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.