General
intraoperative principles
Laparoscopic cholecystectomy is the treatment
of choice for gallstone disease. The most accepted technique was outlined by
Reddick and Olsen. 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
almost all of these injuries can be avoided. This chapter highlights important
technical steps that should be taken during any form of laparoscopic surgery to
avoid complications.
Creating a
pneumoperitoneum
The most common method of obtaining a
pneumoperitoneum is by blind puncture using a Verres needle. Although this
method is fast and relatively safe, there is a small but significant potential
for intestinal or vascular injury on introduction of the needle or first
trocar. The routine use of the open technique for creating a pneumoperitoneum
avoids the morbidity related to a blind puncture. To do this, a 1-cm vertical or
transverse incision is made at the level of the umbilicus. Two small retractors
are used to dissect bluntly the subcutaneous fat and expose the midline fascia.
Two sutures are inserted each side of the midline incision, followed by the
creation of a 1 cm opening in the fascia. Free penetration into the abdominal
cavity is confirmed by the gentle introduction of a finger. Finally, a Hasson
(or other blunt-tip) trocar is inserted and anchored with the fascial sutures (Fig.
70.1). The open technique may initially appear time-consuming and even
cumbersome. With practice, however, it is overall more efficient.
Preoperative
problems
Previous
abdominal surgery
Previous abdominal surgery is no longer a
contraindication to laparoscopic surgery, but preoperative evaluation is
necessary
to assess the type and location of surgical scars. As mentioned earlier, the
open technique for insertion of the first trocar is safer. Prior to trocar
insertion, the introduction of a fingertip helps to ascertain penetration into
the peritoneal cavity and also allows adhesions to be gently removed from the
entry site. After the tip of the cannula has been introduced, a 00-laparoscope
is used as a blunt dissector to tease adhesions gently away and to form a
tunnel towards the quadrant where the operation is to take place. This step is
accomplished by a careful pushing and twisting motion under direct vision.
With experience, the surgeon learns to differentiate visually between thick
adhesions that may contain bowel and should be avoided, and thin adhesions that
would lead to a window into a free area of the peritoneal cavity (Fig.
70.2).
Obesity
Laparoscopic surgery has proved to be a safe
and effective procedure in the obese population. In fact, some procedures are
less difficult than their open counterpart for the morbidly obese patient.
Technical difficulties occur, however, in obtaining pneumoperitoneum, in
reaching the operative region adequately and in achieving adequate exposure in
the presence of an obese colon. Increased thickness of the subcutaneous fat
makes insufflation of the abdominal cavity more difficult. With the closed
technique, a larger Verres needle is often required for morbidly obese patients.
Pulling the skin up for fixation of the soft tissues is better accomplished with
towel clamps. Only moderate force should be used to avoid separating the skin
farther away from the fascia. The needle should be passed at nearly a right
angle to the skin and preferably above the umbilicus where the peritoneum is
more firmly fixed to the midline. The open technique of inserting a Hasson
trocar is easier and safer for obese patients. The main difficulty is reaching
the fascia. A larger skin incision (1—3 cm) starting at the umbilicus and
extending superiorly may facilitate this. To reach the operative area
adequately, the location of some of the ports has to be modified, and in some
instances, larger instruments are necessary. When the length of the laparoscope
appears to be insufficient to reach the operative area adequately, the initial
midline port should be placed nearer to the operative field.
Operative
problems
Perforation of
the gall bladder
Perforation of the gall bladder is more common
with the Iaparoscopic technique than with the open technique. Some authors have
reported an incidence of up to 30 per cent, but this did not appear to be a
factor in increasing the early postoperative morbidity. However, it is well
known that bile is not a sterile fluid and bacteria can be present in the
absence of cholecystitis. Unless the perforation is small, closure with
endoloops should be attempted to avoid contamination.
Bleeding
In some of the larger series, bleeding has
been the most common cause for conversion to an open procedure. Bleeding plays
a more important role in laparoscopic surgery because of factors inherent to the
technique. These include a limited field that can easily be obscured by
relatively small amounts of blood, magnification that makes small arterial
bleeding look like a significant haemorrhage and light absorption that obscures
the visual field.
How
to avoid bleeding. As in any surgical procedure, the best way to handle
intraoperative bleeding is to prevent it from happening. This can usually be
accomplished by identifying patients at high risk of bleeding, by clear
understanding of the laparoscopic anatomy and by careful surgical technique.
Risk
factors which predispose to increased bleeding include:
•
cirrhosis;
•
inflammatory condition (acute cholecystitis, diverticulitis);
•
coagulation defects: these are contraindications to a laparoscopic
procedure.
