Art Of Laparoscopic Surgery: Textbook & Atlas (4 Volumes) [2 ed.] 9352708458, 9789352708451

Table of contents :
Cover
Book Title
Copyright Page
Dedicated
Preface
Acknowledgments
Contents
Volume 1: Basic Laparoscopic Surgery1.
Chapter-1: History of Laparoscopic Surgery
Chapter-2: Instrumentation and Imaging Systems in Laparoscopy
Chapter-3: Anesthesia for Laparoscopic Surgery
Chapter-4: Sterilization and Disinfection of Laparoscopic Instruments
Chapter-5: Laparoscopic Space Access
Chapter-6: Laparoscopic Tissue Approximation
Chapter-7: Laparoscopic Hemostasis
Chapter-8: Setting-up of Laparoscopic Operation Theater
Chapter-9: Room Layout
Chapter-10: Preoperative Imaging in Minimally Invasive Surgery
Chapter-11: Diagnostic Laparoscopy: Indications, Tuberculosis, and Adhesiolysis
Chapter-12: Staging Laparoscopy in Malignancy
Chapter-13: Laparoscopy in Pregnancy
Chapter-14: Reoperative Laparoscopic Surgery
Chapter-15: Specimen Retrieval Systems in Laparoscopic Surgery
Chapter-16: Complications of Laparoscopy
Chapter-17: Single Incision Laparoscopic Surgery
Chapter-18: Robotic Surgery
Chapter-19: Laparoscopy in Pediatric Surgery: Current Practice
Chapter-20: Metabolic Surgery: Current Concepts
Chapter-21: Video-assisted Thoracic Surgery and Thymectomy
Chapter-22: Head and Neck Minimal Access Surgery
Chapter-23: Minimally Invasive Hernia Surgery: Current Practice
Chapter-24: Training in Laparoscopy
Chapter-25: Occupational Hazards for the Laparoscopic Surgeon
Chapter-26: Documentation in Laparoscopic Surgery
Chapter-27: Laparoscopic Training for Staff Nurse
Chapter-28: Enhanced Recovery after Surgery
Index
Volume 2: Esophagogastric Surgery
Section-1: Esophagus
Chapter-29: Anatomy of the Mediastinum, Esophagus, Hiatus, and Diaphragm
Chapter-30: Laparoscopic Management of Achalasia Cardia
Chapter-31: Gastroesophageal Reflux Diseases
Chapter-32: Laparoscopic Management of Gastroesophageal Reflux Diseases
Chapter-33: Laparoscopic Repair of Paraesophageal Hernia
Chapter-34: Reoperative Antireflux Surgeries
Chapter-35: Laparoscopic Management for Peptic Esophageal Stricture
Chapter-36: Thoracoscopic or Laparoscopic Management of Benign Esophageal Diseases
Chapter-37: Thoracolaparoscopic Management of Boerhaave’s Syndrome
Chapter-38: Foreign Bodies in the Foregut: Minimally Invasive Approach
Chapter-39: Corrosive Injuries of Esophagus: Minimally Invasive Approach
Chapter-40: Minimally Invasive Surgery in Esophageal Carcinoma: Current Concepts
Chapter-41: Thoracolaparoscopic McKeown Esophagectomy
Chapter-42: Laparoscopic Esophagogastrectomy and Intrathoracic Anastomosis (Ivor Lewis Esophagectomy)
Chapter-43: Laparoscopic Transhiatal Esophagectomy
Chapter-44: Complications of Esophagectomy
Section-2: Stomach and Duodenum
Chapter-45: Laparoscopic Management of Peptic Ulcer Disease
Chapter-46: Laparoscopic Management of Gastric GIST
Chapter-47: Gastric NET and Duodenal NET: Minimally Invasive Approach
Chapter-48: Minimally Invasive Approach for Foreign Body in Stomach
Chapter-49: Corrosive Injuries of Stomach: Minimally Invasive Approach
Chapter-50: Laparoscopic Management of Gastric Volvulus
Chapter-51: Laparoscopic Management of Median Arcuate Ligament Syndrome
Chapter-52: Laparoscopic Duodenojejunostomy for Wilkie’s Syndrome
Chapter-53: Laparoscopic Duodenal Excision in Nonampullary Tumors
Chapter-54: Laparoscopic Surgery for Morbid Obesity: Current Concepts
Chapter-55: Minimally Invasive Surgery for Gastric Carcinoma: Current Concepts
Chapter-56: Laparoscopic D2 Subtotal and Total Gastrectomy
Section-3: Postscript
Chapter-57: Anesthetic Considerations in Thoracoscopic Esophagectomy
Chapter-58: Early Postoperative Management in Thoracolaparoscopic Esophagectomy
Chapter-59: Palliative Procedures in Upper GI Malignancies
Chapter-60: Robotics in Upper Gastrointestinal Surgery
Chapter-61: Thoracolaparoscopic Esophagectomy in Abnormal Anatomy (Situs Inversus Totalis)
Chapter-62: Single-Incision Laparoscopy in Esophagogastric Surgery
Index
Volume 3: Colorectal Surgery
Chapter-63: Introduction
Chapter-64: Applied Laparoscopic Anatomy of the Colon, Rectum and Anal Canal
Chapter-65: Laparoscopic Colorectal Surgery Preoperative Workup and Staging
Chapter-66: Laparoscopic Colorectal Surgery: Evidences
Chapter-67: Laparoscopic Appendectomy
Chapter-68: Laparoscopy in Small Bowel Obstruction
Chapter-69: Intussusception
Chapter-70: Laparoscopic Excision of Meckel’s Diverticulum
Chapter-71: Laparoscopic Management of Midgut Malrotation
Chapter-72: Laparoscopic Management of Inflammatory Bowel Disease: Crohn’s and Ulcerative Colitis
Chapter-73: Laparoscopic Management of Rectal Prolapse
Chapter-74: Laparoscopic Management of Parastomal Hernia
Chapter-75: Laparoscopic Right Hemicolectomy: IRETA with Uncinate Process Approach
Chapter-76: Laparoscopic Left Hemicolectomy
Chapter-77: Laparoscopic Anterior Resection and Ultralow Anterior Resection
Chapter-78: Laparoscopic Intersphincteric Resection with Coloanal Anastomosis
Chapter-79: Laparoscopic Abdominoperineal Resection
Chapter-80: Laparoscopic Total and Subtotal Colectomy
Chapter-81: Laparoscopic Total Proctocolectomy with Ileal Pouch-anal Anastomosis
Chapter-82: Laparoscopic Stoma Creation
Chapter-83: Laparoscopic Management of Sigmoid Volvulus
Chapter-84: Laparoscopic Hartmann’s Procedure Reversal
Chapter-85: Laparoscopic Management of Colovesical Fistula
Chapter-86: Laparoscopic Management of Diverticular Disease
Chapter-87: Laparoscopic Management of Rectovaginal Fistula
Chapter-88: Single-Incision Multiport: Laparoscopic Colorectal Surgery
Chapter-89: Transanal Endoscopic Microsurgery/Transanal Minimally Invasive Surgery
Chapter-90: Combined Endoscopic Laparoscopic Procedure in Colorectal Surgery
Chapter-91: Complications of Laparoscopic Colorectal Surgery
Index
Volume 4: Hepato-Pancreato-Biliary Surgery
Section-4: Biliary
Chapter-92: Anatomy of Biliary System: Laparoscopic Bile Duct Injury Management
Chapter-93: Laparoscopic Cholecystectomy, Indications, and Management
Chapter-94: Laparoscopic Management of Acute Cholecystitis
Chapter-95: Laparoscopic Management of Difficult Gallstone Disease
Chapter-96: Laparoscopic Cholecystectomy in Cirrhotic Liver Problems and Management
Chapter-97: Laparoscopic Modified Subtotal Cholecystectomy Indications and Techniques
Chapter-98: Laparoscopic Bile Duct Injury and Management
Chapter-99: Laparoscopic Treatment of Common Bile Duct Stones
Chapter-100: Laparoscopic Choledochal Cyst Excision
Chapter-101: Laparoscopic Management of Carcinoma Gallbladder
Section-5: Liver
Chapter-102: Anatomy of Liver
Chapter-103: Laparoscopic Management of Benign Nonparasitic Hepatic Cysts
Chapter-104: Laparoscopic Management of Hepatic Hydatid Disease
Chapter-105: Laparoscopic Management of Liver Abscess
Chapter-106: Laparoscopic Parenchymal Transection Techniques and Instruments
Chapter-107: Laparoscopic Minor Hepatectomy
Chapter-108: Laparoscopic Hepatic Resection
Chapter-109: Laparoscopic Donor Hepatectomy
Chapter-110: Laparoscopic Radiofrequency Ablation in Hepatic Malignancies
Section-6: Spleen
Chapter-111: Laparoscopic Splenectomy
Chapter-112: Laparoscopic Splenopexy
Section-7: Pancreas
Chapter-113: Anatomy of Pancreas
Chapter-114: Role of Laparoscopy in Acute Pancreatitis and its Complications
Chapter-115: Laparoscopic Management of Chronic Pancreatitis
Chapter-116: Laparoscopic Radical Distal Pancreatectomy
Chapter-117: Laparoscopic Spleen-preserving Distal Pancreatectomy
Chapter-118: Laparoscopic Median Pancreatectomy
Chapter-119: Laparoscopic Uncinate Process Excision
Chapter-120: Laparoscopic Pancreas-preserving Duodenectomy
Chapter-121: Laparoscopic Whipple Procedure
Chapter-122: Laparoscopic Management of Annular Pancreas
Chapter-123: International Summit on Laparoscopic Pancreatic Resection (ISLPR) “Coimbatore Summit Statements”
Index

Citation preview

ART OF LAPAROSCOPIC SURGERY Textbook and Atlas

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ART OF LAPAROSCOPIC SURGERY Textbook and Atlas Second Edition VOLUME 1 BASIC LAPAROSCOPIC SURGERY

C Palanivelu  MS MCh FRCS FACS PhD DSc

Chair, Division of Surgical Gastroenterology and Minimal Access Surgery Director, GEM Hospital and Research Center Coimbatore, Tamil Nadu, India

JAYPEE BROTHERS MEDICAL PUBLISHERS The Health Sciences Publisher New Delhi | London | Panama

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Jaypee Brothers Medical Publishers (P) Ltd Headquarters Jaypee Brothers Medical Publishers (P) Ltd 4838/24, Ansari Road, Daryaganj New Delhi 110 002, India Phone: +91-11-43574357 Fax: +91-11-43574314 E-mail: [email protected] Overseas Offices JP Medical Ltd 83 Victoria Street, London SW1H 0HW (UK) Phone: +44 20 3170 8910 Fax: +44 (0)20 3008 6180 E-mail: [email protected]

Jaypee-Highlights Medical Publishers Inc City of Knowledge, Bld. 235, 2nd Floor Clayton, Panama City, Panama Phone: +1 507-301-0496 Fax: +1 507-301-0499 E-mail: [email protected]

Jaypee Brothers Medical Publishers (P) Ltd Bhotahity, Kathmandu, Nepal Phone: +977-9741283608 E-mail: [email protected] Website: www.jaypeebrothers.com Website: www.jaypeedigital.com © 2020, C Palanivelu and Jaypee Brothers Medical Publishers The views and opinions expressed in this book are solely those of the original contributor(s)/author(s) and do not necessarily represent those of editor(s) of the book. All rights reserved. No part of this publication may be reproduced, stored or transmitted in any form or by any means, electronic, mechanical, photocopying, recording or otherwise, without the prior permission in writing of the publishers. All brand names and product names used in this book are trade names, service marks, trademarks or registered trademarks of their respective owners. The publisher is not associated with any product or vendor mentioned in this book. Medical knowledge and practice change constantly. This book is designed to provide accurate, authoritative information about the subject matter in question. However, readers are advised to check the most current information available on procedures included and check information from the manufacturer of each product to be administered, to verify the recommended dose, formula, method and duration of administration, adverse effects and contraindications. It is the responsibility of the practitioner to take all appropriate safety precautions. Neither the publisher nor the author(s)/editor(s) assume any liability for any injury and/or damage to persons or property arising from or related to use of material in this book. This book is sold on the understanding that the publisher is not engaged in providing professional medical services. If such advice or services are required, the services of a competent medical professional should be sought. Every effort has been made where necessary to contact holders of copyright to obtain permission to reproduce copyright material. If any have been inadvertently overlooked, the publisher will be pleased to make the necessary arrangements at the first opportunity. The CD/DVD-ROM (if any) provided in the sealed envelope with this book is complimentary and free of cost. Not meant for sale. Inquiries for bulk sales may be solicited at: [email protected]

-----------------------------------------------------------------------------------------------------------------------------------------------------------------------• Creative Design • Copy Editing • Imaging Dr R Parthasarathi MS FMAS PhD

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Art of Laparoscopic Surgery Textbook and Atlas (Vol-1) First Edition: 2005 Second Edition: 2020 ISBN: 978-93-5270-845-1

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Dedicated to My beloved parents (Late) Shri P Chinnusamy and Mrs Kaliammal. My family ever loving wife Jaya, daughter Priya, son-in-law Senthilnathan, son Praveen Raj, daughter-in-law Prabha, grand sons Master Mukhil and Master Aadith and grand daughters Selvi Saaral and Selvi Aki. My teachers and patients who made this possible.

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Preface It is a matter of great pleasure for me that my previous edition of “Art of Laparoscopic Surgery—Text and Atlas”, has been well-accepted by the surgical fraternity and has also got translated in other languages like Spanish, Korean and Chinese. Since the publication of first edition, Minimal Access Surgery has evolved into a much broader specialty and now most of the surgeries are done by minimal access approach. Successful publication of my previous books including Art of Laparoscopic Surgery—Basic and Advanced Techniques, CIGES Atlas of Laparoscopic Surgery, Palanivelu’s Textbook of Surgical Laparoscopy, Operative Manual on Laparoscopic Hernia Surgery has inspired me to make this edition by including recent advances and techniques with more illustrations and images. The second edition has been divided into four volumes—Volume 1: Basic Laparoscopic Surgery; Volume 2: Esophagogastric Surgery; Volume 3: Colorectal Surgery; and Volume 4: Hepato-Pancreato-Biliary Surgery. Each chapter is written with a detailed operative description cum Atlas. It describes in detail, the thought process, decision-making and the requisite advanced laparoscopic techniques with step-by-step description of the operative procedure and adequate number of high quality intraoperative pictures. Volume 1: It is compiled in such a way to provide a detailed description to give an overall view about the various basic aspects of laparoscopic surgery, the instrumentation, energy devices, training modules operation theater staff nurse training and laparoscopic operation setup. This volume will be helpful to various minimally invasive surgeons in all the fields like General surgeons, Gastrointestinal surgeons, Urology surgeons, Surgical oncologists and Gynecologists. Volume 2: Esophagogastric surgery includes detailed description of the diseases of esophagus and stomach ranging from benign diseases to malignancies. Cancer esophagus and stomach particularly thoracoscopic esophagectomy in prone technique Ivor Lewis two stage esophagectomy and D2 radical gastrectomy have been described in detail. Volume 3: Colorectal surgery include the detailed description of various minimally invasive colorectal procedures involving the most recent approaches described like minimally invasive inter sphincteric resection for low rectal malignancies. Cancer colon including transverse colon and rectum, prolapse rectum, total proctocolectomy with ileoanal pouch anastomosis have been in details. Volume 4: Hepato-pancreato-biliary surgery describes in detail all the minimally invasive hepatobiliary surgeries. Performing the World first laparoscopic Whipple’s operation have been described along with guidelines and selection for laparoscopic derived in the first international summit on laparoscopic pancreatic resection. Also a chapter on laparoscopic donor hepatectomy included in this book. I have also added certain innovative techniques and modifications, various operative procedure presented and discussed in international forum. I am glad to say that few of the procedures explained in the following chapters have been done for the first time in the history of laparoscopic surgery. I am confident that this book will help the surgeons grasp the current concepts of laparoscopic surgery and the technical details of the various procedures would give them a detailed overview, enabling them to replicate the same. I always remind myself of the famous quote: “Look behind you at what you have already accomplished Look up and believe that the sky is the limit Look down to make sure you’re on the right path Look ahead and claim success in everything you do.”

C Palanivelu

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Acknowledgments I would like to acknowledge all my dedicated team members. Upper Gastrointestinal Dr R Parthasarathi, Dr S Saravankumar, Dr M Bharath Cumar, Dr N Ramesh, Dr Bhushan Chittawadagi Hepato-Pancreato-Biliary Surgery Dr P Senthilnathan, Dr N Anand Vijai, Dr VP Nallankilli, Dr S Srivatsan Gurumurthy Dr Senthil Anand Colorectal Surgery and Proctology Dr S Rajapandian, Dr R Sathayamurthy, Dr Senthil Ganapathi, Dr Harish Kakkilaya, Dr Samrat Jankar, Dr Vikram Annamaneni Bariatric and Metabolic Surgery Dr P Praveen Raj, Dr Siddhartha Bhattacharya Dr Shivanshu Mishra Medical Gastroenterology Dr Mohd Juned Khan, Dr Sridhar Anesthesiology Dr Sudarsan Kasthuri, Dr Vigneshwaran, Dr MS Prabhakar, Dr M Magila, Dr Dhivahar G, Dr D Raghunath Radiology Dr B Srikanth, Dr P Kuppuraj, Dr S Devalatha Medical Superintendent Dr P Sivaprakasam Nursing—Operation theatre nurses headed by Mrs Malathi Hariharan My immense appreciation goes to Dr R Parthasarathi, for his meticulous editorial work along with compiling scores of color photographs and illustrations in specific order to add to this rich material, spread over this book. Mr S Pasupathy and Mr R Alagarsamy for providing editorial support and Mr R Venkatachalam for technical support. I would like to specially appreciate the work by my surgical gastro resident, Dr Raghavendra Gupta GHV and other residents for their contribution towards updating each chapter and adding upon bibliography.

C Palanivelu

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Contents Volume 1: Basic Laparoscopic Surgery

1. History of Laparoscopic Surgery

1



2. Instrumentation and Imaging Systems in Laparoscopy

13



3. Anesthesia for Laparoscopic Surgery

35



4. Sterilization and Disinfection of Laparoscopic Instruments

47



5. Laparoscopic Space Access

62



6. Laparoscopic Tissue Approximation

73



7. Laparoscopic Hemostasis

111



8. Setting-up of Laparoscopic Operation Theater

127



9. Room Layout

130

10. Preoperative Imaging in Minimally Invasive Surgery

135

11. Diagnostic Laparoscopy: Indications, Tuberculosis, and Adhesiolysis

152

12. Staging Laparoscopy in Malignancy

175

13. Laparoscopy in Pregnancy

186

14. Reoperative Laparoscopic Surgery

201

15. Specimen Retrieval Systems in Laparoscopic Surgery

212

16. Complications of Laparoscopy

225

17. Single Incision Laparoscopic Surgery

233

18. Robotic Surgery

251

19. Laparoscopy in Pediatric Surgery: Current Practice

259

20. Metabolic Surgery: Current Concepts

264

21. Video-assisted Thoracic Surgery and Thymectomy

271

22. Head and Neck Minimal Access Surgery

279

23. Minimally Invasive Hernia Surgery: Current Practice

287

24. Training in Laparoscopy

297

25. Occupational Hazards for the Laparoscopic Surgeon

311

26. Documentation in Laparoscopic Surgery

316

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xii

Art of Laparoscopic Surgery Textbook and Atlas 27. Laparoscopic Training for Staff Nurse

325

28. Enhanced Recovery after Surgery

330

Index

I-1–I-10

Volume 2: Esophagogastric Surgery SECTION 1: ESOPHAGUS 29. Anatomy of the Mediastinum, Esophagus, Hiatus, and Diaphragm

337

30. Laparoscopic Management of Achalasia Cardia

359

31. Gastroesophageal Reflux Diseases

384

32. Laparoscopic Management of Gastroesophageal Reflux Diseases

392

33. Laparoscopic Repair of Paraesophageal Hernia

414

34. Reoperative Antireflux Surgeries

430

35. Laparoscopic Management for Peptic Esophageal Stricture

440

36. Thoracoscopic or Laparoscopic Management of Benign Esophageal Diseases

446

37. Thoracolaparoscopic Management of Boerhaave’s Syndrome

474

38. Foreign Bodies in the Foregut: Minimally Invasive Approach

482

39. Corrosive Injuries of Esophagus: Minimally Invasive Approach

497

40. Minimally Invasive Surgery in Esophageal Carcinoma: Current Concepts

507

41. Thoracolaparoscopic McKeown Esophagectomy

523

42. Laparoscopic Esophagogastrectomy and Intrathoracic Anastomosis (Ivor Lewis Esophagectomy)

546

43. Laparoscopic Transhiatal Esophagectomy

566

44. Complications of Esophagectomy

572

SECTION 2: STOMACH AND DUODENUM 45. Laparoscopic Management of Peptic Ulcer Disease

579

46. Laparoscopic Management of Gastric GIST

598

47. Gastric NET and Duodenal NET: Minimally Invasive Approach

617

48. Minimally Invasive Approach for Foreign Body in Stomach

623

49. Corrosive Injuries of Stomach: Minimally Invasive Approach

633

50. Laparoscopic Management of Gastric Volvulus

644

51. Laparoscopic Management of Median Arcuate Ligament Syndrome

654

52. Laparoscopic Duodenojejunostomy for Wilkie’s Syndrome

658

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Contents 53. Laparoscopic Duodenal Excision in Nonampullary Tumors

665

54. Laparoscopic Surgery for Morbid Obesity: Current Concepts

676

55. Minimally Invasive Surgery for Gastric Carcinoma: Current Concepts

689

56. Laparoscopic D2 Subtotal and Total Gastrectomy

710

xiii

SECTION 3: POSTSCRIPT 57. Anesthetic Considerations in Thoracoscopic Esophagectomy

731

58. Early Postoperative Management in Thoracolaparoscopic Esophagectomy

739

59. Palliative Procedures in Upper GI Malignancies

744

60. Robotics in Upper Gastrointestinal Surgery

748

61. Thoracolaparoscopic Esophagectomy in Abnormal Anatomy (Situs Inversus Totalis)

751

62. Single-Incision Laparoscopy in Esophagogastric Surgery

754

Index

II-1–II-10

Volume 3: Colorectal Surgery 63. Introduction

765

64. Applied Laparoscopic Anatomy of the Colon, Rectum and Anal Canal

776

65. Laparoscopic Colorectal Surgery Preoperative Workup and Staging

792

66. Laparoscopic Colorectal Surgery: Evidences

804

67. Laparoscopic Appendectomy

821

68. Laparoscopy in Small Bowel Obstruction

852

69. Intussusception

870

70. Laparoscopic Excision of Meckel’s Diverticulum

881

71. Laparoscopic Management of Midgut Malrotation

892

72. Laparoscopic Management of Inflammatory Bowel Disease: Crohn’s and Ulcerative Colitis

904

73. Laparoscopic Management of Rectal Prolapse

912

74. Laparoscopic Management of Parastomal Hernia

931

75. Laparoscopic Right Hemicolectomy: IRETA with Uncinate Process Approach

938

76. Laparoscopic Left Hemicolectomy

955

77. Laparoscopic Anterior Resection and Ultralow Anterior Resection

967

78. Laparoscopic Intersphincteric Resection with Coloanal Anastomosis

990

79. Laparoscopic Abdominoperineal Resection

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xiv

Art of Laparoscopic Surgery Textbook and Atlas 80. Laparoscopic Total and Subtotal Colectomy

1024

81. Laparoscopic Total Proctocolectomy with Ileal Pouch-anal Anastomosis

1040

82. Laparoscopic Stoma Creation

1062

83. Laparoscopic Management of Sigmoid Volvulus

1070

84. Laparoscopic Hartmann’s Procedure Reversal

1081

85. Laparoscopic Management of Colovesical Fistula

1091

86. Laparoscopic Management of Diverticular Disease

1102

87. Laparoscopic Management of Rectovaginal Fistula

1118

88. Single-Incision Multiport: Laparoscopic Colorectal Surgery

1129

89. Transanal Endoscopic Microsurgery/Transanal Minimally Invasive Surgery

1145

90. Combined Endoscopic Laparoscopic Procedure in Colorectal Surgery

1156

91. Complications of Laparoscopic Colorectal Surgery

1164

Index

III-1–III-10

Volume 4: Hepato-Pancreato-Biliary Surgery SECTION 4: BILIARY 92. Anatomy of Biliary System: Laparoscopic Bile Duct Injury Management

1187

93. Laparoscopic Cholecystectomy, Indications, and Management

1195

94. Laparoscopic Management of Acute Cholecystitis

1224

95. Laparoscopic Management of Difficult Gallstone Disease

1239

96. Laparoscopic Cholecystectomy in Cirrhotic Liver Problems and Management

1275

97. Laparoscopic Modified Subtotal Cholecystectomy Indications and Techniques

1282

98. Laparoscopic Bile Duct Injury and Management

1292

99. Laparoscopic Treatment of Common Bile Duct Stones

1304

100. Laparoscopic Choledochal Cyst Excision

1333

101. Laparoscopic Management of Carcinoma Gallbladder

1356

SECTION 5: LIVER 102. Anatomy of Liver

1375

103. Laparoscopic Management of Benign Nonparasitic Hepatic Cysts

1392

104. Laparoscopic Management of Hepatic Hydatid Disease

1399

105. Laparoscopic Management of Liver Abscess

1430

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Contents 106. Laparoscopic Parenchymal Transection Techniques and Instruments

1432

107. Laparoscopic Minor Hepatectomy

1438

108. Laparoscopic Hepatic Resection

1452

109. Laparoscopic Donor Hepatectomy

1469

110. Laparoscopic Radiofrequency Ablation in Hepatic Malignancies

1479

xv

SECTION 6: SPLEEN 111. Laparoscopic Splenectomy

1491

112. Laparoscopic Splenopexy

1510

SECTION 7: PANCREAS 113. Anatomy of Pancreas

1521

114. Role of Laparoscopy in Acute Pancreatitis and its Complications

1529

115. Laparoscopic Management of Chronic Pancreatitis

1546

116. Laparoscopic Radical Distal Pancreatectomy

1561

117. Laparoscopic Spleen-preserving Distal Pancreatectomy

1570

118. Laparoscopic Median Pancreatectomy

1575

119. Laparoscopic Uncinate Process Excision

1586

120. Laparoscopic Pancreas-preserving Duodenectomy

1592

121. Laparoscopic Whipple Procedure

1601

122. Laparoscopic Management of Annular Pancreas

1633

123. International Summit on Laparoscopic Pancreatic Resection (ISLPR) “Coimbatore Summit Statements”

1640

Index

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IV-1–IV-10

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CHAPTER

History of Laparoscopic Surgery BEGINNING OF LAPAROSCOPIC SURGERY The field of minimally invasive surgery (MIS) has experienced explosive growth in the last three decades. Though the art of surgery has gone through a complete evolutionary process over the centuries due to antisepsis, antibiotics, anesthesia, and the concept of aseptic surgery, the field of laparoscopic surgery has witnessed major changes only in the recent past. Few major breakthroughs have marked the development of the keyhole approach using laparoscopic imageguided surgery. Landmark events are—invention of the incandescent bulb by Thomas Edison; development of lens scopes (1870–80s); invention of the rod-lens system by Hopkins (1950s); fiber-optic cold light transmission (1960s); computer chip video camera (1980s). George Kelling, the German surgeon from Dresden, was the first to use the cystoscope in a living dog in Hamburg in 1901.1,2 A needle was introduced and room air was injected through sterile cotton to create pneumoperitoneum, named the procedure “Kolioscope”. He had performed the same procedure in 2001 and 2010 mentioned after Hans Christian Jacobaeus of Stockholm reported his experience in human, claimed to be the first to perform the procedure on humans, in a report on 115 patients laparoscopy and 72 thoracoscopy.3 Zollikofer of Switzerland advocated the use of CO2 for insufflation instead of filtered air or nitrogen to avoid intra-abdominal explosions and promote rapid absorption of the gas.4 Orndoff introduced pyramidal trocar system, very safe is still in practice.5,6 Boesh, the Swedish surgeon, performed the first laparoscopic tubal ligation with electrocoagulation in 1936.7 In 1938, John Veress developed a spring-loaded needle for creation of pneumothorax in patients with tuberculosis.6 Closed Veress needle technique to create pneumoperitoneum is considered to be the perfect method. Raoul Palmer, the French surgeon from Paris,

1

in the 1940s, introduced continuous intra-abdominal pressure monitoring and emphasized the importance of gravity in exposure during laparoscopic surgery.8

MAJOR TECHNOLOGICAL BREAKTHROUGHS The development of cold light and the Hopkins rodlens system brought significant progress in laparoscopy. Forestier introduced brighter illumination by fiberoptic technology without the risk of burns. In 1953 Hopkins introduced rod-lens system incorporating the advantages of principles of light transmission and improved clarity.9 Kurt Semm, a German gynecologist, invented the automatic insufflator enable monitoring and maintaining adequate intra-abdominal pressure (1966).7 The first appendectomy was also done him during a gynecological procedure. It was again a gynecologist who designed the alternative mode of access of pneumoperitoneum. Hasson from Chicago published a report on 1971 about open laparoscopy, an alternative and safe access with specially designed cannula with a sleeve called Hasson cannula.10 Outer sleeve was anchored to rectus sheath for trocar holding.

DEVELOPMENT OF LAPAROSCOPIC SURGERY Charge-coupled device (CCD) video camera was the beginning of major development in laparoscopic surgery.

Laparoscopic Appendectomy Kurt Semm was the first to perform laparoscopic appendectomy during a routine gynecological procedure in 1983.7 He introduced extracorporeal suture ligation technique and same he applied to control the mesoappendix, and ligated the base with a Roedor loop. O’Regon of Canada was the first to remove an

2

Art of Laparoscopic Surgery Textbook and Atlas acutely inflamed appendix in 1986, but published his data in 1991.11,12 After the results of large series of 625 appendectomies, by Ger and associates, laparoscopy approach in acute appendicitis has become more popular.

endoscopic retrograde cholangiopancreatography (ERCP) and extraction has failed.

Laparoscopic Cholecystectomy

It is interesting to note that the first laparoscopic hernia repair was performed before laparoscopic cholecystectomy. It was again performed by an enthusiastic gynecologist, Ger, in 1982, by approximating the internal ring with stainless steel clips.14 Various techniques of hernia repair like plug and patch and IPOM (intraperitoneal onlay mesh repair) have been described for inguinal hernia. The IPOM developed by Tay and Smoot in 1991 was very effective for smaller defects but recurrence was high when it was performed for larger defects.15 The revolutionary concept of extraperitoneal repair of inguinal hernias was developed by Arregui16 and Dion17 (TAPP or transabdominal preperitoneal approach) and Dulucq and McKernan (TEP or transabdominal extraperitoneal approach). Now, laparoscopic approach for inguinal hernias is the preferred approach in tertiary care centers with adequate expertise.

Charles Filipi and Fred Mall performed the first laparoscopic cholecystectomy in dogs in 1985.11 Philippe Mouret performed the first laparoscopic cholecystectomy in 1987 at Lyon in France but did not publish. It was brought to the world by his staff nurse Claire Jupiter who had confronted Francois Dubois when he said had done laparoscopic cholecystectomy in a meeting in paris.11,13 Subsequently, Video presentation of laparoscopic cholecystectomy by prof Perissat in sages was the new information to surgeons in US which brought great enthusiasm. Cuschieri (Scotland), McKernan and Saye(Maritta, Georgia), and Reddick and Olsen had performed laparoscopic cholecystectomy on both sides of the Atlantic. But the controversy regarding the first surgeon to perform laparoscopic cholecystectomy arose when Erich Muhe from Germany also staked his claim. He claimed that he had performed the first laparoscopic cholecystectomy in September, 1985 in Germany.13 He created pneumoperitoneum by Veress needle technique, and completed the surgery within 2 hours. Muhe presented his work in April 1986, in the Congress of German Surgical Society in Munich. Not encouraged by the response and adverse criticism, he again presented his work in further surgical meetings in Colague in October, 1986 and Mainz in 1986. Based on the success of laparoscopic cholecystectomy, reports about successful surgeries for various procedures started appearing frequently in the early 1990s.

Common Bile Duct Exploration As an extension of laparoscopic cholecystectomy, Berci described laparoscopic intraoperative cholangiogram in 1991. Sackier reported transcystic exploration of the common bile duct (CBD), while Stroker reported choledochotomy and CBD exploration with closure of CBD over a T tube. Subsequently, numerous reports have appeared about the feasibility and success of laparoscopic CBD exploration. Now, laparoscopic CBD exploration is the preferred treatment for CBD stones in any tertiary center where facilities and expertise are available, if preoperative

Laparoscopic Inguinal Hernia Repair

Laparoscopic Vagotomy Katkhouda established the feasibility of the laparoscopic approach to peptic ulcer disease by performing anterior seromyotomy.18 In 1990, Bailey and Zucker in the USA popularized the anterior highly selective vagotomy combined with posterior truncal vagotomy.19 Bernard Dallemagne of Belgium was the first to perform highly selective anterior and posterior vagotomy.20

Laparoscopic Cancer Surgery Esophagus Professor Cushieri described thoracoscopic assisted esophagectomy in 1992: initially with the lateral decubitus approach and later the prone approach. Subsequently, only sporadic reports were published. Professor Lukedicth published 222 cases of lateral decubitus esophagectomy which popularized the procedure. We popularized thoraco-laparoscopic esophagectomy using the prone approach with single lumen endotracheal tube double-lung ventilation, and published 130 cases in JACS in 2006.21 The prone approach has since become very popular globally as it is technically superior and is associated with low morbidity and mortality.

History of Laparoscopic Surgery

Stomach

Liver Liver resection was performed in 1995 and anatomical liver resection in 2002.

Pancreas Michael Gagner reported the first distal pancreatectomy and hand-assisted laparoscopic pancreatoduodenectomy hybrid technique wherein open reconstruction was done. He reported his experience in SAGES in 1996. Due to higher complications he reported that he stopped doing laparoscopic pancreatoduodenectomy. I did the first totally laparoscopic whipple operation in 1998 including laparoscopic pancreatico jejunostomy and presented the video in SAGES. I was invited to present the video in the World Congress of Endoscopic Surgery in 2000.

Other Gastrointestinal Surgeries The first laparoscopic fundoplication was performed by Dellemagne in 1991,22 while Delaitre reported the first laparoscopic splenectomy in 1991.23 Peter Goh performed the first laparoscopic gastrectomy in 1991,24 while the first laparoscopic colectomy was performed by Jacobs et al. and Schlinkert et al. independently in the same period. With the increasing role of laparoscopic surgery, bariatric surgery is slowly becoming a specialty of its own. The first laparoscopic placement of an adjustable gastric band was performed by Bernard Cadiere in 1992 using an unmodified Kuzmak’s band. Belachew and Legrand performed the first laparoscopic banding in 199325 with the Bioenterics Lap-band and Clark and Wittgrove performed the first laparoscopic Roux-en-Y gastric bypass.26

Laparoscopic Excision of a Choledochal Cyst in Adults The first pediatric laparoscopic choledochal cyst excision was done in 1995 in Japan. We did the first such procedure in adults in 1996 and also shown live part of international

Other Specialties Urologists evinced keen interest in the development of minimal access surgery in their specialty and now almost all surgeries are being performed through this approach. The credit of performing the first nephrectomy for benign disease goes to Clayman (1991).27 The first adrenalectomy was performed by Higashihara et al. in 1992.28 In 1992, Kozminski and Partamanian performed the first laparoscopic-assisted ileal conduit urinary diversion while Schuessler reported the first radical prostatectomy. Gaur developed retroperioneoscopy for minimally invasive renal surgery. As part of developing laparoscopic urology, we started live workshops demonstrating laparoscopic nephrectomy, orchidopexy, pyeloplasty, etc. at Coimbatore.

Reduced Port/Single Incision Surgery Endosuturing and Knotting Zalton Szabo, pioneer laparoscopic surgeon, introduced the art of endoscopic suturing techniques, which was an important landmark in the history of laparoscopy.29 With adequate expertise in endosuturing, all advanced laparoscopic surgeries can be performed safely without the need for high-tech instruments, hemostasis can be achieved, and effective reconstruction possible after resection. During regular any untoward incidence either vascular injury or bowel injury can be effectively managed without open conversion.

DEVELOPMENT OF LAPAROSCOPIC SURGERY IN INDIA GEM Experience in Laparoscopic Surgery Tehemton Udwadia did the first laparoscopic cholecystectomy in India at Mumbai. The second center to start laparoscopic surgery was done at Coimbatore by me. Since then, almost all advanced laparoscopic procedures have been introduced first time at Coimbatore. After formal training in laparoscopic surgery with Eddie Reddick (USA), I established the Coimbatore

Chapter 1

Professor Peter Go of Singapore did the first laparoscopic gastrectomy for benign disease. Professor Kitano reported the first laparoscopic gastrectomy for early cancer. Now, minimally invasive gastrectomy has become the popular approach in Japan, Korea, China, and other countries.

workshop on laparoscopic pediatric surgery in 1997 at Bangalore. I have Presented a video on laparoscopic Choledochal cyst excision and Hepaticojejunostomy in SAGES, St Louis, in 2001.

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Art of Laparoscopic Surgery Textbook and Atlas Institute of Gastrointestinal Endosurgery (CIGES) in India in 1991; it was the first laparoscopic gastrointestinal (GI) surgery center in South India. This center has played a major role in the development of advanced laparoscopic surgeries. Many innovative procedures have been developed and presented at various international congresses, securing several SAGES, ACS, and other international societies awards. In South India, more than 90% of stones are pigment stones and are difficult to treat by laparoscopy. My plenary lecture on the various problems of laparoscopic management of gallstones in cirrhotic patients was much appreciated in the 5th World Congress of Endoscopic Surgery at Philadelphia.30 Our presentation on laparo­ scopic subtotal cholecystectomy for difficult gallbladder has won the best paper award at the 6th World Congress of Endoscopic Surgery at Rome in 1998.31

Appendicitis Although appendicitis is the simplest and most common operation performed by general surgeons, the laparoscopic approach is not uniformly performed. There are wide variations in the placement of ports, dissection techniques, and methods of removal. We practice the two hand dissection technique that is—placing the camera in the supra pubic position and performing the surgery from the umbilical and right iliac fossa ports. We remove the appendix through the umbilical port. This technique was presented during the third international congress new technology and newer techniques Luemberg 2005 and the 15th World Congress of Digestive Surgery in Seoul in 1996.32 We have performed over 13,000 appendectomies through this approach since 1991. With appendicitis being the most common surgery to be performed by all general surgeons, I feel that this approach is simple, easy, and can be adopted.

Laparoscopic Hernia Surgery The concept of laparoscopic hernia repair was very slow to evolve in the early 1990s. I learnt laparoscopic hernia repair and received formal training from one of the pioneers in total extraperitoneal repair, Professor McKernan at Ethicon Endosurgery Institute, USA, in 1992. I also learnt transabdominal preperitoneal (TAPP) attending postgraduate course in ACS at New Orleans. I have been performing laparoscopic hernia repair through the TAPP approach since 1992. I have also learnt

the extraperitoneal approach performed by Prof. Dulucq of France. Many workshops and courses were conducted in Coimbatore with the help of pioneers in the field of laparoscopic surgery, such as Professor Dulucq from France, Professor McMahon, Professor Steve Nixon from the United Kingdom, to increase awareness of laparoscopic hernioplasty among the Indian surgical fraternity. A world record was created on the second year anniversary of our institute (Gem Hospital) by successfully operating on 34 hernias in 28 patients including two children in just 13.30 hours. Laparoscopic hernia repair was considered costly and difficult this event changed the outlook of the surgeons since then laparoscopic hernia repair accepted as the standard procedure. For ventral hernias, we reported the first series on closure of primary defect and intraperitoneal mesh reinforcement and presented it in the International Congress of American Hernia Society in 2005 at Boston. Primary closure of the defect was promoted with the interest of improving Abdominal wall function but alsoreduces recurrence less than 1%, whereas without closure recurrence was around 4%. My presentations during American Congress of Hernia Society were well appreciated and the same were published. Professor Kukleta named this technique IPOM plus. Primary closure of the defect is now the standard of care in all ventral hernia repair.

Endoscopic Component Separation Totally Endoscopic component separation external, posterior, and transversus abdominis release all were promoted at our institute for treating very large incisional hernias. Subsequently, eTEP, eTAPP, eRS extraperitoneal technique mesh hernioplasty has become the standard of care. Intra-abdominal adhesion prevented. Cost considerably has got reduced by using polypropylene mesh and avoiding mechanical fixators.

Minimally Invasive Cancer Surgery Laparoscopic cancer surgery is being conducted regularly at our center. The first laparoscopic abdominoperineal resection (APR) was performed in January 1993 and colectomy for cancer was performed in the same year. We performed laparoscopic esophagectomy and gastrectomy in 1995. In hepatobiliary pancreatic surgery, the first liver resection was performed in 1995, totally

History of Laparoscopic Surgery

Laparoscopic Diaphragmatic Hernia Repair In June 1996, I had the opportunity to operate laparo­ scopically on a 23-year-old woman with acute gastric vol­ vulus due to congenital diaphragmatic hernia during her 6th month of pregnancy. This was the first laparoscopic diaphragmatic hernia repair, followed by a series of various types and complicated diaphragmatic hernia repairs.

Laparoscopic Surgery in Pregnancy We have performed a series of laparoscopic appendec­ tomies and cholecystectomies in pregnant patients. Lapa­roscopic Heller’s cardiomyotomy in a pregnant lady in her 5th month who had total dysphagia even after two dilatations is one of our significant achievements.

Thoracoscopic and Laparoscopic Surgery and Foreign Body Removal We have removed impacted denture from the esophagus successfully by the thoracoscopic approach in two patients till now. Many of the laparoscopic procedures are unique and first of their kind in the world and have been presented and discussed in many international conferences.

Authoring Books My first book on laparoscopic surgery The Art of Laparoscopic Surgery in 1997 was received well among the surgical fraternity and this encouraged me to come up with the Atlas on Laparoscopic Surgery the following year. The Textbook of Surgical Laparoscopy was published in 2002 due to repeated requests from my surgical colleagues for an exhaustive book on laparoscopy and considering the importance of laparoscopy in developing countries. The second edition of the CIGES Atlas of Laparoscopic Surgery in 2003 was also received well by the international community. I felt that I should share my recent experiences with friends and colleagues for the benefit of patients and

I have compiled my experiences in laparoscopic surgery over the past two and half decades in this book. Both of my books have been published in other languages as well, such as Spanish, Chinese, and Korean. Three editions of the Laparoscopic Hernia Repair Operative Manual have been published. GEM hospital had taken a leading role in innovation teaching and making every procedure cost effective and affordable to patients from all socioeconomic strata.

3D Laparoscopic Surgery and Robotic Surgery Till 2015 I did not see any outcome better than laparos­copy and we were not keen in Robotic Surgery. I saw professor Liu Rong PLA General Hospital Beijing doing robotic Whipple faster than laparoscopic, I realized technology surely may make the difference. Our first SI Da Vinci was bought in December 2016. We have perspectively evaluating the difference laparoscopic and Robotic application. We also won the best video award of the third international congress of Robotic surgery Taipei Taiwan 2017 for Robotic Esophagectomy for cancer Esophagus. Now, we are evaluating between 3D laparoscopic and Robotic Surgery. Olympus new rigid 30° 3D system is an excellent system, which has rotatable lens.

GEM Televersity Through GEM televersity started in October, 2017 through which we are streaming live surgeries daily across the globe (www.gemteleversity.com). It is first of its kind where we are streaming online live laparoscopic surgeries with free subscription to surgeons across the world. Everyday, live surgery performed by the senior most faculty with detailed stepby-step explanation will be transmitted. The queries from audience will be answered simultaneously/after finishing the procedure. The entire unedited version of live surgeries will be made available in offline mode for future viewing. Apart from this, we have included various surgeries performed during different conferences and continuing medical education (CME) lectures for the benefit of budding surgeons.

ORIGINAL CONTRIBUTIONS TOWARDS LAPAROSCOPIC SURGERIES I am from an ordinary agricultural-based family. Since my childhood, I was very keen to promote better medical

Chapter 1

laparoscopic Whipple procedure in 1998, and anatomical liver resection in 2002. We performed the first laparoscopic esophagogas­ trectomy with intrathoracic anastomosis for adeno­ carcinoma of the cardia. Morbidity of the operative procedure is low and the operative time is almost the same as the conventional Whipple’s operation.

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Art of Laparoscopic Surgery Textbook and Atlas facilities among rural villages in India. I have decided to become a GI surgeon after seeing the unsuccessful surgical management of esophageal cancer. I was always looking for various means to facilitate faster recovery post surgery. Professor Hollander video presentation of laparoscopic cholecystectomy (which was actually performed by prof Dubois as mentioned by Professor Hollander) made me more enthusiastic towards minimally invasive laparoscopic surgery. Later, I became very passionate in adapting laparoscopic approach for many other surgeries. My paper at world congress of endoscopic surgery held Philadelphia, USA in 1996, of laparoscopic cholecystectomy in a patient with cirrhotic liver was the best oral presentation and I also gave a plenary lecture. Subsequently Professor. Kenneth A Forde (Editorin-Chief of Surgical Endoscopy Journal) had sent a letter to me appreciating my paper as the best paper of all and requested me to send the same for special publication. During my journey, I have developed many procedures by my own, modified some of the existing procedures in a cost-effective manner. At the same congress, I have witnessed Michael Gagner presenting his experience of Laparoscopic pancreatoduodenectomy and reconstruction though a laparotomy as a “Hybrid” technique. After his presentation, he himself had told that he had abandoned doing it laparoscopically, as it had no benefit. It was a thought provoking incident to me. I felt the results may be improved, if entire procedure

of Whipple’s is completed laparoscopically, at least in selected cases if we can do it. I was the first surgeon in the world to perform Whipple’s procedure entirely in laparoscopic manner in 1998. I have presented the video of it at Society of American Gastrointestinal and Endoscopic Surgeons (SAGES) 2000 held at Atlanta, USA, which was a big surprise to many surgeons who have attended it. I have been invited to present the master video during world congress of International Federation of Societies of Endoscopic Surgeons (IFSES) and Endoscopic and Laparoscopic Surgeons of Asia (ELSA) in 2000 held at Singapore. I was the first in the world to perform the laparoscopic Whipple’s procedure in a live conference, Laparosurg 2007, held at Coimbatore, India which was attended by almost 1,000 delegates. First international summit on laparoscopic pancreatic resection was also held at Coimbatore on 7th and 8th of October 2016, which have been published as “Coimbatore Summit Statements”33 (Figs. 1.1 and 1.2). I have performed live thoraco-laparoscopic esophagectomy with patient in prone position for cancer esophagus during advanced laparoscopic workshop at Bordeaux, France. I have been invited to England to demonstrate live thoraco-laparoscopic esophagectomy during AUGIS at Manchester in 2004, which was awarded as best video in American College of Surgeons (ACS) 2005. I have also performed live thoraco-laparoscopic

Fig. 1.1: Laparosurg live transmission.

History of Laparoscopic Surgery

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Chapter 1

Fig. 1.2: Laparosurg 2007 participants.

Fig. 1.3: Thoraco-laparoscopic esophagectomy live at Endoscopic and Laparoscopic Surgeons of Asia (ELSA) congress, Hong Kong, 2005.

esophagectomy during ELSA congress held at Hong Kong in 2005 (Fig. 1.3). Initially, I never considered writing articles as a priority. As the Japanese surgeons team in the audience were impressed with the procedure and requested to publish the same for the purpose of documentary evidence for them to adopt the new technology in their country, we had published the article in the subsequent year which was published in Journal of the American College of Surgeons (JACS) describing

the technique with patient in prone position my series of 130 thoraco-laparoscopic esophagectomies in prone position.21 Since then, this technique is being widely adopted across the globe. Later, I realized the importance of publication. We have contributed many outstanding videos including minimally invasive cancer surgery, single incision laparoscopic surgery to SAGES and ACS libraries.

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Art of Laparoscopic Surgery Textbook and Atlas I have been awarded Olympic silver medal for laparoscopic pancreatic surgery in SAGES 2009, Phoenix, USA (Fig. 1.4). I have invented a special trocar to drain laparoscopically hydatid cyst of liver/spleen, which avoids spillage of contents, which is later named as Palanivelu Hydatid System (PHS).34 The video of drainage of hydatid cyst bagged me best video award in the category of best video at SAGES—2010. At world congress of endoscopic surgery in 2014, which was held at Paris, members of European Society of Endoscopic Surgery (EAES) had selected me as one

among the two for the award of great contributors award in developing laparoscopic surgery in the world (as per the opinion poll by the members of EAES and as mentioned by the president of EAES professor Mario). I for the first time in the world had performed transvaginal appendectomy (NOTES). 35 I had performed donor liver hepatectomy laparoscopically, which is considered as the first in India (Fig. 1.5). I have performed Whipple’s procedure robotically, in a pediatric girl of 12 years which is the first reported robotic surgery in a young girl in 2017 (Fig. 1.6).

Fig. 1.4: Olympic silver medal in laparoscopic surgery, Society of American Gastrointestinal and Endoscopic Surgeons (SAGES) 2009, Phoenix, USA.

Fig. 1.5: Laparoscopic living donor liver hepatectomy.

History of Laparoscopic Surgery

9

Chapter 1 Fig. 1.6: Robotic Whipple’s for 14-year-old girl.

Fig. 1.7: Brochure of Laparofit 2014, 1st web streaming conference in the world.

We have conducted an online conference, first time in the history of medical field in 2014. From our GEM hospital at Coimbatore in which facul­ ties from 14 countries had participated and 1,026 dele­ gates had registered in the Asia-Pacific region (Fig. 1.7).36 We also were able to transmit the high-definition (HD) quality video form GEM hospital operation theatre to conference venue in Coimbatore. In 2014, AMASICON conference, we were able to successfully transmit 3D quality video output form GEM

hospital operation theater to conference venue in Hotel Marriott, Dubai. We have successfully transmitted full 4K— technology videos during ISES-2017, and ACRSICON, 2017 conference from GEM Hospital operation theater to conference venue in Coimbatore, which got a lot of applaud from the surgeons who have attended. I always have passion towards treating patients by MIS approach, which helps in making them to resume to routine work faster and also towards, developing new

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Art of Laparoscopic Surgery Textbook and Atlas procedures or modifying existing procedure in a more safer way. I have traveled across the world and, learnt many technical tips form the best people of the world, Now I have complied all my experience in this book for benefit of young surgeons.

FUTURE OF SURGERY The introduction of MIS has drastically changed the way in which surgeons treat patients. Initially, they relied on their direct senses (primarily vision and touch) to diagnose illness, monitor the condition of patients, and perform invasive procedures. Now, minimal access surgery has changed the entire scenario. Anatomical information is now presented as either radiographic or video images to the surgeons who operate on seeing the monitors. Now with the introduction of various innovative technology like HDTV video systems, integrated OR endosuites, integrated digital reporting and documentation, head-mounted displays, surgical robotics, Virtual Reality training, and integration of the various imaging modalities like ultrasound, computed tomography (CT) scan, and magnetic resonance imaging (MRI) in real time, the surgeon will have better knowledge of the disease and will be able to treat the patient more effectively. Now, surgeons are able to go through a complete unified real time investigation during surgery. Surgeon may practice in virtual reality trainers. Second expert opinion is possible by beaming the pictures. If needed, can get expert guidance by telesurgery. Complex procedures can be performed with the help of robotic instruments and telecommunication facilities. The patient will ultimately benefit from this unified approach, which integrates all technological innovations for the benefit of mankind.

• Thoraco-laparoscopic esophagectomy for midoesophageal carcinoma, New York, USA, 200242 • Laparoscopic extraction of complicated hydatid cyst of liver, Los Angeles, USA, 200343 • Thoracoscopic extraction of impacted denture in the mid-third esophagus, denver, USA, 200444 • Laparoscopic transhiatal esophagectomy for Carcinoma esophagus, Denver, USA, 200445 • Laparoscopic total gastrectomy with jejunal pouch reconstruction for carcinoma body of stomach, Hollywood, Florida, USA, 2005 • Thoracoscopic mobilisation of esophagus, 2013 • Laparoscopic single incision posterior mesh rectopexy, 2013 • Laparoscopic single incision right hemicolectomy, 2013 • Single incision laparoscopic excision of lower third esophageal diverticulum, 2012 • Laparoscopic Collis gastroplasty for short esophagus, 2012 • Single incision transabdominal preperitoneal hernia repair, 2012 • Reconstruction for carcinoma stomach, 2010 • Laparoscopic D2 lymph node dissection with total gastrectomy and jejunal pouch reconstruction, 2010 • Laparoscopic total gastrectomy with jejunal pouch for cancer of the stomach, 2010 • Laparoscopic extraction of complicated hydatid cyst liver with biliary rupture, 2010 • Laparoscopic pylorus preserving pancreaticoduodenectomy (Whipple’s Procedure), 2010 • Totally laparoscopic proctocolectomy with intracorporeal ileal pouch anal anastomosis, 2010 • Thoraco-laparoscopic esophagectomy in prone position for carcinoma middle third esophagus, 2009.

SAGES VIDEO LIBRARY CATALOG

REFERENCES

The following SAGES presentations have been significant contributions of our institute: • Laparoscopic Whipple’s operation for cancer pancreas, Atlanta, USA, 200037,38 • Laparoscopic excision of choledochal cyst and Hepaticojejunostomy, St Louis, USA, 200139 • Laparoscopic lateral pancreaticojejunostomy for chronic pancreatitis, St. Louis, USA, 200140 • Laparoscopic enucleation of benign tumor of lower esophagus, New York, USA, 200241

1. Kelling G. Ueber Oesophagoskopie, Gastroskopie and Kolioskopie. Munch Med Wochenschr. 1902;1:21-4. 2. Kelling G. Ueber die Mogliehkeit die Zystoskopie bei Untersuchungen seroser Hohungen anzuwenden. Munch Med Wochenschr. 1910;45:2358. 3. Ott D. Illumination of the abdomen (ventroscopia) (in Russian). J Akushi Zhensk Boliez. 1901;15:1045-9. 4. Gunning JE. The history of laparoscopy. J Reprod Med. 1974;12:222-6. 5. Boyce HW. Laparoscopy. In: Schiff L, Schiff R (Eds). Diseases of the Liver. Philadelphia, PA: JB Lippincott; 1982. pp. 333-48.

History of Laparoscopic Surgery 25. Belachew M, Jacqet P, Lardinois F, et al. Vertical banded gastroplasty vs adjustable silicone gastric banding in the treatment of morbid obesity: a preliminary report. Obes Surg. 1993;3(3):275-8. 26. Wittgrove AC, Clark GW, Tremblay LJ. Laparoscopic gastric bypass, roux-en-y: preliminary report of five cases. Obes Surg. 1994;4(4):353-7. 27. Clayman RV, Kavoussi LR, Soper NJ, et al. Laparoscopic nephrectomy: initial case report. J Urol. 1991;146(2): 278-82. 28. Higashihara E, Tanaka Y, Horie S, et al. A case report of laparoscopic adrenalectomy. Nippon Hinyokika Gakkai Zasshi. 1992;83(7):1130-3. 29. Szabo Z, Hunter J, Berci G, et al. Analysis of surgical movements during suturing in laparoscopy. Endosc Surg Allied Technol. 1994;2(1):55-61. 30. Palanivelu C. Laparoscopic cholecystectomy in cirrhotic liver. Presented at Fifth World Congress of Endoscopic Surgery, 15-17 March 1996. Philadelphia, USA. 31. Palanivelu C. Laparoscopic modified subtotal cholecystectomy: indications and techniques. Presented at Sixth World Congress of Endoscopic Surgery, 31 May–6 June, 1998. Rome, Italy. 32. Palanivelu C. Laparoscopic appendicectomy—new two hand technique. Presented at 15th World Congress of Digestive Surgery, 11–14 September 1996. Seoul, South Korea. 33. Palanivelu C, Takaori K, Abu Hilal M, et al. International Summit on Laparoscopic Pancreatic Resection (ISLPR) “Coimbatore Summit Statements”. Surg Oncol. 2018;27(1):A10-5. 34. Palanivelu C, Senthilkumar R, Jani K, et al. Palanivelu hydatid system for safe and efficacious laparoscopic management of hepatic hydatid disease. Surg Endosc. 2006;20:1909-13. 35. Palanivelu C, Rajan PS, Rangarajan M, et al. Transvaginal endoscopic appendectomy in humans: a unique approach to NOTES--world’s first report. Surg Endosc. 2008;22:1343-7. 36. Parthasarathi R, Gomes RM, Palanivelu PR, et al. First Virtual Live Conference in Healthcare. J Laparoendosc Adv Surg Tech A. 2017;27(7):722-5. 37. Palanivelu C. Results of hand sutured laparoscopic hernioplasty: effective method of repair. Presented at Sixth World Congress of Endoscopic Surgery, 31 May–6 June, 1998. Rome, Italy. 38. Palanivelu C. Laparoscopic Whipple’s operation for cancer pancreas. Presented at Society of American Gastrointestinal Endo Surgery (SAGES meet), 2000. Atlanta, USA. 39. Palanivelu C. Laparoscopic excision of choledochal cyst and hepaticojejunostomy. Presented at Society of American Gastrointestinal Endo Surgery (SAGES meet), 2001. St. Louis, USA. 40. Palanivelu C. Laparoscopic lateral pancreatojejunostomy for chronic pancreatitis. Presented at Society of American Gastrointestinal Endo Surgery (SAGES meet), 2001. St. Louis, USA.

