Laparoscopy
Laparoscopy is an operation performed in the abdomen or pelvis using small incisions with the aid of a camera. The laparoscope aids diagnosis or therapeutic interventions with a few small cuts in the abdomen.
Laparoscopic surgery, also called minimally invasive procedure, bandaid surgery, or keyhole surgery, is a modern surgical technique. There are a number of advantages to the patient with laparoscopic surgery versus an exploratory laparotomy. These include reduced pain due to smaller incisions, reduced hemorrhaging, and shorter recovery time. The key element is the use of a laparoscope, a long fiber optic cable system that allows viewing of the affected area by snaking the cable from a more distant, but more easily accessible location.
Laparoscopic surgery includes operations within the abdominal or pelvic cavities, whereas keyhole surgery performed on the thoracic or chest cavity is called thoracoscopic surgery. Specific surgical instruments used in laparoscopic surgery include obstetrical forceps, scissors, probes, dissectors, hooks, and retractors. Laparoscopic and thoracoscopic surgery belong to the broader field of endoscopy. The first laparoscopic procedure was performed by German surgeon Georg Kelling in 1901.
Types of laparoscopes
There are two types of laparoscope:- A telescopic rod lens system, usually connected to a video camera
- A digital laparoscope where a miniature digital video camera is placed at the end of the laparoscope, eliminating the rod lens system
Also attached is a fiber optic cable system connected to a "cold" light source to illuminate the operative field, which is inserted through a 5 mm or 10 mm cannula or trocar. The abdomen is usually insufflated with carbon dioxide gas as the safety, harms, and benefits of other gasses is uncertain. This elevates the abdominal wall above the internal organs to create a working and viewing space. CO2 is used because it is common to the human body and can be absorbed by tissue and removed by the respiratory system. It is also non-flammable, which is important because electrosurgical devices are commonly used in laparoscopic procedures.
Procedures
Patient position
During the laparoscopic procedure, the position of the patient is either in Trendelenburg position or in reverse Trendelenburg. These positions have an effect on cardiopulmonary function. In Trendelenburg's position, there is an increased preload due to an increase in the venous return from lower extremities. This position results in cephalic shifting of the viscera, which accentuates the pressure on the diaphragm. In the case of reverse Trendelenburg position, pulmonary function tends to improve as there is a caudal shifting of viscera, which improves tidal volume by a decrease in the pressure on the diaphragm. This position also decreases the preload on the heart and causes a decrease in the venous return leading to hypotension. The pooling of blood in the lower extremities increases the stasis and predisposes the patient to develop deep vein thrombosis.Gallbladder
Rather than a minimum 20 cm incision as in traditional cholecystectomy, four incisions of 0.5–1.0 cm, or, beginning in the second decade of the 21st century, a single incision of 1.5–2.0 cm, will be sufficient to perform a laparoscopic removal of a gallbladder.Since the gallbladder is similar to a small balloon that stores and releases bile, it can usually be removed from the abdomen by suctioning out the bile and then removing the deflated gallbladder through the 1 cm incision at the patient's navel.
The length of postoperative stay in the hospital is minimal,
and most patients can be safely discharged from the hospital the same day.
Colon and kidney
In certain advanced laparoscopic procedures, where the specimen removed is too large to pull through a trocar site, an incision larger than 10 mm must be made. The most common of these procedures are removal of all or part of the colon, or removal of the kidney. Some surgeons perform these procedures completely laparoscopically, making the larger incision toward the end of the procedure for specimen removal, or, in the case of a colectomy, to also prepare the remaining healthy bowel to be reconnected. Many other surgeons feel that since they will have to make a larger incision for specimen removal anyway, they might as well use this incision to have their hand in the operative field during the procedure to aid as a retractor, dissector, and to be able to feel differing tissue densities, as they would in open surgery. This technique is called hand-assist laparoscopy. Since they will still be working with scopes and other laparoscopic instruments, CO2 will have to be maintained in the patient's abdomen, so a device known as a hand access port must be used. Surgeons who choose this hand-assist technique feel it reduces operative time significantly versus the straight laparoscopic approach. It also gives them more options in dealing with unexpected adverse events that may otherwise require creating a much larger incision and converting to a fully open surgical procedure.Conceptually, the laparoscopic approach is intended to minimise post-operative pain and speed up recovery times, while maintaining an enhanced visual field for surgeons. Due to improved patient outcomes in the early 21st century, laparoscopic surgery has been adopted by various surgical sub-specialties, including gastrointestinal surgery, gynecologic surgery, and urology. Based on numerous prospective randomized controlled trials, the approach has proven to be beneficial in reducing post-operative morbidities such as wound infections and incisional hernias, and is now deemed safe when applied to surgery for cancers such as cancer of colon.
The restricted vision, the difficulty in handling of the instruments, the lack of tactile perception, and the limited working area are factors adding to the technical complexity of this surgical approach. For these reasons, minimally invasive surgery has emerged as a highly competitive new sub-specialty within various fields of surgery. Surgical residents who wish to focus on this area of surgery gain additional laparoscopic surgery training during one or two years of fellowship after completing their basic surgical residency. In OB-GYN residency programs, the average laparoscopy-to-laparotomy quotient is 0.55.
In veterinary medicine
Laparoscopic techniques have also been developed in the field of veterinary medicine. Due to the relatively high cost of the equipment required, it has not become commonplace in most traditional practices today but rather limited to specialty practices. Many of the same surgeries performed in humans can be applied to animal cases – everything from an egg-bound tortoise to a German Shepherd can benefit from MIS. A paper published in JAVMA in 2005 showed that dogs spayed laparoscopically experienced significantly less pain than those that were spayed with traditional "open" methods. Arthroscopy, thoracoscopy, and cystoscopy are all performed in veterinary medicine today.Advantages
There are a number of advantages to the patient with laparoscopic surgery versus an open procedure. These include:- Reduced hemorrhaging, which reduces the chance of needing a blood transfusion.
- Smaller incision, which reduces pain and shortens recovery time, as well as resulting in less post-operative scarring.
- Less pain, leading to less pain medication needed.
- Use of regional anesthesia for laparoscopic surgery, as opposed to general anesthesia required for many non-laparoscopic procedures, can produce fewer complications and quicker recovery.
- Although procedure times are usually slightly longer, hospital stay is less, and often with a same day discharge which leads to a faster return to everyday living.
- Reduced exposure of internal organs to possible external contaminants, thereby reduced risk of acquiring infections.
Disadvantages
While laparoscopic surgery is clearly advantageous in terms of patient outcomes, the procedure is more difficult from the surgeon's perspective when compared to conventional, open surgery:- Laparoscopic surgery requires pneumoperitoneum for adequate visualization and operative manipulation.
- The surgeon has a limited range of motion at the surgical site, resulting in a loss of dexterity.
- Poor depth perception.
- Surgeons must use tools to interact with tissue rather than manipulate it directly with their hands. This results in an inability to accurately judge how much force is applied to tissue and higher risk of damaging tissue by applying more force than necessary. This limitation also reduces tactile sensation, making it more difficult for the surgeon to feel tissue and making delicate operations such as tying sutures more difficult.
- The tool endpoints move in the opposite direction to the surgeon's hands due to the pivot point, making laparoscopic surgery a non-intuitive motor skill that is difficult to learn. This is called the fulcrum effect.
- Some surgeries generally turn out better for the patient when the area can be opened up, allowing the surgeon to see the surrounding physiology, to better address the issue at hand. In this regard, keyhole surgery can be a disadvantage.