Laparoscopic General Surgery

Myriam J. Curet MD¹

Sherry M. Wren MD¹

Maureen M. Tedesco MD¹

Ruth M. Fanning MB, BCh, MRCPI, FFARCSI²

Clifford A. Schmiesing MD (Laparoscopic general surgery)²

Jay B. Brodsky MD (Laparoscopic bariatric surgery)²

Jerry Ingrande MD, MS (Laparoscopic bariatric surgery)²

Brendan Carvalho MBBCh, FRCA (Laparoscopy in pregnancy)²

¹SURGEONS

²ANESTHESIOLOGISTS

LAPAROSCOPIC REPAIR OF PERFORATED PEPTIC ULCER

SURGICAL CONSIDERATIONS

Description: Duodenal ulcer perforation occurs in 5-10% of duodenal ulcer patients and is responsible for more than 70% of deaths associated with PUD. These patients can present in shock and often are extremely volume depleted. Open repair is indicated if the patient has a “hostile” abdomen, if there is simultaneous bleeding and perforation, if the patient is hemodynamically unstable, if the patient has significant cardiovascular or respiratory risk factors that would make them not tolerate a pneumoperitoneum, or if the surgeon has inadequate experience with the laparoscopic approach. In addition, trained OR personnel and equipment must be available. Risk factors associated with unsuccessful laparoscopic repair include shock on admission, delayed presentation (> 24 h), underlying comorbidities, age > 70 yr, and ASA III to IV. For laparoscopic repair, the patient is often placed in a modified lithotomy position with the surgeon standing between the legs. In this case, both arms can be left out. Alternatively, the patient may be in a supine position with the surgeon standing on the patient’s left side. In this case, the patient’s left arm should be tucked. The patient should be placed in a reverse Trendelenburg position. Access to the abdomen is obtained at the umbilicus with either a Veress needle or a Hasson technique (peritoneal entry through a ˜1 cm skin incision). Two to four additional ports are placed. Generally, the perforation site can be easily identified by laparoscopy. Occasionally, the surgeon may ask the anesthesiologist to insufflate air through an orogastric or nasogastric tube to help localize the perforation site. Several methods of repair have been reported. The most common involves suture closure of the perforation with omentopexy. Occasionally omentopexy or suture repair alone is used. Reports of closure with fibrin glue have also been published, although this technique may be associated with a higher leak rate. Some surgeons will perform endoscopy after repair to ensure adequate closure. Extensive irrigation of the peritoneal cavity (6-10 L or more) is recommended. The position of the operating table is frequently changed during irrigation to allow better access to the entire abdominal cavity. Adequate irrigation can take 20-30 min. Conversion rates are quite high (10-15%) with inability to localize the perforation the most common reason for conversion to open surgery.

▪ SUMMARY OF PROCEDURE

Position	Supine, low lithotomy
Incision	3-5 ports
Antibiotics	Cefoxitin 1-2 g iv preop
Surgical time	1-1.5 h
Closing considerations	Port closure only
Special instrumentation	Gastroscope; oro- or nasogastric tube
EBL	< 75 mL
Postop care	2-4 d hospital stay; liquids on postop day 1
Mortality	Typically < 0.1% (as high as 3% in some series)
Morbidity	6-10% overall, including: Abscess (2-8%) Suture leak (˜5%) Ileus (3-6%) pneumonia
Pain score	3

ANESTHETIC CONSIDERATIONS

See Anesthetic Considerations following Laparoscopic Cholecystectomy, p. 591.

Suggested Readings

1. Lunevicius R, Morkevicius M: Management strategies, early results, benefits, and risk factors of laparoscopic repair of perforated peptic ulcer. World J Surg 2005; 29(10):1299-310.

2. Sanabria AE, Morales CH, Villegas MI: Laparoscopic repair for perforated peptic ulcer disease. Cochrane Database Syst Rev 2005; 4:CD004778.

