Laparoscopic Surgery

Author: Dr John Maa University of california SF 2008-07-29

Evolving Trends in Laparoscopic Surgery

Keywords: minimally invasive surgery, hand-assisted laparoscopic surgery, bandaid, keyhole and pinhole surgery, laparoscope, Da Vinci, NOTES

Laparoscopic surgery is a modern surgical technique that has transformed the practice of surgery.  This minimally invasive surgical intervention allows surgeons to perform operations through small incisions (usually less than one centimeter) compared to the larger incisions required in traditional “open” surgical operations.  Patients benefit by reduced post-operative pain, shortened hospital stays, improved cosmetic results, and faster recovery times.

  Due to these improved patient outcomes, demonstrated cost effectiveness, and patient demand, laparoscopic surgery has been widely accepted by both patients and surgeons over the last two decades.  Dramatic advances in instrumentation, camera video technology, and laparoscopic equipment driven by industry have accelerated the further development of the field of laparoscopy.  In some hospitals as many as 50% of all procedures are being performed laparoscopically, and predictions are that over 70% of current procedures can be performed by laparoscopy without major technological advances. 

Historical timeline in the evolution of laparoscopic surgery

        The modern era is traditionally regarded to have begun with the introduction of first laparoscopic cholecystectomy or “lap chole” (gallbladder removal) in 1987, but laparoscopic procedures have actually been performed since 1806.   

        For several decades in the twentieth century, gynecologists had used laparoscopy for purposes of diagnosis and performance of simple procedures such as tubal ligation for birth control.

1901 Georg Kelling performed the first laparoscopic procedure in animals and described the creation of pneumoperitoneum (air in the abdominal cavity) and trocar (a hollow tube) placement.

1910 Hans Christian Jacobaeus of Sweden reported the first laparoscopic operation in humans. Over the next several decades, numerous individuals refined and popularized the approach further for laparoscopy.

1983 The first laparoscopic appendectomy was performed by Semm as part of a gynecologic procedure

1985 Muhe of Germany performed the first successful laparoscopic removal of gallbladder in humans.  However, this was not well publicized until years later, and Mouret of France is often credited with the first reported laparoscopic cholecystectomy in 1987

1991 Gaegea introduces the laparoscopic fundoplication (stomach wrap around the esophagus or swallowing tube) for gastroesophageal reflux

1992 The National Institutes of Health Consensus Conference concludes that laparoscopic cholecystectomy is now the preferred alternative to open cholecystectomy

2005 A transgastric appendectomy is performed by Rao and Reddy in India

2007 The first Natural Orifice Transluminal Endoscopic surgery (NOTES) procedure to remove a gallbladder without any visible external scars is reported in the United States

What are the advantages of laparoscopic surgery?

There are a number of advantages to the patient with laparoscopic surgery versus an open procedure. These include:

            1) Smaller incisions, which result in smaller scars and a superior cosmetic outcome

            2) Less postoperative pain and reduced requirements for pain medications

            3) A shortened length of hospital stay

4) A reduced time to recover and earlier return to work

5) Reduced tissue trauma, with decreased need for transfusion, and also a reduced risk of incision-related complications such as wound infections and hernias

6) A decreased risk of forming scars in the abdomen (adhesions) that could lead to future bowel obstructions

7) Providing the ability to make a diagnosis in unclear situations, and thereby sometimes avoiding the need for open surgery or “laparotomy” altogether

What are the disadvantages of laparoscopic surgery?

Some of the disadvantages include:  

1) Increased cost, resulting from the need for advanced equipment and its maintenance, capital costs, and advanced instruments. This may be offset by shortened length of hospitalization.

2) Longer operating time; in many instances, laparoscopic operations take longer than the same operation performed in the “open” traditional technique

3) Does not eliminate the possibility of life threatening complications, which can result from injuries to either blood vessels or intestine.

4) The requirement for general anesthesia, whereas some of the open alternate operations can be performed under epidural or local anesthesia.

5) Rarely, postoperative pain is actually increased, as more dissection may be necessary to compensate for the smaller incisions (laparoscopic hernia), and the carbon dioxide used to inflate the abdomen can irritate the lining of the abdomen (peritoneum) and cause transient shoulder pain. 

