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Lesser catabolic response. Lower levels of insulinlike growth factor and more modest increases in counter -regulatory hormones (cortisol, catecholamines) are seen after laparoscopic cholecystectomy than in open cholecystectomy.

Attenuation of the inflammatory response. Compared with open surgery, laparoscopy results in smaller increases in interleukin-6 (IL -6) and C-reactive protein (CRP) levels and less elevation of the erythrocyte sedimentation rate (ESR).

Less cell -mediated immunosuppression (as measured by lymphocyte proliferation) occurs after laparoscopy than after laparotomy. Total lymphocyte counts are higher and better preservation of delayed - type hypersenstivity is seen after laparoscopic procedures.

It is hypothesized that the lesser degree of immunosuppression seen during some laparoscopic procedures may result in fewer postoperative complications and improved outcomes after cancer surgery, such as a lower incidence of local recurrence or systemic metastases. However, the effect of laparoscopy on tumor biology in humans is complex and poorly understood. In fact, some research suggests that a carbon dioxide pneumoperitoneum is potentially harmful due to local immunosuppression from impaired macrophage function in the peritoneal cavity. It is not possible to draw any definitive conclusions about the effects of laparoscopy on tumor biology in humans at the present time.

I Complications

General morbidity and mortality. The overall mortality rate and incidence of major complications after laparoscopic procedures is similar to that seen with open procedures. The types of complications are similar as well.

A wound infection rate of 0.1%–2% is acceptable in “clean” surgical wounds and should be comparable to wound infection rate of the open technique for any specific procedure. Wound infection rates during laparoscopic intestinal surgery are higher, especially in the larger extraction incision used to remove the specimen (10%–15%).

Complications specific to laparoscopy. A few complications seen after laparoscopic procedures are due specifically to laparoscopic techniques or instrumentation and are therefore not seen during open procedures. These include:

Complications due to needle or operating port insertion:

Abdominal wall vessels or nerves may be injured due to direct trocar laceration in about

1%–4% of cases. Abdominal wall hematomas may occur as well. Avoiding placement of trocars through the rectus abdominus muscle limits these complications.

Abdominal wall herniae may occur through 10 -mm or larger trocar sites. They usually occur at the umbilicus.

Abdominal organ injury may occur, especially with adhesions from previous surgery. Placement of an orogastric tube and urinary catheter prior to insufflation may decrease the risk of bladder or bowel perforation but does not eliminate the risk of this complication.

Complications due to pneumoperitoneum:

Pneumomediastinum, pneumothorax, or subcutaneous emphysema. These are usually the result of excessive insufflation pressures (>20 mm Hg), though subcutaneous emphysema is common after many routine, uncomplicated laparoscopic procedures.

Decreased cardiac output and cardiac arrhythmia can occur due to compression of intra - abdominal venous return or acidosis from hypercarbia. In rare cases, sudden cardiovascular collapse may occur, usually in patients with prior existing cardiopulmonary disease. These complications are prevented by proper anesthetic monitoring and careful attention to end -tidal CO2 levels.

Postoperative shoulder pain occurs in 10%–20% of patients. It is referred pain from the diaphragm believed to be due to either stretching of the diaphragm by the pneumoperitoneum or direct irritation of the diaphragm by CO2 . The pain resolves spontaneously and causes no long-term morbidity.

Gas embolism may occur due to direct placement of an insufflation needle into a vessel or carbon dioxide flow directly into an open vessel exposed in dissection. This extremely rare complication may be fatal if not recognized and promptly treated.

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Complications due to laparoscopic instrumentation. Examples include thermal or mechanical injury to underlying bowel, blood vessels, or diaphragm from the electrocautery or other thermal energy sources. Fortunately, major bowel or vascular injuries occur in <1% of cases. Mortality is 5% following inadvertent bowel injury during laparoscopy. Visceral injuries may also be caused by excessive traction on organs due to the loss of tactile feedback. These complications almost always require reoperation and may be life threatening if missed. Constant vigilance and a high index of suspicion are necessary to prevent and recognize them.