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6. Orndoff BH. The peritoneoscope in diagnosis of diseases of the abdomen. J Radiology. 1920;1:307-25. 7. Semm K. Atlas of Gynecologic Laparoscopy and Hysteroscopy. Philadelphia, PA: WB Saunders; 1977. pp. 7-14. 8. Palmer R. Instrumentation et technique de la coelioscopie gynecologique. Gynecol Obstet. 1947;46:420-31. 9. Hopkins HH. The modern Urological Endoscope. In: Gow JG, Hopkins HH (Eds). Handbook of Urological Endoscopy. Edinburgh: Churchill Livingstone; 1978. pp. 20-33. 10 Hasson HM. Open laparoscopy vs. closed laparoscopy: a comparison of complication rates. Adv Plan Paren. 1978;13:41-50. 11. Davis CJ, Filipi JC. A history of endoscopic surgery. In: Arregui ME (Ed). Principles of Laparoscopic Surgery— Basic and Advanced Techniques. New York, NY: SpringerVerlag; 1995. pp. 3-20. 12. O’Regan PJ. Laparoscopic appendectomy. Can J Surg. 1991;34(3):256-8. 13. Alexander G, Emma J. Laparoscopic surgery historical perspectives. In: Zucker K (Ed). Surgical Laparoscopy. Philadelphia, PA: Lippincot Williams and Wilkins; 2001. pp. 3-11. 14. Ger R. The management of certain abdominal herniae by intra-abdominal closure of the neck of the sac. Preliminary communication. Ann R Coll Surg Engl. 1982;64(5): 342-4. 15. Toy FK, Smoot RT Jr. Toy-smooth laparoscopic hernioplasty. Surg Laparosc Endosc. 1991;1(3):151-5. 16. Arregui ME, Davis CJ, Yucel O, et al. Laparoscopic mesh repair of inguinal hernia using a preperitoneal approach: a preliminary report. Surg Laparosc Endosc. 1992;2(1): 53-8. 17. Dion YM, Morin J. Laparoscopic inguinal herniorrhaphy. Can J Surg. 1992;35(2):209-12.. 18. Katkhouda N, Mouiel J. A new technique of surgical treatment of chronic duodenal ulcer without laparotomy by videocoelioscopy. Am J Surg. 1991;161(3):361-4. 19. Zucker KA, Bailey RW. Laparoscopic truncal and selective vagotomy for intractable ulcer disease. Semin Gastrointest Dis. 1994;5(3):128-39. 20. Dallemagne B, Weerts JM, Jehaes C, et al. Laparoscopic highly selective vagotomy. Br J Surg. 1994;81(4):554-6. 21. Palanivelu C, Prakash A, Senthilkumar R, et al. Minimally invasive esophagectomy: thoracoscopic mobilization of the esophagus and mediastinal lymphadenectomy in prone position—experience of 130 patients. J Am Coll Surg. 2006;203:7-16. 22. Dallemagne B, Weerts JM, Jehaes C, et al. Laparoscopic Nissen fundoplication: preliminary report. Surg Laparosc Endosc. 1991;1(3):138-43. 23. Delaitre B, Maignien B. Splenectomy by the laparoscopic approach. Report of a case. Presse Med. 1991;20(44):2263. 24. Goh P, Tekant Y, Isaac J, et al. The technique of laparoscopic Billroth II gastrectomy. Surg Laparosc Endosc. 1992;2(3):258-60.

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Art of Laparoscopic Surgery Textbook and Atlas 41. Palanivelu C. Laparoscopic enucleation of benign tumor of lower esophagus. Presented at Society of American Gastrointestinal Endo Surgery (SAGES meet), 2002. New York, USA. 42. Palanivelu C. Thoracolaparoscopic esophagectomy for mid oesophageal carcinoma. Presented at Society of American Gastrointestinal Endo Surgery (SAGES meet), 2002. New York, USA. 43. Palanivelu C. Laparoscopic extraction of complicated hydatid cyst of liver. Presented at Society of American

Gastrointestinal Endo Surgery (SAGES meet), 2003. Los Angeles, USA. 44. Palanivelu C. Thoracoscopic extraction of impacted denture in the mid third esophagus. Presented at Society of American Gastrointestinal Endo Surgery (SAGES meet), 2004. Denver, USA. 45. Palanivelu C. Laparoscopic transhiatal esophagectomy for carcinoma esophagus. Presented at Society of American Gastrointestinal Endo Surgery (SAGES meet), 2004. Denver, USA.

Instrumentation and Imaging Systems in Laparoscopy INTRODUCTION The importance of incorporation of technological advancements in the surgical field cannot be overemphasized. It is a well-known fact that even though endoscopic techniques have been present for a long time, their widespread use was limited by constraints in imaging systems. Modern technological advances have led to the production of sophisticated, precision-quality imaging equipment and instruments, which have, in turn, revolutionized the field of laparoscopic surgery. With the introduction of charge-coupled device (CCD) cameras and better illumination, the scope of laparoscopic surgery has expanded significantly. Another requirement for safe performance of laparoscopic surgery is the availability of precision instruments. Conventional surgical instruments have gone through a thorough refinement process based on decades of surgical experience and are now being adapted to laparoscopic surgery. The majority of laparoscopic instruments has been developed in the last two decades, and still more research is needed for the development of perfect laparoscopic instruments. Laparoscopic surgical techniques are associated with some disadvantages for the surgeon such as the lack of tactile sensation, and the difficulty of spatial orientation during surgery because of three-dimensional (3D) imaging.

IMAGING SYSTEMS Optical engineering and imaging technology have played a major role in the evolving field of minimally invasive surgery by producing real lifelike images that help in accurate dissection. Optic-based technologies have the potential to further improve the capabilities of laparoscopic surgery.1 The basics of video imaging systems include the telescope, camera, light cable, light source, and the monitor. For a perfect image to be seen, it is essential that all the components of imaging

CHAPTER

2

system and their connecting systems should be in perfect condition. A defect in any of the above-mentioned parts will result in significant deterioration of the image quality and will ultimately affect the surgery.

Camera The camera forms the most important and vital part of the imaging system. The resolution of previously available tube cameras was adequate for just diagnostic laparoscopy and basic surgeries. Currently CCD cameras are widely used. These charge-coupled cameras contain silicon wafers, which are divided into multiple tiny sensors called pixels. These light-sensitive elements transform incoming light signals into electronic signals depending on the energy of light. The resolution of the camera is directly proportional to the number of pixels that a camera contains. In a single-chip camera, multiple color sensors are provided in a single chip providing a single image. The monitor resolution needed for these cameras is usually around 400–600 lines.2 Currently available cameras are three-chip cameras that capture light in three components. Unified light is split into a red, green, and blue spectrum by a prism located in the head of the camera. These signals are then captured by separate CCDs, which contain multiple sensors.3 This information is broken down into binary code and after further processing, like filtering, noise reduction, data compression, and resolution enhancement, the final image is sent to the monitor. Currently available cameras have the capability of producing videos with resolutions as high as 950 lines.4 These result in extremely high-quality images that help the surgeon in advanced laparoscopic surgeries. Nowadays, high-definition (HD) laparoscopic cameras (Figs. 2.1A and B) are the most widely used camera in laparoscopic surgeries. Image quality, however, will depend on the camera acquisition standard that’s been put on a given HD system. The main difference

14

Art of Laparoscopic Surgery Textbook and Atlas

Fig. 2.1A: KARL STORZ spies camera.

Fig. 2.1B: Olympus Evis Exera CV-190.

between standard definition (SD) and HD video formats is better visualized by comparing the vertical and horizontal resolution. Typical SD formats offer a 4:3 aspect ratio, 640 by 480 horizontal and vertical lines. The HD format provides a 16:9 aspect ratio, 1,280 by 720 horizontal and vertical lines. The 1,080 HD standard also offers a 16:9 aspect ratio, but 1,920 by 1,080 horizontal and vertical lines—seven times the SD resolution at 480 lines. The temporal resolution may be the quantity of captured images expressed as frames per second (fps). The 720p standard represents progressive scanning-capturing the whole frame as you image 60 times per second. The 1,080i standard represents interlaced scanning-capturing two fields of half images with alternating lines that are then combined to produce each complete frame. In laparoscopic operations for HD endoscopy, 1,080p60 (1,080p at 60 fps) may be the highest standard readily available for acquiring and displaying images, while offering a superior viewing experience for surgeons. Because progressive scanning offers twice the temporal resolution when compared with interlaced scanning, it is well suited for fast paced objects and capturing still images, developing a quasi-3D image. Anatomical structures become visible, which were hidden in the flatter SD image.

Almost like other optical systems in entertainment technology, video camera lenses create circular images. Nevertheless, movies, shows, and sports events are viewed on the broadcast HDTV set with a wide-screen 16:9 aspect ratio. This is accomplished by over framing the look, so that the wide-screen sensor is totally taught in circular optical image. The same is true for laparoscopic surgery where surgeons watch a monitor screen filled through the surgical image. The adjacent image (peripheral vision) demonstrates the problem for two different aspect ratios. Wide-screen image acquisition increases the horizontal field of view (panoramic image) and decreases the vertical field of view. With laparoscopic instruments primarily entering the concept of view laterally, a wide-screen 16:9 aspect ratio seems advantageous. Pulling back the telescope slightly can make amends for losing in vertical field of view. Another positive effect is the fact that a telescope positioned further in the site of surgical interaction catches less debris and smoke on the front window, improving image quality. Many brands of HD camera are available in the market. Karl Storz has come up with IMAGE 1STM HD camera platform. The IMAGE 1STM camera platform

Instrumentation and Imaging Systems in Laparoscopy

15

Chapter 2

Fig. 2.2A: 4K Olympus Camera System.

Fig. 2.2B: Sony 55" 4K monitor (Medical grade).

offers surgeons a single system for all applications. As a modular camera platform, IMAGE1 S™ combines various technologies (e.g. rigid, flexible, and 3D endoscopy) in one system and can therefore be adapted to individual customer needs. Furthermore, near-infrared/indo­ cyanine green (NIR/ICG) for fluorescence imaging, the integration of operating microscopes and the use of VITOM® 3D is possible via the camera platform.

Similarly, Olympus CV 190 and Stryker 1488 HD 3-chip camera are available with comparable features. In addition to HD, ultra-HD, or 4K imaging system has come in the field of laparoscopy. Ultra-HD or 4K has four times higher resolution than HD system (ultra-HD—3,840 × 2,160 and Full 4K—4,096 × 2,160). Olympus in association with Sony has come up with Full 4K imaging system (Figs. 2.2A and B) with one-touch

16

Art of Laparoscopic Surgery Textbook and Atlas autofocus, which achieves the optimal view, immediate autofocus to the center, simplifying usage during the surgery. All these cameras need white balancing before introduction into the abdomen to get a true color image of the internal organs. During white balancing, the camera is calibrated against a white light as a reference value. It is imperative that white balancing should be done under similar lighting conditions that is—the light source should be on and the camera should be focused on a white piece of cloth away from the overhead lamps. The manual focus should be adjusted at the beginning of every operation and should be fine-tuned for the distance between the scope and the organs that have to be dissected.5 Apart from white balancing, there are other facilities that are available in modern day cameras. Some cameras provide the option of zoom, which can be used in situa­ tions where finer dissection and hemostasis is needed. But it is always better to move the camera toward the area of dissection, rather than zooming in. Some cameras offer digital enhancement as another option. This creates a sharper image by performing contrast enhancement of edges, lines, and controls. But the disadvantage with this feature is the development of grains that distort the quality of the image. Currently available cameras can even work under low light conditions to produce a uniformly bright image with good resolution. Some have the ability to view images under infrared lights. HD camera and 4K imaging systems are associated with additional features like near-infrared (NIR) and fluorescence imaging. These features can be used during complex biliary surgeries and colorectal using ICG.2 Despite advancement in technology, these cameras offer only a two-dimensional view without depth perception. Recently, 3D cameras are being made available, which incorporate stereoscopic vision into imaging technology.6,7 Though these 3D cameras have been exciting in the beginning, it is not widely used in many centers due to many factors, such as prohibitive costs, absence of clear-cut benefits, and others.6-9 The basic principle behind this technology is capturing the image with two CCDs placed close together on the tip of the laparoscope. Each chip captures the image separately and they are displayed either on the monitors or the head display units. In head display units,10-13 the images are projected on the liquid crystal display located in the goggles. The images from the right camera

chip are displayed on the right eye and those from the left chip go to the left. Two separate images seen in both eyes are reconstructed by the brain into a 3D image with depth perception. In monitor-based displays, viewers are required to wear special goggles to integrate the two image channels into one. 3D laparoscopic cameras may have an important role in the era of robotic surgery.

Laparoscope The British physicist Hopkins invented the present day laparoscope in 1952. The conventionally used thin lens system had multiple objective lenses separated by air. The images produced by this system were inferior due to insufficient light and poor quality. Present day, laparoscopes have a series of rod lens in the center (these replace the large air gaps in the previous system) with a rim of optical fibers on the outer aspect. The optical fibers carry light into the abdominal cavity and the rod lens system transmits the image from the abdomen to the camera. The camera, which is attached to the proximal end of the laparoscope, captures these images, processes them, and displays them on the monitor. The rod Hopkins systems provide an excellent field of vision with minimal distortion.14 Various types of laparoscopes have been designed based on the size and angle of vision. The size of laparoscopes varies from 0.8 mm to 14 mm in diameter (Figs. 2.3 and 2.4). The routinely used 10 mm laparoscopes offer excellent clarity and resolution. The brightness of the image reduces with the reduction in the size of the scope. A 5 mm scope generally transmits only 10% of the light when compared to a 10 mm scope. But now with improvements in optical fiber technology scopes of even 2 mm diameters produce bright and clear images. We routinely use 10 mm scopes for most of our surgeries. The 3 mm laparoscopes are mainly used in pediatric patients or for patients in whom adhesions are expected. In case of adhesions, the pneumoperitoneum is created initially by Veress needle puncture in the left hypochondrium and the miniscope is inserted. Subsequently, a 10 mm scope is inserted under vision. There are various types of laparoscopes based on the angle of vision. The forward viewing laparoscope (0°) is used by some surgeons for all procedures. The angled view scopes (30°/45°) provide a flexible field of vision when compared to the forward viewing scopes. These scopes provide an unobstructed view of the dissecting area from a distance. It allows more space for the maneuverability

Instrumentation and Imaging Systems in Laparoscopy

17

Chapter 2

Fig. 2.3: Various sizes of scopes.

Fig. 2.4: Laparoscopic 10 mm scopes.

of instruments and has the ability to look around corners. For example, suturing a mesh to the abdominal wall will be difficult with a 0° scope, whereas the same suturing with a 30° scope upturned toward the abdominal wall is relatively easy. Oblique viewing scopes are more difficult to operate, because the orientation of the telescope and the video camera must be maintained throughout. But with experience, this combination provides greater versatility. We routinely use a 30° scope for all our procedures. Fogging of the lens is a problem when the “cold” laparoscope is introduced into the peritoneal cavity. This results in a dull and hazy image. We routinely use a sponge soaked in warm saline or povidone–iodine

solution to clean the lens during the surgery. Antifogging solutions may be used for this purpose. Electric warmer flasks that maintain the temperature of the saline are very handy in a temperature-controlled theater environment. Another reason for fogging is the passage of the cold CO2 by the side of the laparoscope. This occurs when the insufflation tube is connected to the optical trocar. This can be avoided by shifting the insufflation to a port other than the camera port. A recent addition to the available array of laparoscopes is flexible or semi-flexible laparoscopes. These provide an added advantage as the tip of the laparoscope can be flexed to any angle to visualize the organs that are

18

Art of Laparoscopic Surgery Textbook and Atlas usually hidden from view. These flexible laparoscopes are available in two forms. The previously available flexible scopes are fiber optic based, which permit the relay of an image from the distal to the proximal end of the instrument by a fiber bundle composed of thousands of fibers. Image quality is poor due to distortion and decreased light when compared to the rod Hopkins system. The newly available digital flexible laparoscopes have utilized advances in CCD camera miniaturization and have a single chip at the distal end. Rather than relaying the optical image, the image is converted into electrical signals, which are then passed to the display terminal; images suffer minimal loss, interference, and distortion in the process. One interesting design uses a single monochrome CCD chip with alternating red, green, and blue illumination to form a color image rather than using three chips and three separate color filters. This reduces space requirements and takes advantage of established high-resolution monochrome CCD chip technology. The image is captured at the distal tip and sent to the processor. The image quality of these scopes is better than that from conventional flexible scopes. These laparoscopes have four-ways deflection for greater flexibility and all round viewing angles. Though there are advantages of flexible laparoscopes, it has not been used widely. They are likely to play an important role in minimal access cancer surgery in the future. Some of the examples of previously mentioned modifications of scopes are Endoeye HD (II), Endoeye Flex 3D, and Endocameleon®. Endoeye HD II (Olympus) is a 10 mm rigid telescope with all-in-one product concept and is completely autoclavable. It comes with a cable attached to its back end containing the light cable and camera cable. The Endoeye Flex 3D is an articulating videoscope provides depth perception and a precise spatial view of anatomy. It has up to 100° of articulation in all directions. With its 18–100 mm depth of field, the Endoeye Flex 3D eliminates the need for manual focus adjustments for maximum ease of use. Endocameleon® is a multidirectional scope that combines the existing Hopkins® technology with a variable direction of view. This guarantees optimal image quality with ideal visualization. The desired direction of view can be adjusted between 15° and 90° during surgery. The Endocameleon® is particularly beneficial for working in tight joint spaces as the all-round view has been greatly enhanced. Maintenance of the laparoscope is extremely important, as these are the work horses of laparoscopic

surgery. The tip of the laparoscope should be cleaned thoroughly before introduction into the peritoneal cavity. Laparoscopes are sealed systems and any damage to the tight seal will result in cloudy image formation due to accumulation of moisture under the lens systems.

Light Sources Light sources are vital equipment that helps in producing images with bright and even illumination. Resultant images will be of poor quality, if light is not adequate and even if all the other equipment of the imaging chain are in perfect condition. There are two types of light sources— halogen and xenon. Halogen lamps are economical and sufficient for basic laparoscopic surgeries. New light sources such as the 250-watt halogen lamp come with condenser systems (Karl Storz) and a built in spare lamp. Xenon lamps are available either in 175 or 300 watts. The xenon 300-watt lamp produces an intense image of light that closely approximates that of the sun and is currently considered the standard light source for laparoscopic surgery (Fig. 2.5). High-intensity xenon lamps are ideal for miniscopes (2 mm) and docu­mentation purposes. These are costly when compared to halogen lamps. Though the xenon light sources are considered as cold light sources, the condensed light at the tip produces considerable heat. Hence, the tips of the laparoscope or the tip of the light cable should not be allowed to touch the drapes or the internal organs; else it might burn the drapes or produce thermal injury to the organs. The approximate life of these xenon bulbs are around 500 hours; present day light sources come with indicators that denote the remaining life of the bulb, so that it can be replaced. The automatic iris and manual control mechanism in the light sources allow for variation in the intensity of light. Some light sources are available with flash generators, which allow for flash color photography when connected to a compatible camera. Recently, light-emitting diode (LED) light sources have been introduced in laparoscopy, which deliver cold, white light that generates virtually no heat (Fig. 2.6). These devices are energy efficient, noiseless, and do not require lamp changes. These LED modules have a life of up to 30,000 hours.

Light Cables Light is transmitted from the light source to the area of dissection through the light cable and the fiber bundle in the laparoscope. The entire length of the cable should be

Instrumentation and Imaging Systems in Laparoscopy

19

Chapter 2

Fig. 2.5: Xenon 300 light source.

Fig. 2.6: Light-emitting diode (LED) light source.

intact to obtain a bright field of vision. Two types of light cables are available—(1) fluid-filled cables and (2) fiberoptic cables. Fluid-filled cables transmit greater amounts of light and conduct more heat than fiber optic cables. The other disadvantages of the fluid-filled cables are they are stiffer, which hinders maneuvering of the angled scopes, their inability to autoclave, and their fragile nature. Fiberoptic cables are more user-friendly when compared to fluid cables. We routinely use fiber-optic cables for all our procedures. Individual fibers in fiber-optic cables are susceptible to damage. A cable with damage to

more than 25% of the fibers should be replaced. Some fiberoptic cables are supplied with a transparent case through which damage to the optical fibers can be readily assessed.

Monitor The monitor is the final link in the imaging chain. A goodquality monitor is essential for acquiring an adequate image. If the monitor does not support the resolution of the camera, then all the advantages of using a high-end camera will be lost. High-resolution medical monitors

20

Art of Laparoscopic Surgery Textbook and Atlas

Fig. 2.7: High-definition light-emitting diode (LED) medical grade monitor.

with multiple inputs are ideal for advanced laparoscopic surgeries. Even though standard resolution monitors have a resolution of about 600 lines, these do not support the present day three-chip cameras. These require highperformance monitors with a resolution of more than 1,600 lines to achieve optimal image presentation. Better resolution is essential during long procedures, especially for oncosurgical procedures, as this would mitigate stress considerably and improve the performance of the surgical team. Apart from traditional monitors, newer versions are available at present, which include high-end analog and digital monitors. The flat panel liquid crystal display, laptop display, and the high-resolution plasma display units will definitely increase the comfort level of surgeons by producing images of excellent quality. These monitors will allow placement at more ergonomic positions when compared to tower-based systems. Tower-based systems have been implicated in a variety of head, neck, and shoulder ailments in laparoscopic surgeons. Digital interface between the video processor and the display units has improved enormously and it is possible to transmit huge quantities of information through these cables (1394, DVI, SDI). Berber et al. have developed a device for the comparison of different camera, cabling, and laparoscope configurations in the operating room,

which can be used as objective criteria to judge the image quality of laparoscopic video systems. Nowadays, most of the centers use HD monitors during laparoscopic surgery (Fig. 2.7). These are capable of 1,920 × 1,080 pixel resolution display. They also feature unique in-plane switching (IPS) technology for high-resolution color accuracy of multiple images, even at 178° wide angle viewing.15

TROCARS AND CANNULAS Trocars serve as the pathway to the abdominal cavity through which various instruments are introduced. The trocars, which are a basic necessity for any laparoscopic surgery, can be a potential weapon that can cause major complications and even death.16 Even though the incidence of trocar site injury is low, it is significant.17-20 The important cause for death in laparoscopy is major vascular injury, second only to anesthetic complications.21,22 The incidence of hollow viscus injury due to trocars is around 0.04–0.14%. It is imperative that the insertion of trocars should be done safely for the successful outcome of laparoscopic surgeries. Various safety modifications have been introduced in order to avoid injuries during the introduction of the trocars. Various trocar tips have been designed to prevent slippage of trocars and increase safety by incorporating

Instrumentation and Imaging Systems in Laparoscopy

21

Chapter 2

Fig. 2.8: Various sizes of reusable trocars.

numerous additions. These basic trocars are available in disposable and reusable forms. The advantages of the disposable trocars are convenience of usage and elimination of elaborate sterilization procedures. The advocates of single use instruments praise the precise quality of the instruments. With the new trocars, the surgeon has an optimal unused instrument every time and can have the latest model at hand with the newest technological refinements. But the main disadvantage with disposable equipment is the cost factor, which is many manifold when compared to reusable trocars. The tips of most reusable trocars are either conical or pyramidal. Blunt conical trocars cause passive dilatation of the port site.23 The design of pyramidal-tipped trocars is centered on the tip configuration for prevention of injury. Pyramidal tip trocars penetrate by sharp dissection and thereby reduce the force required to transverse the abdominal wall. Some trocars have been designed with blades at the tip with plastic shields around them. This consists of an exposed blade for entry into the abdominal wall and a plastic shield that is released upon peritoneal entry to safely cover the blade.24 This mechanism may result in injuries, if the shield does not deploy quickly enough or if strong adhesions are present. The optical view trocar has a clear shaft and a conical tip. The laparoscope can be inserted into the trocar and the trocar

can be pushed under visual guidance.25 The abdominal wall layers can be seen as they are traversed and these can be used safely in the presence of adhesions. Even though these trocars are claimed to produce less complications, several reports have been published about the injuries produced by these trocars.18,26 The incidence of trocar injuries is related to the force required for insertion. In order to reduce the force required to insert a trocar various modifications have been attempted. Electrosurgical trocars have been designed that use thermal energy to create an opening rather than physical force. This consists of a plastic tipped trocar with a diathermy loop on the tip. These are not used routinely due to its potential to injure the bowels in case of adhesions. Ultrasonically activated trocars are found to be associated with decrease in insertion time and force when compared to conventional conical trocars.27-29 The true application of these types of trocars have not been clearly defined though they are prevalent in the market30,31 (Fig. 2.8).

Hasson’s Trocar and Cannula Hasson has described an alternative method of access for reducing the incidence of injuries. He utilizes Veress needle insertion with a specially designed valve. The Hasson cannula consists of three pieces—(1) a cone-

22

Art of Laparoscopic Surgery Textbook and Atlas shaped sleeve, (2) a metal or plastic sheath with a trumpet or flap valve, and (3) a blunt-tipped obturator. On the sheath or on the cone-shaped sleeve, there are two struts for affixing two fascial sutures.32 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 in the incision on the fascia. This creates an effective seal, so that the pneumoperitoneum will be maintained.

use reusable metal cannulas with pyramidal trocars and flap valves for most of our surgeries. These are economical and there is no hindrance in maintaining the sterility of these instruments. We resort to disposable trocars in special situations, for example, with Endo GIATM staplers, laparoscopic ultrasound probes, and morcellators. Another indication for using radiolucent disposable trocars is during intraoperative cholangiogram where the use of metal cannulas may obstruct vision.

Valve Design

Balloon Trocars

Valve mechanisms are essential for the control of leaks from the pneumoperitoneum. Various valves are in use:33 • Trumpet valve: The trumpet valve is based on the design of a trumpet as its name implies. The outer knob has to be pressed completely to release the seal to permit insertion or withdrawal of instruments. Trumpet valves are cumbersome to use and sometimes can scratch the instruments and remove insulation, if it is not fully open. Their sharp edges may damage the instruments and hence are not suitable for insulated instruments and laparoscopes. • Flap valve: Flap valves are spring-loaded devices that cannot be controlled from outside during the insertion and withdrawal of instruments. These valves have to be dismantled from the trocars and cleaned thoroughly, if they are used in reusable instruments. The springs are the main weak points of this valve mechanism. The other disadvantage is the reduced sealing efficacy, if any tissue material is caught between the valves. Both trumpet valves and flap valves are manually controlled. • Passive valve: Passive valves are those which cannot be manipulated from outside the trocar yet help in maintaining the seal. They open and close automatically with the passage of the instrument. The plastic or silicon rubber sleeve that is used in the disposable cannulas is simple, but cannot be autoclaved. Newer passive cannulas with magnetic flap valves are available in the market, which provide adequate sealing. Multifunctional valve systems have been developed that are very useful. Even though many types of trocars are available in the market, each has its advantages and disadvantages. The surgeon has to choose the trocar and cannula based on his preference, indication, and economics. We

The latex-free balloon trocars provide enhanced stability throughout laparoscopic procedures by additional fixation from above and below the abdominal wall, reducing unintentional cannula migration. The atraumatic stabilization helps to minimize fascial trauma while also maintaining pneumoperitoneum, even after incisions have been enlarged for specimen removal. 5 mm balloon trocar is supplied with a retention disk for stability and 12 mm balloon trocar has an adjustable gel anchor grip with suture tabs for additional fixation. After trocar insertion, the balloon is inflated with air through the inflation port of cannula using the syringe supplied. Once in position, the gel anchor or retention disk is adjusted to the required cannula depth to gently fix the cannula to the patient’s abdominal wall. 5 mm and 12 mm balloon trocars reduce abdominal intrusion by 48% and 44% respectively compared to standard threaded cannulas by fixing the cannula into position at the distal end. The reduced intra-abdominal cannula depth increases working space and in turn enhances visibility.

StepTM Trocars Step™ bladeless trocars are innovative products that incorporate Step™ Radial Dilation technology with a truly bladeless obturator. Step™ radially expanding technology allows the Step™ bladeless trocars to yield a smaller wound for an equivalent cannula size compared to conventional bladed trocars. Step™ bladeless trocars are available in short (90 mm) and standard (100 mm) working lengths in 5-mm, 10-mm, and 12-mm diameters.

Veress Needle The Veress needle (Fig. 2.9) is the most commonly used needle to induce pneumoperitoneum. This has

Instrumentation and Imaging Systems in Laparoscopy

23

Chapter 2 Fig. 2.9: Veress needle (A—disposable Veress needle; B—reusable Veress needle).

a spring-loaded blunt tip that retracts into a sharp sheath. During insertion, the blunt tip retracts exposing the sharp sheath. This sharp sheath penetrates the fascia and the peritoneum. Once the peritoneum is breached, resistance is lost and the blunt tip springs forward, protecting the bowel and viscera. The smaller caliber and shape of the needle allows it to penetrate the tissues by separating rather than cutting them, thereby reducing the chances of injuring the abdominal viscera. The central sheath has a connector for the insufflation tube.34 These needles are available in various diameters and lengths. The Veress needle is available either as a disposable or reusable instrument. It is important that the needle be sharp, so that less force is necessary to introduce it through the abdominal wall. Forcible introduction of a blunt needle might cause disastrous vascular injury. The needle is hollow inside and insufflation can be done. The diameter of the needle is 2 mm and the length is usually around 12–15 cm.35 The smaller diameter of the needle does not allow insufflation of more than 2.5  L of CO2 per minute. This serves as protection against untoward incidents due to the sudden stretching of the visceral peritoneum such as vagal shock and cardiac arrhythmias. The condition of the needle has to be checked before use every time. The patency of the needle has to be checked by flushing saline through it. The spring mechanism of the outer sheath can be checked by withdrawing the sheath and leaving it to assess whether the outer sheath springs back to the original position. Another way of checking is by pushing the blunt tip against a hard surface to be certain that the outer blunt sheath will retract and allow the sharper needle inside to pierce the abdominal wall and spring forward again on entry into the peritoneal cavity.

Insufflator Working space can be created by either pneumoperi­ toneum or by abdominal lift systems. Though gasless lift techniques are used sparingly, pneumoperitoneum remains the standard method. It was in 1966 that Kurt Semm introduced the concept of automatic insufflation devices that are capable of monitoring intra-abdominal pressures. This reduced the dangers associated with insufflation of the abdomen that existed prior to the use of these systems. Intra-abdominal pressure must be maintained at 12–14 mm Hg in order to avoid complications such as gas embolism or drop in blood pressure as a result of decreased venous return due to collapse of the inferior vena cava. Modern day insufflators are designed to deliver high volumes of gas into the abdominal cavity at a predetermined flow rate with the help of a sophisticated electronic mechanism. They monitor intra-abdominal pressure constantly and halt the flow immediately when the set intra-abdominal pressure is reached. The flow commences again when the pressure drops below the set value, during maneuvers like suctioning. Accurate pressure control is more important during maneuvers that increase and decrease intra-abdominal pressure like use of suction irrigation apparatus and during argon beam spray coagulation. The indicators on the insufflator denote all the vital information that is needed for the surgeon (like intra-abdominal pressure, rate of inflow of the gas, and volume of gas used from the cylinder). The third indicator should be used only as a guide to the amount of gas used; it also varies depending on the leakage of gas during exchange of instruments and during suction and irrigation. Insufflation devices should be capable of delivering at least 10 L/min, when performing major surgeries. Gas leak is inevitable at multiple trocar

24

Art of Laparoscopic Surgery Textbook and Atlas

Fig. 2.10: Insufflator.

sites during the change of instruments or along the cannulas. When pressurized CO2 expands, it cools down and has the potential to reduce the body temperature of the patient. Some insufflators have facilities for heating the CO2 before its passage into the abdomen. It has been shown that the thermal capacity of CO2 is not sufficient to cause a significant temperature drop during surgery and the body is capable of increasing the temperature by 20 minutes. Hence, these devices are not being used routinely. Irrigation liquid has the potential to reduce body temperature and it is advisable to maintain the temperature of irrigation fluid around that of the human body. The entire operating team should be familiar with the controls and gauges of the insufflator. The indicators that denote the gas level of the cylinders should be checked periodically to avoid gas wastage. It is a good practice to check the indicator level just before induction of a case and also at the beginning and the end of the day’s list. Paramedical personnel should be instructed to close the cylinders that supply CO2 at the end of the list, as an undetected leak in the tubes that connect the cylinder and the insufflator might empty the whole cylinder during the night. Carbon dioxide is the most popular gas for insufflation because of its suppression of combustion, high solubility, and low cost (Fig. 2.10).

Suction and Irrigation Apparatus Irrigation and aspiration are important during laparoscopic procedures, particularly for maintenance of a clear visual field and hemostasis. Even minimal quantities of blood will absorb a great deal of light and cause insufficient illumination.

There are two types of apparatus that are available. The roller pump type pushes the irrigation fluid through the tubing with the help of motorized rollers. The other type increases the pressure in the irrigation fluid reservoir with the help of motorized pumps. The increased pressure in the reservoir pushes the fluid through the tubes. Adjusting the set pressure in the fluid reservoir can control the flow of the irrigation fluid. Many manufacturers incorporate irrigation and aspiration into a single dual-control instrument. There is a practice of using heparin in the irrigation fluid to prevent pooled blood from clotting and facilitate its removal during suctioning. However, we do not follow this in our routine surgical practice. The suction tip is highly useful for intermittent suction and can be used as a blunt dissecting instrument in the place of finger dissection in conventional surgery. The suction irrigation probes are available at 5 mm and 10 mm diameters and we routinely use 5 mm instruments in our practice, as there is no sudden loss of pneumoperitoneum with these instruments. The rapid loss of pressure with the use of 10 mm suction probes is a hindrance during surgery.

SURGICAL INSTRUMENTS Though various instruments that are available, basic laparoscopic surgeries need only a few when compared to conventional surgery. The main difference between conventional and laparoscopic instruments is the presence of long shafts and the attached handgrip. The effector retains the same basic design as of conventional instruments. These instruments are usually around 33 cm long for its effective reach in the abdominal cavity.

Instrumentation and Imaging Systems in Laparoscopy

Hand Grips Handles should be designed ergonomically, so that there is minimal discomfort during handling of the instruments. Various types of handles are available for different purposes. Generally, locking systems is preferable for instruments that are used for retraction and suturing. Active dissection instruments like the curve dissector should not have a locking mechanism.37 The basic design of the hand grip can be classified as ring, shank, and pistol handles. The ring and shaft

handles can be either in line (coaxial) with the shaft of the instruments or at an angle (radial). Electrosurgical instruments come with a wire bend design. The hand grip of the suction irrigation apparatus is usually toggle mode or trumpet mode. These are the commercially available instrument handles that are in routine use. There are many newly designed ergonomic handles that have been reported in the literature, but these are yet to be used routinely. It has been reported in the literature that hand size is a significant determinant of difficulty when using laparoscopic surgical instruments. Individuals using glove sizes 6.5 or smaller experience significantly more difficulty using common laparoscopic instruments.38 The ideal design for handles of laparoscopic instruments should have the following ergonomic requirements:39 • Grip opening between 65 mm and 90 mm • Ring dimension: Length 30 mm and width 24 mm • Angle between grip and tube between 140 and 240 • Presence of spring • Opening and closure by flexors/extensors of the fingers • Thumb use for the rotation knob • Big contact area • Little opening/closing force required.

Ring and Shank Handles These are the most common types of handle grips that are used for one-handed manipulation during dissection, cutting, and other maneuvers. These handles are cheaper, easy to use, can be resterilized, and are interchangeable with several instruments.37 A ratchet can be attached to these handles. Being symmetrical they can be used both by the right and left hands. These types of handle help to manipulate the effector as well as to hold and direct the whole instrument. The arrangement of the handle and shape of the functional element is very important for the ergonomic quality and performance of the instrument. Many handles are positioned at about 70–900 to the axis of the shaft.

Pistol Handles Pistol handles allow integration of several different functions because of the handle volume. The thumb, index, and middle fingers are used, while the ring and little fingers are used to hold and direct the instrument.

Chapter 2

The special instruments and holding instruments are usually longer than the routine laparoscopic instruments. Currently available instruments are either disposable or reusable. Reusable instruments are mainly used in our centers. The handles, shaft with insulation, and inner effector are the main parts of the instruments. Most instruments are interchangeable and can be fitted as per the surgeon’s own preference. The insulation of the shaft should be examined thoroughly for any visible loss of the sheath to avoid electrosurgical accidents. Ideally, reusable instruments should have the following prerequisites:36 • Instrument position should be stable when the jaws are activated. • The jaws should be adequately elastic, so as to permit atraumatic grasping and other jaw functions. • Instruments should be easy to disassemble and reassemble. • Parts should be designed, so that they are interchangeable between similar instruments. • Cleaning and sterilization of parts should be easy. • The outer sleeve should be easily replaceable. • Functional checks should be done easily on all parts and automatically take place prior to each application. • The number of parts should be minimal and should be upgradable at a reasonable price. • The various parts should be easily available in the market and the instruments should be serviceable. In case of weakness or breakage, only the defective parts should require replacement. • Instruments should be of a simple design with a minimum number of hinges and bolts to reduce wear and tear. Since the hand grip design of is similar for all instruments, we will discuss this in common and then discuss the various tips that are available.

25

26

Art of Laparoscopic Surgery Textbook and Atlas The production of reusable instruments is cumbersome, elaborate, and expensive. These are available usually for disposable use. The handgrip of the suction probe is available either as the trumpet model or cylinder model with thumb manipulation or the toggle model with finger manipulation. We find the toggle model with thumb manipulation easier to use than the other instruments.

Types of Instruments Besides the basic instruments such as insufflation needles, trocars, and cannulas, hand instruments can be divided as dissecting instruments, retractors, suturing instruments, and other instruments.

Dissecting Instruments These instruments are available in reusable as well as disposable forms. We routinely use the reusable form, as these are long lasting and cost-effective. Though various types of dissecting instruments, such as Maryland dissector, Kelly’s dissector, Dolphin nose dissector, are available, the preference of the surgeon for a particular type of dissector is the deciding factor in the selection of the instrument.40 Some surgeons prefer straight dissectors, while others prefer curved dissectors. Most of the currently available instruments have interchangeable core, shaft, and handles. The handles of the dissecting instruments should not have a handle as this might interfere with working. It is better to have instruments with rotating shafts as these help the surgeon in dissection and avoids uncomfortable positioning of the wrist during manipulation of tissues. Most of these instruments have insulation sheaths and provision for connecting monopolar diathermy. We routinely use a blunt grasper without ratchet on the left hand during endosuturing. This helps in applying countertraction during suturing and for atraumatic holding of the suture material during suturing. Graspers are usually used for maintaining adequate exposure of the operating field. These are available in various forms, diameters, and lengths. These instruments usually have a ratchet mechanism to hold the tissues in position. The tip of these instruments has different designs, such as the rat tooth and alligator, that varies according to the amount of grip applied on the tip. Generally, 5 mm graspers are used for retraction of the gallbladder, retraction of the esophagogastric (EG) junction during upper gastrointestinal procedures after application of the umbilical tape, or during retraction of the esophagus in

thoraco-laparoscopic esophagectomy (after application of the umbilical tape). Usually, 10 mm graspers are for retraction of organs such as the colon and the stomach. Larger graspers usually have built-in locking springs that automatically lock and grasp the tissues in resting position. Scissors are available in either disposable or reusable forms. We routinely use the double-action curved scissors for dissection and refrain from application of cautery, while the blades of the scissors are open as this might cause blunting of the blades. Blades must be sharp; therefore, reusable scissors must be monitored closely and sharpened regularly. Reusable scissors can also be used as coagulators, but the blades lose their sharpness faster. We use locally made uninsulated scissors for cutting suture materials. Many types of scissors, like microscissors and hook scissors, are available for various applications. Microhook scissors are used for incising the common bile duct or cystic duct during laparoscopic common bile duct exploration (Table 2.1).

Clip Appliers Two different types of clip appliers are available. Medium large (9 mm) is used preferably to clip the cystic duct, while medium (7 mm) is used to clip the cystic artery. Larger clips (11 mm) may be used to control thick, wide cystic ducts or large colonic vessels, and they can be applied with medium large clip appliers. Disposable clip appliers usually come with 20 preloaded clips per unit, and can be applied in succession, which saves time. However, these instruments are not cost-effective. Absorbable clips (Absolok, Ethicon) are preferred to clip cystic ducts and add to safety by working at the tip. It is also used to aid suturing by applying continuous suturing at the beginning and at the end instead of knotting (Fig. 2.11).

Suture Assistant Instruments and Devices Needle holders: Coaxial locking systems are preferable to the pistol-type needle holder. The ringless handle affords greater maneuverability. These should be strong and with heavy handles with tapering tips and a single moving jaw, which are easy to catch. The tip of the needle holder can be either straight or curved; we regularly use the straight tip needle holders. There are pairs of suturing devices (Berci–Szabo) designed for use with both hands. I prefer an ordinary grasper with serrated jaws for using as a left hand instrument. I find it much easier to handle the needle, sutures, and tissues.

Instrumentation and Imaging Systems in Laparoscopy

27

Table 2.1: Dissecting instruments. Description

Dissectors

Maryland

Calot’s dissection, Basic instrument for isolation of vascular dissection double pedicles, dissection in action jaws hernias

Curved dissector with long blades

Dissection of large vessels

Blunt dissector grasper (nontoothed serrated jaws, atraumatic)

Aids during dissection Commonly used as with Maryland left-hand instrument during suturing

Grasper (toothed, serrated jaws, traumatic)

For holding thick and edematous gallbladder, removal of foreign bodies

Right angle

Dissection in difficult areas

Curved Metzenbaum

Dissection, division of cystic duct, vascular pedicles during ligation

Scissors

Photograph

Use

Remarks

Available in stainless steel or disposable material can be used with cautery. Application of cautery should be done only after closing the blades, otherwise the sharpness of the instruments might be lost

Contd…

Chapter 2

Type

28

Art of Laparoscopic Surgery Textbook and Atlas Contd… Type

Bowel clamps

Description

Photograph

Use

Straight

Division of suture material

Suture cutter

Division of suture material

Allis (10 mm)

Retraction of omentum during gastrectomy. Used in positioning the anvil and shaft of the circular stapler during laparoscopic anterior resection, esopha­gogastrectomy

Endo Babcock (10 mm)

Retraction of bowel larger bowel in anterior resection, right and left colectomies, rectopexy. Retraction of stomach in Heller’s cardiomyotomy, fundoplication

Babcock (10 mm) (reusable)

Retraction of bowel larger bowel in anterior resection, right and left colectomies, rectopexy. Retraction of stomach in Heller’s cardiomyotomy, fundoplication

Achalasia scissors

Used in Heller’s cardiomyotomy

Remarks

Economical and easy to use

Specially designed for division of muscle without injuring the mucosa

Contd…

Instrumentation and Imaging Systems in Laparoscopy

29

Contd… Description

Hooks

L-shaped

Spatula

Stone holding forceps

Photograph

Use

Remarks

Chapter 2

Type

Peritoneal incision near infundibulum during laparoscopic cholecystectomy and opening of the bowel

Dissection of gallbladder from liver bed, coagulation of liver bed after removal of gallbladder

Bowel grasper (plain)

For manipulation of small bowel during diagnostic laparoscopy

Bowel grasper

For manipulation of small bowel during diagnostic laparoscopy. Helps in transmediastinal endodissection during transhiatal esophagectomy

Claw forceps

During circular anastomosis in anterior resection (docking of anvil and shaft of the circular stapler)

10 mm

For removal of stones from the gallbladder and spilled stones in the peritoneal cavity

Traumatic instrument, should be used with caution

Contd…

30

Art of Laparoscopic Surgery Textbook and Atlas Contd… Type

Description

Retractors

Liver retractor 10 mm

Photograph

Use

For retraction of small Screw mechanism bowel and left lobe at the handle that of liver releases a number of blades that flare out on extension. Another screw mechanism, which shifts the axis of the tip of the instruments as shown in the figure

Remarks

Gold finger

Used in gastric bypass and major liver resection

Nathanson retractor

For retraction of left lobe of liver

Esophageal hook

Retraction of esophagus during thoracoscopy Retraction of larger veins

Biopsy forceps

5 mm biopsy forceps

For peritoneal biopsy and liver biopsy

Easy to use

Cholangiogram forceps

Olsen clamp

For cannulation of cystic duct during CBD exploration

It is a must for CBD exploration

Economical and simple design

Contd…

Instrumentation and Imaging Systems in Laparoscopy

31

Contd… Description

Suction nozzle

Photograph

Use

Remarks

5 mm, stainless steel, Toggle mode, finger manipulation

Suction and irrigation. Can also be used as finger for blunt dissection

Application of the probe over a piece of gauze piece at the tip prevents in rapid loss of pneumoperitoneum

Hydatid trocar

Palanivelu’s Hydatid System

Laparoscopic evacuation of Hydatid cyst

Needle holder

Ethicon type 5 mm

For endosuturing and Very versatile knotting instrument

Ethicon type 3 mm

For endosuturing and Very versatile knotting instrument

Conventional needle holder, coaxial ring handle

We use it mainly for retraction of liver in fundoplication, for following the thread in intracorporeal suturing

Veress needle

Veress needle

Introduction of pneumoperitoneum, pneumothorax

Clip applicators

10 mm reusable

Occlusion of cystic duct and artery. Occlusion of veins Also used in running stitches at the beginning and at the end instead of knotting

Now absorbable clips are available

Contd…

Chapter 2

Type

32

Art of Laparoscopic Surgery Textbook and Atlas Contd… Type

Description

Photograph

Use

5 mm reusable

Used to clip the small vessels

Endo Bulldog clamps

For occlusion of major vessels and bile duct

Loop applicator

3 mm applicator

For application of Endoloops

Port closure device

Suture passer

For closure of ports

Suture grasper

For closure of ports

Remarks

Self-made loops with conventional suture materials are economical

(CBD: common bile duct)

Suture passer devices: There are various types of suture passers that are commercially available for closure of ports and transfascial ligature during ventral hernia repair. These devices can also be used for control of bleeding from the abdominal wall. I have designed a pair of instruments for port closure. The thread passer has a side slit to carry the thread into the peritoneal cavity on one side to the trocar. Once the thread is in the peritoneal cavity, the thread passer is withdrawn. The port

closure needle is inserted on the other side and the thread is grasped and pulled out of the abdominal cavity. The port tracts are approximated by holding both ends of the thread pulled outside. Fixation devices: • Tackers™ and other fixation devices: “Tackers” are the first 5 mm mechanical fixation devices to be introduced in laparoscopic surgery. The tackers

Instrumentation and Imaging Systems in Laparoscopy

33

Chapter 2

Fig. 2.11: Hem-o-lok® clip applicator.

use coils that are screwed into the tissues through the prosthesis. These devices require adequate counterpressure from the outside area to anchor the mesh and the tissues effectively.   The new salute fixation device from Onus Medical has a stainless wire that is formed into the shape of a key ring during application. The tissues are held together between the rings. The stainless steel wire is cut off once the key ring shape is formed. This differs from other devices as this is not a performance device like staplers or Tackers. These can be used for inguinal and ventral hernia repair. • Endoanchor: “Endoanchor” from Ethicon Endo Surgery Inc is the latest introduction in the group of fixation devices. This has an anchor-like fixation device made of Nitinol. This is a 5 mm instrument that contains 20 anchors. This anchor has two levels of lateral extension—(1) the proximal shorter extension that holds the tissues and (2) the distal larger protrusion, which supports the mesh. The method of application of the anchor is different from other devices. The trigger is fired initially and this causes the movement of the inner shaft with the anchor outside the sheath. Maintaining the trigger in the fixed position, the mesh can be adjusted and the instrument pressed over the intended area of fixation. Slow release of the trigger at this stage causes deployment of the anchor.  Securestrap™ is a 5 mm mesh fixation device by Ethicon, it uses straddle-shaped absorbable Tackers. This device can be used in various angles owing to its strap design, which helps the mesh to be fixed

to the abdominal wall using two-point fixation technique. Fixation device contains either 12 or 25 synthetic absorbable straps, preloaded into the devices 36 cm long shaft. The instrument is designed for introduction and use through a 5 mm or larger laparoscopic port sleeve. Larger diameter sleeves will require use of a converter. The Ethicon Securestrap™ Absorbable Fixation Device straps are made of a blend of polydioxanone dyed with D&C Violet No. 2 and an L(-)-lactide/glycolide copolymer. The inserted length of the strap is 6.7 mm. • ProTack™ fixation device: ProTack™ titanium fixation device is a 5-mm single-use instrument with 30 titanium helical fasteners. The tack is helical, made of titanium, and is nonabsorbable. The ProTack™ device comes in a 30 tack configuration. Width of each tack is 3.96 mm.

REFERENCES 1. Boppart SA, Deutsch TF, Rattner DW. Optical imaging technology in minimally invasive surgery. Current status and future directions. Surg Endosc. 1999;13(7):718-22. 2. Schwaitzberg S. Imaging in endoscopy. In: Nathaniel J Soper, Lee L Swanström, Eubanks WS (Eds). Mastery of Endoscopic Surgery. New York: Lippincott Williams & Wilkins; 2004. 3. Schwaitzberg SD. Imaging systems in minimally invasive surgery. Semin Laparosc Surg. 2001;8(1):3-11. 4. Kourambas J, Preminger GM. Advances in camera, video, and imaging technologies in laparoscopy. Urol Clin North Am. 2001;28(1):5-14. 5. Heniford BT, Mathews B. Basic instrumentation for laparoscopic surgery. In: Greene FL, Heniford BT (Eds).

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Art of Laparoscopic Surgery Textbook and Atlas Minimally Invasive Cancer Management. New York: Springer-Verlag; 2001. pp. 36-45. 6. Chan AC, Chung SC, Yim AP, et al. Comparison of two-dimensional vs three-dimensional camera systems in laparoscopic surgery. Surg Endosc. 1997;11(5): 438-40. 7. Chiu AW, Babayan RK. Retroperitoneal laparoscopic nephrectomy utilizing three-dimensional camera. Case report. J Endourol. 1994;8(2):139-41. 8. McDougall EM, Soble JJ, Wolf JS Jr, et al. Comparison of three-dimensional and two-dimensional laparoscopic video systems. J Endourol. 1996;10(4):371-4. 9. Mueller MD, Camartin C, Dreher E, et al. Threedimensional laparoscopy. Gadget or progress? A randomized trial on the efficacy of three-dimensional laparoscopy. Surg Endosc. 1999;13(5):469-72. 10. Maithel SK, Villegas L, Stylopoulos N, et al. Simulated laparoscopy using a head-mounted display vs traditional video monitor: an assessment of performance and muscle fatigue. Surg Endosc. 2005;19(3):406-11. 11. Cheah WK, Lenzi JE, So J, et al. Evaluation of a headmounted display (HMD) in the performance of a simulated laparoscopic task. Surg Endosc. 2001;15(9):990-1. 12. Minnich DJ, Schell SR. Evaluation of face-mounted binocular video display for laparoscopy: outcomes of psychometric skills testing and surgeon satisfaction. J Laparoendosc Adv Surg Tech A. 2003;13(5):333-8. 13. Herron DM, Lantis JC, Maykel J, et al. The 3-D monitor and head-mounted display. A quantitative evaluation of advanced laparoscopic viewing technologies. Surg Endosc. 1999;13(8):751-5. 14. Cockett WS, Cockett AT. The Hopkins rod-lens system and the Storz cold light illumination system. Urology. 1998;51(5A Suppl):1-2. 15. Berber E, Pearl JM, Siperstein AE. A simple device for measuring the resolution of videoscopic cameras and laparoscopes in the operating room. Surg Endosc. 2002;16(7):1111-3. 16. Champault G, Cazacu F, Taffinder N. Serious trocar accidents in laparoscopic surgery: a French survey of 103,852 operations. Surg Laparosc Endosc. 1996;6(5): 367-70. 17. Orlando R, Palatini P, Lirussi F. Needle and trocar injuries in diagnostic laparoscopy under local anesthesia: what is the true incidence of these complications? J Laparoendosc Adv Surg Tech A. 2003;13(3):181-4. 18. Thomas MA, Rha KH, Ong AM, et al. Optical access trocar injuries in urological laparoscopic surgery. J Urol. 2003;170(1):61-3. 19. Bhoyrul S, Vierra MA, Nezhat CR, et al. Trocar injuries in laparoscopic surgery. J Am Coll Surg. 2001;192(6):677-83. 20. Schafer M, Lauper M, Krahenbuhl L. Trocar and Veress needle injuries during laparoscopy. Surg Endosc. 2001;15(3):275-80. 21. Saville LE, Woods MS. Laparoscopy and major retroperitoneal vascular injuries (MRVI). Surg Endosc. 1995;9(10):1096-100.

22. Nordestgaard AG, Bodily KC, Osborne RW Jr, et al. Major vascular injuries during laparoscopic procedures. Am J Surg. 1995;169(5):543-5. 23. Leibl BJ, Schmedt CG, Schwarz J, et al. Laparoscopic surgery complications associated with trocar tip design: review of literature and own results. J Laparoendosc Adv Surg Tech A. 1999;9(2):135-40. 24. Jarrett JC. Laparoscopy: direct trocar insertion without pneumoperitoneum. Obstet Gynecol. 1990;75(4):725-7. 25. String A, Berber E, Foroutani A, et al. Use of the optical access trocar for safe and rapid entry in various laparoscopic procedures. Surg Endosc. 2001;15(6):570-3. 26. Sharp HT, Dodson MK, Draper ML, et al. Complications associated with optical-access laparoscopic trocars. Obstet Gynecol. 2002;99(4):553-5. 27. Gossot D, Validire P, Matsumoto S, et al. Development of an ultrasonically activated trocar system. Surg Endosc. 2002;16(1):210-14. 28. Waxman K, Birkett DH, Sackier JM, et al. Clinical and laboratory evaluation of an electrosurgical laparoscopic trocar. Surg Endosc. 1994;8(9):1076-9. 29. Melzer A, Riek S, Roth K, et al. Endoscopically controlled trocar and cannula insertion. Endosc Surg Allied Technol. 1995;3(1):63-8. 30. Nio M, Ishii T, Amae S, et al. An experimental study on the utility of a 3-mm ultrasonically activated trocar system. J Pediatr Surg. 2004;39(12):1842-4. 31. Matsumoto S, Kawabe N, Mizuno Y, et al. The ultrasonic trocar provides an easy, sharp, bloodless, and repeatable approach to the abdominal cavity. JSLS. 2002;6(4):401-5. 32. Hasson HM. A modified instrument and method for laparoscopy. Am J Obstet Gynecol. 1971;110(6):886-7. 33. O’Rourke NA. The valve design of disposable and reusable trocars. Endosc Surg Allied Technol. 1995;3(1):48-50. 34. McKernan JB, Champion JK. Access techniques: Veress needle—initial blind trocar insertion versus open laparoscopy with the Hasson trocar. Endosc Surg Allied Technol. 1995;3(1):35-8. 35. Piccigallo E, Jeffers LJ, Reddy KR, et al. Experience with a 1.2-mm pneumoperitoneum needle for laparoscopy. Gastrointest Endosc. 1988;34(6):471-3. 36. Matern U, Waller P. Instruments for minimally invasive surgery: principles of ergonomic handles. Surg Endosc. 1999;13(2):174-82. 37. Berguer R. Surgical technology and the ergonomics of laparoscopic instruments. Surg Endosc. 1998;12(5): 458-62. 38. Berguer R, Hreljac A. The relationship between hand size and difficulty using surgical instruments: a survey of 726 laparoscopic surgeons. Surg Endosc. 2004;18(3):508-12. 39. Van Veelen MA, Meijer DW. Ergonomics and design of laparoscopic instruments: results of a survey among laparoscopic surgeons. J Laparoendosc Adv Surg Tech A. 1999;9(6):481-9. 40. Park AE, Mastrangelo MJ Jr, Gandsas A, et al. Laparoscopic dissecting instruments. Semin Laparosc Surg. 2001;8(1):42-52.

CHAPTER

Anesthesia for Laparoscopic Surgery INTRODUCTION Although laparoscopy was first introduced in the beginning of the 20th century, therapeutic laparoscopic procedures have only recently become well established. Laparoscopic surgery gained significance since it reduces trauma to the patient, reduces morbidity, and reduces the hospital stay. During laparoscopy, the pneumoperitoneum and the patient position induce pathophysiological changes that complicate anesthetic management. Moreover, the duration of laparoscopic surgery, risk of unsuspected visceral injury, and difficulty in estimation of blood loss also make anesthesia for laparoscopy a high-risk procedure. Hence, anesthesiologists should have a thorough knowledge of these changes associated with laparoscopy and should weigh the benefits and complications for each patient (Box 3.1 and Table 3.1).

RESPIRATORY CHANGES DURING LAPAROSCOPY The main effect of pneumoperitoneum is increase in PaCO2, which depends on the patient’s condition, gas used for pneumoperitoneum, duration of laparoscopy, associated complications like subcutaneous emphysema, pneumothorax, etc. and anesthetic technique. Moderate hypoxemia also occurs, which is usually not of clinical significance in young healthy patients. These changes produce deleterious effects in patients with respiratory, cardiovascular, or other systemic diseases.1 The ventilatory changes during laparoscopy are influenced by the alterations in patient’s position and the insufflation of peritoneal cavity with gas, resulting in increased intra-abdominal pressure (IAP).

