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.