Bleeding
from a major vessel. Damage to a large vessel requires immediate assessment of
the magnitude and type of bleeding. When the bleeding vessel is identified, a
fine-tip grasper can be used to grasp it and apply either electrocautery or a
clip, depending on the size of the vessel. When the vessel is not identified
early and a pool of blood forms, compression should be applied immediately with
a blunt instrument, a cotton swab or with the adjacent organ. Good suction and
irrigation are of utmost importance. After the area has been cleaned, pressure
should be released gradually to identify the site of bleeding. Insertion of an
extra cannula may be required to achieve adequate exposure and at the same time
to enable the concomitant use of a suction device and an insulated grasper.
Although most of the bleeding vessels can be controlled laparoscopically,
judgement should be used not to prolong bleeding but to convert to an open
procedure at an early stage whenever control of bleeding is not achieved
promptly.
Bleeding
from the gall-bladder bed. Bleeding from the gallbladder bed can usually be
prevented by performing the dissection in the correct plane. When a bleeding
site appears during detachment of the gall bladder, the dissection should be
carried a little farther better to expose the bleeding point. After this step
has been performed, direct application of the electrocautery usually controls
the bleeding. If bleeding persists, indirect application of the electrocautery
is useful because it avoids detachment of the formed crust. This procedure is
accomplished by applying pressure to the bleeding point with a blunt insulated
grasper and then applying electro coagulation by touching this grasper with a
second insulated grasper that is connected to the electrocautery. One must be
careful to keep all conducting surfaces of the graspers within the visual field
while applying the electrocautery current.
Bleeding
from a trocar site. Bleeding from the trocar sites is usually controlled by
applying upward and lateral pressure with the trocar itself. Considerable
bleeding may occur if the falciform ligament is impaled with the substernal
trocar or if one of the epigastric vessels is injured. If significant continuous
bleeding from the falciform ligament occurs, haemostasis is achieved by
percutaneously inserting a large straight needle at one side of the ligament. A
monofilament suture attached to the needle is passed into the abdominal cavity,
and the needle is exited at the other side of the ligament using a grasper (Fig.
70.3). The loop is suspended and compression is achieved. Maintaining
compression throughout the procedure usually suffices. After the procedure has
been completed, the loop is removed under direct laparoscopic visualisation
to ensure complete haemostasis. When significant continuous bleeding from the
abdominal wall occurs, haemostasis can be accomplished either by pressure or
by suturing the bleeding site. Pressure can be applied using a Foley balloon catheter. The catheter is introduced into
the abdominal cavity through the bleeding trocar site wound, the balloon is
inflated, traction is placed on the catheter and it is bolstered in place to
keep it under tension. The catheter is left in
situ for 24 hours and then removed. Although this method is successful in
achieving haemostasis, the author favours direct suturing of the bleeding
vessel. This manoeuvre is accomplished by extending the skin incision by 3 mm
at both ends of the bleeding trocar site wound. Two figure of eight sutures are
placed in the path of the vessel at both ends of the wound.
Evacuation
of blood clots. The best way of dealing with blood clots is to avoid them. As
mentioned, careful dissection and identification of the cystic artery and its
branches, as well as identifying and carrying out dissection of the gall bladder
in the correct plane, avoid bleeding from the cystic vessels and the hepatic
bed. Nevertheless, clot formation takes place when unsuspected bleeding occurs
or when inflammation is severe and a clear plane is not present between the
gall bladder and the hepatic bed. The routine use of 5000—7000 units of
heparin per litre of irrigation fluid helps to avoid the formation of clots.
When extra bleeding is foreseen, a small pool of irrigation fluid can be kept in
the operative field to prevent clot formation. After clots have formed, a
large-bore suction device should be used for their retrieval. Care should be
taken to avoid suctioning in proximity to placed clips.
Principles of
electrosurgery during laparoscopic surgery
Electrosurgical injuries during laparoscopy are potentially serious. The vast majority occurs following the use of mono-polar diathermy. The overall incidence is between one and two patients per 1000 operations. Electrical injuries are usually unrecognised at the time they occur, with patients commonly presenting 3—7 days after injury with complaints of fever and abdominal pain. As these injuries usually present late, the reasons for their occurrence are largely speculative.
The main theories are: (1) inadvertent
touching or grasping of tissue during current application; (2) direct coupling
between a portion of bowel and a metal instrument which is touching the
activated probe (Fig. 70.4); (3) insulation breaks in the electrodes; (4) direct
sparking to bowel from the diathermy probe; and (5) current passage to the bowel from recently coagulated,
electrically isolated tissue. Bipolar diathermy is safer and should be used in
preference to mono-polar diathermy, especially in anatomically crowded areas. If
monopolar diathermy is to be used important safety measures include attainment
of a perfect visual image, avoiding excessive current application and meticulous
attention to insulation. Alternative methods of performing dissection such as
ultrasonic devices may improve safety.