Position Reverse Trendelenberg semi lateral tilt. Technique (cid:142)(cid:3) Create pneumoperitoneum (via umbilical route). Introduce 30(cid: 13) angled telescope. Place three further cannulas, 10mm in epigastrium and two 5mm in left mid-clavicular and left anterior axillary lines. (cid:142)(cid:3) Exploratory laparoscopy looking especially for accessory spleens in the hilum, gastrosplenic ligament, splenocolic ligament, splenorenal ligament and greater oment um. LAPAROSCOPIC SPLENECTOMY1 327 (cid:142)(cid:3) Divide splenocolic ligament with harmonic scalpel. (cid:142)(cid:3) Dissec t the short gastric vessels and divide them using clips, harmonic scalpel or bipolar diathermy. (cid:142)(cid:3) Retract the spleen medially, divide lienorenal ligament close to the splenic capsule using diathermy or harmonic scalpel. (cid:142)(cid:3) Clear any adhesions posteriorly to create a space for a laparoscopic stapling device to be placed across the hilum. (cid:142)(cid:3) Locate the hilar vessels. Transect it using an Endo GIA ensuring that fund us of the stomach or the tail of the pancreas is excluded. Other methods of ligation such a s clips or ties may also be used. (cid:142)(cid:3) Insert Endocatch II instrument into 12mm cannula and place spleen in bag. Withdraw the bag and remove the spleen piecemeal after section- ing into smaller pieces wit h sponge-holding forceps or digital fracture technique. (cid:142)(cid:3) If spleen is required intact for histological examination or is too large to be placed in a retrieval bag, use a small Pfannenstiel incision for organ removal. (cid:142)(cid:3) The harmonic scalpel facilitates control of the short gastric vessels and splenic attachments and reduces the operative time. Operative complications (cid:142)(cid:3) Bleeding. Correct any coagulation defect preoperat ively. Control hemorrhage with cautery, clips, endoloops, Endo GIA Staplers or open conversion. (cid:142)(cid:3) Injury to adjacent organs \200\224colon, stomach, small bowel, pancreas. Laparotomy may be required. (cid:142)(cid:3) Subphrenic abscess. Start antibiotics and drain percutaneously under CT guidance. (cid:142)(cid:3) Pancreatitis and pancreatic fistula. Percutaneous drainage for fistula. (c id:142)(cid:3) Overwhelming postsplenectomy infection (OPSI). Patients should receive preop erative vaccination at least 2 weeks before surgery. Give advice regarding immunization, fo reign travel and prophylactic antibiotics. (cid:142)(cid:3) Thrombocytosis. Can lead to DVT and pulmonary embolus. Routinely use subcutaneous heparin and TED stockings. CHAPTER 9 Laparoscopic surgery 328 Laparoscopic inguinal hernia repair Laparoscopic hernia repair has the advantages of reduce d discomfort after surgery, early return to full activity, low incidence of wound infec- ti on and chronic groin pain. Recurrence rates are comparable to Lichten- stein open mesh repa ir. In January 2001, the National Institute for Clinical Excellence (NICE) guidelines sugge sted that open mesh repair should be the preferred procedure for primary unilateral inguina l hernias, and the laparoscopic repair should be considered for recurrent or bilateral her- nias. NICE has also expressed a preference for one of the two laparo- scopic techniques av ailable, the totally extraperitoneal (TEP) rather than the transabdominal preperitoneal (TA PP) method, even though there is no proven difference in outcome between the two techniques . These guidelines have been controversial and are widely debated. Indications (cid:142)(cid:3) Recurrent inguinal hernia \200\224universally accepted indicat ion. Open sur- gery for recurrence is more difficult, with higher risk of damage to cord structures, inclu ding testicular vessels and higher risk of recurrence. (cid:142)(cid:3) Bilateral hernia \200\224laparoscopic surgery permits repair in the same session with shorter convalescence time. (cid:142)(cid:3) The role of laparoscopic repair of primary unilateral hernia is debated and is not recommended by NICE. Contraindications (cid:142)(cid:3) Patients unfit for general anesthesia (cid:142)(cid:3) A ctive infectious or inflammatory process (mesh at risk) (cid:142)(cid:3) Strangulated/incar cerated hernia (cid:142)(cid:3) Previous retropubic open prostate surgery. Preparation (cid:142)(cid:3) Obtain informed consent including conversion to open repair if necessary (cid:142)(cid:3) Consent for contralateral repair if unsuspected hernia identifi ed at laparoscopy (cid:142)(cid:3) Mark the hernia side (cid:142)(cid:3) Empty the urinary bladder immediatel y before induction of anesthesia (cid:142)(cid:3) Place the patient supine with the head en d slightly lower (Trendelenburg position) \200\224keep bowel away from operating site (cid:142)(cid:3) Place the monitor at the foot end of the table (cid:142)(cid:3) The