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58
2.5 Anesthesia in Videolaparoscopic and Thoracoscopic Surgery
45
40
Group1
35
30
25
20
Group 2
15
10
Piritramid consumption (mg)
5
0
123456810
Measuring intervals (hrs.)
Fig. 2.5.3 A significantly smaller quantity of postoperative opioid anal-
gesics (piritramid) is required during patient-controlled analgesia in the
laparoscopic surgery group (group 2) as compared with the conventional
lower abdominal surgery group (group 1).
Bibliography
Braun U, Voigt E. Die Rolle von ventilatorischen Verteilungsstörungen bei der
späten postoperativen Hypoxämie nach Oberbauchlaparotomien. Anesthesist 1978; 27:163.
Crozier TA, Hamo M, Braun U. Lungenfunktionsveränderungen und späte
Hypoxämie nach laparoskopischer Cholezystektomie. In Vorb.
Crozier TA, Sydow M, Siewert JR, Braun U. Postoperative pulmonary compli-
cation rate and long-term changes in respiratory function following
esophagectomy with esophagogastrostomy. Acta Anaesth. Scand 1992;
36:10.
Eger EH, Saidmann LJ. Hazards of nitrous oxide bowel obstruction and
pneumothorax. Anesthesiology 1965; 26:61.
Felts JA, Poler SM, Spitznagel EL. Nitrous oxide, nausea, and vomiting after
outpatient gynecologic surgery. J. Clin. Anaesth. 1990; 2:168.
Frazee RC, Roberts JW, Okeson GC, Symmonds RE, Snyder SK, Hendricks JC,
Smith RW. Open vs. laparoscopic cholecystectomy. Ann. Surg. 1991;
213:651.
Greville AC, Clements EA, Erwin DC, McMillan DL, Wellwood JM. Pulmonary
air embolism during laparoscopic laser cholecystectomy. Anaesthesia
1991; 46:113.
Hanekop GG, Bautz M, Crozier TA, Ensink FBM, Decking R, Lüders H, Kettler
D. Postoperative Analgesie − eine vergleichende Studie bei laparoskopischen Cholezysektomien und Unterbaulaparotomien. Zentralbl.
Chir. 1993; 118:592.
Hovorka J, Korttila K, Erkola O: Nitrous oxide does not increase nausea and
vomiting following gynaecological laparoscopy. Can. J. Anaesth. 1989;
36:183.
Johannsen G, Andersen M, Juhl B. The effect of general anaesthesia on the
haemodynamic events during laparoscopy with CO
Scand. Anaesthesiol. 1989; 33:132.
Joris J, Cigarini I, Legrand M, Jacquet N, DeGroote D, Franchimont P, Lamy M.
Metabolic and respiratory changes after cholecystectomy performed via
laparotomy or laparoscopy. Brit. J. Anaesth. 1992; 69:341.
Kelman GR, Swapp GH, Smith I, Benzie RJ, Gordon NLM. Cardiac output and
arterial blood-gas tension during laparoscopy. Brit. J. Anaesth. 1972;
44:1155.
-insufflation. Acta
2
operative observation in the recovery room, and sufficient postoperative analgesia. To this extent, the perioperative anesthetic
management of the laparoscopic surgery patient does not present any special problem for the anesthesiologist. Here too, intraoperative and postoperative complications are most effectively reduced when the surgeon and anesthesiologist
cooperate closely in assessing clinical considerations when
deciding whether this method is indicated.
Leighton TA, Lio S-Y, Bongard FS. Comparative cardiopulmonary effects of
carbon dioxide versus helium pneumoperitoneum. Surgery 1993; 113:527.
Luiz T, Huber T, Hartung HJ. Veränderungen der Ventilation während la-
paroskopischer Cholezystektomie. Anaesthesist 1992; 41:520.
McGrath BJ, Zimmermann JE, Williams JF, Parmet J. Carbon dioxide em-
bolism treated with hyperbaric oxygen. Can. J. Anaesth. 1989; 36:586.