LAPAROSCOPIC ESOPHAGEAL FUNDOPLICATION

SURGICAL CONSIDERATIONS

Description: Approximately 40% of Americans suffer from heartburn, and most cases are treated medically. Indications for esophageal fundoplication (to ↑ lower esophageal sphincter pressure) include complications of GERD, such as stricture, respiratory problems, esophageal ulcerations, and Barrett’s esophagus (a premalignant condition). Other indications include failure of medical management or an unwillingness to submit to a lifetime of medication. Most patients with GERD are treated laparoscopically; those undergoing laparoscopic fundoplication have the benefits of a minimally invasive approach—decreased pain, earlier return of GI function, earlier ambulation, earlier discharge, quicker return to normal activities, decreased incidence of wound infections and hernias. The most common fundoplication is the Nissen (360°) wrap and its variations include the Rossetti modification, a Toupet (270° posterior) wrap, and the Dor (anterior) wrap. Before surgery, patients with GERD should have documented esophageal hyperacidity (by either pH probe or by esophagitis revealed on upper endoscopy), and also should have a hypotensive sphincter (demonstrated on manometry). Typically, they will have been treated with proton pump inhibitors (e.g., lansoprazole) and sometimes with prokinetic agents (e.g., metoclopramide). The patient is placed supine in a low lithotomy position, with the surgeon standing between the legs. The abdomen is entered ˜2 cm above the umbilicus with either a closed (Veress needle: blind placement) or open (Hasson trocar: direct visual placement through small skin incision) technique. A total of five trocars are inserted—two in the LUQ, two in the RUQ, and one at the umbilicus. The stomach should be decompressed either with an OG tube or with a gastroscope. The liver is elevated with a liver retractor, and the gastroesophageal (GE) junction and both diaphragmatic crura are dissected out. The hiatus should be closed with one or two sutures. The esophagus is encircled (Fig. 7.7-1A), and the vagal nerves are identified and preserved. The short gastrics are then taken down to decrease tension on the wrap. The fundus is brought in through the retroesophageal window (Fig. 7.7-2). An esophageal dilator (56-60 Fr) generally is placed (often by the anesthesiologist) to calibrate the wrap. Passage of the dilator is possibly the most hazardous part of the procedure because it may cause perforation of the esophagus at the GE junction. As the dilator approaches the stomach, it is important to watch the junction on the video monitors to ensure that the dilator is not being held at an angle that will risk perforation. The anesthesiologist should stop passing the dilator immediately if any resistance is felt. The dilator is withdrawn. An NG tube may be placed at this time.

Variant procedure or approaches: Open surgery (see Esophageal Surgery, p. 490) may be indicated if the patient has had previous gastric surgery or if there is a complication with an ongoing laparoscopic procedure. In the Rossetti modification, the short gastrics are not taken down, which decreases operative time. The Dor fundoplication is an anterior hemifundoplication in which the fundus is wrapped and sutured to the left and right sides of the esophagus and to the left and right crura, but anteriorly. A Dor fundoplication is often used in combination with a Heller myotomy for treatment of achalasia. A Toupet procedure (Fig. 7.7-1B) is a posterior hemifundoplication
in which the two walls of the fundus do not actually meet. The stomach is sewn to the left and right walls of the esophagus and then are anchored to the right and left crura. In the past, these procedures were performed commonly in patients with a high risk of postop dysphagia (e.g., those who have impaired esophageal peristalsis or a preop stricture). Now, because of their higher failure rate, they are seldom performed except in patients with severe esophageal dysmotility, such as patients with scleroderma. These procedures are identical to the Nissen fundoplication except for the wrap itself.

Figure 7.7-1. A: Nissen fundoplication. B: Partial fundoplication (Toupet procedure).

Figure 7.7-2. Gastric fundus is pulled posteriorly and to the right of the esophagus, with the fundus itself used as a retractor, reaching from right to left behind the esophagus to grasp the fundus and retract it back to the right side behind the esophagus. Placing caudad traction on the wrapped fundus, the GE junction and distal esophagus can be brought further into the abdominal cavity. (Reproduced with permission from Baker RJ, Fischer JE: Mastery of Surgery, Lippincott Williams & Wilkins, Philadelphia: 2001.)

Usual preop diagnosis: GERD, with or without esophagitis, esophageal stricture, or Barrett’s esophagus

▪ SUMMARY OF PROCEDURE

Position	Supine low lithotomy
Incision	Five ports, upper abdomen
Special instrumentation	Harmonic scalpel; bipolar cautery or endoscope. Esophageal dilators should be available.
Antibiotics	Cefazolin 1-2 g iv
Surgical time	1.5-2.5 h
Closing considerations	Port closures only; muscle relaxation may be needed for fascial closure
EBL	< 75 mL
Postop care	1-2 d hospital stay; liquids on pod 1
Mortality	< 0.1%
Morbidity	Overall: 8% Atelectasis: common Esophageal or gastric perforation: rare (most commonly associated with passage of NG tube or esophageal dilator) Hemorrhage from short gastrics or splenic tear Pneumothorax (does not usually require treatment) Postop dysphagia
Pain score	4

ANESTHETIC CONSIDERATIONS

See Anesthetic Considerations following Laparoscopic Cholecystectomy, p. 591.

