today the tension free
hernioplasty is one of the most successful variations of hernia repair.
Recently,
with the introduction of minimal access techniques and the subsequent success
of laparoscopic cholecystectomy, surgeons have investigated the possibility of
repairing inguinal hernias using such an approach. The advantages to using a
minimal access approach to hernia repair are mainly to do with patient comfort
rather than hospital stay. Although laparoscopic hernia repair can be done as a
day-case procedure, so can open hernia repair. Multiple hernias and recurrent
hernias are more effectively dealt with using a laparoscopic approach.
As with the open approach many variations on
the laparoscopic approach have been developed, some of which have already
fallen from favour.
Transabdominal
preperitoneal repair (TAPP). The procedure is carried out under general
anaesthesia, the patient’s abdomen is inflated with carbon dioxide gas, the
peritoneum is incised above the hernia and a prosthetic mesh is stapled over the
defect. The peritoneum is once again apposed over the mesh by the use of a
stapling device.
Extraperitoneal
repair. In this repair the abdominal cavity is not entered but instead surgical
balloons are inflated in the extraperitoneal space, and endoscopic trocars and
instruments are placed in this operating tunnel (Fig.
70.8). Again a stapled
prosthetic mesh is used for repair. By not incising the peritoneum this
decreases the risk of mesh eroding into bowel and the occurrence of bowel
obstruction due to herniation of the small bowel through the staple line in the
peritoneum.
Results
thus far have been encouraging: the repair has been shown to be effective and
safe if it is carried out in a major laparoscopic centre with well-equipped and
trained laparoscopic surgeons. Solid conclusions about recurrence rates cannot
be made as the follow-up period is too short.
Laparoscopic
antireflux surgery
Gastro-oesophageal reflux disease (GORD) is
one of the most common disorders affecting the gastrointestinal system. Whilst
the use of antacids, H2-receptor antagonists and proton pump
inhibitors may allow healing of oesophagitis to take place, GORD is often a
chronic or recurrent problem requiring long-term medical management. Open
surgery for selected patients has been shown to be effective, but is a major
undertaking associated with considerable morbidity. Hence the possibility of
treating this condition effectively whilst exploiting the benefits of a minimal
access approach is very attractive.
Techniques of
laparoscopic antire flux surgery
The advantages of laparoscopic cholecystectomy
over open surgery in terms of postoperative pain, hospital stay, return to
normal activity and cosmesis have led to the application of this approach to
several gastrointestinal procedures. Whereas open antireflux surgery provides
poor exposure using either abdominal or thoracic approaches, a laparoscopic
approach provides an unparalleled view of the diaphragmatic hiatus. Indeed, the
anatomical detail provided by this technique combined with the potential
benefits of minimal access surgery have led to the reincarnation of several
antireflux operations that were rarely performed in the past.
The
laparoscopic Nissen fundoplication was introduced in 1991 and is the most widely
performed laparoscopic antireflux procedure. The operation is essentially the
same as the open version with a few exceptions. Access is achieved via a five
port arrangement with the surgeon standing to the left, right or between
the legs of the patient, depending on preference. Whilst mobilisation of the
oesophagus is underway it is important that the liver be adequately retracted, a
process facilitated by the use of fan retractors. An enlarged left lobe of the
liver is a relative contraindication to fundoplication as it may make retraction
difficult and dissection hazardous.
The
Rossetti modification of the Nissen repair involves using just the anterior
fundus to perform the wrap (Rossetti). This reduces the amount of gastro-oesophageal
dissection needed and also makes division of the short gastric vessels
unnecessary. Division of all short gastric vessels may be required for a
Nissen fundoplication to ensure a short, loose wrap to reduce the incidence of
mechanical complications. The wrap is secured with four or five silk sutures
which may be tied by an intracorporeal or extracorporeal technique. Nissen did
not consider closure of the hiatus by bringing the crura together behind the
oesophagus, an important step in the procedure. However, several authors
advocate crural closure to promote physiological function of the lower
oesophageal sphincter and prevent upward displacement of the wrap.
Given
the recent introduction of the procedure and short followup times, results for
the laparoscopic Nissen repair are promising. Operative times are, on average,
less than 2.5 hours and conversion rates are low. The incidence of operative and
postoperative complications is low and comparable to that reported from open
series. Intraoperative complications include unrecognised pleural lacerations
requiring chest drainage, hepatic laceration, gastric perforation and wrap
necrosis with perforation. Most patients experience gastrointestinal side
effects in the postoperative period, the commoner ones being early satiety,
hyperflatuence, diarrhoea, nausea and odynophagia, but these become less
common with time. A low incidence of postoperative
As
with all laparoscopic surgery it can never be assumed that just because a
procedure can be performed laparoscopically, it should be adopted. As none of
the laparoscopic versions of antireflux operations represents a major departure
from their open counterparts, there is no reason to expect better symptomatic
results. There should, however, be a reduction in hospital stay and wound
complications, and earlier return to normal activities. In the past,
gastroenterologists have perhaps been reluctant to refer patients for
antireflux surgery, perceiving it to be a major undertaking in a field where the
procedure of choice is by no means agreed upon. However, if laparoscopic
antireflux surgery shows itself to be safe and effective, one might see a
lowering of the threshold for referral. The important point is that the
selection criteria should not change. As to the question of which procedure, the
answer lies in long-term randomised prospective trials. Assessment of
symptomatic success should be done objectively, for example using Visick
grading. pH studies should be performed preoperatively and postoperatively to
document healing, and where possible, assessment should be performed by
independent parties.