Peterson HB, DeStefano F, Rubin GL, Greenspan JR, Lee NC, Ory HW. Deaths
attributable to tubal sterilization in the United States, 1977 to 1981. Amer.
J. Obstet. Gynec. 1983; 146:131.
Rademaker BM, Ringers J, Odoom JA, de Wilt LT, Kalkman CJ, Oosting J. Pul-
monary function and stress response after laparoscopic cholecystectomy:
comparison with subcostal incision and influence of thoracic epidural
analgesia. Anesth. Analg. 1992; 75:381.
Riedel H, Lehmann-Willenbrock E, Mecke H, Semm K. Die Häufigkeitsver-
teilung verschiedener pelviskopischer (laparoskopischer) Operationsverfahren und deren Komplikationsraten. Eine Statistik der Bundesrepublik
Deutschland der Jahre 1983 bis einschließlich 1985. Geburtshilfe Frauenheilk. 1988; 48:791.
Steffey EP,Johnson BH, Eger EI. Nitrous oxide intensifies the pulmonary arte-
rial pressure response to venous injection of carbon dioxide in the dog.
Anaesthesiology 1980; 52:52.
Tannière-Ruflé ML, Rius J, Levante A, Conseiller C. Preoperative assessment
classification of risk. In Conseiller C, Cousin MT, Desmonts JM et al. Complications of anesthesia operative risk, p. 285. Amsterdam: Excerpta Medica; 198.
Taylor E, Feinstein R, White PF, Soper N. Anaesthesia for laparoscopic
cholecystectomy: Is nitrous oxide contraindicated? Anesthesiology 1992;
76:541.
VacantiCJ, Van Hourten RJ, Hill RC. A statistical analysis of the relationship of
phyiscal status to postoperative mortality in 68 388 cases. Anesth. Analg.
Curr. Res. 1970; 49:564.
Voigt E, Braun U, Schorer R. Closing volume und ventilatorische Verteilungs-
störungen. Anaesthesist 1976; 25:112.
WeylandW,Crozier TA, Bräuer A,Georgius P,Weyland A, Neufang T, Braun U.
Anästhesiologische Besonderheiten der operativen Phase bei laparoskopischen Operationen. Zbl. Chir. 1993; 118:582.
Wittgen CM, Andrus CH, Fitzgerald SD, Baudendistel LJ, Dahms TE, Kaminski
DL. Analysis of the hemodynamic and ventilatory effects of laparoscopic
cholecystectomy. Arch. Surg. 1991; 126:997.
3. Laparoscopic Exploration, Diagnosis, and Staging
3.1 Visual Exploration of the Peritoneal Cavity
F. Götz, A. Pier
59
Goals and Methods
Laparoscopic exploration of the peritoneal cavity was first performed in dogs by Kelling in 1901. Jacobaeus, in 1909, was the
first surgeon to practice exploratory laparoscopy in a clinical
setting. Today, visual exploration of the peritoneal cavity is the
first step in any laparoscopic procedure.
In cancer patients, peritoneal exploration can provide impor-
tant staging information for adjuvant preoperative radiotherapy
or chemotherapy if conventional noninvasive diagnostic
methods are inconclusive. Blunt or penetrating abdominal
trauma may benef it by laparoscopy to ascertain if surgical treatment is indicated.
Knife wounds must be inspected to verify possible damage to
internal organs. Minor intraabdominal lesions can be treated
immediately without converting to a laparotomy.
Every laparoscopic operation begins with peritoneal explora-
tion. Fig. 3.1.1 illustrates a standard laparoscopic procedure.
Most organs and tissue structures can be seen laparoscopically
through one portal. In certain cases, the surgeon can enhance
visualization by lavage with a saline solution at body tempera-
ture. The magnified image of the surgical site is in full view of
the entire operating team whose members can then contribute
to the evaluation of the findings, the planning of a strategy, and
the coordinated execution of an operative cure.
