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14 Fundamentals ofBasic Laparoscopic Setup
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14.3.2 Extracavitary MIS
Extracavitary laparoscopic surgery is a technique
that uses balloon attached to a laparoscopic camera to develop a space in the extraperitoneal or
extrafascial plane and then use low-pressure
insufation to maintain it open. Extracavitary
laparoscopic surgery uses the same instrumentation as traditional laparoscopic surgery. Not entering the peritoneum will avoid the risk of adhesion
formation. Also, insufation of extraperitoneal
space is associated with less physiologic disturbances than pneumoperitoneum. Yet, CO2 may
produce extensive subcutaneous emphysema if
high pressures are used during insufation. Direct
absorption of CO2 into the subcutaneous space
may lead to metabolic acidosis.
Gaining access to the extracavitary space may
be performed by two different techniques, via
balloon dissection or subcutaneous laparoscopic/
endoscopic devices. Balloon dissection is the
most commonly employed technique for good
for extraperitoneal hernia repair and the retroperitoneal approach used for adrenalectomy,
lumbar discectomy, necrotic pancreatectomy, and
occasionally for para-aortic lymph node
dissection.
Totally extraperitoneal hernia repair is the
most frequent extraperitoneal MIS performed.
An infraumbilical incision is made contralateral
to the hernia site. The anterior rectus sheath is
incised transversely, and the rectus muscle sin
retracted laterally to allow a 10mm blunt trocar.
Either a blunt dissection (Fig.14.10a) or by balloon dissector (Fig. 14.10b) is then used to
develop the preperitoneal space under direct
visualization. Once this potential space has been
created, the extraperitoneal space is insufated to
10 mm hg to avoid excessive subcutaneous
emphysema. This results in a surgical eld/working space that is reduced, but it avoids the complications associated with intraperitoneal
laparoscopic surgery like adhesions and trocar
site hernias and reduces risk of intestinal damage
and post-op ileus.
14.3.3 Hand-Assisted Laparoscopic
Surgery (HALS)
At times, the goals of surgery are unable to be
fully met while exclusively employing the laparoscopic approach. This is especially true when
the operation necessitates the use of tactile feedback such as in feeling for tumor. Several systems (Fig. 14.11: GelPort™, Applied Medical)
exist that allow the surgeon inserts his or her
hand through a large, airtight port which maintains pneumoperitoneum. This, of course, necessitates a larger abdominal wall incision upwards
of 7–8 cm. Proponents of HALS argue it may
assists with the learning curve of laparoscopy,
retraction, blunt nger dissection, allows for
rapid control to bleeding vessels, and can be used
Fig. 14.10 (a) TEP direct access with blunt dissection. (b) Balloon-assisted dissection
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Fig. 14.11 Handassisted GelPort™
M. Rafols et al.
before full conversion to laparotomy. It has also
been shown to be advantageous by reducing
operating time and conversion rates while maintaining all the oncological principles and patient
safety [11, 12].
14.4 Patient andSafety
Monitoring
From anesthetic induction to extubation, patient
safety monitoring is paramount. Laparoscopy
adds new challenges both the surgeon and anesthesiologist should keep in mind. To start, initial
pneumoperitoneum proceeds with a rapid stretching of the peritoneal membrane. This may lead to
a vasovagal response with bradycardia and hypotension necessitating immediate desufation and
possible addition of uids and/or a vagolytic.
Furthermore, once the abdomen is expanded
to include an extra 4–6 L at a pressure of
12–16mmHg, venous return via the inferior vena
cava may become compromised. This is especially true in the patient who is positioned in
reversed Trendelenburg [13]. With venous pooling within the lower extremities, a substantial and
replicable risk exists for deep-venous thrombosis
which should be avoided with intraoperative
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sequential compression devices or preoperative
anticoagulation.
Mentioned earlier is the risk for gas emboli,
less likely with CO2 pneumoperitoneum, though
still a serious possibility. An uncharacteristic
hypotensive episode should warrant suspicion
which may unfortunately be confused for the
vasovagal response of pneumoperitoneum. A
“mill wheel” murmur may become apparent by
listening with an esophageal stethoscope, and the
patient should be placed in the Trendelenburg
and left lateral decubitus position to trap the gas
in the apex of the right ventricle, allowing for
immediate aspiration via central venous catheter
access.