Due to Pneumoperitoneum Both nitrous oxide (N2O) and air have been tried to create pneumoperitoneum, but discontinued because

3

of their flammability and risk of gas embolism. Hence, carbon dioxide (CO2) is the most common gas used for pneumoperitoneum since it does not support combustion, is readily available, is relatively inexpensive and its high solubility minimizes the potential complications associated with vascular injury and gas embolism. The CO2 is absorbed from the peritoneal cavity and carried by blood through the systemic and portal veins and excreted via the lungs. Hence, the pulmonary excretion of CO2 and PaCO2 increases progressively and plateaus after approximately 20 minutes at 125% of baseline value.2 Even though we expect very high increase and PaCO2, it does not happen clinically because of impaired peritoneal perfusion due to hemodynamic changes and enormous buffering capacity of the blood. The increase in IAP produces cephalad shift of the diaphragm resulting in reduction of functional residual capacity (FRC), total lung volume (TLV), and pulmonary compliance. If FRC decreases below the closing volume, atelectasis and intrapulmonary shunting may occur, resulting in hypoxemia. These changes

Box 3.1: Venous thromboembolism (VTE) and laparoscopic surgery risk factors. • Previous history of VTE • Age > 40 • Immobility • Varicose veins • Cancer • Chronic renal failure • Obesity • Peripartum • Congestive heart failure • Myocardial infarction • Hormone replacement therapy • Oral contraceptive pills • Inflammatory bowel disorders • Severe infection • Surgical duration > 1 hour • Pelvic procedures

36

Art of Laparoscopic Surgery Textbook and Atlas Table 3.1: Society of American Gastrointestinal and Endoscopic Surgeons (SAGES) suggested Venous thromboembolism (VTE) prophylaxis. Procedure

Risk factor

Recommendation

0 to 1

None, PCDs, LMWH

2 or more

PCDs, LMWH

0 to 1

None, PCDs, LMWH

2 or more

PCDs, LMWH

Diagnostic laparoscopy

2 or more

PCDs, LMWH

Laparoscopic inguinal hernia

2 or more

PCDs, LMWH

0 or 1

PCDs, LMWH

2 or more

PCDs and LMWH

0 or 1

PCDs, LMWH

2 or more

PCDs and LMWH

0 or more

PCDs and LMWH

Laparoscopic cholecystectomy

Laparoscopic appendicectomy

Laparoscopic fundoplication

Laparoscopic splenectomy Other major laparoscopic procedure, Roux-en-Y etc.

(LMWH: low-molecular weight heparins; PCD: pneumatic compression devices)

produce ventilation/perfusion mismatch with increased physiological dead space, which is evident by increased arterial to alveolar gradient for partial pressure of CO2 [(aA) D CO2].3,4 The increase in (a-A) D CO2 can also be due to reduced cardiac output associated with laparoscopy and this is exaggerated in patients with pulmonary or cardiovascular disease. The ventilatory function is further deteriorated by Trendelenburg position and general anesthesia (GA). The increase in IAP and Trendelenburg position with resultant cephalad shift of carina may result in endobronchial movement of the endotracheal tube and one lung ventilation, leading to hypoxia and hypercarbia.

Due to Position of the Patient The Trendelenburg position reduces FRC, TLV, and pulmonary compliance, and facilitating atelectasis. This can be minimized by judicial application of positive end-expiratory pressure (PEEP). These changes are more marked in morbidly obese, elderly, and debilitated patients. The position of the endotracheal tube should

be checked after the change of patient position. The reverse Trendelenburg position improves respiratory function; hence, it is the most preferred position as far as respiratory system is concerned.

Influence of Anesthesia Laparoscopic surgery can be performed under local/ regional anesthesia, GA with spontaneous breathing or under GA with controlled ventilation. Under local or regional anesthesia, PaCO2 is unaltered by pneumoperitoneum.3 However, minute ventilation is increased, mainly by an increase in the rate of breathing. The constant PaCO2 under local anesthesia may be explained by the absence of ventilatory depressant effect of GA. In spontaneously breathing patients under GA, intraperitoneal insufflation of CO2 increases minute ventilation, but this increase is not sufficient enough to keep PaCO2 within normal limits. Rises in PaCO2 up to 60.8 + 10.9 mm Hg had been reported.5 This is related to the ventilatory depressant effect of the general anesthetic agents that blunt the ventilatory response to hypercapnia and increased IAP.

Anesthesia for Laparoscopic Surgery

CARDIOVASCULAR CHANGES DURING LAPAROSCOPY The significant changes due to pneumoperitoneum with CO2 are hypercarbia, which is responsible for sympathetic stimulation resulting in tachycardia, hypertension, and arrhythmias on one hand, and the reduction in cardiac output proportional to the IAP on the other.

Effect of Position The head-down position increases the venous return, central venous pressure (CVP), and hence the stroke volume, but the arterial blood pressure does not change significantly because of reflex vasodilatation and bradycardia.6,7 Hence, under clinical conditions, when the head-down tilt does not exceed 150, the hemodynamic changes are not significant in healthy individuals, but in patients with pre-existing heart disease, the increased

venous return and CVP may produce decreased cardiac index and increased myocardial oxygen consumption. In addition, the Trendelenburg position increases intracranial pressure (ICP) and intraocular pressure; hence, should be avoided in patients with increased ICP or acute glaucoma. The head-up position results in pooling of blood in the periphery leading to reduced venous return, cardiac output, and blood pressure, the severity of which depends upon the steepness of the tilt.8 Venous stasis is aggravated by lithotomy and pneumoperitoneum leading to deep vein thrombosis (DVT) and pulmonary embolism. Hence, legs must be freely supported, avoiding pressure over popliteal fossa and anti-DVT stockings to be applied. Intermittent calf compression devices would reduce the risk of DVT (Fig. 3.1).

Effects of Pneumoperitoneum The hypercarbia resulting from CO2 pneumoperitoneum produces sympathetic stimulation leading to tachycardia, arrhythmia, and increased blood pressure. On the other hand, the increased IAP reduces the cardiac output, which can reach 50% of the preoperative value.8 The decreased cardiac output can be related to decreased preload, increased afterload, and altered myocardial function.

Fig. 3.1: Pneumatic compression device used to prevent deep vein thrombosis, particularly in obese and high-risk patient.

Chapter 3

Carbon dioxide rises progressively after the start of gas insufflation and will plateau after 15–25 minutes. The cardiac and/or respiratory disabled patients will manifest larger respiratory changes than healthy patients. When patients are ventilated mechanically under GA with increased minute volume (to be adjusted for individual patient) PaCO2 may be kept within normal limits.

37

38

Art of Laparoscopic Surgery Textbook and Atlas Even though the CVP is increased during pneumoperitoneum, the actual venous return is reduced. The increase in CVP is due to the increased intrathoracic pressure resulting from transmission of increased IAP. The venous return is reduced due to the pressure effect of pneumoperitoneum on inferior vena cava.9 In spite of reduction in cardiac output, the blood pressure increases from the onset of pneumoperitoneum due to compression of abdominal blood vessels resulting in increased systemic vascular resistance (SVR).10 Since these changes take some time to return to the preinsufflation values after exsufflation, the role of humoral factors like catecholamines, renin, prostaglandin, vasopressin, etc. has been suggested. Out of these, vasopressin is considered to be the important one, because plasma vasopressin levels correlate with changes in IAP. Increased IAP decreases blood flow to the intraabdominal organs. Splenic, mesenteric, and intestinal mucosal blood flow are decreased. The intestinal mucosal ischemia results in decreased intestinal mucosal pH, which may delay the return of normal bowel function. Renal blood flow and glomerular filtration are reduced. Coronary blood flow is unchanged or increased in relation to the cardiac output. These hemodynamic changes are well tolerated by healthy patients. Reflex bradycardia is one of the most common effects seen during pneumoperitoneum. Releasing the IAPs reverses the sequence (Box 3.2).

HYPOTHERMIA Intraoperative hypothermia is another problem during laparoscopy and there is a reduction of 0.30C/50L of gas flow; hence warming of the insufflation gases to 300C is recommended during prolonged surgery.11

COMPLICATIONS OF LAPAROSCOPY AND ANESTHETIC CONCERNS As for any other surgery, laparoscopy is also not devoid of complications. Even though morbidity and mortality are low, severe, and sometimes fatal complications can occur. Since most of the complications are related to surgical technique, the laparoscopy is always better to be performed by/or under the guidance of an experienced surgeon. With better understanding of the pathophysiological changes during laparoscopy and

Box 3.2: Effects of pneumoperitoneum. Respiratory system: • ↑ PaCO2 • Splinting of diaphragm • Lung volumes and capacities ↓ • Lung compliance ↓ • Airway resistance ↑ • Mismatch ↑ • Hypoxia and hypercarbia Cardiovascular system: • Hypercarbia and sympathetic stimulation • Tachycardia, arrhythmias, and ↑ BP • SVR ↑ • Compression of IVC; reduced venous return • Cardiac output ↓ • Splanchnic blood flow decreased; delayed return of bowel function. Renal: • Renal blood flow ↓ • GFR ↓ and urine output ↓ Intracranial pressure ↑; intraocular pressure ↑ Regurgitation and aspiration Hypothermia Influenced by change of position and anesthesia (BP: blood pressure; GFR: glomerular filtration rate; IVC: inferior vena cava; SVR: systemic vascular resistance; PaCO2: partial pressure of carbon dioxide in arterial blood)

better experience of the surgeon and anesthetist the mortality rate came down from 2 in 10,000 in the early 1970s to 1 in 100,000 by the end of the decade.12 The incidence of major complications is less than 2% in gastrointestinal laparoscopic surgery in most studies (Table 3.2).13,14

Traumatic Complications Vascular injury is responsible for 30% of major complica­ tions of laparoscopic surgery. Injury to the vessels in the abdominal wall can result in parietal hematoma and hem­orrhagic shock. Major vessel injury is often catastrophic and sometimes fatal. Vessels in the retroperitoneum may also be injured leading to huge hematoma with loss of large volume of blood before it is recognized. Hepatic and splenic injury can lead to hemorrhagic shock. Gastric dilatation due to facemask ventilation can increase the chance of gastric perforation during trocar insertion. Unrecognized gastrointestinal perforation can lead to peritonitis, subdiaphragmatic abscess, septic shock, and death. Injury to bladder, kidney, and ureter

Anesthesia for Laparoscopic Surgery

39

Table 3.2: Complications and management. Prevention and management

Vascular/visceral injury

• Empty the stomach and bladder before pneumoperitoneum • Careful introduction of Veress needle and trocar • Complete survey of abdominal organs before proceeding for surgery

Subcutaneous emphysema

• • • •

Proper placement of Veress needle/trocar Reduce inflation pressure to optimum low level Postoperative O2 supplementation till emphysema settles Reduce inflation pressure to optimum low level 3. Postoperative O2 supplementation till emphysema settles

Pneumothorax/pneumomediastinum: • Sudden/progressive hypoxia • Peak airway pressure • Subcutaneous emphysema

• • • • • •

Delay/avoid ICD (difficulty in pneumoperitoneum) FiO2; stop N2O Adjust ventilation Reduce IAP PEEP (if no pulmonary trauma) Usually spontaneous resolution within 1 hour after exsufflation

• • • • • • •

Stop insufflation and release pneumoperitoneum Steep head down and left lateral position FiO2 increased; stop N2O Reduce IAP PEEP (if no pulmonary trauma) Usually spontaneous resolution within 1 hour after exsufflation Usually rapid reversal (CO2 highly soluble)

Cardiovascular complications: • Arrhythmias • Brady-/tachycardia • Hypo-/hypertension • Circulatory collapse

• • • • • • • • •

CVS problems (hypertension, ischemia) treated preoperatively Avoid excessive IAP Correct hypoxia/hypercarbia Slow insufflation/exsufflation Correct hypovolemia Slow gradual change of position Avoid halothane Atropine/inotropes for bradycardia/hypotension Beta-blocker, verapamil, nifedipine, nitroglycerin for tachycardia/ hypertension

• Aspiration

• Preoperative antacids and H2-antagonists • Use of cuffed endotracheal tube • Empty the stomach prior to pneumoperitoneum

• Nerve injury

• • • •

Diagnosed by: • Auscultation • Radiography • Abnormal motion of hemidiaphragm Gas embolism: • “Gas lock” in vena cava or right atrium • Tachycardia, hypotension, hypoxia • CVP • Arrhythmias • ECG changes (right heart strain) • Circulatory collapse • Recovery delayed; coma, fits, paresis or blindness Diagnosed by: • Precordial or esophageal stethoscope; metallic or mill-wheel murmur • Aspiration of gas through CVP catheter • Precordial/esophageal Doppler • Capnometry (biphasic ETCO2) • Precordial/esophageal Doppler • Capnometry (biphasic ETCO2)

Proper positioning of the patient Adequate padding over vulnerable areas Avoid overstretching of arm Protect the eyes Contd…

Chapter 3

Complication

40

Art of Laparoscopic Surgery Textbook and Atlas Contd… Complication

Prevention and management

• Hypothermia

• Warming and humidification of insufflation gas • Warming IV fluids, blood, irrigation fluid • Warm blanket/mattress

(CVP: central venous pressure; CVS: cardiovascular system; ETCO2: end-tidal carbon dioxide; FiO2: fraction of inspired oxygen; IAP: intra-abdominal pressure; ICD: implantable cardioverter-defibrillator; IV: intravenous; PEEP: positive end-expiratory pressure)

can also occur. Hence, it is always mandatory to make sure that the stomach and bladder are empty before the trocar insertion.

Respiratory Complications • Subcutaneous emphysema • Pneumothorax • Pneumomediastinum • Pneumopericardium. Improper placement of Veress needle and/or trocar and insufflation of gas can lead to subcutaneous emphysema. The potential channels of communication between the peritoneal cavity and the pleural and pericardial sacs may open when IAP increases leading to pneumothorax or pneumopericardium. Moreover, gas diffusion into the thorax may occur through the defects in the diaphragm or weak points in the aortic and esophageal hiatus. Pneu­ momediastinum can lead to subcutaneous emphysema of neck and face, aggravated by prolonged duration of surgery and head-up tilt. One of the most important causes of pneumothorax is the pleural tear during surgery at the gastroesophageal junction like Heller’s cardiomyotomy, fundoplication, etc. The rupture of pre-existing pulmo­ nary bullae following high-inflation pressures during laparoscopy can also lead to pneumothorax. A pneumothorax should be suspected when there is sudden or progressive hypoxemia (cyanosis, reduced oxygen saturation), increased peak airway pressure, and/or subcutaneous emphysema. The diagnosis can be confirmed by auscultation, radiography, and appreciation of abnormal motion of one hemidiaphragm by the laparoscopist.

Gas Embolism The most dreaded complication of pneumoperitoneum is gas embolism; but fortunately the incidence is very low.

It can occur when gas is insufflated into a vessel due to misplaced trocar or Veress needle, when small bubbles of gas entering injured veins and when large amount of gas gets absorbed into the portal circulation where bubbles can be formed and trapped.15 These bubbles are released into the circulation after exsufflation, which may explain delayed occurrence of gas embolism.16 The consequences of gas embolism depend upon the rate of entry of gas into the vessel, size of the bubbles, and physical characteristics of the gas. Usually, small bubbles get trapped in the pulmonary circulation. Rapid insufflation can produce larger bubbles that form a “gas lock” in the vena cava or in the right atrium.17 This increases the right atrial and ventricular pressure and reduces the cardiac output leading to circulatory collapse and finally death; it may also result in paradoxical embolism in the cerebral and coronary circulation occasionally, with catastrophic consequences.18 The inhalation of N2O does not increase the size of CO2 bubbles. During laparoscopy, gas embolism should be suspected in the presence of tachycardia, hypotension, hypoxemia, increased CVP, cardiac arrhythmias, electrocardiography (ECG) changes of right heart strain, and circulatory collapse. The immediate neurological symptom is often limited to bilateral mydriasis. At the end of anesthesia, coma, delayed awakening, seizures, paresis, or paralysis suggests CO2 in the cerebral vessel; blindness occurs in 20% of cases. A precordial or an esophageal stethoscope may detect gas embolism early. Initially a metallic murmur can be heard. With increasing volume of gas, classical “mill–wheel murmur” is heard. The first hemodynamic change associated with gas embolism is an increase in pulmonary artery pressure. Aspiration of gas or foaming blood by Swan Ganz catheter confirms the diagnosis. Precordial Doppler can detect as little as 2 mL of gas passing through right atrium19 and esophageal Doppler is even more sensitive in detecting

Anesthesia for Laparoscopic Surgery

Aspiration of Gastric Contents The increased IAP facilitates regurgitation, but at the same time, the pressure of the lower esophageal sphincter is increased, which reduces the risk of regurgitation. However since the drugs and coexisting diseases like hiatus hernia can increase the risk of regurgitation, preoperative use of antacids and H2-antagonists is advised.

Cardiovascular Complications The most common cardiovascular problem during laparoscopy is cardiac arrhythmias. Hypercarbia, hypoxia, hemodynamic changes, and vagal reflexes precipitate arrhythmias. Halothane, especially in the presence of hypercarbia, is more arrhythmogenic; hence to be avoided. Agents like isoflurane or enflurane and mechanical ventilation are advised. Peritoneal stretching due to insufflation or surgical manipulation can increase vagal tone and produce bradycardia. Hemodynamic changes during laparoscopy and gas embolism can also produce arrhythmias.

The reduced venous return, associated cardiovascular diseases, hypovolemia, intraoperative hemorrhage, and excessive IAP all precipitate circulatory arrest.

Nerve Injury Various patient positions can result in nerve compression or overextension. Overextension of arm stretching brachial plexus should be avoided. During Trendelenburg position, the shoulder braces can impinge on brachial plexus. In lithotomy position, common peroneal nerve is more vulnerable.

POSTOPERATIVE BENEFITS After laparoscopy, patient has improved and early recovery and better maintenance of homeostasis. The acute phase reaction is less; C-reactive protein and interleukin-6 concentrations are reduced following laparoscopy when compared to open procedure,20 but the stress response is the same in both groups, which may be due to pain and discomfort produced by peritoneal stretching, hemodynamic, and ventilatory disturbances. The laparoscopy is less traumatic and avoids prolonged exposure and manipulation of intestines; hence, less postoperative ileus, early feeding, less duration of IV infusion and short hospital stay; hence less expensive for the patient. The analgesic requirement is significantly reduced and the respiratory dysfunction is less and the recovery is quicker.

ANESTHETIC MANAGEMENT (TABLE 3.3) Patient Selection Laparoscopy should be avoided in patients with intraperitoneal, peritoneojugular, or ventriculoperitoneal shunts; it is contraindicated in patients with raised ICP and acute glaucoma. Laparoscopy can be used safely in obese patients and in patients with severe respiratory disease. Even though there is higher risk of pneumothorax and inadequate gas exchange in these patients, this is offset by reduced postoperative respiratory dysfunction and pulmonary complications. In patients with chronic respiratory disease the PETCO2 may not correlate well with PaCO2 and hence arterial blood gas (ABG) analysis should be done. In obese patients, since high IAP is required to raise the abdominal wall, significant reduction in cardiac output and FRC, and elevation of dead space

Chapter 3

gas emboli as small as 0.5 mL. The very low incidence of gas embolism, invasive monitoring with Swan Ganz catheter, and cost of Dopplers preclude routine use of these monitors during laparoscopy. Capnometry is one of the most valuable noninvasive techniques to detect CO2 embolism. End-tidal CO2 (PETCO2) alterations are biphasic. In the initial stages, small volumes of CO2 embolus are excreted through lungs and increasing PETCO2. When larger volumes are involved, PETCO2 is reduced due to reduced cardiac output and increased physiological dead space. As soon as gas embolism is diagnosed, insufflation should be stopped and pneumoperitoneum should be released. The patient should be placed in steep head down and left lateral position to prevent gas entering pulmonary vessels from right ventricle. Fraction of inspired oxygen (FiO2) should be increased, hyperventilation to be done to increase CO2 excretion, and N2O administration to be stopped to enhance CO2 bubble resorption. If these measures are not effective, a central venous catheter can be passed to aspirate gas. Cardiopulmonary cerebral resuscitation should be instituted, if situation warrants. Usually with treatment, there is rapid reversal of clinical signs since CO2 is highly soluble in blood.

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Art of Laparoscopic Surgery Textbook and Atlas Table 3.3: Coexisting problems and management. Problems Respiratory problems

Cardiac disease (hypertension, IHD, LV dysfunction: EF ≤ 30%)

Obesity

Pregnancy

Infants and children

Day-care laparoscopic surgery

Management • Preoperative preparation with antibiotics, bronchodilators, mucolytics, steroids, chest physiotherapy, incentive spirometry, etc. • Stop smoking • Selection of suitable anesthetic agents • If possible, under local/regional anesthesia • Use of volatile agents; minimize NM blockers • Optimum low IAP for pneumoperitoneum (8–10 mm Hg)/Laparolift technique • Adjust ventilation to avoid hypoxia/hypercarbia • High FiO2/judicial use of PEEP, if required • Preoperative evaluation and optimization • Drugs continued on the day of surgery (except anticoagulants and antiplatelets) • Monitor: Intra-arterial line, pulmonary artery catheter • Slow insufflation/low IAP (8–10 mm Hg) • Correction of hypovolemia • Drugs: Isoflurane, vasodilators (nifedipine, nitroglycerin), beta-blocker (metoprolol, esmolol), inotropic agents • Gasless laparoscopy/N2O pneumoperitoneum? • Preoperative evaluation for hypertension, IHD, peripheral vascular disease, smoking, obstructive sleep apnea, airway and intubation problems, diabetes mellitus and other endocrine problems • Pulmonary function tests and ABG • Incentive spirometry • Awareness about breathing and leg exercises postoperative • Suitable operation table, extra large BP cuff, adequate padding over pressure points • DVT and antibiotic prophylaxis, antacid, H2-antagonists; avoid sedation • Continuous monitoring of patient position • Careful introduction of Veress needle; confirm position; then insufflations • Monitor respiratory and hemodynamic changes after induction, after pneumoperitoneum and after position change • PEEP, if necessary • Postoperative: Head up, O2 supplement, pain and PONV control, monitoring • Keep ready for BIPAP/SIMV ventilation • If surgery is mandatory, plan during second trimester to avoid preterm labor and to have more working space • Avoid injury to uterus; open laparoscopy or alternative entry site for Veress needle and trocar • Adjust ventilation to avoid maternal and fetal acidosis • Fetal monitoring, with transvaginal USG, if required • Gasless laparoscopy/N2O pneumoperitoneum? • Epidural anesthesia? • Pneumoperitoneum has major effect on cardiac function • Low respiratory reserve and high O2 consumption; prone for hypoxia and hypercarbia • More absorption of CO2 from greater peritoneal surface area • IAP < 6 mm Hg in infants < 4 months; others 10 mm Hg • Adequate fluid replacement • Ensure availability of blood • Consider co-existing diseases, nature of surgery, and perioperative problems • Patient counseling • Short-acting agents like propofol, fentanyl • Pain control: Preemptive analgesia, port sites infiltration with local analgesics and NSAIDs • Control of PONV

(ABG: arterial blood gas; BIPAP: biphasic positive airway pressure; BP: blood pressure; DVT: deep vein thrombosis; EF: ejection fraction; IAP: intra-abdominal pressure; IHD: ischemic heart disease; LV: left ventricular; NSAIDs: nonsteroidal anti-inflammatory drugs; PEEP: positive end-expiratory pressure; PONV: postoperative nausea and vomiting; SIMV: synchronized intermittent mandatory ventilation; USG: ultrasonography)

Anesthesia for Laparoscopic Surgery

Premedication Premedication should be decided by individual anes­ thetist depending upon the type and duration of surgery and patient’s needs. Antacids and H2-antagonists may be used to reduce the risk of acid aspiration. Antiemetics like metoclopramide and ondansetron may be useful in preventing postoperative nausea and vomiting (PONV). DVT prevention (antistasis stockings and low-molecular weight heparin) is mandatory since pneumoperitoneum favors peripheral pooling of blood. Perioperative use of nonsteroidal anti-inflammatory drugs (NSAIDs) may reduce postoperative pain and narcotic requirement and thereby reducing PONV. Glycopyrrolate is very useful in reducing secretions. Sedatives may be required in children and in anxious patients.

Monitoring During laparoscopy, routine monitoring should include noninvasive blood pressure measurement,

ECG, capnometry, and pulse oximetry. CO2 embolus is associated with biphasic change in PETCO2; initial increase results from increased CO2 elimination followed by a decrease related to the decreased cardiac output. A progressive increase in PETCO2 may be due to endobronchial intubation, subcutaneous emphysema, or pneumothorax. In patients with cardiac and/ or respiratory disease, PETCO2 and PaCO2 may not correlate and hence radial artery cannulation should be considered for ABG analysis. Increased intrathoracic pressure interferes with CVP and pulmonary artery pressure measurements. An esophageal stethoscope and/or a precordial Doppler (to diagnose gas embolism) are recommended by some. Body temperature and muscle relaxation monitoring are helpful in long surgical procedures.

TECHNIQUE OF ANESTHESIA Preoperative evaluation of the patient should focus on coexisting diseases and the extent of surgery. Basic investigations should include hematocrit, blood group, urine analysis, blood urea and sugar, and coagulation profile. Further evaluation (ECG, chest X-ray, pulmonary function studies, electrolytes or other blood tests, and cardiac/pulmonary evaluation) should be based on patient’s condition. Availability of blood should be confirmed and good intravenous access is essential for the risk of major vascular injury.

General Anesthesia Endotracheal intubation and mechanical ventilation are the techniques of choice for laparoscopy. It prevents hypoventilation, reduces the chance of aspiration of gastric contents, and provides good muscle relaxation and optimal operative conditions. Thiopentone and propofol remain the drugs of choice for induction. Ketamine, diazepam, etomidate, and propofol have been recommended for induction and maintenance of anesthesia (total intravenous anesthesia). Propofol is associated with quick recovery and less PONV. Succinylcholine can be used for endotracheal intubation and muscle relaxation is maintained with nondepolarizing agents like pancuronium, vecuronium, or atracurium. Narcotic supplementation is done with morphine, pethidine, buprenorphine, fentanyl, or pentazocine. It should be remembered that the use of narcotic (morphine, fentanyl) during laparoscopy can

Chapter 3

can occur. Hence, one should be vigilant in monitoring cardiorespiratory systems in these patients. When a pregnant patient has to undergo laparoscopy, one has to remember that the fetus relies on its mother having a low PaCO2 for efficient gas exchange across the placenta and hence maternal hypercarbia must be avoided. Another problem is that uteroplacental blood flow may be compromised due to reduction in cardiac output during laparoscopy. Hence, maternal and fetal monitoring should be continuous and should include PaCO2. Hemodynamic changes associated with pneumop­ eritoneum might be deleterious in patients with compro­ mised ventricular function and in patients with ischemic heart disease.21 Hence, postoperative benefits of laparos­ copy must be balanced against the intraoperative risks. In patients with co-existing diseases, gasless lapa­ roscopy/N2O pneumoperitoneum may be considered.22 The insufflation and exsufflation should be as slow and as smooth as possible. IAP must be maintained as low as possible. The gasless laparoscopy (Laparolift) for lower abdominal and pelvic surgery can be performed under regional anesthesia itself; there is no problem of gas leak and conventional instruments can be used; the main disadvantage with the technique is that the surgeon may not get a motionless operative field as with pneumoperitoneum because of the movement of the viscera due to respiration.

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Art of Laparoscopic Surgery Textbook and Atlas cause spasm of sphincter of Oddi23 and may confuse cholangiographic finding by mimicking an impacted common bile duct (CBD) stone. This could lead to unnecessary exploration of CBD. N2O can be used as an adjuvant to maintain anesthesia but it should be noted that in the event of bowel perforation, it can support combustion of bowel gas.24 The use of N2O during laparoscopic surgery remains controversial because of the possibility of N2O causing bowel distension, more chances for combustion and increased incidence of PONV; but we routinely use N2O for maintenance of anesthesia in adults as well as in children and for pneumoperitoneum in high-risk cardiac patients or during regional anesthesia, without compromising surgical access as well as patient safety and comfort. Isoflurane, with less cardiac depression and with vasodilating properties, is the volatile agent of choice. Halothane also can be used in low concentrations (0.5%) to prevent awareness and to subdue sympathetic overactivity. Minute ventilation should be increased by 15–50% to maintain PETCO2 between 30 mm Hg and 35 mm Hg; to prevent barotrauma, minute ventilation should be increased by increasing respiratory rate rather than tidal volume. Veress needle should be introduced with the abdominal wall lifted and the needle should be held in such a way that it is introduced under control; this will prevent vascular injury. Peritoneal insufflation should be done slowly to prevent sudden stretching of peritoneum and bradycardia. IAP should be kept as low as possible; 12–14 mm Hg is ideal; more than 15 mm Hg is not required; in pediatric cases and in patients with coexisting diseases, it may even be reduced to 10 mm Hg. Stomach and urinary bladder should be decompressed before trocar insertion. Intraoperative bleeding may be difficult to detect or quantify because of the visual magnification system and the limited fields used during dissection. The use of laryngeal mask airway (LMA) during laparoscopy is controversial. LMA does not prevent pulmonary aspiration and cannot guarantee airway seal when airway pressure is above 20 cmH2O. Hence, it should be used very carefully only in selected patients. On the rare occasions when the LMA has to be used, as in difficult airway maintenance or failed intubation, it is important to decompress the stomach before placement of the LMA. ProSeal™ LMAs have side part for gastric tube insertion.

Local and Regional Anesthesia It reduces the side effects of GA like muscle pain, sore throat, airway trauma, and PONV and allows verbal contact with the patient. It reduces anesthesia time and postoperative recovery is quick. As the patient is awake, he can inform the symptoms of potential complications (pneumothorax, embolism, dysrhythmias, and ventilatory difficulties) early and hence they can be managed promptly. Regional anesthesia provides good muscle relaxation and postoperative pain relief. During regional anesthesia, N2O may be used for pneumoperitoneum, since CO2 is more irritant. Regional anesthesia is usually associated with patient anxiety, pain, discomfort etc. which may warrant intravenous sedation that can result in severe hypoxia and hypercarbia. It can produce hypotension and local anesthetic toxicity. The level of block should be high enough (up to T4) to prevent peritoneal discomfort. In patients with respiratory disease or morbid obesity, this high level block may interfere with ability to cough or remove secretions and increase the risk of atelectasis and hypoxemia. Other problems like postspinal headache or urinary retention may delay the discharge of the patient. One can expect that sympathetic blockade associated with regional anesthesia can offset the increase in afterload associated with pneumoperitoneum; on the other hand, sympathetic blockade may exaggerate the decrease in venous return and promote vagal reflexes. Epidural block does not provide complete analgesia; shoulder pain secondary to diaphragmatic irritation is mediated by phrenic nerve. Hence, this technique should not be used for procedures necessitating extensive organ mobilization or high IAP. It should be restricted to short procedures performed by skilled surgeons in cooperative patients.

RECOVERY AND POSTOPERATIVE PERIOD Since the respiratory and hemodynamic changes outlast pneumoperitoneum, eternal vigilance and essential monitoring should be continued during transport and in the recovery room also. The postoperative increase in O2 consumption due to high incidence of shivering (up to 50%) and hypoxemia due to respiratory dysfunction make O2 administration mandatory after laparoscopy even in healthy patients. The increased cardiac output and improved circulation may enhance remaining CO2

Anesthesia for Laparoscopic Surgery

THORACOSCOPY a. Lateral decubitus position and single lung ventilation with double lumen endotracheal tube—OLV b. Prone position and double lung ventilation. The technique of thoracoscopy differs from laparoscopy in several aspects. There is no need for gas insufflation; the operative exposure is obtained by unilateral lung deflation with a double lumen endotracheal tube and selective one lung ventilation. The major physiological changes are due to the lateral decubitus position and one lung ventilation. The advantages of thoracoscopy are less postoperative pain, less pulmonary dysfunction and short hospital stay when compared to open thoracotomy. Lateral decubitus positioning must be done carefully to protect lines and tubes and to avoid patient injury. Strict attention to avoid neurological complication is essential. In this position the dependent lung receives more blood flow and the non-dependent lung receives more ventilation which can lead to significant mismatch. During thoracoscopy, the nondependent lung is collapsed by selective ventilation of dependent lung. This results in obligatory intrapulmonary shunt through the collapsed lung and may lead to hypoxemia. The shunting is reduced to some extent by gravity and surgical manipulation and the most important factor in this regard is hypoxic pulmonary vasoconstriction (HPV). HPV increases the pulmonary vascular resistance and diverts the blood to the ventilated lung units. The double lumen tube is technically more difficult to place. It is passed either blindly or with the aid of a

fiberoptic bronchoscope. Correct position is confirmed with chest auscultation and bronchoscope. One lung ventilation is associated with varying degrees of hypoxemia due to shunting and has a propensity of tracheal tube displacement. It is unsafe for reintubation. It is also associated with difficulty in selection sizing and is also associated with risk of major tracheobronchial injury. The contributory factors are the decreased volume of dependent lung due to compression by abdominal contents, mediastinum and positioning effects, fluid transudation and accumulation of secretions. Initially 100% oxygen may be used to correct hypoxemia; tidal volume is set at approximately 6–8 mL/kg and the rate is adjusted to maintain PaCO2 around 40 mm Hg. Hyperventilation is deleterious because the increased air way pressure may increase the pulmonary vascular resistance worsening the intrapulmonary shunt and resultant hypocarbia may also inhibit HPV. If hypoxemia persists, selective PEEP to the dependent lung will help by increasing the lung volume, keeping in mind that PEEP can increase pulmonary vascular resistance and shunting. The application of CPAP to the nonventilated lung improves oxygenation by slightly but constantly distending the lung with oxygen. One can combine the above two techniques known as differential lung PEEP/CPAP to provide the best arterial oxygenation. A less desirable alternative is to interrupt the procedure and intermittently ventilate the nondependent lung. Finally, if hypoxemia is refractory unilateral clamping of pulmonary artery of the non ventilated lung may be required which may necessitate open thoracotomy. In addition to routine ASA monitoring, radial artery cannulation for continuous blood pressure monitoring and frequent ABG determinations is essential. The decision on central venous or pulmonary artery catheter placement and on postoperative elective ventilation depends on the patient’s preoperative cardiopulmonary status and the extent of surgery. Advantages of double lung ventilation are—better intraoperative oxygen status, sufficient exposure of operative field, reexpansion of lung is easier by simply shutting down CO2, favorable oxygenation due to reduced shunt fraction as in OLV. Thus, DLV has advantages of potentially reducing the chances of postoperative respiratory complications compared to differential pulmonary ventilation.

Chapter 3

absorption from peritoneal cavity that can result in hypercapnia. Pain is much less following laparoscopy hence usually NSAIDs (diclofenac, ketorolac, tramadol) may be sufficient; if required narcotic analgesics can be used. The infiltration of port sites with local anesthetic (0.25–0.5% bupivacaine) might be considered to reduce incisional pain. Thorough washing of peritoneal cavity to remove the carbonic acid formed might reduce the diaphragmatic irritation and shoulder pain. The PONV should be controlled with antiemetics like metoclopramide, ondansetron, etc. Depending upon the laparoscopic procedure performed, oral intake can be started on the same day and the patient can be discharged in the evening or next day morning.

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Art of Laparoscopic Surgery Textbook and Atlas

SUMMARY The minimally invasive surgery is not synonymous with minor surgery. Patients will undoubtedly benefit from less trauma, less pain, less postoperative ileus, less postoperative pulmonary dysfunction, quick recovery, short hospital stay, and better cosmesis but lifethreatening intraoperative complications are possible. The complications may be related to pathophysiological changes associated with intraperitoneal gas insufflation, patient positioning, and the surgical technique. General anesthesia with intubation and mechanical ventilation is the technique of choice for laparoscopy. LMA might be safe in selected patients. Spontaneous breathing should be restricted to short laparoscopic procedures. Regional anesthesia should be limited to quick lower abdominal or pelvic procedures and in cooperative patients. Intravenous sedation can result in profound alterations in gas exchange during laparoscopy. The discovery of an alternative insufflating agent to CO2 is eagerly awaited as the number of high-risk patients undergoing laparoscopic surgery rises. The technique of Laparolift (gasless laparoscopy) may be considered in patients with coexisting diseases; N2O also may be used for pneumoperitoneum in selected patients.

REFERENCES 1. Baratz RA, Karis JH. Blood gas studies during laparoscopy under general anesthesia. Anesthesiology. 1969;30:463-4. 2. Puri GD, Singh H. Ventilatory effects of laparoscopy under general anesthesia. Br J Anaesth. 1992;68:211. 3. Ciofolo MJ, Clergue F, Seebacher J, et al. Ventilatory effects of laparoscopy under epidural anesthesia. Anesth Analg. 1990;70:357-361. 4. Sha M, Ohmura A, Yamada M. Diaphragm function and pulmonary complications after laparoscopic cholecystectomy. Anesthesiology. 1991;75(Suppl.):A255. 5. Scott DB, Julian DG. Observations on cardiac arrhythmias during laparoscopy. Br Med J. 1972;1:411-4. 6. Sibbald WJ, Paterson NAM, Holliday RL, et al. The Trendelenburg position: haemodynamic effects in hypotensive and normotensive patients. Crit Care Med. 1979;7:218-24. 7. Yukinobu A, Nishikawa T. Heart rate responses to body tilt during spinal anesthesia. Anesth Analg. 1991;73:385-90.

8. Joris JL, Noirot DP, Legrand MJ, et al. Hemodynamic changes during laparoscopic cholecystectomy. Anesth Analg. 1993;76:1067-71. 9. Diamant M, Benumof J, Saidman LJ. Hemodynamic effects of increased intra abdominal pressure: interaction with hypovolemia and halothane anesthesia. Anesthesiology. 1978;48:23-7. 10. Johannsen G, Andersen M, Juhl B. The effects of general anaesthesia on the haemodynamic events during laparoscopy with CO2 insufflation. Acta Anaesthesiol Scand. 1989;33:132-6. 11. Ott DE. Laparoscopic hypothermia. J Laparoendosc Surg. 1991;1:127-31. 12. Semm K. Statistical survey of gynaecological laparoscopy pelviscopy in Germany. Endoscopy. 1979;11:101-6. 13. Cuschieri A, Dubois F, Mouriel J, et al. The European experience with laparoscopic cholecystectomy. Am J Surg. 1991;161:385-7. 14. Strasberg SM, Sanabria JR, Clavien PA. Complications of Laparoscopic cholecystectomy. Can J Surg. 1992;35: 275-80. 15. Yacoub OF, Cardona I, Coveler LA, et al. Carbon dioxide embolism during laparoscopy. Anesthesiology. 1982;57:533-5. 16. Root B, Levy MN, Pollack S, et al. Gas embolism death after laparoscopy delayed by trapping in the portal circulation. Anesth Analg. 1978;57:232-7. 17. Shulman D, Aronson HB. Capnography in the early diagnosis of carbon dioxide embolism during laparoscopy. Can J Anaesth. 1984;31:455-9. 18. Butler BD, Hills BA. Transpulmonary passage of venous air emboli. J Appl Physiol. 1985;59:543-7. 19. English JB, Westinskow D, Hodges MR, et al. Comparison of venous air embolism monitoring methods in supine dogs. Anesthesiology. 1978;48:425-9. 20. Joris J, Cigarini I, Legrand M, et al. Metabolic and respiratory changes after cholecystectomy performed via laparotomy or laparoscopy. Br J Anaesth. 1992;69:341-5. 21. Lehot JJ, Leone BJ, Foex P. Effects of altered PaO2 and PaCO2 on left ventricular function and coronary hemodynamics in sheep. Anesth Analg. 1991;72:737-43. 22. Batra MS, Discoll JJ, Coburn WA, et al. Evanescent Nitrous Oxide pneumothroax after laparoscopy. Anesth Analg. 1983;62:1121-3. 23. Jones RM, Detmer M, Hill AB, et al. Incidence of choledochoduodenal sphincter spasm during fentanyl supplemented anesthesia. Anesth Analg. 1981;60:638-40. 24. Neuman GG, Sidebotham G, Negoiann E, et al. Laparoscopy explosion hazards with nitrous oxide. Anesthesiology. 1993;78:875-9.

Sterilization and Disinfection of Laparoscopic Instruments INTRODUCTION Laparoscopic surgery requires the use of delicate optical and electronic equipment, which can be easily damaged by inappropriate handling and maintenance. Handling of laparoscopic instruments is the biggest challenge for operative room (OR) personnel today because of their complex alignment. The risk of bacterial and viral infections related to laparoscopy is a significant problem. Contamination among patients or by environmental bacteria can occur when sterilization or disinfection procedures are inadequate. The level of disinfection achieved is determined by the type and concentration of germicide, the exposure time, the temperature, and the number and types of microorganisms present. The type of microorganisms eliminated is usually determined by their resistance to disinfection. Bacterial spores, myco­ bacterium including atypical mycobacteria, nonlipid viruses such as polio and rhino viruses, fungi such as candida and Cryptococcus species, vegetative bacteria such as Pseudomonas and Salmonella species, lipid viruses hepatitis B virus (HBV), human immuno­ deficiency virus (HIV), and herpes simplex virus (HSV) are the microorganisms in descending order of in vitro resistance to germicidal chemicals.1 Rooms and equipment dedicated to disinfection have to be well adapted to this use and specific staff must be trained. Proper personal protective equipment (PPE) should be

CHAPTER

4

worn, which includes an impervious gown or apron, heavy-duty gloves, and eye protection to avoid splatters from lumen brushes. This chapter discusses the rationale behind the guidelines for sterilization and disinfection and proper handling of laparoscopic instruments. Various methods available for sterilization and disinfection are discussed here and their use depends on the sensitivity of the instrument or equipment to be sterilized.

CLASSIFICATION OF MEDICAL DEVICES Medical devices, equipment, and surgical materials are divided into three general categories depending on the potential risk of infection involved in their use as recommended by Spaulding (Table 4.1). It is important to understand the terms cleaning, disinfection, and sterilization before proceeding to the actual process of sterilization. These terms are explained in Table 4.2.

CLEANING The initial and most important step is thorough cleaning to remove gross soil, including microorganisms (bioburden), which allows the disinfectant or sterilizing agents to work effectively. Organic materials may inacti­ vate these agents or present a barrier that prevents

Table 4.1: Classification of medical devices. Critical items

Instruments or objects that are introduced directly into the bloodstream or into other normally sterile areas of the body

Examples of critical items are surgical instru­ ments, cardiac catheters, implants, pertinent components of the heart-lung oxygenator, and the blood compartment of a hemodialyzer

Semicritical items

Instruments are introduced into body cavities and therefore come into contact with intact mucous membranes, but do not ordinarily penetrate body surfaces

Examples for such instruments include non­ invasive flexible and rigid fiberoptic endoscopes, endotracheal tubes, anesthesia breathing circuits, and cystoscopes

Noncritical items

Items that do not ordinarily penetrate, but touch only intact skin

Crutches, bed boards, blood pressure cuffs, and a variety of other medical accessories

48

Art of Laparoscopic Surgery Textbook and Atlas disinfectants from reaching all surfaces of an instrument. Manual cleaning is the safest method to use for rigid endoscopic instruments and accessories.2 These instru­ ments should be wiped frequently to remove any visible soil and should be immersed in an enzymatic cleaning solution immediately following a procedure to initiate the decontamination procedure. Channels should be flushed copiously and jaws should be brushed vigorously. These instruments are extremely difficult to clean because of the long shaft and jaw assembly, which may trap debris. Due to the positive pressure of the insufflated abdomen, blood and other body fluids flow into these channels and may be difficult or impossible to remove. Some of these instruments cannot be disassembled to facilitate manual cleaning. Table 4.2: The terms cleaning, disinfection, and sterilization.

Manual cleaners must be evaluated for their ability to remove organic soils. Dish detergents and skin cleansers are not recommended, as they may not remove organic soils effectively and in fact may leave a residue on the instruments that may inhibit the subsequent disinfection or sterilization process. Enzymatic detergents are excel­ lent choices for cleaning endoscopic instruments. The enzymes used in these detergents are specific to protein, sugar, or fat. Choose an enzyme detergent that is effective for the materials and solutions to which the instrument is exposed. If an instrument is not cleaned properly, it cannot be sterilized or disinfected. Appropriate cleaning brushes that is, clean and dedicated for the purpose, should be used for all accessible channels and ports. These brushes should, if not supplied for single use, be reprocessed in accordance with the manufacturer’s instructions. The use of a brush or a set of brushes for different types of instruments is recommended to help with the trace ability of the instruments during their life cycle. Brushes made up of nylon are best for laparoscopic instruments and accessories.

Term

Definition

Cleaning

The physical removal of organic material or soil from the objects and is a prerequisite for disinfection or sterilization

Disinfection

A process that eliminates many or all pathogenic microorganisms without removal of bacterial spores

Ultrasonic Washers

Sterilization

A process that destroys or eliminates all forms of microbial life including spores and is carried out in hospitals and clinics by physical or chemical methods

After rinsing of instruments under running tap water without using detergents or any other solution, laparo­ scopic or robotic instruments can be cleaned using ultra­ sonic washing machines (Fig. 4.1). Ultrasonic washers

Fig. 4.1: Ultrasonic washer.

Sterilization and Disinfection of Laparoscopic Instruments

49

Chapter 4 Fig. 4.2: Ultrasonic cleaning is in progress. Inside picture shows the blood stain and biodegradable material coming out from the instruments.

work based on the principle of “cavitation” wherein high frequency of ultrasonic waves produce tiny bubbles of vaporized liquid from specially designed solutions. These bubbles implode on the surface of the instruments and clean soil over the instruments. These are simple but effective machines in removing the clotted blood, fibrin from instruments, joints, crevices of instruments. Certain principles of using ultrasonic washers can improve the effectiveness of ultrasonic cleaning: • Instruments should be disassembled • Instruments should not be densely packed in the tank • Instruments of unlike metals should not be placed together, e.g. stainless steel instruments with alumi­ num instruments • Instruments with glass, cork, plastic should not be placed in ultrasonic washer (Fig. 4.2). Ultrasonic washers may be used for the most rigid endoscopic components and accessories with the exception of the telescope due to the small joints and jaws. Irrigation pumps are available for flushing instrument lumen and components.

STERILIZATION The term defines the complete elimination or destruction of all forms of microbial life. Sterilization is the preferred process for rigid endoscopic instruments.3 Many are

now heat tolerant and all components, including the telescope, are autoclavable. It is usual for manufacturers to mark instruments as autoclavable. Unfortunately, heat sterilization processes are impractical for heat sensitive flexible instruments and many lensed endoscopic instru­ ments. It is therefore essential that the heat, chemi­cal, pressure, and moisture tolerance of the instru­ment be established from the manufacturer before selecting the method of decontamination to ensure that the process will not damage the endoscope. Sterilization processes require routine monitoring, regular and preventive maintenance, and periodic testing of the sterilizer.

Types of Autoclave Based on the method of removing air in the chamber, autoclaves can be divided into two types, i.e. Type N and Type B. Type B autoclaves use vacuum to remove air in the chamber where as Type N do not.

Downward Displacement Autoclave Downward displace­ ment autoclave uses gravity to displace air out of auto­clave. As steam is lighter than air, once steam start filling the chamber, it pushes the air outside through a valve in the bottom of the chamber. Once the temperature reaches the optimum level, valve closes automatically and sterilization process begins.

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Art of Laparoscopic Surgery Textbook and Atlas

Fig. 4.3: Automatic autoclave. Things are being loaded in to the autoclave, which will be deli­ vered to the sterile room on the other side of the autoclave.

Positive Pressure Displacement In this type, pressure of the steam pushes the air out. Steam is created in a sepa­rate chamber and is released into the other chamber with a blast and the air goes out from the sterilization chamber.

Negative Pressure Displacement In this type, vacuum is used to remove air out the chamber and after that steam is released into the sterilization chamber as a pressure blast.

Triple Vacuum Autoclave It works based on the principle of vacuum-based removal of air from the sterilization chamber but the only difference is three cycles of removal of air from sterilization chamber and pressure blast of steam into the chamber. Steam is the most common and least expensive method of sterilization.4 Steam autoclaving (5 minutes at 1,350°C or 15 min at 1,210°C under 15 psi) is excellent for metallic instruments and tools that will not lose their temper during repeated heating and for some nonplastic materials. Steam under pressure is preferred to the use of liquid chemical disinfectants for the dis­ infection of all invasive or surgical endoscopic instru­ ments. Even instruments and telescopes marketed as “autoclavable” will last longer, if processed by alternative methods.

Porous load autoclaves that sterilize at 121–124°C for a minimum of 15 minutes or 134–137°C for a minimum of 3 minutes are suitable for processing autoclavable rigid endoscopic instruments and accessories. These should be processed in accordance with the manu­ facturer’s instructions, and wherever possible using higher temperature. It is important to note that instru­ ments with narrow lumens, from which air cannot be readily displaced or instruments contained within packaging must be sterilized in a porous load sterilizer that has been validated for the load. Others should be processed in a basket or tray and covered on removal from the sterilizer. Steam sterilized endoscopic instru­ ments should not be rapidly cooled as this may stress components and shorten the life of the instrument (Fig. 4.3).

Gas Sterilization Ethylene oxide (EO) gas has been the standard for steri­ lizing heat-sensitive items. EO sterilization is carried out in sterilizers. The sterilization cycle consists of the following phases for automatic, general-purpose sterilizers: • An initial chamber evacuation, humidification, and EO charging phase. • A dwell period during which sterilization takes place. • A final chamber evacuation phase that may include aeration.

Sterilization and Disinfection of Laparoscopic Instruments

These are summarized below. In sterilization chamber, aeration cabinet, or aeration room: • Poorly installed or maintained sterilizer/aerator. • During removal of the load from the sterilizer on completion of the sterilization cycle. • In hospitals, from inadequate aeration due to poor ventilation, inadequate heating, or insufficient aeration time. • In industrial aeration rooms, during the aeration process; entry without use of PPE. • From leaks in the liquid/gas supply lines of the chamber. • During the emptying of vent line, condensate trap­ ped by maintenance personnel.

Materials Transfer • While transferring freshly sterilized articles from the sterilization chamber to the aeration cabinet. • When opening multiple layered packs after sterili­ zation.

Exhaust Lines • Inadequate disposal of exhaust gases. • Loose fittings.

Automated Ethylene Oxide Sterilizer Nowadays, automated EO sterilizer is available. Older types of machine come with cylinders and carry the risk of gas leakage and the hazards associated with gas leakage. Advantages of newer types include gas cartridges that can be used as per the chamber size, automated aeration at the end of each cycle and double door, so that sterile areas can be separated from the sterilization room.

Acute effects in humans from inhalation are as follows: • High vapor concentrations of EO (of the order of 1,000 ppm) can cause irritation and damage to the eyes and upper respiratory system, hoarseness, cough, headache, nausea and recurrent vomiting, fatigue, and pulmonary edema. • Less frequently reported effects include muscular weakness, abdominal discomfort and diarrhea, and nervous system disorders. Acute effects in humans from skin contact are listed below: • EO liquid has the capacity to cause burns on contact with the skin and mucous membranes. These burns resemble frostbite, owing to rapid evaporation, and consequent cooling. Symptoms of exposure can be delayed, often appearing 1–6 hours later. • Delayed skin burns (blisters) can occur, if EO con­ taminated shoes and clothing are not removed promptly. • Repeated contact with high-vapor concentrations can cause a burning sensation, inflammation of the skin, parched lips and mouth, itching, irritation, and allergic dermatitis. • Contact with unaerated articles may cause erythema (skin redness), inflammation, and tissue damage. The after effects in humans from eye contact are given below: • Contact of liquid EO with the eyes can cause severe burns. • Conjunctivitis and cataracts have been reported following eye exposure to EO. Thus, caution should exercised before eliminating EO, since some of the alternatives have significant pro­ cessing limitations and materials compatibility issues, including device lumen size (that can be sterilized) or lack of storage life of the devices (just-in-time sterili­ zation). The Steris System (Steris, Mentor, Ohio) uses per acetic acid in a proprietary liquid processor to sterilize items in less than 30 minutes at 50–55°C. This method is a just-in-time process and sterility cannot be main­ tained for long-term storage (Fig. 4.4).6

Alternative Methods Dry heat (170°C for 1–2 hours) is effective, but cannot be used for any flammable or meltable material, or metallic materials that can lose temper.

Chapter 4

Most items are sterilized at 54.4°C (130°F) for about 150 minutes; heat-sensitive items are sterilized at 37.8°C (100°F) for about 5 hours. Following sterilization, it is necessary to remove the gas, which is trapped or absor­ bed during sterilization. In hospitals, this is carried out in a combined sterilization/aeration chamber or in an aeration cabinet. EO is readily removed from most materials within 12 hours by a continuous flow of warm air at 50–60°C in a hospital-type aeration cabinet. There are two major routes of exposure for EO that a person may encounter in a work situation:5 1. Inhalation of vapor 2. Direct skin contact with liquid.

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Art of Laparoscopic Surgery Textbook and Atlas

Fig. 4.4: Ethylene oxide (EO) sterilizer with automatic aeration other side of the autoclave.

Plasma Sterilization New sterilization technology based on plasma was patented in 1987. Apart from solid, liquid, and gas state of the matter, plasma is the fourth state of the matter. In a closed chamber with vacuum, free radicals in plasma state are generated using radiofrequency energy or microwave energy. These free radicals interact with cell components of microorganisms and destroy them. The effectiveness of the sterilization depends on the vacuum and the type of the seed gas used. Routinely hydrogen peroxide plasma is used as seed gas. It is a rapid sterilization process and is safe for instruments, patients, operators, and also environment. Sterilization process by Sterrad has five phases. First phase is vacuum phase in which the air in the chamber is removed and vacuum is created and enters the second injection phase where hydrogen peroxide vapors are injected into the chamber. In the next diffusion phase, these vapors get distributed into the chamber and the loaded content get exposed these vapors. At the end of the diffusion phase, chamber pressure is reduced and plasma phase is initiated in which radiofrequency waves act on hydrogen peroxide vapors and form plasma state of peroxide forms. In this phase, free radicals are generated and act on the microorganisms. When the radiofrequency is turned off, all the free radicals combine with each other and form water or oxygen, nontoxic environmental friendly residues. In the final vent phase, filtered air is

drawn into the chamber, so that chamber can be opened. Sterrad 100Nx comes with four different types of cycles of sterilization like standard cycle, duo cycle, express cycle, and flex cycle designed for different instruments. Gas plasma is a highly active gas containing ions, molecules, and free radicals that are capable of inacti­ vating microorganisms. It is a complicated process that has been developed and adapted for the sterilization of medical devices. This is an emerging technique that is not currently widely available.7 Vapor phase hydrogen peroxide (VHP) has been offered as a method for the decontamination of rooms, sterilizing of dental instruments, and is an emerging technology for the sterilization of endoscopes. Generally, VHP is delivered via vacuum or using air as a carrier gas to items requiring sterilization. Cycle times can vary depending on the load size, hydrogen peroxide con­ centration, and temperature. This too is an emerging technique that is currently not widely available (Figs. 4.5 to 4.7).7

DISINFECTION A disinfection process is one that is intended to significantly reduce the number of pathogenic micro­ organisms on instruments by removing and/or killing them. Bacterial spores are not necessarily killed by disinfection; however, their numbers may be reduced as a result of the cleaning process.

Sterilization and Disinfection of Laparoscopic Instruments

53

Chapter 4 Fig. 4.5: Instrument tray for Sterrad sterilizing system.

Fig. 4.6: Packing method for Sterrad sterilizing system.

Efficacy of Disinfection The efficacy of disinfection8 depends on: • The number of microorganisms present on items to be disinfected. • Biocidal action of the disinfectant or disinfection process (chemical concentration, pH, temperature, water quality, humidity).

• Effective contact between the biocidal agent and the microorganisms (presence of crevices, lumina, hinges). • Biocidal agents and apparatus being appropriate for the item(s) being disinfected. Level of disinfection can be divided into high, intermediate, and low. High-level disinfectants are sporicidal, bactericidal, virucidal, and fungicidal agents

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Art of Laparoscopic Surgery Textbook and Atlas

Fig. 4.7: Sterrad sterilizing system 100 NX.

that remove the maximum bio-burden, with the excep­ tion of some spores. High-level disinfection (HLD) is usually achieved by using a germicide capable of producing sterility but exposing the instrument for less time than is needed for sterilization.9 Food and Drug Administration (FDA) regulates label claims as they pertain to the use of the product to disinfect medical instrumentation, particularly the time required to kill specified organisms. The disinfectants discussed briefly below are listed alphabetically and not in order of preference.10 Before choosing a specific disinfectant the compati­ bility of the instruments with the disinfectant should be checked to reduce the likelihood of causing damage to endoscopic instruments during processing.

Alcohols Ethanol or isopropanol at an appropriate concentration (typically 70% v/v) are the alcohols most commonly used for disinfection. Alcohol has good bactericidal and fungicidal properties, is active against most types of viruses, and has been shown to be tuberculocidal. Alcohol is fast acting, but does not penetrate well into organic matter. It is therefore most effective when used on clean surfaces and is often used as a base for other bactericides. Camera head, cable, and plug (using the

attached water-resistant cap) can be immersed in a disinfectant solution. The housing of the charged couple device (CCU) outside of the camera head may be wiped with disinfectant alcohol.