III Laparoscopic Procedures

A Laparoscopic cholecystectomy

Indications include:

Patients with biliary colic or symptomatic cholelithiasis

Patients presenting with acute cholecystitis

Patients with evidence of biliary dyskinesia or chronic cholecystitis with gallstones

Other conditions: Very large gallstones (>3 cm), gallbladder polyps

Note: Asymptomatic cholelithiasis in diabetic patients is no longer felt to be an indication for cholecystectomy. Cholecystectomy for asymptomatic gallstones in other high-risk groups (organ transplant patients, other immunosuppressed patients) is controversial.

Contraindications

Absolute contraindications: Suspicion of malignancy, uncontrolled coagulopathy

Relative contraindications: Severe gallbladder inflammation (acute or chronic), hepatic cirrhosis, portal hypertension, biliary fistula

Complications

Common bile duct injuries occur four to five times more often during laparoscopic cholecystectomy than with the open technique. The incidence varies from 0.2%–1% , with most estimates around 0.5%. Common bile duct injury is one of the most devastating consequences of laparoscopic

cholecystectomy, producing duct obstruction and jaundice, cholangitis, or peritonitis. This complication requires laparotomy and major biliary reconstruction.

A bile leak may develop from the gallbladder bed or cystic duct stump. Cystic duct stump leaks are most commonly due to a metal clip or tie coming off the duct. Leaks can be difficult to diagnose because they usually occur after discharge and have nonspecific symptoms such as fever, failure to thrive, nausea, vomiting, and abdominal pain. If suspected, the patient should undergo either an abdominal ultrasound or computed tomography (CT) scan to diagnose any fluid collections. If one is present, it usually can be drained percutaneously. This is typically followed by a hydroxy iminodiacetic acid (HIDA) biliary scan and endoscopic retrograde cholangiopancreatography (ERCP) to diagnose the level of leak or obstruction. A biliary drain (internal stent) is also placed in the bile duct to the duodenum to allow free drainage of bile. Most leaks can be controlled by a combination of percutaneous drainage and ERCP drainage. Obstructions are usually surgically repaired, though some partial obstructions can be managed by endoscopic or percutaneous balloon dilation.

A retained common bile duct stone occurs in about 10% of patients with common bile duct stones found during cholecystectomy. Management is the same as for primary common bile duct stones.

The conversion rate to open cholecystectomy ranges from 2%–10%. Factors prompting a laparotomy include any situation that hinders the accurate identification of biliary anatomy such as uncontrolled bleeding, dense adhesions, severe acute cholecystitis, or suspected common bile duct injury.

Management of common bile duct stones. Several generally accepted options are used at present, depending on surgeon preference and available resources:

Preoperative ERCP to clear the common bile duct of stones prior to laparoscopic cholecystectomy

Laparoscopic cholecystectomy, intraoperative cholangiography, and common bile duct exploration during the same procedure

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Laparoscopic cholecystectomy followed by postoperative ERCP to clear the common bile duct

Laparoscopic cholecystectomy followed by ERCP is most commonly performed option today. However, it is preferable to perform laparoscopic cholecystectomy and intraoperative cholangiography with stone extraction if the surgeon is skilled in this technique.

Cholangitis is best treated with endoscopic drainage with ERCP and antibiotics. A laparoscopic cholecystectomy can be performed during the same hospitalization, after resolution of the cholangitis.

Controversies and conclusions

Many studies have compared laparoscopic cholecystectomy with open cholecystectomy.

Laparoscopic cholecystectomy has been demonstrated to be safe and cost-effective when compared with open cholecystectomy and is the procedure of choice in most biliary tract diseases requiring cholecystectomy.