At the conclusion of the operation, it is imperative that all trocars are removed under direct
visualization. A trocar that perhaps injured an
epigastric vessel upon entry may partly mask
bleeding for the duration of the surgery.
Postoperative hypotension, a profound drop in
hemoglobin and hematocrit, and out of proportion abdominal pain the next morning will then
leave the surgeon scratching his or her head only
to realize the critical error was failing to visualize
each trocar removal. However, when discovered
at the time of surgery, intervention may include
direct pressure or full-thickness abdominal wall
suture.
14.5 Special Considerations
14.5.1 Pediatrics
Laparoscopic surgery in the pediatric population
is carried out very similar to that of the adult
population. It is no surprise that instrumentation
and insufation should be scaled down due to
size. Trocar diameters for traditional approaches
rarely exceed 5mm. Otherwise, techniques such
as single- incision laparoscopic appendectomy
are commonplace and employ a single, 10mm
trocar. With less abdominal wall girth and subcutaneous tissue, usually, pediatric laparoscopic
surgery can be accomplished with insufation
pressures of 8 mmHg rather than 15 mmHg.
With inguinal hernia repairs even, muscle relaxation may prove to be unnecessary, and the
patient may only require laryngeal mask airway
rather than conventional endotracheal tube intubation [
13].
14.5.2 Pregnancy
Several factors should be considered prior to and
during laparoscopic surgery in the pregnant
patient. Surgical intervention should aim to
ensure mother’s safety without inducing a great
amount of fetal risk. First and foremost, the surgeon must consider timing. Laparoscopy can be
performed safely during any trimester of pregnancy, though waiting until the second trimester
may reduce the rates of spontaneous abortion and
preterm labor, specically in laparoscopic cholecystectomy [14, 15].
Initial trocar placement should be based on
fundal height. To avoid direct injury to the uterus,
it is prudent to begin with a subcostal trocar. All
three aforementioned techniques for placement,
i.e., Veress, Hasson, or optical trocar, can be used
when starting at the subcostal margin, and an
underlying fundus is clearly not palpable.
Insufation may begin once access is safely
established. Insufation pressure between 12 and
15mmHg is considered safe and has not increased
adverse outcomes for the patient or fetus, and it
should be noted the physiologic contractions of
pregnancy induce a far greater intra-abdominal
pressures [16].
Pregnancy inherently induces a hypercoagulable state which leads to DVT or PE in 0.5–3.0/1000
pregnancies [17]. Abdominal pressures exceeding
14 mmHg can signicantly alter femoral vein
hemodynamics (diameter, cross-sectional area,
peak systolic ow) when compared to a low-pressure insufation of 8mmHg [18]. Unfortunately,
studies accounting for the combined hypercoagulable effects, and subsequent adverse outcomes, of
pneumoperitoneum during pregnancy are lacking
at this time.
14.5.3 Elderly
Limitations for surgery in the elderly have more
to do with recovery than the actual procedure.
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M. Rafols et al.
Decreased mobility hampers recovery and allows
for the milieu of postoperative risks that increase
morbidity and mortality which is certainly exacerbated by a large, open incision. The advent of
laparoscopic surgery has facilitated, most profoundly, the acute postoperative period where
decreased pain, earlier mobility, and hastened
discharge from the hospital have been repeatedly
demonstrated. With this, what were once considered too dangerous of surgeries for a frail, elderly
patient may be accomplished when an open incision is now out of the equation. The concern lies
with whether or not the benets gained outweigh
the theoretical cost of a longer operation which
may induce greater physiologic demands. Indeed,
the evidence supports improved outcomes with
laparoscopic surgery and the elderly; in fact, they
have the most to gain from this approach [19].
14.6 Postoperative Care
andComplications
14.6.1 Nausea
In laparoscopic surgery, postoperative nausea
and vomiting (PONV) may be increased when
compared to open surgery. The etiology is often
multifactorial and can be due to anesthetic technique used, postoperative pain and pain management, and factors intrinsic to the patient. Risk
factors which may lead to PONV include female
gender, young age, lower ASA risk score, history
of PONV or motion sickness, nonsmoking, preoperative anxiety, and increased procedure length
with the use of volatile anesthetic agents.
Prevention of PONV, such as with antiemetics or
reduction in opioid use, can make the patient
more comfortable and hasten their recovery.