Aldehydes Glutaraldehyde, a member of the aldehyde11 family, has bactericidal, fungicidal, and virucidal activity. It is sporicidal but acts slowly. It is generally noncorrosive to most materials, although this is dependent upon the formulation of the disinfectant. Alkaline solutions require activation and have a limited life, while acidic solutions are more stable and do not require activa­ tion but act slowly on spores at ambient temperatures. Glutaraldehyde penetrates organic matter slowly and is not greatly inactivated by its presence but it is a strong fixative causing hardening of protein deposits. Many glutaraldehyde-based products are designed to be used at room temperature. Formulations that can be used at elevated temperatures may have higher activity at lower concentrations and shorter contact times. One of the most commonly used is CIDEX® Solution. CIDEX® Solution provides HLD in 20–45 minutes and 10-hour sterilization. It is noncorrosive to instru­ ments and has excellent compatibility with a wide range of materials. The CIDEX® Solution is 2.4% alkaline

Sterilization and Disinfection of Laparoscopic Instruments

Procedure • The first step in the disinfection/sterilization process is thorough cleaning. Contaminated instruments must be thoroughly cleaned prior to disinfection or sterilization since residual organic matter will decrease the effectiveness of the CIDEX® Solution. To remove debris, thoroughly clean all instrument surfaces and the lumina of hollow instruments with a mild protein dissolving detergent such as ENZOL® Enzymatic Detergent. CIDEX® Solutions are compatible with enzymatic detergents (e.g. ENZOL® Detergent) which are mild in pH, low foaming, and can easily be rinsed from instruments. Detergents that are either highly acidic or alkaline are contraindicated as cleaning agents since improper rinsing could affect the efficacy of the CIDEX® Solutions by altering their pH.13 • Following cleaning, rinse instrument surfaces and lumen with large amounts of fresh water to remove residual detergent. • Remove excess moisture from instrument prior to disinfecting or sterilizing. This will help to prevent water from rapidly diluting the CIDEX® Solution below its minimum effective concentration (MEC). Once the instruments have been properly cleaned, it is now ready to begin using the CIDEX® Solution.

• Prepare CIDEX® Solution for use by first adding the entire contents of the activator to the solution that changes its color to green, thereby indicating that the solution is ready for use. Do not use activated solution beyond the stated 14- or 28-day reuse life. Note: The activator contains a rust inhibitor. Do not add any other agent. Record the date of activation (mixing date) and expiration date in the space provided on the CIDEX® Solution container label, in a log book, or on a label affixed to the CIDEX® Solution tray or any secondary container. • Immerse clean instruments completely in the CIDEX® Solution. Fill the entire lumen of hollow instruments. To reduce exposure to glutaraldehyde vapors, which can be irritating, cover the CIDEX® Solution tray or bucket with a secure lid. Soak instru­ ments for the amount of time required for disinfec­ tion or sterilization. • Remove instruments using a sterile technique and rinse thoroughly with sterile water. The quality of rinse water used is dependent on the intended use of the instrument. • Dry the instruments. Disinfected or sterilized equip­ ment should be used immediately or stored in a manner to minimize recontamination (Fig. 4.8). It is important to note that CIDEX® Solutions may expire prior to the reuse date stated on the label. Do not rely solely on days in use. To determine whether the MEC of CIDEX® Solution is still present, CIDEX® Solutions must be tested prior to each use with the appropriate CIDEX® Solution Test Strip. Safe working practices should be adopted. Disinfection should be carried out in a dedicated room away from other staff and members of the public. Vapor extraction equipment should be made available in rooms where glutaraldehyde is used and these rooms should be provided with a sink with running water so that staff and patients are protected from exposure to glutaraldehyde during the activation, preparation, use, and discharge of the disinfectant (Table 4.3).

Chlorine Dioxide In the healthcare sector, chlorine dioxide, as an aqueous solution, is being used as a high-level disinfectant. Chlorine dioxide is a powerful but selective oxidizing agent and therefore material compatibility needs to be considered carefully; titanium, stainless steel, sili­ cone rubber, ceramics, polyvinyl chloride (PVC), and

Chapter 4

glutaraldehyde and has a 14-day maximum reuse life. The CIDEX® Plus solution is 3.4% alkaline glutaraldehyde and has a 28-day maximum reuse life. Ortho-phthalaldehyde (OPA), a member of the alde­ hyde family, has recently been introduced as a liquid chemical disinfectant for medical devices. OPA is a fast acting, high-level disinfectant with tuberculocidal acti­ vity although it has only limited activity against bacterial spores. While being a member of the aldehyde group of chemicals, it is more stable and has a lower vapor pres­ sure than glutaraldehyde making it less hazardous to use. The solution is compatible with a wide range of laparo­scopic instruments. A commercial formulation of 0.55% OPA solution, which requires no activation, is now available. For example, CIDEX® OPA solution.12 It is efficient, requiring 12-minute soak time at room tem­perature (20°C) for manual reprocessing. It allows to schedule more procedures with quick scope turna­ round. It is effective against glutaraldehyderesistant mycobacteria. No activation or mixing is required.

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Art of Laparoscopic Surgery Textbook and Atlas

Fig. 4.8: Stainless steel CIDEX® tray (acid resis­ tance grade).

Table 4.3: Hazards, prevention, and treatment of glutaraldehyde exposure. Types of hazard/ exposure

Acute hazards symptoms

Fire

Not combustible

Prevention

First aid/fire fighting In case of fire in the surroundings: all extinguishing agents allow

Explosion

—

—

—

Inhalation

Cough, headache labored breathing nausea, wheezing

Ventilation, local exhaust, or breathing protection

Fresh air, rest. Artificial respiration, if indicated refer for medical attention

Skin

Redness

Protective gloves, protective clothing

Remove contaminated clothes Rinse and then wash skin with water and soap

Eyes

Redness, pain

Safety goggles, or eye protection in combination with breathing protection

First rinse with plenty of water for several minutes (remove contact lenses, if easily possible), then take to a doctor

Ingestion

Abdominal pain nausea, diarrhea, vomiting

Do not eat, drink, or smoke during work. Wash hands before eating

Rinse mouth, give plenty of water to drink, refer for medical attention

polyethylene are generally considered to be compatible with chlorine dioxide. The antimicrobial activity of chlorine dioxide is similar to that of chlorine, although it has greater sporicidal activity and can be used at room temperature.

Peroxygen Compounds Peracetic acid is a peroxygen compound. Its anti­ microbial activity has been reported in the literature as bactericidal, tuberculocidal, fungicidal, virucidal,

Sterilization and Disinfection of Laparoscopic Instruments

Super Oxidized Saline Super oxidized saline is a mixture of active species, pri­ marily hypochlorous acid, derived from salt by electro­ lysis through a proprietary electrochemical cell.15 It is sporicidal and mycobactericidal, as long as there is minimal or no soiling. It should not be stored for more than 24 hours prior to use.

Potential Disadvantages of Using Chemical Disinfectants • Risk of recontamination of instruments and transfer of infection with reusable disinfectants. • The need to determine concentration of active components in reused disinfectants. • Risk of exposing both users and patients to chemical substances potentially harmful to their health. • Rapid inactivation of many disinfectants by the presence of organic matter (residue after cleaning), detergent, and rinse water. • Difficulty in ensuring that all parts of the item are in contact with the disinfectant. • Some organisms develop resistance to a disinfectant or its components. • Incompatibility of certain disinfectants with some instrument materials.

KEY POINTS ON PREVENTIVE CARE AND MAINTENANCE OF ENDOSCOPIC INSTRUMENTS How to decontaminate and clean after use? Step 1: Immediately after use,15 gently wipe the laparo­ scope, fiber-optic light source, cable, and plastic tubing

with Luer-Lok™ with a cloth soaked in 60–90% ethyl or isopropyl alcohol to remove all blood and organic material. Note: Because alcohol rapidly kills HBV and HIV, this step protects handlers against possible hepatitis B and AIDS infection. Step 2: Completely disassemble the laparoscopic equip­ ment: operating laparoscope, trocar, forceps, Veress needle. Step 3: Place disassembled parts in a basin of clean water and mild, nonabrasive soap. Step 4: Wash all outer surfaces using a soft cotton cloth. Step 5: Clean inner channels with a cleaning brush supplied with the laparoscope kit. Use a circular motion to remove particulate matter. (Organic matter hidden in the narrow channels may cause infection later.) Be careful not to forcibly push the brush against the closed end of the inner tube as this may cause damage. Step 6: Rinse all parts thoroughly with clean water (running water or from a basin) three times. Use the brush to remove soap and particles from the inner channels. (Soap, if not thoroughly rinsed away, will decrease the effectiveness of the disinfectant.) Step 7: Dry equipment with a clean, soft, cotton cloth or air dry. (Excess water will dilute the disinfectant, decreasing its effectiveness.) Step 8: Clean lenses at least weekly, and more often as needed, but do not touch the lenses with fingers. Step 9: HLD (for 20 minutes) or sterilization (overnight), or if not needed immediately, careful storage in instru­ ment container after cleaning and drying until next use. (Instruments should be given HLD immediately prior to use to prevent recontamination). How to clean lenses of laparoscope? Step 1: Remove the plastic eyepiece of the laparoscope prior to cleaning the proximal lens with acetone or 60–90% alcohol (Acetone and other organic solvents can severely damage plastic). Step 2: Clean lenses with a cotton swab soaked in alcohol or acetone (cotton will not scratch the lens, and alcohol and acetone will not weaken the cement around the lens). Step 3: While cleaning, do not touch lenses with fingers (skin oils may damage the lenses). Step 4: Clean lenses at least weekly, and more often as needed.

Chapter 4

and sporicidal. Peracetic acid is more effective than glutaraldehyde at penetrating and removing organic matter, for example, biofilms.14 It is known to be highly corrosive and its use as a disinfectant in its natural state is therefore limited unless a corrosion inhibitor is included in the formulation. Peracetic acid can be used either at an elevated temperature in a dedicated system or as a cold disinfectant solution, depending on the chosen system. Peracetic acid is provided either as a concentrated, buffered solution that contains corrosion inhibitors or as a powder. The solution is diluted to the recommended concentration.

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Art of Laparoscopic Surgery Textbook and Atlas How to sterilize? Step 1: Decontaminate, wash, and dry all instruments to be sterilized as described above. Step 2: In a well-ventilated area, wear gloves to prevent skin irritation, completely immerse clean, dry, disas­ sembled instruments and cleaning brush in a plastic container at least 8 cm (3 inches) in depth that contains 2–4% glutaraldehyde (e.g., CIDEX®). The disinfectant must touch all surfaces in order to be effective. Note: Avoid placing instruments on top of each other, as this may damage them. Step 3: Cover the container during the disinfection procedure (This will decrease the rate of evaporation and will keep dust out of the solution). Step 4: Allow to soak for 8–10 hours in most glutaral­ dehydes, and at least 24 hours in 8% formaldehyde. Both agents work best at room temperature. Sterilization cannot be assured at temperatures less than 200°C (680°F). Because instructions vary, carefully read manufacturer’s instructions for each product. Step 5: Use sterile gloves to carefully remove instruments from the solution (forceps or lifters may damage the instruments). Step 6: Rinse three times with sterile water to completely remove all traces of the disinfectant. If sterile water is unavailable, rinse in cooled water, which has been filtered and boiled for 20 minutes. Use a sterilized or high-level disinfected brush to assist with rinsing the narrow channels of the instruments (This keeps movable parts from sticking due to any remaining disinfectant). Finally, rinse completely with 60–90% ethyl or isopropyl alcohol. Allow to dry and use immediately. Do not store laparoscopic instruments that have been rinsed with alcohol because residue can cause movable parts to stick. Step 7: Air dry in a sterile container with a cover. (Laparoscopic instruments and accessories can be stored for up to 1 week in this container.) How to do high-level disinfection (HLD)? Step 1: Decontaminate, wash, and dry all items to be high-level disinfected. Step 2: In a well-ventilated area, after wearing gloves to prevent skin irritation, completely immerse clean, dry disassembled instruments and cleaning brush in a plastic container (as above) containing either 8% formaldehyde or a 2–4% glutaraldehyde (e.g. CIDEX®)

solution. The disinfectant must touch all surfaces in order to be effective. Step 3: Cover the container during the HLD process (this will decrease the rate of evaporation and will keep dust out of the solution). Step 4: Allow to soak for 20 minutes. Step 5: After 20 minutes, use high-level disinfected or sterile gloves to carefully remove instruments from the solution (forceps or lifters may damage the instruments). Step 6: Rinse three times with cooled water that has been filtered and boiled for 20 minutes in order to completely remove all traces of the disinfectant. (This will prevent the solution from irritating the patient’s skin and keep the movable parts from sticking.) Although not neces­ sary, sterile water can be used in the place of boiled water. Use a high-level disinfected brush to assist with rinsing the narrow channels of the instruments. Step 7: Allow to air dry in a high-level disinfected con­ tainer or dry with a high-level disinfected soft, cotton cloth and place immediately on the instrument table. How to store? Step 1: Decontaminate, wash, and dry all instruments to be stored. Step 2: Assemble laparoscope and trocar. Step 3: Place laparoscope and trocar in the padded container supplied with the equipment and store in a cool and dry place. Remember—before using stored laparoscopic instruments and accessories such as tro­ cars, they must be disassembled, cleaned, and either sterilized or high-level disinfected.16,17

DISINFECTION AND STERILIZATION OF OPERATION THEATERS Operative room disinfection and sterilization is an important aspect in maintenance of operation theaters to reduce surgical site infections. Centre for Disease Control and prevention (CDC) recommended against fogging of healthcare facilities in 2003 and 2008 guide­ lines and recent guidelines suggested further research in this regard.18-20 It is almost impossible to completely sterilize an operation theater and also not required. Important principle of maintenance of operation theater is keep it as dry as possible as most of the micro­ organisms depend on water except spores. Disinfection

Sterilization and Disinfection of Laparoscopic Instruments

Principles of disinfection in operation theaters are: • Keep the room clean and dry • Keep the traffic of personnel to the minimum • Keep the air entry from the door as minimum as possible • Clean the human fluid spillage with appropriate dis­ infectant, e.g. sodium hypochlorite • Floor should be cleaned with vacuum cleaners or wet mops and broom should not be used because they increase the bacterial load in the air. • It is unnecessary to disturb the roof surface daily and should be cleaned when they appear dirty or at the times of remodeling. • Walls should be cleaned with disinfectant solution or with Bacillol Wettask tissue mops (alcohol-based solution containing tissue mops). • Operation tables should be cleaned with disinfectant solution in-between the procedures and whenever spilled with body fluids, it is advised to use sodium hypochlorite solution. • Wastes should be discarded in color-coded bags and surgical gowns should never be discarded inside the operation theaters.

• At the end of the day, all the operation table tops, door handles, lighting system should be cleaned with disinfectant solution and floor should be cleaned with disinfectant solution. • Schedule of disinfection may vary from hospital to hospital.

Our Policy of Operation Theater Disinfection At our institute, our routine practice is that all walls and roof are cleaned with Bacillol Wettask tissues at the end of the day and floor is cleaned with Bacillocid special solution (1,6-dihydroxy-2,5-dioxahexane, glutaralde­ hyde, benzalkonium chloride, and alkyl urea derivative) in 0.5% concentration. After that, all the doors are closed, air conditioners were switched off and fogging is done with Bacillocid special solution in concentration based on the cubic feet of each operation theater (Fig. 4.9). Every week, all the trolleys, operation table, and equipment are kept outside, floors, walls are washed with Bacillocid special solution and roof is mopped with disinfectant solution and fogging will be done. Biweekly culture is done from swabs taken from all the surfaces (operation table at the head end, overhead lamp, four walls, floor

Fig. 4.9: Fogging equipment with Bacillocid special solution.

Chapter 4

of operation theaters can be done at periodic intervals depending on the case load.

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Art of Laparoscopic Surgery Textbook and Atlas Box 4.1: Tips for prolonging the life of laparoscopic instruments. • Failure to completely disassemble and clean the laparoscopic instruments properly is the most common cause of problems. In addition, blood and other organic material left to dry on the instruments are difficult to remove and may be a source of infection. • Never autoclave or boil laparoscopes because heat will damage the optics. Always sterilize or high-level disinfect with chemical sterilants or disinfectants such as glutaraldehyde. • Remove instruments from the disinfectant solution as soon as timing requirements are met. Prolonged immersion may shorten the life of the instrument. • Rinse at least three times with cooled sterile (or boiled) water after cold sterilization or high-level disinfection, respectively, to remove residue. Residue can cause movable parts to stick. • Wear sterile or high-level disinfected gloves to handle instruments after final processing. Forceps and clamps may damage the laparoscope. • Avoid picking up or handling instruments in groups or bunches. Do not bend or drop instruments. • Avoid piling instruments or cables on top of each other to prevent damage or fiber breakage. • Do not use Savlon®, as it is not a high-level disinfectant and has been associated with clouding laparoscope optical lenses. • Loosely coil all cables including those attached to cameras and power sources. • Reduce intensity of light sources to low and allow them to cool before turning off the power. This will prolong the life of the bulbs.

below the head end of the table, instrument trolley, AC duct) and air. Many alternative methods are in usage like ultraviolet radiation and hydrogen peroxide for environ­ mental disinfection/sterilization are available but standard recommendations are not available about these methods (Box 4.1).

CONCLUSION Reusable endoscopic instruments can be reprocessed safely and effectively, providing they are cleaned and sterilized or disinfected according to the manufacturers’ recommendations. All cleaning, disinfecting, and sterili­ zing processes must be standardized and monitored to ensure process quality. The debate regarding the merits of sterilization versus high-level disinfection of laparoscopic instruments will continue until welldesigned scientific studies are completed. Until then, the CDC and Association of Professionals in Infection Control and epidemiology (APIC) guidelines are appropriate. Whenever feasible, equipment should be sterilized and if not feasible high-level disinfection is adequate.

REFERENCES 1. Spach DH, Silverstein FE, Stamm WE. Transmission of infection by endoscopy instruments. Ann Int Med. 1993;118:117-28.

2. Australian Standards 4187:1998. Code of Practice for Cleaning, Disinfecting and Sterilising Reusable Medical and Surgical Instruments and Equipment, and Maintenance of Associated Environments in Health Care Facilities. Sydney: Standards Australia. 3. Ayliffe GA, Babb JR, Bradley CR. Sterilisation of arthroscopes and laparoscopes. J Hosp Infec. 1992;22:265-9. 4. European Standard EN 554. Sterilisation of Medical Devices—Validation and Routine Control of Sterilisation by Moist Heat. 5. Department of Employment, Training and Industrial Relations. Division of Workplace Health and Safety, Hazardous Substances, Case Study, 2nd edition. Brisbane: Department of Employment, Training and Industrial Relations; 1998. 6. Block SS. Disinfection, Sterilisation and Preservation, 4th edition. London; Lea & Febiger; 1999. 7. Rutala WA, Weber DJ. (2001) New sterilization and disinfection methods. Emerging Infectious Diseases. [online] Available from www.cdc.gov/ncidid/eid/ vol7no2/rutala.htm. [Accessed August, 2018]. 8. Queensland Health. Disinfection and Sterilisation Infection Control Guidelines. Queensland: Queensland Health; 2001. 9. Gardner J, Peel M. Introduction to Sterilisation, Disinfection and Infection Control, 3rd edition. Melbourne, VIC: Churchill Livingstone; 1998. 10. McDonnell G, Russell D. Antiseptics and disinfectants: activity, action and resistance. Clin Microbiol Rev. 1999; 12:147-79. 11. Churchill L, Melbourne FS, Maillard JY, et al. Comparison of the mycobactericidal activity of ortho-phthalaldehyde, glutaraldehyde and other dialdehydes by a quantitative suspension test. J Hosp Inf. 2001;48:214-21.

Sterilization and Disinfection of Laparoscopic Instruments 18. CDC. (2003). Guidelines for Environmental Infection Control in Health-Care Facilities. [online] Available from https://www.cdc.gov/infectioncontrol/pdf/guide­lines/ environmental-guidelines.pdf. 19. Rutala WA, Weber DJ; The Healthcare Infection Control Practices Advisory Committee (HICPAC). (2008). Guideline for Disinfection and Sterilization in Healthcare Facilities, 2008. [online] Available from https://www. cdc.gov/infectioncontrol/pdf/guidelines/disinfectionguidelines.pdf. [Accessed August, 2018]. 20. CDC. (2009). 2009 update of 2008 Guideline for Disinfection and Sterilization in Healthcare Facilities. [online] Available from https://www.cdc.gov/infection­ control/guidelines/disinfection/updates.html. [Accessed August, 2018].

Chapter 4

12. Johnson & Johnson. Cidex OPA: Directions for Use. Sydney, Australia: Johnson & Johnson (Australia) Pty Ltd; 2001. 13. Rutala WA. APIC guideline for selection and use of disinfectants. Am J Inf Cont. 1996;24:313-42. 14. Rutala WA, Weber DJ. Disinfection of endoscopes: review of new chemical sterilants used for high-level disinfection. Inf Cont Hosp Epidemiol. 1999;20:69-76. 15. Altobelli LC. Laprocator™ Preventive Care and Maintenance. Baltimore, MD: JHPIEGO Corporation; 1980. 16. Tallentire A, Sinclair CS. Sterility Maintenance—Porous Packaging Materials. Advances in Sterilization of Medical Products, Volume III. Sydney, Australia: Johnson & Johnson (Australia) Pty Ltd; 1982. 17. Wolf R. Instruction Manual: Laparoscopy Instruments (Ref. E1-05-82). Rosemont, IL: Richard Wolf Medical Instruments Corp.; 1984.

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CHAPTER

Laparoscopic Space Access INTRODUCTION Laparoscopic space is the working space that is created by the surgeon either in the peritoneum or between the layers of the extraperitoneal structures for performing the surgery. Creation of intraperitoneal space is usually done by insufflation of gas. Rarely, this space is main­ tained with the help of various lift systems in patients who cannot withstand continued high intra-abdominal pressures.1-5 Creation of extraperitoneal space is done either by a combination of blunt dissection and carbon dioxide insufflation or with the help of specialized devices like balloon dissectors.6 The gasless lift techniques that have been described as minimizing complications of pneumoperitoneum are slowly being given up as these are cumbersome and the space created is not as adequate as in pneumoperitoneum. The interest that was shown in these techniques has gradually waned and surgeons are more commonly using pneumoperitoneum.

PNEUMOPERITONEUM Closed Veress Needle Technique Veress Needle A Veress needle is a spring-loaded needle used to create pneumoperitoneum for laparoscopic surgery. Of the three general approaches to laparoscopic access, the Veress needle technique is the oldest and most traditional. It is one of such a kind of instrument, which has not got any significant changes from the time of initial invention in 1932. It is invented by a Hungarian Janos Veres (1932), a internist mainly to collapse/drain the pleural effusion in tuberculosis patients safely. Raoul Palmer introduced the use of the Veress needle in laparoscopy to establish a pneumoperitoneum. It has a sharp end, out of which emerges a blunt tip. The blunt tip is attached internally to a spring.

5

The theory behind the needle is that as the needle is pushed perpendicularly against the skin, the blunt tip retracts, allowing the sharp end to pierce the skin and subcutaneous tissues. Once the needle penetrates the peritoneum, the needle no longer encounters any resistance. The blunt end, being attached to a spring, re-emerges to protect the bowel and other intraabdominal organs from inadvertent puncture. Veress needle should be held like a dart. Never move the Veress needle after insertion sideto-side, as this maneuver can enlarge a 1.6 mm puncture injury to an injury of up to 1 cm in viscera or blood vessels.7

Umbilical Puncture The patient is positioned in supine position with head down at an angle 10–20° to displace the intestines cranially. In the absence of operative scars, the peri­ umbilical site (thinnest site) is the most preferred site for Veress needle insertion. Depending on the shape of the umbilicus, either a transverse or vertical stab is made with a number 15 or 11 knife (Fig. 5.1). The shaft of the Veress needle should be held by the right hand, keeping the distal length of the needle tip just adequate to traverse the entire thickness of the abdomen wall. While inserting the needle, the little finger and ulnar border of the right palm is propped against the abdomen.8 The abdominal wall is lifted midway between the pubic symphysis and umbilicus by the left hand (Fig. 5.2). The Veress needle is inserted either at a 45° caudal angle9 to the abdominal wall (in asthenic or minimally obese patients) or perpendicular (in markedly obese patients). 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 little easier to stabilize the umbilicus and lift it up. During the insertion of the needle, there is a sensa­ tion of initial resistance, followed by giving of way at

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63

Chapter 5 Fig. 5.1: Umbilical puncture using number 15 knife blade. Curved artery forceps is used to expose the subumbilicus.

Fig. 5.2: Method of inserting the Veress needle. Lower abdomen is lifted by the left hand.

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 (Spring test). Failure to hear the click may indicate improper positioning of the needle.

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Confirmation of Needle Position The following tests should be performed in sequence to confirm proper placement of the needle: • Atmospheric air is sucked into the abdomen with an audible Hiss once the needle tip enters the peri­ toneal cavity due to negative intra-abdominal pressure (Hiss test). • A syringe with partially filled saline is attached to the Veress needle and aspirated. Egress of any blood, bowel contents, or urine indicates inadvertent entry of the needle into a vessel, bowel, or bladder, respectively. • Instill 5 mL of saline into the peritoneal cavity and aspirate. If the needle is in the peritoneal cavity, the saline should flow inside without resistance and should not enter the syringe on reaspiration. Aspiration of fluid during this time indicates that the tip of the needle is either inside a portion of intestine or in-between the layers of the abdominal wall (Fig. 5.3). • Drop test: A drop of saline is placed on top of the Veress needle and the abdominal wall is slightly elevated. The drop of saline is sucked inside the peritoneal cavity due to the negative intraperitoneal pressure. If free flow is not present, the needle is

either not in the coelomic cavity, or it is adjacent to a structure. A successful drop test does not guarantee intraperitoneal placement.10 • Finally, if the needle truly lies in the peritoneal cavity, it should be possible to advance it 1–2 cm deeper into the peritoneal cavity without encountering any resistance. • Percussion over the quadrants: Loss of liver dullness with 5–10 cc of insufflation indicates proper posi­ tioning of the needle in the peritoneal cavity (Fig. 5.4).9

Insufflation of CO2 After ascertaining that the tip of the Veress needle lies in the peritoneal cavity, the insufflation tube is connected to the Veress needle. The pressure in the abdomen during initial insufflation should always register less than 3 mm Hg. If high pressure is noted immediately and if the insufflator does not show any flow, the needle is gently rotated to assess whether the tip of the needle is resting against the abdominal wall, omentum, or the bowel. If the abdominal pressure remains high (i.e. needle is in between adhesions, omentum, or in the preperitoneal space), the needle is withdrawn and insertion is attempted once more. If necessary, the process is

Fig. 5.3: Performing the saline test.

Laparoscopic Space Access

65

Chapter 5 Fig. 5.4: Percussion on the liver—obliteration of liver dullness is assessed.

repeated a few times till it is certain that the needle tip is within the peritoneal cavity. It is always better to make sure of the intraperitoneal position of the needle before insufflation. The needle is carefully stabilized during insufflation to minimize side-to-side movements of the tip before adequate distension. Unnecessary manipulation of the needle tip may lead to inadvertent injuries. After adequate distension, the needle can be gently rotated in all directions to assess for the presence of adhesions. Resistance at any point may indicate intra-abdominal adhesions. Gradual insufflation of CO2 during the initial period decreases the incidence of postoperative pain (particularly in the shoulder). Rapid insufflation may also lead to complications like cardiac arrhythmias. Continuous monitoring of pulse and blood pressure is crucial for detection of a vagal reaction during the early phase of insufflation. If the pulse rate drops, the CO2 is let out immediately. Reinsufflation can be started after administration of atropine and when the heart rate returns to normal. • There are marked differences in CO2 gas flow • Veress needles allows: 0.85–2.38 L/min • Disposable trocars: 3.91–9.61 L/min.

While using Hasson’s technique for open intraabdominal access, we advice to keep the flow rate initially at 2–2.5 L/min. Reusable trocars: 5.27–21.07 L/min at reference pressure of 12 mm Hg, if used for insufflation only.

Placement of Trocars Various types of trocars are available, disposable and reusable. Pyramidal faceted trocars are preferred over conical-tipped trocars. Once the pneumoperitoneum is created, the Veress needle is removed and the incision is extended to the size of the trocar. The trocar is inserted into the peritoneal cavity by holding the trocar as shown in Figure 5.5. The position of the index finger guards against the sudden entry of the trocar into the peritoneal cavity. The lower abdomen should be lifted up to avoid inadvertent injury to intra-abdominal structures due to the sudden thrust of the trocar. In obese patients, initial intraperitoneal pressure can be increased to 20 mm of mercury (Hg) for easy insertion of the first trocar. Pressure should be brought down to 12 mm Hg for placement of the subsequent trocars under vision. The trocars are introduced more or less in a vertical path through the umbilicus, instead of the periumbilical position (Fig. 5.6).

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Fig. 5.5: Method of holding the reusable trocar with the right hand.

Fig. 5.6: Insertion of the trocar in the umbilicus. Abdominal wall lifted by the left hand.

Alternate Puncture Sites In the presence of a scar in or around the umbilicus, there is a substantial risk of bowel injury due to adhesions.

In these cases, alternate sites of needle puncture are preferred. The subcostal, left epigastric region, or right iliac fossa are other sites for needle insertion. A 3 or 5 mm cannula and laparoscope should be used for

Laparoscopic Space Access

67

Chapter 5 Fig. 5.7: Alternative site for Veress needle inser­ tion in the presence of lower abdominal scar. Needle is placed in the upper part of epigastrium and directed toward left side.

initial entry, preferably in the left side of the epigastric region (Palmer’s point) in case of lower abdominal scar. The other trocars can be inserted under direct vision. The right lower quadrant approach is better for upper abdominal scars. Other methods of introducing Veress needle have also been described.11 At GEM Hospital, we prefer to subxiphoid position (two finger breadth below xiphoid process), slightly toward the left after entering, to avoid injury to falciform ligament (Fig. 5.7).

Problems • Insufflation of gas at other sites: Extraperitoneal space, omental emphysema12-15 • Injury to the vessels can be caused by scalpel, Veress needle, or trocar • Injury to the bowel • Peritoneal hypothermia • Abdominal wall hernia.

Open Laparoscopy Technique In order to decrease the incidence of injuries asso­ciated with the blind insertion of the Veress needle and initial trocar, Hasson had proposed a blunt minilaparo­tomy access called open Hasson’s technique.16 Hasson’s open access device is available as either reusable or disposable,

held in place by the use of stay sutures passed through the fascial edges and attached to the body of the cannula, which serves to create a watertight seal. It has an olive sleeve that slides up and down the shaft of the cannula to allow for variations in abdominal wall thickness.

Technique As with other access techniques, an intraumbilical incision (1–3 cm length) is made and the subcutaneous tissue is bluntly dissected and retracted by a curved retractor on either side. Two clamps are used to lift the linea alba. A horizontal or vertical defect of about 1.5 cm is made. The peritoneal fat is dissected bluntly till the peritoneum is identified. The peritoneum is held with a hemostat and incised.10,17 Excessive dissection in the preperitoneal plane is not advisable, as the peritoneum falls away from the fascia; the surgeon may be “lost” in this plane. Two absorbable sutures (preferably polyglactin) are placed on either sides of the fascial defect. The Hasson’s cannula with its blunt obturator is advanced into the peritoneal cavity until the olive abuts the fascia. The obturator is removed and the sutures are firmly attached to create a seal with the fascia. The laparoscope is then introduced for laparoscopic surgery. Closed or open laparoscopy, which is better? In the early years of laparoscopic surgery, many surgeons began with closed Veress needle technique and the

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Fig. 5.8: Entry with visiport. Inset picture shows the layers of the abdominal wall.

majority still follow the same technique. I prefer closed Veress needle technique through alternate sites to open Hasson’s cannula. In my experience of more than two and half decades, I have adopted open Hasson’s method in less than few patients, where there were multiple scars. The alarming incidence of needle or primary trocar injuries is usually due to faulty technique. Proper holding of the needle and trocar-controlled insertion make closed access as safe as open Hasson’s technique. It is not easy to enter the abdominal cavity though an incision away from the midline by open cannula method (in patients with midline scars) particularly in the presence of a thick abdominal wall. I prefer to opt for closed Veress needle technique through the alternate site as it has been proven that the incidence of compli­ cations in the open Hasson’s technique is not signifi­ cantly different from that in closed Veress technique.18 Safety is in the hands of the surgeon, not in the instru­ ment or method.

Visiport Disposable optical obturator, which has a blunt clear window at the distal end along with the crescent shaped knife blade and a pistol grip handle with trigger at the proximal end. It allows 10 mm 0° camera through it which allows for visualization. When the trigger is pulled, the blade extends approximately 1 mm and immediately retracts. This action permits controlled sharp dissection of the tissue layers. The laparoscope permits visualization as the obturator passed through the abdominal wall. It is essential to assure that the image is in clear focus prior to use with midline deployment. The subcutaneous fat, the linea alba, the peritoneal fat and peritoneum

can be clearly and reliably visualized layer-by-layer. The combination of flow steady gently pressure with the firing of blade only through these recognizable abdo­minal wall layers are essential components of safe entry (Fig. 5.8).19

Complications Overall morbidity and mortality related to laparoscopic access are low. It is difficult to define, which technique is better. Surgeons must make decisions regarding the most appropriate access technique based on their own skills and training. 1. Bleeding: Usually the inferior epigastric artery is vulnerable to injury, which may be controlled by direct compression by the trocar, by suture ligature, transfascial suture or by Foley’s catheter tamponade. 2. Visceral injury: If needle puncture alone is present, which is shown by leakage of turbid yellow fluid, the needle may be removed and reintroduced at a different place. In case of trocar laceration, it is better to suture the bowel either laparoscopically or by a minilaparotomy. 3. Major vascular injury: Vessels like aorta, inferior vena cava, iliac vessels may be injured.20,21 If central or retroperitoneal expanding hematoma occurs, the surgery should be immediately converted to open surgery. Mesenteric hematoma may be left as such.

EXTRAPERITONEAL SPACE APPROACH Bartel first described Extraperitoneal Endoscopic Surgery (EES) in 1969. Wickham and Miller described the use of CO2 and endoscopic visualization in 1993. Gaur introduced balloons for retroperitoneal dissection

Laparoscopic Space Access

Advantages

Disadvantages

Decreased risk of bowel injury

Small working space

Decreased problems with bowel retraction

Orientation can be confusing

Less postoperative ileus

Inadvertent entry into peritoneum causes loss of working space

Closure of peritoneum not required when mesh implanted retroperitoneally

Retractors often needed to displace peritoneal sac

Less adverse hemodynamic Prior extraperitoneal dis­ effects from retroperitoneal section is a relative contra­ insufflation indication to this approach

in 1993 and Mirsch and co-workers described the use of a trocar-mounted balloon for extraperitoneal dissection in 1994. Some surgeons prefer initial space creation by finger dissection. I prefer laparoscope for dissection under pressure insufflation. A 0° laparoscope should be used. Extraperitoneal space can be expanded by instrumental dissection through different ports. Advantages and disadvantages of EES are given in Table 5.1.

Indications • • • • • • • • •

Totally extraperitoneal (TEP) inguinal hernioplasty Retroperitoneal endoscopically assisted spine surgery Renal surgery Adrenalectomy Varicocele ligation Pelvic lymph node dissection Bladder neck suspension Aortoiliac surgery Lumbar sympathectomy.

Anatomic Considerations Knowledge of anatomic landmarks is essential for orientation in the extraperitoneal spaces. The preperi­ toneal space can be divided into three spaces. The retropubic space (space of Retzius) is the space between the pubic bone and the bladder. This space is obliterated by prior preperitoneal surgery. The “space of Bogros” is lateral and proximal to the space of Retzius.

The lumbar retroperitoneal space is the posterior continuation of the space of Bogros bounded by the vena cava and aorta medially, the psoas dorsally, the colon anteriorly, and transversalis fascia laterally. This space contains the kidney, adrenal, ureter, and Gerota’s fascia.

Extraperitoneal Approach Creation of extraperitoneal space for inguinal hernia will be discussed in the following paragraphs. The extraperitoneal approach is made possible by the fact that the peritoneum in the suprapubic region can be easily separated from the anterior abdominal wall. Sufficient space is created for dissection of the hernial sac and insertion of the mesh.22 Several techniques can be used to develop this space, for example, Phillips, McKernan, and Dulucq’s technique. Our approach is similar to McKernan, where the trocar enters the plane between the rectus muscle and posterior rectus sheath. In Dulucq’s approach, the preperitoneal space is insufflated by using the Veress needle initially and then the trocar directly enters preperitoneal space, in a plane deeper than that created by McKernan. In another method that is followed by Phillips, the pneumoperitoneum is created initially and the laparoscope enters the peritoneal cavity. Under vision, the two working ports are placed in the preperitoneal space. Subsequently, the laparoscope is withdrawn and reintroduced into the preperitoneal space. After placing the ports, the method of dissection remains the same in all approaches (Figs. 5.9 to 5.11).

Potential Problems • Peritoneal rent with CO2 leak. Peritoneal rent should be closed to continue the surgery. • Peritoneal tear may necessitate a transabdominal laparoscopy or open surgery. • Venous or arterial bleeding.

CHOICE OF INSUFFLATING GAS Understanding the physiology of pneumoperitoneum is essential for performing laparoscopy in a safe manner. Many gases such as air, CO2, nitrous oxide, helium, and argon are available for use in laparoscopy.23,24 The following characteristics constitute an ideal insufflating agent.

Chapter 5

Table 5.1: Advantages and disadvantages of extra­ peritoneal endoscopic surgery.

69

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Art of Laparoscopic Surgery Textbook and Atlas

Fig. 5.9: By subumbilical incision, anterior rectus sheath is exposed and with a small incision over the anterior rectus sheath, rectus muscle is exposed (A—anterior rectus muscle; B—rectus muscle).

Fig. 5.10: By retracting the rectus muscle later­ ally, posterior rectus is exposed (A—posterior rectus sheath).

• It should be colorless, inert, and nonexplosive. • Agent’s solubility should be low in the peritoneal cavity. • Solubility in the blood should be high. • It should be readily available, nonexpensive, and nontoxic.

Air Air was the first gas used to produce pneumoperi­ toneum. Now its use has been largely abandoned. The main disadvantage is the risk of an air embolism. As little as 300 mL in the venous circulation and 1 mL of air in the coronary circulation may lead to death.

Laparoscopic Space Access

71

Chapter 5 Fig. 5.11: Insertion of 10 mm cannula into the extraperitoneal space.

Carbon Dioxide Carbon dioxide is an odorless, colorless gas and is the most commonly used gas for insufflation during laparo­ scopic procedure. This gas rapidly dissolves in the blood­ stream and has a greater safety margin. It is associated with relatively low risk of venous gas embolism and does not support combustion in the presence of electro­ cautery. CO2 used for insufflation is medical grade CO2, which is high pure (99.99%). The main disadvantages are hypercarbia and acidosis. CO2 diffuses across the peritoneum into the bloodstream, which is carried away by the blood and eliminated by the lungs. During continuous insufflation, the body stores of CO2 continuously increases and it may take several hours for the accumulated CO2 to be eliminated, particularly after a long laparoscopic procedure. The direct effect of CO2 and acidosis can lead to decrease in cardiac contractility, pulmonary hypertension, and systemic vasodilatation. Widespread sympathetic stimulation results in tachycardia, vaso­ constriction and increased central venous pressure, mean arterial pressure, pulmonary artery pressure, and pulmonary vascular resistance. Acidosis and hyper­ carbia limit the safety of longer and more complicated laparoscopic procedures in patients with compromised respiratory function. Sometimes there may be a need for

conversion. Surgical emphysema seen in postoperative patients usually resolve within 2–3 days.25

Nitrous Oxide Nitrogen is a biologically important, colorless, gaseous element found freely in the air. It is much more soluble in blood and body fluids. This gas is associated with insignificant changes in acid-base balance and decreased pain. Its property to support combustion and the inherent hazard to the operating personnel are its main disadvantages.26,27

Helium Helium is a colorless, tasteless gas that is obtained from natural gas. This gas is neither combustible nor supports combustion. Its main advantages are its minimal effect on acid-base balance and the absence of associated hypercarbia and acidosis. Like air, it is associated with a small risk of gas embolism. The postoperative subcutaneous emphysema after use of helium takes several days to be absorbed.28-30

Argon The colorless, odorless, noncombustible, chemically nonreactive argon gas31 may be a good alternative to

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Art of Laparoscopic Surgery Textbook and Atlas CO2 in patients with decreased respiratory reserve. It maintains a stable acid-base balance in patients.

CONCLUSION The creation of space in laparoscopic surgery is routinely performed by closed Veress needle technique in our institute. The incidence of complications following access by Veress needle technique and by open Hasson’s technique are not significantly different and the main deciding factor for selection of the technique seems to be surgeon preference. The initial enthusiasm for gasless lift techniques has now waned and most surgeons prefer pneumoperitoneum. CO2 continues to be the most common gas used for creation of pneumoperitoneum.

REFERENCES 1. Hill D, Maher P, Wood C, et al. Gasless laparoscopy. Aust N Z J Obstet Gynaecol. 1994;34(1):79-80. 2. Paolucci V, Gutt CN, Schaeff B, et al. Gasless laparoscopy in abdominal surgery. Surg Endosc. 1995;9(5):497-500. 3. Weaver DW. Gasless laparoscopy for complex surgical procedures. Int Surg. 1994;79(4):314-6. 4. Johnson PL, Sibert KS. Laparoscopy. Gasless vs. CO2 pneumoperitoneum. J Reprod Med. 1997;42(5):255-9. 5. Seidman DS, Goldenberg M. Gasless laparoscopy in gynecologic surgery. Harefuah. 2001;140(4):337-42. 6. Palanivelu C. Laparoscopic Space creation and Physio­ logical Significance. Coimbatore: Gem Digestive Diseases Foundation; 2002. 7. Vilos GA, Ternamian A, Dempster J, et al. Laparoscopic Entry: A Review of Techniques, Technologies, and Complications. J Obstet Gynaecol Can. 2007;29(5):433-47. 8. Piccigallo E, Jeffers LJ, Reddy KR, et al. Experience with a 1.2-mm pneumoperitoneum needle for laparoscopy. Gastrointest Endosc. 1988;34(6):471-3. 9. Williams PP. Avoiding laparoscopy complications. Fertil Steril. 1974;25(3):280-7. 10. Nuzzo G, Giuliante F, Tebala GD, et al. Routine use of open technique in laparoscopic operations. J Am Coll Surg. 1997;184(1):58-62. 11. Vakili C, Knight R. A technique for needle insufflation in obese patients. Surg Laparosc Endosc. 1993;3(6): 489-91. 12. Munro MG. Laparoscopic access: complications, techno­ logies, and techniques. Curr Opin Obstet Gynecol. 2002;14(4):365-74. 13. Di Vita G, Frazzetta M, Cortese E, et al. Complications of the laparoscopic access. G Chir. 1996;17(1-2):31-6. 14. Christensen BJ, Fisher KS. Laparoscopic access to the preperitoneal space. JSLS. 1998;2(1):97-8. 15. Holub Z. Clinical problems and complications in laparo­ scopic access. Ceska Gynekol. 2000;65(6):464-70.

16. Hasson HM. Modified instrument and method for laparo­ scopy. Am J Obstet Gynecol. 1971;110:886-7. 17. Ballem RV, Rudomanski J. Techniques of pneumo­ peritoneum. Surg Laparosc Endosc. 1993;3(1):42-3. 18. Merlin TL, Hiller JE, Maddern GJ, et al. Systematic review of the safety and effectiveness of methods used to establish pneumoperitoneum in laparoscopic surgery. Br J Surg. 2003;90(6):668-79. 19. Lapham T, Tarnoff M, Kim J, et al. Five-year experience with a bladed optical trocar in an uninsufflated abdomen in bariatric surgery. Boston, MA: Tufts-New England Medical Center. 20. Usal H, Sayad P, Hayek N, et al. Major vascular injuries during laparoscopic cholecystectomy. An institutional review of experience with 2589 procedures and literature review. Surg Endosc. 1998;12(7):960-2. 21. Nordestgaard AG, Bodily KC, Osborne RW Jr, et al. Major vascular injuries during laparoscopic procedures. Am J Surg. 1995;169(5):543-5. 22. Palanivelu C. Anatomy of abdominal wall and inguinal Region. In: Palanivelu C (Ed). Operative Manual of Laparoscopic Hernia Surgery. Coimbatore: Gem Digestive Diseases Foundation; 2004. pp. 39-57. 23. Dahn S, Schwalbach P, Maksan S, et al. Influence of different gases used for laparoscopy (helium, carbon dioxide, room air, and xenon) on tumor volume, histomorphology, and leukocyte-tumor-endothelium interaction in intravital microscopy. Surg Endosc. 2005;19(1):65-70. 24. Dahn S, Schwalbach P, Wohleke F, et al. Influence of different gases used for laparoscopy (helium, carbon dioxide, room air, xenon) on tumor volume, proliferation, and apoptosis. Surg Endosc. 2003;17(10):1653-7. 25. Elhendawy AO, Abd-Raboh OH, Ismail TA, et al. Randomized Comparative Study Between Laparoscopic Trans­ abdominal Pre-Peritoneal Versus Totally Extra­ peritoneal Approach in Inguinal Hernia Repair. Advanc Surg Sci. 2018;6(1):1-6. 26. Neuman GG, Sidebotham G, Negoianu E, et al. Laparoscopy explosion hazards with nitrous oxide. Anesthesiology. 1993;78(5):875-9. 27. Verheecke G. Nitrous oxide and laparoscopy. Anaesthesia. 1991;46(8):698. 28. Bongard FS, Pianim N, Liu SY, et al. Using helium for insufflation during laparoscopy. JAMA. 1991;266(22): 3131. 29. Neuhaus SJ, Gupta A, Watson DI. Helium and other alter­ native insufflation gases for laparoscopy. Surg Endosc. 2001;15(6):553-60. 30. O’Boyle CJ, deBeaux AC, Watson DI, et al. Helium vs carbon dioxide gas insufflation with or without saline lavage during laparoscopy. Surg Endosc. 2002;16(4): 620-5. 31. Reichert JA. Argon as distending medium in laparoscopy compared with carbon dioxide and nitrous oxide. J Am Assoc Gynecol Laparosc. 1996;3(4 Suppl):S41.

CHAPTER

Laparoscopic Tissue Approximation

6

INTRODUCTION

Instrumentation

Tissue approximation in laparoscopy can be performed by a wide range of techniques like extracorporeal knotting, loop ligatures, intracorporeal suturing, and knotting and also with the help of various suture-assist devices. Knowledge of endosuturing provides a great sense of confidence to reconstruct a vital organ, to repair an inadvertent injury or to control bleeding after other methods are unsuccessful or inappropriate. The surgeon faces the technical challenge to perform intracorporeal maneuvers under video guidance with a less than ideal visual image with limited movements. These challenges can be overcome by following a mental choreography of step-by-step maneuvers and by repeated training to master this skill. A skilled laparoscopic surgeon must be able to perform laparoscopic suturing and knotting to make advanced, complex procedures more perfect and safe. The mechanical stapling devices also form an essential part of the laparoscopic surgeon’s armamentarium. Though intracorporeal suturing and knotting is preferred to staplers due to its adaptability and cost-effectiveness, mechanical staplers have several advantages in certain situations. This chapter will discusses about the various types of tissue approximation and the methods of extracorporeal and intracorporeal knots and sutures, suture-assist devices, and also about the mechanical stapling devices. Initially, the basics of equipment needed for endosuturing and the ergonomics of endosuturing will be discussed followed by detailed description of creation of endoloops, square knots, and practical tips on endosuturing.

Usually a pair of needle holder and grasper is used. The active hand (right) holds the needle holder and the passive hand (left) holds the grasper. Various types of needle holders are available and the surgeon should opt for one pair of needle holder and grasper and continue to practice with the same rather than changing the instruments frequently. With practice, the surgeon becomes accustomed to the instruments and starts using it as an extension of his hands. The needle holder should have a coaxial handle with a locking mechanism. It should be strong with a heavy handle. The tip is usually tapered either with straight or curved tip with a single moving jaw. The coaxial needle holders are better than the pistol type holder as it associated with less strain, greater maneuverability, and rotation, which is essential requirement for endosuturing. Various types of needle holders with different handgrip designs have been tested.1 The pistol type limits the rotatory movements of hand and might lead to compression nerve damage due to the awkward position. Straight axial handle needle holders (Fig. 6.1) helps in precise and ergonomic hand manipulation allowing maximum holding power, this is most useful in suturing especially in areas like suturing anterior abdominal wall. The assisting grasper held by the nondominant hand is used to assist the right hand in handling the needle and sutures and providing counter traction during suturing. It should be short, straight and rounded tip instrument with minimal serrations in order to avoid crushing effect on thread while tying the knot. The conventional 5 mm atraumatic grasper without ratchet will be an ideal left hand instrument during suturing.

EQUIPMENT AND INSTRUMENTATION Video Equipment High-standard resolution imaging system is important, since greater visual acuity is necessary for accurate tissue approximation.

Trocars The tip of the trocars should be kept as short as possible inside the peritoneal cavity. Trocars that are too long

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Fig. 6.1: Axial handle needle holder (EthiconTM).

interfere with the movement of instruments and also prevent adequate opening of the jaws of the needle holder.

Suture Material The conventional suture material with the needles can be used in laparoscopy and there is no need for any specialized needles and sutures.2 The surgeon should be familiar with the characteristics of the suture material. Approximately 8–10 cm of suture length is needed for first suture with additional 2 cm for each suture. An incision that requires six sutures will approximately need 20 cm [10 + (5×2)] length of suture material. Manipulation of longer threads is cumbersome and frustrating, especially in the learning period. Selection of suture material should be based upon the tissue response and the handling characteristics of the suture material. For example, a slipknot requires fewer loops, if the material is chromic catgut as in Roeder’s knot. If it is polydioxanone (PDS) or polypropylene, it needs additional throws or different looping system. The ideal suture material for easy handling and knotting is vicryl. Silk has good pliability, but also has sticking and fraying tendency. PDS sutures can be used for approximation of crura in hiatal hernia repair. For intestinal anastomosis, the use of 2-0 PDS is preferred. For anastomosis involving delicate tissues like choledochojejunal anastomosis or common bile duct (CBD) suturing after “T” tube placement, thinner sutures are preferred. Because of magnification, 5-0 or 6-0 PDS may be

used in suturing pancreaticojejunostomy, vascular reconstruction, etc.

Barbed Sutures These are designed initially in 1960 as a knot-free device to reduce the operating time.3-5 Usually made of monofilament thread, which along its longitudinal axis has structures called “barbs”. Barbs are created by making cuts into a drawn thread material. The barbs are mad in such a way that they pass through the tissues in a single direction and when pulled in the opposite direction the barbs prevent the backward movements, hence prevent slippage and the need for knotting. They are available in absorbable and nonabsorbable suture materials, bidirectional/ unidirectional varieties. They are later being used in various gynecological, orthopedic, and gastrointestinal surgeries. In laparoscopy, the usage of barbed sutures is increased as they simplify the need for cumbersome intracorporeal knotting. Commercially available varieties are Quill Self-Retaining System (SRS; Angiotech, Vancouver, BC, Canada), the V-Loc (Covidien, Dublin, Ireland), and the Stratafix (Ethicon, Somerville, NJ). At our center, we are using barbed sutures in bariatric procedures to reinforce the staple line and for mesenteric defect closure and uterine defect closure after myomectomy. Few studies have shown good results in intestinal anastomosis. In a study of 38 patients, intestinal anastomosis following radical gastrectomy was done using barbed (V-Loc) suture with no significant complications.6

Laparoscopic Tissue Approximation

Needles In choosing a needle, apart from strength and sharpness, visibility and curvature are important in laparoscopic suturing. The early pioneers used straight needles because curved needles could not be taken into the peritoneal cavity through the ports. Later ski needle (curved tip, with straight shaft) that were easy to pass through the trocars were introduced.8 Many surgeons prefer curved needles due to the familiarity in using these needles in conventional surgeries and for good tissue pick up. But, in practice, all conventional needles can be used in laparoscopic surgery. The needles can be straightened just to the extent that is needed for it to pass through the trocar. The needles are taken inside the peritoneal cavity as described below in Figures 6.3 to 6.6. Nonswedged needle should not be used, because of the danger of loss of the needle in the peritoneal cavity. Usually 10 mm trocar allows 31 mm size needle. Self-aligning laparoscopic needle holder/self-orienting laparoscopic needle holder—needle is automatically oriented into a desired position for suturing. Has self-aligning jaw with curved gripping surface, one of the jaw’s gripping surface has a corresponding concave shape. These curved surfaces preferably contain a plurality

of corresponding transverse grooves. These grooves facilitate the receiving, orienting, and securely gripping of a curved surgical needle within the jaws of the device. We generally do not advice this for surgeons who are new to laparoscopy because this is slipping, the knot is difficult with this type of needle holder.

ERGONOMICS AND HANDLING OF CAMERA • Manipulation angle: It is the angle formed between two instruments converging and working in the operative field (Fig. 6.2). • Azimuth angle: It is the angle formed between the optical (scope) shaft and instrument. • Elevation angle: It is the angle formed by the direction of shaft of an instrument in relation to the horizontal axis of the patient. Manipulation angle ranging from 45° to 75° with equal azimuth angles is recommended. Manipulation angles below 45° or above 75° are accompanied by increased difficulty and degraded performance. Task efficiency was reported be better with equal azimuth angles than with unequal azimuth angles. Achieving equal azimuth angles may be difficult in many practical situations, but in principle, azimuth inequality should be avoided because it degrades task efficiency. There exists a direct correlation between the manipula­ tion and the elevation angles. With a manipulation angle of 60°, the corresponding optimal elevation angle which yields the shortest execution time and optimal quality

Fig. 6.2: Triangulation of instruments for suturing [A— needle holder (right hand instrument); B—holding forceps (left hand instrument)].

Chapter 6

In an another study of 50 patients, they found that barbed sutures can be used for enterotomy closure in laparoscopic surgeries.7 In our institution, we do not prefer usage of barbed sutures for intestinal anastomosis.

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Art of Laparoscopic Surgery Textbook and Atlas performance is 60°. Wide manipulation angles necessitate wide elevation angles for optimal performance and task efficiency. When a 30° manipulation angle is imposed by the anatomy or build of the patient, the elevation angle should be also 30° as this combination carries the shortest execution time. The best ergonomic layout for endoscopic surgery consists of a manipulation angle ranging from 45° to 75° with equal azimuth angles.

Degree of Freedom in Laparoscopy • Insertion/withdrawal • Rotation around instrument axis • Yaw and pitch (left/right and forward/backward rotation around incision point) • Rotation around its axis • Open/closing of the instrument.

PASSAGE OF NEEDLE INTO ABDOMINAL CAVITY Method 1 (Personal Technique) 10 mm metal converters or reducing sleeves are used as needle drivers for introducing thread and needle into the peritoneal cavity. Larger needles are slightly straightened to reduce the curvature so as to accommodate the needle into the sleeve. The needles are then loaded in a reverse fashion into the sleeve by holding the thread, 1 cm away from the needle and delivered into the peritoneal cavity. By this method, all conventional needles can be used in laparoscopic procedure. While removing, the needles are taken back into the sleeve in a reverse fashion (Fig. 6.3).

Method 2 In thin individuals and in children, the needle can be inserted into the abdomen by direct puncture through the abdominal wall (Figs. 6.4A and B). The needle is then pulled inside the abdominal cavity by needle holder under vision.

Method 3 Trocar is removed briefly and a 5-mm instrument holding the thread along with the needle is passed through incision directly (Figs. 6.5A to C). A similar technique is employed in removal of the needle. The trocar is removed initially and subsequently the needle along with the thread.

Method 4 Needle holder is brought out through other 5 mm port and loaded with suture material. It is dragged through the abdominal cavity (Figs. 6.6A and B).

LOADING OF NEEDLE BY NEEDLE HOLDER The thread is caught by the right hand needle holder about 2 cm away from the needle and pulled to the right. Now the needle will lie horizontally over the tissues with sharp tip facing to the left. The static jaw of the needle holder is placed beneath the needle and the moving jaw is gently closed over the needle with slight downward

Fig. 6.3: Reverse loading of the needle with thread into the reducer (A—needle holder within the reducer; B—reducer).

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Chapter 6

A

Figs. 6.4A and B: Direct puncturing of the needle through abdominal wall.

B

pressure over the tissues. The needle automatically gets positioned at right angle. Then the needle is held with a firm grip. Optimum holding angle is more than 90° and the gripping point is at the middle and proximal third of the shaft of the needle (Figs. 6.7A to D).9

ADJUSTING THE NEEDLE DIRECTION It is advisable to rotate the needle holder on all directions to confirm whether long axis of the needle holder and

the needle are perpendicular to each other. If not, the following maneuver helps in proper positioning of the needle. If the tip faces the surgeon, the left hand instrument is used to gently push the needle so that it falls at right angle to the jaws of the needle holder. If the tip faces away from the surgeon, the open jaws of the left hand grasper are used to adjust the needle towards the surgeon. It is important to hold the needle holder with appropriate grip while adjusting the needle and suturing. Maintenance of minimal grip while holding the needle,

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A

B

C

Figs. 6.5A to C: Taking the needle through 5 mm port.

