Updated Topics in Minimally Invasive Abdominal Surgery

UPDATED TOPICS IN
MINIMALLY INVASIVE
ABDOMINAL SURGERY
Edited by Ahmed AbdelRaouf ElGeidie

UPDATED TOPICS IN
MINIMALLY INVASIVE
ABDOMINAL SURGERY
Updated Topics in Minimally Invasive Abdominal Surgery
Copyright © 2015 Second Edition
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First published October, 2011, second - 2015
Published December 12, 2015
ISBN-10: 953-307-773-5
ISBN-13: 978-953-307-773-4
Contents
Preface IX
Part 1 Laparoscopic Biliary-Pancreatic Surgery 1
Chapter 1 Transcylindrical Cholecystectomy for

the Treatment of Cholelithiasis and Its
Complications Cholecystectomy Under Local Anesthesia 3
E. Javier Grau Talens, Julio Horacio Cattáneo,
Rafael Giraldo Rubio and Pablo Gustavo Mangione Castro
Chapter 2 Laparoscopic Cholecystectomy in High Risk Patients 27

Abdulrahman Saleh Al-Mulhim
Chapter 3 Gallbladder Surgery, Choice of Technique: An Overview 37

E. Nilsson, M. Öman, M.M. Haapamäki and C.B. Sandzén
Chapter 4 Laparoscopy-Assisted Distal Pancreatectomy 53

Masahiko Hirota, Daisuke Hashimoto, Kazuya Sakata, Hideyuki
Kuroki, Youhei Tanaka, Takatoshi Ishiko, Yu Motomura,
Shinji Ishikawa, Yoshitaka Kiyota, Tetsumasa Arita,
Atsushi Inayoshi and Yasushi Yagi
Part 2 Laparoscopic Liver Surgery 61
Chapter 5 Laparoscopic Liver Resection 63

Robert M. Cannon and Joseph F. Buell
Chapter 6 Hilar Glissonean Access in Laparoscopic Liver Resection 77

Akihiro Cho
Chapter 7 Laparoscopic Liver Surgery 87

Steven A. White, Rajesh Y. Satchidanand and Derek M. Manas
Part 3 Laparoscopic Appendectomy 113
Chapter 8 Laparoscopic Appendectomy 115

Konstantinos M. Konstantinidis and Kornilia A. Anastasakou
VI Contents
Chapter 9 Appendicitis and Appendicectomy 137

Sami M. Shimi
Part 4 Laparoscopic Hernia Repair Surgery 155
Chapter 10 Laparoscopic Hernia Repair 157

Eva Deerenberg, Irene Mulder and Johan Lange
Chapter 11 Laparoscopic Incisional Hernia Repair 181

Anita Kurmann and Guido Beldi
Part 5 Laparoscopic Solid Organ Surgery 193
Chapter 12 Spleen Preserving Surgery and

Related Laparoscopic Techniques 195
Lianxin Liu, Dalong Yin and Hongchi Jiang
Chapter 13 Laparoscopic Gastropexy for the Treatment of

Wandering Spleen With or Without Gastric Volvulus 205
Caroline Francois-Fiquet,Yohann Renard,
Claude Avisse, Hugues Ludot, Mohamed Belouadah
and Marie-Laurence Poli-merol
Part 6 Miscellaneous Laparoscopic Procedures 223
Chapter 14 Laparoscopic Approach to Abdominal Sepsis 225

José Sebastião Santos, Carlos A.M. Donadelli,
Rafael Kemp, Alberto Facury Gaspar and Wilson Salgado Jr.
Chapter 15 Role of Endoscopy in Laparoscopic Procedures 237

Mohamed O. Othman, Mihir Patel and Timothy Woodward
Preface
It goes without saying that the introduction of laparoscopy, with its well-known
advantages, changed the face of surgery. Big surgeons make big incision is now
proved to be incorrect dictum. Now surgeons can work via key holes to reach areas
considered to be very difficult to reach in open surgery. No more ugly big wounds, no
more adhesions, less pain, rapid recovery …. and many more. For all these benefits,
patients ask their surgeons for laparoscopy. However, laparoscopy is not that easy. It
requires new skills and talents that differ from those required in open surgery. It is
more difficult and needs more experience and training.
We tried in this book to present evidence-based up-to-date information in laparoscopic

surgery. This book does not cover all minimally invasive abdominal surgery; only
included selected topics covering a variety of medical conditions. Each chapter is
written by an expert in laparoscopy. The book is geared not only toward surgical
residents in-training, but also to expert surgeons who seek for a recent solution of
some controversies.
I would like to dedicate this book to my wife Reham, my daughter Salma and my son
Omar. Undertaking this book steals time from family, and I very much appreciate
their support.
I believe you will find this book up-to-date and a useful read that could help you in
growing your surgical knowledge about laparoscopy for the sake of your patients.
Ahmed AbdelRaouf ElGeidie

Gastroenterology Surgical Center, Mansoura University,
Egypt
Part 1
Laparoscopic Biliary-Pancreatic Surgery

1
Transcylindrical Cholecystectomy for the

Treatment of Cholelithiasis and Its
Complications: Cholecystectomy
Under Local Anesthesia
E. Javier Grau Talens, Julio Horacio Cattáneo,
Rafael Giraldo Rubio and Pablo Gustavo Mangione Castro
Siberia-Serena Hospital, Talarrubias (Badajoz)
Extremadura University
Spain
1. Introduction
Cholecystectomy is the primary treatment of cholelithiasis. But the prevention of the
formation and the dissolution of the stones were popular in the 80's . The clinical use of the
chenodeoxycholic and after the ursodeoxycholic acid emerged in the 70's, when proved that
this acids reduced biliary cholesterol saturation in bile. Important aspects were significant
but reversible hepatotoxicity in 3%, diarrhea in 8%, abandonment of treatment in 15% and a
similar proportion of abdominal pain. Probably, more important was the increase in total
serum cholesterol and low density lipoprotein during treatment with chenodesoxycholic
acid. In general, ursodeoxycholic acid appears to have fewer side effects, works faster and
causes less liver damage. In patients with small cholesterol stones and floating radiolucent
treated with ursodeoxycholic acid, for 6-12 months, partial or complete dissolution can be
expected in 40-55% of cases.
The direct dissolution of cholesterol gallstones using methyl tert-butyl ether (MBTE)
requires the insertion of a percutaneous transhepatic catheter in the gallbladder. The MBTE
(5-10 mL) should be infused in a manner that involves the calculi but does not flow into the
common bile duct and duodenum. In 4-16 hours the stones are dissolved. The patient
should stay overnight in the hospital. Side effects include pain and nausea; haemolysis and
duodenitis are serious consequences of the spilling of the solvent into the duodenum .
Transabdominal mechanical lithotripsy is another treatment modality, which leads to
fragmentation of the stones in selected cases in almost 100% of patients.
All of these treatments have in common the recurrence of stones (from 45% to 70% at 5 or 7
years of follow-up), due to persistence of a place for the precipitation of cholesterol crystals
(gallbladder) and bile prone to precipitate (lithogenic bile). A report by Gilliland and
Traverso in 1990 settled any doubts about the alternatives in the treatment of cholelithiasis
(Gilliland & Traverso, 1990) These authors reviewed outcomes of 671 cholecystectomy
patients during the years 1982-1987 and found no mortality and 2.2% of complications. They
conclude that open cholecystectomy is a definitive treatment for symptomatic cholelithiasis
with minimal risk to the patient and a high degree of cure of the symptoms.
4 Updated Topics in Minimally Invasive Abdominal Surgery
The first truly major surgery on the biliary tract was performed in 1867 in Indiana (USA).
John S. Bobbs, professor of surgery at the Medical College of Indiana, operates a tumor in
the right upper quadrant in a 30 year old woman, at home and under general anesthesia,
resulting in the diagnosis of gallbladder hydrops which was evacuated and drained. It was
the first cholecystostomy performed in the history.
Fifteen years later, in 1882, Carl J. Langenbush of Berlin performed the first cholecystectomy
by lithiasis, after exercising cholecystectomy in cadavers for several years. However, as
more than a century later would happen with the laparoscopy and in the same Germany,
Langenbush's communication in the German Congress of Surgery of three cases of
cholecystectomy that evolved successfully, was received with apathy and without due
consideration that the time reserved.
1.2 Development of mini-lap (small-incision) cholecystectomy

Minilaparotomy was used for several decades for the diagnosis of obstructive jaundice.
Through a small incision is valued, in addition to the aetiology, the operability by palpation
of the gallbladder and hilum liver and usually the diagnosis included a
cholecistocholangiography.
In 1982 F. Dubois and B. Berthelot (Dubois & Berthelot, 1982) published the first paper on
the minilaparotomy for operations on the bile duct, performing the procedure in 1500
patients, including alongside cholecystectomy, some cases of choledochotomy,
sphincterotomy and choledochoduodenostomy. All these interventions were carried out
with a transverse or oblique skin incision 3 to 6 cm in length, but the duration of surgery,
the authors say, was "twice that of a normal operation". Intervention was carried out with
the help of an autostatic (if no more than one assistant was available), a vaginal valve for
retraction of the liver, a malleable valve for retraction of the hepatic flexure of the colon and
the positioning of two packs for the separation of the colon and stomach, referenced with a
tape.
The description of the intervention with this procedure and its duration arise a suspicion of
some difficulty with exposure of the structures and the easement of the procedure.
However, the authors describe: a minimization of cosmetic damage, solidness of the wall
closure an a reduction of pain and postoperative ileus.
Moss, in 1983, published the first cases of cholecystectomy with stay less than 24 hours, and
in 1986, 100 cases. Later, he operates 160 patients by midline laparotomy, with an incision
that "barely allows the surgeon's hand”, which were discharged the day after surgery
without receiving narcotics, tolerating food intake between 8 and 18 hours and only 3
readmissions. The author concluded in 1996 that the benefits of laparoscopy may be more
related to the enthusiasm and expectations for the new technology that in the technique by
itself (Moss, 1996).
In 1985, Morton (Morton, 1985) performs a cost containment study of cholecystectomy with
intraoperative cholangiography in 96 patients through an incision of 4 to 5 cm with a mean
operating time of 45 minutes. The average stay was 2.5 days and analgesic requirements
were lower than in the classical subcostal incision. The period of sick leave decreased
significantly.
Goco and Chambers in 1988 (Goco & Chambers, 1988) studied the impact of mini-
cholecystectomy in the management of health expenditure, considering the reduction of
hospital costs compared to traditional cholecystectomy. The authors conclude, by analyzing
450 interventions, that a 4-cm incision produces an average stay of 1.22 days and that the
savings stay was 4.78 days per case. Rating the daily cost at $ 200 USA in 1988, it is easy to
Transcylindrical Cholecystectomy for the Treatment
of Cholelithiasis and Its Complications: Cholecystectomy Under Local Anesthesia 5
see the savings produced by minilaparotomy, especially if applied to the 600,000

cholecystectomies performed annually in the United States.
Despite these and further studies, minilaparotomy was never popular. For example, out of
seven standard textbooks: Norton al al., (Harris, 2008). Sabiston (Arendt & Pitt, 2004),
Schwartz (Schwatz 1989), Doherty (Doherty, 2010), Maingot (Karam & Roslyn, 1997),
Marlow & Sherlock (Dawnson, 1985). Morris & Malt (Britton & Bickerstaff, 1994), only the
latter describes the technique of cholecystectomy by minilaparotomy.
1.3 Laparoscopic cholecystectomy – Eric Mühe

Laparoscopy has not only caused a revolution in the treatment of cholelithiasis, but that has
changed an old surgical proverb: "a large incision, a great surgeon." It seems reasonable to
assert that "a smaller incision, less abdominal wall trauma and better aesthetic results." The
era of minimally invasive surgery began and laparoscopy has been extended to almost all
abdominal surgical operation and almost any procedure has been performed by
laparoscopic approach, including resections and all types of gastrointestinal suture.
Interestingly, laparoscopic cholecystectomy was not well received by the German Surgical
Society when E. Mühe reported the first operation in 1986. On September 12, 1985, Mühe
selected with great care the first patient to perform the first laparoscopic cholecystectomy,
almost five years after the first laparoscopic appendectomy by Semm. Like him, Mühe
performed the pneumoperitoneum with the Veress needle, inserted the trocar and
introduced his own "galloscope" through the umbilicus. Two hours later he concluded
successfully the first laparoscopic cholecystectomy (Litynski, 1996). His presentation at the
congress was not published and only a summary appeared in Langenbecks Archiv für
Chirurgie 1986 (Mühe, 1986). However, with subsequent amendments Mühe concluded that
inserting the laparoscope (galloscope) as close as possible to the gallbladder the
"cumbersome" pneumoperitoneum could be avoided. After several cholecystectomies
without gas, trying to simplify and adapt the technique to be used by most surgeons, he
realized that the optical instrument was not necessary, "with or without galloscope, the
magic surgical approach could be the same". Soon operated through sheath of the
galloscope without the optical instrument with the advantages of minimal incision:
- The abdominal musclulature is not cut
- Little postoperative pain that disappears in two or three days
- short Immobilization(even elderly patients need to be in bed only the day of operation)
- Short hospital stay (4-5 days)
- Quick return to work (50-75% earlier than with traditional surgery)
This outlined the bases of minimally invasive surgery. Sadly, Mühe didn´t publish the
evolution of his technique for cholecystectomy in any international journal and we haven´t
hat notice of it until 1996 with the Litynski´s. book.
Many reasons can be considered to explain the success of laparoscopic cholecystectomy:
1. It is obvious that the ports, about 1 cm, scattered in the upper abdomen and a umbilical
opening for the introduction of optic, produce a minimal aesthetic disorder.
2. The trauma to the abdominal wall caused by an incision about 15 cm is large and has a
well-known impact on the respiratory physiology, a greater possibility of formation of
adhesions, hernias and, above all, pain.
3. The acceptance by the patient has been quick, because it was publicized with all of the
above advantages. The charisma of laparoscopic technology is undeniable, its elegance,
too.
4. The commercial pressure has been relentless. Technological research has been
overturned in the design and implementation of increasingly sophisticated and safer
instruments. Sponsoring of the learning of the technique to the interested surgeons was
a strategic objective.
5. Finally, the health financier had an opportunity to reduce hospital stays.
Given all the above mentioned facts it is obvious that the introduction of the technique is an
undeniable fact and that, at present, nobody doubt that laparoscopy is the technique of
choice for cholecystectomy. However, the advantages of laparoscopic cholecystectomy have
been put in evidence, deliberately, with the open cholecystectomy with a generous wound
of about 15 cm. But what if the comparison is made against a technique that uses an incision
of 5 cm or smaller? It is possible that the above mentioned advantages were less obvious
and that the assessment had to be made over other aspects than aesthetics, postoperative
pain, parietal trauma, hospital stay, re-employment, etc., entering the field of cost, security
and benefits to the patient.
2. Laparoscopic vs. small-incision cholecystectomy

A review in 1993 (Olsen, 1993) concluded that there are no good studies comparing
conventional cholecystectomy by minilaparotomy or by laparoscopy. However, it was
apparent that the small incision was better than the big one and that the length of the
incision appears to be associated with hospital stay and return to the workplace. The
ultimate goal is to achieve a safe surgery with the maximum benefit for the patient, and the
keys are: knowledge of anatomy, good surgical view and a proper exposure. This last key to
safety, exposure, is a limiting factor for minilaparotomy, which leads the question of how
small an incision can still provide a exposure to perform the cholecystectomy safely. For
Olsen, the answer is the laparoscopy, which allows for smaller incision, but it is noteworthy
that the sum of the incisones made for the insertion of four trocars is about 4 cm and two-
dimensional view. An incision of this size can provide adequate exposure for
cholecystectomy under direct three-dimensional vision.
An overview of the Cochrane Hepato-Biliary Group reviews in January 2010 (Keus et al.,
2010) revealed the evidence to date of the revisions that assess the effect of differents
techniques of cholecystectomy: open, small-incision, or laparoscopic. A total of 5246 patients
in 56 randomized trials are included. Total complications of laparoscopic cholecystectomy
and small-incision were similar (17%), hospital stay and convalescence were not
significantly different, small-incision cholecystectomy operative time was shortest (16.4
minutes) and is less costly. In our study of 1998 (Grau-Talens et al., 1998) small-incision
cholecystectomy was $ 1003 U.S less costly than laparoscopic. The effects of anesthesia and
surgery on lung function have been well studied (Lindell & Hendenstierna 1976). There is a
reduction in FVC (Forced Vital Capacity) and FEV1 (Forced Expiratory Volume in one
second) to 75% of baseline for a separate incision without cutting the muscles, while
reducing down to 40-55% in the subcostal incisions and midline laparotomy. An incision
that spares the muscular section can prevent postoperative pulmonary complications. The
restrictive pattern of lung dysfunction in postoperative abdominal surgery is influenced by
several factors and is not well understood. The size, location and direction of the incision are
responsible for the alteration of mechanical ventilation, by themselves and the pain. Kind of
anesthetic agent and diaphragmatic dysfunction are also involved (Craig 1981).
In some studies, laparoscopic cholecystectomy has shown lower spirometric reductions

when compared to open cholecystectomy (Frazee et al., 1991) and to mini-lap (McMahon et
al., 1994) although the latter with incisions between 5 and 10 cm. Presumably, a reduction in
the length of the incision could be rewarded by a smaller reduction in the impairment of
lung physiology, ie, an incision of 4.5 cm, uniform to all layers of the abdominal wall could
improve postoperative spirometric results as happened in our study (Grau-Talens et
al.,1998) wich shows that the reduction of spirometrics values were similar in laparoscopic
and small-incision cholecystectomy, ie over 20% of preoperative value for FVC and 25% for
FEV1. The results obtained by keus et al. are similar to ours (Keus et al 2008).
3. Treatment options in biliary lithiasis complications