6) The inability to perform a thorough and rapid exploration of some areas of the abdomen, as in often necessary in trauma exploratory surgery.

How is laparoscopy performed?

The abdominal wall represents a barrier between the surgeon and access to the contents of the abdomen, and the primary advantage of laparoscopy is to minimize trauma to the healthy abdominal wall.  Access to the abdominal cavity is achieved with either a needle (Veress insertion) or by a mini-incision (Hasson).  Carbon dioxide is then blown in to a pressure of 15 mm Hg; this creates a working space by elevating the abdominal wall above the internal organs.  A long, rigid rod-lens scope (the laparoscope) and light cord for illumination are then inserted and used to examine the abdominal organs. 

Magnified images of the operative field are projected onto one or more television monitor screens, allowing nurses, assistants, and anesthesiologists to monitor the progress of the operation. 

Several plastics tubes of either 5mm or 12mm diameter with an air-tight valve, called trocars, are placed in strategic locations to allow the easy insertion, removal and exchange of instruments. 

The number of additional ports necessary is related to the complexity of the procedure.  Laparoscopic instruments are designed with the same intent as in open surgery, but differ markedly in their length (about 12 inches long).  Laparoscopic scissors, graspers, retractors, and other tools are inserted through the trocars to manipulate the tissues.  

Surgical staplers and electrosurgical devices that cut and seal tissues are used to remove organs or join segments of intestine together.  The use of these sophisticated instruments (trocars, staplers) which are usually disposable is partly responsible for the higher cost of laparoscopic surgery.

In some cases gasless laparoscopy is performed, which is achieved by lifting the abdominal wall with retractors rather than blowing in (insufflating) carbon dioxide. Newer laparoscopes incorporate a camera on the tip which converts images into digital signals and then sends them to the screen with greater resolution.  Many technological advances including vessel sealing devices to cut blood vessels and stop bleeding, and an ultrasonically activated scalpel, are used in more complex procedures.

 

Why is laparoscopic surgery more difficult for the surgeon?

While the smaller incisions are clearly of benefit to the patient, laparoscopy presents inherent limitations for the surgeon.  In laparoscopy, the three dimensional operative field of open surgery is replaced by a two dimensional screen image with a concomitant loss of information.  The restricted vision and illumination, with a lack of depth perception, can result in errors of misperception.  Rapid bleeding is harder to control and quickly obscures vision.

 

 

Laparoscopy permits the surgeon to readily assess only surface anatomy, with the inability to directly feel or “palpate” organs and other anatomic structures.  This can be somewhat compensated by the use of ultrasound, but the inability to apply manual pressure to control bleeding is another challenge. 

 

 

Laparoscopic instruments have a reduced degree of freedom and can be awkward to manipulate.  Laparoscopic suturing in particular requires new hand-eye coordination skills.  The added level of difficulty could be compared to eating with chopsticks versus eating with your hands.  The surgeon must adeptly use body position, placement of extra retractors, operative table positioning, and different angles to dissect, suture, and remove specimens.  Often, a more extensive dissection is necessary to compensate for the reduced access from the small incisions.

The surgeon must also have the knowledge to troubleshoot any mechanical difficulties involving the additional equipment in emergency situations.  As this technique requires a different skill set, some surgeons may not be comfortable with laparoscopic procedures, so for more complex operations, patients should consider seeking an experienced laparoscopic surgeon.

 

Which step of laparoscopy can be the most challenging and life threatening?

A major source of serious complications in laparoscopic surgery is the initial access to the peritoneum to insufflate carbon dioxide.  The standard use of a large bore needle (the Veress needle) to insufflate air is the simplest and most rapid to gain access, but can also result in bowel or vascular injury and resultant bleeding and fatal air emboli (air bubbles in the bloodstream). 

 

While the rate of injury of bowel is low (0.025 to 0.2%), an unrecognized missed injury to the bowel (enterotomy) can result in delayed perforation and peritonitis (inflammation of the thin membrane that covers the abdominal wall) with a mortality of 5%.  In some instances it is recognized that the bowel has been entered if bowel contents escape when the trocar is placed, or when the internal surface of the bowel lumen is seen when the laparoscope is inserted. 