Surgical Risks and Patient Information
In purely diagnostic procedures, the surgical risks are identical
to those described in chapter 2.2.
Special Preparations
See chapter 2.2.
Alternate Procedures
쐌 Diagnostic imaging.
쐌 Peritoneal lavage and analysis of peritoneal fluid.
쐌 Exploratory laparotomy.
Anesthesia
General anesthesia.
Patient Positioning
Supine.
Indications
Surgical exploration of the peritoneal cavity is indicated where:
1. history, physical examination, laboratory findings, and diag-
nostic imaging provide inconclusive results;
2. the disorder requires treatment.
The purpose of exploration is to establish the type, location,
size, complicating factors, and characteristics of pathologic lesions, and to obtain biopsies for cytologic and histologic examination if possible.
Note: The surgeon’s most difficult task is to conclude that there
are no pathologic findings.
For exploration in the presence of abdominal trauma, see chap-
ter 3.2.
For exploration of the acute abdomen, see chapter 3.3.
For exploration in the presence of tumor, see chapter 3.6.
Contraindications
쐌 Incomplete clinical, laboratory, and diagnostic imaging stu-
dies.
쐌 Disorder that does not require treatment.
쐌 Patient who cannot tolerate anesthesia and operation.
Position of the Operating Team
See chapter 10.6.
Trocar Placement
Generally a transumbilical incision is made to insert the trocar.
A second trocar inserted in the lef t middle abdomen is helpful
for handling the probe. Open trocar placement is an alternative
(see chapter 2.2.)
Operative Technique
See chapters 3.2 and 3.3.
Complications
See chapters 3.2 and 3.3.
60
3.1 Visual Exploration of the Peritoneal Cavity
g
f
a Lower abdomen. View of the
anteflexed uterus and the superior aspect of the bladder.
b Pouch of Douglas with probe lift-
ing the fundus of the uterus, fallopian tubes, and ligamentum
teres.
c Left lower abdomen. Left ovary
and fallopian tube with
fimbriated funnel.
h
i
d Left lower abdomen. Deep ingui-
nal ring.
e Right lower abdomen. Deep in-
guinal ring.
f Right upper abdomen. Right he-
patic lobe with gall bladder, right
colon flexure, and greater omentum.
g Right upper abdomen. Right he-
patic lobe.
h Left upper abdomen. Spleen with
gastrosplenic ligament and body
of the stomach.
i Left upper abdomen. Left hepatic
lobe with falciform ligament of
the liver, stomach, and greater
omentum.
e
a
b
Fig. 3.1.1a−i Exploration of the peritoneal cavity. Every laparoscopic
operation begins with a visual peritoneal exploration. With the advent of a
standardized procedure for exploring the peritoneum, laparoscopic
operations have produced some surprising incidental pathologic findings.
Proceed in numerical order, first inspecting the organs of the lower abdomen (a, b and c). After inspecting the right groin area (e, 1), carefully ex-
amine the uterus, fallopian tubes, and ovaries in the female patient (a, b
and c) for possible pathologic changes.
Complete examination of the uterus is not always possible due to its usu-
ally anteflexed position. Mobilize the uterus with a probe to reveal the
pouch of Douglas (b). Placing the patient in Trendelburg’s position is help-
ful. Often you will find clear fluid in the pouch of Douglas. This often
comes from a previously conducted peritoneal lavage. A pool of opaque
serous fluid indicates the presence of an inflammatory process in the peri-
toneum. A pool of bloody serous fluid in female patients indicates that
menstruation has occurred, and is not generally a sign of a pathological
condition. Often closer examination of the lower abdomen will reveal en-
d
c
dometriosis at the usual susceptible sites. These patients should be referred to a gynecologist for further treatment. Disorders of the ovaries,
fallopian tubes, and fimbria (c) are easily diagnosed. After examining the
left lower abdomen and deep inguinal ring (d), move the laparoscope into
the right upper abdomen (5). After inspecting the gall bladder (f) and the
right hepatic lobe (g, 6a, 6b), you can now examine the entire surface of
the liver (g) for pathologic changes. The exploration extends superiorly as
far as the diaphragm and medially as far as the falciform ligament of the
liver. Examination of the left upper abdomen (h, i) is important for confirmation of pathologic changes. Lifting the left hepatic lobe with a probe
exposes the cardia, the lesser curvature, and the pylorus (7).
