Introduction
The development of endoscopic surgery can be compared in importance to the introduction of anaesthesia into surgical practice and the impact will be felt well into the next century. The enthusiasm for the endoscope now is in marked contrast to the rejection of the laparoscope in the past. It is true that gynaecologists have always used laparoscopy but few general surgeons embraced the technique, mostly because only a limited number of organs could be seen and not many abdominal operations are possible with one eye and one hand occupied with a laparoscope. It is the development of video equipment that has made the revolution possible.
It was also fortuitous and fortunate that the first operation to make endoscopic surgery a household word should have been cholecystectomy. The endoscopic operation is identical to an open procedure, it is not particularly difficult to do in most cases, and the benefits to the patient were, and still are, dramatic. There has been some evidence of overenthusiasm. A few obsolete operations have been resurrected because they are easy to do laparoscopically and a few serious complications have occurred but overall the advantages are obvious and patients themselves have been pressing to have an endoscopic operation where possible.
The intention in this section is to illustrate what is presently possible in detail for some operations and in outline for others. Many more endoscopic operations will have been described by the time this chapter is published and we shall leave the reader to discover more information either elsewhere in this book or in a specialist text.
The abdomen
The significant disadvantages of a major abdominal wound and the success of laparoscopic cholecystectomy has ensured the rapid development of endoscopic abdominal surgery. The retroperitoneal organs, with the exception of the kidney, are inaccessible at the moment and most of the operations, like cholecystectomy, are endoscopic adaptations of a conventional operation. A few procedures, for example hernia repair, explore new ideas and more of these can be expected.
Gastroenterology
Laparoscopic cholecystectomy
Laparoscopic cholecystectomy was first performed in 1987 by Phillipe Mouret in Lyons, France. The operation was immediately accepted by the surgical community and has been followed by a worldwide wave of enthusiasm for endoscopic surgery. The laparoscopic operation reduces the access required to an absolute minimum whilst at the same time achieving the same objective as a conventional open cholecystectomy.
Patient selection
Every patient who needs a cholecystectomy and is fit for a general anaesthetic should be suitable for the laparoscopic technique although pregnancy and portal hypertension might make the operation difficult. However, some of these patients will also have stones in the bile duct and, at the present time, laparoscopic exploration of the ducts is not widely available. It is important to identify these patients in advance and we select patients for preoperative endoscopic cholangiography on the basis of a history of jaundice, abnormal liver function tests, and dilatation of the bile ducts on ultrasound examination. Normal liver function tests virtually exclude the presence of ductal stones and only half the patients with an abnormal ultrasound will have an abnormal ERCP (endoscopic retrograde cholangiopancreatography). Any stones that are found on the preoperative cholangiogram can be removed, when appropriate, through an endoscopic sphincterotomy and the patient can then have a laparoscopic cholecystectomy at a later date. Preoperative intravenous cholangiography is preferred in some centres.
There are no absolute contraindications to a laparoscopic operation although the discovery of some unsuspected disease or problem during a preliminary laparoscopy may require a full laparotomy. Obesity is not a contraindication. The view of the operative field is just as good in a fat patient as it is in a thin one and the absence of an abdominal incision reduces the incidence of complications. Dense peritoneal adhesions, acute cholecystitis, severe chronic cholecystitis, and difficulty in identifying the anatomy in Calot's triangle can make continuing with a laparoscopic operation dangerous. Conversion to an open operation in these circumstances, which is necessary in about 5 per cent of patients, demonstrates good surgical judgement and must not be regarded as a failure.
Principles
The principles of the laparoscopic operation are the same as those in an open procedure. The cystic duct and the cystic artery are dissected out, occluded and divided, and the gallbladder is then dissected out of the liver bed. Diathermy haemostasis is used where necessary and the gallbladder is extracted from the abdomen through either the umbilical or the epigastric port.
In contrast to the open operation the common bile duct is not always seen and retrograde dissection is not really feasible because upward retraction of the fundus of the gallbladder is essential for exposure of Calot's triangle. Cholangiography can be done before the cystic duct is ligated and divided if necessary.
