Concise Review for Primary-Care Physicians

Transcription

1 Concise Review for Primary-Care Physicians Laparoscopic Surgical Procedures JOHN H. DONOHUE, M.D. Therapeutic laparoscopic surgical procedures have rapidly become well established. Two commonly stated advantages are decreased postoperative pain and shortened hospitalization and recovery times in comparison with an open surgical procedure. Currently, laparoscopic cholecystectomy is the procedure of choice for most patients with symptomatic gallstones, and many stones in the common bile duct can be retrieved by laparoscopic techniques. Laparoscopic appendectomy is a reasonable alternative with improved diagnostic capabilities in comparison with open appendectomy. Laparoscopic antireflux procedures, bowel resections, and repair of inguinal hernias are being performed in ever-increasing numbers; however, long-term results for these procedures are needed and are unavailable at the present time. Various diagnostic and palliative procedures can be done with use of laparoscopic techniques; they provide effective management with minimal perioperative morbidity. Solid organ resections can be safely undertaken laparoscopically in selected patients in whom the target organ is not massively enlarged. Currently, the indications for laparoscopic operations continue to broaden; however, long-term evaluation of laparoscopic surgical results and further improvements in technique and instrumentation are necessary before the appropriate and complete spectrum of laparoscopic surgical procedures will be realized. (Mayo Clin Proc 1994; 69: ) Although laparoscopy was first described at the beginning of the 20th century, this procedure was generally ignored until recently. Before the advent of laparoscopic cholecystectomy 7 years ago, laparoscopy was seldom used except by gynecologists for simple pelvic procedures (such as tubal ligation, lysis of adhesions, and ovarian cystectomy) and a small group of surgeons who practiced diagnostic laparoscopy. With the demonstration that laparoscopic removal of the gallbladder was feasible and safe, the development of therapeutic laparoscopy, which had been slow and concentrated in a few medical centers, became a worldwide frenzy of activity to pursue the performance of a wide variety of abdominal surgical procedures. In this article, the current status of these revolutionary changes will be reviewed, and individually established and accepted laparoscopic operations performed by general surgeons will be highlighted. In addition, the general criteria for selection of patients and the indications for and shortcomings of laparoscopy will be discussed. Gynecologic laparoscopic procedures will not be addressed in this review. INDICATIONS Numerous intra-abdominal procedures can now be performed laparoscopically. The laparoscopic approach should From the Division of Gastroenterologic and General Surgery, Mayo Clinic Rochester, Rochester, Minnesota. Address reprint requests to Dr. J. H. Donohue, Division of Gastroenterologic and General Surgery, Mayo Clinic Rochester, 200 First Street SW, Rochester, MN be considered for these operations if ( 1 ) the same or a similar procedure can be performed as would be done with a laparotomy, (2) the surgical team has sufficient experience and skill to complete the operation with good results, and (3) the laparoscopic procedure provides some benefit over a conventional procedure. Some laparoscopic operations that can be undertaken have no proven advantage over the same open procedure. Certain operative techniques, especially laparoscopic suturing, can be difficult and necessitate special training. In general, laparoscopy can be used for diagnosis, staging of tumors, and treatment. Specific applications will be discussed in detail under Surgical Procedures. For therapeutic procedures, diminished postoperative pain and shortened times for hospitalization and recovery are the most commonly stated advantages of a laparoscopic over an open procedure. The ease of performing a laparoscopic procedure should not alter the indications from those accepted for an open operation. The magnitude of these benefits must be weighed against longer operative times, higher equipment costs, and potentially more common or severe complications. Even the occasional occurrence of a severe complication, which would rarely or never be associated with a conventional procedure, should dampen enthusiasm for laparoscopy and prompt réévaluation of the laparoscopic operation. Cosmesis, related to limited abdominal incisions, should not be a compelling reason to perform a procedure laparoscopically. Laparoscopy should be undertaken when the diagnosis of an acute intra-abdominal event may be amenable to Mayo Clin Proc 1994; 69: Mayo Foundation for Medical Education and Research

