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SURGICAL TECHNIQUES OF LAPAROSCOPY
PATHOPHYSIOLOGY OF PNEUMOPERITONEUM
COMPLICATIONS OF LAPAROSCOPY
COMPLICATIONS OF NEEDLE AND TROCAR INSERTION
COMPLICATIONS FROM PNEUMOPERITONEUM
EVALUATION OF ABDOMINAL PAIN
EVALUATION OF TRAUMA
Common Bile Duct Exploration
Acid reflux Procedures
Lysis of Adhesions
Inguinal Hernia Repair
Diaphragmatic Hernia Repair
Elective surgery for the gastrointestinal tract was initiated by intrepid individuals whose talents reflected courage, manual dexterity, and digital celerity. The advent of general anesthesia, muscle relaxants, and antibiotics facilitated the introduction of more complex procedures and allowed a safe outcome for the patient. In almost a century of gastrointestinal surgery, few advances can compare to the revolution engendered by the advent of minimally invasive surgery. The interface of creative surgeons and the science of biotechnology has given rise to a novel consideration of hoary techniques and dogma. With the introduction of laparoscopic surgery has come the recognition of both advantages and difficulties. The benefits conferred on patients by less invasive procedures, decreased pain, and shorter recovery have to be weighed against overenthusiasm of application and the problems created by a lack of familiarity with new techniques and instruments. Nevertheless, the introduction of novel technology in a field almost synonymous with tradition has provided a unique opportunity to reevaluate current therapeutic strategies and options.
The introduction and acceptance of laparoscopic surgery for gastrointestinal disease will undergo a number of phases. In the first, the introduction and application of new technology to perform old procedures will be evaluated. The learning curve of surgeons and the selection of patients are the primary considerations in this phase. Thereafter, consideration will be given to the application of alternative technologies not previously considered in surgery but thought of more as part of the industrial and technological complex. In this context, robotic surgical components, self-propelling devices, memory metals, and implanted miniature visual instruments are examples. The final phase will be the evolution of a generation of surgeons capable of developing therapeutic strategies radically different from those implemented by the first wave of laparoscopic surgeons, who used relatively simple and crude instrumentation. In the last phase, the ultimate goal will be the interface of the problem-solving powers of a medical mind with the manometer precision of a robotic instrument. Thus, there already are prototype operating devices with which long-range telemetric control of surgical robotic instrumentation is possible. Although this may seem exotic, technology of this sort has already been tested, patented, and employed in the aerospace and military programs. The resources and technology currently used to explore outer spacemight be better utilized resolving the problems of inner space as exemplified by the peritoneal cavity.
This chapter provides an overview of the current status of laparoscopic surgery as it is applied to the management of conditions of the gastrointestinal tract that are considered to require surgical intervention. In brief, it documents the techniques and balances the applications against potential advantages and disadvantages. In essence, this overview proposes to shine a light on a surgical technique which has languished too long in the dark.
Attempts at minimally ini,asive therapy for afflictions of the gastrointestinal tract date back to the time of Hippocrates, who described noninvasive remedies for conditions such as intestinal obstruction, rectal prolapse, and hemorrhoids 1. Hippocrates also detailed the use Of d speculum, or primitive anoscope, for examining hemorrhoids. Early endoscopists were hampered by the lack of a satisfactory light source. Thus, until the nineteenth century, physicians relied on sunlight reflected by mirrors or focused through flasks of water 2. In the early 1800s, physicians began using candles or paraffin lamps for illumination; however, the idea of "a magic lantern into the human body" was for the most part scorned and ridiculed 3.
The first experimental laparoscopy was performed in Berlin in 1901 by the German surgeon Georg Kelling, who used a cystoscope to peer into the abdomen of a dog after first insuffiating it with air 4. Kelling was an early advocate of the ability of minimally invasive surgery to avoid unnecessary laparotomy and decrease hospital stays. The first human laparoscopy was performed in Sweden by jacobeus in 1910 to investigate ascites. Diagnostic laparoscopy enjoyed some popularity in the early twentieth century, but early laparoscopists were limited by a lack of technology 5 (Fig. 1). The first laparoscopes had a light source at the distal end, and pneumoperitoneum was achieved by means of air insulation through the scope. Initially, intraabdominal thermal injury, along with bowel and vascular injuries, posed the most significant problems. In 1929, Kalk advocated a second puncture site for the establishment of pneumoperitoneum, described several diagnostic and therapeutic laparoscopic procedures, and devised a sophisticated lens system. He has been called by some the "father of modern laparoscopic surgery" 2. Fiberoptic technology and closed-circuit videolaparoscopy evolved in the 1950s. This development enabled surgeons to deliver more intense light with less heat, and allowed the participation of an assistant in the procedure. As a result, more sophisticated procedures could be undertaken, and the modality was embraced primarily by gynecologic surgeons. Kurt Semm in particular became a powerful advocate of laparoscopy and was responsible for the development of numerous laparoscopic instruments, including an automatic air insufflation device, an electrocoagulator, and an aspiration/irrigation system .5 In addition, he described techniques for laparoscopic tubal thermocoagulation, oophorectomy, and adhesolysis and is credited with performing the first laparoscopic appendectomy in 1983 (6).
While the majority of general surgeons remained skeptical of laparoscopy, a few groups recognized its potential. Initially, however, only diagnostic procedures were considered .7 8 By 1982, the first laparoscopic liver biopsy had been reported.' Meanwhile, surgeons in Chicago and Dundee were developing the technique of laparoscopic cholecystectomy in animal models 10. The first human laparoscopic cholecystectomy was performed by Mouret in France in 1987,11 and groups in the United States 12 13 and the United Kingdom 14 followed in 1988 and 1989, respectively. Soon afterward, the lay press applauded the "new" surgery, and popularity in the public domain culminated in patients demanding this “Band-Aid” surgery instead of traditional techniques.
Thus began the modern laparoscopic era. As this document attests, it has in a short time earned a unique niche in general and gastrointestinal surgery. Virtually no abdominal organ is exempt from laparoscopic techniques. The application of more sophisticated technology will no doubt yield more refinements and applications.
