Transperitoneal and Extraperitoneal Pelvic Procedures

The patient is positioned in the supine position with the legs on split-leg positioners or elevated in stirrups that have knee and leg supports to avoid perineal nerve injury. The table is angled (flexed) slightly at the hip to accentuate the pelvis. The patient’s arms are tucked at the sides; plastic sleds can be used to support the arms. Adequate padding should be applied to the arms and legs. A slightly snug chest strap should be placed directly across the patient’s chest. The table is placed in the 30-degree Trendelenburg position. Genitalia are draped into the operative field, which extends from the mid chest to thighs and from midaxillary line to midaxillary line. The surgeon stands on the side of the table where he or she is comfortable, and the assistant stands on the side of the table opposite the surgeon (Fig. 9–6).

Figure 9–6 Placement of the operative team for pelvic surgery: 1, operating table; 2, surgeon; 3, assistant; 4, anesthesiologist; 5, scrub assistant; 6, laparoscopic cart/tower; 7, auxiliary video monitor; 8, anesthesia equipment; 9, suction/irrigation unit; 10, scrub assistant’s instrument table; 11, electrocautery unit #1; and 12, electrocautery unit #2.

Robotic Surgery

For robotic procedures involving the kidney and adrenal gland the patient is positioned exactly as described for transperitoneal upper abdominal surgery as described earlier. The surgeon and assistant stand on the side opposite the pathologic process. The robotic tower is positioned on the ipsilateral side of the pathology such that the robotic arms stretch over the patient and can then be docked to the preplaced ports. In general it is best to angle the robot slightly such that the lens is pointing directly toward the site of interest (Fig. 9–7 on the Expert Consult website). Following this the surgeon ungowns and takes his or her place at the surgeon’s console while the assistant remains on the side of the table opposite the robotic tower.

Figure 9–7 Placement of the operative team and robotic tower for transperitoneal renal surgery.

For robotic procedures on the pelvis the patient is positioned exactly as described earlier for laparoscopic pelvic procedures. After port placement the robotic tower is placed between the patient’s legs and the assistant can remain on either side of the table depending on surgeon preference. The scrub nurse/technician can be positioned on the same side as the assistant to facilitate passing instruments because passing instruments across the robotic arms can be cumbersome.

Pneumoperitoneum

The insufflant system (i.e., insufflator, tubing, and chosen gas) is essential for establishing a pneumoperitoneum. This is brought into use after either closed (i.e., Veress needle) or open (i.e., Hasson cannula or hand-assist device) access to the peritoneal cavity is established. If hand-assisted or single-port access laparoscopy is to be performed, the pneumoperitoneum can be established directly after placement of the port.

Most commonly, CO₂ is used as the insufflant because it does not support combustion and is very soluble in blood (LD₅₀ for CO₂ is 1750 mL) (air = 357 mL) (Bordelon and Hunter, 1994). However, in patients with chronic respiratory disease, CO₂ may accumulate in the bloodstream to dangerous levels. Accordingly, in these patients, helium may be used for insufflation once the initial pneumoperitoneum has been established with CO₂ (Leighton et al, 1993). The drawback of helium is that it is much less soluble in blood than CO₂; however, its use precludes problems of hypercarbia. For this reason, even in patients with chronic respiratory disease, the procedure is initiated with CO₂ and then the change is made during the case to helium if necessary. Other gases that were once used as insufflants (room air, oxygen, nitrous oxide) are no longer routinely used because of their potential side effects (e.g., air embolus, intra-abdominal explosion, potential to support combustion). “Noble gases” such as xenon or argon are inert and nonflammable but are not routinely used for insufflation because of their high cost and poor solubility in blood.

Closed Technique: Veress Needle

Sites for Needle Passage

Disposable (70- or 120-mm, 14-gauge, and 2-mm outer diameter) as well as nondisposable (metal) Veress needles can be used. Proper needle function is ensured before the procedure. The blunt tip of the needle is tested to make sure it retracts easily; also, the needle is connected to the CO₂ line to ensure that there is no resistance to gas inflow (i.e., at 2-L/min flow, pressure remains at ≤2 mm). Lastly, saline is flushed through the needle with the tip manually occluded to make sure there is no leakage at the juncture between the shaft and the hub of the needle.

With the patient in the supine position, the head of the bed is lowered 10 to 20 degrees; insertion of the Veress needle is commonly accomplished at the superior border of the umbilicus (Fig. 9–8). There are certain advantages to choosing the umbilical area as the site for initial trocar placement: the abdominal wall is thinnest, and postoperative cosmesis is excellent. However, this point of entry is fraught with the potential for injury to a major vessel, in particular the left common iliac vessels, aorta, or vena cava.

Figure 9–8 Insertion of Veress needle at umbilicus. The towel clips stabilize the abdominal wall as the needle is advanced.

(From Clayman RV, McDougall EM, editors. Laparoscopic urology. St. Louis: Quality Medical Publishing; 1993.)

Another important factor with regard to passing the Veress needle is body habitus; in obese patients, the umbilicus tends to migrate inferiorly. In nonobese patients the umbilicus lies in its commonly described position, directly above the bifurcation of the aorta and vena cava. Thus, for umbilical access in nonobese patients the Veress needle should be passed through the abdominal wall angled toward the pelvis to avoid injury to the bowel and great vessels that lie directly beneath. In more obese patients, because the umbilicus lies more caudad, less angulation is needed and the Veress needle should be passed perpendicular to the umbilical incision (Loffer and Pent, 1976). In addition, it has also been found that pneumoperitoneum pressure and volume as well as the ease of trocar or needle insertion is not significantly affected by body habitus. In a combined human and porcine study, McDougall and associates (1994) prospectively performed pressure-volume analysis on 41 individuals undergoing transperitoneal laparoscopic procedures and found that 94% of the maximal intraperitoneal volume is achieved with an insufflation pressure of 15 mm Hg. Additional pressure (up to 30 mm Hg) did not significantly increase volume. Furthermore, in the porcine component of the study, elevation of the pneumoperitoneum pressure above 15 mm Hg did not significantly ease bladed trocar insertion. Therefore the pneumoperitoneum pressure need never be raised above 15 mm Hg unless it is done so in the setting of a vascular venous injury to control bleeding (a discussion of this technique is outlined later).

If the patient is in a lateral decubitus position, then the Veress needle is passed 2 fingerbreadths medial and 2 fingerbreadths superior to the anterior superior iliac spine. Just before insertion of the Veress needle a 12-mm incision is made in the previously described area, in anticipation of placing a 10- to 12-mm trocar. The subcutaneous tissues are spread with a Kelly clamp, and the anterior fascia is secured with an Allis clamp. The abdominal wall is stabilized, but not lifted, with the Allis clamp. The Veress needle is grasped at midshaft and is passed perpendicularly through the 12-mm incision using a gentle, steady pressure; two points of resistance are traversed: the abdominal wall fascia and the peritoneum. With this approach, the only organ at risk is the bowel; neither a vascular organ nor a major vessel can be injured using this insertion site.

Other potential insertion sites when the patient is either supine or in a lateral decubitus position are at the Palmer point (i.e., subcostal in the midclavicular line on the right side) and at the corresponding site on the left side. In this instance, stabilization or even a slight upward tension on the Allis clamps is essential; the needle if inserted too deeply will potentially hit the liver on either side or, rarely, the spleen, so care must be exercised. Chung and coworkers (2003) applied this method of laparoscopic access and trocar placement in 622 consecutive cases. Prior abdominal surgery had been performed in 192 patients (31%), and the BMI was 30 or greater in 98 patients. Blind Veress needle placement was successful in 579 (93%), and outcome was not associated with laterality, type of surgery, or prior surgery. In 34 cases (5%), a minor laceration to the liver was managed conservatively without sequelae; and in 21 cases (3%) the omentum or falciform ligament was traversed without significant injury. No major complications, such as vascular or hollow-organ perforation, were caused by either the Veress needle or trocar. Neither the spleen nor bowel was ever injured. No patient developed an incisional hernia at the upper quadrant trocar site (Chung et al, 2003).

Aspiration/Irrigation/Aspiration

With the use of a 10-mL syringe containing 5 mL of saline, the Veress needle is aspirated to check for blood or bowel contents. If this test result is negative, then the saline is injected into the abdominal cavity; this should occur without any resistance. Next, the plunger of the syringe is again withdrawn; no fluid should return into the barrel of the syringe. An additional injection of 2 to 3 mL of saline will help to expel any omentum that may have been sucked into the needle tip with the original aspiration technique. Lastly, the syringe is detached from the Veress needle and any fluid left in the hub of the needle should fall swiftly into the peritoneal cavity (i.e., the “drop” test).

Advancement Test

If the needle has truly just entered the peritoneal cavity, then the surgeon ought to be able to advance the needle 1 cm deeper without the tip meeting any resistance. Resistance at this stage usually means the needle is still in the preperitoneal space and needs to be advanced through the remaining peritoneum.

Once proper needle placement is verified, insufflation is started at 2 L/min with the abdominal pressure set at 10 mm Hg. If free flow of CO₂ is noted (i.e., intra-abdominal pressure remains <10 mm Hg), then after 0.5 L has entered the abdomen the flow can be increased to maximal capacity of 9 L/min (however, no more than 2 L/min flow can be achieved through a 14-gauge needle) and the abdominal pressure set at 15 mm Hg. As soon as the preset limit of 15 mm Hg of intra-abdominal pressure is reached, free flow stops.

In a previously operated abdomen, Veress needle insertion should be performed in an unscarred quadrant of the abdomen. Alternatively, if there is no scar-free area, then an open technique (see later) should be used.

Open Access Techniques

The pneumoperitoneum can be more easily, and in one’s early experience, more safely established using an open technique; however, its use involves making a larger incision and increases the chances of port-site gas leakage during the procedure. The open technique is recommended specifically when extensive adhesions are anticipated. Studies in general surgery have shown the open technique to be as efficient as the closed approach and slightly more or equally as safe (Bonjer et al, 1997).

In the unscarred abdomen, a 2-cm semicircular incision is made at the lower edge or slightly below the umbilicus. The fascia and peritoneum are opened individually with a transverse incision, sufficient to accommodate the surgeon’s index finger. After visual and digital confirmation of entry into the peritoneal cavity, two 0 silk traction sutures are placed on either edge of the fascia. Next, the Hasson cannula is advanced through the incision with the blunt tip protruding (Fig. 9–9A). The funnel-shaped adapter of the Hasson cannula is advanced until it rests firmly in the incision, and it is then tightened onto the cannula with the attached screw; fixation to the abdominal wall is provided with the fascial sutures that are wrapped around the struts on the funnel-shaped adapter of the Hasson cannula, thereby anchoring it in place. After removal of the obturator, free flow of CO₂ into the peritoneal cavity is achieved by attaching the CO₂ tubing to the cannula. The insufflator can be set at maximum inflow, thereby creating the pneumoperitoneum quickly.