2 Mayo Clin Proc, August 1994, Vol 69 LAPAROSCOPIC SURGICAL PROCEDURES 759 laparoscopic management (that is, pain in the right lower quadrant of the abdomen in a young woman) or will not benefit from laparotomy (such as diffuse visceral necrosis from vascular occlusion). Laparoscopy can provide valuable staging information in patients with malignant lesions not likely to be palliated surgically. Minute peritoneal and hepatic metastatic lesions or limited malignant ascites can be readily detected by laparoscopy; thus, an unnecessary celiotomy can be avoided. SELECTION OF PATIENTS Tolerance of General Anesthesia. Except for simple diagnostic laparoscopic procedures, general anesthesia is conventionally used. Regional anesthesia, including epidural and spinal blocks, can be used in selected patients, but discomfort from peritoneal distention and manipulation may necessitate heavy sedation or conversion to general anesthesia. Because of the usual requirement for general anesthesia, the patient must be sufficiently fit to tolerate mis procedure. Often, patients with a major cardiovascular or respiratory disease can safely tolerate a laparoscopic procedure, but the anesthesiologist must pay particular attention to the effects of increased abdominal pressure and absorption of carbon dioxide caused by the pneumoperitoneum. In general, a patient considered an acceptable anesthetic risk for a conventional operation should be an equally good (or better) candidate for the same procedure done laparoscopically. Transperitoneal Access. -The second consideration for selection of patients is the transperitoneal access to the operative field. Body habitus is of minimal importance in this regard. In fact, morbidly obese patients may be more easily treated for some conditions laparoscopically than conventionally, if instruments long enough to traverse the abdominal wall are available. Intra-abdominal adhesions, from previous surgical or radiation therapy, and acute or chronic inflammation constitute considerable problems for laparoscopic surgeons. If previous open procedures have shown that dense fibrous adhesions are present at the operative site, laparoscopy should not be considered. Although peritonitis and multiple previous surgical procedures around the prospective operative field can make laparoscopic operations difficult or impossible, the feasibility of a laparoscopic surgical approach should at least be assessed before laparotomy is done. To attempt laparoscopy will be far more rewarding than to be surprised at celiotomy by the paucity of adhesions. Visualization can also be hampered intraoperatively by enlarged organs most commonly, the distended bowel or the gravid uterus. Because of concerns about teratogenesis, elective laparoscopic procedures should be avoided during the first trimester of pregnancy. Emergency laparoscopic procedures are associated with no known increased risk to fetus or mother in comparison with an open surgical procedure. Because of uterine size, laparoscopy,may be technically impossible near term. Type of Procedure. The last critical factor in the selection of patients relates to the specific laparoscopic procedure proposed. Laparoscopic surgical procedures should follow the same principles as open abdominal operations. The management of large solid neoplasms laparoscopically is generally contraindicated if an extirpative procedure is to be considered curative, because of problems in mobilizing and extracting the tumor. Large incisions are necessary for massive tumors, whether mobilized by laparoscopic or by open techniques. The limited access by laparoscopy in these situations imposes unwarranted risks of hemorrhage and other complications. If the procedure cannot be done appropriately with minimally invasive techniques because of the necessary manipulations, the individual circumstances found preoperatively or intraoperatively, or the surgeon's laparoscopic skill level, laparotomy is indicated. Fortunately, if difficulty arises during a laparoscopic procedure, celiotomy can be done. At no time should conversion to an open surgical procedure be regarded as a complication when an operation cannot be appropriately and safely completed laparoscopically. SURGICAL PROCEDURES Biliary Tract Operations. In most general surgeons' laparoscopic practices, laparoscopic cholecystectomy is the main procedure performed. Patients who undergo this procedure should have symptomatic gallstones and a preoperative assessment for symptoms and signs of biliary tract disease, including biliary ultrasonography and determination of serum levels of bilirubin, alkaline phosphatase, and hepatic transaminases. Almost all uncomplicated cases of chronic cholecystitis can be treated by laparoscopic cholecystectomy. Although the performance of routine versus selective operative cholangiography is a matter of surgeon preference, all patients who are suspected of having choledocholithiasis, whose anatomy is unclear intraoperatively, or who have a suspected bile duct injury should undergo operative cholangiography, preferably with high-quality fluoroscopic equipment. Although early reports of common bile duct injury rates of 0.5% or more (in comparison with 0.1 to 0.2% for open cholecystectomy) were not unusual, the frequency of these disastrous complications seems to be declining rapidly. 13 Most likely, better results are attributable to increased surgical experience and improved judgment rather than widespread use of routine cholangiography. Many patients with acute cholecysitis can be managed laparoscopically by experienced surgeons, but some patients still require laparotomy when the gallbladder cannot be dissected free, the adjacent structures cannot be delineated, or the gallbladder has ruptured or is too friable to handle