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The operative technique involves a number of stages. The establishment of pneumoperitoneum is the first step. Afterward, insertion of trocars for the introduction of the camera and surgical instruments is undertaken. A Veress needle (spring-loaded with a blunt tip) (Fig. 2) is inserted through a small paraumbilical incision to initiate the pneumoperitoneum. The patient is placed in Trendelenburg's position to displace the small bowel from the pelvis. The Veress needle is inserted pointing inferiorly, and insufflation Of C02 is begun until an intraperitoneal pressure of 12 to 18 mmHg is attained. The needle is then removed and replaced with a 10-mm trocar (Fig. 3) through which the videolaparoscope is inserted. The peritoneal cavity is inspected to identify any injury caused by the initial insertions. Then the remaining trocars are placed under direct laparoscopic observation, minimizing the possibility of visceral injury. The different instruments needed to undertake the procedure may then be inserted through the trocars. The sites, sizes, and number of trocars placed may vary with the procedure.
Operative indications for laparoscopic surgical procedures are the same as those for their open counterparts. The goal of laparoscopic surgery is to perform procedures in a manner not significantly different from standard techniques but without opening the peritoneal cavity. The minimally invasive technique allows less morbidity, shorter hospitalization, and improved cosmetic results. While the only absolute contraindication is an inability to tolerate general anesthesia, patient and technique selection should be guided by the experience of the surgeon with a particular procedure. Thus, a surgeon should choose patients on the basis of the likelihood of being able to undertake the laparoscopic procedure successfully (Table 1). Patients who require conversion from laparoscopic to open procedures have "the worst of both worlds," i.e., increased operating room time and the costs associated with laparoscopic techniques without the benefits. Nonetheless, it is appropriate to convert to open surgery if undue difficulty is experienced by the operator. While it is impossible to predict with certainty which patients will require conversion, guidelines exist. Obese patients and those with prior abdominal operations generally prove more difficult. In cases which require pelvic dissection, previous gynecologic procedures may obscure dissection planes or be associated with dense adhesions. Adhesions to a right upper quadrant incision may make mobilization of the right side of the colon particularly difficult. However, patients with prior appendectomies may have adhesions which actually improve exposure of the cecum by providing anterior traction. While these situations make dissection, either laparoscopic or open, more tedious, with experience, surgeons have gained skill in lysing adhesions and identifying tissue planes through the laparoscope. Other relative contraindications include severe portal hypertension, coagulopathy, and diffuse carcinomatosis of the abdomen (Table 1).
Table 1 Patient Selection
Patients should be evaluated medically as they would be for any open procedure, with particular attention paid to their cardiac and pulmonary status. Any laparoscopic procedure may need to be converted to an open one, and so patients deemed unfit for laparotomy should not undergo an elective laparoscopic procedure.
A difficult decision is engendered by pregnancy. Several considerations are essential in this circumstance, including initial trocar placement to avoid injuring the gravid uterus, the physiologic effects Of C02 pneumoperitoneum on the fetus, and an alteration in technique resulting from the presence of an enlarged uterus." While the scope of this chapter precludes a detailed discussion of these issues, they will be briefly considered. The most common indications for laparoscopic surgery during pregnancy are appendicitis, cholelithiasis, and ectopic pregnancy. During the first trimester of pregnancy, the uterus remains in the pelvis. Thus, Veress needle insertion through the umbilicus is generally safe. After-, ward, the enlarged uterus usually precludes adequate visualization of the gallbladder or appendix, and these procedures may have to be performed by open surgery.
Close attention to the acid-base status and hemodynamic parameters of the mother is essential. The patient should be rolled approximately 30 degrees to the left to avoid inferior vena cava compression, and low intraperitoneal insufflation pressures should be used. The fetal heart rate should be monitored during anesthesia induction and periodically during the procedure.
Before the introduction of laparoscopic cholecystectomy, laparoscopy was used predominately for short procedures in relatively young, healthy patients. In the laparoscopic gynecologic procedures performed 20 to 30 years ago, intraabdominal pressures (IAPS) as high as 40 mmHg were used. Initial physiologic studies focused on such patients and found no significant pulmonary or cardiovascular compromise. 16,17 While many of these data are valuable and applicable to general surgical patients, individuals with significant cardiovascular or pulmonary disease present unique and challenging problems.
The physiologic changes associated with pneumoperitoneum depend on the IAP, the amount Of C02 absorbed, the circulatory volume of the patient, the ventilatory technique used, the underlying pathologic conditions, and the type of anesthesia used.18
Carbon dioxide pneumoperitoneum has two main effects on pulmonary function: the mechanical changes associated with increased IAP and the biochemical alterations resulting from absorbed C02 (Table 2). Thus, the elevated IAP creates a ventilation-perfusion mismatch that is manifested by an in-creased shunt and physiologic dead space. The increase in dead space is due to atelectasis and decreased functional residual capacity and may be minimized by maintaining low insufflation pressures or using positive end expiratory pressure (PEEP) ventilation. These changes are more pronounced in patients with cardiac or pulmonary disease. 19 Careful monitoring of arterial blood gases is necessary in high-risk patients to prevent acidosis. Hypercarbia and associated acidosis may be controlled by increasing minute ventilation.
Table 2 Physiology of Pneumoperitoneum
* Ventilation-perftision mismatch
Increased physiologic dead space Atelectasis
Decreased functional residual capacity
* Need for increased minute ventilation
* Increased airway pressure
* Cardiac output
Varies with intraabdominal pressure:
<20 mmHg, no change to increased
>20 mmHg, decreased
* Increased central venous pressure
* Increased lower extremity venous pressure
Changes in hemodynamics resulting from increased IAP are variable and unpredictable. A consistent finding in all human studies is an increase in central venous pressure and arterial pressure in patients during 15- to 20-mmHg pneumo-peritoneum. The critical pressure is approximately 25 mmHg."," At this point, patients manifest increased central venous pressure (CVP), peripheral venous pressure, and airway pressure and experience tachycardia and hypertension (Table 2).
The head-down position and acidosis tend to increase cardiac output. Acidosis can also lead to vasoconstriction and an increase in total peripheral resistance. 11,21 Venous return from the legs is hindered by the increased IAP, decreasing cardiac output and predisposing the patient to deep venous thrombosis. Thus, pneumatic compression boots are used during most laparoscopic procedures.
