Laparoscopic surgery

Laparoscopic surgery is a minimally invasive technique used to perform surgical procedures within the abdominal cavity, utilizing specialized instruments introduced through small incisions made on the abdominal wall. The abdominal cavity is first accessed using a trocar or a Veress needle, most commonly in the midline (peri-umbilical region). The peritoneal cavity is then insufflated with carbon dioxide (CO₂). A fiber-optic instrument (laparoscope) is inserted into the first trocar to visualize the abdominal cavity and to allow for other ports to be created under direct vision. Laparoscopy is often the preferred diagnostic procedure for most elective gastrointestinal and gynecological surgeries. It is contraindicated in patients with shock, cardiac/pulmonary failure, and in cases of dilated bowel loops/perforation peritonitis. There are several advantages of laparoscopy over laparotomy as the incisions used are much smaller (e.g., less postoperative pain, fewer respiratory complications). However, the surgery is technically more challenging and complications (e.g., hemorrhage, bowel injury) are difficult to control laparoscopically. Complications unique to laparoscopy (secondary to CO₂ insufflation of the peritoneal cavity) include hypercarbia, pneumothorax, pneumomediastinum, venous air embolism, and postoperative shoulder pain. Proper patient selection and good surgical technique minimize the risks and complications of laparoscopy.

Nearly all elective abdominopelvic surgeries can be performed laparoscopically. A few examples include:

• Gastrointestinal surgery: : e.g., cholecystectomy, appendectomy, hernia repair, bowel resection
• Gynecological surgery: : e.g., hysterectomy, oophorectomy
• Urological surgery: e.g., nephrectomy, pyeloplasty
• Diagnostic laparoscopy
  • Allows direct visualization of the abdominal cavity, as well as biopsy of suspicious areas (lymphadenopathy) or collection of peritoneal fluid (for culture or cytology) through small incisions in the abdominal wall. ^[1]
  • Commonly used to avoid laparotomy in the following situations:
    • Evaluation of acute abdominal pain with negative imaging
    • Abdominal trauma with negative imaging when an intra-abdominal injury is suspected (e.g., diaphragmatic tear)
    • Staging of cancers
    • To determine resectability of cancers: gastric cancer, pancreatic/biliary tract cancer, etc.

• Absolute contraindications ^[2]
  • Hemodynamic instability/shock
  • Acute intestinal obstruction with dilated bowel loops
  • Increased intracranial pressure
• Relative contraindications ^[2][3]
  • Cardiac failure
  • Pulmonary failure
  • Pregnancy/large pelvic masses
  • Soft tissue infection at port sites
  • Expected (extensive) adhesions from a previous abdominal surgery
  • Abdominal aortic aneurysm (may be associated with increased risk of vascular rupture)

We list the most important contraindications. The selection is not exhaustive.

1. Anesthesia: general anesthesia (most common), spinal anesthesia with/without epidural anesthesia may be used in some cases ^[4]
2. Access to the peritoneal cavity (laparoscopic entry): A trocar/Veress needle is inserted through the abdominal wall (generally midline) into the peritoneal cavity.
   • Trocar: An instrument with a sharp conical end that is used to establish a portal of entry into a body cavity.
3. Creating a pneumoperitoneum: The peritoneal cavity is insufflated with carbon dioxide (CO₂). ^[5]
   • Allows visualization of abdominal contents and creation of operative space
   • Raises intra-abdominal pressure due to the insufflation of gas within a closed cavity
4. Creation of other port sites
5. Removal of instruments and trocars
6. Evacuation of pneumoperitoneum
7. Closure of the port sites: Fascia of port sites > 5 mm must be sutured at the end of the surgery. ^[6]

• Advantages of laparoscopy over laparotomy include:
  • Less postoperative pain, which leads to:
    • Early mobilization → decreased risk of developing deep vein thrombosis, pulmonary embolism, or pneumonia
    • Minimal use of analgesics
    • Shorter hospital stay
  • Shorter duration of postoperative ileus
  • Better cosmetic outcome (smaller scars)
  • Less intra-abdominal adhesion formation
• Disadvantages of laparoscopy are mainly technical:
  • The surgical field is converted to a two-dimensional image on a monitor.
  • Technically more challenging than laparotomy
  • Difficulty in controlling intra-operative hemorrhage
  • Laparoscopy-specific complications (see below)

Intra-operative complications

• Injury to adjacent organs (e.g., blood vessels, bowel, bladder, solid intra-abdominal organs)
• Aspiration of gastric contents
• Intra-abdominal pressures > 20 mmHg should be avoided as it may potentially lead to:
  • The diaphragm being pushed upwards → decreased total lung volume and increased airway pressure
  • Compression of the IVC → decreased venous return to the heart → decreased cardiac output
  • Increased systemic vascular resistance (compression of arteries) and release of catecholamines (adrenaline, noradrenaline) → tachycardia
  • Compression of renal arteries → decreased glomerular filtration rate → decreased urine output
• Pneumothorax ^[7]
• Pneumomediastinum (rare) ^[8]
• Subcutaneous emphysema ^[9]
  • Condition that results from entrapment of air or gas into the subcutaneous tissues
  • Typically presents with sudden, painless soft tissue swelling, often around the upper chest, neck, and face
• Hypercarbia and respiratory acidosis
• Venous air embolism (rare) ^[10]

Most intra-operative complications (pneumothorax, respiratory acidosis, air embolism) are indications to convert the procedure to a laparotomy (open procedure).

Postoperative complications

• Early postoperative complications ^[11]
  • Shoulder pain
  • Atelectasis
  • Deep vein thrombosis
• Late postoperative complications
  • Incisional hernia
  • Port site metastasis

We list the most important complications. The selection is not exhaustive.