3.1 Acute cholecystitis
Early cholecystectomy is the best treatement for acute cholecystitis. Laparoscopic
cholecystectomy was a relative contraindication in acute cholecystitis, but now is the
preferred aproach for most patients. The first articles appear in the early 90´s (Cooperman,
1990) (Yamashita et al., 2007). However, in our experience, cholecystectomy in this way was
not easy: the difficulties are related to the inflammatory process, with greater difficulty for
dissection and recognition of structures, the possibility of further contamination of the
cavity (not the surgical wound), the need for instruments to 10 mm in diameter, greater
difficulty in haemostasis and, of course, a greater proportion of conversions (35%) and
duration of the intervention.
With these preliminary considerations we began to operate the acute cholecystitis by early
transcylindrical cholecystectomy (within 72 hours or more of admission), thinking that the
abdominal wall injury should not be higher than laparoscopy, even using the cylinder of 5
cm in diameter, that manipulation of the gallbladder (gripping, aspiration, recovery of
stones etc.) could be done in a simpler way than by laparoscopy, and that contamination of
the surgical wound could be avoided by the protective and insulating effect of the cylinder.
We have only found an article of acute cholecystitis treated by minilaparotomy in the
context of a randomized study comparing minilaparotomy with conventional laparotomy
(Assalia et al., 1997). The authors show figures contrasting results in a very favourable way,
not only with traditional laparotomy, but with the laparoscopic approach. In this article the
average time (+ /-SD) of the intervention was 69.1 (+ / - 17.0) minutes and mean hospital
stay was 3.1 days.
3.2 Choledocholithiasis
The choledochotomy was first performed in 1884 by Kummel and in 1889 by Thornton and
Abbe, who made the first ideal suture of the choledochotomy. In the late nineteenth and
early twentieth century the common bile duct exploration was guided by the subjective
clinical impression of the surgeon, until the introduction of intraoperative cholangiography
by Mirizzi in 1937. In the Massachusetts General Hospital (Bartlett & Waddell, 1958) were
reviewed 1000 choledochotomy for suspected choledocholithiasis with a mortality of 1.8%
(three times higher than simple cholecystectomy) and 16% global choledocholithiasis. In the
presence of previous pancreatitis, stones were found at choledochotomy in 12% of the
patients; in the presence of jaundice or a reliable history of jaundice, 35%; in the previous
situation more palpable stone in 99%; with bile duct larger than 1 cm diameter, 58%;
jaundice and only cystic dilated (greater than 4 mm), 50%; when occurred only jaundice and
small stones (<0.5 cm) in 34%. In patients without jaundice, the presence of stones in the
choledochotomy was as follows: If calculation palpable, 89%; if dilated common bile duct,
53%; if the cystic duct dilated, 29%; and in the presence of small stones, 16%.
With the arrival of cholangiography the negative common bile duct exploration decreased
from 50% to 6%, the incidence of retained stones also fell from 25% to 11%. Moreover,
although it was not popular until the 70, the introduction of rigid choledochoscope in 1941
by McIver reduced the incidence of retained stones. A big progress in the treatment of
retained stones was the introduction of endoscopic sphincterotomy in 1974 by german and
japanese authors (Classen &Demling, 1974) with a success rate of 95%, 15% morbidity and
mortality from 0.2 to 1.5% ( Escorrou et al., 1984), relativized the problem of retained stones
and its treatment and compared favourably with surgical sphincterotomy, whose mortality
was 2.9 to 4.4%.
With the introduction of laparoscopic cholecystectomy, surgery for gallstones changed and
preoperative endoscopic retrograde cholangiography became the rule in the care of patients
suspected of gallstones in the bile duct to avoid open choledochotomy. In experienced
centres, the success rate of ERCP in the extraction of common duct stones is 90% but 1%
overall mortality and complication rate of 6% to 10% (Fink, 1993). The risk of mortality and
morbidity should be added to the subsequent laparoscopic cholecystectomy. If we accept a
risk of death of 0.3% and 5% complication rate for laparoscopic cholecystectomy, the overall
mortality of the sum of the two procedures can be 1.3% and morbidity of 11 to 15% (Tomkin,
1997).
Other notable aspects of this sequence of treatments (first ERCP and posterior
cholecystectomy) are: the cost and the negative ERCP, ie, discriminating which patients
have choledocholithiasis preoperatively. A study by Koo and Traverso (Koo &Traverso,
1996) revealed that the history is the best predictor of choledocholithiasis, but was only able
to predict 45% of cases, surpassing the biochemistry of liver function and ultrasound. For
this reason, preoperative ERCP is rewarded with the discovery of choledocholithiasis in no
more than 50% of cases, which are obviously exposed to morbidity and mortality, and raise
the cost of surgical practice. In another recent study, ERCP was performed only if the
patient had any of the following criteria: dilatation of the bile duct by ultrasound, gallstone
pancreatitis or abnormalities of liver function tests (Katz et al., 2004). ERCP was performed
in 41 patients and stones were found in 22 (53.7%). The authors conclude that dilatation of
the bile duct along with liver function abnormalities are the most useful, with a yield of 82%
correct in detecting choledocholithiasis.
In the last decade has improved radiological assessment of patients with suspected common
bile duct stones. Transabdominal ultrasounds are not very sensitive in detecting common
bile duct stones, but if ultrasounds are negative and liver function is normal, the chances of
choledocholithiasis are minimal. Magnetic resonance cholangiopancreatograpy and
endoscopic ultrasonography have high sensitivity and specificity (grater than 90%) and are
the best options as preoperative assessment (Werbesey & Birkett 2008). There are different
diagnostic and therapeutic options to address the common bile duct, but not an algorithm
that can be considered the standard criterion. The management of this disease depends on
the experience and the possibilities of available technology of each working group. The
therapeutic approaches are:
- Preoperative ERCP and later laparoscopic cholecystectomy
- Laparoscopic surgery and rendezvous
- Laparoscopic cholecystectomy and, if necessary, laparoscopic common bile duct

exploration
- Transcylindrical cholecystectomy and, if necessary, transcylindrical common bile duct
exploration
- Conventional open surgery
- Laparoscopic cholecystectomy more postoperative ERCP
The first option does not seem reasonable for the reasons already discussed, the last remains
reserved for the failures of laparoscopic choledochotomy and retained stones. Conventional
open surgery may remain as an option, but at the much higher wall trauma, the greater
number of stays, the worse aesthetic outcome and greater disability after surgery. A
randomized study demonstrated a greater benefit for the treatment of choledocholithiasis
with laparoscopic common bile duct exploration than with postoperative ERCP (Rhodes et
al., 1998).
Laparoscopic exploration of common bile duct has been developed in the 90's, almost
simultaneously with laparoscopic cholecystectomy, and is performed through the cystic
duct or choledochotomy. Laparoscopic choledochotomy is technically demanding, is a
difficult procedure that requires a great deal of laparoscopic skill (Kroh & Chand, 2008). In
this sense, a simple technique, as is the transcylindrical approach, can have a place in the
common bile duct exploration.
In our Hospital this is the algorithm for suspected choledocholithiasis:
4. Transcylindrical cholecystectomy
In 1992, we started laparoscopic cholecystectomy in the Hospital Verge del Toro (Mahon,
Menorca, Spain) after a training period at another hospital. The technique quickly settled in
the hospital, in a time of full discussion of the validity of this approach and the need for
prior training. We conducted a series of 11 laparoscopic cholecystectomy, until the absence
of capnography and other circumstances prevented continuation of the procedure The
laparoscopic view of Calot's triangle, with the camera close enough to the structures, as it’s
set to perform the dissection, does not focus more than a few square centimetres area, which
is where the dissections and sections between clips of the cystic duct and cystic artery are
performed. It crossed our minds that this limited field, but sufficient for the laparoscopic
dissection, could be constructed in a straightforward manner, without camera, with a
cylindrical or tubular separator that prevented the interposition of intraperitoneal mobile
structures between the surgeon's eyes and structures hepatocystic triangle. Of course, the
dissection should be performed through the cylinder with material that could be used in
laparoscopic or open surgery. With these premises we entrust the construction of the first
steel cylinder, 5 cm in diameter and 10 in length, with a polypropylene plunger, like a
piston, which protruded from the distal end, with the purpose of helping to introduce and
reject the intraperitoneal mobile structures, which could interpose and hinder the
hepatocystic triangle. The first time we use it (August 1993) we were rewarded with the
success of an intervention without mishap. With the cylinder of 5 cm in diameter were
obtained an incision 6-7 cm in length, which could be reduced by a smaller diameter
cylinder, therefore, we inquired the construction of another cylinder, 3.8 cm in diameter and
with the same length. The choice of length is based on measurements made in emergency
surgery, from skin to the triangle hepatocystic. Cholecystectomy with the new cylinder was
still easy, but with an incision 4.5 cm length uniform in all the layers of the abdominal wall,
aesthetics and a smooth postoperative period where they drew more attention to nausea
and vomits than pain. Hepatocystic triangle dissection and recognition of the structures left
us less uncertainty than in the laparoscopic approach, we could ensure the identity of the
structures and fingertip exploration of the consistency of the organs. We considered it a safe,
as it allowed the steps of the classical open cholecystectomy. We decided to call the
technique transcylindrical cholecystectomy. The first communication in a conference dates back
to 1994 when we presented a video communication with the first 20 cases in "The X Surgical
Day of District Hospitals” (Tarragona, May 6, 1994). That same year it was admitted to the
"XX National Congress of Surgery of the Surgical Spanish Association" Madrid, November,
1994 (Grau-Talens et al., 1994).
The review of the literature on minilaparotomy cholecystectomy and the method used by
the authors showed no results of a technique similar to ours, although other types of
separators or optical instruments have been developed (O´Dwyer et al.,1990), (O´Kelly et al.,
1991) (Rozsos et al.,2003) (Russell & Shankar, 1987) (Shumacher & Kohaus 1994). Rozsos et
al., 1997 distinguish between: microlaparotomy, where the incision is less than 4 cm in
length, modern minilaparotomy, where it comes to 4-6 cm incision and classical
minilaparotomy, with 6-8 cm.
The first operation of transcylindrical cholecystectomy under local anesthesia and
sedation dates to 1996, in a patient with low body mass index and followed by other cases
performed sporadically. The experience accumulated over 15 years and 387 interventions
(Grau-Talens & Giner, 2010) showed us the safety and applicability of transcylindrical
cholecystectomy and was applied to realization of the technique in outpatient surgery in
the Hospital Siberia-Serena (Talarrubias, Badajoz, Spain), where we offer the
transcylindrical cholecystectomy under local anesthesia and sedation to all patients with
almost no exceptions (Grau-Talens et al., 2010). Patients greatly appreciate the possibility
of not being entirely deprived of consciousness and not to be connected to a respirator
during cholecystectomy perhaps resulting in a reduction of preoperative anxiety and
stress.
4.1 Selection of patients for transcyndrical cholecystectomy in hospitalization and

day-case surgery under local anesthesia plus sedation
Between 1993 and 2008 the patients with symptomatic cholelithiasis, recovering from
mild/moderate acute biliary pancreatitis or acute cholecystitis were treated by
transcylindrical cholecystectomy. Since 1996 we treat choledocholithiasis in this way.
Informed consent was requested for each patient explaining both the novelty of the
transcylindrical cholecystectomy and its rationality, like a minilaparotomy, for aesthetic and
functional benefits of a small incision, in order to prevent biliary colic and complications of
lithiasis (acute cholecystitis, pancreatitis or recurrent pancreatitis and gallbladder cancer),
with emphasis on uncertainty about other symptoms such as headache, dyspepsia, bitter
taste, abdominal pain not related to gallstones and food intolerance. All possible and
reasonable complications are listed in the informed consent of the Asociación Española de
Cirujanos (Spanish Association of Surgeons), the patient read and sign before being
included in the surgical waiting list.
With the exception of a randomized study period for comparison with laparoscopic
cholecystectomy this series of cases should be considered consecutive. In this way, 387
patients have been included in the study.
Although the 3.8 cm cylinder has been used in most cases, the 5 cm cylinder was used,
primarily, in the following situations: diagnosis of acute cholecystitis, strong suspicion of
choledocholithiasis (medical history jaundice, common bile duct dilatation greater than 12
mm) and when doubt exists in the identification of structures of the hepatocystic triangle
with the cylinder of 3.8 cm. This was used in light of the diagnosis of biliary colic, regardless
of the ultrasound findings (normal gallbladder or sclerotic) and in patients recovering from
acute pancreatitis. Intraoperative cholangiography was performed selectively.
From 2008 to the present day we exercise our practice in the Hospital Siberia-Serena
(Badajoz, Spain), a public community hospital with short-stay and ambulatory surgical
facilities. All of our patients are referred to us for elective surgery. The surgical emergencies
are translated to de District General Hospital in the area, nevertheless, we accept
hospitalized patients with complications of biliary lithiasis and are operated as a as soon as
possible. Include patients with cholelithiasis, acute cholecystitis, acute pancreatitis before
discharge and choledocholithiasis. We have 4 beds for patients who require hospitalization
for short stay surgery.
Patients scheduled for day-case surgery must meet the general criteria of suitable personal
and familiar environment and distance from the centre of not more than 45 minutes,
together with the ASA I-III.
The selection of patients who would undergo transcylindrical cholecystectomy under local
anesthesia plus sedation was done under the following assumptions:
1. Acceptance by the patient to undergo the procedure under local anaesthesia, and the
possibility that it will be converted to general anaesthesia if necessary
2. Assessment by the surgeon that the patient meets the general requirements to be
involved in ambulatory surgery
3. The assessment by the anaesthesiologist in charge of the case, the degree of patient
anxiety, which might conspire with the necessary cooperation of the latter in the case of
sedation and local anaesthesia, in addition to the usual pre-anaesthetic evaluation.
4.2 The cylinders

Initially we have designed and constructed a stainless steel cylinder with a polypropylene
perforated plunger, like a piston, which protrudes from one end. It is 10 cm long and 3.8 cm
in diameter providing a surgical field area of 11.33 cm2, and another which is 10 cm long but
5 cm in diameter providing to surgical field area of 19.62 cm2 . These sizes have been based
on the distance between the wall and the hepatocystic triangle, measured in open surgery,
and the minimally area necessary for the identification and dissection of its structures.
We currently use a transparent methacrylate plunger that there exercises an effect of
magnifying glass and once introduced into the abdomen allows visualization of the surgical
field before unplugging (figure 1).
Fig. 1. Cylinders used in Transcylindrical cholecystectomy

The cylinder commonly used is made of stainless steel, though we occasionally use a
cylinder totally made in methacrylate to facilitate intraoperative cholangiography. The size
of cylinders is always 10.0 cm long and either 3.8 or 5 cm in diameter. But we have cylinders
12 and 14 cm in length, rarely needed in the bigest patients or abnormal liver depth under
the ribs in the subdiaphragmatic space. In young people, the use of a cylinder of 2.8 cm in
diameter produces an almost imperceptible scar (Figure 2, 3).
Fig. 2. Methacrylate cylinder, 2,8 cm in diameter
4.3 Technique and equipment

To introduce the 3.8-cm cylinder one makes a right transversal-epigastric incision of 4.5 cm
two fingerbreath lateral to the midline, approximately at the seventh or eighth
costochondral cartilages level. One then proceeds with a longitudinal incision of the rectus
sheath, splitting the muscle and cutting the posterior leaf and peritoneum. This is an
uniform 4.5 cm section of all the abdominal wall layers. A suture of polypropylene (No. 1) is
then passed through the whole thickness of the wall (not including the skin) on both side of
the incision, which helps to guide the introduction of the cylinder. We make sure that there
is nothing adhering and check the normality of neighbouring organs by two finger
exploration.
Once it is past the surface of the skin it is softly slided and enters without difficulty to its full
extent towards the hepatocystic triangle. While we are inserting the cylinder we are seeing
the intraperitoneal structures through the transparent plunger, especially the white
appearance of the anteromedial aspect of the gallbladder and Hartmann's pouch and we can
see, with a little pressure , the cystic duct and common bile duct (Figures 4, 5). Any
gallbladder adherence to the hepatic flexure of the colon or omentum can be freed.
Fig. 3. Incision of 3,5 cm in length
Fig. 4. Cylinder bottom through the methacrylate plug

Before reaching a working position of the cylinder, this is gently moved inside of the
abdomen. The blunt shape of the plunger end, slightly protruding from the intra-abdominal
side of the cylinder, facilitates this movement. The plunger can be withdrawn and
reintroduced as many times as necessary to identify anatomical structures. Lamp lights
usually suffice to illuminate the operative field, but a cold light may be of help occasionally.
Fig. 5. View of the hepatocystic triangle through the plug

Part of the gallbladder with its infundubulum is visible at the bottom of the cylinder, as well
as the omentum, duodenal bulb or colon. The infundibulum or Hartmann Pouch is grasped
with tissue Foerster forceps and is drawn anterior and laterally and a medium swab inside
the cylinder is used to displace the organs that impede the sight of the angle between the
gallbladder and the hepatoduodenal ligament. Afterwards the hepatocystic triangle is
dissected using conventional material (Figure 6).
The peritoneum is incised on the hepatocystic triangle, close to the gallbladder neck, and the
fat is carefully dissected away on the free edge of the angle between the infundibulum and
the hepatoduodenal ligament using gauze pledget held in an other Foerster forceps, until
the cystic duct (Figure 7) and common bile duct are clearly defined (no always this later).
Afterwards, we check that the cystic duct follows clearly from the gallbladder neck. If the
cystic duct lymph node and cystic artery are not yet visible, the dissection is done gently
upwards to discover the cystic artery, which will be followed up to its entrance into the
gallbladder (a right angle dissector is required). The cystic artery can be sectioned between
two distal clips and a proximal one.
Fig. 6. Calot’s triangle (as shown by the arrow) after extracting the plug
At this time, surgeon and assistant must agree on the identity of the visible anatomic
structures and make sure that there are no more tubular structures above the cystic duct,
other than the cystic artery. Accessory extrahepatic ducts and ductus subvesicularis have to
be taken into account, as well as the double cystic artery or any abnormal situation or origin.
Once the cystic duct has been identified, a silk ligature is passed around it and prepared for
cholangiography (performed selectively) and sectioned with two distal clips. To finish the
dissection of the hepatocystic triangle we retract the infundibulum or corpus with the help
of a pledget gauze, as much as we can, from its bed in the liver, keeping the dissection close
to the gallbladder wall (to avoid structures of the hilum). Separation of the gallbladder from
the hepatic bed follows in a retrograde fashion using electrocautery. Perhaps, this is de more
laborious part of the procedure because we needs to change the point of traction to free the
corpus and fundus that are attached to the liver in a somewhat posterior position. The
puncture and emptying of the gallbladder helps freeing it and, finally, we extract it from the
interior of the cylinder.
We check out the hepatocystic zone and the gallbladder bed by means of the reintroduction
of the cylinder and check for oozing and bile spill from the gallbladder bed. Bleeding can be
restrained by gentle pressure of a moist gauze pad through the cylinder or electrocautery.
The subhepatic space is irrigated with saline solution through the cylinder and after closing
the posterior wall (polydioxanone sulphate) the wound is irrigated again.
Fig. 7. Cystic duct with right angle dissector
4.4 Transcylindrical cholecystectomy under local anaesthesia plus sedation

All patients were fitted to the following protocol:
1. In the preparation area an intravenous cannula was placed, vital signs were monitored,
and was given 50 mg ranitidine and metoclopramide 10 mg intravenously.
2. Once in the operating room after the patient monitor ECG, pulse oxymetry (SpO2), BIS
(bispectral index) and noninvasive blood pressure we proceeded to the supply of
oxygen with nasal cannula with the end tidal CO2 (ETCO2), Midazolam 0.05 mg/kg/ev
and initiation of infusion of remifentanil in doses of 0.05 mcg/kg/min to 0.1 mcg/kg/
min.
The objective was to obtain a sedation 2-3 on the Ramsay scale and/or a BIS value of 70 to 85
before the application of local anesthesia. For anesthesia of the abdominal wall surgical area
was used 300-500 mg of mepivacaine 1% was used. The infiltration began in the line
previously marked for incision, which is located in the epigastrium about 4 cm to the right
of the midline and 3 cm from the costal margin. Follows the infiltration of the muscular
plane and transverse oblique, lateral to the incision site with the intention of blocking the
intercostal nerves VII-IX in the lateral costal margin. Finally we infiltrate the rectus muscle
of abdomen in the epigastric region right under the incision line (Figure 8). Once the
cylinder has been introduced the triangle of Calot is infiltrate with 2-4 cc of 2% mepivacaine
(Figure 9). At the end of surgery and subcutaneous muscle planes were infiltrated with 10-
20 ml of bupivacaine 0.25%.
Before leaving the operating room the patients receives: paracetamol 1g/ev, dexamethasone
8mg/ev, ondansetron 4mg/ev and ketorolac 1mg/kg, although the latter was avoided in
patients 70 years or older.
Fig. 8. Local anesthesia on intercostals nerves IX-VII and incision planes
Fig. 9. Infiltration with mepivacaine 2% of the hepatocystic triangle

All patients were assessed for pain after the procedure and were discharged when they met
the criteria (pain control, oral tolerance, no bleeding, nausea or vomiting, etc.), and follow
analgesia regime alternating paracetamol 1g/6 h and metamizole 1g/6h orally at home.
At 24 hours, through a telephone call, we assessed the pain at rest and with movement
(scale of Andersen). In the fifth day, in outpatient visit, we check for the general status, the
sate of the wound and the pain is assessed with a visual analog scale (VAS).
4.5 Surgical technique in acute cholecystitis and choledocholithiasis

In acute cholecystitis we always use the 5 cm cylinder, the gallbladder is emptied with the
help of an aspirator and a bile sample is send for culture. The dissection of the Calot triangle
is done with a swab and if there are difficulties in closing the cystic duct is we use a ligature
or stitch of poliglycolic acid. The cystic artery is treated in the same manner as above. The
haemostasis of the liver may require more time. A Jackson-Pratt drain by counterincision is
the norm in acute cholecystitis and common bile duct exploration.
If the intraoperative cholangiogram shows the presence of stones and a dilated bile duct
(Figure 10 ), we prepare the field for a transcylindrical choledochotomy if the stone could
not be pushed through the papilla with a Fogarty catheter. After the cholecystectomy and
haemostasis of the liver, we proceed to vary the angle of the cylinder to direct medially, to
put it in the hepatoduodenal ligament, taking as reference the cystic duct stump. Once in the
position, the bile duct is seen on the lateral border of the ligament once the fat is cleared
away with blunt dissection.
Fig. 10. Cholangiography with cylinder in place

