Basic principles and techniques of laparoscopic procedures

The safe performance of Laparoscopic Cholecystectomy demands that certain basic principles are to be observed meticulously.

While adopting a new technique "The Principle of learning to walk before one can run" must be kept in mind.

Laparoscopic (minimally invasive) surgery is the fastest growing speciality in the last decade. Like Laparoscopy, no other technique has gained so much popularity, development and has advanced in short period in all surgical specialities and super-specialties. To make the procedure more safe and to avoid complications, morbidity and mortality proper indications and selection of cases and appropriate surgery should be planned. The procedure should be explained to the patient and relatives and proper consent for Laparoscopic / open surgical procedure should be taken.

1. For Laparoscopic procedure, the operating room must be of adequate size, because after keeping the equipment trolley and two instrument trolleys there must be comfortable movement by the staff. It must be fitted with all necessary electrical connections preferably through voltage stabilizer or UPS for better performance of the equipment.
2. Before starting the procedure and putting the patient on the operating table the adjustability and movements of the table i.e. head up & head down tilt, as well as lateral tilt and lithotomy must be checked. Preferably there should be a radiolucent table-top.
3. All equipment and instruments must be well maintained and in working order, should be checked before starting each procedure. Surgeon himself or trained nurse must have basic knowledge of maintenance and trouble shooting during procedure if instrument fails, and should clean the instruments themselves for better life of instruments.
4. Preferably equipment trolley must be made with 5-6 shelves to accommodate all equipments i.e. T.V. Monitor, CCD Camera unit, VCR, light source, Co₂ insufflator, suction-irrigation unit. This way it occupies less floor space in the operating room.
5. Open surgery set should be kept ready on a separate trolley so in case of an emergency, conversion to open surgery is easily done without losing much time.
6. Any surgical procedure is a team -work but laparoscopic procedure is more demanding for teamwork. There must be a regular team (for better co-ordination and good results) includes – Assistant Surgeons, O.T. Nurse, Circulating nurse and technician. All should have a complete knowledge of laparoscopic principles and instruments.
7. In the near future a time may come when it will be possible to perform almost any surgical procedure by minimally invasive surgery but it is mandatory that a surgeon must be well trained for open surgery as well.
8. Bladder and bowel must be empty for good visibility and to avoid injury to structures. For pelvic surgery catheterization and upper abdominal surgery N. G. tube should be passed to keep urinary bladder and stomach empty respectively. For upper abdominal surgery if patient has passed urine before coming to operating room then catheterization is not necessary. Laxatives given the previous night or giving enema may help specially in pelvic surgery.
9. To avoid slipping of the patient in presence of excess tilt, strapping of patient to the table will help.
10. Most convenient position of the patient is supine but lithotomy may be necessary depending upon operation being performed and surgeon's preference.
11. Some surgeons prefer to regularly apply crepe bandages to the legs to avoid D.V.T.
12. There are various positions for surgeons to stand while performing procedures, it is surgeon's preference but surgeon should stand diagonally opposite the organ to be operated and telescope / camera operator may stand side by side. The basic rule is that a surgeon, the field being operated upon and the monitor should be approximately in a straight line. For pelvic surgery right handed surgeon usually stands on left side and left handed surgeon on the right side. For upper abdominal surgery some surgeons regularly use extended lithotomy position and stand in between the thighs of the patient and monitor is kept at the head end of the table. Depending on procedure a second assistant may stand on opposite side and another T.V. monitor may help for better vision.
13. General anesthesia with endotracheal intubation and controlled positive pressure ventilation is a must for most of the laparoscopic procedures so that there will be good relaxation. Some procedures can be done under epidural or local anesthesia.
14. Before starting the procedure all connections are made and checked. Gas and suction-irrigation tubes, camera, light-source and diathermy cables. Two diathermy cables may be required depending upon "Male" or "Female" connection on the instruments. Bipolar diathermy is safer than monopolar diathermy. To cover the camera cable a sterile plastic cover or cloth sheath can be used.
15. Heparinized solution can be kept in a tray for keeping the used instruments so that blood clots will not block and damage the instruments.
16. Before making initial entry head low tilt position should be made. Incision is usually made at the umbilicus. It may be:  
    1. Infraumbilical.
    2. Supraumbilical.
    3. Transumbilical.