Suggested Readings

1. Bammer TM, Hinder RA, Klaus A, et al: Five-to eight-year outcome of the first laparoscopic Nissen fundoplications. J Gastrointest Surg 2001; 5(1):42-8.

2. Champion JK, McKernan JB: Laparoscopic Toupet fundoplication. In: Zucker KA, ed. Surgical Laparoscopy, 2nd edition. Lippincott Williams & Wilkins, Philadelphia: 2001, 401-8.

3. Cowgill SM, Gillman R, Kraemer E, et al: Ten year follow up after laparoscopic Nissen fundoplication for gastroesophageal reflux disease. Am Surg 2007; 73(8):748-53.

4. Dallemagne B: Laparoscopic Nissen fundoplication. In: Ballantyne GH, ed. Atlas of Laparoscopic Surgery. WB Saunders, Philadelphia: 2000, 92-101.

5. Hughes SG, Chekan EG, Ali A, et al: Unusual complications following laparoscopic Nissen fundoplication. Surg Laparosc Endosc Percutan Tech 1999; 9(2):143-7.

6. Zucker KA: Laparoscopic Nissen fundoplication technique. In: Surgical Laparoscopy, 2nd edition. Lippincott Williams & Wilkins, Philadelphia: 2001, 375-400.

LAPAROSCOPIC HELLER MYOTOMY ± ANTIREFLUX PROCEDURE

SURGICAL CONSIDERATIONS

Description: Laparoscopic and thoracoscopic esophageal myotomies have become much more common over the last 5 yr as confidence in laparoscopic esophageal surgery—particularly antireflux surgery—has increased. These procedures are performed for achalasia, an uncommon condition in which the lower esophageal sphincter fails to relax with swallowing, and in which the body of the esophagus is aperistaltic and dilates. Patients typically complain of dysphagia with chest pain and may experience regurgitation. The etiology of this condition remains unknown.

Treatment options consist of pneumatic dilation, botulinum toxin injection of the lower esophageal sphincter, or surgical myotomy. Pneumatic dilation remains the most common procedure performed for achalasia and is effective in ˜60% of patients. Many gastroenterologists are reluctant to perform this procedure, however, because of the risk of esophageal perforation, which is generally considered to be ˜3-5%, but may be as high as 10%. Botulinum toxin injection is a newer technique that is effective to some degree in most patients, but the duration of its effectiveness is short. Most patients require retreatment within 1.5 yr, and the efficacy of retreatment may diminish over time. In many centers, surgical myotomy (Heller’s operation) has become the procedure of choice for the treatment of achalasia.

The patient is positioned as for a laparoscopic antireflux procedure—supine in the lithotomy position with reverse Trendelenburg. The abdomen is usually entered with a Veress needle (blind) or Hasson trocar (direct vision) at the umbilicus, and five laparoscopic ports are placed across the upper abdomen—two beneath the left costal margin, two beneath the right costal margin, and one in the midline either at the umbilicus or midway between the umbilicus and the xiphoid. The liver is elevated, and the ligamentous attachments anterior to the esophagus are divided. The esophagus is not usually encircled; and, as hiatal hernias are uncommon with achalasia, crural repair is seldom necessary.

The myotomy is begun at the gastroesophageal junction using monopolar cautery, bipolar scissors, or a harmonic scalpel (ultrasonic cutting/coagulation). It is carried proximally until normal musculature is encountered. Some surgeons perform intraop esophagoscopy to ensure that the myotomy has been carried proximally enough and that there has not been a mucosal perforation. Generally, a myotomy of 5-8 cm is adequate, although sometimes a longer myotomy may be necessary. Some surgeons then perform a very loose, partial fundoplication to prevent reflux. This can be performed as an anterior or posterior fundoplication, bringing the fundus either anterior (Dor fundoplication-our preference) or posterior (Toupet fundoplication) to the esophagus. The stomach is secured to the esophageal wall and crura with sutures, and an NG tube may be passed. The ports are removed and port closure carried out.

