Comprehensive Laparoscopic Surgery

Comprehensive

Laparoscopic Surgery Editors Ajay Kriplani, Parveen Bhatia, Arun Prasad, Deepak Govil, H. P. Garg

FIAGES Book.indb 1

3/23/2007 11:04:49 AM

© Copyright 2007 Indian Association of Gastro Intestinal Endo Surgeons (IAGES), IAGES Secretariat Global Hospital & Endosurgery Institute, 307, 308, Ambika Vihar, New Delhi-110087. All rights reserved. No part of this book, including interior design, cover design and icons, may be reproduced or transmitted in any form, by any means (electronic, photocopying, recording or otherwise) without the prior written permission of the publisher / author / editors. Trademarks All brand names and product names used in this book are trademarks, registered trademarks or tradenames of their respective holders. Design i-Links ‘n’ Grafix Pvt. Ltd. I-48a, Kirti Nagar, New Delhi - 110015 email: [email protected]   web: www.ilng.in Ph: 41424288, 87 Printed at Sagar Printers, 1880 Udai Chand Marg, Kotla Mubarakpur, Near South Extension-I, New Delhi Ph: 24698383 e-mail: [email protected]

FIAGES Book.indb 2

3/23/2007 11:04:49 AM

Foreword From the tiny acorn does the tall oak tree grow. A humble small beginning can snowball into a giant new form if its growth is pursued with dedication, commitment, courage and passion. In 1993, a small group of 30 odd surgeons from all over the country met in Mumbai and set up the Indian Association of Gastrointestinal Endo-Surgeons. The avowed purpose of the Association was to promote and nurture the growth and spread of Minimal Access Surgery throughout India so as to give the obvious and profound benefits of Minimal Access Surgery to all our people in all places. Never in their wildest imagination could the Founder-Members have dreamt that this surgery would spread so far, penetrate so deep into small towns of India and reach such a high standard of performance as to place India in the forefront of laparoscopic endeavour. IAGES members from all over India, right from Guwahati, Srinagar, Jammu to Salem, Coimbatore, Nagercoil and all over have spread and advanced MAS in 14 short years over the country and added voluminously to the world literature and teaching methodology on this subject. Since its inception, IAGES has set the bench mark of democratic functioning—biannual election to Office by secret postal ballot, involvement of the entire country in its active leadership, stepping back completely of senior members to hand over the running of the Association to

FIAGES Book.indb 3

the next group of younger, more energetic and dynamic members. The strength of the Association has received world recognition both by the stature of the Faculty at its numerous Conferences, as also by being unanimously accepted as a Member Society of the International Federation of Societies of Endoscopic Surgeons (IFSES). Having spread MAS all over the country, the entire current Executive Committee with Dr. Kuldip Singh as President and Dr. Parveen Bhatia as Secretary have realised the value and wisdom of ensuring that all surgeons doing all laparoscopic surgery have, each one of them, attained a certain level of skill and knowledge to ensure the safety and well-being of every single patient. This is the raison d’être of this Fellowship Course with Dr. Ajay Kriplani as its Convenor. The purpose of the Course is not to claim that IAGES is a superior, regulatory body, not to drum up Membership, not to offer a piece of paper, at a price, with a few signatures on it—the sole intent of this Fellowship Course is to further the primary purpose of the Founder Members by spreading MAS to the smallest moffisul and ensuring a high uniform quality to our surgery both by teaching as also by personal example, stressing not just the technical advances but also the humane aspects of this surgery. Dr. Tehemton E. Udwadia

Founder President – IAGES

3/23/2007 11:04:49 AM

FIAGES Book.indb 4

3/23/2007 11:04:49 AM

Foreword In the past decade, since the inception of minimal access surgery, there have been major advances in this field. The excitement that general surgeons first experienced with Laparoscopic Cholecystectomy has been transplanted into a variety of other specialties, all of which have found promising applications for minimal access surgery. Almost all the surgeries are being done with the minimal invasive technique, seeing the obvious advantages it provides to the patients. Basic principals of the surgery remain the same whereas the approach has been changed. To start with it was through experience and existing skills that surgeons had to utilize to master this technique. As we see now that minimal access surgery in itself has become a full specialty and with all the major changes in the legislation and patient expectations, more and more stress is being paid on the mentor training in the field of minimal access surgery. The specialty courses have already been started in many institutes across the country but even then, it needs continuous updating of the technique and skills to progress in the field and provide the best possible patient care. This series has been compiled keeping in view the common procedures and the common complications that occur during these procedures. This book will go a long way in guiding the surgeons to improve upon the technique, avoid the complications and provide the excellent results to their patients. Dr Kuldip Singh,

President, IAGES

FIAGES Book.indb 5

3/23/2007 11:04:49 AM

FIAGES Book.indb 6

3/23/2007 11:04:50 AM

Preface The thought to bring out this book was conceived while planning the first Fellowship Course of the IAGES at New Delhi. It was decided to request all the speakers to also write a chapter. The aim was to give detailed description about the topic which cannot be covered during the limited time of the lecture. Despite the short time, the authors responded promptly and have put in their best efforts to write about their specialised field of interests. The book includes 27 chapters ranging from basic to advanced laparoscopic procedures. It provides comprehensive theoretical as well as practical aspects of situations specially faced by the Indian surgeons. The articles have more than 450 endoscopic and graphic illustrations. The authors, Minimal Access Surgeons of eminence with specialised interests in the areas have significantly contributed to the development of Laparoscopic Surgery in India. The Comprehensive Laparoscopic Surgery is intended for the young and the experienced Laparoscopic Surgeons alike. This is only the beginning with a vision to transform into a textbook. Editors

FIAGES Book.indb 7

3/23/2007 11:04:50 AM

FIAGES Book.indb 8

3/23/2007 11:04:50 AM

Acknowledgements We are grateful to the President, Dr. Kuldip Singh and Executive Committee members of Indian Association of Gastro Intestinal Endo-Surgeons (IAGES) for entrusting us the responsibility of conducting the 1st Fellowship Course (FIAGES) from 29th March to 1st April, 2007 at New Delhi. The response of all the speakers and delegates for the course has encouraged us to compile the work into a book form ‘Comprehensive Laparoscopic Surgery’. We are thankful to all the authors who responded to our request of sending the complete text at such a short notice. The book Comprehensive Laparoscopic Surgery would not have seen the light of the day without the untiring efforts of Drs. Aloy Jyoti Mukherjee, Shyam Sunder Pachisia, Sushank Rastogi, Hari S. Sidhu, Daipayan Ghosh and Tarun Jain. We thank Mr. Arun Kumar and Mr. Amit Mattoo for their secretarial assistance. Mr. Manuj Bajaj and his team members Manoj Malik, Izzur Rahman, Rajesh Kumar, Ritesh Malhotra have done an excellent job in designing the book. We would definitely like to give complements to Mr. Bhupender Sagar and his team at Sagar Printers especially Mr. Chander Kant Pant. Ajay Kriplani, Parveen Bhatia, Arun Prasad, Deepak Govil, H. P. Garg

FIAGES Book.indb 9

3/23/2007 11:04:50 AM

FIAGES Book.indb 10

3/23/2007 11:04:50 AM

Contents Foreword by Dr. T. E. Udwadia Foreword by Dr. Kuldip Singh Preface Acknowledgements List of Contributors Chapter 1........................................................................................................................1 Landmark historic events, Endovision system: Maintenance and trouble shooting G. R.Verma, S.Thiagarajan Chapter 2........................................................................................................................9 Laparoscopic Hand Instruments, Accessories and Ergonomics Amitabh Goel Chapter 3........................................................................................................................20 Sterilization and Maintenance of Instruments & Equipment Deepraj S. Bhandarkar, Avinash N. Katara Chapter 4........................................................................................................................26 Energy sources in Laparoscopy and their optimal use Rajeev Sinha Chapter 5........................................................................................................................40 Endosuturing and Tissue Approximation in Laparoscopic Surgery Rajesh Khullar Chapter 6........................................................................................................................52 Physiology of Pneumoperitoneum and Anaesthesia in Laparoscopic Surgery V. Muralidhar

FIAGES Book.indb 11

3/23/2007 11:04:50 AM

Chapter 7........................................................................................................................57 Peritoneal Access and Creation of Pneumoperitoneum for Laparoscopic Surgery Zameer Pasha Chapter 8........................................................................................................................64 Operative Technique for Laparoscopic Cholecystectomy Tehemton E. Udwadia Chapter 9........................................................................................................................77 Difficult Laparoscopic Cholecystectomy Kuldip Singh, Ashish Ohri Chapter 10......................................................................................................................81 How to predict difficult Laparoscopic Cholecystectomy and when to convert? Subhash Khanna Chapter 11......................................................................................................................90 Detection and Management of CBD Stones in the Era of Laparoscopic Cholecystectomy Jyotsna S. Kulkarni Chapter 12......................................................................................................................95 Management of Post-operative Complications after Laparoscopy Cholecystectomy B. Krishna Rau Chapter 13......................................................................................................................100 Understanding Endoscopic Anatomy of Inguinal Region Parveen Bhatia Chapter 14......................................................................................................................119 Laparoscopic Trans Abdominal Pre-Peritoneal (TAPP) Repair of Inguinal Hernia A.K. Kriplani, Shyam S. Pachisia, Daipayan Ghosh Chapter 15......................................................................................................................131 Laparoscopic Inguinal Hernia Repair—Tep Technique Pradeep K. Chowbey Chapter 16......................................................................................................................135 Laparoscopic Appendicectomy M. G. Bhat Chapter 17......................................................................................................................140 Laparoscopic Oesophageal Procedure Minimally Invasive Surgery for Esophageal Achalasia K. Ravindranath

FIAGES Book.indb 12

3/23/2007 11:04:50 AM

Chapter 18......................................................................................................................149 Laparoscopy in Gastric Outlet Obstruction due to Peptic Ulcer Disease K. Ravindranath Chapter 19......................................................................................................................155 Laparoscopic Gastrectomy K. Ravindranath Chapter 20......................................................................................................................159 Laparoscopic Surgery for Colon and Rectal Cancer Deep Goel, Naresh Garg, V. K. Malik Chapter 21......................................................................................................................163 Laparoscopic Splenectomy Abhay N. Dalvi Chapter 22......................................................................................................................169 Laparoscopic Urological Surgery Rajesh Ahlawat Chapter 23......................................................................................................................178 Laparoscopic Adrenalectomy A.K. Kriplani, Hari S. Sidhu Chapter 24......................................................................................................................186 Laparoscopic Gynaecological Surgery for General Surgeon Pradeep Kumar Garg, Alka Kriplani Chapter 25......................................................................................................................198 Laparoscopic Adjustable Gastric Banding for Morbid Obesity A. K. Kriplani, Aloy J. Mukherjee, Daipayan Ghosh Chapter 26......................................................................................................................212 Laparoscopic Roux-en-Y Gastric Bypass M. Lakdawala, S. Goel, V. Lotwala Chapter 27......................................................................................................................221 Video Assisted Thoracic Surgery (VATS) Arun Prasad

FIAGES Book.indb 13

3/23/2007 11:04:50 AM

List of Contributors Aloy Jyoti Mukherjee

Abhay N. Dalvi

MS, Attending Consultant, Department of Laparoscopic and GI Surgery,

MS, Consultant GI & Laparoscopic Surgeon, Unit Chief, General Surgery,

Indraprastha Apollo Hospitals, Sarita Vihar, New Delhi-110076.

Associate Consultant Surgical Gastroenterology, Seth G.S. Medical College & KEM Hospital, Mumbai, Maharashtra.

[email protected]

[email protected]

Ajay Kumar Kriplani MS, Senior Consultant, Department of Laparoscopic and GI Surgery,

Alka Kriplani

Division of Bariatric Surgery, Indraprastha Apollo Hospitals, Sarita Vihar, New Delhi-110076.

All India Institute of Medical Sciences, Ansari Nagar (E), New Delhi-110029

M.D, FAMS, FICOG, FICMCH, FIMSA, Professor, Department of Obstretics & Gynaecology,

[email protected]

[email protected] [email protected] www.obesitysurgeries.com

Amitabh Goel

Avinash N. Katara

MS., FAIS, FICS, Senior Consultant & Incharge, Minimal Access Surgery,

MS, DNB, MNAMS, MRCS (Ed), Fellow-MIS (Singapore) Minimal Access, Obesity & General Surgeon,

Department of Minimal Access Surgery, P. D. Hinduja National Hospital & Research Centre, Mumbai-400016, Maharashtra. [email protected]

Choithram Hospital & Research Centre, Indore–452014, Madhya Pradesh. [email protected]

Arun Prasad

Ashish Ohri

MS, FRCS, FRCS (Ed), Senior Consultant Minimal Access Surgeon,

MS, Senior Resident,

Indraprastha Apollo Hospitals, Sarita Vihar, New Delhi–110076.

Department of Surgery, Dayanand Medical College & Hospital, Ludhiana, Punjab.

[email protected]

FIAGES Book.indb 14

www.surgerytimes.com

3/23/2007 11:04:50 AM

B. Krishna Rau

H. P. Garg

MS, FRCS (Eng and Ed), FRCS (Thailand), FIAMS (Hon), FACG, FICS, FIGSC, Professor Emeritus, Dr. MGR Medical University, Chennai,

MS, Senior Consultant, General & Laparoscopic Surgeon,

Consultant Surgeon, Cancer Institute, Chennai, Tamil Nadu.

Department of Surgery, Indraprastha Apollo Hospitals, Sarita Vihar, New Delhi-110076.

[email protected]

[email protected]

Deep Goel

Hari S. Sidhu

DNB, FRCS, Consultant, Minimal Invasive & Colorectal Surgery,

MS,

Sir Ganga Ram Hospital, New Delhi–110060.

Department of Laparoscopic and GI Surgery,

Senior Registrar,

goel _ [email protected]

Indraprastha Apollo Hospitals, Sarita Vihar, New Delhi-110076.

Deepak Govil

Jyotsna Kulkarni

MS, PhD (GI Surgery), Senior Consultant, Laparoscopic & Surgical Gastroenterologist,

MS., FRCS, Consultant, Minimal Access Surgery, Kulkarni Endo-Surgery Institute & Reconstructive Urology Centre,

Department of Surgical Gastroenterology, Indraprastha Apollo Hospitals, Sarita Vihar, New Delhi-110076.

Pune–411038, Maharashtra. [email protected]

[email protected]

www.kulkarniendosurgery.com

Deepraj S. Bhandarkar

K Ravindranath

MS, FRCS, FICS, FAIS, FACG, Consultant, Minimal Access Surgeon,

MS, FRCS (Ed), FCS (Glasgow), Minimal Access Surgeon & Surgical Gastroenterologist, Managing Director, Global Hospitals,

Department of Minimal Access Surgery, P. D Hinduja National Hospital & Research Centre, Mumbai-400016, Maharashtra.

Hyderabad–500004. Andhra Pradesh. hyd2 _ [email protected] [email protected]

[email protected] www.laparoscopyindia.com

Kuldip Singh

Daipayan Ghosh

MS, FRCS, Professor of Surgery,

DNB Student,

Dayanand Medical College & Hospital, Ludhiana–141002, Punjab.

Department of Laparoscopic and GI Surgery, Indraprastha Apollo Hospitals, Sarita Vihar, New Delhi-110076.

[email protected] [email protected]

[email protected]

MS, Chief, Minimal Access Surgery,

G. R. Verma MS, MNAMS, FICS, FRCS, Professor of Surgery,

Post Graduate Institute of Medical Research, Chandigarh–160023, Punjab.

Muffazal Lakdawala Saifee Hospital & Chief Bariatric Surgery, Dr. L. H Heeranandani Hospital, Mumbai–400008, Maharashtra. [email protected] www.obesenomore.com

[email protected]

M. G. Bhat MS, FRCS (England), FRCS (Ed), FICS, DMIRCSED (Infomatics), DMLE (Law) Consultant Gastroenterology & Laparoscopy,

Wockhardt Hospital, Bangalore–560025, Karnataka. [email protected]

FIAGES Book.indb 15

3/23/2007 11:04:50 AM

Naresh Garg

S. Thiagarajan

MS, Consultant Surgeon,

MS, Department of Surgery,

Sir Ganga Ram Hospital, New Delhi–110060.

Post Graduate Institute of Medical Research, Chandigarh–160023, Punjab.

Parveen Bhatia

Subhash Khanna

MS, FICS, Medical Director & Consultant Laparoscopic Surgeon,

MS, FICS, Swagat Endolaparoscopic Surgical Research Institute,

Global Hospital & Endosurgery Instutite, New Delhi - 110087

Guwahati, Assam. [email protected]

[email protected] www.bhatiaglobalhospital.com

Pradeep Chowbey

Shyam Sunder Pachisia MS, Junior Consultant,

Sir Ganga Ram Hospital, New Delhi–110060.

Department of Laparoscopic and GI Surgery, Indraprastha Apollo Hospitals Sarita Vihar, New Delhi-110076

[email protected] [email protected]

[email protected]

MS, MNAMS, FIMSA, FAIS, FICS, FACS, Chairman Minimal Access & Bariatric Surgery Centre,

www.chowbey.com

Pradeep Kumar Garg MD, Assistant Professor,

Department of Obstretics & Gynaecology, All India Institute of Medical Sciences, New Delhi–110029. pkgarg _ [email protected]

Rajeev Sinha

S. Goel MD, Consultant Anaesthesist,

Dr. L. H. Heeranandani Hospital, Mumbai–400008, Maharashtra.

Tehemton Erach Udwadia MS, FCPS, FRCS(Eng), FACS, FICS(Hon), FAMS, FARSI(Hon), Emeritus Professor of Surgery, Grant Medical College & J.J. Hospital,

M.L.B Medical College, Jhansi, Madhya Pradesh.

Consultant Surgeon, Head Department of M.A.S. P.D. Hinduja National Hospital, Consultant Surgeon, Parsee General Hospital, Breach Candy Hospital, Mumbai–400001. Maharashtra.

sinha _ [email protected]

[email protected]

MS, Professor & Head, Department of Surgery,

www.sinharga.com

Rajesh Ahlawat MS, MCh (Urology), Director, Urology and Renal Transplantation,

Fortis Hospital, Noida. Fortis Hospital, Vasant Vihar, New Delhi.

V. Muralidhar MD, Department of Anaesthesiology & Critical Care,

Indraprastha Apollo Hospitals, Sarita Vihar, New Delhi–110076. murali22 _ [email protected]

[email protected]

[email protected]

Rajesh Khullar

V. Venkatesh

MS, FICS, Senior Consultant, Minimal Access & Bariatric Surgery Centre,

MS, Consultant Surgeon,

Sir Ganga Ram Hospital, New Delhi–110060.

V. G. Hospital, Coimbatore–641034.

[email protected]

[email protected]

www.sgrh.com

FIAGES Book.indb 16

3/23/2007 11:04:50 AM

V.K Malik MS, Senior Consultant Surgeon,

Department of General Surgery Sir Ganga Ram Hospital, New Delhi–110060. [email protected]

V. Lotwala M.S, Consultant Surgeon,

Dr. L.H Heeranandani Hospital, Mumbai–400008, Maharashtra.

Zameer Pasha MS, FICS, FAIS, FAIMS, Dip. MAS, Chairman, Shahnawaz Hospital,

Trichy–620018, Tamil Nadu. [email protected] [email protected]

FIAGES Book.indb 17

3/23/2007 11:04:51 AM

1

Landmark historic events, Endovision system: Maintenance and trouble shooting G.R.Verma, S.Thiagarajan As we enter in the 21st century, we are witnessing dawn of a new era in which closed body operating procedures are more often being performed through minimal access. This development is the result of vision and work of many dedicated individuals. They include early pioneers of endoscopy who planted the seed and finally the modern pioneers who pushed and expanded these frontiers to give rise the birth of modern laparoscopy. Therapeutic laparoscopic surgery was introduced into the surgical practice recently and within a short span of time, it has become established as gold standard for the treatment of chronic cholelithiasis and many advanced laparoscopic procedures can be performed safely. Laparoscopic surgery, what we witness today, is the culmination of over a century of painstaking efforts of the number of pioneers in the fields of optics, instrumentation and video laparoscopic camera. Few advances in medicine occur in isolation. The innate human curiosity to peer inside the body cavities can be traced back to ancient times. However, due to primitive technology and crude instruments, many of these ambitions were not realized. It is probably safe to say that first laparoscopy would not have been performed had it not been for the efforts of many physicians in 19th century to develop endoscope. The device in Fig.1 developed by Theodore Stein in mid 1880 contains all the elements of the current endoscopic documentation system. There was a crude endoscope and a high intensity light source. Illumination was created by continuously feeding a magnesium wire into an ignition chamber using a clockwise mechanism. Light from this combustion was reflected into the tube using a mirror. Finally the image

FIAGES Book.indb 1

was focused on to a photographic plate through coupling optics.

Fig. 1: Early endoscopic device by Theodore Stein

The word laparoscopy is derived from a Greek word lapara, meaning “the soft part of the body between ribs and hip, flank, loin” and skopein, which means “to look at or survey”. First documented laparoscopy was undertaken in 1901 by Damitri Oksarovich Ott (18581929) of St. Petersburg, Russia, using gynecologic head mirror, an external light source and a speculum to perform the procedure. He termed the procedure “Ventroscopy” (1). In 1902, George Kelling (Fig.2) of Dresden, Germany outlined the technique of visualizing the peritoneal cavity and it’s contents in a dog by inserting

3/23/2007 11:04:51 AM



Landmark historic events, Endovision system: Maintenance & trouble shooting

Fig. 2: George Kelling of Dresden, Germany

a cystoscope inserted through a trocar and creating pneumoperitoneum with filtered air. At the same time, a Swedish surgeon, Jacobaeus (Fig. 3) in 1910, coined the term “ laparoscopy” (2) which has subsequently become the accepted terminology used to describe almost all varieties of this form of intervention. He published his experience on the technique of laparoscopy in humans for the first time. The next technological advance in laparoscopic technology was provided in 1920 by Benzamin Orndoff (3) who developed a sharp pyramidal point on laparoscopic trocar to facilitate puncture.

Fig. 3: Hans Christian Jacobaeus of Stockholm, Sweden

FIAGES Book.indb 2

Professor Kalk (Fig. 4) from Germany pioneered the use of laparoscopy for disorders of liver and biliary tract. He introduced the oblique viewing optics from longitudinal axis permitting better inspection of organs, as the image could be changed by altering the viewing direction of the optics such that the lens moved around the object. In 1929 he was the first to describe dual puncture technique. The use of second puncture opened the way for the development of operative laparoscopy. The next significant development in laparoscopic technology occurred in 1938 when Hungarian surgeon, Janos Varess (Fig. 5) described a spring loaded needle with an inner stylet that automatically converted the sharp cutting edge to a rounded end by incorporating a side hole (4) . for creation of pneumoperitoneum. He was the chief physician at the Komitat hospital in Hungary. The needle had initially been used to create a pneumothorax to treat tuberculosis. The first description of operation performed under laparoscopic vision came from Fervers in 1933. He performed laparoscopic adhesiolysis with biopsy instruments. He used oxygen as distending medium and experienced “great concern” at the audible explosion and flashes of light produced by electrocautery within the abdominal cavity. He recommended changing to carbon di oxide as insufflating gas for creating pneumoperitoneum. Kurt Semm, a gynecologist (Fig.6), played the vital role in the development of operative laparoscopy. It was Semm who developed the automatic insufflating device that monitored intra abdominal pressure and gas flow in 1963 (5). Prior to this, air was introduced by most workers into peritoneal cavity with the help of a syringe. Semm

Fig 4: Professor Kalk, promoter of the oblique (45 degrees) lens system

3/23/2007 11:04:51 AM



Comprehensive Laparoscopic Surgery 

Fig. 7: Phillipe Mouret, France Fig. 5: Janos Varess, Hungarian Surgeon

designed the pre tied suture loop (Roeder knot) to allow adequate haemostasis. He also developed a high volume suction/irrigation apparatus with design modifications to prevent tube clogging. Many more instruments i.e. needle holder, micro scissors, clip applier, morcellator were conceptualized, created and first utilized at Kiel University by him. He also created pelvi trainer, designed to teach surgeons the video eye hand coordination and suture tying techniques He was the first person to perform laparoscopic appendectomy in 1982 and soon thereafter, using his instruments, Erich Muhe, a surgeon from Boblingen performed first laparoscopic cholecystectomy in 1985. Unfortunately his technical presentation to Congress of German Surgical Society met with considerable resistance. The surgery was later performed with the help- of video camera in France by Phillipe Mouret (Fig. 7) in 1987.

Fig 6: Gynecologist Kurt Semm of Kiel, Germany

FIAGES Book.indb 3

No one has contributed more widely to the development and use of laparoscopy in general surgery than George Berci (6) in Los Angeles, both in the design of instrumentation and identifying clinical situations in surgical practice where laparoscopy would materially benefit management of the patient. He pioneered the use of laparoscopy for the management of diagnostic dilemmas, especially in emergency situations, and was instrumental in the development of laparoscopy for trauma. Endovision system for laparoscopy Video camera It is safe to say that the development of laparoscopic surgery would not have been possible without the video laparoscopic camera in 1986.This instrument allowed all members of the operating team to view operative field simultaneously, permitting the type of coordinating movements required for complex operative procedures. Prior to that operative laparoscopy was restricted to the individual directing the operative procedure and participation by other members of the surgical team was limited. The foundation of the laparoscopic camera is the solid state chip sensor. The most commonly used sensor is charged coupled device (CCD). The CCD is composed of small pieces of silicone called pixels, which are arranged in rows and columns and are sensitive to light. When light strikes a pixel, the silicon emits electricity, which is transmitted to the monitor. The electronic signals are then reconstructed on the monitor to give the video image. The resolution of the CCD is determined by number of the pixels on the sensor. The resolution

3/23/2007 11:04:51 AM



Landmark historic events, Endovision system: Maintenance & trouble shooting

is defined as the number of vertical lines that can be discriminated as separate in three quarters of the width of the monitor screen. The laparoscopic camera requires at least 300 lines of resolution to provide an adequate image. Now a day’s triple chip camera are available, with each chip devoted to only one color of the spectrum. Since the major spectrum is derived from three colors i.e. red, green and blue, modern three chip camera is able to reconstruct the image consisted of these three primary colors and provide excellent resolution and color but they are significantly more expensive. Light source & transmission One of the primary problems in the development of video laparoscopy was the insufficient light. A typical light source consisted of a lamp “ bulb”, heat filter, a condensing lens and manual or automatic intensity controlled circuit. Lamp or bulb is the most important part of the light source. The Quality of light depends on the lamp used. Several Modern types of light sources are currently available on the market. These light sources mainly differ on the type of bulb used. Four types of lamp are used more recently. 1. Quartz halogen. 2. Incandescent bulbs 3. Metal halide vapor arc lamp 4. Xenon. A normal light source (a light bulb) uses approximately 2 % in light and 98 % in heat. This heat is mainly due to the infrared spectrum of light and due to obstruction in the pathway of light. If Infrared will travel through the light cable than the cable will be intolerably hot. A heat filter is introduced to filter this infrared to travel in fiber optic cable. A cool light source lowers this ratio by creating more light, but does not reduce the heat produced to zero. The purpose of condensing lens is to converge the light emitted by lamp to the area of light cable input. In most of the light source it is used for increasing the light intensity per square cm of area. Most common type of light source was halogen bulb. It is highly efficient crisp light source with excellent color rendering. The electrodes are made up of Tungsten. They utilize halogen gas that allows the bulb to burn more intensely without sacrificing its life. They have average life of 2000 hours. These lamps are cheap and can be used for laparoscopic surgery if low budget set up is required. However, they lack in providing the natural white light color. Metal halide vapor arc lamp is a mix of compounds, (mostly salts of rare earths and halides as well as mercury which provided the conduction path) is carefully chosen to produce an output which approximates

FIAGES Book.indb 4

to “white light” as perceived by the human eye. There are two types of metal halide lamp, iron halide and gallium iodide lamp. Although the light generated was white but not exactly the replica of natural light. This problem has largely been eliminated with the introduction of high intensity Xenon light source. Xenon lamps consist of a spherical or ellipsoidal envelope made of quartz glass, which can withstand high thermal loads and high internal pressure. For ultimate image quality, only the highestgrade clear fused silica quartz is used. It is typically doped, although not visible to the human eye, to absorb harmful UV radiation generated during operation. The color temperature of Xenon lamp is 6000-6400 K. The operating pressures are tens of atmospheres at times, with surface temperatures exceeding 600 degrees C. The light emitted by xenon lamp is slightly bluish and more natural compared to halogen lamp. However, most of the cameras at present analyze and compensate these variations by means of automatic equalization of whites (2100 K to 10000 K), which allows the same image to be obtained with both light sources. A proper white balancing before start of the operation is a very good practice for obtaining a natural color. The white light is composed of the equal proportion of Red, Blue and Green Color and at the time of white balancing the camera sets its digital coding for these primary colors to equal proportion assuming that the target is white. And if at the time of white balancing the telescope is not seeing a perfectly white object then the setup of the camera will be very bad and the color perception will be very poor. Prior to the introduction of fiber optic cables, the light source was incorporated in the laparoscope itself making it heavier, and cumbersome. In 1954 a major breakthrough in technology occurred in the development of fiber optic cables. The principle of fiber optic cable was based on the total internal reflection of light. Light could be transmitted through a curved glass rod due to multiple total internal reflections at the walls of the rod. Light would enter at one end of the fiber and emerge at the other end after numerous internal reflections with virtually all of its strength. Now a days two types of light cable are available in market. 1.  Fiber Optic cable 2.  Liquid crystal Gel cable. The optical cables are made up of a bundle of optical fiber glass thread swaged at both ends. They have a very high quality of optical transmission, but are fragile. In fact, some of the fibers may break due to repeated use. The broken fibers are seen as black spots when cable is viewed against day light. The gel cables are made up of a sheath that is filled with a clear optical

3/23/2007 11:04:52 AM



gel. (Liquid crystal) and swaged at both ends by quartz. Theoretically they are capable of transmitting 30% more light than optic fibers. Due to more light and better color temperature transmission this cable is recommended in those circumstances where documentation (movie, photography or TV) is performed. They pose three problems 1. The quartz swaging at the ends is extremely fragile, especially when the cable is hot. The slightest shock, on a bench for example, can cause the quartz end to crack and thus cause a loss in the transmission of the light 2. These cables transmit more heat than optical fiber cables 3. They are more rigid due to metal sheath, which makes them more difficult to maintain. Of the most crucial invention in operative laparoscopy was by British Physicist, Harold Hopkins in 1952, who developed the idea of the rod lens system. Prior to this development, endoscopes were constructed on an optical system that comprised relay and field lenses made from glass with long intervening air spaces. In Hopkins system, the roles of glass and air are interchanged such that the optical system consists of air lenses and long glass air spaces. As the refractive index is now predominantly that of glass, the light transmission capacity of the endoscopes is doubled. A second advantage of Hopkins rod lens system relates to the “larger radius of clear aperture” available at the viewing optic that was not possible with conventional endoscopes. Maintenance Light Cable: Handle it carefully and do not twist it. After the completion of operation, cable should preferably be disconnected from the endoscope and then from light source. Avoid direct fall of light on eyes. The retina can get damaged. The cable should be periodically cleaned with cotton swab moistened with alcohol. The outer covering of the cable should be cleaned with mild detergent or disinfectant. The fiber optic cable should not be placed near the patient when it is connected to illuminated light source. The heat generated may cause burn Instruments Meticulous care should be taken in mechanically cleaning all the parts of all laparoscopic instruments. The handles are un-screwed, inserters taken out and the hollow sheath is cleaned with running water or syringe. Instruments are wiped dry gently and lubricated with silicone oil. These are the vital steps before sterilization or disinfection of laparoscopic instruments. All metal instruments or part

FIAGES Book.indb 5

Comprehensive Laparoscopic Surgery 

that can undergo sterilization using a steam autoclave should be handled in this manner. Suction/ Irrigation tubes are thoroughly cleaned with running tap water before autoclaving them. Telescope and Camera The telescope eye piece, light cable slot and its patient end must be cleaned with warm water and the patient end, additionally with camera cleaner liquid. The ends of the telescope are sensitive to heat; hence it should be sterilized with chemical sterilizer. Laparoscopic camera will be damaged by heat as well as repeated exposure to chemical germicides. More over the irregular configuration of the surface of camera makes the disinfection difficult and unpredictable. Therefore camera are best treated with the use of barrier such as sterile plastic/ cotton sleeve to avoid contamination of operating field. They are most expensive parts of equipment, hence must be handled with utmost care. Avoid crumpling of its lead and never use alcohol/ spirit to clean the camera head. Instead use camera head cleaner supplied by company or it can be simply cleaned with moist warm cotton. Sterilization It is defined as complete elimination/ destruction of all forms of microbial life. It can be achieved with steam, gas or chemical sterilants. Disinfection which is a relative term means elimination of many or all pathogenic organisms except bacterial spores. It is divided into three levels, high, intermediate and low. High level disinfection eliminates all organisms with exception of large number of bacterial spores. Intermediate level disinfection destroys all organisms except spores, most bacteria and some fungi. Low level of disinfection can destroy most bacteria, some viruses and some fungi. High level disinfection is accomplished by 2% Glutaraldehyde solution, a most popular chemical sterilant used for high level disinfection of laparoscopic equipments. The minimum recommended exposure time is 10 minutes, although some workers prefer and recommend for 20 minutes. It can sterilize the instruments only after ten hours of exposure. The life of the solution is generally 20-25 days. The potency and use life of the solution is determined more by use pattern and not strictly by time. The heavy use and inadvertent dilution or contamination will require early change of sterilant. It should be mentioned that no addition to described protocol is required to deal with HIV or hepatitis-B

3/23/2007 11:04:52 AM



Landmark historic events, Endovision system: Maintenance & trouble shooting

Table 1 1.

Problem

Cause

Solution

Poor insufflation/loss of pneumoperitoneum.

CO, tank empty

Change tank

Open accessory port stopcock(s)

Inspect all accessory ports close stopcock(s)

Leak in sealing cap or stopcock. Excessive suctioning

Change cap or cannula Allow abdomen to re-insufflate

Instrument cleaning channel screw cap missing

Replace screw cap

Loose connection of insufflator tubing at Tighten connection source or at port 2.

3.

4.

5.

Excessive pressure required for insufflation (initial or subsequent)

Inadequate lighting (partial/ complete loss)

Lighting too bright

No picture on monitor(s)

Hasson stay sutures loose.

Replace or secure sutures

Veress needle or cannula tip not in free peritoneal cavity

Reinsert needle or cannula

Occlusion of tubing (kinking, table wheel, inadequate size tubing, etc.)

Inspect full length of tubing, replace with proper size as necessary

Port stopcock turned off

Assure stopcock is opened

Patient is “light”

More muscle relaxant

Loose connection at source or at scope

Adjust connector

Light is on “manual minimum”

Go to “automatic”

Bulb is burned out

Replace bulb

Fiber optics are damaged

Replace light cable

Automatic iris adjusting to bright reflection from instrument Monitor brightness turned down

Reposition instruments, or switch to “manual” Readjust setting

Light is on “manual-maximum”

Go to “automatic”

“Boost” on light source activated.

Deactivate “boost”

Monitor brightness turned up

Readjust setting

Camera control unit or other components (VCR, printer, light source, monitor) not on

Make sure all power sources are plugged in and turned on

Cable connector between camera control Cable should run from “video out” on unit and/or monitors not attached camera control unit to “video in” on properly primary monitor; use compatible cables for camera unit and light source Cable should run from “video out” on primary monitor to “video in” on secondary monitor

FIAGES Book.indb 6

3/23/2007 11:04:52 AM



Comprehensive Laparoscopic Surgery 

6.

Problem

Cause

Solution

Poor quality picture. a. Fogging, haze

Condensation on lens of cold scope entering warm abdomen.

Gently wipe lens on viscera; use anti-fog solution, or warm water, gently wiping on liver or uterine surface is preferable

Condensation on scope eyepiece, camera Detach camera from scope (or camera lens, coupler lens from coupler), inspect and clean lens as needed b. Flickering electrical interference

c. Blurring, distortion

7.

8.

FIAGES Book.indb 7

Inadequate suction/ irrigation

Absent/inadequate cauterization

Moisture in camera cable connecting plug

Use compressed air to dry out moisture (don’t use cotton-tip applicators on multi prong plug)

Poor cable shielding

Replace video cable between monitors

Insecure connection of video cable between monitors

Reattach video cable at each monitor

Incorrect focus

Adjust camera focus ring

Cracked lens, internal moisture

Inspect scope and camera, replace as needed

Occlusion of tubing (kinking, blood clot, etc.)

Inspect full length of tubing; if necessary detach from instrument and flush tubing with sterile saline

Occlusion of valves in suction/ irrigator device

Detach tubing, flush device with sterile saline

Not attached to wall suction

Inspect and secure suction canister connectors, wall source connector

Irrigation fluid container not pressurized

Inspect compressed gas source, connector, pressure dial setting

Patient not grounded properly

Assure adequate patient grounding pad contact, and pad cable electro-surgical unit connection

Connection between electro-surgical unit and pencil not secure

Inspect both connecting points

Foot pedal or hand switch not connected to electrosurgical unit

Make connection

3/23/2007 11:04:52 AM



Landmark historic events, Endovision system: Maintenance & trouble shooting

contaminated equipments. Both hepatitis and HIV virus are inactivated many physical and chemical processes much less potent than high level disinfection. A new sterilization process, marketed as STERIS is also available. Its active agent is per acetic acid, generally considered to be a stronger germicide that has very little harmful effects on optical instruments. It has the advantage of being a closed system and is not subject to various factors responsible for bringing down the efficacy of chemical germicide.

6. Berci G, Shore JM, Panish J,Morgenstern L. Evaluation of a new peritoneoscope as a diagnostic aid to the surgeon. Ann Surg 1977; 135: 32-35. 7. Airan MC. Equipment set up and trouble shooting. in The SAGES manual, fundamentals of laparoscopy and GI endoscopy, Caro EH, Scott C, editors, Springer. New York 2003; 1-11.

Trouble shooting Laparoscopic procedures are inherently complex. Many things can go wrong. The surgeon must be sufficiently familiar with the equipment to troubleshoot and solve problems. Table 1 gives an outline of the common problems, their cause, and suggested solutions. In conclusion, I would say that the pace of development of diagnostic laparoscopy which was hitherto slow but steady over the last century has entered into an exciting era of laparoscopic surgery with invention of miniaturized video endoscopes, quality light source and successful performance of laparoscopic cholecystectomy. Credit goes to many scientists who steadfastly continued their efforts to bring this science to the current state of art. The laparoscopic instruments are long, fine and insulated; hence, they are more vulnerable to wear and tear. Gentle handling and thorough mechanical cleaning & lubrication prior to sterilization/ disinfection will increase their life and efficiency. A laparoscopic surgeon should have knowledge of instrument functioning, basic knowledge of supportive equipments and able to manage the trouble shooting.

References 1. Ott D. Illumination of the abdomen (Ventroscopia) J Akush Zhnesk Boliez 1901; 15: 1045-49. 2. Jacobaeus HC. Ueber die moglichkeit die zystoskopie bei untersuchung serosar hohlungen anzuwenden. Munich ,Med Wochenschr. 1910; 57: 2090-92. 3. Orndoff BH. The peritoneoscope in diagnosis of diseases of the abdomen. J Radiol 1920; 1: 307. 4. Veress J. Neues instrument zur Ausfuhrung von Brust-order Bauchpunktionenund Pneumothorax behandlung. Dtsch Med Wochenshr. 1938; 41: 1480-81. 5. Semm K. History, In Operative Gynecologic Endoscopy, J.S.Sanfilippo, R.L.Levine, editors, New York, Springer- Verlag, 1989.

FIAGES Book.indb 8

3/23/2007 11:04:52 AM

2 Laparoscopic Hand Instruments, Accessories and Ergonomics Amitabh Goel Laparoscopic procedures are inherently complex. Due to the complex modern technology, many things can go wrong. Equipment and instrumentation have a much greater impact and importance in laparoscopic surgery. This is a fact that visualization and tactile exploration of the operative field is always only indirectly achieved through optical systems and instruments. The surgeon must be sufficiently familiar with the equipment to use it, troubleshoot and solve the inherent problems. I. Imaging System Imaging system includes the Laparoscope, Light source, Light cable, Camera, and Monitor.

down as well look up the anterior abdominal wall and side ways. The scope is attached with light cable and the distal tip is inspected for fibre bundle transmission. If the fibre damage is 25% or more then the scope must be replaced. B. Light Source The new light source (fig. 2) such as 250 watt halogen lamp has been provided with a condenser system, But Xenon lamp (cold light source) gives better visual clarity. The light intensity can be regulated manually or automatically. High intensity Xenon lamp gives better visual and photographic clarity.

A. Laparoscopes Laparoscopes are either rigid or fibre optics (fig. 1). Commonly used are rigid ones, like 0°, 30°, 3mm, 5mm, and 10mm. The 30° angled scopes can be rotated and can see.

Figure 02: Light Source

C. Light Cable

Figure 01: Laparoscopes

FIAGES Book.indb 9

Light carrier is very important. It may either be a fluid or a glass fibre light cable (fig. 3). In the cable, there should not be sharp bends and cracks in the plastic sheath, if it

3/23/2007 11:04:53 AM

10

Laparoscopic Hand Instruments Accessories and Ergonomics

E. Monitors The video monitor must generate high resolution image after the S-VHS connection. Larger video screen is preferred, 20 inches and above, non flickering medical monitors with high resolutions more then camera is preferred (fig. 5).

Figure 03: Light Cable

is there, then the cable should be changed for good light transmission. The cable is available at different diameters and lengths. The diameter of the fibre bundle should always be chosen slightly larger then the lens system and should not be too long.

Figure 05: Monitor

D. Cameras

II. Gas for pneumoperitonium

Now high resolution, small and light weight cameras are available, which is easy to handle, they provide picture of optimal sharpness, high resolution and excellent colour reproduction. A single chip camera has resolution of point 450-600; But the 3 chip cameras with more then 750 horizontal lines give excellent visual clarity. Usually single chip camera is adequate for routine laparoscopic surgeries but if surgery is recorded for later inclusion in larger film or video production, three chip camera is preferable. Now a recent version of digital 3 chip camaras with integrated image processing modules is available (fig. 4).

Air was the first gas used to produce pneumoperitoneum, but has largely been abandoned. The main disadvantage of air is the risk of air embolism. Characteristics of the ideal insufflating agent The ideal insufflating agent during laparoscopic procedures should be colorless, physiologically inert, and non explosive in the presence of electrocautery or laser coagulation. 2. Its solubility in blood should be high. 3. The insufflating gas should be readily available, inexpensive, and nontoxic. 1.

1. Carbon dioxide Carbon dioxide is an odorless, colorless gas. It is a readily available, stable, naturally formed in the tissues and subsequently eliminated by the lungs. Due to these features, Carbon dioxide is the most commonly used gas for insufflation during laparoscopic procedure. Advantages 1. It has relatively low risk of venous gas embolism 2. It does not support combustion

Figure 04: Camera

FIAGES Book.indb 10

Disadvantages 1. Hypercarbia and acidosis 2. The direct effects of carbon dioxide and acidosis can

3/23/2007 11:04:55 AM



Comprehensive Laparoscopic Surgery

lead to decreased cardiac contractility, pulmonary hypertension and systemic vasodilation.

11

Disadvantage 1. The major possible physiologic disadvantage is cardiac depression.

2. Nitrous Oxide Nitrogen is biologically inert, colorless, gaseous element that is found free in the air. Nitrous oxide has been suggested for the procedures performed under local anesthesia, or for patients with pulmonary disease undergoing longer procedures. Advantages 1. Insignificant changes in acid-base balance. 2. Decreased pain Disadvantages 1. Supports combustion in the presence of hydrogen or methane gas. 3. Helium (He) Helium is a colorless, odorless, tasteless gas that is obtained from natural gas. This inert gas is neither combustible itself, nor supports combustion. Helium is less soluble in water than carbon dioxide.

III. LAPROFLATTOR The Electronic CO2 Laproflattor is a general purpose insufflation unit for use in laparoscopic operations (fig. 6). Controlled pressure insufflation of the peritoneal cavity is used to achieve the necessary work space for laparoscopic surgery by distending the abdominal wall and depressing the hollow organs. Automatic insufflators allow the surgeon to preset the insufflating pressure and it supplies gas until the required intra-abdominal pressure is reached. The insufflator activates and delivers gas automatically when the intra-abdominal pressure falls because of gas escape or leakage from the ports. Insufflation pressure can be continuously varied from 0 to 30 mm Hg; total gas flow volumes can be set to any value in the range 0-9.9 liters/mm. Patient safety is ensured by optical and acoustic alarms as well as several mutually independent safety circuits. The important indicators of insufflators are preset pressure, actual pressure, flow rate and total gas used.

Advantage 1. The main physiologic advantage is the minimal effect on acid- base balance. Disadvantages 1. The development of postoperative subcutaneous emphysema has been observed, as it is relatively poorly soluble in water. 2. Risk of venous gas embolism because it is less soluble in water then carbon dioxide. It is more diffusible because of its low density. 4. Argon Argon gas is colorless, odorless, noncombustible, and chemically nonreactive. Advantage 1. The major physiologic advantage is stable acid base status.

FIAGES Book.indb 11

Figure 06: Insufflator

IV. Suction Irrigation Machine It is used for flushing the abdominal cavity and cleaning during endoscopic operative intrusions. It has been designed for use with the 26173 AR suction /instillation tube. Its electrically driven pressure/suction pump is protected against entry of bodily secretions. The suction irrigation machine is used frequently at the time of laparoscopy to make the field of vision clear. Most of the surgeons use normal saline or ringer lactate for irrigation purposes. Sometimes, heparinized saline is used to dissolve blood clot to facilitate proper suction in case of excessive intra-abdominal bleeding.

3/23/2007 11:04:55 AM

12

Laparoscopic Hand Instruments Accessories and Ergonomics

Suction and Irrigation hand apparatus Irrigation and suction are very important during laparoscopic surgeries specially to maintain clear visual field and maintained hemostasis. It comes in 5mm and 10mm reusable sizes (fig 7). The suction tip is highly

aspiration of pleural effusion keeping in mind that its spring mechanism and blunt tip will prevent the injury of lung tissue. Veress needle consists of an outer cannula with a beveled needle point for cutting through tissues (fig. 8). Inside the cannula there is an inner stylet, which is loaded with a spring. This spring springs forward in response to the sudden decrease in pressure encountered upon crossing the abdominal wall and entering the peritoneal cavity. The lateral hole on this stylet enables CO2 gas to be delivered intra-abdominaly. Veress needle is used for creating initial pneumoperitoneum so that the trocar can enter safely and the distance of abdominal wall from the abdominal viscera should increase. Veress needle technique is the most widely practiced way of access. It is very important to check veress needle every time before using it, for its (1) potency and, (2) spring action. Veress needle is available in three lengths 80mm, 100mm, 120mm. In obese patient 120mm and in very thin patient with scaphoid abdomen 80mm veress needle should be used. Veress needle should be held like a dart at the time of insertion.

Figure 07: Suction and Irrigation Hand Instrument

useful for intermittent suction and as blunt dissecting instrument in place of finger, as we use in conventional surgeries. V. Operative hand instruments

Figure 08: Veress Needle

Reusable and disposable instruments are commercially available. Disposable instruments provide better performance and higher safety on single use. To make it cost effective the surgeon has to reuse the disposable instruments after sterilisation. Reusable instruments are significantly cheaper in the long run, however, they need proper cleaning and maintenance.

2. Hassan Cannula It is less commonly used than veress. It usually reduces the risk of vascular and hollow visceral injury. It is an extremely safe instrument to enter the abdomen, especially in a patient who has previously undergone intra-abdominal procedures. This cannula consists of three pieces: a cone-shaped sleeve, a metal or plastic sheath with a trumpet or flap valve, and a blunt tipped obturator. On the sheath there are two struts for affixing two fascial sutures. These sutures are then wrapped tightly around the struts. Thereby firmly seating the coneshaped sleeve into the laparoscopic port. This creates an effective seal to maintain penumoperitoneum.

A. Insuffalation cannulas 1. Veress Needle Veress needle was invented by a chest physician for

FIAGES Book.indb 12

3/23/2007 11:04:56 AM



Comprehensive Laparoscopic Surgery

13

Figure 09: Hassan Cannula

Figure 10: Tips and Trocars

B. Trocars

the incidence of injury of viscera. Trocar and cannula are of different sizes and diameter depending upon the instrument for which it is used. The diameter of cannula ranges from 3 mm to 30 mm; the most common size is 5mm and 10 mm (fig. 11). Some new disposable trocar designs incorporate unique design features such as direct serial incision of the tissue under visual control [Excel trocar-(fig.12)].

The word “trocar” is usually used to refer to the entire assembly but actual trocar is a stylet which is introduced through the cannula. The trocars are available with different type of tips (fig. 10). The cutting tips of these trocars are either in the shape of a three edged pyramid or a flat two edged blade. Conical tipped trocars are supposed to be less traumatic to the tissue. The tip can be penetrated through the parietal wall without cutting and a decreased risk of herniation or haemorrhage is reported. Cannulas are in general made from plastic or metal. Plastic devices whether they are transparent or opaque, need to be designed in such a way as to minimize the reflection of light from the telescope. Reusable and disposable trocars are constructed by a combination of metal and plastic. The tip of disposable trocar has a two edged blade. These are very effective at penetrating the abdominal wall by cutting the tissue as they pass through. Most of the disposable plastic trocar have a spring loaded mechanism that withdraws the sharp tip immediately after it passes through the abdominal wall to reduce

Figure 11: Different Sizes of Trocars

FIAGES Book.indb 13

3/23/2007 11:04:58 AM

14

Laparoscopic Hand Instruments Accessories and Ergonomics

C. Reducing Sleeve It is used to reduce the size of the port from 10mm to 5mm or 5mm to 3 mm, so that pneumoperitoneum is maintained when ever surgeon changes the instrument from larger diameter to smaller diameter (fig. 13). D. Needle holder Laparoscopic needle holder is available with a straight or curved tip. Two needle holders are necessary to perform swift endo-suturing, although endo-suturing can be done satisfactorily with a single needle holder and a grasper. In-line grip needle holders are ergonomically better than pistol grip needle holder (fig. 14). Figure 12: Xcel Trocar

All the cannulas have a valve mechanism at the top. Always inspect the trocar to ensure that all the valves move smoothly and, that the insufflation valve is closed (to avoid losing pneumoperitoneum). The valves of cannula provide internal air seals, which allow instruments to move in and out within cannula without the loss of pneumoperitoneum. These valves can be oblique, transverse, or in piston configuration. These valves can be manually or automatically retractable during instrument passage. Surgeon should remember that sharp trocars although looking dangerous are actually better than blunt ones, because they need less force to introduce inside the abdominal cavity and the chances of inadvertent forceful entry of full length of trocar is lesser. The end of the cannula is either straight or oblique. An oblique tip is felt to facilitate the easy passage of the trocar through the abdominal wall.

Figure 13: Reducing Sleeve

FIAGES Book.indb 14

Figure 14: Needle Holder

3/23/2007 11:04:59 AM



Comprehensive Laparoscopic Surgery

15

E. Port closure instrument These are self innovative hand instruments to close the laparoscopic ports, especially 10mm or larger ports, if needed (fig. 15).

Figure 15: Different Types of Port Closure Figure 16: Disposable (left) and Reusable (right) Hand Instruments

VI. Other Hand Instruments Disposable or Reusable Instruments (fig. 16) Several factors should be considered at the time of choosing laparoscopic instrument, including cost, availability and reliability. Reusable instruments are expensive initially but in long run they are cost effective. In developing countries, disposable instruments are very rarely used because labour cost is low compare to the cost of disposable instrument. In Europe and USA, surgeons often choose to use disposable instrument in order to save high labour cost. The disposable instruments are not sterilized properly by dipping in gluteraldehyde because they are not dismountable. Insulation of disposable instrument also can be torn easily which can lead to electrosurgical injuries.

FIAGES Book.indb 15

Laparoscopic hand instruments vary in diameter from 1.8 to 12mm but majority of instruments are designed to pass through 5 to 10mm of cannula. The instruments are also of different lengths (vary from company to company, usually varies from 18 to 45cm) but they are ergonomically convenient to work with if they have same length of approximately 36 cm in adult and 28 cm in pediatric practice. Shorter instruments 18 to 25cm are adapted for cervical and pediatric surgery. Certain procedures for adult can also be performed with shorter instrument where the space is constricted. Forty-five centimetre instruments are used in obese or very tall patients. For better ergonomics half of the instruments should be inside the abdomen and half outside. If half of the instrument is in and half out, it behaves like a class-1 lever; and it stabilizes the port nicely and thus surgery becomes convenient.

3/23/2007 11:05:01 AM

16

Laparoscopic Hand Instruments Accessories and Ergonomics

Most of the laparoscopic procedures require a mixture of sharp and blunt dissection techniques, often using the same instrument in a number of different ways. Many laparoscopic instruments are available in both re-usable and disposable version. Most re-usable instruments are partially dismountable so that it can be cleaned and washed properly. Some manufacturer have produced modular system where part of the instrument can be changed to suit the surgeon favorite attachment like handle or working tip. Most laparoscopic instruments like graspers and scissors have basic opening and closing function. Many instruments manufactured during past few years are able to rotate at 360 degree angle which increases the degree of freedom of these instruments. Most of the hand instruments have three detachable parts. a. Handle b. Insulated outer tube c. Insert which makes the tip of the instrument.

multifunctional laparoscopic handles have attachment for suction and irrigation. The Cuschieri Ball Handle was invented by Prof. Sir Alfred Cuschieri. This handle lies comfortably in surgeon’s palm. This design reduces the fatigue of surgeon and eases rotation of the instrument by allowing rotation within the palm rather than using wrist rotation. Squeezing the front of the handle between the thumb and the first fingers increases the jaw closing force; squeezing the rear of the handle between the thenar eminence of the thumb and last fingers opens the jaws. Cuschieri pencil handle also has great ergonomic value specially when used with needle holder. This handle allows the angle between the handle and the instrument to be altered to suit the surgeon’s wrist angle. The conveniently placed lever of this pencil handle when pressed can change the angle. Just like ball handle, pressure at the front increases the jaw closing force while pressure at the rear opens the jaw.

a. Different Handles of Hand instrument (fig. 17)

The insulation covering of outer sheath of hand instrument should be of good quality in hand instrument to prevent accidental electric burn to bowel or other viscera. Insulation covering may be of silicon or plastic. At the time of cleaning the hand instrument, utmost care should be taken so that insulation should not be scratched with any sharp contact. A pin hole breach in insulation is not easily seen by naked eye but may be dangerous at the time of electro surgery.

Certain instrument handles are designed to allow locking of the jaw. This can be very useful when the tissue needs to be grasped firmly for long period of time preventing the surgeons hand from getting fatigued. The locking mechanism is usually incorporated into the handle so that surgeon can easily lock or release the jaws. These systems usually have a ratchet so that the jaws can be closed in different positions and to different pressures. Most of the laparoscopic instrument handles have attachments for unipolar electrosurgical lead and many have rotator mechanism to rotate the tip of the instrument. Some

Figure 17: Different types of Handles

FIAGES Book.indb 16

b. Insulated outer tube (fig. 18)

Figure 18: Outer Sheeth

3/23/2007 11:05:02 AM



Comprehensive Laparoscopic Surgery

17

HF Electro surgery spatula (Berci) HF Electro surgery knife 5. Knife

c. Insert of Hand Instrument (fig. 19)

3.

Insert of hand instrument varies only at the tip. It may be grasper, scissors, or forceps. This grasper may have single action jaw or double action jaw. Single action jaw open

4.

Scissors (fig. 22) Scissors are one of the oldest surgical instruments used by surgeons. Scissors are used to perform many tasks in open surgical procedure but its use in minimal access surgery is restricted. In minimal access surgery scissors require greater skill because in inexperienced hand it may cause unnecessary bleeding and damage to important structures.

Figure 19: Inserts

less than double action jaw but close with greater force thus, most of the needle holders are single action jaw. The necessary wider opening in double action jaw is present in grasper and dissecting forceps. Single action graspers and dissectors are used where more force is required. d. Different type of Graspers (fig. 20 & 21) These graspers are good when you don’t have control over depth and surgeon wants to work in single plane in controlled manner particularly during adhesiolysis.

Figure 20: Single Action Jaw Grasper

Figure 22: Scissors

Types of Laparoscopic Scissors 1. Straight Scissors 2. Curved Scissors 3. Serrated Scissors 4. Hook Scissors 5. Micro-tip Scissors Spatula, Hook and Harmonic Scalpel (fig.23)

Figure 21: Double Action Jaw Graspers

e. Instruments for Sharp Dissection 1. 2.

Scissors Electro surgery hook

FIAGES Book.indb 17

Spatula has a flat tip for dissecting the gall bladder from the liver bed. It is much safer than the hook. Hook has a L shaped tip. Usually it is used to dissect the gall bladder from the bed of the liver. Some surgeons also use this instrument for opening of the intestine. Now a days in modern laparoscopic surgery ultrasonic scalpel (Harmonic scalpel) is available for advanced procedures.

3/23/2007 11:05:02 AM

18

Laparoscopic Hand Instruments Accessories and Ergonomics

Figure 23: Spatula, Hook and Harmonic Scalpel

Clip Applicator (fig. 24) They are available as either disposable or reusable. Reusables are of of three sizes, large, medium large and medium. They are used to clip cystic artery and cystic duct according to their size. Disposable clip applier comes with preloaded 20 clips per unit as the Protack (commonly used in mesh repair in hernia) comes in 30 per unit.

Figure 24: Clip Applicator

Includes: instrument, machines and OT design Involves: understanding the interactions between humans with other elements in the system to optimize human well-being and overall performance of the system Operative laparoscopy has changed the concept of surgery from prolonged painful recuperative periods with long scars of open surgery to short stay, painless, and cosmetically satisfying surgery. This has been achieved at the expense of surgeons’ discomfort and fatigue, thus putting both the surgeon and patient at risk. Inadequate knowledge about ergonomics together with ergonomically deficient design of laparoscopic instruments has been cited as possible causes. Increased technological complexity and sometimes poorly adapted equipment have led to increased complaints of surgeons’ fatigue and discomfort during laparoscopic surgery. Ergonomic Variable

ERGONOMICS Word derivation: ergon (labor) and nomia (arrangement) Concept: of designing the working environment to fit the worker, instead of forcing the worker to fit the working environment Application: to make the OT more user-friendly, to reduce stress, to increase efficiency and safety

FIAGES Book.indb 18

The important variables which have been studied include hand size, handle to tip force transmission, optimum height of the surgeon’s hand and height of the operating table, view site in relation to monitor position and the technique of gripping the instruments. Hand size Hand size is an important variable to consider when designing laparoscopic hand tools. This is because laparoscopic surgeons, especially women using glove sizes 6.5 or smaller, experience musculoskeletal problems while using common laparoscopic instruments.

3/23/2007 11:05:04 AM



Moreover, subjects who reported musculoskeletal problems performed a significantly greater percentage of laparoscopic cases and found the stapler and graspers difficult to use for a greater percentage of time than those not reporting problems. Handle to tip force transmission Data from the Society of American Gastrointestinal and Endoscopic Surgeons (SAGES) reveal that laparoscopic instruments suffer from ergonomically inadequate handle designs and inefficient handle to tip force transmission, which lead to surgeons’ fatigue, discomfort, and hand paresthesias. Studies quantifying forearm and thumb muscle workload by processed electro-myogram (EMG) demonstrated that the peak and total muscle effort of forearm and thumb muscles were significantly greater when the grasping task was performed using the laparoscopic instrument. This was found to be more prevalent among junior laparoscopic surgeons having less than two years of experience. Optimum height Discomfort and difficulty ratings were lowest when instrument handles were positioned at elbow height. The position of laparoscopic instrument handles needed to be close to surgeons’ elbow level to minimize discomfort and upper arm and shoulder muscle work. This was found to correspond to an approximate table height of 64 to 77 cm above floor level. Technique of gripping Palm grip hand position with the pistol handle (thumb outside the ring with the palm resting on the thumb ring) is more efficient than the finger-in-ring grasp because it significantly reduces the muscle forces required for grasping with a laparoscopic instrument. Many surgeons do, in fact, use the palm grasping hand position for sustained grasping tasks during laparoscopic surgery. Moreover, use of finger tips rather than finger base during finger-in-ring grasp during tissue dissection reduces discomfort. Majority of the surgeons performing regular laparoscopy are unaware of the complications of nerve injury and neuropraxia following improper gripping technique. Experience in laparoscopic surgery does play a major impact on knowledge about ergonomical problems. Operating for prolonged hours with eyes focused on video monitors results in eye strains among laparoscopic

FIAGES Book.indb 19

Comprehensive Laparoscopic Surgery

19

surgeons. Placement and adjustment of monitors have little benefit in improving the situation though experience resulted in some improvement. Use of laparoscopy is associated with significant ergonomic problems, hence proper training and awareness among laparoscopic surgeons is essential in India. This is only possible if an authorized accreditation council sets up guidelines and oversees the training programs, thus making laparoscopy safer for both surgeons and patients.

References 1. Carol E.H. Scott-Conner, ‘The SAGES Manual’1998. SpringerVerlag, New York, USA. 2. Dr. C. Palanivelu .CIGES Atlas of Laparoscopic Surgery 2000. Jaypee Brothers Medical Publishers (p) Ltd. New Delhi, India. 3. Dr. Parveen Bhatia, Dr. Suviraj J. John 2003. Laparoscopic Hernia Repair. Global Digital Services, New Delhi , India. 4. http://www.simbionix.com/LAP_Mentor.html 5. http://w w w.indianjsurg.com /article.asp?issn = 0972-2068; year=2005; volume=67; issue=3; page=164;page=166

Acknowledgements 1. Dr. Vandana Bansal, MS, FAIS Consultant Dept. of MAS, Choithram Hospital, Indore 2. Dr. S.P. Jaiswal, Ph.D., MBA Consultant Dept of Pathology, Choithram hospital & Research Centre, Indore. 3. Mr. Shailendra Carpentar, MBA Computer Designer

3/23/2007 11:05:04 AM

3 Sterilization and Maintenance of Instruments & Equipment Deepraj S. Bhandarkar, Avinash N. Katara INTRODUCTION

CLEANING AND STERILIZATION

Laparoscopic surgery requires sophisticated and precisely calibrated instruments. The fundamental difference between instruments used in open surgery and those utilized for laparoscopic surgery is that the latter are more complex in design and yet delicate in construction. Thus the laparoscopic instruments (LI) are more prone to lodging of bioburden (micro-organisms and debris) within their crevices. Thus, the LI are difficult to clean, sterilize adequately and maintain as compared to their counterparts used in open surgery. Moreover, owing to their delicate design, gentlest methods have to be used for cleaning as well as sterilization. Also, meticulous cleaning, maintenance as well as sterilization are necessary so that not to compromise the safety of the patient, the surgeon or other operating room personnel. The increase in complexity of the laparoscopic procedures as also the emergence of resistant strains of bacteria, mycobacteria, fungi and viruses has made it imperative to effectively clean and disinfect instruments. Sterilization is the absolute elimination or destruction of all forms of microbial life. It can be achieved with steam, gas or chemicals. On the other hand, disinfection is the relative elimination of pathogenic organisms except spores. Disinfection can be: a) High level - where all life forms except the spores are destroyed, b) Intermediate level - where some fungi, viruses and spores are spared, or c) Low level - where fungi, viruses, spores and mycobacteria remain undestroyed. For laparoscopic instruments ideally sterilization or at least high level disinfection should be used.

Optimal processing of LI involves several steps that reduce the risk of transmitting infection from used instruments and other items to health care personnel. These are 1) Dismantling, 2) Decontamination, 3) Precleaning, 4) Cleaning and rinsing, 5) Drying 6) Sterilization and 7) Storage. For proper processing, it is essential to perform the steps in correct order. Most major hospitals have a Central Sterile Supplies Department (CSSD) where the instruments are transported from the operating room for processing. Even in hospitals or nursing homes that do not have an elaborate CSSD, the basic steps in processing of instruments can be adhered to provided a well-established protocol is in place, and designated personnel are given the responsibility for the same. Proper processing of instruments forms an integral aspect of their care and this should undoubtedly go a long way in increasing their life span and trouble-free service.

FIAGES Book.indb 20

Dismantling The design of LI should be such that they should allow easy dismantling (Figure 1). Instruments that cannot be dismantled completely are liable to harbour blood / debris within the shafts and compromise safety of the patients in whom they are used subsequently (Figure 2) Decontamination Decontamination is the process used to reduce bioburden on reusable medical devices. The process begins in the theatre itself with the nursing staff wiping off visible

3/23/2007 11:05:04 AM



Figure 1: Dismantling of laparoscopic hand instruments by personnel in the CSSD

Figure 2: Blood drops (arrow) on the insert become apparent on dismantling the instrument

blood tissue and body fluids from the instruments with a damp sterile sponge. At the end of this all soiled or contaminated instruments should be placed in a container containing a disinfectant solution such as 0.5% chlorine and allowing them to soak for 10 minutes (Figure 3).

Comprehensive Laparoscopic Surgery 21

Figure 4: Decontamination in a purpose-built bath in the CSSD

The instruments should not be left in this solution for longer period of time as they may get damaged. Once the instruments reach the CSSD, a purpose-built bath is used for decontamination of their decontamination prior to proceeding with the next step in the cycle . Modifications of the standard cleaning processes are required to clean rigid endoscopic instruments effectively. Instruments designed with an external gasket, an internal seal that does not totally occlude the internal space, or no gasket should be placed in the vertical position in enzymatic cleaning and rinsing solutions, instead of the standard horizontal position, so that the air trapped within the instrument is allowed to escape and replaces with the solution. All solutions should be irrigated through cleaning ports of instruments. During the process of manual cleaning, special attention should be given to intricate and delicate operating mechanisms located at the distal end of many instruments. An ultrasonic cleaner will enhance the cleaning of hard-to-reach places. At the end of decontamination, the instrument should be safe for handling without exposure to blood-borne pathogens. Precleaning After the instruments have reached the sterile supplies processing area, which is preferably a controlled environment, a pre-cleaning treatment with an enzymatic product is recommended. A number of enzymatic (Figure 5) products are available, viz. protease, lipase, amylase, which are effective in enhancing the cleansing process for difficult-to-clean instruments. These break down blood and other protein soil and facilitate cleaning. These enzymes are proteins, and must be removed by thorough cleaning.

Figure 3: Instruments soaked in a disinfectant for decontamination

FIAGES Book.indb 21

3/23/2007 11:05:05 AM

22

Sterilization and Maintenance of Instruments & Equipment

Figure 5: Enzymatic preparation used for precleaning

has several small moving parts and crevices; build up of residues may eventually lead to corrosive damage and pathogenic colonization (bioburden). Many hospitals adopt the technique of washing their instruments in soap scrubs. Although physical cleaning is partially effective, enzymatic and detergent based cleaners which dissolve and lift organic material from the surface of instruments are better suited to ensuring that instrument surfaces are clear of blood and other body fluids and proteinaceous material prior to the sterilization process. For laparoscopic instruments this is best carried out using soft brushes that allow the inner surfaces of the instruments to be cleaned thoroughly (Figures 6 and 7).

Cleaning

Rinsing

Any instrument designed for autoclaving requires specialised cleaning prior to sterilization. Users need to ensure that no residual, proteinaceous material or organic residue remains on the instrument surface. This is particularly important where the instrument

Laparoscopic instruments are best rinsed in running water so that all the particulate matter as well as residues of chemicals used for contamination and cleaning are completely cleared from them. It is useful to have “cleaning guns” with fine, pointed nozzles to rinse the

Figure 6: Cleaning the instrument tip with a toothbrush. Inset shows dried

Figure 8: Rinsing of instruments under running water

blood on the tip of a dissector.

Figure 7: A long soft brush cleans the inner surface of a laparoscopic cannula.

FIAGES Book.indb 22

Figure 9: A water jet being used to clean the shaft of hand instruments

3/23/2007 11:05:06 AM



Comprehensive Laparoscopic Surgery 23

shafts of the laparoscopic hand instruments (Figure 8). The jet of water is able to clean these instruments far better than rinsing them in stagnant water.

using an oven. The latter, however, may be available only in CSSD units.

Ultrasonic Cleaner

The Centers for Disease Control (CDC) recommends that rigid laparoscopic instruments be sterile or, if that is not feasible, that they be high-level disinfected. There are three sterilization processes available to us - steam, ethylene oxide and peracetic acid. Because of product knowledge and proprietary design information, the instrument manufacturer is the only one who can provide sterilization recommendations.

