Preoperative
evaluation
Preparation of
the patient undergoing laparoscopic surgery
Although the patient may only be in hospital
for a few hours, careful preoperative management is essential to minimise
morbidity.
Preparation
is very similar to that for open surgery, and aims to ensure that:
•
the patient is fit for the procedure;
•
the patient is fully informed and consented;
•
operative difficulty is predicted where possible;
•
appropriate theatre time and facilities are available.
History
Patients must be fit for general anaesthesia
and open operation if necessary. Potential coagulation disorders (for example,
associated with cirrhosis) are particularly dangerous in laparoscopic surgery.
As adhesions may cause problems, previous abdominal operations or peritonitis
should be documented.
Examination
Routine preoperative physical examination is
required as for any major operation. Although laparoscopic surgery in general
allows quicker recovery, it may involve longer operating time and the
establishment of the pneumoperitoneum may provoke cardiac arrythmias. Severe
chronic obstructive airways disease and ischaemic heart disease may be
contraindications to the laparoscopic approach.
Particular
attention should be paid to the presence or absence of jaundice, abdominal
scars, palpable masses or tenderness.
Moderate
obesity does not increase operative difficulty significantly, but massive
obesity may make pneumoperitoneum difficult, and standard instrumentation may be
too short. Access may prove difficult in very thin patients, especially• those
with severe kyphosis.
Premedication
Premedication is the responsibility of the
anaesthetist, with whom coexisting medical problems should be discussed, for
example significant ischaemic heart disease.
Pro phylaxis
against thromboembolism
Venous stasis induced by the reversed
Trendelenburg position during laparoscopic surgery may be a risk factor for deep
vein thrombosis, as is a lengthy operation and the obesity of many patients.
Subcutaneous heparin and TEDs should be used routinely in addition to pneumatic
leggings during the operation. Patients already taking warfarin for other
reasons should have this stopped temporarily or converted to intravenous
heparin, depending on the underlying condition, as it is not safe to perform
laparoscopic surgery in the presence of a significant coagulation deficit.
Urinary
catheters and nasogastric tubes
In the early days of laparoscopic surgery
routine bladder catheterisation and nasogastric intubation were advised. Most
surgeons now omit these but it remains essential to check that the patient is
fasted, and has recently emptied the bladder, before the blind insertion of a
Verres needle.
In formed
consent
The basis of many complaints and much
litigation in surgery, especially laparoscopic surgery, relates to the issue of
informed consent. It is mandatory that the patient understands the nature of
the procedure, the risks involved and, where appropriate, what alternatives are
available. A locally prepared explanatory booklet concerning the laparoscopic
procedure to be undertaken is extremely useful.
In
an elective case a full discussion of the proposed operation should take place
in the out-patient department with a surgeon of appropriate seniority,
preferably the operating surgeon, before the decision is made to operate. On
admission it is the responsibility of the operating surgeon and anaesthetist
to ensure that the patient has been fully counselled, although the actual
witnessing of the consent form may have been delegated. The patient should
understand what laparoscopic surgery involves and that there is a risk of
conversion to open operation. If known, this risk should be quantified, for
example the increased risk with acute cholecystitis or in the presence of
extensive upper abdominal adhesions. The conversion rate will also vary with the
experience and practice of the surgeon. Common complications should be
mentioned, such as shoulder tip pain and minor surgical emphysema, as well as
rare but serious complications including injury to the bile ducts and visceral
injury from trochar insertion or diathermy.
A
few patients may insist on having an open procedure (probably influenced by
accounts of mishaps) and the surgeon should be prepared to. offer this,
although most will opt for laparoscopy if the surgeon offers an extensive
experience and impressive safety record.