Laparoscopic Surgery - "Keyhole" Surgery
Definitions
Laparoscopy
Laparoscope
Laparoscopic “Port”
Trocar
Laparoscopic Surgery – The Procedure
Advantages of Laparoscopic Surgery
Complications of Laparoscopic Surgery
Complications Specific to Laparoscopic Cholecystectomy – Removal of the Gallbladder
Complications of Laparoscopic and Laparoscopic-Assisted Colonic Surgery
Complications of Laparoscopic Hernia Repair
Definitions
Laparoscopy
Laparoscopic surgery is also known as “keyhole” surgery.
Laparoscopy involves the insertion of a telescope in the abdominal cavity for inspection and possibly treatment of the abdominal organs.
Laparoscope
The laparoscope is the telescopic viewing instrument. In order to slide this into the abdominal cavity a laparoscopic “port” is achieved.
A very small camera is mounted on the end of the telescope and the video picture is displayed on a large television monitor.
Laparoscopic “Port”
The port consists of a cannula (or hollow tube). The cannula usually contains some form of valve mechanism to prevent gas escaping from the abdominal cavity.
Trocar
The cannula is inserted into the abdominal cavity using a sharp pointed spear-like instrument called a trocar.
Laparoscopic Surgery – The Procedure
The first step in performing any laparoscopic procedure is to fill the peritoneal cavity with gas, usually carbon dioxide, to create space in which to operate. Occasionally a Veress needle is inserted into the abdomen to achieve this. This hollow needle has a spring-loaded blunt tip which only retracts to reveal the needle tip when encountering resistance.
The skills required by surgeons undertaking laparoscopic surgery are very different from those employed by a surgeon performing open surgery. The laparoscopic surgeon operates by viewing a large television monitor displaying the laparoscopic image in a magnified, but two-dimensional, form. The direction of the image is remote and displaced from the direction of the instruments.
Advantages of Laparoscopic Surgery
The advantages of laparoscopic surgery include:
- Reduced physical consequences
- Better cosmetic outcome
- Fewer wound complications
- Fewer respiratory complications
- Shorter hospital stay when compared with open surgery
- Earlier return to normal activity when compared with open surgery
Complications of Laparoscopic Surgery
As noted above, the first step in performing any laparoscopic procedure is fill the peritoneal cavity with gas, usually carbon dioxide, to create space in which to operate. Occasionally a Veress needle is inserted into the abdomen to achieve this. This hollow needle has a spring-loaded blunt tip which only retracts to reveal the needle tip when encountering resistance. Ideally, the needle tip will be covered when lying in a cavity. If inserted in an unsafe manner, the Veress needle or the trocar may hit and perforate bowel or major blood vessels (the abdominal aorta and the inferior vena cava).
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Often the injury is recognisable instantly because of the accumulation of blood obscuring the view and a drop in blood pressure. If recognised, immediate repair can be carried out. In other cases when the bleeding occurs but is not seen the problem may not be identified may be delayed until the patient goes into shock from low blood pressure.
Bowel injury may go unrecognised at the initial operation, and may be identified days later as peritonitis or weeks later as abscesses in the abdomen or fistulae (an abnormal passage), and can be fatal.
Electrosurgical equipment (diathermy) is used in laparoscopic surgery both for cutting tissues and for stopping bleeding. Diathermy injuries to viscera both inside and outside the field of view can result from direct contact with instruments with defective insulation. Diathermy injury to bowel can cause peritonitis several days after surgery. This can follow an apparently uneventful initial recovery and may be caused by necrosis and perforation of the affected bowel. Such injuries can be avoided by always keeping the instrument in direct vision when diathermy current is applied, and by avoiding the use of diathermy on adhesions connected to bowel. An adhesion is a band of scar tissue that binds anatomic surfaces together that are normally separate from each other. Adhesions most commonly form in the abdomen, after abdominal surgery, inflammation or injury. All diathermy instruments should be regularly inspected for the intactness of their insulation, and must be renewed or replaced if defective.
There are also complications specific to each type of laparoscopic procedure. Laparoscopic surgeons have developed methods of avoiding the most serious complications.
Complications Specific to Laparoscopic Cholecystectomy – Removal of the Gallbladder
Cholecystectomy is the laparoscopic removal of the gallbladder.
Injury to the common bile duct is the most serious complication of laparoscopic cholecystectomy. Major injury to the common bile duct may be caused by clipping, cutting, or removing a segment of the common bile duct. Minor injuries from a cut, but not a complete severance, produce bile leaks. Injuries produced by clipping or cutting usually arise because of a surgical error in identifying the common bile duct as the cystic duct. When the anatomy is unclear the surgeon has the option to convert to open cholecystectomy. Excessive traction (pulling) by the assistant on the gallbladder may distort the anatomy, and should be avoided. Diathermy injuries to the common bile duct may result in perforation of the bile duct days later or strictures forming months or years later.
A number of bile duct injuries are not recognised during the operation. Subsequently the patient suffers abdominal pain, fever or jaundice. The results of surgical repair of such injuries are better when the injury is recognised during the operation. Multiple repair procedures have a poor outcome.
The incision required for conversation to open surgery is considerably larger than the minor incisions required for laparoscopy. In the case of bile duct reconstructive surgery after a major bile duct injury the abdominal incision may be two to three times the length of the incision for a standard open cholecystectomy.
Often the negligent complications from laparoscopic cholecystectomy are not from the surgery itself but the management and care after the operation. If the patient experiences excessive pain, sickness, vomiting or jaundice this should prompt clinical investigations to diagnose the cause of the problem.
Complications of Laparoscopic and Laparoscopic-Assisted Colonic Surgery
Laparoscopic surgery on the colon can be complicated by trocar injuries to bowel, bladder and blood vessels as in other laparoscopic procedures. Failure to identify the ureter (one of a pair of tubes that carry urine from the kidney to the bladder) can result in damage to the ureter – similar to bile duct injuries at laparoscopic cholecystectomy.
Complications of Laparoscopic Hernia Repair
Laparoscopic repair of groin hernia (protrusion of an organ through an abnormal opening in the muscle wall) when compared to open surgery reduces the pain experienced after the procedure and assists in achieving early return to work. The usual method is by use of a mesh to repair the defect. Blood vessels or the urinary bladder may be damaged during the procedure. Vascular injuries (injuries to the blood vessels) are generally regarded as negligent.
Failure to cover the mesh with peritoneum (the membrane that lines the abdominal wall) properly can cause adhesion of bowel loops to the mesh leading to bowel obstruction. An adhesion is a band of scar tissue that binds anatomic surfaces together that are normally separate from each other. Adhesions most commonly form in the abdomen, after abdominal surgery, inflammation or injury.
Summary
This is only a very short summary of what is a complicated medico-legal topic. All claims for medical negligence require a detailed assessment of the factual, medical and legal issues surrounding the circumstances of the treatment. Raleys can help you find a way through this maze.
