Laparoscopic surgery

Cholecystectomy as seen through a laparoscope

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Editor-In-Chief: C. Michael Gibson, M.S., M.D. [1]; Associate Editor-In-Chief: Ahmad H. Othman, M.D.[2]

Overview

Laparoscopic surgery, also called minimally invasive surgery (MIS), bandaid surgery, keyhole surgery, or pinhole surgery is a modern surgical technique in which operations in the abdomen are performed through small incisions (usually 0.5-1.5cm) as compared to larger incisions needed in traditional surgical procedures. Laparoscopic surgery includes operations within the abdominal or pelvic cavities, whereas keyhole surgery performed on the thoracic or chest cavity is called thoracoscopic surgery. Laparoscopic and thoracoscopic surgery belong to the broader field of endoscopy.

The key element in laparoscopic surgery is the use of a laparoscope: a telescopic rod lens system, that is usually connected to a video camera (single chip or three chip). Also attached is a fiber optic cable system connected to a 'cold' light source (halogen or xenon), to illuminate the operative field, inserted through a 5 mm or 10 mm cannula to view the operative field. The abdomen is usually insufflated with carbon dioxide gas to create a working and viewing space. The abdomen is essentially blown up like a balloon (insufflated), elevating the abdominal wall above the internal organs like a dome. The gas used is CO₂, as it is common to the human body and can be removed by the respiratory system if it absorbs through tissue. It is also non-flammable, which is important due to the fact that electrosurgical devices are commonly used in laparoscopic procedures.

History

It is difficult to credit one individual with the pioneering of laparoscopic approach. In 1902 Georg Kelling of Dresden performed the first laparoscopic procedure in dogs and in 1910 Hans Christian Jacobaeus of Sweden reported the first laparoscopic operation in humans. In the ensuing several decades, numerous individuals refined and popularized the approach further for laparoscopy. It was not until 1985 when, with the advent of a new and specialized computer chip television camera, the approach was broadened in scope to include surgical resection of organs such as gall bladder. The first successful laparoscopic removal of gall bladder in humans was reported in 1987 in France. The introduction of computer chip television camera was a seminal event in the field of laparoscopy. This innovation in technology provided the means to project a magnified view of the operative field onto a monitor, and at the same time freed both the operating surgeon's hands, thereby facilitating performance of complex laparoscopic procedures. Prior to its conception, laparoscopy was a surgical approach with very limited application and used mainly for purposes of diagnosis and performance of simple procedures in gynecologic applications.

The introduction in 1990 of a laparoscopic clip applier with twenty automatically advancing clips (rather than a single load clip applier that would have to be taken out, reloaded and reintroduced for each clip application) made surgeons more comfortable with making the leap to laparoscopic cholecystectomies (gall bladder removal). Dr. Eddie Joe Reddick was the surgical guru for this procedure in the U.S., and he played a huge role in training the first generation of laparoscopic general surgeons.

Procedures

Laparoscopic cholecystectomy is the most common laparoscopic procedure performed. In this procedure, 5-10mm diameter instruments (graspers, scissors, clip applier) can be introduced by the surgeon into the abdomen through trocars (hollow tubes with a seal to keep the CO₂ from leaking). Rather than a minimum 20cm incision as in traditional cholecystectomy, four incisions of 0.5-1.0cm will be sufficient to perform a laparoscopic removal of a gallbladder. Since the gall bladder is similar to a small balloon that stores and releases bile, it can usually be removed from the abdomen by suctioning out the bile and then removing the deflated gallbladder through the 1cm incision at the patient's navel. The length of postoperative stay in the hospital is usually 2-3 days.

In certain advanced laparoscopic procedures where the size of the specimen being removed would be too large to pull out through a trocar site, as would be done with a gallbladder, an incision larger than 10mm must be made. The most common of these procedures are removal of all or part of the colon (colectomy), or removal of the kidney (nephrectomy). Some surgeons perform these procedures completely laparoscopically, making the larger incision toward the end of the procedure for specimen removal, or, in the case of a colectomy, to also prepare the remaining healthy bowel to be reconnected (create an anastomosis). Many other surgeons feel that since they will have to make a larger incision for specimen removal anyway, they might as well use this incision to have their hand in the operative field during the procedure to aid as a retractor, dissector, and to be able to feel differing tissue densities (palpate), as they would in open surgery. This technique is called hand-assist laparoscopy. Since they will still be working with scopes and other laparoscopic instruments, CO2 will have to be maintained in the patient's abdomen, so a device known as a hand access port (a sleeve with a seal that allows passage of the hand) must be used. Surgeons that choose this hand-assist technique feel it reduces operative time significantly vs. the straight laparoscopic approach, as well as providing them more options in dealing with unexpected adverse events (i.e. uncontrolled bleeding) that may otherwise require creating a much larger incision and converting to a fully open surgical procedure.

Conceptually, the laparoscopic approach is intended to minimise post-operative pain and speed up recovery times, while maintaining an enhanced visual field for surgeons. Due to improved patient outcomes, in the last two decades, laparoscopic surgery has been adopted by various surgical sub-specialties including gastrointestinal surgery (including bariatric procedures for morbid obesity), gynecologic surgery and urology. Based on numerous prospective randomized controlled trials, the approach has proven to be beneficial in reducing post-operative morbidities such as wound infections and incisional hernias (especially in morbidly obese patients), and is now deemed safe when applied to surgery for cancers such as cancer of colon.