Figure 9–9 Various trocar designs showing (A) Hasson type, (B) bladed, (C) fascial dilating, and (D) screw-like designs. Enlarged images of the bladed and dilating tips are provided.

A far simpler type of open cannula is a balloon retention device (e.g., Blunt Tip Trocar With Balloon Tip, US Surgical, Norwalk, CT) (Fig. 9–10 on the Expert Consult website). Once the cannula is positioned in the abdominal cavity, the balloon is inflated; the cannula is pulled upward until the balloon is snug on the underside of the abdominal wall. Next, the soft foam collar on the outside surface of the cannula is slid downward until it is snug on the skin and locked in place. This process creates an excellent seal, precluding gas leakage as well as subcutaneous emphysema.

Figure 9–10 Blunt tip trocar with balloon tip.

(Courtesy of US Surgical, Norwalk, CT.)

Balloon Dilation

Gradual distention of a balloon dilator in the retroperitoneal space atraumatically displaces the mobile fat and moves the peritoneum forward relative to the immobile body musculature. This device thus creates a working space equivalent to the size of the balloon.

Commercially Available Balloons

A commercially available trocar-mounted preperitoneal balloon dissector (PDB) (Covidien Ltd., Mansfield, MA) is commonly employed. The transparent, high-tensile strength silicone balloon is inflated with a sphygmomanometer bulb insufflator using room air (Fig. 9–11). The balloon has a maximum capacity of 800 mL (40 pumps of the inflating bulb). A primary advantage is that the balloon is affixed to the end of a stiff, hollow, transparent plastic shaft. The shaft allows precisely directed placement of the balloon dilator (see later). Furthermore, because the laparoscope can actually be inserted into the shaft of the balloon dilator during the inflation process it provides the capability for endoscopic confirmation of the proper positioning of the transparent balloon and of the adequacy of the controlled radial dilation of the extraperitoneal area. Balloon dilators are commercially available in two different shapes: a round balloon for dilation of the pelvic extraperitoneal space and a horizontally oriented, oblong-shaped balloon for dilation of the retroperitoneal space.

Figure 9–11 Example of a commercially available balloon dilator for creating space in the retroperitoneum: preperitoneal balloon dissector.

(Courtesy of Covidien Ltd., Mansfield, MA.)

Technique for Balloon Placement: Open (Hasson) Technique

This is the most commonly employed technique because it affords the greatest precision during development of the retroperitoneal space (Gill, 1998). Initial access is obtained through a 2.0- to 2.5-cm transverse incision in the midaxillary line, just below the tip of 12th rib. The wound is opened with a pair of S-retractors. Under direct vision, the posterior layer of the lumbodorsal fascia is incised and muscle fibers are split or divided. The retroperitoneal space is entered, under direct vision, by making a small incision in the anterior thoracolumbar fascia with an electrocautery blade or, less commonly, by bluntly piercing the fascia digitally or with a hemostat. Care should be taken that this fascial opening is snug around the index finger and no larger, so that intraoperative air leak is minimized. Index finger palpation of the belly of the psoas muscle posteriorly and the Gerota fascia–covered inferior pole of the kidney anteriorly confirms proper entry into the retroperitoneal space (Fig. 9–12A). The index finger is employed to digitally create a space in this precise location for placement of the balloon dilator; two inflations of the balloon are then done—one directed cephalad and the second directed caudad to fully dilate the retroperitoneal space (see Fig. 9–12B). Thus, balloon dilation is performed anterior to the psoas muscle and fascia and outside and posterior to the Gerota fascia. In cases involving definitive ureteric mobilization (e.g., retroperitoneoscopic donor nephrectomy, nephroureterectomy, ureterolithotomy, pyeloplasty), an additional balloon dilation may be performed more caudad to the primary site of dilation (Gill et al, 1995). Similarly, during a retroperitoneoscopic adrenalectomy, it is helpful after the initial balloon dilation to move the balloon up higher in the retroperitoneum and perform a second even more cephalic balloon dilation along the undersurface of the diaphragm (Sung and Gill, 2000).

Figure 9–12 A, Access into the right retroperitoneum. Through the primary port incision at the tip of the lowest (12th) rib, open access is gained into the retroperitoneum after piercing the thoracolumbar fascia. Finger dissection is performed anterior to the psoas muscle and fascia to create a space for insertion of the balloon dilator. Confirmation that the finger dissection is indeed being performed in the proper plane is obtained by palpating the psoas and erector spinae muscles between the retroperitoneally located index finger and the fingertips of the opposite hand positioned on the patient’s back. The fat-covered lower pole of the kidney can be palpated in a cephalad direction by turning the finger clockwise in the retroperitoneum on the right side. B, Balloon dilation in the posterior pararenal space facilitates the creation of a working space for retroperitoneal laparoscopic nephrectomy (coronal view).

(Reprinted with permission, Cleveland Clinic Center for Medical Art & Photography © 1998-2011. All Rights Reserved.)

Open (Hasson) Technique

A 1.5- to 2-cm curvilinear incision is made along the inferior umbilical crease. The anterior rectus sheath is incised vertically for 1.5 cm, and the rectus muscle is separated in the midline to expose the posterior rectus sheath. With the surgeon’s index finger positioned posterior to the rectus muscle and anterior to the posterior rectus sheath, gentle tunneling motions are made in a caudal direction until the area of the symphysis pubis is reached. At this distal location, the fascia transversalis is punctured with the fingertip and gentle side-to-side digital dissection is performed in the prevesical space, posterior to the pubic bone. Into this predeveloped space, a balloon dilator (see earlier) is inserted and distended to create an adequate working space. Balloon dilation effectively displaces the prevesical fat and reflects the peritoneum cephalad. The balloon is initially inflated in the midline and then re-inflated on either side to further expand the working area (Meraney and Gill, 2001).

Caveat: The classic Hasson cannula requires the placement of two 0 silk sutures into the fascia that are then affixed to the cone-shaped portion of the cannula to effect a seal between the cannula and the fascia. This arrangement invariably results in a significant leakage of gas because the seal is rarely airtight. Indeed, in earlier studies of retroperitoneoscopy, excessive subcutaneous emphysema and higher carbon dioxide levels were the norm owing to use of the standard Hasson cannula (Wolf et al, 1995; Ng et al, 1999); this situation was rectified with the introduction of the open access blunt port, which has a balloon to secure it against the underside of the abdominal wall and a soft foam cuff to secure it to the outer abdominal wall, thereby effecting an airtight seal (Ng et al, 1999).

Access Technology: Trocars, Hand-Ports, and Single-Port Access

Hand-Assist Devices

The first generation of hand port devices consisted of the Handport, Intromit, and Pneumosleeve. As with most first-generation laparoscopic devices, they were adequate with regard to functionality but each had its drawbacks (Stifelman and Nieder, 2002). These products have now been replaced by a second generation of improved devices: The Gelport (Applied Medical, Rancho Santa Margarita, CA), the Omniport (Advanced Surgical Concepts, Wicklow, Ireland), and the LapDisc (Ethicon Endosurgery, Cincinnati, OH).

The Gelport (Fig. 9–13A on the Expert Consult website) consists of a gel-like disc that easily admits the surgeon’s hand and then molds around the wrist and arm. The latest Gelport design has a 12-cm footprint. To set up the two-piece Gelport system the surgeon inserts the lubricated wound protector through a 7- to 8-cm incision and adjusts it to create a tight seal across the abdominal wall. A gel disc is then snapped on top of the wound protector and held in place with a small lever. The Gelport offers the advantages of never losing a pneumoperitoneum on hand exchange because it immediately seals after hand removal and it does not require adjustment to maintain a seal. Additional instruments can be passed alongside the surgeon’s hand, through the gel material, also without loss of the pneumoperitoneum.

Figure 9–13 Hand port devices. A, Gelport. B, Omniport. C, LapDisc.

The Lapdisc (see Fig. 9–13B on the Expert Consult website) is a one-piece unit that has an inner diaphragm that is used to anchor it across the abdominal wall and an outer appliance that dials down a thin plastic sheet, like a camera iris, around the surgeon’s wrist. Although this device has a low profile and small footprint (12 cm) it does result in loss of the pneumoperitoneum every time the hand is removed and reinserted and instruments cannot be passed parallel to the surgeon’s hand.

The Omniport (see Fig. 9–13C on the Expert Consult website) is a balloon-like device that anchors itself as one piece across the abdominal wall. The inflated device also creates a seal between itself and the surgeon’s wrist. The device has a smaller footprint (12 cm); however, it must be uninflated and reinflated each time a hand is exchanged, which results in loss of the pneumoperitoneum. Furthermore, no additional devices can be passed parallel to the surgeon’s hand through the device.

In a recent study, 130 urologists participating in a series of hand-assist courses evaluated the different devices for a variety of features. The overall scores in this study were 8.6, 7.4, and 7.3 on a scale of 10 (10 being best) for the Gelport, LapDisc, and OmniPort, respectively (Patel and Stifelman, 2004). Advantages of the Gelport included sturdiness, ease of hand exchange, maintenance of the pneumoperitoneum, as well as the ability to pass both a hand and a laparoscopic instrument simultaneously. Of note, the price to the surgeon of using a hand-assist device is not inconsequential. For the surgeon, pain and numbness of the hand/wrist/forearm and, to a lesser extent, overall fatigue are much greater when using a hand-assist device versus standard laparoscopy (Monga et al, 2004; Gofrit et al, 2008).

Access Devices and Techniques for LESS

There are two basic methods used to achieve intra-abdominal access for LESS. One technique is to make a 2.5-cm incision, typically periumbilical or transumbilical (although an alternate site may be necessary), through which a skin flap can be raised off of the abdominal wall fascia. Then, through this single incision several (two to four) standard 5-mm laparoscopic ports can be placed in close proximity to one another. A laparoscope and working instruments can then be placed through these ports. The size of the skin incision should correspond to the surgical task at hand. If the procedure does not require removal of a large intact specimen, then the incision should be minimized to as little as 2.5 cm. If the procedure requires large intact specimen removal (as in donor nephrectomy), then the incision should be large enough to extract the specimen.

Another technique is to use a commercially available single site surgery device. These devices currently require a single incision that is typically placed periumbilically or transumbilically unless the procedure dictates an alternate site. Currently there are three devices that are available for commercial use. The TriPort (Advanced Surgical Concepts, Bray, Ireland) is a two-piece system consisting of an inner diaphragm that works like a wound protector and an outer piece containing the ports (Fig. 9–14A). The wound protector component is adjustable and cinches down the outer attachment, creating a tight seal on the abdominal wall. The TriPort, which requires a 12- to 25-mm incision, has room for a 5-mm laparoscope and two 5-mm working instruments plus a separate insufflation valve. The same manufacturer also makes a four-port model called the QuadPort that contains two 12-mm and two 5-mm instrument insertion sites; it requires a 2.5- to 6.5-cm incision. The Uni-X (Pnavel Systems, Cleveland, OH) is a similar device that is anchored to the abdominal wall by preplaced facial sutures. It has three 5-mm insertion sites and can be placed through a 1.5-cm incision (Kaouk et al, 2008b).

