Basic Transumbilical Procedures |
261 |
Laparoscopic Cholecystectomy
Our preferred technique is to have one hand atop the other, with the left hand sitting on the right in a supinated position, and the right hand below the left in a pronated position (Fig. 15.4). The procedure is performed in the same fashion as the standard cholecystectomy, with one exception - the retracting grasper for the fundus would be inserted below the 5 mm trocar with a scope; ideally, the insertion occurs at about 6 o’clock. We have found with others that the insertion of a long ratcheted 36 cm needle-nosed grasper without a trocar is most beneficial, as it doesn’t interfere with the other 5 mm trocar. It is imperative, though, to be careful when inserting this instrument, as it is done without direct visualization; we recommend the exploration of this area with a 10-mm scope at the end of the procedure.Another technique is to retract the fundus using a Keith needle inserted through the skin just under the right costal margin. This unfortunately does not allow for the same good retraction as the grasper.
The cystic duct is then slowly and carefully, dissected out. Minimal cautery is used as to avoid any burn injury to the adjacent structures (e.g., the duodenum or common bile duct). Once the junction of the cystic duct and the gallbladder is identified, and the junction between the cystic and hepatic ducts is also seen, a 5-mm clip applier is inserted and clips are placed in the usual fashion. The cystic artery is also dissected and divided, and the gallbladder is removed in the gallbladder fossa.
At this point, two 5 mm trocars are enlarged to allow the insertion of a 10-mm trocar and a bag in which the gallbladder is removed. The 10 mm trocar allows the insertion of a 10-mm scope in order to explore the area of insertion of the trocars for recognition of any possible bowel injury, and all the trocars are then removed. The fascia that allowed the insertion of the 10 mm trocar is then closed using the usual vicryl sutures, and cosmetic closure of the umbilicus finishes the procedure.
Laparoscopic Appendectomy
The same concepts and patient positioning are used as with traditional laparoscopy; the difference here is the use of the harmonic shear to coagulate the meso-appendix, and the ligation of the appendix itself is performed using two endoloops at the base and one endoloop more distally. The appendix is then divided and removed in a 10-mm bag inserted through the enlarged 10 mm incision inside the umbilicus.
Laparoscopic Inguinal Hernia Repair
Our preferred technique for traditional laparoscopy is the TEPP approach; however,the TAP technique is slightly easier with SALS. The trocar placement for this method is the same as for SALS cholecystectomy, and the technique is similar to the usual laparoscopic TAP.
262 |
Chapter 15 Single-Access Laparoscopic Surgery (SALS) |
Alternative |
It is possible to insert a device provided by several manufacturers that allows for a good |
Technique |
CO2 seal. These devices are made of rubber or silicone gel, are perforated to allow the |
Using |
insertion of small trocars. |
Disposable |
The big difference with our basic technique is the need for one incision only on the |
Devices |
fascia to insert the disposable rubber seal. |
|
The disadvantage is the need for a slightly larger skin and fascial incision. It is also |
|
not very amenable for a purely intraumbilical insertion. |
|
The advantage is the possibility of slight rotation of the device and the attached |
|
ports allowing to compensate for the lack of horizontal freedom of the hands and |
|
enabling the hands to position themselves better in our favorite position (left hand above |
|
right one). |
Selected Further Reading |
263 |
Binenbaum SJ, Teixeira JA, Forrester GJ, Harvey EJ, Afthinos J, Kim GJ, Koshy N, McGinty J, Belsley SJ, Todd GJ (2009) Single-incision laparoscopic cholecystectomy using a flexible endoscope. Arch Surg 144(8):734–738
Dunning K, Kohli H (2009) Transumbilical laparoscopic cholecystectomy: a novel technique. Arch Surg 144(10):957–960
Hall RC (2008) Is natural orifice transluminal endoscopic cholecystectomy as safe as laparoscopic cholecystectomy? Arch Surg 143(6):604; author reply 604-605
Huscher CG, Mingoli A, Sgarzini G, Brachini G, Binda B (2009) Feasibility of colonic and gastric standard laparoscopic procedures with a single skin incision approach. Arch Surg 144(10):977
Leroy J, Cahill RA, Asakuma M, Dallemagne B, Marescaux J (2009) Single-access laparoscopic sigmoidectomy as definitive surgical management of prior diverticulitis in a human patient. Arch Surg 144(2):173–179
MacDonald ER, Ahmed I (2009) Another step toward scarless surgery. Arch Surg 144(6):593–594
Marescaux J, Dallemagne B, Perretta S, Wattiez A, Mutter D, Coumaros D (2007) Surgery without scars: report of transluminal cholecystectomy in a human being. Arch Surg 142(9):823–826
Selected
Further
Reading
Advanced 16
Laparoscopic
Suturing
Techniques
Laparoscopic suturing is a fundamental skill in advanced laparoscopic surgery. It requires a great deal of patience and practice. The mastery of this skill will enable the surgeon to perform many complex laparoscopic procedures and to laparoscopically repair complications should they occur.
Monitors
In performing complex laparoscopic surgery, the ergonomics of the operating room are of paramount importance. The monitor should be comfortably located at the level of surgeon’s eyes, facing the surgeon on the side of the lesion. For example, during a cholecystectomy the monitor should be positioned on the patient’s right side in direct line of vision of the surgeon. While during a laparoscopic Nissen the surgeon stands between the legs of the patient in the French position with the monitor placed at the head of the patient facing the surgeon.
Ergonomics of
the Operating
Room (OR Table
Height, Monitor
Placement)
OR Table
The height of the table should correspond to the surgeon’s height, which will naturally place the surgeon’s arms at the correct position to maneuver the laparoscopic instruments. The wrists should be straight, and the elbows comfortable. If the wrists are flexed (Fig. 16.1), either the table is too high or the trocars are placed too high. To fix a height discrepancy between the surgeon and the table, one should either readjust the table or use steps. If the problem is not fixed with adjustment of the table, the ports are placed too high and need to be repositioned to a lower location.
N. Katkhouda, Advanced Laparoscopic Surgery,
DOI: 10.1007/978-3-540-74843-4_16, © Springer-Verlag Berlin Heidelberg 2011