The spleen should be included in the exploration (h, 8). Handle the probe
carefully to avoid damaging parenchymal organs such as the liver or
spleen.
Note: After completing the exploration of the peritoneum, precisely record all pathological and normal findings.
Indications
61
Step-by-Step Procedure
I Preparations
1. Select the pressure level according to chapter 2.2.
2. Operating room nurse and surgeon test the snap mechanism
of the Veress needle.
II Establishing the pneumoperitoneum (see chapter 2.2)
1. Select pressure level according to patient’s size, age, and
weight (6−8 mm Hg for children; 10−14 mm Hg for adults).
2. Connect all equipment required for operation.
3. Make a periumbilical skin incision (approx. 1 cm).
4. Insert the Veress needle.
5. Perform safety tests: rotation, injection, aspiration, suction,
and manometer tests (see chapter 2.2).
6. Perform insufflation procedure according to chapter 2.2. Caution: insufflate infants at 1 l/min maximum.
III Placing the trocars
1. Make the skin incision 2 mm larger than the diameter of the
selected trocar.
2. Gently advance the trocar while twisting it slightly with your
wrist and palm, holding your middle finger against the tube of
the trocar as a safety stop.
3. Control any bleeding in the immediate vicinity of the trocar
tube.
IV Diagnostic laparoscopy
1. Place an instrument trocar (see chapter 2.2).
2. Explore the peritoneal cavity using a probe.
3. Aspirate and remove biopsy material in appropriate situations.
4. Make diagnosis and determine indication for or against therapeutic procedure(s).
5. If necessary and feasible, expand the diagnostic technique into
a therapeutic procedure by laparoscopy or laparotomy.
Bibliography
Barry RE, Brown P, Read AE. Physician’s use of laparoscopy. Brit. med. J. 1978;
2:1276.
Brantley JC, Riley PM. Cardiovascular collapse during laparoscopy: a report
of two cases. Amer. J. Obstet. Gynecol. 1988; 159:735.
Cuschieri A. Diagnostische Laparoskopie und laparoskopische Adhäsiolyse.
In Buess G, Cuschieri A, Périssat J. Operationslehre der endoskopischen
Chirurgie, 1/193. Berlin: Springer; 1993.
Gai H. Acute abdominal pain. Surg. Endosc. 1988; 2:28.
Götz F. Die endoskopische Appendektomie nach Semm bei der akuten und
chronischen Appendizitis. Endosk. heute 1988; 2:5.
Götz F, Pier A, Schippers E, Schumpelick V. Diagnostische Laparoskopie. In
Götz F, Pier A, Schippers E, Schumpelick V. Laparoskopische Chirurgie,
p. 26. Stuttgart: Thieme; 1991.
Götz F, Pier A, Schippers E, Schumpelick V. Laparoskopische Chirurgie. Stutt-
gart: Thieme; 1991.
Goetz O. Ein neues Verfahren zur Gasfüllung für das Pneumoperitoneum.
Münch. med. Wschr. 1921; 51:233.
Irvin T. Abdominal pain: a surgical audit of 1190 emergency admissions. Brit.
J. Surg. 1989; 76:1121.
Jacobaeus HC. Über die Möglichkeit, die Zystoskopie bei der Untersuchung
seröser Höhlen anzuwenden. Münch. med. Wschr. 1910; 57:2090.
Kelling G. Oesophagoskopie, Gastroskopie und Zölioskopie. Münch. med.
Wschr. 1901; 49:21.
Korbsch R. Die Laparoskopie nach Jakobaeus. Berl. med. Wschr. 1921;
38:696.