surgeo n stands on the side opposite the hernia. Technique Repair can be performed by either TAPP approach or TEP approach. TAPP approach (cid:142)(cid:3) Create pneumoperitoneum. (cid:142)(cid:3) Position the cannu lae; one at the umbilicus (12mm) and one on each side at the lateral border of the rectus muscle (both 5mm). LAPAROSCOPIC INGUINAL HERNIA REPAIR1 329 (cid:142)(cid:3) Establish the anatomy from medial to lateral \200\224bladder, medial umbil ical ligament (obliterated umbilical artery), area of direct inguinal hernia, inferior epig astric vessels, internal ring, and anterior superior iliac spine. (cid:142)(cid:3) The internal ring is confirmed by looking for two divergent structures, wh ich emerge from it; medially the vas deferens (round ligament of the uterus in females) ben eath the peritoneum, and laterally a less distinct ridge caused by the gonadal vessels. Bet ween the two is the \200\230triangle of doom \200\231; deep to the peritoneum are the exte rnal iliac vessels. (cid:142)(cid:3) Identify whether the hernia is direct (medial to infer ior epigastric vessels) or indirect (lateral to inferior epigastric vessels), unilateral or bilateral. (cid:142)(cid:3) Create a peritoneal flap from lateral to deep ring to medial umbilical lig ament horizontally and well above and below the inguinal ring verti- cally. Inferiorly, str ip the peritoneum off the gonadal vessels and vas for a few centimeters (beware not to dama ge them). (cid:142)(cid:3) Create an identical contralateral space for bilateral hernia. (cid:142)(ci d:3) Retract the direct sac, or small indirect sac along with the peritoneal flap. (cid:142)(cid:3) Divide the large indirect sac at the level of the external ring and leave the distal part in situ. (cid:142)(cid:3) Introduce a 15 (cid:190)(cid:3)10cm mesh through the umbilical port and en sure it covers the entire posterior wall, extending behind the pubic bone to cover direct, indirect and femoral ring. (cid:142)(cid:3) Fix the mesh at Cooper \200\231s ligament and along the upper border with staples or sutures. Biologically compatible glues may be an inexpensive alternative to stap ling or suturing. (cid:142)(cid:3) Do not apply staples below and lateral to the ileopubic tract to avoid injury to the lateral femoral cutaneous nerve. Never staple close to the \200\230triangle of doom \200\231. (cid:142)(cid:3) Close the peritoneal flap by using staplers or by suturing (prevent gaping between the flaps). (cid:142)(cid:3) Ensure complete peritoneal coverage of the mesh to avoid small- bowel obstruction. (cid:142)(cid:3) Close the rectus sheath at the 10mm port site. TEP approach Without entering the peritoneal cavity, this approach reduces the risk of port site hernia and possibly bowel adhesions. Presence of a lower abdominal incision may make the TEP operation difficult or impossible because of adherence of the peritoneum to the mus cles and tissues of the anterior abdominal wall. Complete withdrawal of a very large indire ct hernial sac may also prove difficult by TEP. Technique (cid:142)(cid:3) Make a transverse sub-umbilical incision to expose the anterior rectus sheath on the side of the inguinal hernia. (cid:142)(cid:3) Divide the anterior rectus sheath to expose the rectus muscle. (cid:142)(c id:3) Retract the muscle laterally. (cid:142)(cid:3) Create an extraperitoneal space behind the rectus abdominis muscle. A specially designed balloon or its substitutes can be used. CHAPTER 9 Laparoscopic surgery 330 (cid:142)(cid:3) Insufflate the extraperitoneal space with carbon dioxide to a pressure of 10mmHg. (cid:142)(cid:3) Expand the space by separating the peritoneum from the posterior abdominal wall up to the anterior superior iliac spine laterally and well beyond the defect vertically in a manner similar to TAPP repair. (cid:142)(cid:3) Place 10mm trocar port at the midline, about 8cm from the pubis. Enlarge the preperitoneal space by blunt dissection. (cid:142)(cid:3) Insert an additional 5mm trocar either in the midline approximately 3cm ca udal to the 10mm trocar or on the side of the hernia at the level of the anterior superior iliacspine (ASIS), along the anterior axil- lary line. (cid:142)(cid:3) Create and dissect extraperitoneal space by endo-scissors. Separate the pe ritoneum from the posterior abdominal wall up to the ASIS laterally and well beyond the def ect vertically in a manner similar to TAPP repair. (cid:142)(cid:3) Dissect and reduce the hernial sac. (cid:142)(cid:3) Introduce a 15 (cid:1 90) 10cm prolene mesh, similar to one used in TAPP. Anchor the upper border of it to the abdominal wall and fix the lower medial part to Cooper \200\231s ligament or pelvic bone with an endo-stapler. (cid:142)(cid:3) Desufflate at the end of the procedure. Ensure the mesh remains flat and does not