14.6.2 Pain
There exist numerous studies which demonstrate
reduced pain after laparoscopic surgery compared to the open approach. As with open surgery, liberal use of a liposomal based local
anesthetic can prevent some of the patient’s pain.
The unique nding of referred shoulder pain due
to diaphragmatic stretching is usually selfand should be treated the same as incisional pain.
It is expected that this will last 1–3days, and this
may be reduced by evacuating pneumoperitoneum at the conclusion of surgery. A systematic
review of 31 studies determined that low- pressure
pneumoperitoneum, low insufation rate, and
active gas aspiration were effective strategies to
reduce the incidence or severity of shoulder pain
after laparoscopic cholecystectomy [20]. Any
unusual increases in pain after hospital discharge
should be evaluated to determine the etiology.
limited
14.6.3 Diet
Resumption of a normal diet depends mostly on
the patient and procedure performed rather than
whether or not the surgery was laparoscopic. For
routine surgeries, i.e., appendectomy or cholecystectomy, regular diet is usually tolerated as
soon as postoperative day 1. Recommending a
normal diet only until after demonstration of
resumed bowel function is a typical rule when
surgery involved anywhere along the gastrointestinal tract. Of course, this is an oversimplication, and dietary restrictions should proceed on
an individualized patient basis, taking into consideration functional levels at baseline.
14.6.4 Activity
Like postoperative pain, return to normal activity
is expedited with the employment of laparoscopic
surgery, and the two of these go hand in hand. Use
of factors that impair wound healing (steroids,
chemotherapy, immunosuppression, and tobacco
use) should be taken into consideration when
instructing patients on when to resume normal
activity. Ultimately, the best judgment for dictating activity will come from the patient listening to
cues of pain and discomfort sensed by their body.
14.6.5 Wound Care
The most obvious advantage of laparoscopic surgery is the size of wound created. Incisions of
14 Fundamentals ofBasic Laparoscopic Setup
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5mm or less require only closure at the cutaneous level, which is typically achieved with one
subcutaneous suture to reapproximate the edges
of the wound. Larger than 10mm, it is recommended that the peritoneum be reapproximated
as well. The surgeon may also choose to use liquid adhesive and/or steri-strip bandages for reinforcement. It is important to instruct the patient
to keep the skin dry for 24–48h. Redness or discharge or increasing pain and swelling are signs
that healing has gone awry, and these should be
addressed promptly. These are often signs of
seroma, infection, hematoma, and/or hernia.
Avoidance of sun exposure and the liberal use of
ultraviolet protection will reduce the darkening
and subsequent visibility of scars.
14.6.6 Injuries
Many injuries may not be readily obvious at the
time of surgery and only present in the postoperative period. Injuries to hollow viscera such as the
stomach, small bowel, colon, bladder, or ureters
can present even up to 7–10days after surgery
despite there being no visible mechanism during
the procedure. Notably, thermal burns from electrocautery, anastomotic leak, and ischemia following devascularization may present hours to
days following skin closure. Signs of tachycardia, anemia, or hypotension should prompt caretakers to pursuit further workup. As previously
reviewed, vascular injuries such as those to the
epigastric or mesenteric vessels can present postoperatively as anything from an abdominal wall
hematoma to hemodynamic instability with profound anemia. Lastly, nerve injuries are best
treated with prevention. This is accomplished
with vigilant attention to detail such as appropriate patient positioning with judicious use of
cushioning, avoidance of excessive division and
traction, and awareness of anatomic structures
when placing sutures, tacks, and staples.
References
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4. Fleshman JW, Fowler DL, Whelan RL.The SAGES
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6. Hazebroek EJ, de Vos tot Nederveen Cappel R,
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10. Evers L, Bouvy N, Branje D, Peeters A.Single- incision laparoscopic cholecystectomy versus conventional four-port laparoscopic cholecystectomy: a
systematic review and meta-analysis. Surg Endosc.
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11. Gupta P, Bhartia V.Hand-assisted laparoscopic surgery
using Gelport. J Minim Access Surg. 2005;1(3):110.
https://doi.org/10.4103/0972-9941.18994.
12. Marcello PW, Fleshman JW, Milsom JW, etal. Handassisted laparoscopic vs. laparoscopic colorectal surgery: a multicenter, prospective randomized trial. Dis
Colon Rectum. 2008;51(6):818–26.
