COURSE TITLE: LAPAROSCOPIC SURGERY FUNDAMENTALS

Transcription

1 COURSE INTRODUCTION The number and types of laparoscopic surgeries have increased over the last 15 years. This CE course will review the basics of laparoscopic surgery, the advantages and disadvantages of laparoscopic surgery, the types of laparoscopic surgery commonly performed, and recent advances in the field of laparoscopic surgery. Ver /2006 1

2 COURSE TITLE: LAPAROSCOPIC SURGERY FUNDAMENTALS Author: Lucia Johnson, MA Ed, CLS(NCA), MT(ASCP)SBB Director of Continuing Education National Center for Competency Testing Number of Clock Hours Credit: 4.0 Course # P.A.C.E. Approved: Yes X No Course Objectives Upon completion of this CE module, the professional will be able to: 1. Identify the basic procedure for a laparoscopic surgery. 2. List the basic instruments used in a laparoscopic surgery. 3. State the advantages of laparoscopic surgery as compared to conventional open surgery. 4. Identify the limitations of laparoscopic surgery. 5. List complications of laparoscopic surgery. 6. Describe disease processes that may require correction and/or treatment with laparoscopic surgery procedures. 7. Describe basic laparoscopic procedures for the following: a. liver, gallbladder, and bile ducts b. endocrine c. abdominal wall d. acid reflux e. female reproductive organs f. urinary tract g. spleen h. intestinal tract i. bariatric surgery 8. List basic laparoscopic procedures in order of difficulty from easiest to most difficult. 9. Describe three recent advances in laparoscopic surgery. Disclaimer The writers for NCCT continuing education courses attempt to provide factual information based on literature review and current professional practice. However, NCCT does not guarantee that the information contained in the continuing education courses is free from all errors and omissions. 2

3 WHAT IS LAPAROSCOPIC SURGERY? Laparoscopic surgery, sometimes called band-aid surgery, keyhole surgery, belly button surgery, videoscopic surgery, or minimally invasive surgery, is a surgical technique that revolutionized abdominal surgery in the late 1980s. Laparoscopic surgery involves making a small cut in the skin, the introduction of a harmless gas into the body cavity to create a working space, and the insertion of a rod shaped telescope (laparoscope) with an attached camera into the newly created space. Other long and narrow surgical instruments may be placed into additional small incisions. By using laparoscopic techniques, internal organs can be examined under high magnification with minimal trauma to the patient. In laparoscopic surgery, the surgeon uses a trocar (a narrow tube-like instrument) to gain access to the abdomen. A laparoscope is inserted through the trocar. The laparoscope contains a fiber optic system to provide light to the surgical region, a lens system attached to a video camera to display a magnified view of the surgical region on a monitor, and channels that allow the surgeon to access the organs using long, thin instruments. The gas used to create space in the surgical area is nitrous oxide or carbon dioxide. By viewing the highly magnified operative region on a video monitor, the surgeon is able to examine and perform precise manipulations to remove diseased and/or damaged tissues. WHAT ARE THE ADVANTAGES OF LAPAROSCOPIC SURGERY? There are advantages to laparoscopic surgical procedures when compared to conventional open surgery. Laparoscopic surgery procedures result in smaller incisions. For example, the abdominal removal of the gall bladder results in approximately an 8" incision. Laparoscopic removal of the gall bladder results in four incisions of approximately ½ " in length. The performance of laparoscopic surgery results in less trauma to the skin and muscles. This in turn provides the patient with a faster recovery time, usually days as opposed to weeks. Post-surgical infections occur less often following laparoscopic surgery as compared to conventional open surgery. The decreased infection rate is thought to be because delicate tissues are not exposed to air over long periods. Video magnification of diseased organs, vessels, and other tissues allows the surgeon to perform delicate maneuvers that minimize trauma to these structures and result in less post-operative pain for the patient. Blood loss during laparoscopic surgery procedures is less when compared to conventional open surgery. 3

4 WHAT ARE THE LIMITATIONS OF LAPAROSCOPIC SURGERY? Listed below are the primary limitations of laparoscopic surgery. Laparoscopic surgery cannot be performed on everyone. Pregnant women, obese individuals, and/or patients with extensive scar tissue from previous surgical procedures may not be candidates for some types of laparoscopic procedures. Surgeons must take time to learn how to perform laparoscopic surgery. Many techniques are highly specialized and cannot be learned during a weekend or even during a weeklong training course. Many training programs for general surgery do not provide enough training for their graduates to perform the more advanced laparoscopic procedures. Some hospitals do not offer many laparoscopic surgery procedures due to the expensive equipment needed to perform it. The image transmitted by the laparoscope to the video monitor is a two dimensional image. For some surgeons, this is a major limitation due to poor depth perception. In laparoscopic surgery, the hand of the surgeon cannot be introduced to move organs away from the actual surgical area. Some physicians find this to be a disadvantage. The restricted vision, the necessity of delicate hand-eye coordination, a limited work area, and lack of hands on feeling may increase the damage to surrounding tissues, either accidentally or due to the difficulty of the procedure. WHAT ARE THE COMPLICATIONS OF LAPAROSCOPIC SURGERY? As with conventional open surgery, laparoscopic surgery procedures carry the risk of complications. Most studies demonstrate that the complications of laparoscopic surgery are minor and occur with a frequency of 1% - 5%. Infection is the most common complication seen after laparoscopic surgery. This complication is not related to the laparoscopic technique itself but depends on the infection control practices of the operating room environment. Other complications are listed below. These complications are not specific to laparoscopic surgery. However, the complications occur with much less frequency than with conventional open surgery. Anesthesia complications such as cardiac arrhythmia and respiratory complications Abdominal wall hematoma Pneumonia Infection Blood clot Hernia Formation of adhesions Blood vessel injury Injury to organs Bleeding 4