roll. Complications (cid:142)(cid:3) Bladder injury: avoid sharp instruments near bladder, avoid patients who may have had previous surgery in the area (previous retro pubic prostatectomy). (cid:142)(cid:3) Bleeding: avoid injury to iliac vessels and inferior epigastric artery by ensuring systematic identification of anatomical structures and avoiding dissection in tria ngle of doom. Take care when stripping the perito- neum from the gonadal vessels. Beware of accessory obturator artery (10% of cases). (cid:142)(cid:3) Damage to vas. (cid:142)(cid:3 ) Seroma/hydrocele: aspirate if large or causing concern. (cid:142)(cid:3) Retention of uri ne: usually resolves spontaneously or following a period of catheter drainage. Cover any ur ethral catheterisation with anti- biotics in early post operative period. Take urological o pinion to rule out latent prostate obstruction in elderly men. (cid:142)(cid:3) Haematoma. (cid:142)(cid:3) Neuralgia: due to injury to genitofemoral or l ateral femoral cutaneous nerves. (cid:142)(cid:3) Bowel obstruction: due to adherence to mesh (disturbing complication occasionally reported with TAPP procedure). (cid:142)(cid:3) Mesh infection. (cid:142)(cid:3) Recurrence: the common cause is technical fault and use of a small mesh. This page intentionally left blank CHAPTER 9 Laparoscopic surgery 332 Laparoscopic Nissen fundoplication Minimal access anti-reflux and hiatus hernia surgery is becoming increas- ingly established throughout the world. Indications (cid:142)(cid:3) Failure of or side effects from medical therapy (cid:142)(cid: 3) Healthy young patients who prefer surgery to lifelong medication (cid:142)(cid:3) Compli cations of gastrooesophageal reflux disease (GERD) \200\224continued oesophagitis, Barrett \200\231s esophagus, oesophageal stricture (cid:142)(cid:3) Complicat ions of large hiatus hernia. (e.g. bleeding, dysphagia) (cid:142)(cid:3) Atypical symptoms of gastro-oesophageal reflux (hoarseness, cough, chest pain, nocturnal choking, recurrent a spiration pneumonia, loss of teeth enamel) with documented reflux on 24-hour pH monitoring. Preparation Investigate to confirm the diagnosis and select patients for surgery. (cid:142) (cid:3) Endoscopy \200\224usually the first test to be performed. Assess hiatus hernia, oes ophageal length, mucosal abnormalities, ulceration, stricture and Barrett \200\231s esophag us. Biopsies of suspected Barrett \200\231s epithelium may show severe dysplasia or carcino ma. In such case, antireflux procedure alone would be inappropriate (resection or close end oscopic surveil- lance may be indicated). (cid:142)(cid:3) 24-hour pH monitor \200\224most specific and sensitive test for GERD. Quan - tifies the actual period of acid contact with the oesophageal mucosa and allows correlati on with subjective feeling of heartburn. A normal 24-hour pH study rules out reflux disease and strongly suggests alter- native diagnosis. (cid:142)(cid:3) Oesophageal manometry \200\224tests for oesophageal motility, helps indi- vidualize the surgery. The lower oesophageal sphincter (LES) pressure in patients with refl ux disease is usually \211 6mmHg and most patients require a 360(cid:13) wrap. A partial wrap is indicated if LES pressure is high or if oesophageal motility is poor (diminished co ntraction amplitude, diminished peristalsis). Patients with aperistalsis may have achalasia and may require different therapy. Abnormal findings may also suggest significant risk of dys- phagia following fundoplication (need to modify the procedure). (cid:142)(cid:3) Barium swallow \200\224in cases of diagnostic or anatomic confusion. Position Lloyd-Davies position with knees slightly flexed and reverse Trendelen- burg posit ion. Surgeon between the legs using 2-handed technique. Technique (cid:142)(cid:3) Create pneumoperitoneum by Veress needle or open Hassan entry. ( cid:142)(cid:3) Angled 30(cid:13) or 45(cid:13) laparoscope is helpful for adequate visuali zation. (cid:142)(cid:3) Five ports are used: two 10mm, three 5mm. Place camera port in the midline at junction of upper 2/3 and lower 1/3 between umbilicus and xiphoid process. Intr oduce subsequent four ports under direct vision, angling them towards the hiatus. Operating ports are in the right LAPAROSCOPIC NISSEN FUNDOPLICATION1 333 (5mm) and left (10mm) midclavicular lines. Place liver retractor through the subxiphoid por t (5mm). This may be hand-held or attached to a mechanical holder secured to the table (Nat ensen \200\231s). Retract the stomach with a grasper or Babcock \200\231s forceps introduce d through the port in left anterior axillary line (5mm). This maneuver opens up the gastro hepatic ligament. (cid:142)(cid:3) Open the avascular aspect of lesser sac; divide the gastro-hepatic ligament from about the level of the left gastric artery to the