Key Facts

Laparoscopic (minimally invasive) surgery has revolutionised surgical practice since the first laparoscopic cholecystectomy in 1987. It is now the standard approach for many abdominal and pelvic procedures.

Epidemiology

Over 60% of general surgical procedures in the UK are now performed laparoscopically. Laparoscopic cholecystectomy accounts for approximately 70,000 procedures annually in England. Robot-assisted laparoscopic surgery is an expanding area, particularly in urology and gynaecology.

Aetiology

The shift to laparoscopic surgery is driven by demonstrable benefits: reduced post-operative pain, shorter hospital stays, faster return to normal activity, and improved cosmesis. Evidence from RCTs (e.g., CLASICC trial for colorectal cancer) has established oncological equivalence for many cancer operations.

Pathophysiology

Pneumoperitoneum effects:

• Cardiovascular: Increased SVR, reduced venous return (compression of IVC), initial decrease then increase in cardiac output
• Respiratory: Reduced FRC, increased airway pressures, atelectasis, hypercarbia from CO2 absorption
• Renal: Reduced renal blood flow and GFR (reversible)
• Neurological: Raised intracranial pressure (relative contraindication in raised ICP)
• Venous stasis: Increased VTE risk from pneumoperitoneum and positioning

Benefits of Laparoscopic Surgery

• Reduced post-operative pain and analgesic requirements
• Shorter hospital stay (often day case)
• Reduced wound complications (infection, hernia)
• Faster return to normal activity and work
• Improved cosmesis

Complications Specific to Laparoscopy

• Access injuries: Trocar injury to bowel, bladder, major vessels (aorta, iliac vessels)
• Gas-related: Subcutaneous emphysema, pneumothorax, gas embolism, shoulder tip pain (diaphragmatic irritation)
• Thermal injury: Diathermy injury to adjacent structures (may present late, days 3-7)
• Port-site complications: Hernia, infection, bleeding

Red Flags

• Haemodynamic instability during insufflation — suspect gas embolism or major vessel injury
• Increasing abdominal distension post-operatively — suspect visceral injury or bleeding
• Delayed peritonitis (day 3-7) — consider unrecognised bowel injury, particularly thermal
• Shoulder tip pain persisting >48 hours — assess for diaphragmatic injury

Bedside

• Intraoperative monitoring: Continuous ETCO2, SpO2, invasive BP for complex cases
• Intra-abdominal pressure: Monitor insufflation pressure (target 12-15 mmHg)
• Post-operative observations: NEWS2 scoring, wound checks

Bloods

• FBC: Post-operative if bleeding suspected
• ABG/VBG: If hypercarbia or respiratory compromise
• Lactate: If peritonitis or bowel injury suspected
• CRP: Rising CRP post-operatively may indicate complication

Imaging

• CXR: If pneumothorax or surgical emphysema suspected
• CT abdomen with contrast: If delayed bowel injury, collection, or bleeding suspected
• USS: For port-site hernias, intra-abdominal collections

Special Tests

• Diagnostic laparoscopy: May be required for suspected missed injury
• Intraoperative cholangiogram: During cholecystectomy if bile duct injury suspected
• Methylene blue test: Detect bladder injury intraoperatively

Non-pharmacological

• Patient positioning: Appropriate position with padding and securing (nerve injury prevention)
• WHO surgical safety checklist: Mandatory for all laparoscopic procedures
• Warm, humidified CO2: Reduces post-operative pain and hypothermia

Pharmacological

• Multimodal analgesia: Paracetamol 1g QDS + NSAID (ketorolac 30mg IV or diclofenac 75mg) + local anaesthetic port infiltration
• Antiemetic prophylaxis: High risk of PONV with laparoscopy — ondansetron 4mg IV + dexamethasone 6.6mg IV
• VTE prophylaxis: LMWH (enoxaparin 40mg SC OD) + IPC, especially for prolonged procedures
• Antibiotic prophylaxis: Procedure-specific (e.g., co-amoxiclav 1.2g IV for cholecystectomy)

Surgical/Interventional

• Open (Hasson) technique: Preferred in patients with previous surgery, adhesions
• Palmer's point: Alternative entry (left hypochondrium) for anticipated midline adhesions
• Critical view of safety: Mandatory in laparoscopic cholecystectomy — two structures (cystic duct and artery) entering the gallbladder with hepatocystic triangle cleared
• Conversion to open: Not a failure — appropriate when anatomy unclear, bleeding uncontrolled, or complications occur

Referral Criteria

• Suspected bile duct injury — urgent hepatobiliary referral
• Major vascular injury — vascular surgery
• Delayed bowel injury — senior surgical review and potential re-operation

• Laparoscopic cholecystectomy: bile duct injury rate 0.3-0.5% (vs 0.1-0.2% open); conversion to open 2-5%
• Overall mortality for laparoscopic cholecystectomy: <0.1%
• Port-site hernia incidence: 1-2% (higher with 12mm ports — fascia closure recommended)
• Return to normal activity: typically 1-2 weeks (vs 4-6 weeks for open surgery)
• Gas embolism is rare (<0.002%) but potentially fatal

Comparison: Laparoscopic vs Open Surgery

Absolute and Relative Contraindications