Controversies

The use of intraoperative cholangiography (IOC). IOC is indicated for two reasons: the detection of common bile duct stones and the identification of biliary anatomy. Though some surgeons practice “routine” IOC, most surgeons use IOC “selectively.” Advantages of IOC

include rapid recognition (and thus repair) of biliary injuries and skill development for more advanced biliary tract procedures. Disadvantages include increased operating time and expense. At the present time, there is no compelling evidence that routine IOC decreases the likelihood of common bile duct injury during laparoscopic cholecystectomy.

B Laparoscopic appendectomy

Indications. Laparoscopic appendectomy is technically possible in nearly all patients with suspected acute or chronic appendicitis, including many with perforation and/or abscess. However, it is most useful in the following situations:

Obese patients. Avoids a large open incision and improves visualization

Patients in whom the diagnosis is uncertain. Visualization of the peritoneal cavity and diagnostic accuracy is much better with laparoscopy.

Females of child -bearing age. This group of patients has a 30% likelihood of having some other diagnosis when operated on for suspected acute appendicitis.

Relative contraindications

An appendiceal abscess is best treated by one of two methods: either percutaneous drainage and interval appendectomy several weeks later or open appendectomy and drainage

Known or suspected appendiceal tumors

Complications

In general, the types of complications are no different than those seen with open appendectomy (bleeding, wound infection, intra -abdominal abscess, incisional hernia, cecal fistula or perforation)

The conversion rate to the open technique ranges from 3%–10% and is usually caused by bleeding; abscess or extensive abdominal contamination; or difficulty localizing, exposing, or dissecting the appendix.

Controversies and conclusions

At least 20 prospective, randomized trials have compared open and laparoscopic appendectomy, with several meta-analyses of these data. Laparoscopic appendectomy is as safe and effective as open appendectomy. However, there appear to be specific advantages and disadvantages associated with the procedure when compared with open appendectomy.

Advantages. Most data show slightly shorter hospital stay, lower incidence of wound infection, more rapid resumption of diet, and less postoperative pain.

Disadvantages. Nearly all data show that laparoscopic appendectomy is more expensive and takes longer to perform than open appendectomy. The risk of postoperative intra -abdominal abscess also appears to be greater after laparoscopic appendectomy.

Summary. Laparoscopic appendectomy is considered the preferred approach by most surgeons in obese patients and in those in whom the diagnosis is uncertain. Laparoscopic appendectomy probably offers no benefit in males with an obvious diagnosis of acute appendicitis. It is unclear whether the recovery benefits of laparoscopic appendectomy outweigh

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the higher incidence of abscess formation associated with laparoscopy. Further randomized studies are needed to clarify the cost -effectiveness, diagnostic accuracy, and incidence of postoperative complications of the two procedures.

FIGURE 30-1 Trocar replacement for the laparoscopic hernia repair, rectosigmoid colectomy, and the pelvic lymphadenectomy. (Redrawn with permission from United States Surgical Corporation. Copyright 1992, United States Surgical Corporation. All rights reserved.)

C Laparoscopic inguinal-femoral hernia repair

Indications. Patient selection for laparoscopic inguinal hernia remains controversial. Widely accepted indications for the laparoscopic approach include a recurrent hernia and simultaneous repair of bilateral herniae.

Contraindications

Absolute. Inability to tolerate general anesthesia (open repair can be performed under local anesthesia in most cases), infarcted bowel in the hernia sac (not safe to place mesh in this circumstance)

Relative. Prior bladder or prostate surgery, hernia repair in children

Technique. Laparoscopic hernia repair can be performed from an intraperitoneal or preperitoneal approach.

The intraperitoneal procedure requires general anesthesia and changes an open regional operation into a major abdominal procedure. Dissection in the peritoneal cavity increases the risk of bowel injury, adhesion formation, and postoperative small bowel obstruction. Most surgeons performing laparoscopic hernia repair use some variation of the preperitoneal procedure.