5 A common patient complaint unique to laparoscopic surgery is gas bloat. Gas bloat is a short-term problem that occurs because of the harmless gas that is injected to create a working space prior to the insertion of a laparoscope. The abdomen becomes filled with air and the muscles are tightened. Until the gas dissipates, the patient may experience severe pain in the upper chest that is not helped by the use of pain medications. The pain has often been compared to the pain experienced in a heart attack. WHAT ARE THE TYPES OF LAPAROSCOPIC SURGERY? In the late 1880s and early 1900s, several physicians around the world developed endoscopic and laparoscopic techniques. Laparoscopic surgery did not gain acceptance in the United States until the 1960s when gynecologists began using laparoscopic techniques to perform evaluations on infertile women and, paradoxically, to perform tubal ligations. Gynecologists soon began using laparoscopic surgery to perform many gynecological surgeries that previously required a large abdominal incision. The first laparoscopic removal of a gallbladder occurred in Since that time, the use of laparoscopic surgery techniques has grown tremendously. Information on some of the more commonly performed laparoscopic surgery procedures follows. The following two websites offer additional optional information on laparoscopic surgery: Specific information about operative procedures: On the left hand column, scroll down and click on Operative Procedure. A page will open with a list of laparoscopic procedures. Scroll down the list on the web page and click on the procedure you want to learn more about. Pictures of laparoscopic procedures: LIVER, GALLBLADDER, AND BILE DUCTS Liver The liver is located in the upper right-hand side of the abdomen under the ribs. The liver is part of the digestive system and, as such, it produces bile. Bile is a substance that helps carry away waste products and is needed for the breakdown and absorption of dietary fats. The liver has a right lobe and a left lobe. Inside the two lobes is the biliary tree that carries bile from the liver to the intestine. The biliary tree consists of smaller bile ducts that connect to larger bile ducts. Blood enters the liver from the hepatic artery and the hepatic portal vein and leaves the liver from the hepatic vein. 5

6 The four main functions of the liver are listed below. When the liver becomes damaged, all of these functions can be disrupted. purification: removes drugs, poisons, and toxins from the body synthesis: makes proteins that fight infection and stop bleeding storage: stores minerals, vitamins, and carbohydrates that are used for energy transformation: changes food into protein to help build muscles and changes certain medications into a form that the body can use Types of laparoscopic liver surgeries include: removal (ablation) of liver tumors by use of radiofrequency, resection of the liver for metastatic tumors, removal of left lobe of the liver, drainage of liver cysts, and injection of chemotherapy directly into the liver (hepatic artery infusion chemotherapy). Radiofrequency Ablation of Liver Tumors When cancer of the liver occurs, the treatment of choice is to remove the malignant portions. In some patients, surgery is not possible and radiofrequency ablation is a procedure that can be used to kill the liver cancer. This procedure can lead to the patient having an increased survival rate and a higher quality of life. This procedure can be performed laparoscopically using ultrasound. The site of the tumor is located using ultrasound. Electrodes are threaded through the laparoscope into the lesion. The electrode is connected to a radiofrequency generator and an electrical current is sent to the tumor. As the cells are heated, they are destroyed. The body will eliminate the destroyed cancer cells over time. Liver Resection Depending on the location of a tumor in the liver, laparoscopic liver resection (removal) of the tumor can be done. Conventional open liver resection surgery results in one of the longest incisions (24" - 30") utilized in abdominal surgery so laparoscopic techniques are of great benefit to the patient. Laparoscopic wedge resection of the liver: This is an option for tumors that are located on the surface of the liver. These can safely be removed without uncontrolled bleeding. Removal of the Left Liver Lobe The left lobe of the liver consists of a medial segment and a left lateral segment. The left lateral segment is often involved with metastatic disease and may require removal. If the tumor is confined only to the left lateral segment, removal of the tumor provides a cure for the patient. This surgery is called laparoscopic lateral segmentectomy of the liver. 6