3 760 LAPAROSCOPIC SURGICAL PROCEDURES Mayo Clin Proc, August 1994, Vol 69 laparoscopically. Once patients with acute biliary pancreatitis have resolution of the pancreatitis, laparoscopic cholecystectomy can usually be done (preferably during the same hospitalization). Persistent pancreatitis in this setting should be managed initially with endoscopie retrograde cholangiography to evaluate for and extract any stone impacted at the ampulla of Vater. In general in patients with acute cholangitis, the best approach is endoscopie biliary decompression preoperatively and subsequent laparoscopic cholecystectomy to eliminate the risk of further gallstonerelated complications. Choledocholithiasis without acute complications can be managed by endoscopie extraction of stones, transcystic duct laparoscopic removal, and laparoscopic or open choledochotomy. The ideal therapy should ensure the highest rate of success with the least morbidity. In a medical center, the preferred management must be most dependent on the levels of expertise locally available for each of these techniques. Transcystic duct explorations are of limited value for extracting stones proximal to the cystic duct-hepatic duct confluence, and large stones cannot always be removed without special stone-fragmenting equipment. For laparoscopic choledochotomy, the surgeon must be facile with laparoscopic suturing techniques, but the success rate in clearing the common bile duct of stones is high. If common duct stones are found at laparoscopy but cannot be retrieved, the surgeon can proceed to open ductal exploration, attempt endoscopie retrieval postoperatively, or observe the patient, depending on individual circumstances. Multiple large stones and complex problems most often will be treated by an open operation, whereas small stones, especially in patients with a small common bile duct, are better treated endoscopically or by observation. 2 4" 6 Gastrointestinal Procedures. Several reports have described good early results with laparoscopic antireflux procedures most commonly, laparoscopic Nissen fundoplication Laparoscopic suturing and advanced operative skills are necessary to fix the fundal wrap in place. The indications for a laparoscopic gastroesophageal reflux operation should be identical to those for an open surgical procedure. Patients should have severe symptomatic reflux or anatomic changes related to this condition. The Nissen procedure cannot be done laparoscopically in patients with appreciable shortening of the esophagus. The hospital stay and recovery time are decreased in comparison with open reflux procedures, and short-term symptomatic and physiologic results (including restoration of a lower esophageal sphincter mechanism and decreased acid reflux) are excellent; however, the long-term durability of this procedure remains unknown. Because peptic ulcer disease is an increasingly uncommon problem, the results from laparoscopic surgical treatment of this condition are limited. Laparoscopic omental patching and peritoneal irrigation are effective treatment for a perforated duodenal ulcer. Severe hemorrhage from peptic ulcer disease not controlled endoscopically cannot reliably be managed laparoscopically at present and remains an indication for open surgical treatment. Definitive elective treatment for recalcitrant or complicated ulcer disease can be done laparoscopically with truncal vagotomy plus drainage or resection, posterior truncal vagotomy plus anterior seromyotomy, or proximal gastric vagotomy The declining frequency of peptic ulcer disease and the trend toward antibiotic plus bismuth therapy for Helicobacter pylori involvement will likely limit future experience with laparoscopic treatment. Gastrectomies for benign and malignant disease have been reported, but the benefits are uncertain, and the risks of inadequate treatment for early-stage carcinoma are currently unknown. Further experience should provide a better understanding of the indications for and the limits of laparoscopic gastric resections. Laparoscopy for suspected appendicitis is a straightforward procedure that has special benefit in young women in whom pelvic inflammatory disease or other nonsurgically treated conditions are often found at exploration. In at least one randomized prospective study in which open and laparoscopic appendectomies were compared, no significant benefit, as determined by postoperative pain, duration of hospitalization, and time to return to work, was noted for the laparoscopic procedure (in fact, the operative time was longer for laparoscopic than for open appendectomy in that study)." Although laparoscopic appendectomy is simple to perform, the benefits of shorter hospital and recovery times (as noted with laparoscopic cholecystectomy) are not evident for many patients. Both open and laparoscopic appendectomies are reasonable options for children and men with suspected acute appendicitis. All types of colon and rectal resections for both benign and malignant disease have been completed with use of laparoscopic techniques. The time needed for resumption of bowel function and the duration of hospitalization seem to be shorter than for open surgical resections, but no randomized study has yet been reported. 2 9 For patients with cancer of the large intestine, adequate bowel margins and removal of mesenteric lymph nodes can be achieved, but reports of tumor implantation in the laparoscopic incisions have caused considerable concern. Although palliative laparoscopic colon resection will effectively decrease postoperative pain and accelerate the return to normal activity, curative resections should currently be undertaken with caution. A randomized trial to compare the results of open and laparoscopic colectomy for carcinoma is planned. Complicated cases of diverticulitis with dense adhesions, abscess cavities, and fistulas present many obstacles to laparoscopic resection,