Lee CM. Acute hypertension during laparoscopy: a case report. Anesth.
Analg. 1975; 54:142.
Lent H. Diagnostische Möglichkeiten mit modernen Laparoskopoptiken. In
Ottenjann R. Fortschritte der Endoskopie, Vol. II, p. 255. Stuttgart: Schat-
tauer; 1970.
Motew M, Invankovich AD, Bienarz J, Albrecht RF et al. Cardiovascular effects
and acid-base and blood gas changes during laparoscopy. Amer. J. Obstet.
Gynecol. 1973; 115:1002.
Nathanson LK. Laparoskopie und Plazieren von Arbeitstrokaren. In Cuschieri
A, Berci G, Klose G. Minimalinvasive Chirurgie der Gallenblase, p. 25. Ber-
lin: Blackwell; 1991.
Nitze M. Eine neue Beleuchtungs- und Untersuchungsmethode für
Harnröhre, Harnblase und Rektum. Wien. med. Wschr. 1879; 24:13.
Röder H. Die Technik der Mandelgesundungsbestrebungen. Ärztl. Rdsch.
München 1918; 57:169.
Salch JW. Peritoneoscopy, an alternative approach to unresolved in-
traabdominal disease. Amer. J. Gastroenterol. 1978; 6:641.
Schippers E, Schumpelick V, Öttinger AP, Anurow M et al. Laparoskopische
Chirurgie − das geringere Abdominaltrauma. Langenbecks Arch. Chir.
1992; 377:14.
Semm K. Erster diagnostischer Rundblick. In Semm K. Operationslehre für
endoskopische Abdominalchirurgie, p. 136. Stuttgart: Schattauer; 1984.
Semm K. Operationslehre für endoskopische Abdominalchirurgie. Stuttgart:
Schattauer; 1984.
Shandall A, Johnson C. Laparoscopy or scanning in oesophageal carcinoma.
Brit. J. Surg. 1985; 72:449.
3.2 Diagnostic Laparoscopy for Trauma
H. Feussner
Objectives and Methods
The purposes of diagnostic laparoscopy for abdominal trauma is
the reliable detection or exclusion of intraabdominal lesions
provided that these cannot b e detected equally quickly and reli-
ably by less invasive diagnostic means. In this way the number
of negative laparotomies should be reduced or, respectively, the
decision for a laparotomy should be accelerated. Under certain
circumstances, it may be possible to manage a detected lesion
directly by laparoscopy.
Indications
Diagnostic laparoscopy is indicated not only for penetrating but
also for blunt abdominal trauma. The important point is to be
aware of the diagnostic possibilities of laparoscopy and to use
the method only when it is appropriate. However, the principle
should not be misused to delay a necessary laparotomy, e. g., in
cases of internal hemorrhage and peritonitis beyond the 12hour limit, and thus endanger the patient.
62
3.2 Diagnostic Laparoscopy for Trauma
nd
2
assistant
Monitor
Insufflator
Electrocantery unit
Surgeon
OR nurse
Fig. 3.2.1 Position of the patient and operating team for diagnostic laparoscopy for abdominal trauma. The patient is supine, the legs are
In contrast to the situation in the English and French speaking
countries, in Germany and some other European countries ultrasonographic diagnosis is almost always carried out as a
screening procedure for abdominal trauma by the surgeon. La-
paroscopy then at most plays a complementary role. In spite of
the high diagnostic value of ultrasonography, laparoscopy does
have its place when, in an emergency situation, there is no
direct access to other imaging procedures (CT, angiography,
etc.) or when there are strong reasons against a possibly negative laparotomy. Laparoscopy for abdominal trauma is indicated
for the following indications.
쐌 Sonographic detection of free intraperitoneal fluid without a
recognizable organ lesion,
쐌 Suspicion of liver, spleen, or stomach injuries,
쐌 Pancreas injury,
쐌 Urgent suspicion of intestinal perforation.
st
assist-
1
ant
Aspiration/
irrigator
placed on moveable supports. If necessary the legs can be raised to provide access to the rectum (“masked lithotomy position”).
