Advanced Techniques in Gasless Laparoscopic Surgery

The following sections are included:

• Preface

• Acknowledgments

• Contents

In reviewing the history of laparoscopic surgery, two major problems must be considered. The first one concerns the need to create enough intraabdominal space for the operation between the anterior-abdomen and the retroperitoneum; and the second is to minimize organ damages during insertion of instruments through the abdominal wall…

Standard open cholecystectomy was first performed by C. Langebuch¹⁰¹ in 1882 and since then it has proved itself to be a highly safe and effective means of treating gallbladder diseases especially cholelithiasis. However, high costs, prolonged hospitalization and prolonged recovery time, pain and morbidity associated with major open surgery have prompted surgeons to explore alternative ways of treating gallbladder diseases. Against this background and with the prevalence of gallbladder diseases, laparoscopic procedure was introduced for the removal of the gallbladder…

Pneumoperitoneum has been an initial procedure in most laparoscopic surgery. Insufflation is essential for the safe insertion of trocars as well as for obtaining a good view of the operative field. The purpose of insufflation is to create an intraabdominal space so as to provide a better view of the operative field and for better manipulation of the instruments…

Pneumoperitoneum, which is carried out for the purpose of creating an intraabdominal space, can be replaced by an alternative method of abdominal wall lifting with subcutaneous wiring. Under an adequate muscle relaxant, the anterior abdominal wall can be pulled up considerably so as to make sufficient space between the wall and intraabdominal organs…

The abdominal wall lifting method has several advantages as compared with the pneumoperitoneum method.

In the abdominal wall lifting method, all operative procedures are performed under normal pressure. Thus pressure-related complications caused by pneumoperitoneum can essentially be avoided, e.g. gas embolism, hypercapnia, arrhythmia, hypertension, atelectasis, mediastinal emphysema, shock and postoperative shoulder pain. Besides, operative maneuvers can be performed smoothly…

The following sections are included:

• CHOLELITHIASIS

• POLYPOID LESIONS OF THE GALLBLADDER

• ANOMALIES OF THE GALLBLADDER AND THE BILIARY TREE

The following sections are included:

• INTRODUCTION

• LIFTING INSTRUMENTS
  • Kent Retractor Set
  • Wires with a Loop
  • Suture Material

• LAPAROSCOPIC VIDEO SYSTEM
  • Color Video System
  • Rigid Scope
  • Fogless Scope
  • Flexible Laparoscopes
  • Zoom Adapter
  • Light Sources and Cables
  • Monitor
  • Digital Hard Copier
  • 35mm Camera

• LAPAROSCOPIC SURGICAL INSTRUMENTS
  • Valveless Trocars
  • Hand Holding Type Forceps
  • Soft Grasping Forceps
  • Serrated Teeth Grasping Forceps
  • Fine Long Grasping Forceps
  • Swab Holding Forceps
  • Ojigi Spatula
  • Long Ojigi Spatula
  • Ojigi Tying Spatula
  • Three-aperture Li gating Forceps
  • Fan Retractors
  • Scissors
  • Needle Holder
  • Clip Appliers
  • Irrigation Aspiration Cannula

• LAPAROSCOPIC SURGICAL EQUIPMENT
  • Electrocautery
  • L-shaped Tip Electrocautery
  • Hooks-shaped Electrodissector
  • Angled Blade Electrodissector
  • Electrodissecting Forceps
  • Rotating Electrodissecting Forceps
  • Electroscissors
  • Lasers; YAG and KTP
  • Ultrasonic Dissectors
  • Harmonic Scalpel
  • Argon Beam Coagulator

• LAPAROSCOPIC DIAGNOSTIC EQUIPMENT
  • Ojigi Ultrasound Probe
  • Choledochoscope
  • Laparoscopic Doppler

While sharp dissections with scissors or electrocautery can sometimes cause injury to vital structures, blunt dissections with peanut swabs are rapid and safe. Peanut swabs can be soaked in epinephrine diluted with water (1:5000), which thus provides for more hemostatic dissections. In this maneuver most of the ductal and vascular structures can be identified and secured. As electrocautery can cause unexpected common bile duct injury, it is strongly recommended that electrocautery should not be used when dissecting close to the cystic duct…

The following sections are included:

• LIGATIONS USING THE OJIGI TYING SPATULA

• LIGATIONS USING THE THREE-APERTURE LIGATING FORCEPS

A major difference between laparoscopic surgery and conventional open surgery, is that the surgeon cannot directly view the operative field in laparoscopic surgery. He visualizes the operative field through a camera which is usually handled by a third person. The cameraman is the key person who manages and produces a good view of the operative field through skillful handling of the scope, because a clear vision is crucial for a surgeon to achieve a smooth operation. Actually, the cameraman's eyes become the surgeon's eyes. In other words, the surgeon sees through the eyes of the cameraman. Harmony between the surgeon and the cameraman is of paramount importance…

