Exploratory Laparotomy – Laparoscopic

Diagnostic Laparoscopy

Laparoscopy is becoming an increasingly valuable tool for evaluating a variety of intra-abdominal and other disorders.

Elective applications include the assessment of chronic abdominal pain, abdominal masses, liver disease, ascites, inguinal hernias, and ventral hernias. Laparoscopy is frequently useful in the diagnosis and staging of malignant neoplasms. The magnified view can often identify small metastatic peritoneal implants that cannot be detected by computed tomography, magnetic resonance imaging, or ultrasonography. It also can help assess tumor response to neoadjuvant chemotherapy or radiation therapy. In some cases, laparoscopy can replace “second-look” laparotomy.

Emergency applications of laparoscopy include the evaluation of acute abdominal pain and peritonitis. Diagnostic laparoscopy is especially useful in assessing acute abdominal pain in young women, whose gynecologic problems are frequently confused with acute appendicitis. In these women, the procedure has been estimated to reduce the rate of unnecessary laparotomies by one third. In medically compromised patients in intensive care settings, laparoscopy can be used to exclude acute biliary tract disease or ischemic bowel disease and thereby avoid nontherapeutic laparotomies. In some medical centers, laparoscopy has occasionally been used to evaluate tangential gunshot wounds and stab wounds to the abdomen; however, this use remains controversial, because the introduction of gas into the peritoneal cavity may lead to severe hypotension in the presence of hypovolemia.

Therapeutic Laparoscopy

As mentioned earlier, laparoscopic cholecystectomy is now considered the gold standard for removing a diseased gallbladder. While the patient is undergoing this procedure, the common bile duct also can be explored and assessed. Laparoscopic tubal ligation is another well-accepted minimally invasive procedure.

Laparoscopic appendectomy is less well accepted than laparoscopic cholecystectomy, because it may not be more cost-effective or less painful than a standard appendectomy. However, laparoscopic appendectomy does have a place in the armamentarium of the general surgeon and is particularly appropriate for patients who are obese, women of childbearing age, and patients whose diagnosis is unclear.

Laparoscopic inguinal herniorrhaphy, which can be performed transabdominally or by using totally extra-peritoneal access to place prosthetic mesh in the preperitoneal space, has ardent enthusiasts and opponents. The procedure seems ideally suited for patients with bilateral or recurrent hernias.

In patients with gastroesophageal reflux disease (GERD), studies have shown that open Nissen fundoplication is more effective than medical management. Although few patients are willing to undergo a major open abdominal or thoracic operation for the treatment of GERD, many more have expressed their willingness to undergo laparoscopic fundoplication or other laparoscopic antireflux procedures. Initial reports indicate that laparoscopic fundoplication yields results similar to those of the open procedure, yet is associated with decreased postoperative pain and a shorter hospital stay. At this time, long-term studies are ongoing to verify the effectiveness of minimally invasive surgery for patients with GERD.

Laparoscopic colon resection in patients with benign colon disease has been reported to decrease the length of the hospital stay and shorten the duration of postoperative ileus, but to cost about the same amount as open colectomy. Randomized trials are currently under way to assess the role of laparoscopic colectomy for the treatment of malignant disease. The largest U.S. trial recently showed laparoscopic-assisted colectomy to be as oncologically successful as open colectomy.

The surgical management of morbid obesity has rapidly expanded in the last decade with the introduction of laparoscopic gastric bypass . This procedure has been shown to reduce wound complications, decrease postoperative pain, and improve respiratory function, all resulting in shorter hospital stays and improved recovery. Weight loss is equivalent to that with the open procedure. Other restrictive bariatric procedures include laparoscopic vertical banded gastroplasty and laparoscopic adjustable gastric banding . These procedures are less technically challenging; however, they have not been shown to reliably produce the same degree of weight loss in the U.S. population.

The surgical removal of solid organs, including laparoscopic splenectomy, laparoscopic adrenalectomy , and laparoscopic nephrectomy, is becoming the standard of care at institutions where the expertise is available.

A variety of other minimal-access procedures have been adopted after initial investigation. These include minimally invasive types of vagotomy, esophagocardiomyotomy, biliary bypass, saphenous vein harvest, pelvic lymph node dissection, salpingo-oophorectomy, hysterectomy, and bladder-neck suspension. Minimally invasive parathyroidectomy with directed single-gland exploration is now possible with the use of preoperative sestamibi scanning and intraoperative rapid parathyroid hormone assay. Anecdotal reports have described pancreatic pseudocyst-gastrostomy, pancreatic resection, gastrectomy, rectal prolapse repair, thyroidectomy, hepatic resection, coronary artery bypass graft, and cardiac valve repair.

Evaluation and Selection of Patients

Candidates for minimal-access surgery should undergo a thorough and careful preoperative history and evaluation, because they must be able to tolerate not only a laparoscopic procedure but also an open procedure if conversion to one becomes necessary.

As surgeons gain more experience, the contraindications to laparoscopic surgery are decreasing. The following remain absolute contraindications to laparoscopic abdominal procedures: advanced generalized peritonitis, hypovolemic shock, massive abdominal distention with clinical evidence of bowel obstruction, uncorrected coagulopathy, and inability of the patient to tolerate a formal laparotomy. Relative contraindications include prior abdominal or pelvic surgery, previous generalized peritonitis, obesity, advanced cardiopulmonary disease, and pregnancy.