Laparoscopic surgery

Question 1

General findings

Complicanze
Hypercarbia, pneumothorax, pneumomediastinum, venous air embolism, and postoperative shoulder pain!

👓CO2 is highly soluble and easily absorbed into the tissues and blood → least risk of causing gas embolism compared to other gasses (since CO2 does not form air bubbles). Other gasses which can be used to insufflate the abdomen include helium, argon, and nitrous oxide (NO).

Answer 1

Laparoscopic surgery is a minimally invasive technique used to perform surgical procedures within the abdominal cavity, utilizing specialized instruments introduced through small incisions made on the abdominal wall. The abdominal cavity is first accessed using a trocar or a Veress needle, most commonly in the midline (peri-umbilical region). The peritoneal cavity is then insufflated with carbon dioxide (CO2). A fiber-optic instrument (laparoscope) is inserted into the first trocar to visualize the abdominal cavity and to allow for other ports to be created under direct vision. Laparoscopy is often the preferred diagnostic procedure for most elective gastrointestinal and gynecological surgeries. It is contraindicated in patients with shock, cardiac/pulmonary failure, and in cases of dilated bowel loops/perforation peritonitis. There are several advantages of laparoscopy over laparotomy as the incisions used are much smaller (e.g., less postoperative pain, fewer respiratory complications). However, the surgery is technically more challenging and complications (e.g., hemorrhage, bowel injury) are difficult to control laparoscopically. Complications unique to laparoscopy (secondary to CO2 insufflation of the peritoneal cavity) include hypercarbia, pneumothorax, pneumomediastinum, venous air embolism, and postoperative shoulder pain. Proper patient selection and good surgical technique minimize the risks and complications of laparoscopy.

Question 2

Indications

Answer 2

Nearly all elective abdominopelvic surgeries can be performed laparoscopically.
A few examples include:
✔Gastrointestinal surgery: e.g., cholecystectomy, appendectomy, hernia repair, bowel resection
✔Gynecological surgery: e.g., hysterectomy, oophorectomy
✔Urological surgery: e.g., nephrectomy, pyeloplasty
Diagnostic laparoscopy: allows direct visualization of the abdominal cavity, as well as biopsy of suspicious areas (lymphadenopathy) or collection of peritoneal fluid (for culture or cytology) through small incisions in the abdominal wall. Commonly used to avoid laparotomy in the following situations →
✔Evaluation of acute abdominal pain with negative imaging
✔Abdominal trauma with negative imaging when an intra-abdominal injury is suspected (e.g., diaphragmatic tear)
Staging of cancers
To determine resectability of cancers: gastric cancer, pancreatic/biliary tract cancer, etc

Question 3

Controindications

Answer 3

💥Absolute contraindications

1. Hemodynamic instability/shock
2. Acute intestinal obstruction with dilated bowel loops (aumentato rischio di perforazione)
3. Increased intracranial pressure (la tecnica può indurre ipercaonia con peggioramento della ICP)

✔Relative contraindications

• Cardiac failure (Pneumoperitoneum increases myocardial workload and oxygen demand (due to tachycardia and increased systemic vascular resistance), which could precipitate a myocardial infarction. The decreased venous return further decreases the cardiac output in patients with cardiac failure.)(si crea un aumento di pressione in cavità addominale!)
• Pulmonary failure (può indurre acidosi respiratoria)
• Pregnancy/large pelvic masses (lo pneumoperitoneo può ridurre la perfusione placentare con rischio di sofferenza fetale)
• Soft tissue infection at port sites
• Expected (extensive) adhesions from a previous abdominal surgery 👓
• Abdominal aortic aneurysm (may be associated with increased risk of vascular rupture)

Question 4

Complications

TACHICARDIA!

Answer 4

Injury to adjacent organs (e.g., blood vessels, bowel, bladder, solid intra-abdominal organs)
✔Aspiration of gastric contents
✔Intra-abdominal pressures > 20 mmHg should be avoided as it may potentially lead to:
1.The diaphragm being pushed upwards → decreased total lung volume and increased airway pressure
2.Compression of the IVC → decreased venous return to the heart → decreased cardiac output
3.Increased systemic vascular resistance (compression of arteries) and release of catecholamines (adrenaline, noradrenaline) → tachycardia
4.Compression of renal arteries → decreased glomerular filtration rate → decreased urine output
✔Pneumothorax
✔Pneumomediastinum (rare)
✔Subcutaneous emphysema
Condition that results from entrapment of air or gas into the subcutaneous tissues
Typically presents with sudden, painless soft tissue swelling, often around the upper chest, neck, and face
✔Hypercarbia and respiratory acidosis
Venous air embolism (rare)

👓Most intra-operative complications (pneumothorax, respiratory acidosis, air embolism) are indications to convert the procedure to a laparotomy (open procedure).

Question 5

Postoperative complications

Answer 5

✔Early postoperative complications

1. Shoulder pain (CO2 irrita il nervo frenico)
2. Atelectasis ( The elevated diaphragm and relatively hypoperfused lung bases increases the risk of postoperative atelectasis and pneumonia.)
3. Deep vein thrombosis

✔Late postoperative complications

1. Incisional hernia (laparocele) (soprattutto con porte di entrata maggiori di 10 mm)
2. Port site metastasis