Figure 9–14 Commercially available ports for LESS surgery. A, Triport. B, SILS port.

The SILS port (Covidien Ltd., Mansfield, MA) can be placed into a 2-cm incision and can house three 5-mm ports or two 5-mm ports and a 5- to 10-mm port (see Fig. 9–14B).

These devices have been used successfully to perform single-site nephrectomy, adrenalectomy, pyeloplasty, renal cyst decortications, and renal cryoablation (Castellucci et al, 2008; Gill et al, 2008; Goel and Kaouk, 2008; Kaouk et al, 2008b; Ponsky et al, 2008b; Rane and Rao, 2008).

Secondary Trocar Placement

Transperitoneal Standard

Number, size, and exact location of secondary trocars depend largely on the intended laparoscopic procedure. Their configuration should be planned so that neither the tips nor handles of the cannulas cross or come into close contact with one another (a problem termed crossing swords and rollover, respectively) such that adequate working space is provided for all instruments to be used during a particular procedure and allowing for effective triangulation at the surgical site by the endoscope and two working ports. In general, it is reasonable to place the ports in a four-point diamond pattern such that the site of the operation is encircled within the diamond. This is particularly important when considering reconstructive renal procedures, because the angle between the horizontal plane and the needle drivers should be less than 55 degrees whereas the angle between the surgeon’s suturing instruments should be in the 25- to 45-degree range (Rassweiler and Frede, 2002).

Secondary trocars are placed under direct optical control. The 30-degree lens is ideal for this portion of the procedure because turning the lens 180 degrees away from the surgical site provides the surgeon with a panoramic view of the anterior abdominal wall. The operative lights are dimmed, and the tip of the laparoscope is moved upward toward the intended site of port placement, thereby, in the thin patient, transilluminating any superficial blood vessels that need to be avoided while passing the trocar. Using a No. 12 hook or No. 15 small blade, a skin incision is made just wide enough to accept the selected cannula. When placing secondary ports, it is of great importance to direct them toward the intended surgical field to provide tension-free maneuverability of the laparoscopic instruments. This is especially important in obese patients because the errant port will provide resistance to the surgeon throughout the rest of the procedure. Similar to placement of the initial port, all secondary ports are advanced through the abdominal wall using a slow, twisting motion and constant pressure. If necessary, the abdominal wall can be elevated by towel clips placed at the edges of the skin incision made for port entry, to facilitate safe advancement of trocars into the peritoneal cavity. Each secondary port is passed into the peritoneal cavity under meticulous endoscopic monitoring. After placement of the second port, a 5- or 10-mm laparoscope is advanced through this port to inspect the entry site of the first trocar into the peritoneal cavity to rule out any inadvertent injury to the bowel, underlying viscera, or an abdominal wall vessel. To prevent dislocation, ports that do not possess self-retaining mechanisms may be anchored to the skin using No. 2 nonabsorbable sutures. In this regard it is very important for the surgeon to never use a plastic retention sleeve with a metal cannula; this combination creates a situation in which stray electrosurgical current may injure the bowel or other structures adjacent to the cannula since the plastic sleeve insulates the abdominal wall, resulting in increased current density along the metal intra-abdominal portion of the cannula.

Transperitoneal: Hand-Assist

When the hand-assist device is in place, then secondary trocars can be placed with digital guidance. After inspection of the abdomen rules out any potentially interfering adhesions, the surgeon’s index finger is placed on the underside of the abdominal wall at the planned site of trocar placement. A skin incision is made over the surgeon’s index finger and the nonbladed trocar is passed with the other hand and guided by the surgeon’s finger into the abdominal cavity. This is a very rapid and safe way to place all of the secondary nonbladed trocars.

Retroperitoneoscopy Approach

After controlled balloon dilation of the retroperitoneum, the balloon dilator is replaced with a 10-mm Bluntport (US Surgical, Norwalk, CT). A feature unique to this port is the presence of an internal doughnut-shaped retention balloon and an external adjustable foam cuff, a combination that effectively creates an airtight seal at the location of the primary port site (see Fig. 9–10 on the Expert Consult website). Use of this device minimizes CO₂ leakage around the 1.5-cm primary port incision, thus reducing the incidence of subcutaneous emphysema and hypercarbia. In our experience this is far superior to the reusable Hasson cannula; with this device efforts directed at minimizing gas leak, such as placing a deep mattress stay suture or placing petroleum jelly gauze around the cannula, were rarely effective.

For retroperitoneoscopy, several port arrangements are possible: a three-port (I distribution) approach can be employed (Gill, 1998; Hsu et al, 1999), the authors prefer a four-port approach (T distribution), whereas Abbou and colleagues (1999) described a five-port approach (W distribution). A 30-degree or flexible laparoscope is used, and all secondary nonbladed ports are introduced under laparoscopic or digital control. The posterior secondary port is placed at the lateral border of the paraspinal muscles along the inferior border of the lowermost (12th) rib, and an anterior port is placed at the anterior axillary line, subcostal; thus the three ports are all in a line, hence an I-shaped configuration (Fig. 9–15). A fourth port may be placed, in the middle axillary line, 2 to 3 fingerbreadths above the anterior-superior iliac spine near the Petit triangle thereby creating a T configuration. Placement of this anterior port any closer to the iliac crest limits the amount of cranial angulation of the cannula. A fifth port can be placed just lateral to the anterior axillary line and on the same level as the fourth port, creating a W configuration. Depending on the anticipated technical difficulty of the procedure, patient obesity, and tumor size, for the I configuration, two 12-mm secondary ports or one 5-mm port and one 12-mm secondary port are used. In either situation, a 12-mm port is routinely placed for the surgeon’s dominant hand to allow interchangeable use of various large-caliber instruments, including a 10-mm Endo Clip applier, a 12-mm Endo GIA stapler, a 10-mm right-angle dissector, and a 10-mm reusable expandable retractor. The two secondary ports should be inserted as far apart as possible to minimize the possibility of instrument tips clashing within the retroperitoneum. The additional two ports can be 5, 10, or 12 mm depending on the surgeon’s preference. Contrary to common conception, the occurrence of an inadvertent peritoneotomy during retroperitoneoscopy does not usually interfere with the subsequent steps of the procedure and conversion to a transperitoneal laparoscopic technique is not mandatory (Gill et al, 2000).

Figure 9–15 For retroperitoneal laparoscopy the patient is positioned in the standard full-flank position. The kidney rest is elevated, and the operating table is flexed to maximize the space between the iliac crest and the lowest rib. A three-port approach is employed. The primary 12-mm port is placed inferior to the tip of the 12th rib. An anterior 12-mm port is placed near the anterior axillary line 3 cm cephalad to the iliac crest. A posterior 5-mm port is placed at the junction of the lateral border of the paraspinal muscles and the 12th rib. (Note: After port placement, the kidney rest is lowered.)

(Reprinted with permission, Cleveland Clinic Center for Medical Art & Photography © 1998-2011. All Rights Reserved.)

Extraperitoneal Access to the Pelvis

After balloon dilation the Bluntport is inserted at the infraumbilical incision. The retention balloon is inflated, and the foam cuff is cinched down onto the abdomen. For robotic procedures a standard 12-mm trocar is placed in the extraperitoneal space and hence care should be taken not to create an incision larger than 12 mm (Esposito et al, 2008). The extraperitoneal space is insufflated with CO₂ at a pressure of 12 to 15 mm Hg, and secondary ports are introduced under visual control. Depending on the procedure to be performed, three to four secondary ports are inserted in a triangle-, diamond-, fan-, or W-shaped configuration. Pneumoextraperitoneum is reduced to 10 to 12 mm Hg for the remainder of the procedure. Unlike with retroperitoneoscopy, the occurrence of a peritoneotomy during extraperitoneoscopy may interfere with the performance of subsequent extraperitoneal dissection and conversion to a transperitoneal technique may be required (Meraney and Gill, 2001).

Robotic Considerations

If a robotic procedure is planned, then the camera port is a 12-mm trocar site and the two (or three if the fourth arm is employed) auxiliary ports are 8 mm. All the ports need to be placed 8 to 10 cm apart to reduce the possibility of the robotic arms clashing with each other. In addition, if the patient is in a flank position, then the lowest port placement should not be inferior to the umbilicus or else the arm may be blocked from a full range of motion by the patient’s upside leg. An assistant’s port is placed on a line either caudal or inferior to the robotic arms; placement of the assistant’s port in between the arms of the robot makes it quite awkward for the assistant to work and limits the range of motion of the assistant’s instrument owing to clashing with the arms of the robot.

Instruments for Visualization

To create a laparoscopic image, four components are required: the laparoscope, light source, camera, and monitor. To record the image, video recorders, digital video disc, and video printers are available. Laparoscopes that are most commonly used have 0- or 30-degree lenses (range, 0 to 45 degrees) and are available in sizes from 2.7 to 10 mm (most commonly, 5 or 10 mm); however, newer deflectable laparoscopes now exist in which the tip of the endoscope can deflect in four directions up to 90 degrees (Olympus, Melville, NY). Another novel endoscope design is the EndoCAMeleon (Karl Storz, Tuttlingen, Germany). This scope maintains the familiar feel of a standard rigid laparoscope but has a variable-view swing prism that enables the surgeon to change viewing angles from 0 to 30, 45, 90, or 120 degrees. An advantage of the EndoCAMeleon is that it has a standard eyepiece, allowing it to be used with most camera systems.

With standard laparoscopes, image transmission employs an objective lens, a rod-lens system with or without an eyepiece, and a fiberoptic cable. From the eyepiece, the optical image is magnified and transferred to the camera and onto the monitor. Light is transmitted from the light source through the fiberoptic cable onto the light post of the laparoscope (Fig. 9–16A on the Expert Consult website). Some newer laparoscopes have a mini charge-coupled device (CCD) camera mounted at the tip (EndoEYE, Olympus, Melville, NY), which improves image quality and avoids the need for an external light chord that can sometimes impede the movement of other instruments (see Fig. 9–16B on the Expert Consult website). Historically the advantage of the larger laparoscopes is that they could provide a wider view, better optical resolution, and a brighter image. However, today, many of the 5-mm laparoscopes provide an image that rivals traditional 10-mm scopes. These 5-mm laparoscopes, especially those designed with a low profile handle and a deflectable tip, are particularly of use for LESS procedures.

Figure 9–16 A, Standard rod/lens laparoscope and camera. B, Laparoscope with a mini-CCD camera mounted at the tip.

