"07 THE CURRENT STATUS OF MINIMAL ACCESS SURGERY_A Maharaj"
07/2002 THE CURRENT STATUS OF MINIMAL ACCESS SURGERY DR. A MAHARAJ COMMENTORS: DRS. E ALIMIA MODERATOR: MR J. MOODLEY INTRODUCTION Minimally invasive surgery has been the most significant development in general surgery. The introduction of LC has seen it emerge as the gold standard for the procedure. Equally relevant, it remains the sole procedure performed by the vast majority of General Surgeons. Fuelled by industry, minimal invasive techniques have been adopted to accommodate every procedure performed by the General Surgeon. This has been done with modifications that are less than satisfactory and fortunately, have not endured. The scepticism that embraces MIS is warranted with the majority of initial reports merely attesting to the performance of the procedure using MIS techniques. Subsequent reports have largely evaluated early outcomes of the MIS techniques with incongruent or congruent open procedures suggesting a superior outcome. To date there are no prospective randomised controlled studies critically evaluating its superiority over traditional procedures especially in the intermediate and long-term. Two aspects have emerged, MIS is expensive and is not universally applicable over the concomitant open procedure. TECHNOLOGY2 Equipment Fibre – optic rod (telescope) mated to video camera. Angled telescopes allow for visualisation around corners. Smaller telescopes are attended with diminution of the operative field. Video Imaging Currently 3 chip cameras are applied. The full impact has yet to be appreciated, as monitor resolution has not been complementary. Insufflators The creation of a working space has proven to be the 1 st Achilles heel of MIS. Critical attention to pressure in appropriate is essential especially in patients with co – morbid factors. Gasless laparoscopy has not evolved adequately to replace CO2 insufflators. CO2 may not be appropriate in certain scenarios eg. borderline respiratory function and for adrenal medullary tumours. Typical flow rates are 6 – 8 l / min and are pressure limited to 15mmHG. Ports and instruments 2 A variety of ports and laparoscopic equivalent of surgical instruments are available in reusable and disposable version in sizes from less than 3mm (needloscopic) to 10mm. Needloscopic surgery is currently only practised by a few enthusiasts and some paediatric centres. The reuse vs. disposable debate rages on fuelled largely by manufacturers of equipment. Most laparoscopic surgeons use a combination of disposables and reusable instruments. BASIC PRINCIPLES1,2,4 Positioning of the patient Critical concept is that organ exposure is gravity assisted. This may require strapping the patient to the table to facilitate access to the target organ. It is pertinent to remember the while visualisation of the peritoneal cavity contents has been touted as one of its advantages, certain procedures limit access where it may be more appropriate eg. extra – peritoneal laparoscopic adrenalectomy. Strategy of Port Placement The proper placement of access ports can vastly reduce the difficulty of an MIS procedure. The “diamond of success” takes cognisance of the optimal working distance from the operative target. Defining the anatomy If there are any anatomic uncertainties, it is always best to convert the procedure to an open approach. PATIENT EVALUATION2,3,4 Contra – indications ABSOLUTE: Hypovolaemic shock, massive bleeding or haemodynamic instability. Severe cardio respiratory disease. RELATIVE Peritonitis Abdominal wall hernias Diaphragmatic hernias Uncontrolled coagulopathies Potential hypertension Multiple previous procedures / extensive intra - abdominal adhesions BENEFITS / DISADVANTAGES Impact of procedure. Where the extent of exposure does not impact on outcome, the value of MIS is eliminated and may even prove detrimental eg. pancreatico- duodenectomy4. Magnification GA mandatory Ventilatory control. Moderate hyperventilation maybe necessary. Anticipate increase in airway pressure especially for deep Trendelenberg position. 