A method of cleaning that is growing in popularity is ultrasonic cleaning (Figure 10). This method is, by far, the most efficient and effective available today. Its ease of use and superior efficiency is quickly making ultrasonic cleaning the preferred choice. In fact, ultrasonic cleaning is 16 times more efficient than hand-cleaning. The instruments are placed in the ultrasonic unit for 1015 minutes and use a neutral pH solution. Attention should be given to the following points during ultrasonic cleaning:

Sterilization

Steam sterilization Steam sterilization in an autoclave is one of the most common forms of sterilization used in health care facilities. Autoclaving at 121 0C for 15minutes is ideal for all reusable metal instruments. It is effective, cheap and non-toxic. Laparoscopes may be sterilized by flash or vacuum steam sterilization. Before sterilization, all instruments that are insulated, all silicone tubing, and

Figure 10: Ultrasonic cleaner

Before placing into the ultrasonic unit, the instruments are cleaned of all visible debris. It’s preferable not to mix instruments made of dissimilar metals (such as aluminum and stainless) in the same cycle. It is important to ensure that the instruments have plenty of room. The ultrasonic cleaner should not be overloaded. As with all types of cleaning, all instruments should be opened so ratchets and box locks are fully exposed to the cleaning process. Upon completion of the cycle, the instruments are removed immediately and rinsed.

Figure 11: Drying of instruments with a jet of air.

Drying The instruments should be dried at the end of the cleaning and rinsing cycle before they are packed for sterilization. This is ideally achieved by using an air gun that blows all the water droplets off the surfaces of instruments or by

FIAGES Book.indb 23

Figure 12: Drying of instruments in an oven.

3/23/2007 11:05:06 AM

24

Sterilization and Maintenance of Instruments & Equipment

Figure 13: Double wrapping of instruments before autoclaving.

Figure 15: Ethylene oxide sterilizer

material. Its main disadvantages are its cost, toxicity, the need for aeration and being a longer process. High level disinfection

Figure 14: Packed trays of laparoscopic instruments being loaded in a high-speed autoclave

all cords should be doubly wrapped in a cloth to prevent contact with the hot metallic container (Figure 13). They are then placed in the autoclave. Flash sterilization is carried out at 135 0C at 30 psi pressure for 60 minutes (Figure 14). This method requires post-vacuum and dry cycles. The instruments should rest on a sterilizer rack for 45 minutes to prevent water condensation on the lens Gas sterilization Using ethylene oxide (EO) is suitable for all disposable instruments, insulated hand instruments and tubings used for gas, suction and irrigation (Figure 15). Endoscopic instruments may be sterilized with either cold or warm EO gas, depending on the manufacturer’s instructions. With cold gas, the temperature is set at 85 0C and the instruments are exposed for 4 hours and 30 minutes. Aeration must then follow for 12 hours. Warm gas sterilization takes place at 145 0C for 2 hour 30 minutes, followed by 8 hours aeration. The advantages of EO are that the items are not damaged, it is non-corrosive to optics and it permeates porous

FIAGES Book.indb 24

When sterilization is not available or feasible, high-level disinfection (HLD) is used for instrument processing. HLD eliminates bacteria, viruses, fungi, and parasites but does not reliably kill all bacterial endospores, which cause diseases such as tetanus, gas gangrene and atypical mycobacterial infections. HLD is suitable for items that will come in contact with broken skin or intact mucous membranes. The effectiveness of HLD depends on (a) the amount and type of microorganisms, organic material (blood, other fluids, tissues), and other matter (such as dirt) present on the instrument or other item and (b) the amount of protection the item gives the microorganisms (such as whether the item has grooves or other areas in which microorganisms can hide). Therefore it is important to decontaminate and thoroughly clean instruments and other items before HLD. Agents that are used for HLD include 2% glutaraldehyde, 6% stabilized hydrogen peroxide and per acetic acid (acetic acid/hydrogen peroxide). Glutaraldehyde has the advantages of having good biocidal activity, non-corrosive to optics and is active in the presence of protein. Glutaraldehyde is irritating to the skin, eyes, and respiratory tract, especially at concentrations of 0.3 parts per million (ppm). The length of time that commercially available glutaraldehyde solutions can be used varies, usually from 14-30 days. It should be tested daily with the manufacturer’s test strip. Always follow the manufacturer’s instructions regarding proper storage temperatures and expiration date. Solutions should be replaced any time they become cloudy. The efficiency of glutaraldehyde is influenced by the organic load, contact

3/23/2007 11:05:07 AM



time and use pattern, concentration, physical configuration of instruments, temperature and pH. OSHA’s established maximum allowable exposure limit for glutaraldehyde is 0.2ppm. Fibreoptic light cords and telescopes need to be soaked in 2% glutaraldehyde for at least 10 minutes. Soaking should not exceed 20 minutes. The endocamera may also disinfected by 10 minutes submersion in 2% glutaraldehyde. Care must be taken to leave the plug end of the cord outside the solution. Alternately, sterile drape over the camera and cord can be used. Soakage of other metallic instruments, including trocars, and hand instruments, is now recommended for 60 minutes, to avoid infection with atypical mycobacterial infection. Formaldehyde, glutaraldehyde from phenolic derivatives, iodophors, hypochlorites, phenolics and quartery ammonium compounds are definitely unpopular and has been condemned. Formaldehyde is potentially cancercausing and extremely irritating to the skin, eyes, nose, and respiratory tract. Furthermore, its efficacy is found wanting, and therefore, routine use of formaldehyde for sterilizing instruments and other items is not recommended. Newer methods of sterilization A priority for hospitals with high workload is the rapid turnaround times for instruments that cannot be sterilized satisfactorily with steam or dry heat. One of the newer sterilizer system - STERRAD (Johnson & Johnson) - uses hydrogen peroxide vapor and low-temperature gas plasma to sterilize most devices quickly with no toxic residues. Usually, the process takes about 75 minutes for wrapped and dry instruments and devices. Inside the chamber, a deep vacuum is drawn. Fifty-nine percent aqueous hydrogen peroxide is vaporized into the chamber. The product is then enveloped in the hydrogen peroxide vapor. Following the diffusion of the gaseous hydrogen peroxide through the load, chamber pressure is reduced, allowing for the generation of low-temperature gas plasma. Radio frequency (RF) energy is applied to the chamber via an RF amplifier, inducing the plasma state. Reactive species are generated from the hydrogen peroxide in this state, reacting with materials and each other. Once the high-energy species have reacted, they recombine to form water vapor, oxygen, and other non-toxic byproducts. Upon completion of sterilization, instruments are dry for immediate use or sterile storage. Thus, recontamination risk is minimized, and since they remain sterile until their next use, time and money is saved by avoiding reprocessing instruments if the case in canceled or delayed. This system takes up minimal space and requires no venting or water hookup. The only

FIAGES Book.indb 25

Comprehensive Laparoscopic Surgery 25

Figure 16: STERRAD sterilizer

utility requirement is electrical hookup. Storage Items should be used or properly stored immediately after sterilization or HLD so that they do not become contaminated. Proper storage is as important as proper decontamination, cleaning, sterilization, or HLD. If items are not stored properly, all the effort and supplies used to properly process them will have been wasted, and the items will be contaminated. Specific instructions for proper storage depend on whether sterilization or HLD has been performed, the method used, and whether the items are wrapped or unwrapped. The shelf-life of a wrapped item is affected by a number of factors, including: The type of packing material used The number of times the pack is handled The number of people who handle the pack The cleanliness, humidity, and temperature of the storage area Whether the packs are stored on open or closed shelves Whether dust covers (such as sealed plastic bags) are used For optimal storage, sterile packs are placed in closed cabinets in areas that are not heavily trafficked, have moderate temperatures, and are dry or of low humidity. Under optimal storage conditions and with minimal handling, properly wrapped items can be considered sterile as long as they remain intact and dry. Storage time and the handling of sterile packs should be kept to a minimum, since the likelihood of contamination increases over time and with increased handling. When in doubt about the sterility of a pack, consider it to be contaminated and resterilize the item before use.

3/23/2007 11:05:07 AM

4 Energy sources in Laparoscopy and their optimal use Rajeev Sinha Many energy sources are available to cut, coagulate and evaporate tissue. A complete understanding of the equipment, energy source physics, potential hazards and limitations is essential if energy source related complications are to be reduced. Energy sources are classified as electrical, laser, ultrasonic, and mechanical. The surgeon must realize that the use of a specific energy source does not in itself lessen the chance of a complication. Energy sources such as electrical, laser, ultrasonic and hydro energy have unique properties that determine their effectiveness and limitations when used during minimally invasive surgery. What is also true is that a particular surgeon may be conversant or may have mastered a particular technique which may not even be familiar to another. It has thus been aptly pointed out that “It’s not the wand but the magician which makes a difference” ELECTROSURGERY Electrosurgery uses an alternating radiofrequency current with a frequency of 500,000 to 2 million Hz per second. This rapid reversal of current means that ion positions across cellular membranes do not change. As a result, neuromuscular membranes do not depolarize, and there is no danger of cardiac defibrillation at these high frequencies unlike household current,which with its low frequency of 60 Hz, can produce ventricular fibrillation. The terms electrocautery and electrosurgery are often used interchangeably in modern surgical practice. However, these terms define two distinctly different modalities. Electrocautery is the use of electricity to heat

FIAGES Book.indb 26

a metallic object which is then used to coagulate or burn. It is important to realize, there is no current flow through the object being marked or cauterized with electrocautery. Electrosurgery, on the other hand, uses the electrical current itself to heat the tissues. As a result, the electrical current must pass through the tissues to produce the effect. The current then flows through the tissues to produce heat from the excitation of the cellular ions. PHYSICS The basic principle of electrosurgery is that current flowing through the body takes the path of least resistance which in the body means tissues with maximal water (thus electrical resistance is in inverse proportion to water content). The most conductive is blood followed by nerve, muscle, adipose tissue and finally least conductive is the bone. It is also important to remember that the path is not always a straight one. As soon as the current passes through a tissue it dessicates (dries out) the tissue because of which the resistance of that tissue rises leading to non conductivity and the current then takes the path through adjacent tissues which have a lesser resistance. Hence the flow pattern of current through live tissue can never be predicted. Also this changing resistance of body tissue during the current flow requires that electrosurgical generators must deliver current at increasing voltages that are matched to the expected tissue resistance of the human body , otherwise, current flow can be too low to produce the desired effect or too great, resulting in injury. The current density is another important variable

3/23/2007 11:05:07 AM



Comprehensive Laparoscopic Surgery 27

determining the biological effect of the current and can be defined as = amperes/area= amperes/cm2 This explains why the pinpoint tip of an electrosurgical pencil works more effectively than a spatula. It follows that in laparoscopy, the less area of contact of the electrode at the intended site of effect, the greater would be the effect. The amount of heat released is directly proportional to the resistance of the tissues. There are 3 types of currents:

earth plate) which takes the current back to the machine after travelling through the body (unipolar circuit). Thus it should be the aim to minimize the distance between the operating electrode and the ground pad. In the bipolar circuit ,because both the positive and negative electrodes are near to each other, the current flow inside the body is minimal and is thus less damaging. The majority ( 85%) of surgeons use monopolar electrosurgery, whereas the rest use bipolar electrosurgery. Electrosurgical generators are essentially of two types: grounded and isolated. The newer isolated generators eliminate the possibility of an alternate site burn by requiring the current to return to the generator. In the early grounded generators the current returned to earth by any contact point and thus caused inadvertent burns.

Isolated Generator system

High Current density

Direct current which is unidirectional and is also known as galvanic current and is used in acupuncture and endothermy but not for electosurgery. 2. Alternating current or AC where the flow changes in a sinusoidal fashion and is used in electrosurgery. 3. Then there is the pulsed current where a high amount of electrical energy is discharged in a very short time. It is used for electromyography and nerve stimulation. 1.

The current circuit has to be completed which is done through either the ground pad (which is incorrectly called

FIAGES Book.indb 27

Both the unipolar and bipolar circuits can further be modified as open and closed circuit. Open circuit is typically formed when the electrode does not make contact with the tissues or the tissue in contact with the electrode is already dessicated. In the circuit, the resistance increases and generator increases the voltage to close the circuit and the wave form also becomes erratic. The current in close circuit is safe and delivers lesser voltage. BIOPHYSICS The electrosurgical effect on the tissue results in 3 definable effects i. cutting ii. coagulation and or fulguration iii. dessication True electrosurgical cutting is a noncontact activity in which the electrosurgical instrument must be a short distance from the tissue to be cut. If there is contact,

3/23/2007 11:05:08 AM

28

Energy sources in Laparoscopy and their optimal use

desiccation will ensue rather than cutting. Cutting requires the generation of sparks of brief duration between the electrode and the tissue. The heat from these sparks is transferred to the tissue, producing cutting. As electrons in the form of sparks bombard cells, the energy transferred to them increases the temperature in a cell. As a result, a temperature is reached at which the cell explodes. The best wave for cutting is a non modulated pure sine wave because current is delivered to the tissue almost 100% of the time that the electrosurgical delivery device is activated. If the cut is made by keeping the probe in contact with the tissue then it is not true cutting rather it is mechanical cutting through cauterized tissue. Fulguration also requires that there should be no contact between the electrosurgical delivery device and the tissue. In contrast to cutting, fulguration requires short bursts of high voltage only 10% of the time to produce sparks but a low power to produce coagulation as compared to cutting. Coagulation and Fulguration thus utilize higher voltage than cutting but the pause between current flow is more (maximum pause in fulguration). Both cause coagulative necrosis of tissues and fluid. Desiccation is the process by which the tissue is heated and the water in the cell boils to steam, resulting in a drying out of the cell. Desiccation can be achieved with either the cutting or the coagulation current by contact of the electrosurgical device with the tissue because no sparks are generated. Therefore, desiccation is a low

power form of coagulation without sparking, and it is the most common electrosurgical effect used by surgeons. The pure cutting current will cut the tissue but will provide poor hemostasis. The coagulation current will provide excellent coagulation but minimal cutting. The blend current is an intermediate current between the cutting and the coagulation current, as one might expect. In actuality, it is a cutting current - the duty cycle or time that the current is actually flowing during activation of the electrosurgical delivery device is decreased from 100% of the time to 50% to 80%. It is important to note that setting the generator to blend mode does nothing to alter the coagulation current that is provided. Only the cutting current is altered so that the duty cycle is reduced to provide more hemostasis. The use of electrosurgery in laparoscopic surgery is complicated by the insufflating gas, which has a low heat capacity. As a result, instruments may not cool as rapidly as in the open environment. In addition the high water content of the gas increases the conductive capacity of the medium. Despite new advances in machines which are safer, complications can still occur and injuries like, bile leaks, intestinal injuries , anastomotic leaks and postoperative bleeding may result from the inappropriate or injudicious use of electrosurgery. Fortunately most if not all injuries can be eliminated by the use of isolated generators, returns, electrode monitoring systems. and active electrode monitoring systems.

“Pure Cut” “Blend 1” “Blend 2” “Blend3” 100% On 80% On 60% On 50% On 20% Off 40% Off 50% Off Low Voltage

“Pure Coag” 94% Off 6% On High Voltage

Blend currents. The blend current is a cutting in which the duty cycle has electrosurgical actions

FIAGES Book.indb 28

3/23/2007 11:05:09 AM



Comprehensive Laparoscopic Surgery 29

Direct coupling Capacitive coupling Surgical glove injury Explosion Ground Pad Failures The large surface area of contact it provides, allows the current to be dispersed over a large enough area that the current density at any one site on the electrode is small enough not to produce thermal damage. Lack of uniform contact can result in significant current concentration and damage. Any conductive low resistance object can “HOOK, LOOK, COOK”.

ELECTROSURGICAL PROBES

Ground pad burn

COMPLICATIONS which can result from the use of electrosurgey include. Grounding failures Alternate site injuries Demodulated currents Insulation failure Tissue injury at a distal site Sparking

FIAGES Book.indb 29

Ground pad burn

3/23/2007 11:05:12 AM

30

Energy sources in Laparoscopy and their optimal use

Ground pad burn

serve as the conduit. Exit of current at these alternate sites can produce injury at an alternate site. Usually such injury results when the site of contact is small, there by providing a high current density. Demodulated currents Modern generators have filters that remove demodulated currents from the current delivered to the patient so that only electrical current of 250 to 2000 kHz is delivered. Demodulated currents occur most commonly when an electrosurgical instrument is activated off metal and then touched to the metal, such as the common practice of “buzzing a hemostat”. Demodulated currents produce neuromuscular activity that is usually of no significance unless directly coupled to the heart through a catheter or during a cardiothoracic surgical procedure. Another example of demodulated current is muscle fasciculation at the site of a laparoscopic cannula during the use of electrosurgery. Insulation Failure Insulation failure is thought to be the most common reason for electrosurgical injury during laparoscopic procedures and more commonly seen with high voltage coagulation wave form. Voyles and Tucker have classified insulation failure into four potential zones of injury. Zone 1 failures are easily seen by the surgeon, Zone2 can only be seen after careful inspection and because the break is small a high current density is achieved. Zone3 is detected by appearance of demodulated current induced fasciculations and Zone4 is injurious to the surgeon or other personnel.The key factor that determines the magnitude of injury from insulation failure resides in the size of the break in the insulation. Paradoxically, the smaller the break, the greater the likelihood of injury if contact of tissue with that site occurs. This is related to the concept of power density. Protection against insulation failure is provided by the active electrode

FIAGES Book.indb 30

Insulation failure zones

Insulation failure from instruments

monitoring system available in many machines. Tissue injury Current passing through structures of small cross sectional area may have current concentrated there, with resultant unintentional thermal injury. For example if the testicle and cord are skeletonized and mobilized from the scrotum, application of energy to the testicle can result in damage to the cord,because the current must return to the indifferent electrode through the small diameter cord before it is dissipated in the body through numerous pathways.Another example of cutting an adhesive band from the gallbladder to the duodenum with electrosurgery. If the adhesion is wider near the gallbladder than on the duodenum, the current density will be greater on the duodenum injuring the duodenum. Sparking and Arcing Jumping of sparks from the electrode to tissues is the mechanism for fulguration and true electrosurgical cutting. However, it can also occur in an unintended

3/23/2007 11:05:13 AM



Comprehensive Laparoscopic Surgery

31

fashion such that injury results, especially in laparoscopic surgery. The ability of electrical sparks to travel over a distance in a gaseous environment is increased when the tissue desiccates and there is a moist, smoky environment. Current can also jump from any place on the uninsulated end of the electrode and need not jump from the tip. In addition, build up of eschar on the electrosurgical instrument may promote arcing to a secondary site. Sparking with monopolar electric current is small. Under normal operating conditions at 30 to 35 W, because sparks jump 2 to 3 mm, 50% of the time, it is not enough to allow significant air or CO2 gaps to be bridged. Direct Coupling Direct coupling occurs when an electrosurgical devices is in contact with a conductive instrument. Direct coupling

Direct coupling

can be reduced by using only insulated instruments and careful attention to avoid contact with any metallic object in the operative field and activating the electrosurgical electrode should only be done inside the visual field and never near the another metal object such as a clip, staple, laparoscope, or metal instrument. Capacitive Coupling Capacitance is stored electrical charge that occurs between two conductors which are separated by an insulator. The capacitively coupled current wants to complete the circuit by finding a pathway to the patient’s return electrode. The charge is stored in the capacitor until either the generator is deactivated or a pathway to complete the circuit is achieved. Capacitive coupling is greatest in the coagulation mode when there is no load on the circuit (open circuit). Capacitive coupling is considerably greater through a 5-mm cannula than through an 11 mm cannula and greater, the longer the cannula. Every object in the room- the surgeon, the patient, the operating table - all have a small but finite

FIAGES Book.indb 31

Capacitive coupling from cannula

Capacitive Coupling

capacitance to earth when two conductors are separated by an insulator. Surgical Glove Injuries Breach can be seen in 15% of new surgical gloves and 50% of gloves after use in surgery. Three mechanisms exist for these holes and burns. High voltage dielectric breakdown occurs because the high and repetitive voltages across the glove (dielectric) breaks the insulative capacity of the glove, resulting in conduction of current to the surgeon and a burn in the glove .DC ohmic conduction is the result of insufficient conductive resistance of the glove. The resistance of gloves decreases with time and with exposure to saline (sweat). The third mechanism is capacitive coupling. The risk of capacitive coupling is inversely proportional to the thickness of the gloves. Explosion In the absence of ether and other explosive anesthetic agents there is still a significant explosive hazard when elecrosurgery is used especially from intestinal gas. Indeed 43% of unprepared bowel contains a potentially explosive

3/23/2007 11:05:14 AM

32

Energy sources in Laparoscopy and their optimal use

mixture or gases. Hydrogen air mixtures composed of 4% to 7% are potentially explosive. For this reason, mannitol, which promotes the production of methane, should be avoided in bowel preparations. Although debated, studies have documented levels of nitrous oxide in the peritoneal cavity during laparoscopy that can support combustion.

the process of desiccation. Bipolar electrosurgery can coagulate vessels upto 7 mm diameter.

Electrosurgical By-products Include biological by products, as well as chemicals and irritants. Although many of these by-products may be mutagenic or carcinogenic, no adverse effects have been documented in the literature.The best studied chemicals that are potentially generated by laparoscopy are methemoglobin and carboxyhemoglobin. Bowel Injuries Usually are unrecognized when they occur and present 3 to 7 days after surgery. Because of this, they carry a high mortality rate resulted from the early experience with tubal sterilization using monopolar electrosurgery. Bipolar Electrosurgery In contrast to unipolar circuits shows a reduction in the amount of tissue damage . Also as compared to unipolar electrosurgery, the overall damage is two times less , there is reduced depth of penetration,less smoke is generated and the risk of perforation is less. On the other hand, hemostasis is not as good.Another obvious advantage of bipolar electrosurgery over monopolar electrosurgery is the absence of a return electrode on the patient which eliminates the possibility of ground pad and alternate site burns , and capacitive coupling. In addition it almost eliminates the risk of insulation failure. Finally, direct coupling can occur only if metal is grasped or placed between the electrodes in a bipolar circuit or extremely close to the electrodes. However as the outer layers of tissue desiccate, the resistance to current flow increases and lateral spread occurs to almost 3-4 mm. Also coagulation may cease before it is completed and therefore bleeding may result. This explains in part the occasional high rates of pregnancy following bipolar sterilization. where the tubes may not be completely blocked. A significant problem with bipolar electrodes is tissue sticking. This can be reduced or eliminated by irrigation of the bipolar electrodes at the time of activation, the irrigant not only cools the electrodes but also the tissue, thereby minimizing conducted thermal injury. Nonelectrolytic solutions such as glycine or weakly electrolytic solutions work best. The principal tissue effect achieved with bipolar electrosurgery is tissue coagulation through

FIAGES Book.indb 32

Bipolar coagulation with Klepinger forceps

Guidelines for the Use of Electrosurgery in Laparoscopic Applications 1. 2.

3.

4. 5.

6.

7.

Avoid using over 30 W of power. Use only the coagulation mode with wire electrodes. If the cutting mode is used, there is more bleeding, and this can obscure the operative field. Because wire electrodes are so thin, one can achieve satisfactory cutting (similar to that achievable at a blend setting) in the pure coagulation surgery. Tissue damage can be reduced by reducing the “on” time of the current. This is controlled by the surgeon using either a handpiece or a foot pedal. Use electrode geometry to achieve precise coagulation or cutting. Choose a smaller contact patch to achieve cutting and a larger contact patch to to achieve coagulation. The tissue has to be placed on tension to achieve cutting. Use the thin wire electrodes to cut. Thick wire electrodes perform poorly because they tend to cause coagulation, and cutting and coagulation cannot be properly achieved. Thinner wire electrodes can be used for precise bloodless dissection. The foot switch or hand switch should be activated for short periods only. If the current is on long, the chance of remote site electrical injury is increased (in the event there is an unrecognized insulation failure) If the surgeon observes blanching of tissue, a precursor of charring, too much power is being used. Charring should be avoided. In the liver bed, this will result in the liver tissue adhering to the electrode and, when the electrode is moved, it will tear the liver tissue.

3/23/2007 11:05:15 AM



Comprehensive Laparoscopic Surgery 8.

The use of the hook can be summarized as - “HOOK, LOOK, COOK”

RECENT ADVANCED TECHNOLOGY AND INSTRUMENTATION IN ELECTROSURGERY With the development of newer generators and innovative instrumentation, better delivery of the appropriate amount of energy results in better sealing of vessels. Argon Beam Coagulator Argon gas is an inert, noncombustible and easily ionized gas that is used in conjuction with monopolar electrosurgery to produce fulguration. Essentially, the electrical current ionizes the argon gas, thereby making a more efficient pathway for the current to flow because the gas is more conductive than air, therefore providing

Argon beam coagulator

a bridge between the tissue and the electrode. Less smoke is produced with the argon beam coagulator because there is less depth of tissue damage. Despite these advantages, the argon beam coagulator suffers from one very significant drawback in laparoscopic surgery, namely, high flow infusion of argon gas into the abdominal cavity which not only increases the intraabdominal pressure to potentially dangerous levels, but can also result in fatal gas embolism. Gyrus PK Tissue Management System The Gyrus PK Tissue Management System (Gyrus Medical, Inc, Minneapolis, Minnesota) instruments provide a unique technology called Vapour Pulse Coagulation (VPC), which produces faster, more uniform results with pulsed energy instantly delivered in a controlled manner. VPC’s pulse-off periods allow

FIAGES Book.indb 33

33

tissue to cool and moisture to return to the targeted area, greatly reducing hot spots and coagulum formation. This technology also results in evenly coagulated target tissue, minimal thermal spread, less sticking, and enhanced hemostasis. It does require its own generator, which works in tandem with the Gyrus PK instruments. The SurgRxEnSealSystem The SurgRxEnSealSystem (SurgRx, Inc., Palo Alto, California) incorporates Smart Electrode Technology. The EnSeal instruments adjust dose energy simultaneously to various tissue types in a tissue bundle each with its own impedance characteristics. This electrode consists of millions of nanometer-sized conductive particles embedded in a temperature-sensitive material. Each particle acts like a discrete thermostatic switch to regulate the amount of current that passes into the tissue region with which it is in contact, thereby generating heat within it. To keep temperature from rising to potentially damaging levels, each conductive nanoparticle interrupts current flow to a specific tissue region engaged by the electrode region. When temperature dips below the optimal fusion level, the individual particle switches back on, reinstating current flow and heat deposition. The process continues until the entire tissue segment is uniformly fused without charring or sticking. Less heat is required to accomplish fusion, as the tissue volume is minimized through compression; energy is focused on the captured segment; and the vessel walls are fused through compression, protein denaturation, and then renaturation. The Ligasure System The Ligasure System (Valleylab, Boulder, Colorado) LVSS (Ligasure vessel sealing system) utilizes a new bipolar technology for vascular sealing with a higher current and lower voltage (180 V) than conventional electrosurgery. It uses a unique combination of pressure and energy to create vessel fusion. This fusion is accomplished by melting the collagen and elastin in the vessel walls and reforming it into a permanent, plastic-like seal. It does not rely on a proximal thrombus as does classic bipolar electrocautery. A feedback-controlled response system automatically discontinues energy delivery when the seal cycle is complete, eliminating guesswork and minimizing thermal spread to approximately 2 mm for most LigaSure instruments. This unique energy output results in virtually no sticking or charring, and the seals can withstand 3 times normal systolic blood pressure.[3] This system also

3/23/2007 11:05:16 AM

34

Energy sources in Laparoscopy and their optimal use

requires a designated generator that works with several different instruments designed by the company. The LigaSure Vessel Sealing System includes :

The Ligasure System

An electrosurgical generator able to detect the characteristics of the tissue closed between the instrument jaws; it delivers the exact amount of energy needed to seal it permanently. 2. Several types of instruments that seal and, in some cases, divide the tissue. Those used are the following: 1.

LigaSure Atlas is a surgical endoscopic device (diameter: 10 mm, length: 37 cm) that seals and divides vessels up to 7 mm in diameter; LigaSure V is a single-use endoscopic instrument (diameter: 5 mm, length: 37 cm) able to seal and divide; LigaSure Lap is a single-use endoscopic instrument (diameter: 5 mm, length: 32 cm); LigaSure Precise is a single-use instrument (length: 16.5 cm) for open procedures specifically designed to provide permanent vessel occlusion to structures that require fine grasping; LigaSure Std is a reusable instrument.

FIAGES Book.indb 34

ULTRASONIC ENERGY Today virtually all laparoscopic procedures can be performed safely and efficiently without electrosurgery by using ultrasound. Furthermore, ultrasonic surgery has also replaced mechanical surgical clips and scissors in many laparoscopic procedures. Physics of Ultrasound: Audible sound waves, are confined to the frequency range of 20 cycle per second (Hz) to about 20,000 cycles per second. A longitudinal wave, whose frequency is above the audible range is an ultrasonic wave. When ultrasonic waves are applied at low power levels, no tissue effect occurs as is the case for diagnostic ultrasound imaging. However, higher power levels and power densities can be harnessed to produce surgical cutting, coagulation, and dissection of tissues. This involves mechanical propagation of sound (pressure) waves from an energy source through a medium to an active blade element. Waves are longitudinal mechanical waves that can be propagated in solid, liquids, or gases. Ultrasonic dissectors are of two types, low power which cleaves water containing tissues by cavitations, leaving organized structures with low water content intact, e.g. blood vessels, bile ducts etc.; and high power systems which cleave loose areolar tissues by frictional heating and thus cut and coagulate the edges at the same time. Thus, low power systems (ultrasonic cavitational aspirators ) are used for liver surgery and neurosurgery (Cusa, Selector) and do not coagulate vessels. High power systems (Autosonix, Ultracision) are used extensively, especially in advanced laparoscopic surgery. The Harmonic scalpel and the AutoSonix system operate at a frequency of 55.5 kHz. Ultrasurgical devices are composed of a generator, handpiece, and blade. The handpiece houses the ultrasonic transducer, a stack of piezo electric crystals sandwiched under pressure between metal cylinders. The transducer is attached to a mount, which is then attached to the blade extender and blade. The harmonic scalpel cools the handpiece with air. AutoSonix and Sonosurg systems rely principally on large diameter handpiece made of heat dissipating materials to remove the heat and prevent heat build up. Ultrasonic cutting, coagulation, and cavitation: The basic mechanism for coagulation of bleeding vessels ultrasonically is similar to that of electrosurgery or lasers. Vessels are sealed by tamponading and coapting with a denatured protein coagulum. Electrosurgery uses electrons and lasers use photons to excite molecules in the tissue.This in turn releases heat and protein is denatured to form a coagulum.Ultrasurgical

3/23/2007 11:05:16 AM



devices denature proteins by mechanical energy of the vibrating probe. Ultrasurgical hook or spatula blade can coagulate blood vessels in the 2 mm diameter range without difficulty and the scissors can coagulate vessels up to 5 mm in diameter. Heat generated with the Harmonic is limited to temperature below 80OC. The overall temperatures achieved by the Harmonic scalpel even after prolonged use remains well below the 250 O to 400O C achieved with electrosurgery and laser surgery. This results in reduced tissue charring and desiccation and also minimizes the zone of thermal injury. Skin incisions made with the ultrasonically activated scalped or cold steel scalpel heal almost identically and are superior to electrosurgically made incisions. This minimal damage may explain the marked reduction in postoperative adhesions to the liver bed following laparoscopic cholecystectomy with the ultrasonically activated scalpel, when compared with electrosurgery or laser surgery in experiments performed in pigs, Although coagulation produced by ultrasonic surgery is slower than that observed with either electrosurgery or laser surgery , nonetheless, it is as effective or even more effective. However greater depth of thermal injury can result with ultrasurgery as compared to electrosurgery if activation persists for more than 10 seconds. Despite the slower rate of tissues coagulation, the entire process of tissue coagulation combined with transaction, the ultimate goal of surgery, is faster with the LCS or hook scalpel than with other energy modalities. The mechanisms of coagulation offer an advantage for ultrasonic surgery over electrosurgery when coagulation the side wall of a blood vessel. Blood vessels are usually not coapted significantly by electrosurgery because of the concomitant reduction in power density. Furthermore, the blood within the vessels has a high heat capacity and acts as a heat sink,which allows one side to coagulate prior to the other, with resultant bleeding from a hole in the wall of the vessel that was in contact with the electrosurgical device.This is not the case with ultrasurgery. Absence of coagulated tissue sticking to the active element, because of the vibration of the active blade, is a unique feature of ultrasurgical coagulation compared with other energy modalities. In addition, the grasper blade allows unsupported tissue to be grasped and coagulated without difficulty, or cut and coagulated as with scissors. The cutting mechanism for the ultrasonically activated scalpel is also different from that observed with electrosurgery or laser surgery. At least two

FIAGES Book.indb 35

Comprehensive Laparoscopic Surgery

35

mechanisms exist. The first is cavitational fragmentation in which cells are disrupted. This occurs primarily in low protein density areas such as liver. This mechanism is similar to that observed with the ultrasonic aspirating device ( CUSA), The later device is composed of an ultrasonic generator that vibrates at 23000 Hz. When coupled with powerful aspiration device , the ultrasonic aspirator fragments cells and aspirates the resulting cellular debris and water. This action leaves collagen rich tissues such as blood vessels, nerves, and lymphatic intact. Thus, these is no cutting or coagulation with the ultrasonic aspirator. In marked contrast, the ultrasonically activated scalpel not only coagulates and cavitates, it also cuts high protein density areas such as collagen or muscle rich tissues. This occurs via the second cutting mechanism , which is the actual “ power cutting” offered by a relatively sharp blade vibrating 55500 times per second over a distance of 80 um. A major advantage of the ultrasonically activated scalpel’s coagulation ability is the absence of melting and charring of tissues. This allows the tissue planes to be clearly and sharply visualized at all times. As a result surgeons can be more precise because they can see better than with other energy forms. Because there is little or no cutting ability with the blade in an activated situation the ultrasonically activated scalpel can also be used as a blunt dissector to aid in identifying tissue planes. It is important to remember that high power ultrasonic dissection systems may cause collateral damage by excessive heating and this is well documented in clinical practice.Ultrasonic surgical dissection allows coagulation and cutting with less instrument traffic (reduction in operating time), less smoke and no electrical current. Mechanical energy at 55,500 vibrations / sec. Disrupts hydrogen bonds & forms a Coagulum Temperature by Harmonic Scalpel-80-100 ° C Temperature through Electro coagulation-200-300 ° C Collateral damage, tissue necrosis. LASER (Light amplification through stimulated emission of radiation.) Principles of Stimulated Emission In a normal population of atom the majority will be in the resting state. A small percentage of atoms will be at the next higher energy level, E1, and decreasing percentage

3/23/2007 11:05:17 AM

36

Energy sources in Laparoscopy and their optimal use

is present at ever-increasing energy levels to En. It is possible by the addition of optical, chemical, or electrical energy from a pump (external) source, to raise the atom in the resting state to higher energy levels. This occurrence is known as the spontaneous absorption of energy. When this occurs more atoms are in the excited or higherenergy state than in the resting state, which is an unstable situation known as a population inversion. Such unstable atoms tend to give off their extra packet of optical energy and return back to the resting state which is known as spontaneous emission. Regardless of what type of energy source was used to create the population inversion, when the atoms release their extra photon of energy it is of

Ethicon Ultracision System

the wavelength determined by the atoms involved. For example with a neodymium :YAG laser the neodymium atoms are raised to higher energy levels with the use of krypton lamp. When the process of spontaneous emission occurs the extra photons of energy that are given of are those of neodymium energy. As these extra photons of neodymium energy strikes other excited neodymium atoms they force the excited neodymium atoms to give off their extra energy and return to their resting state. This process is known as Stimulated Emission. Both photon of neodymium energy are emitted exactly in the same phase. Thus one incoming photon has been amplified to two outgoing photons.As this process is repeated more photons are recruited into the beam and the process of light amplification by stimulated emission is produced. All this activity takes place within a laser cavity. The laser cavity is a cylinder that is closed at both ends by mirrors. The mirror in the back is a fully reflecting mirror, whereas the mirror in the front has a small aperture in the middle, through which the laser beam can be released. Any atoms traveling parallel to the laser cavity may be

FIAGES Book.indb 36

reflected back and forth between the mirrors at the ends. In addition an energy pump of some sort such as the krypton lamp used in the neodymium laser is needed in order to create the population inversion. As the atoms are raised to the higher energy levels they begin to bounce around within the laser cavity. Most of the energy escapes tangentially into the interstices surrounding the cavity and must be removed by a heat sink. A small percentage of the beam however is trapped between the mirrors and continually bounces back and forth running parallel to the cavity. These photons of energy that are trapped between the mirrors continue to recruit more and more of the excited atoms by the process of stimulated emission and thus continue to amplify their beam. By using a foot pedal the surgeon has three options as to how the beam can be released from the cavity. The first mode is known as the continuous wave (CW). In the CW mode, the beam continues to be emitted at a steady rate for as long as the foot pedal is depressed. The level of energy emitted is determined by the power setting on the machine. In the pulse mode, the pulse is released for a limited period of time as determined by the machine setting. There is then a fixed interval between pulses. In the interval between the pulses it is possible for the power in the laser cavity to climb higher then it does in CW mode. Thus higher peak power are possible when using a pulsed setting. In the Q switched mode , a shutter like device similar to the one in the camera allows for the escape of energy in exceedingly narrow pulses. In this situation, the power achieved within the laser cavity between pulses is extremely high. This is the type of laser used frequently in ophthalmologic procedures, and the power in these lasers tend to be measured in milliwatts. High power and short pulse duration are the hallmark of ophthalmologic lasers.

Laser Physics

3/23/2007 11:05:18 AM



Comprehensive Laparoscopic Surgery

37

Unique Properties of the Lasers.

HIGH- VELOCITY WATER- JET DISSECTION

First the light is monochromatic. The laser emits light over a very narrow, welldefined wavelength. Second, the light is coherent. Because of the properties of stimulated emission, laser light is perfectly in the phase; that is each peak and valley of the sine wave curves align exactly. Finally the laser beam is nondivergent (upto 1degree of divergence).

High-velocity high-pressure water- jet dissection involves the use of relatively simple devices to produce clean cutting of reproducible depth. Other advantages are the

Biophysical Principles Three major types of medical lasers are available commercially today, all named for the medium in the laser cavity. The carbon dioxide laser has a wavelength in the far infrared region of the spectrum at 10600nm. Ninety seven percent of its energy is absorbed at the point of contact with a penetration of only 0.1 mm. With the argon laser approximately 55 percent of the power is reflected back from the tissue, and the reminder is absorbed. The argon laser is absorbed by hemoglobin or melanin selectively and does not penetrate more than 1.0 mm. The neodymium : YAG laser is within the near infrared region of the spectrum at 1060nm. 50 percent of its energy is reflected back from the tissue, while the other 50 percent is absorbed. It is not absorbed preferentially by any pigment. Its penetration is 4.0 mm into tissue. All three of these lasers work fundamentally by thermal action. When tissue is heated by any of these lasers up to 60OC , there is no permanent or visible damage to the tissue. By 65OC , denaturation of protein occurs. The tissue will visibly turn white or grey and will disintegrate approximately 4 to 7 days later. This is the temperature range in which the Nd:YAG laser works. Once tissue has been heated to 90OC to 100OC, there is tissue drying, some shrinkage, and permanent damage due to dehydration. Over 100OC carbonization or blackening of tissue occurs. As the temperature rise continues there is evolution of gas with tissue vaporization. This is the temperature in which the CO2 and argon laser works. The only laser system that does not work by the thermal cavity is argon pumped dye laser combined with hematoporphyrin derivative. In this laser system hematoporphyrin derivative is administered intravenously 48 hours prior to therapy. The hematoporphyrin derivative in certain organ system of the body including the bladder is concentrated within the tumor cells in preference to the normal cells. When exposed to the red light, the hematoporphyrin derivative is excited and cleaves oxygen to from singlet oxygen within the mitochondria, leading to cell death. This is a non thermal effect.

FIAGES Book.indb 37

Laser unit with hand pieces

cleansing of the operating field by the turbulent flow zone and the small amount of water required to complete dissection.Specific problems were identified with the use of this modality. The “hail storm” effect result in excessive misting which obscures vision. This has been solved to some extent by incorporating a hood over the nozzle. The non-haemostatic nature of this modality, difficulty in gauging distance and poor control of the depth of the cut are additional drawbacks. The spraying of tissue fragments renders it also oncologically unsound. The present use of water- jet dissection is limited to dissection of solid organs. HYDRO DISSECTION Hydro dissection uses the force of pulsatile irrigation with crystalloid solutions to separate tissue planes. The

3/23/2007 11:05:19 AM

38

Energy sources in Laparoscopy and their optimal use

operating field at the same time is kept clear. Like water jet dissection no haemostasis is achievable. The use of this dissecting modality is restricted to pelvic lymhadenectomy and pleurectomy in thoracoscopic surgery. RADIOFREQUENCY ABLATION Radiofrequency ablation is minimally invasive method that uses thermal energy to destroy tumor cells. Initially computed tomography or ultrasound is performed to locate the tumor. A special needle is introduced into the tumor using direct image guidance. This is equivalent to a standard needle biopsy. The needle is attached to a radiofrequency generator. The generator sends radiofrequency through the needle, which generates heat from frictional movement of ions. The heat destroys the tumor cells. In RFA, energy is delivered through a metal tube (probe) inserted into tumors or other tissues. When the probe is in place, metal prongs open out to extend the reach of the therapy. RF energy causes atoms in the cells to vibrate and create friction. This generates heat

(up to 100o C) and leads to the death of the cells. The efficacy of treatment is assessed by CAT scan one month following treatment. Re-treatments are often necessary. Risks of the procedure include bleeding, although this is extremely rare.Prongs pop open to deliver RF energy, which generates heat that kills cancer cells.

This drawing simulates an RFA probe inserted through the skin and into a tumor. RF energy is directed through the tube from a small generator, and sensors record the temperature of the treated tissue.

Fig: A small needle with an active tip that is water-cooled to prevent charring or overcooking, and a coaxial needle system with inner hot hooks deployed once inside the tumor

1. Tumor located

2. RFA needle placed in tumor

FIAGES Book.indb 38

3/23/2007 11:05:20 AM



Comprehensive Laparoscopic Surgery

39

Reference Surgical Laparoscopy, Second Edition, Edited by Karla A. Zucker 2. Principles of Laparoscopic Surgery, Basic and Advanced Techniques - Maurice E. Arregui Robert J. Fitzgibbons, Jr. Namir Katkhouda J. Barry McKernan Harry Reich, with foreword by - Lawrence W. Way 3. Schwartz’s Principles of Surgery - F. Charles Brunicardi Dana K. Andersen Timothy R. Billiar David L. Dunn John G. Hunter Raphael E. Pollock 4. Sabiston Text Book of Surgery - The biological Basis of Modern Surgical Practice , By Townsend Beauchamp Evers Mattox 5. Schellhammer PF. Electrosurgery: principles, hazards and pre-cautions. Urology 1974;3: 261-268. 6. Tucker RD. Laparoscopic electrosurgical electrosurgical injuries: survey results and their implications. Surg Laparosc Endosc 1995;5: 311-317. 7. Ata AH, Bellemore TJ, Meisel A, et al. Distal thermal injury from monopolar electrosurgery. Surg Laparosc Endosc 1991;1: 223-228. 8. Voyles CR, Tucker RD. Unrecognized hazard of surgical electrodes passed through metal suctionirrigation devices. Surg Endosc 1994:8:185-187. 9. Hoenig DM, Chrostek CA, Amaral JF. Laparosonic coagulating shears: alternative method of hemostatic control of unsupported tissue. J Endourol 1996;10;431-433 10. Spivak H, Richardson WS, Hunter JG. The use of bipolar cautery, laparosonic coagulating shears, and vascular clips for hemostasis of small and medium sized vessels, Surg Endosc 1998;12:183-185. 11. Chopp RT, Shah BB, Addonizio JC. Use of ultrasonic surgical aspirator in renal surgery. Urology 1983;22:157-159. 12. Grochmal SA, Weekes A, Garratt D, et al. Applications of the laparoscopic ultrasonic aspirator for admanced gynecologic operative endoscopic procedures. J Am Assoc Gynecol Laparosc 1993; 1: 43-47. 1.

3. Tines employed

MICROWAVE ABLATION An alternative means of producing thermal coagulation of tissue involves the use of microwaves to induce an ultra-high-speed (2450 MHz) alternating electric field, causing the rotation of water molecules. Although the use of microwaves for tissue ablation is not new, the majority of the clinical experience with this technique to ablate liver tumors comes from Japan. Percutaneous microwave ablation was first used as an adjunct to liver biopsy in 1986, but it has since been used for hepatic tumor ablation. As with RF ablation, microwave ablation involves placement of a needle electrode directly into the target tumor, typically under US guidance. Each ablation also produces a hyperechoic region around the needle, similar to that observed with RF ablation. Unlike RF ablation, however, no retractable prongs are used, and the resulting ablation tends to be much more elliptical. CRYOTHERAPY Used in the laparoscopic ablation of secondary tumor deposits in the liver, usually when the lesions are inoperable for whatever reason, Laparoscopic Cryotherapy with implantable probe destroys tumours by rapid freezing to -40°C or lower. The lesion re-vascularises for a short period (12-14 hours) on thawing but because the vasculature and the tumour parenchyma are damaged beyond repair, hemorrhagic infraction ensues.

FIAGES Book.indb 39

3/23/2007 11:05:20 AM

5

Endosuturing and Tissue Approximation in Laparoscopic Surgery Rajesh Khullar Endoscopic surgery is rapidly becoming a popular alternative to traditional procedures for variety of diseases and many of these procedures may require the utilization of Laparoscopic suturing. Laparoscopic ligation and suturing is used for approximation of tissues and it is also an effective way of providing hemostasis. The adaptation of tissue and suturing for hemostasis and reformation of anatomic structures has been considered one of the most demanding of endoscopic technical skills. Endoscopic procedures are performed by looking at a two dimensional TV screen with up to 6 times magnification, eliminating depth perception and the tactile feeling of the tissues; this requires significant hand – eye coordination. The advanced endoscopic procedures require the laparoscopic surgeon to master suturing. Each surgeon performing laparoscopic procedures should be thoroughly familiar with basic principles of knotting and suturing. Knots in surgical practice In context with laparoscopic surgery the knots are categorized as a. Intracorporeal Knots b. Extracorporeal Knots

double half knot

Opposite Half knots

single half knot

Fig. 1.1

Fig. 1.2

The ligature knot It is more secure than the reef knot and employs an initial double knot followed by a single half knot Fig 1.2. The double knot It consists of two double half knots. Fig 1.3. The Mayo knot It consists of two identical half knots forming a granny knot followed by a third and opposite half knot which looks the completed knot. Fig 1.4

Intracorporeal Knots These are tied with in the body cavities utilizing needle holders. The various knots used in Endoscopic practice are:

double half knot

single half knot

The square knot (Reef knot) It is a safe knot for securing small blood vessels and consists of two opposite half knots. Fig. 1.1.

FIAGES Book.indb 40

Fig. 1.3

Fig. 1.4

3/23/2007 11:05:21 AM



Comprehensive Laparoscopic Surgery

The surgeons knot It consists of a double half knot followed by two single half knots. Fig 1.5. The favored internal knot for interrupted suturing in Endoscopic surgical practice is either a surgical knot or a square knot.

single half knot single half knot

Wrapping techniques for knotting

Fig. 1.6a

double half knot

square knot

41

Fig. 1.6b

There are two basic techniques of wrapping most commonly practiced by Endoscopic surgeons Overwrap method (Fig 1.7) Underwrap method (Fig 1.8) Essentials in intracorporeal knot tying: A length of ligature material used for trying a knot (like a rope) can be considered as consisting of three sections

Fig. 1.5

IDEAL STITCH An ideal stitch is one which holds the tissue edges together with correct tension and resists reverse slippage. The three stages in knotting 1. Tying the knot (configuration 2. Working or drawing the knot (shaping) 3. Snuggling or locking the knot (securing) All the three stages are important and a knot is secure only if it is tied correctly, drawn (shaped) to conform to the anatomy of the knot and locked tightly. As Clifford Ashely wrote ‘a knot is never nearly right; it is either exactly right or is hopelessly wrong’.

Fig. 1.7

The ideal characteristics of a surgical knot are It should be safe It should be quick and It should easy to tie Triadic relationship of port sites In suturing set up in Endoscopic surgery it is critical to always maintain a set of relationship between the both sides. The telescope and suturing port sites form a triad with the optical port in the center, and suturing ports on either side (Fig 1.6 a and 1.6 b). Fig. 1.8

FIAGES Book.indb 41

3/23/2007 11:05:29 AM

42

Endosuturing and Tissue Approximation in Laparoscopic Surgery

(Fig 1.9 & 2.0a ) the end the bight the standing part

The essentials which should be followed while intracorporeal knotting are as follows: good magnification economy of movement directional hold principle avoidance of instrument crossing correct knot – tying choreography execution of the knots close to the tissue surfaces closed instrument jaws except during grasping awareness of dominant versus assisting instruments during the knotting process correct wrapping techniques knots configured and tied close to the tail The tying of a square slip knot (Figure 2.1 a, b, c, d, e, f, g): Extracorporeal Knots

Fig. 1.9

External or extracorporeal slip knots are used in

Fig. 2.0a Bight : C loop

Fig. 2.1a

Fig. 2.0b Bight : Reverse C loop

Fig. 2.1b

FIAGES Book.indb 42

3/23/2007 11:05:43 AM



Fig. 2.1c

Comprehensive Laparoscopic Surgery

43

Fig. 2.1f

Fig. 2.1g

Fig. 2.1d

endoscopic surgery for: ligature of vessels and tubular structures in continuity transfixation of large vascular pedicles interrupted suturing with external knots In all these situations, the knot is tied and drawn externally and then ‘slipped down’ by a knot pusher to the intended target and then tightened (locked) by traction on the standing part against the knot pusher. Extracorporeal versus Intracorporeal knots

Fig. 2.1e

FIAGES Book.indb 43

In most instances during endoscopic surgery, intracorporeal knotting using instrument – tied knots is preferred to extracorporeal tying. However in the following situations extracorporeal knotting is preferred: Ligature in continuity of large vessels Suturing in areas of limited access where the working space is restricted In the approximation of edges of defects where the force requires to approximate the edges is substantial

3/23/2007 11:05:55 AM

44

Endosuturing and Tissue Approximation in Laparoscopic Surgery

Rules governing external slip knotting (Fig 2.2) The following rules should be followed for safe ligature for slip knots in endoscopic surgery are:

surgeons. The general preference which exist in today’s practice are as follows :

Fig. 2.3a

Fig. 2.2

the type of the thread must be 1.5m and the guage should be 2/0 or greater. The type of slip knot selected depends on the ligature material being used. Certain slip knots provide sufficient holding strength with catgut but not with other materials. For any ligature material, the holding force (resistance to reverse slipping) of any surgical slip knot varies directly with its caliber. Thus the holding strength of a 1/0 slip knot is roughly twice that of the 2/0 equivalent. Stiff hydrophobic monofilament material should be avoided as it exerts a lesser frictional hold and has a greater tendency to spill than braided.

Fig. 2.3b

Extracorporeal knots used in endoscopic surgical practice Modified Tayside knot Roeder knot (Figure 2.3 a, b, c, d) Modified Roeder (Melzer) knot Cross square knot Blood knot Modified blood knot Eye – hook knot Suture material In endoscopic surgical practice there is a large variation in choice of suture material used amongst individual

FIAGES Book.indb 44

Fig. 2.3c

3/23/2007 11:06:05 AM



Comprehensive Laparoscopic Surgery

45

Curved needle Tendency to swivel require more experience. Most commonly we use a 25mm and a half circle needle for endosuturing. Compound curved needle

Fig. 2.3d

A) Absorbable sutures Catgut- Poor gliding ability Vicryl- Good maneuverability PDS- Excellent gliding ability, no need to follow during intracorporeal anastomosis B) Non-absorbable sutures Silk- it is braided and so more traumatizing Prolene- Monofilament but has memory so makes it very tedious to use Ethibond- Monofilament with less memory and better maneuverability than prolene

Endoski needle This combined needle was developed especially for laparoscopic use in order to combine the positive attributes of the curved needle in terms of needle passage through tissues with the ease of handling of straight needles. The dynamic suturing component is essentially a tapered ½ circle. This is followed by a passive straight shaft (body) which is 1.5 times the length of the curved section (Figure 2.4). Szabo – Gardiner flat needle (Figure 2.5) Laparoscopic considerations : The followings considerations should be kept in mind while endosuturing:

Needles Surgical needles are penetrating devices which are designed to pass sutures through tissues with minimum trauma. Objective of surgical needles to provide a secure grip for the needle driver. to penetrate the object to be sewn and create a channel for the thread to enter. to provide a means by which thread can be trailed Needle used in Laparoscopic / Endoscopic surgical practice Straight needle The advantage of using straight needle in endoscopic surgery are: easy to introduce even through the smallest port direction of the needle tip is not altered by the needle swivel with in the jaws of needle holder the positioning of the straight needle involves movement in the 2-D plane

FIAGES Book.indb 45

Fig. 2.4

Prevention of needle loss Secure grasping Ease of tissue penetration Techniques of endo suturing When placing a stitch, either for tissue plane or cut edge re-approximation, the inclusion or exclusion of particular tissue layers (Figure 2.6) plays an important role in the healing process and restoration of normal physiology. The process of obtaining the correct suture depth in endoscopic surgery is technically challenging and involves four variables: visualization eye-hand coordination the role of the assisting instrument in suturing

3/23/2007 11:06:08 AM

46

Endosuturing and Tissue Approximation in Laparoscopic Surgery

3) Adjusting the needle direction If adjustment of the needle is needed, this can be accomplished in three ways: maintaining a light grip on the needle and pulling the thread taut so that angle of the needle is changed maintaining a light grip and brushing the tip of the needle gently against the nearby tissues forward for backward in the 3 o’ clock direction reducing the grip of the needle and gently hooking it on superficial fibres of the serosal layer in an avascular area A commonly used but inefficient technique involves using the assisting the assisting instrument to reposition the angle of the needle. Fig. 2.5

4) Needle driving Principles Angle of approach and direction of the force: The tip of the needle must approach tissue at

Fig. 2.6

judgment and tactile feedback Steps of endo suturing Fig. 2.7

1) Introduction and retrieval of the suture to the operative field For transfer to and from the operative field, the suture is grasped by the assisting grasped by the assisting grasper some 2-3cm behind the needle. The needle should only be held during suturing, otherwise it can be dangerous. 2) Loading the needle in the needle driver There are two techniques for loading the needle. The choice depends on the exact circumstances and the proximity or otherwise of a smooth serosal surface : the deposit – pick-up technique (Figure 2.7) the dangling pirouette technique (Figure 2.8) Fig. 2.8

FIAGES Book.indb 46

3/23/2007 11:06:18 AM



Comprehensive Laparoscopic Surgery

right angles regardless of the configuration of the needle. The direction of the driving force apply through the needle driver must be perpendicular to the cut surface or tissue edge. Fig 2.9. Needle deflection: Needle deflection occurs when the needle is not pushed directly opposite to the plane of tissue resistance and the extent of deflection is directly of the driving force from the perpendicular interface with the resistance offered by the tissue. Counter pressure in needle driving: The correct application of counter pressure or counter traction expedites suturing.

47

Exit bite : the needle should be pulled away from the tissue surface only for a short distance enough to enable the maneuverability needed for reloading needle in the driver. 5) Advancing the thread Pulling on the needle is limited to the initial extraction of the suture, thereafter the needle is dropped and the thread is pulled by grasping it using either the assisting instrument or with the active needle driver. The two handed pull entails the sequential use of the assisting grasper and active needle holder and is the most efficient method but requires experience and coordination. 6) Knot tying Following successful tissue passage the suturing and intracorporeal knot tying is proceeded with as described earlier. Equipment and instrumentation for laparoscopic suturing The practice of endosuturing requires two components of instrumentation: a. The static component which includes the video systems. b.

Fig. 2.9

Technique of needle driving: The needle driver is the dominant handed instrument and the assistant grasper is grasped. Needle positioning: A slowly driven needle passage results in a smoother and more successful passage. The needle is driven with a delicate grip and the direction of the pushing force is maintained head on against tissue resistance. Entrance bite: for the entrance bite, the needle tip should be in a position that is perpendicular, or nearly so, to the tissue surface. The driver is then supinated rotating the needle clockwise, thereby pushing it down through the tissues and then forward and upwards penetrating appropriate tissue layers. Extracting the needle : two methods are generally used one, when the needle tip is grasped by the assisting instrument, when only the tip of the needle is shown. Second when a half circle needle is used, it is simply extracted after extensive rotation and not along the horizontal plane.

FIAGES Book.indb 47

The dynamic component which includes the actual hand instruments.

Video equipment Laparoscope The modern laparoscope is based on the Hopkins’ rodlens system which provides good illumination, excellent depth of field, a clear sharp image and minimal peripheral barrel distortion. In order to duplicate the natural viewing position of a surgeon during suturing, the forward 30 o oblique objective (Fig 3.1 a, b). Hand Instruments Needle drivers the most important component for endosuturing is a needle holder. The need for ideal type of laparoscopic suturing instruments to facilitate fluent choreographed two handed movements necessary for efficient tissue approximation led to the development of Coaxial

3/23/2007 11:06:19 AM

48

Endosuturing and Tissue Approximation in Laparoscopic Surgery

Fig. 3.1a

Fig. 3.2

Fig. 3.3 Fig. 3.1b

handles. A coaxial stem-to-handle relationship allows for the greater maneuverability and rotation necessary for laparoscopic suturing. This straight line relationship reduces the complexity of movement coordination making it more ergonomic. A cylindrically shaped handle design permits a smooth 360 degrees rotation of the instrument. Another important feature which facilitates internal half knotting in areas of difficult access is for the end of one of the needle drivers to be coaxially curved. The SzaboBerci Needle driver sets and the Cuschieri needle sets utilizes this feature. (Fig 3.2 and 3.3 respectively). Staplers in laparoscopic Sugery Indications Gastrectomy. Gastric Bypass. Resection anastomosis. Splenectomy. Bilio-pancreatic diversion.

FIAGES Book.indb 48

Requirements of Laparoscopic Surgery Maximum reach and versatility. Staple line security. Hemostasis. Thick tissue penetration. Precise staple formation (even at the distal edge) Types of Staplers used in laparoscopic Surgery There are two types of staplers used in laparoscopic surgery Linear staplers. Circular staplers. Staplers in laparoscopic Surgery

Description

Staple Leg Length (mm)

Closed staple height

No. ofStaples

Reload Color

Staple Rows

Vascular/ Thin

2.5 mm

1.0

66

White

6

Standard

3.5 mm

1.5

44

Blue

4

Thick

4.1 mm

2.0

66

Green

4

3/23/2007 11:06:27 AM



Comprehensive Laparoscopic Surgery

49

Autosuture Endo GIA universal (Fig 3.4) Can be fired upto 25 times. Same gun can be used for all staple heights and cartridge sizes. XL size for obese patients Features of Tyco Gun and Cartridge 2 triple staggered rows. Straight and articulating cartridges available. New knife for each application. Sizes : 2.0/2.5/3.5/4.8.

Fig. 4.1

Fig. 4.2

Fig. 3.4

Fig. 4.3

Ethicon Stapling Gun Fig 4.1, 4.2 & 4.3    

Can be fired upto 8 times. Different gun to be used for different length of cartridge. It could be a straight or an articulating stapler. The XL size should be use for obese patients

White – small gut. Blue / Gold– stomach (except pylorus). Green – pylorus / redo surgery.

Echelon TM The innovation that resulted is a multiple-squeeze approach for the cutting and stapling, which required careful attention to user feedback to make it intuitive. Other improvements include increases in efficiency, intuitiveness and overall surgeon satisfaction. Fig 4.4a Gold Catridge Fig 4.4 b Has 6 rows of staples. Tissue penetration of compressible staple is 1.8mm. Used mainly on gastric tissue. Recommendations for use in laparoscopic surgery Grey – mesentery.

FIAGES Book.indb 49

Fig. 4.4a

Precautions Avoid excessive use of gun. No excess tissue. Right cartridge.

3/23/2007 11:06:31 AM

50

Endosuturing and Tissue Approximation in Laparoscopic Surgery

Fig. 4.4b

Fig. 4.5b

Under run when in doubt. Good vascularity. Circular stapler (Fig 4.5a & 4.5b) Characteristics Single use Head tilt / straight head Double staple row Circular knife blade Various Sizes of Circular Staplers are shown in Fig 4.6, 4.7, 4.8a & 4.8b Features of the Premium Plus CEEA* are shown in Fig 4.9

Fig. 4.6

Fig. 4.7

Precautions Fig. 4.5a

Indications Gastrojejunostomy Colo-Rectal surgery Curved stapler very useful Preferred sizes 21mm and 25mm Safe and ensures optimum size of stoma

FIAGES Book.indb 50

When using stapling devices ensure you are familiar with their assembly and function. Careful preparation and meticulous set up of the anastomotic site is as essential when stapling as when suturing. These instruments are not intended for use where surgical stapling is contraindicated. Ensure that you select the correct sized instrument for the task required.

3/23/2007 11:06:35 AM



Comprehensive Laparoscopic Surgery

51

Szabo Z et al. Slip-Knot suspension: a fail safe microanastomosis technique for small caliber vessels. Microsurgery 1992; 13: 100-12. 7. Advanced Laparoscopic Suturing Techniques Course, Center for Advanced Training and Research, Candler Hospital, Savannah, Georgia, September 14-15, 1994. 6.

Fig. 4.8

Fig. 4.9

References 1. Ashley CW. The Ashley Book of Knots. London: Faber and Faber, 1994. 1.

2.

3.

4.

5.

Szabo Z, Gardiner BN. Training model for laparoscopic gastojejunostomy. Poster session, Society of American Gastrointestial Endoscopic Surgeons, Nashville, USA, April 1994. Szabo Z, Berci G. Extra and intracorporeal Knotting and suturing technique. In: Berci G, ed. GI Endoscopy Clinics of North America, Philadelphia: W B Saunders: 1993, pp 367- 79. Semm K. Tissue-puncher and loop ligation. New aids for surgical-therapeutic pelviscopy (laparoscopy) = endoscopic intraabdominal surgery.Endoscopy 1978; 10: 119-24. Semm K. Tissue-puncher and loop ligation. New aids for surgical-therapeutic pelviscopy (laparoscopy) = endoscopic intraabdominal surgery.Endoscopy 1978; 10: 119-24. 5.Szabo Z, Hunter J, Berci G, Sackier A, Cuschieri A. Analyses of surgical movements during suturing in laparoscopy. End Surg 1994; 2: 55-61.

FIAGES Book.indb 51

3/23/2007 11:06:36 AM

6

Physiology of Pneumoperitoneum and Anaesthesia in Laparoscopic Surgery V. Muralidhar Gases for insufflation / creation of the pneumoperitoneum The creation of the pneumoperitoneum is the essential component for laparoscopic procedures Although a gasless approach has been described using an intraabdominal lift, this approach has never been reported in patients of paediatric age. There are several characteristics which are considered optimal for this gas1. As the surgical procedure may involve electrocautery, the gas which cannot support combustion is essential. Although oxygen and air would not have significant physiological consequences when absorbed, they support combustion and also would have significant deleterious effects with intravascular embolization. Although nitrous oxide would have limited physiological effects when absorbed and is highly soluble, thereby limiting its effects with intravascular embolism, like air and oxygen, nitrous oxide supports combustion. Although both helium and argon result in little or no change in PaCO2 when compared to CO2 pneumoperitoneum, the volume of gas that must be injected intravenously to cause death is markedly less with these inert agents than with CO2. Because of the problems with other gases, CO2 remains the only agent commonly used during laparoscopic procedures. The ideal gas for insufflation during laparoscopy must have the following characteristics; Limited systemic absorption across the peritoneum Limited systemic effects when absorbed. Rapid excretion if absorbed Incapable of supporting combustion High solubility in blood

FIAGES Book.indb 52

Limited physiological effects with intravascular systemic embolism. The principle physiological changes during laparoscopy are summarized below; Changes due to Patient position Intraperitoneal insufflation of CO2 is performed with the patient in a 15-200 Trendelenburg position2. The patient’s position is then changed to a steep reverse Trendelenburg (rT) position with right lateral tilt to facilitate retraction of the gallbladder fundus and minimize diaphragmatic dysfuction. The patient’s position may have significant effects on the haemodynamic consequences of pneuoperitoneum. In a series of 13 patients undergoing laparoscopic cholecystectomy, use of transesophageal echocardiography (TOE) monitoring, has shown a significant reduction in left ventricular end-diastolic area on assumption of rT position, indicating reduced venous return. Left ventricular ejection fraction has been shown to be maintained throughout in otherwise healthy patients. However, changes in left ventricular loading conditions might have adverse consequences in patients with cardiovascular disease. Trendelenburg position also causes decreased FRC and decreased pulmonary compliance. Reverse trendelenburg position can also cause decreased LV preload with decreased LVEF. Mechanical effects of pneumoperitoneum Increased intra abdominal pressure associated with pneumoperitoneum may compress venous capacitance vessels causing an initial increase, followed by a

3/23/2007 11:06:36 AM



sustained decrease in pre-load2-6. Compression of the arterial vasculature increased after-load and may result in a marked increase in calculated systemic vascular resistance (SVR). Cardiac index may be significantly reduced, and the magnitude of this effect is proportional to intra-abdominal pressure achieved. In healthy subjects undergoing laparoscopic cholecystectomy, using transoesophageal Doppler has shown that cardiac output is depressed to a maximum of 28% at an insufflation pressure of 15mm Hg but is maintained at a insufflation pressure of 7mmHg. In an animal model, the threshold IAP which had minimal effects on haemodynamic function is 12 mmHg and recommend this pressure limit to avoid cardiovascular compromise during CO2 insufflation. Summary of Haemodyanamic Changes due to Mechanical pressure of CO2 insufflation Increased systemic vascular resistance (SVR) Increased Mean Arterial pressure (MAP) Minimal change in heart rate (HR) Increased cerebral blood flow (CBF) Increased intracranial pressure (ICP) Decreased renal blood flow (RBF) Decreased portal blood flow Decreased splanchnic blood flow Decreased pulmonary compliance CO2 absorption Significant hypercapnia and acidosis may occur during laparoscopy due to CO2 absorption. Hypercapnia may cause a decrease in myocardial contractility and lower arrhythmia threshold. The anticipated direct vascular effect of hypercapnia, producing arteriolar dilation and decreased SVR, is modulated by mechanical and neurohumoral responses, including catecholamine release. Neurohumoral response Potential mediators of the increased SVR observed during pneumoperitoneum include vasopressin and catecholamines6. Hypercapnia and pneumoperitoneum are likely to cause stimulation of the sympathetic nervous system and catecholamine release. A number of investigators have reported activation of the reninangiotensin system with vasopressin production and a marked increase in plasma vasopressin immediately after peritoneal insufflation in healthy patients, and the profile of vasopressin release parallels the time course of

FIAGES Book.indb 53

Comprehensive Laparoscopic Surgery

53

changes in SVR. A fourfold increase in plasma rennin and aldosterone concentrations correlating with increases in MAP was observed changes in CI and SVR suggests a possible cause – effect relationship. In summary, the haemodynamic response to peritoneal insufflation has been well described, an depends on the interaction of factors that include 1. patient positioning, 2. neurohumoral response 3. patient factors including cardiorespiratory status and intravascular volume. Pre-Operative Evaluation As with any pre-operative evaluation, the goal is to identify ongoing acute conditions or chronic problems which may affect the plan for anaesthesia7. The pre-operative examination must also identify previously undiagnosed conditions, with minimally invasive surgical procedures, the pre-operative laboratory evaluation depends more on the patient’s status than on the procedure itself. Because any of these minimally invasive procedures carries the potential for blood loss related to vascular damage from a trocar, a haematocrit and type and screen are suggested. Pre-medication and anaesthetic induction For non-emergent procedures, the American Society of Anaesthesiologists (ASA) fasting guidelines should be followed. In the majority of patients scheduled for minimally invasive procedures (laparoscopy or thoracoscopy), any of a number of anaesthetic induction techniques (intravenous and inhalational) are acceptable7. In specific circumstances, gastrointestinal (GI) prophylaxis may include oral antacids, motility agents, and H2 antagonists followed by a modified rapid sequences induction with cricoid pressure. The intravascular status and baseline cardiovascular function should be considered when deciding on the choice of agent and the route for anaesthetic induction. Intravenous induction with a barbiturate or propofol, with their associated negative inotropic and vasdilatory properties, can result, in hypotension in patients with altered cardiovascular contractility or hypovolaemia. In such settings, etomidate provides effective anaesthesia without deleterious effects on cardiovascular function. Pre-operative medication may not be required in the older adolescent patient and the newborn or infant less than 9-12 months of age. The decision concerning the

3/23/2007 11:06:36 AM

54

Physiology of Pneumoperitoneum and Anaesthesia in Laparoscopic Surgery

use of pre-medication is dependent on the physical status of the patient and associated conditions. For the majority of elective or semi-elective procedures, our practice includes inhalation induction using sevoflurane in 100% oxygen, 15-20 minutes after pre-medication with intravenous medazolam. Airway management Endotracheal Intubation and controlled mechanical ventilation comprise the accepted anaesthetic technique to reduce the increase in PaCO2 and to avoid ventilatory compromise due to pneumoperitoneum and initial Trendelenburg position7. The laryngeal mask airway (LMA) has been used widely during pelvic laparoscopy. Continuous oesophageal pH monitoring and clinical monitoring failed to detect gastro-oesophageal reflux in patients undergoing gynaecological laparoscopy using LMA. However, this evidence cannot be extrapolated to upper abdominal laparoscopy, and high intra-abdominal pressures during laparoscopic cholecystectomy may increase the risk of passive regurgitation of gastric contents. Cuffed endotracheal tube placement will minimize the risk of acid aspiration should reflux occur. The choice of neuromuscular blocking drug will depend on the anticipated duration of surgery and the individual drug side-effect profile. Reversal of residual neuromuscular blockade with neostigmine has been reported to increase the incidence of post-operative nausea and vomiting (PONV) following laparoscopy compared with spontaneous recovery, and some practitioners avoid its use. However, other investigators have found no effect on the incidence of PONV associated with the use of neostigmine, and specifically in patients undergoing outpatient gynaecological laparoscopy. The use of neostigmine and glycopyrrolate did not increase the incidence or severity of PONV. Even minor degrees of residual neuromuscular blockade can produce distressing symptoms and must be avoided. Therefore, any benefit from omitting neostigmine must be balanced against the risk of inadequate reversal of neuromuscular blockade. Monitoring Standard intra-operative monitoring is recommended for all patients undergoing laparoscopic cholecystectomy7. Invasive haemodynamic monitoring may be appropriate in ASA III or IV patients to monitor the cardiovascular response to pneumoperitoneum and position changes and to institute therapy. Endo Tracheal CO2 is most

FIAGES Book.indb 54

commonly used as a non-invasive indicator of PaCO2 in assessing the adequacy of ventilation during laparoscopic procedures. Patients with low forced expiratory and vital capacity volumes, and higher ASA status showing significant increases in PaCO2 during CO2 pulmonary function tests, may predict those patients at risk for development of hypercapnia and acidosis during laparoscopic cholecystectomy. Even in normal patients it would seem prudent to monitor PaCO2 at all times during the procedure to avoid adverse outcome. Persistent refractory hypercapnia or acidosis may require deflation of the pneumoperitoneum, Intra-operative and post-operative anaesthetic care Several options are available for anaesthetic induction, including inhalation or intravenous techniques. Intravenous access is generally secured in the upper extremity if possible, because there are the theoretical effect of increased IAP and decreased onset time of medications administered into a vein in the lower extremity. While standard practice in paediatric anaesthesia includes the use of uncuffed ETTs in children less than 6-8 years of age, an excessive leak around an uncuffed ETT may make maintaining minute ventilation during laparoscopy more difficult. As such, tracheal intubation with a cuffed ETT (0.5 cm smaller than that calculated based on age) with inflation of the cuff to a minimum occlusive pressure is an acceptable option to limit difficulties with ventilation with the increase in IAP and its effects on resistance and compliance. Following endotracheal intubation, a nasogastric tube is passed to decompress the stomach and limit the potential for inadvertent damage during trocar placement. For prolonged procedures, a urinary catheter is placed. Monitoring consists of standard ASA monitoring. Maintenance anaesthesia consists of a combination of an inhalational agent supplemented with intravenous opioids (fentanyl 3-5mg/kg)7. While any of the inhalation agents are acceptable, halothane may be problematic if hypercarbia develops. Nitrous oxide is generally avoided owing to its potential for exacerbating postoperative nausea and vomiting, its controversial effects on bowel size, as well as the potential for its diffusion from the blood stream into the peritoneal space. During laparoscopy, it is possible to achieve intraperitoneal concentrations of nitrous oxide which will support combustion. Neuromuscular blockade can be provided by any of a number of non-depolarizing agents based on the

3/23/2007 11:06:36 AM



Comprehensive Laparoscopic Surgery

anticipated duration of the procedure. If not administered as part of the pre-medicant, an anticholinergic agent is administered to prevent vagal reflexes during the laparoscopic procedure. Due to the potential for respiratory changes, exhaled tidal volume and PIO are monitored during insufflation. Alterations in compliance and resistance may necessitate changes in ventilatory parameters to prevent hypercarbia (increasing respiratory rate, increasing PIP) or hypoxaemia (increasing FiO2, application of PEEP, lengthening of the inspiratory time, or use of an inspiratory pause). Regardless of the duration of the procedure, minute ventilation may need to be increased by 25-30% to maintain nomocarbia. While much attention has been focused on the respiratory effects to CO2 absorption across the peritoneum and the increased IAP, several other aetiologies should be considered if cardiorespiratory compromise occurs during laparoscopy. Especially with upper abdominal procedures (Nissen fundoplication), CO2 can dissect along the mediastinal fascial planes into the thorax, resulting in pneumothorax. Additionally, there is a potential for gas embolism. The physiological consequences of gas embolism are related to: (a) gas, (b) volume, (c) rate of entrainment and (d) patient’s haemodynamic and volume status. Owing to its solubility in blood, there are generally few consequences with CO2 embolism unless a large quantity is injected. When the rate of gas entrainment exceeds the lungs’ capacity to excrete it, pulmonary artery pressure rises, resulting in right heart failure and dilation with impedance of left ventricular filling related to ventricular interdependence. Devices to detect gas embolism (least to most sensitive) Aspiration of air from central venous catheter Mill-wheel murmur heard with oesophageal stethoscope Pulmonary artery catheter End-tidal CO2 (variable response with CO2 embolism) End-tidal nitrogen (useful only for air, not CO2 embolism) Pre-cordial Doppler Transoesophageal echocardiography.