We must ensure that we are below the confluence of the cystic duct (the duodenum can be
see in the field), which will expose the common bile duct (keep in mind that the confluence
may be low). Two stay sutures using polyglactin 3-0 are located on both sides of the midline
of the common bile duct to pull at the time of a vertical choledochotomy as short as possible
(2-3 cm), but enough for the manoeuvres of stone removal (Figure 11).
Fig. 11. Coledocotomy about to be performed. Two stay sutures pull the common bile duct.
Randall stone forceps can not be used, but the Fogarty catheter, catheter irrigation and
flexible choledochoscope are used. Before performing any manoeuvre, we introduce a gauze
ball referenced with a thread at the proximal end of the choledochotomy, to prevent the
displacement of the stone proximal to the hepatic duct when dragging with the Fogarty
catheter rather than externalized through the incision of choledochotomy. Finally, we
introduce the flexible choledochoscope and confirm the absence of calculations. The closure
of the choledochotomy we do it with polyglactin 3/0 on a Kehr T tube.
Between the fifth and seventh postoperative day a control cholangiogram is performed, and
the patient discharged. The T tube is left in place for 14 days.
4.6 Results
We have to distinguish between two clearly defined periods in the evolution of the
implementation of transcylindrical cholecystectomy. A first period, from 1993 to 2008, of the
beginning of the technique and treatment of patient in hospitalization and a second period
since 2008 until today as outpatient surgery and short stay, mainly under local anesthesia
plus sedation. in total we performed 633 operations: 387 belonging to the first stage and 247
to the second.
The results of surgery of the first stage have already been published. In summary:
Total no. of patients 387
Completed transcylindrical 364
Ampliation to open cholecystectomy, no. (%) 23 (5.9)
Duration of simple cholecystectomy, mean (SD) 43,5 (13.3)
Length postoperative hospital stay mean (range), 2.0 (1-6)

days
Postoperative complications
Bile leakage, no. (%) 2 (0.5)
Reoperation for bleeding, no. (%) 2 (0.5)
Bile Duct injury, no. (%) 0
Death, no. (%) 11 (0.3)

1 Death from multiple organ dysfunction syndrome due biliary peritonitis
Table 1. Overall results of cholecystectomy between 1993-2008

The 3.8 cm cylinder was used in 261 cases and the 5 cm in 103 as first choice or an
alternatively because of difficulties in recognition of the structures. The main cause of
enlargement to open surgery was the fibrotic alteration triangle hepatocystic. The number of
conversion is not negligible, but our philosophy has been not to subject the patient to the
risk of intervention with uncertainty in identifying the structures of the hepatocystic triangle
in order to prevent complications. For that we have not hesitated to convert to a classic
laparotomy when facing at a reasonable difficulty.
A survey of satisfaction with the aesthetics of the procedure yielded a 90% satisfied or very
satisfied.
4.6.1 Transcylindrical cholecystectomy under local anesthesia plus sedation in day-

case surgery
Today we are performing the majority of our cholecystectomies as day-case surgery. Local
anesthesia and sedation is the anesthetic technique that we offer at all our patients and that
we use unless the patient's preference for general anesthesia. A pilot study of 60 cases was
published in Endoscopy (Grau Talens et al., 2010), but now we have performed the
procedure in 222 patients, highlight a patient with choledocholithiasis too operated under
local anesthesia and sedation, excellently tolerated; while that in 25 other general anesthesia
was used for suspected acute cholecystitis (8 patients), suspected choledocholithiasis (3
patients) and specifically stated preference for the patient in the other cases (14 patients).
Local anesthesia was initiated in 222 patients with demographic and anthropometric
characteristics in Table 2.
Patients, no. 222

Men/woman 55/167
Age, mean (range) years 55.2 (17-90)
BMI1, mean (range) kg/m2 29.9 (19-46)
Height, mean (range) cm 160.5 (140-185)
Eight, mean (range) kg 77.0 (43-122)
Acute pancreatitis, no. 21
Acute cholecystitis previous2 34
1 Body mass index
2 Acute cholecystitis with a Hospital General admission
Table 2. Demographic and clinical characteristics of patients operated under local anesthesia
plus sedation
As it can be seen our patients are obese in almost half the cases and 35 patients had a BMI
equal to or greater than 35 (15.8%). Previous acute cholecystitis was detected in 18 of 55 men
(33%), but only in16 of 167 women (9%).
Convalescent patients of acute pancreatitis were operated on before hospital discharge and
an intraoperative cholangiography was performed.The results of surgery can be read in
Table 3.
No. Patients in day-case program 197

Postoperative hospitalization. No. (%) 15 (7.6)
Converted to general anaesthesia. No. (%) 69 (31)
Converted to open surgery. No. (%)** 7 (3.1)
Duration. Mean (SD) 49.4 (22.4)
Intraoperative cholangiography. No. (%) 17 (7.6)
Common bile duct exploration. No. 2*
Wound infection. No. (%) 5 (2.2)
Subhepatic collection. No. (%) 1 (0.4)
Visual Analog scale. Mean (range) 2.0 (0-8)
* a surgery completed under local anesthesia and sedation
** An open surgery for carcinoma of the gallbladder
Table 3. Results of 222 patients scheduled for transcylindrical cholecystectomy under local
anaesthesia plus sedation
Nausea and vomiting have virtually disappeared. Pain at rest on the fifth postoperative day
is almost nonexistent, while the pain with the movements of sitting or standing is mild and
all the patients are able to self care.
Only 6 patients have expressed some discomfort during the operation, but the procedure
was well tolerated and there was satisfaction in all cases, even where they were converted to
general anesthesia.
The 5 cm cylinder was used in 2 cases of suspected choledocholithiasis and thirteen cases of
postinflammatory anatomical distortion that hinders the recognition with the 3.8 cm cylinder
The vast majority of cases that required intubation (Table 4) was due to poor anatomical
conditions related to persistent inflammation or scarring, but it is also true that a patient
with a bulky or potent abdominal muscles (even with normal BMI) is a factor in
consideration, since the absence of relaxation of the abdominal wall increases distance from
the skin to the hepatocystic triangle and the cylinder of 10 cm length can be short.
Scarring or inflammatory anatomy 46

Big or muscular patient 16
Poor tolerance 6
Respiratory depression 1
Table 4. Causes of conversion to general anesthesia

In some cases we have changed the cylinder of 10 to 12 cm with satisfactory results.
As previously mentioned, in 34 cases, of our patients had suffered a hospital admission for
an attack of acute cholecystitis with ultrasound which showed a thickened gallbladder wall.
Despite having passed more than 8 weeks after hospital discharge and be asymptomatic, we
have found during the intervention that the process is not cured and present frank acute
cholecystitis in 7 cases (20%). Of the 69 patients converted to general anesthesia, 29 were
men in a series with 55 men. Obviously, the male sex is a definite risk factor for conversion
to general anesthesia, as gallstone disease seems more severe in men while the abdominal
muscles are larger. In our series both the height and weight is significantly higher in males,
but not BMI which is slightly below the average (28.9 kg/m2).
In cases of conversion to a classical laparotomy incision the bad anatomy can also blame as
responsible, in fact, five of seven cases converted belong to patients with acute cholecystitis
previous and three of the 7 are male. In one case cystic clips were dislodged while reviewing
the operative area.
However it is, starting the procedure under local anesthesia and sedation does not produce
a significant delay in time, only a few minutes, since the decision to intubate the patient is
taken quickly and everything is ready for this eventuality, but it is likely that in the future
the general anesthesia be used from the begin in the men who have had an admisssion for
acute cholecystitis.
4.6.2 Transcylindrical cholecystectomy in the treatment of acute cholecystitis and

choledocholithiasis
In total 99 patients were operated for acute cholecystitis: 45 suspected prior to the
intervention and operated in emergency basis or in the first 72 hours after admission (but
not from the onset of symptoms, because in our experience, half of the patients came in a
mean of 36 hours after the pain). The operation for acute cholecystitis is more laborious,
with and greater needs of conversions to classic laparotomy, which in our series occurred in
13 cases. In all cases except one that ended with a cholecystostomy, the gallbladder has been
removed. The duration of the intervention is significantly higher than cholecystectomy for
uncomplicated lithiasis is related to the need for more time for dissection and hemostasis.
Two superficial wound infections, 2 postoperative subhepatic collections and a third at 9
months after surgery treated by percutaneous puncture and a biliary leak through drainage
for 15 days with spontaneous closure are noteworthy complications. At least 3 days of
hospitalization and antibiotic treatment follow the surgery.
In our experience, common bile duct exploration presents no special difficulties except
juxtapapillary interlocking stone, making it difficult to remove. The location of the bile duct,
dissection, and preparation is as simple as in open laparotomy. In 30 cases we performed
transcylindrical choledochotomy with an average of 119 minutes, with a range between 70
and 182 minutes of the proceedings. A stone inpacted in a dilated common bile duct
required a choledochoduodenostomy. One patient experienced postoperative bleeding
requiring intervention without finding the bleeding point.
5. Conclusion
Despite technological advances and the practice of surgery becoming more expensive, we
developed a technique for the treatment of gallstones and its complications achievable with
natural view of the structures and conventional reusable material. The technique has proven
to be fast simple and safe, applicable to all patients. Local anesthesia and sedation provides
a quick recovery and many patients lose the fear of the intervention. Both in acute
cholecystitis in choledocholithiasis we have obtained good results. The patients suspected of
choledocholithiasis are operated and an intraoperative cholangiography is made. The
transcylindrical exploration of the common bile duct is performed whenever introperative
cholangiography demonstrated stones.
6. References
Arendt, SA. & Pitt, HA. (2004) Biliary Tract. In: Sabiston Textbook of Surgery: The Biological
Basis of Modern Surgical Practice. Townsend, CM., Beauchamp, RD., Evers, BM., &
Mattox, KL., editors, pp. 1597-1641. 17th edition. Elsevier Saunders, ISBN 0-8089-
2295-5, Philadelphia.
Assalia, A., Kopelman, D., Hashmonai, M. (1997). Emergency minilaparotomy
cholecystectomy for acute cholecystitis: prospective randomized trial--implications
for the laparoscopic era. World J Surg 1997, Vol. 21, No. 5, pp. 534-9. ISSN 0364-2313.
Bartlett, MK., & Waddell, WR. (1958). Indications for common duct exploration. Evaluation
in 1000 cases. New Eng J Surg 1958, Jan 23, Vol. 258, no. 4, pp. 164-7, ISSN:0028-4793.
Britton, J., & Bickerstaff, KI (1994). Benign Diseases of the Biliary Tract. In: Oxford Textbook of
Surgery Morris, PJ., & Malt, RA., editors. Oxford University Press, pp. 1209-1241.
ISBN 0192626035, New York.
Classen, M., & Demling, L. (1974). Endoscopic sphincterotomy of the papilla of vater and
extraction of stones from the choledochal duct. Deutsch Med Wochenschr 1974, Mar
15, Vol. 99, N0.11, pp. 496-7, ISSN 0012-0472.
Cooperman, AM. (1990). Laparoscopic cholecystectomy for severe acute, embedded, and
gangrenous cholecystitis. J Laparoendosc Surg 1990, Vol. 1, No. 1, pp. 37-40. ISSN
1052-3901.
Craig, DB. (1981). Postoperative recovery of pulmonary function. Anesth Analg, Jan 1981, vol
60, No. 1, pp. 46-52, ISSN 0003-2999.
Dawnson, JL. (1985). Colecistectomía. En: Cirugía de la vesicular y vías biliares, Marlow, S., &
Sherlock, S., editores, pp. 319-335, Salvat Editores S.A., ISBN 84-345-2263-21985,
Barcelona
Doherty, GM. (2010). Current diagnosis and treatment surgery. 13th edition, Lange Medical
Books/McGraw-Hill, ISBN 978-0-07-16389-4, New York.
Dubois, F. & Berthelot, B. (1982) Cholécystectomie par mini-laparotomie. Nouv presse Med,
April 1982 3;Vol.11, No. 15, pp.1139-41, ISSN 0301-1518, OCLC 9262901.
Escorrou, J., Cordova, JA., Lazortes, F., Frexinos, J., & Ribet A (1984). Early and Late
complications after endoscopic sphincterotomy for biliary lithiasis with and
without the gallbladder “in situ”. Gut, Jun 1984, Vol. 25, No. 6, pp. 598-602, ISSN
0017-5749.
Fink, AS. (1993). To ERCP o not to ERCP: that is the question. Surg Endosc 1993, Vol. 56, pp.
375-376, ISSN:0930-2794.
Frazee, RC., Roberts, JW., Okeson, GC., Symmonds, RE., Snyder, SK., Hendricks, JC., &
Smith, RW. (1991). Open versus laparoscopic cholecystectomy. A comparison of
pulmonary function. Ann Surg, Jun 1991, Vol. 213, No. 6, pp. 651-3, ISSN 0003-4932.
Gilliland, TM., & Traverso, LW. (1990). Modern standards for comparison of
cholecystectomy with alternative treatments for symptomatic cholelithiasis with
emphasis on long term relief of symptoms. Surg Gynecol Obstet, Jan 1990, Vol.170,
No 1, pp. 39-44. ISSN 0039-6087.
Goco, IR. & Chambers, LG. (1988). Dollars and cents: minicholecystectomy and early
discharge. South Med J, Feb 1988, vol. 81, No. 2, pp. 161-3. ISSN 0038-4348.
Grau-Talens, EJ., & Giner, M. (2010) Transcylindrical gas-free cholecystectomy for the
treatment of cholelithiasis, cholecystitis, and choledocholithiasis. Surg Endosc, Sep
2010, Vol. 24, No. 9, pp. 2099-104, ISSN 0930-2794.
Grau-Talens, EJ., Cattáneo, JH., Giraldo, R., Mangione-Castro, PG. & Giner, M. (2010)
Transcylindrical cholecystectomy under local anestesia plus sedation. A pilot
study. Endoscopy, May 2010; Vol. 42, No. 5, pp. 395-9, ISSN 0013-726X.
Grau-Talens, EJ., García-Olives, F., & Rupérez-Arribas, MP. (1998). Transcylindrical
cholecystectomy: new technique for minimally invasive cholecystectomy. World J
Surg, May 1998; 22, No. 5 pp.153-8, ISSN 0364-2313.
Grau-Talens, EJ., Pérez-García, G., & Rupérez-Arribas, MP. (1994). Colecistectomía
transcilíndrica. Cirugía Española, Noviembre 1994, vol. 56, Suplemento 1, p.297,
ISSN 00-9739-X.
Harris, H W. (2008). Biliary system, In: Surgery. Basic science and clinical evidence, Norton, JA.,
Barie, PS., Randal Bollinger, R., Chang, AE., Lowry, SF., Mulvihill, SJ., Pass, HI., &
Thompson, RW., Editors, pp. 911-942, Second Edition, Springer Scoience+Business
Media,LLC, ISBN 978-0-387-30800-5, New York.
Karam, J. & Roslyn, JL. (1997). Colelithiasis and Cholecystectomy. In: Maingot´s Abdominal
Operations, Zinner, MJ., Schwartz, SI., & Ellis, H, editors.. Tenth edition. McGraw-
Hill, pp.1717-1738. ISBN 0-8385-6106-3, New York.
Katz, D., Nikfarjam, M., Sfakiotaki, A., & Christophi, C. (2004). Selective endoscopic
cholangiography for the detection of common bile duct stones in patients with
cholelithiasis. Endoscopy, Dec 2004,Vol. 36, No. 12, pp. 1045-9. ISSN 0013-726X.
Koo, KP., & Traverso, LW. (1996). Do preoperative indicators predict the presence of
common bile duct during laparoscopic cholecystectomy? Am J Surg, May 1996, vol
171, No. 5, pp.495-9. ISSN 0002-9610.
Kroh, M., Chand, B. (2008). Choledocholithiasis, endoscopic retrograde

cholangiopancretography, and laparoscopic common bile duct exploration. Sur
Clin N Am, Dec 2008, Vol. 88, No. 6, pp. 1019-1031. ISSN0039-6109.
Lindell, P., & Hendenstierna, G. (1976). Ventilation efficiency after different incisión for
cholecystectomy. Acta Chir Scand 1976, Vol.142, No. 8,pp. 561-5, ISSN 0301-1860
Litynski, G. (1996). Highlights in the history of laparoscopy. The development of laparoscopic
techniques. A cumulative effort of internists, gynecologist and surgeons. Barbara Bernert
Verlag, ISBN 3-9804740-6-2, Frankfurt/Main.
McMahon AJ, Russell IT, Ramsay G, Sunderland G, Baxter JN, Anderson JR, et al (1994).
Laparoscopic and minilaparotomy cholecystectomy: a randomized trial comparing
postoperative pain and pulmonary function. Surgery, May 1994, Vol.115, No. 5 pp.
533-9, ISSN 0039-6060.
Morton, CE. (1985). Cost containment with the use of "mini-cholecystectomy" and
intraoperative cholangiography. Am Surg, Mar 1985, Vol 51, No. 3, pp. 168-9. ISSN
0003-1348.
Moss, G. (1996). Raising the outcome standards for conventional open cholecystectomy. Am
J Surg, Oct 1996, Vol. 172, No. 4, pp. 383-5. ISSN 0002-9610.
Mühe, E. (1986). Die erste cholecystektomie durch das laparoskop. Langenbecks Arch Chir
1986; Vol. 369, No.1, p.804. ISSN 1435-2443
O’Kelly, TJ., Barr, H., Malley, WR., & Kettlewell, M. (1991). Cholecystectomy through a 5 cm
subcostal incision. Br J Surg; Jun, Vol. 78,N0. 6, p. 762, ISSN:0007-1323.
O'Dwyer, PJ., Murphy, JJ.,& O'Higgins, NJ (1990). Cholecystectomy through a 5 cm subcostal
incision. British J Surg, Oct 1990, Vol. 77, No. 10, pp. 1189-9, ISSN 0007-1323.
Olsen DO (1993). Mini-Lap cholecystectomy. Am J Surg, Apr 1993, Vol. 165, No. 4, pp 440-3,
ISSN 0002-9610.
Rhodes, M., Sussman, L., Cohen, L., & Lewis, MP. (1998). Randomised trial of laparoscopic
exploration of common bile duct versus postoperative endoscopic retrograde
cholangiography for common bile duct stones. Lancet, Jan 17, 1998,Vol. 351(9097),
pp.159-61, ISSN 0140-6736.
Rozsos, I., Ferenczy, I., & Rozsos, T. (1997). The surgical technique of microlaparotomy
cholecystectomy. Acta Chir Hung 1997, Vol. 36, (1-4), pp 294-296, ISSN:0231-4614.
Rozsos, I., Ferenczy, J., & Schmitz, R. (2003). Micro and mini-cholecystectomies in the 21st
century Orv Hetil 2003, Vol. 144, pp. 1291-1297, ISSN 0030-6002.
Russell, RCG., & Shankar, S. (1987). The stabilized ring retractor. A technique for
cholecystectomy. Br J Surg, Sep 1987, Vol. 74, No. 8, pp. 826, ISSN:0007-1323.
Schumacher, FJ., & Kohaus, HM. (1994). Cholecystectomy via a surgical tube in 800 patients.
Chirurg, Apr 1994, Vol 65, No. 4, pp. 373-6, ISSN 0009-4722.
Schwarts, SI. (1989). Gallbladder and Extrahepatic Biliary System. In: Principles of Surgery
Schwarts, SI. Shires, GT. Spencer, FC. & Husser, WC, editors. pp. 1381-1412, Fith
edition, McGraw-Hill Book Company, ISBN 0-07-055822-1, New York.
Werbesey, JE., Kirkett DH. (2008). Common bile duct exploration for choledocholithiasis.
Surg Clin N Am 2008, Dec, Vol. 88, No. 6, pp.1315-28. ISSN 0039-6109.
Yamashita, Y., Takada, T., Kararada, Y et al (2007). Surgical treatment of patients with acute
cholecystitis: Tokyo guidelines. J Hepatobiliary Pancreat Surg 2007; Vol. 14, No. 1, pp.
91-7, ISSN 0944-1166.
Zeus, F., Gooszen, HG., & Van Laarhoven, CJ. (2010). Open, small-incision or laparoscopic
cholecystectomy for patients with symtomatic cholecystolithiasis. An overview of
Cochrane Hepato-Biliary Group reviews. Cochrane Database Syst Rev 2010,Jan 20;
Issue 1, CD008318, ISSN 1469-493x, 1361-6137.
2
Laparoscopic Cholecystectomy
in High Risk Patients
Abdulrahman Saleh Al-Mulhim
King Faisal University
Saudi Arabia
1. Introduction
High risk patients who are candidates for laparoscopic cholecystectomy differ from the
patients who have no existing risks and comorbidities in terms of the methods to be used as
well as the expected outcomes. In order to recognize the safety of laparoscopic
cholecystectomy, different cases of high risk patients undergoing laparoscopic
cholecystectomy were gathered which demonstrate their conditions during laparoscopic
cholecystectomy. These articles focused on patients with cardiopulmonary diseases,
diabetes mellitus, sickle cell diseases, renal diseases, liver cirrhosis, during pregnancy and in
the elderly. The results of the different cases showed that laparoscopic cholecystectomy is a
safe procedure to be utilized and it is therefore recommended as the treatment of choice, as
long as it is done cautiously and skillfully in all the high risk groups. The consequences of
this technique including the bile duct injury, influence of pneumoperitoneum on
cardiorespiratory system and other complications are outweighed by the benefits that the
patients acquire after the surgery.
Patients who are high risk and undergo traditional cholecystectomy carries high morbidity
and mortality as compared to laparoscopic cholecystectomy. The introduction of
laparoscopic cholecystectomy has decreased the number of contraindications in the past
recent years and in which more studies are focused on the constant modifications in terms
of the assessed risks as well as the indications for the procedure.[1]
Patients who have past or recent medical conditions who are at risk of presenting
perioperative complications and those who cannot survive an operation are the ones
classified as high risks patients.[2] The issue that is always brought up for patients with such
conditions is whether the benefits of laparoscopic cholecystectomy offset the risks involved
especially with the new methods used in the procedure such as CO2 insufflation and
pneumoperitoneum.[3]
There are collated cases which demonstrate the conditions of the high risks patients during
laparoscopic cholecystectomy. These articles focused on patients with cardiopulmonary
diseases, diabetes mellitus, sickle cell diseases, renal diseases, liver cirrhosis, during
pregnancy and in the elderly.
2. Patients with cardiopulmonary diseases