3 COMPLICATIONS2 Position related Femoral or peroneal neuropathy from lithotomy Trendellenberg – pooling of blood, decreased preload and decreased cardiac output. DVT Trocar placement Bowel, solid organ, bladder and vascular injuries Bowel injuries increased in patients with hernias or previous surgeries A mortality of 5% is associated with laparoscopic bowel injuries Incisional hernias with port size >5mm Pneumo peritoneal related complications Pneumothorax, pneumo mediastimun, CO2 embolism, hypercarbia with acidosis. DIAGNOSTIC LAPAROSCOPY4,7,9,11 Diagnostic laparoscopy is gaining acceptance as an alternative to diagnostic laparotomy and as an adjunct to radiological investigations to eliminate extensive exposure in patients in whom this may prove detrimental. Liver tumours : Evaluation of metastases and secondaries (30 – 40% with hepato-biliary carcinoma undetected by CT scan) CT good for intra parenchymal lesions > 1cm Laparoscopy good for small surface lesions and peritoneal seedlings Staging : Role in lymphoma, pancreatic, gastric and oesophageal tumours Lymph node assessment - The advantage is that it allows biopsy under direct vision. Chronic liver disease: Biopsy under vision is performed in chronic liver disease. Equivocal abdominal exam: In females with RIF or Non specific abdominal pain to exclude appendicitis, chronic PID and endometriosis. Abdominal trauma: Some centres advocate laparoscopy in the context of both blunt and penetrating trauma in stable patients. The limitations of the technique - the small bowel is difficult to assess (only 20% picked up in one series)4 - tension pneumothorax with diaphragmatic injuries. Solutions are gasless systems (these are cumbersome) and to pressure limit the pneumoperitoneum to 10mmHg 4 Laparoscopic ultrasound4,7 Allows for high-resolution real time imaging of organs due to direct contact of a probe with the viscera. Compensates for the surgeons inability to palpate organs at laproscopic surgery Allows one to evaluate liver metastases, the CBD for stones (as sensitive and less likely to technical failure that intra- operative laparoscopic cholangiogram). LAPARASCOPIC CHOLECYSTECTOMY2,3,4,9 Laparoscopic cholecystectomy is the proto type laproscopic surgical procedure and has established itself as the gold standard therapy for symptomatic cholelithiasis Indications Symptomatic cholelitiasis There is no controversy regarding the need for cholecystectomy in patients with symptomatic cholelithiasis except when medical contra-indications to surgery exist and percutaneous cholecystectomy may be employed as a temporary measure. Asymptomatic cholelithiasis There is no rationale for routine cholecystecomy either open or laproscopic in patients with asymptomatic cholelithiasis as complication rates are low and patients progress to symptomatic cholelithiasis before complicating. However certain relative indications exist in asymptomatic patients4. Salmonella carriers Immuno-compromised patients The risk of malignancy – porcelain gall bladder, family history of gall bladder cancer, residents of areas with endemic gall bladder cancer i.e. Peru and Chile Children Biliary dyskinesia - patients with RUQ pain in whom there is no demonstrable pathology and a gall bladder ejection function of less than 35% on hepato-biliary scan with cholecystokinin injection - is also considered an indication 4. Contraindications Any contraindications to general anaesthesia or laproscopic surgery Third trimester pregnancy A “hostile” abdomen is a relative contraindication and dependant on the experience of the surgeon Technique Performed under general anaesthesia with the patient in the reverse Trendellenberg position. The bladder is emptied. A 3 or 4 port technique is used with the surgeon on the left along with camera operator. The assistant stands on the right. French surgeons have described a three port technique with the patient in lithotomy and use of a robotic arm to operate the camera. 5 A pneumoperitoneum is created as previously described and the first port inserted either blindly or with open dissection (the Hasson technique) The gall bladder is grasped and fundus retracted to the right and upward while Hartman‟s pouch is retracted laterally. This splays the cystic duct and CBD and makes them appear as distinct structures. Too much upward traction could cause tenting of the CBD and possible injury. The blunt dissection involving a tearing action to the fat and fibrous tissue in Calots triangle will expose the cystic duct and artery. The artery is clipped and divided before the duct in order to properly expose the duct and any variations in anatomy. It is not necessary to expose the CBD and any attempts to routinely do so may increase the risk of injury. After clipping and division of the cystic duct the gall bladder is dissected off the liver and delivered through the umbilical port. Routine laproscopic CBD cholangiography is not currently advocated. It may be indicated in patients with abnormal