7 Drainage of Liver Abscesses Cysts Healthy individuals can develop liver cysts. Liver cysts should only be treated if they are causing significant symptoms such as pain, bleeding, and digestive complaints. It is not recommended that a liver cyst merely be drained, as the cyst will rapidly fill up after the procedure. The treatment should include removal of the wall of the cyst. A laparoscopic technique can be performed that removes part of the wall of the cyst so that the liquid in the cyst can freely drain into the abdominal cavity. The body will then remove the liquid from the abdominal cavity. Injection of Chemotherapy into the Liver An advanced laparoscopic technique can be performed to insert a catheter into the hepatic artery for the purposes of delivering chemotherapy directly to the liver. A pump can be attached to the catheter just under the skin and chemotherapy can begin. Direct infusion of chemotherapy drugs into the liver has many benefits when compared to conventional chemotherapy for liver cancer. These include better response, delayed growth of the tumor, increased survival rates, reduced side effects, and enhanced quality of life. Gallbladder The gallbladder is a pear-shaped organ located on the underside of the liver. Its function is to store bile and empty it into the intestine. The gallbladder is connected to the intestine by a series of bile ducts. The cystic duct is the primary bile duct. The gallbladder is most active after a meal. In some individuals, gallstones form within the gallbladder and build up over a period of time. The stones vary from the size of sand granules to several centimeters in size. The most common symptoms of gallbladder disease are caused by the periodic or continuous blockage of the bile ducts by a gallstone. The gallbladder itself can become filled with stones that lead to infection, chronic inflammation, or acute inflammation of the gallbladder. If a stone blocks the cystic duct, bile can back up into the liver causing jaundice or pancreatitis. Symptoms of gallbladder disease include fever, nausea, vomiting, right upper abdominal pain, heartburn, back pain, and/or jaundice. Laparoscopic removal of the gallbladder is called a laparoscopic cholecystectomy. The surgery begins with the patient laying on his/her back. The anesthesiologist may insert a tube into the stomach to empty it after administering the anesthesia. Several small abdominal incisions are made and the surgeon inserts the laparoscope. The surgeon inserts additional instruments through the other incisions. The bile duct and artery at the base of the gallbladder are identified and closed off using small metal clips. Dye may be injected into the bile ducts and x-rays taken (cholangiogram) for the purposes of identifying the presence of stones in the bile ducts. The surgeon gradually frees the gallbladder from the underside of the liver. Large stones and the bile in the gallbladder are removed, allowing the gallbladder to deflate. The surgeon then guides the deflated gallbladder to an incision site and removes it. The entire procedure takes from one to three hours. 7

8 Sometimes, it is not possible for the surgeon to remove the gallbladder laparoscopically. This is usually due to being unable to see or handle the organs safely. The surgeon then must convert to conventional open surgery for patient safety. Bile Duct Bypass Bile duct cancer, pancreatic cancer, chronic pancreatitis, and injury to the bile duct from cholecystectomy are some of the disorders that can cause a bile duct to narrow. This affects the draining of bile into the intestine and bile accumulates in the blood. The patient becomes jaundiced. In certain patients, a laparoscopic procedure can be performed to allow bile to drain into the intestine thus bypassing the bile duct. A segment of the intestine is brought up to a normal uninjured bile duct and this bile duct is sutured to the intestine. The narrowed bile duct that is not functioning is removed. ENDOCRINE TUMORS Endocrine glands are specialized structures found in different parts of the body. These glands secrete hormones. The presence of benign or malignant tumors is the reason for operating on the endocrine glands. The primary non-sex hormone secreting endocrine glands are the adrenal glands and the pancreas. Both of these organs are located deep in the abdomen and laparoscopic surgery avoids the long and large incisions required in conventional open surgery. Adrenal Gland The adrenal glands are triangle-shaped glands that sit on top of the kidneys. Each adrenal gland is separated into two distinct structures, the adrenal medulla and the adrenal cortex. The adrenal medula is the body s main source of the hormones epinephrine and norepinephrine. In the adrenal cortex, some cells are the source of cortisol, some produce testosterone, and some regulate water and electrolyte concentrations by secreting aldosterone. Diseases of the adrenal cortex include Addison s disease (hypoadrenalism) and Cushing s syndrome (hyperadrenalism). These disorders are generally treated with medications and not surgery. The primary disease of the adrenal medulla is pheochromocytoma, a catecholaminesecreting tumor. (Catecholamines are epinephrine and norepinephrine.) Benign tumors and metastatic cancer can occur in either or both the adrenal medulla and cortex. In the event of metastatic cancer, an adrenal gland would only be removed if it were the only site of metastatic cancer. The adrenal gland may be removed on one side or both sides at the time of surgery depending on the nature of disease. 8

9 Pancreas The pancreas is a small, elongated organ in the abdomen. It is described as having three portions: a head, a body, and a tail. The pancreatic head lies by the second part of the duodenum and the tail extends towards the spleen. The pancreatic duct spans the length of the pancreas and empties into the duodenum at the ampulla of Vater. The common bile duct joins the pancreatic duct at or near the ampulla of Vater. The pancreas has two functions: an exocrine function that produces pancreatic juice containing digestive enzymes and an endocrine function that produces hormones, including insulin. Tumors of the pancreas can be divided into two types: non-functioning islet cell tumors and functional islet cell tumors. Functional Islet Cell Tumors Functional islet cell tumors include insulinomas and gastrinomas. When these tumors are present, the patient can have dramatic symptoms as the tumors secrete hormones that produce side effects due to the excessive secretion of the hormones. Insulinomas produce excessive amounts of insulin. The blood glucose (sugar) levels of a person with this type of tumor are low. Symptoms include tiredness, weakness, tremors, and hunger. Extremely low blood glucose levels can result in psychiatric symptoms. A low blood glucose and a high insulin level confirm the diagnosis of an insulinoma. The tumor is detected by CT scan, MRI scan, or an endoscopic ultrasound. Usually, insulinomas are benign. Gastrinomas produce excessive amounts of gastrin. A patient with a gastrinoma presents with severe recurrent peptic ulcer disease. More than 60% of gastrinomas are cancerous and the tumor eventually spreads to the liver and other parts of the body. Gastrinomas are diagnosed by measuring the levels of gastrin and its response to a hormone called secretin. Laparoscopic Enucleation of Pancreatic Islet Cell Tumors Many insulinomas and gastrinomas are small and often on the surface of the pancreas. These tumors are enclosed in their own lining. An operation called laparoscopic enucleation can be performed to remove this type of tumor. In this procedure, the tumor and lining are removed and the pancreas is left intact. If the tumors are large, surgery that is more complicated is required. Some of these surgeries may be performed using laparoscopic procedures; some require conventional open surgery. The laparoscopic procedures require expertise and not all surgeons may be able to provide this service. These procedures include laparoscopic distal pancreatectomy that is used when the tumor is in the body and tail of the pancreas, laparoscopic central pancreatectomy when the tumor is in the neck of the pancreas, and laparoscopic Whipple operation performed when the patients have chronic pancreatitis, ampullary cancer, and non-functional types of pancreatic cancer. 9