A special variant is the offset “working laparoscope,” which includes a working channel for passage of basic laparoscopic instrumentation; use of this type of laparoscope enables the surgeon to work in a direct line with the image and may allow a reduction in the number of trocars needed to accomplish a particular procedure. However, the working channel occupies space that would otherwise be used for the optical system; thus the resulting image is usually of lesser quality compared with that of laparoscopes without this feature.

The camera system consists of a camera and a video monitor. All currently made cameras can be gas or liquid sterilized, thereby facilitating their use and limiting possible intraoperative contamination. For standard laparoscopes the camera is attached directly to the end of the laparoscope and transfers the view of the surgical field through a cable to the camera box unit. After reconstruction of the optical information the image is displayed on one or two video monitors.

A wide variety of cameras are currently available: single-chip, single-chip/digitized, three-chip, three-chip/digitized, interchangeable fixed-focus lenses, zoom lenses, beam splitter, and direct coupler. Three-chip cameras are superior to single-chip cameras in that they provide a higher-quality image with superior color resolution. Again, some endoscopes have the added advantage of having the chip directly at the tip of the laparoscope such that the images are directly processed without interruption thus greatly improving image quality (EndoEYE, Olympus, Melville, NY). This allows the entire system to be built into the handle such that the endoscope connects directly to the camera box; as such, a better image is obtained and the handle has a very low profile (see Fig. 9–16B on the Expert Consult website). To obtain a “true” upright image of the surgical field on the monitor, the camera’s orientation mark must be placed at the 12-o’clock position. With 0-degree laparoscopes the camera is locked to the eyepiece in the “true” position. In contrast, with the 30-degree laparoscope the camera is loosely attached to the eyepiece of the laparoscope so the laparoscope can be rotated. Accordingly, the assistant must hold the camera in the “true” upright position with one hand while rotating the laparoscope through a 360-degree arc to peer over and around vascular and other intra-abdominal structures; the 30-degree lens thus provides the surgeon with a more complete view of the surgical field than does a 0-degree lens. A more recent advancement in laparoscope technology is the four-way deflectable endoscope (EndoEYE Deflectable Tip Video Laparoscope, Olympus, Melville, NY), which offers many potential angles from which to view a structure but requires an adept assistant.

Instrumentation for Grasping and Blunt Dissection

Most graspers and dissectors are used in their 5-mm size but are available in a range from 3 to 12 mm, in predominantly reusable forms. Grasping instruments have either single-action (only one jaw moves during opening) or double-action (both jaws move) tip design.

Wide variations exist with regard to configuration of tip, surface characteristics of jaws, handle design, and possible electrosurgical properties. Tip designs include blunt-coarse, pointed (dolphin), straight (duck bill), curved (Maryland), and angled. The surface of the jaws may be atraumatic or traumatic. Serrated or smooth surfaces allow gentle tissue manipulation in atraumatic graspers (e.g., bowel forceps with a 3-cm long grasping jaw). Traumatic graspers have toothed or clawed surfaces on their jaws to allow them to grasp and hold tissues firmly. In addition, each of these instruments may be equipped with tip-rotation and/or articulating features. Both reusable and disposable instruments are available.

Depending on the design of the handle, grasping instruments may be locking or nonlocking. Most nonlocking forceps have a scissor-type handle. Different designs allow for locking capabilities; in particular, bar-type and spring-loaded locking handles are convenient when prolonged grasping of tissue is required. Some newer dissectors in addition to grip and rotation actually offer additional degrees of freedom by means of an articulating joint activated through wrist movements of the surgeon (RealHand, Novare Surgical, Cupertino, CA; Autonomy Lapro-Angle, Cambridge Endoscopic Devices Inc., Framingham, MA) (Fig. 9–17). These instruments are most helpful if one is to perform a LESS procedure because the angulation of the shaft then provides the triangulation necessary for approaching the surgical field. In addition, the shafts of these instruments may be of variable length (i.e., 34, 45, or 75 cm), again allowing for less clashing of handles during a LESS procedure.

Figure 9–17 Examples of deflecting graspers. A, RealHand (Novare Surgical, Cupertino, CA). B, Autonomy Lapro-Angle

(Cambridge Endoscopic Devices Inc., Framingham, MA).

In addition to standard dissecting instruments, both the laparoscopic suction apparatus as well as the “heel” of the hook electrode can be used for effective and rapid blunt dissection. Along these same lines, the development of laparoscopic “peanuts” or Kittners (i.e., 5- and 10-mm gauze-tipped disposable dissectors) has been most helpful. These disposable blunt dissectors typically come with the usual absorbent material on the tip, in which case the device needs to be continually switched out for a fresh Kittner owing to absorption of fluid or blood during the procedure. A newer nonporous material has now been affixed to the 10-mm Kittners, allowing one device to suffice through an entire case (Vascular Technologies Inc., Nashua, NH). These dissectors can be twirled or moved side to side or up and down in an area of adipose tissue to rapidly tease away the fat surrounding vital structures such as the renal hilum or the adrenal gland. In addition, the device can be used to raise an entire “line” of tissue (e.g., pararenal fat), allowing for its rapid and safe division because neither the shaft nor tip of the Kittner will conduct electrosurgical current.

Instrumentation for Incising and Hemostasis

Laparoscopic scissors, scalpels, electrocautery, and lasers (CO₂, neodymium:yttrium-aluminum-garnet [Nd:YAG], or potassium titanyl phosphate [KTP]) are used to incise or cut tissue during laparoscopic surgery.

Laparoscopic scissors are available in disposable and nondisposable forms. The blades of laparoscopic scissors are shorter than their open surgical counterparts. The configuration of the tip may be useful for selected situations: serrated tips for cutting fascia, hooked tips for cutting sutures, microscissors for spatulating the ureter during a pyeloplasty, and curved tips for dissection. Incision of the tissue is achieved using either an electrosurgical (“hot”) or a mechanical (“cold”) approach. The scissors may come with either permanent blades or with replaceable tips; the latter ensures “sharp” scissors for each procedure. In addition, the shaft of the scissors may rotate and, in some disposable scissors, even articulate up to 90 degrees. The latter feature is particularly helpful when spatulating the ureter during a pyeloplasty.

A laparoscopic scalpel is also available. It is of particular use for incision of the ureter during laparoscopic ureterolithotomy.

For electrosurgical incision of tissue, a selection of different electrodes is available: needle electrodes (Corson type) produce fine cuts that are useful in making peritoneal incisions, spatula electrodes are used in blunt dissection and cutting, and hook electrodes (J and L configurations) are of particular value during dissection of vessels because tissue can be pulled away from delicate structures before the cutting current is activated. The thinner the metal tip of the probe, the higher the density of the electrical current, and the greater the cutting power.

As with all insulated instruments, certain precautions must be followed during monopolar electrosurgery to avoid local or distant transmitted thermal injury. Consequently, the electrosurgical probe should not be activated unless the metal part is in complete view. The insulation of the electrosurgical instrument should be carefully checked for any damage. The probe should not be activated unless it is in direct contact with the tissue to be incised. Also, use of the monopolar electrosurgical instrument through a metal rather than a plastic cannula decreases the chances of inadvertent electrosurgical injury owing to capacitive coupling. In this regard, one should never use a metal trocar in conjunction with an outer plastic retaining ring because stray current can no longer be harmlessly dissipated through the metal cannula directly to the surrounding peritrocar abdominal wall and hence, any juxtaposed visceral structure may be damaged in an area remote to the laparoscopist’s vision. The same precautions apply with monopolar equipped grasping forceps, which might be used during a procedure to obtain hemostasis.

To avoid the potential dangers of stray current from use of monopolar electrosurgical equipment, the surgeon can use monopolar current in conjunction with active electrode monitoring (Encision Inc., Boulder, CO). This instrumentation is constructed such that there is ongoing feedback during activation of the electrosurgical current; as such, any break in the insulation of the shaft results in immediate deactivation of the instrument.

Surgical Pharmaceuticals

Recently, a vast array of topical hemostatic agents, sealants, and glues have entered the surgical realm. These agents, depending on their individual properties, can be used for a variety of surgical tasks and have become a valuable addition to the surgeon’s tray.

Fibrin-Based Glue

Fibrin glue has been used to promote hemostasis in parenchymal beds, in particular after partial nephrectomy or to seal a liver laceration. The two components of the fibrin glue, fibrinogen and thrombin, are delivered through separate channels and then combine at the tip of the delivery system during application to the tissue. Fibrin glue has an adhesive quality once dry where it essentially hardens into a rubbery coagulum. Tisseel VH Fibrin Sealant (Baxter, Glendale, CA) has the maximum concentration of human fibrinogen available (75 to 115 mg/mL). It can be delivered by means of a laparoscopic applicator in liquid form or in an aerosolized form. One disadvantage of Tisseel is that it requires a preparation time of 20 minutes before it can be applied by the surgeon. If the application at hand requires immediate application (bleeding) then fibrin glue is not a viable option unless it has been prepared in anticipation of possible hemorrhage. Once prepared, Tisseel VH has a shelf life of 36 hours.

Another fibrin-based sealant that can be delivered in a similar manner is Evicel (Johnson & Johnson, New Brunswick, NJ). This agent, which contains 40 to 60 mg/mL human fibrinogen, comes frozen and thus requires no reconstitution. It can be thawed in the hand in 5 minutes and available in another minute. Once thawed, Evicel has a shelf life of 1 month under refrigeration (Tredree et al, 2006). Another advantage is that it contains no bovine serum components (e.g., aprotinin) and hence can be used in individuals with allergies to bovine-derived products. This product can also be applied laparoscopically with an available applicator.

Although all types of fibrin glue use pooled human fibrinogen, the preparations are treated to inactivate viruses. As of 2006 there were no reported cases of viral transmission to a recipient (Tredree et al, 2006).

Non–Fibrin-Based Surgical Hemostats

In contrast to the fibrin-based glues, other hemostatic agents such as thrombin-soaked oxidized cellulose particles (FloSeal, Baxter, Glendale, CA; Surgifoam, Johnson & Johnson, Princeton, NJ) have no adhesive capability at all but are excellent hemostatic agents in the presence of active bleeding from parenchymal surfaces such as a partial nephrectomy bed, a liver/spleen laceration, or an oozing adrenal bed. This agent is also prepared by the scrub assistant and takes 2 minutes to prepare. It is applied through a tube applicator with a syringe. It is most effective when pressure is applied after its delivery; this can be done either with an instrument (e.g., 10-mm gauze-tipped dissector) or with a bolster.

Avitene Microfibrillar Collagen Hemostat (Davol, Cranston, RI) is an active collagen hemostat that accelerates clot formation by enhancing platelet aggregation and the release of fibrin. Similar to FloSeal, it has no tissue sealing capability but is useful for counteracting parenchymal bleeding. EndoAvitene is available in a preloaded endoscopic delivery system designed for use in endoscopic procedures. Developed to easily pass through standard trocars and cannulas, it is available in both 5- and 10-mm diameters.