Variant procedure or approaches: Although most of these procedures are being performed laparoscopically, they also can be performed by thoracoscopy or thoracotomy. If a thoracoscopy or thoracotomy is performed, a DLT is placed to allow collapse of the left lung.

Usual preop diagnosis: Achalasia

▪ SUMMARY OF PROCEDURE

Position	Supine lithotomy, reverse Trendelenburg
Incision	Five ports, upper abdomen
Special instrumentation	Laparoscopic instrumentation ± gastroscope
Antibiotics	Cefazolin 1-2 g iv
Surgical time	1.5-2 h
Closing considerations	None
EBL	Minimal
Postop care	2-d hospital stay; liquids on pod 1
Mortality	Rare
Morbidity	Insignificant atelectasis: Common Esophageal or gastric perforation: Rare Pneumothorax (does not usually require treatment) Gastroesophageal reflux: > 15%
Pain score	4

ANESTHETIC CONSIDERATIONS

See Anesthetic Considerations following Laparoscopic Cholecystectomy, p. 591.

Suggested Readings

1. Bonatti H, Hinder RA, Klocker J, et al: Long-term results of laparoscopic Heller myotomy with partial fundoplication for the treatment of achalaisa. Am J Surg 2005; 190(6):874-8.

2. Bonavina L: Minimally invasive surgery for esophageal achalasia. World J Gastroenterol 2006; 12(37):5291-5.

3. Jeansonne LO, White BC, Pilger KE, et al: Ten-year follow-up of laparoscopic Heller myotomy for achalasia shows durability. Surg Endosc 2007; 21(9):1498-1502.

4. Sharp KW, Khaitan L, Scholz S, et al: 100 minimally invasive Heller myotomies: lessons learned. Ann Surg 2002; 235(5):631-9.

LAPAROSCOPIC CHOLECYSTECTOMY, ± COMMON DUCT EXPLORATION

SURGICAL CONSIDERATIONS

Description: This operation typically is performed for symptomatic gallstones or acute cholecystitis. A laparoscopic approach is preferred over an open cholecystectomy because of its minimally invasive nature, which allows earlier recovery and return to normal activities. Laparoscopic cholecystectomy may be contraindicated for patients with uncorrectable coagulopathy, severe COPD, or severe cardiac disease (unable to tolerate ↑ intraabdominal pressure). In addition, patients with prior abdominal surgery or with acute cholecystitis are at a higher risk for conversion to open surgery. The operation begins with access to the abdominal cavity at the umbilicus, either with a Veress needle (closed technique: blind placement) or a Hasson trocar (open technique: ↓ risk of vascular, bowel, and bladder injury). If a Veress needle is to be used, the patient will need an OG tube and a Foley catheter to decompress the stomach and bladder before proceeding. CO2 is insufflated to an intraabdominal pressure of 15 mm Hg. If the patient develops ventilatory or hemodynamic problems, consider decreasing the intraabdominal pressure to 10-12 mm Hg. A total of four trocars are used—one at the umbilicus and three in the RUQ. The patient is placed in a reverse Trendelenburg position and rotated to the left to move the stomach, duodenum, and transverse colon away from the operative field.

Figure 7.7-3. Surgical anatomy for laparoscopic cholecystectomy and common duct exploration.

The cystic artery and cystic duct (with hepatic duct = triangle of Calot) are clipped and cut (Fig. 7.7-3). The gallbladder is then dissected off the liver with monopolar cautery, placed in a bag, and brought out, usually through the umbilical cord site. Hemostasis is then achieved, the area is irrigated with NS, and the 10-mm trocar sites are closed. The rate of conversion to an open operation is ˜5% for elective gallbladder surgery and ˜10% for acute cholecystitis. Should this occur, the operation is then converted to an open cholecystectomy (see p. 572).

Cholangiography can be added easily to the laparoscopic cholecystectomy. A clip is placed high on the cystic duct; then a small incision is made in the duct just beneath the clip. A cholangiocatheter may be introduced and dye injected into the biliary tree. X-rays—either fluoroscopy or, more commonly, hard copy—are used to assess the biliary anatomy and to look for stones within the ductal system. Cholangiography carries few risks, generally adds about 10-15 min to the procedure, and can be used to identify the important anatomy ˜85% of the time. Some surgeons perform it routinely during all cholecystectomies; others perform it selectively and only if there is evidence that the patient has had common duct stones or if the anatomy is in question.