It was only a few years ago that surgeons and institutions worldwide started to adopt this new technique with very little knowledge and experience. Many new techniques are still in a stage of development; therefore, adequate training programs have not yet been established at many institutions. Therefore it is important to develop training programs for both skilled practitioners and residents…

Laparoscopic instruments and equipment are expensive. They are relatively new to almost everybody in the operating theater, and so special attention should be paid to their maintenance. Maintenance of highly sophisticated cameras and video systems is of immense importance. Such cameras are extremely sensitive to humidity and temperature, which can affect the quality of vision. Good maintenance of the optical component and light source is equally important for maintaining excellent vision, and also for avoiding accidents such as camera and video system failures which in turn disturb the smooth operation…

Routine clinical examinations are performed to evaluate the fitness of the patient for general anesthesia and for the operation. Plain X-ray of the chest, plain abdominal X-ray, ECG, and pulmonary function tests are performed before surgery. Urine and stool analyses should be carried out. Blood biochemistry evaluation for the hepatic, pancreatic and renal function is also vital. Tumor markers should be checked out, if any malignancies are suspected. Complete blood count with total and differential counts, hemoglobin estimation, ESR, bleeding time, clotting time and other tests for bleeding disorders are also carried out. Bleeding disorders in particular may cause considerable problems during laparoscopic procedures…

Preoperative preparation of the patient is the next step in laparoscopic cholecystectomy. The procedures should be explained fully to the patient and his or her family. The risks of a laparoscopic surgery and the possibility of a conversion to a conventional open surgery should be clearly explained to the patient and relatives…

For laparoscopic cholecystectomy, a special operating room set-up is essential. In most institutions, this operation is carried out by a surgeon, an assistant surgeon, a scrub nurse and a cameraman. But in the author's series, there is an operating surgeon, along with a cameraman and a scrub nurse, the latter to manage the instrument trolley. Normally, in an open surgery, the assistant surgeon retracts the gallbladder cephalic over the liver, which opens a plane of the neck of the gallbladder. This maneuver can be performed by the cameraman with his left hand without any difficulty…

Laparoscopic cholecystectomy with abdominal wall lifting is usually performed under general anesthesia unless this is contraindicated. The same also applies to the procedure done under pneumoperitoneum. Sufficient muscle relaxant is required to create enough space intraabdominally for the surgery. Even if the effect of the muscle relaxant wears off during operation, the surgeon can still continue with the operation safely in the abdominal wall lifting method. In the pneumoperitoneum method, on the other hand, the surgeon can't do so because the chances of gas embolism occurring become very high at this stage of the operation. This is one of the important advantages of the abdominal wall lifting method where anesthesia is concerned…

After proper positioning of the patient on the operating table, painting (skin sterilization) is carried out. Skin sterilization is similar to that of an open surgery. During skin preparation, umbilical cleaning should be reconfirmed. If the cleaning of the umbilicus has not been done properly, it should be cleaned again. After skin preparation, two-sided clamp bars are fixed at the level of the axilla to form the arch for abdominal wall lifting. The height of the poles should be at a maximum on both sides. When the procedure was first developed, the poles were placed at the same level on both sides of the patient, either at the level of the nipple or the axilla. But later on, the author modified the position of the arch obliquely by fixing the right-side pole at the level of the nipple and the left-side one at the level of the eye. With this improvement, collision of the surgeon's hand with the pole or arch could be avoided…

A 4 mm skin incision is made on the right anterior axillary line, at the midpoint between the lowest end of the right costal margin and the right anterosuperior iliac spine. A pair of artery forceps is used to stretch the skin incision so that it can accommodate two wires…

Two thick sutures (Ethibond No. 5) are used on both sides as hangers for lifting up the subcutaneous wires. The right side suture bites are taken at two points to hold the wires the lower bite is to hold two wires placed at the crossing point of the wires, while the upper bite on the right mid-clavicular line holds one wire only. On the left side, two bites are also taken at the umbilicus level and at the level of the xyphoid process above, respectively. The upper bite is taken at the crossing point of two wires…

Though the hanger lifting method provides a wide view in most of the cases, the lifting effect is unequal in some cases, resulting in a slightly oblique ceiling. When the hanger thread is too short, the abdominal skin is hurt by the suture itself. When this kind of unbalance occurs, its correction is very difficult or sometimes impossible. In order to solve these problems, the plate lifting method was devised…

The first trocar is the umbilical or the navel trocar for insertion of the laparoscope. The author recommends the insertion of this trocar through a 10 mm long skin incision just above the umbilicus. The longitudinal or horizontal skin incision is preferred by surgeons but the author advocates the smallest possible incision for cosmetic reasons…