Infra-umbilical incision is most commonly used and less risk of injury to great vessels.

Supra-umbilical incision- the advantage is that needle and trocar being automatically directed towards the defect in linea alba at umbilicus but there is risk of injury to great vessels.

Trans-umbilical vertical incision allows easy entry and gives a good cosmetic result.

There are two methods for initial entry:

I.  Closed method – where about 1-1.5cm skin and subcutaneous deep incision is made (linea alba or rectus sheath should not be incised) and through this Veress needle for pneumoperitoneum and primary trocar are inserted.

II. Open method – (Hasson) little larger 2-2.5cms incision is made through all layers, introduction of Veress needle is not required for pneuomoperitoneum and special blunt trocar is used. A purse-string suture is applied through all the layers and tied over the cannula. Some surgeons regularly prefer this technique to the blind technique (closed method).

Advantages – Avoid risk of injury to viscera and vessels in difficult cases and in presence of adhesions.

Disadvantages  – Larger incision is required.

More time is required for initial entry or if there is gas leak                                during surgery.

Gas leak and surgical emphysema, if peritoneum is not included in the purse-string suture.

In suspected adhesions in the lower abdomen, first entry can be through left upper abdomen.

After the incision the abdominal wall below the umbilicus is lifted in the mid line by the surgeon or on both sides by surgeon and assistant. Abdominal swab may be used for proper grip. This gives little safety i.e. umbilicus is lifted up from the great vessels. The Veress needle must be checked for its patency before inserting. The Veress needle is held between the thumb and three fingers and little finger rests on abdominal wall as support and guide. It should be angled and pointed towards the pelvis. As the needle pierces the linea alba and peritoneum the hub moves to resting place. At this stage side to side movements must be free. To test further the position of the needle-

• Push some saline and it should go without any resistance
• Aspiration should not show any gas, blood, intestinal contents or injected saline.
• The syringe is removed and then saline drop test is performed, the abdominal wall is lifted up & the drop will be sucked in due to negative pressure in the peritoneal cavity. This shows that the needle is in.
• The final confirmation is after the insufflation of abdomen with Co₂. The gas tube is connected and insufflation is started with a flow rate of 1-2ltr per/min and intraperitoneal presence of needle can be confirmed:

(a) On electronic insufflator indicator.

(b) Steady flow of gas.

(c) Low pressure in the peritoneal cavity.

(d) Symmetrical distension of abdomen.

(e)Increasing resonance on percussion over  the subphrenic area.

(f)Increasing resistance by the anesthetist.

Intra abdominal pressure should be kept between 12-14mm of Hg.

Some surgeons use gasless laparoscopy where special instrument laparolift is used.

INSERTION OF PRIMARY OR FIRST TROCAR

First or primary trocar is a blind port and should be done with all possible precautions. It must be gripped properly; the index finger should be extended along the shaft towards the tip and the hub of the trocar. Infra umbilical abdominal wall is lifted as for Veress needle and trocar is pushed in with slow rotating movements with constant pressure with the palm. A sudden loss of resistance indicates entry into the peritoneal cavity, which is confirmed by hissing sound of escaping gas

The telescope is now inserted and gas tube is connected. All procedures begin with detailed examination of peritoneal cavity.

Disposable or safety trocars are also available in which as soon as resistance is gone or entered in the peritoneal cavity the sharp tip of trocar will go inside.

Now special trocars are also available where first entry is done under direct vision. The trocar tip is made up of transparent material and it accommodates the telescope so that issue can be entered under vision.

Whatever type of veress needle and trocars are used all the safety measures must be followed.

ADDITIONAL OR SECONDARY PORTS

All secondary or additional ports are inserted under vision i.e. the area must be free from adhesions and no important structure comes in the way. By transilluminating the abdominal wall from inside injury to any veins can be advised while making incisions or pushing trocars. Site of each port should be far enough so that instruments will have free movements.

VISIBILITY

After white balancing, the telescope is inserted in the peritoneal cavity, being it is cold; condensation may occur on the tip and cause blurred vision. This can be prevented by prewarming of telescope in hot saline or by applying antifog, savlon or povidone iodine solution. Drop of the blood on the value of cannula should be wiped. If the blood is smeared over the tip of the telescope can be gently wiped against the liver. If the vision is still not clear telescope should be removed and cleaned and rewarming or a drop of antifog solution should be applied. If blurred vision persists then focusing, monitor and camera must be checked for any fault.