Chemical-Based Sealants

BioGlue (CryoLife, Inc., Kennesaw, GA) is a two-component adhesive composed of purified bovine serum albumin and glutaraldehyde. The solutions are mixed during application from a controlled delivery system. The glutaraldehyde then crosslinks the BSA molecules to each other and then to the tissue protein at the site of use. Once applied, the agent polymerizes within 20 to 30 seconds and reaches its full bonding strength within 2 minutes. The delivery system comes ready for immediate use. BioGlue is a sealant and must be applied to a dry field and allowed to dry. Thus it cannot be used to counteract active bleeding but can be used to seal a raw, nonbleeding surface.

CoSeal (Baxter, Glendale, CA) is a completely synthetic product composed of two distinct polyethylene glycol polymers that chemically bond together to seal tissue surfaces, suture lines, and synthetic grafts. It does not require thawing, heating, or light activation and hence can be ready in 1 minute. It must be applied to a dry (non-bloody) surface because it does not interact with the clotting cascade and hence is not useful in the setting of active hemorrhage.

Now that the benefits of such substances have come into the spotlight in surgery it is important for the surgeon to be familiar with the properties of these various agents and thereby able to choose one that is most appropriate for the job at hand. A comparison of popular hemostatic agents is presented in Table 9–2.

Table 9–2 Some Commonly Used Topical Tissue Sealants and Hemostatic Agents

Instrumentation for Suturing and Tissue Anastomosis

Suturing and knot tying are among the most difficult tasks in laparoscopic surgery. A significant amount of practice is needed to achieve a sufficient level of proficiency. Laparoscopic needle holders have one fixed jaw and one jaw that opens by squeezing the spring-loaded handle of the instrument (Fig. 9–18). They all have a locking mechanism to secure the needle in their jaws; this is done with a ratchet, spring-loaded, or Castroviejo-type mechanism. Some needle holders also possess a feature that allows the jaws to rotate around the main axis relative to the handle. The handles may be straight or provide a pistol-type grip. In addition to standard rigid needle drivers some companies have recently developed articulating needle drivers that aid in obtaining more optimal suturing angles with the needle. The actuation of the articulation mechanism is controlled by the surgeon’s wrist motion (see Fig. 9–17) (Laparo-Angle, CambridgeEndo, Hopkinton, MA; RealHand, Novare Surgical, Cupertino, CA).

Figure 9–18 Different handle designs for commonly used laparoscopic needle drivers.

The Endo Stitch (Covidien Ltd., Mansfield, MA) device is an innovative, disposable, 10-mm instrument that facilitates laparoscopic suture placement and knot tying (Adams et al, 1995). The suture is secured to the center of a straight needle with two pointed ends, thereby allowing tissue penetration in either direction. The needle is shuttled back and forth between the jaws of the instrument after each passage through the tissue, applying a long-known principle used in sewing machines. In this way, passing the needle through the tissue and regrasping the needle after it has traversed the tissue become simple tasks because they are done by a one-handed squeeze of the handle and a flip of the needle-securing lever, respectively. Use of this sewing apparatus has had a major impact on decreasing operative times, especially in laparoscopic pyeloplasty (Chen et al, 1998). However, one drawback of suturing in this manner is that the site of needle passage is invariably larger than the needle itself (i.e., because the suture is passed alongside the needle each time); hence if used to close a cavotomy there is oozing along the needle tract that requires placement of either fibrin glue or thrombin-soaked oxidized cellulose. With experience with standard laparoscopic needle holders and especially with the advent of robotic-assisted procedures, use of the Endo Stitch has become less common.

Lapra-Ty clips (Ethicon Endo-Surgery, Somerville, NJ) are a very useful adjunct to suturing and knot tying. These 3.5-mm clips are made of absorbable polydioxanone and are designed to provide secure anchoring of sutures for up to 14 days in low-tension to mid-tension environments (Ames et al, 2005). According to the manufacturer, these suture anchors can be secured to the end of a single strand of polyglactin 910 (Vicryl) suture as fine as 4-0. Experimental models from two different laboratories have shown that these clips are least likely to fall off of polyglactin 910 sutures from size 1-0 to 3-0 (Ames et al, 2005; Weld et al, 2008). In the laboratory environment Lapra-Ty clips have been shown to be slip resistant with 2-0 Monocryl and PDS suture as well. In multiple test trials for each suture type, a percentage of monofilament sutures size 3-0 and smaller as well as 4-0 suture of any type did have slippage of the clip. Hence, it seems logical to avoid Lapra-Ty use with 4-0 suture and to avoid excessive tension when using these clips with 3-0 monofilament suture. The clip acts as a knot, thereby precluding time-consuming intracorporeal laparoscopic knot tying (Fig. 9–19). When they are used to secure a single suture, it is helpful if the suture has a pre-tied loop on its end; the needle is passed through the tissues to be secured and is then passed through the pre-tied loop. Next, the suture is pulled taut, thereby tightening its hold on the encircled tissue; the Lapra-Ty clip is then affixed to the suture material just as it exits the loop. For a running suture, the Lapra-Ty clip can be used both to anchor the end of the suture and to secure the suture on completion of the run. It has also been found to be useful for anchoring bolsters during renorrhaphy for laparoscopic partial nephrectomy (Orvieto et al, 2004).

Figure 9–19 Example of a Lapra-Ty Clip (Ethicon Endo-Surgery, Somerville, NJ) affixed to a suture.

Instrumentation for Stapling and Clipping

Stapling Devices

Various stapling devices are available for tissue occlusion and division (Fig. 9–20). The Endo GIA Universal 12-mm stapler/linear cutting device (Covidien Ltd., Mansfield, MA) requires a 12-mm port and delivers two triple-staggered rows of staples and simultaneously cuts in between the rows. The universal stapler can be loaded with a variety of 30-, 45-, or 60-mm loads and fired any number of times. Similarly, the ETS-Flex 45 stapler (Ethicon, Somerville, NJ) also requires a 12-mm port and delivers two triple rows of staples while cutting between rows 3 and 4. This stapler has a maximum fire limit of 8 staple loads. Articulating/roticulating staplers are available from both companies, which enable the surgeon to properly align the instrument with the tissue to be occluded and divided. Each staple load cartridge is color coded depending on the size of the staples: 2.0-mm staples (gray) or 2.5-mm staples (white) are preferred for vascular (renal vein or renal artery) stapling, whereas 3.8-mm (blue) and 4.8-mm (green) staples are used in thicker tissues (ureter, bowel, bladder). In addition, for laparoscopic live donor nephrectomy, a single Endo-TA (linear noncutting) stapler can be used to secure the patient’s side of the renal vein, thereby providing a longer donor renal vein, because there is no need to trim staples from the vessels before anastomosis in the recipient (Meng et al, 2003). Linear noncutting staplers deliver either three or four staple rows, 30 or 60 mm long. These staplers can also be used to close an enterotomy after a side-to-side bowel anastomosis. When using laparoscopic staplers, special attention must be paid to the markers on the cartridge to ensure that all the targeted tissue is properly situated proximal to the markers before the cartridge is fired. The stapler should not be fired across any previously placed clips because this is thought to possibly cause stapler malfunction. Indeed, in a 9-year review of stapler use (1992–2001), Brown and Woo (2004) noted U.S. Food and Drug Administration–recorded reports of 112 mortalities and 2180 injuries attributed to use of the stapler; overall, malfunctions were reported 22,804 times.

Figure 9–20 Example of a laparoscopic stapling device.

Instrumentation for Specimen Entrapment

Various organ entrapment and retrieval systems are available. Depending on the size of the tissue and on whether in-situ morcellation or intact organ retrieval is planned, the laparoscopic surgeon is able to choose among different-sized sacks, materials, and designs. Studies have been conducted to test organ retrieval bags for permeability to tumor cells and bacteria before and after morcellation, as well as for stability during morcellation and resistance to tearing forces (Urban et al, 1993; Rassweiler et al, 1998b). The originally designed (1990) LapSac (Cook Urological, Spencer, IN), which is made of nylon with a polyurethane inner coating and a polypropylene drawstring, is the least susceptible entrapment sack to tearing (Eichel et al, 2004) or leakage of cells. However, deployment of the LapSac and subsequent organ entrapment remain challenging endeavors. To aid in the opening of the LapSac, the neck of the sack can be modified at the time of surgery by the surgeon; using a nitinol guidewire a double wrap (every other hole) of the guidewire is placed around the neck of the sack, such that both ends of the guidewire exit the sack similar to the drawstring (Sundaram et al, 2002). The outward expansion of the nitinol guidewire serves to “open” the neck of the sack. The drawstring is then cut and removed. The sack is loaded onto a nondisposable two tine LapSac introducer (i.e., Cook Urological, Spencer, IN). For a right kidney, the sack is rolled from top to bottom in a clockwise manner, whereas for a left kidney it is rolled from top to bottom in a counterclockwise manner; the handles of the two tine introducer and the ends of the nitinol guidewire should all be on the same side. This ensures that as the sack is unwound in the abdomen, the bottom of the sack remains caudal to the neck of the sack thereby facilitating its complete expansion in the abdomen. If this is not done, then the bottom of the sack lies cephalad to the body of the sack and the surgeon needs to expend additional energy and time to move the bottom of the sack caudal. As a rule, it is easiest to deploy the LapSac through the umbilical or supraumbilical 12-mm port site with the laparoscope placed in the subcostal midclavicular 12-mm port; if an 8 × 10-inch sack is being used (i.e., the largest available sack) the cannula is removed and the LapSac is passed under endoscopic guidance through the 12-mm incision site. Once the sack is completely in the abdomen it is then unwound and the introducer is removed; the 12-mm port is replaced. Atraumatic grasping forceps are then used to unfurl the sack. The sack is further expanded by passing the laparoscope into it and moving the endoscope in an ever-widening circle as it is being withdrawn; the nitinol guidewire at the neck of the sack further aids the opening of the sack. The specimen is moved cephalad until it lies on the surface of the liver or spleen before the entrapment sack is inserted. The three tabs of the mouth of the sack can be secured with locking grasping forceps, thereby opening the sack as though it were a tent. The base of the sack is then moved to a position beneath the edge of the liver or spleen; the specimen can then be moved into the sack. Up to a 2-kg specimen can be secured within the LapSac.

Other entrapment sacks offer marked advantages when the only goal is organ entrapment and intact removal, rather than morcellation. These sacks have spring wires that, when activated by the surgeon, deploy the bag after its introduction into the abdomen; this facilitates tissue entrapment because the broad wire supports stabilize the opened sack, thereby allowing the surgeon to literally scoop the specimen into the sack (Fig. 9–21). The entrapped specimen can easily be withdrawn through a hand-assist site or by enlarging a laparoscopic port site, usually to 5 to 7 cm for most specimens.