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Chapter 6

A

Figs. 6.6A and B: Method 4—needle holder along with the needle is introduced first through the 5 mm port after that cannula is pushed in.

B

firm grip while adjusting the needle, and tight grip while suturing is very important. The needle should be never held at the tip. This causes unnecessary loss of sharpness resulting in increased tissue trauma and bleeding. After adequate experience both hands are used alternatively to adjust the needle position and also to change the needle into reverse direction.

HANDLING OF NEEDLE Entrance and exit, bight and knot tying are the main movements repeated during tissue approximation. The needle should follow the tip in passing through the tissue and direction of force is assembled on the same axis. It is advisable learn the endosuturing techniques

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Art of Laparoscopic Surgery Textbook and Atlas by continues practice rather than depending on various gadgets. The principles and techniques of needle loading, handling, and driving are presented, as are the series of movements involved in tying an intracorporeal squareslip knot.10

METHODS OF TISSUE APPROXIMATION • Manual ºº Extracorporeal knots –– External slip knots

Fig. 6.7A: Place the needle in horizontal position.

Fig. 6.7B: Lower jaw of the needle holder is introduced behind the needle and tissue is being pressed.

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Chapter 6 Fig. 6.7C: While pressing the tissue down, the needle will be lifted automatically and then held by the needle holder.

Fig. 6.7D: Needle is in right angle position to take bright.

■■ Externally created slip knots ■■ Extracorporeal surgeon’s knot ■■ Endoscopic Babcock clamp method –– Preformed slipping endoloops ■■ Roeder’s knot ■■ Modified GEM loop knot ºº Intracorporeal knots –– Square knot

–– Surgeons knot ºº Suturing –– Single suture –– Continuous suture • Mechanical stapling technique ºº Linear staplers ºº Circular staplers

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Extracorporeal Knots Externally Created Slip Knots The suture is passed around the structure to be ligated and is brought out through the trocar sheath. After creation of the knot, the knot is pushed into the field by using knot pusher. The assistant must provide a guide for the suture with an open grasper to prevent abrasion, traction, or avulsion of the structures. The newly available “cutting knot pusher” permits immediate cutting of the slipknot after tightening.9

Extracorporeal Surgeon’s Knot After passage of the suture through the tissue in the abdominal cavity, both ends are exteriorized through the trocar sheath. The conventional surgeons knot is made externally and the knot is pushed into the field, while two ends of suture are kept tense. The knot is locked in place by knot pusher. Additional throws are made similar fashion to make the knot secure.

• •

• • •

The suture should be threaded from outside to inside. Both the suture ends are held with one hand and maintaining slight traction. The Babcock clamp is advanced into the trocar pushing the Surgeons’ knot inside the abdominal cavity near the tissue that is sutured. The arms of the Babcock are slightly spread inside to tighten the knot. Further tightening of the knot can be done by traction of the threads from outside. The Babcock clamp is withdrawn and the same procedure is repeated for additional knots.

Preformed Slipping Endoloops

Endoscopic Babcock Clamp Method Technique

Loop ligatures are used to ligate pedicles. Though commercially made loops are available, self-made loops are cheaper. The loop is formed with a slip knot, at the tip of the pusher rod. The Roeder knot is widely used in laparoscopic surgery for extracorporeal tying. In laparoscopic surgery, the Roeder knot with dry chromic catgut has a substantial safety factor ratio of 55:1 in ligation of vessels up to 3 mm diameter. This knot is commercially available as pretied suture ligatures.

• A conventional “surgeons” knot is made externally. • Both ends of the suture are brought through fenes­ trations in the tip of the endoscopic Babcock clamp.

Roeder’s knot (Figs. 6.8 to 6.17) • Keeping the thread between the thumb and index finger, a loop is made (Fig. 6.8)

Fig. 6.8: Tail end is brought around the index finger in anticlockwise manner (A—tail end).

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Chapter 6 Fig. 6.9: Half knot is formed by making the knot anticlockwise.

Fig. 6.10: Tail end is taken around the loop three times (three turns) without knot.

• Initial half knot is made (Fig. 6.9) • The half knot is held by the index finger and the thumb of the surgeon and three and half round turns are placed in front of the half knot over the two limbs of the loop (Fig. 6.10)

• A second half knot is made between the tail and one limb of the loop • The knot is pulled to stack the three and half turns between the first and the second half knot.

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Fig. 6.11: First turn is being made.

Fig. 6.12: Completion of first turn.

Modified GEM knot: We use our modified technique of creation of endoloops as described in Figures 6.18 to 6.31, which is easy to practice. These endoloops are made in the theater during surgery by using conventional suture materials like chromic catgut, vicryl, or polypropylene. Apart from the thread we need plastic knot pusher (plastic rod) and 5–3 mm

reducer sleeve. The knot pusher and the reducer sleeve are always kept together as a single unit. The suture material is threaded into the plastic knot pusher throughout its entire length and withdrawn at the other end. The loop is made from the suture material that emerges out of the tip of knot pusher. After the creation of the endoloops, the excess tail is cut and the loop is withdrawn completely

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Chapter 6

Fig. 6.13: Second turn is in progress.

Fig. 6.14: Tail is taken around one limb of functional loop to make a knot.

into the reducer sleeve. The loop is introduced into the abdominal cavity through one of the ports for application. Key points in application of the endoloop: • There should not be any gap between the knot and end of the pusher rod. • The loop is passed through the right side working trocar and the grasper from the left hand working trocar.

• The loop is placed over the pedicle or tissue to be looped. • The grasper is passed through the loop and the tissue to be ligated is caught and pulled out of the loop, while the loop is kept steady. • The left hand instrument is given to the assistant to maintain constant traction on the tissue.

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Fig. 6.15: Knot is being made with one limb of functional loop.

Fig. 6.16: Knot is being secured.

• The thread is held by the right hand and the plastic knot pusher is slowly pushed towards the pedicle to tighten the loop. The pedicle is kept in the center of the loop during this maneuver. The loop, pedicle, and the trocar should be in a single line. • Once the loop is narrowed slightly, it can be adjusted fully tightened.

• The plastic knot pusher is removed and a 5-mm scissors is introduced through the trocar and the suture material is divided. The traction on the suture material is maintained with the left hand, otherwise the thread can entangle between the reducing sleeve and the trocar.

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Chapter 6

Fig. 6.17: Completion of Roeder’s knot.

Fig. 6.18: Formation of GEM loop knot. Standing part is held by the left hand and the tail end is held by the right hand (A—tail end; B—bight; and C—standing part).

Indications for endoloop application: • Ligation of pedicles. • Temporary closure of the gallbladder wall perforation to prevent bile leak or stone slippage and closure of the wide cystic duct during laparoscopic cholecystectomy. • Ligation of the base of the appendix.

• Control of the bleeding vessels. • Ligation of the neck of the hernias sac in indirect hernia.

Intracorporeal Suturing and Knotting Both intracorporeal and extracorporeal knot tying techniques have an important role in laparoscopic

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Fig. 6.19: A loop is formed by holding the standing part and the bight together.

Fig. 6.20: The tail end is passed over the first loop to form the second loop.

surgery. Intracorporeal knot tying is preferred as it virtually mimics the methods used in open surgery, more effective tissue approximation using less suture material at a short operative time.11,12 The series of movements involved in tying an intracorporeal square-slip knot have been described.9,13

Intracorporeal suturing and knotting is performed entirely within the peritoneal cavity by laparoscopic instru­ ments. These knots and sutures are similar to open surgical methods. The “needle rotor” facilitates intracorporeal swiveling and positioning of the needle because one jaw can be moved longitudinally over the other.12

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Chapter 6 Fig. 6.21: The tail end is brought out through the second loop to form a first knot.

Fig. 6.22: First knot is formed by pulling the tail end. The completed knot is secured between thumb and the ring finger.

Square and Surgeon’s Knot • Create a C-loop and hold the long end of the thread with the right hand instrument. The short tail end of the thread should be just adequate to tie the knot. At the same time it should not be too short as the thread

may be pulled out of the tissues accidentally during suturing. • The thread is looped over the stationary left hand instrument using the right hand instrument and then both the instruments are moved towards the short tail end. During the maneuver, the left hand

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Fig. 6.23: The tail end is passed through the first loop (first turn).

Fig. 6.24: First turn is formed.

should be held steady, partially lifted away from the tissues. • The left instrument grasps the tail end and pulls it out of the loop to complete the first half knot. • Secure the knot with simultaneous traction on both the ends, keeping the knot at the center.

• A reverse C loop is created. Now the left hand instrument holds the long end of the thread. • Now the right hand instrument is used to loop the thread over the stationary left hand instrument and then the short tail end is grasped by the right hand instrument and the ends are pulled to complete

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Chapter 6 Fig. 6.25: First turn is secured between thumb and the ring finger. Second turn is also done, similar to the first turn.

Fig. 6.26: The tail end is passed over the first loop to form the second loop (like first knot).

the square knot. The tension in the knot should be adequate at the end of the knotting. Whenever knotting is done, always work with the tip of the right and left instrument close to each other. Never put tension over the “C” loop while doing the wrapping. After wrapping both the instruments along with the loop should move together like a single unit to hold the tail. Before tightening the loop, the wrapped suture should

be dislodged from the instruments to avoid loop getting stuck to the instrument jaws (Figs. 6.32 and 6.33).

Square Knot Twisting Method (Personal Technique) Here only the left hand is used to create the loop to wrap around the right hand needle holder. After taking

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Fig. 6.27: Completion of second knot.

Fig. 6.28: The tail end is passed over the first loop to form the second loop (like first knot).

a bight, hold the thread with left hand about 5–6 cm distal to the exit point. Keep the tail end at around 1 O’clock position. Then, take the thread which is held by the left hand forceps towards the tail to create inverted “U” loop. Use the right hand forceps to from a knot by twisting method as we do in open surgery and then

catch the tail end to make a half knot. Then dislodge the loop and tighten the knot. While tightening the knot, bring the tail end to 7 O’clock position. This completes the first half knot. Without leaving the thread bring the left hand forceps towards the tail which is now placed at 7 O’clock position

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Chapter 6 Fig. 6.29: A knot is formed by pulling the tail end through the third loop (similar to making first knot).

Fig. 6.30: A knot is formed by pulling the tail end through the third loop (similar to making first knot).

to create another inverted “U” for the secured knot. Twisting the loop again around the right hand forceps completes the second knot. After this, dislodge the loop and tighten the knot. This technique is exactly similar to that of open technique. While doing these knots, the right and left hand forceps tip should work close to each other.

In practice, one can easily learn combined action of wrapping and twisting for quick and effective tying and suturing at speed equal to or faster than conventional suturing. It is better to perform a continuous suture than an interrupted one (Figs. 6.34A to F).5

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Tightening of the First Half Knot (Personal Technique) The first half knot may become loose in certain situations (e.g. polypropylene). The square knot will not be secure unless the first half knot is tightened. In these situations I have found the following technique useful. Irrespective of whether the first half knot is loose

or tight, the second half knot is made. Subsequently, the first half knot can be tightened by tightening the second half knot with the needle holder remaining in the second half knot. Once the first knot is tight the tip of the needle holder is pulled out and the knot is secured by giving equal pressure on either sides. This technique of knot securing is very helpful particularly at difficult locations (Figs. 6.35A to D).

Fig. 6.31: Completion of GEM loop knot.

Fig. 6.32A: Creation of C loop by right hand instrument (needle holder).

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Chapter 6 Fig. 6.32B: Left hand instrument (grasper) placed over the C loop.

Fig. 6.32C: Looping of the long end of the thread over the grasper (by needle holder) and the grasper holds the short end of the thread.

Fig. 6.32D: By pulling the left hand instrument, first half knot is formed.

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Fig. 6.33A: Reverse C loop formed by grasper.

Fig. 6.33B: Needle holder kept below the C loop.

Fig. 6.33C: Looping of the long end of the thread over the needle holder (by grasper) and the needle holder holds the short end of the thread.

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Chapter 6

Fig. 6.33D: Square knot formed by pulling the two ends.

Square Knot to Slip Knot After the needle has passed through the tissue, the needle end is pulled to produce a tail end of approximately 1.5 inch. The first over hand throw is created using a needle holder and holding forceps. An opposite throw is created using the instruments and the knot is approximated, but not tightened. The needle end of the suture is held with needle holder with right hand and the short end with another instrument with left hand, both of them are pulled in a straight line alignment, then the knot rotates. Now pull the two ends then you can observe knot slipping down and the initial loose knot gets tightened up (Figs. 6.36A to F).10

Suturing Technique Suturing and intracorporeal knotting is the most challenging part following a laparoscopic procedure. Intracorporeal knotting can be the starting and finishing point of continuous suturing and interrupted suture lines.

Interrupted Suturing A linear suture line may be approximated either interrupted or continuous suturing. During each interrupted stitches, the needle should be placed perpendicular to the suture line. The entry and exit scooping motion should follow a 3 O’clock and 9 O’clock direction relative to the surgeon’s frontal plane.12 A suspension slip knot technique is used if there is tension

in the tissue or poor visibility, e.g. posterior seromuscular layer with interrupted suturing.

Continuous Suturing Tissue approximation by continuous suturing is more rapid, but difficult to perform. This technique begins and ends with an anchoring knot, the tail end of which can be tied to the loop of the last stitch. This can be either running stitch with or without locking.

Starting a Running Suture A continuous linear suture line may be initiated with either square knot or prettied jamming slip knot. Pretied slip knot may be either by Dundee jamming loop knot or by simple slip knot. The slip knot is created externally from the tail end. The needle is passed through the tissue and through the loop. The sutures are grasped at the tip of the short end of the loop slide with the right hand instrument and the long thread by the left hand, pulled with equal tension on opposite side and is converted into square with another throw up of knotting.

Completing a Running Suture At the completion of a running suture line, the tail of the suture may be secured to the last loop of the suture with square knot. Aberdeen knot with double looping, loop within a loop may also be used to secure the running suture.

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Fig. 6.34A: After taking bight, the standing part is held by the left hand instrument.

Fig. 6.34B: Left hand instrument which is holding the standing part of the thread is brought close to the tail end. It forms a natural loop.

Fig. 6.34C: After forming the loop (under wrap) the tail end is held by the right hand instrument.

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Chapter 6 Fig. 6.34D: By pulling the right hand instrument, first half knot is formed.

Fig. 6.34E: After forming loop (over wrap) the tail end is held by the right hand instrument.

Fig. 6.34F: Square knot is formed.

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Port Closure Devices It is important to suture the port site that is 10 mm or more, in order to avoid herniation. There are various types of suture passers that are commercially available for closure of ports and transfascial ligature during ventral hernia repair. These devices can also be used for control

of bleeding from the abdominal wall. We have designed a pair of instruments for port closure. The thread passer has a side slit to carry the thread into the peritoneal cavity on one side to the trocar. Once the thread is in the peritoneal cavity, the thread passer is withdrawn. The thread grasper is inserted on the other side and the thread is grasped and pulled out of the abdominal cavity

Fig. 6.35A: Square knot is formed.

Fig. 6.35B: After making the second loop, the tail end is held by the right hand instrument.

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Chapter 6 Fig. 6.35C: By keeping the needle holder in same position, standing is pulled by the left hand instrument. This will aid the tightening of the first knot.

Fig. 6.35D: After tightening the first knot, the right hand instrument is pulled and second knot is formed.

(Figs. 6.37 to 6.41). By holding both ends of the thread pulled outside, the port tract is approximated.

Laparoscopic-assisted Mechanical Stapling Techniques The staplers help laparoscopic surgeons in tissue approximation, transection of blood vessels in major

procedures, and resection of organs and lung biopsy during thoracoscopy. The tissue trauma following stapled resection and anastomosis is generally less when compared to suturing by conventional methods. The principles of tissue approximation like minimal tissue handling; avoidance of contamination by bowel contents and avoidance of tumor handling can be easily accomplished by use of staplers. The staplers generally

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Fig. 6.36A: First knot is loose and second knot is tightened.

Fig. 6.36B: Holding the lengthier end of the thread with right hand needle holder.

Fig. 6.36C: With left hand instrument, hold the smaller end of the thread.

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Chapter 6 Fig. 6.36D: Bring both of them in a straight-line alignment, observe the knot direction is changed.

Fig. 6.36E: Tighten both the ends in a straight line, the knot slips down.

Fig. 6.36F: Initial loose knot gets tightened.

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Fig. 6.37: Port closure devices.

Fig. 6.38: Port closure technique (epigastric port in laparoscopic cholecystectomy) (A—epigastric port site; B—thread introducer inserts the thread into the peritoneal cavity through one side of the port).

reduce the time required for various reconstructions during major laparoscopic procedures. The safety record of staplers is equal to and often better than that of manual sutures in terms of contamination, but in terms of bleeding in the immediate postoperative

period manual suturing causes lesser bleeding than stapling. Professor Humer Hütl, a Hungarian surgeon, demonstrated the first mechanical device using staples in 1908. It placed two double rows of fine steel wire

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Chapter 6 Fig. 6.39: The suture material is grasped by the left hand instrument. The thread grasper is introduced through the other side of the port.

Fig. 6.40: Thread grasper holds the suture material.

staples so that the stomach or the duodenum could be transected, leaving a double row of staples on each side of the transection. This device was designed for use in distal gastrectomy. The design had all the three principles that are still used in internal stapling devices in the modern

era, namely B-shaped configuration of closed staples, placement of staples in double staggered rows, and use of fine wire as the staple material. Despite the success of these early devices, staplers were considered as providing only temporary closure, and an additional layer was added

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Fig. 6.41: Extracorporeal knot approximates the trocar port.

by suture. Over the years, major improvements have taken place including the disposable staple cartridge preloaded with staples of different sizes and patterns. Thus, a surgeon can obtain the optimal configuration for a procedure by simply inserting the appropriate reloading unit. Another recent development is the “single-patientuse-reloadable” staplers. These instruments provide the same convenience and potential cost savings of the preloaded, disposable devices. In addition, the capability of using disposable reloading units for repeated applications of one instrument during a surgical procedure results in a lower average cost per firing. Experience with the stapling instruments and techniques has elevated the operative surgery to a higher level of sophistication and reduced the need for physically wearing prolonged repetitive maneuvers. Manual suturing in laparoscopy is tedious and mechanical stapling anastomosis makes reconstruction phase of advanced procedure more effective. Effective and safe use of mechanical stapling devices depends upon good basic surgical technique, including clean, atraumatic dissection, careful hemostasis, attention to tissue condition and blood supply, and creation of tension-free anastomosis.

Staple Configuration (Fig. 6.42) Internal staplers join tissues with B-shaped staples of fine metal wire. As the instrument is fired, the open legs

of the staple are driven through the tissue and the staple assumes the shape of the alphabet “B”. This B-shaped staple will allow small vessels to pass through the openings in and between the staples, thus maintaining the viability of the tissue margin between the staple line and the cut edge to remain viable. However, such staple lines are not in themselves hemostatic. When an appropriate closed staple height is used, modern staples apply a clamping pressure of approximately 8 g/mm2, a level that promotes normal hemostasis, yet prevents leakage. Indeed, the slight, transient seepage along the transected edges of a stapled closure can be considered an indication of adequate blood supply to the tissue margin. Placement of staples in a double staggered row provides effective tissue closure. Clinical and experimental experience has now shown that everted staple closures heal as well as the traditional inverted closures.

Access Routes for Staplers in Laparoscopy The staplers should reach the bowel for its application. In laparoscopy different access routes are made use for introduction of staplers. These can either be inserted through one of the abdominal ports or through the mouth or through anus. Ports are the most common access routes for staplers. These are usually 12 mm ports as the staplers are larger

Laparoscopic Tissue Approximation

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Chapter 6 Fig. 6.42: Color coding of staplers routinely used.

than the routine laparoscopic instruments. Care should be taken in selection of these ports so that the desired orientation of the stapler and bowel is maintained. These ports should be closed with port closure needle as port site hernias can occur. Transoral route is preferred for esophagogastric anastomosis in bariatric surgeries and in esophagogastrectomy for adenocarcinoma of cardia. The anvil is introduced into the esophagus with a help of Ryle’s tube and the anastomosis is performed. In anterior resection the shaft of the circular stapler is introduced transanally after anal dilatation, while the anvil is placed in the proximal bowel.

Linear Staplers As the name suggests, a linear device places staples in two or three double staggered rows. Linear staplers with parallel closing jaws usually place a double staggered row of staples, and do not contain a knife. Forked staplers typically place three double staggered rows of staples, and usually (but not necessarily) contain a knife that transects the tissue between the two double rows. They are known as linear cutters. The flexible or articulating linear staplers are another variation. They have flexible or articulating components between the body and jaws that allow positioning versatility. This helps in easier division of structures in a narrow pelvic cavity. For example, in anterior resection and ultra low anterior resection the main difficulty of the presently available linear stapler is

the inability to divide the rectum at a plane perpendicular to the long axis. These staplers can bend at the tip and allow for better alignment of the stapler to avoid an angled stapled line. Applications of linear stapler: These staplers are commonly used to close internal organs prior to transection and to close the common opening or enterotomy after the creation of an anastomosis with a linear cutter or an intraluminal stapler. They are loaded with larger, heavier staples for use in gastric procedures. Biopsy or wedge resection of the lung and closing of the bronchus are some of the thoracic procedures in which linear staplers are commonly used. Applications of linear cutter: Since the linear cutter transects as it staples, this device is commonly used to transect organs, and to create side-to-side and functional endto-end anastomosis. When used to create a gastrostomy, the linear cutter applies a double staple line on the edges, which aids in hemostasis. Multifire Endo GIA 30, 45, or 60 places six staggered rows of titanium staples and divides the tissue between 3rd and 4th rows (Figs. 6.43 to 6.45). The instrument is available 35 mm (intestinal) blue in color, 25 mm (vascular) white in color, and 41 mm green in color thicker tissue. Each multifire gun can be used for more than 10 applications and cartridges can be used according to the tissues. There are cartridges available at different lengths of 3, 4, 5, or 6 cm. If longer transection is required, more than one cartridge or multifire GIA 60 instrument

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Fig. 6.43: Echelon Endo GIA stapler (Ethicon) with flexi tip.

Fig. 6.44: Ethicon Endo GIA stapler with powergun.

Fig. 6.45: Stapled division of small bowel (60 mm white cartridge used).

may be used. Cartridges with 2.5, 3.5, and 4.8 mm staple pins are available. This can be used for total of four firings. Tri-staple technology: • Generates less stress on tissues during compression and clamping.

• Allows greater perfusion into the staple line. • Provides superior performance in variable thickness.

Intraluminal (Circular) Staplers This instrument places staples in a double-staggered row, but in a circular configuration. Hence, they are

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Chapter 6

Fig. 6.46: Intraluminal circular stapler.

also known as circular staplers (Fig. 6.46). The staples are driven through the tissue as the instrument is fired. Simultaneously, a circular knife cuts a uniform stoma in the joined tissue. Thus, these staplers are used to create anastomosis between hollow viscera. Intraluminal staplers are available with various head diameters, permitting matching of instrument size to organ lumen. Application of intraluminal staplers: This type of instrument has a wide range of applications for inverted end-to-end, end-to-side, and side-to-side anastomosis throughout the alimentary tract, from the esophagus to the rectum. Circular stapling technique: Circular staplers are available in various diameters (21, 25, 27, 29, 31, and 33 mm). The shaft is either straight or curved. The size is chosen according to the diameter of the bowel. 25 mm or 27 mm stapler is preferred for esophagogastric or jejunal end-to-side anastomosis while 29 mm or 33 mm staplers are preferred for end-to-end colorectal anastomosis in anterior resection. The Premium CEEA Endopath Stealth endoscopic circular stapler device has an anvil, which has a shaft and stapling device rod. The stapling device rod has a nondetachable spiked rod on one end and the handle on the other end. The anvil is detached from the assembly and placed in the proximal bowel and a purse string suture is applied either by extracorporeal or intracorporeal method. A suture is tied through the tip of the white spike in the stapling device rod before it is inserted into the distal segment of the bowel. This helps in easy removal of the spike. The primary use of the spike is to reduce the level of trauma to the bowel while it pierces the distal end of the bowel. The stapling device rod in introduced though the anus. The spiked rod in the head of the stapling device is advanced while a grasping instrument pushes the distal

bowel against the stapled end to prevent tearing of the bowel. The spike is advanced through the stapled line till the entire rod projects through the distal bowel. The spike is then withdrawn from the stapling device rod by traction on the attached suture. The anvil is then gradually engaged to the stapling device rod by screwing motion of the knob at the end of the rod. After docking the anvil-shaft assembly, both the proximal and distal segments of the bowel is examined to ensure the bowels are not twisted. The anvil is approximated to the stapling device until contact is made and tightened further as indicated on the stapling device. Once this is ensured, the staplers are fired to create a circular anastomosis. After firing, the handle is turned anticlockwise to dislodge the stapler and removed gently. The anvil is opened and examined for the two intact tissue donuts.

ENDO STITCH Many surgeons have found it extremely difficult to perform laparoscopic knotting and suturing and have been reluctant to perform advanced complex procedures. Many devices have been designed to assist the surgeon in suturing. Endo Stitch (US surgical) has been found to be very useful in making single suture as well as continuous suturing. The manufacturer has made it available several suture materials with this device, which includes silk, nylon, and an absorbable lactomer. The main disadvantage of this technique is its limited indications. As the gap between the jaws is only 4 mm, tissues with greater thickness cannot be sutured. This may be a useful adjunct for suturing for beginners in laparoscopic surgery. The tip of the instrument has two jaws and a doublepointed needle with an accompanying suture attached to one of the jaws. The needle can be passed between the two jaws by closing the handles and moving the toggle switch or lever. This greatly facilitates endosuturing.14 The jaws of the instrument are placed around the tissue to be sutured

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Art of Laparoscopic Surgery Textbook and Atlas and the handles are approximated to close the jaws on the tissue. The needle is passed from one jaw to the other through the tissue with the help of the toggle switch. As the handles are released, the jaws open and the needle is gently pulled through the tissues. The jaws of the device are returned to the neutral position so that the surgeon can then remove the Endo Stitch. From this point, extracorporeal or intracorporeal knots can be performed depending on the skill of the surgeon. In extracorporeal knotting the Endo Stitch thread is pulled out and the routine technique is followed. The loops are made outside and slide down inside with a knot pusher and the knot is made. In intracorporeal technique, the needle is passed through the tissue and is held by the opposite jaw. The thread is twisted over the jaw that holds the needle to create the first half knot of surgeons knot. The needle is then shifted to the opposite jaw and pulled to complete the square knot. Intracorporeal suturing can be performed easily and more quickly. The decrease in time taken for intracorporeal suturing with these suture-assist devices may improve the outcome of the surgery, especially for the beginners.7 The Endo Stitch enhanced laparoscopic skills and was the preferred instrument for laparoscopic knot tying and suturing among surgical residents.15

SEAMGUARD—BIOABSORBABLE STAPLE LINE REINFORCEMENT Reinforcement made from a synthetic copolymer— polyglycolic acid:trimethylene carbonate (PGA:TMC) with a synthetic buttressing material engineered to reduce perioperative leaks and bleeding. It provides added strength to staple line and predictably absorbed within 6–7 months.

CONCLUSION Tissue approximation by laparoscopic intracorporeal knotting is highly effective in terms of safety and costeffectiveness. The various suture-assist devices that are available to achieve hemostasis, division and anastomosis, and prevent of spillage. These gain importance as surgeon is working in an difficult environment without tactile feedback. Moreover, accurate assessment of the

anastomosis is difficult in these situations. The staplers will play a major role in the laparoscopic surgery. In complex procedures, which are either difficult by hand sewn or requires multiple anastomosis, mechanical stapling is a well-accepted procedure.

REFERENCES 1. Van Veelen MA, Meijer DW, Uijttewaal I, et al. Improvement of the laparoscopic needle holder based on new ergonomic guidelines. Surg Endosc. 2003;17(5):699-703. 2. Shimi S, Banting S, Cuschieri A. Laparoscopy for advanced pancreatic cancer; Bilioenteric anastomosis for advanced disease. Br J Surg. 1992;79(4):317-9. 3. Cortez R, Lazcano E, Miller T, et al. Barbed sutures and wound complications in plastic surgery: an analysis of outcomes. Aesthet Surg J. 2015;35(2):178-88. 4. Tsukada T, Kaji M, Kinoshita J, et al. Use of Barbed Sutures in Laparoscopic Gastrointestinal Single-Layer Sutures. JSLS. 2016;20(3):e2016.00023. 5. Croce E, Olmi S. Intracorporeal knot-tying and suturing techniques in laparoscopic surgery: technical details. JSLS. 2000;4(1):17-22. 6. Emam TA, Hanna G, Cuschieri A. Ergonomic principles of task alignment, visual display, and direction of execution of laparoscopic bowel suturing. Surg Endosc. 2002;16(2):267-71. 7. Pattaras JG, Smith GS, Landman J, et al. Comparison and analysis of laparoscopic intracorporeal suturing devices: preliminary results. J Endourol. 2001;15(2):187-92. 8. Bautista T, Shabbir A, Rao J. et al. Enterotomy closure using knotless and barbed suture in laparoscopic upper gastrointestinal surgeries. Surg Endosc. 2016;30: 1699-703. 9. Szabo Z, Hunter J, Berci G, et al. Analysis of surgical movements during suturing in laparoscopy. Endosc Surg Allied Technol. 1994;2(1):55-61. 10. Meng MV, Stoller ML. Laparoscopic intracorporeal square-to-slip knot. Urology. 2002;59(6):932-3. 11. Hasson HM. Laparoscopic suturing. J Am Assoc Gynecol Laparosc. 2000;7(4):592-5. 12. Shirk G. Laparoscopic Suturing. J Am Assoc Gynecol Laparosc. 2000;7(4):594-5. 13. Pasic R, Levine RL. Laparoscopic suturing and ligation techniques. J Am Assoc Gynecol Laparosc. 1995;3(1):67-79. 14. Melzer A, Schurr MO, Lirici MM, et al. Future trends in endoscopic suturing. Endosc Surg Allied Technol. 1994;2:78-82. 15. Nguyen NT, Mayer KL, Bold RJ, et al. Laparoscopic suturing evaluation among surgical residents. J Surg Res. 2000;93(1):133-6.

CHAPTER

Laparoscopic Hemostasis INTRODUCTION The advent of laparoscopic surgery has created new technical challenges and problems. Hemostasis has been a key issue in minimally invasive surgery. If tissue becomes blood stained during laparoscopic surgery, ability to recognize the structures will be impaired due to absorption of the light by hemoglobin in the red blood corpuscles. Most of the times, hemorrhage is one of the common reason for conversion from laparoscopic method to open. Prevention of bleeding and control of hemorrhage requires the timely and appropriate use of technology. A wide variety of hemostatic modalities are available that can be used during laparoscopic surgery. Surgical clips, staples, and sutures are among some of the mechanical means of hemostasis. In some areas of the abdomen traditional means of securing hemostasis may be technically difficult, unreliable, or inefficient. It is in these circumstances novel energy sources like highfrequency electrosurgery, ultrasonics, vessel sealer, and thunderbeat are particularly useful in providing secure hemostasis. Electrosurgery and ultrasonic energy are the most common energy sources used in laparoscopic surgery. The principles are quite similar to those that govern the conversion of energy to heat within the tissues. A basic understanding of how each energy source functions, as well as their limitations and potential complications, allows the surgeon to make careful choices of operative settings and avoid potential problems. These two energy sources have facilitated the development of advanced laparoscopic surgery by allowing rapid and secure division of vascular structures. An ideal hemostatic device should have the following properties, but in the clinical situation, this does not exist. Surgeons are forced to select between the currently available devices based on the equipment, its advantages, and disadvantages.1

7

• An ideal hemostatic instrument: –– Should grasp, dissect, coagulate, and divide the tissue –– Should be ergonomically comfortable and easy to operate –– Should provide feedback when hemostasis has been secured –– Should cause no lateral thermal damage –– Should be available in a variety of configurations for both open and laparoscopic surgery. • Mechanical methods: –– Mechanical clips –– Linear stapling devices –– Pretied suture loops –– Simple ligatures –– Suturing • Energy-induced hemostasis: –– Electrosurgery –– Ultrasonic dissection –– LigaSure –– Thunderbeat –– Enseal –– Argon beam coagulation –– Cavitational ultrasonic surgical aspirator (CUSA) • Adjuvants of hemostasis.

MECHANICAL METHODS OF HEMOSTASIS Endoscopic Clipping Method Initially, 10 mm clip appliers were developed with long shafts to facilitate ligation of small ducts and vessels as in conventional surgery. Metallic clips made of titanium are most often used. They are inert, least tissue reactive, and inert to radiation. Use of titanium clips does not inter­ fere with available investigative facilities such as ultra­ sound, computed tomography (CT) scan, and magnetic resonance imagining (MRI) scanning.

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Art of Laparoscopic Surgery Textbook and Atlas Different sizes of clips are available, medium: 7 mm, medium-large: 9 mm, and large: 11 mm. Medium size is used for small vessels like the cystic artery; mediumlarge for structures like the cystic duct and appendicular artery; and large clips for larger vessels such as left gastric or colonic vessels. The clip applicators are available in reusable and dis­ posable forms. The commonly available disposable clip applicators contain preloaded 20 clips each in medium and medium-large clip sizes separately. Advantages of preloaded 5 mm clip applicators are threefold like they can deliver 9 mm clips, can deliver the clips faster and comes with piston handle. Reusable clip appliers are available from several manufacturers (Karl Storz, Ethicon, and Covidien) that allow the surgeon to considerably decrease the cost, but these instruments have to be reloaded after application of each clip (Fig. 7.1). Before applying the clip, visuali­ zation of both sides of the clip is mandatory to ensure adequate tissue approximation. Rotation of the shaft so that the beveled edge faces the surgeon effectively prevents inadvertent clipping of nontarget tissues. Angled clip appliers are used for safe application of clips in difficult situations. Nonabsorbable (Hem-o-lok) and absorbable clips with the double locking system (Lapro-clip) are also available in various sizes with which clipping of ducts and small vessels and also the base of the appendix can be done even. Hemo-o-lok clips are available in various sizes of 7, 10, 13, and 16 mm with color coding. Some surgeons prefer absorbable clips during suturing to hold the thread at the beginning and the end of continuous suturing. Most of the Asian and Western countries are currently preferring to use absorbable clips.

Complications Improperly applied clips without locking system can slip, resulting either in bleeding or bile leakage. Properly applied clips are very difficult to manipulate along the axis of the structure, but it can be easily pulled out if traction is applied along the long axis of the clips (due to the presence of serrations). It is not advisable to manipulate the clips unnecessarily by suction or any other instruments close to it. The clips can dislodge if the structure is divided too close to the clips. Hence, an adequate gap must be maintained between the clip and the cut edge to prevent slippage. Slippage can be prevented by applying titanium clip after the applying the Hem-o-lok clip. The theoretical migration of clips into common bile duct has been raised. Flush clipping of the cystic duct at the junction with common duct may lead to migration. Clipping the cystic duct 5 mm away from the cystic duct—common bile duct junction will avoid this com­ plication. Loop ligature adds to the safety if the clipping is not proper. In such cases, it is advisable to apply the loop proximal to the clip rather than towards the divided end. Inadvertent ischemic necrosis can occur due to the application of metallic clips close to the bile duct or bowel wall, which might lead to stricture or perforation.

Linear Stapling Device Although these instruments are used primarily for anastomotic purposes, they are of vital use to prevent major hemostatic complications. Endoscopic linear cutters facilitate the hemostatic division of tissue. There are various linear staplers with different staple

Fig. 7.1: Reusable clip applicator [A—large clip (11 mm); B—medium-large (9 mm); and C— medium (7 mm)].

Laparoscopic Hemostasis In case of injury to major vascular structures like aorta or inferior vena cava or bleeding from a retracted vessel, intracorporeal suturing using needle holder helps in hemostasis and requires good coordination between two hands and the operating team.

Pretied Loop Ligatures

General Principles

Slip knots have limited use in primary hemostasis because the vessels or vascular pedicles must be divided, grasped, and then encircled by the loop. However, the loops are extremely useful to secure bleeding vessels after transection. This can be performed in two ways. Firstly an atraumatic grasper is passed through another port and through the loop of the suture ligature. The second grasper grasps the stump of the bleeding structure and the first grasper is released. The loop is snagged down over the shaft of the instrument securing the bleeding vessel. In the second method, a clip can be applied proximally to the proposed site of the division, divide, and then apply an endoloop to the stump so that better hemostasis can be obtained.

Electrocautery, ultrasonic waves are the energy forms that are most often used. The principles are quite similar to those that govern the conversion of energy to heat within the tissues. When an alternating current frequency (500 Hz to 3 MHz) is applied across the cell, the cations and anions rapidly oscillate within the cytoplasm and elevate the temperature within the cell. • At or above 45°C, tissue necrosis starts. • 50–80°C, irreversible protein denaturation and coagulative necrosis occurs. • 80–100°C, total desiccation of tissue and carboni­ zation occurs leading to drying and shrinkage of tissues. • At or above 100°C, water vaporization leading to cellular destruction occurs. The surgeon observes

Simple Ligatures Suturing can be in both intracorporeal and extracorpo­ real method. Intracorporeal suturing is a relatively skillful task when compared to extracorporeal suturing. Simple ligation of the vessel is done by placing intracorporeal square knot around the vessel to be ligated. While making extracorporeal knotting, it is better to keep a long thread and care must be taken to not injure tissue or vessel when knot is being pushed.

Suturing In laparoscopic surgery, it has been used primarily for tissue approximation and to perform the anastomosis.

ENERGY-INDUCED HEMOSTASIS Before utilizing the energy devices, it is considerably important to understand basic terminology and physics of the energy devices (Table 7.1). A basic understanding of how each energy source functions, applications, limitations, and the potential complications allows the surgeon to make careful choices of instruments, opera­ tive settings so that hazards of instrumentation can be avoided.

Table 7.1: Basic terminology and physics of the energy devices. Current (I)

The number of electrons moving past a given point per second, measured in amperes

Voltage (V)

The force that pushes electric current through the resistance and it is an electro­motive force or potential difference expressed in volts

Resistance (R) The lack of conductivity or the opposition to the flow of electric current, measured in ohms

Chapter 7

sizes (2.5 mm vascular, 3.5 mm intestinal, and 4 mm colonic), coded with different colors for identification during application. Many surgeons use vascular staplers for control of vascular pedicles such as splenic hilar vessels, inferior mesenteric pedicles, etc. Anastomosis by linear stapler makes perfect hemostatic cutting with simultaneous anastomosis, which is very useful in clinical practice. Inspection on both sides of the device is mandatory before firing the stapler in order to ensure that vital structures are not included in stapling area and also it is important to make sure that the entire tissue is within the active area as indicated in between the marks or numbers on both sides of the device. At our institute, we use incorporeal suturing to secure named vessels as a hemostatic method for cost reduction whenever needed.

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Art of Laparoscopic Surgery Textbook and Atlas a plume of gas and smoke that represents water vapor. • Above 125°C, complete oxidation of proteins and lipids lead to carbon residue or eschar formation.

Electrosurgery In laparoscopic surgery, electrosurgery is one of the most commonly used energy systems. The laparoscopic electrosurgical injuries are more common when com­ pared to conventional surgery, as the manipulative skills for laparoscopy are slightly different, with different spatial orientation and hand-eye coordination, coupled with lack of tactile feedback.2 Though popular and costeffective, the combination of electrosurgery and laparo­ scopy can be a dangerous situation that is often poorly understood. It has been estimated that the laparoscope allows the surgeon to view only 10% of the live electrode at any one time and the rest of the instrument is hidden from the field of vision. Based on this, four zones of possible energy transfer are identified and discussed in further sections of this chapter. Apart from the direct injury due to accidental appli­ cation of the instrument on unnecessary tissue, injury can also happen due to factors that are to a large extent, beyond the surgeon’s direct control. Stray electrical energy can escape from monopolar instruments, causing serious burns and tissue damage, including bowel perforation and lead to disastrous complications including death. These often go undetected and present with extremely difficult patient management challenges. Stray currents occur as a result of various mechanisms such as insulation failure, direct coupling, or capacitance coupling. The exact incidence of laparo­ scopic electrosurgical complications is very hard to ascertain as most of these complications are treated without determining the exact cause.3 However, the rough incidence of the laparoscopic electrosurgical complications has been reported to be 2.3 per 1,000 electrosurgical procedures in the 1970s4 and 2–5 per 1,000 in the 1990s.5,6

Physics of Electrosurgery Electrocautery versus electrosurgery: When the highfrequency electrical current (frequency range of 300,000–600,000 Hz) is passed through a tissue, it is heated by conduction and this causes the hemostasis.7 This is entirely different from electrocautery, where the electrical current is used to heat the surgical instrument,

and the heat of the instrument is transferred to the tissue.

Mechanism of Monopolar and Bipolar Electrosurgery In monopolar electrosurgery, the current flows from the generator to the patient through the active electrode. It reaches the generator back through the return electrode. As the contact area of the active electrode is much less than the return electrode the current gets concentrated in the active electrode to produce the desired effect. The return electrode should have a surface of 22 square inches and place over a muscular surface, coated with a conductive gel to enhance conductance. Whereas in bipolar surgery, the active and the return electrodes are separated by just a few millimeters and the current passes directly between the two prongs of the instruments. The lateral thermal damage of the tissues is much less in bipolar instruments when compared to monopolar instruments.

Modes and Effects of Electrosurgery Cutting current (continuous wave, high frequency, and low voltage) produces focal and rapid tissue heating and a cutting effect—heating occurs so rapidly that there is minimally associated coagulation necrosis and therefore no hemostasis. Coagulating current (pulsed waveform, low frequency, and high voltage) produces a slow heating that causes protein denaturation. Hemostasis occurs via coagulation necrosis in and around the target tissues.

Application of Electrosurgery in Laparoscopy In laparoscopic surgery due to its limited visual field, the control of even the smallest amount of bleeding is desirable. All laparoscopic electrosurgical procedures are performed with the pulsed coagulation current in blend mode. Even though only coagulation type of current is used in laparoscopic surgery, all the effects of electro­ surgery like cutting, coagulation, and fulguration can be achieved by varying the current density. For example, a cutting effect can be achieved by using the tip of the hook with its smaller surface area using coagulation type of current. If the shoulder of the same hook is applied over the target, we can achieve a coagulation effect. The current density is reduced in this situation as it passes through a wider surface area when compared to the tip

Laparoscopic Hemostasis

Types of Injuries Electrosurgical injuries can occur to any part of the body. Improper placement of return electrodes may result in burns in the area of inadequate contact. Injuries can occur to any viscera in the abdominal cavity. The bowel injuries are the most dangerous injuries as they can result in fatalities. The small bowel is more commonly affected than the large bowel. Apart from bowel, biliary system, ureter, and other viscera can get injured during the use of electrocautery. These injuries can present as acute events or present as late complications such as strictures in biliary tracts and ureters or as fistulas.8 Most of the electrosurgical injuries present between 4th and 10th postoperative days.

Mechanism of Injuries The electrosurgical injury can occur as a result of the direct application, insulation failure, direct coupling, capacitive coupling, and other causes.

Fig. 7.2: Insulation failure injury.

Direct application: Direct application is usually due to inadvertent activation of the electrosurgical probe on a vital structure. Incidences have been reported where iliac artery injuries have occurred during dissection in the pelvis.8 These injuries can also occur if the assistant accidentally presses the footswitch when the tip of the instrument is touching the vessel. This can also occur when the footswitch is accidentally pressed when it is moved from one area to the other as the surgeon moves to operate from one position to a different position. Even though these injuries occur in conventional surgery, the probability in laparoscopic surgery is more due to the limited field of vision. Insulation failure: This type of failure occurs when there is a loss of the insulation sheath that covers the active electrode either due to overuse or due to repeated cleaning and sterilization (Fig. 7.2).9 Four zones of possible of electrosurgical injuries are identified as shown in Table 7.2. The severity of the injury is inversely proportional to the size of the insulation defect, as the current gets more focused when it passes through a smaller crack when compared to a larger one. Checking the instruments carefully for any visible loss of insulation is extremely important. Greater vigi­ lance is required with a reusable instrument as the insu­ lation is more subject to damage and the current can

Chapter 7

of the hook. Fulguration can be achieved by keeping the instrument at a small distance away from the tissue so that the current arcs from the active electrode to the tissue to produce a shallow coagulation. The same principle can be applied to various instruments such as the spatula, scissors, etc.

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Art of Laparoscopic Surgery Textbook and Atlas easily be transmitted to the abdominal wall producing thermal burns in the skin. Direct coupling: These injuries occur when the tip of the active electrode comes in direct contact with another metal instrument (Fig. 7.3). If the instrument is activated when the tip is touching the laparoscope or any other uninsulated material, the current may pass from the electrode to the laparoscope or another uninsulated metal instrument and cause a burn where the second electrode comes in contact with a viscus.10

Table 7.2: Four zones of possible of electrosurgical injuries. Zone 1

Insulation failure within the visible field of vision

Zone 2

Insulation failure between zone 1 and trocar end which is not visible

Zone 3

Insulation failure of the part of the instrument within the trocar

Zone 4

Insulation failure near the surgeon end of the instrument

Fig. 7.3: Direct coupling injury.

If the laparoscope is placed through a metal cannula, the current on the laparoscope will reach the return electrode through the metal cannula (Fig. 7.4). But this is not possible if the laparoscope passes through a plastic sheath, as the current will not be able to reach the return electrode. Some surgeons use the direct coupling effect to coagulate tissue grasped in one instrument by touching it with another active instrument. Caution must be employed as this can potentially lead to current directed towards nontarget structures. Capacitive coupling injuries: A capacitor is defined as two conductors separated by an insulator. Capacitors can store electric charge. During laparoscopic electrosurgery, the electrosurgical device behaves as one conductor, the surrounding metal cannula behaves as the other conductor, and the intervening intact insulating sleeve of the electrode behaves as an insulator. This arrange­ ment can serve as a capacitor and accumulate electric charge if the electrode is activated before the tip is placed in contact with the tissue. As long as the metal cannula is in direct contact with the abdominal wall, the charge may escape safely to the return electrode.

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Chapter 7

Fig. 7.4: Return of electrical current in the anterior abdominal wall through the metal trocar.

If a plastic sleeve with a fascial thread is used to anchor the metal cannula to the abdominal wall, then this safety mechanism might be lost. The accumulated energy may not be able to reach the return electrode. Instead, it may discharge through a point of contact between the cannula and the intestine. Therefore, the arrangement of an electrosurgical device within a metal cannula that is anchored with a plastic sleeve is potentially dangerous.11 A useful rule of thumb is to always use metal sleeves with a metal cannula and plastic sleeves with plastic cannula so as to avoid these injuries. Capacitive coupling can also occur between an electrode and another metal instrument (Fig. 7.5). Capacitive coupling can be avoided by not activating the cautery until the tip is in contact with tissue so that the current has a route to reach the ground and is not transferred into a capacitor. Alternate ground pad burns: The placement of the return electrode is extremely important. If the area in contact is not sufficiently large, it can produce burns at the site of the return electrode or at places remote to that of the return electrode. The current that is not able to pass through the return electrode reaches the ground through paths of least resistance like towel clips, and electrocardiography (ECG) leads and causes

burns in that area.12 To avoid ground pad burns, nowadays, ground pads with a wide surface area like MegaSoft® are used. These wide areas are effective in preventing ground pad burns and also carry the advantage of longevity. Other injuries: A recognized hazardous situation is when electricity is applied to a relatively isolated tissue. For example, if the monopolar current is applied to the completely dissected appendix, the only path that the current may follow to the return electrode is through an instrument or through the small area of tissue that still attaches the appendix or ovary. This situation may predispose to one of these three types of injury or may lead to an isolation burn—a concentration of energy into the small area of tissue that attaches, for example, the appendix to the caecum, creating a cecal burn or necrosis. The surgeon may be injured by low resistance conduction through a wet glove or through a hole in the glove.13

Prevention of Laparoscopic Electrosurgical Injuries14 • A complete and thorough knowledge of the bio­ physics of electrosurgery

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Fig. 7.5: Capacitive coupling injury.

• Thorough preparation and training of the operating room staff and regular equipment maintenance • Bowel preparation is important if it is anticipated that the large bowel is at risk • Choosing proper current waveform mode • Improvement of dexterity and hand-eye coordi­ nation by training • Avoiding activation of the electrode when the tip of the instrument is not in the field of vision • Avoidance of hybrid trocar sleeves • Use of electrosurgical accessory safety equipment like return and active electrode monitoring system to detect the stray currents, newer design generators, and smoke evacuation systems to improve visualization • Setting up of a laparoscopic team that includes a biomedical engineer, perioperative nurses, and other operating room personnel and promoting continued education activities. Recently a concept of active electrode monitoring has been introduced. These have a conductive sheath over the insulated portion of the instrument. Any energy that is stored in the instrument due to insulation failure, capacitance coupling are collected by these conductive sheaths. If the energy reaches beyond a threshold the generator is automatically shut off and an audible

alarm is given. This helps the surgeon in identifying the problem and take corrective actions.

Unique Problems Associated with Electrosurgical Injuries These injuries pose unique problems in relation to recognition of these injuries. More than 75% of these injuries are unrecognized at the time of occurrence. Moreover, these may not cause clear-cut or rapid symptoms and abnormal laboratory values. As these are often unrecognized the possibility of these injuries are rarely thought of in the postoperative period. When the patient is not improving as expected, usually con­ servative measures are applied till the patient develops septicemia. The degree of peritonitis depends upon the amount of spillage and the length of time between perforation and exploration. Managing patients at the end of the spectrum may not be effective at all times and can even cause mortality.

Management of Electrosurgical Injuries As these patients do not develop signs of classic peri­ tonitis, a suspicion of this possibility should always be kept in patients who are not improving and who have

Laparoscopic Hemostasis

LigaSure (Valleylab) LigaSure is a used radio frequency current and control­ led pressure to achieve hemostasis. Energy is delivered continually with low voltage and high current flow (amperage) in a bipolar mode to reduce the risk of injury and eliminate the need for a patient return electrode (grounding pad). This is a bipolar electrosurgical hemostatic device consisting of a specialized electro­ surgical generator and handset, that seals the lumen of a blood vessel of up to 7 mm in diameter by delivering the appropriate amount of energy to the tissue and denaturing collagen and elastin of the vessel wall.16 The simultaneous delivery of mechanical and electrical energy remodels the vessel tissue to form a desiccated absorbable collagen seal out of native vessel protein. The temperature of the tissue remains relatively low, minimizing the thermal spread and reducing sticking and charring. It has a tissue sensing technology with which it automatically changes the amount of current needed to seal the tissue, is delivered exactly. When tissue response indicates a successful seal, a cool cycle is entered, during which time the device position is maintained and the generator is shut off. The generator emits an audible tone during the cooling period, to indicate cycle completion. On average, the entire sealing and cooling cycle takes approximately 5 seconds. Using this instrument a precise amount of energy is delivered to the target tissue, and no excess energy is delivered to the surrounding tissue, limiting the lateral

thermal spread. It has been reported that the thermal spread to the adjacent tissue is limited to less than 1.5 mm beyond the tissue within the jaws of the instru­ ment.17 It was reported that the use of this instrument resulted in prolonging of the operative time as the surgeons had to remove the instrument after application and then reintroduce the scissors for the division of the vessel.18 The use of LigaSure has been reported in various conventional surgeries like thyroid surgery,19 hemor­ roidectomy,20 pancreatic and liver surgery,21,22 and also in laparoscopic surgeries like colectomy,23 nephrectomy,24 and splenectomy.25 Though there are many advantages of these instruments, there are some pitfalls also. The instrument is large and is not suited for dissection of the tissue in the abdominal cavity. LigaSure is a specialized bipolar device (Valleylab) that is highly useful to control the bleeding of vessels such as the inferior mesenteric artery, splenic artery, etc. After repeated use of the forceps, it becomes sticky and tends to avulse the tissues that are held and may lead to bleeding. By mistake, if the trigger is activated before coagulation, the knife may divide the vessels resulting in a formidable situation.

LigaSure Advance™ It is a recent advancement in the LigaSure device that tried to overcome the disadvantage of inability to per­ form tissue dissection. LigaSure Advance™ comes with monopolar cautery tip using which tissue dissection can be done and with the same device monopolar cautery can be applied (Figs. 7.6A and B).

Enseal™ It is another vessel device from SurgRx (Ethicon) works based on the similar principle of LigaSure. It comes with both straight and curved blades. The important advan­ tage is that it can be connected to the harmonic scalpel central system and thus avoids the need of purchasing another vessel sealing system.

Argon-enhanced Electrosurgery This is very identical to that of the monopolar cautery except for the presence of a constant stream of argon gas that completes the circuit. This method avoids direct contact between the electrode and the tissue. This results in denaturation of surface proteins and formation of a

Chapter 7

increasing abdominal pain after surgery. These patients demand an expedient evaluation, even if it requires a negative laparoscopy.15 Even subtle symptoms such as the inability to void may be an early manifestation of bowel injury. A lower gastrointestinal (GI) bleed can denote a thermal injury to the lower GI tract. Recognition and immediate attention to the management of the complications can minimize the damage and even save the patient’s life. Superficial injuries recognized during the procedure can be treated either with prophylactic plication sutures by laparoscopy or after exteriorization of the bowel. In case of full-thickness perforation, wide excision (5 cm margin) to include the area of coagulation necrosis guards against reperforation. Rarely, there is a need for colostomy in these bowel injuries. Injuries recognized in the postoperative period should be managed as any other perforation.

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Fig. 7.6A: LigaSure generator.

Fig. 7.6B: Hand instruments.

shallow eschar. Argon is an inert, nonreactive noble gas, rapidly absorbed into the bloodstream and excreted by the lungs. It is neither combustible nor does it support combustion. In conventional surgery, argon beam cutting has shown less blood loss than conventional electrosurgery. The significant limited cutting current ability, lack of tactile feedback, and concern about gas embolism limits routine use. It has a definite role in the advanced procedure requiring control of solid organ parenchymal bleeding via a minimally invasive approach.

In endoscopy, argon beam is used for destruction of dysplastic mucosa and also hemocoagulation of bleeding from varices, tumor bleeds, etc. (Figs. 7.7A and B).

Ultrasonic Energy Devices (Harmonic Scalpel) Of all the energy devices that are developed till now, the harmonic scalpel is most surgeon friendly instrument and it helped in the evolution of laparoscopic surgery.

Laparoscopic Hemostasis

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Chapter 7

A

Figs. 7.7A and B: Argon-enhanced electrosurgery unit and probe.

B

Ultrasonically activated scissors and related instruments use high-frequency waves (more than 55,000 Hz) to induce mechanical vibration at the cellular level.26,27 The result is a localized heat generation from friction and shear producing a predictable pattern of thermal destruction. The basis of these devices is the piezoelec­ tric crystal, which vibrates in a characteristic frequency when an electric field is applied. The crystal is attached

to a rod which carries the vibration to the instrument tip, which moves in the long axis.28 The heat and vibration together denature proteins by disrupting hydrogen bonds, leading to the formation of a sticky coagulum in a localized area around the instrument tip, at a lower temperature. The ability to coagulate small blood vessels with minimum heat transmission causes less tissue trauma

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Art of Laparoscopic Surgery Textbook and Atlas than electrocautery. Because there is no electric energy transmitted to the tissues, there is no risk of electrical burn. The vibration of the edge results in a sawing action and cutting of the tissue with coagulation of the immediately adjacent tissues and of blood vessels with a diameter of up to 2 mm. The vibration of the blunt instrument causes coagulation and control of larger vessels reliably up to 5 mm.29 The coagulation is related to the amount of mechanical pressure exerted at the tip as well as the surface area over which contact is made with the tissues. Histological studies have shown that the microscopically visible tissue damage produced by harmonic scalpel extends only 1–2 mm from the point of incision, a tenth as far as is seen with electrocautery.

Advantages Another potential advantage of ultrasonically activated devices is superior visualization. Because the harmonic scalpel operates at relatively low temperatures when compared with electrically activated devices, desiccation by boiling off of tissue water and charring does not occur, eliminating much of the troublesome steam and smoke produced by electrosurgery. As the temperature never exceeds beyond 800°C, the tissue charring effect is almost nil.30 Hence, the operation is always clean and allows identification of tissue plane precisely in a bloodless field. Operation of the harmonic scalpel on tissue does produce a fine mist of particulate matter, which quickly deposits onto tissue surfaces. The post­ operative adhesions may be reduced by the harmonic scalpel. At our institute, we have used the harmonic scalpel to almost every GI, urology, and gynecological laparoscopic procedures and it is an excellent tool for laparoscopic surgery. The device can function as combination grasper, coagulator, retractor, and dissector in a single instru­ ment. These sorts of instruments have the potential to reduce the number of instrument exchanges required to perform an operation and thus reduce operative time and cost, especially when combined with other advanced technologies. A combination of cutting coagulation in various degrees can be achieved with the harmonic scalpel by selecting the appropriate configuration of the blade and power level setting (level 1 coagulation only and level 5 cutting only). For vascularized adipose tissue, the rounded blade with a medium power setting (2–3) usually suffices. A larger

vessel of 2 mm and above would require the flat edge of the activated blade on a lower power pressure setting to slowly coagulate the vessel and pressure on the anvil cuts the vessels. Even for routine surgeries, we find it very useful for tasks like the division of mesoappendix or cystic artery without clips or ligation. In control of vascular pedicles such as colonic vessels, harmonic control of vessels and dissection may be performed successfully. This versatile tool can grasp, bluntly dissect, sharply cut, and coagulate.