55

function is supported by ventilation with 100% oxygen, discontinuation of inhalation anaesthetic agents, and resuscitation with fluids and inotropic agents as needed. Several devices are available to monitor for gas embolism, with transoesophageal echocardiography being the most sensitive. However, based on the low incidence of clinically significant gas embolism during minimally invasive procedures, our current practice during laparoscopy and thoracoscopy includes standard ASA monitors. Following completion of the procedure, complete evacuation of CO2 is mandatory to limit problems with post-operative pain and nausea/vomiting. Owing to the relatively high incidence of nausea and vomiting following laparoscopic procedures, our practice includes the pre-emptive use of a serotonin antagonist such as managed with a multi-modality approach, including acetaminophen, non-steroidal anti-inflammatory agents, opioids, local infiltration of the trocar insertion sites and regional anaesthesia. Our current practice includes the administration of acetaminophen (15mg/kg orally with midazolam pre-medication or 40mg/kg per rectum after the induction of anaesthesia), fentanyl (2-3 mg) and ketorolac (0.5 mg/kg, maximum 30mg) during the procedure, and either local infiltration of the trocar insertion sites or regional block with a rectus sheath block or caudal epidural block. In most cases, at completion of the surgical procedure, residual neuromuscular blockade is reversed and the patient’s trachea extubated. Aetiology of changes of ventilation during laparoscopy Mainstem intubation Endotracheal tube obstruction Pneumothorax Acid aspiration Bronchospasm Atelectasis Mucus plugging Excessive intra-abdominal pressure Decreased FRC from increased IAP / patient positioning Inadvertent gas embolism Decreased cardiac output Hypercarbia from CO2 absorption Anaesthesia machine malfunction

The first step in treatment is identifying the problem and notifying the surgeon to stop insufflating or to release the pneumoperitoneum. Cardiovascular

FIAGES Book.indb 55

3/23/2007 11:06:37 AM

56

Physiology of Pneumoperitoneum and Anaesthesia in Laparoscopic Surgery

Other Complications Vascular injury Inadvertant extraperitoneal insufflation Pneumothorax Pneumoperitonium Gas embolism Special Situations needing modification Day care / Ambulatory Pregnancy Paediatric Gastric and bowel surgery

Reference 1. Junghans T, Bohm B, Grundel K et al. Does pneumoperitonium with different gases, body positions and intraperitoneal pressures influence renal and hepatic blood flow. Surgery 1997; 121: 206-211. 2. Schiller WR. The Trendelenburg position. Surgical aspects. In Martin JT (ed.) Positoning in Anesthesia and surgery, 2nd edn, pp 117-126. Philadelphia: WB Saunders 1987. 3. Bardoczky GI, Engelman E, Levarlet M et al. Ventilatory effects of pneumoperitoneum monitored with continuous spirometry. Anesthesia 1993; 48: 309-311. 4. Fahy BG, Barnas GM, Nagle SE et al. Changes in lung and chest wall properties with abdominal insufflation of cabon dioxide are immediately reversible. Anesthesia and Analgesia 1996; 82: 501505. 5. Jakimowicz J, Stultins G , Smulders F. Laproscopic insufflation of the abdomen reduces portal venous flow. Surgical Endoscopy 1998; 12: 129-132. 6. O’ leary E, Hubbard K, Tormey W et al. Laproscopic cholecystectomy: haemodynamic and neuroendocrine responses after pneumoperitonium and changes in position. British Journal of Anaesthesia 1996; 76: 640-644 7. Best practice and research. Clinical Anaesthesiology. Edited by H. Van Aken; volume 16 no. I, March 2002, Anaesthesia and Minimally Invasive Surgery. Guest editor N Badner. Bailliere Tindall an Elsevier Science Company, London, U.K.

FIAGES Book.indb 56

3/23/2007 11:06:37 AM

Peritoneal Access and Creation of Pneumoperitoneum for Laparoscopic Surgery

7

Zameer Pasha Abdomen, termed Pandora’s box is, certainly a temple of surprises. Gaining access to create space for operability with gas or without is the first and foremost step in minimal access surgery. Any act well begun is half done. And this ought to be done sans complications with safety being the prime concern. The creation of pneumoperitoneum brings out panoramic view of the entire abdomen in all its glory and clarity with precision. Our aim is to achieve this view and space for our surgical dissection, suturing and achieve homeostasis, with completion of procedure to everyone’s satisfaction with success. The patient has to be relaxed. Every step has to be forethought, and carried out with clinical precision and tactile finesse. The avalanche of literature describing iatrogenic accidents during creation of pneumoperitoneum with veress needle and trocars is to create an awareness only and knowledge of pros and cons is essential to tread safe and sure paths to success. There are two techniques for creation of Pneumoperitoneum: 1. Closed and 2. Open technique. (Hassan method)

FIG. 1

prior to initial insertion and also the patency of lumen by checking the gas flow through the needle. ii. Both disposable and reusable (nondisposable) Veress needles are available. The former is a one-place plastic design (external diameter, 2mm; 14 gauge; length, 70 or 120 mm), whereas the latter is made of metal and can be disassembled. Check the Veress needle for patency by flushing saline through it. Then occlude

I. Closed Technique i.

Veress Needle:- This is spring loaded central slim trocar and the needle traverses the rectus sheath and enters the peritoneum. The inner trocar retracts as the needle encounters resistance and springs back on entering the peritoneal cavity. This spring loaded mechanism has to be confirmed to be in working order FIG. 2

FIAGES Book.indb 57

3/23/2007 11:06:39 AM

58

Peritoneal Access and Creation of Pneumoperitoneum for Laparoscopic Surgery

FIG. 5

FIG. 3

the tip of the needle and push fluid into the needle under moderate pressure to check for leaks. Replace a disposable Veress needle if it leaks; check the screws and connections on a reusable Veress needle. Next, push the blunt tip of the Veress needle against the handle of a knife or a solid, flat surface to be certain that the blunt tip will retract easily and will spring forward rapidly and smoothly. A red indicator in the hub of the disposable needle can be seen to move upward as the tip retracts. Place the supine patient in a 10-to-20 degree head-down position. If there are no scars on the abdomen, choose a site of entry at the superior of inferior border of the umbilical ring. There are several ways to immobilize the umbilicus and provide resistance to the needle. The inferior margin of the umbilicus can be immobilized by pinching the superior border of the umbilicus between the thumb and forefinger of the nondominant hand and rolling the superior margin of the umbilicus in a cephalad direction. Alternatively, in the anesthetized patient, a small towel clip can be placed on either side of the upper margin of the umbilicus; this makes it a bit easier to stablize the umbilicus and lift it upward.

FIG. 4

FIAGES Book.indb 58

FIG. 6

Next, make a curvilinear incision in the midline of the superior or inferior margin of the umbilicus. With the dominant hand, grasp the shaft (not the hub) of the Veress needle like a dart and gently pass the needle into the incision – either at a 45-degree caudal angle to the abdominal wall (in the asthenic or minimally obese patient) or perpendicular to the abdominal wall in the markedly obese patient. There will be a sensation of initial resistance, followed by a give, at two points. The first point occurs as the needle meets and traverses the fascia and the second as it touches and traverses the peritoneum. As the needle enters the peritoneal cavity, a distinct click can often be heard as the blunt-tip portion of the Veress needle springs forward into the peritoneal cavity. Connect a 10-ml syringe containing 5 ml of saline to the Veress needle. There are five tests that should be performed in sequence to confirm proper placement of the needle. 1. Hiss Test:-This is the sound of air flowing into the negative pressure of the peritoneum through the Veress needle as accentuated by elevation of the

3/23/2007 11:06:42 AM



Comprehensive Laparoscopic Surgery

2.

3.

4.

5.

abdominal wall, when the tip of the needle is correctly positioned. Unfortunately, the listener’s ear has to be close to the top of the Veress needle to hear the “hiss”, and theatre noise often precludes this. Aspiration Test:- A Syringe filled with saline connected to the Veress needle is used next. Fluid instilled into the peritoneal cavity will flow away from the tip of the needle and cannot be aspirated back into the syringe. If fluid is aspirated back, an incorrect needle tip placement is likely. In addition, is bowel content or blood is aspirated, the incorrect position of the needle tip is again obvious. Negative Pressure Test:- The insufflation tubing from the insufflator should next be connected to the Veress needle. Monitoring the peritoneal pressure prior to any insufflation at this point will reveal a slight negative pressure easily accentuated by abdominal wall elevation. Early Insufflation Pressures:- The next clue to correct positioning is monitoring of the insufflation pressure which should not exceed 8mm Hg at 11 litre/min. The static pressure must not exceed 3mm Hg. Pressures of > 15mm Hg with a low or no flow of gas indicate incorrect needle tip position. Volume Test:- In the average adult the volume required to distend the peritoneum adequately, and which creates a pressure of 8-10 mm Hg is about 2.5 liters of gas. If the static pressure as measured by the insufflator reaches these pressures with less than 1 liters of gas, suspicion should arise that the needle tip is incorrectly placed. If this is extraperitioneal then it will often be accompanied by asymmetric anterior abdominal wall distension.

Monitor the patient’s pulse and blood pressure closely for a vagal reaction during the early phase of insufflation. If the pulse falls precipitously, allow the CO2 to escape, administer atropine, and reinstitute insufflation slowly after a normal heart rate has returned. After 1 litre of CO2 has been insufflated uneventfully, increase the flow rate on the insufflator to > 6 litre/min. Once the 15 mm Hg limit is reached, the flow of CO2 will be cut off. At this point approximately 3 to 6 litre of CO2 should have been instilled into the abdomen. When percussed, the abdomen should sound as through you are thumping a ripe watermelon. II. Alternate Entry Sites Prior abdominal surgery mandates care in selection of the initial trocar site and may prompt consideration of

FIAGES Book.indb 59

59

use of the open technique. If the previous incisions are well away from the umbilicus, the umbilical site may still be used, with either a closed or open technique. A midline scar in the vicinity of the umbilicus increases the risk that adhesions will be tethering intra-abdominal viscera to the peritoneum at that level. In this situation, the closed technique may still used, but it is safer to use an alternate insertion site. This site should be well away from the previous scar and lateral to the rectos muscles, to minimize the thickness of abdominal wall traversed and avoid the inferior epigastria vessels. In general, patients with prior low vertical midline scars should be approached through a trocar placed at the lateral border of the rectus muscle in either the left or right upper quadrant. With previous upper vertical midline incision or multiple incisions near the midline, the right lower quadrant site may be appropriate. Alternatively, it is possible to perform an open technique with the Hasson Canula. a) Upper Abdomen In the upper abdomen, the subcostal regions are good choices. Carefully percuss the positions of the liver and spleen to avoid inadvertent injury to these organs, and decompress the stomach with a nasogastric or orogastric tube. b) Lower Abdomen The right lower quadrant, is preferable to the left because many individuals have congenital adhesions between the sigmoid colon and anterior abdominal wall. Decompress the bladder when using a closed insertion technique at, or caudal to the umbilicus. III. Insufflation of Peritoneal Cavity Carbon dioxide is the standard gas used for most operative laparoscopy. It does not support combustion, after absorption from the peritoneum it is readily excreted via the lungs and, if accidentally injected directly into a blood vessel resulting in carbon dioxide embolism, this is more easily treated than air or nitrous oxide embolism (especially if the rate of insufflation is kept at 11/min). Of maximal importance in the setting of operative laparoscopy is the equipment used to deliver the carbon dioxide to the peritoneum. Optimum exposure is obtained with a constant pneumoperitoneum at 10-15 mm Hg pressure. Operative laparoscopy entails the use of multiple cannula and the frequent changing of instruments. Gas leakage is significant and the early

3/23/2007 11:06:42 AM

60

Peritoneal Access and Creation of Pneumoperitoneum for Laparoscopic Surgery

generation of insufflators could only cope with automatic flow rates of 11/min, which could be manually increased to 31/min. This resulted in repeated fluctuations of carbon dioxide pressure with loss of view, and incurred delays necessitated by refilling of the peritoneal cavity. This problem was further compounded when the lavage / suction equipment was used. The latest generation of automatic electronic insufflators has resolved this problem. This insufflator is capable of automatic flow rates of up to 81 litres/min. Operative procedures without this machine are tedious and time-consuming. In addition, it provides good monitoring of the pressure within the abdomen, which can also be pre-selected and adjusted. Maintenance of a low intra-abdominal pressure is especially useful in women with lax abdominal walls following pregnancy, where very adequate visualization can be obtained at pressures of 100 mm Hg. The benefit will be a decrease in postoperative shoulder-tip pain caused by diaphragmatic stretching. If during the induction of the initial pneumoperitoneum the needle tip is felt to be incorrectly positioned the following steps should be taken. If the pressure test, volume test or aspiration test suggest extraperitoneal insufflation then the needle is simply withdrawn and re-inserted. The number of passes required should be recorded in the operation note. If arterial blood is aspirated back then simple withdrawal of the needle and re-insertion is reasonable. However, if blood fountains back up the Veress needle, major vessel injury is likely and a laparotomy should be performed. If bowel content is aspirated, then the needle is withdrawn and re-inserted, in another site if local adhesions are suspected. In this event, it is important to inspect the area of bowel injury when the laparoscope is first introduced. If the hole in the bowel consists of a simple puncture, the administration of antibiotics and local lavage / suction followed by careful postoperative observation may be all that is required. More extensive injuries, e.g. when the bowel has been tangentially lacerated, require immediate suture repair either laparoscopically or by open operation. In all cases an initial scan of the peritoneum and organs in the region of Veress needle insertion is mandatory. Any sign of retropertioneal haemorrhage is suggestive of major vessel injury. Pneumo-omentum, carbon dioxide in the bowel mesentery, or retroperitoneum can simply be left to resorb.

FIAGES Book.indb 60

IV. Test for Adhesions A 12 cm long, 0.8 mm needle attached to a saline-filled syringe is introduced perpendicularly through the abdominal wall in the region where initial trocar insertion is envisaged. As the needle is advanced, gas is slowly aspirated, and continuous bubbling is observed in the syringe. This will stop suddenly when visceral peritoneum is touched. The level of the needle at the skin is then marked with a finger on the shaft of the needle, and bubbling of the gas is observed as the needle is withdrawn until bubbling stops again. The distance for which the needle has been withdrawn to the point where bubbling stopped gives an accurate idea of the distance between visceral and parietal peritoneum. By repeating the procedure at 45 degree a mental picture of the underlying carbon dioxide cushion can be built up. The presence of mental or bowel adhesions is suggested by erratic variation of the size of the carbon dioxide cushion at cushion at different angles. This guide indicates an area for safe introduction of the laparoscope trocar. This test is not always required. It is particularly useful in patients with previous laparotomy. V. Placement of First Cannula -> Blind Entry The site for insertion of the first trocar which holds the laparoscope is usually around the umbilicus. This should be altered as and when the sounding test suggests underlying adhesion of bowel or momentum in most cases straightforward insertion is possible. Two approaches are possible here: direct or “Z” routes. If a pyramidal trocar is used this can only be introduced with safety directly through the linear alba. The “Z” technique, which is only possible with the a traumatic conical system, entails advancement of the trocar / cannula through an initial subcutaneous path before passage of the instrument through the rectus abdominis. The advantages of the “Z” technique include avoidance of the weak linea alba and the creation of a shutter type closure after withdrawal of the trocar. The disadvantage, in the context of laparoscopic cholecystectomy, is enhanced difficulty of extraction of the gallbladder through the “trap-door” particularly when the stone load is large. A direct tract (through the linea alba) is therefore preferable. In any event the defect in the linea alba or rectus sheath should be approximated by suture at the end of the procedure to decrease the risk of subsequent incisional hernia formation. In patients likely to have adhesions, the risk and severity of organ trauma is reduced if a 5.5mm cannula

3/23/2007 11:06:42 AM



FIG. 7

is inserted in the first instance and an in initial scan of the underlying omentum, bowel and retroperitoneum is made to exclude injury. Once the surgeon is satisfied with the position and absence of latrogenic damage, the small cannula is replaced by a 11mm cannula using the trocar dilation system. When the possibility of significant adhesions is high as in patients after complicated or multiple previous surgical intgerventions, or when the sounding test suggests bowel or omentum is adherent to the parietal peritoneum, insertion of the cannula tip should be done under vision. This eminently safe technique, which is to be highly recommended in these difficult cases, is accomplished by a 5.5mm cannula with a beveled tip which is inserted to just beyond the linea alba, such that its tip lies in the extraperitoneal fat if the direct route is used, or the rectus abdominis muscle if the “Z” technique of insertion is adopted. The central trocar is then withdrawn and replaced with the 5 mm forward-viewing telescope connected to the light source. Under vision, and by gentle rotation, the cannula is advanced through the muscle and extraperitoneal fat until the peritoneum is reached. Intact pneumoperitoneum free of adhesions will appear as a translucent membrane with clearly visible small blood vessels on its surface. By contrast, in the presence of adherent bowel or

Comprehensive Laparoscopic Surgery

61

omentum the peritoneum assumes an opaque appearance on transillumination with the telescope. When this is encountered, the position of the cannula tip is altered until clear translucent peritoneum is visualized. This provides a “safe window” for entry of the cannula into the peritoneal cavity. This is achieved by cannula rotation and gentle pressure from the wrist. Once the surgeon is satisfied that the 5.5 mm cannula is correctly positioned, it may then be replaced with the 11 mm cannula using the trocar dilation technique. Finally, if the surgeon has no experience with the above techniques or when they cannot be used with safety (which is rare), open dissection down to the peritoneum should be considered (open laparoscopy). Only a small opening in the peritoneum is made to limit gas leakage. Special cannula, e.g. Hassan, are available for this purpose. II “Open” Technique With Hasson Cannula The open Hasson cannula provides the surgeon with an alternative, extremely safe method to enter the abdomen, especially in a patient who has previously undergone intraabdominal procedures. In these patients in particular, the blind insertion of a trocar would be fraught with then potential for in jury to the abdominal viscera. Some surgeons use the open cannula routinely in all patients for placement of the initial umbilical trocar.

FIG. 9

FIG. 10 FIG. 8

FIAGES Book.indb 61

3/23/2007 11:06:46 AM

62

Peritoneal Access and Creation of Pneumoperitoneum for Laparoscopic Surgery

The open cannula consists of three pieces: a coneshaped sleeve, a metal or plastic sheath with a trumpet or flap valve, and a blunt-tipped obturator. On the sheath or on the cone-shaped sleeve can be moved up and down the sheath until it is properly positioned; it can then be tightly affixed to the sheath. The two fascial sutures are then wrapped tightly around the struts, thereby firmly seating the cone-shaped sleeve into the fasciotomy and peritoneotomy. This creates an effective seal so the pneumoperitoneum will be maintained. Make a 2 to 3 cm transverse incision at the selected entry site (in the quadrant of the abdomen farthest away from any of the preexisting abdominal scars or in the periumbilical skin crease if there has been no prior midline surgery) Dissect the subcutaneous tissue with scissors, and identify and incise the underlying fascia. Gently sweep the preperitoneal fat off the peritoneum in a very limited area. Grasp the peritoneum between hemostats and open sharply. This incision should be just long enough to admit the surgeon’s index finger. Confirm entry into the abdominal cavity visually and by digital palpation, to ensure the absence of adhesions in the vicinity of the incision. Place an absorbable suture on either side of the fascial incision. Some surgeons place the fascial sutures first, use theses to elevate the fascia, and then make the fascial incision. Insert the completely assembled open cannula through then peritoneotomy with the blunt tip of the obturator protruding. Once the obturator is well within the abdominal cavity, advance the conical collar of then open cannula down the sheath until it is firmly seated in the peritoneal cavity. Secure the collar to the sheath with the setscrew. Next, twist or tie the two separate fascial sutures around the struts on the sheath or collar of the open cannula, thereby fixing the cannula in place. Connect the CO2 line to the sidearm port of the cannula and withdraw the blunt-tipped obturator. Establish pneumoperitoneum with the insufflator set a high flow. Increase intra-abdominal pressure to 12 to 15 mm Hg. With facility, it is possible to establish pneumoperitoneum just as fast (or faster) with the open technique as can be done with Veress needle and “closed” trocar passage. Indeed, many surgeons consider this to be the safest way to establish pneumoperitoneum. If a Hasson cannula is not available, a standard cannula from an open trocar can be placed by an open technique. In this case, place two concentric pursestring monofilament sutures in the midline fasica and make an incision into the free peritoneal cavity through the center

FIAGES Book.indb 62

of the purse strings. Keep both sutures long, and pass the tails of each suture through a 3 cm segment of a red rubber catheter, thereby creating two modified Rummel toumiquests. Place a standard laparoscopic sheath (with sharp-tipped trocar removed), cinch the pursestring sutures against the sheath and secure by placing a clamp on the red rubber catheter. At the conclusion of the operation, close the fasica by simply tying the sutures. Beware of Compliations 1. Bleeding from abdominal wall a. Cause and Prevention:- This problem usually manifests itself as a continuous stream of blood dripping from one of the trocars, and/or as blood seen on the surface of the abdominal viscera or omentum. Less commonly, delayed presentation as a hematoma of the abdominal wall or rectus sheath may occur. This source of bleeding is usually the inferior epigastric artery or one of its branches. Abdominal wall hemorrhage may be controlled with a variety of techniques, including application of direct pressure with the operating port, open or laparoscopic suture ligation, or tamponade with a Foley’s catheter inserted into the peritoneal cavity.

FIG. 11

3/23/2007 11:06:47 AM



Comprehensive Laparoscopic Surgery b.

Recognition and management:- To determine the point at which the vessel is injured, cantilever the trocar into each of four quadrants until the flow of blood is noted to stop. Then place a suture in such a manner that it traverses the entire border of the designated quadrant. Specialized devices have been made that facilitate placement of a suture, but are not always readily available. The needle should enter the abdomen on one side of the trocar and exit on the other side, thereby encircling the full thickness of the abdominal wall. This suture can either be passed percutaneously using a large curved No. 1 absorbable suture as monitored endoscopically, or using a straight Keith needle passed into the abdomen and then back out using laparoscopic grasping forceps. The suture, which encircles the abdominal wall, is tied over a gauze bolster to tamponade the bleeding site.

2. Visceral Injury a. Cause and Prevention:- Careful observation of the steps enumerated above will minimize the chance of visceral injury. However, placement of the Veress needle is a blind maneuver, and even with extreme care puncture of a hollow viscus is still possible. b. Recognition and Management:- If aspiration of the Veress needle returns yellowish or cloudly fluid, the needle is likely in the lumen of the bowel. Due to the small caliber of the needle itself, this is usually a harmless situation. Simply remove the needle and repuncture the abdominal wall. After successful insertion of the laparoscope, examine the abdominal viscera closely for significant injury. If, however, the laparsocopic trocar itself lacerates the bowel, there are four possible courses of action, depending on the surgeon’s experience: formal open laparotomy and bowel repair or resection; laparoscopic suture repair of the bowel injury; laparoscopic resection of the injured bowel and reanastomosis; minilaparotomy, using an incision just large enough to exteriorize the injured bowel segment for repair or resection and reanastomosis (similar to the technique of laparoscopic – assisted bowel resection). If possible, leave the trocar in place to assist in identifying the precise site of injury. 3. Major Vascular Injury a. Cause and Prevention:- Major vascular injury can occur when the sharp tip of the Veress needle or the trocar nicks or lacerates a mesenteric or retroperitoneal vessel. It is rare when the open (Hasson Cannula) technique is used.

FIAGES Book.indb 63

b.

63

Recognition and Management:- If aspiration of the Veress needle reveals bloody fluid, remove the needle and repuncture the abdomen. Once access to the abdominal cavity has been achieved successfully, perform a full examination of the retroperitoneum to look for an expanding retroperitoneal hematoma.

If there is a central or expanding retroperitoneal hematoma, laparotomy with retroperitoneal exploration is mandatory to assess for and repair major vascular injury. Hematomas of the mesentery and those located laterally in the retroperitoneum are generallyn innocuous and may be observed. If during closed insertion of the initial trocar there is a ruch of blood through the trocar with associated hypotension, leave the trocar in place (to provide some tamponade of hemorrhage and assist in identifying the tract) and immediately perform laparotomy to repair what is likely to be an injury to the aorta, vena cava, or iliac vessels.

References 1. Baadsgaard SE, Bille S.Egeblad K.Major vascular Injury during gynecologic laparoscopy: report of a case and review of published cases. Acta Obstet Gynecol Scand 1989; 68: 283-285. 2. Chapron CM, Pierre F.Lacroix S.Quer4leu D, Lansa J, Dubuission J-B .Major vascular injuries during gynecologic laparoscopy. J Am coll Surg 1997; 185:461-465. 3. Deziel DJ, Millikan KW, Economou SG, Doolas A, Ko ST, Arin MC. Complications of laparoscopic cholectystectomy: a national survery of 4,292 hospsitals and an analysis of 77,604 cases. Am J Surg 1993; 165:9-14. 4. Oshinsky GS, Smith Ad,. Laparoscopic needle and trocars: an overview of designs and complications. J.Laparoendosc Surg 1992;2:117-125 5. Riza ED, Deshmukh As. An improved method of securing abdominal wall bleeders during laparoscopy. J.Laparoendosc Surg 1995;5:37-40. 6. Soper NJ.Laparoswcopic cholecystectomy. Curr Probl Surg 1991;28:585-655. 7. Soper NJ.Odem RR, Clayman RV, McDougall EM, eds. Essentials of Laparoscopy, ST.Louis: Quality Medical Publishing 1994. 8. Wolfe WM, basic R.Instruments and methods. Obstet Gynecol 1990;75:456-457.

3/23/2007 11:06:47 AM

8 Operative Technique for Laparoscopic Cholecystectomy Tehemton E. Udwadia Gallstone is one of the commonest disease processes treated by the surgeon. A method of laparoscopic cholecystectomy is described, which has been used for seventeen years and in a few thousand cases, and which we feel has stood the test of time. No claim is made that this method is any better than any other method used by other surgeons, but no apology is offered for making this chapter tediously long. Laparoscopic Cholecystectomy is the flagship of laparoscopic surgery and the bench mark for all laparoscopic surgery in terms of efficacy, safety, patient acceptance and market penetration. It is the foundation of laparoscopic surgery. Any laparoscopic procedure demands that the surgeon’s eye, hands, the camera, the operative field and the monitor be in one line. [FIG. 1, 1a] Laparoscopic cholecystectomy comprises of four clear steps: Step One: Creation of pneumoperitoneum and insertion of trocars.

FIG. 1a: Eye, hand, camera, operation site, monitor in one straight line.

Step Two: Separation of all adhesions to the gallbladder and the surrounding liver, with exposure of the peritoneal fold in which the cystic duct and artery are situated. Step Three: Dissection and skeletonisation of the cystic duct and cystic artery and occlusion and division of these structures. Step Four: Dissection and extraction of the gallbladder and closure of incisions. STEP ONE Creation of pneumoperitoneum and first trocar entry are discussed in Chapter 7. As soon as the telescope is inserted a quick inspection is done of the peritoneal cavity to exclude obvious pathology and iatrogenic injury. The usual incisions for trocar insertion for laparoscopic cholecystectomy are: [FIG. 2]

FIG. 1

FIAGES Book.indb 64

3/23/2007 11:06:49 AM



Comprehensive Laparoscopic Surgery

65

A 1 cm long infra-umbilical incision for the telescope trocar. 2. A 5 mm incision in the right mid-axillary line about 5 - 8 cm below the rib margin. 3. A 5 mm incision at the right mid-clavicular line about 2 cms. below the costal margin. 4. A 1 cm incision approximately at the junction of upper third and lower 2/3rd of a line between the xiphisternum and umbilicus. 1.

FIG. 3: Mid axillary trocar inserted angled towards the gall bladder

FIG. 2: Standard sites of skin incisions

While these are the usual recommended sites for trocar entry, each case merits placement of incision after visual examination according to the individual anatomy e.g. enlarged / shrunken liver. Adhesions in front of the ascending colon may require the mid-axillary trocar to be placed more anteriorly or more headwards. Adhesions might require totally unconventional placement of the trocar to circumvent these adhesions, but it is preferable to dissect / divide these adhesions before the trocar are inserted at normal sites. After the first entry of the infra-umbilical trocar, all subsequent trocar are inserted under vision to ensure that during penetration no abdominal structure is injured. Each accessory trocar is pointed in the direction of the gallbladder as it penetrates the abdominal wall. This is a necessary step to minimize trauma to the abdominal wall by avoiding angulating the trocar towards the gallbladder if it is not directed primarily in that direction and ensuring that all instruments through the trocar are angled in the correct direction. The first trocar (trocar 2) is inserted in the right mid-axillary line [FIG. 3]. The main function of the instrument inserted through this trocar is to displace the fundus of the gallbladder headwards and this is best done from as lateral a position as possible. The caecum and the ascending colon are identified to ensure that the site of

FIAGES Book.indb 65

penetration is well anterior to the peritoneal reflection from these structures. It must be stressed again that the trocar is pointed in the direction of the gallbladder as it penetrates the abdominal wall. This may seem obvious, but needs stressing as we have observed that the natural tendency when inserting a trocar through the abdominal wall under laparoscopic video image is to make it penetrate at right angles to the abdominal wall through the shortest possible route. The next trocar to be inserted (trocar 3) is the one in the right mid-clavicular line and the distance below the costal margin is determined by the size of the liver. Instruments manipulated by the surgeon’s left hand will pass through this trocar, whereas instruments from the right hand trocar will pass through the epigastric port. Optimal coordination of the left and right hand require the ports be so placed that the instrument tips work in the abdomen at as wide an angle as possible. To ensure this, the sub-costal port should be placed as lateral as possible, without interfering with instruments through the mid axillary port. The epigastric trocar is inserted just to the right of the falciform ligament. [FIG.4]. If it is inserted too close to the umbilicus the telescope and the operating instruments are almost parallel to one another with the result that the tip of the instrument, particularly the tip of the scissors or the clip applicator, cannot be visualized clearly. We feel that if one has to err, it should be by placing the trocar closer to the xiphisternum and further away from the umbilicus, so that the operating end of the instrument is seen at right angles with reference to the telescope and the tip of the instrument can be clearly visualized. The significance of this is best observed while ligating, clipping, or dividing the duct and the artery. The telescope and all the instruments passed through

3/23/2007 11:06:49 AM

66

Operative Technique for Laparoscopic Cholecystectomy

FIG. 4: Epigastric trocar just right of the falciform ligament

FIG.: 4a The three working ports in position

correctly positioned trocar sheaths are always at angles to each other and never parallel to any one, ensuring optimal coordination [FIG. 4a]. The sequence in which the trocar is inserted varies with different surgeons but the end result should be the same. The patient is now placed in a 15o head high position and the table tilted with the right side up. To gain adequate exposure a fifth port may on occasion be required (e.g. to retract the liver) [FIG. 5]. A distended stomach and duodenum can greatly obscure the field hence a nasogastric tube in all cases. While two 10 mm and two 5 mm trocar are in standard use, one 10 mm trocar (for telescope) and three 5 mm or even smaller size can be used. STEP TWO All adhesions which impair visualization and retraction of the gall bladder are divided by unipolar or bipolar diathermy. A grasping forceps inserted through the midaxillary trocar grasps the fundus of the gallbladder and

FIAGES Book.indb 66

FIG. 5: 5th port for improved exposure / retraction

firmly retracts it headwards, pointing towards the right shoulder, thereby functioning as a Deaver retractor, exposing the body of the gallbladder and the adhesions around the gallbladder. The assistant/nurse holds the forceps maintaining the desired degree of traction on the fundus. If there is no assistant the handle of this forceps can be fixed to the drapes with a towel clip to maintain the desired degree of traction. Adequate retraction of the gallbladder is a prerequisite of laparoscopic cholecystectomy. Many factors could make retraction difficult: a. A grossly distended gallbladder is impossible to grasp without risk of rupture and should be aspirated under visual control with a needle inserted at the fundus. Bile leak from the puncture site can be prevented by grasping the fundus at the puncture site. b. A contracted fibrosed gallbladder does not permit the grasper on the fundus to push it upwards to retract the liver. This may require a 5th trocar in the left hypochondriac region for direct liver retraction. c. A very thick-walled gallbladder may require a toothed grasper for retraction. d. A stone impacted in the neck of the gallbladder with dense surrounding fibrosis and adhesions is, a major obstacle to retraction. The main purpose of retraction is to retract the neck of the gallbladder laterally to place the cystic duct and artery on the stretch, and maintain the cystic duct at right angles to the CBD Adhesions and fibrous thickening around the neck make this very difficult. Dissection should commence at the gallbladder neck and move medially mm by mm. e. Anterior and superior surface of the liver adherent to the anterior abdominal wall/diaphragm cause difficulty in retraction. These adhesions should be

3/23/2007 11:06:50 AM



Comprehensive Laparoscopic Surgery

67

severed to permit free liver movement upwards. Most of these adhesions are avascular and can be easily divided by sharp dissection. f. A fibrotic cirrhotic liver adds greatly to the difficulties already present by the greatly increased vascularity of portal hypertension. The grasper on the fundus cannot push the rigid liver upwards. We invariably use a 5th port for retracting the liver with a suction tube which helps maintain a clear dissection field. The method we adopt to separate adhesions is to grasp them as close to the gallbladder wall as possible, or rather on the gallbladder wall, thereby shearing them off the gallbladder in an avascular plane [FIG. 6]. The movement of the forceps is always from the gallbladder towards those structures around the gallbladder to which it is adherent, i.e. the omentum, the colon, and the duodenum. Starting at the area closest to the fundus, the adhesions are gradually separated towards the Hartman’s pouch [FIG. 7]. If adhesions do not strip easily, sharp diathermy dissection in the same plane is used.

FIG. 7: Adhesions gradually separated by blunt or sharp dissection towards Hartman’s pouch

be done in a clear field with optimal magnification, aided with a 30o telescope. At no stage should the integrity of either the Bile Duct or duodenum be compromised. One can never repeat often enough, or stress strongly enough that patience and precision are the fundamentals of safe laparoscopic surgery. STEP THREE

FIG. 6: Dissection hugs the avascular plane on the gall bladder wall

All adhesions to the liver adjacent to the gallbladder have also to be divided. These require sharp dissection to avoid shearing of the liver capsule with troublesome bleeding. Once this is done, the left hand forceps (from the subcostal port) grasps the Hartman’s pouch and retracts it laterally. With traction on the fundus headwards, on Hartman’s pouch laterally, and with the duodenum displaced medially by the right hand forceps through the epigastric port, the peritoneal fold of the cystic duct and the cystic artery is placed on the stretch. The problem adhesions are when the gallbladder in the area of Hartman’s pouch and gallbladder neck is densely adherent to the Common Bile Duct, Common Hepatic Duct, or duodenum. Dissection in such a situation must

FIAGES Book.indb 67

At open surgery, the surgeon uses both hands, but the right hand is predominant as it has free contact with and access to tissue. At laparoscopic surgery the right hand uses a 36-39 cm long instrument through an entry port which acts as a fixed fulcrum greatly restricting freedom of movement. At laparoscopic surgery, the left hand is vitally important as by altering the degree and direction of traction it displays different areas for dissection. It literally feeds tissue to the right hand for dissection, coagulation, clipping, cutting and suturing. Appreciation of the importance of the left hand and its intelligent use is one of the most vital points in safe and smooth laparoscopic surgery, and must be ingrained from the beginning of one’s endeavour in this surgery, so that ultimately the laparoscopic surgeon is ambidextrous. We have standardized a routine method of cystic duct dissection. With the left hand lifting Hartman’s pouch upwards and laterally, the posterior aspect of Hartman’s Pouch is displayed. Dissection commences in the safest area by division of the peritoneal fold between the Hartman’s Pouch and liver [FIG. 8] moving in that posterior plane medially towards the cystic duct. With the help of curved dissectors or a hook dissector, and pinpoint diathermy, the posterior junction of the gallbladder and cystic duct is clearly defined. [FIG. 8a]. By adhering to a plane flush with the gallbladder - cystic duct junction and dissecting deeper and medially a “posterior window”

3/23/2007 11:06:51 AM

68

Operative Technique for Laparoscopic Cholecystectomy

[FIG. 10]. Traction on Hartman’s Pouch is now altered to pull it down and laterally exposing the anterior peritoneal fold of Calot’s triangle. Once again dissection begins by clearing the junction between Hartman’s Pouch anteriorly

FIG. 8: Commencement of posterior dissection

FIG. 10: Commencement of anterior dissection

FIG. 8a: Posterior dissection deepend at neck-duct junction

is created whereby the dissection is deepend behind the Hartman’s Pouch and commencement of the cystic duct till the liver can be seen through this window [FIG. 9]. Gradual medial-ward dissection clears the cystic duct in this area. Once the window and clearance of the gallbladder cystic-duct junction and lateral aspect of the duct is completed posteriorly, anterior dissection is commenced

FIG. 9: Large clear “posterior window”

FIAGES Book.indb 68

FIG. 10a: Deepening of anterior dissection

FIG. 11: Cystic duct and artery skeletonised upto the gall bladder

3/23/2007 11:06:53 AM



and its reflection on the liver, gradually moving medially to and on the artery and the duct [FIG. 10a]. The cystic artery is identified at this stage and dissected separate from the cystic duct. Once the lateral ends of the duct and artery are dissected, circumferential dissection proceeds medially till the entire circumference of both structures is dissected, skeletonised and carefully scrutinized [FIG. 11]. Dissection of the cystic duct is carried out with firm lateral traction on Hartman’s pouch. This helps open the angle between the cystic duct and C.H.D. [FIG. 12]. Dissection of the cystic duct stops short about 1 cm. from the CBD to avoid any chance of injury to the CBD.

Comprehensive Laparoscopic Surgery

69

Sharp dissection by hook or scissor is safer than forced or rough traction-teasing. Once the cystic duct is fully dissected and skeletonised, trans-cystic duct laparoscopic cholangiography, if indicated, can be carried out [FIG. 13].

FIG. 13: Trans cystic-duct cholangiography. An infant feeding tube: soft, smooth and sterile, makes an ideal cholangiography catheter. A loosely applied clip prevents reflux

FIG. 12: Lateral traction keeps the cystic duct away from the common hepatic duct. Duct dissection stops short 1 cm. or so from CBD junction.

The more the adhesions, or the more uncertain the anatomy, the more the dissection should move further up the neck of the gallbladder so that the entire circumference of the gallbladder is dissected at the neck before dissecting the cystic duct medially towards the CBD This stresses the most important safety theme in Laparoscopic cholecystectomy. At open surgery I was taught, and in turn taught, that the vital area of dissection is the cystic duct and the CBD junction. It cannot be emphasized strongly enough that at laparoscopic cholecystectomy, the vital area of dissection is circumferential dissection of the gallbladder and cystic duct junction. This dissection is the essence of safe laparoscopic cholecystectomy. A structure not seen at open surgery but by virtue of magnification often present at laparoscopic cholecystectomy is a branch of the cystic artery to the cystic duct which needs to be divided to ensure full skeletonization of the duct. The greater part of the dissection is blunt dissection with the ‘Maryland” dissector, or the tip of the irrigationsuction cannula. It is stressed that dissection is always in the direction from the gallbladder towards the CBD

FIAGES Book.indb 69

The artery is clip occluded after dissecting the artery to where it enters the gallbladder. Two medium size clips are applied on the body side of the artery and a third on the artery flush with the gall bladder [FIG. 14, 14a)]. This ensures it is the cystic artery which is divided. An abnormally wide “cystic” artery should arouse suspicion of a “humped” right hepatic artery with a short cystic artery - hence the need to dissect the cystic artery flush with the gall bladder. After the artery is divided, the medial and lateral peritoneal folds extending up to the liver on either side of

FIG. 14: Clips on the fully dissected artery. The specimen side clip is always flush with the gall bladder

3/23/2007 11:06:54 AM

70

Operative Technique for Laparoscopic Cholecystectomy

Reusable clip applicators are used with the smaller medium size clip to occlude the artery as the small clip gives a firmer occlusion of this thin structure. We do not advocate use of the large clip in laparoscopic cholecystectomy - as it is unnecessary and potentially dangerous.

FIG. 14a: Division of Cystic artery

the neck are divided [FIG. 15] so that the gall bladder duct junction is fully mobilized to give the “elephant head” appearance [FIG. 15a]. This visually ensures there is no abnormal duct entering the cystic duct. We do not clip the duct till the “elephant head” is clearly demonstrated. This is the surest way of identifying any aberrant duct [FIG. 16].

FIG. 16: Aberrant duct entering cystic duct. Excessive lateral traction has angled the entry of the aberrant duct

FIG. 15: Division of medical and lateral peritoneal folds at neck of the gall

Our dictum is: Cystic duct upto 3 mm diameter: medium clip, Cystic duct 3 to 5 mm diameter: medium-large clip, Cystic duct over 5 mm diameter: ligature. The size of various structures can be easily determined by comparing with known size of tips of various instruments. The clip should be applied only after dissection of the entire circumference of the duct and artery. The direction of traction by the left hand on the Hartman’s Pouch at this stage is ALL important. Traction should be laterally so that the Cystic Duct is at right-angles to the Common Hepatic Duct and Common

bladder to create the elephant head

FIG. 17: Lateral traction at time of clip application takes the cystic duct away FIG. 15a: The safety of the “elephant head”

FIAGES Book.indb 70

from the CHD

3/23/2007 11:06:56 AM



Comprehensive Laparoscopic Surgery

71

Bile Duct junction [FIG. 17]. This ensures that the clip is applied only to the Cystic Duct and does not take a bite of the Common Hepatic Duct. If at this stage traction is in an upward-medial direction the Cystic Duct would be aligned parallel to the Common Hepatic Duct and the tip of the clip could take a bite of the Common Hepatic Duct [FIG. 18]. When we reviewed the videos of patients referred to us for post laparoscopic cholecystectomy bile duct injuries we noticed that failure of lateral traction during cystic duct dissection or clipping was an important causes of common hepatic duct injury. What

FIG. 19 Clip application : a) Distal limb of the applicator is seen. b) Clip at right angles to duct. c) Clip takes full circumference of duct. d) Decrease of lateral traction to avoid CBD tenting

FIG. 18: Incorrect traction upwards and medially at time of clip application could endanger the CHD

is loosely termed “CBD” injuries after laparoscopic cholecystectomy are almost always common hepatic duct injuries. The clip is driven home only when the distal limb of the clip can be seen behind the duct or artery to ensure no other structure is caught in the clip. This can be optimally seen when the telescope and the clip applicator are at right angles to each other. The clip is applied at right angles to the structure to be occluded which is “fed” into the clip by left hand traction to ensure that the full circumference of the duct/artery is within the clip [FIG. 19]. The position of the CBD is visualized before clip occlusion. If the clip is not properly positioned or does not have a bite of the full diameter of the structure, it should be removed by grasping at the angle and tugging in the direction of the clip. The lateral traction of the left hand is reduced just before clip occlusion or ligature of the cystic duct to ensure that the CBD is not tented into the clip or ligature. We ensure we leave a stump of atleast 0.5 cm of the cystic duct medial to the site of occlusion. Two clips on the body side and one at the neck of the gallbladder are applied and the duct divided close to the clip on the specimen side [FIG. 20].

FIAGES Book.indb 71

FIG. 20: Clips in position

Once both the cystic artery and the cystic duct are divided the stumps of both these structures are carefully examined [FIG. 21].

FIG. 21: Stumps of both artery and duct are inspected. Once liver retraction is lost it may be difficult to inspect the stumps

3/23/2007 11:06:57 AM

72

Operative Technique for Laparoscopic Cholecystectomy

STEP FOUR By changing the direction of traction on the gallbladder the peritoneal folds are made taut first laterally and then medially and with sharp scissor or hook dissection with diathermy, the gallbladder is gradually dissected off the gallbladder fossa starting from the neck and working towards the fundus [FIG. 22], [FIG. 23]. We feel it advantageous to proceed in this direction because: 1) maximum tension can be maintained on the peritoneal folds and 2) the liver is retracted upwards so that the gallbladder fossa is at all times displayed and any bleeding from it can be clearly visualized and coagulated carefully. With diathermy dissection, the stretched areolar tissue with occasional vessels or ductules are divided. The

enter a deeper plane going into the liver tissue, or conversely, the gallbladder wall is nicked. If opened, the gallbladder wall around the rent should be held by a grasping forceps and a loop ligature or clip applied around the tear, sealing it. There is often an arterial bleeder at the fundus which needs specific coagulation. We keep the final fundus connection undivided and use the gallbladder for traction to examine the liver bed for any bleeding which is coagulated [FIG. 24]. Sometimes hepatic venous ooze is difficult to stop with diathermy . Under these circumstances, the dissected gallbladder can be used as a tampon and compressed against the liver bed for a few minutes, stopping the bleeding.

FIG. 24: Fundal attachment retracted to display entire fossa and ensure FIG. 22: Scissor dissection off the fossa

FIG. 23: Hook dissection off the fossa

traction of the forceps on the fundus as also the direction and degree of traction of the left hand are constantly altered to keep the area under dissection on the stretch, permitting smooth dissection of the gallbladder. While dissecting the gallbladder, it is possible that one may

FIAGES Book.indb 72

complete haemostasis

Where there is gross fibrosis / adhesions at the neck of the gallbladder and the integrity of the CBD is compromised, we advocate the fundus first dissection, and clip or endo loop the cystic duct flush with the gall bladder [FIG. 25, 26, 27]. This is the safe method for a “partial cholecystectomy”. Occasionally, there is no plane of dissection between a small contracted gallbladder and the liver bed. Rather than enter deep into the hepatic tissue it may be prudent to excise the gallbladder leaving a small part of the wall stuck to the liver bed behind, sucking bile and carefully collecting all spilled stones. The mucosa of the gallbladder wall adherent to the liver is carefully diathermized. To minimize bleeding, this is our standard method of gallbladder dissection in cirrhosis. Once hemostasis is secured, the abdomen is irrigated and sucked clean. The left tilt and head-high position of the patient is reversed. The abdomen is carefully examined and any fluid collection is aspirated, re-checking the pelvis and sub-diaphragmatic areas.

3/23/2007 11:06:58 AM



FIG. 25: Commencement of fundus first dissection with hook

FIG. 26: Continuation of fundus first dissection

Comprehensive Laparoscopic Surgery

73

FIG. 28: Extraction of gall bladder can be via epigastric or umbilical 10 mm port

the gallbladder to ensure that the edge of the sheath does not shear the gallbladder. The grasping forceps, the gallbladder and the sheath are all removed as one unit. This permits the neck of the gallbladder in most cases to be brought out to the abdominal surface. The gallbladder neck is then grasped with an artery forceps. With firm rotary movement it is withdrawn while the telescope/ camera keeps the intra-abdominal part of the gallbladder constantly under vision to ensure that the intraabdominal part is not so distended that it could rupture. When the gallbladder is grossly distended with bile, the bile is aspirated through the neck of the gallbladder with a fine tipped mastoid suction cannula. A haemostat can be passed by the side of the gallbladder through the epigastric incision and its jaws opened gently to stretch and dilate the peritoneum and fascia permitting easier extraction of the gallbladder without enlarging the incision [FIG. 29]. Very thick-walled, fibrotic non collapsible, gallbladders are best removed through the umbilical port (telescope at epigastric port) after extending the sheath incision. This is also the

FIG. 27: Endo loop ligation at neck of gall bladder

The gallbladder neck is drawn into the 11 mm trocar and is gradually extracted from the abdominal cavity with the 11 mm. trocar [FIG. 28]. When the gallbladder is not distended and contains small stones its extraction is not a problem. The gallbladder is not pulled out through the trocar. The grasping forceps and the entire trocar sheath are withdrawn from the abdominal cavity with

FIAGES Book.indb 73

FIG. 29: Gentle dilation of epigastric port with tips of haemostat

3/23/2007 11:07:00 AM

74

Operative Technique for Laparoscopic Cholecystectomy

favoured mode of extraction in very obese patients. A contaminated gall bladder (e.g. gangrenous or ruptured) is extracted in a plastic bag to avoid any contact with the abdominal wall incision [FIG. 30].

FIG. 32: Ovum forceps extraction of multiple gall stones

FIG. 30: A contaminated / ruptured gall bladder is “bagged” for extraction

A vexing problem in laparoscopic cholecystectomy is extraction of the gallbladder when it bears a heavy stone load [FIG. 31]. We use an ovum forceps as a stone extractor. The ovum forceps has large, scooped, spoon-shaped grasping ends, is strong enough to crush any gallstone, can pass through a 1 cm. incision in the neck of the exteriorized gall bladder and can evacuate a large stone load with each withdrawal [FIG. 32].

with monitoring of pulse, B.P., ECG, oxygen saturation. All patients are administered I.M. analgesics the night after surgery. A well rested patient will not require any further analgesic. Peristalsis usually returns 4 - 6 hours after surgery at which time oral fluids are started. All patients have I.V. Cephalosporin intra operative, the night of surgery and if indicated the next morning. It is unusual in the Indian setting for patients to be discharged the same day - most patients go home the next or on the 2nd post-operative day. Any deviation from the normal, smooth, pain-free recovery of a laparoscopic cholecystectomy should cause anxiety. Pain, fever, distension, ileus, jaundice, abdominal guarding or rebound if ever seen should ring alarm bells. Variations in patient position, trocar insertion method of occlusion or dissection are mere details and frills. The essence of all methods is identical - clear dissection and display of relevant anatomy, creating the “elephant head”, secure occlusion of the duct and artery, dissection of the gallbladder in the correct tissue plane, hemostasis, clear visual field at all times. SOME TAKE-AWAY SUGGESTIONS

FIG. 31: Gall bladder with heavy stone load

POSTOPERATIVE MANAGEMENT The naso gastric tube is removed on the O.T. table. All patients are kept in the recovery room for about one hour,

FIAGES Book.indb 74

1. Hug the gallbladder. If as a routine, in every case, (not just the difficult one), dissection commences at the neck of the gallbladder circumferentially and progresses all around the cystic duct towards the CBD, and creating the “elephant head” the integrity of the biliary tract is ensured [FIG. 33]. 2. Assume every case has a short duct and/or other anatomical abnormalities. Anatomical abnormalities in the triangle of Calot are normal. 3. A “short” cystic duct can be “lengthened” after dissecting and

3/23/2007 11:07:01 AM



Comprehensive Laparoscopic Surgery

FIG. 33: This poster is part of our laparoscopic cholecystectomy equipment!! dividing the cystic artery flush with the gall bladder and teasing out fibrous bands which kink and shorten the duct. 4. Laparoscopic cholangiography is no substitute for careful dissection. Its main indication is to exclude or confirm presence of CBD calculi. 5. Bleeding. Panic reaction to bleeding by panic clip application or bulk diathermy leads to disaster. This is the basic principle of open surgery - and applies even more stringently to laparoscopic surgery. The immediate response to brisk bleeding should be compression - most effectively by the gallbladder, followed by flushing and suction. If after several minutes of continuous, efficient compression by gallbladder or a gauze strip the bleeding site cannot still be clearly identified, precisely grasped and carefully clipped or coagulated it may, be a good idea to consider conversion. Gentle pin-point coagulation or the smallest clip (medium) should be used to arrest bleeding - never the extra large clip which could partially or totally occlude the adjacent hepatic duct / artery [FIG. 34]. It bears repeating that vital structures, ducts and vessels, are crammed in a very small area very close to the cystic duct and artery, prone to diathermy or clip injury.

75

6. Bile in the peritoneal cavity is a cause for concern. A common cause of bile leak is when the grasping forceps used for retracting the gall-bladder tears the gallbladder wall. The rent should be immediately grasped with a bigger bite of the wall and closed with an endo-loop. Thin-walled, very distended gallbladders should be aspirated before being grasped. Similarly, bile can leak when the cystic duct has not been fully clip occluded at the neck of the gallbladder and leaks bile contained in the gallbladder after division of the duct while the gallbladder is being dissected from the gallbladder fossa. Biliary contamination of the peritoneal cavity is not to be taken lightly and if it does occur requires very thorough irrigation and suction. After the gallbladder has been excised, the entire area is flushed and examined. If bile contamination is now seen, it could have a sinister significance - this can be from the gallbladder fossa, a divided duct of Lushka, an inadequately occluded cystic duct, a divided accessory duct, or injury to the CBD. 7. Spilled Stones or slipped clips in the peritoneal cavity can cause complications and must be retrieved. [FIG. 35] [FIG.35a] [FIG. 36] 8. A very narrow CBD can be mistaken as the continuation of a distally inserted cystic duct. Hence our insistence the sinologist always reports the size of the CBD.

FIG. 34: Panic clipping with large clips resulted in CHD and right hepatic artery injuriesvv

FIAGES Book.indb 75

FIG. 35, 35a: Slipped clips must be removed

3/23/2007 11:07:02 AM

76

Operative Technique for Laparoscopic Cholecystectomy

FIG. 36: Spilled stones spell danger and must be retrieved 9. The over-confident surgeon and the “easy” case spell danger. 10. 1A drain, when indicated, adds to safety. 11. 1Malignancy is a total (and perhaps only) contraindiacation to laparoscopic cholecystectomy. 12. 1Diathermy complications are discussed elsewhere and hence not stressed here, but the potential danger of diathermy must always be kept in mind. Diathermy injury is a common cause of early and late complications in laparoscopic cholecystectomy 13. 1Suture the sheath at both 10 mm ports. Omental prolapse, incisional or Richter hernia are not uncommon. 14. 1Examine the specimen and check histopathology report in every case. This is mandatory as the patient leaves hospital before the histopathology report is received. 15. 1Complications detected at surgery have far lower morbidity. 16. 1We have a mandatory follow-up one week (at which time the histopathology report is checked) and again three months after surgery.

Acknowledgements I thank Dr. Manu Shankar, Associate Consultant, and Dr. Jency George Kurien, Senior Resident, Hinduja Hospital, for help with harvesting and arranging the illustrations.

FIAGES Book.indb 76

3/23/2007 11:07:03 AM

9 Difficult Laparoscopic Cholecystectomy Kuldip Singh, Ashish Ohri Laparoscopic cholecystectomy is one of the most common procedures being performed by the general surgeons all over the world. High incidence of cholelithiasis combined with the lack of health care facilities and the lack of awareness on the part of the patient contributes to the very common presentation of the patient in the advanced stage of the disease. With more and more endeavors being made in the field of laparoscopy, more and more complicated cases which were relatively contraindicated a few years ago, are now being tackled laparoscopically. However one should be very careful in the cases with complicated gall stone disease to avoid any disastrous complication which can result in “biliary cripples”. Safe dissection is the key, to complete laparoscopic cholecystectomy (LC) successfully. Every case should be considered as difficult until completed successfully. Level of difficulty may vary with the skill and experience of the surgeon. An inexperienced surgeon ascending the learning curve, may find conditions like intra abdominal adhesions, acutely inflamed friable gall bladder, gangrenous gall bladder and fibrotic calot’s triangle to be of insurmountable difficulty. In such situation, there should not be any hesitation to call for the expert help if available or to convert the surgery which should not be considered as a failure. Another important variable that deserve mention is the co-ordination between the operating team and theatre staff. There should be no compromise in the routine check and again the preoperative check to ensure the proper functioning of the equipment. A well trained assistant will go a long way to make the surgery safe. However some conditions are really difficult to tackle irrespective of the experience

FIAGES Book.indb 77

and skill of the surgeon. We consider LC to be difficult when we encounter 1) dense adhesions at the triangle of Calot (frozen triangle of Calot prohibiting proceeding laparoscopically without risk), 2) contracted and fibrotic gallbladder, 3) previous upper abdominal surgery, 4) gangrenous gallbladder, 5) acutely inflamed gallbladder, 6) empyema gallbladder including Mirizzi’s syndrome 7) previous cholecystostomy and 8) cholecystogastric or cholecystoduodenal fistula.1 Difficult access Access to the peritoneal cavity to create the pneumoperitoneum may be difficult in the previously operated cases. In such cases, creating pneumoperitoneum by open technique or use of veress needle through the Palmer’s point (2 cm below the left costal margin in the mid clavicular line) may be the useful alternatives to the umbilical point.2 The safest entry can be made into the peritoneal cavity by adhering to the basic principle of lifting the anterior abdominal wall with the help of two towel clips placed on the either side of umbilical incision into the rectus sheath and then pushing the spring loaded veress needle through the sheath. Intra abdominal adhesions One may encounter formidable intra-abdominal adhesions in the previously operated cases which can be taken down both bluntly and with the judicious use of sharp dissection to reach the margin of the liver. Inferior margin of the liver acts as the landmark when we are not

3/23/2007 11:07:03 AM

78

Difficult Laparoscopic Cholecystectomy

able to see the gall bladder under the dense adhesions. Dissection close to the liver margin exposes the fundus of the gall bladder which is elevated to give the counter traction to dissect the adhesions till the neck of the gall bladder. Difficult intra operative pathology The dissection should be done keeping in mind the anatomy of the hepatobiliary system and proceed step by step till the removal of gallbladder: 1. Landmark to approach gall bladder – Our routine policy has been to stay close to the liver margin, either medially or laterally to start with, to look for gall bladder under the adhesions.3 2. Lift the Hartmann’s pouch from the cystic duct to ensure the safe circumfrential dissection around the cystic duct. Hartmann’s pouch is the normal redundant part of the infundibulum of the gallbladder which lies folded over the cystic duct and becomes adherent to the duct in cases of inflammation of gallbladder. Lifting the pouch early in the dissection allows easier definition of the gall bladder cystic duct junction and circumfrential dissection around the cystic duct. 3. Define gall bladder neck – to have visualization and proper exposure of cystic artery at the level of gall bladder neck.3 4. Define gall bladder/cystic duct junction–surgical dissection of cystic duct and cystic artery should begin adjacent to or near the point of origin of cystic duct or near point of entry of the vessel.3 5. Identification of cystic lymph node as a landmark to define cystic duct and cystic artery.3 6. Calot’s triangle-Dissection in calot’s triangle should be commenced at a later stage only after identifying gall bladder/ cystic duct junction.3 the point to keep in mind while dissecting the calot’s triangle is that the tip of the curved dissector should be facing anterolaterally towards the gallbladder to avoid the injury to the liver or the CBD. 7. Rouviere’s sulcus - It is a 2-5 cm sulcus running to the right of liver hilum anterior to caudate process and usually containing right portal triad or its branches. The sulcus indicates the plane of CBD accurately.4 8. Proper localization of common bile duct should be done from time to time during surgery by retracting the duodenum downwards, keeping in mind the plane of rouviere’s sulcus and retracting the right lobe of liver with proper traction to the Hartmann’s pouch.

FIAGES Book.indb 78

9.

Maintain the plane of dissection in the cholecystic plate while removing the gallbladder from the liver. Dissection deeper to this plane will cause injury to the liver and may cause troublesome bleeding while dissection superficial to this plane may cause perforation of the gallbladder and spillage of bile. Moreover dissection in the plane superficial to the cholecystic plate in the subserosa of gallbladder will violate the oncologic plane if the biopsy of the gallbladder shows an incidental Stage 1 carcinoma and the redo surgery in the form of extended cholecystectomy is mandatory in such situation.

Useful aids to dissection which needs mention include placement of additional trocar, frequent irrigation and suction, use of suction canula for dissection, use of gauze piece in case of minor bleed and adequate traction on the infundibulum of gall bladder to display structures in the calot’s triangle. Every effort should be made to avoid the spillage of bile into the peritoneal cavity as this will increase the incidence of postoperative infection, abscess formation and also make the incidental stage 1 carcinoma into Stage 4. In the recent literature use of harmonic scissors has been reported to be safer than electrocautery but it is still not a viable option in a cost constrained country. Reportedly better outcome has been reported with the use of fundus first technique in a recent study but it requires more evidence to be used as an alternative.5 Intra-operative cholangiogram (IOC) Laparoscopic cholecystectomy can be performed safely without routine IOC.6 Although there has been stress on the routine use of IOC in LC in the past to delineate the extrahepatic biliary anatomy and to know the status of the CBD,7 selective use of IOC has been recommended in recent studies when the learning curve for the LC is over.8 Wider availability and efficient application of the ultrasonographic imaging and ERCP may be the reason to recommend selective rather than routine use of IOC.6,9 Emphasis should be on detecting choledocholithiasis pre-operatively and subject the patient to LC after CBD clearance. For the purpose of teaching one may consider the need for the selective use of IOC to make the young surgeons oriented to the technique and interpretation of the procedure. A new technique has been described by injecting the methylene blue into the lumen of gall bladder to delineate the cystic duct and CBD. This technique seems easier to perform, without any radiation exposure and less time consuming than conventional IOC.10

3/23/2007 11:07:03 AM



Comprehensive Laparoscopic Surgery

Conversion to open surgery Conversion to the open procedure should not be taken as a failure or a complication on the part of the surgeon. More and more difficult cases being taken up for LC which will increase the incidence of conversions also. Series vary widely in the conversion rates depending upon the number of patients and the experience of the surgeon. Common reasons for conversion are listed in Table 1. When to convert

Table 1 Unclear anatomy Failure to progress in dissection Injury to major blood vessel Injury to abdominal viscus Injury to bile duct Choledocholithiasis untreatable by laparoscopic technique as per the facilities and expertise available A recent report emphasizes the fact that the outcome of the patient is not influenced by the rank of the surgeon performing the surgery.11 However, the consensus has been that every surgeon has to undergo a learning curve for the laparoscopic procedure and develop his dexterity in laparoscopy. Endoscopic simulators and endotrainers are of great help for the young surgeons. Bile duct injuries Bile duct injury is the most catastrophic event that can happen to a patient undergoing LC, leaving the patient with high morbidity and high treatment cost. Surgical literature is full of the series and meta analyses emphasizing the fact that incidence of bile duct injuries have risen after the advent of LC. The learning curve contribution to bile duct injuries is now much less important as the surgical residents learn the procedure under direct supervision of more experienced surgeons. Data are insufficient to determine precisely the frequency of bile duct injuries, but one of the latest large studies from Italy reports the incidence of bile duct injuries as 0.42% which is still more than open cholecystectomy.