4 Mayo Clin Proc, August 1994, Vol 69 LAPAROSCOPIC SURGICAL PROCEDURES 761 and these complex problems are still usually better approached by open surgical techniques. Patients with uncomplicated, symptomatic colonie diverticulitis should be considered for laparoscopic treatment, as should patients with colonie volvulus, rectal prolapse, and, in some cases, inflammatory bowel disease. Small bowel resection, intubation, and placement of a gastrostomy tube (when the obstructed esophagus prevents endoscopie placement) are miscellaneous laparoscopic gastrointestinal procedures that have been reported and have benefits over traditional techniques. The surgical literature contains case reports of cystogastrostomies for pancreatic pseudocysts (termed an "endoluminal surgical technique" because it is performed through the lumen of the stomach), small hepatic resections, and liver cyst fenestrations, as well as limited pancreatic resections. At least two pancreatoduodenectomies have been successfully completed laparoscopically, but this procedure currently represents a technical tour de force and has no demonstrable advantages over a traditional operation. Additional experience must be accumulated to justify the regular performance of many major gastrointestinal procedures laparoscopically. Repair of Inguinal Hernia. No commonly performed general surgical procedure has more technical variations than inguinal hemiorrhaphy. Various laparoscopic approaches have been described, but most practitioners of these operations advocate a tension-free repair in which a piece of nonabsorbable prosthetic mesh is placed in the preperitoneal space usually by a transabdominal approach but in some instances by using an extraperitoneal technique. Early results indicate a 1 to 2% recurrence rate, but the limited patient follow-up to detect both failure to repair the defect and other long-term complications remains a shortcoming of this operation. The risk of abdominal injury or postoperative intestinal obstruction from adhesions is unique to transabdominal laparoscopic hernia repair and must be minimized if this approach is to be a suitable option. 12 Many surgeons reserve laparoscopic hemiorrhaphy for recurrent or bilateral hernia because this approach avoids previous scar tissue and does not place tension on the repairs. Because a large piece of prosthetic mesh covers the hernia (the sites of direct, indirect, and femoral hernias are generally reinforced by the prosthesis), patients may resume normal activities as soon as they are comfortable postoperatively. Some reports describe subjective, but not objective, data for less postoperative pain than with conventional hemiorrhaphy procedures. Because of the unique risks and the absence of long-term results, laparoscopic hemiorrhaphy is not routinely preferred for uncomplicated, initial hernia repairs, nor should it be used in the pédiatrie population. Ideally, a prospective comparative study of laparoscopic and open tension-free hernia repairs will be undertaken to determine which approach is preferable for this common surgical problem. Miscellaneous Abdominal Procedures. Several solid organ resections, including splenectomy, adrenalectomy, and nephrectomy, have been undertaken laparoscopically In general, affected patients have been carefully selected so that the target organ is not massively enlarged and, most often, has been involved by a benign process. Because of the limitations of removing a large specimen (a tissue blender or fragmentation of the specimen is used to overcome this limitation, but these procedures preclude histologie evaluation of an intact specimen) and the potential spillage of malignant cells, open surgical techniques are preferred for locally advanced malignant tumors removed for curative intent. Diagnostic and staging laparoscopic procedures have increasingly been used since the advent of therapeutic laparoscopic general surgical techniques. For patients with intraabdominal malignant tumors that (1) have a high probability of peritoneal or hepatic metastatic involvement undetectable with computed tomography or other noninvasive tests and (2) do not necessitate laparotomy for palliation, laparoscopy can readily detect small metastatic lesions from which biopsy specimens can be easily obtained, and unnecessary celiotomy can be avoided.' 4 Biopsy samples of intra-abdominal lymphomas can be both histologically typed and fully staged. The limited incisions and rapid patient recovery (days rather than weeks) expedite the initiation of nonsurgical treatment. Certain surgical groups have extensive laparoscopic experience in pelvic and retroperitoneal lymph node dissections for staging and treating genitourinary malignant lesions. When done properly, this laparoscopic procedure is comparable to an open nodal dissection, but considerable skill and meticulous technique are necessary. Some palliative procedures for malignant obstructions, including gastric (gastrojejunostomy), biliary (cholecystoenterostomy), intestinal, and colonie bypass or ostomy formation, can be done laparoscopically. 