The preperitoneal procedure remains extraperitoneal and avoids these possible complications as well as those of insufflation and pneumoperitoneum. This procedure can be performed with spinal or

epidural anesthesia in some patients, thereby avoiding the consequences of a general anesthetic. Because of its advantages, the preperitoneal approach is recommended. A 1-cm infraumbilical incision is created in the midline. The anterior rectus fascia on the side of the hernia is opened, and the rectus muscle is mobilized laterally. A balloon-dissecting trocar is introduced anterior to the posterior rectus fascia, gently advanced to the pubis in the preperitoneal space, and expanded with 700 cc of saline, opening up the preperitoneal space. A working space is maintained by insufflating carbon dioxide to 8 mm Hg pressure in the extraperitoneal space. Two additional operating ports are placed into the preperitoneal space (Fig. 30 -1). The hernia sac is reduced, and the pubis, inguinal ligament, spermatic cord structures, Cooper ligament, and epigastric vessels are exposed. Polypropylene mesh is then secured with a laparoscopic hernia stapler to

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the pubis, Cooper and inguinal ligaments, and the lateral abdominal wall, completing the repair.

Complications

The risk of recurrent hernia after laparoscopic hernia repair is 1%–5% within the first 5 years of surgery. This is comparable to the recurrence rate after open inguinal hernia repair. Reliable longterm recurrence rates for laparoscopy are not yet known.

Genitofemoral and lateral femoral cutaneous nerve injuries can result in significant postoperative groin and thigh pain. They are usually caused by inadvertent staple placement too close to the nerves. Knowledge of the anatomic courses of these nerves prevents staple applications in these areas.

Adhesion formation from an intraperitoneal repair can lead to small bowel obstruction. The surgeon must be careful when placing the balloon-dissecting trocar. It can easily penetrate the peritoneum, forcing conversion to an intraperitoneal approach and thus the problems associated with that approach.

Injury to bowel, bladder, or major blood vessels. Though rare, these injuries occur more commonly after laparoscopic than open repair.

Controversies and conclusions. Recent large meta-analyses and randomized trials have begun to clarify the role of laparoscopic inguinal hernia repair.

Advantages. Earlier return to normal activity, less postoperative pain and numbness

Disadvantages. Longer operative times, higher risk of rare serious injuries (viscera and vessels)

Summary. Laparoscopic hernia repair can be performed safely and with similar short-term recurrence rates to open hernia repair. The potential advantages of a laparoscopic approach have been offset to some extent by improvements in the open technique, including routine use of prosthetic mesh. More data is needed to determine long-term recurrence rates and cost -effectiveness of the laparoscopic approach.

D Laparoscopic incisional hernia repair

Indications. Any symptomatic abdominal wall fascial defect, asymptomatic defects > 4 cm 2 in area,

“Swiss -cheese” abdomen (multiple small fascial defects)

Contraindications

Absolute. Loss of abdominal domain

Relative. Incarcerated incisional hernias, patients with cirrhosis or portal hypertension, patients with a history of long-term peritoneal dialysis (they may develop a thick inflammatory peel in the abdomen). Also, hernias of the lateral abdominal wall and lumbar region are much more technically difficult than anterior abdominal wall hernias near the umbilicus.

Technique. The abdomen is usually entered laterally, away from the umbilicus, as most incisional hernias involve the midline. Three or four operating ports are placed laterally on one or both sides of the hernia. Lysis of adhesions is usually necessary to visualize the hernia defect. Great care must be taken during this step to avoid injury to underlying organs. There are often additional hernia defects seen during laparoscopy that were not appreciated on physical exam. The size of the hernia defect(s) is measured, and an appropriate-sized piece of prosthetic mesh is chosen. Polytetrafluorethylene (Gore-Tex) is used most commonly. The mesh should be sufficiently large to overlap the edges of the hernia defect by 2–3 cm in all directions. The mesh is rolled and placed into the abdomen, where it is then deployed over the hernia defect and is secured using sutures, metal tacks, or both.