Bowel injury is not as life-threatening as an injury to a major blood vessel, which can result in rapid bleeding and death.  The aorta and vena cava can be as little as a few centimeters away from the abdominal wall when a patient lies supine (face up).  The rate of major vascular injury is less than 0.05%, and injuries will typically be recognized by visible bleeding or hypotension (low blood pressure).   This will almost certainly mandate immediate blood transfusion, and conversion to a laparotomy/ open procedure.

In an effort to minimize this risk, alternate techniques of insertion of the needle used to insufflate air have been developed.  The use of an open technique for abdominal access was described by Hasson in 1971 and utilizes blunt entry into the abdomen, followed by direct vision for placement of the additional trocars.  New optical trocars that allow the surgeon to visualize the layers of the abdominal wall during entry are a safer alternative, but do not eliminate the risk completely.

Why is it sometimes necessary to convert from a laparoscopic to an open procedure?

For any given laparoscopic procedure, “conversion” or switching to the traditional open procedure may become necessary.  Reasons for this may include bleeding, inadequate exposure, excessive scarring (adhesions), and an inability to make progress and complete the procedure.  Risk factors for conversion include previous abdominal operations, history of peritonitis, distended bowel, and presence of cancer.  Some patients with existing pulmonary disorders may not tolerate pneumoperitoneum, resulting in a need for conversion to open surgery after the initial attempt at laparoscopic approach.  If a procedure cannot be completed laparoscopically, then the decision to convert to open should be regarded as good judgment with the intent to maximize patient safety, rather than as a complication or failure.  Hence patients are always asked to give their consent for both laparoscopic and open procedures, with the understanding that the laparoscopic approach will be attempted first, but conversion to open may always become necessary.

How are organs or tumors removed?

Many small specimens (e.g., appendix, lymph node, gallbladder) can be removed through the standard 12 mm port used for the camera placement.  Usually the organ or tumor is placed in a special bag so that it can be safely retrieved without spillage. 

 

In operations where the size of the specimen being removed would be too large to extract through a 12 mm trocar site (e.g., spleen, kidney, or colon), several options exist, including:

1) removing the specimen in pieces,

2) placing the specimen in a bag and grinding it down in size (morcellation), or

3) making a larger incision for removal (especially if the tissue is needed intact for pathological examination). 

When removing large specimens, a key decision for the surgeon is whether to employ advanced strategies and attempt to complete as much of the procedure as possible through the laparoscopic approach (and to make a mini-laparotomy incision to remove the specimen), or to perform hand-assisted laparoscopic surgery.

What is “hand-assisted” laparoscopic surgery?

If a larger incision will ultimately be necessary for specimen removal, the option exists to make the incision early in the procedure and to have the surgeon's hand in the operative field during the procedure to aid as a retractor, dissector, and to be able to palpate or feel the tissues, as would be done in open surgery.  This technique is called hand-assisted laparoscopic surgery. 

Since carbon dioxide will still have to be maintained in the patient's abdomen to create a working space for the laparoscope and instruments, a device known as a hand access port (a sleeve with a seal that allows passage of the hand) must be used and is placed in an incision that is about eight centimeters in length.  Some surgeons feel that the hand-assist technique reduces operative time significantly compared to the completely laparoscopic approach, as well as providing more options in dealing with unexpected adverse events (i.e., uncontrolled bleeding), but it does require this larger incision for the hand port.

How is laparoscopy used for both for diagnosis and treatment?

For diagnosis:

Diagnostic laparoscopy has long been used in gynecology to determine the cause of chronic abdominal pain, and to diagnose causes of pelvic pain or infertility.  It is employed in general surgery in the setting of acute of chronic abdominal pain for which the cause is unclear after non-invasive imaging like computed tomography (CT) scans, and where it can help the surgeon decide where to make a subsequent incision.  Laparoscopy can also be used to obtain a biopsy of an abnormality seen on CT scan, to determine the extent and spread of cancers and, in trauma settings, to diagnose intra-abdominal injury or bleeding.  It can also avoid an unnecessary operation by clarifying that a patient has incurable disease.