In rare circumstances, laparoscopic common duct exploration may be carried out to treat common duct stones. A number of techniques have been used, most employing a thin fiberoptic choledochoscope passed through the cystic duct into the common duct. This procedure is performed in only a relatively few centers. More commonly, endoscopic retrograde cholangiopancreatography (ERCP) will be used, either preop or postop, to demonstrate the presence or absence of stones and to remove any stones that are found.

Variant procedure or approaches: Open cholecystectomy (p. 572) remains the major alternative to laparoscopic cholecystectomy, either because the cholecystectomy is predicted to be technically difficult or because of the illness of the patient. Approximately 5% or less of laparoscopic cholecystectomies are converted to open cholecystectomy intraop because of difficulties with the procedure. ERCP remains the most common means of treating choledocholithiasis in the industrialized world with laparoscopic techniques used in a relatively small number of centers and by a small number of surgeons. Open common duct exploration is occasionally necessary for stones not retrievable by ERCP (generally < 5%).

Usual preop diagnosis: Acute or chronic cholecystitis, usually with cholelithiasis, with or without choledocholithiasis

SUMMARY OF PROCEDURE

Position	Supine
Incision	For upper abdominal ports
Special instrumentation	Routine laparoscopic instruments. May require fluoroscopy and choledochoscopes for cholangiography, common duct exploration; OG tube
Antibiotics	Cefazolin 1-2 g iv
Surgical time	0.5-2 h; may be longer for common duct exploration.
Closing considerations	Muscular relaxation helpful for closure of umbilical port site
EBL	Minimal
Postop care	Usual discharge within 24 h
Mortality	< 1/1000
Morbidity	Bile leak: 1% Common duct injury: 0.5% Hemorrhage (requiring transfusion) Infection Injury to bowel Major vascular injury: Uncommon
Pain score	3

ANESTHETIC CONSIDERATIONS

(Procedures covered: repair of perforated peptic ulcer; laparoscopic esophageal fundoplication; laparoscopic Heller’s myotomy and antireflux surgery; laparoscopic cholecystectomy)

PREOPERATIVE: LAPAROSCOPIC FUNDOPLICATION/HELLER’S MYOTOMY

Indication for surgery include failed optimal medical management, high volume reflux, severe esophagitis, and benign stricture. Severe reflux may lead to airway and pulmonary symptoms as well.

Respiratory	Patients may have a history of gastroesophageal reflux resulting in aspiration, particularly when recumbent. Recurrent aspiration may result in bronchospasm, pneumonia, and chronic pneumonitis. A prolonged history of reflux may give rise to premalignant Barrett’s esophagus, which may result in stricture formation and weakness of the esophageal wall. Achalasia may result in severe regurgitation and aspiration. Pulmonary physiological changes include both restrictive and obstructive lung defects and broncho-alveolar injury. Physical exam may show wheezing, and rhonchi. Tests: Consider PA & lateral CXR. Consider baseline arterial blood gases and pulmonary function tests if significant compromise of pulmonary function is present.
Cardiovascular	Patients with both reflux and achalasia may present with chest pain. Typically the pain of reflux is sharp and substernal. Chest pain in achalasia may radiate to the neck, back, and arms and may be difficult to differentiate from pain of cardiac origin. Differentiation should be made before surgery both by careful history taking and appropriate tests. Tests: Consider ECG (r/o MI as cause of pain), exercise or chemical stress testing if source of chest pain remains unclear. Other tests as indicated from H&P.
Laboratory	Patients with severe inflammation and erosion may suffer from an iron deficiency anemia. Consider CBC. Otherwise as indicated from H&P.
Premedication	These patients may be at risk for aspiration and should be treated with full-stomach precautions. H₂ antagonists and continue proton pump inhibitors.

PREOPERATIVE: LAPAROSCOPIC CHOLECYSTECTOMY

The preop evaluation of patients undergoing open cholecystectomy is discussed under Anesthetic Considerations for Biliary Tract Surgery, p. 580.