The restricted vision, the difficulty in handling of the instruments (new hand-eye coordination skills are needed), the lack of tactile perception and the limited working area are factors which add to the technical complexity of this surgical approach. For these reasons, minimally invasive surgery has emerged as a highly competitive new sub-specialty within various fields of surgery. Surgical residents who wish to focus on this area of surgery, gain additional training during one or two years of fellowship after completing their basic surgical residency.

The first transatlantic surgery (Lindbergh Operation) ever performed was a laparoscopic gallbladder removal.

Advantages

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

• reduced blood loss, which equals less risk of needing a blood transfusion.
• smaller incision, which equals less pain and shorter recovery time.
• less pain, which equals less pain medication needed.
• Although procedure times are usually slightly longer, hospital stay is less, and often with a same day discharge which equals a faster return to everyday living.
• reduced exposure of internal organs to possible external contaminants thereby reduced risk of acquiring infections.
• can be used in Gamete intrafallopian transfer (GIFT) surgery to put the eggs back into the fallopian tubes

Risks

Some of the risks are briefly described below:

• The most significant risks are from trocar injuries to either blood vessels or small or large bowel. The risk of such injuries is increased in patients who are obese or have a history of prior abdominal surgery. The initial trocar is typically inserted blindly. While these injuries are rare, significant complications can occur. Vascular injuries can result in hemorrhage that may be life threatening. Injuries to the bowel can cause a delayed peritonitis. It is very important that these injuries be recognized as early as possible. There is an excellent review of trocar injuries by the FDA at: http://www.fda.gov/cdrh/medicaldevicesafety/stamp/trocar.html
• Some patients have sustained electrical burns unseen by surgeons who are working with electrodes that leak current into surrounding tissue. The resulting injuries can result in perforated organs and lead to peritonitis.
• Many patients with existing pulmonary disorders may not tolerate pneumoperitoneum (gas in the abdominal cavity), resulting in a need for conversion to open surgery after the initial attempt at laparoscopic approach.
• Not all of the CO₂ introduced into the abdominal cavity is removed through the incisions during surgery. Gas tends to rise, and when a pocket of CO₂ rises in the abdomen, it pushes against the diaphragm (the muscle that separates the abdominal from the thoracic cavities and facilitates breathing), and can exert pressure on the phrenic nerve. This produces a sensation of pain that may extend to the patient's shoulders. For an appendectomy, the right shoulder can be particularly painful. In some cases this can also cause considerable pain when breathing. In all cases, however, the pain is transient, as the body tissues will absorb the CO₂ and eliminate it through respiration.
• Coagulation disorders and dense adhesions (scar tissue) from previous abdominal surgery may pose added risk for laparoscopic surgery and are considered relative contra-indications for this approach.
• Patients can often have trouble walking after surgery for a few days

Laparoscopic surgery in pregnancy

Laparoscopic surgery can be performed safely and effectively in pregnant women. The benefits and risks of laparocopic surgery in pregnancy are similar to those in non-pregnant women in addition to the fetal risks.

Special considerations:

1. Timing of procedure: the ideal time for performing a laparoscopic surgery is similar to other surgical procedures, early during second trimester.
2. Patient position: the ideal position in pregnant woman is left recumbent position to avoid compression of the vena cava and aorta by the gravid uterus.
3. DVT prophylaxis: Pregnancy is recognized as a hypercoagulable state thus DVD prophylaxis should be used during the procedure. Sequential Compression Devices are adequate for most cases but in cases of high-risk patients, anti coagulation should be administered.
4. Trocar placement: modification of port sides is necessary when the uterus is significantly enlarged.
5. Intra-abdominal pressure: Intra-abdominal pressure should be maintained at a lower level through out the surgery as to not decrease the blood flow to the placenta.
6. Procedure time: it is important to minimize the procedure time in order to decrease the risk of complications, especially for the fetus.

Robotics and technology

This is a laparoscopic robotic surgery machine developed by Intuitive Surgical.

The process of minimally invasive surgery has been augmented by specialized tools for decades. However, in recent years, electronic tools have been developed to aid surgeons. Some of the features include:

• Visual magnification - use of a large viewing screen improves visibility
• Stabilization - Electromechanical damping of vibrations, due to machinery or shaky human hands
• Simulators - use of specialized virtual reality training tools to improve physicians' proficiency in surgery, examples are: (example 1), (example 2) and (example 3).
• Reduced number of incisions

Robotic surgery has been touted as a solution to underdeveloped nations, whereby a single central hospital can operate several remote machines at distant locations. The potential for robotic surgery has had strong military interest as well, with the intention of providing mobile medical care while keeping trained doctors safe from battle.

See also

• Arthroscopic surgery
• NOTES (Natural Orifice Transluminal Endoscopic Surgery)
• Albulassim, Arab physician

References

• Surgical Device Poses a Rare but Serious Peril from the New York Times (Registration required)
• "Laparoscopy in Urology". Journal of Minimal Access Surgery. 1 (4). 2005.
• Intuitive Surgical - Developer of robotic surgery machines.
• Pinhole surgery or microlaparoscopy
• [3]