The complications of laparoscopic surgery can be divided into two categories: those which are specific to the procedure itself or result from anesthesia and are common to all operations and those which are unique to laparoscopy, such as injury from trocar insertion (Table 3). It is a matter of debate whether laparoscopic procedures are inherently more risky than their open counterparts. Several factors must be considered in attempting to answer this question. First, a laparoscopic surgeon has only a two-dimensional view, with a restricted field of vision. Second, tactile feedback is limited, and thus visual cues become more critical in identifying anatomy. Additionally, the increasing reliance of the surgeon on technology adds an intangible layer of separation between the doctor and patient. Although these limitations are real, the learning curve appears to be steep, with rapid acquisition of skill. While the field of vision may be restricted, objects are magnified, and resolution is of exceptional quality with current digital cameras. Areas which are difficult to inspect in an open procedure are now usually extremely well visualized. Technological alternatives such as 30-degree and 45-degree laparoscopes or flexible devices have further amplified visibility. Newer modalities such as laparoscopic ultrasound have helped replace the sense of touch, enabling visualization of liver metastases, blood vessels, and bile duct stones. Finally, it seems that surgeons are able to adapt to these limitations. Thus, after a relatively brief period of adaptation, complication rates (e.g., for cholecystecomy) are not significantly different when undertaken by the open or the closed technique22. With more complex procedures, the equilibra tion of skills may take longer to achieve.
Table 3 Complications
Needle and Trocar Insertion
Veress needle insertion and trocar insertion may cause injury to the intestines, stomach, bladder, or major vascular structures (Fig. 4). The rate is higher for insertion of the needle and primary trocar, as this is done blindly. The overall incidence of visceral injury in several large series ranges from 0.05 to 0.2 percent 23.
Vascular Injury. The most life-threatening laparoscopic complications are those to the large retroperitoneal blood vessels. A survey of 77,604 laparoscopic cholecystectomies identified 36 (0.05 percent) injuries to the aorta, inferior vena cava, or iliac vessels.24 The mortality in these patients was 8.8 percent. In a collected series of 16 major vascular injuries,mortality was 13 percent 25.
To avoid serious complications from these injuries, early recognition and prompt treatment are critical. Thus, the Veress needle should be aspirated after insertion to identify bright red (arterial) blood. In this circumstance, the needle should be left in place and immediate laparotomy should be undertaken 26. Some authors have advocated proceeding with laparoscopy if aspiration reveals blood 23 and exploring the patient only if there is evidence of hemodynamic instability. However, given the high mortality associated with this complication and the risk of gas embolism if insufflation is attempted, this seems to be an unwise management strategy.
Gastrointestinal Injury. Clinically significant stomach or intestinal injury from needle or trocar insertion has been reported in approximately 0.01 to 0.4 percent of patients. 23,26 A larger number of these injuries may, however, go unrecognized because of the ability of the stomach and intestines to heal small injuries. Undetected bowel injury is a major contributor to postoperative mortality. Such patients present with sepsis or peritonitis. Intraabdominal abscess or fistulas may occur at a later date. In a survey of over 75,000 laparoscopic cholecystectomies, 4.6 percent of patients with gastrointestinal injuries died 24.
A significant proportion of bowel injuries may result from initially unrecognized thermal burns from electrocautery devices. However, when an injury presents late, it is often difficult to determine the exact cause. Management of an intestinal injury depends on the etiology and severity. Thermal injuries from laser or electrocautery devices are generally more severe than they appear, and surrounding areas of intestine may necrose after several days as a result of intramural spread of energy at the time of the injury. For this reason, resection of the involved area should be undertaken 26. Mechanical injury from a needle, trocar, or other instrument can be managed by simple observation, primary repair, or resection. Repair or resection can be performed either laparoscopically or by laparotomy, depending on the level of experience of the surgeon.
Genitourinary Injury. There are few data on the incidence and etiology of genitourinary injury during laparoscopy. Bladder injuries generally occur during trocar insertion, and an indwelling bladder catheter helps minimize this complication. Management of bladder injury is similar to that of bowel injury. Veress needle punctures may be managed conservatively with bladder decompression. Larger injuries induced by trocars or dissection should be primarily repaired.
Ureteral injury is usually a consequence of a thermal burn, ligation, or laceration caused by inadequate exposure or poor dissection. This injury can be avoided by preoperative placement of ureteral stents, which facilitate identification of the ureters. All ureteral injuries should be explored promptly at open surgery 26.
Cardiovascular Changes. Absorbed carbon dioxide leads to hypercarbia and acidosis. This may cause myocardial irritability, as manifested by an increased rate of cardiac dysrhythmias, most notably ventricular ectopy." These effects are not seen with nitrous oxide pneumoperitoneum, but as a result of its ability to support combustion, this is used mainly for diagnostic procedures. The mechanical effects of increased IAP cause variable changes in the cardiac output (see "Pathophysiology of Pneumoperitoneum").
Extraperitoneal Insufflation. This commonly occurs because of improper positioning of the Veress needle, resulting in preperitoneal insufflation and subcutaneous emphysema. Subcutaneous emphysema rarely results in serious sequelae. Intraabdominal structures such as the omentum and mesentery may also be inadvertently insufflated, increasing their chance of being injured and obscuring visualization.
Pneumothorax. This may occur during upper abdominal procedures when injury occurs to the diaphragm,,resulting in a sudden collapse of the lung on the affected side. Occasionally, however, pneumothorax may develop without diaphragmatic injury, possibly as a result of retroperitoneal dissection of C02 . This may have a more subtle onset manifested by increased ventilatory pressures and arterial desaturation. Treatment in either instance is by insertion of a thoracostomy tube.
Gas Embolism. Reports of gas embolism are unusual and have ranged from 0.002 to 0.0016 percent. The etiology is presumably venous injury combined with high insufflation pressures. 26 Signs of gas embolus include circulatory collapse, an abrupt increase in end-tidal C02, a so-called mill-wheel cardiac murmur, and flash pulmonary edema. Cardiac arrhythmias may occur, and electrocardiographic alterationsincluding a widened QRS complex may be evident 27. Treat ment consists of placing the patient in Trendelenburg's position with the left side down (the Durant position) to prevent the gas from entering the pulmonary outflow tract, aspiration of the gas with a central venous catheter, and external cardiac massage to fragment large bubbles 20, 26.
Hernia. This has been reported to occur in 0.1 to 0.3 percent of patients 23. The larger the diameter of the cannula used, the more likely the possibility of herniation. Wound infection is a predisposing factor. It is generally recommended that fascial defects from cannulas 10 mm or larger be sutured.