LFTs, dilated ducts, multiple small stones and recent history of pancreatits, jaundice or cholecystitis. In some centres laproscopic ultrasound is practised as a less technically demanding but equally sensitive modality of imaging the duct. Results Laparoscopic cholecystectomy has proven advantages – these are: Shorter hospital stay Less time to resume normal duties Lower pain scores and less use of opioids Return to normal diet sooner Greater patient satisfaction More cholecystectomies are now being done than ever before since the advent of the laparoscope3. Initially it was thought that this was due to symptomatic patients previously unwilling to have surgery now opting for a more acceptable procedure. However the increase has been more than transient and this is one of the chief criticism of laparoscopic procedures i.e. It is largely patient driven and has caused surgeons to lower this threshold for surgery with the availability of a technique they perceive as safer but not without its own morbidity. COMPLICATIONS4 Morbidity ranges from 1 – 9% and CBD injuries 0,2 – 0,7% and largely depend on the surgeons experience. Conversion rates are from 1,8 – 7,8%. Specific complications include haemorrhage, bile leaks, retained stones, wound infections and incisional hernias. Other complications are pneumoperitoneum related and insertion related as described previously. LAPAROSCOPIC MANAGEMENT OF CBD STONES4 With the advent of laproscopic cholecystectomy efforts were made to avoid CBD exploration and patients with suspected CBD stones were either excluded from laproscopic cholecystectomy or underwent pre operative ERCP with clearance of the duct and subsequent laproscopic cholecystectomy. Stones discovered intra- op or post-op were dealt with, with post-operative sphincterotomy. With the development of advanced laproscopic skills and equipment it is now possible to explore the common bile duct laproscopicaly. A criticism of laproscopic CBD exploration is that it does not allow for biliary decompression and bypass which maybe indicated in a dilated system. Methods currently in use rely either on choledochotomy or trans – cystic exploration after balloon dilation of the cystic duct and employ balloon trolling of the CBD, 6 fluoroscopic guided wire basket retrieval, ampullary balloon dilation or flexible biliary endoscopy with wire basket retrieval. Complications Perforation of the cystic duct or extra hepatic ducts, bile leaks, pancreatitis or persistent cholangitis Delayed stricture Retained stones or basket LAPAROSCOPIC ANTI REFLUX SURGERY2,4,12 GORD and symptoms there of heartburn, dysphagia, chest pain, vomiting, asthma and pneumonia are relatively common and usually respond to medical therapy. The goal of therapy is to treat symptoms and prevent complications. The complication rate in those patients who have oesophagitis is high (20%) and include Barrets oesophagitis, stricture, oesophageal ulcer and haemorrhage. Indications for surgery4,12 Failure of conservative measures to control symptoms (lifestyle modification and diet). Persistence of symptoms on maximal medical therapy, usually proton pump inhibitors Non-compliance or difficulty tolerating medical therapy. Failure to prevent complications on medical therapy. Prior to the advent of laparoscopic surgery few patients came to surgery largely because of the morbidity of the open Nissens and other fundoplications done via upper midline laparotomy for essentially a non-life threatening condition. Since the advent of laproscopic surgery which offers a safe alternative with short hospital stay and faster return to function, GORD surgery is now the commonest laproscopic procedure performed after a cholecystectomy. Technique The technique consists of a four port access to the abdomen with the surgeon between the patient‟s legs in the lithotomy position in steep reverse Trendellenberg. The liver is retracted by a fixed retractor and the fundus is retracted to the right. The peritoneal attachment to the left is divided and dissection carried out towards the spleen with the ultrasonic scalpel. The gastrosplenic ligament is divided next and the greater curve is displaced to the right and caudally. The oesophagophrenic membrane is divided along the left and then the right to mobilise 3cm of tension free intra abdominal oesophagus. The Hiatus is closed around the oesophagus with non-absorbable sutures at 0,5 cm intervals to approximate the Crura. The tightness of the closure may be measured using a 52FR bougie The last step consists of creation of the fundoplication. The anterior and posterior portions of the fundus are grasped and wrapped around the oesophagus. These are secured by interrupted sutures over a distance of 2 – 3cm and anchored to the hiatus once complete. 