10 Non-Functional Islet Cell Tumors Patients with non-functioning islet cell tumors do not have any symptoms from secretion of pancreatic hormones since the tumor does not secrete any hormones into the blood. These tumors grow for a long time before they are discovered. Most patients experience abdominal pain and jaundice. Some patients do not have symptoms and the disease is discovered when being followed up for some other type of disease such as breast cancer. More than 50% of all non-functioning islet cell tumors are malignant. They are usually diagnosed by CT or MRI scans. Surgical treatment of small non-functional islet cell tumors is the same as for functional islet cell tumors. However, the tumors are often quite large when diagnosed and the more complicated laparoscopic techniques and conventional open surgery must be performed. ABDOMINAL WALL (HERNIA) A hernia is a weakness or tear in the abdominal wall. An organ or fatty tissue pushes the inner lining of the abdominal wall (the outer layer of muscle, fat, and tissue that extends from the bottom of the ribs to the top of the thighs) through a weak area in the abdominal muscles, causing a bulge of the abdominal wall. The area where a hernia occurs may have been weak at birth or it may have been weakened by age, injury, or a previous surgical incision. The bulge can contain fat, intestine, or other tissue. Hernias can be reducible or nonreducible. When the fat or tissue can be pushed back into the abdominal cavity, it is said to be reducible. The hernia will flatten and disappear. When the fat and tissue cannot be pushed back into the abdomen, the hernia is said to be nonreducible. Nonreducible hernias must be surgically repaired because they can contain intestine that can lose it blood supply (called strangulation), causing extreme pain, the blockage of digestion, and even gangrene. The different types of abdominal hernias follow. Epigastric hernia: This type of hernia occurs in the upper to middle part of the abdomen, above the navel. Men are more likely to have an epigastric hernia than women, and the majority occurs in people between 20 and 50 years of age. Umbilical hernia: The type of hernia occurs in the navel. These hernias can occur in babies, children, and adults. Femoral hernia: A femoral hernia occurs in the area between the abdomen and the thigh, and it appears as a bulge on the upper thigh. This type of hernia is more common in women. Incisional hernia: An incisional hernia occurs at the site of an incision from a previous surgery. The surgical scar creates a weakness in the abdominal wall. An incisional hernia can occur months or years after the initial surgery. 10

11 A hernia may cause sharp or dull pain that gets worse when the individual has a bowel movement, urinates, or lifts a heavy object. The pain may worsen when the individual stands for long periods. Aspirin and acetaminophen may relieve minor discomfort. If the intestine strangulates, the individual may have blood in the stool, constipation, fever, severe pain, vomiting, and even shock. When these symptoms occur, emergency surgery is needed. Almost all abdominal hernias can be repaired using laparoscopic surgery techniques. The surgeon makes an incision at the site of the hernia and either moves the contents of the hernia back into the abdominal cavity or removes the contents. The weakened area of the abdominal wall is strengthened by placing synthetic mesh behind the area. The mesh is typically made from polyester or polypropylene. A hernia can develop in anyone. However, hernias are more likely to develop in individuals that have a chronic cough, are obese, pregnant, strain to lift heavy objects, have persistent sneezing (allergy sufferers), or strain during bowel movements. For individuals who have had a hernia repair, recurrence can be prevented by the individual maintaining a healthy weight, exercising the abdominal muscles, eating high fiber foods, and receiving medical treatment for chronic constipation, allergies, or chronic cough. ACID REFLUX (Gastroesophageal Reflux Disease or GERD) The most common symptom of GERD is heartburn. Symptoms can worsen and include regurgitation, choking, and chest pain. Of most concern is the permanent damage that GERD causes the esophagus. Some people who have GERD develop a condition known as Barrett s esophagus. About 5 10% of people with Barrett s esophagus develop cancer of the esophagus. Food travels from the mouth down the esophagus to the stomach. Along the way, food passes through a one-way valve called the lower esophageal sphincter (LES) which is the opening into the stomach. The LES allows food to enter the stomach, and then closes quickly. With GERD, the LES does not close off the top of the stomach and allows food and fluids to wash back, or reflux, into the esophagus. Sometimes the top of the stomach slips through an enlarged LES and results in a hiatal hernia. This makes the GERD worse. A procedure called laparoscopic Nissen Fundoplication treats the reflux by making a new valve mechanism at the lower esophagus as a barrier to reflux. During the procedure, the surgeon raises the liver to expose the junction between the stomach and the esophagus. The procedure recreates the LES by wrapping the very top of the stomach around the esophagus. If a hiatal hernia is present, it is repaired during the procedure. A common post-operative syndrome following Nissen Fundoplication is gas bloat. The new valve created during the procedure may cause resistance to the passage of food causing more air to be swallowed. During a gas bloat episode, which can last up to 3 hours, the patient experiences abdominal distention, nausea, and an increase in flatulence. A soft diet can help prevent this syndrome. Gas bloat occurrences lessen with time. 11