Figure 9–21 Organ retrieval bag.

Instrumentation for Morcellation

Various techniques of tissue morcellation have been used in laparoscopic surgery. The simplest method for fragmentation of tissue within the entrapment sack is use of the index finger or ring forceps. The first mechanical morcellation devices worked by punching out pieces of tissue (i.e., serrated-edge macro-morcellators) (Semm, 1991). They were designed for removing relatively small amounts of tissue. The advent of laparoscopic nephrectomy resulted in the development of a foot-activated, aspirating, electrical morcellator for tissue fragmentation and evacuation (Cook Urological, Spencer, IN) (Clayman et al, 1992). However, this instrument is no longer available, having been removed from the market in 2001. Traditionally, ring forceps or a large Kelly clamp have been used. Recently, however, it has been shown that ring forceps are the preferred instrument for manual morcellation because they are less likely to puncture the entrapment sack (Eichel et al, 2004). A larger type of ring forceps that has proved helpful in this regard is the Sopher forceps that are commonly used in obstetrics and gynecology; the sturdy jaws of the Sopher forceps are 14 × 45 mm versus only 12 × 22 for the usual ring forceps. If morcellation is performed intracorporeally, the entrapment sack should be a LapSac; however, a variation recently reported by Landman and colleagues for morcellation uses one of the plastic entrapment sacks. In this method, the morcellation is performed above the abdominal wall, by extending the extraction site incision to 3 cm in length. All tissue is fragmented and removed under direct vision above the abdominal surface; at no time is the morcellating instrument out of the direct vision of the surgeon. With this approach, specimens could be morcellated rapidly, with the entire entrapment and morcellation process taking only 13 minutes for clinical specimens as large as 700 g; also fragment size increased from 1.5 to 4.5 g, which might afford better tissue assessment with regard to capsular, vascular, or renal sinus fat invasion (Landman et al, 2003).

When morcellating a renal malignancy, the neck of the sack is triply draped to preclude any contamination: a towel drape, sticky drape (Ioban, 3M, St. Paul, MN) and nephrostomy drape are commonly used. At the end of the morcellation procedure, the morcellating surgeon and assistants re-gown and re-glove. The extraction site can be bathed in povidone-iodine in an effort to further reduce the chance of any wound seeding. Indeed, there has been only one noted wound seeding with morcellation in a LapSac (Fentie et al, 2000); however, with intact specimen extraction without entrapment there has also been a wound seed reported (Iwamura et al, 2004). Indeed, in a multi-institutional study, comprising 2064 radical nephrectomies among which 826 were removed by entrapment and morcellation, there was no instance of a wound seeding with tumor (Micali et al, 2004).

Instrumentation for Aspiration and Irrigation

Available as disposable and nondisposable devices, a combination of aspiration and irrigation abilities in one instrument is most practical. The aspirator, which is connected to a suction system, consists of a 5- or 10-mm metal tube, with suction controlled by either a one-way stopcock or a spring-controlled trumpet valve. The irrigation channel is also operated by either a one-way stopcock or a trumpet valve. The irrigation fluid is pressurized to allow for effective delivery of the irrigant and flushing of any bleeding site for accurate hemostasis. Usually, saline or lactated Ringer solution is used as the irrigation fluid. Heparin (5000 units/L) may be added to prevent blood clots from forming, should there be any intraoperative bleeding.

Instrumentation for Retraction

Retractors greatly facilitate laparoscopic surgery. They help expose the area of surgical interest by holding away tissue and organs (e.g., fat, liver, bowel). Sometimes they also facilitate vascular dissection by putting tissue and/or organs closely associated with the vascular structures on stretch. Many varieties of retractors with different features are available. The simplest retractor is a metal bar with an atraumatic tip or a curved saddle shape; the latter is helpful for retracting a vessel during lymph node dissection. Similarly, the disposable laparoscopic “peanut,” in either its 5- or 10-mm rendition, is very helpful because it can both dissect and atraumatically retract tissue.

However, the most useful retractors are the expanding types: fan retractors with three or four atraumatic finger-like extensions, fan retractors with V-hinge joints, balloon retractors, and kite-style instruments (e.g., PEER retractors) (Jarit, Hawthorne, NY) (Brooks, 1993). The 5-mm kite style retractor provides a 2 × 3-cm retracting area, whereas the 10-mm instrument doubles the area of direct retraction to 4 × 3 cm (Fig. 9–22 on the Expert Consult website); this type of retractor is very helpful for firm retraction, such as on the kidney to put the renal hilum on stretch.

Figure 9–22 PEER retractor. A, Closed: 5 mm (1) and 10 mm (2). B, Open: 5 mm (1) and 10 mm (2).

Another type of retractor is malleable and thus can be shaped to the needs of the surgeon. The Diamond-Flex angled 80-mm triangular retractor (Snowden Pencer, Tucker, GA) can be adapted to many different angles, curves, and shapes, and the surgeon can lock in its particular configuration. This feature is of particular value when retraction of a delicate organ such as the liver is required. This instrument forms a broad retracting surface 8 cm in length.

Retraction of tube-like structures (e.g., vessels, ureter) can also be achieved by placing a suture, a vessel loop, or an umbilical tape around the tissue and applying traction either with a grasper inside the abdomen or by pulling the ends of the retraction loop out of the abdomen through a small stab incision using a Carter-Thomason device (Carter, 1994) or by encircling the structure with a suture affixed to a Keith needle, which can be passed across the abdominal wall, around the structure to be retracted and then back out the abdominal wall (see later under Exiting the Abdomen). The retraction loop can then be secured under slight tension on the surface of the abdomen with a small hemostat. Care should be taken during the use of this technique because excessive tension may injure the structure being retracted.

Also, for blunt retraction, the surgeon’s hand, placed into a hand-assist device, is most helpful. In this regard, two key aspects for retraction are of note. First is the concept that the hand should be deployed such that the palm faces the laparoscope as much as possible. In this manner, tissue is brought by the hand toward the laparoscope. It is helpful to use a brown glove that will not reflect the light as much as the standard glove. A second helpful maneuver is the C configuration, as described by Strup, to dissect the renal hilum (Strup et al, 2005). In this maneuver the forearm is passed through the hand-assist device parallel to the aorta/cava while the palm faces laterally. The wrist is flexed to 45 to 90 degrees to allow the fingers to lift the kidney while the thumb pushes inferomedial to retract the tissues overlying the renal hilum. Accordingly, excellent traction and countertraction are achieved, which may speed a safe hilar dissection (Wolf, 2005).

Robotic Instrumentation

For the da Vinci Robotic System (Intuitive Surgical, Sunnyvale, CA) the camera lens fits through a variety of standard 12-mm disposable trocars. The 8- and 5-mm instruments fit through proprietary reusable 8- and 5-mm trocars that couple directly with the robotic arms. These reusable metal trocars have disposable valves that must be changed with each new case. Similarly, a wide variety of articulating instruments are available. The proprietary Endowrist technology offers articulation at the tip of the instruments with 7 degrees of freedom, mimicking the wrist movements of the surgeon at the robotic console (Fig. 9–23). A full line of 8-mm scissors, dissectors, bipolar dissectors, electrocautery cutting devices, needle drivers, clip appliers, retractors, as well as an ultrasonic scalpel are available. The 5-mm line of instruments is slightly more limited but still offers a relatively complete line of instruments. It should be noted, however, that the 5-mm robotic laparoscope offers a two-dimensional (2D) not 3D image. All robotic instruments for the da Vinci Surgical System (except the laparoscopes) have a 10-case limit before they must be replaced. The number of “lives” left on each instrument should be recorded with each case. An additional safety feature on all robotic grasping devices is a small Allen bolt that can manually open the jaws of the instrument in the case of a robotic arm malfunction or loss of power in which the grasper is locked on to tissue or a needle at the time of failure. Of note, robot failure is quite rare; in the series from the University of Chicago, a robot failure was recorded in less than 1% of cases; half of these problems (e.g., failure to power up, optical malfunction) were discovered before the patient entered the operating room. In addition, in the few instances in which there was a system malfunction (e.g., loss of 3D vision, robotic arm failure) during the case (0.4%) the procedure could still be completed without converting to an open option (Zorn et al, 2007).

Figure 9–23 Examples of 8-mm interchangeable instruments for the da Vinci Robotic System.

Instrumentation for LESS

A detailed description of abdominal access and access devices for LESS such as the TriPort and Uni-X has previously been presented in this chapter. By definition, in LESS, all of the instrumentation for the case including a camera/lens for visualization as well as working instruments to perform the procedure must be placed though a single incision. This creates ergonomic challenges with regard to instrument collisions inside and outside the abdominal cavity. Furthermore, the typical trocar arrangement for laparoscopy that affords one the ability to “triangulate” is largely lost with LESS. Much of the emphasis on instrumentation for LESS therefore centers on minimizing instrument collisions outside the abdominal cavity and re-creating the “triangulation” necessary to approach the surgical site safely (Fig. 9–24).

Figure 9–24 Deflecting laparoscopic instrumentation can be used to maintain triangulation during LESS.

(Reprinted with permission, Cleveland Clinic Center for Medical Art & Photography © 1998-2011. All Rights Reserved.)

With regard to endoscope choice, one issue encountered is that the light cord often attaches to the telescope at a 90-degree angle and can thus hinder the movement of the lens or other instruments (see Fig. 9–16A on the Expert Consult website). To avoid this problem one can use an endoscope that has the light cord attached end-on from the back directly into the endoscope (Karl Storz, Tuttlingen, Germany) or a one-piece endoscope that already has an end-on integrated light cord (Olympus, Orangeburg, NY) (see Fig. 9–16B on the Expert Consult website). Alternatively an extra-long laparoscopic lens can be used to keep the light cord away from the shorter standard working laparoscopic instruments. Similarly, using laparoscopic instruments of different lengths can help keep the handles from clashing with one another.

With regard to overcoming the parallel nature of the instrument paths and reestablishing a triangular arrangement of instrumentation, several technologic advances have been developed so far. At the very least an angled lens (30- or 45-degree fixed angle) should be used. Preferably, a laparoscope with a deflecting tip (Olympus EndoEYE) or adjustable angle tip (Karl Storz EndoCAMeleon) should be used because these telescope designs offer the greatest adjustability for optimal viewing.

Additionally, the use of articulating instrumentation is essential to avoid instrument collision outside the abdomen and to achieve proper triangulation for tissue retraction, exposure, and dissection. Disposable articulating instruments are available from Real Hand (Novare Surgical Systems, Cupertino, CA) and from Autonomy Laparo-angle (Cambridge Endo, Framingham, MA) (see Fig. 9–17). In the near future, curved laparoscopic instrumentation (not yet commercially available) will likely be quite helpful and may provide a nondisposable alternative to the current articulating instruments, which are all one-time-use items.