Wound Infection. This is an unusual occurrence and depends on the operation performed. Procedures such as diagnostic laparoscopy have extremely low rates of approximately 0.1 percent 23. Wound infection rates after laparo scopic cholecystectomy may be as high as 1 percent, generally at the site of gallbladder removal 22, 23. This is comparable with the rate seen with open procedures. The use of a bag or another device to remove the specimen may decrease the incidence of infection 28-31. This difference has been most notable in appendectomies in which bag retrieval is used, with several series reporting zero incidence of wound infection. Other prospective studies have confirmed a lower infection rate in laparoscopic appendectomy versus the open procedures 29. 32.
Tumor Recurrence. Abdominal wall recurrence after resection of colorectal and gallbladder cancers or diagnostic evaluation of ovarian and gastric cancers has been noted. 33-43 Current reports reflect a seemingly higher frequency of this situation, although this may not be the case, given the increased number of laparoscopic procedures performed. Nevertheless, it is an area of considerable concern for surgeons who are contemplating the laparoscopic resection of malignant neoplasms. To some extent these recurrences appear to be analogous to wound infections and occur at the site where the specimen is removed.
Extreme care must be exercised in removing malignancies through laparoscopic incisions, with a low threshold for enlarging incisions or retrieval of specimens in a protective bag.
Laparoscopy was utilized as a diagnostic modality for many years. Its potential in the establishment of a definitive diagnosis is well recognized. The use of diagnostic laparoscopy became less popular with the advent of improved radiologic modalities such as computed tomography and ultrasound," but the limitations of these diagnostic tests are well recognized, and diagnostic laparoscopy has thus undergone a renaissance (Fig. 5). This reflects the increased use of other laparoscopic procedures and the advent of improved technology which has facilitated the acquisition of information. The development of laparoscopic ultrasound (Fig. 6) has added a new modality in the evaluation of solid organs, and current research in radioimmune-guided surgery (RIGS) may prove valuable in detecting microscopic foci of malignancy that are not evident with current imaging devices.
The goals in staging laparotomy for cancer are to safely establish a definitive tissue diagnosis and to assess resectability, with the objective of avoiding unnecessary surgery (Fig. 7).
Several groups have reported that stage IV Hodgkin's disease can be diagnosed without laparotomy 45, 46. Using local anesthesia, percutaneous liver and occasionally splenic biopsies were undertaken with laparoscopic guidance. While the staging of Hodgkin's disease is now generally accomplished without the need for laparoscopy or laparotomy because of improved imaging modalities, this represented an important initial step in the development of diagnostic laparoscopy.
Survival from esophageal cancer often reflects its stage at diagnosis, with curative surgery possible in only a minority of patients. Assessment of resectability may be difficult with conventional radiologic and endoscopic techniques, although endoscopic ultrasound has shown promise. 17 Laparoscopy is superior to computed tomography and ultrasound in detecting abdominal tumor spread, especially small (<l cm) he48,49 patic, peritoneal, and omental metastases. Patients with unresectable disease are thus spared the morbidity and longer hospital stay of laparotomy, which are not insignificant in such debilitated individuals. With increased emphasis on multimodality therapy (preoperative chemoradiation), accurate pretreatment staging is possible with combined laparoscopy and thoracoscopy.'o
Gastric cancer has a relatively low resectability rate, which may not be definitively ascertained by radiologic or endoscopic techniques. A difference between gastric and esophageal cancer, however, lies in the greater need for palliative surgery to obviate bleeding or obstruction in gastric cancer. Although laparoscopic gastrojejunostomy and gastric resection are feasible, few surgeons have been trained in these techniques. For this reason, diagnostic laparoscopy for gastric cancer should be limited to asymptomatic lesions and to definitively establishing staging in patients who are at high risk for palliative surgery.
In a stud Y52 of 40 patients considered to have resectable gastric tumors after evaluation with ultrasound and computed tomography, laparoscopy identified unresectable disease in 40 percent (5 with metastases and 11 with advanced local disease). In the remainder who underwent laparotomy, the resectability rate was 87 percent.
Pancreatic cancer ranks second as a cause of death from gastrointestinal malignancies. Detection at an early stage is difficult, with 60 percent of individuals exhibiting distant metastases and 14 percent showing local or regional lymph nodeinvolvement at presentation 53. While the majority of these patients have unresectable disease, there is a small subset of patients with favorable characteristics, i.e., tumors less than 2 cm and no lymph node metastases. 54
Laparoscopy has been utilized in conjunction with computed tomography and angiography to study 55 consecutive 55 patients with carcinoma of the head of the pancreas. Laparoscopy was useful in identifying small peritoneal metastases. If all studies were negative, the resectability rate was reported as 78 percent. Whether this will confer any benefit in terms of the long-term outcome remains to be proved. The addition of laparoscopic ultrasound may further amplify delineation of pancreatic lesions 56. With improved endoscopic stenting devices as well as laparoscopic techniques for biliary bypass 57, even patients with symptomatic lesions may benefit from laparoscopic evaluation.
While percutaneous biopsy of a liver mass is now generally performed under CT or ultrasound guidance, laparoscopy may detect additional smaller lesions. For lesions that are identifiable with these imaging modalities and that can be percutaneously biopsied, laparoscopy holds little advantage 58. In patients with uncorrectable coagulation abnormali ties and a critical need for tissue diagnosis, biopsy under direct laparoscopic vision provides an opportunity to contr bleeding at the biopsy site. In diseases such as hepatic cirrh sis, chronic hepatitis, and fatty infiltration, direct visualiz tion is extremely useful in assessing the pattern and severi of disease 59. A review of blind percutaneous biopsy vers laparoscopically directed biopsy for the diagnosis of cirrhos in over 6000 patients revealed a false-negative rate of 24 pe cent for blind biopsy, compared with only 9 percent for laproscopy 60.
A novel technique for assessing fibrosis in chronic hepat tis is observation of the lobular pattern of the liver surfac after intravenous injection of indocyanine green 61. With thi technique, the presence or absence of bridging fibrosis was assessed with a sensitivity of 89 percent and a specificity 80 percent 61.
Definitive diagnosis of enterhopathies such as celiac sprue Crohn's disease, and general malabsorptive or diarrheal dis orders is often possible only with a small bowel biopsy While duodenal or occasionally jejunal biopsy is possibl endoscopically, the diagnosis may require a more specifi site. Laparoscopy offers the potential for full-thickness, spe cifically directed biopsy." It also affords the option of visual ization of the serosal surface of the bowel, which may aid i confirming diagnoses, especially in cases of suspecte Crohn's disease.
