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 increased incidence of bile duct injury compared with open cholecystectomy. However, with better understanding of the mechanisms of injury and with proper training, virtually all of these injuries can be avoided. This chapter highlights important technical steps during routine laparoscopic cholecystectomy with particular emphasis on the safe performance of a difficult cholecystectomy.

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.

  Types of laparoscopic hernia repair

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 dysphagia has been attributed by one author to the enforcement of a liquid diet for 3 weeks after surgery.

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.