Hemodynamic and respiratory effects of the pneumoperitoneum are the most common
hazards of surgical intervention in cardiac and pulmonary disease patients. Popken[1] stated
that the advantages of laparoscopic cholecystectomy are more rapid recovery of lung
function and a shorter stay in hospital. Catani [4] declared that changes in cardiovascular
function due to the insufflation are characterized by an immediate decrease in cardiac index
and an increase in mean arterial blood pressure and systemic vascular resistance.
2.1 Cases
Popken et al [1] published a study regarding patients with cardiopulmonary impairment
where they used laparoscopic cholecystectomy in 19 high-risk patients (ASA IV) and 465
patients with a lower operative risk (ASA I-III). The authors state that out of 484 patients,
there were 5 percent who suffered intraoperative cardiopulmonary complications. There
were three who belonged to the high-risk group (15.8%) and 21 to the lower risk groups
(4.5%). There were general postoperative complications that occurred in 14 cases (2.9%). The
authors noted that the number of days spent in hospital was 4.96 to 7.6 in average days in
the high-risk group versus 2.23 to 4.8 days in groups ASA I-III. They concluded that high-
risk patients shows a raise perioperative rate of complications in laparoscopic
cholecystectomy but they also stated that it is not basically a contraindication for this
operative method.
Tillman et al. [2] also investigated their laparoscopic cholecystectomy cases in 17 patients
with severe cardiac dysfunction. They reported that there were three of the 17 patients who
required administration of nitroglycerin to maintain the MAP and SVR within the accepted
limits while one also required administration of dobutamine to maintain CI. There was no
myocardial morbidity or mortality in the perioperative period according to their report.
They concluded that laparoscopic cholecystectomy in patients with severe cardiac
dysfunction results in significant hemodynamic changes.
3. Patients with diabetes mellitus

It has been believed that patients with diabetes mellitus is considered before as a risk factor
in patients who undergo laparoscopic cholecystectomy commonly because of symptomatic
gallbladder stones.[5] This is due to reports (Chang,M.D)[6] that a high plasma glucose level is
associated with a poor neurologic recovery score in patients after cardiopulmonary
Laparoscopic Cholecystectomy in High Risk Patients 29
resuscitation. Researchers said that even if consciousness is restored, neurologic deficit may
remain in hyperglycemic patients. [5] Therefore it is important to maintain an adequate
plasma glucose level (120-180 mg/dl) during anesthesia as well as in the pre-operative
period.
Specialists agree that in order to achieve strict plasma glucose control, the plasma glucose
level is checked and controlled with hypoglycemic agent such as insulin regularly and
frequently which helps prevent acute and chronic complications of DM. They said that
stress caused by surgery and anesthesia induces hyperglycemia causing higher blood
glucose levels in DM patients who underwent surgery than in patients who did not have
surgery. [5]
3.1 Cases
Bedirli et al. [8] gathered the data for their laparoscopic cholecystectomy cases where there
are eight hundred sixty-two patients with symptomatic gallbladder stones who underwent
laparoscopic cholecystectomy. They took into consideration the age, sex, risk classification of
the American Society of Anesthesiologists (ASA), laboratory tests, operative records,
morbidity and length of hospital stay for each patient. They noted that almost half of their
cholecystectomies which comprised 111 patients were performed as acute surgery due to
cholecystitis. There were conversions to open surgery which were required in 16% of the
diabetic patients undergoing LC. They concluded that when feasible, LC was a safe
procedure in diabetes.
Paajanen et al [9] studied 2,548 consecutive patients (1,581 LC, 967 OC) with symptomatic
gallstones who underwent cholecystectomy. They summed up that from 1995 and 2008, they
operated 227 patients with diabetes 45 of these patients had type 1 diabetes. They made a
comparison with the preoperative data and the operative outcome of the diabetic patients
who underwent laparoscopic cholecystectomy and open cholecystectomy. They had
observed that more complications occur in the open cholecystectomy group than in the
laparoscopic cholecystectomy group. Upon their analysis they stated that comorbidities of
diabetes were associated with an elevated risk for complications but obesity or acute
surgery was not independently associated with postoperative complications. The authors
concluded that laparoscopic cholecystectomy is a safe procedure in diabetic patient as
compared to open cholecystectomy where there is a significant reduction in operative risks
and complications.
4. Patients with sickle cell diseases

Among the genetic disorders, sickle cell disease is the most common around the world.
People who are affected are at an increased risk of developing pigmented gallstones [10] and
it is said that this risk increases with age. Perioperative and postoperative complications
which are mainly vaso-occlusive crises (VOC) may occur as a result of surgeries for
symptomatic stones. Minimal risks have been associated with the introduction laparoscopic
cholecystectomy because of its advantages over the traditional open surgeries.
4.1 Cases
It is believed that minimally invasive therapy can reduce morbidity and mortality in sickle
cell disease patients. The safety of laparoscopic cholecystectomy in such patients has already
been recognized. Rachid et al [10] reported the results of their experience on laparoscopic
cholecystectomy in sickle cell disease patients in Niger, which is included in the sickle cell
belt. Their study covered 45 months and included 47 patients operated by the same surgeon.
The average age was 22.4 years (range: 11 to 46 years) and eleven (23.4%) of them were aged
less than 15 years. The types of sickle cell disease found were 37 SS, 2 SC, 1 S beta-
thalassemia and 7 AS. The indications for their surgeries were biliary colic in 29 cases
(61.7%) and acute cholecystitis in 18 cases (38.3%). Their mean operative time was 64
minutes. Reports from the authors states that there were conversions to open
cholecystectomy in 2 cases (4.2 %) for non recognition of Calot‘s triangle structures. They
reported four cases of postoperative complications of vaso-occlusive crisis and one case of
acute chest syndrome. Their mean postoperative hospital stay was 3.5days (range: 1 to 9
days). There was no mortality encountered. The authors concluded that laparoscopic
cholecystectomy is a safe procedure in sickle cell patients and that it should be a
multidisciplinary approach and involve the haematologist, anaesthesiologist and a surgeon.
Haberkem et al [12] studied a group of 364 patients who underwent cholecystectomy. There
were ninety-eight percent of their patients who had symptomatic cholelithiasis. Their total
perioperative morbidity was 39% and they reported that while total morbidity is not
affected by preoperative transfusion, the incidence of specific sickle cell events is higher in
those patients who were not transfused preoperatively than in those who were.
Laparoscopic cholecystectomy was accompanied by shorter hospitalization time (6.4 days)
than the open cholecystectomy (9.8 days) and noted that perioperative outcomes were the
same with both techniques. The authors concluded that conservative preoperative
transfusion and use of the laparoscopic technique are necessary for patients with sickle cell
disease who will be undergoing cholecystectomy to prevent further complications.
5. Patients with renal diseases

Management of gallstones in renal transplant patients was always questioned because of the
related complications. It has been found out that patients with renal disease have a higher
incidence of coronary artery disease (CAD) and peripheral vascular disease (PVD)
compared to the general population because they have the traditional risk factors for CAD
such as advanced age, diabetes, hypertension and lipid disorders as well as a high
prevalence of such as hyperhomocysteinemia, abnormal calcium phosphate metabolism,
anemia, increased oxidative stress and uremic toxins.[27]
5.1 Cases
Ekici et al [25] conducted a study where they assessed laparoscopic cholecystectomy (LC) in
patients with end-stage renal disease treated with continuous ambulatory peritoneal
dialysis. There were eleven patients receiving peritoneal dialysis treatment and 33 patients
without end-stage renal disease who had undergone an elective LC were compared. They
reviewed all their medical records and the laboratory values as well as the outcomes and
results. Their peritoneal dialysis group showed a higher frequency of associated disease and
previous abdominal surgery, a lower hemoglobin and platelet count and elevated alkaline
phosphatase, blood urea nitrogen and creatinine values. There was one procedure in each
group that was converted to an open cholecystectomy. There were no other catheter-related
complications that occurred. The authors concluded that laparoscopic cholecystectomy may
be performed with low complication rates in patients undergoing continuous ambulatory
peritoneal dialysis with an experienced team.
Banli et al [26] evaluated the outcomes of laparoscopic cholecystectomy in renal transplant

patients with symptomatic gallstone disease. They reviewed the records of 155 kidney
transplant patients, including 16 patients who underwent laparoscopic cholecystectomy.
They found out that the shortest interval time between transplantation and cholecystectomy
was 2 years. Surgical morbidity were seen in two of the patients with no mortality and no
graft loss. They concluded that laparoscopic cholecystectomy can be performed safely with
low morbidity in renal transplant patients who have symptomatic gallstone disease.
6. Patients with cirrhotic diseases

Liver diseases are always considered risk factors in operations due to increase risks of
complications and sometimes can even be the cause of death. Liver decompensation is also
one reason why clinicians are hesitant to recommend surgeries due to the possible
occurrence of abnormal clearance of proteins, abnormal excretion, ascites and portal
hypertension. [11]
There are also factors being considered such as the patients Child-Pugh score, the length
and extent of the surgery as well as postoperative complications.[23] The Child-Pugh score is
used to evaluate and assess the condition of a patient with liver disease as well as predict
mortality during surgery. Nowadays it is also used to establish the prognosis and the
required treatment for the disease. [23]
Another recent assessment tool is the Model for End-Stage Liver Disease, or MELD, a
scoring system for assessing the severity of chronic liver disease. This system uses the
patient's values for serum bilirubin, serum creatinine, and the international normalized ratio
for prothrombin time (INR) to predict the patient’s survival after surgery. [11]
6.1 Cases
Cucinotta et al [7] accumulated the records of 22 laparoscopic cholecystectomies which they
performed in patients with cirrhosis Child-Pugh A and B. These data were gathered from
January 1995 to July 2001. There was no death reported and the average duration of the
surgeries were 115 minutes and were noted that they were shorter than the usual open
cholecystectomy. They also stated that blood transfusion was not required in all the
surgeries and that the intraoperative complications that occurred were liver bed bleeding.
They also noted some postoperative morbidities such as hemorrhage, wound complications,
cardiopulmonary complications and intraabdominal collections in 36% of the patients but
reported that they were all controlled. They observed the length of hospital stay in patients
with an average of 4 days. The authors concluded that with laparoscopic cholecystectomy
having lower morbidity, shorter operative time and with reduced hospital stay, it can be
safely done in patients with cirrhosis Child-Pugh A and B who are carefully selected and
screened as to their need for surgery.
Another study was also done by Delis et al [15] from January 1995 to July 2008 where they
performed 220 laparoscopic cholecystectomies in patients Child–Pugh class A and B patients
with MELD scores ranging from 8 to 27. Their indications for the said operations were
symptomatic gallbladder disease and cholecystitis. They reported that no deaths occurred
and observed that there were postoperative morbidities that occurred such as hemorrhage,
wound complications and intra-abdominal collections but they were controlled. They stated
that intraoperative difficulties due to liver bed bleeding were experienced in 19 patients.
There was a necessity to convert 12 of their cases to open cholecystectomy. Their median
operative time was 95 minutes while their median hospital stay was 4 days. They reported
that patients with preoperative MELD scores above 13 showed a tendency for higher
complication rates postoperatively. The authors concluded that laparoscopic
cholecystectomy can be performed safely in selected patients with cirrhosis Child–Pugh A
and B and symptomatic cholelithiasis with acceptable morbidity.
Leone et al [16] presented their cases between January 1994 and December 2000 where there
were 1,100 laparoscopic cholecystectomies for symptomatic gallbladder diseases. They
reported that there were 24 cirrhotic patients who had well-compensated cirrhosis (Child’s
class A or B). The authors reported that there were no operative mortality and the
postoperative complication rates were 20.8%. They estimated that the intraoperative blood
loss was 37.08 ml in average. Their average hospital stay 3.61 days. The authors concluded
that laparoscopic cholecystectomy in patients with compensated cirrhosis is safe and should
be the treatment of choice for these patients. They further stated that laparotomy should be
applied only if the surgeon considers the operation inadequate to be continued
laparoscopically.
7. Patients who are pregnant