hiatus using diathermy forc eps or harmonic scalpel. (cid:142)(cid:3) Extend the dissection to the right to allow identification of right crus. Adequate crural dissection reveals the esophagus, which can then be separated from right an d left crura with gentle dissection. Never grasp the esophagus for retraction. (cid:142)(cid:3) Fully mobilize the angle of His from the left crus and free the medial part of greater curve from the diaphragm. (cid:142)(cid:3) Create a window posterior to the esophagus, just below the left crus and a bove the posterior gastric fundus. Identify and preserve both vagus nerves. Insert a soft s ling to retract the esophagus. (cid:142)(cid:3) Divide the short gastric vessels only if necessary to create a loose floppy wrap without tension. (cid:142)(cid:3) Reconstruct the normal hiatus by closing the left and right crura with two or three interrupted 2/0 Ethibond sutures. Avoid injury to the posterior wall of the esoph agus. Maintain a distance of approximately 1cm between the highest suture and the esophagus . (cid:142)(cid:3) Pass atraumatic forceps behind the esophagus from right to left, grasp the greater curve of the stomach, pull it behind, forming the wrap. Use shoeshine maneuver in which surgeon alternately retracts the left and right portions for proper wrapping. Use thr ee interrupted 2/0 Ethibond sutures to form a 2 \200\2233cm wrap for a standard Nissen fund oplication (360(cid:13)). Place a full-thickness suture through the stomach but include onl y the muscular wall of the esophagus to avoid the risk of post- operative oesophageal leaka ge. Some prefer fashioning a wrap over bougie (56F) to prevent tying too tightly but there is a small risk of oesophageal perforation by this. Do not pass a nasogastric tube unless y ou suspect injury to the stomach or esophagus. Difficulties (cid:142)(cid:3) Large paraoesophageal hernia \200\224consider anterior repair with mesh reinforcement. (cid:142)(cid:3) Laparoscopic partial fundoplication \200\224various techniques e.g. Toupet fundoplication. Consider in patients with compromised oesophageal motility, in order to dec rease the risk of postoperative dysphagia. (cid:142)(cid:3) Open conversion \200\224if dens e adhesions, difficult exposure due to large left lobe of the liver, uncontrolled bleeding or repair perforations. Postoperative care (cid:142)(cid:3) Encourage oral fluid intake after 6 hours. (cid:142)(ci d:3) Start sloppy diet within 24 hrs. (cid:142)(cid:3) Soft diet for the next 2 weeks (eati ng slowly, chewing carefully and avoiding meat and bread). Most patients can be discharged within 48 hours. CHAPTER 9 Laparoscopic surgery 334 Complications (cid:142)(cid:3) Oesophageal perforation (<1%) \200\224more likely in severe oesophagitis or large hiatus hernia. Avoid forceful introduction of bougie (if used), disse ct bluntly and gently around esophagus and do not grasp the esophagus for retraction. (cid:142)(cid:3) Bleeding \200\224during dissection of short gastric vessels or from accide ntal injury to the spleen or liver. (cid:142)(cid:3) Pneumothorax (1 \200\2235%) \200\224caused by dissection into the mediasti num and pleura. (cid:142)(cid:3) Subcutaneous and mediastinal emphysema \200\224in extensive dissection of large hiatus hernia. (cid:142)(cid:3) Dysphagia \200\224remains the most troublesome and frequent complication. Minimized by formation of loose floppy fundal wrap, use of Toupet partial fundoplication in stead of Nissen complete fundoplication in patients with oesophageal dysmotility (weak or u ncoordinated peristalsis). If dysphagia continues to be severe after three to four weeks po stoperatively, dilatation is performed. Reoperation for dysphagia is seldom necessary. (cid:142)(cid:3) Wrap migration and para-oesophageal herniation \200\224due to failure to r epair the oesophageal hiatus and breach of the pleura. Always close crura, prevent vomiting with routine use of ondansetron. Surgical correction may be required. (cid:142)(cid:3) Gas bloating, inability to belch and hyperflatulence \200\224occur occasio n- ally, usually improve with time. (cid:142)(cid:3) Delayed gastric emptying, dumping, and diarrhea. (cid:142)(cid:3) Recurren t reflux symptoms \200\224consider suture line failure, slipped fundoplication, paraoesopha geal hernia, dysphagia secondary to fundoplication. This page intentionally left blank CHAPTER 9 Laparoscopic surgery 336 Laparoscopic cholecystectomy Indications (cid:142)(cid:3) Symptomatic cholelithiasis (cid:1 42)(cid:3) Acute calculous cholecystitis (cid:142)(cid:3) Acute acalculous cholecystitis (c id:142)(cid:3) Gallstone pancreatitis (cid:142)(cid:3) Symptomatic gallbladder polyp. Contraindications (cid:142)(cid:3) Absolute: Cirrhosis with portal hypertension due to low peripheral resistance and increased risk of