Contraindications
Diagnostic laparoscopy is contraindicated for patients with cardiovascular problems. If abdominal hemorrhage is the suspected cause and emergency laparotomy is indicated, laparoscopy should not be attempted, since massive abdominal bleeding can practically never be managed by laparoscopy even if the
source can be identified. Head trauma with suspected increased
intracranial pressure is also a contraindication since insufflation
of the abdomen may possibly have a deleterious effect on intracranial pressure and perfusion.
Surgical Risks and Informing the Patient
In emergency situations the possibilities for informing the
patient are limited. In every case, however, the possible necessity of a conversion to open surgery and other therapeutic
measures including even an enterostomy must be mentioned.
Special Techniques of Diagnostic Laparoscopy for Abdominal Trauma
The particular surgical risks do not differ in principle from those
of elective diagnostic laparoscopy. The danger of false negative
evaluations, especially of perforations of the hollow organs,
must be taken into account.
Special Preparations
In contrast to elective laparoscopy, for example for staging, only
few preparatory measures are usually possible.
In all cases a gastric tube and a rectal tube are recommended. At
the slightest suspicion of a stomach or colon injury methylene
blue solution can then be instilled during the examination in
order to detect or exclude a leakage. The urinary catheter required in all patients with multiple injuries can be used in the
same way.
Anesthesia
In comparison to laparoscopy for staging the procedure in
sharp, penetrating abdominal trauma can be performed more
often under local anesthesia. The selected trocar sites, which
should be as far distant from the lesion as possible, are infil-
trated with a local anesthetic; a mild sedative is often helpful. In
the majority of cases, however, general anesthesia is required
for blunt trauma and the occasional stable patient with a gunshot wound.
63
Positioning (Fig. 3.2.1)
Since diagnostic laparoscopy after abdominal trauma often re-
quires changing the patient’s position appropriate measures
must be taken to facilitate extreme changes of position (foot
and shoulder cushions). In cases of suspected lesions in the
lower abdomen the masked lithotomy position is almost always
to be recommended so that, if necessary, the legs may be angled
to provide access to the perineum (bladder, rectum).
Positioning of the surgical team and the monitor depend on the
suspected location of the main lesion. For the upper abdomen
the monitor is placed cranial to the patient, for the lower abdomen caudal.
Approaches (Fig. 3.2.2)
The number and location of the trocar sites depend on the injury pattern with the first trocar being inserted through a peri-
umbilical port.
Special Techniques of Diagnostic
Laparoscopy for Abdominal Trauma
After placement of the first trocar the 30° optical system is in-
troduced and a survey of the abdomen is made. This begins with
an inspection of the parietal peritoneum (Fig. 3.2.3) by appro-
priate rotation of the optics, especially when a penetrating
trauma is suspected. The continuously improving small endoscopes, measuring between two and five millimeters, may be
used to the same advantage as the 30° optical systems since
their size allows repeated placement in all abdominal quad-
Fig. 3.2.2 Trocar placement in laparoscopy for abdominal trauma. Three
trocars are usually needed. The 30° laparoscope is introduced through
the first trocar (10/12 mm). The positions of the other two working ports
depend on the specific case.
T1 10/12-mm periumbilical incision
T2 5-mm incision for auxiliary instrument (i. e., grasper)
T3 10/12-mm incision
T4 5-mm incision
T5 10/12-mm incision
Procedure
1 Establish the pneumoperitoneum.
2 Insert the trocars.
3 Examine the upper abdomen (reverse Trendelburg position).
4 Examine the lower abdomen (Trendelburg position).
(5 Instillation of methylene blue into the stomach/colon.)