Laparoscopic
splenectomy
Laparoscopic splenectomy has been reported as
a feasible and attractive procedure on selective patients with hematological disorders. The criteria for the effectiveness of laparoscopic splenectomy
include: technical feasibility, safety and, most importantly, long-term
recurrence rates of thrombocytopenia. The ultimate aim is cure, through the
removal of all splenic tissue including accessory spleen. Open splenectomy has
already achieved these goals with a technical feasibility of 100 per cent and an
operative mortality of 0—4 per cent. The postoperative complication rate is
10—20 per cent and long-term cure rate is 65—9 0 per cent in patients with
idiopathic thrombocytopenia purpura (ITP).
The
majority of reported series on laparoscopic splenectomy has essentially
focused on the technical problem of laparoscopic feasibility. The purpose of
this review is to describe a technical modification of laparoscopic splenectomy
using the hand port system to facilitate hand-assisted laparoscopic splenectomy.
Selection of
patients
Not all patients or all haematological
disorders can be treated by a laparoscopic-assisted approach. In the author’s
experience, obesity, a previous history of upper abdominal surgery and the
presence of an acute coagulation abnormality are relative contraindications to
hand-assisted laparoscopic splenectomy. ITP represents the base indication, but
patients with congenital spherocytosis, haemolytic anaemia, Hodgkin’s disease,
lymphoma, splenic tumour and thrombocytopenia related to acquired immunodeficiency
syndrome are all considered to be suitable. Although normal sized spleens are
best suited for a laparoscopic approach, the hand-assisted method significantly
facilitates the excision of large spleens where difficulties in laparoscopic
access alone significantly complicate laparoscopic mobilisation, access to the
splenic hilum and extraction. Abdominal computed tomography (CT) is the best
preoperative investigation to measure the splenic volume in order to detect the
pancreatic tail impacted within the splenic hilum, exclude lymph nodes at the
splenic hilum and detect accessory spleens.
Preoperative
management
All patients receive preoperative pneumoccocal
vaccination, especially children. Patients with ITP receive high doses of
immunoglobulin G to increase their platelet count to an almost normal value;
however, in the remaining patients, platelet transfusions might need to be used
at the time of surgery.
Operative steps
Exposure of the spleen and access to the
splenic hilum are the most critical factors in achieving a safe dissection. The
vertical approach to the splenic hilum is mandatory with:
•
high insertion of the trocar along the left costal margin;
•
rotation of the table to the right side;
•
use of reverse Trendelenburg position for the operative table;
•
use of a 300 laparoscope.
Dissection
is then performed laterally and posteriorly by dividing the lateral peritoneal
reflection of the spleen anteriorly upward in the inferior part of the
gastrosplenic ligament. The splenic hilum is approached anteriorly and
inferiorly. This approach is greatly facilitated if posterior, lateral
mobilisation of the spleen up to the splenophrenic ligament is achieved, with
the liberation of the upper part of the spleen. The hilar vessels are isolated
with the fingers from the pancreatic tail and stapled using an endoscopic
stapling device. Finally, the short gastric vessels are secured within the upper
part of the gastrocolic ligament with complete mobilisation of the superior
port of the spleen.
The
second operative step is the extraction of the surgical specimen which is
usually facilitated and greatly simplified in the presence of a hand inside, so
the spleen can be placed in a heavy plastic bag and extracted through the hand
port device. During all intraoperative manipulations, one must be careful to
avoid parenchymal tear and spillage to prevent splenosis. Some authors have
advocated the use of preoperative splenic embolisation before laparoscopic
splenectomy.
Potential
advantages are reported to be easier dissection, shrinkage of the enlarged
spleen, and reduction of operative blood loss and a certain amount of
autotransfusion before splenectomy.
Disadvantages
include the invasiveness of the procedure, high cost, higher complication rates
and lack of diagnosis of accessory spleen in its most unusual location.
Another
disadvantage of the laparoscopic approach for splenectomy appears to be a
significant increase in the operative time; however, with the use of the hand
port device, in the author’s experience, the operative time is no longer than
that of an open splenectomy.
Laparoscopic
splenectomy is technically feasible in both normal sized and enlarged spleens.
In the hands of the experienced laparoscopic surgeon the procedure is safe and
has a low complication rate. The most common intraoperative complication is
haemorrhage, which is responsible for most cases of conversion. Careful
intraoperative search for and removal of accessory spleen is essential during
the procedure, which is once again enhanced with the use of the hand-assisted
device.