bleeding which is difficult to control. (cid:142)(cid:3) Relative contraindications include cirrhosis, coagulopathy, pregnancy (second trimester) and severe cardio respiratory insufficiency. Preparation (cid:142)(cid:3) Confirm diagnosis on ultrasound, provides information about th e stones, gallbladder wall thickness (chronic cholecystitis), pericholecys- tic fluid (acute cholecystitis), and the size of the common bile duct (CBD). FBC, U&E, liver function tests, and blood is obtained for group and save. Evaluate the overall surgical risk including car diorespi- ratory assessment. (cid:142)(cid:3) MRCP/ERCP in patients with a history of jaundice, abnormal LFTs or dilated common duct on USS. (cid:142)(cid:3) Rule out other pathology e.g. gastritis, peptic ulcer disease, irritable b owel syndrome and pancreatitis in patients with atypical symptoms and presentation. (cid:142)(cid:3) Administer single dose of antibiotic for prophylaxis at the start of the operation. Give further two doses postoperatively doses if there is bile leak during the op eration. Treat the patients with acute cholecystitis and cholangitis as their clinical cour se warrants. (cid:142)(cid:3) Institute thromboprophylaxis (subcutaneous heparin and TED stock- ings) be cause the reverse Trendelenburg position and pneumoperito- neum increases the risk for deep venous thrombosis. (cid:142)(cid:3) Use a radiolucent operating table which allows on table cholangiography. ( cid:142)(cid:3) Obtain informed consent for laparoscopic cholecystectomy including discussi on of possible conversion to an open procedure. Conversion rates vary with experience of th e surgeon and are 2 \200\2235%. Conversion rate is higher with previous upper abdominal sur gery, acute chole- cystitis, or CBD stones. Consider conversion as good surgical judge- men t rather than failure. Position (cid:142)(cid:3) Supine (classical) \200\224UK and North America. Surgeon stands o n left side of the patient. (cid:142)(cid:3) Leg abduction position (frog-legged) \200\224French approach. Surgeon stands between the patient \200\231s legs. LAPAROSCOPIC CHOLECYSTECTOMY1 337 Technique (cid:142)(cid:3) Perform under general anesthesia with endotracheal tube and full abdominal relaxation. (cid:142)(cid:3) A urethral catheter is unnecessary provided patient empties his/her bladde r before coming to the theater. Insert NG tube only if the stomach is distended with gas to facilitate exposure. (cid:142)(cid:3) Access the abdominal cavity using an open (Hassan) or closed (Veress) technique. Surgeon \200\231s preference usually determines the choice of technique. Introdu ce 10mm umbilical port for the camera; achieve pneumoperitoneum and maintain intraabdominal pressure of 12mmHg. (cid:142)(cid:3) Place other ports under direct vision as demonstrated in Fig. 9.1 10mm with 5mm reducer in the epigastrium 2 \200\2235mm below the xiphisternum (working port); 5m m anterior axillary line (lateral port) to retract fundus of gall bladder; 5mm right upper quadrant port placed in right mid clavicular line to manipulate the neck of the gallbladder . (cid:142)(cid:3) Laparoscope the entire abdomen to exclude injury/bleeding during creation of pneumoperitoneum, and also to identify any gross additional disease. (cid:142)(cid:3) Place the patient in reverse Trendelenburg position with tilt to the left to allow the colon and omentum to fall inferiorly. (cid:142)(cid:3) Use most lateral grasper to grasp the fundus of the gallbladder and push i t (laterally and anteriorly) over the anterior edge of the liver by pro- gressive traction. Avoid this maneuver in patients with contracted gall- bladder or fibrotic/cirrhotic liver. In these cases, push fundus gently against the liver with care not to penetrate the parenc hyma of the liver. (cid:142)(cid:3) Dissect the adhesions off the gallbladder. (cid:142)(cid:3) Identify the H artmann \200\231s pouch and grasp it with the lateral working grasper, pull it laterally ex posing Calot \200\231s triangle, which includes the cystic duct and artery as well as the c ommon bile duct. Constantly maintain this traction. Start the posterior dissection of Calot \200\231s triangle, divide the inferior peritoneal leaf. (cid:142)(cid:3) Start anterior dissection from Hartmann \200\231s pouch and move toward th e cystic duct. This is particularly important in acute cases, when anatomi- cal landmarks a re difficult to find. Separate/divide peritoneum over the Calot \200\231s triangle as far b ack as the liver. (cid:142)(cid:3) Create a window posterior to cystic duct and cystic artery. (cid:142)(cid: 3) Gently separate the cystic duct from the cystic artery by using dissector. (cid:142)(cid :3) Define junction of cystic duct with gall bladder, defining the junction with CBD is not necessary. In doubt, check with an