For treatment:

Procedures that only involve cutting or suturing tissues together (Nissen fundoplication, lysis of adhesions) are ideal for laparoscopy, as removal of a specimen is not necessary, and the larger incision for exposure alone is avoided. 

            The more advanced cases involve removal of a specimen, and a malignant tumor is particularly challenging.  Sometimes the specimen can be removed without extending the incisions, but in other cases the specimen must be removed by extending the incision at the end at the end of the procedure, (known as lap assistance), or by using a hand-assisted port.  (See below for the list of procedures where laparoscopy is typically performed.)

What wound related complications can be avoided with laparoscopy?

Hernias occur in incisions approximately 10% of the time after traditional open surgery.  With the smaller incisions of laparoscopic surgery, the incidence of hernias is far lower, as well as that of other wound-related complications like infections or seroma (fluid collection).   

Are there contraindications to laparoscopic surgery?

A patient with unstable vital signs or for whom a prolonged time in the operating room would be undesirable are strong reasons not to perform laparoscopy.  Previous abdominal surgery resulting in intra-abdominal adhesions, liver failure (cirrhosis), bleeding disorders, obesity, acute inflammation, pregnancy, and existing cardiopulmonary disease may be relative contraindications, meaning that the risk and benefit of laparoscopy must be carefully weighed.  In patients with abdominal sepsis, laparoscopy could theoretically increase the risk of spreading infection.

Can I undergo a repeat laparoscopic procedure after a previous laparoscopy?

Repeat laparoscopy can be performed safely for a patient who has undergone a previous laparoscopic operation, but special care must be taken during the initial entry into the abdomen.  After any operation, “adhesions” or bands of scar tissue that binds 2 parts of your tissue together that are normally separated, occur.  This increases the likelihood of injury to organs during entry into the abdomen because organs ordinarily are not adherent to the abdominal wall , become fixed in one location and make them more prone to injury. It may be necessary to enter the abdomen at an alternate site (in the left upper abdomen -- Palmer's point) or to use an alternate technique (Hasson technique) to avoid entry complications. 

It is also very important for a patient to inform their surgeon that they have undergone a previous laparoscopic procedure, and what was performed.  Often the umbilical incision heals so well that it is difficult to visualize the previous scar.   Historically, most surgeons could deduce which operations a patient had previously undergone by the location and size of a patient's abdominal scars from open surgery, but this ability is substantially limited by laparoscopy. 

For which procedures has laparoscopy replaced the open approach?

For the following general surgical procedures, laparoscopy has replaced open surgery as the first choice treatment in healthy patients without complex anatomy or intra-abdominal scarring:

1) Laparoscopic cholecystectomy is the first choice of treatment for gallstones.  The primary advantages are reduced postoperative pain and a shortened time of recovery.  Laparoscopic cholecystectomies can often be performed on an outpatient basis, with many patients able to return to work within the next few days.

 

An early observation of increased injuries to the common bile duct in the 1990's has waned as surgeons have become more experienced with the procedure, and through the judicious use of an intraoperative cholangiogram (a radiological procedure used to look at the gall bladder and bile ducts during surgery).

 

2) Laparoscopic antireflux procedure (Nissen) is the laparoscopic technique now preferred by most surgeons for the treatment of gastroesophageal reflux disease.  Laparoscopic fundoplication has replaced open fundoplication predominantly as a result of the outstanding results published from the initial experience.  This approach provides excellent control of symptoms, shorter hospital stay, and fewer complaints of swallowing difficulties postoperatively.

 

 

 

 

3) Laparoscopic gastric bypass for weight reduction in morbidly obese patients is a technically challenging and advanced procedure requiring expert surgical skills, but a large amount of existing data supports this approach.  Both the a) laparoscopic roux-en-y gastric bypass and b) laparoscopic banding (LAP-BAND) have been widely adopted. The laparoscopic procedure has been demonstrated to have a decreased mortality, wound infection, and hernia rates compared to the open procedure, and are deemed safe and cost-effective.