(6 Laparoscopic ultrasonography.)
rants, often by a single puncture (2−3 mm). In a second step all
regions of the abdomen including the surfaces of organs (liver,
spleen, omentum, periteal peritoneum) are examined. The
search for free intraabdominal fluids (blood, gastrointestinal
contents) must be very careful, in particular in predictable areas
(perihepatic, perisplenal, in the lower abdomen, and between
the loops of the small intestine).
Only then are the individual regions and organs examined
specifically (Figs. 3.2.4 to 3.2.15). In contrast to laparoscopy for
staging, the active preparatory expenditure for this is usually
low.
64
3.2 Diagnostic Laparoscopy for Trauma
a
Figs. 3.2.3a and b Diagnostic laparoscopy. Examination of the parietal
peritoneum in the left upper abdomen. Begin the systematic examination
in the left upper abdomen. Carefully inspect the parietal peritoneum with
a 30-degree oblique forward-viewing laparoscope. Advance the laparoscope close to the structures to avoid missing possible early signs of a
parietal injury.
a
b
Figs. 3.2.4a and b Diagnostic laparoscopy. Elevating the left hepatic
lobe. Rotate the laparoscope to inspect the left hepatic lobe, the anterior
wall of the stomach, the greater omentum, and the spleen. After carefully
examining these organs, insert an elevator through trocar 2 to lift the left
hepatic lobe to expose the inferior aspect of the lobe, and the cardia,
lesser curvature of the stomach, and lesser omentum.
b
a
Figs. 3.2.5aand b Diagnostic laparoscopy. Examining the peritoneum in
the right upper abdomen. Move the laparoscope inferiorly to the right of
the falciform ligament of the liver. The examination of the right upper abdomen also begins with an inspection of the parietal peritoneum. Next examine the right hepatic lobe including the falciform ligament and the inferior border of the liver.
a
b
Figs. 3.2.6a and b Diagnostic laparoscopy. Elevating the right hepatic
lobe. With the elevator inserted through trocar 2, lift the right hepatic
lobe to expose the hepato-duodenal ligament and gall bladder.
b
Special Techniques of Diagnostic Laparoscopy for Abdominal Trauma
65
a
Figs. 3.2.7a and b Diagnostic laparoscopy. Examining the right middle
and lower abdomen. Place the patient into the Trendelburg position.
Move the laparoscope through the right middle abdomen into the lower
abdomen and inspect the ascending colon, cecum, right iliac vessels, and
pelvis. Sometimes visualization can be improved by inclining the operating table to the left.
a
b
Figs. 3.2.8a and b Diagnostic laparoscopy. Examining the left middle
and lower abdomen. Move the laparoscope clockwise to inspect the left
middle and lower abdomen. This should expose the left colic flexure, descending colon, greater omentum, and sigmoid colon.
b
Diaphragm
Lesions of the diaphragm are usually detected very reliably. In
the region of the left diaphragm the stomach and spleen can be
displaced sufficiently with a suitable instrument to provide a
good view of the dorsal parts. On the right, most of the free diaphragm is also well visualized with the exception of the right
dorsal sections.
Liver
Most relevant liver injuries can also be detected directly by laparoscopy. In the case of penetrating injuries with a ventral to
dorsal direction, dorsal inspection of the right lobe of the liver is
sometimes necessary in order to detect a possible injury. Laparoscopic ultrasonography can also be useful to detect intrahepatic hematomas.
Spleen
Most injuries to the spleen can be diagnosed quickly and localized in the hemodynamically stable patient. Injuries on the surface of the spleen can under favorable circumstances be controlled by electrocautery, harmonic scalpel, or biological glues.
More severe lesions require open surgical management.
Stomach
Stomach lesions can often be detected directly. If the findings
are equivocal the stomach should be instilled with methylene
blue through the naso-gastric tube in order to exclude small, occult lesions. In favorable cases stomach lesions can be managed
by laparoscopic surturing or stapling techniques.