Finally, the use of the robot for LESS procedures has been introduced in the laboratory, originally by Box and colleagues (2008) to perform a transumbilical and transvaginal nephrectomy. Subsequently using the robot arms on both the transumbilical navel port system and on a transvaginal port, Haber and associates (2008) successfully performed a series of pyeloplasties, partial nephrectomies, and total nephrectomies. To be sure, the ability of the robotic arms to articulate is a major plus and one can envision that LESS will follow the path of standard laparoscopy into the robotic age.

Instrumentation for Natural Orifice Transluminal Endoscopic Surgery (NOTES)

The concept of NOTES is not truly new; indeed, the first NOTES procedure would have been Philipp Bozzini’s cystoscopy in 1804. What is new is the use of flexible endoscopic technology to perform procedures heretofore unthinkable with a transgastric (e.g., appendectomy in 2004 by Rao and Reddy) or transvaginal approach (e.g., appendectomy in 2004 and cholecystectomy in 2007 independently by Bressler and then Marescaux). Over time these increasingly complex endoscopes have developed from purely diagnostic instruments for visualization of intraluminal surfaces to highly functional endoscopes capable of carrying therapeutic tools that can be used to treat visualized problems. Recently, further advances in this type of technology have led to the development of endoscopes specifically for transluminal surgery. The potential advantages of transluminal endoscopic surgery are better cosmesis, less pain, elimination of the risk for wound infection, hernias, and a reduction in adhesions (Swanstrom et al, 2008a, 2008b).

There are several prototype endoscopes currently under evaluation for NOTES. Generally these endoscopes offer larger working channels than standard endoscopes and allow larger instrumentation. Some endoscopes such as the Transport (USGI Medical, San Juan Capistrano, CA) are designed with a guideable locking overtube through which other instruments can be placed; within the 20-mm overtube there are four ports (7 mm, 6 mm, 4 mm, and 4 mm) to accommodate the endoscope and up to three additional instruments. One of the working channels houses a standard 6-mm endoscope for vision, and the other working channels are for instrumentation (Fig. 9–25A on the Expert Consult website). Some endoscopes offer triangulating instrumentation. Major hurdles still exist in terms of developing better and more effective instrumentation and especially devices for suturing and enterotomy closure. The Transport, for instance, can be used to perform enterotomy closure using special suture anchors (g-Cath, USGI Medical, San Juan Capistrano, CA) (see Fig. 9–25B).

Figure 9–25 B, Special suture anchors for enterotomy closure (g-Cath, USGI Medical, San Juan Capistrano, CA).

Figure 9–25 A, Example of Transport (USGI Medical. San Juan Capistrano, CA).

Thus far, in urologic practice, NOTES is still in an experimental phase, albeit the seminal paper on this topic being Gettman and associates’ porcine transvaginal nephrectomies in 2002. Case reports of NOTES transgastric and transvaginal nephrectomy (Isariyawongse et al, 2008), transgastric and transvesical (Lima et al, 2007) and transvaginal and transumbilical (actually NOTES assisted) nephrectomy with the Transport system (Box et al, 2008) in swine have been reported; however, NOTES has not been applied clinically as of the end of 2008.

Port Removal

Port removal and fascial closure are key elements of the procedure that, if not performed in a step-by-step, organized fashion, can result in major, possibly fatal, complications. Herniation, possible bowel incarceration, and postoperative hemorrhage are the results of a poorly performed or haphazard, overly rapid exiting of the abdomen.

Before port removal is initiated, the operative site and the intra-abdominal entry sites of each cannula must be carefully inspected with the intra-abdominal pressure lowered to 5 mm Hg. After achieving perfect hemostasis, the surgical site is irrigated with the option of leaving behind 500 to 1000 mL of irrigation fluid, which contains cefazolin, 1 g/L, and heparin, 5000 U/L. Whether this maneuver truly results in a lower incidence of postoperative adhesions or in less infection is undetermined. To avoid any possible acute herniation of intra-abdominal contents into the previous port sites, removal of all laparoscopic ports must be undertaken strictly under laparoscopic visual control.

In the rare case in which bladed trocars are used, after inspection at 5 mm Hg, the first 10- or 12-mm port is removed and the fascia at the entry site is secured with 0-0 Vicryl. This is most efficiently accomplished using a commercially available dual-channeled cone and a suture-passing device such as a Carter-Thomason suture passer (see later) (Inlet Medical, Eden Prairie, MN). This suture is not tied at the time of placement, but instead a 10-mm plastic introducer rod is passed back into the abdominal cavity through the port site incision. The 10-mm cannula is then slid over the 10-mm plastic introducer and the plastic introducer is removed. In this manner, the ports can continue to be used for the passage of the 10-mm laparoscope and the passage of a grasping forceps to facilitate the closure of each 10-mm port site. Accordingly, all fascial sutures are placed under direct endoscopic control as the 10-mm laparoscope is moved from port to port to visualize the placement of each suture. After all fascial sutures have been placed, each 5-mm port is removed under endoscopic control at 5 mm Hg pressure; 5-mm ports are not closed in the adult but are closed in the pediatric patient (there is also a 5-mm cone to aid closure of the 5-mm port with a needle-nosed suture passer). Then each of the non–endoscope-bearing 10-mm ports can be removed under endoscopic control and the fascial suture can be tied and the closure inspected endoscopically. The final 10-mm port is removed with the endoscope in place to assess for any bleeding along the tract; however, the hemostasis of this port site should have been ensured at the time of placement of the fascial closure suture. In this manner, each port is visually assessed for any bleeding at 5 mm Hg, thereby precluding the possibility of removing a port and missing an injured vessel. After removal of all ports, the CO₂ is allowed to pass out passively through the 5-mm port sites.

Presently, with the shift away from bladed to nonbladed trocars, the need for port closure for even 12 mm ports has come into question. Reports by Shalhav have shown that 12-mm ports regardless of site (i.e., midline vs. transmuscular) do not require fascial closure (Siqueira et al, 2004). In the literature, the switch from bladed to blunt trocars has resulted in a marked decrease in abdominal wall bleeding (from 0.83% to only 0.16%) and in port site hernia formation (1.83% to 0.19%) (Hashizume and Sugimachi, 1997; Thomas et al, 2003).

With regard to the hand-assist device, it should be removed before removal of the other port sites. The hand-assist device wound is closed as one would close a typical abdominal wound; however, recent data support an interrupted closure with nonabsorbable suture (Troxel and Das, 2005) because complications from the hand-port site (11%, see later) exceed what would be expected with a standard laparoscopic approach by almost fourfold overall. Indeed, wound infection, hernia or dehiscence at the hand-port site has been noted in 6.8%, 3.5%, and 0.5% of patients, respectively, in the series from the University of Michigan (Montgomery et al, 2005). After closure, the pneumoperitoneum is reestablished and the other port sites are closed as previously described. Proceeding in this fashion precludes the chance of injuring the bowel or omentum beneath the hand-port site and ensures an airtight closure.

Instrumentation for Port Site Closure

Several possibilities for closure of port sites exist. The simplest method is retracting the skin with Senn retractors, grasping the fascia with Kocher clamps, and suturing it with absorbable 0-0 suture. However, in any patient with a BMI greater than 30, securely accessing the fascia is very difficult to accomplish.

Fortunately, several devices for complete en bloc closure of fascia, muscle, and peritoneum under direct vision have been developed (Carter 1994; Monk et al, 1994; Garzotto et al, 1995; Elashry et al, 1996). These work well in patients of all sizes.

The Carter-Thomason needlepoint suture passer (Inlet Medical, Eden Prairie, MN) consists of a 5-, 10-, or 12-mm cone that has two integrated, hollow, angled, cylindrical passages located 180 degrees opposite each other (Fig. 9–26). With the sharp-needlepoint, single-action grasper, the 0-0 Vicryl suture is inserted through one of the cylinders in the metal or plastic cone, thereby traversing muscle, fascia, and peritoneal layers in an ever-widening angle; the end of the suture is grasped with a 5-mm grasper through one of the other ports. The needlepoint grasper is reintroduced through the other cylinder of the cone, and the intra-peritoneal end of the suture is grasped by the needlepoint grasper and pulled out of the abdomen. The cone is slid off both ends of the suture. Subsequently, closure of the fascia, muscle layer, and peritoneum is accomplished by tying the suture. The Carter-Thomason needlepoint device not only is helpful for wound closure but also can be used as a fifth port during nephrectomy to help hold the sack open or to encircle the ureter with a vessel loop through a small stab incision.

Figure 9–26 Carter-Thomason device. Cone (A); needle-point, single-action grasper (B); and tip of grasper in open condition (C).

The disposable Endo Close suture carrier (Covidien Ltd., Mansfield, MA) is a device with a spring-loaded suture carrier at its tip. Loaded with a suture, the device traverses fascia, muscle, and peritoneum alongside the port. After reinsertion on the opposite side of port entry, it is reloaded with the suture, aided by a 5-mm grasper, and is pulled out again under optical control so that the suture can then be tied.

A far simpler, less expensive, homemade solution is available to all surgeons for closing ports in a large patient. This angiocatheter technique applies the previously described principles. A 14-gauge, sheathed needle is passed alongside the port through the abdominal layers. After removal of the needle, a 0-0 Vicryl suture is inserted through the angiocatheter sheath until it is deep inside the peritoneal cavity. After the sheath is removed, the same maneuver is repeated on the opposite side, but this time a 30-inch 0-0 Prolene suture folded in half is passed into the peritoneal cavity through the sheath to act as a retrieving loop. A 5-mm grasper passed through another port is then passed through the loop of 0-0 Prolene suture and used to grasp the end of the 0-0 Vicryl suture. The 0-0 Vicryl suture is pulled through the Prolene loop and released. By pulling the Prolene loop upward through the angiocatheter sheath, the entrapped 0-0 Vicryl suture is then retrieved from the abdomen. After the angiocatheter sheath is removed, the two ends of the suture can be tied or the cannula replaced until all of the designated port sites have been properly sutured (see later).