Diseases in the abdomen requiring surgical intervention during pregnancy present unique
challenges to their diagnosis and management [17]. These are said to be due to the changes in
physiology and abdominal anatomy characteristic of pregnancy. These changes make
laparoscopic surgery technically more difficult, the obstetrician must determine the status of
pregnancy such as gestational age, viability and inform the patient about the risks related to
pregnancy and surgery itself [18].
There are several mechanisms that have been proposed by specialists for increased fetal
morbidity and mortality associated with laparoscopic surgery during pregnancy including
direct uterine trauma, fetal trauma, intraamniotic CO2 insufflation, trauma to maternal
abdominal organs and vessels, decreased uterine blood flow and oxygen delivery,
teratogenic effects of anesthetic drugs, fetal acidosis due to CO2 pneumoperitoneum,
adverse effects of anesthesia on maternal hemodynamic and acid-base balance, increased
risk of thromboembolic disease, the effect of underlying abdominal pathology, manipulation
during surgery and effects of postoperative medications [18,20] Therefore laparoscopic
cholecystectomy has been used cautiously in pregnant women. This is due to the possible
mechanical problems related to the pregnant uterus and the other is fear of fetal injury
resulting from instrumentation or the pneumoperitoneum.
7.1 Cases
To assess the effects of laparoscopic cholecystectomy on both the mother and the unborn
fetus, Abuabara et al [19] reviewed their surgical experience over a 5-year period where 22
patients ranging from 17 to 31 years underwent laparoscopic cholecystectomy during
pregnancy. They noted that the gestational ages ranged from 5 to 31 weeks where there are
two patients who are in their first trimester, 16 in the second and four in the third. Their
indications for surgery were persistent nausea, vomiting, pain, and inability to eat in 17
patients, acute cholecystitis in three and choledocholithiasis in two. The surgeons
established pneumoperitoneum in all patients and their results were all 22 patients survived
the surgical procedure without complications and there were no fetal deaths or premature
births related to the procedure. The authors concluded that laparoscopic cholecystectomy
during pregnancy is safe for both the mother and the unborn fetus and if at all possible,
when laparoscopic cholecystectomy is indicated, it should be performed either in the second
trimester or early in the third.
Wishner et al [21], members of the Norfolk Surgical Group, gathered their data for the
laparoscopic cholecystectomy cases from May 1991 to June 1994 where they performed the
operations on 1,300 patients. There were six of these patients who were operated on during
pregnancy. They were able to successfully perform the operation on all the six patients and
observed that the overall course of the operation is the same with non-pregnant patients.
They reported that there were no significant complications to either the patient or the fetus.
It was reported later that all the six patients delivered healthy babies and noted no signs of
complications. The authors concluded that laparoscopic cholecystectomy can be performed
safely in pregnant patients and that it should be considered in any patient who presents
with symptomatic cholelithiasis during pregnancy.
8. Elderly patients
Age is one of the critical factors affecting the mortality and morbidity rates after open
cholecystectomy for both acute and chronic cholecystitis [2, 3]. Several series of open
cholecystectomy [4, 5] report death as a complication occurring almost exclusively in patients
over 60 years of age [6]. Smith and Max [7] found that the morbidity-mortality rate after open
cholecystectomy was 25% for patients aged 60-69 as opposed to 50% for patients over 70.
Ageing patients with symptomatic cholelithiasis frequently have associated medical
disorders. They may be at higher risk of postoperative complications. Evaluation of the
results of the laparoscopic approach in the aged would allow patients and surgeons to make
decisions on the most appropriate treatment for symptomatic cholelithiasis.
8.1 Case
Brunt et al[22] gathered their laparoscopic data for 421 patients from 1989 to 1999 which were
extremely elderly or older than 80 years to determine whether extremely elderly patients,
age 80 years or older, were at higher risk for adverse outcomes from laparoscopic
cholecystectomy than patients younger than 80 years. The patients were divided into two
groups: group 1 (age 65-79 years; n = 351) and group 2 (age, 80-95 years; n = 70). The authors
noted that the advanced age (group 2) was associated with a higher mean American Society
of Anesthesiology (ASA) class and a greater incidence of common bile duct stones, as
compared with those of younger age (group 1). Mean operative times in group 2 were 45-
106 minutes as compared with 38 to 96 minutes in group 1, a difference that is not
significant. The authors noted that the extremely elderly group had a four times higher rate
of conversion to open cholecystectomy and a longer mean postoperative hospital stay of 1.4
to 2.1 days. They also stated that Grades 1 and 2 complications were more common in group
2. They reported that one patient in group 1 had a myocardial infarction 13 days
postoperatively, and two deaths occurred in the extremely elderly group within 30 days
postoperatively. The authors concluded that laparoscopic cholecystectomy in the extremely
elderly is associated with more complications and a higher rate of conversion to open
cholecystectomy than in elderly individuals younger than 80 years. The greater chance of
encountering a severely inflamed or scarred gallbladder and common bile duct stones as
well as increasing comorbidities likely account for these differences in outcome.
Mayol et al[24] gathered the outcome of all their laparoscopic cholecystectomy patients
between 60 and 70 years of age and patients over 70 who underwent laparoscopic
cholecystectomy for symptomatic non-malignant gallbladder disease. They found out that
the operative time and conversion rates were similar with both groups. They noted that the
overall morbidity rate was 14.5% and there was no perioperative mortality that occurred.
There was a recurrent biliary surgery done in two patients from the above 70 group. There
were also postoperative endoscopic retrograde cholangiography and sphincterotomy that
was done in four patients from the below 70 group. They also found out that the mean
postoperative stay was longer for older patients above 70 years of age. The authors
concluded that simple laparoscopic cholecystectomy is safe in the aged even for patients
over 70. They stated that this procedure is associated with a short hospital stay and low
rates of re-admission and recurrent biliary surgery.
9. Conclusion
With the success of laparoscopic cholecystectomy on different high risk patients, it is
therefore recommended as the treatment of choice. The consequences of this technique
including the bile duct injury, influence of pneumoperitoneum on cardiorespiratory system
and other complications are outweighed by the benefits that the patients acquire after the
surgery and these consequences can be prevented by performing the operation cautiously
and skillfully in all the high risk patient groups.
10. References
[1] Popken F, Küchle R, Heintz A, Junginger T. [Laparoscopic cholecystectomy in high risk
patients]. Chirurg. 1997 Aug;68(8):801-5. German.
http://www.ncbi.nlm.nih.gov/pubmed/9522071
[2] H.A.Tillmann Hein, MD, Girish P. Joshi, MB BS, MD, FFARCSI, Michael A.E. Ramsay,
MD, L.George Fox, MD, Bradley J. Gawey, MDab§, Christopher L. Hellman, MD,
John C. Arnold, MDa
[3] Wahba RW, Béïque F, Kleiman SJ. Cardiopulmonary function and laparoscopic
cholecystectomy. Can J Anaesth. 1995 Jan;42(1):51-63. Review. PubMed PMID:
7889585.
[4] Catani M, Guerricchio R, De Milito R, Capitano S, Chiaretti M, Guerricchio A, Manili G,
Simi M. ["Low-pressure" laparoscopic cholecystectomy in high risk patients (ASA
III and IV): our experience]. Chir Ital. 2004 Jan-Feb;56(1):71-80. Italian.
[5] Hawthorne GC, Ashworth L, Alberti KG. The effect of laparoscopic cholecystectomy on
insulin sensitivity. Horm Metab Res. 1994 Oct;26(10):474-7.
[6] Chul Ho Chang, M.D., Yon Hee Shim, M.D., Youn-Woo Lee, M.D., Yong Beom Kim,
M.D., and Yong-Taek Nam, M.D. , Pain Medicine, Yonsei University College of
Medicine, 134, Sinchon- dong, Seodaemun-gu, Seoul 120-752, Korea.
[7] Cucinotta E, Lazzara S, Melita G. Laparoscopic cholecystect omy in cirrhotic patients.
Surg Endosc. 2003 Dec;17(12):1958-60. Epub 2003 Oct 28. Review.
[8] Bedirli A, Sözüer EM, Yüksel O, Yilmaz Z. Laparoscopic cholecystectomy for
symptomatic gallstones in diabetic patients. J Laparoendosc Adv Surg Tech A. 2001
Oct;11(5):281-4. PubMed PMID: 11642663.
[9] Paajanen H, Suuronen S, Nordstrom P, Miettinen P, Niskanen L. Laparoscopic versus
open cholecystectomy in diabetic patients and postoperative outcome. Surg
Endosc. 2010 Jul 27. [Epub ahead of print] PubMed PMID: 20661751.
[10] Sani Rachid, Lassey James Didier, Mallam Abdou Badé, Chaibou Maman Sani, Abarchi
Habibou. Laparoscopic cholecystectomy in sickle cell patients in Niger. The Pan
African Medical Journal. 2009;3:19
[11] Kamath PS, Wiesner RH, Malinchoc M, Kremers W, Ther neau TM, Kosberg CL,
D'Amico G, Dickson ER, Kim WR (2001). "A model to predict survival in patients
with end-stage liver disease". Hepatology 33 (2): 464–70.
[12] Friedman LS. The risk of surgery in patients with liver dis ease. Hepatology 1999;
29:1617-23.
[14] Charles M. Haberkern, Lynne D. Neumayr, Eugene P. Orringer,Ann N. Earles, Shanda
M. Robertson, Dennis Black, Miguel R. Abboud, Mabel Koshy, Olajire Idowu,
Elliott P. Vichinsky, and the Preoperative Transfusion in Sickle Cell Disease Study
Group. Blood, Vol. 89 No. 5 (March 1), 1997: pp. 1533-1542
[15] Delis S, Bakoyiannis A, Madariaga J, Bramis J, Tassopoulos N, Dervenis C. Laparoscopic
cholecystectomy in cirrhotic patients: the value of MELD score and Child-Pugh
classification in predicting outcome. Surg Endosc. 2010 Feb;24(2):407-12. Epub 2009
Jun 24. PubMed PMID: 19551433.
[16] Leone N, Garino M, De Paolis P, Pellicano R, Fronda GR, Rizzetto M. Laparoscopic
cholecystectomy in cirrhotic patients. Dig Surg. 2001;18(6):449-52. PubMed PMID:
11799294.
[17] Modrzejewski A, Lewandowski K, Pawlik A, Czerny B, Kurzawski M, Juzyszyn Z. [Gall
bladder stones during pregnancy in the age of laparoscopic cholecystectomy].
Ginekol Pol. 2008 Nov;79(11):768-74. Review. Polish. Machado NO, Machado LS.
Laparoscopic cholecystectomy in the third trimester of pregnancy: report of 3 cases.
Surg Laparosc Endosc Percutan Tech. 2009
[18] Comitalo JB, Lynch D. Laparoscopic cholecystectomy in the pregnant patient. Surg
Laparosc Endosc. 1994 Aug;4(4):268-71.
[19] Abuabara SF, Gross GW, Sirinek KR. Laparoscopic cholecystectomy during pregnancy
is safe for both mother and fetus. J Gastrointest Surg. 1999 Jan-Feb;1(1):48-52;
discussion 52.
[20] Reyes-Tineo R. Laparoscopic cholecystectomy in pregnancy. Bol Asoc Med P R. 1997
Jan-Mar;89(1-3):9-11. Review.
[21] Wishner JD, Zolfaghari D, Wohlgemuth SD, Baker JW Jr, Hoffman GC, Hubbard GW,
Gould RJ, Ruffin WK. Laparoscopic cholecystectomy in pregnancy. A report of 6
cases and review of the literature. Surg Endosc. 1996 Mar;10(3):314-8. Review.
[22] Brunt LM, Quasebarth MA, Dunnegan DL, Soper NJ. Outcomes analysis of laparoscopic
cholecystectomy in the extremely elderly. Surg Endosc. 2001 Jul;15(7):700-5. Epub
2001 May 2. PubMed PMID: 11591971
[23] Pugh RN, Murray-Lyon IM, Dawson JL, Pietroni MC, Williams R (1973). "Transection of
the oesophagus for bleeding oesophageal varices". The British journal of surgery 60
(8): 646–9.doi:10.1002/bjs.1800600817
[24] Julio Mayol, Javier Martinez Sarmiento, Francisco J. Tamayo, Jesus Alvarez Fernandez
Represa. Age Ageing (1997) 26 (2): 77-81.doi: 10.1093/ageing/26.2.77
[25] Ekici Y, Karakayali F, Yagmurdur MC, Moray G, Karakayal H, Haberal M.
Laparoscopic cholecystectomy in patients undergoing continuous ambulatory
peritoneal dialysis: a case-control study. Surg Laparosc Endosc Percutan Tech. 009
Apr;19(2):101-5. PubMed PMID: 1939027
[26] O. Banli, N. Guvence, H. Altun Transplantation Proceedings.June 2005 (Vol. 37, Issue 5,
Pages 2127-2128)
[27] Yeh CN, Chen MF, Jan YY. Laparoscopic cholecystectomy for 58 end stage renal disease
patients. Surg Endosc. 2005 Jul;19(7):915-8. Epub 2005 May 3. PubMed PMID:
15868265.
3
Gallbladder Surgery, Choice of Technique:

An Overview
E. Nilsson, M. Öman, M.M. Haapamäki and C.B. Sandzén
Department of Surgical and Perioperative Sciences, Umeå University,
Sweden
1. Introduction
The first cholecystectomy was performed by Langenbuch in 1882 (1), and the surgical
approach changed very little in the next century. However, in the 1980s, reports began to
appear that described the removal of the gallbladder through a 3-8 cm, muscle-sparing
incision (small-incision cholecystectomy, or minicholecystectomy) (2-17). A few years later,
laparoscopic cholecystectomy entered the scene (18, 19). These two minimally-invasive
techniques have largely replaced the traditional open cholecystectomy, which used a 10 – 20
cm incision in elective gallbladder surgery (20). In 1993, a consensus conference at the
National Institute of Health concluded that the experience of small-incision surgery or mini-
laparotomy cholecystectomy was limited; and that laparoscopic cholecystectomy could be
performed at a treatment cost that was equal to or slightly less than that of open
cholecystectomy and offered substantial cost savings to the patient and society by reducing
the time off work (21). The alternative to surgical removal of the gallbladder, lithotripsy
combined with chemical dissolution of gallstones is restricted to single stone disease and
runs a risk of stone recurrence (22, 23). However, it has been found to be associated with
good long-term quality of life in selected patients (24).
The aim of this review is to discuss factors that influence the choice between
cholecystectomy techniques, taking into account the applicability and cost of each technique.
2. Methods
We conducted a literature search, including a search of the Cochrane Library and PubMed
(year 2010) with the keyword “cholecystectomy” and used the principles of evidence based
medicine in the presentation of the findings (25-29).
3. Results and discussion

Cholelithiasis, the magnitude of the problem
The prevalence of cholelithiasis in European population is currently 10-15%, and it increases
with age and female gender (30-33). Patients with cholelithiasis may be asymptomatic or
symptomatic. Biliary colic is the only symptom specific to cholelithiasis (34). It is
characterised by a high intensity, long duration pain located in the right upper abdominal
quadrant; it can be referred, and often appears at night (35). Cholelithiasis may be
complicated by acute cholecystitis, common bile duct stones (with pancreatitis or jaundice),
or fistula (32). Gallstone disease is the most common among all abdominal diseases that lead
to hospital care in the Western world (36); recently, an increase of hospital admissions for
gallstone disease has been observed in England (37). This has made gallstone disease a
health care problem with considerable economic consequences; moreover, this problem will
most likely increase with increases in population age (38). The annual direct cost in the
United States has been estimated to be approximately six billion USD (39, 40). No
randomised controlled trials have favoured operative treatment of asymptomatic patients
with cholelithiasis (41). A wait-and-see management approach may also be adopted for
symptomatic patients with uncomplicated disease (42), particularly those with atypical
symptoms (43). With the introduction of the laparoscopic technique, the cholecystectomy
incidence increased substantially (15 – 80%) in Europe (38, 44, 45), Canada (46), the United
States (47, 48), and Saudi-Arabia (49).
Comments on cholecystectomy techniques
Details of the laparoscopic technique (Figure 1) are readily available to any trainee and will
not be discussed here. Essential equipment for small-incision cholecystectomy include
Fig. 1. Laparoscopic cholecystectomy with trainee (right). Consultant surgeon and nurse
closely follow the operation.
Harrington-type retractors, headlamps, and magnification loops (Figure 2) (14). Briefly, the
incision is performed over the right rectus muscle, two to three fingers below the xiphoid
process (Figure 3) (10, 14). The anterior and the posterior rectus sheath are divided. The
Gallbladder Surgery, Choice of Technique: An Overview 39
rectus muscle is left intact, but one or two cm may be divided medially. Intra-abdominal
dissection is initiated at the triangle of Calot, although in patients with inflammation, a
“fundus down” dissection may be advantageous. Before wound closure, a local anaesthetic
agent is administered liberally in the rectus muscle compartment as well as subcutaneously.
The rectus sheaths are sutured with non-absorbable suture and the subcutaneous layer with
absorbable suture. When an extension of the incision must be performed in small-incision
cholecystectomy, the incision is rarely extended lateral to the rectus muscle. Conversion
from laparoscopic to open cholecystectomy typically requires a traditional 10 – 20 cm
subcostal incision through the rectus muscle, the oblique muscles, and the transverse
muscle, with the risk of causing denervation injury and subsequent incisional hernia.
Fig. 2. Headlights and x2.5 magnification loops are necessary for performing a safe small-
incision cholecystectomy.
Minimally-invasive techniques and day-case surgery
Both small-incision cholecystectomy (6, 7, 14, 17, 50-52) and laparoscopic cholecystectomy
(50, 52-56) are compatible with ambulatory surgery. A Cochrane review has considered
laparoscopic day-case surgery safe and effective for selected patients with symptomatic
cholelithiasis (57).
Randomised controlled trials that compared open cholecystectomy, small-incision cholecystectomy,
and laparoscopic cholecystectomy
Cochrane reviews demonstrate that small-incision and laparoscopic cholecystectomy should
be considered equivalent with respect to complications and recovery, but the small-incision
cholecystectomy requires a shorter operation time (58). However, trials with large numbers
of patients are necessary to determine potential differences in serious adverse advents (59).
Open cholecystectomy is associated with a longer hospital stay than the two minimally-
invasive techniques (58). One randomised controlled trial concluded that small-incision
cholecystectomy was also suitable for obese patients (17). Patient opinion of the cosmetic
outcome of surgery did not differ significantly between small-incision and laparoscopic
cholecystectomy one year after surgery (60). For both groups, the median value concerning
patient views of the scar was 1 on a scale of 1 to 10, where 1= does not bother me at all, and
10=very disturbing. To judge the external validity of conclusions reached in randomised
controlled trials, it is necessary to know outcomes for non-randomised patients treated at
the units that participated in the trial. In one trial that compared the two minimally-invasive
cholecystectomy techniques, the patients that received operations, but were excluded from
the trials were older and tended to have more advanced disease (higher ASA-scores, more
co-morbidities, more complications from gallstone disease) than the patients included in the
trials (61).
Fig. 3. Place for small-incision cholecystectomy. The incision is 6 -7 cm long, located over the
right rectus muscle, 2 – 3 fingers below the xiphoid process (to the right). The costal margins
are indicated by dots.
Cholecystectomy techniques from a population based perspective
In Sweden, laparoscopy has been the predominant cholecystectomy technique since 1993
(Sandzén et al, unpublished). From 2000 through 2003, 28% of patients who underwent
cholecystectomy for benign, biliary diseases in Sweden had their operations completed as
open procedures (62). Those patients showed a higher likelihood of having an acute
admission and a complicated gallstone disease compared to patients that underwent
laparoscopic cholecystectomy. They also had a higher mortality than expected, considering
age and sex of the background population, both within 90 days of admission for
cholecystectomy and 91-365 days postoperatively, indicating that these patients were sicker
than the Swedish population in general. This suggested that efforts should be undertaken to
reduce the surgical trauma in open biliary surgery (62). In the United States, 25% of all
cholecystectomies were performed as open operations from 1998-2001, and 5-10% of
laparoscopic cholecystectomies were converted to open operations (63). In Scotland, an
audit reported that the open technique for gallbladder surgery was used in 11.4% of all
cholecystectomies (4.0% primary and 7.4% converted laparoscopic) and concluded that also
in the 2000s, open cholecystectomy is a common procedure with limited room in current
trainee programs(64). Similar conclusions have been drawn from studies in the United
States (65-67). Training programs for open cholecystectomy and common bile duct
procedures have been considered necessary (68).
Population based studies have demonstrated that the incidence of bile duct injuries has
increased after the introduction of laparoscopic cholecystectomy (69). In Sweden, there was
a small to moderate long-term increase in the risk of bile duct injury after introduction of the
laparoscopic technique compared to the prelaparoscopic era (70). This may be an
underestimation of the real change, as the majority of bile duct injuries may be treated
without reconstructive surgery today (71).
Cholecystectomy for complicated gallstone disease
The cholecystectomy technique should be chosen based on the particular type of gallstone
complication in order to achieve smooth, early, definitive treatment. The complications
include acute cholecystitis, common bile duct stones, and acute biliary pancreatitis.
For acute cholecystitis, an early randomised controlled trial showed that small-incision
cholecystectomy was safe, reliable, and had advantages compared to traditional open
cholecystectomy (72). Another randomised controlled trial found no clinically significant
differences between traditional open cholecystectomy and laparoscopic cholecystectomy
(73). Observational series have demonstrated that both small-incision (74) and laparoscopic
cholecystectomy (75-79) are suitable for treating acute cholecystitis. According to meta-
analyses, an early operation (open or laparoscopic) does not carry a higher risk of mortality
or morbidity compared to delayed surgery, and therefore, should be the preferred treatment
(80, 81). This is also applicable to older patients (81, 82). Laparoscopic cholecystectomy for
acute cholecystitis, whether performed early or delayed, is associated with a higher
conversion rate compared to elective cholecystectomy (81). In England, 40% of patients with
acute gallbladder disease had an open operation (converted laparoscopic or traditional open
cholecystectomy) (83). In Denmark, in 2004, 36% of cholecystectomies for acute cholecystitis
were completed as open procedures (84). In Sweden, from 1995 through 1999, 68% of
patients aged 70 years and older had open operations for acute cholecystitis (85).
Concomitant removal of common bile duct stones via choledochotomy can be successfully
performed with open cholecystectomy (86), small-incision cholecystectomy (87), or
laparoscopic cholecystectomy (88-90). According to a Cochrane review, choledochotomy is
superior to endoscopic sphincterotomy for bile duct clearance in open gallbladder surgery.
In contrast, laparoscopic choledochotomy and endoscopic sphincterotomy are equally
effective in the short term, although the latter alternative requires an increased number of
procedures (91). In laparoscopic surgery, endoscopic sphincterotomy is the method
preferred by most surgeons for common bile duct clearance (37, 66, 92). However,
laparoscopic choledochotomy and trancystic common bile duct exploration (93) with
concomitant cholecystectomy are achievable, effective alternatives. Long-term observational
studies have shown that, following endoscopic sphincterotomy, there is a risk of infection,
gallstone formation, pancreatitis (94-98), and biliary carcinoma (96). After endoscopic
retrograde cholangiopancreatography (ERCP), a prerequisite for sphincterotomy, there is an
increased risk for cancer in bile ducts, liver, and pancreas compared to the background
population (99). A Cochrane review indicated that patients with gallbladder in situ should
be offered a cholecystectomy following common bile duct stone removal, provided they are
fit for surgery (100). An observational study recommended a cholecystectomy within one
week of sphincterotomy (101). Further randomised controlled trials are necessary to assess
the benefits and risks of T-tube versus primary closure after both open (102) and
laparoscopic common bile duct exploration (103, 104).
In acute pancreatitis, an early etiological diagnosis (<48 h after admission) is
recommended, and in mild and moderate acute pancreatitis of biliary origin, an early
cholecystectomy is recommended (105-109). In acute biliary pancreatitis without
cholangitis, early ERCP does not lead to a significant reduction of complications or
mortality (110). Deviations from these recommendations are common (111-117). However,
a recent audit demonstrated that it is possible to follow the guidelines for acute biliary
pancreatitis with a low associated mortality (118). According to one randomised trial (119)
and other observational studies, in acute biliary pancreatitis, an early cholecystectomy can
shorten the hospital stay (120, 121) and reduce the risk for recurrent pancreatitis (122)
compared to a delayed operation.
Health care costs
An early randomised controlled trial concluded that hospital costs were higher for small-
incision cholecystectomy than for laparoscopic cholecystectomy (123); in one trial no
significant difference was found between the two methods (124). However, in all other
randomised controlled trials, health care costs were found to be lower for small-incision
compared to laparoscopic cholecystectomy also when re-usable laparoscopic instruments
were used (125-129). In a cost-minimising analysis, small-incision cholecystectomy appeared
to be more cost-effective than laparoscopic cholecystectomy, both from hospital and societal
perspectives (130). To our knowledge, no formal systematic review has compared the costs
of small-incision cholecystectomy and laparoscopic cholecystectomy. However, in a recent
overview of Cochrane reviews, it was concluded that small-incision cholecystectomy ”seems
to be less costly” (58). Observational studies have supported that view (14-16). In
laparoscopic surgery, endoscopic sphincterotomy is associated with a longer hospital stay
(131) and is more costly than choledochotomy (132, 133). Health care costs are ultimately
determined by more factors than the surgical technique used. Factors that modify the
response to surgical trauma, including the use of steroids, use of ondansetron, or liberal
administration of fluid (134-141), advice to patients concerning pain medication and
postoperative activity may affect convalescence, return to work, and finally, the societal cost
for cholecystectomy (142). Long-term costs for cholecystectomy should include costs for
repair of abdominal wall hernias following large, subcostal incisions (Figure 4). Finally,
overall costs for surgical training should take into account the costs for two learning curves
for laparoscopic trainees (laparoscopic cholecystectomy and open cholecystectomy in case of
conversion) versus one curve for minicholecystectomy trainees (small-incision

