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 (C02, from leaking)
four incisions of 0.5-1.0 cm 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 he removed from the abdomen by suctioning out the bile and then removing the deflated gallbladder through the 1 cm incision at the patient’s navel. The length of postoperative stay in the hospital is minimal, and same-day discharges are possible in cases of early morning procedures.
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, C02 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
There are a number of advantages to the patient with laparoscopic surgery versus an open procedure. These include:
- Reduced hemorrhaging, which reduces the chance of needing a blood transfusion.
- Smaller incision, which reduces pain and shortens recovery time, as well as resulting in less post-operative scarring.
- Less pain, leading to less pain medication needed.
- Although procedure times are usually slightly longer, hospital stay is less. And often with a same day discharge which leads to a faster return to everyday living.
- Reduced exposure of internal organs to possible external contaminants thereby reduced risk of acquiring infections.
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 have below average body mass index 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.
- 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 can also lead to peritonitis. This risk is reduced through the use of bipolar. instead of monopolar (patient-current-return) electrosurgical tools.
- There may be an increased risk of hypothermia and peritoneal trauma due to increased exposure to cold, dry gases during insufflation. The use of heated and humidiﬁed CO2 may reduce this risk
- 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 C02 introduced into the abdominal cavity is removed through the incisions during surgery. Gas tends to rise. and when a pocket of C02 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 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.