For a smooth operation, the selection of trocar sites is extremely important. For abdominal wall lifting, the sites of the trocars vary slightly from those of pneumoperitoneum. This is because of the need to avoid the clash of instruments with the lifting thread, hooks or subcutaneous wires (Fig. 22.1). Improper selection of trocar sites may restrict the hand movements of the operating surgeon as well as the operative view. The umbilical trocar is placed above or below the umbilicus. If the position of the scope is such that it is closer to the lifted roof, a wider view can be achieved…

The view and orientation of the operative field in laparoscopic cholecystectomy differ greatly from that of an open surgery. Mistakes are likely to be made in identifying biliary structures because of the change in the orientation.

In an open surgery, the surgical anatomy of the liver is usually observed in an anteroposterior view. On the other hand, in laparoscopic surgery, the laparoscope is introduced obliquely through the umbilical trocar, and the image of the inferior surface of the liver appears enface on the monitor screen. One should keep in mind that the surgical anatomy remains the same, but it is viewed from a different direction…

The following sections are included:

• INSPECTION OF THE ABDOMINAL CAVITY

• LIVER RETRACTION

• INSPECTION AROUND NECK REGION

• SEROSAL INCISION AROUND THE NECK

• DISSECTION OF THE CALOT'S TRIANGLE

• IDENTIFICATION AND PROPER DISSECTION OF THE CYSTIC DUCT

• PROPER DISSECTION OF THE CYSTIC DUCT WITH OJIGI SPATULA

• LIGATION AND DIVISION OF THE CYSTIC DUCT

• LIGATION, CLIPPING AND RESECTION OF THE CYSTIC VESSELS

• DISSECTION OF THE LIVER BED

• IRRIGATION AND SUCTION

• REMOVAL OF THE GALLBLADDER

• LAPAROSCOPIC DRAIN

• CLOSING OF THE TROCAR SITE INCISION

The following sections are included:

• INTRAOPERATIVE ULTRASONOGRAPHY

• INTRAOPERATIVE CHOLANGIOGRAPHY

In the case where a stone is incarcerated in the neck of the gallbladder or where the cystic duct is very short with firm adhesions around it, the operative anatomy of the billiary tree may not always be clear. In such cases, the incidence of injury to the right hepatic or common bile duct is more common in laparoscopic cholecystectomy than in conventional open surgery. In this respect the fundus-first technique is considered as an alternative method to minimize common bile duct injury…

The postoperative management of the patient in laparoscopic cholecystecomy by the abdominal wall lifting method is very simple. The convalescence period is very short and usually the patient can be discharged on the third postoperative day, resuming normal activities in a week. Postoperative paralytic ileus is very rare, since there is no significant change in the intraabdominal environment and there is almost no manipulation of other organs…

The incidence of early and late postoperative complications is relatively low with laparoscopic cholecystectomy by the abdominal wall lifting method as compared to that of the pneumoperitoneum method.

Bleeding from the cystic artery due to slipping of a clip or ligature, bile leakage from the injured duct or from the liver bed, and development of biliary peritonitis, are possible early complications which may require intensive emergency management…

Generally, in case of acute cholecystitis, laparoscopic cholecystectomy should be performed as soon as possible. Adhesion around the gallbladder would be very thick and strong during the second or third week following the onset of acute symptoms. Therefore, if the condition of the patient does not allow an emergency operation, it is advisable to postpone surgery for at least one month or longer…

In cases with negative cholecystogram in drip infusion cholangiography (DIC), a stone (or stones) is usually impacted in the neck, obstructing the cystic duct. The gallbladder presents a considerable degree of chronic inflammation, and there are associated fibrosis and adhesions around it. It is sometimes difficult to grasp the gallbladder in such cases. Particularly in instances of empyema and hydrops of the gallbladder, it is almost impossible to do so. In cases of excessive distention or a very thick walled gallbladder, suction and emptying of the gallbladder (by puncturing or making a small incision) is often necessary to grasp the gallbladder firmly…

The following sections are included:

• VERY LARGE SINGLE STONE

• MULTIPLE SMALL STONES

• STONES IMPACTED IN THE NECK OF THE GALLBLADDER

• STONE IN THE CYSTIC DUCT

A preoperative diagnosis of anatomical variations of the biliary tree considerably reduces the chance of bile duct injury. The possibility of anatomical variations should be checked carefully by drip infusion cholangiography (DIC), DIC-tomography or DIC-CT, preoperatively.

