Exploratory Laparoscopy Periprocedural Care

Updated: Jan 29, 2016
  • Author: Umashankar K Ballehaninna, MD, MS; Chief Editor: Kurt E Roberts, MD  more...
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Periprocedural Care

Patient Education and Consent

Although laparoscopic surgery is generally associated with overall decreased pain and morbidity, there remains the potential for serious complications, similar to those associated with standard open incisional surgery.

Patients should understand the inherent risks associated with laparoscopic procedures, namely conversion to open surgery due to hemorrhage, bowel injury, failure to progress, and/or other complications.

Additional complications unique to laparoscopy include fatal gas embolism, problems due to hypercarbia, postoperative crepitus, and pneumothorax, as well as procedure-specific complications such as bowel injury during diagnostic laparoscopy.

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Equipment

Laparoscopic equipment and instrumentation continue to evolve at a rapid speed. With an aim to confine the scope of this article, discussion is limited to the basic equipment necessary to perform diagnostic laparoscopy.

Tools for visualization

The components necessary to create a laparoscopic image include a laparoscope, video camera, light source, and a display monitor.

The most commonly used laparoscopes are those with 0º or 30º lenses with a diameter of 10 mm (range, 2.7-12 mm). A fiberoptic light cable transmits light from the light source. Image transmission is provided by a lens system within the laparoscope using the same fiberoptic cable. The transmitted image is processed by the camera system and displayed on a video monitor.

The light source consists of high-intensity halogen, mercury, or xenon vapor bulbs with an output of 250-300 W. Some units are equipped with automatic brightness adjustment capabilities. Digital video disk recorders (DVD-Rs) or videocassette recorders (VCRs) and video printers are often used to record or preserve laparoscopic images or procedures.

Larger diameter laparoscopes provides better optical resolution and enable brighter imaging with improved resolution. A 30º laparoscope is preferred to a 0º laparoscope for most procedures because it provides a wider delineation of the surgical field and allows imaging of relatively inaccessible intra-abdominal regions with only a slight movement of the camera.

Equipment to create pneumoperitoneum

An insufflant system consists of insufflator, tubing, and a chosen gas to obtain the pneumoperitoneum. Insufflation can be achieved by either a closed (Veress needle) or open (Hasson cannula) method.

CO2 is the most commonly used insufflant agent because it is very soluble in blood and rapidly expelled by lungs. Moreover, it does not support combustion. But in patients with chronic respiratory disease, CO2 may accumulate in the bloodstream, leading to dangerous hypercapnia. In these patients, other insufflant gases (helium, xenon, argon, krypton, room air, oxygen, nitrous oxide) are alternatives but the potential side effects include poor solubility, increased incidence of air embolism, or increased incidence of fire (with air and oxygen), and higher cost.

Basic instruments needed to perform diagnostic laparoscopy

Instruments for grasping and dissection include a 5-mm Maryland dissector, blunt-tip dissecting forceps, atraumatic grasping forceps, and L- or J- shaped hook dissector.

Instruments for incising and hemostasis include 5-mm laparoscopic scissors, electrocautery (unipolar or bipolar) and/or a newer energy device, such as the LigaSure vessel sealing system (Valleylab Inc., Boulder, CO) or an ultrasonically activated scalpel).

Instruments for clipping and stapling (5 mm or 10 mm; range, 5-12 mm) are useful to prevent or stop bleeding. Also a variety of stapling devices (linear cutting vs noncutting, intestinal versus vascular) are available but usually not essential to perform diagnostic laparoscopy.

Instruments to perform biopsy and specimen retrieval include cup biopsy forceps can for liver biopsy. Depending on the size of the tissue and whether the organ is retrieved intact or after in situ morecellation, a variety of organ entrapment and retrieval systems are available. Although retrieval bags are needed in patients with lymphoma or patients who had a therapeutic resection, in most patients undergoing staging laparoscopy for cancer, liver, lymph node, or peritoneal biopsy specimens can be directly retrieved through the 12-mm port without the need for a retrieval bag.

Instruments for suction and irrigation are necessary to improve visualization and prevent accumulation of blood or irrigation fluid. Most commonly, a disposable battery-powered suction-irrigation setup is used, consisting of 5 L of normal saline solution used as an irrigant and a 5- or 10-mm metal tube used as a laparoscopic suctioning device. However, while using the suctioning device, it is important not to come in direct contact with tissues to prevent serosal damage.