Appendicitis. The diagnosis of appendicitis in wome of childbearing age is a problem which continues to plague physicians. There is no reliable noninvasive test that conclusively rules it out, and negative appendectomy rates of 5 to 15 percent are currently considered acceptable (Fig. 8). It is this group of patients in whom diagnostic laparoscopy may have substantial benefit. In 1980, Leape and Ramenofsk y8 successfully reduced the negative appendectomy rate from 10 percent to 1 percent by employing selective laparoscopy in patients with an equivocal diagnosis. Although similar results have been reported," not all series reflect this level of success. 64 The main problem is often difficulty in adequately visualizing the appendix, particularly if it lies in the retrocecal position.
Ciltically II] Patients. The evaluation of an acute abdomen in individuals in intensive care units is often challenging. In many instances, the mental status of the patient obviates an accurate diagnosis, and other confounding variables may cloud the situation. It is possible to perform diagnostic laparoscopy at the bedside with local anesthesia and sedation. In a study of 25 intensive care unit patients with a suspected abdominal pathologic condition, the accuracy of laparoscopy was 96 percent in determining the need for laparotomy.
Other. Certain groups of patients, such as those on corticosteroid therapy, diabetic patients, and patients with neurologic deficits, pose difficult diagnostic problems. Moreover, comorbid diseases may make a negative laparotomy a risky procedure, while the delay in diagnosing an abdominal pathologic condition such as ischemic bowel or covert perforation is often fatal.
While no organized studies are available to support its use, it seems probable that diagnostic laparoscopy would maximize diagnostic accuracy while reducing the need for unnecessary laparotomy or potentially harmful expectant management.
Diagnostic laparoscopy is useful in the evaluation of both blunt and penetrating abdominal trauma. Peritoneal lavage is a widely used and generally accurate technique for assessing the need for laparotomy. It is sensitive, rarely missing a significant intraabdominal injury," but may lead to laparotomy for relatively minor injuries which could be managed expectantly. A prospectively randomized study evaluated peritoneal lavage versus laparoscopy performed with local anesthesia and intravenous sedation after blunt trauma.rr' The negative laparotomy rate was lower in the laparoscopy group (8 percent versus 2 7 percent for peritoneal lavage). The difference did not, however, attain statistical significance. The retroperitoneum is an area in which both laparoscopy and lavage provide only limited information. Diagnostic laparoscopy may be of some use in evaluating tangential gunshot wounds" and stab wounds. If the peritoneum is not violated by the bullet or knife, early discharge of the patient is possible and laparotomy can be avoided.
|MORE ABOUT LAPAROSCOPIC CHOLECYSTECTOMY|
The success of cholecystectomy initiated the laparoscopic surgical revolution of the late 1980s (Figs. 10 and 11). It continues to rank among the most commonly performed laparoscopic procedures in North America." While the scope of this article precludes a detailed consideration of all the data relevant to this procedure, several important aspects will be discussed.
Incidence. Laparoscopic cholecystectomy has gained popularity among both surgeons and the lay public. This is reflected in reports that the cholecystectomy rate has increased because of alterations in the public perception and evidence of decreased morbidity.69-" Thus, surgeons may be more likely to recommend this procedure to individuals with marginal symptoms, and patients are more likely to accept a less invasive procedure widely popularized by the media than to live with these symptoms.
Complications. Because of this increased prevalence and public demand for the procedure, it is unlikely that a large randomized trial will be undertaken. This has led to concern that rates of complications, most notably common bile duct injuries, may be higher than they are with open procedures. Two modestly sized prospectively randomized studies have been reported, with 70 (72) and 74 (73) patients, respectively. The overall complication rate between open and laparoscopic surgery was not significantly different.
Several retrospective analyses of over 1000 patients undergoing laparoscopic cholecystectomy have been reported 22, 24, 69, 74, 75. The overall rates of common bile duct injury ranged from 0.25 to 0.6 percent. There is evidence of a relatively steep learning curve. Thus, the possibility of bile duct injury decreases significantly after a surgeon has performed 13 operations (22) or when procedures are undertaken at institutions where more than 100 laparoscopic procedures have been performed 24. At present, these figures are slightly higher than those reported for open cholecystectomy (O to 0.4 percent) 23. It is probable that improved training and increase awareness of the critical areas of the operation will result in a further decrease of this complication.
Mortality after laparoscopic cholecystectomy ranges from 0 to 0.1 percent in large series 22,24,69,74,75. The deaths were largely attributable either to comorbid diseases or to the complications of iatrogenic injuries sustained during surgery. These figures are somewhat lower than those reported after open cholecystectomy (O to 0.5 percent)23 and may reflect patient selection.
Conversion to open cholecystectomy is not regarded as a complication of laparoscopic cholecystectomy but instead reflects the exercise of appropriate judgment in successfully and safely accomplishing the procedure. Reported conve sion rates range from 3.6 to 6.9 percent. 22,24,69,74,75 The indic tions include unclear anatomy, bleeding, and common bil duct injury and are more common in the elderly, in thos with acute cholecystitis, and in patients with gallstone pan creatitis.'g As experience with laparoscopy and patient selec tion grows, conversion rates below 2 percent can be anticipated 10.
Recovery. Two prospectively randomized studie showed a statistically significant improvement (decrease) i hospital stay, return to full activity, and requirement (de crease) for opiate analgesia 72,73. The average hospital stay ranged from 1.2 to 3 (22,72,73,75) days, lower than the typical 4 to 7 days after open cholecystectomy.
While data regarding postoperative length of stay an overall convalescence are important, one has only to observ patients after traditional and laparoscopic cholecystectomy t be convinced that the latter represents a quantum leap for ward in patient satisfaction.
A number of techniques are available at the time of surger for evaluation and stone clearance of the common bile duct Cholangiography can be performed via the gallbladder o through the cystic duct. There is a debate about whether rou tine cholangiography should be undertaken, Proponents cit increased awareness of anatomy and identification of com mon bile duct stones. Preoperative endoscopic retrograd cholangiography (ERCP) is a potential option for common bil duct anatomic definition and identification of common bil duct stones. Initial low yield rates have lessened enthusias for this approach. Preemptive removal of a common duc stone facilitates laparoscopic cholecystectomy and obviate the need for open exploration of the common bile duct.