Operative technique
Preparation
General anaesthesia with full abdominal relaxation is essential and patients should receive the usual prophylaxis against wound infection and venous thrombosis. A urethral catheter is unnecessary provided that the patient empties his or her bladder before coming to the theatre and we only insert a nasogastric tube if the stomach is distended with gas. The patient lies flat on the operating table and the surgeon stands on the left side with the television monitors and the associated electronic equipment on either side at the head of the table (Fig. 22) 865. Some surgeons prefer the patient in the Lloyd Davies position and stand between the legs to operate. The exposure of Calot's triangle is sometimes improved by elevating the head of the table and rotating the patient to the left.
Placing the cannulae
The Veress needle and the first 11 mm cannula are placed through the umbilicus (Fig. 23) 866. We do not hesitate to adopt an open technique if there is any difficulty and we always do so if there is a paraumbilical hernia as this can be repaired at the end of the operation. The abdomen is inspected as soon as the forward viewing endoscope is inserted although only the gallbladder, the stomach, and the liver are well seen in most circumstances.
Three further ports are needed and they should be placed under direct vision and after careful assessment of the anatomy of the individual patient. An 11 mm port is placed in the epigastrium and the tip should come through the right leaf of the falciform ligament. Two 5.5 mm ports are placed immediately below the right costal margin (Fig. 23) 866. The medial one should complement the epigastric port and lie in the correct position in relation to the operative field whilst the lateral one is placed over the fundus of the gallbladder.
Occasionally in fat patients a fifth port to depress the duodenum and the colon is helpful and then a 5.5 mm cannula is inserted just to the left of the midline halfway between the umbilical and the epigastric ports. Cholangiography catheters and t-tube drains either come with their own special ports or are inserted through separate small incisions placed below the costal margin.
Dissecting Calot's triangle
A grasping forceps is placed through the right lateral port and is fixed to the fundus of the gallbladder. The gallbladder and the attached liver are then retracted upwards towards the patient's right shoulder. This opens up the subhepatic space (Fig. 24) 867. Any adhesions to the gallbladder are divided and a second grasping forceps is attached to the neck of the gallbladder and pulled laterally to expose Calot's triangle.
Dissection through the epigastric port with the dolphin nosed forceps (Fig. 25) 868 starts at the junction of the gallbladder with the cystic duct. The peritoneum, fat, and loose areolar tissue around the gallbladder is grasped and gently torn down towards the bile duct. This continues until the inferior aspect of the cystic duct is clearly seen. Any troublesome bleeding should be stopped at once with diathermy but care must be taken not to burn the bile duct. The superior aspect of the cystic duct is cleaned in the same way and eventually the duct is surrounded. Curved forceps can be useful for this (Fig. 26) 869. The cystic duct is therefore clearly identified as a direct extension from the neck of the gallbladder and this is important because the junction of the cystic duct with the common bile duct is not always seen. Most of this dissection is done from the front but by varying the position and the placement of the forceps on the neck of the gallbladder it is often possible to expose the posterior aspect of Calot's triangle. The cystic artery is then exposed in the same way (Fig. 27) 870. Both structures are clipped and divided (Fig. 28) 871. Sometimes the cystic duct must be divided before the cystic artery can be safely dissected. Occasionally the cystic duct is too large to fit inside a clip. It must then be tied off with a Roeder knot.
The dissection is not always easy, particularly if there is a lot of fibrosis from chronic inflammation. The loss of tactile sensation is a disadvantage but there are some substitutes. Significant structures, such as an artery or a duct, contain elastic tissue and will twang if they are tweaked. Fibrous tissue has no such elasticity. As always it is important not to rush a difficult dissection because time often reveals the anatomy. Furthermore the variations in anatomy are no different from an open operation and the same rules therefore apply. No significant structure should be divided until the surgeon and his assistant are completely happy that they both understand the anatomy.
Peroperative cholangiography
The technique is identical to open cholangiography although it is rarely needed if a policy of preoperative cholangiography is adopted (Fig. 29) 872. A cholangiogram will delineate the anatomy but if this is in doubt it is probably safer to convert to an open operation.
