Laparoscopy (aka minimally invasive surgery, keyhole surgery) is a surgical technique where operations are performed away from their actual location, through small incisions (usually 0.5-1.5cm) elsewhere in the body.
Laparoscopy includes operations within the abdominal or pelvic cavities. Thoracoscopy is keyhole surgery performed on the thoracic or chest cavity.
Laparoscopy. Laparotomy. What exactly do these words mean. And what exactly is a "lap"? Are we looking into the lap ?
Not really. "Laparo" is Greek for "abdomen". So it's things we do through the tummy. "Oscopy" means we are using a scope - taking a look at things. "Otomy" on the other hand, means "to cut". So laparoscopy is where we are looking at the tummy, and we do this using a small incision. Laparotomy on the other hand involves cutting, so it's a large cut we make so we can access the tummy space.
Use of a laparoscope (i.e. a long fiber optic cable system), which allows viewing the affected area by snaking the cable from a more distant, but more easily accessible location
Also attached is a fiber optic cable system, connected to a cold light source (halogen or xenon), to illuminate the operative field [internally inside the body], inserted through a 5mm or 10mm cannula or trocar (i.e. metal or plastic sharpened tip, connected to a cannula, allowing other objects to port through)
The abdomen is usually insufflated (i.e. body cavity inhaled with something) with CO2 gas, elevating the abdominal wall above the internal organs, creating a working and viewing space. CO2 is used because it is common to the body, can be absorbed by tissue, and removed by the respiratory system. It is also non-flammable, because electrosurgical devices are commonly used
Specific surgical instruments include:
Smaller incision, which:
Reduces bleeding, which reduces the chance of requiring a blood transfusion
Reduces pain, leading to less pain drugs needed
Results in less post op scarring
Reduces exposure of internal organs to possible external contaminants, thus reducing risk of acquiring infections
Shortens recovery time
Hospital stay is less, and often can have same day discharge
What is the good thing about multiple smaller incisions, rather than 1 big one, to do surgery?
The big advantage is the smaller incision. This means less bleeding. Less pain. Less scarring. Less infections. Quicker recovery. Less time in hospital.
Trochar injuries, during insertion into the abdominal cavity, as it is typically inserted blindly. The risk of these injuries are higher in patients who have a low BMI, or a Hx of prior abdominal surgery. This includes:
Vascular injuries, that can result in hemorrhage
Penetration of the small or large bowel, that can cause a delayed peritonitis
At the wound sites, hematoma, and wound infection
Sustained electrical burns, unseen by Dr's who are working with electrodes, that leak current into surrounding tissue. This can result in perforated organs, and can lead to peritonitis. This risk can be eliminated by utilizing active electrode monitoring
Relating to insufflation:
Insufflation injury, causing peritoneal trauma
Hypothermia, due to increased exposure to cold, dry gases
Patients with existing lung disease may not tolerate pneumoperitoneum (gas in the abdominal cavity), requiring conversion to open surgery, after an initial attempted laparoscopic approach
Pain extending to the patient's shoulders, due to not all CO2 introduced into the abdominal cavity being removed, and as gas tends to rise, a pocket of CO2 rises in the abdomen, pushing against the diaphragm (muscle separating the abdominal from the thoracic cavities, and facilitates breathing), and exerts pressure on the phrenic nerve
Coagulation disorders and dense adhesions (scar tissue) from previous surgery, may pose added risk, and are considered relative contraindications
Intra-abdominal adhesion formation, associated with both lap and open surgical approaches. Complications include chronci pelvic pain, bowel obstruction, and female infertility. Methods to minimize include surgical humidification therapy, use of physical barriers (e.g. films or gels, broad-coverage fluid agents to separate tissues during healing following surgery)
Procedure times are usually slightly longer
Benefits recede with younger age
May be inferior to open surgery in certain conditions
More difficult from the surgeon's perspective:
Limited range of motion at the surgical site, resulting in a loss of dexterity
Poor depth perception
Must use tools to interact with tissue, rather than manipulate it with their hands. Thus, it's hard to determine how much force is being applied, risk of damaging tissue. There is also reduced tactile sensation, important for Dx, and making delicate operations e.g. tying sutures
The tool's endpoints move in the opposite direction to the surgeon's hand, called Fulcrum effect, making it a non-intuitive motor skill that is difficult to learn
The Dr can't see the whole picture surrounding physiology, to better address the situation at hand
What bad things can happen, due to multiple smaller incisions, rather than 1 big one, to do surgery?
The initial stick, called the trochar, is inserted blindly, which can damage structures inside like the small and large bowel, blood vessels. There's also the risk of hernias, and at all the wounds, infection and hematoma. There can also be burn injuries, by the diathermy. Insufflation injury, causing peritoneal trauma. Hypothermia, due to insufflation cold gases. The insufflation gas, may make existing lung disease worse. The gas can also cause pain in the shoulders.