4) Laparoscopic adrenalectomy has emerged as the procedure of choice for adrenal tumors, including benign tumors, pheochromocytoma, metastases, and adrenal cancer.  Patients who have undergone laparoscopic surgery have a much shorter hospitalization (an average of one to two days rather than five to seven for the open approach), more rapid recovery, and reduced discomfort.  The procedure does require extra advanced skills, and likely should be performed by an expert surgeon in a center of excellence.

For which procedures is laparoscopy equivocal to the open approach?

For the following procedures, data is still being collected to determine if the laparoscopic approach yields equivalent outcomes to open surgery, and both open and laparoscopic procedures are widely performed.

1) Laparoscopic appendectomy: An open appendectomy has a short recovery and hospital stay, and is performed through a small incision.  Thus the relative advantage of laparoscopy is reduced.  Several studies have demonstrated the feasibility and safety of laparoscopic appendectomy, but it is also associated with  increased costs.  The use of laparoscopy may be most appropriate for women in whom the preoperative diagnosis is less certain because their pain may be due to gynecologic reasons, for patients with an unusual presentation of symptoms, and in obese patients because an open appendectomy is more difficult than laparoscopically in obese patients because of their thicker abdominal fat.

 

 

2) Laparoscopic hernia:  The primary advantages of laparoscopic hernia repair are to avoid injury to the nerves innervating the groin, and to provide a different approach to recurrent hernias.  There are two primary approaches: the transabdominal preperitoneal (TAPP) and the totally extraperitoneal repair (TEP). Both involve placing a mesh screen over the hernia defect.  A primary concern is that the rate of recurrence of the hernia is higher with the laparoscopic approach, though postoperative pain is reduced and time to recovery shortened.  Current data suggests performing a laparoscopic repair if there are bilateral hernias and if a previous open approach has resulted in recurrence, but there is particular controversy about the risk/ benefits of a unilateral hernia repair.

3) Laparoscopic Splenectomy: The laparoscopic approach has been extensively reported as both feasible and safe, and some surgeons believe that laparoscopic splenectomy has replaced the open approach for disorders not requiring an intact specimen to analyze splenic architecture.  However, very large spleens are often encountered that present challenges with specimen retrieval, and there is concern of possible spillage of the spleen into the splenic cavity.  The laparoscopic approach does result in a shorter hospital stay, but requires longer operative times as well as significant experience and skill, and may be associated with increased blood loss.

4) Laparoscopic lysis of adhesions: If a bowel obstruction is the result of a single scar, then the laparoscopic approach is ideal to cut this adhesion without creating additional scars that could result in future obstruction.  However, not infrequently there are multiple problematic scars, and the procedure cannot be completed safely laparoscopically.  In those instances the laparoscopy can be the initial part of a lap-assisted procedure, with the intent to begin a limited dissection and identify a safe entry point into the abdomen for subsequent laparotomy.  However, this is associated with increased operating room time and costs, thus some surgeons advocate beginning with open surgery at the onset.

5) Laparoscopic colon and small bowel resection: Resection (removal) of the small bowel and intestine is more challenging, as it requires dissection in a larger portion of the abdomen, and control of several major arteries and veins.   There is considerable variability in laparoscopic techniques for colon resection.  Some surgeons perform only a portion of the procedure laparoscopically, and then make an incision to complete the resection (laparoscopic assisted colectomy); others perform the entire resection laparoscopically or with hand- assisted laparoscopic surgery.  Either of these approaches is relatively well accepted for for benign disease, but concerns persist if colon cancer is present, with the particular concern of a possible port site recurrence.  A key limitation is that the length of hospitalization is unlikely to be significantly reduced by laparoscopic surgery, since the healing of the bowel anastomosis is the key determinant of length of hospital stay, rather than the degree of postoperative pain or wound healing.

There remain many advanced and complex procedures for which the laparoscopic approach is still under investigation and being evaluated by clinical trials.  Perhaps with continued technology improvement for better exposure and control of bleeding, new strategies will be developed for major pancreatic, liver, esophageal, duodenal resection, and solid organ transplantation.  

Is laparoscopy safe for cancer surgery?