12 HEART One type of heart disease is hardening of the arteries. Hardening of the arteries of the heart causes blockages in the vessels that result in the heart muscle not receiving enough oxygen. Lack of oxygen causes the heart muscles to pump blood ineffectively. Another type of heart disease involves one or more of the four heart valves. Rheumatic fever, birth defects, and hardening of the arteries can cause the heart valves to fail to open and close correctly. Heart blockages can be treated surgically by the use of balloons to open the narrowed arteries and the use of small metal stents to keep the arteries open. Sometimes the narrowed artery needs to be cut out and replaced with a vein from another part of the person s body. This is called bypass surgery. Heart valves can be fixed or replaced with mechanical or animal heart valves. Some people who need heart surgery are candidates for the newer laparoscopic surgery techniques. Individuals who only need one heart vessel bypassed, and those requiring replacement of the aortic or mitral valves may be candidates for laparoscopic cardiac repair surgery. Individuals who are having repeat heart surgery and those requiring the replacement of more than one valve or more than one bypass usually need to undergo more conventional open surgery. FEMALE REPRODUCTIVE ORGANS As discussed earlier, gynecologists were the first surgeons to use laparoscopic surgery techniques. In the beginning, laparoscopic techniques were used for tubal ligation and evaluation of uterine tissues for causes of infertility. Now there are numerous gynecological surgeries performed using laparoscopic techniques. HYSTERECTOMY Hysterectomy is the surgical removal of the uterus and cervix, which can be done with or without removal of the fallopian tubes and ovaries. The indications for a hysterectomy include, but are not limited to, excessive uterine bleeding, uterine fibroids, cancer, disease of the fallopian tubes, vaginal relaxation, uterine prolapse, endometriosis, and chronic pelvic pain. A laparoscopic hysterectomy is performed by making one incision just below the belly button and two smaller incisions near the hipbones. After the laparoscope is inserted and the gas added to create a working space, the uterus is cut away from the blood supply and from the cervix. It is then cut into strips and pulled out of the abdominal cavity. If the cervix, fallopian tubes, and/or ovaries need to be removed, the same procedure is repeated. 12

13 ENDOMETRIOSIS Endometriosis is a condition where endometrial tissue, which normally lines the uterus, grows in other parts of the body. Typically, it grows in the abdominal cavity and most often attaches to the ovaries, fallopian tubes, outer surface of the uterus, intestines, or other abdominal organs. Endometriosis can cause severe pain and can interfere with the ability to become pregnant. Endometriosis can be painful enough for a woman to request a hysterectomy. However, if a woman wants to retain her ability to have children, the endometrial tissue can be removed using laparoscopic surgery. A surgeon can destroy the endometrial tissue by cutting it out, burning it out with a laser, or dissolving it by electrocoagulation. Electrocoagulation uses a high-frequency electrical current that is applied with a metal instrument or needle. OTHER GYNECOLOGICAL LAPAROSCOPIC PROCEDURES Laparoscopic surgery techniques can be used to remove uterine fibroids, correct uterine prolapse, remove adhesions, remove ovaries, resolve tubal pregnancy, and as mentioned before, perform tubal ligations. URINARY TRACT The urinary tract consists of the kidneys, ureters, bladder, and urethra. Laparoscopic surgery techniques have been used to dissolve kidney stones, remove the bladder (for cancer), remove a diseased kidney, remove a kidney for transplantation, treat urinary incontinence, removal of cysts in the kidney, correct a narrowing or kinking of a ureter (pyeloplasty), and remove the prostrate. It is not unusual for a urinary catheter to be left in place for a few days following laparoscopic procedures on the urinary tract. Drainage tubes may also be left in one of the laparoscopic incisions for a few days after surgery. Laparoscopic Cyst Decortication Simple cysts are the most common lesions of the kidney. Symptoms are usually caused by the size of the cyst. The presence of urinary cysts can cause high blood pressure and/or interfere with kidney function. When symptoms develop, single cysts can be aspirated with a needle inserted through the skin and into the cyst. For patients with recurring cysts or cysts that cannot be drained by using a needle, laparoscopic techniques can be used to drain the cysts. If a cyst is thought to be malignant, a biopsy of the cyst wall can be made. 13