intraoperative cholangiogram. (cid:142)(cid:3) Coagulation in Calot \200\231s triangle should be minimal and used with extreme caution. (cid:142)(cid:3) Apply two proximal and one distal titanium clips to the cystic duct and artery. (cid:142)(cid:3) Withdraw the applicator and introduce the scissors or endoshears instrument is inserted to cut them. CHAPTER 9 Laparoscopic surgery 338 2 - 4cm subxyphoid 2 - 4cm subcostal on midclavicular line 10mm epigastric 5mm port Parallel to umbilcus On midaxillary line 10mm umbilical Port 5mm port Fig. 9.1 Port sites for laparoscopic choleeystectancy Retract the Hartmann \200\231s pouch upwards and place the tension on the surgical plane be tween the gallbladder and its liver bed. Begin dissection at the infundibulum of the gallbl adder and proceed to the fundus with the aid of an electrosurgical hook or scissors, althou gh more recently, the harmonic scalpel has been used. Facilitate by alternate anterolateral and anteromedial traction. Take care not to enter the gallbladder, which would release sto nes or the liver, which would cause bleeding. (cid:142)(cid:3) On reaching the fundus inspe ct the liver bed. Ensure haemostasis. Separate the gallbladder from its bed. (cid:142)(cid:3) Extract the gallbladder from the umbilical or epigastric port using claw s haped gallbladder extraction forceps (alligator forceps). Pull forceps, cannula and neck of the gallbladder out of the fascial opening. (cid:142)(cid:3) Use endobag to extract the ga llbladder in cases of empyemas and iatrogenic perforations of gallbladder with spilled gallstones. (cid:142)(cid:3) Drainage is not always necessary. When in doubt, drain (bleeding or oozing from liver bed, bile leak). (cid:142)(cid:3) Perform final inspection of the abdomen. (cid:142)(cid:3) Deflate the abdo men and remove the trocars under direct vision. (cid:142)(cid:3) Close the muscle sheath of trocar size 10mm with 2/0 Vicryl or PDS on J needle to prevent herniation. Use subcutaneous Vicryl or Steristrips to close the skin . (cid:142)(cid:3) Infiltrate all port wounds with long-acting local anesthetic. Difficulty and cautions (cid:142)(cid:3) Cystic artery \200\224beware of a short cystic art ery arising from looped right hepatic artery. Early division of the cystic artery \200\224r isk of bleeding from the posterior branch if overlooked; other anomalous origin cystic arte ry of the hepatic or right hepatic artery from the superior mesenteric artery. LAPAROSCOPIC CHOLECYSTECTOMY1 339 (cid:142)(cid:3) Cystic duct \200\224short cystic duct \200\223risk of damage to common bil e duct; Accessory cystic duct \200\224postoperative bile leakage if unrecognized. (cid:142) (cid:3) Perforation of gallbladder \200\224aspirate bile, locate and remove stones, place gall bladder and large stone in retrieval bag, thoroughly irrigate the cavity with no rmal saline. (cid:142)(cid:3) Decompression \200\224initial decompression facilitates approach to tense gall bladder in acute cholecystitis (mucocele/empyema). (cid:142)(cid:3) Wide cystic duct \200\224tie with a Roeder knot/Endoloop or apply Endo GIA staples. (cid:142)(cid:3) Difficult extraction \200\224multiple or large stone. The neck i s opened out- side the abdomen, bile is sucked out and the stones can either be crushed or removed with Desjardin forceps to debulk the gallbladder. Thick walled gallbladders may be extracted by extending the fascial opening. Temptation of excessive traction should be avoi ded. (cid:142)(cid:3) Porcelain gallbladder \200\224calcified rim, difficult grasping or decompr ession due to higher incidence of carcinoma; the specimen should be removed in a nonporous retriev al bag. (cid:142)(cid:3) Large/floppy left lobe of the liver can obstruct the view of Calot \200 \231s trian- gle. Use a liver retractor placed through an additional 5mm port in the left upper quadrant . (cid:142)(cid:3) Retrograde, fundus first in difficult cholecystectomy (acute, inflamed, distortion of Calot \200\231s triangle). (cid:142)(cid:3) Subtotal cholecystectomy \200\224very difficult. Chronic fibrotic, Calot \200\231s triangle obliterated \200\224divide gallbladder at Hartmann \200\231s pouch, extract stones , ligate the pouch with endoloop/oversew. (cid:142)(cid:3) Partial cholecystectomy \200\224if gallbladder very adherent to liver, dia ther- mize mucosal surface of residual gall bladder (partial cholecystectomy). (cid:142)(cid:3) Open conversion \200\224consider in technical difficulties, anatomic uncer tain- ties or anomalies, uncontrollable bleeding, suspected common duct injury, visceral or major vessel damage. (cid:142)(cid:3) Intraoperative cholangiogram \200\224liberal use is desirable to clarify d ifficult anatomy and to detect common bile duct stones. Some surgeons use it routinely for education and training and others