Disadvantages The active blade can injure bowel, blood vessel, or any structure that comes in contact during activation. Another disadvantage is that it can not seal the vessels and it does not have functions like cutting or coagulation and dependent primarily on the amount of traction given by the surgeon.

Harmonic ACE Advances Harmonic ACE is next generation probe with 5 mm curved probe that helps in easy dissection near delicate tissues (Fig. 7.8). When compared to older versions of the harmonic probe, the Harmonic ACE has the follow­ ing advantages like the increased transaction speed as the probes move through tissues quickly while main­taining hemostasis. It also has increased vessel-sealing capability and effectively seals vessels up to 5 mm and decreases the need for instrument exchange. This probe also has a hand activated mechanism, which is more user-friendly. Harmonic ACE+ brought the additional inclusion of tissue adaptability technology so that adjusted desired energy can be delivered to the tissue causing advanced hemostasis. harmonic ACE7+ comes with an extra advanced hemostasis button and it can be used to seal 7 mm blood vessels. Latest development of harmonic scalpel is harmonic HD is yet to launch and is going to replace the all the existing probes. This probe has wider and slender jaw that can produce higher burst pressures providing better sealing of as bigger as 7 mm vessels.

Sonicision™ It is another advanced energy device based on ultrasonic energy from Covidien. It is the first cordless ultrasonic dissector and comes with a reusable generator and battery and limitation of single usage of the probe.

Laparoscopic Hemostasis

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Chapter 7 Fig. 7.8: Ultracision harmonic scalpel generator with 5 mm hand instruments.

Fig. 7.9: Thunderbeat.

Thunderbeat

Cavitational Ultrasonic Surgical Aspirator

It is a revolutionary technology with the integration of both ultrasonic energy and advanced bipolar sealing system into a single probe to overcome disadvantages of either of the two (Fig. 7.9). It can seal vessels up to 7 mm size and has tip amenable to perform tissue dissection.

The cavitational ultrasonic surgical aspirator (CUSA) works on the same principle as that of the ultrasonic dissection (Fig. 7.10). This was introduced in the market in 1976, which was combined with suction and irrigation. Later the electrosurgery was also com­

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Fig. 7.10: Cavitational ultrasonic surgical aspirator.

Fig. 7.11: Liver parenchymal dissection using cavitational ultrasonic surgical aspirator.

bined with CUSA and with the extension of the hand­ piece to 30 cm and reduction of the diameter to 10 mm, it is now possible to use it in laparoscopic surgery. The handpiece consists of an acoustic vibrator, a coupler, and an interchangeable tip. The acoustic vib­ rator consists of the piezoelectric cells and the coupler that is a hollow cylindrical pipe of 30 cm diameter, with a diameter of 2 mm at the tip of the cylinder. The tip of the instruments oscillates to and fro at a frequency 23,000 Hz/sec with a maximal displacement of 200 µm. When ultrasonic waves are delivered to tissues with a larger amount of water contents, alternating positive and negative pressure agitates the molecules of the liquid particles.

During the negative phase, cavitation occurs which enlarges in size continuously as there is little chance for the bubble to shrink to the original size due to rapid alteration of the two phases. The cells explode after it reaches a critical size of 170 µm and this causes fragmentation of the cells. When this energy is applied to the liver tissues, the hepatocytes will be desiccated and aspirated by the device, isolating the bile ductules and venules. These structures contain more collagen and fibrous tissue and less of water and the ultrasonic energy are less efficient in these tissues. At the end of the application of CUSA to the liver, the remaining structures can be tackled either by division with har­ monic scalpel, clip, or by ligatures (Fig. 7.11). The hand­

Laparoscopic Hemostasis

ADJUVANTS OF HEMOSTASIS These adjuvants would be helpful for control of hemor­ rhage in laparoscopy in situations like surface bleeding from liver, spleen, and gallbladder. Examples include Abgel, Surgicel SNoW, and Evicel.

Abgel® It is absorbable gelatin sponge that can aid coagulation so that minor bleedings can be rapidly controlled. It is gamma sterilized and prepacked and should not be resterilized. It absorbs 40–50 times of its weight of blood rapidly and adheres to the bleeding site. In laparoscopy, a single Abgel can be divided into three parts, rolled longitudinally so that they can be placed inside peritoneal cavity through 10 mm port. Uniform porosity of Abgel helps in hemostasis.

Surgicel SNoW® It is oxidized regenerated cellulose that helps in controlling oozing of blood. Some studies are claiming that it has antimicrobial properties along with hemo­ static activity.

Evarrest It is a fibrin patch that can be applied at the sites of minor bleeding with proper access.

Surgiflo It is a flowable gelatin matrix which can be applied over bleeding from tight and irregular places.

Evicel It is liquid form of fibrin sealant and forms tight matrix over the surface thereby providing hemostasis. It comes with two different solutions fibrin and thrombin. These two solutions mix during the injection over a surface and forms a uniform layer rapidly so that hemostasis is achieved.

Note: All these adjuvants should be a last resort in the armamentarium of hemostats after mechanical and energy application. It should be remembered that these adjuvants in every sense and should not form the pri­ mary line of hemostasis.

CONCLUSION The surgeon has excellent hemostatic tools at his dis­ posal when compared to their counterparts in the olden days due to the technological advancements. Even today new hemostatic tools are being invented and tried for use in humans. Each technology has its advantages, limitations, and has to be used selectively. Knowledge of these equipment can help the surgeon in decisionmaking and finally improve the outcome of the surgery either in open or laparoscopic procedures.

REFERENCES 1. Fried GM. Hemostatic Tools for the Gastrointestinal Surgeon: Ultrasonic Coagulator vs. Bipolar Ligation. J Gastrointest Surg. 2001;5(6):216-8. 2. Azziz R. Training, certification, and credentialing in gynecologic operative endoscopy. Clin Obstet Gynecol. 1995;38(2):313-8. 3. Tucker RD, Volyes CR. Laparoscopic electrosurgical com­ plications and their prevention. AORN J. 1995;62:49-78. 4. Loffer FD, Pent D. Indications, contraindications, and complications of laparoscopy. Obstet Gynecol Surv. 1975;30(7):407-27. 5. Hulka JF, Levy BS, Parker WH, et al. Laparoscopicassisted vaginal hysterectomy: American Association of Gynecologic Laparoscopists’ 1995 membership survey. J Am Assoc Gynecol Laparosc. 1997;4(2):167-71. 6. Cooper MJ, Fraser I. Training, and accreditation in endoscopic surgery. Curr Opin Obstet Gynecol. 1996; 8(4):278-80. 7. Soderstrom R. Principles of electrosurgery as applied to gynecology. In: Rock JA (Ed). Te Linde’s operative Gynecology. Philadelphia: Lippincott-Raven; 1997. pp. 321-6. 8. Nduka CC, Super PA, Monson JR, et al. Cause and prevention of electrosurgical injuries in laparoscopy. J Am Coll Surg. 1994;179(2):161-70. 9. Vancaillie TG. Electrosurgery at laparoscopy: Guidelines to avoid complications. Gynaecological Endoscopy. 1994;3:143-50. 10. Phipps JH. Understanding electrosurgery: safety and efficiency. In: In Lower A, Sutton C, Grudzinskas G (Eds). Introduction to Gynecological Endoscopy. Oxford, UK: Iris Medical Media; 1996. pp. 39-56. 11. Martin DC, Soderstrom RM, Hulka JF. Electrosurgery safety. Am Assoc Gynecol Laparosc Tech Bull. 1995;1:1-7.

Chapter 7

piece contains an irrigation device, which constantly cools the rapidly vibrating tip, while continuous suction through the center of the cylindrical coupler keeps the field clear. This has been effectively used in various situations like liver resections,31-35 partial nephrectomy, splenorrhaphy,36 and other gynecological procedures.37

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Art of Laparoscopic Surgery Textbook and Atlas 12. Moak E. Electrosurgical unit safety. The role of the perioperative nurse. AORN J. 1991;53(3):744-6. 13. Tucker RD, Ferguson S. Do surgical gloves protect staff during electrosurgical procedures? Surgery. 1991;110:892-5. 14. Wu MP, Ou CS, Chen SL, et al. Complications and recom­ mended practices for electrosurgery in laparoscopy. Am J Surg. 2000;179(1):67-73. 15. Soderstrom RM. Bowel injury litigation after laparoscopy. J Am Assoc Gynecol Laparosc. 1993;1(1):74-7. 16. Thomsen S, Pearce JA, Kennedy JS. Mechanisms of electrosurgical fusion for large vessel hemostasis. Minim Invasive Ther. 1995;4:19. 17. Kennedy JS, Stranahan PL, Taylor KD, et al. High-burststrength, feedback-controlled bipolar vessel sealing. Surg Endosc. 1998;12(6):876-8. 18. Heniford BT, Matthews BD, Sing RF, et al. Initial results with an electrothermal bipolar vessel sealer. Surg Endosc. 2001;15(8):799-801. 19. Lachanas VA, Prokopakis EP, Mpenakis AA, et al. The use of LigaSure Vessel Sealing System in thyroid surgery. Otolaryngol Head Neck Surg. 2005;132(3):487-9. 20. Palazzo FF, Francis DL, Clifton MA. Randomized clinical trial of LigaSure versus open haemorrhoidectomy. Br J Surg. 2002;89(2):154-7. 21. Belli G, Fantini C, Ciciliano F, et al. Pancreaticoduo­ denectomy in portal hypertension: use of the LigaSure. J Hepatobiliary Pancreat Surg. 2003;10(3):215-7. 22. Romano F, Franciosi C, Caprotti R, et al. Hepatic surgery using the LigaSure vessel sealing system. World J Surg. 2005;29(1):110-2. 23. Araki Y, Noake T, Kanazawa M, et al. Clipless handassisted laparoscopic total colectomy using LigaSure Atlas. Kurume Med J. 2004;51(2):105-8. 24. Constant DL, Florman SS, Mendez F, et al. Use of the LigaSure vessel sealing device in laparoscopic livingdonor nephrectomy. Transplantation. 2004;78(11):1661-4. 25. Romano F, Caprotti R, Franciosi C, et al. Laparoscopic splenectomy using LigaSure. Preliminary experience. Surg Endosc. 2002;16(11):1608-11.

26. Gossot D, Buess G, Cuschieri A, et al. Ultrasonic dissection for endoscopic surgery. The EAES. Technology Group. Surg Endosc. 1999;13(4):412-7. 27. Payne JH. Ultrasonic Dissection. In: Arregui ME (Ed). Principles of Laparoscopic Surgery. New York: SpringerVerlac; 1995. pp. 749-56. 28. Payne JH Jr. Ultrasonic dissection. Surg Endosc. 1994; 8(5):416-8. 29. Marino BM, Bigliani S, Drago GW, et al. Use of ultrasonic surgery in laparoscopic cholecystectomy. Minerva Chir. 1994;49(3):195-7. 30. Gill BS, MacFadyen BV Jr. Ultrasonic dissectors and minimally invasive surgery. Semin Laparosc Surg. 1999;6(4):229-34. 31. Rau HG, Schauer R, Pickelmann S, et al. Dissection techniques in liver surgery. Chirurg. 2001;72(2): 105-12. 32. Rau HG, Wichmann MW, Schinkel S, et al. Surgical techniques in hepatic resections: Ultrasonic aspirator versus Jet-Cutter. A prospective randomized clinical trial. Zentralbl Chir. 2001;126(8):586-90. 33. Yamamoto Y, Ikai I, Kume M, et al. New simple technique for hepatic parenchymal resection using a Cavitron Ultrasonic Surgical Aspirator and bipolar cautery equipped with a channel for water dripping. World J Surg. 1999;23(10):1032-7. 34. Asahara T, Dohi K, Nakahara H, et al. Laparoscopyassisted hepatectomy for a large tumor of the liver. Hiroshima J Med Sci. 1998;47(4):163-6. 35. Rau HG, Meyer G, Jauch KW, et al. Liver resection with the water jet: conventional and laparoscopic surgery. Chirurg. 1996;67(5):546-51. 36. Chopp RT, Shah BB, Addonizio JC. Use of ultrasonic surgical aspirator in renal surgery. Urology. 1983;22(2):157-9. 37. Thompson MA, Adelson MD, Jozefczyk MA, et al. Structural and functional integrity of ovarian tumor tissue obtained by ultrasonic aspiration. Cancer. 1991;67(5):1326-31.

Setting-up of Laparoscopic Operation Theater INTRODUCTION In any surgical specialty hospital, operation theaters form the heart of the hospital where each and every minute detail of equipment and utmost coordination between different teams and team members counts to perform the proposed procedure effectively and safety. The word “operation theater” was used in the United Kingdom for the reason as medical students were allowed to observe the surgical procedures. The oldest operation theater is in London established in 1822.1 Surgeons and most of the medical personnel do have less knowledge about the physics behind the electronics and the working mechanism of the gadgets like electrosurgical units, camera system, and light source. But it is essential for the surgeon, the captain of the ship, to have considerable knowledge about all the equipment inside the operation theater. Surgeon would be finally responsible to bring the best possible output from the operation room staff by bringing coordination among the staff and should be the troubleshooter for minor malfunctioning of the equipment and he/she should be aware of the setup of the operation theater. Exact details of the design of the laparoscopic operating room obviously depends on the procedure being performed.1 This chapter is written with an intent to throw some light on the operative room design, setup, and maintenance.

TYPES AND ZONES OF OPERATION THEATERS Operation theaters were classified into three types like single operation theater suite, twin theaters (if two operation theaters are present), and operation theater complex (if more than two operation rooms are present). The area of operation theater are divided into four zones like protective zone, clean zone, aseptic zone, and disposal zone.2 Protective zone includes preand postoperative rooms, change rooms, and stores.

CHAPTER

8

Clean zone connects protective zone to aseptic zone i.e. operation theater. Disposal areas from each operation theater connect to disposal zone.

CONSTRUCTION OF OPERATION THEATERS It would be an unrealistic idea to construct an ideal operation theater by integrating all the available technology, especially in the era of rapidly advancing technological aids to the surgeon. Concept of modular operation theater is designed to bring this idea of ideal operation theaters to reality. Many advances are getting included day by day to this unbounded world of modular operation theaters (Fig. 8.1).

Modular Operation Theaters Designs Location and Dimensions Generally speaking, it would be better to construct operation theater in floors where natural light and air are abundantly available.2 In multistoried building, it is recommended to construct the operation theater in first floor and should be easily accessible to laboratory, radiological services, and should be away from outpatient department and attendant’s traffic. Proper facility for transport of patients like ramp and electrically operated lift that can accommodate stretchers of patients should be installed and should be isolated from general lift system. The recommended size of each room should be around 6.5 m × 6.5 m × 3.5 m.3 Floor should be nonslippery and should not be made with tiles with joints or crevices in between and should be nonconductive of electricity.

Doors and Walls Usually single door is recommended of size of width about 1.2–1.5 m. However, another door can be placed

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Fig. 8.1: Photograph of GEM Hospital OR room, an example of fully equipped modular operation theater with supportive audio visual aids with video streaming facility.

for hospital waste management. Sliding doors generate lesser air currents compared to flap valve type of doors. Automated sliding doors or doors that can be opened by foot pedal are better as these help surgeons and other personnel can enter the room without touching the doors after scrubbing. Walls can be designed of glass completely either transparent or with designs over them or with stainless steel of single sheet without any crevice or joints so that cleaning and maintenance becomes easy. Walls coated with antimicrobial paint over galvanized (GI) surface are also available. However, the effectiveness of the antimicrobial paints is not yet established. Creating a nonporous smooth surface over the walls is the central idea of all the walls so that it remains uninhabitable for the microorganisms. Storage in the operation theater should be avoided as much as possible. However, one wall can be fitted with storage wherein all the suture materials and disposables for the concerned case can be stored.

Illumination Lighting system includes both central light and peripheral lights. Central lights of light-emitting diode (LED) system can be suspended over a pendent and should be well designed so that maximum intensity of the light focuses on the operative field. However, in laparoscopic surgeries maximum duration of the surgery is performed with light source via telescope and hence central light system gives durability. Despite of this fact, better illumination system

would be very helpful during the times of conversion to open method.

Atmosphere inside Operation Theater Atmospheric temperature of 18–22°C and humidity of 40–60% should be maintained inside the operation theater is recommended.2 Coming to the air circulation systems inside the operation theaters, positive pressure of should be maintained so that air from the outside can not enter inside. A pressure of 5 cm of H2O with flow of air from ceiling downwards so that air can be pushed out. There are two types of ventilation systems present in operation theater—recirculating and nonrecirculating.4 Nonrecirculating systems condition the air inside the system with 20–30 air changes per hour and exhaust the air and anesthetic gases outside. Recirculating systems is better as some of the air is removed, adjusts the temperature of the room, and air circulates back into the room. Laminar air flow systems of types like vertical, horizontal, or recent exponential flow are available. Comparative evidence is lacking to recommend one above the other.5 High efficiency particulate air filtration systems reduce the particle load and are being recommended for theaters performing transplantation. One more recent advance is installation of ultraviolet radiation emitter in the air filtration systems to reduce the microbes load in the air entering operation theaters.

Setting-up of Laparoscopic Operation Theater

Pendant Systems To facilitate cleaning of the floors and to avoid exposed lines, wires or tubes, pendant system is developed. These are supporting structures brought into the room from the ceiling carrying gas tubes, wires, etc. Over these pendant systems, anesthesia work stations, gas insufflator, light source, monitors, multiparameter medical monitors, and illumination system can be installed without the need of trolleys.

Monitors and Imaging Setting up of monitors is very important to perform an ergonomically comfortable surgery. Nowadays, monitors suspended on pendant are available which can be adjusted depending on the need of the type of the surgery. Second or third monitor can be installed depending on the requirement. Retrieving and archiving of imaging of the patient and instillation of the same on the monitor with touch screen facility would increase the comfort to the surgeon especially in hepatopancreatic and biliary surgeries.

Ductal System Gas pipe systems of oxygen, carbon dioxide, nitrous oxide, suction, and air should be properly insulated with color coding. Installing control system of each tube at the entrance of operation theater could help in selective controlling of the gases and suction.

Audiovisual Support Recording and transmission of the performed surgical procedure forms the digital documentation and can help in reviewing and improving one own skill level. Currently available technology allows surgeon to perform this task with technical support from a competent engineer. It is better to connect all the theaters to one central audiovisual room wherein data storage, retrieval, and data editing can be performed.

Telemedicine Transmission of performed surgery or live surgery can be done with installation of high-bandwidth internet connection. This helps in conducting medical education programs and web conferences so that surgeons across the globe can view and interact with each other. This could become the futuristic way of conducting scientific conferences.6 Nowadays, various companies like Olympus, Stryker, etc. are coming up the concept of modular operation theaters at the time of construction of hospital, which are relatively expensive. Despite of installation of highest level of equipment, it is still possible that the equipment may malfunction. Therefore, it is very important to come to the operating room sufficiently early to assure proper setup and to ascertain that all instruments are available and in good working condition.1,7 Time spent in positioning the equipment and operating table before the patient is placed on the operating table is responsible to some extent for successful completion of the procedure. Ultimate goal in medicine and technology in the field of medicine should be available to mankind at an affordable price and be helpful to improve the safety of the patient and the captain called surgeon!

REFERENCES 1. “50th Anniversary of the Opening of the Old Operating Theatre Museum”. The Old Operating Theatre Museum & Herb Garret. London: The Old Operating Theatre, Museum & Herb; 2015. 2. Bridgen RJ. The Operating department/Organisation and Management/Electricity & Electromedical Equipment/ Static Electricity. Operating Theatre Technique, 5th edition. London: Churchill Livingstone; 1988. pp. 9-109. 3. Harsoor SS, Bhaskar SB. Designing an ideal operating room complex. Indian J Anaesth. 2007;51:193-9. 4. Gupta SK, Kant S, Chandrashekhar R. Operating unit— planning essentials and design Considerations. J Acad Hosp Adm. 2005;17:01-12. 5. James M, Khan WS, Nannaparaju MR, et al. Current Evidence for the Use of Laminar Flow in Reducing Infection Rates in Total Joint Arthroplasty. Open Orthop J. 2015;9:495-8. 6. Parthasarathi R, Gomes RM. First Virtual Live Conference in Healthcare. J Laparoendosc Adv Surg Tech. 2017;27(7):722-5. 7. Winer WK, Lyons TL. Suggested set-up and layout of instruments and equipment for advanced operative laparoscopy. J Am Assoc Gynecol Laparosc. 1995;2(2):231-4.

Chapter 8

Before starting any operation theater for the first time for performing surgeries, a minimum of serial 6 weeks cultures should show no growth, as recommended by hospital accreditation board. Periodical disinfection of operation theaters should be done as part of prevention of surgical site infections and are discussed in sterilization and disinfection chapter.

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CHAPTER

Room Layout INTRODUCTION The proper training of operating room personnel in the setup, use, and troubleshooting of the equipment is very impor­tant in videoscopic surgery. Exact details of the design of the laparoscopic operating room obviously depends on the procedure being performed.1

GENERAL CONSIDERATIONS1-4 Operative Room Setup Operative room setup has been discussed in Chapter 8.

Optimum Position of Equipment and Team The optimum position and orientation for the operating team is determined according to the procedure. In con­ ven­tional operation, the surgeon stands either to the right or left of the patient. Unlike conventional surgery, in laparoscopic surgery the following is to be considered: • Surgeon’s position • Number of assistants (one or two) • Staff nurse • Monitors—the video image must be in straight line with the ports and surgeon • Equipment trolley, anesthesia trolley, etc.

Checklist An equipment checklist helps to ensure that all items are available, minimizes the delay in the start of the procedure, and ensures a hassle free surgery. A laparo­ scopic surgery safety checklist had been pub­lished by the Society of American Gastrointestinal and Endoscopic Surgeons (SAGES) to ensure the safe con­ductance of minimal invasive surgery.5 Most of the equipment and instruments listed here are needed for any operative

9

laparoscopy. Additional equipment may be needed for advan­ced procedures. • Anesthesia equipment with monitors • Electric operating table • Two video monitors • Suction irrigators • Electrosurgical unit with grounding pad equipped with current monitoring system • Laparoscopic equipment in a cart on wheels is impor­ tant for shifting to various positions: –– Light source –– Insufflator –– Video recorders, printers (optional) –– Camera processor unit –– C-arm X-ray unit • Instrument table with following laparoscopic instru­ ments: –– No. 15 scalpel blade and handle –– Veress needle/Hasson cannula –– Gas insufflation tube –– Fiberoptic cable to connect laparoscope with light source –– Video camera with cord preferably covered with sterile sleeves made of polythene or cloth which can be used instead of immersing the whole assembly in Cidex® solution –– Electrocautery cable for instruments –– A set of hemostats –– Small retractors –– Trocars and cannula—size and number according to the procedure and surgeon’s choice –– Atraumatic graspers –– Locking toothed graspers –– Needle holders –– Dissectors—curved, straight, and right angled –– Bowel grasping forceps –– Babcock forceps –– Scissors—Metzenbaum, hook, and microtip

Room Layout

•

•

•

BASIC ROOM SETUP • With the operating table position and all equipment in the room, reassess the configuration.6 • Check the equipment and ascertain the following: –– There should be two full CO2 cylinders in the room, one will be used for the procedure, second is spare in case the pressure in the first cylinder becomes low. –– Each type of gas cylinder has a unique kind of fitting and failure to fit properly may indicate that the cylinder contains a different type of gas (e.g. O2). • Attention to detail is important: –– Assure table tilt mechanism is functioning. –– Consider leg support and extra safety strap for large patients. –– Check the X-ray cassette plate for proper position. –– Notify the radiology technician. –– Ensure the availability of Foley’s catheter and Ryle’s tube. –– Check the insufflator and confirm that the alarm is set appropriately.

–– Check and confirm the presence of full volume in the irrigation fluid container. –– Check the electrosurgical unit, make sure that the auditory alarm of the machine is functioning properly and the grounding pad is appropriate for the patient, properly placed and functioning. • Before starting the procedure, connect the light cable and camera to the laparoscope. Focus the laparoscope and white balance it. Place the laparoscope in warm saline or electrical warmer. Verify the following: –– Check the Veress needle for proper plunger/ spring action and assure easy flushing through stopcock and needle channel. –– Confirm that the stopcocks on all cannula are closed. –– Check the rubber visors for cracks. –– Ensure free movements of instrument handles and jaws. The SAGES had recommended a laparoscopy trouble­ shooting guide based on 20 points grouped in to the duties of the circulating and scrub technicians (Box 9.1).

TROUBLESHOOTING Laparoscopic procedures are inherently complex. Many things can go wrong. The surgeon must be sufficiently familiar with the equipment to troubleshoot and solve the problem. Box 9.1 gives the outline of the common problems, their cause, and suggested solution.6,7

COMPLICATIONS AVOIDANCE, DETECTION, AND MANAGEMENT Basic and advanced laparoscopic surgery is safe, but not risk free. Complications tend to occur during the procedure or in the postoperative recovery period. Pro­ per preoperative preparation and assessment must be focused on the inciting disease process and on the identification of potential sources of surgical com­ p­ lication.8,9 One must strictly adhere to the World Health Organization (WHO) surgical safety checklist to ensure that all such potential sources are identified and appro­ priately addressed.

Preoperative Workup A proper preoperative workup will minimize the intra- and postoperative complications. Preoperative

Chapter 9

•

–– Fan retractors—10 mm or 5 mm –– Specialized retractors such as endoscopic curved retractors –– Biopsy forceps –– Trucut biopsy core needle Monopolar electrocautery dissection tools: –– L-shaped hook –– Spatula—spade type dissector coagulator –– Ball-tipped coagulator Ultrasonic activated scalpel: –– Scalpel—10 mm or 5 mm –– Ball coagulator especially for control the diffuse oozing of blood –– Hook coagulator –– Scissor dissector/coagulator –– Spade type dissector Endocoagulator probe: –– LigaSure –– Enseal –– Thunder beat Basket containing: –– Clip appliers—medium, medium large –– Endoscopic stapling devices –– Pretied suture ligatures –– Endoscopic suture materials –– Endobag

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Art of Laparoscopic Surgery Textbook and Atlas Box 9.1: SAGES laparoscopy troubleshooting guide. Duties of the circulating technician • Assure table tilt mechanism is functional. Assure the table and joints level, and kidney rest down. • Consider using foot board and extra safety strap. • Position patient properly on operating room table for cholangiography. • Assure notification of radiology technologist with time estimate. • Assure proper mixing and dilution of cholangiogram contrast solution for adequate image. For surgeons utilizing fluoroscopy for cholangiography, the patient should be placed on a table capable of supporting this task and appropriate shielding should be available. • Assure availability of Foley catheter and nasogastric (NG) tube. • Assure all power sources are connected and appropriate units are switched “on” (do not use multisocket single source or the circuit will overload). • Assure adequate volume of compressed gas (at insufflator and pressure irrigator). Backup full tank must be available. Ensure wrench and gasket are available. • Assure insufflator alarm is set appropriately. Assure tight connection between insufflator tubing and Luer-lock adapter. • Assure full volume in irrigation fluid container (recheck during case). • Check the electrosurgical unit; make sure auditory alarm of machine is functioning properly and the grounding pad is appropriate for the patient. • Check Veress needle for proper plunger/spring action and assure easy flushing through stopcock and/or needle channel. • Assure closed stopcocks on all ports. • If utilizing the gasless technique, assure that the operating room table has side arms capable of supporting the abdominal lift unit and that appropriate blades for the unit are available. Duties of the scrub technician • Check sealing caps for cracked rubber and stretched openings. • Check to assure instrument cleaning channel screw caps are in place. • Assure free movement of instrument handles and jaws. • If Hasson cannula to be used, assure availability of stay sutures and retractors. Check valves, plunger, spring, and seals on reusable Hasson cannula. • Assure adequate printer film and video tape if documentation is desired. • Periodically send scissors and reusable trocars for sharpening.

preparations are similar to those of any general surgical patient. Evaluation of cardiac and respiratory systems is mandatory to ensure a safe operation. It must always be remembered that the cardiac system is significantly affected by laparoscopy due to the mechanical effects of pneumoperitoneum, the hemodynamic effects of the absorbed CO2, and the volume shifts caused by patient positioning.

Preoperative Checklist An ideal preoperative checklist for laparoscopic surgery must include: • History and physical examination • Evaluation of other medical problems and current medication • Evaluation of cardiac and respiratory systems • Normalization of fluids and electrolytes • Antibiotics • Prophylaxis against deep venous thrombosis • Evaluation of genitourinary system

• Appropriate laboratory and radiologic studies • Informed consent for laparotomy if necessity arises • Other consent as appropriate for the case (for exam­ ple, consent for stoma).

Deep Vein Thrombosis All surgical patients, particularly elderly and cardiac patients, are at risk for the development of deep vein thrombosis (DVT)10 and this should be a major consi­ dera­tion in the planning of a laparoscopic procedure. All patients undergoing laparoscopic surgery should be considered moderate risk unless they are less than 40 years with no predisposing factors. Several factors increase the risk for DVT. These include age more than 60 years, immobility more than 72 hours, history of DVT or pulmonary embolism, varicose veins, obesity, myocardial infarction, chronic obstructive pulmonary disease, cerebrovascular accident, operation more than 2 hours, venous stasis disease, malignancy, pregnancy, severe sepsis, and known hypercoagulable state.

Room Layout

SELECTION OF PATIENTS FOR LAPAROSCOPIC PROCEDURE Proper selection is very important to avoid major com­ plications on the table. Selection of patients for laparo­ scopy should be considered depending on the individual patient risk and the disease process and the surgeon should also judge his expertise in dealing with them.

CONTRAINDICATIONS TO LAPAROSCOPY There are certain risk factors that make the patient abso­ lutely or relatively contraindicated for lapa­roscopy.11,12 Contraindications to laparoscopy may be considered as absolute or relative. These classifications tend to change over time, but an understanding of when laparo­ scopy is not indicated or presents greater risk is of utmost importance.

Absolute Contraindications • Hypovolemic shock, massive • Bleeding, hemodynamic instability • Severe cardiac disease.

Relative Contraindications • • • • • • • •

Peritonitis of uncertain origin Abdominal wall hernia Diaphragmatic hernias Uncorrected coagulopathies Cirrhosis of liver Portal hypertension Multiple previous surgical procedures Late stage pregnancies.

Hypovolemic shock along with massive acute blee­ ding that may obscure the view making it difficult to precisely localize the source of bleeding constitutes a contraindication as it requires quicker intervention than laparoscopy will permit. Severe cardiac disease may also be an absolute contraindication to laparoscopy if insuf ­fl ation and patient positioning will exacerbate the underlying conditions. Most other contraindications can be considered relative and the extent to which each of these conditions precludes laparoscopic surgery may change over time, with the development of new techniques and advan­ ced instrumentation. Pregnancy was once thought to be an absolute contraindication to laparoscopy, but laparoscopy can be safely performed during any trimes­ ter of pregnancy when operation is indicated as per the recent SAGES guidelines for the use of laparoscopy during pregnancy. Peritonitis, especially of uncertain origin, usually requires a formal exploration, but laparoscopy may assist in identifying the inciting event and direct the placement of the surgical incision. Abdominal wall hernias, particularly those previously repaired with mesh, may complicate laparoscopic sur­ gery and may lower the safety threshold. Diaphragmatic hernias may preclude adequate insuf ­fl ation and should be considered by the surgeon and anesthesiologist when deciding on the surgical app­ roach. Uncorrected coagulopathies may be a relative contraindication and portal hypertension may lead to increased abdominal wall bleeding and complications during the surgical dissection. Multiple prior abdominal operations with significant intra-abdominal adhesions may severely impair visua­ lization and increase the risk of intestinal injury. With careful technique, including an open placement of initial trocars, this risk can be minimized. Meticulous dissection while taking down abdominal wall adhesions, freeing of intra-loop intestinal bands, and scrupulous identification of important landmarks will convert a difficult and dangerous procedure into a straight­ forward case. Preoperative bowel preparation may be important in decreasing the hazards.

CONCLUSION The advent of laparoscopic surgery has provided surgeons with new techniques to deal with familiar problems. Laparoscopy can reduce hospital stay, decrease post­ operative pain, and hasten recovery

Chapter 9

Precautions that reduce the incidence of DVT include: • Com­ pression stockings in the lower extremities increase the blood flow in the femoral veins and reduce the potential of stasis. • Intermittent pneumatic compression device may be used in high-risk category patients. • The most widely used agent for DVT prophylaxis is heparin. A single dose of 5,000 U preoperatively and continued every 12 hours till the patient is ambulant, prevents the incidence of postoperative DVT by 50%. • With the availability of low molecular weight heparin analogs, the risk of bleeding has decreased considerably.

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Art of Laparoscopic Surgery Textbook and Atlas time. The key to successful laparoscopy is appropriate patient selection, preparation, and efficient supervision during surgery. With close attention to preoperative and postoperative care, these unique procedures will be safe, effective, and enduring.

REFERENCES 1. Winer WK, Lyons TL. Suggested set-up and layout of instruments and equipment for advanced operative laparoscopy. J Am Assoc Gynecol Laparosc. 1995;2(2): 231-4. 2. Kenyon TA, Urbach DR, Speer JB, et al. Dedicated minimally invasive surgery suites increase operating room efficiency. Surg Endosc. 2001;15(10):1140-3. 3. Way L, Bhoyrul S, Mori T. Fundamentals of Laparoscopic Surgery. New York: Churchill Livingstone; 1995. 4. Cushieri A, Buess G. Operative Manual of Endoscopic Surgery. Berlin Heidelberg New York: Springer Verlaag; 1992. 5. Varela E, Brunt LM. SAGES Laparoscopic Surgery Safety Checklist. In: Tichansky D, Morton J, Jones DB (Eds). The

SAGES Manual of Quality, Outcomes and Patient Safety. Boston, MA: Springer; 2012. 6. Paz-Partlow M. Basic Instrumentation and Trouble­ shooting. In: Phillips EH, Rosenthal RJ (Eds). Operative Strategies in Laparoscopic Surgery. New York: Springer Verlaag; 1995. pp. 3-9. 7. Airan M. Equipment Setup and Troubleshooting. In: Scott-Conner C (Ed). The SAGES Manual: Fundamentals of Laparoscopy and GI Endoscopy. New York: Springer Verlag; 2003. pp. 1-11. 8. Deziel D. Avoiding laparoscopic complications. Int Surg. 1994;79:361-4. 9. Mirhashemi R, Harlow BL, Ginsburg ES, et al. Predicting risk of complications with gynecologic laparoscopic sur­ gery. Obstet Gynecol. 1998;92(3):327-31. 10. Nguyen NT, Luketich JD, Friedman DM, et al. Pulmonary embolism following laparoscopic antireflux surgery: a case report and review of the literature. JSLS. 1999;3(2):149-53. 11. Berci G, Cushieri A. Laparoscopic Biliary Surgery. Oxford: Blackwell Science; 1992. 12. Berci G. Laparoscopic Cholecystectomy and Surgical Endo­s­copy. Philadelphia: Saunders; 1993.

Preoperative Imaging in Minimally Invasive Surgery INTRODUCTION In every surgical patient, proper preoperative imaging is essential in accurate diagnosis and helps in planning management. Ultrasonography (USG) abdomen, upper gastrointestinal (GI) endoscopy, colonoscopy, endo­ scopic ultrasound (EUS), contrast-enhanced computed tomography (CECT) chest and abdomen, and magnetic resonance imaging (MRI) abdomen and pelvis are routinely ordered investigations in gastroenterology patients. Ultrasonography abdomen is the routine and basic initial investigation, helps us in identifying various abdominal conditions, like appendicitis, gallbladder (GB) calculi, various cystic lesions of liver, ascites, etc. CECT abdomen helps in doubtful conditions and in preoperative staging of various GI malignancies. MRI abdomen/pelvis is advised in hepatic/biliary lesions, suspected rectal lesions, and gynecological malignancies. Endoscopy is used for diagnosis and for biopsy of suspected lesions. Ultrasonography, CECT abdomen, and MRI are routinely used at various centers and here in this chapter we are mainly focusing on the EUS and laparoscopic ultrasound (LUS), which are not routinely used.

ENDOSCOPIC ULTRASOUND/ ECHOENDOSCOPE Endoscopic ultrasound was first developed by Olympus corporation to improve imaging of pancreaticobiliary system.1 In 1980, the first mechanical radial EUS (180° mechanical radial scanner) was applied clinically (DiMagno et al., 1980). Endoscopic ultrasound probes are available in various diameters (2–2.9 mm), frequencies (12–30 MHz), and lengths (170–220 cm). Higher ultrasound frequency yields higher resolution at the expense of reduced depth of penetration (reported depths of penetration are

CHAPTER

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29 mm for the 12 MHz probe and 18 mm for the 20 MHz probe).2 Acoustic coupling between the probe and tissue can be achieved by several methods, including close apposition of the probe to tissue with air aspiration, instillation of liquid into the gut lumen, use of a condom over the tip of the endoscope, and use of a balloon sheath over the probe.

Radial Endoscopic Ultrasound The radial type scans in a plane perpendicular to the axis of the scope to produce 360° images similar to a computed tomography (CT) “slice.” The transducer appears as a “bull’s-eye” within the image.

Linear Endoscopic Ultrasound The linear array type scans in a plane parallel to the axis of the scope. It is therapeutic in nature. It has the advan­ tage of allowing visualization of a needle while perfor­ ming a procedure.

Catheter-based Endoscopic Ultrasound Probes (Miniprobes) They consist of a cable with a mechanical transducer at its end. The majority of miniprobes use a radial trans­ ducer; however, dual-plane reconstruction probes are also available and these allow the user to scan simul­ taneously in both linear and radial planes. The miniprobe is inserted down the working channel of a regular endoscope. Air is removed from the lumen, which is then filled with water to allow transmission of the ultrasound.

Contrast-enhanced Diffusion Endoscopic Ultrasound It helps in differentiating hypervascular from hypo­ vascular areas.

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Contrast-enhanced Harmonic Endoscopic Ultrasound It helps in better visualization of the microcirculation and parenchymal perfusion, and better differentiation of tissue enhancement for more accurate classification.

Uses of Endoscopic Ultrasound Diagnostic Uses • For staging of GI lesions • Endoscopic ultrasound-guided fine needle aspira­ tion (EUS-FNA) • Endoscopic ultrasound-guided tissue elastic imaging (EUS elastography).

In Upper Gastrointestinal Malignancies Esophageal malignancies The pooled sensitivity and specificity of EUS for asses­ sing tumor depth per T stage were 81.6% and 99.4% for T1, 81.4% and 96.3% for T2, 91.4% and 94.4% for T3, and 92.4% and 97.4% for T4 (Fig. 10.1). “Sensitivity, specifi­ city, and accuracies for the diagnosis of malignant lymph

nodes (LNs) by EUS were 49–99%, 33–99%, and 71–96%. EUS-FNA staging was better than EUS staging as it has no clinically obvious complications, has sensitivity 81–97%, specificity 83–100%, and accuracy 83–97%.” After neoadjuvant treatment, because of fibrosis and inflammation which are indistinguishable from residual tumor, the accuracy of EUS is lower than initial staging accuracy.3 Stomach malignancies (Figs. 10.2 and 10.3) Endoscopic ultrasound is used mainly in staging of gastric cancers, especially in early gastric cancer (EGC). Lesions on EUS are found as areas of focal thickening, irregularity, or disruption of the layers. The accuracy of EUS in T staging varies from 65% to 92.1%. For N staging the accuracy varies from 66% to 90%. EUS-FNA for nodal staging, the accuracy has improved and the sensitivity, specificity, and positive predictive value of EUS-FNA are reported to be 92%, 98%, and 97%, respectively. However, it cannot detect distant metastasis and hence has to be followed by other modalities like CECT abdomen to rule out metastasis. EUS cannot be used when entire length of lesion cannot be assessed as in cases of stricture. Ulceration and diffuse type of histology are also impor­ tant factors in determining the accuracy of EUS.

Fig. 10.1: Diagnostic endoscopic ultrasound in staging of esophageal cancer.

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Chapter 10 Fig. 10.2: Radial endoscopic ultrasound gastro­ intestinal stromal tumor (GIST) esophagogastric junction.

Fig. 10.3: Conglomerate lymph nodes seen in the celiac region proved to be tuberculosis.

Periampullary Tumors Ampullary tumors are hypoechoic masses at the ampulla, which produce interface loss between different duodenal wall echogenic layers. The sphincter of Oddi

may be difficult to visualize, but would appear as a thin hypoechoic layer surrounding the pancreaticobiliary duct. The accuracy in T staging for ampullary carcinomas was 72.7% for EUS and accuracy in N staging for ampullary carcinomas was 66.7%.

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Pancreas Chronic pancreatitis: Rosemont criteria for diagno­sing chronic pancreatitis (CP) were developed based on EUS imaging. Major criteria for CP were: • Hyperechoic foci with shadowing and main pan­ creatic duct (PD) calculi • Lobularity with honeycombing. Minor criteria for CP were cysts, dilated ducts more than and equal to 3.5 mm, irregular PD contour, dilated side branches more than and equal to 1 mm, hyperechoic duct wall, strands, nonshadowing hyperechoic foci, and lobularity with noncontiguous lobules. Recently, the image enhancement technique of elastography has been used to help improve the diag­ nostic capabilities of EUS for CP. Pancreatic cysts: EUS-FNA has formed the cornerstone of the diagnosis of pancreatic cysts, with analysis of cyst fluid markers such as carcinoembryonic antigen (CEA) and amylase helping to discriminate mucinous from nonmucinous lesions, and to confirm communication with the PD (Fig. 10.4).4 Pancreatic masses: Endoscopic ultrasound has a high sensitivity and specificity for the detection of focal masses in the pancreas and has greater sensitivity and accuracy compared to CT, especially for smaller lesions less than 3 cm (Figs. 10.5 and 10.6).

Contrast-enhanced harmonic endoscopic ultra­ sound (CEH-EUS) may help localize a mass lesion within the pancreas that is suspected on cross-sectional imaging, but not initially visualized on EUS, can improve the staging of pancreatic cancers with respect to vascular involvement, and may help guide the target of biopsies within a particular lesion when performing FNA.4 Therapeutic uses in pancreatic lesions: Celiac plexus block and neurolysis: EUS-guided celiac plexus block/celiac plexus neurolysis (CPB/CPN) is performed using a linear echoendoscope via a trans­ gastric approach from the proximal stomach. EUS can be effectively performed as a safe day procedure. The principle involves combining endoscopic surgery. Drainage of pancreatic fluid collections (PFCs): EUS and fluoroscopic imaging to facilitate the creation of a transgastric or transduodenal fistulous tract into the encapsulated PFC, through which stents (plastic pigtail or covered metal) are placed to maintain the patency of the cystogastrostomy or cystoduodenostomy tract to enable ongoing drainage.

Biliary Pathology Gallstones: Microlithiasis (radiological invisibility stones less than 5 mm in diameter and/or stones less than 3 mm in diameter) in the GB may be undetected by

Fig. 10.4: Pancreatic cyst with pancreatic duct in the neck of the pancreas.

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Chapter 10 Fig. 10.5: Pancreatic mass with portal vein (PV) infiltration.

Fig. 10.6: Pancreatic body mass impinging on the splenoportal confluence.

transabdominal ultrasound and rarely detected on other imaging modalities including multidetector CT and MRI. In some patients with microlithiasis, biliary sludge and/or gallstones can be detected by EUS, with its high spatial resolution.

Endoscopic ultrasound should be considered as a minimally invasive highly accurate diagnostic tool for idiopathic pancreatitis after conventional radiography fails to detect any gallstones as there is high incidence of microlithiasis and/or biliary sludge.5

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Fig. 10.7: Distal common bile duct (CBD) intra­ ductal lesion suggestive of malignancy.

Nowadays, many gastroenterologists are preferring to use EUS to assess common bile duct (CBD) (Fig. 10.7) calculi in case of doubtful situations instead of magnetic resonance cholangiopancreatography (MRCP) as one can do endoscopic retrograde cholangiopancreato­ graphy (ERCP) in the same sitting if any CBD calculi are found on EUS. Gallbladder polyp: EUS can differentiate the double layered structure of GB wall and provide higher resolu­ tion for imaging small polypoidal lesions.6 Gallbladder carcinoma: Diagnostic accuracy of EUS has been shown for T stage—Tis stage 100%, T1 stage 75.6%, T2 stage 85.3%, and T3–4 stage 92.7%. EUS also adds the possibility of FNA for tissue diagnosis of the primary as well as LNs, where diagnostic accuracy approaches 100%. Postcholecystectomy syndrome: Cystic duct or GB rem­ nant with or without stones is one of the important causes of postcholecystectomy syndrome. Diagnosis of residual GB with gallstones remains difficult. EUS is an excellent diagnostic modality in this situation. Endoscopic ultrasound‐guided gallbladder drainage: EUS‐guided gallbladder drainage (EUS‐GBD) is recently gaining alternative for management of acute cholecystitis

in high‐risk surgical patients. It is performed by using plastic stents, nasobiliary catheters, covered self‐ expandable metal stents, and, most recently, lumen‐ apposing metal stents (LAMSs). Rectal lesions: The overall accuracy of T staging for rectal cancer varies between 70% and 90%. The overall accu­ racy of N staging by EUS is 73–83%. In case of assessing the postneoadjuvant patients, we assess evidence for tumor regression from surroun­ ding organs, not exactly for tumor, nodes, metastasis (TNM) staging, in particular the anal sphincters, vagina, and prostate. In this way EUS can direct therapy in patients who have undergone neoadjuvant therapy as a prelude to possible sphincter-sparing surgery.

LAPAROSCOPIC ULTRASOUND Intraoperative laparoscopy was first reported by Schlegel et al. in 19617 and LUS by Fukuda et al. in 1981 in patients with liver tumors.8 The use of LUS is gaining popularity and is set to become a valuable tool in the armamen­ tarium of laparoscopic surgeons. LUS has increased accuracy of staging in hepatobiliary, pancreatic, and gastric neoplasms.

Preoperative Imaging in Minimally Invasive Surgery

Equipment

Technique We use SSD-5000 Aloka ultrasound scan with laparo­ scopic color Doppler probe in our operation theater (Fig. 10.8). The imaging system is so accurate that even 2–3 mm lesions can be easily identified.

Fig. 10.8: Aloka Prosound SSD-5000.

Chapter 10

The addition of pictures allows the surgeon to operate by looking at a single monitor, instead of having to alter­ nately view the laparoscopic and ultrasound monitors. Hand-eye coordination is significantly impaired if this function is not used. This can be done either with the help of video mixers or by the use of the recently available monitors that allow for two different inputs. Laparoscopic ultrasound probes are sterilized in glutaraldehyde solutions before use. During sterilization, only the distal part of the equipment should be immersed in the solution. Care should be taken to avoid immersion of the connecting cable assembly as it can cause significant damage to the cables. Ethylene oxide sterilization can also be done. To minimize transducer sterilization time and increase its availability in several different operating rooms, some clinicians use especially designed waterproof gaskets and plug covers that cover the entire instrument (transducer, handle, and cord).

The patients are placed in supine minimal Trendelenburg position to allow the upper abdominal organs to fall away from the field of vision. Routine evaluation of the abdomen is done after creation of pneumoperitoneum. Selection of the appropriate port is essential for laparoscopic assessment. During the initial phase, surgeons may find it easier to perform the scan through the umbilical port as it helps in easier orienta­tion of cross-sectional anatomy (Fig. 10.9). The ultrasound probe can be used in various ports to improve visuali­ zation of different quadrants of the abdominal cavity. For assessment of the biliary tree, the probe is placed over the CBD as proximally as possible and slowly withdrawn with minimal rotatory movements. The orientation of the probe is changed when it reaches the distal end and this part of the CBD is screened through the duodenum. The proximal bile duct, confluence, and hepatic ducts can be screened through the right lobe of the liver. The assessment of liver lesions is done by placing the ultrasound probe opposed to the surface of the liver and moving the probe in a sweeping or lawn mowing fashion from medial to lateral side starting from the falciform ligament. The same process is repeated after withdrawing the probe for around 4 cm to scan the parenchyma in the lower portion. Flexible probes are more useful in assessing the liver close to the dome of the diaphragm (Fig. 10.10). The process is repeated till the entire right lobe is screened. The left lobe of the liver is assessed in a similar fashion. A thorough evaluation of the dome of the liver may require placement of the LUS transducer through a left paramedian port and the right upper quadrant port due to the physical boundaries determined by the falciform ligament. The hepatic veins and portal venous system are examined, followed by close inspection of the inferior vena cava. Newly discovered masses are aspirated or biopsied under guidance. Ultrasound of pancreas involves the assessment of head, body, and tail. Air in the stomach can be aspirated and saline injected to enhance the acoustic interface and to avoid artifacts. The head of the pancreas can be assessed through the antrum and body of the stomach and tail of pancreas placing the probe directly over the pancreas after entering the lesser sac. The celiac axis, peripancreatic, periportal, and periaortic LNs are then evaluated. The use of a Doppler USG probe usually helps in identification of the vessels and their relation to the

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Art of Laparoscopic Surgery Textbook and Atlas tumor. Colonic tumors are not ideal for assessment by LUS due to presence of gas in the colon. The laparoscopic surgeon is often familiar with deflecting type instruments and will be comfortable maneuvering the laparoscopic probe to the desired

location in the abdomen. It is always better that the surgeon takes an active role in LUS and learn the technique with the help of a radiologist. The presence of an experienced sonologist is helpful for recognition of anatomic landmarks, location and extent of the

Fig. 10.9: Cross-sectional view of the stomach during laparoscopic ultrasound.

Fig. 10.10: Laparoscopic ultrasound probe— 7.5 MHz with flexible tip.

Preoperative Imaging in Minimally Invasive Surgery

Indications Laparoscopic ultrasound is particularly useful in the assessment of parenchyma of solid organs (liver, spleen, kidney, or adrenal) and retroperitoneal structures. It is also used to assess the CBD during bile duct surgery and as a part of staging laparoscopy in patients with hepatobiliary and pancreatic cancers prior to laparo­ tomy. Laparoscopy in combination with LUS has also demonstrated potential benefits in the preoperative staging of hepatobiliary, pancreatic, esophageal, and gastric neoplasms.

Liver The resectability of primary and secondary liver tumors can be assessed by LUS. It helps in detection of addi­tional liver lesions in patients with metastasis, which are not detected by routine preoperative investigations like CT and USG. Around 20% of patients who underwent LUS before radio frequency ablation had one or more lesions that were not picked up by the CT scan.10 The addition of LUS to diagnostic laparoscopy resulted in the detection of new tumors in 33% of patients with liver tumors. In some series, there was a significant change in the management strategy as high as 38%11 following laparoscopic ultrasonogram (Figs. 10.11 to 10.13). Apart from detection of additional lesions, it also provides essential information during hepatic resec­ tions. It helps in localization of the tumor and assess­ ment of vital structures close to the lesion, helping the surgeon to carry out a safe resection. At present, the sensitivity of LUS varies from 80% to 100% and the specificity varies from 75% to 100%. When compared to other preoperative imaging studies, LUS seems to increase sensitivity by 10–20% for assessment of liver tumors.12 Laparoscopic ultrasound can be used for various therapeutic purposes in liver conditions. It can be effectively used to drain abscesses, biopsy liver masses,

Fig. 10.11: Laparoscopic ultrasound shows hepatic mass in the 8th segment of liver.

Chapter 10

lesion, and other subtle abnormalities during the lear­ ning curve. The role of the surgeon in ultrasound imaging has been stressed in various forums and the American College of Surgeons and Society of American Gastrointestinal Endoscopic Surgeons (SAGES) have realized its importance; they recommend basic and LUS techniques to all their surgical trainees. Surgeons can start performing routine ultrasound examinations in common cases such as laparoscopic cholecystectomy; once they understand the basic principle of LUS they can identify various structures and artifacts. Once the technique has been mastered, the surgeon will be in a better position to assess the lesions during surgery based on surgical expertise and imaging techniques.9

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Fig. 10.12: Color Doppler study of hilum of liver.

Fig. 10.13: Color Doppler assessment of hepatic tumor.

for interstitial tissue ablation for malignancy, and assist in deroofing of the liver parenchyma in case of liver cysts. Various interstitial tissue ablation methods are available for management of primary and secondary tumors of the liver. LUS helps in localization of these

tumors, assessment of tumor margins, and in real time monitoring during ablation. In radiofrequency ablation, the hypoechoic area becomes hyperechoic after adequ­ ate ablation which is denoted by degassing or bubbling. The diameter of the ablated tissue measured by LUS

Preoperative Imaging in Minimally Invasive Surgery

Gallbladder and Biliary Tree It has been demonstrated that LUS is a more sensitive and specific investigative modality for detection of CBD stones when compared to intraoperative cholangio­ gram (IOC). LUS has a sensitivity of around 80–100% in detection of stones.13-16 Time and cost studies also suggest that laparoscopic USG of the biliary tract may be less expensive than IOC. A cholangiogram takes approximately 10–15 minutes when compared to 4–9 minutes for laparoscopic USG.17 The learning curve for assessment of bile duct stones is approximately around 20 cases and has been shown to be more cost-effective when compared to IOC.9 In cases of acute cholecystitis with extensive inflammatory phlegmon, the localization of cystic duct and its insertion into CBD is extremely difficult. IOC is often not possible due to cystic duct block and moreover the cystic duct is usually not delineated. Anatomic road mapping of the biliary system with LUS aids the surgeon in preventing bile duct injuries. Abnormally placed vessels in the hilum can also be visualized by color Doppler study (Figs. 10.14 and 10.15).

Pancreas Assessment of pancreatic tumor by LUS has shown to decrease negative laparotomies. The signs of vascular infiltration like thrombosis of the vessels, luminal narrowing, loss of hyperechoic interface between vessel and tumor, and protrusion of tumor into the vessel clearly identifies patients with vascular infiltration. It can also be used to assess nodal status. Laparoscopy combined with LUS is more specific and accurate in predicting tumor resectability than laparoscopy alone (88–89% vs 50–60%).18,19 Endocrine tumors of the pancreas can be easily localized by LUS. The sensitivity of LUS in detecting pancreatic insulinomas is comparable to open intra­ operative ultrasound.20-22 It can also be used in benign conditions such as pseudocysts of the pancreas to define the center of the pseudocyst and the thinnest area of communication between stomach and cyst and for identification of dilated PD during pancreaticojejuno­ stomy. Patients recovering from necrotizing pancreatitis may develop abscesses or infected necrosis and localization and determination of the best access route to the area of necrosis can be determined by LUS. It can also identify the location of the PD and guide the surgeon in avoiding injury to the duct, thus reducing the risk of pancreatic fistula (Figs. 10.16 and 10.17).

Fig. 10.14: Ultrasound study of inflammatory mass in the gallbladder (GB) area shows empyema of the gallbladder.

Chapter 10

should be 1 cm more than the diameter of the lesion to ensure complete ablation.

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Fig. 10.15: Laparoscopic ultrasound for locali­ zation of common bile duct stone (A—basket; B—ultrasound probe).

Fig. 10.16: Ultrasound study of the pancreas during Whipple’s procedure showing periampul­ lary growth.

Gastroesophageal Tumors Inclusion of LUS in treatment protocols will lead to better identification of those patients that can be offered curative resections. The TNM staging of laparoscopy and

LUS is superior to the staging provided by preoperative imaging including conventional USG, CT, and EUS. The resectability rates following LUS is also higher when compared to controls.23,24

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Chapter 10 Fig. 10.17: Color Doppler study of localize the splenic vessels during laparoscopic pancreatic cystadenoma excision.

Fig. 10.18: Laparoscopic ultrasound study shows lesser omental node.

Others Diagnosis and staging of lymphoproliferative disorders includes assessment of LNs, nodal and liver biopsies, and, in selected cases, splenectomy. LUS helps the surgeon in localization of the nodes and in obtaining biopsies (Fig. 10.18).25

Laparoscopic ultrasound may be helpful in locating the adrenal vein when a large amount of retroperitoneal fat covers the vein. It also helps in localization of the adrenal gland. LUS has also been used for localization of nodules in thoracoscopy and in various other therapeutic procedures like celiac

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Art of Laparoscopic Surgery Textbook and Atlas ganglionectomy and chemical ablation of nerves in inoperable pancreatic tumors.25

Limitations Laparoscopic ultrasound is not particularly useful for identification of colonic or small bowel tumors due to the presence of gas and feces. At present, biopsy of a lesion with the currently available probes is difficult except for the most experienced surgeons. Development of especially designed puncture probes will help in accu­ rate biopsy of deep-seated lesions of the liver. Some authors have warned about the risk of tumor cell implantation at port sites, especially in patients with malignant ascites. But now, it has been proven that the incidence of port site metastasis is not greater than the incidence in open surgeries. The learning curve appears to be determined by the surgeon’s ability to interpret the images and is highly operator dependent.

