Laparoscopic Surgery

Dr. Rakesh Durkhure

Laparoscopy is a procedure to look inside your stomach by using a laparoscope. A laparoscope is like a thin telescope with a light source. It's used to light up and magnify the structures inside the stomach. A laparoscope is passed into the stomach through a small slit( cut) in the skin. A laparoscopy may be done to find the cause of symptoms similar to abdominal pain, pelvic pain, or swelling of the stomach or pelvic region. It may also be done if a former test such as an X-ray or scan has linked a problem within the abdomen or pelvis. Laparoscopy enables a doctor to see easily inside your abdomen. Some common conditions which can be seen by laparoscopy include

  1. Endometriosis
  2. Pelvic inflammatory disease
  3. Ectopic pregnancy
  4. Ovarian cyst
  5. Assessing fallopian tube conditions
  6. Appendicitis

In addition to simply looking within, a doctor can also use fine instruments which are passed into the abdomen through another small slit in the skin. The used instruments are used to cut, trim, biopsy, and grab tissues inside the abdomen. This laparoscopic surgery is occasionally called ‘ keyhole surgery' or' minimally invasive surgery. Laparoscopic surgery can be used for various procedures. Some generally performed operations include-

Removal of the gallbladder. This is occasionally called a laparoscopic cholecystectomy or' lap choly' for short. It's now the most common way for a gallbladder to be removed.

  1. Hernia repairs
  2. Removal of the appendix
  3. Removal of parts of the intestines
  4. Female sterilization
  5. Treating ectopic pregnancy
  6. Removal of areas of endometriosis
  7. Division of scar tissues around ovaries and fallopian tubes
  8. Removal of fibroids
  9. Removal of the womb and ovaries

In general, compared with traditional surgery, with laparoscopic surgery, there's generally

  1. Lesser pain following the procedure.
  2. Lesser risk of complications.
  3. A shorter hospital stay and a quicker recovery.
  4. A much smaller scar.

Laparoscopy and laparoscopic surgery are generally done whilst you're asleep under general anesthesia. The skin over the abdomen is cleaned. The surgeon or gynecologist also makes a small incision( cut) about 1- 2 cm long near the navel( belly button). Some gas is fitted through the cut to blow out the abdominal wall slightly. This makes it easier to see the internal organs with the laparoscope which is gently pushed through the incision into the abdominal hollow. The surgeon or gynecologist also looks down at the laparoscope or looks at pictures on a television monitor connected to the laparoscope.However, one or further separate small incisions are made in the abdominal skin, If you have a surgical procedure. These allow thin instruments to be pushed into the abdominal cavity. The surgeon or gynecologist can see the ends of these instruments with the laparoscope and so can perform the needed procedure. When the surgeon or gynecologist is finished, the laparoscope and other instruments are removed.

The incisions are stitched and dressings are applied.

  1. Operations gaining acceptance
  2. Diagnostic Laparoscopy

Laparoscopic surgery encompasses a spectrum of basic to advanced procedures. As a diagnostic tool, laparoscopy permits the exploration of the abdomen without the morbidity of a laparotomy incision. Although CT, MR imaging, and transabdominal sonography frequently do not show tumors less than 1-2 cm in diameter, laparoscopy detects metastases as small as 1 mm in diameter on peritoneal surfaces. Furthermore, direct laparoscopic guidance ensures safer, more accurate tissue sampling than percutaneous biopsy. Laparoscopic ultrasonography allows surgeons to image past organ surfaces and delineate anatomy more accurately. We routinely use laparoscopic sonography during abdominal explorations to teach residents sonographic interpretation. In our hospital, sonograms are transmitted from the operative suite to the radiologist’s office for a definitive interpretation of uncertain findings. In trauma, a surgical dictum has been to explore all gunshot wounds of the abdomen. With a small laparoscope inserted under local anesthesia in the emergency department, surgeons can evaluate tangential gunshot wounds and stab wounds in the abdomen. Patients with wounds that do not penetrate the abdominal fascia may be conservatively managed, and unnecessary laparotomies avoided. Wounds identified at Laparoscopy also have been repaired laparoscopically. Diagnostic laparoscopy for trauma remains controversial, however, because retroperitoneal wounds, such as duodenal injuries, may not be recognized and go untreated. A combined approach in the future with laparoscopy to examine the peritoneum and CT to image the retroperitoneum may increase diagnostic accuracy.

