Laparoscopy has evolved tremendously in the past 40 years, from a diagnostic tool to a surgical platform with nearly as many therapeutic applications as open surgery. In the most capable hands the only current primary limitation to minimally invasive approaches to most gastrointestinal (GI) cancers is the size of the incision required for removal of the specimen(s). However, it is clear that the most advanced techniques require extensive training and operative skill to perform safely and consistently on unselected patients. Given these skill sets are not realistically achievable by many surgeons, some techniques such as minimally invasive esophageal, hepatic, and pancreatic resections will remain in the purview of highly specialized practitioners. More recently, laparoscopy is being supplanted by the addition of the robotic minimally invasive platform with its promise of improved surgical exposure and increased instrument dexterity. It seems likely that with the continued advancement of technology in the field, the frontier of minimally invasive surgery will continue to expand.
While advanced laparoscopic and robotic-assisted techniques require highly specialized skill sets, diagnostic and staging laparoscopy techniques have broad clinical applicability to many GI malignancies, are easily performed, and often provide valuable information that directly impacts clinical decision making. Here we describe the use of laparoscopy in the diagnosis and treatment of common GI malignancies.
Preoperative history and physical examination are performed with particular attention to cardiopulmonary comorbidities, coagulopathy, and overall functional/nutritional reserve as with any open surgery. As laparoscopy is nearly always performed under general anesthetic and with CO2 insufflation of the abdomen, there can be significant physiologic stress, particularly in patients with limited cardiopulmonary reserve. In most cases these comorbidities may be mitigated, allowing safe conduct of operation.
The patient is positioned supine, pressure points padded, and secured to the operating table. Arms may be extended or tucked according to surgeon preference and region(s) of the abdomen to be explored. After induction of anesthesia with medical paralysis, the peritoneum is accessed via either an open (Hasson) or closed (Veress or optical separator trocar) technique. Initial access is commonly at the umbilicus for Hasson and Veress techniques when there have been no prior operations, otherwise access may be gained through a paramedian incision (Fig. 7-1). Optical separators are best utilized in the left upper quadrant through the rectus muscle where adhesions are typically sparse. The authors prefer an optical trocar technique in most instances. CO2 insufflation at 12 to 15 mm Hg is used except where cardiopulmonary disease prohibits full insufflation and lower pressures of 10 to 12 mm Hg may be used.
Port placement; C = camera; 1,2 – working ports; O = optional – placed at discretion of surgeon based on need for retraction or an additional assistant instrument.