An initial concern that delayed the acceptance of laparoscopic cancer surgery was the concern that long term survival and cure rates would be reduced.  Concerns were raised about the adequacy of tumor resection, tumor spillage, and inadequate clearance of involved lymph nodes, as well as possible earlier recurrence of tumor. Additionally, several early reports suggested an increase in the incidence of tumor spread to the trocar sites, which could result from tumor implantation, direct contact of the tumor with the trocar site, or biologic factors (such as the pneumoperitoneum) which stimulate development at these sites.  However, with careful attention to avoid tumor spilling, equivalent outcomes have been reported.

At this time, there is no conclusive evidence that the laparoscopic procedure is associated with worse long-term outcome, and some reports suggest that patients have improved survival following laparoscopic colectomy (colon removal) for cancer.  However before laparoscopic colectomy can be advocated routinely for colorectal cancer, recurrence and survival data from larger, multi-center randomized trials, such as the one sponsored by the National Cancer Institute, must be analyzed. One distinct advantage is that the laparoscopic approach can sometimes identify untreatable disease, and avoid an unnecessary laparotomy.

What are the other unique complications related to laparoscopic surgery?

Every laparoscopic procedure carries with it the traditional well described complications described for the open procedure.  However laparoscopy also adds additional unique rare complications, some of which can be life threatening.  Treatment of many of these will require immediate conversion to an open procedure. 

1) Hernia or bleeding from trocar sites. Bleeding can occur if a blood vessel is pierced (as seen in the dilated umbilical veins in the patient with liver disease below), while hernias occur most likely in a 12 mm port site and can result in a small bowel obstruction.

2) Inadvertent injury from laparoscopic instruments and retractors, especially thermal burns or a missed enterotomy (injury to the small bowel).  One of the most dreaded complications is a missed enterotomy, which can occur off screen or during trocar insertion.

3) Complications associated with the carbon dioxide pneumoperitoneum, especially the injection of carbon dioxide into a major vascular structure (a CO2 embolus).

4) Bladder and stomach injury from the Veress needle insertion (this can be minimized by having the patient void (urinate) preoperatively or by placing a catheter to drain urine from the bladder, and by placing a nasogastric tube in the stomach to drain gastric contents).       

5) A bowel obstruction from dislodged clips and staples. Though this can also occur with open surgery, it is more frequent with laparoscopic surgery.

What are some procedure-specific complications of which I should be aware?

Many complications associated with advanced laparoscopic procedures are inherent to the operative procedure, regardless of the approach. 

Complications of specific procedures:

Gallbladder:                Bile duct injury, bile fistula, hemorrhage, abscess from lost gallstones, retained common duct stones

Appendix:                   Abdominal abscess, wound infection, appendiceal perforation during manipulation

Colon resection:          Trocar site recurrence, bowel injury, ureteral injury, duodenal injury

Inguinal Hernia:         Recurrence of hernia, bowel erosion, mesh infection, nerve entrapment

Nissen:                        Perforation of the esophagus, vagus nerve injury, pneumothorax, dysphagia, gas bloat, paraesophageal hernia.

What are ileus and adhesions?

Two concerns after traditional open abdominal surgery are the delay of return of normal intestinal function immediately postoperatively (known as an ileus), and the possibility of developing scarring (adhesions) within the abdomen that may cause a bowel obstruction months or years later.  Ileus often results in a prolonged hospital stay until normal intestinal function returns, and bowel obstructions can result in repeat hospitalizations and the need for additional surgery to alleviate the blockage.

A key advantage of laparoscopic surgery is that it reduces the risks of both ileus and adhesions by minimizing manipulation of the bowel and tissue trauma.  Many studies have demonstrated an earlier return of bowel function after laparoscopic procedures compared to open procedures.  Adhesion formation after laparoscopic surgery is substantially decreased when compared with open surgery so the incidence of bowel obstruction is reduced.

Can laparoscopy be performed in children?

While pediatric surgeons were among the early pioneers in the advances of laparoscopic surgery in the 1970's, few pediatric surgical procedures were performed for over two decades.  With increasing experience, miniaturization of equipment and evolution of techniques, pediatric surgeons have now embraced this approach.  Laparoscopic appendectomy, Nissen, hernia repair and pyloromyotomy (spreading of a valve opening to the stomach) are now performed routinely by experienced surgeons. Careful attention to matching the size of the patient to the instruments is important to ensuring high quality outcomes.