The available techniques for exploring the common duct a the time of laparoscopic cholecystectomy include, in order o increasing invasiveness, balloon catheter manipulation (use to push stones into the duodenum, dredge the common duc for stones, or dilate the arnpulla), fluoroscopically guided bas ket extraction, and choledochoscopy (either transcystic or through a choledochotomy) (Fig. 12). The utility of such techniques is operator-dependent, but success rates of 96 to 98 percent have been reported 76,77.
Antireflux Procedures. Gastroesophageal reflux reflects the consequences of malfunction of the valvular mechanism of the cardioesophageal junction. Open surgical ftindoplication techniques have been utilized successfully for over 40 years to restore this function 78, 79. These techniques are effective, but substantial morbidity is associated with a large upper abdominal incision, and poor access may culminate in splenic damage. The introduction of H2-receptor blockers and, more recently, proton pump inhibitors has led to a reassessment of the utility of medical treatment. Potent acid inhibition offers symptomatic improvement for the majority of patients but does nothing to correct the fundamental problem of a defective lower esophageal sphincter. In addition, the consequences of long-term potent acid inhibitory therapy have not been fully determined. A recent prospective randomized study of patients with complicated reflux reported that the results of surgery are superior to those of medical therapy for both symptomatic relief and the improvement of the ondoscopic appearance of the esophageal mucosa 80.
Fundoplication is a technique ideally suited for the laparoscopic approach. Visualization of the esophagogastric junction (Fig. 13) is generally better than in open operations, since the laparoscope can access areas deep under the diaphragm that are not easily visualized at open operation. In addition, the assistant may be able to facilitate the procedure instead of blindly retracting, as is often the case in the open procedure. Since no anastomosis is performed and manipulation of the lower gastrointestinal tract is minimal, postoperative ileus is not a problem and patients can be discharged earlier.
The two procedures which are most commonly performed laparoscopically for reflux are the Nissen (360-degree wrap) and the Toupet (270-degree wrap) procedures 78,81. Early data from patients undergoing laparoscopic Nissen procedures have been good, with symptomatic relief in over 90 percent of patients. In addition, a shortened hospital stay, decreased convalescence, and low rates of dysphagia and gas-bloat syndrome have been noted 82-84.
Cardiomyotomy. Achalasia is a relatively rare disease, affecting only about 1 in 100,000 persons 85. Although blind, repetitive balloon dilatation has been widely utilized for treatment, the only prospectively randomized study undertaken demonstrated a clear advantage for surgical esophagomyotomy or cardiomyotomy 86. The laparoscopic approach to this procedure (Fig 14) (85,87) has the same theoretical advantages as it does for antireflux procedures. Thoracoscopic esophagomyotomy has also been described 88. Only a limited number of patients have undergone the procedure; thus, it is unclear if the advantages will be fully realized. The early results are promising.
Procedures for Peptic Ulcer Disease. Surgical therapy for peptic ulcer disease has dramatically devolved since the advent of H2-receptor blockers. Elective surgery for ulcer disease is unusual, but in emergency surgery for complications, the ulcer-related mortality rate is unchanged 89. For complications such as perforation and gastric outlet obstruction, laparoscopic procedures are appropriate 90. These procedures include primary repair with omental patch for perforation and gastrojejunostomy in cases of obstruction. Management of bleeding by laparoscopic techniques has not been reported, but gastrectomy has been undertaken and is potentially feasible in a stable patient. Considerable technical experience is necessary for procedures of this magnitude. Nevertheless, the same thing could have been said about the first report of gastrectomy by the open technique in 1879.
Indications for elective surgical treatment include patients refractory to medical therapy and young patients who may face a lifetime of acid inhibitory therapy. Issues of compliance, cost-effectiveness, and long-term results may be important factors, but detailed information is not available. Treatment options include truncal vagotomy accompanied by a drainage procedure (pyloroplasty or pyloric balloon dilatation), highly selective vagotomy, gastric seromyotomy (which is functionally similar to highly selective vagotomy), and a combination of seromyotomy and vagotomy (Figs. 15 and 16). Early results of two series have been reported, 91,92 with rates of ulcer healing over 95 percent in both. This is clearly an area of evolution in laparoscopic surgery, but further studies are necessary before its true role can be defined. At best, the results should presumably be comparable to those obtained by open surgery, with the added advantage of a minimally invasive technique.
Antrectomy. A number of antrectomies and gastrotomies have been described for benign gastric lesions 93 or peptic ulcer disease 51. Although technically feasible, total gastrectomy has not been described. Experience with these techniques is relatively recent, and few cases have been reported.
Proceduresfor Gastric Obstruction. Gastrojejunostomy is the standard open procedure performed for advanced, unresectable gastric cancer either as a prophylactic measure or for actual obstruction. With the increased popularity of laparoscopic gastric cancer staging, laparoscopic gastrojejunostomy may be performed more frequently 51.
Resection. Indications for laparoscopic resection of the small bowel are the same as those for open procedures and include benign and malignant neoplasms, strictures or inflamed areas from radiation or inflammatory bowel disease, Meckel's diverticulum, and bleeding arteriovenous malformations. Operations can be performed by constructing the anastomosis inside the peritoneal cavity (intracorporeal anastomosis) 94 or by bringing the loops to the outside through a 9small incision (extracorporeal anastomosis) (Fig. 17) 95. The technique used depends on the nature and location of the lesion. A problem arises, however, when one is attempting to remove large specimens through small port incisions. If an abdominal incision has to be extended to facilitate specimen removal, extracorporeal anastomosis can be undertaken expeditiously. Occasionally the specimen may be small enough to be removed through a 12-mm port or is suitable for morcellation and bag retrieval. In such instances, intracorporeal anastomosis is an option, provided that the surgeon is technically capable of undertaking intracorporeal bowel anastomosis, which requires considerable skill.
