A8. Indications and contraindications of laparoscopic surgery. About laparoscopic techniques in general

Laparoscopic surgery is a minimally invasive technique used to perform surgery within the abdominal cavity. It’s a less invasive alternative to open surgery (laparotomy), as only smaller “keyhole” incisions are made on the abdomen. It involves inserting a laparoscope into the abdominal cavity, which projects images onto external screens, allowing the surgeon to visualise the abdominal organs. The laparoscope has a light source to illuminate the otherwise dark abdominal cavity.

Gas inflation

The abdominal cavity is inflated with gas to allow for greater visualisation, a process which establishes pneumoperitoneum. The cavity is inflated with CO2 gas at a pressure of 12 – 15 mmHg. After the surgery, as much CO2 as possible is removed. The remaining CO2 is slowly resorbed by the peritoneum.

Entry into the abdomen

Multiple laparoscopic entry techniques used to pierce the abdominal wall and gain abdominal access. This is the point of laparoscopy in which most complications related to the procedure occurs. The laparoscope is inserted within or immediately next to the umbilicus. The two most important are:

Using a Veress needle (a Hungarian invention of course), is the oldest and most traditional method. A Veress needle consists of an outer sharp cannula and an inner dull stylet. The sharp cannula is used to penetrate the abdominal wall, after which the spring-loaded stylet springs forward and prevents sharp injury to abdominal organs. Gas is then insufflated through the Veress needle
Open (Hasson) entry involves making a regular surgical incision through the abdominal wall, inserting a blunt trocar under direct visualisation, providing gas insufflation, and then inserting the laparoscope.

The primary port is inserted into the umbilicus for the laparoscope, but additional ancillary ports are needed to insert other necessary instruments, like instruments for grasping, holding, cutting, coagulation, aspiration, etc. Whether two or three ancillary ports are necessary depends on the type of surgery and the preference of the surgeon.

The Veress needle was initially developed to collapse the lungs of tuberculosis patients, with the intention that this would allow the TBC lesions to heal. It was later repurposed for laparoscopic surgery.

If, during a laparoscopic surgery, the surgeon decides that laparoscopy is not fit for the surgery (due to newly discovered lesions or intraoperative complications), the laparoscopy may be converted to laparotomy (open surgery).

Variations

Single incision laparoscopic surgery (SILS) or laparoscopic endoscopic single site surgery (LESS) are recent approaches where only a single access site is used. This gives a better cosmetic result, but is more difficult, requires more training, and takes longer.

Natural orifice transluminal endoscopic surgery (NOTES) is another recent technique where natural orifices are used as entry points, thereby allowing for surgery without any external scars. Possibilities include transvaginal cholecystectomy, transgastric appendectomy, etc.

Surgeries commonly performed laparoscopically rather than open

Nearly all surgeries in the abdomen and pelvic can be performed laparoscopically. In most cases, laparotomy is preferred in acute cases, and laparoscopy is preferred in elective cases.

Contraindications

Haemodynamic instability
Dilated bowels due to ileus
Increased intracranial pressure

Advantages and disadvantages

Advantages

Decreased postoperative pain
Earlier return to normal activities after surgery
Fewer postoperative complications
Shorter hospital stay (same-day surgery is possible)
Smaller scars
More cost effective

Disadvantages

More technically difficult to perform, due to loss of depth perception (as the field of view is two-dimensional), limited field of view, limited working space, the fulcrum effect (i.e. hand motions are paradoxical, so left is right, down is up, etc.)
Complications (haemorrhage, bowel injury) are more difficult to control

Complications

Post-operative shoulder pain is common and occurs due to CO2 irritating the phrenic nerve, causing referred pain to the shoulder.

True complications are very rare. Most occur during the most dangerous step, the laparoscopic entry. Possibilities occlude:

Vascular injury (mostly aorta)
Visceral injury (bladder or bowel)
Solid organ injury
Gas embolism

Routinely placing a bladder catheter in patients undergoing laparoscopic surgery reduces the risk for bladder puncture. Potentially life-threatening complications include perforation of bowel or major arteries.