INDOCYANINE GREEN Indocyanine green (ICG) is an anionic, water-soluble, relatively hydrophobic, tricarbocyanine molecule with a molecular mass of 776 Daltons. ICG dye was developed for near infra-red (NIR) photography by the Kodak research laboratories in 1955 and FDA approved for clinical use in 1959. Following intravenous injection, ICG is rapidly bound to plasma proteins, especially lipoproteins, with minimal leakage into the interstitium. Depending on liver vascularization and function, ICG is rapidly extracted by the liver without modifications and nearly exclusively excreted by the liver appearing unconjugated in the bile about 8 minutes after injection. When injected outside blood vessels, ICG binds to proteins and is found in the lymph, reaching the nearest draining lymph node usually within 15  minutes. After 1–2 hour, it binds to the regional lymph nodes, deposited into macrophages. The usual dose for standard clinical use is 0.1–0.5 mg/mL/kg. ICG becomes fluorescent once excited either using a laser beam or by NIR light at about 820  nm and longer wave lengths, the absorption peak is around 807 nm, and the emission peak is around 822  nm. The fluorescence released by ICG can be detected using specifically designated scopes and camera.

Role in Laparoscopy The imaging is generated by the high-end full high definition camera system connected to a laparoscope with 30° field of direction and 10  mm diameter equipped with a specific filter for optimal detection of the NIR fluorescence and white light without manual switching. The powerful xenon light source provides both visible and NIR excitation light. Switching from standard light to NIR is controlled by the surgeon by means of a pedal.

Fluorescence-guided Lymphadenectomy Intraoperative sentinel node (SN) mapping guided by ICG fluorescence imaging. 0.5% ICG solution is injected into the submucosa endoscopically (1 to 3 days before the operation) or subserosa intraoperatively at four sites (0.5 mL each) around the tumor. Lymph nodes taking up ICG appeared as round spots emitting clear fluorescence and were defined as the fluorescent nodes (FNs) (Figs. 10.19A and B). The FNs were dissected out carefully from the surrounding fatty tissue. The lymph nodes in the dissected specimens were isolated from the surrounding tissues on the back table, and examined to determine if they also exhibited internal fluorescence. All the fluorescent lymph nodes were regarded as representing the FNs. After the operation, it was ensured, if possible, that no fluorescent spots remained in the resected specimens. Tajima et al. in their study SN mapping guided by indocyanine green fluorescence imaging in gastric cancer concluded that ICG fluorescence imaging–guided SN mapping could be useful in predicting the metastatic status in the lymph nodes in gastric cancer.26 Dissection of LBs containing FNs with laparoscopic surgery may be a promising approach as a new type of minimally invasive surgery for patients with cT1- or cT2- stage gastric cancer having no metastasis in the FNs.

Fluorescence-guided Laparoscopic Cholecystectomy As ICG, once injected, concentrates in bile, it is possible to outline the biliary tree anatomy, especially in Calot’s trian­ gle, by visualization under NIR light, during laparoscopic cholecystectomy, in both elective and acute settings.

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Chapter 10 Fig. 10.19A: Robotic Wertheim's hysterectomy. View after lymphadenectomy.

Fig. 10.19B: ICG camers shows fluorescent nodes along the vessels.

The ICG dye was injected intravenously at least 15 minutes before surgery to allow ICG to concentrate in the bile. If the vascular anatomy of the cystic artery required clarification, a small bolus of 2–3  mL of 0.4  mg/mL/kg was injected. Fluorescence appeared at the level of the Calot’s triangle defining the cystic artery after 60 seconds.

Fluorescence-guided Laparoscopic Hepatectomy Boundaries of hepatic segments prior to anatomic resection can be identified by fluorescence imaging (Figs.  10.20A and B). Using a standard vial of 25 mg, diluted with water solution, ICG is usually given at the standard dose of 2.5 mg

(1 mL) intravenously few seconds before viewing the ducts. Alternatively, 2.5 up to 12.5 mg can be injected intravenous (IV) 30–90 minutes before and during surgery. Mizuno et al. reported a single experience regarding the use of ICG-NIR-FC for donor hepatectomy in LDLT.27 It was found useful to identify the exactly cutting line of the bile duct, which was appropriate for both donor and recipient under guidance of this imaging.

Fluorescence-guided Laparoscopic Colorectal Resection ICG-enhanced fluorescence was used during laparo­ scopic colorectal resection in order to verify the adequate perfusion of the large bowel prior to anastomosis.

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Fig. 10.20A: Laparoscopic right hepatectomy.

Fig. 10.20B: hepatectomy.

ICG

camera

view

of

right

Once injected into a peripheral or central vein, ICG became fluorescent under NIR light, providing a “realtime” confirmation of the bowel perfusion. Thus, this helps to define the point of resection after mesenteric division as well as demonstrates the presence of an ischemic or “non-optimal” perfusion before performing the anastomosis. Use of ICG was associated with improved knowledge of perfusion and subsequently revision of anastomotic sites, it also helped to reduce postoperative interventions for anastomotic leaks.28,29

CONCLUSION Laparoscopic ultrasound is a promising investigative tool in the surgical armamentarium of the laparoscopic

surgeon who wishes to take laparoscopic surgery to newer frontiers. With newly available technology such as three-dimensional (3D) ultrasound and growing interest among surgeons to learn the technique, LUS will enhance our ability to stage malignancies and assess resectability in a better way. It will also serve as a cost-effective and simple tool for various therapeutic options like radiofrequency ablation.

REFERENCES 1. Gress FG. The early history of interventional endoscopic ultrasound. Gastrointest Endosc Clin N Am. 2017;27(4):547-50. 2. Liu J, Carpenter S, Chuttani R, et al. Endoscopic ultra­ sound probes. Gastrointest Endosc. 2006;63(6): 751-4.

Preoperative Imaging in Minimally Invasive Surgery 17. John TG, Greig JD, Carter DC, et al. Carcinoma of the pancreatic head and periampullary region. Tumor staging with laparoscopy and laparoscopic ultrasonography. Ann Surg. 1995;221(2):156-64. 18. Van Delden OM, Smits NJ, Bemelman WA, et al. Comparison of laparoscopic and transabdominal ultra­ sonography in staging of cancer of the pancreatic head region. J Ultrasound Med. 1996;15(3):207-12. 19. Angelini L, Bezzi M, Tucci G, et al. The ultrasonic detection of insulinomas during surgical exploration of the pancreas. World J Surg. 1987;11(5):642-7. 20. Jaroszewski DE, Schlinkert RT, Thompson GB, et al. Laparoscopic localization and resection of insulinomas. Arch Surg. 2004;139(3):270-4. 21. Lihara M, Kanbe M, Okamoto T, et al. Laparoscopic ultrasonography for resection of insulinomas. Surgery. 2001;130(6):1086-91. 22. Berends FJ, Cuesta MA, Kazemier G, et al. Laparoscopic detection and resection of insulinomas. Surgery. 2000;128(3):386-91. 23. Anderson DN, Campbell S, Park KG. Accuracy of laparoscopic ultrasonography in the staging of upper gastrointestinal malignancy. Br J Surg. 1996;83(10): 1424-8. 24. Finch MD, John TG, Garden OJ, et al. Laparoscopic ultrasonography for staging gastroesophageal cancer. Surgery. 1997;121(1):10-7. 25. Bezzi M, Silecchia G, De Leo A, et al. Laparoscopic and intraoperative ultrasound. Eur J Radiol. 1998;27(Suppl 2): S207-14. 26. Tajima Y, Yamazaki K, Masuda Y, et al. Sentinel node mapping guided by indocyanine green fluorescence imaging in gastric cancer. Ann Surg 2009;249:58-62. 27. Mizuno S, Isaji S. Indocyanine green (ICG) fluorescence imaging-guided cholangiography for donor hepatectomy in living donor liver transplantation. Am J Transplant 2010. pp. 2725-6. 28. Jafari MD, Lee KH, Halabi WJ, et al. The use of indocyanine green fluorescence to assess anastomotic perfusion during robotic-assisted laparoscopic rectal surgery. Surg Endosc. 2013;27:3003-8. 29. Kudszus S, Roesel C, Schachtrupp A, et al. Intraoperative laser fluorescence angiography in colorectal surgery: a noninvasive analysis to reduce the rate of anastomotic leakage. Langenbeck’s Arch Surg. 2010;395:1025-30.

Chapter 10

3. Saadany SE, Mayah W, Kalla FE, et al. Endoscopic ultra­ sound staging of upper gastrointestinal malignancies. Asian Pac J Cancer Prev. 2016;17(5):2361-7. 4. Teshima CW. Endoscopic ultrasound in the diagnosis and treatment of pancreatic disease. World J Gastroenterol. 2014;20(29):9976. 5. Alizadeh AHM. Endoscopic Ultrasonography (EUS) and Gallbladder. In: Abdeldayem HM (Ed). Updates in Gallbladder Diseases. InTech; 2017. pp. 97-109. 6. Robinson O’Neill DE, Saunders MD. Endoscopic Ultrasonography in Diseases of the Gallbladder. Gastroenterol Clin N Am. 2010;39(2):289-305. 7. Fukuda M, Mima F, Nakano Y. Studies in echolaparo­ scopy. Scan J Gastroenterol. 1982;(Suppl 78):186. 8. Soper NJ. Laparoscopic ultrasound for gastrointestinal surgeon. J Gastrointest Surg. 2001;5(2):219-20. 9. Foroutani A, Garland AM, Berber E, et al. Laparoscopic ultrasound vs triphasic computed tomography for detecting liver tumors. Arch Surg. 2000;135(8):933-8. 10. Machi J, Sigel B. Operative ultrasound in general surgery. Am J Surg. 1996;172(1):15-20. 11. Senagonre AJ, Marcello PW. Laparoscopic Ultrasound in Minimally Invasive Procedures in the Abdomen and Pelvis. In: MacFadyen BV (Ed). Laparoscopic Surgery of the Abdomen. New York: Springer-Verlag; 2004. pp. 446-50. 12. Greig JD, John TG, Mahadaven M, et al. Laparoscopic ultrasonography in the evaluation of the biliary tree during laparoscopic cholecystectomy. Br J Surg. 1994; 81(8):1202-6. 13. Rothlin MA, Schlumpf R, Largiader F. Laparoscopic sonography: an alternative to routine intraoperative cholongiography? Arch Surg. 1994;129:694-700. 14. Barteau JA, Castro D, Arregui ME, et al. A comparison of intraoperative ultrasound versus cholangiography in the evaluation of the common bile duct during laparoscopic cholecystectomy. Surg Endosc. 1995;9(5):490-6. 15. John TG, Banting SW, Pye S, et al. Preliminary experience with intracorporeal laparoscopic ultrasonography using a sector scanning probe. A prospective comparison with intraoperative cholangiography in the detection of choledocholithiasis. Surg Endosc. 1994;8(10):1176-80. 16. Wade TP, Comitalo JB, Andrus CH, et al. Laparoscopic cancer surgery. Lessons from gallbladder cancer. Surg Endosc. 1994;8(6):698-701.

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Diagnostic Laparoscopy: Indications, Tuberculosis, and Adhesiolysis

CHAPTER

11

INTRODUCTION

Acute Abdomen

Diagnostic laparoscopy has been in the armamentar­ ium of the gynecological surgeon for many years as a useful technique for evaluating pelvic pathology. It is now one of the most frequently performed gynecological procedures. However, diagnostic laparoscopy has been embraced by the general surgeon for the diagnosis of a wide range of abdominal diseases and the application of laparoscopic technique to the treatment of many of these diseases has accelerated the use of laparoscopy as a diagnostic tool. The first large series of diagnostic laparoscopy in humans was presented in the United States in 1920 by Orndoff, who described 42 cases of peritoneoscopy. Kark and Bruhl in 1928 and Ruddock in 1937 demonstrated the efficacy and safety of diagnostic laparoscopy with reports of 500 patients without a single mortality.1 Since the founding work of these and other pioneers diagnostic laparoscopy has evolved into an invaluable tool for diagnosis of intra-abdominal and pelvic pathology. Surgeons are now expanding the role of laparoscopy and the number of treatment options available through laparoscopy is increasing rapidly.

The patient presenting with acute abdominal pain continues to provoke much diagnostic consternation. Diagnostic laparoscopy is particularly useful when the presentation of acute abdominal pain suggests an intraabdominal catastrophe but exact diagnosis remains obscure. With detailed history taking and a complete physical examination, the differential diagnosis list usually narrows to a few prime suggestions. Standard laboratory testing in these patients includes a complete blood count with differential, a chemistry panel including amylase and liver enzymes, and three-way abdominal radiography. Ultrasonography plays an important role in confirming suspected pathology in an emergency setup. The extent to which one relies on further testing depends on many factors, including:

INDICATIONS

• Likelihood of obtaining an exact diagnosis • Whether or not further diagnostic accuracy will indeed change treatment options • Cost of further investigations • Cost of missing a nonoperable cause • Local expertise.

The indications for laparoscopy are numerous and still expanding. However, there are several widely accepted indications for diagnostic laparoscopy, which are listed here.2 Current indications for diagnostic laparoscopy: • Acute abdomen • Chronic abdominal or pelvic pain • Infertility • Liver disease and liver tumors • Ascites • Tumor staging • Evaluation of an abdominal mass • Trauma • Miscellaneous.

Diagnostic accuracy of laparoscopy in acute abdomen has been reported by Beauchamp et al. varying from 93% to 100%; in 20% to 38% of patients and laparoscopy revealed either no abnormality or discovered a disease requiring no surgery for proper management, thus avoiding an unnecessary burden of nontherapeutic laparotomies. In an another study by Nagy et al. diagnostic accuracy of laparoscopy in acute abdominal conditions is noted to be 91%, and laparotomy was found unnecessary in 54% of patients.3 Relative contraindications for the laparoscopic approach in acute conditions are hemodynamic instability, abdominal distension, fecal peritonitis, and perforated cancer.4

Diagnostic Laparoscopy: Indications, Tuberculosis, and Adhesiolysis

Bowel Obstruction

The diagnosis of acute mesenteric ischemia is an important consideration in the elderly patient with abdominal pain who is confined to the intensive care unit (ICU).5 The value of a good history, physical examination, and ancillary tests cannot be overemphasized. Laparoscopy can effectively establish or exclude this elusive diagnosis. The degree of vascular compromise can be evaluated visually using an accurately colorbalanced monitor. The accurate diagnosis and staging of intestinal ischemia allows for a number of therapeutic options. Clearly, if intestinal viability is lost, then bowel resection can proceed undeterred, either using standard open techniques or laparoscopically assisted methods. If the bowel is questionably viable, and an embolectomy is not indicated, then one can further support the patient medically and return later for a second laparoscopic assessment. By leaving the cannula in place beneath sterile dressings, we were able to reassess the level of bowel ischemia subsequent to the patient’s measured resuscitation. This second-look laparoscopy was performed at the bedside with minimal sedation by using the existing ports. With appropriate support, bowel viability was assured without the stress of a full laparotomy (Fig. 11.1).

One useful application of diagnostic laparoscopy is in patients who present with intermittent bowel obstruction with distension for which the cause remains obscure and in patients with internal hernia or closed loop obstructions from intestinal adhesions with potentially compromised bowel without abdominal distension. These patients can present vexing diagnostic problems, but at the same time, delay in accurate diagnosis can result in significant morbidity. Laparoscopy also plays an important role in identifying the infrequent causes of bowel obstructions. These less frequent causes include a persistent vitellointestinal tract, a Meckel’s diverticulum with inflammatory adhesions, intestinal intussusception, or adhesions from a torsioned epiploic appendix.6

Perforated Viscus Bowel perforation in association with abdominal conditions such as appendicitis, diverticulitis, or peptic ulcer disease is common. Laparoscopy for suspected perforated duodenal ulcer or ileal perforation confirms the diagnosis and the laparoscopic treatment is straightforward and complete.7 This approach allows

Fig. 11.1: Diagnostic laparoscopy shows gangrene of the small bowel segment. A— Gangrenous segment.

Chapter 11

Intestinal Ischemia

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Art of Laparoscopic Surgery Textbook and Atlas not only closure, omentopexy, and complete peritoneal lavage, but also allows for the discovery of alternate pathology if a duodenal or ileal perforation is not found. For example, if the perforation is from the large intestine significant treatment advantages follow.

Acute Right Lower Quadrant Abdominal Pain The increasing use of laparoscopic appendectomy has liberalized the laparoscopic evaluation of right lower quadrant (RLQ) pain.8 The wide differential diagnosis and high negative appendectomy rate have led many to adopt diagnostic appendectomy in virtually all females with RLQ pain who would otherwise undergo appendectomy. The situation of the female with RLQ pain is especially well suited to differentiation and treatment through the laparoscope.8 One of the most common diagnostic dilemmas confronting the active general surgeon is when women of childbearing age present with vague, lower abdominal or pelvic pain. But the general surgeon must be prepared to identify, triage, and occasionally treat women with acute reproductive organ pathology. The most common findings in patients with acute abdominal pain are appendicitis, acute salpingitis, pelvic inflammatory disease, ruptured ovarian cyst, adnexal torsion, and ectopic pregnancy. Other pathology commonly encountered includes ruptured ovarian cysts, torsion of the fallopian tubes and ovary, ruptured endometrium, and infarction or degeneration of uterine myoma. Naturally, nongynecologic pathology can be encountered, such as terminal ileitis, mesenteric adenitis, and Meckel’s diverticulitis.

Differential Diagnosis • Acute RLQ abdominal pain • GI causes: –– Appendicitis –– Mesenteric adenitis –– Terminal ileitis –– Meckel’s diverticulitis. • Gynecological causes:9 –– Acute salpingitis –– Pelvic inflammatory disease –– Ruptured ovarian cyst –– Tubo-ovarian abscess –– Infarcted uterine myoma –– Adnexal torsion –– Ectopic pregnancy.

Negative Explorations for Acute Pain Whereas an accurate diagnosis is obtained in over 70% of patients who receive diagnostic laparoscopy for acute pain syndromes, the options upon discovering no obvious cause for the patient’s clinical syndrome vary with the individual situation. For example, when diagnostic laparoscopy is used to rule out appendicitis and no obvious appendiceal pathology is found, one is advised to remove the appendix on a routine basis. An infrequent exception is encountered when patients present with terminal ileitis involving the base of the cecum. If uninvolved with Crohn’s disease, the appendix can be removed safely, thereby removing future diagnostic uncertainties during episodes of abdominal pain. However, if the disease approaches the cecum, one is advised to avoid resection in order to minimize the chance of producing an enteric fistula. Even if a nondiagnostic laparoscopy is the result of a complete exploration, two advantages are likely: 1. The majority of patients are spared a more extensive and debilitating operation 2. The negative results are highly reliable, that is, significant pathology is rarely missed. With operator experience, the diagnostic certainty and security of findings invariably increases. For this reason alone, the indications for diagnostic laparos­ copy in patients with acute abdominal pain should expand.

Chronic Abdominal or Pelvic Pain One of the most frustrating problems in gastrointestinal and gynecological medicine is chronic abdominal pain. When all noninvasive tests have failed to detect any disease process, diagnostic laparoscopy should be considered as a final step to rule out organic disease. Common causes of chronic pelvic pain are: • Endometriosis • Fitz-Hugh–Curtis syndrome • Adhesions • Malignancy. Few types of patients are more difficult to manage than those with chronic abdominal pain. Most patients in this group have already undergone many diagnostic procedures. These searches for pathology often include such procedures as upper and lower gastrointestinal endoscopies, computed tomography (CT), and screening for undetected carcinoma.

Diagnostic Laparoscopy: Indications, Tuberculosis, and Adhesiolysis more prone to hemorrhage following biopsy.10 However, during laparoscopy, directed hemostasis can be applied to any bleeding biopsy site using electrocautery or other hemostatic techniques. Evaluation of primary or secondary hepatic malignancies may be improved with laparoscopy as 80–90% of these lesions are at the surface of the liver and two-thirds of the liver surface can be visualized with the laparoscope. Laparoscopy may reveal small (90%) of significant intra-abdominal injuries associated with wounds in this location. The percentage of patients with abdominal stab wounds who have significant intraabdominal injury is much less than that of patients with gunshot wounds to the abdomen. Therefore, a greater number of these patients are candidates for laparoscopic examination. A more extensive assessment of the diaphragm, stomach, colon, and small bowel is indicated in this group of patients. The skilled laparoscopist can perform a complete examination of the peritoneum without conversion to laparotomy and can perform laparoscopic repair of some limited injuries. Laparoscopy for evaluating blunt trauma is less well defined than that for assessing penetrating trauma.12 Few surgeons would suggest that laparoscopy is the best initial method for assessing the abdomen in the blunt-trauma setting. The efficacy of sonography and CT in the diagnosis of blunt injury has limited the role of laparoscopy to that of an adjunctive technique for the further assessment of solid organ injuries that have already been identified by sonography or CT. Laparoscopy is an excellent method for the real-time examination of hepatic or splenic lacerations to determine the presence of continued hemorrhage. When laparoscopy is performed as a prelude to exploratory laparotomy in patients initially treated with observation, the demonstration of hemostasis may alter the surgeon’s plan to perform laparotomy in patients with hemoperitoneum secondary to an isolated solid organ injury. Blood may be removed from the peritoneal cavity by laparoscopy-guided suction catheters and may be processed for auto transfusion. The appropriate role for laparoscopy in the evaluation and operative management of trauma patients remains to be determined.14 Nevertheless, laparoscopic examination

Diagnostic Laparoscopy: Indications, Tuberculosis, and Adhesiolysis

Miscellaneous Other indications in which laparoscopy may prove useful include obscure gastrointestinal bleeding, and secondlook post-treatment evaluation with chemotherapy and radiotherapy, fever of unknown origin, critically ill with suspected abdominal pathology, etc.

CONTRAINDICATIONS Contraindications, both relative and absolute, are described in the given below sections.2

Absolute Contraindications Patient with known ruptured diaphragm should not undergo pneumoperitoneum. Insufflation of the abdo­ men may lead to tension pneumothorax and consequent hemodynamic and respiratory deterioration. A patient who is so severely sick or injured that hemodynamic reserves are exhausted should not undergo laparoscopy to find the source of the problem as the hemodynamic changes induced by pneumoperitoneum will further aggravate the problem.

Relative Contraindications A patient with highly distended air or air or fluid-filled loops of bowel should probably not undergo laparoscopy because the risk of perforating the bowel is markedly increased. If such a patient required laparoscopy, the Hasson technique could be considered for access to the peritoneal cavity. Uncorrected coagulopathies increase the risk of bleeding, and as a result the success rate of laparoscopy is lowered and the complication rate increases. Patients suffering from severe cardiac disease should receive a careful workup before undergoing laparoscopy. Stable angina is not a contraindication, but close communication with the anesthesiologist regarding intraoperative hemodynamic changes is

important. Severe obstructive lung disease may lead to hypercarbia from the CO2 pneumoperitoneum, and a resultant acidosis may develop. Some concerns about abdominal infections include dissemination of infection, induction of bacteremia, decreased oxygenation of the affected tissue secondary to increased intra-abdominal pressure, and CO2 diffusion.

APPROACH TO DIAGNOSTIC LAPAROSCOPY Instruments The instrumentation of diagnostic laparoscopy does not vary much from the instrumentation required for any laparoscopic procedure.15 A standard light source, fiber optic cable, and insufflator, all commonly used for laparoscopic cholecystectomies, will suffice. A standard 10-mm trocar, disposable or reusable, for the laparoscope, is essential as is at least one 5-mm or smaller trocar. Instruments such as a blunt probe, suction irrigation, atraumatic graspers, as well as a good pair of laparoscopic scissors should be readily available. Clip appliers, stapler, and needle driver should also be available. A uterine manipulator, such as the Hulka tenaculum, is very useful if the patient has been placed in the lithotomy position; hemostatic devices are also required. After induction of general anesthesia, the patient can be placed either flat or in a modified lithotomy position. The former position is preferred for male patients when the diagnosis is very unlikely to be of pelvic origin, whereas the latter is preferred in female patients when the diagnosis is less clear. The bladder should be emptied. A pelvic examination in the female is advisable.

INITIAL PORT PLACEMENT The umbilicus is usually chosen for the site of Veress needle insertion and ultimately as laparoscope port because it represents the thinnest accessible portion of the anterior abdominal wall. Alternative sites for Veress needle insertion include a position 2–3 cm below the midpoint of the left costal margin or the left ninth intercostal space. From these positions, both a gas-distended stomach and an enlarged spleen can be endangered. Insertion of the Veress needle in the left lower quadrant (LLQ) and the supraumbilical point has also been described. In most circumstances, an umbilical port (usually 10 mm) is used for the scope. If the diagnosis

Chapter 11

bears promise in specific groups of patients, and therapeutic closure of injuries to hollow viscera and the diaphragm appears to be readily feasible. As experience with laparoscopy grows in traumatology circles, it is reasonable to expect that the role of laparoscopy in the trauma setting will increase. Similar considerations have limited the acceptance of thoracoscopy in trauma patients, and further accrual of patients and studies to define its role should be forthcoming in the near future.

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Art of Laparoscopic Surgery Textbook and Atlas is not obvious, a second port to allow manipulation of the intra-abdominal organs is required. If RLQ pain is the indication, a second port should be considered, either in the midline just above the symphysis pubis or in the LLQ; this allows good manipulation of the bowel, appendix, and pelvic organs. If upper abdominal pain is the presenting problem, then a left upper quadrant (LUQ) port with possible addition of an epigastric port should be considered to allow manipulation of the upper abdominal organs.

laparoscopy methods for diagnostic and therapeutic procedures. Two of the more obvious reasons for considering the use of smaller and smaller instruments include less trauma to the abdominal wall and fewer difficulties with closure of wounds. Although it is too soon to evaluate fully the potential advantages of using smaller instruments through smaller wounds, it makes axiomatic sense to use less traumatic equipment, unless safety or viewing clarity is affected adversely, especially for relatively straightforward procedures.

Position of Surgeon

Conversion

The surgeon should be placed opposite the area being exposed and work across the midline of the abdomen. If the RLQ is being explored for possible appendicitis, then the surgeon should be standing on the patient’s left side. If the LUQ is being explored, the surgeon should be on the patient’s right. Conversely, the assistant (in most instances) is best located on the opposite side to the surgeon. Monitors should be placed directly in front of both surgeon and assistant to aid in keeping visual–hand alignment.

The basic premise in converting to an open procedure is that one cannot perform the necessary procedure laparoscopically. Although that may seem basic and an oversimplification, this premise is often overlooked or unappreciated. A list of factors affecting the decision to convert can be found in the following section. The reason that a procedure cannot be finished laparoscopically is often a result of one of several factors: visualization, instrumentation, or complication.

Procedure The Hasson technique is becoming the preferred method; however, the Veress technique is still acceptable.16 A thorough examination of the upper and lower abdomen should be carried out in a systematic fashion. If this does not reveal the diagnosis, a 5-mm trocar or mini laparoscopy port can be placed in the lower abdomen. The midline suprapubic position is an excellent choice. An instrument to move around the bowel, pelvic organs, and appendix is necessary. All adhesions should be carefully taken down to expose the area of interest; this should be done in nonvascular tissue planes and bleeding should be kept to an absolute minimum as blood may severely limit visualization and thus the ability to complete the diagnostic evaluation. A routine order of areas to be explored will ensure all areas are explored and none is missed. The order of this examination is variable depending on both the surgeon and the patient’s presenting symptoms.

Mini Laparoscopy Recent trends and improvements in laparoscopy instrumentation have spurred the introduction of mini

Indications for Conversion to Open Procedure • Complication not amenable to laparoscopic control or repair: –– Massive bleeding –– Complex enterotomies –– Cystotomy –– Ureter injury –– Other organ injury that cannot be assessed adequately. • Lack of visualization: –– Bloody field –– Anatomic details unclear –– Retraction problems –– Exposure difficulties. • Instrumentation problems: –– Obese patient—trocar and instrument-length problems –– Instrument angle. Complications leading to conversion to an open procedure include any complications that cannot be handled in a safe fashion laparoscopically, of course depending on the surgeon’s abilities. Well-accepted indications for conversion to an open procedure are massive bleeding, complex enterotomies, or inability to fully determine the nature of the complication. A lack

Diagnostic Laparoscopy: Indications, Tuberculosis, and Adhesiolysis

TUBERCULOSIS OF THE ABDOMEN In 1882, Robert Koch discovered Mycobacterium tuberculosis. This opened the doors for definitive diagnosis and development of anti-tubercular drugs, the first being streptomycin in 1940. Tuberculosis is a potentially fatal contagious disease that can affect any organ in the body. Although it can be treated, cured, and prevented, we have never come close to wiping it out. Few diseases has caused so much distressing illness for centuries and claimed so many lives.17 Today, it continues to be a major health problem in developing countries. Tuberculosis has been declared a global emergency by WHO and is the most significant communicable disease worldwide. Abdominal tuberculosis comprises tuberculous infection of the gastrointestinal tract, mesenteric lymph nodes, peritoneum, omentum, and solid organs—liver and spleen. Tuberculosis of the genitalia and urinary tract are sep­ arate entities. Even though abdominal tuberculosis is the most common form of extrapulmonary tuberculosis, it is still ill understood by clinicians and researchers alike.18,19 Primary tuberculosis has no other focus and secondary disease has other foci like the lung. In this section, we will deal with tuberculosis of the gastrointestinal tract.

Incidence The overall incidence of the disease is increasing due to the increase in AIDS (acquired immunodeficiency

syndrome). There are 8–10 million new cases each year worldwide causing 3 million deaths.17 It is more common in old age and poor socioeconomic groups. Gastrointestinal tuberculosis forms 1% of all general hospital admissions in India and accounts for twothirds of abdominal tuberculosis. Bockus et al. have reported that primary abdominal disease is mainly hyperplastic (70%) and secondary disease is mostly ulcerative (30%).

Mode of Spread Mycobacterium tuberculosis spreads to the abdomen by different routes. If it is caused by ingestion of contaminated food it is called primary intestinal tuberculosis, and if it is caused by swallowing infected sputum it is called secondary. Peritoneum, mesenteric nodes, and intestine may become infected through blood or lymphatic spread. The bacteria can also spread directly from infected adjacent organs. In females, a common route is through the genital organs. Spread can occur through bile from a focus in the liver.

Clinical Features The general symptoms of gastrointestinal tuberculosis20 in order of frequency and their incidence are as follows: • Abdominal pain: 86% • Weight loss: 63% • Fever: 61% • Anorexia: 48% • Vomiting: 46% • Abdominal distension: 37% • Ascites: 37% • Borborygmi: 35% • Abdominal mass: 33% • Diarrhea: 22% • Constipation: 24% • Hematochezia: 4%

Clinical Signs • • • • • •

Anemia: 91% Bowel obstruction: 21% (11% of all obstructions) Malabsorption: 14% Bleeding per rectum: 4% Bowel perforation: 3% (7% of all perforations) Vague (nonobstructive): 29%

Chapter 11

of visualization, or unclear anatomy, is one of the most frequent reasons for conversion to an open procedure. Visualization can often be enhanced by the addition of a scope of 300°, 450°, or greater. The ability to expose the area of interest to complete the examination is of paramount importance. Several techniques have been advocated to improve laparoscopic exposure including tilting the table head-up, or head-down, and lateral angulations. Instrumentation can also be a limiting factor during laparoscopic surgery. Addition of ports and advanced instrumentation alleviates some of these problems, but if one is unable to perform the necessary procedure with the instruments available, an indication for conversion to open exists. The abilities and judgment of the surgeon play a key role. It is paramount to remember that the decision to convert a laparoscopic procedure to an open one is not a failure but rather sound surgical judgment.

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Classification • Peritoneal tuberculosis: –– Acute –– Chronic: -- Ascitic type: Generalized or localized -- Fibrous type: Adhesive, plastic, miliary nodule -- Peritoneal folds: Mesenteric adenitis, cysts, abscess, adhesion, and omental. • Gastrointestinal tuberculosis: –– Ulcerative –– Hyperplastic –– Fibrotic • Solid organ tuberculosis: –– Liver –– Spleen –– Gall bladder –– Common bile duct –– Pancreas. Organ Incidence Peritoneum 37.6% Mesenteric lymph nodes 6.2% Esophagus 0.16% Stomach 1.0% Duodenum 2.0% Small bowel 27% Ileocecal 22.9% Appendix 0.4% Colon and rectum 9.2% Liver 0.04% Pancreas 4.7% The terminal ileum and ileocecal junction are most commonly involved. This is due to abundant lymphoid tissue, slower rate of absorption, and prolonged stasis which provides longer contact time. Tuberculosis of the omentum, spleen, pancreas, gall bladder, and common bile duct is very rare but has been reported. We will discuss tuberculosis of the peritoneum, ileum, ileocecal, appendix, rectum, spleen, liver, and gall bladder.

Tuberculosis of Peritoneum The acute form is rare and it occurs as part of the miliary phase of the disease, following perforation of intestinal disease or dissemination from a ruptured caseating node. The chronic type is more common and presents as ascites, generalized or localized. There are miliary nodules which can coalesce and form adhesions.

This results in the formation of an abdominal cocoon that encases the bowels. The omentum thickens and gets rolled up.21 Clinically, it presents as a subacute obstruction. The abdomen has a characteristic doughy feel, with visible intestinal peristalsis. Ultrasonography being a widely available investiga­ tion is now a “low threshold” diagnostic procedure for all patients suspected as having abdominal tuberculosis. It can accurately demonstrate small quantities of ascitic fluid and is an effective method for detection of peritoneal disease.22 The reported findings include multiple, thin, complete, and incomplete septae—visible echogenic debris seen as fine strands or particulate matter within the fluid. These strands of septae may be due to the high fibrin content of the exudative ascitic fluid. Septae have also been reported in a few cases of malignant ascites. Peritoneal thickening and nodularity are the other sonographic features. Peritoneal involvement is usually associated with widespread abdominal disease involving lymph nodes or bowel. The wet type is the most common. The fluid demonstrates high attenuation at CT due to its high protein and cellular content.23 The dry or plastic type is uncommon and is characterized by caseous nodules, fibrous peritoneal reaction, and dense adhesions. The fibrotic fixed type consists of large omental masses, matted loops of bowel and mesentery, and, on occasion, loculated ascites (Fig. 11.3). Computed tomography may also demonstrate tethering of bowel loops. Infiltration of the mesentery, when associated with a large amount of ascites, may have a stellate appearance.24 The treatment is a course of antitubercular drugs. In case of intestinal obstruction, surgery is indicated.

Tuberculosis of Ileum and Ileocecal Junction This is the most common site of gastrointestinal tuberculosis due to the abundance of lymphoid tissue. The symptoms are vague, dull abdominal pain; colicky pain after eating in case of intestinal obstruction which is relieved by vomiting; diarrhea in which stools are bulky and foul smelling; flatulence; nausea; altered bowel habits; and borborygmi. Abdominal distension is present in case of ascites or obstruction. Patients are anemic and malnourished. There may be visible intestinal peristalsis and palpable bowel loops. An ileocecal mass may be palpable in the right iliac fossa (a differential diagnosis for right iliac fossa mass). Complications are intestinal obstruction, malabsorption,

Diagnostic Laparoscopy: Indications, Tuberculosis, and Adhesiolysis

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Chapter 11 Fig. 11.3: Fibrotic type of tuberculosis of peritoneum.

perforation (and peritonitis which tends to be localized), and lower gastrointestinal bleed (accounts for 5% of causes of lower gastrointestinal bleed).25 Barium studies demonstrate spasm and hypermotil­ ity with edema of the ileocecal valve in the early stages of the disease followed by thickening. A widely gaping ileocecal valve with narrowing of the terminal ileum (Fleischner sign) or a narrowed terminal ileum with rapid emptying of the diseased segment through a gaping ileocecal valve into a shortened, rigid, obliterated cecum (Stierlin sign) may also be seen. Focal or diffuse aphthous ulcers also occur in the early stages. These ulcers are larger than those seen in Crohn’s disease and tend to be linear or stellate, following the orientation of lymphoid follicles (i.e. longitudinal in the terminal ileum and transverse in the colon). In advanced cases, symmetric annular stenosis and obstruction associated with shortening, retraction, and pouch formation may be seen.20 The cecum becomes conical, shrunken, and retracted out of the iliac fossa due to fibrosis within the mesocolon, and the ileocecal valve becomes fixed, irregular, gaping, and incompetent. CT may show circumferential wall thickening of the cecum and terminal ileum associated with adjacent mesenteric lymphadenopathy.24 Characteristic CT features include asymmetric thickening of the ileocecal valve and medial wall of the cecum, exophytic extension engulfing the terminal ileum, and massive lymphadenopathy.23

Pathology Ulcerative: These lesions are deep and transversely placed in the direction of lymphatics. They are usually multiple and common in the ileum. There is also a

marked increase in the mesenteric fat which wraps around the bowel. Perforation is rare. Hyperplastic: These lesions occur as a result of reduced bacterial virulence and increased host resistance. There is marked thickening of the bowel wall due to a fibroblastic reaction in the submucosa and subserosa. Mass lesions are formed due to the involvement of adjacent mesentery, lymph nodes, and omentum. Sclerotic: This is associated with single or multiple strictures, typically called “napkin-ring” strictures.22 They may involve a short or long length of bowel. There may be an enterolith formation proximal to the stricture.

Treatment Perforation: Resection of affected segment and primary anastomosis (simple closure is not recommended). Ileocecal mass with obstruction: Limited resection with a 5-cm margin and primary anastomosis (ileocolic or enteroenteric bypass to be avoided). Early removal of drainage tubes is advisable as there is increased risk of fistula formation if left for more than 7 days.

Tuberculosis of the Appendix Incidence of primary disease is 0.1–0.3%. Secondary involvement as part of ileocecal tuberculosis is 1.5–3%. There are three types: acute, chronic (presents as mass), and latent (accidental finding).26 Appendectomy specimen should be sent for histopathology in all cases, especially in endemic areas, as tuberculosis is likely to be missed.

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Fig. 11.4: Miliary tuberculosis involving the small bowel.

Tuberculosis of the Colon Colon is the fourth most common site of gastrointestinal tuberculosis.27 Primary disease is rare. Both ulcerative and hyperplastic types are seen; the former being more common. The ulcerative type gives rise to strictures and the hyperplastic type gives rise to superficial ulcers. Symptoms are abdominal pain, diarrhea, or alternating bowel habits, intestinal colic, and features of obstruction (Fig. 11.4). Transverse colon is most commonly affected, though the entire large bowel can get involved in which case there is thickening and fixity.27 There will be bloody diarrhea with mucus. This condition mimics carcinoma. Treatment is surgery, that is, limited resection of affected part or subtotal colectomy if disease is extensive.22,27

Endoscopic Features (in Order of Frequency) • • • • • • • •

Ulcers: 77% Nodules: 70% Ileocecal valve: 48% Multiple sites: 29% Strictures: 25% Segmental disease: 20% Polypoidal lesions: 14% Diffuse: 4%

Tuberculosis of the Rectum Gupta et al. have reported an incidence of 4.5%.23 The common presentation is hematochezia and is due

to ulceration of mucosa. Obstruction is caused by annular stricture or fibrosis of mucosal ulcers. It mimics cancer and is usually not amenable to antitubercular chemotherapy. Limited resection is indicated if stenosis persists 3–6 months after antitubercular therapy (ATT); if there is difficulty in differentiating from cancer; and if cancer and tuberculosis coexist (Fig. 11.5).20

Tuberculosis of the Liver Hepatic tuberculosis is rare these days and mostly diag­ nosed accidentally. Its involvement occurs most com­ monly in patients with disseminated tuberculosis.22 The lesions are typically granulomas, with or without central caseating necrosis. Tuberculous periportal lymph nodes can cause obstructive jaundice by compressing the bile duct. Liver enzymes, especially alkaline phosphatase, are elevated. Radiographically, it is of two types: micronodu­lar (miliary) and macronodular (rare). Micronodular disease manifests as multiple and tiny foci. The macronodular type manifests as diffuse liver enlargement with multiple lesions or as a single tumorlike mass. Both types display low attenuation at CT scan and show central enhancement on contrast-enhanced imaging.23 Calcification may be present in chronic cases. The diagnostic yield of liver biopsy in patients with hepatomegaly and raised alkaline phosphatase and gamma-glutamyltransferase is exceptionally high, in several series between 91% and 100% of cases.28 However, the detection of granulomas is not specific for tuberculosis.

Diagnostic Laparoscopy: Indications, Tuberculosis, and Adhesiolysis

163

Chapter 11 Fig. 11.5: Miliary tuberculosis involving the rectum.

Fig. 11.6: Miliary tuberculosis involving the liver.

Granulomatous hepatitis is common in sarcoidosis, drug-induced hepatitis, for example, allopurinol and sulfonamides, and disseminated cryptococcosis. Contraindications to liver biopsy are clotting abnormalities (prolonged international normalized ratio or INR and partial thromboplastin time or PTT), thrombocytopenia, ascites, and dilated intrahepatic bile ducts—in jaundiced patients (should be excluded

by ultrasonography). Treatment is antitubercular drugs based on ethambutol as all others are hepatotoxic. Differential diagnoses for hepatic tuberculosis are metastasis, lymphoma, fungal infections, sarcoidosis, primary tumor, leprosy, brucellosis, infectious mononucleosis, inflammatory bowel disease, syphilis, drug-induced liver damage, chronic active hepatitis, and abscess (Fig. 11.6).20,22

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Tuberculosis of the Spleen

Diagnosis

Splenic tuberculosis is rare and may be primary or secondary. It presents as an abscess or hypersplenism and is common in AIDS.22 Ultrasonogram shows multiple, low echoic, irregular nodules, “moth-eaten” spleen.24 Splenectomy is the treatment of choice.

The diagnosis is not always easy as the symptoms are vague and depend on the site or organ of involvement. Tuberculosis of the individual organs is described under their respective headings. Here we describe the general principles of investigating a suspected case. Hematological examination may show presence of anemia and an elevated erythrocyte sedimentation rate (ESR) (>90%). However, these are nonspecific findings and may not aid much in diagnosis. The tuberculin test may be positive but it is not of much value as it does not differentiate between an active and inactive disease.33 Serological tests like soluble antigen fluorescent antibody (SAFA) and enzyme-linked immunosorbent assay (ELISA) are not sensitive, are nonspecific, and can only suggest a probable diagnosis.33 In ascites, peritoneal fluid is straw colored with proteins more than 30 g/L, cells more than 1,000 cu/mm (mostly lymphocytes), ascitic/blood glucose ratio of less than 0.96, and adenosine deaminase levels of more than 33 U/L. Acid fast bacilli (AFB) are rarely seen on smear but may be cultured from the ascitic fluid.33 Confirmation of the diagnosis of tuberculosis at any site is ideally established by demonstrating AFB on smear, or mycobacterial culture from the tissue, or by demonstrating caseating granulomas at histopathology. Since abdominal tuberculosis is paucibacillary, the

Tuberculosis of the Gallbladder The first case of gallbladder tuberculosis in the world was reported by Gaucher in 1870.19 Only 50 cases have been reported since then.29 Presenting symptoms are vague and diagnosis is made only after cholecystectomy. The normal gallbladder is resistant to tubercular infection due to the inhibitory factors in bile. The presence of underlying pathology like cholelithiasis or common bile duct obstruction predisposes to tuberculosis; rarely there will be any other pathology.30 The route of spread is canalicular, lymphatic, or hematogenous (Fig. 11.7).31

Tuberculosis of the Common Bile Duct The intrahepatic biliary tree can become infected but common bile duct involvement is extremely rare. Only a few cases have been reported, the first one by Ratanarapee et al. from Bangkok in 1991.32 The patient presented with obstructive jaundice. Treatment is T-tube drainage with ATT.

Fig. 11.7: Miliary tuberculosis involving the entire peritoneum, liver, and gallbladder.

Diagnostic Laparoscopy: Indications, Tuberculosis, and Adhesiolysis

Role of Laparoscopy Laparoscopy is diagnostic in 92% of patients with abdominal tuberculosis.34 Our findings also support previous work on the value of laparoscopy, the most specific diagnostic test for abdominal tuberculosis, with its advantage of histological confirmation. However, positive identification of M. tuberculosis is made only in 50% of cases. Unfortunately, laparoscopy still tends to be used as a last resort, and our series was no exception.35 With the growing availability of experienced laparoscopists, the morbidity of laparoscopy is much less of an issue. The complication rate is less than 5%.35 Our findings strengthen the evidence that for patients with a relevant background and clinical history, laparoscopy is the investigation of choice.34,35

Differential Diagnosis It includes Crohn’s disease, carcinoma, lymphoma, ulcerative colitis, and fungal lesions.

Antitubercular Drugs Traditionally, the 9 month AKT was given to the patients with abdominal Koch’s, however it is now proven that the 6-month therapy is as effective as 9-month therapy in patients with intestinal TB and may have the additional benefits of reduced treatment cost and increased compliance.36 In a Cochrane review they found no evidence to suggest that 6-month treatment regimens are inadequate

for treating people that have intestinal and peritoneal TB.37 In India, according to recommendations made during a meeting of the INDEX-TB guidelines group in July 2015 at AIIMS, New Delhi: • First 2 months: Four-drug regime— –– INH (8 mg/kg/day) + rifampicin (10 mg/kg/day) + ethambutol (15 mg/kg/day) + pyrazinamide (1.5 g/day). • Next 6 months: Three-drug regime— –– INH + rifampicin + ethambutol.

LAPAROSCOPIC ADHESIOLYSIS Intra-abdominal adhesions are common and a major clinical problem. Most of them occur as a result of injury to the peritoneum, in the form of surgery or infection.38 After laparotomy, 95% of patients are found to have adhesions on subsequent operations.39 Although in most of the patients adhesions do not cause any problem, some develop lifelong adhesion-related disease. Adhesions are the most common cause of small bowel obstruction (40–64%). It is a common cause of secondary infertility in females (39%).40 Adhesions have also been proposed to cause chronic abdominal and pelvic pain. Clinical problems related to adhesions: • Small intestinal obstruction • Secondary female infertility • Ectopic gestation • Chronic abdominal and pelvic pain • Difficult reoperations. Acute appendicitis and appendectomy are potent causes of adhesions. A collective analysis of six series shows that 36% of patients (680 of 1,897) presenting with postoperative adhesional intestinal obstruction had undergone appendectomy.41 In women, the most common cause of postoperative adhesive intestinal obstruction is a previous hysterectomy.42 A large retrospective study based on the Scottish National Health Service medical record linkage database was published in 1999.43 All patients who underwent open abdominal or pelvic surgery in 1986 were followed for 10 years. Of all readmissions, 5.7% were directly due to adhesionrelated problems and 3.8% required reoperation; 22.1% of readmissions occurred in the first year after the initial operation, but readmissions continued steadily throughout the 10-year period. The rate of readmission after initial midgut and hindgut surgery was significantly higher than after foregut, gynecological,

Chapter 11

yield of organisms is low and characteristic histological changes are taken as diagnostic. Moreover, getting tissue for histology may not always be possible. Plain radiogram of abdomen, barium studies, endoscopy, and laparoscopy are all described under various headings. CT scan of the abdomen is only marginally more specific for abdominal tuberculosis than USG, though the abdominal CT scan is much more sensitive than USG in detecting high-density ascites and changes of thickening in mesentery, peritoneum, bowel wall, and omentum.24 Studies show that the CT scan is superior to USG except in the presence of bowel wall dilatation. While CT scan appears to be more sensitive and specific, USG has the advantage of being less expensive, widely available, and easy to perform.23

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Fig. 11.8: Adhesion of small bowel and colon to the abdominal wall.

Fig. 11.9: Adhesiolysis using scissor (A—traction of bowel with the left hand instrument).

and other abdominal operations. Management of these adhesion-related problems results in a large surgical workload and is a burden to healthcare systems (Figs. 11.8 and 11.9).

In a review of 388 patients with abdominal adhesions, 79% had a history of surgery, 18% had a history of peritoneal infection, and 11% had congenital adhesions.44 Peritoneal injury, from a variety of causes, leads to

Diagnostic Laparoscopy: Indications, Tuberculosis, and Adhesiolysis

Investigations Plain X-ray of the abdomen frequently provides helpful information on the diagnosis and the possible level of obstruction. The sensitivity of a plain X-ray for the detection of complete intestinal obstruction is about 50%.46 The sensitivity is lower for detection of incomplete intestinal adhesive obstruction. Small bowel follow-through using gastrographin has both a diagnostic and a therapeutic effect, as the hyperosmolar contrast agent stimulates peristalsis and reduces edema of the bowel wall. Contrast-enhanced CT is increasingly used in the assessment of patients with small bowel obstruction. Airfluid levels, the absence of mass lesion, and a transition zone between dilated prestenotic and empty poststenotic bowel loops characterize complete intestinal obstruction caused by adhesions. The sensitivity and specificity reported for CT are 100% and 83%.47 The sensitivity of CT for detection of intestinal ischemia in strangulated bowel was reported to be 100% with a specificity of 61%. Hysterosalpingography can detect peritubal adhesions. Transvaginal ultrasound scan is useful in the diagnosis of pelvic adhesions. Patient-assisted laparoscopy or conscious pain mapping is used for identifying the cause of chronic abdominal or pelvic pain. This requires the patient to be awake enough during the initial diagnostic laparoscopy to assist the surgeon in identifying the source of the

discomfort. A conscious form of sedation is used along with liberal use of local anesthetic agents at the sites of trocar insertion. Mini-laparoscopic or needlescopic (2 mm) instruments are used to minimize the patient’s procedure-related discomfort. The distension is limited to 8 or 10 mm Hg. The surgeon then probes the suspicious areas, awaiting comment from the patient. After the patient identifies the areas of pain, the conscious sedation is converted to full anesthesia and adhesiolysis or other therapeutic procedures are completed. Some researchers have reported dramatic success with conscious pain mapping.48,49 Larry Demco reported patient-directed laparoscopy on 100 patients with abdominal or pelvic pain.50 In 12, the procedure was aborted due to pain or problems in entering the peritoneal cavity; 61 had endometriosis, 16 had symptomatic adhesions, 5 had unrecognized inguinal or abdominal hernias, 1 had occult colon cancer, 1 had dropped a stone from a previous cholecystectomy, 1 had pain from previously placed staples, and 1 was diagnosed to have Crohn’s disease. Two patients had no obvious cause for their symptoms.

Management The initial management of adhesive intestinal obstruc­ tion is nasogastric suction and correction of fluid and electrolyte imbalance. When clinically indicated, the sur­ gical treatment of intestinal adhesion is adhesiolysis. This can be performed either laparoscopically or by laparo­ tomy. Even though no prospective randomized trials are available, currently laparoscopy is replacing laparotomy as the method of choice for elective adhesiolysis. Laparo­ scopy is associated with less peritoneal injury, less de novo adhesion formation, and has the other advantages of minimally invasive surgery (De novo adhesions are those that occur where no adhesions existed prior to sur­ gery. It has to be differentiated from recurrence of adhe­ sions at the same site after adhesiolysis).

Indications • Selected cases of small bowel obstruction: –– Mild abdominal distension –– Proximal obstruction –– Single band obstruction (preoperative diagnosis not possible). • As an initial step in performing any laparoscopic pro­ cedure where previous adhesions hinder adequate visualization or access to abdominal organs.

Chapter 11

peritoneal inflammation and with it the production of plasminogen activator inhibitors. These inhibitors result in the loss of normal mesothelial fibrinolytic activity and, if prolonged, this allows the organization of fibrinous adhesions into permanent fibrous adhesions. Proinflammatory cytokines stimulate peritoneal production of plasminogen activator inhibitors. Normal peritoneum possesses fibrinolytic activity, which, if not impaired, will lyse fibrin within the inflammatory exudates before organization takes place. There is a wide variation among patients in their tendency to develop adhesions. Ivarsson et al. demonstrated, in a prospective clinical study using second-look laparoscopy, that patients who developed severe and dense adhesions have lower levels of tissue plasminogen activator activity and ten-fold higher plasminogen activator-inhibitor-1 levels in their peritoneal fluid compared with those who developed milder and softer adhesions.45

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Art of Laparoscopic Surgery Textbook and Atlas • Pelvic adhesiolysis for female subfertility • Chronic abdominal pain (controversial) • Chronic recurrent intestinal obstruction.

Acute Small Bowel Obstruction Although acute bowel obstruction is often mentioned as an absolute contraindication to laparoscopy, several reports of successful treatment with laparoscopy have been published recently. The obvious limitations are that of access and visualization in the setting of small bowel distension. Most of the researches advocate an open technique for initial access. Distended intestines are much more fragile than a normal bowel and hence one must be very careful when manipulating them. The best candidates for primary laparoscopic treatment of bowel obstruction are those with a history of only one or two previous operations, early ( 35 kg/m2 with obesity-related comorbidities • Age between 16 and 65 years • Acceptable surgical/medical risk • Failure of effective and lasting weight loss with appropriate nonsurgical treatment • Psychological stability • A well-informed and motivated patient with realistic expectations • Commitment to prolonged lifestyle change and longterm follow-up evaluation • Supportive family and social environment • Resolution of alcohol or substance abuse • Absence of active psychosis and untreated severe depression

But the above guidelines does not appropriately consider ethnic differences, the Asian Pacific Metabolic and Bariatric Surgery Society (APMBSS 2005) put forward Asia specific guidelines where indication for bariatric surgery for Asian people has been modified to a BMI ≥37 irrespective of comorbidities or BMI ≥32 with DM or 2 significant obesity-related comorbidities.18 Surgery is recommended for patients with in the age of >18 and 10 mL). It is also important that the other etiologies (congenital adrenal hyperplasia, androgen-secreting tumors, or Cushing syndrome), potentially resulting in a hyperandrogenic state are excluded. The pathophysiology of PCOS is complex and is characterized by chronically elevated levels of luteinizing hormone (LH) and insulin resistance.56 This insulin resistance is associated with type 2 diabetes and compensatory hyperinsulinemia has been consistently documented in patients with PCOS.57 It is also been noted that the severity of insulin resistance correlates with the severity of the clinical and metabolic phenotype of PCOS. Hence the evaluation of all PCOS patients should include a complete T2DM profile (GTT, HbA1C and HOMA-IR). Sustained weight loss is the currently available definitive intervention expected to have a lifelong effect on reducing the long-term complications of PCOS. Bariatric surgery, by means of significant weight loss and other weight independent factors as described earlier, helps correct insulin resistance and hyperinsulinism, hence by improving fertility, lipid and androgen profiles. It has been shown that a reduction of 5–10% EWL has resulted in resumption of ovulation within weeks of surgery.58 In the study by Jaamal M et al, it was shown that weight loss after RYGB had a dramatic effect on several manifestations of PCOS, with a 100% successful conception rate, even without hormonal therapy. Regulation of the menstrual cycle and remission of T2DM occurred immediately, and improvement in hirsutism occurred relatively slowly. Hence, bariatric surgery is

a very effective therapy for obese patients with clinical manifestations of polycystic ovarian disease (PCOD).

CONCLUSION Bariatric surgery has proven to be the most effective therapy for sustainable weight loss and resolution of many obesity related comorbidities. Polycystic ovarian disease is considered to be the ovarian manifestation of metabolic syndrome associated with insulin resistance. Bariatric surgery, by means of weight dependent and independent factors, has proven to be very effective in improving insulin resistance and associated clinical features of PCOD. Pregnancy needs to be planned at least 12 months following the bariatric surgery in tandem with a trained bariatric nutritionist for better nutritional management.

REFERENCES 1. McGee DL. Body mass index and mortality: a metaanalysis based on person-level data from twenty-six observational studies. Ann Epidemiol. 2005;15:87-97. 2. Must A, Spadano J, Coakley EH, et al. The disease burden associated with overweight and obesity. JAMA. 1999;282:1523-9. 3. Anonymus. Overweight, obesity, and health risk. National Task Force on the Prevention and Treatment of Obesity. Arch Intern Med. 2000;160:898-904. 4. Calle EE, Rodriguez C, Walker-Thurmond K, et al. Overweight, obesity, and mortality from cancer in a prospectively studied cohort of U.S. adults. N Engl J Med. 2003;348:1625-38. 5. World Health Organization (WHO). World Health Statistics 2. 2012. Geneva: WHO; 2012. Available from: http://www.who.int/gho/publications/world_health_ statistics/EN_WHS2012_Full.pdf, accessed on November 28, 2012. 6. Ogden CL, Carroll MD, Fryar CD, et al. Prevalence of obesity among adults and youth: United States, 20112014. NCHS Data Brief 2015;219:1-8. 7. World Health Organization (WHO), Fact Sheet No. 311. 2013. Media Center; Obesity and Overweight. Available at: http://www.who.int/mediacentre/factsheets/fs311/ en/.Accessed April 2013. 8. Ng M, Fleming T, Robinson M, et al. Global, regional, and national prevalence of overweight and obesity in children and adults during 1980-2013: a systematic analysis for the Global Burden of Disease Study 2013. Lancet 2014; 384(9945):766-81. 9. Weiner RA. Indications and principles of metabolic surgery. Chirurg. 2010;81(4):379-94 [in German]. 10. Anonymus. Obesity: preventing and managing the global epidemic. Report of a WHO consultation. World Health Organ Tech Rep Ser. 2000;894:i-xii.1-253.

