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 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 exploratory (diagnostic) laparoscopy.
Equipment
Laparoscopic equipment and instrumentation continue to evolve at a rapid speed. With the aim of confining 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, a video camera, a 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 recorders 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 through either a closed (Veress needle) or an open (Hasson cannula) method.
Carbon dioxide 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.
In patients with chronic respiratory disease, carbon dioxide may accumulate in the bloodstream, leading to dangerous hypercapnia. Accordingly, in these patients, other insufflant gases (eg, helium, xenon, argon, krypton, room air, oxygen, and nitrous oxide) are alternatives; however, the potential side effects include poor solubility, increased incidence of air embolism, greater risk 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 various newer energy devices, such as the LigaSure vessel sealing system (Valleylab, 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. Various stapling devices (linear cutting vs noncutting, intestinal vs vascular) are also available but usually are not essential to the performance of diagnostic laparoscopy.
Instruments for performing 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 number of organ entrapment and retrieval systems are available. Although retrieval bags are needed in patients with lymphoma or patients who had a therapeutic resection, direct retrieval of specimens through the 12-mm port without the need for a retrieval bag is feasible in most patients undergoing staging laparoscopy for cancer, liver, lymph node, or peritoneal biopsy.
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 the suctioning device is in use, it is important to refrain from direct contact with tissues so as 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, the one most commonly used for for diagnostic laparoscopy is a liver retractor, which is useful for examining the undersurface of liver, as well as the 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 for ruling out inoperable disease in patients with gallbladder or cholangiocarcinoma.
Patient Preparation
Laparoscopic procedures can accentuate the risk of developing deep vein thrombosis (DVT) through the following two mechanisms:
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Increased venous pooling secondary to reverse Trendelenburg position (cranial end at higher level than foot end)
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Inferior vena cava (IVC) compression attributable to elevated intra-abdominal pressure
Elastic compression stockings applied to legs can improve venous return but may not be sufficient. For patients at moderate-to-high risk for developing DVT (eg, with morbid obesity, operative duration >30 min, a history of previous DVT or pulmonary embolism [PE], or certain cancers with an increased association with DVT) should receive prophylaxis with fractionated or unfractionated heparin.
For preparing the patient, povidone-iodine solution or any solution that is institutionally approved should be used. In most cases, the area of scrubbing and draping extends from nipple to midthigh. However, this area can be extended in accordance with the underlying pathology. For example, in the case of diagnostic laparoscopy for cancer of the esophagus or esophagogastric junction, the thorax and neck should also be cleaned and draped. In patients with pelvic or urologic malignancies, both the groin and the external genitalia should also be prepared 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. [25]
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 carbon dioxide concentration monitoring, peripheral nerve stimulation, and use of a body temperature probe. End-tidal carbon dioxide can be used as a noninvasive substitute for arterial carbon dioxide 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. [45]
Positioning
The majority of abdominal laparoscopic procedures are performed with patients in the supine position, whereas the lithotomy position is favored for pelvic pathologies (eg, rectal cancer, gynecologic malignancies, or pelvic conditions).
Both arms are typically tucked to the patient's sides 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 when pelvis-based surgery is performed or a prolonged procedure is anticipated.
To facilitate an unobstructed view, gravity is often used to move the structures and 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 carbon dioxide pressure. The light source, camera controls, and any recording devices are also on this cart.