2 ' 5 In patients without curative treatment options and expected survival of months or years, these procedures may relieve symptoms and provide durable improved quality of life. Development of combined approaches with endoscopie, radiographie, and laparoscopic techniques should broaden the applications and improve the results for these palliative procedures. CONCLUSION The availability of laparoscopic cholecystectomy prompted the development of other minimally invasive surgical procedures. Although various laparoscopic abdominal procedures have been reported in the literature, limited experience and follow-up preclude definite comment on the applicability and preference for many of these operations. Laparoscopic surgical procedures have specific shortcomings and indica-

5 762 LAPAROSCOPIC SURGICAL PROCEDURES Mayo Clin Proc, August 1994, Vol 69 tions that will likely change with time. Currently, most patients with stone disease of the biliary tract, as well as many patients with severe symptomatic gastroesophageal reflux, suspected appendicitis, benign colonie disease that necessitates resection, or recurrent inguinal hernia, should be considered candidates for a laparoscopic operation. Diagnostic, staging, and palliative laparoscopic procedures should be used whenever indicated. At present, laparoscopic oncologic surgical procedures, particularly for malignant tumors of the large intestine, should be undertaken cautiously in patients with localized disease. The indications for laparoscopic operations for cancer and other more infrequently 10. performed laparoscopic procedures will become ap- parent during the next few years as increased experience and longer follow-up become available. 12. REFERENCES 1. Holohan TV. Laparoscopic cholecystectomy. Lancet 1991; : Soper NJ, Brunt LM, Kerbl K. Laparoscopic general surgery. N EnglJMed 1994;330: Southern Surgeons Club. A prospective analysis of 1518 laparoscopic cholecystectomies. N EnglJMed 1991;324: Petelin JB. Laparoscopic approach to common duct pathology. Am JSurg 1993; 165: Phillips EH, Carroll BJ, Pearlstein AR, Daykhovsky L, Fallas MJ. Laparoscopic choledochoscopy and extraction of common bile duct stones. World JSurg 1993;17:22-28 van der Hul RL, Plaisier PW, Hamming JF, Bruining HA, van Blankenstein M. Detection and management of common bile duct stones in the era of laparoscopic cholecystectomy. Scand J Gastroenterol 1993;28: Cuschieri A, Hunter J, Wolfe B, Swanstrom LL, Hutson W. Multicenter prospective evaluation of laparoscopic antireflux surgery: preliminary report. Surg Endosc 1993;7: Weerts JM, Dallemagne B, Hamoir E, Demarche M, Markiewicz S, Jehaes C, et al. Laparoscopic Nissen fundoplication: detailed analysis of 132 patients. Surg Laparosc Endosc 1993;3: Monson JR. Advanced techniques in abdominal surgery. BMJ 1993;307: Mouiel J, Katkhouda N. Laparoscopic vagotomy for chronic duodenal ulcer disease. World JSurg 1993;17:34-39 Täte JJ, Dawson JW, Chung SC, Lau WY, Li AK. Laparoscopic versus open appendicectomy: prospective randomised trial. Lancet 1993; 342: Macintyre IM. Laparoscopic herniorrhaphy [editorial]. Br J Surg 1992;79: Gagner M, Lacroix A, Boite E, Pomp A. Laparoscopic adrenalectomy: the importance of a flank approach in the lateral decubitus position. Surg Endosc 1994;8: Fernandez-del Castillo C, Warshaw AL. Laparoscopy for staging in pancreatic carcinoma. Surg Oncol 1993; 2(Suppl l):25-29 Nathanson LK. Laparoscopic cholecyst-jejunostomy and gastroenterostomy for malignant disease. SurgOncol 1993;2(Suppl 1):19-24 Questions About Laparoscopic Surgical Procedures (See article, pages 758 to 762) Note: One or more answers may be correct. 1. Which of the following is not a possible indication for a laparoscopic surgical procedure: a. Procedure is comparable to an open operation b. Available surgeon has sufficient skill to perform the procedure c. Laparoscopic procedure offers benefits over conventional operation d. Patient recovery and resumption of normal activities will be expedited e. Tissue manipulation and suturing will be simplified 2. An absolute contraindication to use of laparoscopic techniques is: a. Morbid obesity b. Moderate respiratory compromise c. Second trimester of pregnancy d. Limited adhesions around the operative site e. Inability to tolerate anesthesia The following is not a candidate for laparoscopic cholecystectomy: a. Patient with biliary pancreatitis b. Patient with insulin-dependent diabetes and asymptomatic cholelithiasis c. Patient with chronic biliary colic d. Patient with symptomatic gallstones and choledocholithiasis detected on ultrasonography e. Patient with gallbladder polyps noted on ultrasonography 4. Which of the following procedures should not currently be performed laparoscopically: a. Repair of inguinal hernia b. Colon resection for benign disease c. Radical pancreatoduodenectomy d. Proximal gastric vagotomy e. Common bile duct exploration 5. Currently, the major shortcoming of several laparoscopic procedures is: a. Inability to perform the procedure routinely b. Postoperative complications c. Lack of long-term follow-up d. Surgeon reluctance to undertake the operation e. Instrument costs Correct answers: ο-ς a> q-ς 3i 3\