13. Holzheimer RG.Laparoscopic procedures as a risk
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case report and review of the literature. Eur J Med
Res. 2004;9(9):417–22.
14. SAGES.Guidelines for diagnosis, treatment and use
of laparoscopy for surgical problems during pregnancy. Surg Endosc. 2007;5(11):3479–92.
15. Glasgow R, Visser B, Harris H, Patti M, Kilpatrick
S, Mulvihill S. Changing management of gallstone disease during pregnancy. Surg Endosc.
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16. O’rourke N, Kodali B-S. Laparoscopic surgery
during pregnancy. Curr Opin Anaesthesiol. 2006;
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Physicians, American Academy of Family Physicians
Panel on Deep Venous Thrombosis/Pulmonary
Embolism, et al. Management of venous thromboembolism: a clinical practice guideline from the
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19. Chesney T, Acuna SA. Do elderly patients have the
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2013;27(7):2275–82.
Fundamentals ofLaparotomy
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Closure
WilliamW.Hope andMichaelJ.Rosen
15
15.1 Introduction
Although not often a highlighted part of abdominal operations, secure laparotomy closure is
essential to minimize the incidence of incisional
hernias and infection. Despite the move to minimally invasive surgery in many common general
surgical operations, the use of laparotomy is still
common and has an estimated incisional hernia
risk ranging from 10 to 23% and up to 69% in
high-risk patient groups with long-term follow up [1–3]. The burden of incisional hernias is a
major health concern with expenditures in excess
of $3 billion per year [4, 5]. Many patient-related
risk factors contribute to the incidence of incisional hernia and include obesity, male gender,
postoperative respiratory failure, previous wound
infection, older age, reoperation, diabetes mellitus, malignancy, malnutrition, history of chemotherapy, jaundice, glucocorticosteroid use,
smoking, and patients with abdominal aortic
aneurysms [6–14]. While these are important factors for the surgeon to consider, they are often
non-modiable. Surgeons, however, can greatly
affect the incisional hernia rate and possibly the
W. W. Hope (*)
New Hanover Regional Medical Center, University of
North Carolina at Chapel Hill, Wilmington, NC, USA
e-mail: William.Hope@nhrmc.org
M. J. Rosen
Cleveland Clinic, Cleveland, OH, USA
e-mail: rosenm@ccf.org
infection rate by their choice of laparotomy closure technique. This should be an area of great
focus for surgeons operating on the abdominal
wall and cavity.
15.2 General Concepts
Many types of incisions for accessing the abdominal cavity have been described, and each has its
particular advantage and disadvantage. The midline laparotomy (or celiotomy) incision is one of
the most often used incisions for accessing the
abdominal cavity. It is versatile, allows rapid
access to all parts of the abdominal cavity, and is
used due to the relative ease of entering the abdomen because of the lack of muscle and vasculature in this area. Although midline laparotomy is
widely used, some have recommended the use of
off midline incisions when possible due to incisional hernia formation [15]. Despite these recommendations, the midline laparotomy incision
remains a mainstay for surgeons and is the focus
of this chapter.
When discussing laparotomy closure, it is
important to have a general knowledge of wound
healing and abdominal wall anatomy. Healing of
fascia and laparotomy incisions follow the same
general principles of wound healing. This
includes an inammatory, proliferative, and maturation phase, although the aponeurosis can take
longer than other tissues to heal [16].
© Springer International Publishing AG, part of Springer Nature 2018
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W. W. Hope and M. J. Rosen
The abdominal wall includes layers of skin,
subcutaneous tissue, supercial fascia, deep fascia, muscle, extraperitoneal fascia, and peritoneum (Figs. 15.1 and 15.2). Surgeons should
understand the linea alba and its surrounding
structures as they relate to laparotomy closure.
the layers of the abdominal wall including skin, subcutaneous tissue, and fascia
The linea alba lies in the midline and is formed
by the fusion of the anterior and posterior rectus
sheath. It runs from the xiphoid process to the
symphysis pubis. The rectus muscles lie lateral to
the linea alba, and when the laparotomy incision
veers off midline, muscle is often exposed, which
can make closure more difcult (Fig.15.3).