1. Cholecystectomy

Laparoscopy is useful for more than diagnosis. The design of instrumentation, clip appliers, and stapling devices has simplified the removal of many diseased organs. The first laparoscopic operation to gain widespread acceptance in the United States was cholecystectomy. By 1992, more than 80% of all cholecystectomies were performed laparoscopically. Through four ports (5-10 mm), the gallbladder is dissected from the hepatic fossa. The cystic duct and artery are clipped and divided, and the gallbladder is removed through the umbilical port incision. Recently published randomized prospective studies have shown laparoscopic cholecystectomy to decrease postoperative pain, shorten hospital stays to less than 24 hr, and return the patient to full activity within 1 week. With experience, the technical complications, especially bile duct injuries, have decreased, demonstrating the learning curve for laparoscopic procedures. In addition to lower morbidity and mortality, laparoscopic cholecystectomy also may be less expensive than open cholecystectomy. Intraoperative cholangiography helps delineate biliary ductal anatomy and prevent iatrogenic injury. We routinely obtain cholangiograms to attain anatomic information and for training purposes. Fluoroscopic images are transmitted in real-time to a gastrointestinal radiologist.The radiologist and surgeon, via an intercom, communicate during the injection of contrast material and together identify anomalous anatomy and filling defects suggestive of abnormalities. In this manner, costly operative time is not squandered, and patients benefit from the radiologist’s and surgeon’s expertise during the operation. In the author’s personal series (NJS), more than 800 laparoscopic cholecystectomies have been performed since November 1989. There has been no mortality and a conversion rate of 2.5% to open cholecystectomy. Major morbidity has occurred in 0.3% of patients. Common bile duct injury is rare and has occurred in 0.2% of these patients. However, other series of laparoscopic cholecystectomy have reported rates of bile duct injury of 0.5% or greater, and a state-wide survey estimated the frequency of this potentially devastating complication to be 7 or 8 times higher than with open cholecystectomy.The radiologist plays an important role in the evaluation and management of bile duct injury.

2. Appendectomy

Laparoscopic appendectomy was first performed by a gynecologist in 1983. A randomized prospective study in the United Kingdom showed laparoscopic appendectomy to decrease pain, expedite hospital discharge, and cause fewer infections. Other theoretical advantages include fewer postoperative adhesions and a lower frequency of intestinal obstruction. When compared with a standard McBurney incision, a more thorough abdominal exploration is also possible laparoscopically. In women, for example, the adnexa is inspected and many gynecologic problems that may account for pain in the right lower quadrant can be excluded. During a laparoscopic appendectomy, the appendiceal stump may be isolated and closed with a preformed loop ligature or alternatively ligated and divided with a stapler. The appendix is placed in a plastic pouch to prevent contamination before it is removed through a port. Despite the shorter hospital stay, laparoscopic appendectomy appears to offer no overall medical cost savings.

3. Inguinal Hernia Repair

Laparoscopic inguinal herniorrhaphy departs from the principle of reproducing the open version of the operation laparoscopically. The first inguinal hernia repairs were done by plugging the fascial defect with a wad of prosthetic mesh or directly closing the defect under undue tension. These approaches frequently resulted in recurrence rates far greater than historical controls and for the most part, have been abandoned. Many surgeons now adopt a traditional Stoppa repair (resurfacing the inguinal floor with prosthetic mesh) by using laparoscopic techniques and have achieved good preliminary results. The peritoneum overlying the hernia is incised, and the inguinal floor defect is covered with mesh that is secured with staples. The peritoneum is then closed to diminish the formation of adhesions between the mesh and bowel. Large reports with short-term follow-up have shown an acceptable recurrence rate and an earlier return to full physical activity when this technique is used. Open hernia repairs are generally performed under local anesthesia as an outpatient procedure. Laparoscopic repairs nearly always require general anesthesia, adding to the risks of the procedure and limiting its indications. Nonetheless, laparoscopic hernia repairs seem appropriate in certain settings. We believe that laparoscopic herniorrhaphies are most beneficial for healthy patients with bilateral defects who would be incapacitated with bilateral groin incisions. Additionally, recurrent hernias previously repaired conventionally may be better repaired the second time laparoscopically through virgin tissue rather than scar tissue. Other patients who would not comply with the traditional wisdom of “don’t lift anything heavier than a telephone book for 6 weeks,” also are suitable for a tension-free laparoscopic repair, which does not rely on suture strength to hold the repair together in the early postoperative period. For laparoscopic herniorrhaphy to gain full acceptance, long-term follow-up and randomized comparisons with traditional herniorrhaphy will be needed. Moreover, laparoscopic hernia repairs will need to become less costly.