Respiratory	Patients presenting for laparoscopic cholecystectomy may present electively or acutely. Increasingly, cholecystectomy is performed in patients with acute cholecystitis. Patients presenting acutely may experience severe abdominal pain, leading to diaphragmatic splinting and basal lung atelectasis. During the procedure, intraabdominal CO₂ insufflation → atelectasis, ↓ FRC, ↑ PIP, ↑ PaCO₂ and ↓ PaO₂; therefore, laparoscopic procedures may be contraindicated in patients with severe respiratory or cardiovascular disease. Postop respiratory function, however, is less impaired (e.g., ↓ FRC 30% vs. 50%) and is recovered more quickly (24 h vs. 72 h) in patients undergoing laparoscopic cholecystectomy than in the open procedure.
Systemic	Patients presenting for laparoscopic cholecystectomy with acute cholecystitis may have evidence of mild to moderate sepsis. They may be febrile, tachycardic, and hypotensive and need resuscitation prior to surgery.
Laboratory	CBC. Consider T&S in patients with recurrent and chronic gall bladder disease. They may have liver adhesions. During the acute inflammatory stage there may be ↑ vascularity → bleeding.
Premedication	Consider midazolam 1-2 mg iv unless patient is unstable or septic. If urgent surgery, check for recent administration of analgesics.

INTRAOPERATIVE

Anesthetic technique: GETA

Induction	Laparoscopic fundoplication and Heller’s myotomy: Consider full stomach precautions and rapid sequence intubation technique (p. B-5). Additional iv access may be required if the arms are inaccessible. Laparoscopic cholecystectomy: Standard induction (p. B-2). In acutely unwell patients, despite resuscitation, patients may be more susceptible to the effects of anesthesia, and positive pressure ventilation. Consider additional iv access, invasive arterial pressure monitoring, and central access in unstable patients. Etomidate may be a useful induction agent in this setting. OG/NGT prior to incision to ensure stomach decompressed.
Maintenance	Standard maintenance (p. B-2). Continue muscle relaxation. Intraabdominal CO₂ insufflation will → ↑ intraabdominal pressure, which will predispose to passive regurgitation of gastric contents. In addition, intraabdominal pressure > 15 mm Hg → ↓ venous return + ↑ SVR → ↓ CO. Controlled ventilation will minimize the possibility of hypercarbia from absorbed CO₂.
Emergence	Given the high incidence of PONV, prophylactic antiemetic rx (e.g., ondansetron 4 mg iv) recommended and should be given 30-60 min before the end of the case (p. B-2).
Blood and fluid requirements	IV: 16-18 ga × 1 NS/LR @ 8-12 mL/kg/h Fluid warmer	Blood loss typically minimal with these procedures, but potential for major bleeding exists. Consider additional iv access, conversion to open procedure if risk factors for increased bleeding present.
Monitoring	Standard monitors (p. B-1) Urinary catheter OG/NG tube	Others as clinically indicated. Prevent hypothermia (forced-air warmer, warming blanket, warm OR, etc.)
Positioning	[check mark] and pad pressure points [check mark] eyes	Initially in Trendelenburg position (↑ venous return, ↓ lung volumes, potential for mainstem intubation) for trocar placement; then reverse Trendelenburg (↓ venous return, ↑ lung volumes) during subsequent portions of the surgical procedure.
Complications	Respiratory: Pneumoperitoneum Hypercarbia/hypoxemia Pneumothorax Pneumomediastinum Endobronchial intubation Cardiovascular: ↓ BP Hemorrhage Dysrhythmias Visceral injury Hypothermia Subcutaneous emphysema	Pneumoperitoneum with CO2 allows the surgeon to operate laparoscopically. This creates cephalad displacement of the diaphragm with ↓ FRC, ↓ pulmonary compliance, and atelectasis. This can manifest as ↑ PIP, ↓ PO₂ and ↑ PCO₂. Ventilation should be controlled during the operation to minimize the effects of pneumoperitoneum and hypercarbia. An increase in MV is appropriate. Pneumothorax can occur 2° retroperitoneal dissection of insufflated CO₂. Pneumothorax will manifest as ↓ PO₂, ↑ PIP, hemodynamic instability (↑ HR, ↓ BP), and possibly subcutaneous emphysema. The position of the ETT may change with altered patient position → endobronchial intubation. ↓ BP can occur 2° patient positioning (reverse Trendelenburg) and from ↓ venous return 2° pneumoperitoneum (↑ intraabdominal pressure > 15 mm Hg). Hemorrhage can result from inadvertent injury to blood vessels (during trocar placement). Vascular injection of CO2 (air embolism) can cause ↓ BP, dysrhythmias, and even cardiovascular collapse. If cardiopulmonary compromise occurs, the pneumoperitoneum can be released to allow for differential diagnosis and treatment. Injury to the viscera may necessitate an open procedure or may go undiagnosed and → other postop complications, depending on the organ that is injured. At all times, be prepared to convert to an open procedure. 2° dry gas insufflation Keep CO2 insufflation pressure < 12 mm Hg.