The cystic duct is occluded distally with a clip and a small proximal incision is made in the cystic duct with fine scissors. A catheter is guided into the duct and held there with a special instrument or a loosely applied titanium clip. Air bubbles must be excluded and the ports, which are radio-opaque, should be held out of the way while the radiographs are taken. We usually use a 1.3 mm umbilical catheter inserted through an intravenous cannula (size 14) although specially designed cholangiography catheters each with its own introducer are available.
Dissection and removal of the gallbladder
Once the cystic duct and the cystic artery are divided the free edge of the lesser omentum falls away. The midcostal grasper is repositioned just above the cystic duct clip and it is pulled upwards and away from the liver to expose the plane between the liver and the gallbladder. The gallbladder is then dissected off the liver bed with scissors, diathermy, or a laser beam starting at the neck (Fig. 30) 873. All the bleeding points on the liver bed are coagulated as dissection proceeds until the gallbladder is only just attached to the liver at the fundus. Any bile or blood that has accumulated is sucked away and, if necessary, a drain is placed in the gallbladder bed before this final strand is divided.
Dissection at the fundus is often difficult and simply requires patience and constant changes of position. If the gallbladder is perforated, and this is preferable to entering the liver itself, the bile and as many stones as possible should be removed. Nevertheless stones are often left behind in the peritoneal cavity where, somewhat surprisingly, they very rarely cause complications.
Once the gallbladder is free the cystic duct is drawn into one of the 11 mm ports and the port and the gallbladder are withdrawn together through the abdominal wall. Usually the fundus of the gallbladder and any contained stones remain within the abdomen and they must be manipulated through the wound. Crushing any large stones, sucking away the bile or extending the incision are sometimes necessary and all of these are easier to do if the gallbladder is inside a plastic bag.
A final inspection of the abdomen is appropriate before all the carbon dioxide gas is allowed to escape and the cannulae are removed. We only suture the abdominal wall if a wound has been enlarged and we prefer to close the skin with adhesive tape rather than with sutures.
Management of stones in the bile duct
The best management of bile duct stones in this new endoscopic era is not yet clear. We prefer to remove any stones from the bile duct at an ERCP procedure before embarking on a laparoscopic operation but this may not be appropriate and, sometimes, is impossible.
Large stones, which tend to occur in older patients with grossly dilated bile ducts, always cause difficulty at endoscopy but they are relatively easy to remove at a laparoscopic exploration of the bile ducts. In young patients it is best not to divide the ampullary sphincter and the duct must be explored surgically. The choice lies between a conventional open operation or one of the newer laparoscopic techniques.
Stones can be extracted from the bile duct through the cystic duct if it is first dilated with a suitable balloon. Instruments, including a narrow cholangioscope, can then be passed into the bile duct and the stones retrieved or broken up under direct vision. Stones in the hepatic ducts are difficult to find, particularly if the cystic duct enters the common duct low down behind the pancreas. A fine tube can be left in the cystic duct at the end to act as a drain and to permit later cholangiography. The precise place of this technique in endoscopic practice is not yet clear.
Direct endoscopic exploration of the bile duct is quite straightforward. A 30° forward oblique telescope gives the best view of the bile duct and a supraduodenal choledochotomy is easily made in the anterior surface of the duct with the diathermy hook and scissors. Stones can be washed out of the duct or removed with a balloon or a basket (Fig. 31) 874. The ducts are then inspected with a choledochoscope and any remaining stones are removed. At the end a t-tube is sutured into the bile duct.
If stones are discovered in the bile ducts unexpectedly during the course of a laparoscopic cholecystectomy the surgeon is left in something of a dilemma. Small stones can probably be safely left to pass spontaneously. Larger stones need to be removed either immediately and surgically or at a later ERCP.
All three choices have disadvantages and deciding between them depends on the findings in the individual patient, the equipment available, and the skill and experience of the surgeon. If stones are left behind in the ducts it is probably wise to leave a drain down to the cystic duct stump in case it leaks. An ERCP should be done within a day or two of operation to remove any residual stones and as soon as retained stones are discovered.
Difficulties and complications
Inserting a cannula or the Veress needle can cause spectacular damage and invisible retroperitoneal aortic injury is one cause of an acute collapse during a laparoscopic operation. Such injuries are fortunately very rare.