Metabolic Surgery: Current Concepts 27. Kumar R, Lieske JC, Collazo-Clavell ML, et al. Fat malabsorption and increased intestinal oxalate absorption are common after Roux-en-Y gastric bypass surgery. Surgery. 2011;149(5):654-61. 28. Odstrcil EA, Martinez JG, Santa Ana CA, et al. The contribution of malabsorption to the reduction in net energy absorption after long-limb Roux-en-Y gastric bypass. Am J Clin Nutr. 2010;92(4):704-13. 29. Ionut V, Burch M, Youdim A, et al. Gastrointestinal hormones and bariatric surgery-induced weight loss. Obesity (Silver Spring). 2013;21(6):1093-103. 30. Vetter ML, Ritter S, Wadden TA, et al. Comparison of bar­ iatric surgical procedures for diabetes remission: efficacy and mechanisms. Diabetes Spectr. 2012;25(4):200-10. 31. Jorgensen NB, Jacobsen SH, Dirksen C, et al. Acute and long-term effects of Roux-en-Y gastric bypass on glucose metabolism in subjects with Type 2 diabetes and normal glucose tolerance. Am J Physiol Endocrinol Metab. 2012;303(1):E122-31. 32. le Roux CW, Welbourn R, Werling M, et al. Gut hormones as mediators of appetite and weight loss after Roux-en-Y gastric bypass. Ann Surg. 2007;246(5):780-5. 33. Guidone C, Manco M, Valera-Mora E, et al. Mechanisms of recovery from type 2 diabetes after malabsorptive bariatric surgery. Diabetes. 2006;55(7):2025-31. 34. Meier JJ, Nauck MA, Schmidt WE, et al. Gastric inhibitory polypeptide: the neglected incretin revisited. Regul Pept. 2002;107(1–3):1-13. 35. Korner J, Bessler M, Inabnet W, et al. Exaggerated glucagon-like peptide-1 and blunted glucose-dependent insulinotropic peptide secretion are associated with Roux-en-Y gastric bypass but not adjustable gastric banding. Surg Obes Relat Dis. 2007;3(6):597-601. 36. Clements RH, Gonzalez QH, Long CI, et al. Hormonal changes after Roux-en-Y gastric bypass for morbid obesity and the control of type-II diabetes mellitus. Am Surg. 2004;70(1):1-4; discussion 4-5. 37. Batterham RL, Cohen MA, Ellis SM, et al. Inhibition of food intake in obese subjects by peptide YY3-36. N Engl J Med. 2003;349(10):941-8. 38. Dakin CL, Small CJ, Park AJ, et al. Repeated ICV administration of oxyntomodulin causes a greater reduction in body weight gain than in pair-fed rats.  Am J Physiol Endocrinol Metab. 2002;283:E1173-E1177. 39. Dakin CL, Small CJ, Batterham RL, et al. Peripheral oxyntomodulin reduces food intake and body weight gain in rats.Endocrinology. 2004;145:2687-95. 40. Korner J, Inabnet W, Conwell IM, et al. Differential effects of gastric bypass and banding on circulating gut hormone and leptin levels. Obesity (Silver Spring). 2006;14(9):1553-61. 41. Dezaki K, Sone H, Koizumi M, et al. A blockade of pancreatic islet-derived ghrelin enhances insulin secretion to prevent high-fat diet-induced glucose intolerance. Diabetes. 2006;55(12):3486-93. 42. Castaneda TR, Tong J, Datta R, et al. Ghrelin in the regulation of body weight and metabolism. Front Neuroendocrinol. 2010;31(1):44-60.

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11. Sacks FM, Bray GA, Carey VJ, et al. Comparison of weightloss diets with different compositions of fat, protein, and carbohydrates N Engl J Med. 2009;360:859-73. 12. Tsai AG, Wadden TA. Systematic review: an evaluation of major commercial weight loss programs in the United States. Ann Intern Med. 2005;142:56-66. 13. Li Z, Maglione M, Tu W, et al. Meta-analysis: pharmacologic treatment of obesity. Ann Intern Med. 2005;142:532-46. 14. Buchwald H, Avidor Y, Braunwald E, et al. Bariatric surgery: a systematic review and meta-analysis. JAMA. 2004;292:1724-37. 15. Buchwald H, Estok R, Fahrbach K, et al. Weight and type 2 diabetes after bariatric surgery: systematic review and meta-analysis. Am J Med. 2009;122:248-56. 16. Sjostrom L, Peltonen M, Jacobson P, et al. Bariatric surgery and long-term cardiovascular events. JAMA. 2012;307:56-65. 17. National Institutes of Health. Gastrointestinal surgery for severe obesity: NIH Consensus Development Conference Statement. Am J Clin Nutr. 1992;55:615S-9S. 18. Thomas GN, Schooling CM, McGhee SM, et al. Hong Kong Cardiovascular Risk Factor Prevalence Study Steering Committee. Metabolic syndrome increases all-cause and vascular mortality: the Hong Kong Cardiovascular Risk Factor Study. Clin Endocrinol (Oxf ). 2007;66(5):666-71. 19. Stefater MA, Wilson-Perez HE, Chambers AP, et al. All bariatric surgeries are not created equal: insights from mechanistic comparisons. Endocr Rev. 2012;33:595-622. 20. Sumithran P, Prendergast LA, Delbridge E, et al. Longterm persistence of hormonal adaptations to weight loss. N Engl J Med. 2011;365(17):1597-604. 21. Isbell JM, Tamboli RA, Hansen EN, et al. The importance of caloric restriction in the early improvements in insulin sensitivity after Roux-en-Y gastric bypass surgery. Diabetes Care. 2010;33(7):1438-42. 22. Trachta P, Dostalova I, Haluzikova D, et al. Laparoscopic sleeve gastrectomy ameliorates mRNA expression of inflammation-related genes in subcutaneous adipose tissue but not in peripheral monocytes of obese patients. Mol Cell Endocrinol. 2014;383(1–2):96-102. 23. Schwartz A, Doucet E. Relative changes in resting energy expenditure during weight loss: a systematic review. Obes Rev. 2010;11(7):531-47. 24. Benedetti G, Mingrone G, Marcoccia S, et al. A Body composition and energy expenditure after weight loss following bariatric surgery. J Am Coll Nutr. 2000;19(2): 270-4. 25. Carrasco F, Papapietro K, Csendes A, et al. Changes in resting energy expenditure and body composition after weight loss following Roux-en-Y gastric bypass. Obes Surg. 2007;17(5):608-16. 26. Werling M, Olbers T, Fandriks L, et al. Increased postprandial energy expenditure may explain superior long term weight loss after Roux-en-Y gastric bypass compared to vertical banded gastroplasty. PLoS One. 2013;8(4):e60280.

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Art of Laparoscopic Surgery Textbook and Atlas 43. Schauer P, Bhatt DL, Kirwan JP, STAMPEDE Investigators. Bariatric surgery versus intensive medical therapy for diabetes—3 year outcomes. N Engl J Med. 2014;370(21):2002-13. 44. Rubino F, Forgione A, Cummings DE, et al. The mechanism of diabetes control after gastrointestinal bypass surgery reveals a role of the proximal small intestine in the pathophysiology of type 2 diabetes. Ann Surg. 2006;244(5):741-9. 45. Morinigo R, Moize V, Musri M, et al. Glucagon-like peptide-1, peptide YY, hunger, and satiety after gastric bypass surgery in morbidly obese subjects.  J Clin Endocrinol Metab.  2006;91:1735-40. 46. Patriti A, Facchiano E, Annetti C, et al. Early improvement of glucose tolerance after ileal transposition in a non-obese type 2 diabetes rat model. Obes Surg. 2005;15:1258-64. 47. Cummings DE, Overduin J, Foster-schubert KE. Gastric bypass for obesity: mechanisms of weight loss and diabetes resolution. J Clin Endocrinol Metab. 2004; 89(6):2608-15. 48. Praveenraj P, Gomes RM, Kumar S, et al. Prevalence and predictors of non-alcoholic fatty liver disease in morbidly obese south Indian patients undergoing bariatric surgery. Obesity Surgery. 2015;25(11):2078-87. 49. Raj PP, Gomes RM, Kumar S, et al. The effect of surgically induced weight loss on nonalcoholic fatty liver disease in morbidly obese Indians: “NASHOST” prospective observational trial. Surgery for Obesity and Related Diseases. 2015;11(6):1315-22. 50. Raj PP, Bhattacharya S, Kumar SS, et al. Non-alcoholic steatohepatitis (NASH) and metabolic surgery in Asia.

Annals of Laparoscopic and Endoscopic Surgery. 2017;2(8). 51. Raj PP, Bhattacharya S, Kumar SS, et al. Comparison of effects of sleeve gastrectomy and gastric bypass on lipid profile parameters in Indian obese: a case matched analysis. Obesity Surgery. 2017;27(10):2606-12. 52. Gomes RM, Palanivelu PR. Non-alcoholic Fatty Liver Disease and the Effects of Bariatric Surgery. In Bariatric Surgical Practice Guide. Springer, Singapore; 2017. pp. 129-36. 53. Palanivelu PR. Polycystic Ovarian Syndrome, Pregnancy and Bariatric Surgery. In Bariatric Surgical Practice Guide. Springer, Singapore; 2017. pp. 123-8. 54. Hart R, Hickey M, Franks S. Definitions, prevalence and symptoms of polycystic ovaries and polycystic ovary syndrome. Best Pract Res Clin Obstet Gynaecol. 2004;18(5):671-83. 55. Stankiewicz M, Norman R. Diagnosis and management of polycystic ovary syndrome: a practical guide. Drugs. 2006;66(7):903-12. 56. Poretsky L, Piper B. Insulin resistance, hypersecretion of LH, and a dual-defect hypothesis for the pathogenesis of polycystic ovary syndrome. Obstet Gynecol. 1994;84(4):613-21. 57. Dunaif A. Insulin resistance and the polycystic ovary syndrome: mechanism and implications for pathogenesis. Endocr Rev. 1997;18(6):774-800. 58. Teede H, Deeks A, Moran L. Polycystic ovary syndrome: A complex condition with psychological, reproductive and metabolic manifestations that impacts on health across the lifespan. BMC Med. 2010;8:41.

Video-assisted Thoracic Surgery and Thymectomy INTRODUCTION Thoracoscopy has been in clinical practice since the beginning of the twentieth century, mainly for diagnostic and rarely for therapeutic purposes. Kelling of Dresden performed the first thoracoscopy on dogs, Hans Christian Jacobaeus did first thoracoscopy to diagnose and lyse the pleural adhesions as an adjuvant to collapse therapy in pulmonary tuberculosis. Development of effective antituberculosis drugs stalled the surgical treatment the progress of thoracoscopy also came to stand still. In 1937, Sattler used thoracoscopy for pleurodesis in spontaneous pneumothorax and Branco in chest trauma in 1946. Modern anesthesia, single lung ventilation, and technological developments in optics and instrumentation paved the way for the “modern era” of thoracoscopy in the early 1970s. The first report of thoracoscopic surgery in children was by Rodger and group. Thymectomy for thymoma was successfully reported in 1992. Now thoracoscopy has developed into a separate specialty of its own.

INDICATIONS Diagnostic Indeterminate pleural effusions, tissue diagnosis, pleura-based masses (metastatic adenocarcinoma, mesothelioma, diffuse interstitial lung disease, indeterminate peripheral pulmonary nodule, mediastinal lymph node biopsy, mediastinal mass biopsy, etc.

Therapeutic Pleuropulmonary Pleural effusion and empyema, pleurodesis, Bullous disease ablation and resection, Wedge resection for early

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stage lung cancer in selected high-risk patients, anatomic resection for lung cancer, etc.

Esophageal Resection of leiomyoma, resection of enteric cysts, videoassisted esophagectomy, etc.

Mediastinal Thymectomy for myasthenia gravis, thymectomy for stage I thymoma, resection of benign mediastinal tumors (teratoma), resection of posterior mediastinal masses (neurogenic), excision of bronchogenic, enteric, and pericardial cysts, drainage of pericardial effusion, pericardiectomy, etc.

Miscellaneous Dorsal sympathectomy and splanchnicectomy, drainage of paravertebral abscess, orthopedic discectomy, etc.

Cardiac and Vascular Internal mammary artery harvest for coronary bypass graft, patent ductus arteriosus ligation, ASD closure, coronary artery bypass surgery (experimental), harvesting of saphenous vein and radial artery.

RELATIVE CONTRAINDICATION FOR VIDEO-ASSISTED THORACIC SURGERY 1. 2. 3. 4. 5. 6.

Dense pleural symphysis Ventilator dependency Noncompliant lung Severe emphysema Pulmonary hilar lesions Pulmonary lesions abutting the upper mediastinum or posterior paravertebral gutter 7. Small (3 cm) pulmonary nodules 9. Chest wall involvement by tumor 10. Small thoracic cavity or significant anatomic restrictions (severe scoliosis) 11. Inability to achieve or tolerate single lung ventilation 12. Inability to achieve ipsilateral pulmonary atelectasis 13. Hemodynamic instability 14. Severe thoracic trauma or intrathoracic hemorrhage 15. Coagulopathy 16. Inadequate visualization or instrumentation to perform procedure.

GENERAL PRINCIPLES

Instrumentation High-resolution imaging system with HD camera and a high-resolution monitor are essential. 3D vision is highly useful for radical lymphadenectomy. 10 mm 0° rigid and 30° and 45° scopes are essential for complex thoracoscopic surgery. Presently flexible scopes are also available. Electrocautery and newer energy devices such as ultrasonic dissector (harmonic scalpel), or vessel sealant are available for resectional surgery. Stapling devices are highly useful for lung resection. The insufflators and other equipment used in thoracoscopy are the same as in laparoscopy.

Anesthesia

Handheld Instruments

It is not all that different from which is performed in conventional thoracic surgery. The preoperative assessment to evaluate coexisting pathology, pulmonary function, and airway anatomy is mandatory. Preoperative monitoring is done in the usual way. Single lung ventilation, using double lumen tube ventilation is generally preferred. Postoperative pain relief is significantly less compare to open thoracotomy will help faster recovery.

In the beginning, video-assisted thoracic surgery (VATS) through mini-thoracotomy was done with the instruments which were the same as the ones used for open surgery. Later, through small surgical incisions slightly modified instruments were used. Presently the instruments are almost similar to laparoscopic instruments. These instruments are used through rigid or flexible trocars. If the collapse of the lung is not adequate, CO2 insufflation may be used. Bronchoscopy is done to assess the endobronchial status depending on the type of surgery. Subsequently, the patient is draped as for any open thoracotomy in emergency situation. Positioning of the camera and the scope is based on the pathology and site of lesion. Right-sided or left-sided thoracoscopy again based on the side of lesion. For esophagectomy, many prefer right thoracoscopic and for thymectomy either side may be used.

Position Two types of position are used. Lateral decubitus with single lung ventilation is the most used approach. For thymectomy supine with lateral tilt is used. Prone position with two lung ventilation was introduced initially Professor Cuschieri and later developed by us, mainly for esophagectomy. Thoracoscopy can be done with or without pneumothorax. Till now most of the thoracic surgeons are using lateral position, single ventilation with open thoracoscopic approach. Minithoracic incision done and valve trocars are used. Regular air flow is maintained and lung retractor is used for exposure. Additional trocars 2–3 are placed under visual guidance. In prone position, many prefer double balloon endotracheal tube using single lung ventilation by selecting the side of the lung. In our approach we use single lumen endotracheal tube use double lung ventilation. Lung partially collapses occupying the compartment of the chest. Mediastinal exposure is excellent and thus mainly used for esophagectomy. Placement of trocars is crucial if endoscopic suturing is planned. Prone position is the most preferred approach as it provides video exposure.

FUTURE PERSPECTIVES In the beginning, unlike laparoscopic surgery, evolution of thoracoscopic surgery took place simultaneously with open surgery and hence there was not much enthusiasm for thoracoscopy. But now with advancements in technology there is renewed enthusiasm.

Thoracoscopic Thymectomy Thymectomy is an effective and accepted treatment for myasthenia gravis. Many surgical approaches for the performance of thymectomy in patients with myasthenia gravis have been described. It is generally accepted that whatever approach is used, completeness of thymectomy is mandatory in order to obtain optimal clinical results.

Video-assisted Thoracic Surgery and Thymectomy

History Video-assisted thoracic surgery approach is generally accepted for a wide variety of intrathoracic surgical procedures, including sympathectomy, management of spontaneous pneumothorax and drainage of empyema, lung biopsy, and resection of pulmonary nodules. Complex operation such as esophagectomy, lung resection, pericardium excision, vascular ligation and valve repair are successfully done routinely in center excellence.

from the medications. Medical treatment is the primary treatment for patients who respond well to medical treatment, surgery only to poor responders.

Evaluation Contrast-enhanced computed tomography (CECT) is the standard investigation for preoperative evaluation of a patient with an anterior mediastinal mass. Magnetic resonance imaging (MRI) may also be used but no additional information. Transthoracic needle aspirates are controversial but may be helpful in the diagnosis of a thymoma.

Anatomy of Thymus

Preoperative Management

The thymus is in the superior mediastinum extending from thoracic inlet caudally over the pericardium. Although classically having right and left lobe, roughly H-shaped configuration with extension of the upper pole of either side into the base of the neck, having attachment to the thyroid gland by the thyrothymic ligament. The lower poles of each side extend down over the pericardium. Also may have 2–3 lobular thymic tissue of variable size. The thymus can be distinguished from its covering fat, which is slightly different in color (pinker or browner in life) and its lobules that are larger, smoother, and denser than fat. Arterial blood supply of the thymus is mainly from the branches of the internal mammary arteries, but the gland may also receive small branches from the inferior thyroid arteries and the pericardiophrenic arteries. Venous drainage may be partially through small veins accompanying these arterial branches. The main venous drainage, is through a centrally located venous trunk on the posterior aspect of the gland that drains into the anterior aspect of the left innominate vein as a single vessel. Occasionally, a branch may enter the superior vena cava. There are venous accompanying vessels along the arteries. Lymphatic drains into anterior mediastinal, pulmo­ nary hilar and internal mammary lymph nodes.

Because of the less invasive approach used, there is no significant exacerbation of myasthenic symptoms perioperatively. Therefore, we have not used specific preoperative management. With recent history of crisis, patients should be stabilized before taking up for surgery.

Indications Indications for thymectomy include resection of the thymic mass, myasthenia gravis in selected patients, or both, patients with myasthenia gravis if medical treatment fails, for a young patient with symptoms of short duration and for a patient who experiences significant disability

OPERATIVE TECHNIQUE OF THORACOSCOPIC THYMECTOMY Anesthetic Management All procedures are performed under general anesthesia with a single-lumen endotracheal tube to administer selective unilateral pulmonary ventilation. A multiagent technique is used with short-acting narcotics and avoidance of neuromuscular blockage acting agents. Extubation is immediate in the operating room upon completion of the procedure.

Operative Positioning Although initially we used a left-sided approach, our most recent experience has been totally through the right thoracoscopy. Patient is placed in a supine position with the right side slightly elevated to approximately 10–20°. The right arm is placed on an arm holder across the upper portion of the patient and draped out of the operative field. These maneuvers afford wide exposure of the right hemithorax.

Advantages of Right Thoracoscopy More room for maneuverability from within the right thoracic cavity because of the absence of the pericardial sac.

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Standard accepted approaches have been primarily transsternal.

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Art of Laparoscopic Surgery Textbook and Atlas Superior vena cava serves as an excellent landmark for initiation of surgical dissection and for identification of the innominate vein.

Surgical Technique The approach has changed little over the past 5 years. We use four trocars for access. The first three trocars are placed in an inverted triangle with the apex of the triangle being in the fifth intercostal space in the mid-axillary line. The second and third trocars (the base of the inverted triangle) are placed in approximately the third and the sixth intercostal spaces in the anterior axillary line. The fourth trocar which is used for retraction of thymic tissues mobilized during the course of the dissection is usually placed further inferiorly later in the procedure. Ascertainment of the correct placement of this trocar is usually performed after dissection has begun when retraction of thymic tissues is necessary and is usually in approximately the seventh intercostal space in the mid-axillary line. The use of a 30° angled scope facilitates exposure during this dissection especially in the left inferolateral portion of the dissection to identify the left phrenic nerve as it courses over the pericardium and to adequately visualize the exposure of the cervical area above the innominate vein.

Pneumothorax CO2 insufflation to 8–10 mm Hg is routinely used. First lung collapses and retracted out of the operative field by gravity. Second the positive pressure “opens up” the mediastinum and allows more room for both visualization and dissection. Third the positive pressure within the mediastinum minimizes minor bleeding that may occur from dissection. Finally, and most important, as dissection is carried into the cervical areas the tissue planes are opened up and visualization is enhanced.

Instruments for Thoracoscopic Thymectomy 1. 2. 3. 4. 5. 6.

Sealed trocars (5 mm × 3, 10 mm × 1) 30° 5 mm thoracoscope 5 mm hook cautery 5 mm endoscopic grasper 5 mm endoscopic clip applier 10 mm endoscopic fan retractor

7. 5 mm harmonic scalpel 8. 10 mm endoscopic specimen bag.

THYMIC DISSECTION Double lung ventilation with single lumen endotracheal tube with pneumothorax 8–10 mm Hg, a 5-mm trocar is placed. The thoracic cavity is safely accessed and two additional 5-mm trocars are placed as previously described. After general examination of the thoracic |cavity, all appropriate structures and landmarks including the thymus gland, phrenic nerve, superior vena cava, and internal mammary vessels are identified. The dissection is by incising the mediastinal pleura beginning inferiorly and anterior to the phrenic nerve and is carried cephalad to the junction of the superior vena cava (SVC) and innominate vein. This dissection is performed with a hook electrocautery or harmonic scalpel. Dissection is then carried out anteriorly just behind the internal mammary vessels along the posterior portion of the sternum. This circumferential line of dissection is then carried inferiorly down to the pericardial reflection and connected with the beginning dissection line. Posterior portion of the dissection first, sweeping the tissue from caudal to cephalad. An avascular plain along the pericardium is usually encountered, and with retraction and careful dissection with the cautery device, complete dissection of all tissues of the pericardium and SVC, mobilized sufficiently to the level of the innominate vein. Then poststernal dissections done. Again an avascular plain is easily achieved and by gentle retraction downward and use of the hook cautery all tissues can be resected off the retrosternal area. Next the junction of the SVC and innominate vein is visualized. Origin of the internal mammary vessels is encountered. Division opens up the dissection planes along the innominate vein. Thymic vein is identified readily possible along the innominate vein, double-clipped and divided, which opens up the area posterior to the innominate vein for dissection of tissue. Devascularization of the thymus gland causes a deeper yellow coloration to the tissue easily distinguished from remaining fatty tissue. Gentle downward traction of the thymic gland, the ligamentous attachments at the superior poles exposed and divided. First the right-sided pole is mobilized and dissected, followed by the left-sided pole (Figs. 21.1A to D).

Video-assisted Thoracic Surgery and Thymectomy

A

Figs. 21.1A and B

B

Postoperative Management The patient is extubated immediately in the operating room and then taken to the recovery room. A chest radiograph is obtained in the recovery room to confirm full expansion of both lungs. Care in an intensive care unit has not been necessary and patients are routinely returned to a standard ward room. Preoperative medications are resumed at the same doses. Oral narcotics are used for pain relief and respiratory therapy with incentive spirometry is administered. Discharge is usually on the

Chapter 21

Working on the left pleura technically is difficult and intact left pleura facilitates dissection. Dissection is performed inferiorly to the pericardiophrenic groove. Most often left phrenic nerve can be identified. Once all they anterior mediastinal tissues have been mobilized, the tissue is placed into an endoscopic bag. The anterior mediastinal space is then reinspected for both residual tissue and for hemostasis. Once removed from the thoracic cavity, the specimen is examined for completeness of dissection. Selectively we place drainage tube.

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C

Figs. 21.1C and D Figs. 21.1A thymectomy.

to

D:

Technique

of

thoracoscopic

D

first postoperative day. Preoperative medications are maintained at the same dosage for the first 2–3 months after surgery, whereupon, depending on the patient’s clinical status, the patient is then weaned off the medications.

DISCUSSION The thymus continues to present a challenge to the surgeons not only as a structure that may affect neuromuscular conduction, but also as the origin of both benign and malignant neoplasms. Controversy

exists regarding early versus late surgery for myasthenia gravis,1 and which operative technique is best suited for removal of the thymus gland. Yim and his group in Hong Kong have published their experience in three reports. Initially they described the right-sided approach and results were good.2,3 Mineo and colleagues have championed a left-sided approach. In their results, the remission and improvement rates were 36% and 96% respectively.4-6 Two other reports on video-assisted thymectomy have been reported, which also showed excellent results.4-6 Ng and collaborators described

Video-assisted Thoracic Surgery and Thymectomy

Thoracoscopic Thymectomy Advantages • Minimally invasive –– Less pain –– Less morbidity –– Less pulmonary dysfunction • Shorter hospitalization –– Better cosmesis –– Less exacerbation of myasthenia perioperatively.

Disadvantages • Requires significant endoscopic experience • Clinical experience is still relatively limited • Comparability to standard approaches not definitely proven.

OTHER LESS INVASIVE APPROACHES Other minimally invasive approaches that have been described include an infrasternal mediastinoscopic approach by Uchiyama and colleagues. They recently reported their experience in 23 patients—the approach was successful in 21 patients. There were no deaths and only one phrenic nerve complication.9 Savcenko and coworkers recently published a case report on using a sternal elevating method to increase visualization between the sternum and the heart to facilitate videoscopic approaches.10 Thymectomy by a partial sternotomy has been described by Pego-Fernandes and associates. They reported their experience in 478 patients over a 26-year period. The complete remission rate was 12.7%, with a significant improvement rate of 62.5% and mild improvement rate of 17.4%. There was no improvement in 7.4% of patients.11 A ministernotomy

approach by using a reversed T upper sternotomy was described by Grandjean and colleagues. This experience was limited to a case report.12 Lastly, a case report of a single patient undergoing thoracoscopic thymectomy using robotic assistance was described by Ashton and coworkers. The procedure was performed using the DaVinci surgical system through a bilateral thoracoscopic approach. Their conclusion was that the procedure could be performed safely and effectively.13

CONCLUSION Benefits of video-assisted and all minimally invasive approaches include performance of a less invasive surgical procedure as manifested by less pain, less pulmonary dysfunction, and less exacerbation of myasthenia compared with the more invasive standard approaches. The additional benefit of better cosmesis is a significant but not critical bonus. In all approaches completeness of thymectomy is paramount for best clinical response. Unfortunately, experience with all minimally invasive approaches is still limited and there are enough variables impacting analysis of outcomes that it cannot be definitively stated that the outcomes are comparable with open approaches. As minimally invasive and video-assisted techniques continue to become more widely used and surgeon experience with more complex procedures is gained, wider experience from more centers can be expected. Reporting of results by all techniques using a standardized classification (MGFA—Myasthenia Gravis Foundation of America) should allow a more meaningful comparison assessment among the different approaches.

REFERENCES 1. Cooper JD, Al-Jilaihawa AN, Pearson FG, et al. An improved technique to facilitate transcervical thymectomy for myasthenia gravis. Ann Thorac Surg. 1988;45:242. 2. Yim AP, Kay RL, Ng SK, et al. Video-assisted thoracoscopic thymectomy for myasthenia gravis. Semin Throac Cardiovasc Surg. 1991;11:65. 3. Yim AP, Kay RL, Ho JK. Video-assisted thoracoscopic thymectomy for myasthenia gravis. Chest. 1995;108:1440. 4. Mineo TC, Pompeo E, Lerut TE, et al. Thoracoscopic thymectomy in autoimmune myasthenia: results of left sided approach. Ann Throac Surg. 2000;69:1537. 5. Mineo TC. Video-assisted completion thymectomy in refractory myasthenia gravis. J Thorac Cardiovasc Surg. 1998;115:252.

Chapter 21

advantages in their experience with a lateral rather than supine position.7 Novellino and colleagues described a technique for bilateral thoracoscopic approaches combined with a transcervical open approach to complete dissection of the upper pole.8 Rockert and coworkers (2003) performed a prospective trial of 20 patients who were randomly allocated to a thoracoscopic thymectomy and concluded that less pronounced impairment and faster recovery of pulmonary function after thoracoscopic thymectomy clearly defined this as minimally invasive.

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Art of Laparoscopic Surgery Textbook and Atlas 6. Mineo TC, Pompeo E, Ambrogi V, et al. Adjuvant pneumomediastinum in thoracoscopic thymectomy for myasthenia gravis. Ann Thorac Surg. 1996;62:1210-2. 7. Ng JW, Yeung GH, Cheng DP. Video-assisted thymectomy in patients with myasthenia gravis: lateral versus supine position (Letter). Thorac Cardiovasc Surg. 1998;115:265-6. 8. Novellino L, Longoni M, Spinelli L, et al. “Extended” thymectomy, without sternotomy, performed by cervicotomy and thoracoscopic technique for the treatment of myasthenia gravis. Int Surg. 1994;79:378-81. 9. Uchiyama A, Shimizu S, Murai H, et al. Infrasternal mediastinoscopic thymectomy in myasthenia gravis: surgical results in 23 patients. Ann Thorac Surg. 2001;72:1902-5.

10. Savcenko M, Wendt GK, Prince SL, et al. Video-assisted thymectomy for myasthenia gravis: an update of a single institution experience. Eur J Cardiothorac Surg. 2002;22:978-83. 11. Pego-Fernandes PM, de Campos JR, Jatene FB, et al. Thymectomy by partial sternotomy for the treatment of myasthenia gravis. Ann Thorac Surg. 2002;74: 204-8. 12. Grandjean JG, Lucchi M, Mariani MA. Reversed T upper ministernotomy for extended thymectomy in myasthenic patients. Ann Thorac Surg. 2000;70:1423-4. 13. Ashton RC Jr, McGinnis KM, Connery CP, et al. Totally endoscopic robotic thymectomy for myasthenia gravis. Ann Thorac Surg. 2003;75:569-71.

Head and Neck Minimal Access Surgery

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22

MINIMAL ACCESS THYROID AND PARATHYROID SURGERY

VARIOUS MINIMAL ACCESS APPROACHES FOR THYROIDECTOMY

First thyroidectomy was done in 1646 by Wilhelm Fabricius using a scalpel. The nineteenth century Albert Billroth, the chair of surgery in Zurich, reported his initial results of 20 thyroidectomies documenting a 40% mortality rate due to intraoperative hemorrhage and postoperative sepsis. Kocher’s important contributions to thyroid surgery include the concept of total thyroidectomy, capsular dissection, and the demonstrated benefit of being a highvolume surgeon. In the late 1890s, thyroid surgery became popular in United States, William Halsted of Baltimore, the Mayo brothers of Rochester, George Crile of Cleveland, and Frank Lahey of Boston made significant contribution, made thyroidectomy safe and practical through the techniques of Kocher.1-3

Mini-open Approach

Minimal Access Thyroid Surgery Problems of bleeding and nerve injury were common. Minimally access development coincided introduction energy devices made thyroid surgery bloodless. To improve nerve outcomes, surgeons have employed magnifying lenses, and even a surgical microscope, to facilitate accurate dissection in the vicinity of the recurrent laryngeal nerve (RLN).4 Terris et al. were able to demonstrate endoscopic thyroidectomy with a very low rate of nerve injury because of the magnified visualization.5 Further developments are minimal access videoguided surgery either reduced incision or remote surgery avoiding scar.

Minimally invasive open surgery involves a central small cervical incision in the natural crease and achieves bloodless surgery with newer energy devices. Delbridge described the technique for minimal access thyroidectomy (MAT) as an extension of the approach used for minimally invasive parathyroidectomy, using 2.5 cm lateral transverse incision made directly over the nodule or over the middle of the thyroid lobe, straddling the medial margin of the sternocleidomastoid (SCM) muscle.

Technique An anterior mini-open thyroidectomy/parathyroidectomy is performed through a small skin crease incision in the central, inferior neck between the strap muscles and is well suited for exploring the lower parathyroid glands which tend to be more anterior. The lateral, or so-called back-door, approach is better for upper parathyroid adenomas which tend to be located posteriorly. In this approach the space between the strap muscles and SCM muscle is entered to expose the plane behind the thyroid. The disadvantage is the potential for a larger incision or bilateral incisions if the contralateral side needs to be explored. Mini-open thyroidectomy/parathyroidectomy has an equivalent cure rate to the traditional bilateral exploration with shorter operative times and shorter hospital stays. Mini-open approach has also been shown to decrease the overall cost per procedure compared to traditional

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Art of Laparoscopic Surgery Textbook and Atlas exploration. Success of parathyroidectomy depends on good preoperative imaging and intraoperative Parathyroid (ioPTH) monitoring, which may not be universally available.

Radioguided Parathyroidectomy Intraoperative radioguided localization, with sestamibi technetium-99m (TC-99m) can be used to aid the standard mini-open parathyroidectomy. TC-99m radiotracer injected 1–2 hr prior to surgery. Handheld gamma probe is used to identify enlarged parathyroid glands. Gamma probe is used to localize, success rates is between 40% and 100%. Gamma probe is useful for planning skin incision and allows identification of ectopic parathyroid tumors. Drawbacks may include the increased cost of the technology, its learning curve, and its lack of substantiated benefit.

Videoscopic Parathyroidectomy Videoscopic parathyroidectomy has gained considerable attention over the last decade. The potential advantages of videoscopic techniques include the magnification provided by the optics, improved cosmesis, and reduced postoperative pain. Gagner et al. performed the first videoscopic parathyroidectomy in 1996, took almost 5 hour and the patient developed hypercarbia and subcutaneous emphysema from his eyelids to his scrotum that took 3 days to resolve. Since Gagner’s initial description, videoscopic parathyroidectomy has continued to evolve and currently can be divided into two subgroups—(1) endoscopic minimally invasive parathyroidectomy (EMIP) and (2) minimally invasive video-assisted parathyroidectomy (MIVAP), depending on how the operating space in the neck is maintained.

MIVAP without Gas Insufflation In 1998, in Pisa, Miccoli introduced the gasless minimally invasive video-assisted thyroidectomy (MIVAT or VAT) using 1.5 cm central incision above the sternal notch. A 5 mm 30° endoscope is inserted through the skin incision. Dissection is performed under endoscopic vision using conventional and endoscopic instruments and techniques. Prof Miccoli demonstrated telelive demonstration during first Conference of Association of Minimal Access Surgeons of India in Delhi 2005. Nodules smaller than 35 mm and early-stage papillary

carcinoma are amenable to this operative technique.6 Reports of MIVAT revealed less postoperative pain, short hospital stay, and morbidity similar to conventional thyroidectomy. This technique has been shown to be as effective as conventional thyroid surgery at removing thyroid cancer.7 In MIVAP, a small transverse skin incision is made 1 cm above the sternal notch. The strap muscles are separated. A 5 mm, 30° scope is inserted through the incision, and dissection is done under visual guidance using specially designed open instruments and external retractors. The operation is similar to mini-open parathyroidectomy, except special instruments and videoscope are used, which allows the operation to be performed through a 1.5 cm instead of a 2.5 cm incision. As with endoscopic MIP, MIVAP can be performed with high cure rates and minimal morbidity. The videoscope provides improved lighting and a magnified view, can be used to perform a bilateral exploration because of centrally placed incision. One major drawback is the need for two experienced assistants, one to maintain external retraction and the other to handle the scope. Large parathyroid adenomas, large goiters, prior neck operations, lack of preoperative localization, and suspicion of hyperplasia are relative contraindications to MIVAP.

Totally Endoscopic Thyroidectomy with Gas Insufflation Pure endoscopic neck surgery was first reported by Gagner for parathyroid surgery8 using CO2 insufflation at 8–12 mm Hg pressure. Camera at the sternal notch and additional trocars at the midline and SCM border. He used miniature camera and instruments. In Marseille, an endoscopic thyroidectomy based on a lateral approach was used, dissecting between the carotid sheath laterally and the strap muscles medially, exposing the RLN and parathyroid glands.9 The indications for endoscopic thyroidectomy have expanded as reports have been published on its use for bilateral neck exploration, lymph node dissection in the central and lateral compartments, and thyroid nodules greater than 3 cm.10-14 Henry et al. described EMIP using a lateral approach in 1999. One 12 mm and two 2.5 mm trocars were inserted at the anterior border of the SCM muscle. The plane between the strap muscles and the carotid was

Head and Neck Minimal Access Surgery

REMOTE-ACCESS SURGERY (EXTRACERVICAL THYROIDECTOMY) Flap techniques has been developed placing incisions outside the cervical region to avoid scar in the neck, include chest/breast, axillary, combined axillary and areolar, postauricular, or oral cavity access points.15-17 These approaches using endoscopic dissection avoids scar in the neck, very popular in Asia. Working from remote has technical limitations and nowadays robotic surgery is being used more and more.18-21 Because of economic considerations and complications, such as excessive blood loss, brachial plexus injury, and

esophageal perforations, robotic approach was largely abandoned in the United States. Robotic facelift thyroidectomy is becoming popular in some centers. This avoids cervical scar, safe and feasible in experienced hands. Remote-access surgery achieves better cosmetic results by avoiding a cervical scar.

Types of Remote-access Surgery • Breast approach (Ohgami, 2000: areolar incision) • Endoscopic axillary approach (Ikeda, 2001) • Robotic axillary approach (Kang et al., 2009). In contrast to the abdomen, the neck has no preformed space to accommodate the scope. Instead, this space is created bluntly and can be maintained with positive pressure, similar to laparoscopic extraperitoneal inguinal hernia surgery, or by lifting up the superficial tissues with instruments or lifting devices. Totally endoscopic minimally invasive relies on gas insufflation, and minimally invasive video-assisted parathyroidectomy uses instruments and lifting devices.22 The types of approaches for minimal invasive thyroidectomy and parathyroidectomy are shown in Flowchart 22.1.

History of Remote-access Thyroidectomy Remote-access parathyroidectomy developed as an extension of endoscopic parathyroidectomy by moving the trocar sites and incisions away from the anterior neck to achieve better cosmetic results. In 2000, Ikeda

Flowchart 22.1: Different approaches of minimal invasive thyroidectomy and parathyroidectomy.

Chapter 22

bluntly dissected and CO2 insufflation was used to maintain the working space. The posterior surface of the thyroid was approached and the parathyroid adenoma was dissected free using 2 mm endoscopic instruments. A modified approach was report by Ikeda et al. in 2002. Several large series comparing EMIP to open parathyroidectomy demonstrated equivalent cure rates with minimal morbidity. EMIP is generally reserved for single-gland disease with adequate preoperative localization. The major advantage of EMIP is the improved lighting and view provided by the endoscope and the limited size of incision regardless of the patient’s body habitus. The major drawbacks are the cost of endoscopy, increased operative time, and possible gas insufflation complications such as hypercarbia, subcutaneous emphysema, and gas embolism.

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Art of Laparoscopic Surgery Textbook and Atlas Flowchart 22.2: Different approaches for minimal access thyroid surgeries.

and Takami reported on six patients who underwent successful parathyroidectomy via an axillary approach and four patients that underwent exploration via an anterior chest approach. Although the operative time was long (180 min for a unilateral axillary approach), all the operations were successful with no significant morbidity. Small series by Landry et al. and Foley et al. also suggested successful outcomes can be achieved via the transaxillary approach but that it was associated with longer operative times and increased costs. In 2011, Karakas et al. described successful transoral parathyroidectomy in two patients. The different approaches for minimal access thyroid surgeries are shown in Flowchart 22.2. Currently miniopen thyroidectomy and completely endoscopic thyroidectomy are in clinical practice.

Various Types of Remote-access Thyroidectomies Trocar incisions are made remote from the neck, infraclavicle, axillary, breast, mouth, and posterior upper neck. Laparoscopic instruments are used widely. Because of remote-access surgery is technically challenging, many use robotic assistance. The assistance of the robot (da Vinci Surgical System, Intuitive Surgical) eliminates some of the limitations of remoteaccess thyroidectomy. The benefits of using the robot

include a three-dimensional view of the operating field, more flexible articulated instruments with greater degrees of freedom of movement and filtering of hand tremors. Robotic thyroidectomy is more expensive. No study has shown the results of robotic is better than nonrobotic remote-access thyroidectomy in outcomes or cosmesis.

Infraclavicular Approach With three infraclavicular incisions, two Kirschner wires are used to lift up and expose the subplatysmal space and allow for gasless dissection of the thyroid. The strap muscles are divided and the thyroid lobe is dissected using open and endoscopic instruments.

Axillary Approach Ikeda and colleagues reported the first transaxillary remote-access thyroidectomy in 2000. This approach can be performed with or without gas insufflation. When using gas insufflation, the subplatysmal space is insufflated to 8–10 mm Hg, and a flexible endoscope or 30% angled is inserted. The thyroid gland is exposed by splitting the sternothyroid muscle. In the gasless approach, an external lift retractor is inserted through a 6 cm incision in the axilla to maintain the operative space.

Head and Neck Minimal Access Surgery

Breast Approach Ohgami and colleagues were the first to describe using circumareolar incisions for trocar sites. Shimazu and colleagues described the axillo-bilateral breast approach (ABBA) in 2003. Choe and colleagues described the bilateral axillo-breast approach (BABA) in 2007, in which a port was used in each axilla. With this approach, a central neck dissection is technically more feasible than with other remote-access approaches. Extensive dissection is needed in this approach. Two incisions are made on each breast at the upper areolar margin, and the subplatysmal space is bluntly created. The working space is maintained using gas insufflation. For unilateral lesion one axillary for bilateral both axillary trocars are placed. The inferior and superior pole vessels are ligated using ultrasonic shears, and the specimen is retrieved through one of the circumareolar port sites. Park and colleagues reported their results of 100 patients using the breast approach for remote-access thyroidectomy. Several reported excellent short-term oncological results with remote-access thyroidectomy.

Transoral Thyroidectomy In 2010 Wilhelm and Metzig reported the first endoscopic transoral thyroidectomy. Sublingual incision trocar was placed into the subplatysmal layer, anterior to the thyroid cartilage, and working space maintained with insufflation. Two additional trocars were placed in the mouth. In 2013, Nakajo and colleagues reported on a gasless transoral video-assisted neck surgery for thyroid resection. Nakajo et al. used an incision at the vestibulum and dissect anterior to the mandible and created the subplatysmal space.

Postauricular Facelift Technique In 2011, Terris et al. described remote-access approach using postauricular facelift incision, within the occipital hairline. In this technique a musculocutaneous flap is

raised, and a fixed retractor system used to maintain the working space and da Vinci surgical trocars are used for dissection. Both axillary and posterior retroauricular robotic approaches have been used successfully. Only the ipsilateral thyroid lobe can be removed through a unilateral facelift incision, while a total thyroidectomy requires bilateral incisions. Unilateral lobe to our choice of procedure is axillary approach. Bilateral axillo-breast approach for total thyroidectomy. Endoscopic or robotic assisted depends on availability of facility, surgeons expertise and patients preference.

ROBOTIC THYROIDECTOMY Robotic-assisted thyroidectomy may be used in all types of endoscopic thyroidectomies. • Gasless transaxillary robotic assisted thyroidectomy • Bilateral axillo-breast robotic assisted thyroidectomy • Robotic facelift thyroidectomy • Transoral robotic thyroidectomy.

Selection Criteria The indications for total endoscopic thyroidectomy by the axillary approach include: 1. Follicular nodule or adenomatous goiter less than 6 cm, Graves’ disease volume less than 100 mL. 2. Thyroid carcinomas: Well-differentiated thyroid carcinoma tumor size less than 15 mm, no evidence of lateral lymph node metastasis, and no local invasion.

Operative Technique—Totally Endoscopic Axillary Thyroidectomy Procedural Details Patient position and placement of trocars—supine, neck is slightly extended with arm raised exposing axillary completely. A 30 mm skin incision is made in the axilla, should be invisible when patient in neutral position. Space is formed over the pectoralis major by dissecting through the deep layer of the platysma muscle. A purse string suture is applied to prevent gas leaking and the trocars slippage. Carbon dioxide is then insufflated up to 4 mm Hg, and 0° scope is used and adequate space is created by telescopic technique. One more 5 mm trocar is placed several centimeters caudal to the camera trocar in the axilla.

Chapter 22

Kang and colleagues reported their results using the transaxillary approach on 581 patients. In addition to improved cosmesis, they were also able to dissect the ipsilateral central lymph nodes when necessary. The disadvantages included a larger dissection for the remoteaccess and difficulty seeing the contralateral thyroid lobe and working from distance technically was difficult.

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Art of Laparoscopic Surgery Textbook and Atlas Subplatysmal space formation: Further subplatysmal space is expanded by sharp and blunt dissection medially extending to the sternal notch. The anterior border of the sternocleidomastoid muscle is identified and dissection is performed between the sternothyroid muscle and the sternohyoid muscle. Sternothyroid muscle is divided with a harmonic scalpel to expose the thyroid gland. Upper pole thyroid dissection: The upper pole of the thyroid gland is dissected bluntly to identify the superior thyroid artery and vein. The superior pole vessels are then dissected away from the larynx medially to avoid injuring the external branch of the superior laryngeal nerve. These vessels are divided with the harmonic scalpel. Superior thyroid artery is clipped and divided if the external nerve lies close to the artery. Lower pole thyroid dissection: The lower pole of the gland is retracted in a cephalad direction, exposes the adipose tissue and cervical thymic tissue inferior to the thyroid gland, which can then be dissected and divided. Inferior parathyroid gland is carefully protected from injury, allowing it to fall inferiorly with the surrounding adipose and thymic tissue. After releasing the inferior aspect of the gland, it is then retracted medially, and the perithyroidal fascia is incised. During this dissection adequate care is taken in preventing injury recurrent laryngeal nerve usually be identified between the trachea and the carotid artery, often in close proximity to the inferior thyroid artery. Lateral view from the axillary port helps to ensure complete visualization of the nerve and then the inferior thyroid artery is divide.

COMPLETION OF THYROID EXCISION The attachments and Berry’s ligament are transected to complete the release of the thyroid gland from the trachea. To prevent nerve should not be handled with instruments and should not use cautery injury nearer the nerve. Minimum 5 mm from the major neurovascular structures and the trachea is ideal to prevent thermal injury. Superior parathyroid gland is identified and preserved before separating the thyroid gland from the trachea.

SUBTOTAL THYROIDECTOMY Dissection of the operative pocket is extended to the level of the thyroid cartilage superiorly and to the medial

border of the contralateral sternocleidomastoid muscle. Strap muscles are transversely divided along the width of the gland. Rest same as described earlier. The inferior parathyroid gland can often be identified and preserved which is located near the branching point of the inferior thyroid artery. The gland is preserved by dissecting the gland in an inferior direction, maintaining the vascular pedicle. If the parathyroid gland cannot be preserved, reimplantation should be performed. The pectoralis major muscle serves as excellent option for reimplantation in BABA thyroidectomy. After dissecting the thyroid gland away from the trachea, the specimen is wrapped with aplastic bag and removed via the 12 mm axillary port. The specimen is inspected with care to identify any excised parathyroid gland. After meticulous hemostasis is achieved with electrocautery, the right and left strap muscles are reapproximated in the midline. Generally drainage tube not absolute essential unless difficult dissection, is placed into the thyroid pocket via an axillary port. The skin of the breasts and axillae are sutured with buried stitches with absorbable sutures.

Bilateral Axillo-breast Approach— Endoscopic and Robotic Thyroid Surgery The advantages of endoscopic or BABA robotic thyroidectomy include the following: 1. View and orientation are similar to conventional thyroidectomy. 2. Symmetrical view of the thyroid gland and the major critical structures. 3. No collision between instruments during the procedure. 4. Excellent cosmetic results. Indications and contraindications are the same. Breast Surgery is an absolute contraindication.

Procedural Details Patient position: The patient is placed in the supine position with a pillow under the shoulders. The patient’s neck is then extended to expose the surgical area properly. Both arms abducted. Trocar placement: A 10 mm trocar is placed at the superomedial border of the right breast used as camera port. Three more 5 mm trocars are placed one at the

Head and Neck Minimal Access Surgery

BABA Robotic Thyroidectomy The surgical robot provides a number of powerful qualities that makes it an excellent tool for remote-access surgeries, which require precise movements in deep and narrow operative fields.

Selection Criteria The indications for robotic BABA have widened: 1. Well-differentiated thyroid carcinomas less than 2 cm 2. Patients with Graves’ disease, male patients 3. Patients with benign nodules up to 8 cm in diameter 4. Prior to the introduction of the robot, men were not typically good BABA candidates due to the prominence of the clavicle and the absence of significant breast tissue (which limits the range and flexibility of the instruments).

Procedural Details Many details of BABA robotic thyroidectomy are the same as with the endoscopic approach. The initial positioning, preparation of the patient, markings, and injections are identical in both techniques. After flap elevation is completed in the same manner as in endoscopic BABA, the robot is docked from left shoulder of the patient. The anesthesiologist and the

ventilator are placed on the right side of the patient. The head of the patient is positioned toward the robotic system.

Robot-assisted Transaxillary Thyroidectomy A 5–6 cm vertical skin incision is made in the axillary area, not visible neater. The precise location of this incision (in a cephalad-caudad vector) should be based on the height of the upper limit of the thyroid gland. Additionally, it should be placed so that it is completely covered with the arm in the anatomic position. The patient cart is placed on the side contralateral to the axillary incision. To avoid interarm collisions, axis alignment is important. The operative table should be positioned slightly oblique, and the center column of patient cart should be aligned with the long axis of the external retractor. The surgical principles of robotic thyroidectomy and conventional open thyroidectomy are the same. Optimal dissection planes can be obtained by traction and countertraction using both a Maryland dissector and ProGrasp forceps, and all dissections and vascular ligations are performed using the harmonic curved shears. Because all four robotic arms are inserted through a single axillary incision, interarm collisions are prevented by using a slightly modified method. The ProGrasp forceps is placed as described earlier and its instrument arm is positioned in a different plane. The console surgeon uses only the wristed motions of the ProGrasp forceps, minimizing the movement of the instrument arm and its external joints.

REFERENCES 1. Terris D. Thyroid and parathyroid diseases. Rio de Janeiro: Thieme Medical Publishers; 2016. pp. 1-3. 2. Kopp P. Theodor Kocher (1841–1917) Nobel prize centenary 2009. Arq Bras EndocrinolMetabol. 2009; 53(9):1176-80. 3. Gemsenjäger E. European Thyroid AssociationMilestones—Theodor Kocher (1841-1917). European Thyroid Association Arch; 2005. 4. Seven H, Calis AB, Vural C, et al. Microscopic thyroidectomy: a prospective controlled trial. Eur Arch Otorhinolaryngol. 2005;262(1):41-4. 5. Terris DJ, Anderson SK, Watts TL, et al. Laryngeal nerve monitoring and minimally invasive thyroid surgery:

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superomedial border of left breast and two in the axilla. Open technique needs little larger incision, Kelly clamp is used to dilate the space and trocar is placed. I used to perform video-guided Visiport technique. Excel trocar with 0° is used to enter the space and space is created by telescopic method. Working space is maintained with gas insufflation 5–6 mm Hg. Under visual guidance other trocars are placed. The myocutaneous flap is raised, up to the thyroid cartilage. Strap muscles and midline raphe can be well visualized, then midline is divided with hook electrocautery from the thyroid cartilage to the suprasternal notch, exposing the isthmus of the thyroid gland. Division of isthmus, lateral dissection keeping medial retraction of the gland, performed using harmonic with “switching motion” technique. The middle thyroid vein is divided before the inferior thyroid artery enters the thyroid. Recurrent laryngeal nerve is carefully protected. Operative technique is same as described in axillary approach.

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Art of Laparoscopic Surgery Textbook and Atlas complementary technologies. Arch Otolaryngol Head Neck Surg. 2007;133(12):1254-7. 6. Miccoli P, Minuto MN, Galleri D, et al. Extent of surgery in thyroglossal duct carcinoma: reflections on a series of eighteen cases. Thyroid. 2004;14(2):121-3. 7. Miccoli P, Elisei R, Materazzi G, et al. Minimally invasive video-assisted thyroidectomy for papillary carcinoma: a prospective study of its completeness. Surgery. 2002;132(6):1070-4. 8. Gagner M. Endoscopic subtotal parathyroidectomy in patients with primary hyperparathyroidism. Br J Surg. 1996;83(6):875. 9. Palazzo FF, Sebag F, Henry JF. Endocrine surgical technique: endoscopic thyroidectomy via the lateral approach. Surg Endosc. 2006;20(2):339-42. 10. Miccoli P, Elisei R, Berti P, et al. Video assisted prophylactic thyroidectomy and central compartment nodes clearance in two RET gene mutation adult carriers. J Endocrinol Invest. 2004;27(6):557-61. 11. Miccoli P, Berti P, Materazzi G, et al. Endoscopic bilateral neck exploration versus quick intraoperative parathormone assay (qPTHa) during endoscopic parathyroidectomy: aprospective randomized trial. Surg Endosc. 2008;22(2):398-400. 12. Bellantone R, Lombardi CP, Boscherini M, et al. Central neck lymph node removal during minimally invasive video-assisted thyroidectomy for thyroid carcinoma: a feasible and safe procedure. J Laparoendosc Adv Surg Tech A. 2002;12(3):181-5. 13. Lombardi CP, Princi P, De Crea C, et al. Minimally invasive video-assisted functional lateral neck dissection

for metastatic papillary thyroid carcinoma. Am J Surg. 2007;193(1):114-8. 14. Lai SY, Walvekar RR, Ferris RL. Minimally invasive video-assisted thyroidectomy: expanded indications and oncologic completeness. Head Neck. 2008;30(11): 1403-7. 15. Duke WS, Terris DJ. Alternative approaches to the thyroid gland. Endocrinol Metab Clin North Am. 2014;43(2):45974. 16. Chantawibul S, Lokechareonlarp S, Pokawatana C. Total video endoscopic thyroidectomy by an axillary approach. J Laparoendosc Adv Surg Tech A. 2003;13(5):295-9. 17. Akasu H, Shimizu K, Kitagawa W, et al. Evaluation of an alternative, subclavicular approach to thyroidectomy. Med Sci Monit. 2002;8(11):CS80-CS82. 18. Ikeda Y, Takami H, Niimi M, et al. Endoscopic thyroidectomy by the axillary approach. Surg Endosc. 2001;15(11):1362-4. 19. Ohgami M, Ishii S, Arisawa Y, et al. Scarless endoscopic thyroidectomy: breast approach for better cosmesis. Surg Laparosc Endosc Percutan Tech. 2000;10(1):1-4. 20. Kang SW, Jeong JJ, Nam KH, et al. Robot-assisted endoscopic thyroidectomy for thyroid malignancies using a gasless transaxillary approach. J Am Coll Surg. 2009;209(2):e1-e7. 21. Terris DJ, Singer MC, Seybt MW. Robotic facelift thyroidectomy: II. Clinical feasibility and safety. Laryngoscope. 2011;121(8):1636-41. 22. Terris S. Minimal invasive and robotic thyroid and parathyroid surgery. New York: Springer Science; 2014. pp. 7-9.

Minimally Invasive Hernia Surgery: Current Practice

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“For ethical, professional and economic reasons, these are the days of hernia surgery without recurrences—REVE STOPPA”

INTRODUCTION Hernia surgery has gone through a major evolution from the days of the truss and castration to the present day laparoscopic extraperitoneal surgery. In the history of surgery, no other procedure has created as much frustration as hernia repairs, which is a sphere that is constantly evolving. Changes were made primarily to reduce morbidity and minimize or prevent recurrence. Postoperative morbidity like local inflammation, pain due to tissue tension, scrotal edema and wound infection, and longer hospital stay were the major problems after open repair. In 1887 Bassini, an Italian surgeon, presented his landmark paper on “Radical Cure of Inguinal Hernia,” in the Italian Surgical Society in Geneva, and revolutionized the concept of surgical treatment of hernias.1 In the Bassini repair and in the modifications that followed, the edges of defects were pulled and brought together by force producing tension on the suture lines.2 These tension repairs resulted in higher recurrences, increased morbidity, and most notably acute and chronic postoperative pain.3,4 Routine use of prosthetic materials, the widespread acceptance of the “tension-free” concept, the realization that the preperitoneal space can be used for a hernia repair and therapeutic laparoscopy are the major changes that followed.5,6 Francis Usher (1908–80) was a pioneer responsible for the development of the “polypropylene” prosthesis.7 Every type of tension-free repair requires a mesh, whether it is done through an open anterior, posterior, or laparoscopic route. Common prosthetic open repair procedures are the Kugel patch repair, the Lichtenstein onlay patch repair, the PerFix™ plug and patch repair, the Prolene Hernia System™ (PHS), and the Stoppa-Rives giant prosthetic repair of the visceral sac (GPRVS).8-12 The Lichtenstein anterior open mesh repair is considered the gold standard in conventional repair. Current understanding of the tension-free repair

concept introduced by Lichtenstein in 1989 was a major shift toward the use of the prosthesis;13 this was based on his report of 1,000 consecutive cases of hernia repair followed for more than a year without any recurrence or infection. Stoppa and colleagues used a giant prosthetic reinforcement implant, a large mesh, for covering all potential defects in both sides.14 It was Nyhus who refined this technique, performed a large number of cases, and established this approach in 1952.15 This technique is important to the laparoscopic surgeon because it is this extraperitoneal space and approach that we are interested.

LAPAROSCOPIC PREPERITONEAL HERNIOPLASTY Two main preperitoneal laparoscopic mesh repair procedures gained popularity: the transabdominal preperitoneal (TAPP) method described by Arregui and Dion, and the totally extraperitoneal (TEP) technique by Mckernan and Dulucq developed independently. Studies reported 0.4% recurrent rates in 10,053 patients in a multicentric trial with a follow-up of 4 years;