POSTOPERATIVE

Complications

PONV (common)

Shoulder pain

Respiratory

From pneumoperitoneum; usually self-limited (p. B-2).

Typical postoperative complications are secondary to pneumoperitoneum but mainly to pain.

Pain management

PCA (see p. C-3).

Oxycodone/hydrocodone in combination with acetaminophen

Shoulder pain responds to ketorolac (15-30 mg iv), or other NSAIDs provided there are no contraindications.

Tests

As indicated from H&P

Suggested Readings

1. Cunningham AJ, Nolan C: Anesthesia for minimally invasive surgery. In: Barash PG, Cullen BF, Stoelting, RK, eds. Clinical Anesthesia, 5th edition. Lippincott Williams & Wilkins, Philadelphia: 2006, 1061-71.

2. Feteiha MS, Curet MJ: Laparoscopic cholecystectomy. In: Zucker KA, ed. Surgical Laparoscopy, 2nd edition. Lippincott Williams & Wilkins, Philadelphia: 2001, 121-32.

3. Gadacz TR: Update on laparoscopic cholecystectomy, including a clinical pathway. Surg Clin North Am 2000; 80:1127-50.

4. Gurbuz AT, Peetz ME: The acute abdomen in the pregnant patient. Is there a role for laparoscopy? Surg Endosc 1997; 11(2):98-102.

5. Hein HA: Hemodynamic changes during laparoscopic cholecystectomy in patients with severe cardiac disease. J Clin Anesth 1997; 9(4):261-5.

6. Keus F, Broeders IA, van Laarhoven J: Gallstone disease: surgical aspects of symptomatic and acute cholecystitis. Best Pract Res Clin Gastroenterol 2006; 20(6):1031-51.

7. Keus F, de Jong JA, Gooszen HG, et al: Laparoscopic versus open cholecystectomy for patients with symptomatic cholecystolithiasis. Cochrane Database Syst Rev 2006; 18(4):CD006231.

8. Nakeeb A, Ahrendt SA, Pitt HA: Calculous biliary disease. In: Greenfield LJ, Mulholland MW, Lillemone MB, Dohersy GM, eds. Greenfield’s Surgery, 4th edition. Lippincott Williams & Wilkins, Philadelphia: 2006, 978-98.

LAPAROSCOPIC SPLENECTOMY

SURGICAL CONSIDERATIONS

Description: Laparoscopic-assisted splenectomy is best suited for normal or slightly enlarged spleens (e.g., idiopathic thrombocytopenic purpura [ITP]). Laparoscopic splenectomy usually is contraindicated in patients who have cancer, large hilar lymph nodes, or portal hypertension. At present, the only absolute contraindication to the procedure is massive splenomegaly, with spleens > 30 cm in the longitudinal axis. There is a high conversion rate (to open surgery) if the size of the spleen is between 20 and 30 cm. Sometimes a hand-assisted approach may be helpful for spleens in this size range. Conversion rates are higher in patients with perisplenitis and morbid myeloproliferative disorders. For the procedure, patients should be placed on a beanbag in a 45° lateral decubitus position or a full lateral decubitus position. The advantage of the 45° right lateral decubitus position is that it is easy to rotate the table and place the patient in a supine position if there is an urgent need for conversion. With the 45° lateral decubitus or the full lateral decubitus position, the kidney rest should be elevated and the OR table should be flexed to increase the area between the costal margin and the superior iliac crest. All pressure points should be padded, and the patient should be secured firmly to the table. The first trocar site is generally in the LUQ (see Fig. 7.7-5). Access can be with a closed (Veress needle or Optiview trocar) or open (Hasson trocar) approach. The initial approach may be to the hilum, short gastrics, or inferior pole. Most surgeons use the harmonic scalpel to take down the various ligaments and to dissect out the hilum, which generally is stapled with an endo GIA. The short gastrics are either taken down with the harmonic scalpel or are stapled. The lateral and superior attachments are taken down last. The spleen is then placed in a bag. Removal of the spleen can be done in several ways. Some surgeons remove it with a morselizer placed through one of the trocar sites. Others enlarge one trocar site slightly and remove the spleen in chunks. For very large spleens, some surgeons make a Pfannenstiel incision and extract it through the pelvis.