14 Laparoscopic Radiofrequency Ablation Tumors of the kidney caused by renal cell cancer can be treated insertion of a radiofrequency probe through one of the laparoscopic tubes. The radiofrequency probe delivers electrical current directly to the tumor, destroying the malignant cells. This technique can also be used on benign tumors. With radiofrequency ablation, the goal is to keep as much of the kidney as functional as possible. Laparoscopic Partial Nephrectomy Some patients with small masses of renal cell cancer cannot be treated by the use of radiofrequency ablation. However, they may be candidates for a laparoscopic partial nephrectomy. In this procedure, the diseased portion of the kidney is removed, leaving some kidney function. Laparoscopic Nephrectomy The removal of an entire kidney may be necessary when the kidney is irreversibly damaged, nonfunctioning, or has widespread renal cell cancer. The use of laparoscopic procedures to remove the entire kidney is now the standard of care and prevents the patient from having an approximate 12" incision that is required for conventional open surgery. In the past, there was concern that the laparoscopic removal of a cancerous kidney could spread tumor cells throughout the abdominal cavity. Laparoscopic nephrectomies have been performed for over a decade and data has shown this is not an issue. The control of renal cell cancer is as successful with laparoscopic nephrectomy as it is with conventional open nephrectomy. Laparoscopic Nephroureterectomy Patients with upper urinary tract transitional cell carcinoma of the renal pelvis or ureter should have both the kidney and ureter removed as well as the cuff of the bladder. This is called a nephroureterectomy. Laparoscopic nephroureterectomy has proven to be a safe alternative to conventional open surgery. For this procedure, three small skin incisions are made. If a pathology evaluation is required, biopsies are taken and sent to the laboratory for a frozen section analysis. If the pathology report indicates that the entire kidney and ureter must be removed, a larger 5 mm 7 mm incision is made and the organs are removed as a whole. Laparoscopic Pyeloplasty Laparoscopic procedures work quite well to correct obstruction or blockage of the ureters. During the procedure, the narrowed or blocked portion of the ureter is cut out and the ureter is reconnected back to the kidney. A small metal stent is inserted to allow healing and drainage of urine from the kidney down to the bladder. 14

15 Laparoscopic Radical Prostatectomy The prostate is a male exocrine gland. It surrounds the urethra just below the bladder. It is located in front of the rectum and can be felt during a rectal exam. The primary function of the prostate is to secrete and store the fluid that makes up one-third of the volume of semen. The prostate is not part of the urinary system. However, the surgeons that generally work on the prostate are urologists. Radical prostatectomy is indicated in individuals with localized prostate cancer. This surgery is the best way to eliminate the cancer. Laparoscopic radical prostatectomy was first performed in the early 1990s. New advances have refined the technique and reduced the length of the surgery. A laparoscopic radical prostatectomy provides the patient with a better convalescence. Urinary Incontinence An estimated 13 million adults of all ages suffer from urinary incontinence. Women account for nearly 85% of the cases. Many of the individuals suffering from urinary incontinence never discuss the problem with their physician. Classification of urinary incontinence follows. Stress incontinence: the involuntary loss of urine during coughing, sneezing, laughing, or exercising Urge incontinence: an abrupt and uncontrollable need to empty the bladder Mixed incontinence: a combination of urge and stress incontinence Overflow incontinence: the involuntary loss of urine from an overfilled bladder without a corresponding feeling or urge to urinate Stress incontinence is best treated with surgery. The other types of incontinence are better treated with prescription drugs. Surgery for stress incontinence involves repairing or lifting the urethra and bladder neck to prevent slippage during straining or sudden body movement. Laparoscopic techniques to connect stress incontinence are as successful as conventional open surgery. SPLEEN The spleen is located in upper left part of the abdomen behind the stomach and just below the diaphragm. The spleen is closely associated with the circulatory system and it functions to destroy old red blood cells, serves as a reservoir of blood, removes debris from the bloodstream, and is a center of activity of the reticuloendothelial system. The spleen can be removed and these functions are taken over by other organs. However, individuals with no spleen are predisposed to certain types of infections. The spleen may need to be surgically removed following abdominal injuries with rupture and hemorrhage of the spleen, in the treatment of certain blood diseases such as idiopathic thrombocytopenia purpura, lymphoma, leukemia, and other similar disorders or in cases of cancer of the spleen. In certain cases, laparoscopic splenectomy is an option for the patient and this technique provides all of the benefits previously discussed. 15

16 INTESTINAL TRACT The intestinal tract includes the small intestine and large intestine. The small intestine is subdivided into the duodenum, jejunum, and ileum. The large intestine is subdivided into the cecum, colon, and rectum. The appendix is also part of the intestinal tract. The intestine is responsible for extracting nutrition from food and absorbing the needed nutrients into the blood. The remaining food materials are made into solid feces and expelled through the rectum. The most common disease of the intestine is gastroenteritis. This is an inflammation of the intestine. It is often caused by bacteria and viruses. Other diseases and disorders of the intestine include polyps, blockage, appendicitis, diverticulosis, diverticulitis, Crohn s disease, ulcerative colitis, irritable bowel syndrome, and cancer. The diseases and disorders of the colon may result in the need to remove a portion of the colon. Laparoscopic surgery can be performed to remove: polyps: tissue growth in intestine; often noncancerous but if they do grow, the chances of them becoming cancerous increases) portions of the colon diseased by cancer: both primary and metastatic cancer of the colon can occur diverticulosis/diverticulitis: diverticulosis occurs when small pouches form on the lining of the colon; diverticulitis occurs when one of the pouches becomes infected, inflamed, and breaks, causing gastrointestinal bleeding inflammatory bowel disease/crohn s disease/ulcerative colitis: conditions usually of an autoimmune origin that cause swelling, inflammation, and sores in the intestine The procedure involves resection (removal of the diseased portion) of the colon and the joining together of the two ends. In the event of colon cancer, surrounding tissue and lymph glands can also be removed laparoscopically. An inflamed appendix (appendicitis) is quite easily removed laparoscopically. BARIATRIC SURGERY Weight loss (bariatric) surgery can potentially cure individuals of numerous diseases including diabetes, hypertension, high cholesterol, sleep apnea, chronic headaches, venous stasis disease, urinary incontinence, liver disease, and arthritis. Bariatric surgery is the only proven method that results in durable weight loss. The first weight loss operations were initially performed in the 1950s at the University of Minnesota. Early types of surgery left the stomach intact and bypassed most of the intestines. These procedures resulted in weight loss because the absorption of calories, proteins, and other nutrients was restricted because the intestines were bypassed. Many patients developed severe life-threatening complications and the procedure had to be reversed. Most procedures in use today result in weight loss because the size of the stomach is reduced and only a small portion of the intestine is bypassed. 16