7 Results Symptom relief in 85 – 95% with typical symptoms being more responsive than atypical symptoms. Objective pH monitoring demonstrates reduction in acid exposure time in almost all patients. Risks for persistently abnormal acid exposure are those with strictures, shortened oesophagus, Barrets oesophagus and extremely abnormal pre-operative acid exposure. Reasons for failure include the symptoms not being caused by reflux, co- existing illnesses whose symptoms are worsened by reflux and thus only partially respond or permanent changes as a result of GORD. These can be minimised by careful preoperative evaluation of symptomology with pH studies, manometery and endoscopy. Laproscopic anti-reflux surgery is a well-established alternative to the open technique with very few detractors. Recent reports from Scandinavia on failure of surgical therapy are a comment on the role of surgery not on the minimally invasive approach12. LAPAROSCOPIC HERNIA SURGERY2,3,4,5 Hernia surgery has always been fraught with controversy regarding the best repair. The myriad available techniques may be divided into two types. The „tension‟ tissue based repair and the “tension free” mesh repair. Amid all the controversy the laparoscopic approach entered the fray with a promise of a recurrence rate of 5-10% shorter convalescence and less pain4. Initial repairs were the ring closure, laparoscopic plug and patch and intraperitoneal onlay mesh (IPOM). These were largely abandoned due to high recurrences and increased incidence of intra-abdominal adhesions. Current techniques are the transabdominal preperitoneal repair (TAPP) and totally extraperitoneal repair (TEP) with TAPP becoming obsolete4. TECHNIQUE OF TEP REPAIR The surgery is carried out under general anaesthesia. An infra umbilical skin incision is made and a balloon dissector is introduced between the peritoneum and pre transversalis fascia. The scope is introduced and the dissection proceeds laterally to expose Coopers ligament. Direct hernias are visualised immediately while indirect hernias are only visualised once the internal ring is seen. The hernia is reduced with traction and may be divided and ligated if adherent and large. A mesh 10 x 15 cm is introduced and the space is deflated under vision to ensure that no rolling occurs. The contra lateral side can be inspected for hernias and repaired if necessary. DISCUSSION For any hernia surgery to gain acceptance it has to be evaluated in a large series over many years and compared to an equivalent operation in order to prove both its long and short-term benefits. Initial reports of the superiority of laparoscopic hernia surgery and its widespread acceptance is currently undergoing a rethink. In a recent meta-analysis a few key points have emerged.5 Laparoscopic surgery requires a general anaesthetic Long-term follow-up is beginning to emerge and recurrence rates may be higher than thought. Very few studies compare laparoscopic surgery (mesh repair) to open mesh repairs. Most are a comparison against both mesh and tissue repairs. In comparison to open repair under local anaesthetic a laparoscopic repair commits one to a mesh and a general anaesthetic with increased operating time and cost as well as 8 risks of nerve injury, adhesions and fistulation. It may have a limited role in the context of recurrent or bilateral hernias in young patients, who tolerate a general anaesthetic easily. APPENDICECTOMY2,3,4 Appendicitis has been recognised since antiquity but it was not until the clinical pathological consequences became evident that the first appendisectomy was described in 1848. It is currently one of the more commonly performed surgical procedures and with the advent of laproscopy it was only natural that this technique would be applied. Indications are unchanged Technique A three-port technique is employed. The appendix is grasped after mobilisation of the caecum for a retro-caecal appendix if necessary. The meso- appendix is dissected and a stapler applied across the appendix. The meso- appendix is dealt with in the same way. An endoloop or extra corporeal knot may also be used to achieve ligation of the appendix stump. The appendix is placed in a plastic bag and retrieved via one of the port holes. When the telescope is inserted a diagnostic laproscopy