Lysis of Adhesions. This procedure is commonly used to resolve small bowel obstruction and occasionally to relieve abdominal pain syndromes 96. The etiology of adhesions is usually related to prior abdominal surgery, although congenital bands and adhesions from intraabdominal or pelvic inflammatory processes may be responsible. While prior surgery represents a challenge in trocar placement, it is no longer a contraindication to laparoscopic surgery. Nevertheless, a history of previous surgery demands the utmost caution in regard to laparoscopic surgery. The initial trocar may be placed using an "open" technique or, alternatively, at a site distant from the previous abdominal incision. The remaining trocars are then placed under direct vision by the laparoscope. At operation, the small bowel is grasped with atraumatic laparoscopic clamps and "run" until the point of obstruction is encountered. The causative adhesions are then divided (Fig. 18). It may be useful to divide any other obvious bands. The results with this technique have been favorable both for resolution of obstructive symptoms and in providing symptomatic relief in patients with chronic abdominal pain syndromes 96.
|HOME||INTRODUCTION TO LAPAROSCOPIC COLECTOMY||HISTORY OF LAPAROSCOPIC COLECTOMY||
CARDIOVASCULAR CHANGES DURING
LAPAROSCOPIC COLECTOMY FOR
LAPAROSCOPIC COLECTOMY AT A
|REVIEW OF 752 LAPAROSCOPIC COLECTOMIES||
Application of videolaparoscopic techniques to colorectal operations was initially limited by the lack of appropriate instruments. Consequently, the first laparoscopic colon resections were "laparoscopically assisted" colectomies; i.e., minilaparotomies were utilized for ligation of mesenteric vasculature, extracorporeal anastomoses, and specimen removal. The first laparoscopic colonic resection using this technique was a right hemicolectomy performed in 1990.97
The introduction of a laparoscopic intestinal stapler, the Endo-GIA 30 (United States Surgical Corporation, Norwalk, CT), allowed transaction of the bowel to be accomplished inside the abdomen (Fig. 19). Using this instrument for ligation of the mesentery and transaction of the colon, Fowler performed a sigmoid resection in October 1990.98 The anastomosis was constructed with a circular stapling device. In rapid succession thereafter, virtually all types of colorectal procedures were accomplished using minimally invasive techniques. These laparoscopic techniques replicate exactly the operation undertaken through large abdominal incisions. Unfortunately, laparoscopic colorectal surgery is extremely difficult, and few surgeons have developed the skills needed for such procedures. Indeed, few surgeons perform these operations. Nonetheless, laparoscopic colorectal operations offer many of the same advantages to patients as do other laparoscopic operations. Patients tend to experience less pain, fewer wound complications, a shorter length of hospital stay, and a quicker return to normal activity. An increased rate of Richter's hernias and tumor implants in wounds after laparoscopic procedures is apparent.
Laparoscopic techniques have been applied to virtually all types of colorectal procedures. The diseases most commonly treated with laparoscopic operations include complications of diverticular disease,99 Crohn's disease 100,101, chronic ulcerative colitis102, rectal prolapse 103-106, constipation 107 Sigmoid volvulus 108, endometriosis 109-111 and benign colorectal neoplasms112-114. Closure of colostomies after a Hartmann's procedure or the creation of a colostomy can be easily accomplished laparoscopically 115-116. Treatment of colorectal malignancies with laparoscopic resections is controversial 117-119. Most surgeons would agree that patients with metastatic disease are appropriate candidates. Disagreement exists, however, about the use of laparoscopic techniques in patients with surgically curable malignancies. This issue reflects the concern about whether adequate en bloc resection can be undertaken using the laparoscopic technique and the apparently high rate of tumor recurrence in trocar sites. Long-term follow-up is not available after laparoscopic resections for colorectal cancers.
Virtually all patients who require colorectal operations are candidates for laparoscopic procedures. A rare patient with severe restrictive pulmonary disease may not tolerate the carbon dioxide pneumoperitoneum. A major obstacle to laparoscopic colorectal surgery is obesity. Consequently, these procedures are easier in thin patients than in overweight patients. The pattern of fat deposition in women appears to facilitate laparoscopic procedures. Women deposit much of their fat within the abdominal wall and very little within the omentum, intestinal mesentery, and retroperitoneum. In contrast, overweight men often have thin abdominal walls but large amounts of fat within the omentum, epiploic tags, mesentery, and retroperitoneum. This results in poor visibility of important anatomic landmarks. Thus, laparoscopic colorectal operations are most easily performed in thin women who have not undergone previous operations.
Several large series of laparoscopic colorectal operations have been published.9' 120-125 These series compiled the early experience of several institutions with a wide variety of procedures. Additionally, these surgeons often used quite different techniques. As a result, the information provided in different papers is often difficult to compare. Furthermore, none of these studies is randomized. Nonetheless, a general pattern (see below) has emerged from these publications. Laparoscopic colorectal operations are more difficult to perform than are other laparoscopic procedures. Even in selected patients operated on by surgeons with considerable laparoscopic colorectal experience, rates of successful completion of the operation laparoscopically range from about 65 to 90 percent. These operations require more time to complete than do open operations, although these figures may reflect the level of experience of the surgeons. Quantitative measures of the size of the specimen, the length of the mesentery, and the number of lymph nodes present suggest that the quality of the operation for colorectal malignancies is maintained when it is performed laparoscopically (only long-term follow-up and comparative studies can confirm this). Blood loss is diminished during laparoscopic colorectal resections, and the requirement for blood transfusion is unusual. The amount of pain and the requirement for pain medication are decreased in patients after laparoscopic operations. The median length of stay after laparoscopic colorectal resections is about 4 to 5 days in most reports. A few studies, however, have reported median stays of 5 to 7 days or longer. 123,124 Performance scores after operation indicate that patients return to normal activity sooner after laparoscopic colorectal operations than after traditional open operations 126.
The currently published series of laparoscopic operations are not randomized series and often reflect a bias in patient selection. Consequently, direct comparison of rates of complications in laparoscopic versus open operations is not possible. The published studies suggest, however, that the rate of intraabdominal complications such as anastomotic leaks and intraabdominal abscesses is not different from that observed with open operations. This is not surprising, since the extent of dissection and the magnitude of resection are the same for both techniques. Moreover, identical techniques are used for the construction of anastomoses. Insufficient laparoscopic operations have been reported to assess accurately either rare complications such as pulmonary embolism or rates of mortality, though both seem comparable for laparoscopic procedures and open operations at specialty centers.
Wound implantation is, however, a worrisome new complication that has been noted and may occur more frequently after laparoscopic colectomies than after open operations 33,36,37,119. These implantations have occurred both at the extraction site of the specimen and at distant trocar sites. The mechanism of this complication is unclear.