Instruments for retraction include laparoscopic retractors, which greatly facilitate exposure by keeping the surrounding structures away from the area of interest. Although they come in various shapes, for diagnostic laparoscopy, most commonly a liver retractor is useful to examine undersurface of liver as well as lesser sac.

Optional equipment includes a laparoscopic ultrasound device, which is useful in patients in whom liver metastasis is suspected for accurately measuring the number, size, and location of metastasis, as well as to rule out inoperable disease in patients with gallbladder or cholangiocarcinoma.

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Patient Preparation

Laparoscopic procedures can accentuate the risk of developing deep vein thrombosis (DVT) by the following two mechanisms:

  • Increased venous pooling secondary to reverse Trendelenburg position (cranial end at higher level than foot end)
  • Inferior vena cava compression (IVC) attributed to elevated intra-abdominal pressure

Elastic compression stockings applied to legs can improve venous return but may not be sufficient. For patients with moderate to high risk of developing DVT (morbid obesity, operative duration >30 min, history of previous DVT or pulmonary embolism [PE], certain cancers with increased association of DVT) should receive prophylaxis with fractionated or unfractionated heparin.

When prepping the patient, povidone-iodine solution or any solution that is institutionally approved should be used. For most cases, the area of scrubbing and draping is performed from nipple to midthigh. However, it can be extended in accordance with the underlying pathology. For example, for a patient undergoing diagnostic laparoscopy for esophageal or gastroesophageal junction cancer, the thorax and neck should also be cleaned and draped. In patients with pelvic or urologic malignancies, both groin and external genitalia should also be prepped and draped.

Anesthesia

Laparoscopic surgical procedures are most commonly performed with general anesthesia and skeletal muscle relaxation. However, in rare circumstances, such as in trauma and intensive care unit (ICU) patients, local anesthesia with intravenous (IV) sedation has been successfully used. [20]

Appropriate anesthetic techniques along with proper monitoring are obligatory for optimal anesthesia care during laparoscopy. Commonly employed monitoring methods include electrocardiography (ECG), noninvasive arterial pressure monitoring, airway pressure monitoring, pulse oximetry, end-tidal CO2 concentration monitoring, peripheral nerve stimulation, and use of a body temperature probe. End-tidal CO2 can be used as a noninvasive substitute for arterial CO2 tension (PaCO2) in evaluating the adequacy of ventilation during laparoscopic surgery.

In hemodynamically unstable patients and in those with cardiopulmonary dysfunction, careful cardiovascular monitoring and arterial blood gas analysis may be necessary.

Nerve stimulation monitoring helps to ensure adequate muscle paralysis, which is necessary for reducing the intra-abdominal pressure required for adequate abdominal distention. [34]

Positioning

The majority of abdominal laparoscopic procedures are performed with patients in the supine position, whereas the lithotomy position is favored for pelvic pathologies (rectal cancer, gynecologic malignancies, pelvic conditions). Both arms are typically tucked to the side of the patient to permit the surgeon and assistant to get closer to the patient. A belt is placed firmly across the pelvis and a foot plate placed against the plantar surfaces to prevent the patient from sliding down if a reverse Trendelenburg position is needed. A Foley catheter is not mandatory but should be used in a patient undergoing pelvis-based surgery or when a prolonged procedure is anticipated.

To facilitate an unobstructed view, gravity is often used to move the structures/organs away from the area of operative interest. For example, during examination of the liver, stomach, or other proximal GI structures, the patient is placed in a reverse Trendelenburg position with a slight left lateral tilt (right side up). To examine pelvic structures, a Trendelenburg position is used (head at the end of the bed at a lower level than feet).

Placement of equipment

Modern laparoscopic surgery is traditionally performed with the surgeon and the assistant standing on the same side of the table and the monitor and table-mounted instrument holder positioned on the opposite side. The scrub nurse stands on the opposite side of the table from the surgeon, with the instrument table towards the end of the table. This facilitates communication between the surgeon and the scrub nurse and allows instruments to be passed more easily.

A secondary monitor can be positioned anywhere in the room to facilitate viewing by the ancillary operating room staff. The cart or laparoscope system holder, with the monitor for the primary surgeon, typically also houses the insufflators placed near the surgeon’s eye level to allow continuous monitoring of CO2 pressure. The light source, camera controls, and any recording devices are also on this cart.

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