FIAGES Book.indb 79

79

Strategies to avoid bile duct injuries12 Adherence to the basic protocol of surgery and progressing step by step while following the landmarks of hepatobiliary anatomy as discussed earlier. Convert when in doubt. Do not clip any structure till anatomy is clear. Use of virtual reality simulation for the training of young surgeons. Application of the objective system like (OCHRA) Observational Clinical Human Reliability Assessment system to identify and categorize the technical errors during LC. Avoid the instinct to remove the gall bladder completely and accept subtotal cholecystectomy as a reasonable alternative to LC when desirable. Use high quality imaging equipment. Minimal use of electro cautery in calot’s triangle. Preferable use of a 300 telescope to have a better view of calot’s triangle. Various systems have been described to classify the bile duct injuries and plan for effective management. The most commonly used classifications are Strassberg classification, Bismuth classification and Stewart Way classification systems. The most important and the classic mechanism of laparoscopic bile duct injury was described by Davidoff et al. Here excessive traction on the infundibulum causes the CBD to align with the cystic duct and the CBD is cut instead of the cystic duct. Further dissection goes on lifting the CBD and again the common hepatic duct is divided near the hilum. When to think “Are you dissecting the CBD instead of cystic duct” The duct when clipped is not fully encompassed by a standard 9 mm clip. Any duct that can be traced without interruption to course behind the duodenum is probably CBD. The presence of another unexpected ductal structure after cutting the first one. Large artery behind the duct. Extra lymphatic and vascular structures encountered in the dissection. Management of bile duct injuries remains an area of high expertise. If the injury is detected intra operatively and necessary facilities with expertise are available, the repair should be done in the same operation. If facilities or expertise is not available, drain the peritoneal cavity and refer the patient to higher centre. However if the injury is detected post operatively, get the ERCP to localize the leak

3/23/2007 11:07:03 AM

80

Difficult Laparoscopic Cholecystectomy

and if possible, stent the system for decompression. If the system is completely blocked, wait for the intrahepatic and hilar ducts to dilate and do the interval repair. The most important fact to be kept in mind is that the best chance for the patient’s long term recovery is at the first repair, so never try to give it a chance if expertise is not available. Salient points Every case should be considered as difficult until completed successfully. Level of difficulty may vary with the skill and experience of the surgeon. Some conditions are really difficult to tackle irrespective of the experience and skill of the surgeon like dense adhesions at the triangle of Calot, contracted and fibrotic gallbladder, previous upper abdominal surgery, gangrenous gallbladder, acutely inflamed gallbladder, empyema gallbladder including Mirizzi’s syndrome, previous cholecystostomy and cholecystogastric or cholecystoduodenal fistula. Creating pneumoperitoneum by open technique or use of veress needle through the Palmer’s point could be the useful alternatives to the umbilical point. The dissection should be done keeping in mind the anatomy of the hepatobiliary system and proceed step by step till the removal of the gallbladder. Conversion to the open procedure should not be taken as a failure or a complication on the part of the surgeon. If CBD injury occurs, the best chance for the patient’s long term recovery is at the first repair.

6. Gilliams A, Cheslyn-Curtis S, Russell RC, Lees WR. Can cholangiography be safely abandoned in laparoscopic cholecystectomy? Ann R Coll Surg Engl 1992; 74: 248–251. 7. Cuschieri A, Shimi S, Banting S, Nathanson LK, Pietrabissa A. Intraoperative cholangiography during laparoscopic cholecystectomy: routine vs selective policy. Surg Endosc 1994; 8:302–305. 8. Misra M, Schiff J, Rendon G, Rothschild J, Schwaitzberg S. Laparoscopic cholecystectomy after the learning curve: what should we expect? Surg Endosc 2005;19: 1266–1271. 9. Barwood NT, Valinsky LJ, Hobbs MS, Fletcher DR, Knuiman NW, Ridout SC. Changing methods of imaging the common bile duct in laparoscopic cholecystectomy era in western Australia: implications for surgical practice. Ann Surg 2002; 235:41–50. 10. Sari YS, Tunali V, Tomaoglu K, Karagoz B, Guneyi A, Karagoz I. Can bile duct injuries be prevented? “A new technique in laparoscopic cholecystectomy”. BMC Surg. 2005 Jun 17;5:14. 11. Knight JS, Mercer SJ, Somers SS, Walters AM, Sadek SA, Toh SK. Timing of urgent laparoscopic cholecystectomy does not influence conversion rate. Br J Surg 2004;91:601-4. 12. 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 Apr;237(4):460-469.

References 1. Singh K, Ohri A. Difficult laparoscopic cholecystectomy: a large series from north India. Ind J Surg 2006; 68(4):205-208. 2. Gunenec MZ, Yesildaglar N, Bingol B, Onalan G, Tabak S, Gokmen B. The safety and efficacy of direct trocar insertion with elevation of the rectus sheath instead of the skin for pneumoperitoneum. Surg Laparosc Endosc Percutan Tech. 2005 Apr;15(2):80-81. 3. Singh K, Ohri A. Anatomic landmarks: their usefulness in safe laparoscopic cholecystectomy.Surg Endosc. 2006 Nov;20(11):1754-8. Epub 2006 Sep 23. 4. Rouviere H. Sur la configuration et la signification du sillon du processus caude. Bulletins et memoires de la societe anatomique de paris. 1924; 94: 355-358. 5. Cengiz Y, Janes A, Grehn A, Israelsson LA. Randomized clinical trial of dissection with electrocautery versus ultrasonic fundus first dissection in laparoscopic cholecystectomy. Br J Surg 2005; 92: 810-813.

FIAGES Book.indb 80

3/23/2007 11:07:03 AM

10

How to predict difficult Laparoscopic Cholecystectomy and when to convert? Subhash Khanna Within a short span of merely two decades since its introduction, Laparoscopic cholecystectomy has become widely accepted as the procedure of choice for symptomatic gall bladder disease. With their growing experience in this surgery, the surgeons have started taking up more complex cases and high risk patients, some of which were considered relative contraindications a couple of years back. Thus with wider application of laparoscopy for technically difficult and high risk patients it was expected that the complication rates would rise as also the rate of conversion to open cholecystectomy. Although 2% to 15% of patients require conversion to open cholecystectomy for various reasons (1,2,3,4) but irrespective of this morbidity and mortality statistics do still favour laparoscopic cholecystectomy over open cholecystectomy. We have tried to look at the various factors and conditions that would help a surgeon to predict a “difficult cholecystectomy”, which are essentially the same as those that increase the complexity of conventional open cholecystectomy. Pre-operative prediction of a difficult laparoscopic cholecystectomy not only helps patient counselling but also helps the surgeon to prepare better for the intraoperative risk and the technical difficulties expected to be encountered. Moreover, the patient safety may further be improved by involving an experienced surgeon both preoperatively in the decision making and also during the surgery. CLINICAL PARAMETERS It is evident from the literature that clinical, laboratory and radiological parameters have been studied extensively to analyze their effect on conversion rates.(4,5,6,7).Starting from a single variable, upto 34 parameters have been

FIAGES Book.indb 81

studied which include, patient demographics e.g. age, ASA classification, sex, body mass index(BMI)etc., alcohol or tobacco use, any concomitant medical condition, chronic obstructive lung disease, diabetes mellitus, cirrhosis, history of previous abdominal surgery etc. Clinical data studies included the presence of fever, tenderness and/ or palpable mass in the right upper quadrant, jaundice, evidence of pancreatitis, present preoperative clinical diagnosis and elective or nonelective surgery. Of the various preoperative variables, some were found to have statistically significant association with conversion rates. Several series have reported an association of advanced age with the need to convert (5, 8, 9, and 10). The strong association between age, conversion and systemic complications can probably be due to increasing comorbidities in older patients. Age probably cannot be taken as an independent risk factor for the need to conversion. On the other hand, a large sex difference was observed in a nationwide study of conversion obtained from National Hospital Discharge Database encompassing 2,916,470 entries for biliary tract disease from 1998 to 2001 (11). Of the laparoscopic cases only 27% were male, whereas for the open operations 42% were male. These findings of the male sex being identified as a significant risk factor for conversion are consistent with similar findings from several single institutions (1, 2, 8, 9, and 12) and also metaanalysis of the literature. (13) Initially laparoscopy was contraindicated in obese individuals mainly because of technical difficulties such as difficult access due to thick abdominal wall, cannula displacement, difficulties in obtaining a pneumoperitoneum, fat laden omentum and falciform

3/23/2007 11:07:04 AM

82

How to predict difficult Laparoscopic Cholecystectomy and when to convert?

ligament and a heavy fatty liver which was difficult to elevate. Although obesity has been considered a risk factor for increased conversion (14, 15), but several investigators have reported conversion rates similar to those in non obese patients.(1, 2, 12, 16). In general, conversion rates, mortality and complications excluding infection are not significantly different among obese and non obese individuals. Laboratory analysis preoperatively not only confirms the diagnosis but may also help to rule out the presence of a complicated gall bladder disease. Although no single specific criteria has been identified to predict the technically difficult Cholecystectomy, but various parameters have been analyzed in different studies which include white blood cell count, total serum bilirubin, alkaline phosphatase, asparate transaminase (AST), alanine transaminase(ALT) and amylase. Leucocytosis is indicative of acute cholecystitis, but if associated with systemic signs of sepsis, it is indicative of complicated cholecystitis such as empyema, perforation or gangrene. Elevated liver function tests are indicative of cholangitis or common bile duct stones and coagulopathy which needs correction prior to cholecystectomy.

clinical judgment is more important than ultrasound findings. Moreover, although the findings of air in the gall bladder wall, intraluminal membranes and marked irregularity of the gall bladder wall are features specific to gangrenous cholecystitis, these may also be present in severe form of acute disease without gangrene (23, 24). Plain abdominal radiography may occasionally be of some help in predicting a difficult cholecystectomy. A plain skiagram may identify a porcelain gall bladder (Fig.1), a large calcified gall stone and an emphysematous cholecystitis or aerobilia due to cholecystoenteric fistula; most of these conditions were earlier considered relative contraindications to laparoscopic surgery.

RADIOLOGICAL RISK FACTORS Abdominal Ultrasonography which is performed in the majority of patients has become a reliable, quick and noninvasive tool to diagnose gall stone disease (17). Apart from its value in establishing the diagnosis, it may also predict the degree of difficulty involved in the procedure. One of the important findings is maximal gall bladder wall thickness of >4.0mm which indicates a contracted fibrotic gall bladder which is difficult to grasp (18) . Apart from this the ultrasound may demonstrate a porcelain gall bladder, calcification of gall bladder wall and a gall bladder containing large stones; all of these are technically difficult due to inability to grasp and retract with standard laparoscopic instruments. Although a meta-analysis of diagnostic characteristics of ultrasonography published in1994 (13) has revealed a sensitivity and specificity of 94% and 78% respectively but little data is available to assess its diagnostic value for the presence and severity of gallbladder inflammation. Although multiple sonographic indicators of acute cholecystitis have been described including sonographic Murphy’s sign, pericholecystic fluid, gall bladder wall thickening and gall bladder distension (20,21), but the ability to predict acute cholecystitis and the ease or difficulty of Cholecystectomy appears to be limited (22), and it seems

FIAGES Book.indb 82

Fig. 1: Porcelain gall bladder seen in plain X ray

Computed Tomography and Magnetic Resonance Imaging are not done routinely, but, it may be of help in evaluating complicated gall bladder disease, especially in diagnosing an intraluminal mass (Fig.2), or pericholecystic abscess (Fig.3) and an associated intra abdominal disorder.

Fig. 2: An intraluminal mass seen on CT scan.

3/23/2007 11:07:04 AM



Comprehensive Laparoscopic Surgery 83

cases and the highest risk of conversion is expected in gangrenous cholecystitis and empyema. Conversion rates and infectious complications are much higher after a delay of 48 hours, (30) therefore, patients admitted with acute cholecystitis should be investigated, hydrated and should be taken up for early cholecystectomy within 48 hours. Conversion rates rise very sharply after a delay of over 96 hours from the appearance of the first symptom.(30,31,32) It is now a well accepted fact that within 72 hours of admission or the attack of pain, cholecystectomy, both open and laparoscopic, may be performed safely (29,33,28). Fig. 3: MR Imaging showing gall bladder perforaion with peri cholecystic abscess

EMPYEMA GALL BLADDER

A Radionucleotide hepatobiliary scan is one of the most sensitive tests to diagnose acute cholecystitis. Unfortunately, it is of limited value in predicting the degree of technical difficulty involved during the surgery. The rim sign characterized by nonvisualisation of the gall bladder and increased pericholecystic hepatic uptake is frequently associated with gangrenous cholecystitis (25), but is present in only small number of cases and thus is not of clinical benefit.

Twe percent to 31 percent of all cases of acute cholecystitis present preoperatively as empyema and gangrenous cholecystitis. (34, 35, 36) (Fig. 4, Fig. 5). The gall bladder becomes thick walled, distended and friable. However, despite the higher conversion rate, laparoscopic cholecystectomy when successful is associated with a better

SPECIFIC PREDICTORS OF DIFFICULT LAPAROSCOPIC CHOLECYSTECTOMY There are several conditions that make laparoscopic cholecystectomy a technically difficult procedure. These include acute cholecystitis, empyema gall bladder, gangrenous cholecystitis, porcelain gall bladder and intrahepatic gall bladder. Apart from these, there are various other conditions where laparoscopic cholecystectomy may be very challenging .These include previous laparotomy and postoperative adhesions, portal hypertension, cirrhosis of liver and surgery in a pregnant patient.

Fig. 4: Empyenma gall bladder with perforation

ACUTE CHOLECYSTITIS Patients presenting with acute cholecystitis with pain ,fever, leucocytosis and abnormal ultrasonography or scintiscan of the biliary tract were treated conservatively only two decades back, but several recent clinical studies have validated the safety and efficacy of early laparoscopic cholecystectomy in an acute setting (26,27,28). One of the most significant factors and independent predictors of conversion is the presence of or a previous attack of acute cholecystitis and some other proposed risk factors are related to this variable.(1, 19, 13, 15). The conversion rate ranges between 10% to 50% (1,29) in such

FIAGES Book.indb 83

Fig. 5: Gangrenous Cholecystitis with a necrotic gall bladder.

3/23/2007 11:07:05 AM

84

How to predict difficult Laparoscopic Cholecystectomy and when to convert?

outcome (36). Perforation of the gall bladder is common and occurs in around 15-20% of cases (37). Usually these cases can be managed and the morbidity is not increased, provided the peritoneal cavity is thoroughly irrigated and sucked dry (Fig.6). Preoperative factors that may help us to determine which patient may require conversion to open cholecystectomy are yet to be clearly defined. The threshold for conversion must be very low.

Some of the studies have mentioned previous abdominal surgery as a risk factor for increased conversion rates. (7, 14, 39) . Surgery of the stomach and duodenum may make laparoscopic biliary surgery more difficult (40), particularly with dense adhesion in the triangle of Calot (1). Previous abdominal surgery is not a contraindication to laparoscopic surgery, but the patient should be warned of increased risk of bowel injury and the greater chance of conversion. PATHOLOGICAL ANATOMY OF BILIARY TRACT AND LIVER

Fig. 6: Bile peritonitis in a case of perforated gall bladder

Apart from access problems due to postoperative adhesions and obesity, a difficult local dissection may be anticipated in some of the pathological conditions of the biliary tract. An evidence of gall bladder calcification or a porcelain gall bladder may be diagnosed on a plain x ray abdomen. Due to reported high incidence (12% to 60%) of gall bladder cancer (40) and the technical difficulty in grasping such calcified gall bladders, one must consider these and take appropriate measures (Fig. 8).

PREVIOUS ABDOMINAL SURGERY Patients with previous abdominal surgery may have no impact on a planned procedure; on the other hand there might be presence of gross adhesions and the laparoscopic procedure may fail. Postoperative adhesions pose problems in creating a pneumoperitoneum and also present the need for adhesiolysis before the gall bladder is visualized (Fig. 7). Preoperative sonography mapping can be done to detect the adhesions (38).Pneumoperitoneum should be created by placing the Veress needle at a site far away from previous scar, or by open Hassan technique. Fig. 8: Porcelain gall bladder seen on laparoscopy

Fig. 7: Gross post operative adhesions seen on laparoscopy

FIAGES Book.indb 84

Cholecystoenteric fistula may be diagnosed preoperatively by the presence of pneumobilia in a plain x ray, and can also be confirmed by a good ultrasonography or CT scan where a fistulous tract communicating with the stomach, duodenum or colon can be seen. Technically these may be slightly difficult to manage as the fistula needs repair, but it is no longer considered a contraindication. (41, 42)(Fig.9). An ERCP is the most reliable method for revealing the presence of bilioenteric fistula (43). An unexpected encounter which at times makes a simple cholecystectomy difficult includes a haemangioma near or at the gall bladder fossa (Fig.10).

3/23/2007 11:07:06 AM



Comprehensive Laparoscopic Surgery 85

Fig. 9: Cholecystoduodenal fistula seen prior to dissection

Fig. 11: Contracted partially intraheptic gall bladder

Fig. 10: A haemangioma near the gall bladder fossa

Fig. 12: Large Calculus at Hartmann’s pouch

TRABECULAR, CONTRACTED AND INTRAHEPATIC GALL BLADDER

bile duct known as Mirizzi’s syndrome (Fig.13). With experience the fistula can be repaired, the stone extracted, and the large cystic duct repaired laparoscopically, or a bypass may be needed necessitating conversion. 0.1% of all patients with gall stone disease would have Mirizzi’s (44) . Extensive adhesions may make visualization of the biliary anatomy exceptionally difficult, consequently ligation or permanent injury of CBD may occur (45). Laparoscopic stapled cholecystofistulectomy; which avoids contamination of peritoneal cavity, may be performed in well equipped centres (42).

A gall bladder may congenitally be partially or completely embedded in the liver parenchyma or may become buried due to recurrent episodes of inflammation. The problem relating to this abnormality is an inability to grasp the fundus of the gall bladder and an absence of avascular plane of dissection between the gall bladder and liver parenchyma, which makes it technically a challenging task (Fig.11). Patients with a small contracted gall bladder or a trabeculated gall bladder due to heavy stone load and multiple criss cross strictures in the gall bladder lumen, are also candidates at risk where the surgeon would have difficulty in holding the gall bladder. Mirizzi’s Syndrome A large calculus at the Hartmann’s pouch (Fig.12) or a stone at cystic duct and common bile duct junction may press the common bile duct causing obstructive jaundice or create a fistula between the cystic duct and common

FIAGES Book.indb 85

CIRRHOSIS OF LIVER WITH PORTAL HYPERTENSION A heavy pathological liver seen in fatty liver and chronic hepatitis is also firm and is difficult to elevate and rotate [Fig.14]. Even a flabby left lobe or an enlarged quadrate lobe may necessitate slight modification of the technique, and an extra access epigastric cannula may be needed for introducing a retractor to elevate the quadrate lobe. The elevated portal venous pressure

3/23/2007 11:07:07 AM

86

How to predict difficult Laparoscopic Cholecystectomy and when to convert?

Most patients can be managed conservatively until the postpartum period, how ever nearly half the patients require repeated hospitalization and thus 40 percent of pregnant patients with symptomatic biliary disease need cholecystectomy during pregnancy (51, 50). Several studies have documented good results with laparoscopic cholecystectomy in the first two trimesters (52). Several technical modifications are required(53) in order to enhance the safety of both mother and fetus (Fig.15).

Fig. 13: Case of Mirizzi’s Syndrome with a calculus at cystic duct-CBD juncion

Fig. 15: Pregnant uterus (24wks) seen in a patient undergoing laparoscopic cholecysectomy

ABNORMAL HEPATO BILIARY AND ARTERIAL ANATOMY Fig. 14: Nodular and Firm liver in Cirrhosis

and extensive collateral portosystemic shunts may cause troublesome bleeding during dissection of the cystic duct and artery. Although technically difficult, laparoscopy has become the preferred method of treatment in recent years(46, 47, 48, and 49) with the specific advantages of absence of wound infection, lower rate of postoperative hepatic failure and reduced risk of viral contamination of the surgical staff (41). It is feasible in most child’s A and B patients with an acceptable conversion rate. Some modification of technique and subtotal cholecystectomy has also been advocated by specialised centres having large series with acceptable postoperative morbidity (49). LAPAROSCOPIC CHOLECYSTECTOMY DURING PREGNANCY Biliary tract disease is the second most frequently encountered inflammatory problem encountered during pregnancy. Gall stones are present in 5 to 12 percent of all pregnancies.(50). The treatment of biliary tract disease is similar for pregnant and non pregnant patients.

FIAGES Book.indb 86

The most dangerous and striking feature of the anatomy of the extra hepatic biliary tree is its variability. Variations of ducts, cystic artery, hepatic artery etc. are all common and even anomalies of the gall bladder are infrequently encountered. A congenital true duplication of the gall bladder, which has an incidence of 1 in 4000, may need special attention as it requires removal of both the lobes (Fig.16) and rarely one of these twins may be intrahepatic. Various anomalous positions of the gall bladder have been described, which includes left sided, transverse, floating, intrahepatic and retrodisplaced gall bladder. The left sided gall bladder may or may not be associated with situs inversus (Fig.17). Whereas the cystic duct joins the common hepatic duct in the usual position, it is expected that there would be associated ductal and vascular anomalies. Therefore while making special access ports one may consider intraoperative cholangiogram in case of any doubt regarding ductal anomalies. The hepatic artery crosses the hepatic duct posteriorly but in about 12% of cases, it may cross anteriorly.

3/23/2007 11:07:08 AM



Comprehensive Laparoscopic Surgery 87

CONVERSION TO OPEN SURGERY When to Convert?

Fig. 16: Double gall bladder with two cystic ducts

Fig. 17: Left sided gall bladder with two cystic ducts

Caterpillar hump of right hepatic artery occurs in 6% to 16% of cases. After crossing the hepatic duct, the right hepatic artery often descends in the triangle of Calot to an area dangerously close to the cystic duct. This tortuous artery gives rise to multiple small branches supplying the gall bladder, which if severed inadvertently, may bleed profusely [Fig18].

Conversion to open surgery is at times perceived as a “failure” of the laparoscopic procedure, and surgeon’s enthusiasm to keep the conversion rate low may lead to unwanted biliary tract injuries and complications. Conversion is appropriate when the key technical points of the procedure are not possible and there is uncertainty about the patient’s anatomy, or if concern for injury exists. There is no clear cut guideline as to the extent to which a surgeon should struggle to complete the procedure laparoscopically and when to convert to open procedure. Although it has been suggested in recent studies (54) that laparoscopic cholecystectomy is associated with less morbidity than open cholecystectomy irrespective of the duration, in contrast, several studies have shown that for an additional interval of 30 minutes, the intraoperative, local and systemic post operative complications rise considerably. If laparoscopic cholecystectomy is extended for more than 2 hours, the risk of perioperative complications is four times higher than that with a surgery which lasts between 30 to 60 minutes(4). The duration of trial dissection may be different depending on the risk score of the patient. When operating on a high risk patient, the surgeon has to make an early decision to convert if dissection seems to be very difficult; early conversion shortens the operation time and decreases morbidity. (15,29). A policy of converting if there is no progress in dissection of Calot’s triangle within 15 to 30 minutes may be adopted for high risk patients(1), whereas in low risk patients, in general, if no progress is made in identifying the biliary anatomy within 1 hour, the procedure is converted to open, and if the structures are seen and the feasibility of dissection is there, the procedure is continued (55). SUMMARY

Fig. 18: A rare anomaly of double caterpillar hump

FIAGES Book.indb 87

The technique of laparoscopic cholecystectomy has been standardized and it has become a routine and safe operation. However, there are numerous conditions which make the operation difficult necessitating conversion to open surgery. Preoperative prediction of a difficult cholecystectomy and the risk of conversion is of great help both to the patient who can plan his work and the surgeon who can also schedule his time and team accordingly. There

3/23/2007 11:07:09 AM

88

How to predict difficult Laparoscopic Cholecystectomy and when to convert?

are various studies regarding the risk of conversion in laparoscopic surgery and many studies have made some prediction using some variables without using any scoring system. A scoring system needs to be designed urgently which would definitely help surgeons in making unbiased standard predictions. We would definitely be able to clearly state and define “difficult cholecystectomy”, prior to taking the patient to the operation theatre, and this would help the surgeon to provide better surgical care to the patient.

REFERENCES 1. Alponat A, Kum CK, Koh BC, et al. Predictive factors for conversion of laparoscopy Cholecystectomy.World J Surg 1997; 21: 629-33 2. Wiebke EA, Pruitt AL, Howard TJ et al. Conversion of laparoscopic to open Cholecystectomy. An analysis of risk factors. Surg Endosc 1996; 10: 742-5. 3. Michael R, Fred B, Ponsky J. Predictive factors for conversion of laparoscopic Cholecystectomy. Amer.J Surg 2002; 184(3):254-8. 4. Giger UF, Risk factors for perioperative complications in patients undergoing laparoscopic Cholecystectomy: analysis of 22,953 consecutive cases from the Swiss Association of Laparoscopic and Thoracoscopic Surgery Database. J Am Coll Surg 2006; 203(5): 723-8. 5. Brodsky A, Matter I, Sabo E et al. Laparoscopic Cholecystectomy for acute Cholecystitis, can the need for conversion and the probability of conversion be predicted? A prospective study. Surg Endosc 2000; 14: 755-60 6. Nachnani J. Pre-operative prediction of difficult laparoscopic Cholecystectomy using clinical and ultrasonographic Parameters. Indian J Gastroenterol. 2005; 24(1):16-8 7. Schrenk P, Woisetschläger, Wayand W. Laparoscopic Cholecystectomy – Cause of conversion in 1,300 patients and analysis of risk factors. Surg Endosc.1995; 9:25-28 8. Schafer M. Krahenbuhl, Buchler MW. Predictive factors for the type of Surgery in acute Cholecystitis. Am J Surg 2001;182:291-7 9. Kama NA, Kologlu M, Dogonay M et al. A risk score for conversion from laparoscopic to open Cholecystectomy. Am J. Surg 2001; 181: 520-5. 10. Kauvar DS, Brown BD, Braswell AW et al. Laparoscopic Cholecystectomy in the elderly: increased operative Complications and conversions to laparoscopy.J Laparoendosc Adv Surg Tech A 2005;15:379-382 11. Livingstone EH, Rege RV. A nationwide study of conversion from laparoscopic to open Cholecystectomy.Am J Surg

FIAGES Book.indb 88

2004;188(3):205-11. 12. Sikora SS, Kumar A, Saxena;et al. Laparoscopic Cholecystectomy can conversion be predicted. World J surg 1995;19: 858-60. 13. Shea JA, Berlin JA, Escarce JJ. Revised estimates of diagnostic test sensitivity and specificity in suspected biliary tract disease. Arch Intern Med(1994) 154: 2573-2581. 14. Hutchinson CH, Traverso LW, Lee FT: Laparoscopic Cholecystectomy: Do preoperative factors predict the need to convert to open? Surg Endosc.1994; 8: 875 15. Liu CV, Fan ST, Lair ECS et al. Factors affecting conversion of laparoscopic cholecystectomy to open surgery. Arch Surg 1996;131: 98-101. 16. Philips H, Carroll BJ, Fallas MJ, et al. Comparison of laparoscopic Cholecystectomy in obese and non obese patients Am J Surg 1994; 60: 316 17. Prian GW, Norton LW, Evle J. Jr, Eiseman B. Clinical indications and accuracy of gray scale Ultrasonography in the patients with suspected biliary tract disease. Am J Surg(1977) 134:705-711 18. Cuschieri A, Berci G.; The difficult Cholecystectomy in Laparoscopic Biliary Surgery.Second Edition. Blackwell Scientific Publications, London; 1992:101-115 19. Shea JA, Healey MJ, Berlin JA, et al. Mortality and complications associated with laparoscopic cholecystectomy.A meta-analysis. Ann Surg 1996;224:609-20 20. Bennett GL, Balthazar EJ. Ultrasound and CT evaluation of emergent gall bladder pathology. Radiol• Clin North Am(2003); 41:1203-1216 21. Menu Y, Vuillerme MP. Non traumatic abdominal emergencies imaging and intervention in acute biliary conditions. Eur Radiol. 2002;12: 2397-2406 22. Bingener J, Schwesinger W, Chopra S et al. Does the correlation of acute Cholecystitis on ultrasound and at surgery reflect a mirror image? Am. Jr. Surg 2004;188(6): 23. Merriam LT, Kanaan SA, Dawes LC, et al. Gangrenous Cholecystitis diagnosed by ultrasound.Radiology 1983; 148:219-21 24. Teefey SA, Barron RL, Radke HM, et al. Gangrenous Cholecystitis new observations on sonography. J Ultrasound Med 1991;10:603-9 25. Hauashi AK, Soudry G, Dibos PE. Rim Sign. Radionuclide imaging in a patient with acute gangrenous Cholecystitis and Cholelithiasis after nonspecific Ultrasonography. Clin Nucl Med. 1997;22:338-9 26. Rattner DW, Ferguson C, Warshaw AL. Factors associated with successful laparoscopic Cholecystectomy for acute Cholecystitis Ann Surg 1993;217:233-6. 27. Bickel A, Rappaport A ,knievski V. Laparoscopic management of acute cholecystitis Surg Endosc 1996;10:1045-1045.

3/23/2007 11:07:10 AM



Comprehensive Laparoscopic Surgery 89

28. Serralta AS ,Bueno JL.Planells MR,et al. Prospective evaluation of emergency versus delayed laparoscopic cholecystectomy for early cholecystitis Surg laparos C Endosc 2003;13:71-75.

44. Hazzan D, Golijanin D, Reissman P, et al. Combined Endoscopic And Surgical management of Mirizzi Syndrome. Surg Endosc 1999; 13(6):618-20

29. Lo CM ,Fan ST,Li CL, et al .Early decision for conversion of laparoscopic to open Cholecystectomy for treatment of acute Cholecystitis Am J Surg 1997;173:513-7

45. Becker CD, Hassler H, Terrier: Preoperative diagnosis of Mirizzi Syndrome: limitations of sonography and computed Tomography. AJR Am J Roentgenol 1984;143(3); 591-6.

30. Eldar S, Eitan A, Bickel A,etal The impact of patient delay and physician delay on the outcome of laparoscopic cholecystectomy for acute Cholecystitis. Am J Surg 1999; 178:303-307

46. Morino M, Cavuoti G, Miglietto C, et al. Laparoscopic Cholecystectomy in Cirrhosis contraindication or priviledged indication? Surg Laparosc. Endosc Percut Tech 2000;10(6):360-3

31. Rutledge D,Jones D, Rege R. Consequence of delay in surgical Treatement of biliary disease. A m J Surg 2000;180: 466-9.

47. Gugenheim J, Casaccia M jr. Mazza D et al. Laparoscopic Cholecystectomy in cirrhotic patients. HPB Surg 1996; 10(2): 79-82.

32. Koo KP; Thirlby RC .Laparoscopic Cholecystectomy in acute Cholecystitis what is the optimal timing for operation? Arch Surg 1996;131:540-4

48. Yeh CN, Chen MF, Jan YY. Laparoscopic Cholecystectomy in 226 cirrhotic patients. Experience of a single center in Taiwan. Surg Endosc 2002; 16(11) 1583-7

33. Keo KP, Thirlby RC. Laparoscopic Cholecystectomy in acute Cholecystitis; what is the optimal timing for operation? Arch Surg 1996; 131:540-544

49. Palanivelu C, Rajan PS, Jani K et al. Laparoscopic Cholecystectomy in cirrhotic patients: The role of subtotal Cholecystectomy and its variants. Am Jr of Surg 2006;203(2):145-151.

34. Eldar S ,Saboo E ,Nash E ,etal. Laparoscopic Cholecystectomy in various type of Gall bladder inflammation, a prospective trial. Surg Laparosc Endos 1998;8:200-7

50. Mekellar DP, Anderson CT, Boynton CJ, et al. Cholecystectomy during pregnancy without fetal loss. Surg Gynecol obstet 1992; 174:465.

35. Singer JA,Mckeen RV .Laparoscopic Cholecystectomy for acute or gangrenous Cholecystitis .Am Surg 1994;60:326-8

51. Ghumman E, Barry M, Grace PA:Management of gall stones in pregnancy. Br. J. Surg 1997;84:1646.

36. Merriam LT,Kanaan SA,Dawes LC ,etal.Gangrenous Cholecystitis, analysis of risk factors and experience with laparoscopic Cholecystectomy. Surgery 1999;126: 680-6.

52. Curet MJ; Allen D, Josloff RK, et al. Laparoscopy during pregnancy. Arch Surg 1996; 13:546

37. Cuschieri A, Dubois F, Mouret P, et al, The European experience with laparoscopic Cholecystectomy. Am J Surg 1991; 161: 385-387

53. Curet MJ. Special problems in laparoscopic surgery, previous abdominal surgery, obesity and pregnancy Surg clin North Amer 2000;80:1093-110

38. Borzellino G,De Manzoni G,Ricci F. Detection of abdominal adhesions in laparoscopic surgery .A controlled study of 130 cases. Surg Laparosc Endosc 1998; 8: 273-6..

54. Habib FA, kolachalam RB, khilnani R. et al. Role of laparoscopic Cholecystectomy in the management of gangrenous Cholecystitis Am J. Surg 2001;181:71-75

39. Jorgensen Jo, Hunt Do: Laparoscopic Cholecystectomy :A prospective analysis of potential cause of failure. Surg Larose Endosc 1993;3:49

55. Zucker KA. Laparoscopic management of Acute Cholecystitis in Surgical Laparoscopy. Second Edition Edited by Karl. A Zucker. Lippincott Williams and wilkins. 2001;142-162

40. Berger DL, Matt RA. Carcinoma of the gall bladder. Oxford Text book of Surgery vol. I edited Peter J Morris, Ronald A malt, at Oxford Medical Publications, New York 1994;23.2: 1240-1242 41. Wang WK, Yeh CN, Jan YY. Successful laparoscopic management of cholecystoenteric Fistula. World Jr of Gastroenterology 2006;12(5):772-775 42. Chowbey PK, Bandoyopadhyay SK, Sharma A. Laparoscopic management of cholecystoerteric fistulas. Jr of Laparoendoscopic and Adv Surgical Techniques 2006; 16(5): 467-472. 43. Yamashita H, chijiiwa K, Ogawa Y et al, The internal billiary fistulareappraisal of incidence, type, diagnosis and management of 33 consecutive cases. HPB Surg 1997; 10:143-147

FIAGES Book.indb 89

3/23/2007 11:07:10 AM

11

Detection and Management of CBD Stones in the Era of Laparoscopic Cholecystectomy Jyotsna S Kulkarni Laparoscopic Cholecystectomy was first performed by Prof Dr Med Erich Muhe of Boblingen, Germany, on 12th September, 1985. He was reprimanded by the German surgical Society for doing this procedure. Later in 1992, he received the highest award from the same society–The German Surgical Society Anniversary Award. Dr. Philip Mouret, of Lyon France, performed laparoscopic cholecystectomy in 1987. Dr Reddick and Dr Olsen of Nashville, Tennessee USA, performed laparoscopic cholecystectomy in 1989 . Since then, laparoscopic cholecystectomy has rapidly become the accepted treatment of choice for patients with symptomatic gallbladder disease. However, though the surgeons were fascinated by the minimally invasive procedure of Laparoscopic Cholecystectomy, their main hurdle was CBD stones. It has been estimated that about 10% of all patients with gall stone disease also have CBD stones. So, the surgeons had to think about the way to diagnose CBD stones – pre, intra and post operatively and the way to treat them in a minimally invasive manner. In 1991, Spaw, Reddick and Olsen published the first description of Laparoscopic-guided Cholangiography. However, though technically feasible, this procedure was often difficult to perform with the instruments available at that time. Hence surgeons relied heavily on preoperative methods of detecting CBD stones such as ERCP (endoscopic retrograde cholangio-pancreatography). If the CBD stones were found pre- operatively, then the surgeons strongly advised patients to undergo endoscopic sphincteroscopy with stone extraction before embarking on laparoscopic cholecystectomy.

FIAGES Book.indb 90

Thus the era of Laparoscopic Cholecystectomy began more than two decades ago. During this period the diagnosis and management of CBD stones has evolved. The diagnosis and management of CBD stones can be made – a. Pre-operative b. Intra-operative c. Post-operative (A) Pre-operative Diagnosis and Management Of CBD Stones Clinical Presentation Majority of patients with persistent common bile duct stones can be easily identified before surgical intervention. 1. Many patients provide history of attacks of upper abdominal pain, starting in the epigastrium or right hypochondrium and radiating to the back or shoulder. 2. Patients sometimes give history of transient jaundice or passing of dark coloured urine. 3. History of fever with chills also could accompany the pain. 4. Patients could also present with cholangitis or acute pancreatitis. Biochemical Tests Elevated serum bilirubin–direct more than indirect 2. Elevated alkaline phosphatase 3. Elevated transaminase levels 4. Elevated amylase or lipase levels 1.

3/23/2007 11:07:10 AM



Comprehensive Laparoscopic Surgery

Radiological Tests Plain x-ray of abdomen may show radio-opaque shadow in the right hypochondrium. 2. Ultrasound of abdomen will show one or two stones in the lower end of the common bile duct. Sometimes, the lower end of the common bile duct may be obscured by gas in the duodenum and hence the stones may not be seen clearly. In that case the ultrasound will show dilated proximal bile duct and sometimes also intra-hepatic biliary dilatation. 3. MRCP (Magnetic Resonance Cholangio Pancreatography) – This is a non invasive procedure and gives an excellent anatomical picture of liver, gall bladder and whole biliary tree. Thus it is specially useful to see stones at the lower end of common bile duct. 4. CT Scan – This is useful when one wants to rule out any other lesion which may be suspected as the cause of obstructive jaundice. 1.

Endoscopic Tests Endo Sonography – This is an invasive procedure, though less invasive than ERCP. A side viewing flexible endoscope which has sonography incorporated, is an excellent tool to diagnose stones at the lower end of common bile duct. 2. ERC (Endoscopic Retrograde Cholangiography)– This is an invasive procedure and will deliniate the anatomy and nature of obstruction of the biliary tree. Besides, it has the advantage of proceeding to therapeutic management to treat the obstruction, depending on its nature. 1.

Treatment Once the common bile stones are detected, ERCP, sphincterotomy and stone extraction is the treatment of choice. If the stones are cleared completely, then this is followed by laparoscopic cholecystectomy. 2. If the common bile duct stones are not cleared completely or if the stones are larger than 2.5 cm, then the surgeon may choose to perform: a. Laparoscopic exploration of CBD and stone clearance followed by laparoscopic cholecystectomy b. Open cholecystectomy with open CBD exploration 1.

FIAGES Book.indb 91

91

(B) - INTRA-OPERATIVE Diagnosis and Management Of CBD Stones Clinical Presentation In the following situations the surgeon would like to confirm the presence of common bile duct stones. Pre-operative biochemical tests show marginally raised bilirubin or alkaline phosphatase. 2. Mild dilatation of the common bile duct, but the lower end not seen well on ultrasonography. 3. Recurrent attacks of jaundice in a patient with multiple gall stones and when pre-operative USG / MRCP / bilirubin is normal. 4. Wide cystic duct seen during laparoscopic dissection. 1.

Diagnosis Intra operative diagnosis of cbd stones can be made by a. Intra operative laparoscopic cholangiogram or b. Intra operative laparoscopic ultra sonography Intra operative cholangiogram is the most commonly performed imaging modality to detect common duct stones. This technique of performing laparoscopic cholangiography is very important since it is the first step if one has to go for laparoscopic trans-cystic or common bile duct exploration. Intra operative ultrasound is also used to detect stones in the common bile duct. For ultrasound of the biliary tree, high frequency probes, in the 7 to 10 MHz range using solid state linear array transducers, are optimal. Laparoscopic ultrasound has certain advantages over operative cholangiogram. 1. There is no radiation 2. It is repeatable 3. It is more sensitive for stones 4. It is more specific Laparoscopic ultrasound has certain disadvantages over operative cholangiogram. 1. Ductal anatomy is not as clearly seen 2. Fatty pancreas or pancreatitis obscures the view 3. Duodenal diverticuli with air can mimic a shadowing stone 4. There is a learning curve 5. The equipment is not available to all

3/23/2007 11:07:10 AM

92

Detection and Management of CBD Stones in the Era of Laparoscopic Cholecystectomy

Treatment Once the diagnosis of common bile duct stones is confirmed intra operatively, the treatment will be influenced by various factors – 1. Condition of the patient 2. Calibre of the CBD and extent of the stone location 3. Level of expertise in ERCP 4. Availability of equipment for laparoscopic CBD exploration 5. Experience of the surgeon in laparoscopic biliary surgery The treatment options will be 1. Complete the laparoscopic cholecystectomy and observe the patient clinically. This option is preferred if the stone in the CBD is very very tiny, since it is observed that only 3 to 5 % of stones detected on routine operative cholangiogram will need intervention and the rest pass away in the course of time. 2. Complete the laparoscopic cholecystectomy and perform post operative ERCP. This option is preferred if the stones are 4 to 5 mm and are unlikely to pass and expertise in ERCP is available. 3. Laparoscopic cholecystectomy with laparoscopic CBD exploration. This can be done in two ways a. Trans cystic duct approach to CBD stones or b. Laparoscopic Choledochotomy: i. Choledochotomy closure with internal stent ii. Choledochotomy closure without stent iii. Choledochotomy closure over a T-tube iv. Choledocho-duodenostomy 4.

Open cholecystectomy with open CBD exploration i. Choledochotomy closure over T-tube ii. Choledocho- duodenostomy iii. Choledocho- Roux loop jejunostomy

a) Laparoscopic Trans Cystic Duct Approach to CBD stones This approach is adopted when there is not much discrepency between the size of the cystic duct and the size of the CBD stones. Indications 1. Single / multiple stones with 6 mm or less diameter 2. Cystic duct diameter 4 mm or more 3. Cystic duct entrance into CBD is straight and lateral 4. Laparoscopic suturing ability poor

FIAGES Book.indb 92

Contra-indications 1. Stone diameter more than 6 mm 2. Cystic duct diameter less than 4 mm 3. Intra hepatic stones 4. Cystic duct entrance into CBD posterior or distal to CBD stone Procedure Dilatation of the cystic duct is critical to the success of trans cystic procedure. A guide wire is passed from the cystic duct opening into the CBD. Then either balloon dilators or sequential bougie dilators are passed over the guide wire. One has to be careful during the procedure as it is possible to avulse the cystic duct from the gall bladder. This can occur from dilating with bougie catheters or over vigorous retraction of gall bladder-cystic duct junction. If this becomes too close to the CBD, it often becomes impossible to instrument the cystic duct stump. This is the most common cause of failure. Hence the incision in the cystic duct should be only 50% of the diameter of the cystic duct and one should not apply unnecessary force on the gallbladder-cystic duct junction, so as to avulse the cystic duct. Choledochoscope should be passed through the cystic duct opening. Direct visualisation of the stone and wire basket entrapment is a safer approach to CBD calculi. Some surgeons also use wire baskets through the cystic duct under fluoroscopic control. Stones are usually larger than the inner diameter of the cystic duct. In that situation, the entrapped stone and the basket ensemblage can become entrapped within the CBD, unable to be removed through the cystic duct opening. When this occurs, the wire must be cut and CBD opened to remove the basket. Thus this “ blind” technique can be time consuming, less successful and can have a high incidence of complications and retained stones. Advantages 1. T-tube is eliminated 2. Risk of CBD stricture after closure of choledochotomy is eliminated. b) - Laparoscopic Choledochotomy for CBD stones This approach is indicated when the CBD stones are large

3/23/2007 11:07:11 AM



Indications 1. CBD size more than 1 cm 2. Adequate dilatation of CD to take the choledochoscope is not possible 3. CBD stones larger than the diameter of cystic duct 4. Failed trans cystic extraction and the CBD is dilated 5. Large impacted lower CBD stone which may require lithotripsy 6. Intra hepatic stones Contraindications 1. CBD diameter less than 6 mm 2. Poor laparoscopic suturing ability Procedure One cm longitudinal incision is taken on the anterior surface of supraduodenal portion of CBD. Choledoscope is inserted through the right midclavicular port. Both laparoscopic and choledochoscopic images are kept in view on same or separate monitors.The scope is carefully advanced into the ductal system. Warm saline is infused continuously into the duct through the working channel of the scope- to give good choledochoscopic view. The stone is located, basket is carefully inserted and manipulated past the stone, opened and withdrawn– thus allowing the stone to be captured into it, as it is removed. For stones which are impacted and larger than 2.5 cm, we use rigid scope – like nephroscope / ureteroscope and crush the stone under vision using lithoclast. Clearance of stones from the CBD is visually checked by passing the rigid scope upto the sphinctor of oddi. Proximal bile duct is also visualized to make sure that there is no stone in the hepatic duct. Once the surgeon is satisfied about the complete clearance of CBD stones, the procedure can be completed using one of the following choices. 1. Choledochotomy closure with internal stent – A 10 cm long Double J (DJ) stent is passed over a guide wire which is inserted through the rigid scope into the duodenum. This ensures that the lower end of DJ is in the duodenum. The guide wire and the scope are withdrawn from the choledochotomy incision. The upper end of DJ is inserted into the common hepatic duct and the choledochotomy incision is closed using 4/0 vicryl continuous suture. About a month later, it is confirmed on ultrasound and with liver function tests, that the CBD is clear of gall stones, before pulling out the DJ stent through gastroscpoe.

FIAGES Book.indb 93

Comprehensive Laparoscopic Surgery

93

Choledochotomy closure without internal stent – The surgeon has to be very sure that there is not a single residual fragment of stone in the CBD as well as no distal biliary stricture. Only then one could take a chance to primarily close the CBD without any stent. 3. Choledochotomy closure over T-tube – Some surgeons prefer to insert a T-tube after completion of ductal exploration through choledochotomy. One of the reasons for this is that this is what they had been doing after open CBD exploration and feel comfortable. The other reason is that it is possible to perform T-tube cholangiogram at the end of the procedure. If the duct is not clear on T-tube cholangiogram, then the surgeon must decide as to whether to a. continue with LCDE b. convert to open CDE or c. leave stones in place for : subsequent ERC sphincterotomy or lithotripsy 2.

4. Choledocho-duodenostomy This procedure is preferred when there is a. Severely dilated CBD b. Presence of distal stricture c. Primary CBD stones Intra Operative ERCP This can be a. Antegrade - In this the sphincterotome is passed from above through the choledochotomy incision and sphincterotomy is performed from above in antegrade fashion. b. Retrograde – In this the sphincterotome is advanced through the doudenoscope and intra operative sphincterotomy is performed in retrograde fashion. Both approaches are cumbersome and may not be successful. (C) - POST OPERATIVE Diagnosis and Management of CBD Stones Clinical Presentation Patient who has had straight forward laparoscopic cholecystectomy could have missed stones in the CBD and could present later with a. Attack of right hypochondriac pain radiating to the back. b.

History of jaundice

c.

History of chills and fever

3/23/2007 11:07:11 AM

94

Detection and Management of CBD Stones in the Era of Laparoscopic Cholecystectomy

Diagnosis This can be confirmed by performing 1. Biochemical testsi. Elevated serum bilirubin ii. Elevated alkaline phosphotase iii. Elevated trans aminase iv. Leucocytosis 2. Ultrasound of abdomen 3. Endo sonography 4. MRCP

If this is not available then one may have to resort to a. Laparoscopic CBD exploration of it is adequately dilated. b. Open CBD exploration with T-tube drainage. c. Laparoscopic or Open choledocho-doudenostomy.

Treatment This will depend on the availability of expertise and the size of the stone. ERCP is the preferred treatment of choice today.

FIAGES Book.indb 94

3/23/2007 11:07:11 AM

12

Management of Post-operative Complications after Laparoscopy Cholecystectomy B. Krishna Rau The complications occurring after cholecystectomy, either by open or laparoscopic technique, are same. In the laparoscopic procedure, there are certain complications peculiar to the minimal access and pneumo-peritoneum. The advent of minimal access surgery for the gallbladder removal saw a spate of complications. This was due to newer technology, eye-hand-foot co-ordination problems, lack of structured training, and the eagerness of surgical fraternity to jump into the new modality of surgery. The complications can be classified by The organ specific complications. ii. Time of onset of complications and iii. The causative factors. i.

Remnant of Hartman’s Pouch with medial insertion of cystic duct

Injury to Bile duct 2. Blood Vessels 3. Bowel 1.

Infection: Localised or Systemic Retained Stone: 1. 2. Abnormal high insertion of cystic duct

The post operative period starts from the time the patient is extubated. The following discussion is based on organ specific complications and deals with the causative factors and its time of onset.

FIAGES Book.indb 95

In CBD Peritoneal spill

Due to pneumo-peritoneum: Sub cutaneous emphysema at port site, neck, mediastinum, Pneumothorax, air embolism, and air entrapment in the peritoneal cavity.

3/23/2007 11:07:12 AM

96

Management of Post-operative Complications after Laparoscopy Cholecystectomy

Biliary Pancreatitis Due to impacted stone at the ampulla Systemic complications of general anaesthesia DVT to cardiac arrest. Bile Duct Injury This is considered the most important and serious complication in view of long term effect on the liver function. Initial high incidence of CBD injuries have now come down to the level seen in open surgical era.

The injury can be a perforation or lateral tear of the CBD wall. Partial or total clipping of the duct, application of single or multiple clips across the duct, cautery burn of the duct, and surgical excision of the CBD. The level of trauma can be from the supra duodenal portion to the porta hepatis level. Bismuth’s classification is applied to the bile duct injury. Bile duct injury results in extravasation of bile into the peritoneal cavity. This causes chemical peritonitis. Bile causes thrombosis of blood vessels along the CBD causing ischemic necrosis. Bile is an excellent culture medium for bacteria. Hence the urgent need to drain the extravasated bile to prevent onset of infection esp. by gram negative organism. CBD exploration by any method increases the chance of biliary leak.

ERCP - Clips across CBD

Post operative Biliary Stricture

Clip across CBD opened at ERCP

Long segment cautery burn of CBD

FIAGES Book.indb 96

Bile can extravasate without injury to the CBD. In clip failure across the cystic duct, bile flows into the peritoneal cavity. Congenital abnormalities of the biliary system eg. Duct of Lushka, low medial insertion of cystic duct, low insertion of cystic duct, duplicated GB with two cystic ducts are known causes of biliary ductal injury and leak without injury to CBD. Very few surgeons drain the GB bed routinely. In these patients the first indication of biliary extravasation is the drainage of bile. As majority do not drain the peritoneal cavity, the first indication of the problem clinically is that the patient does not feel good, is not active and develops tachycardia. Clinical suspicion requires urgent evaluation. US will detect fluid accumulation in the peritoneal cavity and determines the quantum of fluid accumulated and whether it is loculated or not. Once fluid accumulation is established, it has to be drained at the earliest. Initially a percutaneous aspiration under US guidance is done. This confirms the presence of

3/23/2007 11:07:13 AM



Transection of CBD

Low Union of Right and Left Hepatic Ducts Cystic Duct Draining into left Hepatic Duct

Post Operative Biliary Leak

bile. If there is re accumulation of bile, bile duct injury is confirmed. Continuous drainage is to be instituted. This can be done by per cutaneous US guided catheter drainage or by laparoscopic technique. The latter provides the advantage of carrying out peritoneal lavage and possible management of the lesion. It should be

FIAGES Book.indb 97

Comprehensive Laparoscopic Surgery

97

emphasised that primary repair should be carried out in a high volume centre specialising in hepato-biliary surgery. Attempts of repair by inexperienced surgeons do more damage to the structures and to the patient in the long run. Further evaluation is required for determining the level and nature of the damage. Many non invasive methods like CT, MRI, 3D Doppler, and scintigraphy are available. Correct anatomical evaluation is obtained by carrying out Endoscopic Retrograde Cholangiography. ERC not only localises the level of the lesion, extent of the lesion and the probable cause, it provides the opportunity to undertake therapeutic procedure – stenting of the CBD Endo therapy entails passing of guide across the site of injury, dilating the narrowed area with balloon or rigid dilators and positioning stent across the pathological area to enable the bile from the proximal biliary segment to drain into the duodenum. The lesions that can be successfully managed by ERC are leak from cystic duct, punctures or lateral tears of CBD and partial clipping of the duct. When ERC procedures fail or lesion is not amenable to endo therapy, surgical repair has to be carried out. The aim of surgery is to restore the passage of bile into the alimentary tract. As stated this should be carried out by an experienced hepato biliary surgeon in a high volume centre. The principle is to anastamose the biliary radicals into an isolated segment of small bowel in order to prevent ascending infection into biliary system leading to cholangitis [bilio enteric]. The procedure becomes relatively simple if there is a segment of common hepatic duct. Other wise dissection has to be extended into the hilar plate to identify all the biliary radicals for anastamosis to jejunum, thereby provide drainage of all the hepatic segments. Late complication of bile duct injury are biliary cirrhosis, portal hypertension and its complications ending in liver failure. Cholecystectomy done for benign stone disease, should not produce a ‘biliary cripple’ patient. Bleeding Immediate post operative bleed indicates failure of primary haemostasis, eg. Slipped clip across the artery. Venous bleed occurs once the intra abdominal pressure is reduced. Clinical features of fall of BP, tachycardia, pallor, presence of fresh blood thro the drainage tube confirms the intra peritoneal bleed. Immediate exploration by open or laparoscopic approach is mandatory. Bleeding point is

3/23/2007 11:07:13 AM

98

Management of Post-operative Complications after Laparoscopy Cholecystectomy

identified and haemostasis obtained. Site of arterial bleed is from cystic artery or from small aberrant vessel. Venous bleed is from the GB bed or from the dilated veins in portal hypertension. If these sites are dry, look for port site bleeder. If there is large collection of blood in the peritoneal cavity it is wise to open the abdomen and employ Pringle manoeuvre to obtain quick control of the bleed. Delayed bleed or secondary bleed follows localised infection leading to vascular erosion. Larger vessel is involved leading to massive blood loss with high morbidity and mortality. Rarely coagulation defect can set in cirrhotic liver due to decompensation of liver function.

Percutaneous Trans Hepatic Choledochoscopy for retained stone

Bowel Injury First part and genu of the duodenum are the commonest areas of injury. The dissection of densely adherent GB from the duodenum can result in immediate perforation. Late duodenal wall necrosis occurs due to cautery burn. Small intestine and colon can get perforated during the exchange and passage of instruments particularly when they are not visually monitored during the introduction. These injuries are not recognised at surgery. Patient develops classical feature of peritonitis within 48 hrs.

Sohendra’s Lithotripter

Injuries related to instrument use. The grasper holding the fundus of the GB can slip and penetrate the diaphragm resulting in pneumothorax, haemo thorax, haemo pericardium, or perforation of myocardium. The under surface of liver can be traumatised. Accidental entry of the instrument into major blood vessel - portal vein, IVC, will result in catastrophe. Use of mono polar electro cautery results in heating up of the tip of the instrument. When this comes in contact with bowel, blood vessel etc. delayed coagulation necrosis occurs. Hence minimal use of mono polar cautery is advised. Similarly the harmonic scalpel tip gets heated and can cause unexpected tissue damage. Mono polar cautery is to be replaced by bipolar cautery wherein the tissue heating is not dissipated to the surrounding structures.

Impacted stone Ampulla

Complications peculiar to Pneumo peritoneum Sub cutaneous emphysema at port site, mediastinum and neck may be noticed at the end of surgery. Pneumo thorax, extensive emphysema can complicate prolonged surgery or by accidental increase in the intra abdominal pressure during surgery. The infiltration of air into the mesentery of bowel

FIAGES Book.indb 98

Stone Extracted

can result in paralytic ileus. Delayed air embolism has been reported, site of entry of air thro an open vein which remained closed during the surgery due to raised intra abdominal pressure. Hypercapnia which occurs after prolonged surgery

3/23/2007 11:07:14 AM



Comprehensive Laparoscopic Surgery

99

through vault of vagina, rectal wall or abdominal wall resulting in localised abscess, when drained discharges gall stones. This is very discomforting to the patient.

Retained CBD Stone – NBC Post Operative Tube Cholangiogram showing low medial insertion of cystic duct with stones in CBD and Cystic Duct remnant

Port Site Hernia This occurs due to defective closure of port sites, esp. in obese patients particularly at the umbilical port.

Stone Abdominal Wall: CT Scan

causes hypertension and cardiac irregularities. Gall Stones If the gall bladder contains multiple small stones and the cystic duct is wide, chances of stones slipping into CBD is high. This can cause post operative obstructive jaundice, cholangitis, and acute biliary pancreatitis. Obstructed CBD, results in increased biliary pressure with chance of clip across the cystic duct giving way, leading to biliary peritonit is and biliary fistula. In almost all cases the stones can be removed by ERC, sphincterotomy, and basketting. Other options are ESWL, percutaneous trans-hepatic approach, or thro T tube tract if present. Intra peritoneal spillage of stones usually passes off without problem. In few cases, it makes its way through the port site, umbilicus most commonly. Occasionally

Complications pertaining to Drainage and T tubes T tubes are usually kept for 6-8 weeks. Due to digestive action, prolonged contact with bile the tube can get disintegrated and get avulsed at the junction of the stem of T and the intra biliary part .This again can be extracted by ERC. Post Cholecystectomy Syndrome Persistence of symptoms following cholecystectomy has been studied extensively. Many factors were considered as cause for persistence of symptoms. Presences of long cystic duct remnant, stone in remnant cystic duct, incomplete or subtotal cholecystectomy were blamed. More commonly it is due to initial wrong diagnosis. Hiatus hernia and diverticular disease of colon being the common culprits. Air Entrapment Syndrome Deflation of pneumoperitoneum after surgery may fail to express the air out of pockets in the peritoneal cavity resulting in abdominal distension and ileus. Complications associated with General Anaesthesia

Post operative T Tube Cholangiogram showing lower end of CBD

FIAGES Book.indb 99

Of the many known complications one has to be wary of deep vein thrombosis and pulmonary embolism. On table mechanisms to prevent DVT should be followed by anti coagulation protocol in high risk patients in the post operative phase.

3/23/2007 11:07:15 AM

13 Understanding Endoscopic Anatomy of Inguinal Region Parveen Bhatia INTRODUCTION “No disease of the human body, belonging to the province of the surgeon, requires in its treatment, a better combination of accurate, anatomical knowledge with surgical skill than hernia in all its variants.” – Sir Astley Paston Cooper, 1804. A safe and successful outcome of any surgical procedure is dependant upon the clear understanding of the surgical anatomy of the relevant area. The laparoscopic view of the groin anatomy is quite different! The laparoscopic view is essentially a posteriorapproach view. Most surgeons are well versed and used to the anterior approach . Changing to a laparoscopic approach needs knowledge of the posterior approach. Certain structures that are clearly visible during the open approach (such as the ilioinguinal nerve, inguinal

FIAGES Book.indb 100

ligament, pubic tubercle and lacunar ligament) are not as clearly visible with the laparoscope. Conversely structures that would require additional dissection during a open approach (such as Cooper’s ligament and the ilio-pubic tract) are clearly visible with a laparoscope. The laparoscopic view is a ‘virtual view’ with a ‘2- dimensional’ handicap. There is the additional loss of tactile feedback. “I know more than hundred surgeons whom I would cheerfully allow to remove my gallbladder but only one to whom I should like to expose my inguinal canal.” – Sir Henage Ogilvie PURE ANATOMY The groin has a unique functional composite of musculo

3/23/2007 11:07:16 AM



Comprehensive Laparoscopic Surgery

skeletal, visceral and neurovascular structures, the collective architecture of which serves to preserve the dynamic physiological integrity of the region. Breakdown of this functional barrier gives rise to hernia. ‘Deep’ repair of inguinal hernia addresses the issue of the ‘point of origin’ rather than the ‘point of presentation’. This practice has two important results. Firstly, the ‘inlay/ posterior’ mesh placement gives a mechanical advantage over the ‘onlay/ anterior’ mesh placement. Secondly covering the entire ‘Myopectineal orifice (of Fruchaud’) the ‘deep’ repair deals with all the potential sites at risk for herniation in the groin.

101

THE PERITONEAL LANDMARKS Since the development of the laparoscopic approach for the treatment of groin hernia an increased attention is being paid to ‘pure anatomy’ issues such as the infraumbilical fossae. These fossae have two important roles1. The fossae delineate the sites of groin herniation. 2. They are an important landmark for orientation during hernia repairs.

THE ‘MYOPECTINEAL ORIFICE OF FRUCHAUD’ In 1956, Henry Fruchaud espoused the theory that all groin (inguinofemoral) hernia originate in a single weak area called the Myopectineal orifice. This oval, funnellike, ‘potential’ orifice formed by the following structures, forms the ‘Myopectineal orifice of Fruchaud’. • Superiorly

Internal oblique and transverses abdominis muscles.

• Inferiorly

Superior pubic ramus.

• Medially

Rectus muscle sheath.

• Laterally

Iliopsoas muscle.

Weakness through this area leads to inguinofemoral hernia. Proper exposure of this area is important during a preperitoneal (posterior) repair! To avoid missing small hernia as well as To achieve adequate fixation. The orifice is divided by the Iliopubic tract and the inguinal ligament into an ‘inguinal’ defect and a ‘femoral defect’.

FIAGES Book.indb 101

The fossae are created by the presence of peritoneal folds, which radiate from the umbilicus or umbilical area.

3/23/2007 11:07:21 AM

102

Understanding Endoscopic Anatomy of Inguinal Region

Median Umbilical Ligament This ligament ascends in the median plane from the apex of the bladder to the umbilicus. It represents the obliterated allantoic duct and its lower part is the site of the rare urachal cyst.

• Supravesical fossae The infra-umbilical area between the median and medial umbilical ligaments. This is the site for the origin of the supravesical hernia. • Medial Umbilical fossae The infra-umbilical area between the medial and lateral umbilical ligaments. This is the site for the ori- gin of the femoral and direct inguinal hernia. • Lateral Umbilical fossae The infra-umbilical area lateral to the lateral umbilical ligament. This is the site for the origin of the indirect inguinal hernia.

Medial Umbilical Ligament This ligament represents the obliterated umbilical artery on each side and can be traced down to the internal iliac artery. Lateral Umbilical Ligament It is the ridge of peritoneum, which is raised by the Inferior Epigastric artery and its companion two veins as they course around the medial border of the internal inguinal ring and then pass upwards into the posterior rectus sheath.

THE AREA AT RISK Hesselbach’s (Inguinal) Triangle Franz Caspar Hesselbach’s (1759-1816) original description of the inguinal triangle were as follows: • Superolateral boundary

Inferior Epigastric vessels

• Medially

Rectus sheath

• Medially

Rectus muscle sheath.

• Inferiorly

Cooper’s ligament (Inguinal ligament in subsequent modification, to assist an ‘anterior’ approach surgeon.)

This ‘at-risk’ area was predisposed to the formation of direct inguinal and femoral hernia! These ligaments delineate the following fossae

FIAGES Book.indb 102

3/23/2007 11:07:26 AM



THE PREPERITONEAL SPACE Understanding of the preperitoneal space and its extensions is crucial to the laparoscopic surgeon. The significance of the preperitoneal space lies in the fact that all posterior approaches for the repair of groin hernia have to traverse this area and work in it. Embryology The genesis of the preperitoneal space occurs in concert with the global development of the abdominal wall. Transversalis Fascia (of Gallaudet) The current understanding of the preperitoneal (properitoneal / extraperitoneal / pareito-peritoneal) space is tied up intrinsically with the anatomy of the transversalis fascia in the infra-umbilical region. The current understanding of the transversalis fascia envisages this fascia as a two layered (bilaminar) structure (confirmed by the laparoscope). Superiorly, the two layers of the transversalis fascia are two distinct entities and inferiorly they insert onto the Cooper’s ligament. The anterior layer is adherent to the rectus abdominis muscle. The posterior layer lies in between the anterior layer and the peritoneum. It divides this space into an anterior (vascular space) and a posterior (Space of Bogros). The old concept envisaged the transversalis fascia as being single layered (unilaminar). The transversalis fascia is now not believed to provide the kind of significant strength and integrity to the groin as earlier believed. Most importantly, it bridges the space between the transversus abdominis arch superiorly and the inguinal ligament and the Cooper’s ligament inferiorly. This crucial area is the “Achille’s heel” of the groin! It is here that direct inguinal herniation occurs. Condensations of the transversalis arch form three (3) named structures in this area-

Comprehensive Laparoscopic Surgery

103

inguinal ligament, although intimately associated with the inguinal ligament with which it is often confused! It is anterior to the Cooper’s ligament and posterior to the inguinal ligament. The iliopubic tract separates the internal ring from the femoral canal. It is visualized as a fibrous (white) tract. It varies in constancy! In only 28% of (open) groin hernia repairs was it found to be above average in density and formed a very strong aponeurotic band. Its significance in the laparoscopic hernia repair lies in the fact that it forms the superior boundary for the ‘Triangle of Pain’, in which lie the nerves of the ilioinguinal region, which are at risk for injury/ entrapment if anchoring of the mesh is performed below the iliopubic tract! Therefore: Laterally, staples / tacks should never be placed below the level of the iliopubic Iliopectineal Arch This is a thickened, tough, fascial structure covering the iliac muscle arches from the anterior superior iliac spine inferiorly to the Iliopubic eminence. It gives origin to a portion of the internal oblique and transversus abdominis muscle as well as the inguinal ligament. It is an important structure as it is a key supporting structure of the lateral groin! Boundaries of the preperitoneal space Anteriorly Posteriorly

- Anterior layer of the transversalis fascia - The peritoneum.

Laparoscopic surgeon should work in the preperitoneal space ie. In the posterior space of Bogros to prevent unneccessory oozing. ‘Space of Bogros’

This condensation of the transversalis fascia, whose fibres are oriented in a vertical direction in comparison to the rest of the fascia forms the medial margin of the internal inguinal ring. It has no significant strength.

This ‘preperitoneal space’ is divided into two by the posterior lamina of the transversalis fascia. The posterior compartment has been now termed as the ‘Space of Bogros (proper)’, described by French anatomist Bogros in 1923. The anterior space has been termed as the ‘Vascular Space’. In some places the posterior lamina is deficient (eg. At the deep inguinal ring), there the peritoneum adheres to the anterior lamina. Medially it is continuous with the space of Retzius.

Iliopubic Tract

‘Prevesical space of Retzius’

The Iliopubic tract is a thickened lateral extension of the transversalis fascia, which runs from the superior pubic ramus to the iliopectineal arch and the anterior superior iliac spine. The iliopubic tract is distinct from the

The preperitoneal space that lies deep to the supravesical fossa and the medial umbilical fossa is the Prevesical space of Retzius (described in 1858, by Swedish anatomist Retzius). This space contains loose connective tissue and

Interfoveolar Ligament

FIAGES Book.indb 103

3/23/2007 11:07:26 AM

104

Understanding Endoscopic Anatomy of Inguinal Region

fat. Dissection of this space during a laparoscopic hernia repair is mandatory to enable proper mesh overlap of the hernial defect to aid in proper mesh placement/ fixation. Important vascular structures in this space are: Vascular i. Arteries External iliac artery with branches Deep circumflex iliac artery Inferior epigastric artery and its branches ii. Veins External iliac vein with tributaries Inferior epigastric veins Deep circumflex iliac vein Deep venous circulation 2. Nerves i. Lateral femoral cutaneous nerve ii. Genitofemoral nerve Genital branch Femoral branch iii. Femoral nerve iv. Ilioinguinal nerve v. Iliohypogastric nerve vi. Sympathetic plexus 3. Lymphatics and lymph nodes i. External iliac group of lymph nodes and associated lymphatics 1.

VESSELS IN THE INGUINAL REGION There are numerous blood vessels coursing the inguinal region and the surgeon needs to be familiar with them to avoid iatrogenic injury and potentially devastating complications. Care has to be paid also to some minor vessels whose importance should not be underestimated. The following description gives the essential details of the vessels in this area. THE EXTERNAL ILIAC VESSELS The external iliac artery and vein lie on the medial aspect of the psoas muscle and course deep to the Iliopubic tract to form the femoral vessels. External Iliac Artery This artery gives off two branches within its distal two (2) cms. 1. Laterally – It gives off the Deep Circumflex Iliac artery, which courses along the iliacus muscle, deep to the Iliopubic tract, putting it at risk for injury during suturing or stapling. It then perforates the transversus abdominis muscle and ascends between the internal oblique and transversus muscles and supplies blood to both muscles. Here they complete an anastomotic circle by joining the iliolumbar and superior gluteal vessels. 2. Medially – It gives off the Inferior Epigastric artery. Near its takeoff the Inferior Epigastric artery gives off two branches Cremasteric branch This vessel penetrates the transversalis fascia and joins the spermatic cord.

1. Normal and aberrant obturator vessels 2. Accessory pudendal vessels (10%) Contents (preperitoneal space) The preperitoneal space is filled up with a variable amount of connective tissue, fat, vessels, nerves and various viscera. The contents are listed below.

FIAGES Book.indb 104

Pubic branches The anastomotic pubic branches course in a vertical fashion inferiorly, crossing the Cooper’s ligament and anastomosing with the obturator artery at the obturator foramen. The Inferior Epigastric artery also gives rise to anterior pubic artery, which accompanied with the Iliopubic vein crosses the superior pubic ramus. In 25-30% (some studies mention as high as 70-80%) of individuals, the anterior pubic branch is large and can replace the obturator artery (Obturator artery originating from the Hypogastric artery is missing). This large arterial branch (Aberrant obturator artery) can partially encircle the neck of a hernia sac and be injured in a femoral hernia repair. It could also be injured while exposing the Cooper’s ligament by freeing it of areolar-adipose connective tissue.