4. Exploration of the Common Bile Duct

During laparoscopic cholecystectomy, 5-15% of patients are found to have choledocholithiasis. When discovered by intraoperative cholangiography or sonography, stones in the common bile duct may be removed laparoscopically. Exploration of the common bile duct with a 7- to 10-French choledochoscope and stone removal with baskets may be successfully performed via the cystic duct in 80-90% of patients [16]. Larger or impacted stones may require a choledochotomy and placement of a T-tube. Expertise is needed to manipulate the choledochoscope and suture the choledochotomy closed. As many surgeons have not yet acquired these skills, they either convert to open laparotomy or rely on ERCP with sphincterotomy and stone extraction.

5. Ulcer Disease

Peptic ulcers are generally treated successfully with antisecretory medications (histamine-receptor antagonist or omeprazole). Patients with biopsy-proven Helicobacter pylon also should be treated with antibiotics. Ulcers that are refractory to medical therapy on complications of ulcers, such as hemorrhage and perforation, have been treated laparoscopically with good results. Perforations may be patched with omentum. Laparoscopic truncal vagotomy on variations of highly selective vagotomy boasts nearly complete ulcer healing and few complications. However, most reports of laparoscopic ulcer surgery are anecdotal and have minimal follow-up data.

6. Gastroesophageal Reflux Disease

Heartburn and indigestion are common complaints among Americans. A recent randomized prospective study showed that conventional open-operative therapy resulted in more effective treatment of complicated gastroesophageal reflux than medical management with H2 blockers. However, few patients were treated operatively due to the perceived morbidity of the surgery. Laparoscopic Nissen fundoplication has demonstrated excellent results in two large series. A Nissen fundoplication is done by wrapping the gastric fundus 360° around the esophageal sphincter. Postoperatively, hospital discharge is generally within 3 days, and more than 90% of patients report complete relief of symptoms. Laparoscopic antireflux surgery appears to be an ideal application of the minimally invasive approach to abdominal disease.

7. Resection of Colon

Laparoscopic bowel resections has been performed to treat benign and malignant diseases. Using laparoscopic techniques, the colon is mobilized and the mesentery is divided. The segment of the colon may be exteriorized through a small incision (laparoscopy-assisted), resected, and anastomosed before being dropped back into the abdominal cavity. Alternatively, resection and anastomosis may be performed totally intracorporeally. The extent of tissue margins and the number of lymph nodes included in the resection specimen suggest that laparoscopic techniques do not compromise an en bloc cancer operation, although long-term follow-up will be necessary for confirmation. Patients usually are discharged from the hospital within 4 days rather than the 7 days required after an open operation. However, potential savings resulting from shorter hospitalization are offset by longer operative times and expensive laparoscopic equipment. Several case reports of tumor metastases to trocar sites after laparoscopy-assisted surgery have raised concern that this approach may spread tumors mechanically. Multi-institutional randomized trials comparing laparoscopic with open colectomy for resectable colon cancers are currently underway.

8. Anecdotal

Many other operations are being studied to determine the overall feasibility of minimally invasive techniques. We have had a laboratory and clinical experience with adrenalectomy, splenectomy, pancreatectomy, gastrectomy, and biliary bypass. Other investigators have performed esophagectomy and pancreaticoduodenectomy (Gagner M, unpublished data). However, just because an operation can be performed with a laparoscope, the question “should we?” lingers. For this, we must await randomized prospective outcome studies, longer periods of postoperative follow-up, and sophisticated cost-benefit analyses.

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