Sudden severe haemorrhage is always a problem and it is best avoided in the first place. A torn cystic artery or a liver laceration are the common causes and haemorrhage from either can be difficult to stop. The usual general principles apply. Blood and clot are sucked or washed away and the best possible exposure is obtained whilst the surgeon applies local pressure to the bleeding area. The scrub nurse prepares the diathermy and a titanium clip applier and when everything is ready the pressure is removed and the bleeding point is identified and occluded. This is much more difficult to achieve with the limitations on movement in an endoscopic environment and there is sometimes no alternative to a laparotomy.
Every surgeon fears damaging a bile duct. In large published series the accident happens once in every 300 laparoscopic cholecystectomies. This is slightly more frequent than during an open operation and probably reflects the introduction of a new technique rather than a fundamental flaw in the operation. Great care should be taken to identify the anatomy correctly and to place any clips properly. It is very easy for a titanium clip to be placed so that the tips partially occlude the bile duct without the surgeon appreciating what has happened and any doubts about the anatomy should lead to an immediate laparotomy. The next most important aspect of a bile duct injury is that it should be recognized at the time. Late presentation of biliary damage is always associated with a poorer outcome. Exactly what is done depends upon the injury and when it is recognized but a laparotomy will usually be needed.
Reactionary haemorrhage is rare and generally requires a laparotomy although with increasing experience a repeat laparoscopy may be sufficient. Bile leaks from the cystic duct stump or the liver bed present with pain in the right upper quadrant, fever and a subhepatic collection on ultrasound. The bile is removed with a percutaneous drain and the leak is identified at an ERCP and is stopped by placing a stent in the bile duct. The drain remains until the drainage ceases and the stent is removed not less than 2 months later. Surprisingly a simple sphincterotomy will not allow the leak to close. A few patients present with a previously unidentified bile duct stone within a few months of their operation and the stone should be removed through an endoscopic sphincterotomy.
Benefits and results
The mortality rate following a laparoscopic cholecystectomy is about 0.1 per cent and the complication rate is about 4 per cent. Both figures are much better than those for an open operation and the cosmetic benefits of four small incisions are important to many patients. At the moment about 1 in every 20 patients needs a laparotomy although we can expect this figure to improve as experience increases. Patients must be warned about this beforehand and sign an appropriate consent form.
Most patients are mobile and can eat and drink later the same day. Some patients are troubled by nausea and vomiting but very few need opiate analgesia. Any drain can be removed after about 12 h and most patients can then go home. The majority are back at work within 2 weeks.
Laparoscopic appendicectomy
Laparoscopic appendicectomy combines the advantages of diagnosis and treatment in one procedure. The usual preoperative preparation is necessary and prophylactic antibiotics are given on induction of general anaesthesia. The patient must consent to an open operation should it be needed.
Placing the cannulae
The patient lies flat on the operating table and the bladder is emptied. After creating the pneumoperitoneum an 11 mm port and endoscope are placed through the umbilicus and the diagnosis is confirmed. Two further ports are needed on either side of the abdomen and should be placed in relation to the position of the appendix. An 11 mm port is placed in the right iliac fossa and a 5.5 mm port in the left iliac fossa.
Operative technique
Any local adhesions are gently divided and the tip of the appendix is grasped and drawn into the port in the right iliac fossa. The appendix mesentery is occluded with bipolar diathermy or a ligature around the appendicular artery and then divided. The base of the appendix is secured with a Roeder knot and then occluded beyond the ligature with bipolar diathermy. The appendix is divided across the burnt area and is removed through the right iliac fossa port. It is not necessary to bury the appendix stump. Free peritoneal fluid or pus can be sucked away and the peritoneal cavity washed although it is important not to flood infected fluid into the pelvis or the subphrenic spaces. It is easy to place a drain to the appendix stump if necessary and the pneumoperitoneum is then released and the ports removed.
Postoperative management
Most patients have less pain from the wounds than after a conventional appendicectomy but the recovery time is only slightly improved. Many patients are toxic from the infection and take time to recover whatever method is used to remove the appendix.
Complications
The only complication specific to the laparoscopic procedure is a low incidence of reactionary haemorrhage as a result of failure to occlude the appendicular artery properly. Septic complications occur just as with any other appendicectomy although wound infection is less serious.