3/23/2007 11:07:27 AM



Comprehensive Laparoscopic Surgery

105

its lateral border and then course along the lateral edge of the external iliac artery, cross the Iliopubic tract and join the spermatic cord at the lateral aspect of the internal ring. Anastomoses between the testicular, differential and cremasteric arteries supply the testicle with rich collateral circulation. The pampiniform plexus drains into testicular veins. The testicular veins drain into the inferior cava on the right and the renal vein on the left. Deferential vessels The deferential artery arises from the inferior vesicle artery, forming a microvascular network with the adventitia of the vas deferens. The deferential veins drain into the pampiniform plexus and vesical plexus. Deep venous circulation of the preperitoneal space (Bendavid) The venous circle/ deep venous circulation of Bendavid is located at the subinguinal space of Bogros. It is a network of deep inferior epigastric, rectusial, suprapubic and retropubic veins. A familiarity with these relatively underestimated vessels is important for surgeons working in the preperitoneal space! This is because damage to these vessels is easy and usually leads to haematoma formation. Iliopubic Vein

Because of this possibility the whole anastomotic ring has in the past been known as the – ‘Corona Mortis.” The Inferior Epigastric artery ascends to anastomose with branches of the Superior Epigastric artery.

This vein courses deeply to the Iliopubic tract and accompanies the anterior pubic branch when this is present, It either empties directly into the Inferior Epigastric vein or joins the venous anastomotic pubic branch to form a common trunk that drains into the Inferior Epigastric vein.

External Iliac Vein

Rectusial Vein (Bendavid)

The vein is medial and posterior to the artery. It receives comparable tributaries. The Inferior Epigastric vein is paired, however, and joins the external iliac vein about 1cm proximal to the takeoff of the Inferior Epigastric artery and is thus predisposed to injury. The Inferior Epigastric vessels cross over the Iliopubic tract at the medial aspect of the internal ring and ascend along the posterior surface of the rectus muscles, invested in a fold of peritoneum called the lateral umbilical ligament.

This vein runs along or is embedded within the lower lateral fibres of the rectus muscle. It forms (Bendavid) consistently a venous anastomotic ring by joining the Iliopubic vein above the pubic crest.

Testicular Vessels These vessels arise from the aorta just below the renal arteries at L2 level. These follow the ureter caudally on

FIAGES Book.indb 105

Retropubic Vein This vein , a small collateral branch of the anastomotic pubic vein is commonly observed on the lower posterior aspect of the pubic ramus, beneath the Cooper pectineal ligament. NERVES IN THE INGUINAL REGION The important nerves in the groin region are the ilioinguinal, genitofemoral, lateral femoral cutaneous nerve and the

3/23/2007 11:07:32 AM

106

Understanding Endoscopic Anatomy of Inguinal Region 3.

Intermediate Cutaneous Branch of the Anterior Branch of the Femoral Nerve

The following three (3) nerves are usually not at risk at laparoscopic hernia repair but can be injured if excessive pressure is applied during mesh fixation, compressing the muscles enough to allow the staples to reach the nerve. It is interesting to note that conversely the below three nerves are at most risk in open hernia repairs. 1. Ilioinguinal Nerve 2. Iliohypogastric Nerve 3. Genital Branch of Genito-femoral nerve

femoral nerve. These nerves arise from the lumbar plexus, innervate the abdominal musculature and provide sensation for the skin and parietal peritoneum. Entrapment causes severe pain, whereas transection results in numbness. These nerves are variably visualized during laparoscopic hernia repair. Therefore, the surgeon must rely on a knowledge of their normal anatomy and a ‘sixth sense’ to avoid injury They do exhibit significant variation in their course! The following three (3) nerves are at risk for injury at laparoscopic hernia repair1. Lateral Femoral Cutaneous Nerve 2. Femoral Branch of the Genito-Femoral Nerve

Communication between the Genito-femoral nerve and Ilioinguinal nerve is common. This results in overlap of sensory innervation, which can cause difficulties in diagnosing which nerve is involved in the complication. LATERAL FEMORAL CUTANEOUS NERVE This nerve is the most commonly injured nerve during laparoscopic hernia repair. Injury of this nerve may be common with inexperienced surgeons performing laparoscopic hernia repair. Course It arises from L2-3, emerges at the lateral edge of the

Muscles Transversus Internal oblique External oblique

FIAGES Book.indb 106

3/23/2007 11:07:33 AM



Comprehensive Laparoscopic Surgery

107

psoas muscle, courses along the iliac fossa, lateral to the iliac vessels. It passes below or through the inguinal ligament, where it lies free in a fibrous tunnel 1cm to the medial side of the anterior-superior iliac spine. Broin et al detailed its course in cadavers and found it was a mean distance of 6.6 cms from the Inferior Epigastric vessels and 5.6 cms from the Internal Inguinal ring as it passes below the Iliopubic Tract. Area of supply Sensory supply to the upper lateral thigh. Common Site of Injury To avoid nerve injury/entrapment, dissection and stapling should be above the Iliopubic Tract. Post-Injury Pain Injury results in pain and numbness in the upper lateral thigh and is called ‘Meralgia Paraesthetica’. Sensory Changes Injury results in pain and numbness in the upper lateral thigh and is called ‘Meralgia Paraesthetica’. GENITOFEMORAL NERVE The femoral branch of the genito-femoral nerve is at risk

FIAGES Book.indb 107

of damage during laparoscopic hernia repair. Injury to the genital branch of the genito-femoral nerve occurs only if excessive pressure is applied during mesh fixation, compressing the muscles enough to allow the staples to

3/23/2007 11:07:34 AM

108

Understanding Endoscopic Anatomy of Inguinal Region

reach the nerve. Injury could also occur to the genital branch of the genitor-femoral nerve by manouvres to reduce the sac of an indirect hernia. Course Arises from L1 and L2, courses through the psoas major muscle to emerge on its ventral surface opposite the third and fourth lumbar vertebrae. It then runs along the anterior aspect of the psoas muscle and divides into the genital and femoral branches, before reaching the internal inguinal ring. The genital branch pierces the Iliopubic tract lateral to the internal inguinal ring and then enters the ring and courses through the inguinal canal. The femoral branch courses beneath the inguinal ligament to the thigh. Area of supply Genital branch supplies the 1. Cremaster, 2. Spermatic fascia and tunica vaginalis of the testis. 3. In the female, this branch should be preserved because it is sensory to the labium majora. 4. It is the efferent branch for the cremasteric reflex. Femoral branch is the cutaneous branch to 1. The skin over the femoral triangle (Anteromedial thigh). 2. It is the afferent branch for the cremasteric reflex. Common site of entrapment Posterior abdominal wall, femoral or inguinal region. Post-injury pain 1.

Groin, scrotum and upper thigh.

FIAGES Book.indb 108

3/23/2007 11:07:36 AM



Comprehensive Laparoscopic Surgery

Sensory changes Hyperalgesia. Point tenderness 1. 2.

Internal inguinal ring. Along Inguinal canal.

Hip joint movement Hyperextension or external rotation of hip increases pain. 2. Walking exacerbates the pain. 1.

Motor signs 1. 2.

Loss of cremasteric reflex. Ejaculatory dysfunction.

FEMORAL NERVE The intermediate cutaneous branch of the anterior branch of the femoral nerve is at risk during laparoscopic

109

hernia repair. Injury to the femoral nerve has also been described in literature. Course The femoral nerve arises from L2-4, emerges from the lateral aspect of the psoas muscle and travels below the inguinal ligament, lateral to the femoral artery (outside the femoral sheath), to divide into sensory and motor branches. Area of supply Supplies the area (sensory) around the medial and intermediate aspects of the upper thigh. Motor supply is to the quadriceps. Common site of injury Posterior abdominal wall posterior to the inguinal ligament. Post-injury pain Over the groin, anterior and medial thigh. Sensory changes Hyperalgesia or dysthesia. Point tenderness None. Hip joint movement Minimal hip extension increases pain. Motor signs Quadriceps muscle weakness and atrophy and loss of patellar reflex. ILIOINGUINAL NERVE Entrapment of the Ilioinguinal nerve is unusual during Laparoscopic hernia repair and only is entrapped / injured if excessive pressure is applied during mesh fixation, compressing the muscles enough to allow the staples to reach the nerve. Course This nerve is smaller than the Iliohypogastric nerve. It arises from L1. It courses retroperitoneally across the quadratus lumborum behind the kidney and then passes anterior to the upper part of the iliacus muscle. It then pierces the transverses abdominis near the anterior end of the iliac crest. Then it pierces the internal oblique, travels

FIAGES Book.indb 109

3/23/2007 11:07:37 AM

110

Understanding Endoscopic Anatomy of Inguinal Region

through the inguinal canal in front of the spermatic cord and exits through the superficial inguinal ring or the adjacent external oblique aponeuorosis. Area of supply Supplies the 1. Skin at the root of the penis. 2. Anterior third of the scrotum (males). 3. A small area of thigh below the medial end of the inguinal ligament. 4. Labia majora (females). 5. Motor supply to the abdominal musculature. Common site of entrapment Common site of entrapment/ injury is medial to the anterior superior iliac spine. [Is only entrapped/ injured if excessive pressure is applied during mesh fixation, compressing the muscles enough to allow the staples to reach the nerve.] Post-injury pain Injury causes pain and burning (paraesthesia) in the lower abdomen (area mentioned in ‘Area of supply’.) Sensory changes Hypoalgesia or hyperalgesia. Point tenderness Medial to anterior iliac spine. 2. Anterior abdomen. 1.

Hip joint movement 1. 2.

Limitation of internal rotation. Extension of hip increases pain.

Motor Signs Abdominal muscle weakness. ILIOIGHYPOGASTRIC NERVE

lumborum behind the lower pole of the kidney. It perforates the transverses abdominis above the iliac crest and gives off a lateral cutaneous branch. The main nerve then pierces the internal oblique immediately above and in front of the anterior superior iliac spine. It then runs deep to the external oblique, just superior to the inguinal canal. It then penetrates the external oblique muscle within 1-2 cms of the superomedial aspect of the external ring. Area of supply It supplies the skin in the suprapubic region with sensory fibres. 2. The lateral cutaneous branch supplies the skin over the posterolateral gluteal region. 3. It also provides the afferent and efferent path- ways for the abdominal reflex whereby stroking the skin in the suprapubic area produces contraction of the rectus abdominis musculature. 1.

Common site of entrapment Common site of entrapment/ injury is medial to the anterior superior iliac spine. [Is only entrapped/ injured if excessive pressure is applied during mesh fixation, compressing the muscles enough to allow the staples to reach the nerve.]

Entrapment of the Ilioihypogastric nerve is unusual during Laparoscopic hernia repair and only is entrapped/ injured if excessive pressure is applied during mesh fixation, compressing the muscles enough to allow the staples to reach the nerve.

Post-injury pain

Course

Hypoalgesia or hyperalgesia.

Injury causes pain and burning (paraesthesia) in the same area. Sensory changes

It arises from T12 and L1. It emerges from the lateral edge of the psoas muscle and crosses in front of quadratus

FIAGES Book.indb 110

3/23/2007 11:07:37 AM



FIAGES Book.indb 111

Comprehensive Laparoscopic Surgery

111

3/23/2007 11:07:42 AM

112

Understanding Endoscopic Anatomy of Inguinal Region

Endoscopic Anatomy of Defects (Trans-abdominal View)

FIAGES Book.indb 112

3/23/2007 11:07:49 AM



Comprehensive Laparoscopic Surgery

Point tenderness 1. 2.

Medial to anterior iliac spine. Suprapubic area.

Motor signs Weakness of the lower abdominal wall APPLIED ANATOMY ANATOMICAL LANDMARKS Anatomical landmarks are a surgeon’s guideposts. A procedure, wherein the surgeon cannot locate the relevant anatomical landmarks, renders the procedure unsafe and condemned to a poor outcome. In the following description, the surgical anatomy is described from the viewpoint of a surgeon performing a TAPP (TransAbdominal Pre-Peritoneal) groin hernia repair. However, all the structures and entities described below are also visualized in a TEP procedure. Thus, the incumbent surgeon is mandated by need, to know and understand the below described structures! The reader is reminded that in the performance of a TEP (Total Extra Peritoneal)

113

LANDMARKS FOR TRANSABDOMINAL PREPERITONEAL HERNIA REPAIR (TAPP) PHASE - I Inguinal Anatomy with the peritoneum intact With the introduction of the laparoscope into the abdomen, 5 (five) important landmarks will need to be identified in the infra-umbilical region! Inferior Epigastric vessels Medial Umbilical Ligament Spermatic vessels Vas Deferens Trapezoid of Disaster 1. Inferior Epigastric vessels The Inferior Epigastric artery is prominently visualized during laparoscopic preperitoneal dissection of groin hernia. Implication It forms the lateral border of the Hasselbach’s triangle. Identifying these vessels differentiates between direct and indirect inguinal hernia. Bleeding from an ‘injured’ Inferior Epigastric artery can be quite brisk. Identification A small calibre vessel, it arises proximal to the inguinal ligament from the external iliac artery, ascends in a medial direction on the anterior abdominal wall toward the lateral border of the ipsilateral rectus muscle, running between the two lamellae of the transversalis fascia.

groin hernia repair,the initial balloon dissection occurs in the space of Bogros medially and finally medio-inferiorly in the vicinity of the pubic symphisis. Thus all the below described structures (Phase I) will appear without the ‘initial’ benefit of the peritoneum covering them. Blunt dissection in the space of Bogros initially reveals areaolar / fattyareolar tissue with relatively minimal vascularity. The pubic symphisis is visualized as a white bony structure.

FIAGES Book.indb 113

Visualisation The artery is most prominent close to its origin from the external iliac artery at the medial margin of the internal ring. Fat may obscure these vessels in obese patients. 2. Medial umbilical ligament (Obliterated Umbilical Artery) Implication Can be confused with the inferior epigastric artery! DO NOT dissect medial to it during a TAPP procedure! Medial dissection to the medial umbilical

3/23/2007 11:07:50 AM

114

Understanding Endoscopic Anatomy of Inguinal Region

whereas the inferior epigastric vessels are directed toward the lateral border of the rectus. 3. Spermatic vessels Implication Forms the lateral border of the ‘triangle of doom’ and the medial border of the ‘triangle of pain’. Identification The testicular artery and vein descend caudally in the retroperitoneum and enter the internal ring on its posterior aspect from a craniad direction. They travel directly over or slightly lateral to the external iliac artery and vein and are joined by the vas deferens before entering the ring. Visualisation Easily visualized as they are covered only by peritoneum. 4. Vas deferens Implication Forms the medial border of the ‘triangle of doom’ and ‘quadrangle of disaster’. Identification From the internal ring, it can be traced medially as it curves over the pelvic brim to disappear behind the bladder. It joins the testicular vessels before entering the internal ring from an inferior and medial direction.

ligament would put the urinary bladder at risk to injury. Identification It courses from the Internal iliac artery as its last branch towards the umbilicus. It becomes apparent midway between the internal ring and Cooper’s ligament. Visualisation It is made apparent by its mesentery. It can be differentiated from the inferior epigastric artery by its course toward the umbilical trocar,

FIAGES Book.indb 114

Visualisation Easily visualized as it is covered only by peritoneum. 5. ‘Trapezoid of Disaster’ (Labeled by Seid) Implication Lying beneath the peritoneum and transversalis fascia (within this triangle) are the external iliac artery and vein and may be damaged with serious consequences! No dissection should take place in this area! No staples should be placed in this area! Identification It is formed by the meeting of the vas deferens and the testicular vessels at the internal ring, which forms the

3/23/2007 11:07:50 AM

Comprehensive Laparoscopic Surgery

115

apex of the triangle. Visualisation Easily identifi ed and visualized as the vas deferens and the testicular vessels are covered only by peritoneum. 6. ‘Triangle of pain’ Implication It describes the area in which the femoral branch of the genitofemoral nerve, the lateral femoral cutaneous nerve and femoral nerve lie. If a surgeon uses staples, he must avoid using it in this area!

FIAGES Book.indb 115

3/23/2007 11:07:52 AM

116

Understanding Endoscopic Anatomy of Inguinal Region

Identification It is bound inferomedially by the gonadal vessels and superolaterally by the iliopubic tract. Visualisation The ‘triangle’ is easily distinguished as it’s borders are recognized easily. (The iliopubic tract is more readily recognized after the peritoneal flaps are raised.) PHASE - II Inguinal anatomy with the peritoneum incised After the peritoneum is dissected away, 4 (four) additional structures need to be identified. They are: Internal Inguinal/ Spermatic ring Iliopubic tract Cooper’s ligament Femoral Canal 1. Internal Inguinal / Spermatic ring Implication Denotes the site of origin of an indirect inguinal hernia. Identification The most reliable indicator of the internal ring is the junction of the testicular vessels and the spermatic cord. The inferior border is bound by the iliopubic tract. Visualisation The appearance of the ring varies depending on the hernia defect. Sometimes the ring is made prominent by the pneumoperitoneum. 2. Iliopubic tract The Iliopubic tract is thickened lateral extension of the transversalis fascia, which runs from the superior pubic ramus to the iliopectineal arch and the anterior superior iliac spine. Implication The iliopubic tract separates the internal ring from the femoral canal. The iliopubic tract is distinct from the inguinal ligament, although intimately associated with the inguinal ligament with which it is often confused! Laterally, staples/ tacks should never be placed below the level of the iliopubic tract!

FIAGES Book.indb 116

Identification It originates laterally from the iliopectineal fascia and the anterosuperior iliac spine and inserts into the superior pubic ramus lateral and superior to the Cooper’s ligament. It is anterior to the Cooper’s ligament and posterior to the inguinal ligament. Visualisation It is visualized as a fibrous (white) tract. 3. Cooper’s ligament This ligament is a condensation of the transversalis fascia and periosteum located lateral to the pubic symphisis. It is several millimeters thick, densely adherent to the pubic ramus and joins the Iliopubic tract and lacunar ligaments at their medial insertions.

3/23/2007 11:07:53 AM



Comprehensive Laparoscopic Surgery

117

Implication This ligament is used to anchor the mesh initially. Identification It takes a curvilinear course medial and inferior to the insertion of the iliopubic tract to form the prominence of the pelvic brim anteriorly. The Cooper’s ligament can readily be palpated as a thick, strong fibrous band and is shiny when freed from surrounding fat and soft tissue. It is visualized as a fibrous (white) curvilinear structure. Visualisation The Cooper’s ligament is readily visible when adipose tissue does not cover it. Otherwise, visualisation needs it to be freed of surrounding adipose tissue. CAUTION Mobilising adipose tissue around the Cooper’s ligament can injure an aberrant obturator artery, which might course over it. Injury to this vessel results in distressing bleeding. This unfortunate morbidity has resulted in the naming of this vessel as - ‘Crown of Death’ / ‘ Corona Mortis’. ‘CORONA MORTIS’ / CROWN OF DEATH / CIRCLE OF DEATH The pubic branch of the Inferior Epigastric artery courses in a vertical fashion inferiorly, crossing the Cooper’s ligament and anastomosing with the obturator artery. In 25-30% of individuals (can be as high as 70-80%), the pubic branch is large and can replace the obturator artery. This large arterial branch (Aberrant obturator artery) can partially encircle the neck of a hernia sac and be injured in a femoral hernia repair. It could also be injured while exposing the Cooper’s ligament by freeing it of areolar-adipose connective tissue. Because of this possibility an enlarged pubic branch of the Inferior Epigastric artery has in the past been known as the – ‘Corona Mortis’. The danger of injury in this area is more significant for obturator veins. 6. Femoral canal Implication It denotes the potential site of origin of a femoral hernia. Identification The canal lies posterior to the iliopubic tract. The

FIAGES Book.indb 117

anterior border is formed by the inguinal ligament, the medial border by the lacunar ligament, the posterior border by the pectineal ligament and the lateral border by the femoral vein. Visualisation It is a potential space (in the absence of a femoral hernia). TECHNICAL ISSUES RELATING TO LAPAROSCOPIC SURGICAL ANATOMY ISSUES RELATING TO EXPOSURE / VISUALISATION Any hernia above the iliopubic tract is an inguinal hernia and one below is a femoral hernia. The inferior epigastric artery should be accurately differentiated from the obliterated umbilical artery to help differentiate direct from indirect inguinal hernia. The dissection should expose the following structures- Cooper’s ligament - Iliopubic tract - Testicular vessels - Internal ring - Spermatic cord - Musculo-aponeurotic transverses abdominis arch. - The preperitoneal tissue should be completely elevated along the peritoneum to reach the correct plane (Space of Bogros). Dissection outside this space leads to bleeding ISSUES RELATED TO DISSECTION Dissection in the ‘Trapezoid of Disaster’ must be avoided!!!

3/23/2007 11:07:53 AM

118

Understanding Endoscopic Anatomy of Inguinal Region

While dissecting around Cooper’s ligament, take care to avoid injury to the branches of the obtu- rator vein.

10. Michael S. Kavic ;Rationale for Laparoscopic Hernioplasty; Chapter 3, pp 33–40; Laparoscopic Hernia repair (Text Book); Harwood Academic Publishers, 199.

ISSUES RELATED TO FIXATION OF MESH

acknowledgements

Staples or sutures should not be placed lateral to the cord or below the iliopubic tract (Trapezoid of Disaster) to avoid injury to the branches of the genitofemoral nerve and the lateral femoral cutaneous nerve. Staples should not be placed lateral to the inter- nal ring in the endopelvic fascia to avoid injury to the ilioinguinal nerve. Cooper’s ligament should be properly exposed as the initial fixation is performed to this structure.

I thank Dr. Suviraj John, Consultant Laparoscopic Surgeon who spent a lot of effort and time in drawing the illustrations for Laparoscopic Hernia Repair: Step by Step approach. I also thank Dr. Tarun Jain, Consultant Surgeon, who has given an indefatigable effort in editing this chapter.

REFERENCES 1. Embryology, anatomy and surgical applications of the preperitoneal space; Kingsnorth et al; Surgical Clinics of North America; Vol. 80, No. 1, February 2000; pp 1–24. 2. The inguinofemoral area from a laparoscopic stand- point: History, Anatomy and Surgical Application; Avisse et al; Surgical Clinics of North America; Vol. 80, No. 1, February 2000; pp 35–48. 3. A selective history of Groin Hernia Surgery in the Early 19th century: The anatomic atlases of Astley Cooper, Franz Hesselbach, Antonio Scarpa and Jules-Germain Cloquet; Ira M. Rutkow; Surgical Clinics of North America, Vol. 78, No. 6, December 1998; pp 921–940. 4. Abdominal wall and hernias; Surgical Anatomy and Technique: A Pocket Manual; J.E. Skandalakis, P.N. Skandalakis, LJ Skandalakis; 2nd edition, Springer 2000; Chapter 4, pp 123–155. 5. Surgical Anatomy of the Inguinal Region and lower Abdominal Wall from the Laparoscopic Perspective: Special Comment; Ricardo G. Annibali; Hernia (Textbook); Nyhus, Condon; 4th edition; pp 64–72. 6. Laparoscopic Hernia Repair; Mark A. Talamani and Chandrakanth Are; Shackleford’s Surgery of the Alimentary Tract; George D. Zudeima and Charles J. Yeo (Ed); W.B. Saunders Company 2002; 5th Edition, Vol. 5, Chapter 12, pp 137–149. 7. Hernias and Abdominal Wall defects; Daniel J. Scott and Daniel B. Jones; Surgery: Basic Science and Clinical Excellence; Norton, Bollinger, Chang, Lowry, Mulvihill, Pass, Thompson (Ed); Springer 2000; pp 137–149. 8. Classification systems and groin hernia; Rutkow and Robbins; Surgical Clinics of North America, Vol. 78, No. 6, December 1998; pp 1117–1127. 9. Surgical anatomy of the inguinal region; Irving Lichtenstein; Hernia Repair without Disability; Irving Lichtenstein, 2nd edition, Ishiyaku Euroamerica Inc. 1986; pp 18–40.

FIAGES Book.indb 118

3/23/2007 11:07:53 AM

Laparoscopic Trans Abdominal Pre-Peritoneal (TAPP) Repair of Inguinal Hernia

14

A.K. Kriplani, Shyam S. Pachisia, Daipayan Ghosh Repair of inguinal hernia is one of the commonest surgical procedures performed worldwide. The lifetime risk for men is 27% and for women is 3%1. Since Bassini published his landmark paper on the technique of tissue repair2 in 1887, numerous modifications have been proposed. Shouldice four layers repair3 enjoyed wide popularity before the concept of prosthetic material was introduced. Even today in Canada, about 25% of inguinal hernia repairs are done by the Shouldice technique as it is cost effective4. Tissue repair is the commonest type of hernia repair in the developing world for the same reason. There has been a revolution in surgical procedures for groin hernia repairs after the introduction of prosthetic material by Usher5 in 1958. Open Pre-peritoneal mesh repair by Stoppa6 was found to significantly reduce recurrence rate for multi-recurrent groin hernias. However, it was associated with significant postoperative pain and morbidity. The concept of Tension Free Open Mesh Repair was first described by Lichtenstein in 19897. Ger reported the first laparoscopic hernia repair in 1982 by approximating the internal ring with stainless steel clips8. The laparoscopic trans-abdominal preperitoneal (TAPP) repair was a revolutionary concept in the hernia surgery and was introduced by Arregui9 and Dion10 in the early 1990s. Laparoscopic groin hernia repair can be done by TAPP approach and also Total Extra Peritoneal (TEP) approach11. Both the techniques of laparoscopic hernia repair reproduce the concept of Stoppa by placing a large mesh in the pre-peritoneal space to cover half of the abdominal wall and all the weak areas

FIAGES Book.indb 119

(myopectineal orifice of Fruchad12 Fig. 1a and 1b) including area of internal ring, Hasselbach’s triangle and the femoral ring. The advantages of laparoscopic repair include the same decreased incidence of recurrence observed with the Stoppa technique with the added benefits of lesser pain, reduced discomfort, short hospital stay and early resumption of normal daily activities. Both the techniques (TAPP and TEP) are safe, effective and have the same advantages. However with TAPP a better view of the inguinal anatomy is achieved and the procedure also has a short learning curve13. TAPP allows evaluation of opposite side as well. In patients with irreducible hernial contents, it is possible to reduce the contents under vision making the procedure simpler and easier14. Patient Selection In the initial part of the learning curve, patient selection is important. Indirect hernial sacs are closely applied to the cord structures and are more often complete, making dissection difficult. Left sided hernias are more difficult to dissect than the right sided ones. Bilateral hernia repair during the learning curve may significantly increase the operating time. Recurrent hernias and irreducible hernias should be repaired only after expertise is gained in repair of simple hernias. Direct or small indirect primary hernias in lean and thin subjects are the best. Indirect, left sided hernias, large, irreducible or complicated hernias in obese patients are best avoided during the learning curve15. Laparoscopic inguinal hernia repair is an advanced laparoscopic procedure. The dissection is performed in the vicinity of major vessels (iliac vein and artery) and

3/23/2007 11:07:54 AM

120

Laparoscopic Trans Abdominal Pre-Peritoneal (TAPP) Repair of Inguinal Hernia

Fig. 1a: External view of Myopectineal orifice of fruchaud.

the potential for injury to adjoining viscera (urinary bladder) is high. It is therefore required that the surgeon planning to undertake the repair should have experience in laparoscopic surgery. Laparoscopic anatomy of the inguinal area is totally different from what is seen during the anterior approach. The surgeon has to learn this anatomy. Familiarisation with this anatomy by working in a unit performing laparoscopic hernia repair regularly is very helpful for proper orientation. Anaesthesia and Position of the Patient

Fig. 1b: Laparoscopically placed mesh covering myopectineal orifice and going onto posterior abdominal wall

FIAGES Book.indb 120

Laparoscopic TAPP hernia repair is performed under general anesthesia. In elderly subjects, a detailed cardiorespiratory work up should be done prior to surgery for safe general anesthesia and pneumoperitoneum. The patient is asked to pass urine just before shifting to the operation theatre. If the patient is more than sixty years of age, has symptoms of prostatic enlargement or post void residual volume is more than 50 ml, it is advisable to place a Foley’s indwelling catheter prior to surgery. This may be removed 24 hours after the surgery. Perioperative prophylactic antibiotics are administered. After induction of anesthesia, irreducible hernial contents, if any, are reduced before painting & draping is commenced.

3/23/2007 11:07:56 AM



The patient lies supine with both arms tucked by the side, to make room for the surgeon and his assistant to stand at shoulder level. The head end of the table is kept 150 low to facilitate creation of pneumo-peritoneum and move the bowel away from the operative field. The monitor is positioned at the foot end of the patient. The operating surgeon stands on the side opposite to hernia. The assistant, who holds the camera, stands on the side of hernia. The scrub nurse positions herself to the left of the patient, standing to the left of the surgeon (Figure 2).

Comprehensive Laparoscopic Surgery

121

peritoneal or obstruction to the flow by the omentum. All quadrants of the abdomen are inspected and percussed to check for uniform pneumo-peritoneum. Insufflation is continued until a pressure of 12 mm Hg is reached, which requires about 2.5 to 3 liters of gas. After satisfactory pneumoperitoneum, the Veress needle is removed and a 10mm port is placed through the supra umbilical incision. During insertion, the abdominal wall is lifted up and stabilized with the left hand and the trocar is directed towards the hollow of the pelvis. A 300 telescope attached to the camera, is introduced and the groin area is visualized. Two 5 mm ports are placed as working ports for the right and left hand of the surgeon, one on each side, at the level of umbilicus in the midclavicular line (Figure 3). These ports should be placed under vision to prevent injury to the inferior epigastric vessels and underlying bowel.

Fig. 2: Operation Theater Layout

It is essential to maintain complete asepsis. All instruments should be properly sterilized by gas sterilisation or disinfected by soaking in activated gluteraldehide (Cidex) for a minimum period of 40 minutes prior to surgery. A 300 telescope provides better exposure of the operative field and one can change perspectives by rotating the telescope, thus further improve exposure, particularly in the area of the symphysis pubis and laterally for the posterior abdominal wall. Pneumoperitoneum and Placements of Ports The Veress needle is used to create pneumo-peritoneum. Patency of the needle and spring function must be checked before insertion. The preferred site of needle insertion is the supra umbilical fold. The spring mechanism gives a click sound immediately on penetrating the parietal peritoneum. Insuffulation is commenced with a set pressure of 12 mm of Hg. A pressure reading of less than 7 mm of Hg suggests that tip position in the cavity. A Higher pressure indicates the tip position to be extra-

FIAGES Book.indb 121

Fig. 3: Port Placement

The hernia defect is inspected and the type of hernia (direct or indirect) is confirmed by the position of defect in relation to the inferior epigastric vessels and cord structures. The spermatic vessels rise from laterally and the vas deferens comes from medially to meet at the internal ring. This forms an inverted V. The inferior epigastric vessels (IEV) can be seen coursing upwards from this point (Figure 4) A direct hernia is medial to the IEV (Figure 5) and therefore medial to the point where the vas deferens and spermatic vessels join to form an inverted V. An indirect hernia is lateral to the IEV and is at the tip of the inverted V formed by the vas deferens and spermatic vessels (Figure 6). The cord structures are seen to enter the inguinal canal through the

3/23/2007 11:07:56 AM

122

Laparoscopic Trans Abdominal Pre-Peritoneal (TAPP) Repair of Inguinal Hernia

Fig. 4: Laparoscopic anatomy of the left groin area. The testicular vessels

Fig. 6: Right indirect inguinal defect lateral to the inferior epigastric vessels. The

(2 ) are rising from the lateral side and vas deferens (3) ascending from the

medial umbilical ligament (1) is seen coursing posteriorly to the internal iliac artery.

medial side to form an inverted V at the internal ring just lateral to the IEV (1).

The vas deferens (2) comes from the medial side and crosses over the medial um-

External iliac artery (4) and vein (5) are seen within the triangle

bilical ligament to join the spermatic vessels (3) at the internal ring (indirect defect).

a clinically occult contra-lateral hernia and its simultaneous repair without any extra cut is an advantage of the TAPP repair and will help in decrease the incidence of subsequent contralateral hernia. This possibility of sub-clinical contra-lateral hernia should be discussed with the patient before surgery and consent for repair, if required, should be obtained. OPERATIVE STEPS Step 1– Incising the Peritoneum

Fig. 5: Laparoscopic anatomy of the left inguinal area before peritoneal reflection and the peritoneal incision

defect in an indirect hernia. The lower and medial margins of an indirect defect are always sharp while the upper and medial margins are indistinct. The type of hernia found during surgery does not change the steps of the procedure but guides the extent of medial or lateral dissection for a minimum overlap of 5 cms. Contra-lateral, clinically occult hernia may be present and can be clearly seen on trans-peritoneal inspection during TAPP repair, while the opposite side can not be examined without dissection during a TEP repair. Thirty percent of patients with a primary unilateral hernia may subsequently develop a hernia of the opposite side as well16. Detection of

FIAGES Book.indb 122

After inserting the telescope, all the anatomical landmarks normally seen before peritoneal reflection are identified as described in the previous chapter. These include the median umbilical ligament in the midline (fold raised by obliterated urachus) and the medial umbilical ligaments on each side (obliterated umbilical arteries ending in the hypogastric artery on each side (Fig 5 & 7). Contents of the hernial sac, if any, are reduced with the help of atraumatic bowel forceps. In case of irreducible hernias, the bowel contents need to be handled with care. In case of omentum, a tear should be avoided as it may cause bleeding. The structures in the posterior abdominal wall are identified after reduction of the contents, namely the external iliac artery and vein in the triangle of doom (Fig 5 & 8). The external iliac artery is mostly identified by its pulsations while the vein is generally seen more clearly with its bluish hue medial to the pulsations.

3/23/2007 11:07:56 AM



Comprehensive Laparoscopic Surgery

123

Fig. 7: The peritoneal folds on the anterior abdominal wall seen during

Fig. 9: Starting peritoneal incision for the right TAPP repair. The direct defect

laparoscopic TAPP repair. Median umbilical ligament (1) raised by obliterated

and triangle of Doom with vas deferens (1), spermatic vessels (3) and external

urachus is in the midline. Medial umbilical Ligament raised by obliterated

iliac artery (2) are also seen.

umbilical artery is seen on each side (2 & 3). A large direct defect is seen just lateral to the left medial umbilical ligament (2).

up with a Maryland dissector in the left hand at the site of intended incision and pulled strongly inwards to lift it from the underlying transversus muscle. With scissors in the right hand, the peritoneum is incised. Carbon dioxide gushes into the space and makes further dissection easier. The incision should be generous to provide good view of structures behind the peritoneal flap and for placing a 15 cms mesh without folds. It extends from above the anterior superior iliac spine to the medial umbilical ligament (Fig 5 & 10). Extending it medially beyond the medial umbilical ligament will increase the chances of injury to the urinary bladder, particularly if the urinary bladder is not empty.

Fig. 8: Left triangle of doom bound laterally by the spermatic vessels (1) and medially by the vas deferens (4). It contains External iliac Artery (2) and Vein (3). The left medial umbilical ligament (5) with the urinary bladder medial to it is also in the view.

The peritoneal incision is begun at a point that is midway between the groin crease and the umbilicus (Fig 5 & 9). An external landmark is used to locate the point of commencement of peritoneal incision which is midway between the inguinal ligament and the umbilicus, generally about 8 cms above the internal ring. Incision on the peritoneum is always made from the right to the left, i.e. from lateral to medial on the right side and medial to lateral on the left side. The peritoneum is picked

FIAGES Book.indb 123

Fig. 10.: Right TAPP repair. The center of the incision is above the indirect defect.

3/23/2007 11:07:58 AM

124

Laparoscopic Trans Abdominal Pre-Peritoneal (TAPP) Repair of Inguinal Hernia

Step 2 – Raising the Peritoneal Flap The correct plane of dissection of the peritoneal flap from the transversus muscle is anterior to the pre-peritoneal fascia through the loose areolar tissue, stripping all the fascia and fat with the peritoneum so that the fibers of the tranversus muscle are bare (Fig 11). The flap is raised by both blunt and sharp dissection. Generally the plane is avascular but any small vessel is carefully cauterized before division. Care should be taken to avoid injury to the IEVs while raising the peritoneum medial to the internal ring. The IEVs are a very important landmark in laparoscopic inguinal hernia surgery. These vessels should always be left attached to the muscle and should never be included in the flap otherwise they may come in the way of dissection and may get injured.

Fig. 12: Right inguinal area after raising the peritoneal flap. The direct defect (1) is seen just lateral to the lateral border of the rectus muscle. The left pubic arch (2), the symphysis pubis (3) and the right pubic arch with the Cooper’s ligament are seen. Laterally, the external iliac artery (4), the cord structures (5) and the arching fibers of the transverses muscles (6) are exposed.

Step 3 – Dissection of Medial peritoneum and Direct Sac Dissection is continued medially to the pubic symphysis to visualize the Cave of Retzius (Fig 12). The medial dissection should go across the midline to the opposite side for a few centimeters, particularly for a direct hernia so that the mesh can be placed with a good overlap over the defect. A direct defect is encountered medially above the cooper’s ligament (Fig 13). In a direct hernia,

Fig. 11: Right TAPP repair. The fat (yellow) is raised with the flap to expose the brown fibers of the underlying muscle. The defect is seen on the lower medial part.

The plane of dissection is easier on the medial side and blunt dissection is sufficient since the areolar tissue is loose and the peritoneum is not adherent to the rectus muscle. This part of the dissection may be done first. On the medial side, continued caudal dissection will identify the shiny Cooper’s Ligament and the pubic bone (Fig 12). Laterally, the peritoneum is slightly adherent to the transversus muscle and sharp dissection may be required, particularly on the left side. Care should be taken not to enter into the transversus muscle, which may bleed if injured. The flap is raised from cephalic to caudal direction. It is easier to raise only the lower flap than to raise a lower and an upper flap.

FIAGES Book.indb 124

Fig. 13: Anatomy of the left inguinal area after removal of the peritoneum.

the hernial sac consists of peritoneal out pouching with a variable amount of extra-peritoneal fat which may sometimes be very large. The direct sac can be easily separated from pseudosac (Fig 14). The pseudosac is

3/23/2007 11:07:59 AM



Comprehensive Laparoscopic Surgery

125

cutaneous nerve of the thigh laterally and the femoral branch of the genito-femoral nerve medially. Step 5 - Dissection of Indirect Hernial Sac and peritoneum over the cord structures

After the medial dissection, the flap is raised Lateral to the internal ring till the anterior superior iliac spine and carried posteriorly over the psoas muscle. Care is taken during this dissection to avoid injury to the nerves overlying the psoas muscle (Fig 15) namely lateral

Dissection of indirect hernial sac is the most demanding step in laparoscopic inguinal hernia repair and is best done after the medial and lateral dissection has been completed. In long standing hernias, the sac becomes densely adherent to the cord structures. The hernial sac is anterior and lateral to the cord structures. Dissection of the sac is performed close to the peritoneum. With a grasper in the left hand, the sac is pulled to the left and the cord structures are dissected away from the sac with the right-handed instrument. A small indirect hernial sac can be easily dissected out into the peritoneal cavity. In case of large/ scrotal indirect hernias, complete dissection of the sac may not be advisable as chances of injury to the cord structures are increased. In such a situation the sac is circumferentially dissected so that a window is created between the sac and the cord structures and then sac may be divided after traction beyond the external ring. The distal part is left in situ but one should ensure that there is no bleeding from the cut end of the distal sac. After reducing the sac, the dissection is continued proximally by stripping the peritoneum with both blunt and sharp dissection over the cord structures to expose and skeletonise the vas and gonadal vessels (Fig 16). Any lipoma associated with the gonadal vessels is also dissected and drawn inwards. No dissection should be done deep

Fig. 15: Retroperitoneal area lateral to the cord structures on the left side.

Fig. 16: Left sided dissection completed. The cord structures (1) can be seen

The lateral cutaneous nerve of the thigh (1) and the femoral branch of the

with wide base proximally and tapering distally, coursing lateral to the epigas-

genito-femoral nerve (2) can be seen coursing on the psoas muscle (3). Both

tric vessels(2) to enter the indirect defect (3). Laterally the femoral branch of the

the nerves enter the thigh below the ileo-pubic tract (4).

genito-femoral nerve (4) can be seen on the psoas muscle.

Fig. 14: The fat contents of the direct hernia being dissected from the pseudosac (arrow)

essentially thinned out fascia transversalis, identified by its glistening appearance and belongs to the parietal wall. One must stay posterior to the pseudosac or else, troublesome bleeding may be encountered. In case of large direct hernias, after reducing the sac, the dome of the pseudosac can be fixed to the pubic bone by stapler to prevent postoperative hematoma or seroma formation. Step 4 – Lateral Dissection

FIAGES Book.indb 125

3/23/2007 11:08:00 AM

126

Laparoscopic Trans Abdominal Pre-Peritoneal (TAPP) Repair of Inguinal Hernia

to the cord structures in the triangle of doom to avoid injury to the great vessels. Step 6 – Preparation and placement of the Mesh Haemostasis should be secured before the mesh is placed and any blood/serum sucked out. If a prominent vein is seen coursing horizontally over the Cooper’s ligament, it should be cauterized, else it may be a source of troublesome bleeding when the mesh is being fixed to the Cooper’s ligament with stapler. A polypropylene mesh of 15cm (transverse) X 12 cm (vertical) is used for repair on each side. Three corners of the mesh are rounded off except the lower lateral corner for orientation (Fig 17). Upper half of the mesh is rolled and secured in that position with 2-0 vicryl suture in the center (Fig 18). The mesh is

now rolled completely and introduced into the operating field through the 10 mm umbilical port by removing the telescope. The telescope is then reinserted. The mesh is taken to the area of dissection and the lower part of the mesh is unrolled. The lower medial part of the mesh is positioned against the Cooper’s ligament (Fig 19). The medial border of the mesh should reach the midline and in direct hernia must cross over to the opposite side

Fig. 19: Right direct hernia defect. The medial end of the half rolled mesh placed over the Cooper’s ligament (1) going beyond the midline for a wide overlap.

for a wide overlap. See through property of the prolene mesh, by virtue of its large pore size, is very helpful in proper positioning of the mesh. The mesh is fixed to the Cooper’s ligament at two points with stapler (Fig 20). The anchoring suture is now cut away and the remaining half of the mesh is unrolled. It is spread over the anterior Fig. 17: Polypropylene mesh for right TAPP repair.

Fig. 20: Close up of the medial end of the right mesh. The mesh is crossing the Fig. 18: The upper half of the mesh is rolled and a central suture applied for easier handling.

FIAGES Book.indb 126

midline and is fixed to Cooper’s ligament with staples. The arrow points to the bulge of the cord structures.

3/23/2007 11:08:02 AM



abdominal wall, to cover the defect widely. Staples are applied over the medial and upper border of the mesh to anchor it to the underlying muscles (Fig 21). Generally 3 to 4 staples are sufficient; one on the medial border and two on the upper border (one on each side of the IEV). No staple should be applied on the lower and lateral parts of the mesh below the ileo-pubic tract to avoid injury to the nerves (triangle of pain). In case of bilateral hernia repair, the meshes should overlap each other in the midline and are fixed to each other with stapler so that they function as one mesh (Fig 22).

Comprehensive Laparoscopic Surgery

127

This can be done either with staplers or with sutures. It may be helpful to decrease the intra-peritoneal pressure to less than 8 mm of Hg for better approximation of the peritoneum. The approximation is started laterally and continued medially. The lower cut edge of the peritoneum is lifted and stapled to the upper peritoneum with overlapping (Fig 23). Generally three or 4 staples are required. Sutured repair of peritoneum is better than stapler to prevent herniation of bowels through the gaps and may cause obstruction17.

Fig. 23: Approximation of peritoneal flaps to extra-peritonealise the prolene Fig. 21: The mesh completely spread out and fixed in place. Note the sides over-

mesh. No gaps or holes should be left between the two flaps since small bowel

lap across the midline, over the cord structures and laterally beyond the defect.

can herniate through these defects with subsequent obstruction.

All carbon dioxide gas is evacuated to empty the abdominal cavity and the scrotum. The ports are removed after lifting the anterior abdominal wall. The sheath of 10 mm port is closed with vicryl suture. Skin cuts are closed with subcuticular monofilament sutures or with glue. A suspensory bandage is used for scrotal support. Postoperative Care

Fig. 22.: Bilateral repair. The two meshes overlap in the midline and are stapled to each other to function as a single mesh.

Step 7 – Reperitonealisation After placement of the mesh, the peritoneal flap is closed over the mesh to prevent bowel and omental adhesions.

FIAGES Book.indb 127

Oral liquids may be started four hours after the surgery. Once the patient tolerates liquids, soft diet may be started thereafter. Sitting up in the bed and early movements and activity should be encouraged. The patient should walk to the toilet to pass urine. This helps to motivate the patient for early ambulation. Good analgesic coverage with injection diclofenac, given intramuscularly, in the evening and early morning on the next day helps in early ambulation and recovery. The patient can be discharged after 24 hours on oral analgesics. Before discharge, the scrotum should be examined for any swelling, to rule out haematoma formation. He is advised to resume full range of normal activities, including driving, in 5 to 7 days.

3/23/2007 11:08:04 AM

128

Laparoscopic Trans Abdominal Pre-Peritoneal (TAPP) Repair of Inguinal Hernia

Complications Laparoscopic hernioplasty is an advanced laparoscopic surgery. Operative technique and experience determines the frequency of complications, time of recovery, and rate of recurrence. A proper technique is essential to achieve good results. A. Intra operative complications The urinary bladder should be emptied before surgery either by self-voiding or by catheterization. A full bladder can create lot of difficulties during medial dissection and also becomes prone to injury. The bladder may sometimes become full intra-operatively if the anaesthetist infuses fluid rapidly or the procedure becomes prolonged. In such a situation, it is preferable to insert a catheter intra-operatively than to struggle with a full bladder. 2. Bowel Injury: the patient should be in a head low position to move the bowels away from the operating field. During TAPP repair, as in all pelvic surgeries, possibility of thermal injury to the bowel exists. The insulation of the instruments should be checked, use of electrical energy should be kept to minimum and while moving the hand instrument, the foot should be off the cautery pedal to prevent accidental thermal injury to intra-peritoneal structures. 3. Bleeding: Inferior epigastric or gonadal vessels can cause bleeding during dissection. Gentle careful dissection will avoid bleeding. Mostly, bleeding may be controlled with monopolar cautery or clips. The most disastrous of all is the iliac vessel injury (in the Triangle of Doom), which requires an emergency conversion. 1.

B. Post Operative Complications 1.

Seroma or Hematoma Formation: Seroma formation is a common complication after laparoscopic hernia surgery. The incidence is in the range of 5 – 25%.15 Seromas generally form at the end of one week and are a cause of significant distress to the patient, since they look like a recurrence. If the possibility of seroma formation is discussed with the patient before surgery, it goes a long way in alleviating their distress. They are common after large hernia and direct hernia repair. Seroma formation is more common during the learning phase and decreases with increasing experience. Gentle careful dissection and perfect haemostasis will decrease the incidence.

FIAGES Book.indb 128

2.

3.

4.

5.

6.

The pseudosac can be tacked to the pubic bone with 2 or 3 tacks in large direct hernia to prevent seroma formation. The scrotum should be completely deflated at the completion of surgery, before the ports are taken out. If seroma is expected, scrotal support should be used for the first 7 to 10 days to prevent their formation. Seromas mostly resolve by 4 to 6 weeks. The patient needs to be reassured about the spontaneous resolution of the swelling. If it does not resolve in 8 weeks, it may be aspirated under aseptic precautions. Urinary Retention: The incidence of urinary retention after laparoscopic hernia repair is about 1.3 – 5.8%18. It is usually precipitated in elderly subjects, especially if symptoms of prostatism are present. These patients are best catheterized prior to surgery and the catheter removed on the morning after the surgery. Neuralgia: This complication is reported to be between 0.5 – 4.6%15 depending on the technique of repair. Understanding the anatomy and location of the nerves lateral to the internal ring and avoiding stapling in the area of the nerves has decreased the incidence. No staples are applied for fixation of the mesh lateral to the cord and below the ileo-pubic tract, in the region the triangle of pain. A general rule is that the stapler should be fired only when the tip of the stapler can be felt by the other hand on the anterior abdominal wall. If the tip of the stapler cannot be felt with the other hand, it is too posterior and is in wrong position. Port site Hernia: Hernia can occur at the 10mm port sites. The sheath of 10 mm port should always be closed with vicryl suture. Mesh infection: Infection of the mesh is a serious complication after any hernia repair. Thorough aseptic precautions during handling of the mesh are important. The hand instruments and ports should be properly sterilized. The mesh should not come in direct contact with the skin. Changing gloves before handling the mesh is a wise precaution. Recurrences: In TAPP, the incidence of recurrence is 0.7 to 1.85%.13, 14 Recurrence after laparoscopic repair is always a technical failure.

3/23/2007 11:08:04 AM



Comprehensive Laparoscopic Surgery

A few keys points should always be remembered to keep the recurrence rate close to zero The peritoneum should be stripped from the midline the medially to the anterior superior iliac spine laterally. Proximally the peritoneum should be stripped off the cord structures for a distance to prevent indirect recurrence. In direct hernia, the dissection should cross the midline. Mesh of 15 x 12cm is recommended, so that the entire myopectineal orifice is covered with wide overlap. The mesh should lie in the pre-peritoneal space without any folds, particularly at the corners. If the mesh is getting folded, the pre peritoneal space should be dissected further. For Bilateral repair, the mesh of both sides should overlap in the center. The mesh should be fixed over the cooper’s ligament with minimum two staples. The polypropylene material has memory and after it is unrolled inside, it may again roll back and leave the defect uncovered. Fixing the upper margin of the mesh further decreases the chances of the mesh rolling back and can help in obtaining a zero recurrence. Outcome of TAPP repair One large series of 12678 cases of TAPP hernia repair showed a mean operating time of 40 min., a morbidity of 2.9%, recurrence rate of 0.7% and a disability from work for 14 days14. Ten cases of urinary bladder injury, eleven cases of bowel injury and two cases of injury to the vas were reported. Most of them were reported during the learning curve. Mesh infection was reported in ten cases. Fourteen patients with seroma formation required reoperation. In another series of 3017 cases of TAPP from two centers17 over seven years, the recurrence was 5% in initial 325 cases when the mesh size was 11cm x 6 cm. It was then increased to 15cm x 10cm. and this decreases the recurrence to 0.16% for the rest of the cases on a follow-up of 45 months. The mean operating time was 40minutes and the rate of seroma formation was 8% with a mean hospital stay of 0.9 nights. Thus, most of the cases had been done as a day care procedure. They had also reported 7 cases of bladder injury, of which 6 were recognized immediately and dealt with laparoscopically. Only four cases had mesh infection, of which three were treated conservatively.

129

One Randomized Controlled Trial19 reported no statistical difference between TAPP and TEP when considering duration of operation, haematoma formation, length of stay, time to return to usual activities and recurrence. Eight non-randomized studies suggest that TAPP is associated with a higher risk of Port Site Hernia and visceral injuries whilst there appears to be more conversions with TEP20. It has been pointed out, however, that placement of the mesh cannot be checked while deflating the pneumoperitoneum14. The advantages of TAPP over TEP are as follows – 1. Recognition of important landmarks and assessment of opposite hernial defects during dissection are easier. 2. In irreducible hernias, adhesions between the omentum, intestine and the sac are released without injuring the structures and managed with fewer complications. 3. Sliding hernia can be recognized immediately and dissection performed easily. 4. Other surgeries like cholecystectomy can be combined with this procedure. Laparoscopic hernia repair by the TAPP technique is an excellent operation for treatment of inguinal hernias. Precondition for excellent results is the strict application of a standardized technique. In experienced hands, all types of hernias, including large scrotal hernias and recurrent hernias after previous preperitoneal repair, can be operated with low morbidity and recurrence rates. However, to achieve favorable results, a strong educational program in laparoscopy is recommended.

References 1. Primatesta P, Goldacre MJ. Inguinal hernia repair; incidence of elective and emergency surgery, readmission and mortality. Int J Epidemiol 1996; 25:835-9. 2. Bassini E: Sulla cura redicala dell’ernia inguinale .Arch Soc Ital Chir 1887;4: 380-388 quoted by Sakorafas GH, Halikias I,Nissotakis C, et al. Open tension free repair of inguinal hernias; The Lichtenstein technique.BMC Surgery 2001;1:3-5 3. Glassow F. Short stay surgery (Shouldice technique) for repair of inguinal hernia. Ann R Coll Surg Engl 1976 Mar; 58 (2): 133-9 4. Chiasson PM, Pace DE, Schlachta CM,et al. Minimally invasive surgical practice: A survey of general surgeons in Ontario. Can J Surg 2004; 47:15-9. 5. Usher F, Cogan J, Lowry T. A new technique for the repair of inguinal and incisional hernias. Arch Surg 1960; 81: 187-194. 6. Stoppa R E, Rives J L, Warlaumont CR et al. The use of Dacron

FIAGES Book.indb 129

3/23/2007 11:08:04 AM

130

Laparoscopic Trans Abdominal Pre-Peritoneal (TAPP) Repair of Inguinal Hernia

in the repair of hernias of the groin. Surg Clin North Am 1984; 64:269-85. 7. Lichtenstein IL, Shulman AC, Amid PK, et al. The tension free hernioplasty. Am J Surg 1989; 157:188-93. 8. Ger R. The management of certain abdominal hernia by intra abdominal closer of the neck of sac. Preliminary communication. Ann R Coll Surg 1982; 64: 342-4. 9. Arregui ME, Davis CJ, Yucel O, et al. Laparoscopic mesh repair of inguinal hernia using a pre-peritoneal approach: A preliminary report. Surg Laparopsc Endosc 1992; 2: 53-8. 10. Dion Y M, Morin J. Laparoscopic inguinal herniorraphy. Can J Surg 1992; 35:209-12. 11. McKernan B. Laparoscopic pre-peritoneal prosthetic repair of inguinal hernias. Surgical Rounds 1992; 7: 579-610. 12. Fruchaud, H.: Anatomie chirurgicale des hernies de I’aine. Paris, Doin, 1956, quoted by Stoppa RE, Warlaumont CR; The Preperitoneal Approach and Prosthetic Repair of Groin Hernia in hernia 3rd edition chapter 10 page 199-225 JB Lippincott Co. USA. 13. Cohen RV, Alvarez G, Roll S. et al. Trans-abdominal or totally extra-peritoneal laparoscopic hernia repair? Surg Laparosc Endosc 1998; 8: 264-8 14. Bittner R, Leibl BJ, Jager C, et al. TAPP- Stuttgart technique and result of large single center series. J of Min Access Surg. September 2006; Vol 2; Issue 3: 158 – 159. 15. Chowbey PK, Pithawala M, Khullar R et al. Complications in groin hernia surgery and the way out. J Min Access Surg 2006;3: 174-7. 16. Technology Appraisal Guidance No. 83 for Laparoscopic Surgery for Inguinal Hernia Repair, Sept 2004 at www.nice.org.uk. Website of NATIONAL INSTITUTE FOR CLINICAL EXCELLENCE, NHS, England. 17. Kapiris SA, Brough WA, Roystpn CM,et al. Laparoscopic TAPP hernia repair – A seven year two center experience in 3017 patients. Surg Endosc 2001 Sep; 15(9):972–5 18. Philips EH, Arregui M, Carroll BJ et al. Incidence of complications following laparoscopic hernioplasty. Surg Endosc 1995; 9: 16 – 21 19. McCormack K, Wake BL, Fraser C et al. Trans-abdominal preperitoneal (TAPP) versus totally extra-peritoneal (TEP) laparoscopic techniques for inguinal hernia repair: a systematic review. May 2005;9(2):109-14. Epub 2005 Feb 10. 20. Wake BL, McCormack K, Fraser C, et al; TAPP vs. TEP Laparoscopic Technique for inguinal hernia repair. Cochrane Database Syst Rev 2005, Jan 25(1): CD004703

FIAGES Book.indb 130

3/23/2007 11:08:05 AM

15 Laparoscopic Inguinal Hernia Repair—Tep Technique Pradeep K. Chowbey The inguinal hernia repair has been a controversial area in the surgical practice from time it has been conceived. The history of inguinal hernia repair over several decades implies how innovations are adopted into surgical practice through combination of scientific and subjective processes. The techniques of laparoscopic hernia repair have evolved in parallel with experience and technology. In the laparoscopic procedure, tension free repair is achieved by placement of a prosthetic mesh to cover the entire groin area including the sites of direct, indirect and femoral hernia. The laparoscopic approach is based on the principle of tension free repair, which has been well established by open operation by Nyhus and Stoppa. The greater availability of space in the extraperitoneal approach facilitates the insertion of a much bigger mesh. Patient selection TEP groin hernia repair is an advanced laparoscopic procedure. It requires greater skills of laparoscopic dissection and manipulation as the working space available is limited. It has a long learning curve and must be done only after acquiring experience in basic laparoscopic procedures and when the learning curve is over. Today, we are well past the learning curve and have performed well over thousand laparoscopic groin hernia repairs. Except for strangulated hernia, at present there are no absolute contraindications for this procedure. Relative contraindications include patients unfit for anesthesia, obese and pregnant patients and patients with a history of lower abdominal surgery.

FIAGES Book.indb 131

Preoperative preparation A thorough history of the presenting complaints and other comorbid conditions should be taken. Specific measures should be taken if the patient is on drugs like Aspirin and warfarin, oral hypoglycemic agents etc. Besides routine hematological investigations, other specific investigations like X-Ray chest, ECG, coagulation profile, pulmonary function test etc should be done for patients with history of cardiac / pulmonary pathology. A written consent should be taken explaining the probable complications and possibility of conversion to open surgery. Following preanesthetic check up and clearance for surgery, the patient is kept fasting overnight. The patient is prepared adequately. Surgical Technique The procedure is done under general anesthesia (regional anesthesia if the patient is unfit for general anesthesia). The patient is catheterized or asked to empty the bladders before surgery and prophylactic antibiotic is given at the time of induction of anesthesia. After induction, complete reduction of the contents of the hernial sac is ensured. Extraperitoneal access A 10mm infraumbilical transverse incision is made. The anterior rectus sheath is exposed and transverse incision is then made on the anterior rectus sheath to one side of the midline to avoid inadvertent opening of the peritoneum [Fig.1]. The margins of incised sheath are held in stay sutures using vicryl 1-0 [Fig.2]. The rectus

3/23/2007 11:08:05 AM

132

Laparoscopic Inguinal Hernia Repair—TEP Technique

Fig. 1: Transverse infraumbilical incision with incision in anterior rectus sheath

Fig. 3: Indigenous balloon trocar

Fig. 2: Stay sutures over incised anterior rectus sheath

Fig. 4: Hassan’s cannula introduced in sub umbilical port

muscle is retracted laterally from the midline and by finger dissection a space is created between the rectus muscle and the posterior rectus sheath.

is attached to the Hasson’s Cannula and insufflation is begun with pressure setting at 12 mm Hg. A 10 mm 30° telescope is used. The camera is introduced through the sub umbilical port and preperitoneal space is visualized. The other two working ports are placed in the preperitoneal space. First, a 5 mm port is placed about 2-3 cm above the pubic symphysis in the midline and second, a 5/10 mm port is placed in the midline midway between the two placed ports (subumbilical and suprapubic) [Fig. 5 & 6].

Balloon dissection of the extraperitoneal space A self made balloon is then inserted in this preperitoneal space. The balloon trocar used by us is an indigenously made trocar where we tie two finger stalls of a size 8 latex surgical glove on the tip of the 5 mm laparoscopic suction cannula [Fig. 3]. The balloon trocar is the inflated with 100-150ml of saline. It not only creates an initial working space but also brings about hemostasis by balloon tamponade. The balloon is then deflated and the cannula is removed. A 10 mm Hassan’s cannula (blunt tip cannula) mounted with a conical sleeve is then introduced into the preperitoneal space through the infraumbilical incision [Fig. 4]. The conical sleeve snuggly fits into the incision and is secured with stay sutures. The insufflation tubing

FIAGES Book.indb 132

Dissection of the extraperitoneal space The surgeon stands on the side opposite to the operating side / or side where hernia is present. Dissection in extra peritoneal space begins by dividing the loose areolar tissue in the midline using sharp and blunt dissection. The first landmark / reference point i.e. the pubic bone is identified which appears as white glistening structure in the midline. The pubic bone is visualized and bared of all connective tissue creating a shelf extending about

3/23/2007 11:08:06 AM



2-3 cm in the retropubic space, which acts as a shelf to place the mesh [Fig.7]. The dissection is then traced laterally towards the side of the hernia. In case of direct hernia, the hernial sac is visualized as a weakness in the Hasselbach’s triangle medial to the inferior epigastric vessels. On the other hand, in the indirect hernia, the inferior epigastric vessels

Fig. 5: Port placement for TEP

Fig. 6: Preperitoneal space

Comprehensive Laparoscopic Surgery

133

are seen before the hernial sac, which is encountered laterally. Once the adhesions are lysed or hernial sac is reduced as in direct hernia, the anatomical landmarks which now become visible are Cooper’s ligament, iliopubic tract, femoral canal and the inferior epigastric vessels [Fig. 8, 9].

Fig. 8: Left direct hernial defect seen after dissection

Fig. 9: Right direct hernial defect

The spermatic cord lies immediately inferior and lateral to the inferior epigastric vessels. The adhesions all around the cord are lysed with caution as the external iliac vessels lie just below the cord structures. The peritoneal extension (sac) is seen as a white glistening structure lying anterolateral to the cord [Fig.10]. The sac is completely dissected off the cord structures and reduced. In cases of complete hernia, attempt should not be made to completely reduce the sac as excessive traction and dissection causes severe postoperative pain and edema. The sac should be transected and ligated using a catgut endoloop or by intracorporeal sutures, leaving the distal sac open in situ [Fig.11]. Fig. 7: Preperitoneal space

FIAGES Book.indb 133

3/23/2007 11:08:07 AM

134

Laparoscopic Inguinal Hernia Repair—TEP Technique

Fig. 10: Right indirect hernial sac with cord structures

Fig. 12: Rolled prolene mesh

Fig. 11: Dissected and ligated right indirect hernial sac

Fig. 13: Prolene mesh being placed for repair

The peritoneal sac with reflection is completely reduced. The vas deferens is seen lying separately on the medial side and gonadal vessels are seen on the lateral side forming a triangle. This triangle, known a “triangle of doom”, is bounded medially by the vas deferens laterally by gonadal vessels with its apex at the internal inguinal ring and the base is formed by the peritoneum. No dissection should be carried within this triangle as it contains the external iliac vessels. Dissection is continued lateral to the cord structures to create adequate space for the placement of mesh. The lateral space contains loose aerolar tissue, which is completely divided using sharp and blunt dissection. The psoas muscle is seen lying on the floor on which lateral cutaneous nerve of thigh and genito femoral nerve can be seen transversing. The anterior superior iliac spine marks the lateral boundary of the dissection. After creating the lateral space adequately the mesh is introduced through the 10mm subumbilical port [Fig.12]. The mesh is placed over the space created so that it covers the sites of direct, indirect, femoral and obturator hernias

FIAGES Book.indb 134

[Fig.13]. The mesh is the secured in place with the help of fixation devices like helical fasteners, staples anchors etc. depending upon the preference of the surgeon. After adequately spreading the mesh, which extends from the midline medially, to lying over the psoas muscle on the lateral side, preperitoneal space is deflated. In cases of bilateral hernias the similar procedure can be done on both the sides through the same three ports made for unilateral repair.

3/23/2007 11:08:08 AM

16 Laparoscopic Appendicectomy M. G. Bhat Appendicectomy is the commonest surgical operation performed and this may be done as an emergency or elective procedure. Laparoscopic appendicectomy (LA) was described in the early 1980s and has gradually become popular with the introduction of video laparoscopy. It is well accepted amongst the laparoscopic surgeons but has not gained the wider acceptance amongst the general surgeons. A UK audit published by the Royal College of Surgeons of England, in 1997 suggested that only 1.2% of patients undergoing appendicectomy had a laparoscopic operation1. A Recent analysis from the University Hospitals in the USA suggests a 20% increase in the utilization of lap appendix, 2. The laparoscopic approach has many advantages1, 2, 3,4, when compared to open appendicectomy. Indications LA is the operation of choice by experienced laparoscopic surgeons for all cases. 2. Acute or Chronic right iliac fossa pain with a doubtful diagnosis of acute appendicitis. Instead of laparotomy, a diagnostic laparoscopy, and appendicectomy will avoid unnecessary laparotomies, 4,5,6 and allow general visualization of peritoneal cavity. 3. In young females where it may be difficult to differentiate other pelvic pathology from appendicitis. 4. Obese patients who will require a large incision for open appendicectomy. 1.

Pre Operative Preparation Pre operative preparation and evaluation are the same as required for open appendicectomy and investigations are done according to clinical assessment. The possibility of conversion to open operation should be explained to the patient. Decompression of urinary bladder and stomach to minimise the risk of injury to these organs should be done as for other laparoscopic procedures. Procedure Laparoscopic appendicectomy is usually performed under GA with the patient in supine and steep Trendelenberg position. The surgeon stands on the left of the patient with the monitors at the foot end. Both upper limbs are placed by the side of the patient. After the ports are inserted, the table is tilted to the left, to make the right side up for help in the dissection. Pneumoperitoneum Is created by the open (our present choice) or Veress needle method and the 1st port (10mm), is introduced. Transumbilical entry is better and gives an excellent cosmetic result. Diagnostic laparoscopy Through the Umbilical port, a 10mm 300 telescope is

FIAGES Book.indb 135

3/23/2007 11:08:09 AM

136

Laparoscopic Appendicectomy

introduced and a complete survey of the peritoneal cavity is performed. The 300 telescope gives more flexibility and wider view. The diagnosis is confirmed and the extent and severity of the inflammatory process is determined and feasibility of laparoscopic approach is assessed. Secondary Ports Two additional 5mm ports are introduced under vision. 2nd port, 5mm just above the symphysis pubis in the midline and 3rd port, 5 mm in the left iliac fossa (Figure 1). For better visualization of the operative field Trendelenberg position is maintained with left tilt of the table.

the operative field by dissecting the lateral and inferior peritoneal attachments. A retrocaecal appendix with adhesions will require mobilization of caecum and ascending colon. The mesoappendix is grasped at its tip with the non-toothed grasper and the appendix is elevated to visualise the mesoappendix fully (Figure 2). Any adhesions are released by endoscissors dissection with or without use of diathermy. Mesoappendix The mesoappendix is now cauterised close to the appendix with the use of bipolar grasper and divided

Lap Appendix

Lap Appendix : Ports

1. Umbilical - 10 2. Retracting - 5 3. Operating - 5

1 3

Bipolar forceps coagulating the mesoappendix

2

Figure 1

Figure 1

Figure 3

Dissection

Lap Appendix

A 5mm manipulator is used to assess the appendix, caecum, ileum, pelvic organs and the rest of the abdominal cavity. A non-toothed grasper is used through the 2nd port for grasping and retracting. The 3rd port is used for the main operation. The appendix is identified and mobilised in

Endo-scissors dividing the mesoappendix

Lap Appendix

5mm Grasper holding the tip of the mesoappendix from 2nd port Figure 2

FIAGES Book.indb 136

Figure.2

Figure 3

Figure 4

Figure 4

with scissors. By repeating this procedure a few times the appendix is separated from the mesoappendix and dissected to the base. Bipolar cauterisation allows specific tissue cauterisation and coagulates the appendicular vessels. This makes the procedure easy

3/23/2007 11:08:10 AM



Comprehensive Laparoscopic Surgery

and cost effective. The appendix is now fully dissected and skeletalised (Figures 3, 4). Ligation and Division of Appendix The base of the appendix is doubly ligated with No.1 Chromic Catgut using a Roeder knot and pushing it with a knot pusher. A third ligature is placed on the appendix about 1cm away from the base ligatures and this ligature is kept long for further grasping of the appendix. The appendix is cauterised using bipolar forceps between the ligatures and divided. Use of ligatures adds to the cost effectiveness of the procedure (Figures 5, 6).

Lap Appendix

this grasper is brought out of the umbilical wound. The appendix is then pulled out of the wound. If the appendix is distended and large, an endobag is used and the bag delivered in the same way. The use of bag prevents contamination of the wound. Irrigation of the area is usually not required (Figures 7, 8). Lap Appendix

Appendix pushed into the Umbilical port

Figure 7

Figure 7

Endo-Loop going to the base of the appendix

137

Lap Appendix

Figure 5

Figure 5

Appendix delivered out from the umbilical port

Lap Appendix

Base of appendix divided between ligatures

Figure 8

Figure 8

Closing the wound

Figure 6

Figure 6

Delivery of the Appendix The grasper holding the ligature on the appendix is pushed into the umbilical port. By withdrawing the telescope and the port gradually

FIAGES Book.indb 137

The linea alba in the umbilical wound is closed with No.1 vicryl. The umbilicus is dressed with a gauze ball dressing without sutures to the skin. The other 2 wounds are closed with 3/0 Subcuticular Monocryl. Intra Operative Problems & Solutions There should be no hesitation to convert to open operation if there are any difficulties in performing the operation.