Can laparoscopic surgery be performed in pregnancy?

If necessary, many laparoscopic procedures can be safely performed during pregnancy.   The second trimester is generally regarded as the safest, as it avoids possible teratogenic effects (developmental defects) on the fetus in the first trimester and the possibility of premature labor in the third. Fetal monitoring is essential to ensure adequate placental blood flow, and care to avoid injury to the fetus during initial entry into the abdomen is critical (most frequently by using the Hasson technique). 

Is a laser still used during laparoscopic cholecystectomy?

Many patients often question whether they will undergo a "laser cholecystectomy."  Initially, a laser was indeed used as the energy source for coagulation and dissection of the gallbladder, but it was soon recognized that electrocautery was less expensive and equally effective, so the use of a laser was discontinued.

Are there any special concerns about anesthesia?

There are several important anesthetic considerations when selecting laparoscopic surgery:

1) Adequate relaxation of the abdominal wall for laparoscopy generally requires general anesthesia, whereas some traditional open procedures can be performed under spinal or even local anesthesia.  

2) The creation of pneumoperitoneum by insufflating carbon dioxide can result in complex cardiac and respiratory physiologic changes.  The first strategy if this occurs is to reduce the pressure of carbon dioxide insufflation, but sometimes the surgeon may need to convert to open for these side effects alone.

a) Cardiac effects can include impaired heart filling and reduced cardiac output, due to increased intra-abdominal pressure and the effect of carbon dioxide on ventilatory parameters.   The insufflation of carbon dioxide can enter into a blood vessel and travel to the heart as an embolus, and cause cardiovascular collapse, or a heart attack. 

            b) Respiratory effects: The increase in intra-abdominal pressure can displace the diaphragm leading to decreased lung volume, increased airway pressures, or collapse of the lung (pneumothorax).  The peritoneal absorption of carbon dioxide may produce hypercarbia (elevated blood levels of carbon dioxide) and acidosis, which may lead to irregular heartbeats in as many as 17% of patients undergoing laparoscopy.  Carbon dioxide insufflated into the abdomen can dissect into subcutaneous tissues resulting in pneumomediastinum (air in the space between the two lungs) and subcutaneous emphysema (air in the tissues under the skin).

When can I be discharged home after basic laparoscopic surgery? 

After many basic laparoscopic (appendix, gallbladder, hernia) procedures, patients can return home the same day, or choose to spend a single evening in the hospital.  The criteria for discharge home include 1) the resolution of nausea and vomiting (which may be more common after laparoscopy than open procedures due to the pneumoperitoneum), 2) being able to empty the bladder, and 3) having adequate pain control with oral medications.  Patients should avoid heavy lifting for approximately two weeks as there are fascial sutures in the belly button, and excessive force may result in a port site hernia.

Is additional training necessary for laparoscopic surgery?

Minimally invasive surgery has emerged as a competitive surgical sub-specialty, as it has been recognized that there is indeed a learning curve associated with mastery of the more complex advanced procedures.  For a basic procedure like laparoscopic cholecystectomy, the learning curve ranges from 10 to 75 procedures. Most surgery residents receive adequate training in the basic laparoscopic procedures of appendectomy, hernia, and cholecystectomy during their general surgery residency, and further advanced training is not necessary. 

However, proficiency in many advanced procedures requires that new skills must be acquired, perfected and maintained as new techniques are introduced.   General surgical residents who wish to focus on advanced laparoscopic surgery complete an additional one to two years of fellowship training after their surgical residency, which focuses on the skills to perform advanced laparoscopic procedures such as gastric bypass, Nissen fundoplication, and laparoscopic colectomy. 

Many of the pioneers and most skilled laparoscopic surgeons did not complete fellowship training, thus specific licensing or credentialing to perform laparoscopy are not formally required.  While extra training is of benefit, it is not mandatory.  A number of well structured, intensive, continuing medical education courses nationally are available, and there is particular interest in the use of simulators and specialized virtual reality training to improve physicians' proficiency in advanced laparoscopic surgery.