cholecystectomy with extended incision when needed).
Medical ethics and cholecystectomy technique
Non-maleficence, beneficence, respect for autonomy, and justice are the cornerstones of
principle-based medical ethics (143). Respect for autonomy involves providing evidence
based information on the risks (including conversion/extended incision) and benefits of
surgery in elective and emergency settings (144). Justice involves the fair distribution of
resources among individuals in need of health care. External factors may affect the practice
of justice (145). However, within the limits set by stakeholders, the health care system and
the surgeon must always consider the cost-effectiveness of surgical care (146).
Fig. 4. Patient with a large abdominal wall hernia following subcostal incision in converted
laparoscopic cholecystectomy.
4. Conclusions
Traditional open cholecystectomy is associated with a longer recovery than small-incision
and laparoscopic cholecystectomy. To make a scientific evidence-based choice between
small-incision cholecystectomy and laparoscopic cholecystectomy, surgeons and health care
providers must scrutinize the evidence from randomised controlled trials and from defined
populations, and they must consider the applicability of the techniques to their own setting.
Conclusions reached may have a profound effect on costs and surgical training.
5. References
[1] Langenbuch C. Ein Fall von Extirpation der Gallenblase wegen chronischer
Cholelithiasis: Heilung. Berliner Klin Wochenschr. 1882;19:725-7.
[2] Dubois F, Berthelot B. [Cholecystectomy through minimal incision (author's transl)]. La
Nouvelle presse medicale. 1982 Apr 3;11(15):1139-41.
[3] Goco IR, Chambers LG. "Mini-cholecystectomy" and operative cholangiography. A
means of cost containment. American Surgeon. 1983;49:143-5.
[4] Morton CE. Cost containment with the use of "mini-cholecystectomy" and intraoperative
cholangiography. American Surgeon. 1985;51:168-9.
[5] Salembier Y. [Cholecystectomy through a short transverse incision]. Presse Med. 1986
Feb 8;15(5):210-1.
[6] Moss G. Discharge within 24 hours of elective cholecystectomy. The first 100 patients.
Arch Surg. 1986 Oct;121(10):1159-61.
[7] Ledet WP, Jr. Ambulatory cholecystectomy without disability. Arch Surg. 1990
Nov;125(11):1434-5.
[8] Pelissier EP, Blum D, Meyer JM, Girard JF. Cholecystectomy by minilaparotomy
without muscle section: a short-stay procedure. Hepatogastroenterology. 1992
Aug;39(4):294-5.
[9] Assalia A, Schein M, Kopelman D, Hashmonai M. Minicholecystectomy vs conventional
cholecystectomy: a prospective randomized trial--implications in the laparoscopic
era. World J Surg. 1993 Nov-Dec;17(6):755-9.
[10] Tyagi NS, Meredith MC, Lumb JC, Cacdac RG, Vanterpool CC, Rayls KR, et al. A new
minimally invasive technique for cholecystectomy. Subxiphoid "minimal stress
triangle": microceliotomy. Ann Surg. 1994 Nov;220(5):617-25.
[11] Belli G, Romano G, D'Agostino A, Iannelli A. Minilaparotomy with rectus muscle
sparing: a personal technique for cholecystectomy. Giorn Chir. 1996;17(5):283-4.
[12] Daou R. [Cholecystectomy using a minilaparotomy]. Ann Chir. 1998;52(7):625-8.
[13] Sharma AK, Rangan HK, Choubey RP. Mini-lap cholecystectomy: a viable alternative to
laparoscopic cholecystectomy for the Third World? The Australian and New
Zealand journal of surgery. 1998 Nov;68(11):774-7.
[14] Seale AK, Ledet WP, Jr. Minicholecystectomy: a safe, cost-effective day surgery
procedure. Arch Surg. 1999 Mar;134(3):308-10.
[15] Oyogoa SO, Komenaka IK, Ilkhani R, Wise L. Mini-laparotomy cholecystectomy in the
era of laparoscopic cholecystectomy: a community-based hospital perspective. Am
Surg. 2003 Jul;69(7):604-7.
[16] Syrakos T, Antonitsis P, Zacharakis E, Takis A, Manousari A, Bakogiannis K, et al.
Small-incision (mini-laparotomy) versus laparoscopic cholecystectomy: a
retrospective study in a university hospital. Langenbecks Arch Surg. 2004
Jun;389(3):172-7.
[17] Harju J, Juvonen P, Eskelinen M, Miettinen P, Paakkonen M. Minilaparotomy
cholecystectomy versus laparoscopic cholecystectomy: a randomized study with
special reference to obesity. Surg Endosc. 2006 Apr;20(4):583-6.
[18] Mühe E. Die erste Cholecystectomie durch das laparoskope. . Langenbecks Arch Chir.
1986;369.
[19] Dubois F, Berthelot G, Levard H. (Cholecystectomy by coelioscopy (see comments)].
Presse Med. 1989;18:980-2.
[20] Roslyn JJ, Binns GS, Hughes EF, Saunders-Kirkwood K, Zinner MJ, Cates JA. Open
cholecystectomy. A contemporary analysis of 42,474 patients. Ann Surg. 1993
Aug;218(2):129-37.
[21] NIH Consensus conference. Gallstones and laparoscopic cholecystectomy. JAMA. 1993
Feb 24;269:1018-24.
[22] Plaisier PW, van der Hul RL, Nijs HG, den Toom R, Terpstra OT, Bruining HA. The
course of biliary and gastrointestinal symptoms after treatment of uncomplicated
symptomatic gallstones: results of a randomized study comparing extracorporeal
shock wave lithotripsy with conventional cholecystectomy. Am J Gastroenterol.
1994 May;89(5):739-44.
[23] Plaisier PW, van der Hul RL, den Toom R, Nijs HG, Terpstra OT, Bruining HA.
Gallstone lithotripsy: the Rotterdam experience. Hepatogastroenterology. 1994
Jun;41(3):260-2.
[24] Carrilho-Ribeiro L, Serra D, Pinto-Correia A, Velosa J, De Moura MC. Quality of life
after cholecystectomy and after successful lithotripsy for gallbladder stones: a
matched-pairs comparison. Eur J Gastroenterol Hepatol. 2002 Jul;14(7):741-4.
[25] www.cebm.net/index.aspx?o=1025. [11 Febraury 2011].
[26] Atkins D, Best D, Briss PA, Eccles M, Falck-Ytter Y, Flottorp S, et al. Grading quality of
evidence and strength of recommendations. Bmj. 2004 Jun 19;328(7454):1490.
[27] Guyatt GH, Rennie D, Meade M, Cook D. Users' Guides to the Medical Literature:
essentials of Evidence-Based Clinical Practice. 2nd ed: MGraw-Hill. Professional,
2008; 2008.
[28] Drummond MF, Sculpher MJ, Torrance GW, O'Brien BJ, Torrance GW. Methods for the
economic evaluation of health care programmes. Oxford: Oxford University Press;
2005.
[29] Maier RV. What the surgeon of tomorrow needs to know about evidence-based surgery.
Arch Surg. 2006 Mar;141(3):317-23.
[30] Jorgensen T. Prevalence of gallstones in a Danish population. Am J Epidemiol. 1987
Nov;126(5):912-21.
[31] Attili AF, Carulli N, Roda E, Barbara B, Capocaccia L, Menotti A, et al. Epidemiology of
gallstone disease in Italy: prevalence data of the Multicenter Italian Study on
Cholelithiasis (M.I.COL.). Am J Epidemiol. 1995 Jan 15;141(2):158-65.
[32] Jorgensen T. Treatment of gallstone patients. Copenhagen: National Institute of Public
Health, Denmark, and Danish Institute for Health Technology Assessment; 2000.
[33] Portincasa P, Moschetta A, Palasciano G. Cholesterol gallstone disease. The Lancet.
2006;368.:230-9.
[34] Berger MY, van der Velden JJ, Lijmer JG, de Kort H, Prins A, Bohnen AM. Abdominal
symptoms: do they predict gallstones? A systematic review. Scandinavian journal
of gastroenterology. 2000 Jan;35(1):70-6.
[35] Berhane T, Vetrhus M, Hausken T, Olafsson S, Sondenaa K. Pain attacks in non-
complicated and complicated gallstone disease have a characteristic pattern and are
accompanied by dyspepsia in most patients: the results of a prospective study.
Scandinavian journal of gastroenterology. 2006 Jan;41(1):93-101.
[36] Beckingham IJ, Krige JE. ABC of diseases of liver, pancreas, and biliary system: Liver
and pancreatic trauma. BMJ. 2001 Mar 31;322(7289):783-5.
[37] Kang JY, Ellis C, Majeed A, Hoare J, Tinto A, Williamson RC, et al. Gallstones--an
increasing problem: a study of hospital admissions in England between 1989/1990
and 1999/2000. Aliment Pharmacol Ther. 2003 Feb 15;17(4):561-9.
[38] Aerts R, Penninckx F. The burden of gallstone disease in Europe. Aliment Pharmacol
Ther. 2003 Nov;18 Suppl 3:49-53.
[39] Sandler RS, Everhart JE, Donowitz M, Adams E, Cronin K, Goodman C, et al. The
burden of selected digestive diseases in the United States. Gastroenterology. 2002
May;122(5):1500-11.
[40] Shaffer EA. Gallstone disease: Epidemiology of gallbladder stone disease. Best Pract Res
Clin Gastroenterol. 2006;20(6):981-96.
[41] Gurusamy KS, Samraj K. Cholecystectomy versus no cholecystectomy in patients with
silent gallstones. Cochrane Database Syst Rev. 2007(1):CD006230.
[42] Festi D, Reggiani ML, Attili AF, Loria P, Pazzi P, Scaioli E, et al. Natural history of
gallstone disease: Expectant management or active treatment? Results from a
population-based cohort study. Journal of gastroenterology and hepatology. 2010
Apr;25(4):719-24.
[43] Halldestam I, Kullman E, Borch K. Defined indications for elective cholecystectomy for
gallstone disease. The British journal of surgery. 2008 May;95(5):620-6.
[44] Lam CM, Murray FE, Cuschieri A. Increased cholecystectomy rate after the introduction
of laparoscopic cholecystectomy in Scotland. Gut. 1996;38:282-4.
[45] Mjåland O, Adamsen S, Hjelmqvist B, Ovaska J, Buanes T. Cholecystectomy rates,
gallstone prevalence, and handling of bile duct injuries in Scandinavia. Surgical
Endoscopy. 1998;12:1386-9.
[46] Cohen MM, Young W, Th‚riault ME, Hernandez R. Has laparoscopic cholecystectomy
changed patterns of practice and patient outcome in Ontario? Canadian Medical
Association Journal. 1996;154(4):491-500.
[47] Steiner CA, Bass EB, Talamini MA, Pitt HA, Steinberg EP. Surgical rates and operative
mortality for open and laparoscopic cholecystectomy in Maryland. The New
England Journal of Medicine. 1994;330:403-8.
[48] Legorreta AP, Silber JH, Costantino GN, Kobylinski RW, Zatz SL. Increased
cholecystectomy rate after the introduction of laparoscopic cholecystectomy.
JAMA. 1993;270(12):1429-32.
[49] Al-Mulhim AA, Al-Ali AA, Albar AA, Bahnassy AA, Abdelhadi M, Wosornu L, et al.
Increased rate of cholecystectomy after introduction of laparoscopic
cholecystectomy in Saudi Arabia. World J Surg. 1999 May;23(5):458-62.
[50] Saltzstein EC, Mercer LC, Peacock JB, Daugherty SH. Outpatient open cholecystectomy.
Surgery, Gynecology & Obstetrics. 1992;174:173-5.
[51] Amjad N, Fazal A. Mini cholecystectomy now a day stay surgery: anaesthetic
management with multi modal analgesia. J Pak Med Ass. 2002;52:291-5.
[52] Harju J, Kokki H, Paakkonen M, Karjalainen K, Eskelinen M. Feasibility of
minilaparotomy versus laparoscopic cholecystectomy for day surgery: a
prospective randomised study. Scand J Surg. 2010;99(3):132-6.
[53] Arregui ME, Davis CJ, Arkush A, Nagan RF. In selected patients outpatient
laparoscopic cholecystectomy is safe and significantly reduces hospitalization
charges. Surg Laparoscop Endoscop. 1991;1:240-5.
[54] Richardson WS, Fuhrman GS, Burch E, Bolton JS, Bowen JC. Outpatient laparoscopic
cholecystectomy. Outcomes of 847 planned procedures. Surg Endoscop. 2001; 15:
193-5.
[55] Vagenas K, Spyrakopoulos P, Karanikolas M, Sakelaropoulos G, Maroulis I, Karavias D.
Mini-laparotomy cholecystectomy versus laparoscopic cholecystectomy: which
way to go? Surg Laparosc Endosc Percutan Tech. 2006 Oct;16(5):321-4.
[56] Victorzon M, Tolonen P, Vuorialho T. Day-case laparoscopic cholecystectomy:
treatment of choice for selected patients? Surg Endosc. 2007 Jan;21(1):70-3.
[57] Gurusamy KS, Junnarkar S, Farouk M, Davidson BR. Day-case versus overnight stay in
laparoscopic cholecystectomy. Cochrane Database Syst Rev. 2008(1):CD006798.
[58] Keus F, Gooszen HG, van Laarhoven CJ. Open, small-incision, or laparoscopic
cholecystectomy for patients with symptomatic cholecystolithiasis. An overview of
Cochrane Hepato-Biliary Group reviews. Cochrane Database Syst Rev.
2010(1):CD008318.
[59] Keus F, Weterslev J, Gluud C, Gooszen HG, van Laarhoven CJ. Trial sequential analyses
of meta-analyses of complications in laparoscopic vs. small-incision cholecystectomy:
more randomized patients are needed. J Clin Epidemiol. 2009 Dec 9.
[60] Ros A, Nilsson E. Abdominal pain and patient overall and cosmetic satisfaction one
year after cholecystectomy: outcome of a randomized trial comparing laparoscopic
and minilaparotomy cholecystectomy. Scandinavian journal of gastroenterology.
2004 Aug;39(8):773-7.
[61] Ros A, Carlsson P, Rahmqvist M, Backman K, Nilsson E. Non-randomised patients in a
cholecystectomy trial: characteristics, procedures, and outcomes. BMC Surg.
2006;6:17.
[62] Rosenmuller M, Haapamaki MM, Nordin P, Stenlund H, Nilsson E. Cholecystectomy in
Sweden 2000-2003: a nationwide study on procedures, patient characteristics, and
mortality. BMC Gastroenterol. 2007;7:35.
[63] Livingston EH, Rege RV. A nationwide study of conversion from laparoscopic to open
cholecystectomy. Am J Surg. 2004 Sep;188(3):205-11.
[64] Jenkins PJ, Paterson HM, Parks RW, Garden OJ. Open cholecystectomy in the
laparoscopic era. The British journal of surgery. 2007 Nov;94(11):1382-5.
[65] Chung RS, Wojtasik L, Pham Q, Chari V, Chen P. The decline of training in open biliary
surgery: effect on the residents' attitude toward bile duct surgery. Surg Endosc.
2003 Feb;17(2):338-40; discussion 41.
[66] Livingston EH, Rege RV. Technical complications are rising as common duct
exploration is becoming rare. J Am Coll Surg. 2005 Sep;201(3):426-33.
[67] Chung RS, Ahmed N. The impact of minimally invasive surgery on residents' open
operative experience: analysis of two decades of national data. Ann Surg. 2010
Feb;251(2):205-12.
[68] Schulman CI, Levi J, Sleeman D, Dunkin B, Irvin G, Levi D, et al. Are we training our
residents to perform open gall bladder and common bile duct operations? The
Journal of surgical research. 2007 Oct;142(2):246-9.
[69] Connor S, Garden OJ. Bile duct injury in the era of laparoscopic cholecystectomy.
British Journal of Surgery. 2006;93:158-68.
[70] Waage A, Nilsson M. Iatrogenic bile duct injury: a population-based study of 152 776
cholecystectomies in the Swedish Inpatient Registry. Arch Surg. 2006
Dec;141(12):1207-13.
[71] de Reuver PR, Grossmann I, Busch OR, Obertop H, van Gulik TM, Gouma DJ. Referral
pattern and timing of repair are risk factors for complications after reconstructive
surgery for bile duct injury. Ann Surg. 2007 May; 245 (5):763-70.
[72] Assalia A, Kopelman D, Hashmonai M. Emergency minilaparotomy cholecystectomy
for acute cholecystitis: prospective randomized trial--implications for the
laparoscopic era. World J Surg. 1997 Jun;21(5):534-9.
[73] Johansson M, Thune A, Nelvin L, Stiernstam M, Westman B, Lundell L. Randomized
clinical trial of open versus laparoscopic cholecystectomy in the treatment of acute
cholecystitis. The British journal of surgery. 2005 Jan;92(1):44-9.
[74] Watanapa P. Mini-cholecystectomy: a personal series in acute and chronic cholecystitis.
HPB (Oxford). 2003;5(4):231-4.
[75] Koo KP, Thirlby RC. Laparoscopic cholecystectomy in acute cholecystitis. What is the
optimal timing for operation? Arch Surg. 1996 May;131(5):540-4; discussion 4-5.
[76] Peng WK, Sheikh Z, Nixon SJ, Paterson-Brown S. Role of laparoscopic cholecystectomy
in the early management of acute gallbladder disease. The British journal of
surgery. 2005 May;92(5):586-91.
[77] Wiseman JT, Sharuk MN, Singla A, Cahan M, Litwin DE, Tseng JF, et al. Surgical
management of acute cholecystitis at a tertiary care center in the modern era. Arch
Surg. 2010 May;145(5):439-44.
[78] Young AL, Cockbain AJ, White AW, Hood A, Menon KV, Toogood GJ. Index admission
laparoscopic cholecystectomy for patients with acute biliary symptoms: results
from a specialist centre. HPB (Oxford). 2010 May;12(4):270-6.
[79] Sanjay P, Moore J, Saffouri E, Ogston SA, Kulli C, Polignano FM, et al. Index
laparoscopic cholecystectomy for acute admissions with cholelithiasis provides
excellent training opportunities in emergency general surgery. Surgeon. 2010
Jun;8(3):127-31.
[80] Papi C, Catarci M, D'Ambrosio L, Gili L, Koch M, Grassi GB, et al. Timing of
cholecystectomy for acute calculous cholecystitis: a meta-analysis. Am J
Gastroenterol. 2004 Jan;99(1):147-55.
[81] Gurusamy K, Samraj K, Gluud C, Wilson E, Davidson BR. Meta-analysis of randomized
controlled trials on the safety and effectiveness of early versus delayed
laparoscopic cholecystectomy for acute cholecystitis. The British journal of surgery.
2010 Feb;97(2):141-50.
[82] Riall TS, Zhang D, Townsend CM, Jr., Kuo YF, Goodwin JS. Failure to perform
cholecystectomy for acute cholecystitis in elderly patients is associated with
increased morbidity, mortality, and cost. J Am Coll Surg. 2010 May;210(5):668-77,
77-9.
[83] David GG, Al-Sarira AA, Willmott S, Deakin M, Corless DJ, Slavin JP. Management of
acute gallbladder disease in England. The British journal of surgery. 2008
Apr;95(4):472-6.
[84] Ainsworth AP, Adamsen S, Rosenberg J. Surgery for acute cholecystitis in Denmark.
Scandinavian journal of gastroenterology. 2007 May;42(5):648-51.
[85] Nilsson E, Fored CM, Granath F, Blomqvist P. Cholecystectomy in Sweden 1987-99: a