pursue a policy of selective cholangiography based on a history of jaundice, pancreatitis, ultrasound evidence of a CBD stone, serum elevation of bilirubin, alkaline phosphatase, and intraoperative abnormal findings or difficul- ties. The cystic du ct is occluded distally with a clip and a small proximal incision is made in the cystic duc t anterosuperiorly with fine scissors. A catheter is guided into the duct and held there wi th a special instrument or a loosely applied titanium clip. The contrast medium is injected during screening. Evaluation of the CBD includes the size of the duct, filling defects, vi sualization of major intrahepatic ducts, and flow of contrast into the duodenum. If the cho langiogram is normal, the catheter is removed and the cystic duct is secured just inferior to the ductotomy with two titanium clips and divided. (cid:142)(cid:3) Co-existing ductal calculi \200\224the usual management consists of endosc opic tone extraction followed by laparoscopic cholecystectomy during the same hospital admission , if possible. The alternative, if local expertise is available, is single stage laparoscop ic management with extraction of the ductal calculi through the transcystic approach, if sm all (<0.6mm), or by direct supraduo- denal common bile duct exploration for large or occlud ing stones. CHAPTER 9 Laparoscopic surgery 340 (cid:142)(cid:3) Carcinoma of the gallbladder \200\224high index of suspicion is important. Consider open conversion with excision of the gall bladder, regional lymphadenectomy and ex cision of trocar site. (cid:142)(cid:3) Diathermy hazards \200\224risk of occult injury. Avoid high-power setting and use diathermy under direct vision only. Postoperative care (cid:142)(cid:3) Remove NG tube (if inserted) at the end of operation. ( cid:142)(cid:3) Postoperative antibiotics are not required for elective cases. (cid:142)(ci d:3) Start clear fluids when the patient is fully awake and proceed to normal diet as tolerated. (cid:142)(cid:3) Remove the drain, if inserted, the following day provided the drainage is minimal. (cid:142)(cid:3) Encourage early ambulation. Most patients are ready for discharge within 2 4 hours. Increasing trend towards day-case laparoscopic cholecystectomy in some centers. (cid:142)(cid:3) Patient is generally able to return to normal activity within 2 weeks. Complications (cid:142)(cid:3) Bleeding \200\224during the operation from the cystic artery or the liver bed. It is usually easily controlled by electrocautery, clips, and or suture ligatures. If haemostasis is not achieved using these methods, the procedure should be conv erted to an open procedure. Major vascular damage (aorta, iliac vessels, and vena cava) can occur during introduc- tion of cannula is rare but reported. It must be remembered that th e distance between the anterior abdominal wall and the aorta and its bifurcation into the i liac vessels averages only 2.0cm in thin patients. Significant bleeding with hypotension re quires immediate laparotomy. (cid:142)(cid:3) Major bile duct injuries \200\224occur when t he common bile duct is mistaken for the cystic duct and divided (complete transection). Oth er mecha- nisms of injury include indiscriminate clipping or cautery to hastily control ble eding, clipping of the cystic duct with the tips of the clip, and occluding the common bile duct. Major bile duct injuries should be referred to and are best treated in specialized u nit for ERCP stenting, for example. (cid:142)(cid:3) Visceral injury \200\224rare but well documented. Can occur with introduct ion of a cannula, insertion of an instrument without visualization or care- less use of ele ctrocautery. (cid:142)(cid:3) Gallbladder perforation \200\224visible stones should be retrieved to prev ent complications related to lost gallstones (Intraabdominal abscess and fistula). (cid:142)(cid:3) Postoperative bile leak \200\2240.02 \200\2232.7%. Patients may present wi th symp- toms of shoulder pain, abdominal pain, and fever. Bile leak may occur from the gallbladder bed, cystic duct (dislodged clips), or as a result of injury to the common bile duct. Most bile leaks resolve spontaneously if adequately drained (ultrasound or CT scan guided), and there is no distal bile duct obstruction. MRCP/ERCP is recommended if no intra- operative c holangiogram was obtained in order to rule out a major ductal injury. ERCP should be perfor med if bile leak persists beyond 1 week after drainage. If a retained common bile duct ston e is found, it is removed. A sphincterotomy and/or stent placement decompresses the biliary system, thus helping resolution of the leak. LAPAROSCOPIC CHOLECYSTECTOMY1 341 (cid:142)(cid:3) Wound infection \200\224may occurs when bile is spilled during extraction of gallbladder or when there is direct contact between