The future of laparoscopic surgery: robotic and NOTES surgery

The field of laparoscopic surgery continues to evolve with current research emphasis on continued miniaturization, the use of fewer ports, and the possibility of scarless surgery.  Two key areas for future development are: 1) Natural Orifice Transluminal Endoscopic Surgery (NOTES) and 2) robotic surgery (Da Vinci).

1) NOTES:  The goal is to use natural orifices (mouth, anus, vagina) to pass instruments into the peritoneal cavity to avoid any visible external scars on the patient.  In 2005, the transgastric removal of an appendix through the stomach was reported in India.  In 2007 the removal of a gallbladder through a transvaginal approach was first reported.  As of 2008 NOTES is still considered experimental, but it is an area of intensive research worldwide.

2) Robotic surgery:  The limitations of instrumentation and optics have stimulated the development of robotic assisted surgery, which seeks to restore the traditional three dimensional visualization and axes of motion in an ergonomic fashion. The first FDA approved robot was the DA VINCI, which features 3-D stereoscopic vision and increased degrees of freedom with the intent to allow easier suturing, the elimination of tremor, and a shortening of the leaning curve. One limitation is the estimated cost of $1.5 million per device.

Robotic surgery has important potential military applications, as it could allow mobile medical care while keeping trained surgeons safe from the battlefront.  It may represent a potential solution in underdeveloped nations to increase access to surgical care, by allowing a single central hospital and surgeon to operate several remote machines at distant locations via telesurgery. The first telerobotic transatlantic surgery was a laparoscopic gallbladder removal by Dr. Michel Gagner performed in New York’s Mount Sinai Hospital who controlled the robot that removed the gallbladder on a French woman at the Louis Pasteur University in Strasbourg, France in September 2001.[i]

Conclusions:

Laparoscopy has revolutionized the practice of surgery, and is now a fundamental component in the contemporary practice and training of surgeons. 

For some procedures the benefit of laparoscopy is clearly apparent, but patients should also recognize that laparoscopic surgery is not appropriate for every operation.  Some patients will continue to require traditional open surgery.  A key principle is that laparoscopy only provides an alternate means of doing the same procedures as in open surgery, and the primary benefit is in quality of life. A principal challenge is to ensure that new techniques are developed in a safe, collaborative, and ethical manner.  Data from prospective randomized trials for many procedures is still accruing, and patients must consider the risks of complications resulting from the introduction of new technologies and equipment.  The risks are also greater early in an individual surgeon's experience with a new procedure, and the risks of serious complications can never be eliminated.  Patients should be aware that for advanced laparoscopic procedures the need for a referral to an expert surgeon may be necessary.  Ultimately, the risk to benefit ratio for each individual procedure depends on a number of factors, including surgeon experience, patient preference, costs, the patient's medical condition, and the availability of specialized technology and equipment.

Weblinks:

http://jama.ama-assn.org/cgi/reprint/287/3/402.pdf

Laparoscopy and cancer surgery:

http://www.cancernews.com/articles/laparoscopiccancersurgery.htm

A review of trocar injuries by the FDA:

http://www.fda.gov/cdrh/medicaldevicesafety/stamp/trocar.html

References:

Neumayer L, et al. (2004). Open mesh versus laparoscopic mesh repair of inguinal hernia. New England Journal of Medicine, 350(18): 1819–1827.
Way LW, Stewart L, Gantert W, Liu K, Lee CM, Whang K, Hunter JG.  Causes and prevention of laparoscopic bile duct injuries: analysis of 252 cases from a human factors and cognitive psychology perspective.  Ann Surg. 2003 (4): 460-9.
Bhoyrul S, Vierra MA, Nezhat CR, Krummel TM, Way LW.  Trocar injuries in laparoscopic surgery.  J Am Coll Surg. 2001 192 (6): 677-83.

McCormack K, et al. (2006). Laparoscopic techniques versus open techniques for inguinal hernia repair. Cochrane Database of Systematic Reviews (1). Oxford: Update Software.

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[i] Kent H.  Hands across the ocean for world’s first trans-Atlantic surgery.  CMAJ 2001; 165: 1374.