74: Minimally Invasive Surgery

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CHAPTER 74 Minimally Invasive Surgery

Prairie Neeley Robinson, MD

1 What are the origins of modern laparoscopic surgery?

P. Bozzini developed the first self-contained endoscope in 1805, using candlelight for illumination. The first clinical laparoscopic examination in humans was performed by H. Jacobaeus in 1910. By the 1970s gynecologic laparoscopic surgery was being performed routinely. The first laparoscopic appendectomy was performed by Semm in 1983, and the first laparoscopic cholecystectomy was performed by Muhe in 1985. Since then the concept and techniques have rapidly expanded to include multiple surgical disciplines. Laparoscopic surgery has become the standard of care for some procedures.

2 What are some currently practiced laparoscopic, thoracoscopic, or endoscopic procedures?

image General surgery: Multiple procedures involving the appendix, colon, small bowel, gallbladder, bile ducts, stomach, esophagus, liver, spleen, pancreas, and adrenals. In addition, hernia repairs, diagnostic laparoscopy, adhesiolysis, gastric bypass, gastric banding, Nissen fundoplication, and feeding-tube placement can be performed laparoscopically
image Gynecologic procedures: Diagnostic procedures for chronic pelvic pain, hysterectomy, tubal ligation, pelvic lymph node dissection, hysteroscopy, myomectomy, oophorectomy, and laser ablation of endometriosis
image Thoracoscopic procedure/video-assisted thoracic surgery: Lobectomy, pneumonectomy, wedge resection, drainage of pleural effusions and pleurodesis, evaluation of blunt or pulmonary trauma, resection of solitary pulmonary nodules, tumor staging, repair of esophageal perforations, pleural biopsy, excision of mediastinal masses, transthoracic sympathectomy, splanchnicectomy, pericardiocentesis, pericardiectomy, and esophagectomy
image Cardiac surgery: Coronary artery bypass, valve repair
image Orthopedics: Joint arthroscopy, including knee, hip, shoulder, wrist, and elbow
image Urologic procedures: Laparoscopic nephrectomy/nephroureterectomy, pyeloplasty, orchiopexy, cystoscopy/ureteroscopy, and prostatectomy
image Neurosurgery: Ventriculoscopy, microendoscopic diskectomy, interbody fusion, anterior spinal surgery and scoliosis/kyphosis correction, and image-guided techniques to approach masses/tumors easily
image Plastic/reconstructive surgery: Breast augmentation, brow lift, face lift, and liposuction techniques
image Transplant surgery: Donor nephrectomy

Improvements in scope technology have allowed many procedures to be performed without large surgical incisions, affording the patient rapid recovery of function. However, the focus of this discussion will be the physiologic concerns associated with abdominal laparoscopy since they are of utmost importance to the anesthesiologist.

3 Are there any contraindications for laparoscopic procedures?

Relative contraindications for laparoscopy include increased intracranial pressure, patients with ventriculoperitoneal or peritoneojugular shunts, hypovolemia, congestive heart failure, or severe cardiopulmonary disease and coagulopathy. Morbid obesity, pregnancy, and prior abdominal surgery were previously considered contraindications to laparoscopic surgery; however, with improved surgical techniques, technology, and experience, most patients with these conditions can safely undergo laparoscopic surgery.

4 What are the benefits of laparoscopy when compared with open procedures?

image Intraoperative benefits: Decreased stress response with a reduction of acute phase reactants (C-reactive protein and interleukin-6), decreased metabolic response with reduced hyperglycemia and leukocytosis, decreased fluid shifts, better preserved systemic immune function, and avoidance of prolonged exposure and manipulation of abdominal contents.
image Postoperative benefits: Less postoperative pain and fewer analgesic requirements, improved pulmonary function (secondary to decreased pain, decreased atelectasis, and earlier ambulation), improved cosmesis because of smaller incisions, fewer wound infections, decreased postoperative ileus, decreased length of hospitalization, and a quicker resumption of normal daily activities.

5 Why has carbon dioxide become the insufflation gas of choice during laparoscopy?

The choice of an insufflating gas for the creation of pneumoperitoneum is influenced by the blood solubility of the gas and its tissue permeability, combustibility, expense, and potential to cause side effects. The ideal gas would be physiologically inert, colorless, and capable of undergoing pulmonary excretion. Although a number of gases have been used (Table 74-1), carbon dioxide (CO2) has become the gas of choice since it offers the best compromise between potential advantages and disadvantages.

TABLE 74-1 Comparison of Gases for Insufflation

  Advantages Disadvantages
CO2 Colorless Hypercarbia
Odorless Respiratory acidosis
Inexpensive Cardiac dysrhythmias, rarely resulting in sudden death
Does not support combustion
Decreased risk of air emboli compared with other gases because of its high blood solubility More postoperative neck and shoulder pain resulting from diaphragmatic irritation (compared with other gases)
N2O Decreased peritoneal irritation Supports combustion and may lead to intra-abdominal explosions when hydrogen or methane is present
Decreased cardiac dysrhythmias (compared with CO2) Greater decline in blood pressure and cardiac index (compared with CO2)
Air   Supports combustion
Higher risk of gas emboli (compared with CO2)
O2   Highly combustible
Helium Inert Greatest risk of embolization
Not absorbed from abdomen

6 How does carbon dioxide insufflation affect PaCO2?

CO2 insufflation increases the partial pressure of carbon dioxide (PaCO2). The degree of increase in PaCO2

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