Complications

Recurrent hernia. Initial data show 5%–10% recurrence rates at 1–2 years after surgery.

Seroma. Ten to 20% of patients develop a fluid collection between the nonporous polytetrafluorethylene and the skin. They resolve spontaneously in most cases, but aspiration is occasionally necessary.

Bowel or bladder injury occurs in about 2% of cases. Bowel injuries that go undetected during the original surgery are often fatal.

Infection. Wound infection occurs in about 1.5%–2% of patients. A few cases require removal of mesh.

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Controversies and conclusions. Laparoscopic ventral hernia repair has been demonstrated to be a safe and effective method of repairing abdominal wall hernias. It can be performed in complex surgical patients with moderate morbidity and low short-term recurrence rates. However, data from existing studies are difficult to compare due to heterogeneous patient populations, different surgical techniques, and variable surgeon experience. More data is necessary to determine morbidity, cost -effectiveness, and long-term recurrence rates when compared with open ventral hernia repair.

E Laparoscopic surgery of the esophagus and stomach

Laparoscopic esophageal myotomy. Also known as laparoscopic “Heller myotomy”

Indications. The primary indication is for achalasia of the esophagus, a motor disorder characterized by a hypertensive lower esophageal sphincter and aperistalsis of the body of the esophagus. The procedure may also be performed using a thoracoscopic approach.

Contraindications

Other esophageal motility disorders such as diffuse esophageal spasm or “vigorous” achalasia that require a longer myotomy that must be performed through the chest.

Severe advanced achalasia with “megaesophagus” or “sigmoid esophagus” (this condition usually requires esophagectomy)

Technique. A vertical cut is made through the outer longitudinal and inner circular smooth muscle

layers, taking great care to avoid perforation of the esophageal mucosa. The length of the myotomy should be at least 7 cm , and it is important to carry the incision down onto the stomach wall for 1– 2 cm to completely destroy the lower esophageal sphincter. A fundoplication is often performed with the myotomy because destruction of the lower esophageal sphincter results in symptomatic gastroesophageal reflux in about 20% of patients.

Complications

Inadequate myotomy , resulting in persistent dysphagia after surgery

Esophageal perforation , which may be life threatening if not immediately recognized.

Controversies and conclusions

Most surgeons consider laparoscopic esophageal myotomy the procedure of choice in patients with achalasia. Data shows that the laparoscopic approach has similar efficacy and safety to open esophageal myotomy with advantages in postoperative recovery. Other therapies such as balloon dilatation, botulinum toxin injection, and medical therapy are not effective long-term treatments in most patients. Further studies are needed to define cost - effectiveness and long-term efficacy of the procedure.

Controversies. The main controversy is technical––whether or not to add a fundoplication to esophageal myotomy to prevent gastroesophageal reflux after destruction of the lower esophageal sphincter. Most experienced laparoscopic surgeons add some type of fundoplication to the myotomy, as it adds no significant morbidity to the procedure. However, there is some disagreement and no true consensus regarding this step.

Fundoplication for gastroesophageal reflux disease (GERD)

Indications. Severe gastroesophageal reflux disease, characterized by:

Failure of medical therapy with proton pump inhibitors

Severe nonhealing esophagitis despite aggressive medical therapy

Complications of GERD. Esophageal stricture, recurrent pneumonia or aspiration, severe asthma

Note: Barrett's esophagus is a controversial indication for fundoplication (III E 2e 2b)

Contraindications

Shortened esophagus. Severe long-standing GERD causes fibrosis and shortening of the length of the esophagus. This results in severe dysphagia or inadequate symptom relief after surgery if an esophageal -lengthing procedure is not performed. A laparoscopic approach should be undertaken with caution in patients with a hiatal hernia larger than 5 cm.

Prior laparoscopic fundoplication is considered a relative contraindication, though experienced laparoscopic esophageal surgeons have reported success in this group of patients.

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