84: Minimally invasive surgery: laparotomy, laparoscopy, and robotic surgery


CHAPTER 84
Minimally invasive surgery: laparotomy, laparoscopy, and robotic surgery


Aashish Rajesh1, Nizamuddin Shaikh2, and David R. Farley2


1University of Texas Health Science Center, San Antonio, TX, USA


2Mayo Clinic, Rochester, MN, USA


Advancements in minimally invasive surgery (MIS) over the last four decades have revolutionized modern surgical practice. With the unique ability to decrease the morbidity associated with large surgical incisions, enhance postoperative recovery, and offer better cosmetic outcomes after surgery, MIS is replacing conventional open surgery for many standard indications. This chapter illustrates some of the techniques employed in MIS with a focus on helping practicing and budding gastroenterologists work collaboratively with surgeons for optimal patient outcomes.


The following sections review some of the surgical conditions often encountered by practicing gastroenterologists that may be treated by MIS approaches.


General surgery


Inguinal hernia

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Figure 84.1 Laparoscopic view of an inguinal hernia. The arrow points to a small, fat‐containing right‐sided inguinal hernia

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Figure 84.2 Illustration demonstrating the totally extraperitoneal (TEP) anatomy and mesh coverage of a right‐sided inguinal hernia repair.

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Figure 84.3 Laparoscopic view of a previous failed mesh ventral hernia repair. A. Mesh covered by peritoneum. B. Titanium clip holding mesh against the anterior abdominal wall. C. Adhesions which may form between the mesh and the bowel postoperatively. Note the right‐sided inguinal hernia seen in the background (seen in Figure 84.1).

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Figure 84.4 The four images demonstrate the laparoscopic dissection and closure of an abdominal wall hernia with a panel of GoreTex®. (a) The initial intraoperative view. (b) The dissection of the hernia sac to reveal the fascial defect. (c) The final fascial defect after the hernia content has been reduced. (d) The application of a panel of GoreTex® to cover the defect. The panel is secured by the use of permanent suture and titanium tacks.


Cholecystectomy


The critical view of safety in laparoscopic cholecystectomy is the view in which only two structures (cystic artery and cystic duct) are seen entering the gallbladder against a clear liver bed. This is illustrated in the video supplement (Video 84.1).

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Figure 84.5 Illustration demonstrating the trocar placements and simplified view of a laparoscopic cholecystectomy (cystic artery and hepatic arterial system not demonstrated in this illustration).


Source: Used with permission of Mayo Foundation for Medical Education and Research, all rights reserved.

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Figure 84.6 Occasionally, the gallbladder (GB) can be partly intrahepatic and difficult to dissect during laparoscopic cholecystectomy. Note the gas‐filled hepatic flexure of the colon (C) adjacent to the underside (*) of the GB.

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Figure 84.7 The gallbladder contents may be aspirated to facilitate decompression and dissection in severely inflamed gallbladders.


Small bowel obstruction (SBO)


Adhesions from previous surgery are the most common cause of SBO in the western world, accounting for roughly 70% of patients presenting with SBO.


Laparoscopic adhesiolysis for the management of SBO has been found to be associated with decreased length of hospital stay, fewer complications, and lower risk of bowel resection.

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Figure 84.8 Dense adhesions tethering bowel to the abdominal wall.

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Figure 84.9 (a,b) The principles of safe laparoscopic adhesion lysis: careful entry into the abdomen with insufflation with CO2, placing adhesive bands on tension, and careful transection of adhesions to avoid trauma to colon, small bowel, and other intraabdominal structures.


Source: Used with permission of Mayo Foundation for Medical Education and Research, all rights reserved.


Colorectal and hepatobiliary surgery


Minimally invasive surgery approaches are widely adopted for diagnosis and resection of colorectal and hepatobiliary pathology.

Photo depicts intraoperative picture of Crohn’s disease (CD) with notable transmural inflammation of the bowel wall and skip lesions involving multiple segments in patches.

Figure 84.10 Intraoperative picture of Crohn’s disease (CD) with notable transmural inflammation of the bowel wall and skip lesions involving multiple segments in patches. Following MIS assessment, surgeons made a 6 cm incision to exteriorize the small bowel to facilitate rapid and safe bowel resections and anastomoses.

Photo depicts asymptomatic and harmless ectopic pancreatic (P) tissue found abutting the small bowel and mesentery.

Figure 84.11 Asymptomatic and harmless ectopic pancreatic (P) tissue found abutting the small bowel and mesentery. The ectopic pancreas was left in place and the planned hand‐assisted colectomy proceeded without difficulty.


Surgeons assisting gastroenterologists


Certain procedures may be best completed with surgeons and gastroenterologists working in tandem. Examples include the following.


Gastrostomy tube (G‐tube)

Photo depicts percutaneous endoscopic gastrostomy tube placement.

Figure 84.12 Percutaneous endoscopic gastrostomy tube placement. Under endoscopic guidance, a needle is used to puncture the transilluminated gastric wall. The tract is then dilated and, using the Seldinger technique, the gastrostomy tube is appropriately positioned with the help of a balloon. PEG tubes are commonly used in patients with neurological diseases with dysphagia to provide enteral nutrition.


Source: Used with permission of Mayo Foundation for Medical Education and Research, all rights reserved.


Per‐oral endoscopic myotomy (POEM)

Photo depicts the POEM procedure performed for achalasia involves an esophageal myotomy created endoscopically by elevating a submucosal tunnel as illustrated.

Figure 84.13 The POEM procedure performed for achalasia involves an esophageal myotomy created endoscopically by elevating a submucosal tunnel as illustrated. With the patient supine, the mucosal incision in the esophageal lumen is created at an anterior or 2 o’clock position or a posterior or 5 o’clock position, 10–15 cm proximal to the lower esophageal sphincter. This results in a submucosal tunnel which is then extended 2–4 cm distally on to the gastric cardia, which releases the hypertrophied muscle of the lower esophageal sphincter.


Source: Used with permission of Mayo Foundation for Medical Education and Research, all rights reserved.


Hand‐assisted surgery

Photo depicts an MIS approach involving the surgeon’s nondominant hand inserted through the abdomen.

Figure 84.14 An MIS approach involving the surgeon’s nondominant hand inserted through the abdomen (the incision is often 6–8 cm in length to assist with the laparoscopic dissection and mobilization).


Source: Used with permission of Mayo Foundation for Medical Education and Research, all rights reserved.


Robotic surgery

Photo depicts the set-up for robotic-assisted surgery.

Figure 84.15 Illustration demonstrating the set‐up for robotic‐assisted surgery. The robotic instruments with their seven degrees of freedom mimic a human hand and facilitate easier dissection within the abdomen.


Source: Used with permission of Mayo Foundation for Medical Education and Research, all rights reserved.

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Nov 27, 2022 | Posted by in GASTROENTEROLOGY | Comments Off on 84: Minimally invasive surgery: laparotomy, laparoscopy, and robotic surgery

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