Cost issues have been compared for laparoscopic versus open colorectal operations in several studies. 122,126,127 In general, operating room costs are increased significantly with laparoscopic colorectal operations compared with open operations. Total hospital costs, however, are decreased or about the same for laparoscopic procedures. The cost reduction is achieved through a shortened length of stay.
Initial randomized trials uniformly support the use of laparoscopic appendectomy rather than traditional approaches. The length of operation is about the same for both groups. The length of hospital stay, the requirements for pain medicine, and the period of disability are all shortened in the laparoSCOPIC groups 32,128. Moreover, in one randomized trial the number of complications, particularly wound infections, was 29 greater in the open group of patients 29. In a retrospective audit, the total hospital cost for a laparoscopic appendectomy was not significantly different from that for an open appendectomy 129.
The surgical technique of laparoscopic appendectomy is well established. The clear advantages of laparoscopy over exploration through a right lower quadrant incision for women with lower abdominal pain have been well documented over decades. Randomized trials have confirmed that after laparoscopic appendectomies patients sustain fewer complications, suffer less pain, are discharged earlier, and return to work sooner. The cost for both procedures is similar. All available information indicates that laparoscopic appendectomy has superior results and will become the standard of care.
Use of the laparoscope engenders a loss of tactile sense. As a result, difficulty exists in performing certain procedures. This has led to a novel opportunity for surgeons and gastroenterologists to be jointly involved in the development of combined techniques of both a diagnostic and a therapeutic nature.
Large, sessile colonic polyps provide a challenge to colonoscopists. While it is desirable to spare patients unnecessary surgery, the risk of perforation or bleeding from colonoscopic polypectomy, particularly in the right colon, leads to many open procedures. In such cases, an alternative approach may be to undertake polypectomy through the colonoscope with laparoscopic observation of the integrity of the serosal surface (Fig. 20).
For some colonic and gastric lesions identified by endoscopy, laparoscopic identification is impossible. Such neoplasms must be identified either preoperatively or intraoperatively by endoscopy. Preoperative identification may be accomplished with India ink injection, or alternatively combined laparoscopy and intraoperative endoscopy can greatly facilitate this process.
Treatment options for choledocholithiasis in the laparoscopic era are numerous 130. A skilled therapeutic endoscopist who can reliably clear a common bile duct by ERC may greatly facilitate laparoscopic cholecystectomy and avoid conversion to an open operation. In patients with preoperative identification of common bile duct stones, preemptive papillotomy and stone extraction may obviate the need for open surgery and allow safe laparoscopic cholecystectomy. 16,111 In appropriately equipped operating rooms, intraoperative endoscopic papillotomy with laparoscopic cholecystectomy may be considered.
|MORE ABOUT LAPAROSCOPIC INGUINAL HERNIA REPAIR|
Hernia repair is one of the most common surgical procedures performed in the United States (Fig. 21). Standard repairs attempt to reconstruct the weakened floor of the inguinal canal either by reapproximating the endogenous tissue or by interposing a piece of mesh. Laparoscopic repair emphasizes placing a piece of mesh over the floor of the canal either from inside the peritoneal cavity or through a preperitoneal approach. An earlier technique of using a mesh "plug" was abandoned because of unacceptable recurrence rates. 132 A multicenter report of 736 laparoscopic hernia repairs using the prosthetic patch technique found a recurrence rate of 2.2 percent at a mean follow-up of 6 months. 113 Recurrence after open repair varies widely, depending on the surgeon, the center where the repair is done, and the length of follow-up. Recurrence for first time hernia repairs assessed over a broad population base ranges from 5 to 10 percent. 90
Critics of laparoscopic herniorrhaphy argue that standard hernia repair is an outpatient procedure done under local anesthesia with no violation of the peritoneal cavity. Despite this, the convalescent period may be as long as 4 to 6 weeks.'30 Laparoscopic repair is associated with less postoperative pain and an earlier return to full activity. 132,133 Long-term recurrence data have not yet accrued, nor is there a prospective randomized study available for comparison of open versus laparoscopic repair efficacy.
The use of mesh to seal defects in the diaphragm requires the use of the same techniques employed for inguinal hernia repair. Access provided by the laparoscope is often superior to that available at open surgery. Little experience is currently available.
Placement of gastrostomy or feeding jejunostomy tubes is ideally suited to the laparoscopic approach because of the often debilitated nature of the patients who require these interventions. Several techniques have been described.","' Percutaneous endoscopic gastrostomy is superior in most instances. Considering the myriad complications associated with total parenteral nutrition, laparoscopic feeding jejunostomy may be a viable alternative for patients with an intact gut.
Splenectomy may be necessary in the management of a variety of hematologic, neoplastic, metabolic, and infectious conditions. 131 In addition, splenic salvage is increasingly popular for traumatized spleens, especially in young patients. Laparoscopic techniques have been applied successfully to splenic surgery, with benefits similar to those noted in other laparoscopic procedures 135.
Laparoscopic surgery reflects the evolution of an exciting collaboration between surgeons and the science of biotechnology. Innovative thought and creative technology have been fused to redefine the management of old problems. Apart from the technical advances, this scenario presages a fundamental alteration in the fashion in which surgeons will practice in the future. It is apparent that "quantum leaps" in medical and surgical thought are necessary if therapy is to evolve beyond a purely technical skill and escape from the dogma which often surrounds manual resolution of complex problems.
While the unbridled enthusiasm of the early days of laparoscopic surgery has been tempered, it is evident that this is not a temporary phenomenon or a gimmick. Although much thoughtful work has been undertaken to assess its impact both on individuals and on society in general, much remains to be done to evaluate procedures and assess long-term results. It is probable that certain techniques will fall into demise once data on long-term results have been evaluated over time or newer technologies have been developed.
Advances in technology are continuing at a rapid rate, and the future types of surgical procedures may be vastly different from those contemplated today. New developments such as virtual reality may make training for surgical procedures more standardized and revolutionize surgical capabilities. 1313 Robotics has reached the point where operations performed with the surgeon at a site remote from the patient (telepresence surgery) are becoming a possibility. The use of special instrumentation may enable tactile feedback and facilitate
It is clear that laparoscopy has gained acceptance and with time will earn its rightful niche in the field of gastrointestinal surgery. As patient satisfaction grows and clinical results improve, the light of laparoscopic surgery will continue to illuminate the resolution of gastrointestinal disease processes.
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