Certain aspects of the laparotomy closure
technique can potentially make this procedure
easier. The laparotomy incision should be made
in the midline and should be as long as needed to
provide adequate exposure. There is no clear consensus on whether to make the skin and fascial
incision using a scalpel or using Bovie electrocautery. Some animal data support the use of
scalpel for skin and fascial incision and report
fewer wound complications and higher tensile
strength [17–20]; however, the benets have not
proven clinically signicant in humans, with no
apparent impact on incisional hernia formation
[20–25]. As previously stated, it is ideal to make
the laparotomy incision through the midline, and
veering off can cause bleeding and can disrupt
layers of the abdominal wall often making closure more challenging and time consuming.
Traditionally, a mass closure technique of suturing fascia and muscle was recommended; however, experimental and clinical studies have led to
the recommendation of closure of the aponeurosis only [15, 16].Fig. 15.1 Side view of a laparotomy incision showing
Fig. 15.2 Layers of the abdominal wall elevated to show
abdominal cavity and skin, subcutaneous tissue, fascial
layers, and muscle
Fig. 15.3 Incision of the posterior sheath showing the
anatomic makeup of the linea alba. When the midline
laparotomy incision veers off midline, the rectus muscle
can be exposed and complicate closure
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15.3 Technical/Practical
Considerations/Safety
Precautions
Several technical considerations are pertinent
when discussing laparotomy closure and include
the type of sutures used and techniques of
closure.
The suture type used for laparotomy closure
has long been a subject of debate. Multiple randomized controlled trials and meta-analyses
have evaluated the ideal suture for closure with
differing conclusions. In general, recommendations are to use a slowly absorbing suture in a
continuous fashion, because this is the most
efcient technique to reduce infection and incisional hernia formation [15]. However, there is
controversy on the details of the suture used.
Many surgeons use a large slowly absorbing
suture on a large needle that is double stranded
(Fig.15.4), while others prefer single stranded.
No denitive research recommends one particular type of stitch; however, many experts have
moved to using smaller suture materials/needles
to facilitate a short bite technique (Fig. 15.5).
For example, a 2-0 PDS Plus II (Ethicon,
Somerville, NJ, USA) on a 31mm needle was
used in a recent randomized controlled trial
comparing outcomes [26].
Several important points regarding closure
should be highlighted. It is imperative to use
meticulous suturing technique by placing the
needle at a 90° angle to the desired tissue/fascia
and gently follow the curve of the needle through
the tissue to minimize tissue trauma (Fig.15.6).
The suture to wound length ratio is a key principle in laparotomy closure. The ratio is calculated
after measuring the length of the wound and also
measuring the amount of suture material used to
close the wound (Figs.15.7 and 15.8). Measuring
suture material used can be done in many ways. It
is usually determined by rst measuring the
amount of suture material available before beginning laparotomy closure and subtracting this
amount from the suture remaining after closure.
Fig. 15.4 Laparotomy closure using a double-stranded
slowly absorbing suture
Fig. 15.5 Suture and needles. Traditionally large needles
on large suture have been used, but recently smaller needles and smaller suture have been proposed
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W. W. Hope and M. J. Rosen
Fig. 15.6 When closing fascia, it is important to practice
meticulous suturing techniques such as entering the tissue
at a 90° angle and following the curve of the needle
Fig. 15.7 Measuring of the laparotomy incision to calculate the suture to wound length ratio
Fig. 15.8 Measuring of the remaining suture following
laparotomy closure. This amount will be subtracted from
the total amount of suture leaving the amount of suture
used to close the fascia. This number can then be used
along with the length of the fascia measurement to calculate the suture to wound length ratio
Using these numbers, the ratio is calculated. A
large body of literature has long supported the
notion that achieving a greater than 4:1 suture to
wound length ratio decreases incisional hernia
formation [27, 28]. Therefore, during laparotomy
closure, the suture to wound length ratio should
be calculated, and closures should be redone
when they fail to meet the 4:1 target. Although
the 4:1 suture to wound length ratio is generally
agreed on, there are many ways to achieve this
ratio, and recommendations on this have recently
changed.
The traditional technique for closure involved
using approximately 1cm bites of fascia and 1cm
advances, and this was based on some experimental studies [29–31]. Recently, this technique has
been challenged as new evidence shows closure
with smaller bites (5–8mm) and smaller advances
(5–8 mm) produces a signicantly lower incisional hernia rate [26, 32] and possibly surgical
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