Carbon Dioxide

CO₂ is the insufflant most commonly used for laparoscopic surgery. Owing to its properties (colorless, noncombustible, and inexpensive), it is favored by most laparoscopists. Prolonged postoperative distention of the abdomen does not occur because CO₂ is quickly absorbed (Wolf and Stoller, 1994). It is highly soluble in water and easily diffuses in body tissues. Because of its high diffusion coefficient relative to oxygen and other respiratory gases, it readily moves out of the peritoneal cavity, owing to a high diffusion gradient caused by the difference in concentration of CO₂ between the intraperitoneal space and the surrounding components (e.g., blood). However, the characteristic of rapid absorption, which lessens the chance of a CO₂ gas embolus, may also lead to potential problems (e.g., hypercapnia, hypercarbia, associated cardiac arrhythmias). In particular, patients with COPD may not be able to compensate for the absorbed CO₂ by increased ventilation; this may result in dangerously elevated levels of CO₂ in these patients, thereby necessitating the direct testing of arterial blood gases during laparoscopy in the pulmonary compromised patient population. Carbon dioxide also stimulates the sympathetic nervous system, which results in an increase in heart rate, cardiac contractility, and vascular resistance. Lastly, CO₂ is also stored in various body compartments (e.g., viscera, bones, muscles). After prolonged laparoscopic procedures it may take hours before the patient has eliminated the extra CO₂ that has accumulated in these storage areas; again, this is more often the case and a problem in patients with pulmonary compromise (Lewis et al, 1972; Puri and Singh, 1992; Tolksdorf et al, 1992; Wolf and Stoller, 1994). Therefore, as previously noted, all patients, and in particular those with pulmonary disease, must be closely monitored after a lengthy laparoscopic procedure for possible signs or symptoms of hypercarbia; indeed, their greatest chance of compromise due to hypercarbia may occur after extubation in the postanesthesia recovery room.

Alternative Gases

Nitrous oxide is less irritating to the peritoneum and causes fewer acid-base changes and cardiovascular adverse effects (e.g., arrhythmias) compared with CO₂ (Scott and Julian, 1972; El-Minawi et al, 1981; Minoli et al, 1982; Sharp et al, 1982). However, some studies have shown that nitrous oxide insufflation reduces cardiac output and increases mean arterial pressure, heart rate, and central venous pressure (Marshall et al, 1972; Shulman and Aronson, 1984). Because nitrous oxide supports combustion it can be used only during laparoscopic procedures that do not involve the use of electrosurgical instruments.

Helium is an inert and noncombustible insufflant. Initial studies performed in various animal models showed favorable effects on arterial partial pressure of CO₂ and pH with no evidence of hypercarbia (Fitzgerald et al, 1992; Leighton et al, 1993; Rademaker et al, 1995). These results were corroborated by clinical studies (Bongard et al, 1991; Fitzgerald et al, 1992; Leighton et al, 1993; Neuberger et al, 1994; Rademaker et al, 1995; Jacobi et al, 1997). As such, helium is particularly useful for the patient with pulmonary disease in whom hypercarbia would be poorly tolerated. In a recent study from Johns Hopkins University, 10 patients at high risk for hypercarbia underwent laparoscopic renal surgery with helium insufflation. These patients were successfully managed, with only one patient developing an end-tidal CO₂ over 45 mm Hg (Makarov et al, 2007). Likewise, if hypercarbia develops during a laparoscopic procedure with CO₂, rather than aborting the procedure or converting to an open approach the surgeon can change the insufflant to helium and usually salvage the case (Brackman et al, 2003). There is also evidence that the use of helium may cause a decrease in tumor cell growth and inflammatory reactions within the peritoneal cavity (Jacobi et al, 1997, 1999; Dahn et al, 2005). It has also been demonstrated that helium insufflation can be used for laparoscopic procedures (e.g., cholecystectomy, appendectomy, hernia repair) performed under local and regional anesthesia in high-risk patients, not only because of its favorable metabolic features but also because of its lack of peritoneal irritation and its association with decreased postoperative pain (Crabtree and Fishman, 1999). However, laparoscopists have to bear in mind that helium may be associated with a higher risk of gas embolism because of its lower blood solubility. When helium is going to be used, it is advised to initially obtain the pneumoperitoneum with CO₂ and then change to helium, thereby lowering the chances of a helium gas embolus. Also, helium is significantly more expensive than CO₂ ($45 vs. $11 per tank). Lastly, when using helium a separate “yoke” (i.e., line from the gas tank to the insufflator) is needed; accordingly, one needs to make sure that a “helium yoke” is available in the operating room or make arrangements to have one provided when performing laparoscopy on patients with severe pulmonary compromise. In practice, the use of helium may be quite difficult; however, argon may also be used in circumstances when hypercarbia occurs. Indeed, the gas from the argon beam coagulator can be used to maintain the pneumoperitoneum. With argon being an inert gas, like helium, the same precautions, however, apply (Badger et al, 2008).

Other insufflants (e.g., room air, oxygen) have been used to establish a pneumoperitoneum in the past. However, possible serious side effects (e.g., air embolus, intra-abdominal explosion, combustion with oxygen and room air) have terminated their clinical use. Other options for insufflants include some of the other noble gases (e.g., xenon and krypton), which are inert and nonflammable; however, their widespread clinical use has not been adopted.

Venous Flow

Animal studies have shown that the effects of the pneumoperitoneum on venous return depend on atrial pressures, which, in turn, are a reflection of the hydration state of the subject (Ivankovich et al, 1975; Diamant et al, 1978; Kashtan et al, 1981). If atrial pressures are low (normal or hypovolemic state), then, during a pneumoperitoneum of up to 20 mm Hg, venous return is reduced owing to increased compression of the vena cava from the pneumoperitoneum. If atrial pressures are high (hypervolemic state), the vena cava resists elevated intra-abdominal pressure and venous return is actually enhanced. However, these principles apply only to an intra-abdominal pressure of up to 20 mm Hg. By further increasing pneumoperitoneum pressures, especially to 40 mm Hg and above, capacitance vessels are collapsed, vascular resistance increases, blood flow decreases markedly, and venous return is significantly reduced. Lower extremity venous return is also reduced by elevated intra-abdominal pressures. Reduced venous blood flow in the lower extremities could facilitate deep vein thrombosis; however, this remains a rare clinical complication of laparoscopy (Jorgensen et al, 1993).

These pathophysiologic insights, gained through animal experiments, have been corroborated by clinical studies (Kelman et al, 1972; Motew et al, 1973; Lee, 1975; Jorgensen et al, 1993).

As a result of these trials, intra-abdominal pressures during laparoscopy should not be allowed to exceed 20 mm Hg over extended periods (Arthur, 1970; Seed et al, 1970; Lee, 1975), and a working pressure of 10 to 12 mm Hg is recommended.

Cardiac Arrhythmias

Tachycardia and ventricular extrasystoles may be seen as results of hypercapnia (Scott and Julian, 1972). Peritoneal irritation may lead to vagal stimulation and subsequently to bradyarrhythmias (Doyle and Mark, 1989). Also, dysrhythmias can serve as clinical warning signs for the occurrence of pneumothorax, hypoxia, and gas embolism (Wolf and Stoller, 1994).

Unreliability of Central Venous Pressure Readings

As previously noted, intravenous pressures may actually rise with low intra-abdominal pressures. In addition, increasing intra-abdominal pressures may artificially elevate central venous pressure readings owing to an increase in intrathoracic pressure. Therefore, it is important for the anesthetist not to rely on central venous pressure readings for any clinical decision making. If information regarding vascular volume and central venous pressure is needed, a Swan-Ganz catheter should be placed.

Pressure-Mediated Effects

Owing to increased intra-abdominal pressure, diaphragmatic motion is limited. Pulmonary dead space remains unchanged, but functional reserve capacity decreases (Wolf and Stoller, 1994). The average peak airway pressure needed to keep up a constant tidal volume increases parallel to the increasing intra-abdominal pressure (Alexander et al, 1969; Motew et al, 1973; Wolf and Stoller, 1994).

Although usually not of great clinical importance in a healthy patient population, it is advisable to use positive end-expiratory pressure techniques when patients with lung disease undergo general anesthesia for a laparoscopic procedure (Ekman et al, 1988; Wolf and Stoller, 1994; Hazebroek et al, 2002).

Non–Pressure-Related Respiratory Effects

The head-down position has an adverse effect on respiration. It elevates the diaphragm and decreases vital capacity. It can also lead to a dislocation of the endotracheal tube that, in turn, may cause right main bronchus intubation. Although of little clinical significance in healthy patients, the head-down position may cause pulmonary edema in patients with increased left-sided heart pressures (Prentice and Martin, 1987). Also, during lengthy procedures performed in the head-down position it is useful to limit fluid administration if possible because it will minimize facial swelling postoperatively.

Oliguria

Increased intra-abdominal pressure was found to be associated with a significant decrease in urinary output. A number of investigators, with the oldest study dating back to 1923, have observed oliguria and anuria associated with an ongoing increase in intra-abdominal pressure (Thorington and Schmidt, 1923; Harmann et al, 1982; Richards et al, 1983). Decreased renal vein blood flow and direct renal parenchymal compression, rather than marked hormonal changes or ureteral compression, have been shown to be the likely reasons for the oliguric state (Chiu et al, 1994; McDougall et al, 1996). Of interest, renal cortical blood flow decreased with increasing intra-abdominal pressures, whereas renal medullary blood flow increased up to pressures of 20 mm Hg; above this level, medullary blood flow also decreased (Chiu et al, 1994). In a porcine study, neither application of dopamine nor insertion of ureteral catheters was able to improve oliguria owing to elevated intra-abdominal pressure (McDougall et al, 1996). These changes occurred regardless of intraperitoneal or extraperitoneal insufflation. Of note, oliguria was not a problem if a gasless, abdominal wall lift method was used to establish the working space in the abdomen. The decreased renal blood flow seen during pneumoperitoneum may be associated with changes in endothelin-1 (ET) and/or nitric oxide (NO). One recent study in a rat model showed that the effects of pneumoperitoneum can be accentuated using ET or NO blockers or avoided by using ET or NO potentiators (Abassi et al, 2008). There is also experimental evidence showing increased apoptosis in the renal cortex and medulla of rats that have undergone pneumoperitoneum compared with controls. The level of apoptosis appears to be pressure dependent, again supporting the use of lower insufflation pressures, as recommended (i.e., ≤12 mm Hg) (Khoury et al, 2008).

These experimental findings in animals have been corroborated in the clinical setting (Iwase et al, 1992; Chang et al, 1994; McDougall et al, 1996); however, at least one recent clinical study did show that low-dose dopamine (2 µg/kg/min) can prevent the dip in urine output associated with pneumoperitoneum (Perez et al, 2002). Whether antidiuretic hormone and plasma arginine vasopressin, both of which have been measured at increased levels by some investigators, play a major role in oliguria during clinical laparoscopic procedures remains unclear (Melville et al, 1985; Solis Herruzo et al, 1989). In general, if one desires to avoid an oliguric state during a laparoscopic procedure, a pressure of 10 mm Hg or less is recommended. In addition, clinically the use of furosemide (Lasix) (mg dose = 20 times the patient’s creatinine), mannitol (12.5 to 25 g), and dopamine at 2 µg/kg/min can help to overcome oliguria. With this regimen and judicious fluid administration, the patient can usually be maintained with a urine output in excess of 100 mL/hr. The key is to use these pharmaceutical modalities in lieu of excessive hydration and fluid boluses (Perez et al, 2002), which may lead to significant fluid overload and edema.