Laparoscopic colectomy
Laparoscopic colonic resection is already possible for the techniques involved are no different to those used in a laparoscopic cholecystectomy or appendicectomy. However, tying and dividing the mesentery can be very tedious and the resection may not include all the important lymph nodes. It also takes a long time and considerable skill to construct a hand-sewn intraperitoneal anastomosis and although stapling guns can help they are presently too expensive for routine use. So a complete laparoscopic colonic resection is not really a practical option at the moment although this situation is unlikely to persist as new technological developments are introduced.
Nevertheless endoscopic techniques can be useful during colonic resection in certain patients. Division of the mesentery under laparoscopic vision is fairly straightforward (Fig. 32) 875 and the segment of bowel can be delivered through a small discreetly placed incision, the resection and anastomosis being completed outside the abdominal cavity. The bowel is returned to the abdomen and any necessary drains are placed before all the ports are withdrawn and the incision closed. This approach minimizes the trauma to the patient and overcomes the problem of removing the specimen from the abdominal cavity.
Other gastrointestinal operations
Once the ideas and the concepts of an endoscopic operation are accepted it takes very little imagination to transfer almost every operation to an endoscopic procedure. Indeed most abdominal operations have already been done laparoscopically somewhere in the world.
Operations around the stomach, such as fundoplication and pyloromyotomy in neonates, are relatively easy to do although there is little demand for vagotomy. Small bowel resections are mostly required during emergency operations and although endoscopic techniques are described most surgeons will be naturally hesitant to embark on such procedures at the moment. The same remarks apply to splenectomy. Liver resections are clearly impractical at present but it is easy to deroof a liver cyst with a diathermy hook and bleeding from a liver biopsy site can often be controlled with a laparoscopic technique, thus avoiding a laparotomy. In both instances it is quite possible to suck away blood or other fluids lying in the peritoneal cavity.
Emergency laparoscopic surgery is still being developed. A perforated anterior duodenal ulcer is easy to close with an omental patch through the laparoscope as any surgeon who has done a laparoscopic cholecystectomy will appreciate. Laparoscopy for intestinal obstruction is difficult because of the distension but it is possible to decompress the bowel and then to divide an adhesive band. Some reports have also suggested that laparoscopy and laparoscopic surgical techniques are useful in patients with abdominal trauma.
Urology
Laparoscopic nephrectomy
This is the only laparoscopic procedure to remove a retroperitoneal organ although the kidney is approached across the peritoneum. The operation can take some time to do and at the moment it is probably best reserved for benign diseases of the kidney.
The patient is placed in the traditional lateral position and the endoscope is inserted at the lateral border of the rectus abdominis muscle level with the umbilicus. Three or four further ports are needed. The peritoneum on the lateral side of the colon is divided and the bowel falls away under gravity. The ureter is identified at the pelvic brim and traced up to the hilum of the kidney. The vascular pedicle is divided with a special stapling gun which inserts six rows of fine vascular staples and divides the tissues down the middle all in one action. The kidney is then freed from its surrounding attachments and removed from the abdomen within a laparoscopic organ bag.
Laparoscopic varicocelectomy
This is a straightforward day-case procedure that divides the testicular veins just above the internal inguinal ring. The endoscope is inserted through the umbilicus in the usual way and two 5.5 mm ports are required on either side of the umbilicus. The testicular vessels are easily seen through the peritoneum just inside the internal inguinal ring and it is a simple matter to divide the peritoneum with scissors, dissect out the testicular veins from the testicular artery, clip the veins, and excise a segment (Fig. 33) 876. Even if the testicular artery is inadvertently included in a clip the testicle should still survive provided that the branches to the spermatic cord from the inferior epigastric artery are not damaged.
Other urological operations
Peritoneal dialysis is widely used in the long-term treatment of chronic renal failure but the Silastic catheter is easily blocked by displacement of the tube out of the pelvis or with omentum wrapped around the side holes. It is easy to insufflate the abdomen through the catheter, remove any omentum adherent to the tubing, and to replace the coiled tip in the pelvis using the laparoscope and a suitable grabber passed though one 5.5 mm port. Transplanted kidneys are sometimes surrounded by collections of lymph (lymphocele) and if percutaneous drainage fails fenestration of the lymphocele into the peritoneal cavity is the best method of treatment. It is easy to cut a hole in the peritoneal wall of a lymphocele with a diathermy hook (Fig. 34) 877. In both instances the benefit to the patient of avoiding a laparotomy is obvious.
