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Laparoscopic surgery

Last updated: March 2, 2021

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Laparoscopic surgery is a minimally invasive technique used to perform surgical procedures within the abdominal cavity, utilizing specialized instruments introduced through small incisions made on the abdominal wall. The abdominal cavity is first accessed using a trocar or a Veress needle, most commonly in the midline (peri-umbilical region). The peritoneal cavity is then insufflated with carbon dioxide (CO2). A fiber-optic instrument (laparoscope) is inserted into the first trocar to visualize the abdominal cavity and to allow for other ports to be created under direct vision. Laparoscopy is often the preferred diagnostic procedure for most elective gastrointestinal and gynecological surgeries. It is contraindicated in patients with shock, cardiac/pulmonary failure, and in cases of dilated bowel loops/perforation peritonitis. There are several advantages of laparoscopy over laparotomy as the incisions used are much smaller (e.g., less postoperative pain, fewer respiratory complications). However, the surgery is technically more challenging and complications (e.g., hemorrhage, bowel injury) are difficult to control laparoscopically. Complications unique to laparoscopy (secondary to CO2 insufflation of the peritoneal cavity) include hypercarbia, pneumothorax, pneumomediastinum, venous air embolism, and postoperative shoulder pain. Proper patient selection and good surgical technique minimize the risks and complications of laparoscopy.

Nearly all elective abdominopelvic surgeries can be performed laparoscopically. A few examples include:

We list the most important contraindications. The selection is not exhaustive.

  1. Anesthesia: general anesthesia (most common), spinal anesthesia with/without epidural anesthesia may be used in some cases [4]
  2. Access to the peritoneal cavity (laparoscopic entry): A trocar/Veress needle is inserted through the abdominal wall (generally midline) into the peritoneal cavity.
    • Trocar: An instrument with a sharp conical end that is used to establish a portal of entry into a body cavity.
  3. Creating a pneumoperitoneum: The peritoneal cavity is insufflated with carbon dioxide (CO2). [5]
    • Allows visualization of abdominal contents and creation of operative space
    • Raises intra-abdominal pressure due to the insufflation of gas within a closed cavity
  4. Creation of other port sites
  5. Removal of instruments and trocars
  6. Evacuation of pneumoperitoneum
  7. Closure of the port sites: Fascia of port sites > 5 mm must be sutured at the end of the surgery. [6]
  • Advantages of laparoscopy over laparotomy include:
  • Disadvantages of laparoscopy are mainly technical:
    • The surgical field is converted to a two-dimensional image on a monitor.
    • Technically more challenging than laparotomy
    • Difficulty in controlling intra-operative hemorrhage
    • Laparoscopy-specific complications (see below)

Intra-operative complications

Most intra-operative complications (pneumothorax, respiratory acidosis, air embolism) are indications to convert the procedure to a laparotomy (open procedure).

Postoperative complications

We list the most important complications. The selection is not exhaustive.

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