is done, a decision is made to convert in the presence of a severe phlegmon or another diagnosis requiring a laparotomy12. Discussion The proponents of laproscopic appendisectomy cite a shorter duration of hospitalisation, less post op pain and better cosmesis. Critics cite longer operative time, greater cost, no difference in hospital stay for complicated appendicitis and increased complication rate in complicated appendicitis (abscess formation is greater and it is speculated that this may be due to CO2 pneumo- peritoneum). A single trocar injury may negate the minor benefits of the laproscopic approach. The laproscopic approach also requires the availability of trained staff and equipment at all hours. Currently laproscopic appendisectomy has not gained widespread acceptance as a routine alternative to the open approach. It may however have a limited role in young females in whom there is a diagnostic doubt2. SPLENECTOMY Indications The commonest indication for a splenectomy is trauma. This indication does not generally lend itself to the laproscopic approach due to haemodynamic instability the duration of any laproscopic procedure, the effects of a pneumo peritoneum on an even subtly hypotensive patient and limitations in assessing and dealing with concomitant injuries. The commonest indication for laproscopic splenectomy is ITP followed by a host of other reticulo-endothelial and myelo-proliferative disorders. Technique The initial technique described was a trans-abdominal approach with the patient supine. A lateral flank approach has been described and is gaining favour. The patient is in the right lateral decubitus position and trocars are placed in the mid clavicular, mid axillary line, mid epigastrium and umbilicus. The splenic flexure and left 9 colon are dissected free of the retro peritoneum with a harmonic scalpel. The short gastric vessels are divided with a harmonic scalpel after ligation or clipping on the gastric side. The avascular tissue is divided and the hilum is approached last. It is exposed with blunt dissection and a linear stapling device is deployed loaded with vascular clips. The spleen is transferred into a specimen bag brought to the skin surface and morsellized within the bag and removed piece meal. A search is made for accessory spleens and those are dealt with. A drain may be left insitu. Hand assisted procedures for lager spleens have been described with the large incision for the hand port in either the mid epigastrium or a Pfanallstien incision. Results The laparoscopic approach is gaining acceptance for normal size spleens. The laproscopic approach results in longer operating time and more bleeding but boasts a shorter post operative stay and less pain. The hand-assisted approach would seem to negate this. LAPAROSCOPIC ADRENALECOMY Indications The laparoscopic adrenalectomy was described by Michael Gagner in 1992 and has since been reported with increased frequency. Most adrenal tumours are small and benign and lend themselves to the laproscopic approach. Contraindications to the procedure include adrenal cortical carcinoma, malignant phaeochromocytoma, large benign mass >5cm, contraindications to laproscopic surgery in general, uncorrected coagulopathy and the need for concomitant abdominal surgery. Technique Operative techniques described are either the supine or lateral flank approach or the lateral trans abdominal approach. The retroperitoneal approach is preferred for bilateral lesions since patients do not require repositioning while lager tumours necessitate a trans abdominal approach. Results Adrenalectomy has been compared to its open versions in retrospective trails and although has a longer operative time, is associated with shorter hospital stay, less bleeding, rapid return to diet and resumption of normal duties 16. Complication rates are lower and the wide spread acceptance of laproscopic adrenalectomy makes it unlikely that prospective randomised trails will ever be conducted. Preliminary data indicate that hormonal function in the contralateral adrenal gland returns sooner 15. LAPAROSCOPIC HELLERS MYOTOMY Oesophageal myotomy was first described by Heller in 1913 for symptomatic relief in patients with achalasia. This required laparotomy or thoracotomy to make a single incision on the oesophagus for symptomatic relief of a condition. In 1991 Cuschieri and colleagues described a laproscopic version of the procedure which allows the same benefit without the morbidity attendant to a laparotomy or thoracotomy. Studies