Chapter 6: Fundamentals of Laparoscopic Surgery

INTRODUCTION

The field of minimally invasive surgery has evolved and grown over the past 3 decades. This was made possible by developments in technology and was fueled by patient demands for less painful operations and quicker postoperative recovery.

Minimally invasive approaches are now widely used for gastrointestinal, bariatric, hernia, and solid organ surgery. It is the surgeon’s responsibility to become familiar with the new set of techniques and instruments, as well as knowing when to apply them and when to convert to an open operation. Furthermore, understanding how to use and troubleshoot the equipment used in these procedures is critical for any surgeon who performs minimally invasive surgery.

PREOPERATIVE CONSIDERATIONS

Patient Selection

As in all surgery, choosing the right operation for the patient is the first step. Since all laparoscopic surgery of the abdomen requires the use of general anesthesia, the ability to tolerate anesthesia is an absolute requirement. Patients with impaired exercise tolerance or a history of shortness of breath will need a preoperative consultation with a cardiologist or pulmonologist. Patients with severe carbon dioxide (CO₂) retention can be difficult to manage intraoperatively because the use of carbon dioxide for pneumoperitoneum exacerbates the condition. By increasing the minute ventilation and decreasing the CO₂ pneumoperitoneum from 15 to 8 to 10 mm Hg, one can control metabolic acidosis. Rarely, when these measures are ineffective at controlling hypercarbia, we have resorted to using nitrous oxide (N₂O) for peritoneal insufflation. While not suppressing combustion (as does CO₂), N₂O supports combustion no more than air and has been proven safe for laparoscopic use. A single, blind, randomized trial has demonstrated that N₂O pneumoperitoneum is associated with decreased postoperative pain compared with CO₂.¹

When deciding if a patient is a suitable candidate for a laparoscopic procedure, it is important to assess patient or procedure characteristics that will lengthen the operative time sufficiently to nullify the benefits of laparoscopy. If the laparoscopic operation takes substantially longer than the open equivalent or is more risky, then it is not prudent to proceed laparoscopically. A history of a prior open procedure or multiple open procedures can make access to the abdomen difficult and will be discussed in detail later in this chapter. Adhesions and scarring in the surgical field from prior surgery can make laparoscopic surgery very difficult and may require use of many novel dissecting and coagulating tools. Operating on patients with severe obesity is challenging specifically because torque on transabdominal ports leads to surgeon fatigue and diminishes surgical dexterity. In addition, the long distance from the insufflated abdominal wall to the abdominal organs can make laparoscopic surgery a “far reach.” Special long ports and instruments are available to overcome this difficulty.

Inability to obtain an adequate working space makes laparoscopic surgery ...