3/23/2007 11:08:11 AM

138

Laparoscopic Appendicectomy

The conversion rate mentioned in the literature is 2 to 5 %, depending upon the experience of the surgeon. The Methods of solving following specific problems are described below. 1.

2. 3.

4. 5. 6. 7.

8.

Mass Formation: Adhesion around the mass needs to be dissected gently with blunt or sharp dissection as in open surgery. Retrograde dissection. Initial identification and ligature of appendix base and further dissection. A loop ligature to the thick and inflamed appendix to hold during dissection. This solves the difficulties of holding the appendix in difficult cases. Mobilisation of the caecum and ascending colon for dissecting retrocaecal appendix. Perforation of the caecum at the base will require suturing the base with 2/0 vicryl. Bleeding – Gentle pressure, bipolar cautery, Harmonic Scalpel or suture the bleeder. Vascular Staplers for the Base of appendix and Mesoappendix is popular in the developed countries. This is much quicker and easier. May be useful in some selected cases. But it adds to the costs and is not necessary. In present day practice, there appears no need for Lap Assisted appendix operations.

Advantages of Laparoscopic Appendicectomy 1.

2. 3. 4.

complete evaluation of the abdominal cavity and definitive treatment of other and co-existing abdominal or pelvic pathology is possible without enlarging the incision. Return to normal activity is faster, with almost similar hospitalisation. Reduced post-operative discomfort and pain. Wound Infection Incidence is almost nil. Cosmetic results are better.

to open procedure. The cost is comparatively higher than the open procedure but this is compensated by the advantages. Laparoscopic appendicectomies performed in our unit from 1993-2005 at Bangalore were audited. 403 available case records out of 460 lap appendix were analyzed. Diagnostic laparoscopy and appendicectomy for chronic right iliac fossa pain was performed in 40, appendicectomy for acute in 340 and elective appendicectomy in 23. There were 4 conversions to open method. In 1997 a prospective trial was conducted to compare the LA with Open appendicectomies. The comparison was between the different units in the department of surgery. The other units during that period only performed open appendicectomies and so there was no bias. 20 prospective consecutive cases in both groups were taken for the analysis. There was no significant difference in the duration of surgery or hospitalisation. LA was advantageous in diagnosis, pain relief, quick return to work, reduced wound infection and cosmesis. The only disadvantage was the marginally increased cost. There were no complications. (Table 1 & 2)

Table 1 Laparoscopic Appendicectomy- 1993-2005 Analysis of data 403 Sex

M:F–22:28

Age(peak)

21-40 - low: 7 high: 52

Duration

average- last 20/50 mts (High-2hrs, low-40mts)

Hospital Stay

average 3 days (High-9, Low-1)

Return to work

1 week

Table 2 Lap & Open Comparison (20:20) (1997) Operation

LAPAROSCOPY

OPEN

Diagnosis

20/20

15/20

Anaesthesia

GA

GA/SP

The only disadvantage is the marginally increased cost. There is an initial learning curve, which will increase the duration of surgery. Conversion to open surgery may be required in difficult cases.

Analgesia

4 Days

7 Days

Duration (in minutes) Hospital Stay

52

51

3 Days

4 Days

Our Experience: Laparoscopic Appendicectomy

Return To Work

7days

10-12 Days

Wound Infection

Nil

3

Cost ( Average.Rs)

11000

7000

Cosmesis

++++

9cm Incision

5.

Disadvantages of Laparoscopic Appendicectomy

LA has been performed as a choice routinely in our unit. With experience we are convinced that it is superior

FIAGES Book.indb 138

3/23/2007 11:08:11 AM



Comprehensive Laparoscopic Surgery

Laparoscopy Appendicectomy as a Laparoscopy Training Tool Appendicectomy, being a frequently performed procedure, it gives opportunity to teach surgeons in training with skills in laparoscopy. Laparoscopic Appendicectomy is being used successfully in many centers to train surgical residents and found to be a safe and effective laparoscopy training procedure7. The dissection, use of cautery and suturing can be learnt effectively.

139

Acknowledgments: I thank my former resident Dr Arvind Shastry for the sketch diagrams in this article.

Conclusion Laparoscopic appendicectomy is feasible and with experience compares well and better with the open method. It definitely is preferable in young women with chronic right iliac fossa pain, in obese patients where a larger incision will be required, when cosmesis is preferred and for quick return to normal activities. It has become the choice of operation in laparoscopy centers.

References 1. Memon current 393-402

MA: Laparoscopic status. Ann R

Appendicectomy – the Coll Surg Engl.1997;79:

2. Nguyen NT, Zainanbadi K, Mavandadi B e all:Trends in Utilization and outcomes of laparoscopic versus open appendectomy. AJS. 2004;188:813-820 3. Frazee RC, Roberts JW, Symmends RE et al: A prospective randomized trail comparing open versus laparoscopic appendicectomy. Ann Surg.1994 219:725-28 4. Barrat C, Catheline JM, Rizk N, et al: Does laparoscopy reduce the ncidence of unnecessary appendicectomies? Surg Laparosc Endosc.1999;1:27-31 5. Styrud J, Eriksson S, Segelman J, Granstrom L. Diagnostic Accuracy in 2,351 Patients Undergoing Appendicectomy for Suspected Acute Appendicitis: A Retrospective Study 1986-1993. Dig Surg.1999;16:39-44 6. Moberg AC, Ahlberg G, Leijonmarck CE et al: Diagnostic laparoscopy in 1043 patients with suspected acute appendicitis Eur J Surg.1993;164:833-40 7. Sai Prasad TR, Chui CH, Jacobsen AS: Laparoscopic Appendicectomy in Children: A trainee’s perspective. Ann Acad Med Singapore. 2006;10:694-7

FIAGES Book.indb 139

3/23/2007 11:08:12 AM

17 Laparoscopic Oesophageal Procedure K. Ravindranath ANATOMY AND PHYSIOLOGY OF THE GASTROESOPHAGEAL JUNCTION The muscular elements of the crural diaphragm derive from the right diaphragmatic crus. The right crus arises from the anterior longitudinal ligament overlying the lumbar vertebrae. Once muscular elements emerge from the tendon, two flat muscular bands form, which cross each other in scissor-like fashion, form the walls of the hiatus, and decussate with each other anterior to the esophagus. The distal end of the esophagus is anchored to the diaphragm by the phrenoesophageal membrane, formed by the fused endothoracic and endoabdominal fascia. This elastic membrane inserts circumferentially into the esophageal musculature, very close to the squamocolumnar junction which resides within the diaphragmatic hiatus (Figure 1 & 2). This configuration is altered during swallowinitiated peristalsis, a sequenced contraction of both the longitudinal and circular muscle responsible for bolus propulsion through the esophagus. With contraction of the esophageal longitudinal muscle, the esophagus shortens and the phrenoesophageal membrane is stretched; its elastic recoil is then responsible for pulling the squamocolumnar junction back to its normal position following each swallow. This is, in effect, “physiologic herniation,” since the gastric cardia tents through the diaphragmatic hiatus with each swallow. Among various laparoscopic procedures being done for oesophageal disorders laparoscopic antireflux procedures have become gold standard,while procedures for achalasia and oesophageal diverticulum are fast

FIAGES Book.indb 140

gaining popularity. Procedures for malignancy are being carried in few centers of excellence.

Figure 1

Figure 2

Laparoscopic fundoplication GERD is one of the most common disorders of western civilization,its prevalence is increasing in India.

3/23/2007 11:08:12 AM



Comprehensive Laparoscopic Surgery

Historically management was more directed towards drugs ,diet ,& lifestyle modification With development of loose,short floppy wrap and introduction of laparoscopic fundoplication it has fast become gold standard for managment of GERD. Gastro Esophageal Reflux Disease (GERD) is defined as the failure of the anti reflux barrier, allowing abnormal reflux of gastric contents into the esophagus. It is a mechanical disorder which is caused by a defective lower esophageal sphincter, a gastric emptying disorder or failed esophageal peristalsis. Exposure of the oesophageal mucosa to acid, enzymes and other digestive secretions, leads to acute and chronic inflammation, with pain, and ulceration or stricture formation if untreated. Medical therapy is the first line of management. Esophagitis will heal in approximately 90% of cases with intensive medical therapy. However, symptoms recur in more than 80% of cases within one year of drug withdrawal. Since it is a chronic condition, medical therapy involving acid suppression and/or pro-motility agents may be required for the rest of a patient’s life. Despite the fact that current medical management is very effective for the majority a small number of patients do not get complete relief of symptoms. Currently, there is increasing interest in the surgical management of gastro-oesophageal reflux disease (GERD).

2.

3.

4.

5.

Symptoms: Heart burn (Retrosternal burning) Regurgitation Pain Respiratory symptoms Diagnostic test: Endoscopy Barium swallow Oesophageal transit +/- Manometry pH monitoring Indications for Surgical management of GRED(1) 1.

Persistent complications due to GERD (eg, peptic stricture)- There are fewer patients comprising this population since the introduction of proton-pump inhibitors (PPIs), but these patients should certainly consider surgery, because there is a clear “failure” of medical treatment.

FIAGES Book.indb 141

6.

141

Barrett’s esophagus- Patients with Barrett’s esophagus usually have severe GERD, and surgery provides excellent control of symptoms. More important, surgical therapy is the only treatment that has demonstrated substantial rates of regression for Barrett’s epithelium.[1] Respiratory complications- Patients with pulmonary (recurrent pneumonia, asthma) or laryngeal (hoarseness, chronic cough, laryngitis) complications often do not respond to medical treatment. Surgical therapy has a higher success rate in this setting, likely because it addresses the reflux that leads to microaspiration. Nevertheless, we lack a diagnostic test that clearly links GERD to these problems; pH monitoring (esophagus and pharynx), laryngoscopy, and pulmonary function testing may help. Persistent regurgitation- PPIs often neutralize the acid and therefore stop the heartburn, but regurgitation persists. The lifestyle effect of this symptom should not be understated, and surgical therapy provides excellent relief for these patients. Young patients- This population represents a relative indication for antireflux surgery. Patients with severe GERD who are under the age of 40 years have a high likelihood of having progressive disease. Surgical therapy can provide long-term relief of GERD and its complications in these patients, as well as abate the costs associated with the use of PPIs. Still, many patients elect to wait until medical therapy fails before pursuing the surgical option, and this is a very reasonable course of action. Failure to respond to medical therapy- While seemingly representing the “perfect” surgical candidate, patients whose symptoms do not respond to PPIs should be treated with caution. As a group, they have an inferior response to therapy likely because many of these individuals have a confounding diagnosis that will not respond to stopping the gastroesophageal reflux. All efforts to rule out cardiac, pulmonary, musculoskeletal, and other gastrointestinal problems should therefore be sought

The choice of technique The choice of techniques typically been based upon anatomic considerations, as well as the surgeon’s preference and expertise. Many of these techniques have been extensively tested and proven to be effective in controlling reflux with minimal side effects. The 360 degree or -Nissen- type fundoplication has emerged as

3/23/2007 11:08:13 AM

142

Laparoscopic oesophageal procedure

the most widely accepted procedure for patients with normal esophageal motility,( 2,3,4,5) First performed in the early nineties by Dallemagne in Belgium, the standard laparoscopic fundoplication is now recognized as the therapeutic modality of choice in the surgical management of gastro-esophageal reflux. Since then, several technical modifications have been introduced with various success. However to date, advances in laparoscopic instrumentation and surgical skills make the standard, 360 degrees laparoscopic fundoplication the most effective antireflux procedure available. Having a precise knowledge of the anatomy of the gastroesophageal junction, understanding the mechanics of the gastroesophageal junction and establishing an accurate diagnosis of gastro-esophageal reflux is absolutely essential for any surgeon performing these procedures. Operative Steps The patient is placed in a modified lithotomy position with the head of the table tilted up 25 degrees. The operating surgeon stands between the patient’s legs while the camera operator stands to the patient’s right and the second assistant assumes a position on the patient’s left. One 10-mm and three 5-mm trocars are placed as shown in Figure 3. The laparoscope is introduced through a port placed in the midline superior to the umbilicus. Placing the 5-mm trocars on either side of the midline allows for triangulation and avoids interference with the camera’s line of vision. Left lobe of the liver is retracted using a fan shaped retractor put through the anterior axillary port. We start the dissection first by dividing short gastric vessels to mobilse the fundus using ultrasonic scissors.

Left crus is then mobilized taking care not to damage the phreno oesophageal ligament. Gastrohepatic ligament is divided taking care not to injure the left hepatic artery arising from left gastric artery in 25% of patients. This exposes the right crus. The right crus is then mobilized by dividing the peritoneum overlying the anterior aspect. By blunt dissection along the medial side of right crus the medistinum is entered. Once oesophagus is visualized along with the crural confluence gentle blunt dissection avoiding injury to posterior vagus posterior to oesophagus allows for circumferential mobilization of oesophagus.Care should be taten not to open the pleura. An umbilical tape is put around the oesophagus to sling it and further help in retraction .Around 5-7cms length of intra abdominal oesophagus should be achieved after the above mobilization. Crural closure is important to prevent the wrap from herniating into the mediastinum This is achieved by placing figure of ‘8’ ethibond suture (2-0) gently approximating the crura. Care should be taken not to excessively tighten the crura which may lead to dysphagia. Three Sixty degree short floppy Fundal wrap is constructed after placing a 50fr bougie through oesophagus into the stomach. The oesophagus should be enveloped by an untwisted fundus before suturing. Floppiness of the wrap is ensured by the (1)-Shoe shine test & (2)-drop test. The wrap is fixed using 2-0 ethibond sutures. The wrap should be 2-3 cms in length just above the O-G junction. Figure 4 & 5.

Figure 4 Figure 3

FIAGES Book.indb 142

3/23/2007 11:08:14 AM



Comprehensive Laparoscopic Surgery

143

Mechanisms of failure Dallemagne et al suggested technical quality was responsible for majority of the failures. Horgan and Pellegrini have concluded that most important technical factors preventing reccurence were effective crural closure,trasns hiatal oesophageal mobilization,attention to the geometry of the fundoplication,and anchoring the wrap to the oesophagus and surroundig tissues. Paraesophageal hernias

Figure 5

Adequate mobilization ensures 2-3cms length of intra abdominal oesophagus above the wrap. After completion the fundoplication suture line should be facing anteriorly. Ryles tube is left in situ and bougie is withdrawn. Haemostasis is ensured before with drawing the ports. LAPAROSCOPIC TOUPET PARTIAL FUNDOPLICATION The mobilization is similar to Nissen’s.The major difference involves a 270 degree wrap in comparision to 360 degree wrap. The fundal edges are fixed to the oesophagus and crura at the crural margins dilator is not necessary to callibrate this partial wrap. RESULTS In their study “Predictors of outcome in 100 consecutive laparoscopic antireflux procedures” JACKSON Patrick G. GLEIBER Michael et al showed that surgical strategies can reproducibly control gastroesophageal reflux disease symptoms in more than 90% of patients. The optimal surgical candidate is a patient under the age of 50 whose typical symptoms completely resolve with acid suppression therapy(6). Partial fundoplication provide less effective reflux control and should be used in those with severe motility disorders, even this is being challenged because the population of patients with GERD induced motility disorders have more severe grade of reflux which would recur with partial wrap (9,10). Post operative complications occur in 8-10%, rate of conversions about 2%.Untoward side effects such as dysphagia has-been reported in 3-10% and generally resolves within 3 months.

FIAGES Book.indb 143

The term hernia refers to a protrusion of all or part of an organ through a tear in the wall of the containing cavity. The diaphragm is a muscular partition between the thorax and abdomen that functions by changing the size of the thoracic cavity during respiration. The esophagus, a collapsible tube approximately 10 inches long, extends from the pharynx to the stomach, piercing the diaphragm in its descent from the thoracic cavity to the abdominal cavity. The normal positioning of the esophagus as it passes through the diaphragm is illustrated in Figure 1. A paraesophageal hernia is an anatomic defect at the junction of the esophagus and diaphragm that may occur in combination with sliding esophageal hernias. The defect may be congenital or may occur as the result of stretching the phrenoesophageal ligament with gradual enlargement of the hernia over a period of time and is most common in late middle-aged or elderly patients. Paraesophageal hernias account for approximately 5% of hernias at the esophageal hiatus. TYPES OF HERNIA Type I or Sliding Hernia. Gastro-oesophageal junction migrates above the oesophageal hiatus. It is the most common type of hiatus hernia (95%). Type II True paraoesophageal hernia is characterized by normally positioned GE junction and an intrathoracically migrated stomach. Type III Mixed hernia with sliding and a Para esophageal component. Symptomatic gastro-oesophageal reflux disease (GERD) is frequently associated with finding of a

3/23/2007 11:08:15 AM

144

Laparoscopic oesophageal procedure

sliding hernia. A number of procedures like Nissen’s fundoplication and its modification (the Toupet procedure), Hill’s procedure and Belsey transthoracic repair have been described. Nissen fundoplication is however, the simplest and most effective. Success has been achieved in performing the laparoscopic Nissen fundoplication, Hill’s repair and Toupet procedure as well as thoracoscopic Belsey Mark IV. Laparoscopic Nissen Fundoplication shows the most promise and has the potential of becoming gold standard. It offers the opportunity for correction of the underlying anatomical and functional defect associated with GERD with lessened discomfort and hospitalisation. Appropriate preoperative evaluation of oesophagogastric junction is essential prior to performing laparoscopic fundoplication. Failure of surgery to control symptoms occurs in up to 10 per cent of cases is a reflection that antireflux surgery has been inadvertently utilized for unrecognized cardiac, hepatobiliary, oesophageal or gastric etiologies. Preoperative evaluation can be divided into mandatory and selective tests. Mandatory Endoscopy UGI with/without biopsy Oesophageal manometry Selective Barium swallow 24 hours pH monitoring Gastric studies At least 3 cm of esophagus must be mobilized into the abdomen to ensure adequate intraabdominal length for fixation. If a hiatal hernia is present the crura are approximated with 2 to 3 sutures of No. 1-0 non-absorbable suture. The short gastric vessels are routinely divided along the upper one-third of stomach using harmonic scalpel. A 2 cm wrap is adequate with incorporation of oesophagus into the wrap to prevent slippage. Postoperatively a chest X-ray is obtained in the recovery room to exclude a pneumothorax. Patients are begun on clear liquids on the day of surgery and soft diet the following day. Average length of stay is 2 days. Intraoperative complications may include injury to visceral organs, bleeding, pneumothorax and vagal injury. Postoperative complications include wrap slippage.

CONCLUSIONS: Laparoscopic antireflux surgery is an effective therapy for patients with gastroesophageal reflux and hiatus hernia may be more effective than medical therapy at improving quality of life (7, 8). References 1. Devault KR, Castell DO, Guidelines for the diagnosis and treatment of gastroesophageal reflux disease, in Guidelines Statement of ACG, AGA, ASGE. 1994, 2. Wetscher GJ, Redmond EJ, Vititi LMH. Pathophysiology of gastroesophageal reflux disease. In: Hinder RA, ed. Gastroesophageal Reflux Disease. ed. Austin: R. G. Landes Company ,1993: 7-29. 3. Ireland AC, Holloway RH, Toouli J, Dent J. Mechanisms underlying the antireflux action of fundoplication. Gut 1993; 34:303-8. 4. Vaezi MF, Richter JE. Synergism of acid and duodenogastroesophageal reflux in complicated Barrett’s esophagus. Surgery 1995; 117:699-704. 5. Kauer WK, Peters JH, DeMeester TR, et al. Mixed reflux of gastric and duodenal juices is more harmful to the esophagus than gastric juice alone. The need for surgical therapy re-emphasized. Ann Surg 1995; 222:525-31. 6. Predictors of outcome in 100 consecutive laparoscopic antireflux procedures JACKSON Patrick G. (1) ; GLEIBER Michael A. (2) ; ASKARI Reza (2) ; EVANS Stephen R. T. (2) ; Department of Surgery, Massachusetts General Hospital, Boston, Massachusetts, ETATS-UNIS 7. (2) Department of Surgery, George Washington University Medical Center, 2150 Pennsylvania Ave., N.W. 6b, Washington, DC 20037, ETATS-UNIS Improvement in quality of life measures after laparoscopic antireflux surgery. T L Trus, W S Laycock, J P Waring, G D Branum, and J G Hunter Department of Surgery, Emory University School of Medicine, Atlanta, Georgia, USA. Ann Surg. 1999 March; 229(3): 331–336. 8. Journal of Laparoendoscopic & Advanced Surgical Techniques Laparoscopic Antireflux Surgery: Long-Term Outcomes and Quality of LifeDec 2006, Vol. 16, No. 6 : 557 -561 9. Oelschlager BK, Barreca M, Chang L, Oleynikov, Pellegrini CA. Clinical and pathologic response of Barrettýs esophagus to laparoscopic antireflux surgery. Ann Surg. 2003;238:458-466. Abstract 10. Oleynikov D, Eubanks TR, Oelschlager BK, Pellegrini CA. Total fundoplication is the operation of choice for patients with gastroesophageal reflux and defective peristalsis. Surg Endosc. 2002;16:909-913. Abstract 11. Sarela AI. Barrett’s oesophagus: Is there a need for laparoscopic anti-reflux surgery?. J Min Access Surg 2005;1:5-7

FIAGES Book.indb 144

3/23/2007 11:08:16 AM



Comprehensive Laparoscopic Surgery

145

Minimally Invasive Surgery for Esophageal Achalasia K. Ravindranath Esophageal achalasia is a primary esophageal motility disorder of unknown etiology. It is an uncommon, benign disorder of the esophagus with an annual incidence of 1 per 100,000 people. It is characterized by progressive loss of peristalsis in the body of the esophagus and failure of a normal or hypertensive lower esophageal sphincter (LES) to relax upon swallowing (Figure 01). No form of treatment returns the esophageal peristalsis or the LES function back to normal. Instead, therapy is aimed at relieving the functional obstruction at the gastroesophageal junction. The characteristic dysphagia may be alleviated by surgery, dilations, or botulinum toxin injections. Video-endoscopic surgery is used increasingly.

study of 42 resected esophageal specimens from patients with achalasia revealed fewer ganglion cells, and ganglion cells, when present, were surrounded by mononuclear cells, suggesting a cause of ganglion degeneration. Clinical features Dysphagia- It is the most common symptom. It occurs mostly in response to solids but can also manifest for liquids. Regurgitation- second most common symptom,occurs in 60% more in supine position and exposes the patient to risk of aspiration. Heartburn-experienced by about 40% of patients, usually caused by stasis and fermantation of food in distal oesophagus. Chest pain- also occurs in 40% of patients at the time of meals. Pre-operative investigations-

Figure 01

The etiology of this condition is unclear, but reason exists to believe that it may be secondary to abnormal innervation of the myenteric plexus of the esophagus. A

FIAGES Book.indb 145

Figure 02

3/23/2007 11:08:16 AM

146

Minimally Invasive Surgery for Esophageal Achalasia

Barium swallow- first test to be done. It shows bird beak appearance at level of narrowing and various degrees of oesophageal dilatation (Figure 02). UGI endoscopy- it rules out presence of peptic or malignant stricture and gastro duodenal pathology. Esophageal manometry-it is important for establishing the diagnosis. The classical findigs are (1)-absence of oesophageal peristalsis, and (2) hypertensive LES, which relaxes only partially in response to swallowing Prolonged pH monitoring-it is useful in few cases-(1)to distinguish false reflux due to food stasis & real acid reflux. In elderly patients with excessive weight loss pseudo achalasia or secondary achalasia should be ruled out, Most common cause being GE junction tumours. Who should be referred for laparoscopic cardiomyotomy?

The procedure begins with a hiatal dissection, followed by the myotomy, and an antireflux procedure. The hiatal dissection consists of mobilization of the distal esophagus, the gastroesophageal junction, the cardia and the fundus. The myotomy is performed by separating the outer longitudinal muscle layer and incising the inner circular mucle layer. It is carried proximally about 5-6 cm from the gastroesophageal junction. Distally, the myotomy is carried across the gastroesophageal junction and on to the stomach for about 1-2 cm. Once the submucosal plane is reached, the mucosa bulges up. This is clearly seen in the magnified laparoscopic view. Once the myotomy is completed, the muscle edges are separated from the underlying mucosa for approximately 40% of the esophageal circumference. Look for any mucosal perforation. If any perforation is encountered, it is closed with a stitch (Figure 04).

Young patients- patients under the age of 40 do not respond well to pneumatic dilation. 2. Patients who fail pneumatic dilations. 3. Patients who are fit for surgery and choose to have surgery. 1.

Laparoscopic myotomy is as safe as BoTx treatment and is a one-shot treatment that cures achalasia in most patients. BoTx should be reserved for patients who are unfit for surgery or as a bridge to more effective therapies, such as surgery or endoscopic dilation (1). In the operating room, the patient is placed in modified lithotomy position. An orogastric tube and a Foley catheter are usually placed. Sequential pneumatic compression devices or perioperative low molecular weight heparin injections are used as prophylaxis for deep venous thrombosis. The abdomen is inflated with CO2. Five trocars are placed in the upper abdomen. They are 5 or 10 mm in size (Figure 03).

Figure 04

Refllux is a common problem after conventional cardiomyotomy. Therefor many surgeons to add a partial fundoplication (Toupet, a posterior fundoplication or Dor, an anterior fundoplication) at the completion of the Figure 03

FIAGES Book.indb 146

3/23/2007 11:08:18 AM



myotomy (Figure 05). Several authors have demonstrated the necessity of fundoplication. They have shown that patients undergoing myotomy without fundoplication have a higher chance of experiencing postoperative gastroesophageal reflux[2,3]. Mattioli et al. has clearly shown in a prospective study that a significantly better long-term outcome results from a transabdominal long cardiomyotomy plus anterior fundoplication as compared to transabdominal long myotomy alone or a transthoracic short cardiomyotomy(4­). The partial fundoplication holds the raw edges of the myotomy open and provides some protection against gastroesophageal reflux, while being sufficiently loose not to obstruct passage of food and liquids.

Figure 05

Complications Perioperative: Mucosal perforation is the most common complication. They are easily recognized, if not immediately, then during the installation of methylene blue dye into the esophagus. These lacerations are clean and are easily repaired with a stitch. As of today, there are no reports of an infection from a small, recognized mucosal laceration during laparoscopic cardiomyotomy. Late perforations are very rare. Pneumothorax is not uncommon during laparoscopic hiatal dissection and esophageal mobilization (approximately 5%). These pneumothoraces are usually small and self-limited. They are best recognized on a postoperative chest film. Intervention is rarely needed as the lung reexpands rapidly as carbon dioxide is absorbed.

FIAGES Book.indb 147

Comprehensive Laparoscopic Surgery

147

Postoperative: Postoperative complications are rare. Persistent dysphagia is the most common postoperative problem, but Heller myotomy offers relief of dysphagia in 90-97% of patients. Postoperative dysphagia may be due to either incomplete myotomy or a megaesophagus in “end-stage” achalasia. Workup of postoperative dysphagia requires careful assessment including a Ba-swallow, endoscopy and esophageal manometry and should prompt reconsideration of the underlying diagnosis. Postoperative dilation can be of help, but if esophageal manometry shows clearly an uncut, high-pressure zone at the gastroesophageal junction, reoperation should be considered. Patients with extremely dilated aperistaltic esophagus generally require esophageal replacement. Postoperative fever, is most commonly due to pulmonary atelectases. However, aspiration must be considered, as these patients are at risk for aspiration during the induction of anaesthesia. If aspiration is not likely, respiratory therapy with incentive spirometry is generally an adequate treatment. Antibiotics may be required if aspiration is suspected, if the fever persists and in patients with underlying pulmonary problems. Outcome Cardiomyotomy for achalasia is one of the ideal procedures for the laparoscopic approach. Magnification of the operative field during laparoscopic surgery allows for a precise division of the muscle fibers with excellent results. Over the past 5-7 years, numerous reports of laparoscopic cardiomyotomy have been published. They show good-excellent results, with relief of dysphagia in 90-97% of patients, with minimal morbidity, a short hospital stay and early return to routine activity Thirteen patients affected by achalasia of the esophagus, undergoing esophagocardiomyotomy with Dor gastroplasty, are reported. No postoperative deaths or complications occurred. Overall long-term results were satisfactory: excellent or good in 92.3% of cases, fair in 7.7%. Manometry after esophagocardiomyotomy as compared to preoperative assessment showed a decreased resting pressure in the esophageal body, in all patients in whom it was elevated, and the appearance of some peristaltic waves in 23.1% of them (3 patients). As for lower esophageal sphincter, some relaxation after deglutition was observed in one patient. The 24h pH monitoring showed signs of gastroesophageal reflux only in one patient. Based on the obtained results which compare well with those of the literature, the authors be believe

3/23/2007 11:08:19 AM

148

Minimally Invasive Surgery for Esophageal Achalasia

that the procedure represents an effective treatment of esophageal achalasia (5). Nevertheless, some unsettled questions still exist with respect to laparoscopic Heller myotomy. Firstly, can laparoscopic Heller myotomy be done after pneumatic dilation?Cosentini et al(8) have also shown that the laparoscopic approach is feasible and effective after pneumatic dilation. Therefore, a previous pneumatic dilation should not deter a surgeon from choosing the laparoscopic approach. Secondly can laparoscopic Heller myotomy be done after botulinum toxin injection? Botulinum toxin injection results in fibrosis and obliteration of the submucosal plane between the esophageal mucosa and musculature This results in a much more difficult dissection and a higher incidence of perforation, as demonstrated by the fact that 2 of our 3 intraoperative perforations occurred inpatients receiving these injections. Therefore, as recommended by some gastroenterologists,(2) , botulinum toxin should be reserved for elderly patients who are not surgical candidates. If a patient has already been treated with this method, the surgeon can anticipate a difficult dissection with a high likelihood of mucosal perforation. Thirdly, is laparoscopic Heller myotomy effective for patients with dilated, aperistaltic esophagous? Some have suggested that marked dilated esophagous associated with “sigmoid” changes as demonstrated by a contrast esophagogram is an indication for esophagectomy with gastric or colon interposition. Patti et al24 reported on a group of such patients who have done well after laparoscopic Heller myotomy. Therefore, it would seem reasonable that these patients can be offered a laparoscopic myotomy first; then if this fails, an esophagectomy can be the definitive procedure. Laparoscopic Heller myotomy has comparable success to open Heller myotomy, and causes less early detriment to quality of life. This should be the primary treatment in all fit surgical patients with achalasia.

Nissen fundoplication. Aust N Z J Surg 1981; 51: 48-51 4. Mattioli S, Di Simone MP, Bassi F, Pilotti V, Felice V, Pastina M, Lazzari A, Gozzetti G. Surgery for esophageal Achalasia 5. Fiori E, Leone G, Iascone C, Cangemi V, Piat G Source Panminerva medica. Date of Publication 1994 Sep Esophagocardiomyotomy with Dor gastroplasty in the treatment of esophageal achalasia 6. Spiess AE, Kahrilas PJ. Treating achalasia: from whalebone laparoscopic. JAMA. 1998;280:638-642. 7. Goldblum JR, Whyte RI, Orringer MB, Appelman HD. Achalasia, a morphologic study of 42 resected specimens. Am J Surg Path. 1994;18:327-337 8. Hunter JG, Trus TL, Branum GD, Waring JP. Laparoscopic Heller myotomy and fundoplication for achalasia. Ann Surg. 1997;225:655-665.

References 1. Randomized controlled trial of botulinum toxin versus laparoscopic heller myotomy for esophageal achalasia. Comments Gastroenterology. 2004 Dec;127(6):1850-2. PMID: 1 2. bjÖrck S, Dernevik L, Gatzinsky P, Sandberg N. Oesophagocardiomyotomy and antireflux procedures. Acta Chir Scand 1982; 148: 525-529 3. Tomlinson P, Grant A. A review of 74 patients with oesophageal achalasia: the results of Heller’s cardiomyotomy, with and without

FIAGES Book.indb 148

3/23/2007 11:08:19 AM

18

Laparoscopy in Gastric Outlet Obstruction due to Peptic Ulcer Disease K. Ravindranath Relevant Anatomy The stomach is located mainly in the left upper quadrant beneath the diaphragm and is attached superiorly to the esophagus and distally to the duodenum. The stomach is divided into 4 portions, the cardia, the body, the antrum, and the pylorus. Inflammation, scarring, or infiltration of the antrum and pylorus are associated with the development of Gastric Outlet Obstruction (GOO). The duodenum begins immediately beyond the pylorus and mostly is a retroperitoneal structure, wrapping around the head of the pancreas. The duodenum classically is divided into 4 portions. It is intimately related to the gallbladder, liver, and pancreas; therefore, a malignant process of any adjacent structure may cause outlet obstruction due to extrinsic compression. PUD manifests in approximately 5% of all patients with GOO. Ulcers within the pyloric channel and first portion of the duodenum usually are responsible for outlet obstruction. Obstruction can occur in an acute setting secondary to acute inflammation and edema or, more commonly, in a chronic setting secondary to scarring and fibrosis. Helicobacter pylori has been implicated as a frequent associated finding in patients with GOO, but its exact incidence has not been defined precisely. Pathophysiology Intrinsic or extrinsic obstruction of the pyloric channel or duodenum is the usual pathophysiology of GOO; as previously noted, the mechanism of obstruction depends upon the underlying etiology.

FIAGES Book.indb 149

Patients present with intermittent symptoms that progress until obstruction is complete. Vomiting is the cardinal symptom. Initially, patients may demonstrate better tolerance to liquids than solid food. In a later stage, patients may develop significant weight loss due to poor caloric intake. Malnutrition is a late sign, but it may be very profound in patients with concomitant malignancy. In the acute or chronic phase of obstruction, continuous vomiting may lead to dehydration and electrolyte abnormalities. When obstruction persists, patients may develop significant and progressive gastric dilatation. The stomach eventually loses its contractility. Undigested food accumulates and may represent a constant risk for aspiration pneumonia. Clinical Nausea and vomiting are the cardinal symptoms of GOO. Vomiting usually is described as nonbilious, and it characteristically contains undigested food particles. In the early stages of obstruction, vomiting may be intermittent and usually occurs within 1 hour of a meal. Early satiety and epigastric fullness are common. Weight loss is frequent when the condition approaches chronicity and is most significant in patients with malignant disease. Physical examination often demonstrates the presence of chronic dehydration and malnutrition. A dilated stomach may be appreciated as a tympanic mass in the epigastric area and/or left upper quadrant.

3/23/2007 11:08:19 AM

150

Laparoscopy in Gastric Outlet Obstruction due to Peptic Ulcer Disease

Diagnostic Procedures Upper endoscopy can help visualize the gastric outlet and may provide a tissue diagnosis when the obstruction is intraluminal. The sodium chloride load test is a traditional clinical nonimaging study that may be helpful. The traditional sodium chloride load test is performed by infusing 750 cc of sodium chloride solution into the stomach via a nasogastric tube (NGT). A diagnosis of GOO is made if more than 400 cc remain in the stomach after 30 minutes. Nuclear gastric emptying studies measure the passage of orally administered radionuclide over time. Unfortunately, both the nuclear test and saline load test may produce abnormal results in functional states. Barium upper GI studies are very helpful because they can delineate the gastric silhouette and demonstrate the site of obstruction. An enlarged stomach with a narrowing of the pyloric channel or first portion of the duodenum helps differentiate GOO from gastroparesis. (Figure 1)

Figure 1

The specific cause may be identified as an ulcer mass or intrinsic tumor. In the presence of PUD, perform endoscopic biopsy to rule out the presence of malignancy. Dehydration and electrolyte abnormalities can be demonstrated by routine laboratory examinations. Increases in BUN and creatinine are late features of dehydration. Prolonged vomiting causes loss of hydrochloric (HCl) acid and produces an increase of bicarbonate in the plasma to compensate for the lost chloride and sodium. The result is a hypokalemic hypochloremic metabolic alkalosis. Alkalosis shifts the intracellular potassium to the extracellular compartment, and the serum potassium is increased factitiously. With

FIAGES Book.indb 150

continued vomiting, the renal excretion of potassium increases in order to preserve sodium. The adrenocortical response to hypovolemia intensifies the exchange of potassium for sodium at the distal tubule, with subsequent aggravation of the hypokalemia TREATMENT Patients with GOO due to benign ulcer disease may be treated medically if results of imaging studies or endoscopy determine that acute inflammation and edema are the principle causes of the outlet obstruction (as opposed to scarring and fibrosis, which may be fixed). If medical therapy conducted for a reasonable period fails to alleviate the obstruction, then surgical intervention becomes appropriate. The choice of surgical procedure depends upon the patient’s particular circumstances. Initial management of GOO should be the same regardless of the primary cause. After a diagnosis is made, admit patients for hydration and correction of electrolyte abnormalities. Remembering that the metabolic alkalosis of GOO responds to the administration of chloride is important; therefore, sodium chloride solution should be the initial IV fluid of choice. Potassium deficits are corrected after repletion of volume status, and after the chloride has been replaced. Place a NG tube to decompress the stomach. Occasionally, a large tube is required because the undigested food blocks tubes with small diameters. When acute PUD has been identified as a primary cause of GOO, focus treatment on reduction of acid production. Histamine 2 (H2) blockers and proton pump inhibitors comprise the mainstay of treatment. Treat H pylori infection, when identified, according to current recommendations. Although most patients improve temporarily with treatment, scarring and fibrosis may worsen over time. These patients are likely to present with recurrent GOO. More than 75% of patients presenting with GOO eventually require surgical intervention (Doberneck, 1987). Pneumatic balloon dilatation of a chronic benign stricture can be performed via endoscopy. Published series using this technique report success rates over 76% after multiple dilatations (Lam, 2004). Patients treated with balloon dilatation, without treatment for H pylori infection, have a higher rate of failure and recurrent obstruction (Taskin, 2000). Patients who are negative for H pylori do not respond favorably to balloon dilatation and should be considered for surgical treatment early in the process (Gouma, 1999).

3/23/2007 11:08:19 AM



Preoperative procedures All patients are subjected to a standard operative evaluation. Correct fluid and electrolyte abnormalities prior to surgery. Perform decompression by NGT and suction and alert the anesthesiologist to the potential risk for aspiration upon induction. Perform a preoperative nutritional evaluation and initiate appropriate nutritional therapy (TPN or enteral feedings via a percutaneous jejunostomy placed distal to the obstruction) as soon as possible.

Comprehensive Laparoscopic Surgery

151

portion of right crus is exposed. Posterior Vagus nerve is identified by opening the phrenoesophageal membrane and transected with harmonic scissors. The anterior Vagus nerve is identified on the anterior aspect of lower esophagus. It is important to identify all the branches and lower esophagus cleared of any nerve fibres on both anterior and posterior aspects to ensure that any aberrant nerve of Grassi is not missed. A specimen of both the nerves should be sent for histological confirmation.

Operative Details Surgical intervention usually provides definitive treatment for GOO, but it may result in its own comorbid consequences. Operative management should offer both relief of obstruction and correction of the acid problem. The most common surgical procedures performed for GOO related to PUD are vagotomy and antrectomy, vagotomy and pyloroplasty, truncal vagotomy and gastrojejunostomy, pyloroplasty, and laparoscopic variants of the afore mentioned procedures. Of these, vagotomy and antrectomy with Billroth II reconstruction (gastrojejunostomy) seems to offer the best results. Vagotomy and pyloroplasty and pyloroplasty alone, although used with some success, can be technically difficult to perform due to scarring at the gastric outlet. A combination of balloon dilatation and highly selective vagotomy has been described, but it is associated with gastroparesis and a high recurrence rate. The role of the laparoscopic approach in the treatment of GOO is under investigation and may represent a valid form of therapy with low morbidity. The experience of several international centers has been published. One group in China performed laparoscopic truncal vagotomy and gastrojejunostomy for GOO related to PUD with nearly complete resolution of symptomatology. They reported no conversions to open procedure or mortalities. Twenty-seven percent of patients did experience transiently delayed gastric emptying, which resolved with conservative measures (Sin, 2004). GOO by intractable chronic duodenal ulcer has been successfully treated with bilateral truncal Vagotomy and Stapled Gastrojejunostomy. A standard five port access is used Figure 02. The left lobe of liver is retracted using a fan retractor placed through subxiphoid port. The lesser sac is entered opening the lesser omentum in the pars flaccida, the avascular area located anterior to caudate lobe. Dissection is continued till muscular

FIAGES Book.indb 151

Figure 02

The Gastrojeunostomy must be performed on the greater curvature at the lowest part of antrum as close to pylorus as possible. Figure 03 The second loop of jejunum is identified and approximated to the body of stomach. Two small incisions are made in both stomach and jejunum to allow the endolinear cutter 65 to be introduced. Before firing the instrument the instrument is closed and rolled to ensure that the anastomosis is in a good position .The inner aspect is checked to look for bleeding or inappropriate stappling. The incisions are then closed using sutures or stapler. Postoperative details Admit patients to a monitor unit after the procedure. Pay special attention to fluid and electrolyte status. Most surgeons agree that perioperative antibiotics are advisable but may be limited to use during the immediate perioperative period in the absence of intervening infection. If a gastric reconstruction is performed, an NGT is recommended. The length of time that the NGT should remain in place is controversial; however, remembering that a previously dilated stomach, the performance of a vagotomy, and the presence of metastatic cancer all may contribute to decreased gastric motility is important. An

3/23/2007 11:08:20 AM

152

Laparoscopy in Gastric Outlet Obstruction due to Peptic Ulcer Disease

responses to the H-2 histamine antagonists or the protonpump inhibitors. B. Patient Position and Room Setup We prefer a modified lithotomy position and operate between the legs of the patient. 2. Place the patient in reverse Trendelenburg position and rotate the right side of the table up slightly. 3. The surgeon generally stands on the patient’s left side and the first assistant and scrub nurse stand on the right. 4. Place the monitors at the head of the table and as close as possible. 1.

C. Trocar Position and Choice of Laparoscope Place the cannula for the laparoscope below the umbilicus in short patients and above the umbilicus in tall patients. A 30-degree laparoscope gives the best visualization (1). 2. Place four additional cannulas (5 mm): a. Right subcostal region at the midclavicular line b. Right subcostal region at the anterior axillary line c. Left subcostal region at the midclavicular line d. Epigastric region 1.

Figure 03

anatomically patent gastrojejunostomy may fail to empty for days. This syndrome of delayed gastric emptying is a well-known entity and requires surgical patience. Aggressive pulmonary toilet, deep venous thrombosis (DVT) prophylaxis, and early ambulation are advisable. Follow-up care Closely monitor patients after surgery and upon discharge. After relief of GOO, patients may continue to experience gastric dysmotility and may require medication to stimulate gastric emptying and motility. Closely monitor patients whose treatment consisted of balloon dilatation because most of these patients require subsequent dilatations in order to achieve satisfactory results.

D. Performing the Vagotomy Four types of vagotomy (Figure 4 & 5). 1. Truncal or total abdominal vagotomy divides the main vagal trunks as they emerge through the hiatus. The dissection at the hiatus and mobilization of the esophagus is the same as if performing a laparoscopic Nissen fundoplication. At the esophagogastric junction, incise the peritoneal covering, and isolate a

Laparoscopic Vagotomy A. Indications The indications for a laparoscopic vagotomy is permanent gastric acid reduction in patients who have idiosyncratic

FIAGES Book.indb 152

Figure.4: Cannula placement for laparoscopic vagotomy.

3/23/2007 11:08:22 AM



Comprehensive Laparoscopic Surgery

3- to 4-cm segment of esophagus. a. Identify the anterior vagal trunk as it runs over the anterior surface of the esophagus. b. Divide the trunk and excise a segment for pathologic confirmation. c. Identify the posterior trunk in the space between the esophagus and the right crus of the diaphragm. Divide this trunk, excising a segment for pathologic confirmation. d. Seek out small fibers from the main trunks to the stomach or esophagus and divide these. e. Truncal vagotomy should be accompanied by a drainage procedure such as pyloroplasty or a Gastro-Jejunostomy 2. A selective (total gastric) vagotomy is performed by dissecting the main vagal trunks to the area where the branch to the biliary tree of the anterior

3.

a. b.

c.

d.

e.

f.

4.

Figure 5: Four types of vagotomy. A. Truncal vagotomy produces total abdominal vagal denervation and requires a drainage procedure to prevent gastric stasis. B. Selective vagotomy spares the vagal branches to the liver and small intestine, but produces a total gastric vagotomy. A drainage procedure is required. This vagotomy is rarely performed. C. Highly selective vagotomy (HSV) produces selective denervation of the parietal cell mass. No drainage procedure is needed, as antral innervation is preserved. D. Posterior truncal vagotomy with

a.

153

trunk divides and transecting a section of vagus distal to the hepatic branch. The celiac branch of the posterior trunk is not easy to identify and a truncal vagotomy may be performed. If a selective vagotomy is performed, a drainage procedure is necessary. A selective laparoscopic vagotomy is rarely indicated or performed. A highly selective (superselective, parietal cell, or proximal gastric) vagotomy (HSV) is vagotomy of choice. It selectively deprives the parietal cell mass of vagal innervation and reduces the sensitivity of the parietal cells to stimulation and the release of acid. It does not require a drainage procedure. The branches of the nerve of Latarjet are divided from the esophagogastric junction to the crow’s foot along the lesser curvature of the stomach. The laparoscopic HSV generally begins at the crow’s foot and proceeds cephalad. Retract the stomach caudad and to the left, and identify the crow’s foot termination of the nerves of Latarjet on the gastric antrum. Incise the gastrohepatic ligament and serially divide the branches (beginning at the Crow’s foot) between clips or using ultracission. Continue the dissection superiorly, dividing the anterior leaf of the gastrohepatic ligament. Once the anterior leaf of the gastrohepatic ligament is divided, the posterior branches are divided in a similar fashion. Magnification with the laparoscope makes visualization of the neurovascular bundles easier. The nerve of Latarjet appears as a silvery thin thread; it must be identified and must not be injured. It is important to isolate the branches. Isolate the vagal trunks for a 3- to-4 cm segment along the esophagus. Posterior branches (nerve of Grassi) to the cardia of the stomach must be identified and divided. Posterior truncal vagotomy with anterior seromyotomy (Taylor procedure) is a modification that is technically easier. Perform a posterior truncal vagotomy as previously described. Perform an anterior seromyotomy by creating a partial-thickness incision along the lesser curvature of the stomach. The mucosa should be exposed but not entered. Oversew the area with a continuous suture to prevent a postoperative leak. No drainage procedure is required.

anterior seromyotomy (Taylor operation) preserves the anterior vagal trunk. No drainage procedure is required.

FIAGES Book.indb 153

3/23/2007 11:08:22 AM

154

Laparoscopy in Gastric Outlet Obstruction due to Peptic Ulcer Disease

E. Complications 1. Gastric or esophageal perforation A.Cause and prevention: Gastric perforation may occur from electrocautery injury or by clipping the branch of the nerve of Latarjet on the serosa of the lesser curvature. Prevent this by careful dissection and isolation of the branches of the nerve of Latarjet as well as by avoiding the use of electrocautery. The power setting of the electrocautery should be low but sufficient to coagulate tissue. If a seromyotomy vagotomy is performed, the area should be oversewn with a continuous suture. Esophageal perforation may occur during hiatal dissection, particularly if manipulations are performed blindly. B.Recognition and management: Bleeding on the lesser curvature of the stomach should be controlled by low-power electrocautery or suture ligation. Excessive use of cautery may produce a delayed perforation and the patient may present with intra-abdominal sepsis 2 to 5 days after operation. The perforation can be confirmed by a Gastrografin study. If no leak is seen and the patient is stable or improving, nasogastric decompression may be sufficient. If a leak is demonstrated or a leak suspected and the patient has evidence of peritonitis and is not improving, then exploratory laparotomy is recommended with oversewing of the area of perforation. If the area is too inflamed to close or if distal obstruction is present, a gastric resection and gastrojejunostomy is usually needed.

B.Recognition and management: The patient complains of fullness, bloating, nausea, or vomiting. An upper gastrointestinal barium series usually shows a large stomach with little or no emptying. This is best managed by nasogastric decompressions and parenteral nutrition for several days and restudying the stomach with another barium series. Prokinetic agents and other drugs such as erythromycin may also be effective. If the patient does not empty the stomach well and chronic problems persist, endoscopic balloon dilatation of the pylorus or surgical drainage procedure (pyloroplasty or gastrojejunostomy) may be required. References 1. Katkhouda N, Mouiel J. A new technique of surgical treatment of chronic duodenal ulcer without laparotomy by videocoelioscopy. Am J Surg 1991;161:361–364. 2. Laws HL, Naughton MJ, McKernan JB. Thoracoscopic vagectomy for recurrent peptic ulcer disease. Surg Laparosc Endosc 1992;2:24–28. 3. Legrand M, Detroz B, Honore P, Jacquet N. Laparoscopic highly selective vagotomy. Surg Endosc 1992;6:90. 4. Sages guide lines

2. Delayed gastric emptying A.Cause and prevention: This complication is more common after truncal and selective vagotomy, particularly if a drainage procedure is not performed. If inadvertent truncal vagotomy is performed during HSV (for example, by injury to the main nerves of Latarjet), gastric stasis may also occur. Loss of parasympathetic innervation to the antrum disrupts normal pyloric function. This can be prevented by performing a drainage procedure with truncal and selective vagotomy or by performing the preferred highly selective vagotomy, with care to avoid injury to nerves of Latarjet.

FIAGES Book.indb 154

3/23/2007 11:08:22 AM

19 Laparoscopic Gastrectomy K. Ravindranath Gastric cancer remains among the top 10 causes of cancer-related deaths for both men and women.2 Radical surgical resection of the tumor is the only hope for cure in these patients.2,12 Officially, the first laparoscopic-assisted distal gastrectomy with a Billroth II gastrojejunostomy was performed by Goh et al in 1992, for the treatment of a complicated peptic ulcer.34 The first laparoscopic gastrectomy, with a Billroth II reconstruction, for cancer was performed by Kitano et al in 1992 and published in 1994.35 Subsequently, several authors have reported successful laparoscopic subtotal or total gastrectomy, demonstrating the important postoperative advantages of this procedure. The recommended treatment of distal gastric cancer consists of a radical resection of the distal 4/5 of the stomach with a free margin of 5 to 6 cm.1–3 The extent of the associated lymph node dissection is still debated. Japanese authors suggest an extended dissection with the routine involvement of D1 and D2 lymph nodes, while an even wider (D3 and D4) dissection is advocated in cases of suspected invasion of more distant lymph nodes.4–8 Western authors often prefer a limited dissection (D1) because of the higher operative mortality and morbidity rates associated with extended lymphadenectomy (D2),9–13 even when distal pancreatectomy is avoided, as well as the lack of a significantly improved long-term survival data.14–18 In the past decade, laparoscopic techniques have gained wide clinical acceptance in surgical practice. This approach offers important advantages when compared with open surgery: reduced intraoperative blood loss, reduced postoperative pain and accelerated recovery,

FIAGES Book.indb 155

earlier return to normal bowel function with earlier resumption of oral intake, early discharge from hospital, and lower financial costs.19–22 The same advantages have been reported after laparoscopic subtotal or total gastrectomy for benign tumors as well as early gastric cancers.23–31 However, laparoscopically assisted subtotal gastrectomy for distal gastric cancer can only be justified and widely accepted as a safer alternative to open surgery if equal long-term results are obtained. This would suggest an equivalent radical oncologic resection. Operative Technique of Laparoscopic Distal Subtotal Gastrectomy The procedure is carried out under general anesthesia with endotracheal intubation and epidural analgesia. The patient lies on the table in the supine position, with legs apart and 20° head-up tilt. The surgeon operates in the “French” position with the camera assistant on his left. Figure 01 CO2 pneumoperitoneum is induced after insertion of the first 10/12-mm cannula at the level of the umbilicus, with a open technique. The stomach and the peritoneal cavity are inspected to rule out adjacent organ invasion and peritoneal seeding. Three other trocars are inserted through the abdominal wall, one in the left upper quadrant, one in the right upper quadrant and one in the midline, just below the xyphoid process. At this stage, intraoperative laparoscopic ultrasonography is carried out to scan the liver surface and assess the presence of deep liver metastases.

3/23/2007 11:08:23 AM

156

Lap Gastrectomy

Figure 01

The gastrocolic ligament is divided using the ultrasonic scissors along the border of the transverse colon, thus including the greater omentum in the specimen to be resected. The dissection is continued to the right toward the pylorus to include the group of infra-pyloric lymph nodes (group 6) Figure 02. The right gastroepiploic vessels are divided flush with anterior surface of the pancreas, coagulated and divided by the harmonic scissors to avoid inadvertent compromise of lymph nodes. The lymph nodes along the pancreatoduodenal artery (group 17) may also be removed at this stage. The Kocher maneuver is accomplished, allowing dissection of the retropancreatic nodes (group 13). The first part of the duodenum is dissected and transected with a 35- or 45-mm cartridge endostapler. The lymph nodes of the hepatoduodenal ligament are dissected and removed en bloc. To accomplish the dissection, a cholecystectomy is performed and the elements of the hepatic pedicle (bile duct, left hepatic artery, right hepatic artery, and portal vein) are carefully isolated and encircled with umbilical tapes. Gentle traction on these structures facilitates and expedites the dissection of nodes. The right gastric artery is divided with the ultrasonically activated scissors at its origin from the common hepatic artery. The lymph node dissection is continued to the left along the common hepatic artery (group 8), celiac axis (group 9), left gastric artery (group 7), and proximal splenic artery (group 11b). Residual oozing after lymph node dissection both along the anterior aspect of the pancreas and the lesser omentum is best controlled by argon plasma coagulation. The left gastric vessels are best approached from below after gentle cephalad traction on the stomach with the greater omentum folded up on the anterior aspect of the stomach The vessels are carefully prepared and separately divided The dissection of the gastrocolic ligament is continued

FIAGES Book.indb 156

toward the spleen; the left gastroepiploic artery is divided either with the harmonic scissors or the endostapler; only the first 2 short gastric vessels are divided using harmonic scissors. Before stomach transection, the cardiac nodes are dissected en bloc: the right cardiac nodes (group 1) are approached continuing the line of dissection of lymph nodes along the left gastric artery. Left cardiac nodes (group 2) are not necessarily dissected for cancer of the distal third of the stomach. When dissected, cephalad traction on the stomach and anterior truncal vagotomy ease the removal of lymphatic tissue. The transection of the stomach and resection of the distal 4/5 of the organ are accomplished by multiple endostapler applications (either 35-mm or 45-mm cartridges).

Figure 02

A 50-cm transmesocolic Roux-en-Y loop is prepared and anastomosed side-to-side to the posterior wall of the gastric stump with a single or double application of endostapler (45- vs. 35-mm cartridge). Interrupted intracorporeal sutures close the access opening on the jejunal limb and the gastric stump. A side-to-side jejunojejunal anastomosis at the foot of the Roux-enY loop is fashioned by further endostapler application and, finally, the access opening on the jejunal limbs is sutured. The Billroth II reconstruction is performed similarly: a transmesocolic, isoperistaltic side-to-side gastrojejunal anastomosis on the posterior gastric wall is fashioned by single or double endostapler application, at a distance of 30 cm from the ligament of Trietz. The access opening on the gastric stump and the jejunum is then closed with interrupted 2-0 or 3-0 vicryl sutures. The specimen, inserted into a retrieval bag, is withdrawn through the large-bore cannula.

3/23/2007 11:08:24 AM



Despite these encouraging results, at present, many doubts still remain about the ability, during the video-assisted laparoscopic procedure, to satisfy all the oncologic criteria met during conventional, open surgery in gastric cancer patients. In 1999, Shirasihi et al reported a series of 40 laparoscopic assisted Billroth gastrectomies and lymphadenectomies for early cancer of the antrum and gasrtric body, with no postoperative morbidity and mortality and no recurrence at a mean follow-up of 21 months.24 In addition, Kitano et al did not observe differences in terms of curability, at a mean follow-up of 21.5 months, in their prospective and randomized series.27 In 2003, Weber et al published the results of their comparative study between a series of 12 patients affected with a gastric cancer and treated by a laparoscopic gastrectomy, and a series of 13 matched open controls. They did not observe differences between the groups in terms of stage of disease, radical resection, extent of lymphadenectomy, and 18-month survival rates.37 As far as we know, this is the first prospective and randomized trial comparing 5-year results of subtotal gastrectomy performed for distal gastric cancer with laparoscopic and open approaches. Patients’ characteristics were similar, as demonstrated by the lack of differences in demographics, ASA status, pTNM stage, size, and grading of the tumor. A radical resection was performed in both groups of patients. All specimens were measured at the end of operation, showing a similar length of resection at the level of both lesser and greater gastric curvatures. Free margins of resection were at 5 to 6 cm from the tumor in all patients, as indicated to ensure a low rate of anastomotic recurrence. The mean number of resected lymph nodes was similar in both groups. Thus, the laparoscopic approach did not limit the feasibility of an oncologically correct resection of the gastric tumor and extended lymphadenectomy. Moreover, 5-year overall and free-disease survival rates were not influenced by the surgical approach, confirming the radicality of the laparoscopic resection. As in other laparoscopic procedures, there is important operative and postoperative advantages in LG patients: lower intraoperative blood loss, earlier resumption of oral intake, and earlier discharge from hospital. These results offer a clear answer to our initial question: in experienced hands, laparoscopic-assisted subtotal gastrectomy for distal gastric cancer is a feasible and safe alternative to open, standard gastric resection, with similar short- and long-term results that testify to the oncologic radicality of the procedure. However, laparoscopic gastric surgery is

FIAGES Book.indb 157

Comprehensive Laparoscopic Surgery

157

demanding from a technical point of view, especially when a D2 lymphadenectomy is performed. Adequate training in laparoscopic techniques and procedures is mandatory prior to embarking on a laparoscopic gastrectomy.

REFERENCES 1. Cuschieri A. Gastrectomy for gastric cancer: definitions and objectives. Br J Surg. 1986;73:513–514. [PubMed]. 2. Siewert JR, Sendler A. The current management of gastric cancer. Adv Surg. 1999;33:69–93. [PubMed]. 3. Hioki K, Nakane Y, Yamamoto M. Surgical strategy for early gastric cancer. Br J Surg. 1990;77:1330–1334. [PubMed]. 4. Maruyama K, Gunven P, Okabayashi K, et al. Lymph node metastases of gastric cancer: general pattern in 1931 patients. Ann Surg. 1989;210:596–602. [PubMed]. 5. Maruyama K, Okabayashi K, Kinoshita T. Progress in gastric cancer surgery in Japan and its limits of radicality. World J Surg. 1987;11:418–425. [PubMed]. 6. Noguchi Y, Imada T, Matsumoto A, et al. Radical surgery for gastric cancer: a review of the Japanese experience. Cancer. 1986;64:2053–2062. 7. Kajitani T, Japanese Research Society for the Study of Gastric Cancer. The general rules for gastric cancer study in Surgery and Pathology. Jpn J Surg. 1981;11:127–145. [PubMed]. 8. Cuschieri A, Weeden S, Fielding J, et al. Patient survival after D1 and D2 resections for gastric cancer: long-term results of the MRC randomized surgical trials. Br J Cancer. 1999;79:1522–1530. [PubMed]. 9. Bunt AM, Hermans J, Smit VT, et al. Surgical/pathologic stage migration confounds comparisons of gastric cancer survival rates between Japan and Western countries. J Clin Oncol. 1995;13:19– 25. [PubMed]. 10. Bunt AM, Hermans J, Boon MC, et al. Evaluation of the extent of lymphadenectomy in a randomized trial of Western- versus Japanese-type surgery in gastric cancer. J Clin Oncol. 1994;12:417– 422. [PubMed]. 11. Bonekamp JJ, Songun I, Hermans J, et al. Randomized comparison of morbidity after D1 and D2 dissection of gastric cancer in 996 Dutch patients. Lancet. 1995;345:745–748. [PubMed]. 12. Bonenkamp JJ, Hermans J, Sasako M, et al. Extended lymph-node dissection for gastric cancer. N Engl J Med. 1999;340:908–914. [PubMed]. 13. Wanebo HJ, Kennedy BJ, Wichester DP, et al. Role of splenectomy in gastric cancer surgery: adverse effect of elective splenectomy on long-term survival. J Am Coll Surg. 1997;185:177–184. [PubMed].

3/23/2007 11:08:25 AM

158

Lap Gastrectomy

14. Griffith JP, Sue-Ling HM, Martin I, et al. Preservation of the spleen improves survival after radical surgery for gastric cancer. Gut. 1995;36:68–90.

29. Reyes CD, Weber KJ, Gagner M, et al. Laparoscopic vs open gastrectomy: a retrospective review. Surg Endosc. 2001;15:928– 931. [PubMed].

15. Sasako M. Risk factors for surgical treatment in the Dutch Gastric Cancer trial. Br J Surg. 1997;84:1567–1571. [PubMed].

30. Asao T, Hosouchi Y, Nakabayashi T, et al. Laparoscopically assisted total or distal gastrectomy with lymph node dissection for early gastric cancer. Br J Surg. 2001;88:128–132. [PubMed].

16. Cuschieri A, Fayers P, Fielding J, et al. Postoperative morbidity and mortality after D1 and D2 resections for gastric cancer: preliminary results of the MRC randomized controlled surgical trial. Lancet. 1996;347:995–999. [PubMed]. 17. Bonenkamp JJ, van de Velde CJ. Lymph node dissection in gastric cancer. Br J Surg. 1995;82:867–869. [PubMed]. 18. Fayers PM, Cuschieri A, Fielding J, et al. Sample size calculation for clinical trials: the impact of clinician beliefs. Br J Cancer. 2000;82:213–219. [PubMed]. 19. Schulze S, Thorup J. Pulmonary function, pain and fatigue after laparoscopic cholecystectomy. Eur J Surg. 1993;159:361–364. [PubMed]. 20. Iwanaka T, Arkovitz MS, Arya G, et al. Evaluation of operative stress and peritoneal macrophage function in minimally invasive operations. J Am Coll Surg. 1997;184:357–363. [PubMed]. 21. Gupta A, Watson DI. Effect of laparoscopy on immune function. Br J Surg. 2001;88:1296–1306. [PubMed]. 22. Carter JJ, Whelan RL. The immunologic consequences of laparoscopy in oncology. Surg Oncol Clin North Am. 2001;10:655– 677. 23. Kitano S, Adachi Y, Shiraishi N, et al. Laparoscopic-assisted proximal gastrectomy for early gastric carcinomas. Surg Today. 1999;29:389–391. [PubMed].

31. Azagra JS, Goergen M, De Simone P, et al. Minimally invasive surgery for gastric cancer. Surg Endosc. 1999;13:351–357. [PubMed]. 32. Vacanti CJ, VanHouten RJ, Hill RC. A statistical analysis of the relationship of physical status to postoperative mortality in 63,388 cases. Anesth Analg. 1970;49:564–566. [PubMed]. 33. Lauren P. The two histological main types of gastric carcinoma: diffuse and so called intestinal type carcinomas: an attempt at histo-clinical classification. Acta Pathol Microbiol Scand. 1965;64:31–49. [PubMed]. 34. Goh P, Tekant Y, Kum CK, et al. Totally intra-abdominal laparoscopic Billroth II gastrectomy. Surg Endosc. 1992;6:160. [PubMed]. 35. Kitano S, Iso Y, Moriyama M, et al. Laparoscopy-assisted Billroth I gastrectomy. Surg Laparosc Endosc. 1994;4:146–148. [PubMed]. 36. Goh PM, Alponat A, Mak K, et al. Early results of laparoscopic gastrectomies. Surg Endosc. 1997;11:650–652. [PubMed]. 37. Weber KJ, Reyes CD, Gagner M, et al. Comparison of laparoscopic and open gastrectomy for malignant disease. Surg Endosc. 2003;17:968–971. [PubMed].

24. Shiraishi N, Adachi Y, Kitano S, et al. Indication for and outcome of laparoscopic-assisted Billroth I gastrectomy. Br J Surg. 1999;86:541–544. [PubMed]. 25. Adachi Y, Suematsu T, Shiraishi N, et al. Quality of life after laparoscopic-assisted Billroth I gastrectomy. Ann Surg. 1999;229:49–54. [PubMed]. 26. Adachi Y, Shiraishi N, Shiromizu A, et al. Laparoscopy-assisted Billroth I gastrectomy compared with conventional open gastrectomy. Arch Surg. 2000;135:806–810. [PubMed]. 27. Kitano S, Shiraishi N, Fujii K, et al. A randomized controlled trial comparing open vs. laparoscopy-assisted distal gastrectomy for the treatment of early gastric cancer: an interim report. Surgery. 2002;131(suppl):306–311. 28. Yano H, Monden T, Kinuta M, et al. The usefulness of laparoscopyassisted distal gastrectomy in comparison with that of open distal gastrectomy for early gastric cancer. Gastric Cancer. 2001;4:93– 97. [PubMed].

FIAGES Book.indb 158

3/23/2007 11:08:25 AM

20 Laparoscopic Surgery for Colon and Rectal Cancer Deep Goel, Naresh Garg, V. K. Malik Minimal access surgery has taken a quantum leap in the last decade and a half. Laparoscopic cholecystectomy has been proven beyond doubt to be the “gold standard” in the management of cholelithiasis. Several other laparoscopic procedures have gradually been accepted and are being practiced by surgeons world wide. Laparoscopic fundoplication, splenectomy, adrenalectomy and nephrectomy are to name a few. Since Jacob’s first laparoscopic colectomy in 1991 there are various reports in literature suggesting that minimal access surgery is probably the way forward in colorectal surgery. Inspite of this belief minimal access surgery for colorectal diseases has not gained momentum amongst the surgical fraternity. Further the use of laparoscopy for Colo-Rectal cancers is seen with more skepticism. The factors responsible for such an outlook are discussed in the following article. Steep learning curve Increased time consumed Oncologic safety including port site metastasis Need for a separate incision for specimen retrieval Intra abdominal vascular control We must discuss colonic cancer and rectal cancer as two separate diseases though a lot of concerns are going to be common. Technical ease and oncological results are bigger challenge for laparoscopic rectal cancer surgery as compared to laparoscopic colonic cancer surgery. This is because there is wide operator to operator dependent discrepancy in terms of disease free survival and local recurrence due to varied surgical technique even in open rectal cancer surgery1,2,3.

FIAGES Book.indb 159

Laparoscopy as a tool can be used in two ways. One for thorough abdominal cavity exploration with simultaneous staging of disease with the help of intraoperative ultrasound. Intraoperative ultrasound can diagnose liver metastasis which may have been missed by routine preoperative imaging techniques. This may not alter the plan of resection of primary disease but intent of resection may change. Moreover the decision of excising the secondary disease may depend upon number of secondaries, their position and institutional policy and also the resection of primary disease whether it is curative or palliative. The adequacy of oncologic resection This is probably the most controversial argument put forward by the surgeons with an antagonist school of thought. The oncological principles for laparoscopic surgery performed are the same as that for the open surgery. These involve Appropriate vessel ligation Adequate resection with 5 cm proximal and distal resection margins Radical mesenteric lymphadenectomy Creation of a reliable anastomosis, and Many of these elements have been evaluated in clinical trials and perhaps the most extensively studied factors have been the number of recovered lymph nodes with the surgical specimens and the adequacy of the resection margins. A recent meta-analysis4 reviewed five randomized controlled trials on these issues and found no significant difference between the laparoscopic and the open approach.

3/23/2007 11:08:25 AM

160

Laparoscopic surgery for Colon and Rectal Cancer

A Cochrane Collaboration review of 7 trials comprising of 688 patients5 also found no difference in the total number of the lymph nodes retrieved in the two groups with a p value of 0.86. The European Colon Cancer Laparoscopic or Open Resection Study Group (COLOR) found identical rates of positive resection margins of 2 % between their two groups6 with a p value of 0.86.The UK Medical Research Council trial of Conventional versus Laparoscopic Assisted Surgery in Colo-Rectal Cancer (MRC CLASICC)7 reported nonsignificant positive circumferential resection margins of 7 % and 5 % with p = 0.45 in lap assisted and open resections respectively. In the COST study8, median number of lymph node record were 12 in both arms. The surgical technique of colectomy or proctectomy is of grave importance in terms of disease free survival and local pelvic recurrence. It is technically very challenging for a beginner to be sure of adequacy of resection. The Laparoscopic Colo-rectal surgery has a very steep learning curve, having said that the learning curve for open colorectal surgery also is not very easy. It has been shown in various studies that people doing high volume colorectal surgeries have better results. In the past decade with the rapid evolution of laparoscopy, the advances in the laparoscopic instrumentation and energy devices have allowed surgeons to perform the surgery with greater ease. Laparoscopic colorectal surgery can be done in three ways Purely laparoscopic Laparoscopic assisted 3. Hand assisted laparoscopic surgery (HALS) 1. 2.

