Handbook of Surgical Consent
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Introduction to laparoscopic surgery
Laparoscopic surgery is a minimal-access surgical technique that involves insufflation of the abdominal cavity with carbon dioxide to allow diagnosis and treatment of intra-abdominal pathologies. The first published laparoscopic procedure in humans dates back to 1910 and is credited to Hans Christian Jacobaeus (Stockholm, Sweden). Since that initial procedure, laparoscopic surgery encountered many controversies before being accepted as a safe alternative to traditional open techniques. The introduction of gas insufflation, improvement of optics, and development of laparoscopic instruments have been key to the modernization of the technique.
There are specific issues regarding laparoscopic surgery that should be considered at disclosure. The specific complications relating to each procedure are discussed in the relevant section. The aim of this chapter is to provide an overview of the issues relating to laparoscopy in general.
Explaining laparoscopic surgery to patients
Laparoscopic surgery can be described to patients as ‘keyhole surgery’, as this is a term that most patients are familiar with. It is also important to break down the steps of an operation. For general surgical laparoscopy this would include:
This procedure is performed under general anaesthesia
Once asleep, a small cut is usually made in the region of the belly button (umbilicus)
A small plastic sheath is inserted into the abdomen and gas is pumped into the abdominal cavity. (The gas used is carbon dioxide because it is highly soluble and rapidly excreted by the body)
The gas pumped into the abdomen elevates the front of your abdominal wall away from internal organs. This creates the necessary space for us to obtain good views and perform the operation
Further small incisions of 5–10mm are made through in which we place further plastic sheaths. Through these plastic sheaths, we insert our instruments
Most often two further incisions are made, however, this number can vary depending on the pathology identified and the intended operation. The location of these incisions depends on the indications for the procedure and also the pathology identified
Conversion to an open procedure is often wrongly included as a risk when patients are being consented for a laparoscopic operation. This is not a risk and should be included as part of the standard operation (i.e. laparoscopic procedure ± conversion to open). The percentage rate of conversion depends on the procedure being undertaken and the experience of the surgeon performing the operation. The important point to emphasize to the patient is that if the operation cannot be safely completed laparoscopically, it will be necessary to convert to open. When consenting, one should also demonstrate the potential incision sites for the open version of the same operation to the patient. This ensures that the patient is fully informed prior to the procedure and aware of the possible outcomes.
Advantages of laparoscopic surgery
Laparoscopic surgery is considered the gold standard technique for cholecystectomy and fundoplication.1,2 Laparoscopic appendicectomy is considered the gold standard technique for resection of the appendix in women of childbearing age.3 It is advocated, but not currently considered the gold standard for male patients, obese patients, and elderly patients. There have been mixed results reported with laparoscopic appendicectomy in pregnant women and the technique should be used with caution in this cohort of patients. Laparoscopic colorectal surgery is an evolving technique and the oncological safety profile cannot be proven as conclusive long-term data do not yet exist.4
Major advantages of laparoscopic surgery over open surgery
References
Complications of laparoscopic surgery
General complications
Complications of laparoscopic surgery are primarily related to the surgery or due to the secondary effects of the pneumoperitoneum. Potential risks/complications include:
Infection
Bleeding/haematoma
Thromboembolism
Adhesion formation
Port site hernia formation
Basal atelectasis/pneumonia
Damage to surrounding structures/Iatrogenic injury
Solid organ damage
Small bowel/colon
Major vascular injury
Bile duct injuries
Bladder
The injuries can occur during trocar insertion (increased risk with Veress needle), due to electrocautery conductivity or as a result of technical failure. Such injuries can go unrecognized at the time of laparoscopy, and therefore a high index of clinical suspicion is necessary in postoperatively unwell patients.
(Complications related to specific procedures are listed under the relevant chapters.)
Complications due to pneumoperitoneum
When absorbed, the systemic effects of carbon dioxide, the gas used for insufflation of the abdomen, include:
Increase in PaCO2
Increase in respiratory rate
Myocardial instability/cardiac dysrhythmia
Decrease in pH
Abdominal compartment syndrome is a rare, serious complication as a result of intra-abdominal hypertension. It is most commonly due to prolonged carbon dioxide insufflation, and if it is unrecognized, it can lead to severe organ dysfunction.
Cardiac complications
Increased venous return
Decreased cardiac output (CO)
Increased systemic vascular resistance
Increased risk of bradycardia (vagal stimulation)
Gas embolism
Respiratory complications
Ventilation/perfusion mismatching
Displacement of the diaphragm
Pneumothorax
Pneumomediastinum
Respiratory failure
New techniques in laparoscopic surgery
Description
Laparoscopic surgery techniques continue to evolve and operating through a single trans-umbilical incision is gaining prominence. The single port technique is most commonly known as single incision laparoscopic surgery (SILSTM) or laparoendoscopic single site (LESS) surgery. To date, operations performed via the single port technique include:
Appendicectomy
Cholecystectomy
Nephrectomy
Colonic resection
Antireflux surgery
Bariatric—gastric band placement and gastric bypass
Inguinal hernia repair
Single port surgery is technically more demanding than traditional laparoscopic surgery and is currently practised by experts in certain centres on select patients. The single port technology has also led to innovation with regards to instruments (e.g. curved/reticulating versions) and camera systems (e.g. flexible). The main demonstrable advantage of single port surgery is that the end cosmetic result is (virtually) scarless. However, given the technique is relatively new, there is no level I evidence proving its efficacy/superiority to traditional laparoscopic surgery. However, it is important to monitor further developments and it remains to be seen whether SILSTM and LESS are adopted in mainstream surgical practice.