66
3.2 Diagnostic Laparoscopy for Trauma
a
Figs. 3.2.9a and b Diagnostic laparoscopy. Examining the pelvis in
women. After inspecting the middle left abdomen, extend the examination into the lower abdomen and rectouterine pouch. Lift the uterus with
a grasper inserted through trocar 2. You may have to apply slight tension
to the rectosigmoid to achieve the desired exposure.
a
b
Figs. 3.2.10 a and b Diagnostic laparoscopy. Approach into the lesser
sac. With grasper inserted through trocar 2, lift the greater curvature of
the stomach to apply tension to the gastrocolic ligament. Using a grasper
and scissors inserted through trocars 4 and 5, open a window in the larger
avascular area inferior to the right gastroepiploic artery. Expand the window far enough to permit inserting the laparoscope through incision T1
or T3.
1 Right gastroepiploic artery (visible in deep layer)
b
a
Figs. 3.2.11 a and b Diagnostic laparoscopy. Examining the posterior ga-
stric fundus and the body of the pancreas. The left lateral aspect of the
lesser sac (i. e., the fundus of the stomach and body of the pancreas) is ex-
amined through incision T1. With an additional instrument, lift the poste-
rior wall of the stomach to expose the diaphragm and the hilus of the
spleen.
a
b
Figs. 3.2.12 a and b Diagnostic laparoscopy. Examining the posterior antral space and the head of the pancreas. Insert the laparoscope through
trocar 3 to bring it into the proper angle for examining the posterior wall
of the antrum and the head of the pancreas. Insert an elevator through
trocar 4 to lift the posterior wall of the stomach to improve visualization.
You may have to separate fine adhesions to permit sufficient examination
of the head of the pancreas.
b
Special Techniques of Diagnostic Laparoscopy for Abdominal Trauma
a
b
Figs. 3.2.13 a and b Diagnostic laparoscopy. Ultrasound probes.
a Rigid ultrasound probes (10 mm in diameter, 7.5 MHz) with a lateral
sonic window are still commonly used. Bringing rigid probes into contact with organ contours can be difficult, particularly in the case of the
right hepatic lobe and pancreas.
b Probes with flexible heads are better suited for convex surfaces, per-
mitting the surgeon to achieve better contact between the ultrasound
head and the organ.
67
a
Pancreas
After opening into the lesser sac the anterior surface of the body
of the pancreas can be seen so that contusions, ruptures, or
other lesions can be diagnosed. A sufficient evaluation of the
head is difficult without a large amount of exposure.
Small and Large Intestine
The reliable exclusion of lesions of the small and large intestines
most certainly places the highest demands on the method and
the laparoscopist. For the deeper sections of the large intestine
the intraluminal instillation (rectal) of methylene blue can be
very helpful.
A reliable inspection of the small intestine by laparoscopy is
very time consuming and the incidence of false negative findings is relatively high. When, in spite of secondary findings (free
intestinal fluid in the abdomen), no lesion can be found by laparoscopy conversion to open operation must be made.
Complications
Intraoperative Complications
In case of a ruptured diaphragm a tension pneumothorax may
develope. Therefore in all patients with suspicious thoraco-
abdominal injury patterns, preventive tube thoracostomy
should be used freely.
b
Figs. 3.2.14 a and b Diagnostic laparoscopy. Using ultrasonography to
examine the right hepatic lobe. Insert the ultrasound probe through trocar 5. Inspect the entire right hepatic lobe in horizontal segments, monitoring the movement of the ultrasound head using the laparoscope inserted through trocar 1. Splitscreen imaging makes it easier to correlate
the ultrasound findings with the position of the ultrasound head. To inspect the left hepatic lobe, the stomach, and pancreas, insert the ultrasound head through trocar 3 while monitoring the movement of the head
with the laparoscope inserted through trocar 1.
Fig. 3.2.15 Diagnostic laparoscopy. Diagram for illustrating intraopera- 컄
tive findings. Sketch major findings on the position diagram immediately
postoperatively so that the information is directly available. Video documentation of important pathologic findings is recommended. Record the
findings documented in the sketch in a short report.