17 The primary procedures used today are the biliopancreatic diversion (conventional open surgery), gastric bypass (conventional open surgery and laparoscopic), and the laparoscopic adjustable band surgery. LAPAROSCOPIC GASTRIC BYPASS The laparoscopic gastric bypass surgery results in weight loss because the stomach is made quite small and food intake is limited. In addition, part of the small intestine is bypassed, resulting in a limitation of the number of calories absorbed. This procedure is formally named the Roux-en-Y limb of intestine gastric bypass (RYGBP). The procedure works by creating a small pouch in the stomach about the size of a hardboiled egg. The small intestine is divided and brought up to the pouch to bypass the majority of the stomach. Advantages of the laparoscopic gastric bypass include: decreased incision pain, decreased need for narcotics, lower risk of incisional hernia, more rapid return of bowel function, improved postoperative lung function, shorter hospital stay, and quicker return to normal activities and work. The laparoscopic RYGBP has reduced postoperative complications as compared to the conventional RYGBP procedure. However, not everyone is a candidate for laparoscopic RYGBP. Individuals who are not candidates for the laparoscopic approach include patients with extremely high body mass index, patient with multiple previous upper abdominal surgeries, and patients with prior bariatric surgery. LAPAROSCOPIC ADJUSTABLE GASTRIC BANDING The adjustable band procedure was developed in Currently several brands of adjustable bands are available: the LAP-BAND System, the Swedish Adjustable Band, and the Mid-Band. No one system has been proven to be better than another. The United States Food and Drug Administration approved the LAP-BAND System in Laparoscopic banding procedures reduce weight solely through the restriction of food intake. The bands can be adjusted. For example, pregnant patients can have their band expanded to accommodate a growing fetus and patients not experiencing significant weight loss can have their bands tightened. The bands are connected by tubing to a reservoir that is placed under the skin. The reservoir can have saline added to increase weight loss or saline withdrawn to reduce weight loss. The saline is added or removed by entering the reservoir with a fine needle through the skin. 17

18 Laparoscopic gastric banding is considered to be the least traumatic of the weight loss procedures. Gastric banding has a lower risk of complications. Some studies have shown that weight loss with laparoscopic gastric banding is as effective as the RYGBP procedure. However, other studies demonstrate that a substantial number of laparoscopic gastric banding patients require re-operation for long-term complications such as band slippage, inadequate weight loss, and saline port problems. LAPAROSCOPIC SURGERY DIFFICULTY SCALE Surgeons performing laparoscopic surgery train extensively in these procedures. The field of advanced laparoscopic surgery is now a recognized sub-specialty with yearlong training programs to teach surgeons these specialized skills. Following is a ranking of laparoscopic surgery procedures in order of increasing difficulty. Gallbladder removal (easiest) Appendectomy Hernia repair Lap-Band Weight Loss Surgery Nissen Fundoplication Splenectomy Bowel Resection for Colon Cancer Gastric Bypass (most difficult) 18

19 ARE THERE ANY NEW ADVANCES IN LAPAROSCOPIC SURGERY? Surgeons have long recognized the limitations of laparoscopic surgery. Their primary concerns have been inability to have a hands on approach as the abdomen is closed, the two dimensional view of the operative site on the monitor, limitation of the instruments, and the inability to do laparoscopic surgery on some individuals due to the contraindication of using gas to create a working space. The following advances in laparoscopic surgery techniques have begun to address the concerns of surgeons. GASLESS LAPAROSCOPIC SURGERY Harmless gas is added to the patient s abdominal cavity during a laparoscopic procedure to create a working space for the surgeon. The resulting process is called a pneumoperitoneum. This process can cause cardiovascular, renal, and neuroendocrine changes. Some patients cannot be considered for laparoscopic surgery as the presence of the pneumoperitoneum may cause serious problems for the patient. These concerns have lead to the development of a gasless method to create the working space. In the gasless procedure, the abdomen is lifted by a pair of wires that have been placed subcutaneously and held in place with thick sutures. Simultaneous lifting of the wires across the abdomen produces a wide, tent-shaped intra-abdominal space sufficient for most laparoscopic surgeries. Gasless laparoscopy is technically more difficult than conventional laparoscopic surgery and is not presently in widespread use in the United States. More research studies on gasless laparoscopy are in progress with the hopes that this technique will provide patients in which the presence of a pneumoperitoneum would be harmful with an option for laparoscopic surgery. ROBOTICS The Food and Drug Administration (FDA) approved the davinci system (Intuitive Surgical Inc.), the first completely robotic surgery device, on July 11, Surgeons use the device while seated at a computer console and a 3-D video imaging system located across the room from the patient. At the end of the laparoscope are advanced articulating surgical instruments and miniature cameras that are manipulated by the surgeon at the computer console. This system has been used in the United States at specialized hospitals for gallbladder removal. The davinci system is currently being tested in Germany for use in certain cardiac bypass surgeries. Barry Gardiner, MD, Director of the Minimally Invasive and Computer-Enhanced Surgery Department at San Ramon Regional Medical Center (San Ramon, CA) states, The davinci system gives the surgeon back the perspective of being inside the operative field, which was lost with laparoscopy surgery. According to Intuitive Surgical, Inc., the davinci system provides the surgeon with the intuitive control, range of motion, fine-tissue manipulation capability, and a 3-D visualization of an open, conventional surgical procedure, while allowing the surgeon to work through small laparoscopic incisions. 19