Figure 7.7-4. Anatomy of the spleen. (Reproduced with permission from Wind GG: The spleen. In Applied Laparoscopic Anatomy: Abdomen and Pelvis. Williams & Wilkins, Baltimore: 1997.)

Figure 7.7-5. Trocar location for splenectomy. (Reproduced with permission from Scott-Conner CEH, Dawson DL: Operative Anatomy, 2nd ed. Lippincott Williams & Wilkins, Philadelphia: 2003.)

Variant procedure or approaches: Open splenectomy (described on p. 645). A hand-assist device can be used for larger spleens. In such a case, a larger incision (˜5 cm) is made either in the midline or the pelvis and a hand is inserted to assist in retracting and dissecting the spleen, while improving visualization.

Usual preop diagnosis: Idiopathic thrombocytopenic purpura (ITP) (60%); hereditary spherocytosis (10%); hemolytic anemia (5%); thrombotic thrombocytopenic purpura (TTP) (5%); lymphoma (5%); hypersplenism (5%)

▪ SUMMARY OF PROCEDURE

Position	Usually 45° lateral decubitus, OR table flexed, beanbag
Incision	3-5 trocar ports; 1 enlarged to extract spleen
Special instrumentation	Vascular staplers; Harmonic scalpel; bipolar instruments Unique considerations Patients should have received vaccinations (pneumococcal, meningococcal, Haemophilus influenzae) preop. DVT prophylaxis; ± stress steroids; ± Plt transfusion.
Antibiotics	Cefazolin 1-2 g iv preop
Surgical time	1-3 h
Closing considerations	Rapid closure not requiring muscle relaxation (following search for accessory spleen)
EBL	< 100 mL; if significant enough to require transfusion, may require conversion to laparotomy.
Postop care	PACU → ward. Generally begin liquids pod 1 and discharge pod 2.
Mortality	0.1 % (predominately related to underlying disease)
Morbidity	5% Hemorrhage Pulmonary complications Injury to pancreas, stomach, or splenic flexure of colon
Pain score	5-6

ANESTHETIC CONSIDERATIONS

PREOPERATIVE

Patients present for laparoscopic splenectomy with a variety of diseases, including ITP, lymphomatous disease (Hodgkin’s and non-Hodgkin’s), autoimmune hemolytic anemia, TTP, hereditary spherocytosis, Evans syndrome, hairy-cell leukemia, hypersplenism 2° portal HTN, sarcoidosis, polycythemia vera, and myelofibrosis. Open splenectomy is usually reserved for traumatic laceration of the spleen. Previous upper abdominal surgery does contraindicate a laparoscopic approach. Laparoscopic cases tend to take longer than open splenectomies. Patients who have been treated with chemotherapeutic drugs will require careful preop exam to evaluate for potentially toxic side effects. See Anesthetic Considerations for (open) Splenectomy, p. 647. Patients should receive pneumococcal, meningococcal, and H. influenza vaccinations at least 1 wk preop.

Respiratory	Splenomegaly may cause left lower-lobe atelectasis. As intraabdominal CO₂ insufflation → further atelectasis, ↓ FRC, ↑ PIP, ↑ PaCO₂ and ↓ PaO₂; therefore, laparoscopic procedures may be contraindicated in patients with advanced lung disease. Tests: Consider P/A & lateral CXR; ABG and PFTs, if clinically indicated.
Cardiovascular	Cardiovascular changes caused by the pneumoperitoneum include ↓ venous return → ↓ CO and ↑ SVR.
Hematologic	Cytopenias are very common. Tests: CBC with differential & Plt count, T&S, consider T&C. Antibodies may be present → allow ↑ time for T&S/T&C. Platelet counts typically low but preop platelet transfusion usually not helpful due to immediate splenic sequestration.
Hepatic	Consider presence of coexisting hepatic dysfunction due to primary disease and/or therapy for it. Tests: Hepatic panel, PT/PTT
Laboratory	See above. As indicated from H&P.
Premedication	Standard premedication (p. B-1).