Gynaecology
In some respects endoscopic surgery has not advanced so rapidly in gynaecology. This is partly because transcervical resection of the endometrium has reduced the need for hysterectomy but also because a laparoscopic hysterectomy, which is perfectly possible, is regarded by some gynaecologists as a rather more complicated version of a vaginal hysterectomy. Endoscopic operations on the fallopian tubes and the ovaries certainly have a place and are particularly valuable in preserving tubal function after the removal of an ectopic pregnancy for example. Laser ablation of endometriosis and the division of pelvic adhesions have been standard for many years and pelvic lymphadenectomy, which is a popular procedure in the United States, is an ideal operation for the endoscopist. For a detailed description of all these operations the reader is referred to a specialist text.
The abdominal wall
Laparoscopic inguinal hernia repair
Most inguinal hernias are repaired through a groin incision and approach the inguinal canal by division of the external oblique aponeurosis. The posterior or preperitoneal approach is also popular but it still involves an incision through the abdominal wall muscles. Either operation is decidedly uncomfortable and very few patients are back at work in less than a month. A nylon darn is the most popular method of repair but synthetic mesh is also used and seems to be particularly successful when it is placed in the preperitoneal plane. Laparoscopic hernia repair avoids the inguinal incision and combines the advantages of plastic mesh and the preperitoneal approach. As in paediatric surgery, where endoscopic hernia repair is not yet established, laparoscopy also identifies the patient with a hernia on the other side.
We describe below a transabdominal extraperitoneal mesh repair of an inguinal hernia which is one technique among many. We do not yet know which is the best, but it is certain that the operative anatomy is strange, the access is awkward, and the iliac vessels are alarmingly close to the operation site.
Principles
The basic objective of a laparoscopic inguinal hernia repair is to deal with the peritoneal sac and then to staple a sheet of plastic mesh over the muscular defect. A direct sac and a small indirect one can normally be easily pulled back into the abdominal cavity. A large indirect sac is best transected at the internal inguinal ring and the residual peritoneum left in the inguinal canal. The peritoneum must also be removed from a femoral hernia but it is then sufficient to plug the femoral canal with a roll of plastic mesh.
Operative technique
General anaesthesia with good relaxation of the abdominal wall is required and all our patients are given prophylactic antibiotics. The patient lies flat on the table although a little head-down tilt is sometimes helpful. A 10 mm endoscope is inserted through the umbilicus and the operation site inspected. Two further ports are needed, one on each side of the umbilicus at the lateral edge of the rectus abdominis. A large 12 mm port to take the stapler is placed on the side of the hernia and a 5.5 mm port on the other side (Fig. 35) 878.
An indirect hernia is very different in appearance from a direct one. The direct sac is a wide necked defect straight through the anterior abdominal wall flanked on the lateral side by the inferior epigastric vessels and medially by the umbilical ligament. An indirect hernia clearly runs obliquely through the abdominal wall muscles and the end of the sac cannot usually be seen. The testicular vessels are visible in the inferolateral corner of the sac at the internal inguinal ring whilst the vas appears as a white cord slipping out of the inferomedial corner and running down over the iliac vessels into the pelvis (Fig. 36) 879.
The operation starts well lateral and superior to the hernia sac by dividing the peritoneum. The peritoneal incision continues horizontally across the top of the internal ring and up to, and sometimes into, the umbilical ligament. The peritoneum is then dissected downwards and is thus pulled out of the hernia although sometimes the sac is best circumcised at its neck.
The testicular vessels and the vas are often rather adherent and the dissection can be somewhat difficult at this stage. The abdominal wall muscles and the inferior epigastric vessels should then be cleaned of any fatty tissue.