When an abnormal anatomy was not revealed at the preoperative stage, mishaps may occur. The most dangerous complication is ligation and resection of the common bile duct or the right hepatic duct. When anatomical variations are suspected during the operation, it is advisable to perform an intraoperative drip infusion cholangiography before clipping or ligation. Placing a radio-opaque thread around the suspected cystic duct structure is very effective in understanding the proper anatomy. Direct cholangiography is not recommended in these cases. If the cholangiography fails to convey the anatomy of the biliary tree, a retrograde cholecystectomy or modified fundus first method is recommended…

The following sections are included:

• OBESE PATIENTS

• OVER-DESCENT OF THE LEFT LOBE OF THE LIVER

The following sections are included:

• A HISTORY OF OLD ABDOMINAL SCAR

• PREGNANCY

• AGED PATIENTS

The following sections are included:

• INTRAOPERATIVE PERFORATION OF THE GALLBLADDER

• INTRAOPERATIVE BLEEDING

• COMMON BILE DUCT INJURY

• INJURIES TO OTHER ORGANS

• FAILURE OF INSTRUMENTS AND EQUIPMENT
  • Failure of Clip Applicator
  • Video System Problems
  • Failure of Instruments

The following sections are included:

• DEVELOPMENT OF COMPUTER AIDED SURGERY (CAS) SYSTEM
  • Image Acquisition
  • Organ Modeling
  • The Surgical Support Subsystem

• THREE-DIMENSIONAL LIVER MODELING
  • Modeling of Liver Surface
  • Modeling of Liver Vessels
  • Modeling of Biliary Tree
  • Complete Display of the Liver

• APPLICATION OF THE CAS SYSTEM TO LAPAROSCOPIC CHOLECYSTECTOMY

• APPLICATION OF THE CAS SYSTEM TO LIVER SURGERY
  • Liver Segmentation Using the CAS System
  • Hepatectomy using the CAS System
  • Spherical Laser Coagulation Therapy and the CAS System

The following sections are included:

• History of Three-Dimensional Vision

• Principle of the Field-Sequential Stereoscopy

• Development of Laparoscopic 3-D Camera and Video System

• Development of 3-D Video Camera System for Pediatric Use

• Early Clinical Applications of 3-D Camera and Video System

• Advantages and Current Limitations in 3-D Imaging

The following sections are included:

• Ojigi Surgical Knife

• Ojigi Electrocautery

• Free Rotatable Ojigi Needle Holder

The following sections are included:

• F-shaped Grasping Forceps

• Suture Picker

• Soft Tissue Holding Forceps

• Intestinal Holding Clamps

• Special Horseshoe-shaped Tissue Holder

In many institutions in the United States, Europe, Asia as well as many other developed and developing countries, laparoscopic general surgery is being increasingly practised. In almost all of these institutions, vigorous research is being carried out as a result of the increasing demand by patients as well as surgeons. A number of major gastrointestinal operative procedures have already been performed in many places…

The following sections are included:

• SUBCUTANEOUS WIRING, LIFTING AND TROCARING

• OPERATIVE PROCEDURE

The following sections are included:

• SUBCUTANEOUS WIRING, LIFTING AND TROCARING

• OPERATIVE PROCEDURE

The following sections are included:

• SUBCUTANEOUS WIRING AND LIFTING

• TROCARING

• OPERATIVE PROCEDURE

The following sections are included:

• MANAGEMENT OF COMMON DUCT CALCULI DISCOVERED BEFORE SURGERY

• MANAGEMENT OF COMMON DUCT STONES DISCOVERED DURING SURGERY

The following sections are included:

• MINILAPAROTOMY

• SUBCUTANEOUS WIRING AND LIFTING

• TROCARING

• OPERATIVE PROCEDURE

The following sections are included:

• MINILAPAROTOMY

• SUBCUTANEOUS WIRING AND LIFTING

• TROCARING

• OPERATIVE PROCEDURE

Laparoscopic surgeries of the solid intraabdominal organs, i.e. spleen, liver and pancreas are also being undertaken at many medical institutions.

Indication for laparoscopic splenectomy is limited. Laparoscopic approach of splenectomy is being practised in some institutions in cases of rather small spleen without hemorrhagic tendency as in hereditary spherocytosis. However, enlarged spleen with hemorrhagic tendency is hard and difficult to hold with the graspers or even to pull with the retractors, hence difficult to remove laparoscopically. Dissection of the pedicles is then extremely difficult and dangerous. Furthermore, the enlarged spleen allows very little space for manipulation and heavy bleeding may occur from extremely friable spleen…

The following sections are included:

• THORACOSCOPIC SURGERY by T. Kohno

• UROLOGICAL SURGERY

• GYNECOLOGICAL SURGERY

• SURGICAL EMERGENCY

• PEDIATRIC SURGERY by K. Yokomori

• PLASTIC SURGERY by S. Kobayashi and K. Ohmori

The following sections are included:

• References

• List of Suggested Reading

• Index