Purely laparoscopic surgery will require not only mobilization, but vascular control, division of bowel and restoration of continuity intra-corporially. This may not have any added advantage over laparoscopic assisted technique as you will have to make an incision at the end of the procedure to deliver the specimen. Most people think that if we can utilize this incision for vascular control, resection of bowel and restoration of continuity we can bring down the cost and time of surgery without compromising on advantages of MAS and oncological principles. HALS Another bunch of surgeons feel that if we can put our hand inside abdomen from a convenient incision we can even mobilize bowel, do blunt dissection, retraction and

FIAGES Book.indb 160

control hemorrhage with the help of hand. This not only gives the surgeon sense of security, and tactile feel, but also bridges the gap between laparoscopic surgery and conventional surgery. The short term outcomes of laparoscopy in Colo-rectal cancer The short term outcomes have been studied considering the following aspects Post–operative pain Numerous randomized controlled trials have demonstrated a significant reduction in pain or analgesic requirements in the immediate post-operative period. In a meta-analysis Abraham4 and coworkers found significant advantages for the laparoscopic colectomy group in pain levels at rest and during coughing. Quality of life Exact QOL between two groups is difficult to measure because of lack of more sensitive and appropriate instruments. Therefore based on literature the patients experienced better quality of life with reduced pain in the immediate post-operative period. Recovery of bowel function Faster recovery of bowel function is another significant advantage seen in the laparoscopic group. Schwenk and colleagues5 found that first passage of flatus was 1 day earlier in the laparoscopic colectomy group (p< 0.0001), and the first bowel movement was 0.9 days earlier (p< 0.0001). Lacy and colleagues9 demonstrated faster initiation of peristalsis and oral intake in laparoscopic group. Length of hospital stay Length of hospital stay is often dependent upon bowel function recovery and severity of postoperative pain. There is high level of evidence suggesting laparoscopic group has shorter stay compared with laparotomy group5. Cost Direct costs following the laparoscopic surgery are higher than the open one. However, the diehard supporters of laparoscopic surgery have argued that the total costs to the society may actually be lower considering the improved

3/23/2007 11:08:25 AM



short term and potential long-term outcomes associated with the minimally access approach. Moreover direct cost in the west depends upon the theater time consumed, this is not the case in most of Asian countries5. Long term outcomes The vast majority of comparative studies published so far have found no significant difference in the long term outcomes between the laparoscopic and open resections, and case series have found recurrence in survival data that measure favorably with accepted rates for traditional colon resections. The long term outcomes have been studied considering the following aspects: Tumor recurrence Disease free survival and Overall survival. Lacy and colleagues have published one of the first landmark randomized controlled trials comparing lap assisted and open resections for the colon cancer reporting tumor recurrences rate of 17% and 27 % respectively with a non-significant trend favoring lap resection (P=0.07). Similarly based on an intention-to-treat analysis, the overall mortality rates were not significantly different between the two groups but the cancer related mortality rates favored the laparoscopic group. The Lacy group also demonstrated that the overall advantages found with the laparoscopic approach were attributable to the locally advanced Stage III disease sub-group. The reason is not exactly known but may be related to immune function alteration with laparoscopy. Another case series has demonstrated similar survival advantage for locally advanced disease10. The COST study group demonstrated that laparoscopic colectomy for curable cancer is safe and at least equivalent to open resection in experienced hands. Port site metastases and tumor dissemination In 1993, Alexander and colleagues11 reported a case of wound recurrence after 3 months following laparoscopic right hemicolectomy for a Dukes C adenocarcinoma. After this there were flood of reports of increased port site metastasis with laparoscopy for malignancy. In a critical review of the literature from 2001, Zmora and colleagues12 analyzed total of 16 series of Laparoscopic colo-rectal resections for carcinoma published between 1993 and 2000, each comprising of greater than 50 patients and found an incidence of port site metastases of less than 1 % among 1737 patients. More recently the data from well designed randomized controlled trials have provided

FIAGES Book.indb 161

Comprehensive Laparoscopic Surgery

161

definitive evidence against a higher incidence of port site metastasis in laparoscopic colon surgery compared with traditional resection. The Clinical Outcomes of Surgical Therapy (COST) study8 reported a wound recurrence rate of 0.5% in laparoscopy group compared with a 0.2% in the open group (n=872, P=0.50). Lacy and colleagues13 found a single case of port site recurrence in the laparoscopic group (n=106) as compared to none in the open group (n= 102) after a median follow up of 43 months. Early high incidence of port metastasis was probably because enthusiastic laparoscopic surgeons ignored oncological principles. Another concern is regarding the accidental tumor spillage during laparoscopic colo-rectal resections that is caused by grasping and manipulating the bowel in the narrow pelvis. The prevalence of intraoperative tumor cell dissemination that is caused by iatrogenic tumor perforation or transaction during laparoscopic APR has been reported to be as high as 5%14. At the moment there are few large studies greater than 50 patients and greater than 3 years follow up15. In two series16,17 where patients underwent laparoscopic rectal resection for advanced tumor, local pelvic recurrence rates were 19% and 25%, quite similar to recurrence rate in the open group. In CLASICC trial7, 242 rectal resections were performed and conversion rate ranges from 34% for rectal cancer as opposed to 25% for colonic cancer. Rate of positive margins were not statistically difficult. This clearly demonstrates that laparoscopic rectal resections even in the hands of experienced surgeons is more technically demanding than laparoscopic colonic surgery. Although large randomized, prospective trials may show that experienced laparoscopic colectomists can achieve good outcomes for patients who have curable intraperitoneal colon adenocarcinoma, these results can not be extrapolated immediately to patients who have rectal cancer. Thus it is critical to evaluate immediate pathology and long term oncological results of laparoscopic proctectomy prospectively before recommending the technique for mass consumption. Summary In the last decade and a half, there has been a rapid technical advancement in laparoscopic techniques to treat colo-rectal cancer, as surgeons have sought to make laparoscopic colectomy and proctectomy more and more routine. In addition to the advances in laparoscopic instrumentation and energy delivery, improvement in hand assist technology have allowed surgeons to approach

3/23/2007 11:08:25 AM

162

Laparoscopic surgery for Colon and Rectal Cancer

laparoscopic proctectomy with better tools. Large randomized, prospective trials have shown that laparoscopic colectomists in the hands of experienced surgeons can achieve good outcomes for patients who have curable intraperitoneal colon adenocarcinoma. These results can not be extrapolated immediately to patients who have rectal cancer. Laparoscopic proctectomy should remain in the hands of well trained, high volume, experienced surgeons who have built a dedicated team for treatment of these patients and who follow them prospectively.

References 1. Read TE, Myerson RJ, Fleshman JW et al. Surgeon specialty is associated with outcome in rectal cancer treatment. Dis Colon Rectum 2002;45:904-14. 2. Porter GA, Soskolne CL. Yakimets WW et al. Surgeon-related factors and outcome in rectal cancer. Ann Surg 1998;227:15767. 3. McArdle CS, Hole D. Impact of variability among surgeons on postoperative morbidity and mortality and ultimate survival. BMJ 1991;302:1501-5. 4. Abraham NS, Young JM, Solomon MJ. Meta-analysis of shortterm outcomes after laparoscopic resection for colorectal cancer. Br J Surg 2004;91:1111-24. 5. Schwenk W, Haase O, Neudecker J et al. Short term benefits of laparoscopic colorectal resection. Cochrane Database Syst Rev 2005;(3):CD003145. 6. The Colon Cancer Laparosocpic or Open Resection Study Group. Laparoscopic surgery versus open surgery for colon cancer: shortterm outcomes of a randomized trial. Lancet Oncol 2005;6:47784. 7. Guillou PJ, Quirke P, Thorpe H et al. Short-term endpoints of conventional versus laparoscopic-assisted surgery in patients with colorectal cancer (MRC CLASICC Trial): multicentre, randomized controlled trial. Lancet 2005;365:1718-26. 8. The Clinical Outcomes of Surgical Therapy Study Group. A comparison of laparoscopically assisted and open colectomy for colon cancer. N Engl J Med 2004;350:2050-9. 9. Lacy A, Garcia-Valdecasas J, Delgado S et al. Postoperative complications of laparoscopic-assisted colectomy. Surg Endosc 1996;11:119-22. 10. Poulin EC, Mamazza J, Schlachta CM et al. Laparoscopic resection does not adversely affect early survival curves in patients undergoing surgery for colorectal adenocarcinoma. Ann Surg 1999;229:487-92.

12. Zmora O, Gervaz P, Wexner SD. Trocar site recurrence in laparoscopic surgery for colorectal cancer: myth or real concern? Surg Endosc 2001;15:788-93. 13. Lacy AM, Garcia-Valdecasas JC, Delgado S, et al. Laparoscopyassisted colectomy versus open colectomy for treatment of non-metastatic colon cancer: a randomized trial. Lancet 2002;359:2224-9. 14. Kockerling F, Rose J, Schneider C et al. Laparoscopic colorectal anastomosis: risk of postoperative leakage. Results of a multicenter study. Laparoscopic Colorectal Surgery Study Group (LCSSG). Surg Endosc 1999;13:639-44. 15. Morino M, Parini Uneventful., Giraudo G et al. Laparoscopic total mesorectal excision: a consecutive series of 100 patients. Ann Surg 2003;237:335-42. 16. Fleshman JW, Wexner SD, Anvari M, et al. Laparoscopic vs. open abdominoperineal resection for cancer. Dis Colon Rectum 1999;42:930-9. 17. Lezoche E, Feliciotti F, Paganini AM et al. Results of laparoscopic versus open resections for non-early rectal cancer in patients with a minimum follow-up of four years. Hepatogastroenterology 2002;49:1185-90. 18. Fowler DL, White A. Laparoscopy-assisted sigmoid resection. Surg Laparosc Endosc 1991;1:183-8. 19. Lacy A. Colon cancer: laparoscopic resection. Ann Oncol 2005;16(Suppl 2):ii88-95. 20. Milsom JW, Bohm B, Hammerhofer KA, et al. A prospective, randomized trial comparing laparoscopic versus conventional techniques in colorectal cancer surgery: a preliminary report. J Am Coll Surg 1998;187:46-57. 21. Kaiser AM, Kang JC, Chan LS et al. Laparoscopic-assisted versus open colectomy for colon cancer: a prospective randomized trial. J Laparoendosc Adv Surg Tech A 2004;14:1062-6. 22. Pietrabissa A, Moretto C, Carobbi A et al. Hand-assisted laparoscopic low anterior resection: initial experience with a new procedure. Surg Endosc 2002;16:431-5. 23. Viithiananthan S, Cooper Z, Betten K et al. Hybrid laparoscopic flexure takedown and open procedure for rectal resection is associated with significantly shorter length of stay than equivalent open resection. Dis Colon Rectum 2001;44:927-35. 24. Yamamoto S., Watanabe M, Hasegawa H et al. Prospective evaulation of laparoscopic surgery for rectosigmoidal and rectal carcinoma. Dis Colon Rectum 2002;45:1648-54. 25. Monson JR, Darzi A, Carey PD et al. Prospective evaluation of laparoscopic-assisted colectomy in an unselected group of patients. Lancet 1992;340:831-3.

11. Alexander RJ, Jaques BC, Mitchell KG. Laparoscopically assisted colectomy and wound recurrence. Lancet 1993;341:249-50.

FIAGES Book.indb 162

3/23/2007 11:08:25 AM

21 Laparoscopic Splenectomy Abhay N. Dalvi Introduction When Philippe Mouret presented the report of first laparoscopic cholecystectomy in April 1989 (Society of American Gastrointestinal and Endoscopic Surgeons, Louisville, Kentucky), shock and disbelief were the initial reactions.1 Improvement in laparoscopic skills and boom in technology since then has revolutionized the world of general surgeons into the world of laparoscopic surgeons, applying this technique to almost all procedures including splenectomy. Delaitre and Maignien first reported a successful laparoscopic splenectomy (LS).2 The procedure over the last decade has been accepted as the gold standard for indications like Idiopathic Thrombocytopenic Purpura (ITP) and has been extended to larger and complicated spleens faced by surgeons in various hematological and non-hematological disorders. Indications and Contraindications ITP is the commonest indication for laparoscopic splenectomy. Hereditary spherocytosis, thrombotic thrombocytopenic purpura and others hematological disorders follow. Hodgkin’s and non-Hodgkin’s lymphomas,3 and chronic lymphocytic leukemia,4 are reported frequently in literature, performed to manage the complications of hypersplenism, debulk disease, and improve response to chemotherapy or for symptomatic splenomegaly.5 Patients with non-Hodgkin’s lymphoma almost never require staging. Patients with Hodgkin’s disease who have diffuse disease (stages III and IV) will all receive chemotherapy. Likewise, patients with limited

FIAGES Book.indb 163

disease (stage I) are usually treated with radiotherapy. Some patients with stage II disease will require surgical staging, which should be performed laparoscopically and will be an indication for splenectomy.6 Literature review reveals that laparoscopic splenectomy is possible in patients when splenectomy is indicated. Contraindications are proportional to surgeon’s experience and expertise. Absolute contraindications to the laparoscopic approach include severe cardiopulmonary disease and other co-morbid conditions making laparoscopic or even open splenectomy impossible to perform. Relative contraindications may include large spleens, trauma, portal hypertension, aneurysms of splenic pedicle, pregnancy, previous abdominal surgery and few others. Massive spleens greater than 4000 gm have been tackled laparoscopically,7 though Terrosu et al8 report higher incidence of conversion, bleeding and morbidity in spleens greater than 2000 gm. Experienced surgeons have reported a successful laparoscopic splenectomy for trauma.9,10 Hashizume et al11 have reported 42 successful splenectomies in cases of cirrhosis with portal hypertension. LS in pregnancy and aneurysms have been reported. Upper abdominal surgery, that had been a relative contraindication has been circumvented by the use of the open technique. Significant obesity is not a contraindication. On the contrary, the post-surgical consequences of open surgery in obese patients often merit the extra laparoscopic effort in these patients. The bottom line that the surgeon has to understand here is “one should know the limitations and convert as early as possible.”

3/23/2007 11:08:26 AM

164

Laparoscopic Splenectomy

Though all indications given in standard textbooks of surgery have been conquered by laparoscopy, the reported frequent indications are: 1. ITP 2. Hereditary Spherocytosis 3. Hodgkins and Non-Hodgkins lymphoma 4. Isolated indications Advances in technology and its success in splenectomy The Harmonic Shears This instrument is possibly the best advance in the practice of laparoscopic and even open surgery. The blades of the working instrument oscillate at 55,000 cycles per second generating local heat in between blades. This induces coagulation of proteins (hemostasis) and helps in cutting of tissues and vessels being dissected. Lateral thermal spread is limited to less than 2 mm, allowing the use of the instrument in difficult spaces like the space between the gastric fundus and the spleen. One should be careful however in using this instrument to seal vessels over 4 mm. Another precaution to be kept in mind that the vessels sealed by this instrument should not be handled as they tend to open and bleed. The harmonic shears has certainly reduced operative time and has lessened blood loss during surgery.

During laparoscopic splenectomy, the pedicle could be transected en bloc, with a single application of a 3-cm vascular linear laparoscopic stapler. Complications such as bleeding occur, but are mostly due to inappropriate technique. Handport Massively enlarged spleens are heavy and difficult to manipulate by thin and nimble laparoscopic instruments. Handport (Lapdisc) is an adjustable device that fits the incision and prevents gas leaks during manipulation, and at rest. Incision is often required for delivery as these are difficult to place in bags. Morcellation may also be contraindicated. Alternatively, when a counter-incision for intact removal of an enlarged spleen is anticipated, placement of the incision can be planned to facilitate surgery with the “hand-assisted” technique.12 Having the hand inside of the abdomen provides the all important touch perception, helps retraction and dissection, control of bleed in necessity and retrieval of the specimen and is a suggested procedure of choice in splenomegaly.13 Pfannenstiel incision is less painful than conventional subcostal incision and is the preferred incision in hand assisted laparoscopic splenectomy.

The Vascular Endostaplers The use of staplers in open surgery has been well known. The same has now been extended to laparoscopy. Intestinal as well as vascular endoscopic staplers are available and can be used in variety of indications.

FIAGES Book.indb 164

The Ligasure Ligasure (Ligasure vessel sealing system) is a new device that imparts precise amount of bipolar energy and pressure to tissue achieving permanent seal. The device can and has been used not only to seal smaller vessels but also the main splenic pedicle with success.14

3/23/2007 11:08:28 AM



Comprehensive Laparoscopic Surgery

165

Preoperative evaluation and preparation Imaging Ultrasonography should be performed on patients with Hereditary Spherocytosis to identify cholelithiasis. Imaging techniques can only mark a pathway to the size of the spleen and possibly accessory spleens. They do not predict the risk of conversion to open surgery. CECT scans were performed to evaluate size of spleen, prediction of conversion and to detect accessory spleens. This has however been given up.17,18 The Use of Needlescope

Splenic Artery Embolization

Tagaya N et al15 have reported three successful laparoscopic splenectomies using a 2 mm telescope. They used three 2 mm ports for telescope and instruments and one 12 mm port for retrieval.

Preoperative embolization of the splenic artery was advocated in large spleens to decrease blood loss during surgery and operative time.19 This method has its own complications (severe presurgical pain, migration of coils, and splenic abscesses) and has been abandoned by most authors.19 Preoperative Preparation In elective situations, all patients should receive polyvalent pneumococcal and Haemophilus influenzae type B vaccinations 2 -3 weeks before surgery. Blood and blood products are essential in taking care of unexpected complications. Technique Position and approach:

The Robotics Use of robotics, though in its infancy in surgical applications have also been successfully applied in laparoscopic splenectomy by Chapman et al.16

All the positions - supine, lateral and angled have been described. The initial literature describes supine position for laparoscopic splenectomy.20 Lateral and angled positions are preferred today. Surgeons who use endostaplers for pedicle transection seem to prefer lateral position. The angled or the partial right lateral position is amenable to urgent conversion to laparotomy if severe hemorrhage occurs and is our preferred position. Two approaches are described: 1. Anterolateral approach 2. Posterior or Posterolateral approach In the anterolateral approach (also known as the “hanging spleen technique”), effect of position and gravity after the dissection of the gastrocolic ligament retracts the viscera and exposes the pancreatic tail and the splenic pedicle.

FIAGES Book.indb 165

3/23/2007 11:08:28 AM

166

Laparoscopic Splenectomy

There is direct access to the splenic artery and vein. The splenic artery can be ligated early in the procedure. Early ligation is supposed to reduce the size and decrease blood loss during surgery. The splenophrenic ligament is the last to be tackled. Despite the 6% incidence of benign pancreatic reaction21,22 and a slightly higher risk of pancreatic injury (9.5%),23 we feel that the procedure does not handle the spleen as much as in posterior approach and in event of conversion, it is easier to tackle the spleen in the same position. Accessory spleens are also easy to look for in this technique. Hence, this is the preferred approach in literature. The posterior (“posterolateral detached spleen”) technique was described by Gagner et al.24 In this approach, the spleen is retracted medially after dividing the splenophrenic and splenorenal ligaments. The pancreatic tail is visualized and so is the splenic pedicle. The approach is reported to have a lesser incidence of pancreatic complications and bleeding.25 This approach requires experience with retroperitoneal laparoscopic dissection technique unfamiliar to an average laparoscopic surgeon as most are trained in open splenectomy by transabdominal technique. The Procedure - Anterolateral approach Carbon dioxide insufflation is created using a Veress needle at umbilicus or open technique at preplanned port site and maintained at 12 mm Hg to 14 mm Hg. The port placement The success story to any laparoscopic procedure lies in accurate port placement. Though books mention ports related to fixed anatomical landmarks, we feel that the port placement be planned after examining the inflated abdomen and the splenic size. The Indian abdomen varies from that of patient from West. The main objective of port placements should be to tackle the splenic pedicle easily. The author normally advocates 4 ports. 1. For the telescope (30 degree) - This port is probably the most important. It usually lies along the line joining the umbilicus and the costal margin in the midclavicular line. 2. Two working ports would lie on either side of the telescope. 3. The fourth port lies in the left anterior or midaxillary line to retract the spleen and use suction when necessary. Care should be taken to place this port so that the port is away from the spleen as well as the working port.

FIAGES Book.indb 166

4.

A fifth port may be required in cases of enlarged spleen or hanging left lobe of liver at the xiphisternum.

Laparoscopic splenectomy is performed in following stages: 1.

Division of the gastrocolic ligament including the short gastric vessels,

2.

Retraction of splenic flexure of the colon by dividing the splenocolic ligament

3.

Control of the splenic pedicle

4.

Hilar dissection

5.

Division of the splenorenal ligament and attachment to the diaphragm

1. Division of gastrocolic ligament including the short gastric vessels The stomach is retracted to the right and the gastrocolic ligament opened. The ligament is divided using monopolar or bipolar electrocautery, clips or harmonic shears. We find that careful use of monopolar coagulation (small intermittent bursts of current) is usually sufficient even for short gastric vessels in an average Indian patient. When lateral thermal spread is a worry specially in the region of the fundus of the stomach and upper pole of the spleen (the two can be awesomely close), or short gastric vessels are of larger caliber than expected, bipolar or clips come in handy. Harmonic shears scores over all these modalities. On opening the gastrocolic and gastrosplenic ligament, the splenic pedicle behind the pancreatic tail is inspected. The spleen is also evaluated for notching of the anterior border, which correlates with a distributed hilar vasculature and is predictive of the level of difficulty. Inspection is also performed for accessory spleens at this stage. It is advantageous to keep some amount of gastrosplenic ligament on the side of splenic hilum so that the same may be handled to retract the spleen laterally when necessary. 2. Retraction of splenic flexure of the colon by dividing the splenocolic ligament The splenocolic ligament is next dissected bringing down the splenic flexure of the colon. The position of the patient and effect of gravity now keeps away the colon from the operative field.

3/23/2007 11:08:28 AM



Comprehensive Laparoscopic Surgery

167

3. The Splenic pedicle Michels (1942) described the importance of distributed and magesterial pattern of arterial supply to the spleen.26 In the distributed pattern, multiple branches arise from the main trunks before entering the spleen, while in the magesterial pattern the artery enters the hilum as a bundle with the vein. The artery is easily located along the superior border of the pancreas (even in obese patients) due to its pulsations. Incision on the visceral peritoneum over this artery makes the dissection easy. The arterial interruption can be achieved using suture knotting, clips, and endostaplers or even using the newer modalities like Ligasure. The author uses intracorporeal knotting as primary modality with clips to ensure secure ligation. There are two described ways of tackling the splenic artery. One is to ligate the splenic artery early in the procedure while others take the branches of the artery while the dissection proceeds along the hilum of the spleen. Early ligation of the vessel is supposed to decrease the size of spleen and cause lesser hemorrhage. Interruption of artery soon changes the colour of the spleen from brown to blue and is a useful indicator of progress of the procedure. If colour of any part of the spleen remains unchanged, it should indicate a separate arterial supply to that part and meticulously looked for during further dissection. We have found this approach satisfying in our experience. The splenic vein is tackled as a part of hilar dissection. In patients where magistral pattern is encountered, endoscopic vascular staplers are used to tackle the completely dissected pedicle en-block in Western countries.

As the dissection proceeds superiorly, one may find a separate pedicle supplying the upper pole or even supply from the pancreatic bed. These also require clipping or shearing using harmonic scalpel.

4. Hilar dissection and the splenic vein The hilar dissection starts at the lower pole of the spleen and proceeds superiorly staying close to the medial surface. This decreases the chances of injury to the pancreas. In enlarged spleens, the tail of the pancreas can come dangerously close to the hilum and make matters worse. Lower polar vessels are often constant and require clips or harmonic shear. The splenic vein is usually a conglomerate of two tributaries. There is a very thin fascia covering the anterior aspect of the vein that needs careful dissection. Entering the correct plane between this fascia and the vein is the key to successful dissection. This is particularly true as the vein is a thinwalled structure that can be easily injured. The splenic vein is interrupted in a similar manner as described for the artery.

Summary

FIAGES Book.indb 167

5. Division of the splenorenal ligament and attachment to the diaphragm Once the hilar dissection is complete, the spleen is detached from the diaphragmatic and renal ligamentous attachments using electrocautery or harmonic shears. 6. Delivery of the spleen The spleen is delivered by use of commercially available puncture resistant bags. The bags are delivered out through one of the ports and the spleen morcellated before removal. Care should be taken that there are no punctures in the bag and spillage into the peritoneal cavity. Enlarged spleens are difficult to place in the bags and may require incision for removal. Pathologists sometimes require the entire specimen for reporting. We have been as a routine, employing Pfannenstiel incision of extraction of the spleen due to larger spleens encountered. Drain is placed after confirming hemostasis in the splenic fossa and ports are closed. Complications The complications of laparoscopic splenectomy as a procedure are the same as that of open splenectomy ranging from intraoperative bleeding, postsplenectomy sepsis, wound/port site infection and pancreatic injury. Most of the complications are technique related.27 Higher pancreatic complications23 like pancreatic injury has been a matter of debate, with a higher incidence as compared to open procedure.

Laparoscopic splenectomy is not difficult if one has experience in open splenectomy. Knowledge of anatomy and experience in laparoscopy are key to success. With practice, patience, determination and low threshold for conversion, the procedure is easy to learn. Pace DE et al28 report no difference in the outcome in this procedure when trained staff were compared to fellows in training. The procedure of laparoscopic splenectomy has the same benefits of minimal invasive surgical techniques as against open surgery and should become the surgeon’s procedure of choice soon in our country.

3/23/2007 11:08:29 AM

168

Laparoscopic Splenectomy

References 1. Vitale GC, Sanfilippo JS, Perissat J. Laparoscopic Surgery: An Atlas for General Surgeons. J. B. Lippencott Company, Philadelphia. 1995. pp 23-25 2. Delaitre B, Maignien B: Splenectomie par voie coelioscopique: 1 observation. Presse Med 20:2263, 1991 3. Schwartz SI: Role of splenectomy in hematologic disorders. World J Surg 20:1156, 1996 4. Delpero JR, Houvenaeghel G, Gastaut JA, et al: Splenectomy for hypersplenism in chronic lymphocytic leukaemia and malignant non-Hodgkin’s lymphoma. Br J Surg 77:443, 1990 5. Kathkouda N, Mavor E. Laparoscopic Splenectomy. In Surg Clin North Amer August 80(4):1285-98; 2000 6. Lefor AT. Laparoscopic intervention in lymphoma management. Semin Laparosc Surg 7(2):129-39; 2000 7. Kercher KW, Mathew BD, Walsh RM, Sing RF, Bachus CL, Heniford BT. Laparoscopic splenectomy for massive splenomegaly. Am J Surg 183(2):192-6; 2002 8. Terrosu G, Baccarani U, Bresdola V, Sistu MA, Uzzau A, Bredola F. Impact of splenic weight on laparoscopic splenectomy for splenomegaly. Surg Endosc 16(1):103-7, 2002 9. Ren CT, Salky B, Reiner M. Hand-Assisted Laparoscopic Splenectomy for ruptured spleen. Surg Endosc 15(3):324; 2001 10. Mostafa G, Mathur BD, Sing RF, Prickett D, Heniford BT. Elective laparoscopic splenectomy for Grade III splenic injury in an athlete. Surg Laparosc Endosc Percutan Tech 12(4):283-6; 2002 11. Hashizume M, Tonikava M, Akahoshi T, Tanoue K, Gutoh K, Konishi K et al. Laparoscopic splenectomy for portal hypertension. Hepatogastroenterology 49(45):847-52; 2002.

17. Katkhouda N, Waldrep DJ, Feinstein D, et al: Unresolved issues in laparoscopic splenectomy. Am J Surg 172:585, 1996 18. Katkhouda N, Hurwitz MB, Rivera RT, et al: Laparoscopic splenectomy: Outcome and efficacy in 103 consecutive patients. Ann Surg 228:568, 1998 19. Poulin EC, Thibault C, Mamazza J: Laparoscopic splenectomy. Surg Endosc 9:172,1995 20. Hashizume M, Sugimachi K, Kitano S, Shimada M, Baba H, Ueno K et al. Laparoscopic Splenectomy. Am J Surg 167:611-4; 1994. 21. Gigot JF, de Goyet JV, Van Beers BE, et al: Laparoscopic splenectomy in adults and children: Experience with 31 patients. Surgery 119:384, 1996 22. Tsiotos G, Schlinkert RT: Laparoscopic splenectomy for immune thrombocytopenic purpura. Arch Surg 132:642, 1997 23. Chand B, Walsh RM, Ponsky J, Broody F. Pancreatic complications of laparoscopic splenectomy. Surg Endosc 15(1):1273-6, 2001 24. Park A, Gagner M, Pomp A: The lateral approach to laparoscopic splenectomy. AmJSurg173:126,1997 25. Gossot D. Laparoscopic Splenectomy: Value of posterior approach. Ann Chir 52(9):941-5; 1998 26. Michels NA: The variational anatomy of the spleen and splenic artery. Am J Anat 70:21,1942 27. Tagarona EM, Espart JJ, Bombuy E, Vidal O, Antigas V, Trias M. Complications of laparoscopic splenectomy. Arch Surg 135(10):1137-40; 2000 28. Pace DE, Chiasson PM, Schlachta CM, Mamazza J, Poulin EC. Laparoscopic surgery: Does the training of minimal invasive surgery fellows affect outcome. Surg Endosc 16(6):954-6; 2002.

12. Romanelli JR, Kelly JJ, Litwin DE. Hand-Assisted Laparoscopic Surgery in US: an overview. Semin Laparosc Surg 9(2):96-103; 2001 13. Tagarona EM, Balague C, Cedan G, Espert JJ, Lacy AM, Visa j et al. Hand-Assisted Laparoscopic splenectomy (HALS) in cases of splenomegaly: a comparative analysis with conventional laparoscopic splenectomy. Surg Endosc 16(3):426-30, 2002. 14. Romano F, Caprotti R, Franciosi C, Fina S, Colombo G, Uggeri F. Laparoscopic splenectomy using ligasure. Surg Endosc 16(11):1608-11;2002 15. Tagaya N, Rokkaku K, Kubota K. Splenectomy using a completely needlescopic procedure: report of 3 cases. J Laparoendosc Adv Surg Tech A 12(3):213-6; 2002 16. Chapman WH 3rd, Albrecht RJ, Kim VB, Young JA, Chitwood WR Jr. Computer-Assisted Laparoscopic Splenectomy with the da Vinci trademark robot. J Laparoendosc Adv Surg Tech A 12(3):155-9; 2002

FIAGES Book.indb 168

3/23/2007 11:08:29 AM

22 Laparoscopic Urological Surgery Rajesh Ahlawat If someone were to name the three revolutionary innovations in the history of surgery, these would be the discovery of antisepsis, the development of anesthesia, and the advent of minimally invasive surgery. The ultimate goal of minimally invasive surgery is to present an alternative to open surgery with equal rewards and decreased morbidity. Conventional laparoscopy offers the advantages of decreased postoperative pain, shorter convalescence, and improved cosmesis. Cortesi reported the first use of laparoscopy for urology surgery as a diagnostic tool in a patient with undescended testes in 1976, but its use for a therapeutic procedure was not noted till Clayman completed the first laparoscopic nephrectomy in 1990. This novel technique, which reproduces the principles of open surgery, has dramatically improved patient outcomes by only changing the operative approach. Basic approach Laparoscopic access for urologic applications may be obtained through several routes viz. transperitoneal, retroperiponeal and extraperitoneal. The issue of the optimal surgical approach in urologic laparoscopy is still controversial and many unanswered questions still remain. Early experience with urologic laparoscopy consisted almost exclusively of transperitoneal procedures. For many surgeons, this approach remains the gold standard for the operative approach of the upper urinary tract. The arguments justifying this view are 1.

A larger working space and thus an easier entrapment of large operative specimens.

FIAGES Book.indb 169

More familiar anatomic landmarks, thus the learning curve is shorter. 3. Anteriorly situated tumors, crossing vessels during pyeloplasty, are managed more easily. 2.

Although trans-peritoneal anatomy may be more familiar to general surgeons, Urologists are well familiar with retroperitoneal anatomy. Retroperitoneal laparoscopy does not seem to be more technically challenging than the transperitoneal counterpart. The retroperitoneal approach has also been claimed to have shorter operative duration. Avoiding the opening of the peritoneal cavity may also ameliorate postoperative comfort and diminish postoperative sequels such as intraperitoneal adhesion formation. The advent of hand-assisted laparoscopy has provided a new minimally invasive alternative for the treatment of a variety of renal conditions requiring surgical intervention. Hand-assisted laparoscopy uses a unique approach that combines the aspects of open surgery with those of conventional laparoscopy, expanding the indications for laparoscopy and bridging the gap between open surgery and conventional laparoscopy. Hand-assisted laparoscopy may represent the pragmatic choice for the established urologist in practice, for whom a formal laparoscopic training is unrealizable. Insertion of the non-dominant hand into the operative field enables the surgeon to overcome some of the obstacles associated with conventional laparoscopy, such as loss of proprioception, tactile sensation, and spatial orientation. Arguments against HAL is the cost of the port, and the 7 cm incision required to place this port even in patients not requiring retrieval of a large specimen. Other

3/23/2007 11:08:29 AM

170

Laparoscopic Urological Surgery

drawback of the HAL approach is that it does not help to acquire and maintain advanced laparoscopic skills, which are necessary for complex reconstructive procedures such as pyeloplasty or radical prostatectomy. Specific applications for benign diseases: Laparoscopic simple nephrectomy Virtually all benign urologic conditions have been impacted with laparoscopic surgery. Since Clayman’s first laparoscopic nephrectomy in 1990, laparoscopic simple nephrectomy has become the most common urologic laparoscopic procedure. All benign conditions requiring nephrectomy (table 1) have been dealt with

Table 1. Indications for laparoscopic simple nephrectomy Renovascular disease Ureteropelvic junction/ureteral obstruction Reflux nephropathy Stone disease Renal dysplasia Renal tuberculosis Xanthogranulomatous pyelonephritis Polycystic kidney disease Native nephrectomy before renal transplant

laparoscopically. Although laparoscopic removal of small atrophic kidneys are ideally suited for the less experienced surgeon, simple nephrectomy remains as one of the great misnomers in urologic surgery. Simple by no means equates to uncomplicated nephrectomy, particularly in situations in which dense inflammation and fibrosis could pose immense challenges toward surgical dissection. Patients with xanthogranulomatous pyelonephritis (XGP), tuberculous nephritis, and prior renal surgery should be reserved for the most experienced laparoscopic surgeons. These patients should be counseled regarding the increased likelihood of complications and possible open conversion. To date, more than 2000 cases of laparoscopic nephrectomy for benign disease have been reported in the literature. Among these, approximate equal numbers have been done via the transperitoneal and retroperitoneal approaches. Review of retrospective studies comparing the two approaches did not demonstrate significant differences in most outcome measures (Table 2). There is no randomized study comparing transperitoneal with retroperitoneal simple nephrectomy, as has been done for radical nephrectomy (1). The radical nephrectomy study indicated shorter operative time with the retroperitoneal approach, with no other differences in postoperative parameters. Overall, no consistent advantages for either approach with respect to operative time, estimated blood loss, conversion rate, and major complications are observed across the different series. Whereas there are theoretical advantages and disadvantages for either

Table 2. Outcomes in some series of laparoscopic nephrectomy for benign disease Study Year

Number of cases

Approach

Mean OR time

Mean EBL, mL

Conversions (%)

complications, (%)Major

Poulsen et al. 2005* (2)

103

TP and RP

190

150

7 (6.7%)

2 (1.9%)

Gupta et al. 2004 (3)

351

RP

98

65

4 (1%)

4 (1%)

Rassweiler et al. 1998**(4)

482

TP and RP

188

46 (9.4%)

29 (6%)

Gill 1998 (5)

36

RP

263

117

2 (5.6%)

0

* Include 39 radical nephrectomies and 23 nephroureterectomies for malignancy. ** Include 38 radical nephrectomies for malignancy. EBL — estimated blood loss; OR — operating room; RP — retroperitoneal; TP — transperitoneal.

FIAGES Book.indb 170

3/23/2007 11:08:29 AM



Comprehensive Laparoscopic Surgery

approach depending on patient characteristics and specific indication, surgeon experience and preference remains the primary driving force. Donor nephrectomy Open donor nephrectomy has been a viable and safe option for over 30 years but carries the morbidity of a relatively large open incision and a long convalescence period. Lack of living donor has been the major cause of ever increasing waiting list of renal transplantation recipients. Ratner in 1995 performed the first laparoscopic live donor nephrctomy (LDN), extracting the kidney through a nine inch midline incision. Within next 10 years, LDN became the gold standard. Success of this operation has impacted favourably to increasing the willingness to donate and thus increasing the donor pool. Ratner reported a greater than 100% increase in live related renal transplants in their center since starting the laparoscopic donor nephrectomy. In our personal single center experience with 384 LDNs since 2000 (mean age 41, range 20 to 78 years, males: female 142:242). Operative time was 170±50.7 min and blood loss was 257±74 ml. Warm ischemia was 3.6 min. Donor’s vascular anomalies included multiple arteries in 32 (double 21, polar 11) and venous anomalies in 20, none requiring conversion to open surgery. Procedure was converted to open in 4 patients, all in first 100 cases. Drop in serum creatinine and estimated GFR postoperatively have been comparable to open surgery. Initially there had been concerns of renal

171

vein thrombosis in the recipients after the right LDN. This was attributed to inability to obtain IVC cuff during laparoscopy, and hence a shorter vein for anastomosis. Since the availability of laparoscopic Satinsky clamps and newer stappling devices, the right donor nephrectomy is no more considered a contraindication for LDN. Major donor complications were seen in 6% (table 3). Most of acute complications were vascular bleeds, or related to parenchymal injuries to spleen or renal upper pole during dissection. Most of chronic donor complications were related to retrieval wound. Five-year patient and graft survival of 91% and 90%, respectively, in recipients, has been similar to best live graft outcome obtained with open donor surgery. Surgical complications in recipients included six peritransplant haematomas requiring exploration, kinking of renal artery in two (corrected postop at re-exploration), one renal artery thrombosis (Day 0, re-explored and revived), one renal vein thrombosis (on 30th post-op day, a right donor kidney), and seven symptomatic lymphoceles (3 drained percutaneously and treated with betadine instillations, 4 marsupialized laparo-scopically). Ureteric complications have been other cause of concern after LDN. Using the basics of keeping gonadal vein with the ureter, including the periureteric tissue, has shown that ureteric complications in recipients are not high after LDN. We have noted only one ureteric stricture 18 months postop after 384 LDNs. Others experience has also shown that ureteric complications were mainly limited to patients with multiple renal arteries in their series (6).

Table 3: Major donor complications of laparoscopic donor nephrectomy (384 cases): *group

complications

n

management

vascular

Arterial clamping, inadvertent

1

Conversion to open

Arterial branch clamping

1

Inadvertent, detected after retrieval, bench repaired

Venous branch bleed

4

conservative

Splenic injury during dissection

6

conservative

Subcapsular hematoma

5

Incised, drained

Upper polar parenchymal tear

3

Suture repaired 1, conservative 2

lung

Atelectasis

2

conservative

Transperitoneal approach

Colonic fistula (10 mm port)

1

Conservative, stopped 12th post-op day

Intestinal obstruction

2

Explored at 6th day, 6th month

Incisional hernia

5

Conservative 2, repaired 3

Wound infection

6

conservative

Solid organs

Retrieval wound

FIAGES Book.indb 171

3/23/2007 11:08:29 AM

172

Laparoscopic Urological Surgery

Adrenalectomy There has been an increase in detection of adrenal incidentalomas. NIH consortium recommends excision of such masses if associated with biochemical evidence of pheochromocytoma, size greater than 6 cm, masses greater than 4 cm with rapid growth rate, or radiographic findings consistent with adenoma. Laparoscopic adrenalectomy (LA) was first described by Gagner in 1992. Lots of data has since gathered to support the use of transperitoneal or retroperitoneal laparoscopic approach for adrenalectomy as opposed to open surgery. The arguments against laparoscopic approach are longer operating time and higher hospital charges. Laparoscopic approach is overwhelmingly preferred approach for smaller adrenal masses including partial adrenalectomy. Only presumed adrenal cortical carcinomas (usually >6 cm) are still approached open. At centers such as ours, where our experience continues to grow, LA is considered superior to open adrenalectomy for most extirpative adrenal surgeries. Pyeloplasty Ureteropelvic junction (UPJ) obstruction is characterized by a functionally significant impairment of urinary transport, caused by obstruction in the area where the ureter joins the renal pelvis. The majority of cases are congenital; however, acquired conditions at the level of the UPJ may also present with symptoms and signs of obstruction. Until recently, open pyeloplasty

Table 4: Largest series of laparoscopic pyeloplasty Series n Approach

and endoscopic techniques have been the main surgical options with the intent of open complete excision, or endoscopic incision of the obstruction. Endoscopic antegrade or retrograde visually controlled incision of the ureteropelvic junction obstruction, or radiologically controlled Acucise (Applied Medical, Laguna Hills, CA) incision do not share the high success rate that results from open-surgical dismembered pyeloplasty (65-70% vs. 95%). The introduction of laparoscopy has allowed minimally invasive reconstructive surgery that mirrors open surgical techniques. In the hands of experienced surgeons, laparoscopic pyeloplasty (LP) offers a less invasive alternative to open surgery with decreased morbidity, shorter hospital stay, and faster convalescence . LP uniformly has given success rates of more than 90% irrespective of whether the length of stenotic segmentis short or long, high or low insertion of PUJ, presence or absence of crossing vessels, presence or absence of calculi or whether the PUJ is primary or secondary. Large series of LP have appeared in literature (9-13). Some of these studies have been summarized in table 4, including our own experience with a variation of dismembered pyelolasty. Notable facts from the table are use of both trans and retroperitoneal route, operative time of only 119 to 246 minutes, and uniform excellent success in all series. Providing a three-dimensional vision, an unprecedented control of the endocorporeal instruments, and an ergonomic surgeon’s position, robots may allow urologists with limited laparoscopic experience to rapidly master

Op time (min)

Bowel Injury FU (mo)

Success (%)

Turk et al (8)

49

Trans

165

0

23

97.7

Soulie et al (9)

55

Retro

185

0

14

88

Janetschek et al (10)

67

59 Trans

119

0

25

98.5

Inagaki et al (11)

147

Trans

246

1.4%

24

95

Moon et al (12)

170

Retro

140

0.6%

15

96.2

Our experience

52

Trans

130

0

25

96

Largest series of Laparoscopic pyeloplasy in literature in top five rows. Our experience has been added at the bottom of the table. n number of cases in series; trans transperitoneal, retro retropeitoneal, op time operating time, FU (mo) follow-up in months.

FIAGES Book.indb 172

3/23/2007 11:08:29 AM



the endocorporeal management of ureteropelvic junction obstruction. There have been plenty of reports in literature recently with robotic assisted laparoscopic pyeloplasty. Lymphocele Lymphocele complicates 1 to 12% of patients following renal transplantation. Lymphocele also complicates 1 to 10% of patients after pelvic lymphadenectomy, as done for proste cancer. Treating options are either percutaneous drainage and sclerotherapy, or transpertoneal laparoscopic marsupialization of the lymphocele(PML). Treatment with percutaneous drainage and sclerotherapy has high morbidity and a high recurrence rate. Hsu reported 91% success and only 6% recurrence after treating 81 lymphoceles with laparoscopic marsupialization (13). Laproscopic treatment of pelvic and post transplant lymphoceles is now a preferred method of management. Female Urology Repair of vaginal vault prolapse remains a surgical challenge irreapecive of abdominal, vaginal, and combined procedures being used to correct the problem. The ideal operation remains elusive with regard to outcomes, morbidity, and economics. As an extension of the abdominal approach, laparoscopy continues to gain favor as an access method, and as a surgical advancement. Recent studies highlight a number of laparoscopic techniques for restoration of apical support that demonstrate feasibility and encouraging results. Further studies are necessary to determine if the minimally invasive nature of laparoscopy can duplicate or surpass standard abdominal and vaginal approaches to repair of pelvic organ prolapse. Vericocele Vericocele is found in upto 15% of normal population, but the incidence is as high as 40% in males with subfertility. Traditional approached for vericocele were retroperitoneal and inguinal. Microsurgical technique has lately been used for vericocele repair to decrease complications like hydrocele and damage to testicular artery, and to decrease the incidence of vericocele recurrence. Laparoscopic vericocelectomy promised to be a cosmetic way to deal with vericocele with lesser complications than conventional approaches due to inherent optical enlargement and good vision. Jarow demonstrated 68% improvement in semen quality and 26% pregnancy rate at one year in a group of 75 patients with vericocele with subfertility. Subsequent studies have

FIAGES Book.indb 173

Comprehensive Laparoscopic Surgery

173

failed to prove any improved convalescence characteristics over microsurgical vericocelectomy, in fact the time off work was significantly longer for laparoscopic group apart from the increase cost. There remains little indication for laproscopic varicocelectomy (LV). It has long been recognized that LV has no advantage over subinguinal or inguinal varicocelectomy in the adult patient population, with regards to outcome success, and may only increase the risk of intraabdominal injury. Recent reports demonstrates the significantly higher incidence of hydrocele formation in the pediatric population treated with LV for clinically significant varicoceles (7). A third of such treated patients ultimately had evidence of development of a hydrocele postoperatively. Half of the patients, who developed a hydrocele, required a hydrocelectomy. The pediatric urologists now recommend against LV for pediatric varicoceles. Subinguinal or inguinal varicocelectomy is preferred in this patient population too. Renal biopsy Percutaneous renal biopsy may be contraindicated in some patients because of obesity, coagulopathy, solitary kidney or failed previous percutaneos biopsy. Options in these situations include open surgical biopsy, CT guided biopsy, transvenous biopsy and laparoscopic guided biopsy. Experience with laparoscopic renal bopsy has provided an abundant biopsy tissue as compared with CT or transvenous biopsy with minimal morbidity in patients where percutaneous biopsy was contraindicated. Oncologic applications In addition to the general advantages of MIS, the use of laparoscopic procedures for oncologic applications must prove no compromise over the oncologic control of the disease, whether positive surgical margins, incidence of intraoperative seedings while retrieving the specimen, or long term oncologic control. Histopathological margin positivity has not been higher with laparoscopic oncologic procedures. Long term oncologic control data is gradually appearing, and seems to be equivalent to open surgery. There has been concern regarding seeding in urologic laparoscopy. In an international survey, the data from 19 institutions performing laparoscopic oncologic procedures was collected for 2,604 radical nephrectomies (40% were morcellated), 555 partial nephrectomies, 559 nephroureterectomies, 3,665 radical prostatectomies, 1,869 pelvic lymph node dissections and 479 retroperitoneal lymph node dissections (14). There

3/23/2007 11:08:30 AM

174

Laparoscopic Urological Surgery

were no cases of seeding from renal cell cancer despite over 3,000 procedures reported, and the use of morcellation in 40% of the radical nephrectomies. However, there were three cases of seeding after nephroureterectomy for known upper tract transitional cell cancer (TCC, 0.5%) and there was one seeding case after a retroperitoneal node dissection (0.2%). Of interest, in the survey, four cases of seeding occurred when a “simple” nephrectomy was done in the face of “unsuspected” TCC. Seedings are a problem even following open radical nephroureterectomy for TCC. There was no case of seeding following laparoscopic radical prostatectomy or pelvic lymph node dissection for prostate cancer. It has been suggested that there is a 6- to 9-day period of relative immunosuppression after a major surgery, and that laparoscopy suppresses the immune system to a lesser degree compared with open surgery for similar procedure. The precise nature of this postsurgical stressinduced immunosuppression is not clear. In fact with a relatively intact immune system following laparoscopy, the port-site or peritoneal seedings would be less common than open surgery as long as violation of the tumor has been prevented. Nephrectomy and nephroureterectomy Laparoscopic radical nephrectomy (LRN) has significant smaller incision with a quick postoperative recovery with less major and minor complication rates than open surgical counterpart. Mean blood loss is less with LRN. MIS benefits have certainly improved the quality of life in these patients. As mentioned earlier there is little risk of peritoneal contamination and port site metastasis after LRN for RCC despite morcellation of specimen before removal. It appears, as mentioned earlier, that port-site seeding associated with LRN is an extremely rare and unlikely event, provided that strict surgical technique is applied and an entrapment sac is used for specimen removal Though morcellation reduces the retrieval incision further, consensus seems to be emerging that all malignant specimens be removed intact in a specimen bag without morcellation. Significant data is now available regarding LRN oncologic efficacy. Five year overall disease specific and acturial survival is similar to open surgery in different retrospective series, which is expected since laparoscopic technique adheres to same surgical principles (Table 5). Since an incision is required to retrieve the intact specimen,

FIAGES Book.indb 174

hand assisted laparoscopy (HAL) has been popular for LRN. HAL has been said to facilitate difficult dissection and reduce operative time, even for larger renal tumors. Cytoreductive nephrectomy may be required in patients undergoing nephrectomy for Renal Cell Carcinoma and has proved its value in independent studies. Such nephrectomy could be performed laparoscopically in only 22% of these patients. The inclusion criteria for cytoreductive nephrectomy included: mass < 14 cm, no renal vein or caval involvement, and absence of bulky lymphadenopathy. Almost half of these were done hand assisted. The best method for doing the procedure appears to be laparoscopic if one considers blood loss and the length of hospital stay (18). Partial nephrectomy For the incidental small renal lesion, removal of the entire kidney by open radical nephrectomy or minimally invasive techniques may prove to be more detrimental in the long term by leaving behind a limited nephron mass. Several studies have demonstrated that disease-free survival and oncologic outcomes of partial nephrectomy are equivalent to radical nephrectomy in carefully selected patients Despite the advantages laparoscopic partial nephrectomy enjoys over conventional open surgery in terms of perioperative morbidity, blood loss, operative time, and hospital stay, the risk of bleeding and technical difficulty of intracorporeal laparoscopic suturing has prevented the widespread use of laparoscopic partial nephrectomy. There is also a concern for prolonged warm ischemia time and subsequent renal dysfunction (19). Numerous adjuncts to dissection and hemostasis like hand assistance, harmonic scalpel, argon beam coagulator, fibrin glue and radiofreuency energy have made significant transformation in last couple of years. Availability of laparoscopic instruments for vascular control and application of intracorporeal cooling has also widened the scope of LPN further. While traditionally employed for absolute indications (single kidney, bilateral tumors, renal insufficiency) and only reserved for elective indications where the primary tumor was 4 cm or less in the presence of a normal contralateral kidney, more recent reports suggest that large and locally advanced (pT2) tumors can also be managed effectively with nephron sparing techniques. Reports from Cleveland Clinic group shows that 4% of their total LPN series of 525 patients were locally advanced (T2, T3a and T3b). LPN could be performed with a mean blood loss of

3/23/2007 11:08:30 AM



Comprehensive Laparoscopic Surgery

175

Table 5. Reports of oncologic follow-up of cT1,T2 tumors following laparoscopic or open radical nephrectomy Approach Patients, n Mean FU, mo Cancer recurrence, n

Cancerspecificmortality, n

Dunn et al 2000 (15) Ono et al 1999 (16) Barrett et al 1999 (17)

Lap

44

25

3

2

Open

30

27.5

3

0

Lap

60

24

2

0

Open

40

28.5

2

1

Lap

85

36

5

1

199 ml (range 100-800), mean warm ischemia time of 29 minutes (range 15-55) and mean OR time of 3 hours (range 2.2-5). The authors reported a major complication rate of 19%, and no patient had a positive margin. Cancer specific survival was 95%. LPN, thus, is feasible even in locally advanced (greater than or equal to T2) renal tumors with oncologic outcomes that mirror those obtained with open approaches (20). Emerging alternative to removal with partial nephrectomy is renal tumor ablation using cryoablation and radiofrequency ablation. Both of these are being performed under laparoscopic control. Cryotherapy destroys tissue by repeat freeze-thaw cycles leading to complete necrosis, while radiofrequency uses alternating electrical current to agitate nearby tissue ions, resulting in frictional heating and destruction of tissue around electrode. Nephron-sparing surgery for renal cell carcinoma has steadily gained acceptance among urologists. Originally reserved for patients with solitary kidney, bilateral tumours, or renal insufficiency, partial nephrectomy has now become the standard of care even in the face of a normal contralateral kidney (21, 22)

of classic open radical retropubic prostatectomy (RRP). In a comparison of LRP with RRP (n 180), the overall positive surgical margin rates were similar (16.9% vs. 20%), however RRP had a greater positive apex margin rate (23). With anatomical nerve sparing technique of LRP, 76% of previously potent man reported potency after 1 year (24). Continence rates were comparable to RRP. Minimal bleeding, reduced blood transfusion rates, shorter hospitalization, and shorter recovery time are some unquestionable advantages of LRP. Robotic assisted laparoscopic prostatectomy (RALP) has gained popularity of late, and not without reasons. Availability of degrees of freedom with the Robotic arms and the availability of 3D vision have successfully transferred the RRP skills to a laparoscopic environment (25). Blood loss is significantly less, as is postoperative pain. Continence and potency data have been favorable. Although likely to be limited to advanced urologic laparoscopic centers, LRP and RALP have established to be a viable surgical alternative to RRP for treating localized prostate cancer.

Prostate cancer

Laparoscopic cystectomy and urinary diversion

Laparoscopic Radical prostatectomy (LRP) is of major interest to Urologists especially considering the incidence and clinical significance of prostate cancer. The procedure comprises several steps of challenging dissection in which the preservation of delicate erectile nerves and external sphincter has to be combined with safe tumor excision. The intervention ends with vesicourethral anastomosis, which is considered the most difficult reconstructive procedure in urologic laparoscopy. LRP has gradually become a standardized procedure, and is now routinely performed around the world. Data from the literature and available experience demonstrates that oncologic and functional results with LRP seem comparable to those

Open radical cystectomy remains the gold standard for nonmetastatic muscle invasive bladder cancer. Depite being first described by Parra in 1992 for benign disease, and later used for invasive carcinoma in 1995 by Sanchez, use of laparoscopic cystectomy has been uncommon. Extensive experience in radical prostatectomy and urethrovesical anastomosis has increased the interest of urologists of late, including the use of robotic assisted techniques. Laparoscopic radical cystectomy (LRC) has been described as a feasible procedure and is still being evaluated. Gerullis and colleagues from Germany have described recently their initial experience with laparoscopic cystectomy with extracorporeal assisted

FIAGES Book.indb 175

3/23/2007 11:08:30 AM

176

Laparoscopic Urological Surgery

urinary diversion in 34 patients (26) with mean operating time of 244min, the mean blood loss of 325ml, and a transfusion rate of 5.9%. All procedures were completed laparascopically without conversion to open techniques, and without major complications, during or after the surgery. Urinary Diversion following cystectomy may be performed using an Ileal conduit, which could be performed laparoscopically with assistance, or perfomed pure laparoscopically. Orthotopic neobladder has also been described, with both extracorporeal suturing as well as pure laparoscopically. Long-term data that allow for definitive conclusions regarding oncologic outcome are lacking. There are few published series that report short-term follow-up, in which information about margin and lymph node positivity is available. There appears to be no overt evidence based on these observations that LRC violates any oncologic principles. Robotic assistance confers advantages, as in LRP, in performing such difficult operation even in experienced hands. Increased use and refinements in surgical technique may serve to increase the use of robotic assistance in treating bladder cancer.

References

RPLND

8. Turk IA, davis JW, Winkelmann B et al. Laparoscopic dismembered pyeloplasty: the method of choice in the presence of and enlarged renal pelvis and crossing vessels. Eur Urol 2002. 42:268-75.

Risk of missing low risk metastatic disease in more than 30% patients despite undetected nodes on CECT abdomen proved the value of RPLND in nonseminomatous testicular tumors. Early open RPLND had significant morbidity in these young patients. With increased awareness regarding the disease spread pattern, the modified unilateral lymphadenectomy templates have significantly reduced morbidity with preserved ejaculation without compromising the efficacy. Laparoscopic RPLND using four trocars is a low morbidity alternative to open lymphadenectomy and has been used in Oncology Institutions with laparoscopic skills with equivalent lymph node positivity. Laparoscopic RPLND has perhaps the greatest impact in decreasing morbidity over similar open procedures. Typical hospital stay of a day with laparoscopy vs. 5 days with open surgery, and convalescence of 2 weeks versus 2 months, respectively, are important differences between the two procedures.

1. Desai MM, Strzempkowski B, Matin SF, et al.: Prospective randomized comparison of transperitoneal versus retroperitoneal laparoscopic radical nephrectomy. J Urol 2005; 173:38–41. 2. Paulsen EU., Eddy nephrectomy. Scand 138-142

B, J

Paulsen J. Urol Nephrol

Laparoscopic 2005; 39:

3. Gupta NP, Goel R, Hemal AK, et al.: Should retroperitoneoscopic nephrectomy be the standard of care for benign nonfunctioning kidneys? An outcome analysis based on experience with 449 cases in a 5-year period. J Urol 2004, 172:1411–1413. 4. Rassweiler J, Fornara P, Weber M, et al.: Laparoscopic nephrectomy: the experience of the laparoscopy working group of the German Urologic Association. J Urol 1998, 160:18–21. 5. Gill IS: Retroperitoneal laparoscopic nephrectomy. Urol Clin North Am 1998, 25:343–360. 6. T. Florian Fuller, Serdar Deger, Annette Büchler, Jan Roigas, Bernd Schönberger, Dietmar Schnorr, Max Tüllmann, Stefan A. Loening, Markus Giessing Ureteral Complications in the Renal Transplant Recipient after Laparoscopic Living Donor Nephrectomy Eur Urol 2006, 50:535-541 7. Hassan JM, Adams MC, Pope IV JC, et al. Hydrocele formation after laparoscopic varicocelectomy. J Urol 175; 1076-1079, 2006)

9. Soulie M, Salomon L, Patard JJ et al. Extraperitoneal laparoscopic pyeloplasty : a multicenter study of 55 procedures. J Urol 2001, 166:48-50. 10. Jannetschek G, Paschel R, Franscher F et al. Laparoscopic pyeloplasty. Urol Clin North Am 2000, 27:695-704. 11. Inagaki T, Kavoussi LR, Jarrett TW et al. Laparoscopic pyeloplasty : the current status BJU Int 2005 95: 102-5 12. Moon DA, El-shazly MA, chang CM et al. Laparoscopic pyeloplasty: evolution of a gold standard. Urology 2006. 67:932-6. 13. Hsu TH, Gill IS, Grune MT, Laparoscopic lymphocelectomy: a multi institutional analysis. J Urol 2000. 163:1096-9. 14. Micali S, Celia A, Bove P, et al. Tumor seeding in urological laparoscopy: An international survey. J. Urol 2004 171: 2151-4. 15. Dunn Md, Portis AJ, Shalhav AL et al. Laparoscopic vs. Open radical nephrectomy: a 9 years experience. J Urol 2000; 164:1153-9. 16. Ono Y, Kinukawa T, Hattori R et al Laproscopic radical nephrectomy for renal cell carcinoma: a fie years experience. Urology 1999; 53: 280-6.

FIAGES Book.indb 176

3/23/2007 11:08:30 AM



Comprehensive Laparoscopic Surgery

177

17. Barrett PH, Fentie DD. Longer follow-up for laparoscopic radical nephrectomy with morcellation for renal cell carcinoma, J Endourol 1999, 13:A62.

23. Brown JA, Garlitz C, Gomella LG et al. pathological comparison of laparoscopic versus on radical retropubic prostatectomy specimens Urology 2003; 62:481-6.

18. Martin SF, Madsen LT, Wood CG. Laparoscopic Cytoreductive Nephrectomy: The M. D. Anderson Cancer Center Experience, Urology 2006; 68:528- 32.

24. Su LM, link RE, Bhayani SB et al. Nere sparing laparoscopic radical prostatectomy: replicating the open surgical technique. Urology 2004; 64:123-7.

19. Desai MM, Gill IS, Ramani AP, Spaliviero M, Rybicki L, Kaouk JH. The impact of warm ischaemia on renal function after laparoscopic partial nephrectomy. BJU Int. 2005; 95:377-83.

25. Menon M, Srivastava A, Tewari A et al. Laparoscopic Robot assisted radical prostatectomy: Establishment of a structured program and preliminary analysis of outcomes. J Urol 2002; 168:945-949.

20. Ukimura O, Haber GP, Remer EM, Gill IS. Laparoscopic partial nephrectomy for incidental pT2 or worse tumors. Urology 2006: 68(s):976-82. 21. Abukora F, Nambirajan T, Albqami N, et al.. Laparoscopic nephron sparing surgery: evolution in a decade. Eur Urol. 2005; 47:48893.

26. Gerullis H, Kuemmel V., Popken G, Laparoscopic Cystectomy with extracorporeal-Assisted Urinary Diversion: Experience with 34 Patients, Eur Urol 2007; 51:193-8.

22. Allaf ME, Bhayani SB, Rogers C, et al Laparoscopic partial nephrectomy: evaluation of long-term oncological outcome. J Urol. 2004; 172:871-3.

FIAGES Book.indb 177

3/23/2007 11:08:30 AM

23 Laparoscopic Adrenalectomy A.K. Kriplani, Hari S. Sidhu First reported by Gagner1 in 1992, laparoscopic approach has replaced open adrenalectomy in many centers across the world. Adrenal gland is one of the most suited organ for laparoscopic removal. It is a small organ, deeply located in the retroperitoneum (Figure 1) and overlapped by adjoining viscera, which necessitate a long muscle cutting incision, often requiring excision of a rib. Minimal access surgery, therefore, dramatically reduces the morbidity. Also, 90% of tumors affecting the gland are benign and majority of them are of small size. They can be effectively managed by laparoscopy with the advantages of reduced post-operative pain, shorter hospitalization, faster recovery and in addition, decreased morbidity of the procedures.

Common indications for laparoscopic adrenalectomy include Pheochromocytoma, Aldosteronoma (Conn’s disease), cortisol producing adenoma, Cushing’s disease (where a bilateral adrenalectomy is required) and incidentaloma (more than 4 cms or growing in size). Laparoscopic adrenalectomy is contraindicated when malignancy is suspected (tumors more than 10 cms in size or with evidence of invasion), in coagulopathies and in patients with multiple previous abdominal operations (relative contraindication). Laparoscopic adrenalectomy requires extensive preoperative workup. In pheochromocytomas, control of blood pressure with alpha adrenergic blockers (and if required, addition of beta blockers) followed by expansion of plasma volume is essential to avoid post operative hypotension due to shrunken circulatory volume. In Conn’s disease, correction of hypokalemia often requires a few weeks of medical treatment and preparation. Pre-operatively, accurate localization of medullary neoplasm is essential to decide optimal approach and also to exclude multiple neoplasia and extra-adrenal tumors, which may also be in extra-abdominal locations in approximately 10 percent of patients. Though generally CT scan of the abdomen will suffice, sometimes even MRI and MIBG (I-131 methyliodobenzoguanidine) scan may fail to yield required information. Surgical techniques

FIGURE 1: Anatomy of the left and right adrenal glands showing their vascular

A variety of laparoscopic approaches for adrenalectomy have been described that closely mimic their open counterparts: the trans-abdominal flank approach, the retroperitoneal approach and the anterior trans-

supply, R= Right adrenal gland, L= Left adrenal gland.

FIAGES Book.indb 178

3/23/2007 11:08:35 AM



Comprehensive Laparoscopic Surgery

179

abdominal approach. The trans-abdominal lateral flank approach is the one most commonly utilized. Trans-abdominal lateral flank approach This approach provides the surgeon with a large working space with excellent access to the superior retroperitoneum. Anatomical landmarks are readily apparent and retraction of the adjacent viscera is facilitated by gravity due to the lateral position. Excellent results with this technique have been reported 2, 3, 4. However, the contra lateral adrenal can not be approached and for bilateral adrenalectomy, repositioning is required. The operating room setup is shown in Figure 2. The patient is placed in the lateral position (Figure 3) with the affected side up and the anterior abdominal wall should hang free from the edge of the operating table (Figure 3). The surgeon stands facing the patient with the camera holder on his left. The monitors are at the head of the table on either side. Initial access to the peritoneal cavity is gained by Veress needle inserted just medial to the anterior axillary line in the sub costal position. Port positions for right and left adrenalectomy are shown in Figure 4.

FIGURE 3: Patient in the lateral decubitus position with right side up for right adrenalectomy.

FIGURE 4: Port positions for right and left adrenalectomy.

FIGURE 2: Operating room lay-out showing position of the surgeon (s) with camera holder (A) on his left and monitors (M1, M2) at the level of the shoulder. AN= Anesthetist, ORT= Operating Room Technician

LEFT ADRENALECTOMY The left colon, the splenic flexure and the spleen must be mobilized en-bloc, as a single unit, up to the upper pole of the spleen. The parietal peritoneum lateral to the descending

FIAGES Book.indb 179

colon is divided and the incision is extended upwards into the posterior leaf of the lieno-renal ligament in the avascular plane. The left colon and the spleen are swept medially in the avascular plane between the Gerota’s fascia and the mesocolon to expose the kidney covered with Gerota’s fascia (Figure 5). This dissection can be easily performed with the help of a blunt suction probe. Greater curvature of the stomach and the uppermost short gastric vessels are generally seen near the upper pole. The spleen and colon fall down due to gravity. The dissection needs to be carried up-to the midline. Large adrenal gland having medullary tumor is easily recognized by its bulge after the colon has been pushed medially. However, identification

3/23/2007 11:08:40 AM

180

Laparoscopic Adrenalectomy

FIGURE 5: Kidney with its Gerota’s fascia is exposed after the descending colon is swept medially

of the left adrenal gland harboring small size cortical adenomas or with hyperplasia, is difficult because the gland has abundant wrapped with fat all around. The best way to identify such an adrenal gland is by identifying the renal vein first (Figure 6). The left adrenal vein is short. It exits from the lower medial aspect of the gland and enters immediately into the upper border of the left renal vein. Dissecting the upper border of the renal vein will identify the adrenal vein which can then be traced into the adrenal gland. The gland is also distinguished by its golden yellow colour which shines against the contrast of the pale perirenal fat. The gland is intimately applied to the medial side of the upper pole of the left kidney and its inferior pole is close to the renal vein. The tail of the pancreas, which may sometimes be immediately anterior to the lower part of the gland, should not be mistaken for the adrenal.

Once the adrenal gland has been identified, the borders of the gland should be defined. The adrenal vein should never be divided as the initial step in the procedure. However in pheochromocytoma, the vein may be clipped or tied without dividing it to avoid sudden peaking of blood pressure during subsequent manipulations. Dissection starts medial to the adrenal vein, clearing the infero-medial angle, proceeding upwards along the medial border. The medial border is cleared all along up to the upper pole. Middle adrenal artery, though a direct branch of the aorta (Figure 1), is generally of insignificant size and is taken care of with a hook electrode. However, in large or vascular tumors like pheochromocytoma, it may be of significant size and should be occluded with a clip and divided (Figure 7). The inferior phrenic vein joins the adrenal vein just above its junction with the renal vein and must be looked for on the medial side. In normal sized gland, the dissection should stay close to the adrenal gland keeping in mind the proximity of the aorta. Near the upper pole, Superior adrenal artery, a branch of inferior phrenic (Figure 1), must be identified (Figure 8) or it may be a source of troublesome bleeding. The artery enters the most cephalic part of the adrenal gland from the medial side and once divided, the upper pole becomes free to be swept towards the renal vein.

FIGURE 7: The middle adrenal artery has been clipped and divided. The adrenal gland (ADR) has been lifted from the muscles (MSL).

FIGURE 6: Displacing the colon and spleen medially exposes the renal vein (RV). The gonadal vessels can be seen draining into the lower border of the renal vein.

FIAGES Book.indb 180

After dividing the superior adrenal artery, the gland is lifted from the back muscles. No vessels are encountered here. The gland is now attached only inferiorly with the adrenal vein (Figure 9) and laterally with the upper pole of the kidney through the Gerota’s fascia. The gland should be carefully separated from the renal vein, particularly in large medullary tumors since the renal vein may be stretched

3/23/2007 11:08:41 AM



Comprehensive Laparoscopic Surgery

181

RIGHT ADRENALECTOMY

FIGURE 8: Clips on the superior adrenal artery. This is the most inaccessible of the adrenal arteries and can be a source of troublesome bleeding if not identified and dealt with.

over the gland. After clearly identifying the junction of the two veins, the adrenal vein is clipped on both the sides and divided. In large tumors, inferior adrenal artery, a branch of renal artery (Figure 1), is of significant size and will require clipping. Separation of the lateral border from the upper pole of the kidney is usually straight forward as no vessel enters the adrenal gland from the lateral side.

