Laparoscopy and Laparoscopic Surgery

Examination of the abdominal cavity and its organs by means of a laparoscope has been available for nearly a century. Until recently, laparoscopy was largely a diagnostic procedure; the instruments were used primarily to visualize and biopsy abdominal organs and other structures, although some treatment was possible in the form of aspiration of cysts and abscesses, lysis of adhesions, ligation of the fallopian tubes, and ablation of endometriosis or cancer by laser. In recent years, rapid and dramatic developments in operative laparoscopy have made laparoscopic cholecystectomy and appendectomy commonplace; other, more complicated operative procedures, such as partial gastrectomy and partial colectomy, have been described using laparoscopic methods.

I. LAPAROSCOPY

A. Indications.

The reliance on diagnostic laparoscopy varies from one medical center to another. In some centers, laparoscopy is used routinely in evaluation of the abdominal conditions discussed in this chapter, whereas in other centers it is used rarely. This variability in the use of diagnostic laparoscopy can be attributed to the advances in computed tomography (CT) and other imaging techniques of the past decade, which have provided alternatives to laparoscopy that are either less invasive or more readily available. In hospitals and medical centers where diagnostic laparoscopy is available, it is usually performed for the following indications.

1. Biopsy of the liver.

This procedure may be done to evaluate a diffuse condition of the liver, such as cirrhosis or an infiltrating disease, or to biopsy a focal defect of the liver that has been identified by CT or ultrasound examination. During laparoscopy, the appearance of the liver also can be assessed; for example, the collateral vessels of portal hypertension or nodularity of cirrhosis or neoplasm may be evident.

2. Determination of cause of ascites.

When the cause of ascites is unknown, laparoscopic examination of the abdominal organs, the omentum, and the peritoneum may provide an answer. The most common causes are disseminated cancer, usually ovarian, and cirrhosis.

3. Staging of Hodgkin’s disease and non-Hodgkin’s lymphoma.

4. Evaluation of patients with fever of unknown origin.

5. Evaluation of patients with chronic or intermittent abdominal pain.

Diagnoses include abdominal adhesions, Crohn’s disease, appendicitis, and endometriosis.

B. Contraindications

include a perforated viscus, abdominal wall infections, diffuse peritonitis, and clinically significant coagulopathy. Chronic lung disease and congestive heart failure are relative contraindications. If laparoscopy is necessary in those instances, sedation should be minimized and the patient should have pulse oximetry and cardiovascular monitoring. Tense ascites interferes with adequate visualization and should be treated before attempting laparoscopy.

C. Technique.

Most diagnostic laparoscopic procedures are performed electively in patients who have fasted and are under sedation and local anesthesia. A small skin incision is made, usually above and to the left of the umbilicus, avoiding surgical scars and abdominal masses. Nitrous oxide or carbon dioxide gas is introduced by a needle to distend the abdomen, and a trocar and cannula are passed through the incision into the peritoneal cavity. The laparoscope is inserted into the abdomen
and, by maneuvering the instrument or positioning the patient, most of the abdominal contents can be examined. Tissue samples can be obtained by brushes, needles, or forceps that are passed through the laparoscope. At the conclusion of the examination, the gas is withdrawn, the instrument is removed, and the small incision is closed with sutures or clips.

D. Therapeutic laparoscopy.

Some conditions can be treated by the laparoscopic techniques described. These treatments include aspiration of cysts and abscesses, lysis of adhesions, ligation of the fallopian tubes, and ablation of endometriosis or cancer by laser. However, the most dramatic advances in therapeutic laparoscopy have been in the area of operative laparoscopy, described in the following sections.

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