currently support its superiority over the open approach. Since achalasia is an oesophageal motility disorder, reflux is common postoperative problem. A partial wrap (Dor Procedure) is often added and has the benefit of protecting the anastomosis should the mucosal be breached as well as keeping the myotomy open. 10 LAPAROSCOPIC SURGERY OF THE LIVER4 While laparoscopic surgery lends itself to solid organ surgery; the liver due to its sheer size, vascularity and the limited experience in open liver surgery has limited laproscopic approaches. In addition the considerable haemorrhage is difficult to control, the risk of CO2 embolism and the need for advanced laproscopic skills as well as specialised equipment (Nd: YAG laser) limit its practice to a few specialised centres where both experimental labs and specialised equipment is available. The only laprasopic liver surgery currently recommended is the unroofing of simple liver cysts. LAPAROSCOPIC THORACOSCOPY4,13,14 The morbidity associated with a thoracotomy incision makes thoracoscopy an attractive option for a host of procedures. Indications include pleural disease, lung resections, pericardial disease, surgery to the thoracic oesophagus and mediastinal procedures. Most are within the ambit of the thoracic surgeon, but general surgical experience with thorcoscopic sympathectomy and splanchinectomy has been extensive locally. Initial enthusiasm for these procedures waned due to frequent recurrences and the morbidity associated with access to the thorax but video assisted thoracoscopy and better understanding of the anatomy of the sympathetic trunk has changed that. THORACOSCOPIC T2 SYMPATHECTOMY Indications Primary hyperhydrosis Chronic regional pain syndromes of the upper limb Vascular conditions viz. Raynauds phenomenon. THORACOSCOPIC SPLANCHINECTOMY Indications Chronic pain in pancreatits Chronic pain in irresectable upper GI malignancies Locally a long pleurotomy with transection of all fibres medial to the sympathetic chain from T5 to the diaphragm has yielded predictable results. The thoracoscopic approach has yielded good results with shorter hospital stay less postoperative pain and faster return to function 13,14. LAPAROSCOPIC COLONIC SURGERY2,3,4,8,9,10 While initial laparoscopic procedures were restricted to the gallbladder and solid organs, as laparoscopic skills advanced it was inevitable that surgery on hollow organs was attempted. The principal differences of the surgery is Non-ablative4. Requires advanced skills to restore continuity of the bowel with a watertight anastomosis. 11 Involves mobilization of a segment with dissection of the mesentery and division of the blood supply. Most procedures are laparoscopic assisted and hemi-colectomies, subtotal-total, total colectomies and AP resection. Initial concerns were longer operating times, concerns about extent of lymph node dissection and margins of resections, and increased port site recurrence. Proponents cite decreasing operating time with increasing experience and similar margins of resection and lymph node dissection 2,10. These are from preliminary series using highly selected groups of patients. The appropriateness of laparoscopic surgery in general and in the context of colorectal malignancy in particular is still under debate.10 CONCLUSION The initial enthusiasm for laparoscopic surgery which saw attempts to adapt it to every form of surgery has been replaced by a more pragmatic approach to a technology that is finding its niche. There are few laparoscopic procedures that are firmly established, some whose suitability is still being investigated and yet others that have demonstrated complete unsuitability to the laparoscopic approach. REFERENCES 1. Brunt LM, Soper NJ. Laparoscopic Surgery. In: Zine – MJ Schwartz SI, ed. Maingots Abdominal Operations. 10th ed Vol 1. Appleton and Lange. 1997: 239- 85. 2. Terry ML, Hunter JG. Minimally invasive Surgery. In Cameron JL, ed. Current Surgical Therapy. 7th Edition. Mosby Inc. 1998: 1364-1476. 3. Scott Conner CE. Laparoscopic Surgery. Surg Clinics N Am. June 1996: 76 (3): 437-639. 4. Eubanks WS, Swanson LL, Soper NJ, ed: Mastery of Endoscopic and Laparoscopic Surgery. Philadelphia, 2000, JB Lipptincott. 5. Cheek CM, Black NA, et al. Grain Hernia Surgery: A Systematic Review. Ann R Coll Surg. Engl 1998; 80 Suppl 1: 51-80. 6. Bowrey DJ, Petis JH Laparoscopic surgery of the oesophagus. Surg Clinics North America. 2000 Aug; 80 (4) : 1213-42. 7. Luck AJ, Madden EJ. 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