On the right side, in the lateral position, the hepatic flexure of the colon generally drops medially (except in obese patients) exposing the upper pole of the right kidney, the duodenum and the inferior vena cava. Any omental adhesions to the inferior border of the liver, if present, have to be taken down. Stripping of the Gleason’s capsule, which may cause troublesome oozing with staining of tissues in the area, should be carefully avoided. The right triangular ligament of the liver needs to be divided generously as an early step for right adrenalectomy so that the liver can be pushed up and rotated medially with a fan retractor for better exposure of the upper pole of the adrenal gland. If the duodenum has not fallen down, the peritoneum lateral to its second part is incised to push it medially for exposing the inferior vena cava (Figure 10). The cava is the cardinal central structure for orientation during dissection of the right adrenal gland.

FIGURE 10: Anatomy of the right adrenal gland. The gland is located in the area bound by the renal vein(RV) below, the inferior vena cava (IVC) medially and  the lower border of the liver above. No dissection is required outside this area.

FIGURE 9: Left renal vein (RV) with the adrenal vein (ADR V) draining into the upper border and the gonadal vein (GV) into the lower border. The Gland has been freed  from all the other attachments

Once the gland is free, haemostasis is checked, including surrounding structures that are at risk for injury like tail of the pancreas, spleen, colon, diaphragm and renal vessels. A drain may be left in the retro peritoneal space if there is any suspicion of pancreatic injury. The specimen is placed in a pouch and removed by enlarging one of the ports.

FIAGES Book.indb 181

In contrast to the left side, the right adrenal gland can be easily identified just lateral to the vena cava and above the renal vein which marks the caudal extent of the dissection. The peritoneum between the medial border of the gland and lateral border of the cava is incised near the accessible lower part of the gland, cephalic to the renal vein. The incision in the peritoneum and fascia is carried upwards between the cava and the medial border of the gland towards the upper pole. This exposes the anterior surface of the adrenal. It is helpful to retract the gland gently away from the cava to enlarge the narrow space between these two structures (Figure 11). The

3/23/2007 11:08:41 AM

182

Laparoscopic Adrenalectomy

Once the vein has been divided, the medial, superior and inferior borders of the gland are mobilized and the gland is lifted from the posterior muscles. Harmonic scalpel is useful during this dissection. This leaves the gland attached only laterally to the Gerota’s fascia and this separation can be easily accomplished. Haemostasis is checked (Figure 13) and the gland in delivered after placing in a pouch. Drains are usually not required.

FIGURE 11: The right adrenal gland (1) has been retracted laterally from the inferior vena cava (2) exposing the back muscles (3).

gland is friable and tearing the gland should be avoided as it may bleed or the tumor capsule may be violated. The adrenal vein is short (5 to 10 mm), lies in the most inaccessible supero-medial aspect of the gland (Figure 1) and drains into the postero-medial aspect of the vena cava (Figure 12). It is helpful to mobilize the gland posteriorly from the muscles in the avascular plane and dissect the upper part of the gland from the bare area of the liver retracting the liver upwards to enhance exposure of the adrenal vein. Haemostasis should be absolute otherwise staining of tissues may make identification of structures difficult. Once the vein is exposed, two clips are applied on the cava side or alternatively the vein may be tied. This is the most difficult aspect of the dissection and great care should be exercised to prevent tearing of the vein.

FIGURE 12: Clips applied on the right adrenal vein (arrow). Before clipping the vein, the superior border of the gland should be dissected away from the Bare area of the liver (B) to expose the vein sufficiently

FIAGES Book.indb 182

FIGURE 13: The bed of the right adrenal gland after adrenalectomy. The upper pole of the kidney (2) and the inferior vena cava (3) can be seen.

Retroperitoneal approach First clinical series of retroperitoneal laparoscopic adrenalectomy was reported by Mercan in 1995(5) Retroperitoneal adrenalectomy is generally carried out with the patient in the lateral position. With the back of the patient near the edge of the table, the surgeon stands on the back of the patient. Initial access to the retro peritoneum is achieved by making an incision just lateral and inferior to the tip of the twelvth rib. The skin with subcutaneous fat is incised and the muscle fibers are split using artery forceps to allow digital entry into the retro peritoneum. The lower pole of the kidney can be palpated with the finger and serves as the guide for proper entry. The retroperitoneal space is then expanded using a balloon dissector or a space maker device staying anterior to the kidney. The initial port is then inserted and an airtight junction achieved (Hasson cannula or other devices). The retro peritoneum is insufflated with carbon dioxide at 12 mm Hg. Subsequent ports are placed under vision and the space is further expanded with laparoscopic dissection. The peritoneum is reflected off the anterior surface of the kidney. Adrenal gland is generally difficult to visualize and the upper pole of the kidney serves as

3/23/2007 11:08:41 AM



the most important guide for orientation. The dissection techniques are same as described for trans-peritoneal approach. Though retroperitoneal approach is used less commonly than the trans-peritoneal route, many large series have been reported with good results(6-8). Exposure in retroperitoneal approach is limited and the space available is less. It is difficult to handle large tumors by the retroperitoneal approach because of the limited space available. There are no landmarks in the retroperitoneal dissection except for the upper pole of the kidney. However, the peritoneal cavity is not violated, mobilization of colon is not required and once expertise in creating retroperitoneal space is acquired, the procedure is simple and takes less time than trans-peritoneal approach. Retroperitoneal approach may be preferred in patients with multiple previous abdominal operations, cardiac diseases and pulmonary conditions with tendency to retain carbon dioxide. In case of difficulty, the retroperitoneal approach can be converted into a trans-peritoneal one. Complications: Haemorrhage The most frequent major complication of laparoscopic adrenalectomy is bleeding, which has also been the primary reason for conversion to open adrenalectomy. Proximity of the glands to the great vessels, multiple vascular pedicles and their location high in the abdomen provides limited access for vascular control. Extreme caution is required while dissecting in this area. Haemostasis must be maintained as concurrently as possible. Every small and inconsequential looking tissue around the gland should be either dealt with monopolar hook or harmonic scalpel. Oozing stains tissues and makes identification of vessels difficult, thereby further increasing risk of bleeding. The adrenal gland, if torn, can itself be a source of significant bleeding. In large pheochromocytomas, delicate veins coursing on the surface of the tumor can cause troublesome bleeding. Meticulous dissection in the extracaplular plane, gentle manipulations and avoiding direct grasping of the gland will reduce the chances of bleeding. On the left side, other sources of bleeding include pancreas and the spleen during their mobilization and retraction. If bleeding occurs from the pancreas, use of electro-cautery is avoided. Gentle pressure with Surgicel (Johnson & Johnson) for a few minutes should

FIAGES Book.indb 183

Comprehensive Laparoscopic Surgery

183

be tried first. If this fails, it is best to take sutures with non-absorbable material. A drain should be placed in such situations. Bleeding from the spleen, particularly is a laceration has occurred, can be difficult to control and pressure should be tried for a longer time. Use of cautery may increase the bleeding. Suturing the laceration or fibrin glue may be used if simpler methods fail. On the right side, bleeding from the liver during retraction will completely obscure the small field. Metallic retractors with thin blades should be avoided. Liberal mobilization of the right triangular ligament makes retraction easier and safer. While on the left side there is always only one adrenal vein, on the right side sometimes there may be a second adrenal vein draining from the lower part of the gland into the vena cava or the renal vein(9). When significant bleeding occurs from a large adrenal artery or the central vein, the space rapidly fills up with blood. Initial temporary control with pressure from a forceps is often essential to adequately assess the magnitude of the problem. Occasionally, forceps with long soft blades (e.g. bowel grasping forceps) may be applied without increasing the risk of extending the tear or injury to the neighbouring organs. After temporary control of the bleeding, blood is sucked out and the area is irrigated. It invariably requires making an additional port since one working port is used for pressure. One can then decide on the best way to control the bleeding by either application of clips or sutures. If massive haemorrhage occurs, one should not hesitate to convert to open surgery and in the event of injury to the adrenal vein, the threshold for conversion should be low on the right side since it virtually amounts to a hole in the vena cava. In retroperitoneal approach, ability to handle bleeding complications is limited because of the shortage of space. During conversion, it is beneficial to maintain the pressure by the laparoscopic instrument. When converting to open surgery, minor bleeders from the parietal muscles should be ignored for rapid access to the intra-abdominal bleeding site. Visceral injury On the left side, colon may be injured inadvertently during mobilization or by electro-cautery. Thermal injuries are more dangerous since they manifest latter in the postoperative course and are not recognized early. Prescribing a purgative the night before surgery to empty the colon enhances the exposure. Use of electro-cautery near the colon should be avoided and any doubtful area should be reinforced with seromuscular sutures.

3/23/2007 11:08:41 AM

184

Laparoscopic Adrenalectomy

Pancreatic tail may sometimes be encountered covering the renal hilum and may be mistaken for the adrenal gland since both have lobular appearance. However, absence of surrounding fat, a well-defined lower border and appearance early in the dissection are pointers towards the pancreas. Left adrenal gland is wrapped all around by fat, is difficult to be seen even after considerable dissection, its bright golden yellow colour and the central vein exiting to join the renal vein are characteristic and unmistakable features for identification. Pancreatic injury is more likely to occur if splenic flexure of colon alone is mobilized to expose the adrenal gland. If spleen is mobilized en-bloc with the splenic flexure, the tail of the pancreas will generally not come in the view and will be protected from injury. A thorough knowledge of the anatomy of the area goes a long way in avoiding injury to the surrounding structures like stomach and short gastric vessels. Injury to the spleen is most commonly in the form of puncture by a dissecting instrument or laceration by the retractor. On the right side, the hepatic flexure generally does not come in the field but the duodenum has to be carefully protected while exposing the inferior vena cava. Use of electro-cautery around the duodenum must be avoided. Hormonal Consequences The most common intra-operative hormonal effects during adrenalectomy for pheochromocytoma are cardiovascular. Intra-operative manipulation of the tumor may release excessive catecholamine into circulation, resulting in life-threatening hypertensive crisis. Because of lack of catecholamines following removal of the tumor, hypotensive crisis may occur as well. Preoperatively, hypertension should be controlled by alpha-adrenergic blocking agents. Adequate control is assessed by documenting postural hypotension. If tachycardia is observed, beta adrenergic blocking agents may be added only after adequate alpha blocking effect has been achieved. In the 48 hours preceding surgery, plasma volume should be replenished by intravenous fluids and plasma to restore the circulating volume, which had shrunken under prolonged catecholamine stimulus. This will prevent post-operative fall of blood pressure. During surgery, the adrenal gland should be handled with extreme gentleness and caution. Intraoperative invasive monitoring of the blood pressure is essential. Catecholamine release from the gland is not due to pneumoperitoneum(9). The surgeon and the anaesthesiologist have to work with close co-operation.

FIAGES Book.indb 184

Intra-operative hypertension is controlled with intravenous sodium nitropruside. The surgery may have to be interrupted in between if blood pressure rises to dangerous levels. In the rare case of unsuspected pheochromocytoma (with no pretreatment), it is wiser to abort the operation that to convert to open surgery(9). Ligation of the adrenal vein as an initial step during adrenalectomy for pheochromocytoma decreases the chances of hypertension during surgery. In retroperitoneal adrenalectomy, the central adrenal vein can be reached only after dissecting the gland all around. However, Tran peritoneal approach permits early exposure and ligation of the renal vein without dissecting the gland and is therefore the preferred approach for this condition. Pneumothorax Accidental injury to the diaphragm can occur when dissection is done so close to it on the left side. Puncture or laceration of the diaphragm can occur with sharp instrument or particularly while using monopolar hook electrode. The resultant transmission of intra-abdominal pressure in the chest produces tension pneumothorax. The anaesthesiologist will experience raised airway pressures. Repair of the diaphragm with or without placement of thoracostomy tube is usually necessary. Careful use of hook electrode and preferably avoiding it in favour of harmonic scalpel during dissecting the upper pole will minimize this injury. Surgical emphysema Surgical emphysema may be seen after retroperitoneal adrenalectomy since the first incision in the muscles for entry into the retro peritoneum is generally larger and gas may enter in the intermuscular planes when an airtight junction is achieved at the skin level. Though disturbing, particularly when extensive, it is generally of no consequence and will generally subside within a few days. Discussion The location of the adrenal gland, its friable parenchyma and the proximity of the great vessels pose significant demands on the surgeon. The degree of difficulty and the consequences of intra-operative mishaps are so significant that only accomplished advanced laparoscopic surgeons should consider attempting this procedure. Pheochromocytomas are particularly challenging because of the hemodynamic changes associated during

3/23/2007 11:08:41 AM



the procedure. Safe creation of pneumoperitoneum with the patients in the lateral decubitus position may tax the ingenuity and innovative skills of the surgeon and one may resort to open entry into the peritoneal cavity. A 30-degree telescope is a must for proper visualization of the operative field. Success of laparoscopic procedure depends on proper exposure of the gland and its neighbouring organs. Reverse Trendelenberg position facilitates exposure of the upper pole. In the trans-peritoneal approach, mobilisaion of the spleen along with the splenic flexure requires retraction of the adjoining organs with increased risk of injury to the colon, spleen, pancreatic tail and renal vessels. One should be careful not to enter the space posterior to kidney otherwise the kidney will obscure the view of the adrenal. No attempt should be made to expose the surface of the adrenal gland on the left side, which should be mobilized along with the surrounding fat. Attempts to expose the gland surface will often lead to tearing of the capsule, bleeding and possibility of tumor implantation (10 to 15 percent of pheochromocytomas may be malignant). For proper exposure in the retroperitoneal approach, it is essential that the peritoneum be lifted off the kidney and renal pedicle up to the midline exposing aorta on the left and medial border of vena cava on the right. During mobilization, any rent in the peritoneum will lead to loss of space because of concomitant pneumoperitoneum. In such an event, placing a Veress needle at the level of the umbilicus will provide exit for the pneumoperitoneum and will stabilize the retroperitoneal space. Ports should be placed at least 5 cms apart otherwise instruments may clutter causing difficulty in dissection. Laparoscopic removal of pheochromocytomas poses many difficulties. Surface of these vascular tumors is covered with friable vessels that bleed on even gentle handling. Early occlusion of the adrenal vein causes further congestion of the gland and increases surface oozing. Electro-cautery of these vessels only worsens the situation. Wide exposure will enable to identify the avascular extra-capsular plane where dissection can proceed with ease, rapidity and without blood loss. Large tumors push the renal vein downwards which gets stretched over the gland and may be difficult to identify, increasing the risk of injury. It is safer to clip the adrenal vein where it exits the gland rather than where it enters the renal vein.

FIAGES Book.indb 185

Comprehensive Laparoscopic Surgery

185

REFERENCES 1. Gagner M, Lacroix A, Bolte E. Laparoscopic adrenalectomy in Cushing’s syndrome and pheochromocytoma. N Eng J Med. 1992:327:1033. 2. Gagner M, Pomp A, Haniford BT, Pharand D, Lacroix A. Laparoscopic Adrenalectomy: lessons learnt from 100 consecutive cases. Ann Surg 1997:226:238-247. 3. Filliponi S, Guerrieri M, Arnaldi GGM, Masini AM, Lazoche E, Mantero F. Laparoscopic adrenalectomy: A report on 50 operations. Eur J Endocrinol 1998:138:548-553. 4. Rutherford JC, Stovaseer M, Tunny TI, Klemm SA, Gordon RD, Laparoscopic adrenalectomy. World J Surg. 1996:20:758-761. 5. Mercan S, Seven R, Ozarmagan S, Tezelaman S. Endoscopic Retroperitoneal adrenalectomy. Surgery (St. Louis) 1995:1108:10711076. 6. Heintz A, Walgenbach S, Junginger T. Results of endoscopic retro-peritoneal adrenalectomy. Surg Endosco 1996:10:633-635. 7. Walz MK, Peitgen K, Hoermann R et al. Posterior retroperitoneoscopy as a new minimally approach for adrenalectomy. Results of 30 adrenalectomies in 27 patients. World J Surg 1996:20:769-774. 8. Fernandez-cruz L, Shaenz A, Taura P et al. Retroperitoneal approach in Laparoscopic adrenalectomy. Is it advantageous? Surg Endosc 1999:113:86-90. 9. Janetschek C, Neumann HPH. Laparoscopic surgery for pheochromocytoma. Uro Clinics North Amer 2001:28:97-105.

3/23/2007 11:08:42 AM

24 Laparoscopic Gynaecological Surgery for General Surgeon Pradeep Kumar Garg, Alka Kriplani Introduction Today, laparoscopic surgery is highly acclaimed surgical modality amongst both patients and medical practitioners. It appears that laparoscopic surgery is applicable in almost every clinical situation. A general surgeon should be familiar with the uterine and adnexal diseases and he or she should be able to tackle these situations in a scientific manner. A general surgeon may have to tackle the incidental adnexal pathologies while doing routine laparoscopic general surgery and these gynaecological situations may include adnexal masses like ovarian cyst, ectopic pregnancy, benign and malignant ovarian tumours, tuboovarian abscess, ovarian torsion, endometriosis resulting into formation of endometriomas etc. Being gynaecologist, here in this chapter we would like to highlight these common gynaecological procedures which can be done by a general surgeon in a simple and scientific way.

the urachus, on either side, are the medial umbilical folds, overlying the obliterated umbilical arteries. Just lateral to each medial umbilical fold is the lateral umbilical ligament (fold), formed by the peritoneum overlying the inferior epigastric vessels (Figures 1-A, 1-B). In most

Figure 1-A: Superficial intraperitoneal anatomy of anterior abdominal wall

Pelvic Anatomy Sound surgical technique is based on accurate anatomic knowledge. Here we will describe some important anatomic relations that are critical during laparoscopic procedures. Anterior abdominal wall The umbilicus is located at the level of L3-L4. The parietal peritoneum over the anterior abdominal wall is elevated at 5 sites, representing the five umbilical folds. The median umbilical fold, running from the dome of the bladder to the umbilicus, covers the obliterated urachus. Lateral to

FIAGES Book.indb 186

Figure 1-B: A) Median umbilical fold, B) Right medial umbilical ford, C) Lateral umbilical fold, D) Left medial umbilical fold

3/23/2007 11:08:42 AM



cases, their location may be visually confirmed through the peritoneum with the laparoscope, avoiding injury to them during the placement of accessory trocars. Pelvic organs The panoramic view of the pelvic organs can be seen in Figure 1-C.

Comprehensive Laparoscopic Surgery

187

Pelvic brim Pelvic brim represents the entry of multiple important structures into the pelvic cavity and must be appreciated layer by layer. From the peritoneal surface towards the sacroiliac joint, the following structures are found crisscrossing each other, and can be recognized laparoscopically as superficial peritoneal landmarks; the peritoneum, the ovarian vessels in the infundibulopelvic ligament, the ureter, the bifurcation of the common iliac artery and the common iliac vein. Dissecting in a deeper layer, the medial edge of the psoas muscle, the obturator nerve and the parietal fascia overlying the capsule of the sacroiliac joint will be exposed. Pelvic side-wall

Figure 1-C: A) Uterus, B) Fallopian fube, C) Ovary, D) Utero-ovarian ligament,

The pelvic side-wall is entered by opening the peritoneal reflection between the round ligament anteriorly, the infundibulopelvic ligament medially and the external iliac artery laterally (Figure 1-E).

E) Broad ligament, F) Uterosacral ligament, G) Pouch of Douglasvv

Pelvic vessels The internal iliac artery travels parallel and just posterior to the ureter (Figure 1-D). The external iliac artery is several centimeters anterior to it on the psoas muscle and can be seen pulsating through the peritoneum. The external and internal iliac arteries may then be followed superiorly to find the bifurcation of the common iliac artery at the pelvic brim overlying the sacroiliac joint. The right common iliac artery may then be followed superiorly to find the bifurcation of the aorta, above the “presacral” space at approximately the fourth lumbar vertebra.

Figure 1-E: The uterine artery has been dissected from the hypogastric artery: The external iliac artery is on the right: The right round ligament appears in the foreground. The indufibulopelvic ligament is medial.tv

Pelvic lymphnode The external pelvic nodes are found along the external iliac artery and vein from the bifurcation of the common iliac vessels to deep circumflex veins caudally. The obturator nodes are found in the obturator fossa, which is bordered medially by the hypogastric artery, laterally by the external iliac vein, the obturator internus muscle and its fascia, and anteriorly by the obturator nerve and vessels. Figure 1-D: 1) Right uterine artery, 2) Ureter, 3) Internal iliac arterytv

FIAGES Book.indb 187

3/23/2007 11:08:44 AM

188

Laparoscopic Gynaecological Surgery for General Surgeon

Broad ligament The base of the broad ligaments are the cardinal ligaments also known as the ligaments of Mackenrodt. Dissection of the pelvic sidewall will lead into this region. It is important to comprehend that the internal iliac artery continues into superior vesical artery and then into the obliterated umbilical artery. Traction on the medial umbilical fold will help identify the internal iliac artery, and the medial offshoot passing superior to the ureter will then be identified as the uterine artery. The upper portion of the cardinal ligament is penetrated by the ureter as it travels into the ureteric “tunnel” just beneath the uterine artery, 1 to 2 cm lateral to the isthmus of the uterus with the uterosacral ligament being just medial. Ureter The lumbar ureter lies on the psoas muscle medial to the ovarian vessels. It enters the pelvic cavity just superficial to the bifurcation of the common iliac artery and just deep to the ovarian vessels, which lie in the infundibulopelvic ligament at the pelvic brim. It lies in the medial leaf of the broad ligament as it courses towards the bladder and can be recognized by its characteristic peristaltic motion. The ureter then passes just lateral to the uterosacral ligament, approximately 2 cm medial to the ischial spine through the upper part of the cardinal ligament at the base of the broad ligament. Here it lies just beneath the uterine artery, approximately 1.5 to 2.0 cm lateral to the side of the cervix. The ureter forms a “knee” turn at this point and travels medially and anteriorly to pass on the anterolateral aspect of the upper third of the vagina towards the bladder.

Figure 2-A: Large fibroid uterus for total laparoscopic hysterectomy

The technique of total laparoscopic hysterectomy The total laparoscopic hysterectomy is done under general anesthesia with the patient in low lithotomy position. Prophylactic antibiotic is administered 30 minutes before the procedure. The bladder is catheterized. The laparoscope is introduced through the 10 mm port in the infraumbilical region. Two to four ancillary 5mm ports are created. These can be situated in the right and left lower quadrants. 1. The round ligaments are divided with bipolar coagulation and scissors (Figure 2-B).

Total laparoscopic hysterectomy (TLH) Hysterectomy is a very common surgery in women. The laparoscopic route has lesser morbidity than an abdominal approach, avoiding the need for a large abdominal scar, less disfiguring and allows early postoperative recovery. However, recent studies have now made it evident that the laparoscopic route has no advantages over a vaginal hysterectomy. The indications for choosing to do a laparoscopic hysterectomy would hence be contraindications for vaginal hysterectomy or any indication of abdominal hysterectomy. This includes severe endometriosis, pelvic adhesions, large fibroids, associated adnexal pathology, need for oophorectomy (Figure 2-A).

FIAGES Book.indb 188

Figure 2-B: Round ligament is being coagulated and cut

The infundibulopelvic ligament is dessicated with bipolar cautery and incised. The ovaries should be pulled inward and cauterization is done close to the ovary to avoid damage to the ureter. If the ovaries need to be conserved then coagulate and cut the uteroovarian ligament (Figure 2-C). 3. The vesicouterine fold of peritoneum is incised. The bladder can then be dissected free from the uterus and pushed down (Figure 2-D). 2.

3/23/2007 11:08:44 AM



Comprehensive Laparoscopic Surgery

189

Figure 2-C: Utero-ovarian ligament and fallopian tube is coagulated and cutv

Figure 2-F: Posterior vaginal wall is coagulated and cut

Figure 2-D: Utero vesical fold is cut so that bladder can be pushed down

Figure 2-G: Anterior vaginal wall is coagulated and cut with the help of unipolar hook

After securing the uterine vessels, the cardinal and uterosacral ligaments are divided (Figure 2-F). This is followed by circumferential culdotomy with division of cervicovagnial attachments (Figures 2-G, 2-H). After all the attachments of the uterus are severed, the uterus is pulled down into the vagina and it can be placed there as a plug to prevent loss of pneumoperitoneum. If the uterus is very big in size as in case of fibroid uterus then the uterus can be morcellated by electronically operated morcellator (Figure 2-I). 6. The vaginal vault is closed with three sutures: one attaching the uterosacrals with the vaginal vault and another in the midline (Figure 2-J). 5.

Figure 2-E: Uterine vessels are sutued with 1-0 vicryl 4.

The broad ligament is cauterized and cut and then uterine artery is skeletonised. Uterine artery can be either coagulated with bipolar cautery, or the ligasure or can be ligated by endosutures with 1-0 vicryl (Figure 2-E).

FIAGES Book.indb 189

Uterine manipulator There are various manipulators available in the market for uterine manipulation during total laparoscopic hysterectomy. The most prominent one is “Clermont Ferrand manipulator”.

3/23/2007 11:08:46 AM

190

Laparoscopic Gynaecological Surgery for General Surgeon

Figure 2-H: Angle of vaginal wall is cut

Figure 2-I: Morcellation of large fibroid uterus Figure 2-K: Various manipulators, RUMI handle with KOH colpotomizer system (top most). Clermont Ferrand manipulator in the middle. Silicon tube in the bottom.

Oophorectomy The incidence of ovarian malignancy below the age of 45 years is very low, so the normal looking ovaries should not be removed while doing total laparoscopic hysterectomy. However, if the patient age is more than 45 years then it is our routine practice to remove ovaries at the time of surgery. In all cases of postmenopausal women we prefer to remove the ovaries. Figure 2-J: Vault of vagina closed with 1-0 vicryl with intracorporeal suturing

It has all reusable components and has a half-cup which is rotatable. There are three rings, which fit into the vagina and control loss of pneumoperitoneum. However, a silicon, curved tube that fits onto the cervix, thereby presenting the fornices can also be used for manipulation of uterus. This tube should be closed at another end with wet gauge or a cap to prevent loss of pneumoperitoneum (Figures 2-K, 2-L).

FIAGES Book.indb 190

Laparoscopic management of adnexal masses Workup of patients in cases of adnexal masses Adnexal masses are frequently found in both symptomatic and asymptomatic women. In premenopausal women, physiologic follicular cysts and corpus luteum cysts are

3/23/2007 11:08:48 AM



Comprehensive Laparoscopic Surgery

191

the serum CA-125 level is not elevated and the patient has no signs or symptoms suggestive of malignancy. Ovarian cyst Broadly ovarian cyst can be classified into three categories: Functional cyst: follicular cyst, corpus luteum cyst, theca lutein cyst Inflammatory: tubo-ovarian abscess Neoplastic: germ cell tumor, benign cystic teratoma, epithelial tumors, serous cystadenoma, mucinous cystadenoma etc.

Figure 2-L: Uterine manipulator in the uterus and vagina

the most common adnexal masses, but the possibility of ectopic pregnancy must always be considered. Other masses in this age group include endometriomas, polycystic ovaries, tubo-ovarian abscesses and benign neoplasms. Malignant neoplasms are uncommon in younger women but become more frequent with increasing age. In postmenopausal women with adnexal masses, both primary and secondary neoplasms must be considered, along with leiomyomas, ovarian fibromas. Information from the history, physical examination, ultrasound evaluation and selected laboratory tests will enable the physician to find the most likely cause of an adnexal mass. Measurement of serum CA-125 is a useful test for ovarian malignancy in postmenopausal women with pelvic masses. Asymptomatic premenopausal patients with simple ovarian cysts less than 10 cm in diameter can be observed or placed on suppressive therapy with oral contraceptives. Postmenopausal women with simple cysts less than 3 cm in diameter may also be followed, provided

FIAGES Book.indb 191

Functional ovarian cyst All are benign and usually do not cause symptoms or require surgical management. The most common functional cyst is the follicular cyst, which is rarely larger than 8cm. These cysts are usually found incidental to pelvic examination, although they may rupture spontaneously, causing pain and peritoneal signs. These usually resolve in 4-8 weeks. Corpus luteum cysts are less common than follicular cysts. A corpus luteum is called a cyst when its diameter is greater than 3cm. Corpus luteum cyst may rupture leading to hemoperitoneum and requiring surgical management. Theca lutein cysts: are the least common of the functional ovarian cysts. They are usually bilateral and occur with pregnancy and in molar pregnancies. They may also be associated with clomiphene citrate, hMG/hCG ovulation induction and the use of GnRh analogues. Sometimes, theca lutein cysts may acquire very large size (upto 30cm) and become multicystic and regress spontaneously. Functional cysts tend to gradually regress or resolve either spontaneously or with hormonal suppressive therapy within 8 weeks. There is no need to remove ovaries in cases of functional ovarian cyst. Laparoscopic management of ovarian cyst Management of benign appearing adnexal masses must follow a protocol that includes obtaining cytology of pelvic and cyst fluid, possible frozen section of a biopsy specimen, and removing the mass for histologic examination. Aspirating a cyst and vaporizing or coagulating the capsule are acceptable alternatives. Laparoscopic management of adnexal masses depends on the patient’s age, pelvic examination, sonographic images and serum markers. A large solid, fixed or irregular adnexal mass accompanied by ascites is suspicious of

3/23/2007 11:08:49 AM

192

Laparoscopic Gynaecological Surgery for General Surgeon

Figure 3-A: Left ovarian dermoid cyst

Figure 3-C: Ovarian cortex incised

Figure 3-B: Most dependent part of ovarian cortex is being coagulated first at

Figure 3-D: Dermoid cyst remoeved intact without spillage from the left ovary

the proposed site of incision

malignancy. Cul de sac nodularity, ascites, cystic adnexal structures, and fixed adnexae occurs with endometriosis and ovarian malignancy. Laparoscopic ovarian cystectomy Laparoscopic ovarian cystectomy should be done in such a way that the cyst does not rupture and with minimal trauma to the residual ovarian tissue (Figures 3-A to 3-H). If the ovarian cyst is very large, the cyst fluid can be aspirated with laparoscopic aspiration needle to minimize spillage and facilitate its removal (Figure 3-I). The suction irrigator system reduces the spillage by inserting the suction irrigator probe into the cyst. However, many cysts rupture during manipulation. The aspirate is sent for cytologic examination. The ovary is then freed from the adhesions to the lateral pelvic wall, uterus or bowel. The cyst and pelvis are irrigated continuously. The most dependent portion of the cyst wall is opened with the help of bipolar forceps

FIAGES Book.indb 192

Figure 3-E: Dermoid cyst is kept inside the glove endobag

and scissors and the internal surface is inspected. If excrescence or papillae are found, the specimen is sent for frozen section. The capsule is stripped from the ovarian stroma using two claw forceps. Bipolar forceps is used to control. Oophorectomy should be done in cases of large ovarian cyst where no identifiable ovarian cortex is seen (Figures 4-A, 4-B, 4-C)

3/23/2007 11:08:51 AM



Comprehensive Laparoscopic Surgery

193

Figure 3-F: Margins of the glove endobag held together with grasper

Figure 3-I: Aspiration of large ovarian cyst by laparoscopic needle

Figure 3-G: Open end of glove endobag is pulled through the site of accessory

Figure 4-A: Large ovarian cyst with identifiable normal ovarian tissues

Figure 3-H: Retrival of dermoid cyst from the abdominal cavity with glove

Figure 4-B: Utero-ovarian ligament is coagulated with bipolar forcep and cut

endobag

Laparoscopy has replaced the laparotomy for the surgical management of ectopic pregnancy, as this is associated with less trauma, faster recovery, fewer adhesions and better results. The common sites for ectopic pregnancy are shown in Figure 5.

Ectopic pregnancy The incidence of ectopic pregnancy is increasing now-adays. This has been attributed to several factors like increases in sexually transmitted diseases, increase in reversal of tubal sterilization and assisted reproductive technology.

FIAGES Book.indb 193

3/23/2007 11:08:53 AM

194

Laparoscopic Gynaecological Surgery for General Surgeon

Figure 4-C: Infundibulo-pelvic ligament is coagulated and cut to remove the ovary

Figure 6-B: Suction canula is inserted between products and tube and saline irrigation is done to detach the product from the fallopian tube

Figure 5: Common sites for implantation of ectopic pregnancy

Surgical technique Conservative surgery : Salpingotomy In a case of ectopic pregnancy if the fallopian tube is unruptured, then salpingotomy should be done and fallopian tube should be preserved (Figures 6-A, 6-B).

Figure 6-A: Incision is given in the fallopian tube with the help of unipolar

Sometimes ectopic pregnancy can be seen laparoscopically in the process of abortion through the fimbrial end with homoperitoneum. In such cases the blood from the peritoneum should be removed with a good suction canula and the products can be removed from the tubal end with the help of hydrodissection and sometimes by grasping the products with grasper. In such cases also tube should not be removed (Figures 7-A, 7-B, 7-C). Standard operative laparoscopy is done with two standard 5mm ipsilateral ports on surgeon’s side, one 5mm port on the right side and infraumbilical port for the laparoscope. The side, size of ectopic pregnancy and the tubal status are assessed thoroughly. We prefer to instill dilute vasopressin (1 amp in 100ml saline) in the mesosalpinx and the antimesentric border of the unruptured ectopic pregnancy. Uterus is anteverted with manipulator. The proximal part of the tube close to the ectopic pregnancy is held by ureteric grasper in the left lower port and with a monopolar point electrode at 40-60 watts of pure cutting current, an optimum incision is made on the tubal seromuscular area. A suction irrigation is placed in the plane between the tubal mucosa and ectopic pregnancy sac first irrigation at high pressure separates the ectopic pregnancy from surrounding tubal mucosal attachment and then immediately suction is applied on the ectopic pregnancy sac which usually comes out effortlessly. Occasionally one has to grasp products of conception if they are stuck to the tube and gently remove out of the tube. Bleeding from incised area is coagulated with bipolar Kleppinger at 25-30 watts. We avoid to close the opening in the tube with suture or bipolar glueing both margins.

hook in a case of ampullary pregnancy

FIAGES Book.indb 194

3/23/2007 11:08:54 AM



Comprehensive Laparoscopic Surgery

195

that the tube should be coagulated carefully, flushed to the tube, to avoid the damage to the ovarian blood supply (Figures 8-A, 8-B, 8-C). The excised tube is then sent for histopathology, with the products of conception. A thorough peritoneal wash is given with saline to remove the residual blood clots and the scattered products of conception. The ovary should not be removed.

Figure 7-A: Ectopic pregnancy in the process of abortion through fimbrial end

Figure 8-A: A large ampullary ectopic pregnancy

Figure 7-B: Products of conception being removed from the tube with the help of hydrodissection

Figure 8-B: Bipolar cautery is used to coagulate mesosalphinx

Figure 7-C: Products of conception being removed through accessory port

Laparoscopy salpingectomy If salpingectomy is needed, as in case of ruptured ectopic tube or when future fertility is not a matter of concern proximal area of fallopian tube is coagulated and cut. We prefer to use Kleppinger bipolar forceps at 25-30 watts and scissors to cut tube and mesosalpinx. One should remember

FIAGES Book.indb 195

Figure 8-C: Tubectomy is being done

3/23/2007 11:08:55 AM

196

Laparoscopic Gynaecological Surgery for General Surgeon

Tubo-ovarian abscess

Common sites for endometriosis

The entire abdominal cavity is thoroughly rinsed with irrigating fluid to remove blood, pus and debris. Using a blunt dissection probe, omentum, small bowel and large bowel are carefully dissected from the pelvic structures. Irrigating fluid helps to develop dissection planes between bowel and pelvic structures. Once the abscess cavity is entered, immediately the entire cavity is rinsed to avoid contamination. The adnexal structures are then dissected free. Since these adhesions are filmy and avascular, scissors dissection is rarely necessary. After separating all the adhesions, the abscess cavity is removed with a tissue grasping forceps and claw forceps. 1-2 liters of fluid is left inside the abdomen to minimize the postoperative adhesive disease.

The disease is usually limited to pelvis and lower abdominal organs. Susceptible tissues and organs are ovaries, uterosacral ligaments, broad ligaments, cardinal ligaments, peritoneum of the lower anterior abdominal wall, urinary bladder, round ligaments, rectovaginal pouch, rectum, sigmoid colon and ureters (Figure 9-A).

Torsion of ovarian cyst Adnexal torsion is a surgical emergency. If detected early, the torsion can be untwisted. When the diagnosis is delayed, the cyst becomes haemorrhagic, necrotic and ischaemic. If the affected structures regain colour after untwisting indicating viability of the organ then there is no need to remove adnexa and the cyst should be aspirated in case of functional ovarian cyst and cystectomy should be performed in other cases of ovarian cyst. The uteroovarian ligament should be shortened by continuous suture using vicryl 1-0 to prevent further torsion of the ovary. Too much delay causes gangrenous changes in the cyst which are irreversible and a salpingooophorectomy is advocated. The causes of ovarian or adnexal torsion include paraovarian cysts, functional and pathologic ovarian cysts, ovarian hyperstimulation, ectopic pregnancy and adhesions. Endometriosis Endometriosis is commonly defined as presence of endometrium at places other than the normal uterine cavity. This article will review the surgical options for treating endometriosis with a specific purpose of enhancing fertility and relieving pain. Endometriosis is a progressive often debilitating disease affecting 10 to 15% of women during reproductive years. Management of this disease depends upon age, extent of the disease, severity of symptoms and the desire for fertility. Intervention is usually indicated for pain, infertility or impaired function of bladder, ureter or intestine.

FIAGES Book.indb 196

Figure 9-A: Endometriosis involving the bowel rectum uterosacral ligament and posterior surface of the ovary

Signs and symptoms The classical triad of dysmenorrhoea, dyspareunia and infertility is the characteristic of the disease. Bimanual pelvic examination may reveal tender uterosacral ligaments, cul-de-sac nodularity, induration of the rectovaginal septum, fixed retroversion of the uterus, adnexal masses and pelvic tenderness. Laparoscopic appearance of endometriosis The classical lesions of endometriosis are pigmented lesions and can be seen as red, purple, raspberries, blue berries, blebs and peritoneal pockets. The nonpigmented form of endometriosis appears as clear vesicles, pink vascular patterns, white scarred lesions, yellow brown patches and peritoneal windows. Early lesions result from proliferation of retrograde menstrual tissue and forms superficial implants and sometimes they become inactive or penetrate deeper and become deep implants. Endometrioma (chocolate cyst) can also be seen as large ovarian cyst (Figure 9-B).

3/23/2007 11:08:56 AM



Comprehensive Laparoscopic Surgery

197

All the peritoneum over bladder is completely removed, peritonealisation occurs in one to two weeks. Malignancy Occasionally, severe atypia is reported in women with ovarian endometriosis. Adenocarcinoma, adenocanthoma, clear cell carcinoma, and endometrioid carcinoma are the most common malignancies associated with atypical ovarian endometriosis. The cyst wall should be sent for histopathological examination and pathologists should emphasize foci of atypical endometriotic epithelium in their reports. Figure 9-B: Large endometriomas (chocolate cysts) adhered to the bowel, posterior surface of the uterus

Radical surgery

Diagnosis CA125 is found to be elevated in this condition and ultrasound may diagnose chocolate cyst of ovary as enlarged cysts with uniform granular hypoechoic fluid collection. Colour Doppler may demonstrate flow around but not within the endometriotic cyst.

Hysterectomies with bilateral salpingo-oophorectomy are indicated for patients with severe symptoms who have not responded to any other form of treatment and are not interested in pregnancy. Bilateral oophorectomy must be performed to eliminate the estrogen that sustains and stimulates the ectopic endometrium.

Operative laparoscopy

Summary

It begins by lysing adhesions between bowel and pelvic organs. The main step of surgery for endometrioma is where the ovaries are dissected from culdesac or pelvic side wall very cautiously trying to avoid spillage of the chocolate material as much as possible. The tubes are freed from adhesions. Endometrial implants and endometriotic cyst lining are resected or vaporized with bipolar coagulation of 30-40 Watts. In patients with significant pelvic pain, laser uterosacral nerve ablation (LUNA) or presacral neurectomy is performed along with treatment of the primary disease occasionally if pain is significant.

Today the laparoscopic surgery has replaced the conventional surgery, as laparoscopic surgery offers all the advantages of minimally access surgery. A general surgeon should be familiar with common gynaecological surgical procedures which can be done laparoscopically to offer all the possible advantages of laparoscopic surgery to the patient.

Scarred and deep peritoneal lesion Lesion can be excised from the peritoneum and draining the chocolate material. Subsequently the peritoneum can be shaved off and fulguration is done. Hydrodissection is useful to identify and develop dissection plane. Peritoneal implants should be destroyed in the most effective and least traumatic manner to minimize postoperative adhesions. The incidence of genitourinary endometriosis is reported in 1-11% of women diagnosed with endometriosis. Bladder lesions are excised in the same way as peritoneal disease followed by cystoscopy to rule out mucosal involvement.

FIAGES Book.indb 197

Suggested readings 1.

2. 3.

4.

5. 6. 7.

Nezhat C, Siegler A, Nezhat F, Seidman D, Luciano A. Operative gynaecological laparoscopy : Principles and techniques. Rogers RM, Childers JM. Laparoscopic gynecologic anatomy – The surgical essential. A review of total laparoscopyc hysterectomy: Role, technique and complications. Current Opinion Obstetrics and Gynaecology 2006; 18(4): 380-384. Laparoscopic hysterectomy. Obstetrics and Gynaecology Clinics of North America 2004; 31(3) : 523-537. Jain N. State of the art: Atlas of endoscopic surgery in infertility and gynecology. Trivedi P. Beyond the boundaries of endoscopic surgery. Telinde’s operative gynaecology.

3/23/2007 11:08:56 AM

Laparoscopic Adjustable Gastric Banding for Morbid Obesity

25

A.K.Kriplani, Aloy J Mukherjee, Daipayan Ghosh Obesity was identified as a disease thirty years ago when, the WHO listed obesity as a disease condition in its International Classification of Diseases in 1979. The prevalence of obesity, and especially of morbid obesity, is increasing worldwide and it is today becoming a significant health hazard. Indeed, obesity rates have now reached epidemic proportions in the western hemisphere, with over 25 per cent of the population being obese in US and 15 percent in Europe1. A similar pattern of increasing degrees of obesity has been demonstrated in the pediatric population. Overweight children and adolescents have a higher risk of becoming obese adults. Prevalence of obesity in India is up to 50% in women and 32.2% in men in the upper strata of the society2. In Delhi alone the prevalence of obesity stands at 33.4% in women and 21.3% in men3. Co-morbidities commonly associated with obesity include diabetes, cardiovascular and respiratory disease, dyslipidemia, degenerative joint disease, stress incontinence, and various types of cancers among others. They are all responsible for a reduced life expectancy1 and an impaired quality of life. Obesity bias and discrimination starts in the earliest social contacts, in preschool children and progresses through childhood and adolescence into adulthood. This prejudice may contribute to depression, eating disorders, and body image disturbance. The practical social implications of morbid obesity are manifold e.g. inability to ambulate, limited options in clothing, stress incontinence, and difficulty with personal hygiene. A direct consequence of the social bias is an economic disadvantage with decreased educational, job and promotion opportunities.

FIAGES Book.indb 198

There is also a direct relationship between increasing BMI and relative risk of dying prematurely. The Framingham data1 revealed that for each pound gained between ages 30 to 42 years, there was a 1% increased mortality within 26 years, and for each pound gained thereafter, there was 2% increased mortality. In the morbidly obese population, the average life expectancy is reduced by 9 years in women and 12 years in men1. Body Mass Index (BMI) Obesity generally is determined by calculating body mass index (BMI), which measures weight for height and is stated in numbers. BMI is calculated by the weight in kilograms divided by height in meter square BMI in Kgs/m2 = Weight (in Kgs) Height (in meters) X Height (in meters) Alternatively, BMI can be calculated by BMI = Weight (in lbs) X 704 Height (in inches) X Height (in inches) Obesity is commonly classified as BMI

Status

Below 18.5

Underweight

18.5 – 24.9

Normal

25 – 29.9

Overweight

30 – 34.9

Obese

35 – 39.9

Severe Obesity

> 40

Morbid Obesity

> 50

Super Morbid Obesity

3/23/2007 11:08:57 AM



Comprehensive Laparoscopic Surgery

Obesity was further classified in the 1998 NIH Clinical Guidelines on the Identification, Evaluation, and Treatment of Overweight and Obesity in Adults 4 into: Obesity

BMI

Class I

30.0 kg/m2 to 34.9 kg/m2

Class II

35.0 kg/m2 to 39.9 kg/ m2

Class III

> 40 kg/ m2

199

substance abuse, bulimia nervosa, and socially disruptive personality disorders. This may help avoid adverse postoperative outcomes, improve recovery and promote compliance. A history of compliance with non-operative therapy may be beneficial in assessing the risk-to-benefit ratio of bariatric surgery. Surgical options The surgical options available for treating morbid obesity are:

MANAGEMENT OF MORBID OBESITY Obesity requires long-term management. The goal of treatment is weight loss to improve or eliminate related health problems, or the risk for them, not to attain an ideal weight. Conservative therapy invariably fails to achieve weight loss, or sustain the weight loss in morbidly obese patients. The patients gain back the lost weight in a short time4. Therefore, surgery is being increasingly considered as the preferred option for these patients1. Surgical treatment of morbid obesity has been established as being safe and effective. It is the most effective therapy available for the morbidly obese population. It markedly lowers body weight, reverses or ameliorates the myriads of obesity related co-morbidities5 and improves the quality of life. Since introduction of laparoscopic techniques in this field, the number of patients being referred for surgery has been on the rise. Indications for surgery Surgical therapy should be considered for individuals who: 1. Have a body mass index (BMI) equal to or greater than 40 kg/ m2 Or 2. Have a BMI equal to or greater than 35 kg/ m 2 with significant co- morbidities. And 3. Previous dietary attempts at weight control have been ineffective. High-risk co-morbid conditions that can justify surgery at a BMI to 35 kg/ m2 include type 2 diabetes, life-threatening cardiopulmonary problems (e.g., severe sleep apnea, Pickwickian syndrome, obesity-related cardiomyopathy), obesity-induced physical problems interfering with a normal lifestyle (e.g., joint disease treatable but for the obesity), and body size problems precluding or severely interfering with employment, family functions, and ambulation 6,7,8,9 Mental status is a difficult area in which to define standards for patient selection. The subject needs to be screened for severe depression, untreated or under treated mental illnesses associated with psychoses, active

FIAGES Book.indb 199

1. Restrictive: a. Vertical Banded Gastroplasty (VBG) b. Laparoscopic Adjustable Gastric Banding (LAGB) In the adjustable gastric band, the amount of restriction can be adjusted10,11 while in the vertical banded gastroplasty it remains fixed 12,13. The popularity of VBG has now been on the decline because of the poor longterm weight loss and complications. 2. Restrictive and Malabsorptive: Roux en Y gastric bypass 14, 15, 16 with a standard limb, long-limb or a very long-limb is a procedure which has been used for the longest time with known long term results. The gastric bypass causes gastric restriction but also relies on varying amounts of intestinal malabsorption as an additional weight loss mechanism 3. Malabsorptive: Biliopancreatic diversion alone or with duodenal switch17. Certain surgeons perform one operation exclusively; other surgeons offer the full range of operations. There is an ever-increasing effort to match a particular patient to a particular operation. To this end, several selection approaches or algorithms have been suggested, although randomized trials that test these algorithms have not been conducted. Increasingly, hormonal changes are being recognized as an important mechanism of post surgical weight loss; recent studies have demonstrated that gastric bypass results in altered release of hunger-causing hormones, such as ghrelin. LAPAROSCOPIC ADJUSTABLE GASTRIC BANDING The development of the Gastric Band The concept of adjustable gastric banding was pioneered by Austrian surgical researchers G. Szinicz and G. Schnapka in 198218. They placed a ring of silicone

3/23/2007 11:08:57 AM

200

Laparoscopic Adjustable Gastric Banding for Morbid Obesity

elastomer around the upper part of the stomach of rabbits. There was a balloon on the inner surface, connected to a subcutaneous port. Addition of saline to the port altered the space within the band. This idea was adapted for clinical use by Dr Lubomyr Kusmak, a Ukranian surgeon working in the USA. From June 1986, he began applying the band to his patients. He found that, when compared with a non-adjustable but otherwise similar silicone band that he had used since January 1983, the patients fared better losing 62.4% of the Excess Body Weight (EBW) compared to 49.4% for nonadjustable band at 4 years, with fewer complications 19. The adjustable silicone gastric band was then modified for laparoscopic placement by creation of a self-locking mechanism and a fixed, initial band circumference rather than the variable system devised by Kusmak, which required closure to a point that generated a fixed pressure. Dr Guy Bernard Cadiere performed the first laparoscopic placement of an adjustable gastric band in 1992 using the unmodified Kusmak band. The first placement of a BioEnterics® Lap-Band® System (SAGB/ LAGB®) was by Drs Mitiku Belachew and Marc Legrand in September, 199320. There are now at least six versions of the laparoscopic adjustable gastric band available commercially, but published data in referred journals are almost totally related to the Lap Band (Inamed Health, CA, USA) and SAGB (Swedish Adjustable Gastric Band; Obtech Medical, 6310 Zug, Switzerland) with a few papers available on the other devices. The Swedish band (Fig.1) is a low pressure high volume band and is the softest amongst the available bands. After closure, the balloon covers the stomach all around (360 degree). For these

reasons it has lesser chances of erosion of the stomach than other bands. Patient Evaluation And Preparation Operations should only be performed within the setting of an obesity treatment program committed to maintaining long-term follow up for evaluation of outcomes. Careful preoperative evaluation and patient preparation are critical to success. Patients should have a clear understanding of expected benefits, risks, and long-term consequences of surgical treatment. Surgeons must know how to diagnose and manage complications specific to bariatric surgery. Patients require lifelong follow-up with nutritional counseling and biochemical surveillance. Surgeons also must understand the requirements of severely obese patients in terms of facilities, supplies, equipment and staff necessary to meet these needs, and should ensure that the specialized staff and/or multidisciplinary referral system is available for the treatment of these patients. This multi-disciplinary approach includes medical management of co-morbidities, dietary instruction, exercise training, specialized nursing care and psychological assistance as needed on an individual basis. A practitioner familiar with relevant bariatric operations should direct post-operative management of the co-morbidities. Contra-indiations for the procedure include: Mentally defective – unable to understand the rules of eating and exercise and therefore unable to fulfill their part of the partnership Malignant hyperphagia – Prader Willi syndrome Portal hypertension Pre-Operative Care:

Figure 1: Swedish Adjustable gastric band (A) with attached connection tube (B) and injection port (C) on which the connection tube can be mounted.

FIAGES Book.indb 200

The bariatric surgery patient needs to be well-informed, motivated, willing to participate in the long term care, change dietary patterns, and embrace a revised lifestyle. The patient is best evaluated, and subsequently cared for by a team approach involving the surgeon, a dedicated dietician, a nurse practitioner, and other specialists when needed. In addition to a preoperative history, physical, and laboratory evaluation, a preoperative discussion or teaching seminar that provides information on postoperative recovery, dietary changes, activity, and clinical outcomes, by the dietician, the bariatric nurse, and the bariatric surgeon, is critical. Availability of a support

3/23/2007 11:08:58 AM



Comprehensive Laparoscopic Surgery 201

group is recommended, as is distribution of literature describing procedures, postoperative diets, exercise etc. Availability of a full spectrum of expert consultants (e.g. cardiologists, pulmonologists, psychiatrists and psychologists) is mandatory. Anti-thrombotic measures need to be in place. Graduated compression stockings may be put on, one day prior to surgery. Low molecular weight heparin shall have to be administered 24 to 48 hours prior to surgery. Anesthetic considerations: Expert anesthesiology support, knowledgeable in the specific problems of the bariatric patient, is necessary. The anesthesiology support includes an understanding of patient positioning, blood volume and cardiac output changes, airway maintenance, and drug pharmacokinetics in the morbidly obese. It is advisable to have preoperative, intraoperative, and postoperative written protocols. Airway access and intubations in obese patients are difficult. Blood pressure monitoring requires a larger sized cuff. Venous access and maintenance requires expertise. Intra-operative pneumatic compression stockings need to be put on both the lower limbs before positioning of the patient is done. Surgical Technique Patient position and Port Placements The patient is put in a modified Lloyd Davies’ Position with the arms outstretched, and a steep reverse Trendelenberg position as much as may be required. A total of 5 or 6 ports are used (Fig 2). There is significant variation in the position of port placement between surgeons who otherwise do the operation in an almost identical fashion and who, at completion of the operation, have the band in exactly the same position. It would therefore appear that the exact port placement is not by itself critical to good outcome and should be dictated by surgeon preference. Factors that shall influence the preference include prior practice of port placement (especially for laparoscopic anti-reflux surgery), preferred instruments and ports and the position of the surgeon (either on the patient’s right side or standing between the patient’s legs). There are times, such as the presence of copious intraabdominal fat, when an extra 5 mm port may be helpful. Generally the addition of a 5mm port is not regarded as a significant event and certainly the safety or ease of the operation should not be compromised for such a reason.

FIAGES Book.indb 201

Figure 2: Port postions for laparoscopic adjustable gastgric banding. The 10 mm port for the laparoscope with a 5 mm port for the left hand dissection and a 15 mm port for the right hand of the surgeon and placement of the band. The 10 mm right midclavicular port is for the liver retraction. A left anterior axillary 5 mm port helps in retraction of the fundus to expose the phreno-esophageal ligament.

The abdomen is inflated to 15 mm Hg by introducing a Veress needle, Alternatively visual access is gained with a 12-mm Excel port (Ethicon Endosurgery) using a 0° laparoscope. The peritoneal cavity is inspected and all subsequent ports are placed under vision. This left subcostal (midclavicular) port shall be subsequently replaced with a 15 mm port for the introduction of the band into the peritoneal cavity. A 10 mm trocar is introduced under guidance of the telescope at a hands’ width distance from the tip of the xiphoid process towards the umbilicus and a thumbs spread to the left of the midline. This will be the camera port. Another 10 mm trocar is inserted in the right subcostal region for liver retractor. Two additional working 5-mm trocars are then placed; one in the anterior axillary line on the left side for fundal retraction by the assistant and the other in the epigastrium for the left hand dissection of the surgeon and the articulating dissector to make a retgrogastric tunnel for the passage of the band. Current Operative Technique Belachew21 described the original technique for LAGB placement. Numerous modifications and variations have subsequently been proposed. The LAGB is specifically designed for laparoscopic placement. Obviously, it can be placed by open technique also when occasionally this becomes necessary, usually due to the presence of very large, fragile liver or copious

3/23/2007 11:08:58 AM

202

Laparoscopic Adjustable Gastric Banding for Morbid Obesity

amounts of intra abdominal fat. The degree of visibility, and therefore accuracy of placement and fixation are much greater with laparoscopic placement. Furthermore, there are fewer peri-operative complications. The operation requires good laparoscopic skills and prior experience with advanced laparoscopic surgery. The Pars Flaccida pathway for placing the band The pars flaccida path22 has now become the recommended approach by most surgeons. This approach has the advantages of ease of dissection and decrease in the incidence of prolapse of the posterior wall of the stomach through the band which was a major flaw of the previously used perigastric technique. The dissection on the lesser curvature of the stomach includes the neurovascular bundle of the lesser omentum. The pars flaccida path requires minimal tissue dissection and therefore little likelihood of encountering bleeding. It is usually quick and safe. It is easily defined, easily taught and places the band in the optimal alignment across the very top of the stomach. It almost never traverses the lesser sac and does not require posterior fixation. If the surgeon wishes to keep open the option of later conversion to gastric bypass, this approach does not compromise subsequent dissection. A potential disadvantage to the pars flaccida path is the possibility of early postoperative obstruction to swallowing due to excess tissue within the band. The amount of fat included with the banded upper stomach is much more variable than with the perigastric approach. With too much fat present, transit of fluid across the band will be excessively delayed or stopped in the early days postoperatively. Particular attention needs to be given to the use of the calibration tube and the dissection of the lesser omental and perigastric fat to ensure the band is not too tight. Step 1. Division of phreno-gastric ligament: By retracting the left liver lobe upward pulling downward on the gastric fundus with an atraumatic grasper, a triangular area is exposed above the gastric fundus in which the 3 sides in clockwise sequence are the diaphragm, the gastrosplenic ligament, and the esophagus. The phenro-gastric ligament in the center of the triangle is divided (Fig.3) using a monopolar hook, thereby releasing the fundus from the diaphragm and exposing the angle of His, the left crus of the diaphragm and the retrogastric pad of fat.

FIAGES Book.indb 202

Figure 3: Incising the phreno-gastric ligament (arrow).

Step 2. Exposure of the right crus: After freeing the gastric fundus, the dissection is shifted to the lesser omentum. A window is made in the lesser omentum with the hook at an avascular site (Fig.4). Continuing the division of the lesser omentum upwards, the right crus of the diaphragm is exposed by detaching the pars flacida (Fig.5).

Figure 4: Incising the gastro hepatic ligament.

The anaesthetist is now requested to introduce the gastric calibration tube and decompress the stomach. The balloon is filled with 15 ml of saline (Fig. 6) and the tube is withdrawn till a resistance is felt against the gastro-oesophageal junction (Fig. 7). The retrogastric tunnel should be made at the center of the balloon for creating a small pouch. This point is noted, the balloon is deflated and the tube is withdrawn into the oesophagus. The peritoneum just medial to the lower part of the right crus is incised at the point intended for placement of the band using diathermy. The Goldfinger (Ethicon Endosurgery) is introduced through this opening (Fig. 5),

3/23/2007 11:09:00 AM



Comprehensive Laparoscopic Surgery 203

Figure 5: Exposing the Right crus of the diaphragm.The goldfinger is being

Figure 8: The tip of the goldfinger emerging through the divided phrenogastric

introduced into the retrogastric space after incising the posterior peritoneum.

ligament

Figure 6: Balloon of the gastric calibration tube inflated with 15 ml of saline.

Figure 9: The goldfinger passed through the retrogastric tunnel

Figure 7: The gastric calibration tube pulled so that the balloon is at the gastro-esophageal junction.

FIAGES Book.indb 203

curving its tip into the retrogastric fat tissue adjacent to the left margin of the crus and directing it toward the exposed angle of His (Fig.8). The tip of the goldfinger comes out to the left of the gastric fundus through the opening made in the phrenogastric ligament (Fig.9). At this point, the sterile SAGB is unwrapped on the back table, and sterile normal saline injected into its tubing with a 5 ml syringe, which is subsequently withdrawn till all the air bubbles are removed. This procedure needs to be repeated a few times to ensure there is no air in the balloon. The connecting tube is clamped with a rubbershod mounted curved hemostat. A knot is tied on the tubing distal to the clamp to maintain the vaccum. The Swedish band comes with a pre-tied Ethibond loop at its tip. The fully deflated balloon is then grasped by this loop with a 5mm grasper and is introduced into the peritoneal cavity through the 15 mm left subcostal port.

3/23/2007 11:09:03 AM

204

Laparoscopic Adjustable Gastric Banding for Morbid Obesity

3. Retro-gastric transit of the band: The pneumoperitoneum is reestablished. The ethibond loop at the tip of the band is snugged into the slit on the tip of the Goldfinger (Fig.10). The Goldfinger is gently pulled through its retro-gastric extraperitoneal path. The shoulder of the band is seen coming out from behind the stomach, at the lesser curve. The balloon side of the band should face the stomach The tip of the band is eased out through the opening pulling the band in place (Fig.11). 4. Band fastening: After the band has been placed in the retrograstric tunnel, the anesthetist is again requested to push the gastric calibration tube into the stomach, inflate the balloon and pull it back till the balloon comes to the GE junction. The band-end tags are locked forming the pouch above the band (Fig. 12). The buckle is glided onto the lesser curvature of the stomach and the band can be seen secured at 450 from the lesser curve to the fundus of the stomach. Interrupted anterior gasro-gastric sutures are taken with 2-0 Ethibond (Ethicon) to cover the band anteriorly, starting close to the greater curve (Fig. 13). Two or three gastro-gastric sutures are required to cover the band (Fig. 14). The buckle of the band at the lesser curve must never be covered with gastrogastric sutures, as this may initiate gastric erosion by the band. The connecting tube is then exteriorized through the subxiphoid port. The precise siting of the band at the top of the stomach is the most critical aspect of the procedure. If it is too low, it causes problems. If the band is too high, it does not work properly and may cause achalasia like symptoms. One must remember that the LAGB is a gastric band, not an esophageal band. The most important mechanism

Figure 10: The ethibond loop on the band snugged into the slit of the goldfinger tip.

FIAGES Book.indb 204

of its action is by inducing a feeling of satiety. Even if patients have not eaten, they do not feel hungry. Patients

Figure 11: The band passed through the retrogastric tunnel.

Figure 12: The band locked in place below the inflated balloon of the gastric calibration tube.

Figure 13: First gastrogastgric suture near the greater curve.

3/23/2007 11:09:05 AM



Comprehensive Laparoscopic Surgery 205

can miss a meal or eat late and not have the perpetual focus on food that they have had for years. This effect allows eating three or less meals per day. When they do eat, the second mechanism of action comes into play, namely, a sense of rapidly achieved fullness. The sense of satiety is probably mediated by the vagal afferent receptors in the apex of the gastric cardia. The band needs to overlay this area to generate this response.

and locked in position (Fig. 15). The IP is then squeezed into the presternal space with its flat bottom facing the sternum and pushed into position. The prolene sutures are tied to anchor the port to the rectus sheath. The 10mm and 15 mm port sheaths need to be closed with vicryl suture using wound closure needle. Following complete reversal of pneumo peritoneum and careful removal of all ports, the skin is sutured with subcuticular sutures.

Figure 14: Gastrogastric sutures in place.

Figure 15: Placement of SAGB injection port over rectus sheath in subxiphoid

The posterior aspect of the band is almost certainly around the distal esophagus as it runs along the line of the left crus. The anterior aspect therefore has to be fixed over the upper stomach to achieve the satiety-inducing effect. There must be correct placement of the gastrogastric sutures as a part of the anterior fixation The calibration tube has two important functions; defining the line of the esophago-gastric junction and enabling a check that the band is not too tight after closure. Additionally, it can be helpful as an aspiration tube to empty the stomach of gas at the commencement of the operation. After closure of the band and with the calibration tube in place, it is important to check that the band can rotate freely and that a grasper can be passed under the band without difficulty. If not, more fat should be removed from the anterior surface of the stomach. 5. Placement of the Access / Injecting Port (IP): The access port should be placed on the anterior rectus sheath just below the sternum. A 5 cm transverse incision is made and the rectus sheath is exposed by dividing the fat. A pouch is made for the placement of the port. Prolene sutures are passed through the holes in the ports and then through the rectus sheath and held in artery forceps. The connecting tube is mounted on the port

FIAGES Book.indb 205

position, the tubing being connected to the injection port using the connector, fixed in place with prolene sutures

Mobilization of the patient is started immediately, i.e. a few hours after surgery. Oral intake is started in the evening after the surgery and quickly increased to 1000 ml on the second day, 1500 on the 3rd day and two liters thereafter. The patient is normally discharged the day after the procedure Outpatient adjustment of the band under fluoroscopy is then used for achieving the optimal tightness. Complications 1. Perioperative Perhaps the most attractive single feature of the LAGB is its safety. It has proved to be one of the safest of surgical procedures, being 7 – 10 times safer than Roux-en- Y gastric bypass (RYGB) in terms of mortality with an overall perioperative complication rate of 1 – 2%. The ASERNIP-S systemic review of the published literature identified an incidence of perioperative complications of 2.6%, to be compared with 29.9% for Vertical Banded Gastroplasty and 23.4% for RYGB23. Operative (30-day) mortality for laparoscopic adjustable gastric banding when performed by skilled

3/23/2007 11:09:06 AM

206

Laparoscopic Adjustable Gastric Banding for Morbid Obesity

surgeons is about 0.1%. Operative morbidity is about 5%. 2. Late complications Late complications have been frequent but are proving to be avoidable with improved technique. Prolapse of the stomach through the band may occur. The clinical features of prolapse are those of obstruction at the upper stomach. There is heartburn, reflux of fluid into the mouth and airway, vomiting after eating, coughing and choking spells with wheezing. A limited barium swallow is the best investigation to define the problem. Uncommonly, the prolapse becomes large and tense, leading to upper abdominal pain, tenderness and the need for emergent exploration to rule out gastric necrosis. Prolapse of the posterior wall of the stomach through the band, the central problem of the perigastric approach, is managed by laparoscopic removal of the band and placement of a new band along the pars flaccida pathway. This procedure has proved to be safe and effective as it allows the patients to continue on with their progressive weight loss. Adherence to the correct technique of pars flaccida pathway has virtually eliminated posterior prolapse. Anterior prolapse occurs equally in the pars flaccida and perigastric approaches and indicates some failure of anterior fixation. If the prolapsed segment is not excessively edematous or hypertrophied, it can generally be managed by mobilization, reduction of the prolapse and refixation. On occassions, removal and replacement is needed. Erosion of the band into the stomach is reported in 3.2% of subjects but with the newer high volume low pressure bands, this problem should be controlled to a large extent. Erosion occurs if the band is filled too rapidly or if the anterior wrap of gastric wall covers a part of, or the entire buckle of the band. Avoidance of sutures in this area has resulted in virtual disappearance of this problem. Post Operative Outcomes Weight Loss Studies of weight loss in bariatric surgery will generally express the outcomes in the terms of percentage of excess weight lost (%EWL), as change in body mass index (BMI) or as absolute weight loss in kilograms or pounds.

FIAGES Book.indb 206

The weight loss occurs more slowly than is usually seen after gastric bypass or bilio-pancreatic diversion. After the initial placement, there is a gentle, progressive weight loss controlled by steady increments of saline added to the system. Once a new stable point of weight has been reached, the weight loss can be maintained and the recidivism of gastric bypass avoided by further small additions of saline24. The maximum weight loss is reported to occur in three or four years, rather than one to two years. Current data indicate that once the maximum weight loss is achieved, the weight remains stable up to at least 6 years. These features reflect the benefit of adjustability. Change in Co-morbidities: There is no more powerful treatment in health care than weight loss in the obese. Numerous diseases are improved or resolved completely and the risk of disease is considerably reduced. a. Type 2 diabetes and insulin resistance Type 2 diabetes is the paradigm of an obesity related disease. In most cases it exists because of the obesity and will disappear with weight loss. The effect of weight loss following gastric banding was studied on a range of health outcomes in 50 obese diabetic subjects from a cohort of 500 consecutive patients25. Fifty patients, with type 2 diabetes were studied preoperatively and again 1-year after surgery. The preoperative mean weight was 137 +/- 30 kg and BMI was 48.2 +/- 8 kg/m2. At 1-year mean weight was110 +/-24 kg and mean BMI was 38.7 +/- 6 kg/ m2 . There was a significant improvement in all measures of glucose metabolism with remission of diabetes in 32 (64%) patients, major improvement of control in 13 (26%) and no change in 5 (10%). Remission of diabetes was predicted by a greater weight loss and a shorter history of diabetes (p 40) to be 42-48% in men and 8-38% in women39. Many studies have shown that there are major improvements in sleep disturbance and sleep disordered breathing in obese subjects associated with weightloss. These improvements are consistent for medical, dietary and surgical methods of weight loss40,41,42,43. Sleep disturbance understandably recurs with weight gain. In a study of 313 consecutive patients with severe obesity (BMI >35) who completed a pre-operative sleep questionnaire and a clinical assessment as a part of the preoperative evaluation prior to Lap-Band placement. A 12-month postoperative study was completed on 123 of these patients, which assessed the characteristics of sleep disturbance and changes in responses to weight loss44. There was a high prevalence of significantly disturbed sleep in both men (59%) and women (45%), with women less likely to have had their sleep disturbance investigated. Observed sleep apnea was more common in men, but day sleepiness was not affected by gender. Waist circumference was the best clinical measure predicting observed sleep apnea. The group lost an average of 48% of excess weight by 12 months. There was a significant

FIAGES Book.indb 208

improvement in the responses to all questions at followup with habitual snoring reduced to 14% (pre-op 82%), observed sleep apnea 2% (33%), abnormal day sleepiness 4% (39%) and poor sleep quality 2% (39%). The sleep quality score changed markedly. Prior to surgery, 29% had poor quality sleep and 28% had good quality sleep. These scores changed to 2% and 76% respectively at one year after operation. g. Depression The twenty-one term Beck Depression Inventory (BDI) has been used as a measure of the characteristic attitudes and symptoms of depressive illness in severely obese subjects presenting for Lap-Band placement. The BDI45 has been used for over 40 years as a measure of the characteristic attitudes and symptoms of depression. It has been validated and used in different ethnic groups, in subjects with co-existent medical conditions and in obese subjects 46,47,48,49,50. For 487 subjects before surgery, the mean BDI score was 17.7 ± 9.2. Higher scores were found in younger subjects, women and those with poor body image. These factors had an independent effect and a combined r2 = 0.14, p