nationwide study of mortality and preoperative admissions. Scandinavian journal
of gastroenterology. 2005 Dec;40(12):1478-85.
[86] Roukema JA, Carol EJ, Liem F, Jakimowicz JJ. A retrospective study of surgical common
bile-duct exploration: ten years experience. Neth J Surg. 1986 Feb;38(1):11-4.
[87] Seale AK, Ledet WP, Jr. Primary common bile duct closure. Arch Surg. 1999
Jan;134(1):22-4.
[88] Martin IJ, Bailey IS, Rhodes M, O'Rourke N, Nathanson L, Fielding G. Towards T-tube
free laparoscopic bile duct exploration: a methodologic evolution during 300
consecutive procedures. Ann Surg. 1998 Jul;228(1):29-34.
[89] Tokumura H, Umezawa A, Cao H, Sakamoto N, Imaoka Y, Ouchi A, et al. Laparoscopic
management of common bile duct stones: transcystic approach and
choledochotomy. J Hepatobiliary Pancreat Surg. 2002;9(2):206-12.
[90] Decker G, Borie F, Millat B, Berthou JC, Deleuze A, Drouard F, et al. One hundred
laparoscopic choledochotomies with primary closure of the common bile duct.
Surg Endosc. 2003 Jan;17(1):12-8.
[91] Martin DJ, Vernon DR, Toouli J. Surgical versus endoscopic treatment of bile duct
stones. Cochrane Database Syst Rev. 2006(2):CD003327.
[92] Hüttl TP, Hrdina C, Geiger TK, Meyer G, Schildberg FW, Krämling HJ. Management of
common bile duct stones - Results of a nationwide survey with analysis of 8 433
common bile duct explorations in Germany. Zentralblatt für Chirurgie.
2002;127:282-8.
[93] Paganini AM, Guerrieri M, Sarnari J, De Sanctis A, D'Ambrosio G, Lezoche G, et al.
Thirteen years' experience with laparoscopic transcystic common bile duct
exploration for stones. Effectiveness and long-term results. Surg Endosc. 2007
Jan;21(1):34-40.
[94] Bergman JJ, van der Mey S, Rauws EA, Tijssen JG, Gouma DJ, Tytgat GN, et al. Long-
term follow-up after endoscopic sphincterotomy for bile duct stones in patients
younger than 60 years of age. Gastrointest Endosc. 1996 Dec;44(6):643-9.
[95] Sugiyama M, Atomi Y. Follow-up of more than 10 years after endoscopic
sphincterotomy for choledocholithiasis in young patients. The British journal of
surgery. 1998 Jul;85(7):917-21.
[96] Tanaka M, Takahata S, Konomi H, Matsunaga H, Yokohata K, Takeda T, et al. Long-
term consequence of endoscopic sphincterotomy for bile duct stones. Gastrointest
Endosc. 1998 Nov;48(5):465-9.
[97] Rolny P, Andren-Sandberg A, Falk A. Recurrent pancreatitis as a late complication of
endoscopic sphincterotomy for common bile duct stones: diagnosis and therapy.
Endoscopy. 2003 Apr;35(4):356-9.
[98] Mandryka Y, Klimczak J, Duszewski M, Kondras M, Modzelewski B. [Bile duct
infections as a late complication after endoscopic sphincterotomy]. Pol Merkur
Lekarski. 2006 Dec;21(126):525-7.
[99] Stromberg C, Luo J, Enochsson L, Arnelo U, Nilsson M. Endoscopic sphincterotomy
and risk of malignancy in the bile ducts, liver, and pancreas. Clin Gastroenterol
Hepatol. 2008 Sep;6(9):1049-53.
[100] McAlister VC, Davenport E, Renouf E. Cholecystectomy deferral in patients with
endoscopic sphincterotomy. Cochrane Database Syst Rev. 2007(4):CD006233.
[101] Schiphorst AH, Besselink MG, Boerma D, Timmer R, Wiezer MJ, van Erpecum KJ, et al.
Timing of cholecystectomy after endoscopic sphincterotomy for common bile duct
stones. Surg Endosc. 2008 Sep;22(9):2046-50.
[102] Gurusamy KS, Samraj K. Primary closure versus T-tube drainage after open common
bile duct exploration. Cochrane Database Syst Rev. 2007(1):CD005640.
[103] Gurusamy KS, Samraj K. Primary closure versus T-tube drainage after laparoscopic
common bile duct stone exploration. Cochrane Database Syst Rev.
2007(1):CD005641.
[104] Leida Z, Ping B, Shuguang W, Yu H. A randomized comparison of primary closure
and T-tube drainage of the common bile duct after laparoscopic choledochotomy.
Surg Endosc. 2008 Jul;22(7):1595-600.
[105] Uhl W, Warshaw A, Imrie C, Bassi C, McKay CJ, Lankisch PG, et al. IAP Guidelines for
the Surgical Management of Acute Pancreatitis. Pancreatology. 2002;2(6):565-73.
[106] UK guidelines for the management of acute pancreatitis. Gut. 2005;54(Suppl 3):1-9.
[107] Banks PA, Freeman ML. Practice guidelines in acute pancreatitis. Am J Gastroenterol.
2006 Oct; 101(10):2379-400.
[108] Taylor E, Wong C. The optimal timing of laparoscopic cholecystectomy in mild
gallstone pancreatitis. Am Surg. 2004 Nov;70(11):971-5.
[109] Kimura Y, Arata S, Takada T, Hirata K, Yoshida M, Mayumi T, et al. Gallstone-induced
acute pancreatitis. J Hepatobiliary Pancreat Sci. 2010 Jan;17(1):60-9.
[110] Petrov MS, van Santvoort HC, Besselink MG, van der Heijden GJ, van Erpecum KJ,
Gooszen HG. Early Endoscopic Retrograde Cholangiopancreatography Versus
Conservative Management in Acute Biliary Pancreatitis Without Cholangitis: A
Meta-Analysis of Randomized Trials. Ann Surg. 2008 Feb;247(2):250-7.
[111] Toh SK, Phillips S, Johnson CD. A prospective audit against national standards of the
presentation and management of acute pancreatitis in the South of England. Gut.
2000 Feb;46(2):239-43.
[112] Hernandez V, Pascual I, Almela P, Anon R, Herreros B, Sanchiz V, et al. Recurrence of
acute gallstone pancreatitis and relationship with cholecystectomy or endoscopic
sphincterotomy. Am J Gastroenterol. 2004 Dec;99(12):2417-23.
[113] Lankisch PG, Weber-Dany B, Lerch MM. Clinical perspectives in pancreatology:
compliance with acute pancreatitis guidelines in Germany. Pancreatology.
2005;5(6):591-3.
[114] Pezzilli R, Uomo G, Gabbrielli A, Zerbi A, Frulloni L, De Rai P, et al. A prospective
multicentre survey on the treatment of acute pancreatitis in Italy. Dig Liver Dis.
2007 Sep;39(9):838-46.
[115] Al-Haddad M, Raimondo M. Management of acute pancreatitis in view of the
published guidelines: are we compliant enough? Dig Liver Dis. 2007 Sep; 39 (9):
847-8.
[116] Sandzen B, Haapamaki MM, Nilsson E, Stenlund HC, Oman M. Cholecystectomy and
sphincterotomy in patients with mild acute biliary pancreatitis in Sweden 1988 -
2003: a nationwide register study. BMC Gastroenterol. 2009;9:80.
[117] Nguyen GC, Boudreau H, Jagannath SB. Hospital volume as a predictor for
undergoing cholecystectomy after admission for acute biliary pancreatitis.
Pancreas. 2010 Jan;39(1):e42-7.
[118] Mofidi R, Madhavan KK, Garden OJ, Parks RW. An audit of the management of
patients with acute pancreatitis against national standards of practice. The British
journal of surgery. 2007 Jul;94(7):844-8.
[119] Aboulian A, Chan T, Yaghoubian A, Kaji AH, Putnam B, Neville A, et al. Early
cholecystectomy safely decreases hospital stay in patients with mild gallstone
pancreatitis: a randomized prospective study. Ann Surg. 2010 Apr;251(4):615-9.
[120] Alimoglu O, Ozkan OV, Sahin M, Akcakaya A, Eryilmaz R, Bas G. Timing of
cholecystectomy for acute biliary pancreatitis: outcomes of cholecystectomy on first
admission and after recurrent biliary pancreatitis. World J Surg. 2003 Mar;27(3):
256-9.
[121] Rosing DK, de Virgilio C, Yaghoubian A, Putnam BA, El Masry M, Kaji A, et al. Early
cholecystectomy for mild to moderate gallstone pancreatitis shortens hospital stay.
J Am Coll Surg. 2007 Dec;205(6):762-6.
[122] Nebiker CA, Frey DM, Hamel CT, Oertli D, Kettelhack C. Early versus delayed
cholecystectomy in patients with biliary acute pancreatitis. Surgery. 2009
Mar;145(3):260-4.
[123] Barkun JS, Caro JJ, Barkun AN, Trindade E. Cost-effectiveness of laparoscopic and
mini-cholecystectomy in a prospective randomized trial. Surg Endosc. 1995
Nov;9(11):1221-4.
[124] McGinn FP, Miles AJ, Uglow M, Ozmen M, Terzi C, Humby M. Randomized trial of
laparoscopic cholecystectomy and mini-cholecystectomy. The British journal of
surgery. 1995 Oct;82(10):1374-7.
[125] McMahon AJ, Russell IT, Baxter JN, Ross S, Anderson JR, Morran CG, et al.
Laparoscopic versus minilaparotomy cholecystectomy: a randomised trial. Lancet.
1994 Jan 15;343(8890):135-8.
[126] Calvert NW, Troy GP, Johnson AG. Laparoscopic cholecystectomy: a good buy? A cost
comparison with small-incision (mini) cholecystectomy. European Journal of
Surgery. 2000;166:782-6.
[127] Srivastava A, Srinivas G, Misra MC, Pandav CS, Seenu V, Goyal A. Cost-effectiveness
analysis of laparoscopic versus minilaparotomy cholecystectomy for gallstone
disease. A randomized trial. Int J Technol Assess Health Care. 2001 Fall;17(4):497-
502.
[128] Secco GB, Cataletti M, Bonfante P, Baldi E, Davini MD, Biasotti B, et al. [Laparoscopic
versus mini-cholecystectomy: analysis of hospital costs and social costs in a
prospective randomized study]. Chir Ital. 2002 Sep-Oct;54(5):685-92.
[129] Nilsson E, Ros A, Rahmqvist M, Backman K, Carlsson P. Cholecystectomy: costs and
health-related quality of life: a comparison of two techniques. Int J Qual Health
Care. 2004 Dec;16(6):473-82.
[130] Keus F, de Jonge T, Gooszen HG, Buskens E, van Laarhoven CJ. Cost-minimization
analysis in a blind randomized trial on small-incision versus laparoscopic
cholecystectomy from a societal perspective: sick leave outweighs efforts in
hospital savings. Trials. 2009;10:80.
[131] Rogers SJ, Cello JP, Horn JK, Siperstein AE, Schecter WP, Campbell AR, et al.
Prospective randomized trial of LC+LCBDE vs ERCP/S+LC for common bile duct
stone disease. Arch Surg. 2010 Jan; 145(1):28-33.
[132] Schroeppel TJ, Lambert PJ, Mathiason MA, Kothari SN. An economic analysis of
hospital charges for choledocholithiasis by different treatment strategies. Am Surg.
2007 May;73(5):472-7.
[133] Topal B, Vromman K, Aerts R, Verslype C, Van Steenbergen W, Penninckx F. Hospital
cost categories of one-stage versus two-stage management of common bile duct
stones. Surg Endosc. 2010 Feb;24(2):413-6.
[134] Holte K, Klarskov B, Christensen DS, Lund C, Nielsen KG, Bie P, et al. Liberal versus
restrictive fluid administration to improve recovery after laparoscopic
cholecystectomy: a randomized, double-blind study. Ann Surg. 2004 Nov; 240(5):
892-9.
[135] Liberman MA, Howe S, Lane M. Ondansetron versus placebo for prophylaxis of
nausea and vomiting in patients undergoing ambulatory laparoscopic
cholecystectomy. American Journal of Surgergy. 2000;179:60-2.
[136] Bisgaard T, Klarskov B, Kehlet H, Rosenberg J. Preoperative dexamethasone improves
surgical outcome after laparoscopic cholecystectomy: a randomized double-blind
placebo-controlled trial. Ann Surg. 2003 Nov;238(5):651-60.
[137] Feo CV, Sortini D, Ragazzi R, De Palma M, Liboni A. Randomized clinical trial of the
effect of preoperative dexamethasone on nausea and vomiting after laparoscopic
cholecystectomy. The British journal of surgery. 2006 Mar;93(3):295-9.
[138] Kehlet H, Wilmore DW. Evidence-based surgical care and the evolution of fast-track
surgery. Ann Surg. 2008 Aug;248(2):189-98.
[139] Karanicolas PJ, Smith SE, Kanbur B, Davies E, Guyatt GH. The impact of prophylactic
dexamethasone on nausea and vomiting after laparoscopic cholecystectomy: a
systematic review and meta-analysis. Ann Surg. 2008 Nov;248(5):751-62.
[140] Fujii Y, Itakura M. Reduction of postoperative nausea, vomiting, and analgesic
requirement with dexamethasone for patients undergoing laparoscopic
cholecystectomy. Surg Endosc. 2010 Mar;24(3):692-6.
[141] Sanchez-Rodriguez PE, Fuentes-Orozco C, Gonzalez-Ojeda A. Effect of dexamethasone
on postoperative symptoms in patients undergoing elective laparoscopic
cholecystectomy: randomized clinical trial. World J Surg. 2010 May;34(5):895-900.
[142] Keus F, de Vries J, Gooszen HG, van Laarhoven CJ. Assessing factors influencing
return back to work after cholecystectomy: a qualitative research. BMC
Gastroenterol. 2010; 10:12.
[143] Beauchamp TL, Childress JF. Principles of biomedical ethics. 5 ed. Oxford: New York:
Oxford University Press; 2001.
[144] Epstein RM, Alper BS, Quill TE. Communicating evidence for participatory decision
making. JAMA. 2004 May 19;291(19):2359-66.
[145] Little M. Ethonomics: the ethics of the unaffordable. Arch Surg. 2000 Jan;135(1):17-21.
[146] Matthews JB. Cost containment: think globally, act locally. Arch Surg. 2010 Dec;
145(12):1136-7.
4
Laparoscopy-Assisted Distal Pancreatectomy

Masahiko Hirota et al.*
Department of Surgery,
Kumamoto Regional Medical Center, Kumamoto-city,
Japan
1. Introduction
The advantage of laparoscopic surgery is obvious and has been extended to pancreatic and
splenic operations. Since 1994, various laparoscopic pancreatectomy, including
pancreatoduodenectomy (Gagner & Pomp, 1994), enucleation (Gagner et al., 1996; Dexter et
al., 1999), and distal pancreatectomy (Gagner et al. 1996; Sussman et al., 1996), have been
performed. As for laparoscopic splenectomy, nowadays it can be conducted safely even for
splenomegaly due to portal hypertension (Hama et al., 2008). Open pancreatic surgery
requires a relatively large incision for a small lesion, and therefore the potential benefits of
the laparoscopic approach are substantial. The most common indications for laparoscopic
pancreatic resection were presumed benign pancreatic diseases, such as insulinoma or
localized neuroendocrine neoplasms and branch type intraductal papillary mucinous
neoplasms. The most common indication for laparoscopic pancreatic resection appears to be
enucleations and distal pancreatectomy. Laparoscopic pancreatectomy, however, is still
technically rather difficult because of the retroperitoneal position of the pancreas and the
complex anatomical relationship between the pancreas and surrounding vessels. Thus,
hand-assisted laparoscopic pancreatectomy is gaining recognition as a new and feasible
technique that introduces a surgeon’s hand into the abdominal cavity during laparoscopic
surgery (Klingler et al., 1998; Shinchi et al., 2001; Kaneko et al., 2004). As a modification of
hand-assisted laparoscopic pancreatectomy, we devised a method of spleen and
gastrosplenic ligament preserving distal pancreatectomy, in which pancreatic resection is
performed under direct vision extracorporeally (Hirota et al., 2009). Furthermore,
laparoscopic assistance is also helpful in no-touch distal pancreatectomy for pancreatic
cancer. For invasive pancreatic ductal cancers, the transection of the pancreas, splenic artery
and vein, left gastroepiploic vessels, and short gastric vessels is performed at first to prevent
the dissemination of cancer cells. Division of the pancreas, splenic artery, and splenic vein is
done under direct vision through minilaparotomy at epigastrium. Division of the left
gastroepiploic and short gastric vessels is done under laparoscope with left hand assistance.
And then, retroperitoneal dissection is performed laparoscopically. In this way, the same
no-touch distal pancreatectomy as open operation can be achieved.
Daisuke Hashimoto, Kazuya Sakata, Hideyuki Kuroki, Youhei Tanaka, Takatoshi Ishiko,
*
Yu Motomura, Shinji Ishikawa, Yoshitaka Kiyota, Tetsumasa Arita, Atsushi Inayoshi and Yasushi Yagi
Department of Surgery, Kumamoto Regional Medical Center, Kumamoto-city, Japan
The three ways of laparoscopy-assisted distal pancreatectomy: 1) for benign lesions, 2) for
low-grade malignant lesions, and 3) for invasive pancreatic ductal cancers, are presented in
this chapter. Laparoscopic procedure is used for the retroperitoneal dissection under the left
hand assistance in all types of lesions including cancers.
2. Laparoscopy-assisted distal pancreatectomy for benign lesions