At this point the anatomy of the whole area should be apparent. Medially the pubic tubercle should be palpable with Cooper's ligament running away posteriorly and laterally. Anteriorly and laterally the posterior aspect of the conjoint tendon should be visible spreading behind the inferior epigastric vessels. The inguinal ligament is rarely identified. A 10 cm by 5 cm sheet of Prolene mesh is rolled up and passed into the peritoneal cavity through the 12 mm port. It is unravelled, manipulated to cover the margins of the hernia defect, and stapled in place. Medially the inferior margin of the mesh can be stapled to Cooper's ligament but laterally great care must be taken not to damage the testicular vessels, the vas, and the femoral nerve. An angled stapling gun helps to place the staples correctly (Fig. 37) 880.
Finally the original peritoneal layer is lifted back up over the mesh and stapled back to the peritoneum on the anterior abdominal wall. Deflating the abdomen can make this easier. The ports are then removed and the muscles at the site of the 12 mm port are sutured if necessary.
Postoperative management
Most patients are up and about later the same day and many of them can go home. There is no reason to restrict their activity in any way as the repair does not depend on muscles healing together and although most patients experience some discomfort in the groin they do not need much analgesia. Most patients are back at work within 2 weeks.
Complications
One alarming development is gross gaseous distension of the scrotum at the end of the operation. Fortunately the carbon dioxide is rapidly absorbed with no serious consequences. An inguinal haematoma is a nuisance and damage to the femoral nerve is a cause of persistent pain in the wound. Infection around the mesh is rare. So far as recurrence is concerned this type of laparoscopic operation appears to have recurrence rates very comparable to the open operation, but only time will tell if the conjecture is true.
The chest
Transthoracic cervical sympathectomy
All the conventional open approaches to the cervical sympathetic trunk are unsatisfactory, either because of poor access and inadequate exposure, or the proximity of important structures. In contrast, the endoscopic operation is easy and safe and the surgeon has an excellent view of the sympathetic trunk. The procedure itself is simple, elegant, and quick.
A pneumothorax with carbon dioxide is created with the patient fully anaesthetized and lying flat on the operating table with the arms abducted to 60°. A 5 mm endoscope is introduced into the chest in the fourth intercostal space at the anterior axillary line and the cervical sympathetic trunk is immediately visible under the parietal pleura on the necks of the 2nd, 3rd, 4th, and 5th ribs (Fig. 38) 881. The stellate ganglion is sometimes seen superiorly. Through a separate port in the fifth intercostal space it is a simple matter to divide the sympathetic trunk just below the stellate ganglion and either to excise a segment or obliterate the chain with diathermy over the second, third, and fourth ribs. A special port with a channel for the endoscope and one for the instruments is available and means that the operation can be done with only one puncture. Both sides can be done at the same time and most patients can go home the next day.
Other thoracoscopic operations
Any technique that avoids a painful thoracotomy is to be welcomed and the new stapling instruments make any form of endoscopic pulmonary resection relatively easy although the specimen has to be removed within an organ bag.
Mediastinal operations and oesophageal resections are also feasible. There are two approaches to oesophageal resection. In one technique the abdominal and cervical dissections take place through conventional incisions but the thoracic oesophagus is mobilized endoscopically across either pleural cavity. The oesophagus and stomach are pulled up into the cervical incision, the tumour resected, and then continuity is restored.
An alternative approach is to mobilize the oesophagus within the mediastinum by dissection under endoscopic vision using a specially designed instrument which is inserted through a cervical incision and slowly advanced down the mediastinum alongside the oesophagus. The stomach is mobilized laparoscopically and, once again, everything is drawn up into the neck where the resection and the anastomosis are performed.
CONCLUSION
Endoscopic techniques are already widely used in other surgical specialties that we have not discussed. Arthroscopy has revolutionized operations on the knee in orthopaedics, for example, and nasal operations are much more accurate when viewed through an endoscope. Every branch of surgery will be influenced in due course and even now fine endoscopes are being made that can be inserted through a tiny burr hole into the subarachnoid space to examine the surface of the brain. It will not be long before neurosurgical operations are possible without the need for a craniotomy.
New operations and new ways of performing old operations are being developed with astonishing speed and endoscopic surgery is still in its infancy. Many future developments will depend on advances in technology but they will also depend on surgical skill. It is also of critical importance that proper evaluation of these developments takes place continually, not only in assessing the quality of the results of endoscopic surgery, but also the cost effectiveness of these procedures.