Diagnostic Laparoscopy

I. What is laparoscopy?
II. Minimally invasive surgery?
III. Indications?
IV. Advantages?
V. Disadvantages?
VI. Steps involved?
I. Pre-theatre prep
II. Positioning & theatre set-up
III. Surgery step(s)
VII. Complications?
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 Is a type of surgical procedure classified as a “minimally invasive”
procedure.
 Procedure allows surgeon to gain access to the peritoneal cavity, without
having to make large incisions.
 Differs from an “open” surgery where incision on skin can be several
inches long.
 Procedure takes its name from the laparoscope – the main instrument
used in this procedure.
 Laparoscope is a slender, tall metal instrument that has both video camera &
light source on its end which allows surgeon to “see” the interior of the
abdomen.

 The core principles of minimally invasive surgery (independent of procedure or
device):
 Insufflate/create space – to allow surgery to take place in the minimal access
setting.
 Visualize – the tissues, anatomical landmarks & the environment for the surgery
to take place.
 Identify – the specific structures for surgery.
 Triangulate – surgical tools (such as port placement) to optimize the efficiency of
their action, & ergonomics by minimizing overlap & clashing of instruments.
 Retract - & manipulate local tissues to improve access & gain entry to the
correct tissue planes.
 Operate – incise, suture, anastomose, fuse.
 Seal/hemostasis.

 Advantages:
 Decrease in wound size.
 Decrease in wound pain.
 Improved mobility.
 Reduction in wound infection,
dehiscence, bleeding, herniation
& nerve entrapment.
 Decreased wound trauma.
 Decreased heat loss.
 Improved visualization.
 Limitations:
 Reliance on remote vision &
operating.
 Difficulty with haemostasis.
 Dependence on hand-eye
coordination.
 Extraction of large specimens.
 Reliance on new techniques.

 Laparoscopy can be used to assist in diagnosing a wide range of
conditions that develop in peritoneal cavity.
 In fact, it can also be used for therapeutic purposes (surgical procedures)
such as removing a damaged or diseased organ/tissue, or obtaining a
sample for further testing.
i. Acute/emergency:
 Upper abdominal pain with suspected perforated peptic ulcer.
 Lower abdominal pain with suspected acute appendicitis.
ii. Elective:
 Investigation of chronic abdominal pain.
 Investigation of subfertility.
 To perform BIOPSY (e.g. omental or lymph node).

 Compared with traditional “open” surgery:
 Less severe post-operative pain.
 Reduced hospital stay (postoperative).
 Earlier return to normal activities.
 Less internal scarring
 Smaller scars

 Takes longer to perform than “open” surgery (if not performed with right
technique).
 Longer time under anaesthesia increases risk of complications, which may occur
few days to few weeks after surgery.
 Possibility of Hernia (incisional)
 Internal bleeding
 Damage to blood vessels & other organs, such as stomach, bowel, bladder
or ureters.

 Always done under GA; therefore NBM 2h & fluids only 4h preop.
 Group and save required.
 Ensure consent is obtained for proceeding to other procedures if they are
anticipated.

 Urethral catheterization: Usual, especially if lower abdominal
pathology/assessment likely, to ensure the bladder is decompressed.
 NGT: NOT required unless the patient is vomiting or gastric
distension/surgery is likely.
 Table positioning: Supine. It is always best to have the patient in leg
extensions. They allow the perineum to be assessed if vaginal
manipulation or lower GI endoscopy is needed and they help to secure
the patient on the table if head downtilt or lateral role is required.
 Monitor/stack position: Depends on the expected pathology.

 Incision: Periumbilical; usually curved infra-umbilical although supra-umbilical is
also used. Vertical infra-umbilical can be used, especially where conversion to a
midline laparotomy is anticipated.
 Exposure of the linea alba: By sharp dissection.
 Incision of linea alba: Elevate with forceps & incision with scalpel.
 Open trochar insertion: Elevate linea alba with forceps, blunt scissor opening of
pre-umbilical fat pad & peritoneum and placement of trochar or:
 Blunt trochar insertion: Elevate linea alba with forceps without a small initial
incision, insert trochar (blunt or with visual assistance using laparoscope inside the
port) or:
 Verres needle insertion: Elevate linea alba with forceps, insert Verres needle using
only thumb and finger pressure, until ‘clink’ felt, test for intraperitoneal placement
with saline ‘drop’ test.
 Insufflation: Use slow flow initially, check for slow pressure flow before increasing
flow rate.
 Assessment: Inspect area beneath insertion port for signs of visceral injury or
bleeding, assess anterior abdominal wall for availability of further port sites,
inspect viscera sequentially.

 Remove catheter unless required for post-operative fluid balance
observation.
 Antibiotics: Only required if pathology found.
 Oral diet: Normal as soon as tolerated.

 Port site infection (<5%)
 Port site herniation (<2% if closed).
 Visceral injury during port insertion/basic laparoscopy & assessment
(<1%).

 References:
 Oxford Handbook of Clinical Surgery, 4th Ed.
 Bailey and Loves, Short Practice of Surgery.

Diagnostic Laparoscopy

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