If 30^o telescope is used visibility is better.

Gentle handling of tissue is must at all times to avoid injury and post operative adhesions. Because of long handles of instruments, tissue perception is not as good as in open surgery.

In laparoscopic surgery it is very important that surgeon must be able to recognize anatomical landmarks in peritoneal cavity.

Diathermy must be used very carefully. Tissue must never be cut or cauterized unless seen clearly and noninsulated part of the instrument must be in the field of vision and should not touch any metallic cannula or other instruments. Bipolar cautery is better option.

Before starting a procedure independently a surgeon must be trained well in laparoscopic surgery and must work with a trained team. He must be able to decide when to abandon the procedure for open surgery.

During any surgical procedure it is essential to be able to prevent or control bleeding meticulously. In laparoscopic surgery there is often less bleeding because of:

• Intra-abdominal pressure is higher than venous pressure.
• Due to use of warm irrigation solution.
• View of target tissue is better.
• Proper identification and dissection of vessels is possible.

Ultracision and Lasers are used in laparoscopic surgery.

Different type of ligatures and sutures and knots (intra and extra corporeal knotting) are used for viscera, vessels and repairs.

Various types of clips and staplers are used for different procedures.

Hydro dissection can be used.

Peritoneal lavage should be done to remove blood, fibrin and debris to avoid adhesion formation.

Removal of tissue from the peritoneal cavity should be done under vision and if tissue is big incision may be enlarged. To avoid infection or implantation of ports:

Endobags should be used -

• Cystic lesions are aspirated and removed.
• Solid organs cut in pieces and removed in endobags.

Removal of all instrument and ports must be under direct vision.

Suturing of all incisions are done with delayed absorbable or non-absorbable sutures, including the linea alba.

PATIENT SELECTION AND PREPARATION FOR SURGERY

Preparation for laparoscopic surgery includes.

• Patient selection.
• Patient information.
• Preparation of the theatre.
• Training of all theatre staff.
• Preparation and positioning of the patient.

PATIENT SELECTION

When first starting laparoscopic surgery it is wise to confine yourself to those cases without features indicative of increased technical difficulty.

For laparoscopic cholecystectomy choose thin patients, with functional gall bladders and normal liver function tests.

Avoid those patients who present with the following characteristics until you have gained some experience.

CLINICAL CRITERIA

• Stocky male patients.
• Morbid obesity.
• Previous upper abdominal surgery.
• Cirrhosis and hepatomegaly.
• Inflammatory mass in right hypochond rium (acute).
• Previous severe acute cholecystectomy.
• Previous percutaneous stone extraction / MTBE dissolution.

Ultrasound / Radiological Criteria.

• Gall bladder wall thickness > 4.0 mm
• Non-contracting gall bladder (US).
• Stone load : packed gall bladder, large calcified stones (US).
• Non-functioning gall bladder (XR).

PATIENT INFORMATION

It is very important that all patients undergoing laparoscopic surgery understand that you cannot guarantee to perform their operation laparoscopically – only by the safest method for them at the time of surgery.

That they will have several small incisions.

That even though the incisions are small all operations have associated risks.

They may have post operative shoulder tip pain.

That they may have to stay in hospital longer than expected if things are not straight forward.

The consequences of open surgery, should it become necessary.

THEATRE AND STAFF PREPARATION

The theatre must naturally be able to supply the relevant equipment and instruments for procedure. In addition appropriate instruments should be immediately available to cope with emergency complications such as major bleeding.

Spare bulbs for the light source and a spare gas cylinder should be available. This type of surgery places great reliance on technology. If you can begin your laparoscopic experience in a theatre where everyone is familiar with their part in the proceedings, it will be to your advantage.

PREPARATION OF THE PATIENT

• Anti-embolic stockings.
• Atropine with the premedication.
• Prophylactic antibiotics.
• A standard anaesethesia with appropriate monitoring.
• A urinary catheter is inserted for the duration of the procedure.
• A nasogastric tube is used to deflate the stomach.
• The patient is placed supine (the North American approach). As the patient will be tipped during the procedure appropriate measures to ensure their safety are instituted.