20 Another robotic system in the clinical trial process in the United States is the Zeus System. The Zeus System, manufactured/distributed by Computer Motion and Medtronic, consists of three interactive robotic arms placed on the operating table, a computer controller (called Hermes ), and a surgeon console. By using voice commands, the surgeon controls the movements of the one robotic arm that inserts the laparoscope and positions the cameras. This device is called AESOP, short for Automatic Endoscopic System for Optional Positioning. The other two robotic arms are manipulated by the surgeon s controls at the console. In Europe, the Zeus system has been used in clinical trials for coronary bypass, mitral valve replacement, gallbladder removal, and Nissen fundoplication. On an interesting note, in 2001, two doctors in New York, using the Zeus system, removed the gallbladder of a woman in Strasbourg, France. This is the first transatlantic surgery. This surgery can been named the Lindberg Operation in honor of American aviator Charles Lindbergh who was the first person to fly solo from New York to Paris in HAND ACCESS DEVICES The loss of the surgeon s ability to put their hand into the abdomen during traditional laparoscopic surgery has limited the use of laparoscopy for complex abdominal surgery on the bile duct, liver, and pancreas. The GelPort Hand Access Device ( Applied Medical, Rancho Santa Margarita, CA) allows the surgeon to insert his/her hand into the patient abdomen while still maintaining the pneumoperitoneum. The surgeon s hand can be used to remove and/or resect an organ while still maintaining a minimal incision length. Clinical trials are in process with this device and surgeons report that the GelPort adds the physical touch and spatial awareness that was missing from laparoscopic surgery. Other similar hand access devices are in development. 20

21 REFERENCES University of Southern California Department of Surgery. New Advances in Laparoscopic Surgery. University of Southern California Department of Surgery. Robot-Assisted Laparoscopic Surgery Using the davinci System. University of Southern California Department of Surgery. Hepatic Artery Infusion Chemotherapy. University of Southern California Department of Surgery. Laparoscopic Liver Surgery. University of Southern California Department of Surgery. Laparoscopic Liver Resection. University of Southern California Department of Surgery. Radiofrequency Ablation of Liver Tumors. University of Southern California Department of Surgery. Laparoscopic Bile Duct Surgery. University of Southern California Department of Surgery. Islet Cell Tumors of the Pancreas. University of Southern California Department of Surgery. Laparoscopic Surgery for Endocrine Tumors. University of Southern California Department of Surgery. Insulinoma. University of Southern California Department of Surgery. Gastrinoma. 21

22 University of Southern California Department of Surgery. Endocrine Tumors of the Abdomen. University of Southern California Department of Surgery. What is Laparoscopic Surgery? Wikipedia, the free encyclopedia. Laparoscopic Surgery. Business Strategies for Medical Technology Executives. Robotic Surgery: The Future is Now. Applied Medical. GelPort Hand Access Device. Medscape from WEBMD. Laparoscopic Complications and Their Prevention. Laparoscopy Hospital. Abdominal Open Access Technique. Laparoscopic Surgery Center Southern California. Advanced Laparoscopy. American Society for Bariatric Surgery. Brief History and Summary of Bariatric Surgery. 22

23 TEST QUESTIONS LAPAROSCOPIC SURGERY FUNDAMENTALS Course # Directions: Please answer these questions from the information in the article presented. 1. A trocar is a/an. a. laparoscope, a rod-shaped telescope inserted into the abdomen b. narrow tube-like instrument used to gain access to the abdomen c. video camera attached to the end of the laparoscope d. working space created by insertion of gas into the abdomen 2. All of the following are advantages of laparoscopic surgery EXCEPT. a. faster recovery time b. increased infection rate c. less blood loss d. smaller incisions 3. General limitations of laparoscopic surgery include. a. not everyone may be a candidate b. not all physicians are skilled in all laparoscopic techniques c. it is too hands off for some surgeons d. all answers are correct 4. Complications following laparoscopic surgery occur with less frequency than with conventional open surgery. a. True b. False 5. Complications that may follow laparoscopic surgery include all of the following EXCEPT. a. infection b. hernia c. lactose intolerance d. pneumonia 6. Studies demonstrate that complications of laparoscopic occur with a frequency of. a. 1% 5% b. 5% - 10% c. 11% - 15% d. 16% - 20% 23