an infected gallbladder and the incisio n. Avoid seeding when removing an infected specimen through a tight trocar site. Use extrac tion bag. (cid:142)(cid:3) Incisional hernia through port sites \200\224most commonly occurs in 10mm port sites. Patient usually presents with pain and small bowel obstruction three to 5 days post-operatively. (cid:142)(cid:3) Deep vein thrombosis \200\224risk related to duration of surgery, reverse Trendelenburg position and the pressure of insufflation. Use DVT prophylaxis such as LMWH a nd TED stockings. (cid:142)(cid:3) Post-cholecystectomy syndrome \200\224this is the persistence of symptoms despite surgery. Some of these patients may have a retained stone in the bile duct \200\224 MRCP or ERCP may be needed. The gallbladder may not have been responsible for the pain in t he first place \200\224the pain may have been due to peptic ulcer, irritable bowel syndrome or to disease of the liver or pancreas. (cid:142)(cid:3) Death \200\224occurs in 0.1 \200\2230.5% of cases (1 \200\2235 per 1000 op erations). The risk increases with age. CHAPTER 9 Laparoscopic surgery 342 Laparoscopic appendicectomy It has been demonstrated to be safe and efficacious. However, i ts superi- ority to the traditional open technique continues to be debated. Decision of lap aroscopic versus open appendicectomy is based on many factors including patient \200\231s w ishes, surgeon \200\231s experience, equipment availability and time of day. Advantages (demonstrated by several prospective clinical trials): ability to explore the pe ritoneal cavity, reduced postoperative pain, decreased rate of wound infection, less postop erative adhesions, shorter hospital stay, more rapid return to normal activity, and better cosmesis. Make a definite diagnosis in females. Disadvantages: higher total cost, increased operating time, need for experienced surgeon/th eater staff and appropriate equipment. It is not yet the gold standard for the management o f appendicitis but may become the standard approach in future. Indication Acute/suspected appendicitis. Preferred in (cid:142)(cid:3) Premenopausal women with uncertain diagnosis (cid:142)(cid:3) Obese patients (large incision otherwise required) (cid:142)(cid:3) Athletes and others wh o need rapid return to full activities (cid:142)(cid:3) Patients concerned about cosmesis. Preparation (cid:142)(cid:3) Informed consent for both laparoscopic and open procedure (cid :142)(cid:3) DVT prophylaxis (cid:142)(cid:3) Prophylactic antibiotics (cid:142)(cid:3) Gen eral anesthesia with endotracheal intubation and muscle relaxation (cid:142)(cid:3) Cathete risation to reduce risk of bladder injury and aid pelvic examination. Position (cid:142)(cid:3) Patient in supine position. (cid:142)(cid:3) Surgeon and assistan t standing on patients left side, nurse on the right and monitor at the foot of the table towards the right. Technique (cid:142)(cid:3) Re-examine the abdomen when patient is anesthetized \200\224appe ndicular mass. (cid:142)(cid:3) Induce pneumoperitoneum using either Veress needle or open technique. (cid:142)(cid:3) Perform quick diagnostic laparoscopy first, through 10mm umbilical port. (cid:142)(cid:3) Place second 5mm suprapubic (lower midline, above symphysis pubis) and third 10mm trocar either in the right lower or right upper quadrant. Upper quadrant pla cement preferred because it allows better caecal retraction. LAPAROSCOPIC APPENDICECTOMY1 343 (cid:142)(cid:3) Trendelenburg with left sided tilt facilitates inspection of the right lower quadrant and appendix. (cid:142)(cid:3) Complete the diagnostic laparoscopy to exclude ovarian cyst, pelvic inflam matory disease, cholecystitis, perforated ulcer, Meckel \200\231s diver- ticulum, colonic d iverticulitis, Crohn \200\231s disease and ischaemic bowel. (cid:142)(cid:3) Identify the a ppendix. Signs of appendicitis include omental adherence, caecal inflammation, presence of turbid fluid in the region of the appendix, increased vasc ular injection of the serosa and wall thickening, perforation and gangrene. (cid:142)(cid:3) Grasp and elevate the tip of the appendix. If tip is not visible, identify the base and then follow this using two atraumatic graspers until you see the tip. (cid:142)(cid:3) Free the appendix off the surrounding adhesions to define its entire length. (cid:142)(cid:3) Divide the mesoappendix with clips, bipolar cautery or linear stapling device or tie. (cid:142)(cid:3) Identify the base of the appendix (convergence of taenia), and secure it with a pretied suture ligature/endoloop or a linear stapling device. (cid:142)(cid:3) Divide the appendix between two pre-tied endoloop ligatures. (cid:142)(cid :3) No need to bury the stump of the appendix. (cid:142)(cid:3) Place the purulent appendix into retrieval bag and remove the specimen.