In benign cases, such as insulinoma, branch type intraductal papillary mucinous neoplasm,
spleen-preserving pancreatectomy is performed. An 8-cm minilaparotomy incision is made
in the middle upper abdomen. For obese patients, 10-cm laparotomy is better. An
abdominal wall disc for hand assistance is placed at the site of the minilaparotomy.
Ultrasonography probe can be inserted through this site for intrapancreatic imaging. A total
of the two trocars are then placed. After abdominal access is established, the gastrocolic
omentum is divided, and the splenic flexure is mobilized. The short gastric and left
gastroepiploic vessels are not divided to prevent splenic volvulus after the operation.
Retrosplenic Gerota’s fascia is transected on the surface of the left kidney (Figure 1a). Then,
the posterior plane of Gerota’s fascia is dissected from lateral to medial direction, allowing
the distal pancreas and spleen detached from retroperitoneum.
a b
Fig. 1. Procedures in laparoscopy assisted distal pancreatectomya) Retrosplenic Gerota’s
fascia is transected on the surface of the left kidney.Then, the posterior plane of Gerota’s
fascia is dissected from lateral to medial direction, allowing the distal pancreas and spleen
detached from retroperitoneum. b)The distal pancreas and spleen are pulled out of the
peritoneal cavity through the minilaparotomy for hand assistance at the epigastrium.
The distal pancreas, spleen, and left side of stomack are then pulled out of the peritoneal
cavity through the minilaparotomy for hand assistance at the epigastrium (Figure 1b).
Laparoscopy-Assisted Distal Pancreatectomy 55
Spleen and gastrosplenic ligament preserving pancreatectomy is performed under direct

vision (Figure 2). The advantage of extracorporeal procedure is the safety and certainty in
dissection of the splenic vessels and preparation of the pancreatic stump. The transected
main pancreatic duct is doubly ligated, and the transected pancreatic stump is sewn
manually. The preserved spleen, stomach and splenic vessels are placed back in the
peritoneal cavity after resection.
Fig. 2. Dissection of the distal pancreas. The distal pancreas (black arrow) is dissected from
the surrounding tissues (spleen, splenic artery, splenic vein, stomach) under direct vision
extracorporeally. White arrow: spleen, black arrow head: splenic vessels.
Distal pancreatectomy with preservation of the spleen was first reported in 1988 (Warshow,
1988). The advantage of preserving the spleen is obvious; it reduces the risk of postoperative
severe inflammation and peripheral blood count aberration. Preserving the spleen has been
a major procedure in distal pancreatectomy. Warshow reported a case of splenic abscess that
occurred after sacrificing the splenic artery and vein (Warshow, 1988). Kimura et al.
reported five patients successfully treated with splenic vessel-preserving distal
pancreatectomy to maintain the blood supply to the spleen and to avoid splenic necrosis
and abscess (Kimura et al., 1996; Kimura et al., 2010). Spleen-preserving pancreatectomy has
recently been shown to have comparable risk of complication to standard pancreatectomy
where the spleen is removed. Nevertheless, spleen-preserving pancreatectomy remains an
uncommon and technically demanding operation, due to the difficulty in dissecting the
distal pancreas from the splenic vessels. Another advantage of our procedure is the safety in
dissecting the distal pancreas from the splenic vessels. The displacement of the spleen with
the inherent risk of torsion or hemorrhage is another disadvantage of spleen-preserving
pancreatectomy. If spleen-preserving pancreatectomy is performed, the spleen is often free
in the abdomen, where it is prone to torsion or trauma. Various techniques have been
described to reposition the spleen (splenopexy). Appu et al. report a novel technique for
splenic repositioning and fixation, using peritoneal pocket (Appu et al., 2005). We
experienced one case of splenic bleeding due to venous congestion after spleen-preserving
pancreatic tail resection using Appu’s splenopexy. After that experience we are preserving
the gastrosplenic ligament.
This approach is suitable for the very distal lesion of the pancreas. However, if the posterior
plane of Gerota’s fascia is dissected, this method could be applied to more proximal lesion.
For obese patients, because the pulling out through the small laparotomy is difficult, 10 cm
incision is preferable. This procedure is applicable only for lesions in the pancreatic body
and tail. For the benign head lesions, another approach should be conducted (Hirota et al.,
2007).
Preservation of gastrosplenic ligament and extracorporeal preparation of transected
pancreatic stump and splenic vessels under direct vision are useful measures for troubles in
spleen-preserving distal pancreatectomy under minimal incision approach assisted by
laparotomy.
3. Laparoscopy-assisted distal pancreatectomy for low grade malignant

lesions
In low-grade malignant cases, such as mutinous cystic neoplasm, solid pseudopapillary
neoplasm, medium-sized neuroendocrine neoplasm, the procedure is almost the same as in
benign cases except the resection of the spleen and splenic vessels for lymph node
dissection. The distal pancreas and spleen are pulled out of the peritoneal cavity through the
minilaparotomy at the epigastrium (Figure 3). Pancreatic resection and closure of the
residual pancreatic stump is performed safely under direct vision extracorporeally.
The successful management of the pancreatic stump remains the challenge of this
procedure. In some laparoscopic enucleation series, the rate for low volume pancreatic
fistula is reported to be high (Mabrut et al., 2005). This complication does not create an
important problem as long as the main duct is not injured. Even though self-limiting, the
pancreatic fistula formation rate remains high after either laparoscopic enucleation or
resection. Pancreatic fistula after distal pancreatectomy has been a topic of decades, even in
the era of laparoscopic pancreatectomy. Patterson et al. collected data from the literature on
morbidity after open and laparoscopic pancreatic resections, and found that the rate of
pancreatic fistula ranged from 20% to 33% after laparoscopic pancreatectomy and from 5%
to 23% after open pancreatectomy (Patterson et al., 2001). The way in which the surgeon
approaches the pancreatic transection seems to be important. Ninety-seven percent of the
patients underwent laparoscopic transection of the pancreas by use of a stapling technique
(Mabrut et al., 2005). Closing the pancreatic stump with interrupted mattress sutures and
selectively ligating the pancreatic duct, the usual practice in open surgery, are more difficult
to replicate laparoscopically. This factor could explain the high rate of pancreas-related
complications. Hand-sewn parenchymal closure and duct ligation are an advantage of this
extracorporeal pancreatic resection, to prevent pancreatic juice leakage, compared with the
procedure done by laparoscopy only. We could safely and securely handle the pancreatic
duct and fine branches of the splenic vessels under the direct vision.
Fig. 3. Dissected distal pancreas and spleen. The distal pancreas and spleen are pulled out of
the peritoneal cavity through the minilaparotomy at the epigastrium. Pancreatic resection
and closure of the residual pancreatic stump is performed under direct vision.
4. Laparoscopy-assisted distal pancreatectomy for invasive pancreatic ductal

cancers
Laparoscopic assistance is also helpful in no-touch distal pancreatectomy for pancreatic
cancer. The aim of no-touch distal pancreatectomy is to decrease the shedding of cancer
cells, and to achieve negative transection margins. All drainage vessels from the pancreatic
body and tail have been ligated and divided during the early phase of the operation.
Squeezing and handling the tumor prior to ligation of the surrounding vessels during
pancreatectomy may increase the risk of shedding cancer cells into the portal vein,
retroperitoneum and/or peritoneal cavity. Although the no-touch isolation technique has
not been shown to increase cancer survival or decrease recurrence, it is theoretically
promising (Hirota et al., 2005; Hirota et al., 2010).
Another aim is to resect cancers by wrapping them within Gerota’s fascia. Perirenal tissue
beyond Gerota’s fascia is often protected from the autodigestion in severe acute pancreatitis.
Because cancer cell invasion is dependent on protease activity, Gerota’s fascia may function
as a barrier against protease-mediated invasion of cancer cells.
Division of the pancreas, splenic artery, and splenic vein is done under direct vision through
minilaparotomy at epigastrium. Following the division of the gastrocolic ligament, the
posterior surface of the pancreatic neck is tunneled by blunt dissection. The pancreas is
transected after ligating the left side of the pancreas. The splenic artery and vein are ligated
and divided at the origin and at the confluence with the superior mesenteric vein,
respectively. As mentioned by Fagniez and Munoz-Bongrand, early division of the
pancreatic neck provides superior access to control the splenic vessels (Fagniez & Munoz-
Bongrand, 1999). Then, division of the left gastroepiploic and short gastric vessels is done
under laparoscope with left hand assistance. At this point, all drainage vessels from the
pancreatic body and tail have been ligated and divided. Lastly, retroperitoneal dissection
behind the Gerota’s fascia is performed lateral to medial direction laparoscopically.
5. Conclusion
Laparoscopic assistance is useful in distal pancreatectomy. This technique can be applied to
both benign and malignant lesions. For benign lesions, preservation of gastrosplenic
ligament and extracorporeal preparation of transected pancreatic stump under direct vision
are useful measures to prevent post-operative complications.
6. References
Appu, S.; Young, A.B. & Lawrentschuk, N. (2005). Peritoneal “pillowcase” for the displaced
spleen post-distal pancreatectomy. Journal of Hepatobiliary Pancreatic Surgery,
Vol.12, pp. 470-473.
Dexter, S.P.; Martin, I.G.; Leindler, L.; Fowler, R. & McMahon, M.J. (1999).Laparoscopic
enucleation of a solitary pancreatic insulinoma. Surgical Endoscopy, Vol.13, pp.
406-408.
Fagniez, P.L. & Munoz-Bongrand, N. (1999), Vascular control during left
splenopancreatectomy in cancer. Annales de Chirurgie, Vol.53:, pp. 632-634, (in
French with English abstract).
Gagner, M. & Pomp, A. (1994), Laparoscopic pylorus-preserving pancreatoduodenectomy.
Surgical Endoscopy, Vol.8, pp. 408-410.
Gagner, M.; Pomp, A. & Herrera, M.F. (1996), Early experience with laparoscopic resections
of islet cell tumors. Surgery, Vol.120, pp. 1051-1054.
Hama, T.; Takifuji, K.; Uchiyama, K.; Tani, M.; Kawai, M. & Yamaue, H. (2008),
Laparoscopic splenectomy is a safe and effective procedure for patients with
splenomegaly due to portal hypertension. Journal of Hepatobiliary Pancreatic
Surgery, Vol.15, pp. 304-309.
Hirota, M.; Shimada, S.; Yamamoto, K.; Tanaka, E.; Sugita, H.; Egami, H. & Ogawa, M.
(2005), Pancreatectomy using the no-touch isolation technique followed by
extensive intraoperative peritoneal lavage to prevent cancer cell dissemination: a
pilot study. JOP, Vol.6, pp. 143-151.
Hirota, M.; Kanemitsu, K.; Takamori, H.; Chikamoto, A.; Ohkuma, T.; Komori, H.;
Miyanari, N.; Ishiko, T. & Baba, H. (2007), Local pancreatic resection with preoperative
endoscopic transpapillary stenting. American Journal of Surgery, Vol.194, pp. 308-
310.
Hirota, M.; Ichihara, A.; Furuhashi, S.; Tanaka, H.; Takamori, H. & Baba, H. (2009), Spleen
and gastrosplenic ligament preserving distal pancreatectomy under a minimum
incision approach assisted by laparotomy. Journal of Hepatobiliary Pancreatic
Hirota, M.; Kanemitsu, K.; Takamori, H.; Chikamoto, A.; Tanaka, H.; Sugita, H.;
Sand, J., Nordback, I. & Baba, H. (2010), Pancreatoduodenectomy using
a no-touch isolation technique. American Journal of Surgery, Vol.199, pp. e65-
e68.
Kaneko, H.; Takagi, S.; Joubara, N.; Yamazaki, K.; Kubota, Y.; Tsuchiya, M.; Otsuka, Y. &
Shiba, T. (2004), Laparoscopy-assisted spleen-preserving distal pancreatectomy
with conservation of the splenic artery and vein. Journal of Hepatobiliary
Pancreatic Surgery, Vol.11, pp. 397-401.
Kimura, W.; Inoue, T.; Futakawa, N.; Shinkai, H.; Han, I. & Muto, T. (1996), Spleen-
preserving pancreatectomy with conservation of the splenic artery and vein.
Kimura, W.; Yano, M.; Sugawara, S.; Okazaki, S.; Sato, T.; Moriya, T.; Watanabe, T.;
Fujimoto, H.; Tszuka, K.; Takeshita, A. & Hirai, I. (2010). Spleen-preserving
distal pancreatectomy with conservation of the splenic artery and vein:
techniques and its significance. Journal of Hepatobiliary Pancreatic Sciences,
Vol. 17, pp. 813-823.
Klingler, P.J.; Hinder, R.A.; Menke, D.M. & Smith, S.L. (1998), Hand-assisted laparoscopic
distal pancreatectomy for pancreatic cystadenoma. Surgical Laparoscopy &
Endoscopy, Vol.8, pp. 180-184.
Mabrut, J.Y.; Fernandez-Cruz, L.; Azagra, J.S.; Bassi, C.; Delvaux, G.; Weerts, J.; Fabre,
J.M.; Boulez, J.; Baulieux, J.; Peix, J.L.; Gigot, J.F.; Hepatobiliary and Pancreatic
Section of the Royal Belgian Society of Surgery; Belgian Group for
Endoscopic Surgery; & Club Coelio. (2005), Laparoscopic pancreatic resection:
results of a multicenter European study of 127 patients. Surgery, Vol.137, pp. 597-
605.
Patterson, E.J.; Gagner, M.; Salky, B.; Inabnet, W.B.; Brower. S.; Edye, M.; Gurland, B.;
Reiner, M & Pertsemlides, D. (2001), Laparoscopic pancreatic resection: single-
institution experience of 19 patients. Journal of the American College of
Surgeons, Vol.193, pp. 281-287.
Shinchi, H.; Takao, S.; Noma, H.; Mataki, Y.; Iino, S. & Aikou, T. (2001), Hand-assisted
laparoscopic distal pancreatectomy with minilaparotomy for distal pancreatic
cystadenoma. Surgical Laparoscopy Endoscopy & Percutaneous Techniques,
Vol.11, pp. 139-143.
Sussman, L.A.; Christie, R. & Whittle, D.E. (1996), Laparoscopic excision of distal pancreas
including insulinoma. Australian & New Zealand Journal of Surgery, Vol.66, pp.
414-416.
Warshow, A.L. (1988), Conservation of the spleen with distal pancreatectomy. Archives of
Part 2
Laparoscopic Liver Surgery

5
Laparoscopic Liver Resection

Robert M. Cannon1 and Joseph F. Buell2
1University of Louisville Dept of Surgery,
2Tulane University Dept of Surgery
United States of America
1. Introduction
Since the introduction of the laparoscopic cholecystectomy, there has been explosive growth
in the field of minimally invasive surgery. Commonly accepted laparoscopic procedures
have now come to include bariatric and anti reflux procedures, distal pancreatectomy,
splenectomy, hernia repair, and colon resection. The adoption of laparoscopy to the field of
liver surgery; however, has been slower to take off. Initial concerns included inadequate
exposure and ability to attain hemostasis, fear of gas embolism, and doubts over the
oncologic adequacy of the less invasive procedure. The earliest reports of laparoscopic liver
surgery were limited to wedge resections for staging or isolated metastases(Lefor, AT &
Flowers, JL 1994). Laparoscopic liver resection finally started to gain serious widespread
attention after publication of Cherqui’s initial thirty patient experience(Cherqui, D et al
2000). Since that time, the field has seen explosive growth, with over 2,804 cases now
described in the world literature(Nguyen, KT et al 2009). Despite its widespread acceptance,
laparoscopic liver resection remains a daunting technical challenge suited to a relatively
small number of centers that have taken the time and effort to develop concurrent expertise
in both open hepatic surgery and laparoscopy. Once these hurdles are overcome; however,
laparoscopic liver resection is a safe and highly effective procedure offering numerous
patient benefits. In this chapter, we will describe the indications for laparoscopic liver
resection, and outline the steps that should be taken by fledgling groups wishing to embark
upon creating a laparoscopic liver resection program.
2. Benign disease
Benign liver tumors represent a diagnostic and therapeutic challenge. Traditionally, a highly
conservative approach to benign hepatic tumors has been favored, owing to the historically
high morbidity and mortality associated with open liver surgery. As operative and
anesthetic techniques have improved, these hurdles have come down. Despite the increased
safety of hepatic surgery, the indications for resection of benign hepatic tumors have
changed little: symptomatic lesions, asymptomatic lesions at high risk of rupture or
malignant degeneration, and inability to exclude malignancy nonoperatively. Because of
concerns over oncologic adequacy, benign lesions represent the ideal starting point for a
laparoscopic liver surgery program. Despite the attractiveness of minimally invasive
surgery; however, surgeons should be cautioned that the ability to perform a laparoscopic
resection should not change the indications for operation.
2.1 Hemangioma
2.1.1 Epidemiology and presentation
Hemangioma represents the most common benign liver tumor, accounting for 5-20% of
liver lesions(Buell, JF et al 2010). These tumors typically occur in females in the third
through fifth decades. Symptoms typically do not occur until the tumors grow relatively
large (>5cm), and typically consist of abdominal pain resulting from stretching of
Glisson’s capsule. There have been reports of spontaneous, traumatic, or iatrogenic
rupture. A rare consequence of hemangioma is a consumptive coagulopathy resulting
from sequestration of platelets and clotting factors within the tumor vasculature known as
the Kasabach-Merritt syndrome. There is no potential for malignant degeneration with
hepatic hemangioma.
2.1.2 Diagnostic evaluation

Hemangiomas demonstrate a typical pattern of enhancement on triple phase contrast
enhanced CT. The lesion appears as a well circumscribed hypodense mass with peripheral
enhancement in the arterial phase that will progress toward the center of the lesion. This
pattern is typically known as centripetal enhancement. Sensitivity of triple phase CT has
been reported from 75-85% with specificity of 75-100%(Trotter, JF & Everson, GT 2001). Even
better results have been reported with the use of magnetic resonance imaging, with reported
sensitivity and specificity of up to 95% and 100%, respectively (Semelka, RC et al 2001).
Because of the highly vascular nature of these tumors, percutaneous biopsy of suspected
hemangiomas is contraindicated.
2.1.3 Indications for surgical resection

As there is no malignant potential, symptomatic disease is the only generally accepted
indication for surgical resection of hemangiomas. It should again be stressed that the
availability of laparoscopy should not extend the indications for operation to asymptomatic
patients. If pain is the indication for surgery, a thorough diagnostic workup is imperative to
rule out other sources before attributing the symptoms to the hemangioma. The indication
for surgery is more clear cut for large ruptured hemangioma, with patients often presenting
in shock. Because of the dire consequences of rupture of large hemangioma, some surgeons
would advocate the prophylactic resection of large lesions in patients with high risk
occupations in areas remote from medical care. This opinion is controversial and should not
be broadly applied.
2.2 Focal nodular hyperplasia

Focal nodular hyperplasia (FNH) is generally thought to arise as a hyperplastic proliferation
of cells arising from an arterial malformation. This malformation may be congenital in
nature such as telangiectasia or arteriovenous malformation, or may result from vascular
injury (Paradis, V 2010; Wanless, IR et al 1985). Hyperplasia is thought to be a polyclonal
process resulting from the hyperperfusion resulting from increased arterial flow (Gaffey, MJ
et al 1996). The polyclonal nature of these lesions has significant impact on the radiographic
evaluation of FNH, as it is the only common benign lesion that appears hot on Technetium
sulfur colloid scan. This is from increased uptake of tracer in Kuppfer cells present within
the lesion.
Laparoscopic Liver Resection 65
2.2.1 Epidemiology, radiographic evaluation, and presentation

FNH is typically an incidentally discovered lesion in women of late child bearing age,
presenting most commonly from age 30 to 50. The female to male ratio has been reported at
up to 8:1 (Mortele, KJ & Ros, PR 2002). Unlike hepatocellular adenoma, FNH is not
influenced by oral contraceptive use. The radiographic appearance of focal nodular
hyperplasia is typically diagnostic. On triple phase computed tomography, FNH will show
transient enhancement on arterial phase. On delayed imaging, the characteristic central scar
then becomes hyperenhancing. This central scar represents the vascular pedicle of the lesion
and is pathognomonic. The most common diagnostic difficulty is distinguishing FNH from
adenoma, which may best be achieved by contrast enhanced MRI. In this setting, sensitivity
and specificity can reach 97% and 100%, respectively (Terkivatan, T et al 2006).
On histologic examination, FHN consists of benign hepatocytes arranged in a nodular
pattern that are separated by fibrous septae originating in the central scar. Steatosis within
the lesion may be evident (Paradis, V 2010). FNH is asymptomatic in upwards of 80% of
cases (Buell, JF et al 2010). In very rare instances, these lesions may present with
hemorrhage. There are no reported cases of malignant degeneration of FNH thus far.
Because of this, there is no indication for resection of asymptomatic lesions, regardless of the
size and number of lesions. Surgical resection is reserved for the rare cases in which the
lesion is symptomatic or when the diagnosis is not secure.
2.3 Hepatocellular adenoma

Hepatic adenoma is a less common benign hepatic neoplasm, arising most commonly in
women of child bearing age. There is a strong association between development of these
lesions and oral contraceptive or androgenic steroid use. While the incidence is 0.1 per year
per 100,000 patients who don’t use oral contraceptives, there is a marked increase to up to 4
per 100,000 oral contraceptive users (Paradis, V 2010). The introduction of modern
contraceptives with lower estrogen content has led to a decrease in incidence (Rooks, JB et al
1979). Less common risk factors for the development of hepatocellular adenoma include
glycogen storage disease type I and type III (Micchelli, ST et al 2008)
2.3.1 Radiographic features

Though typically presenting as solitary lesions, adenoma may also be present as multiple
lesions. Hepatic adenomas can grow quite large, with tumors of up to 30cm reported in the
literature. Ultrasonography typically lacks diagnostic utility for adenomas, which can range
from hypo to hyper-echoic. Reported sensitivity of ultrasound is only around 30%(Di, SM et
al 1996). The CT appearance is that of a discrete, hypodense lesion showing enhancement
on arterial phase followed by washout on later images. T1 weighted MRI will show a hypo-
to hyperintense lesion, while T2 images will show a lesion that is more isointense.
Enhancement with gadolinium contrast is typically present on the arterial phase, with rapid
washout in the venous phase. The fat content of these lesions creates a typical decrease in
intensity on fat-suppressed MRI images (Motohara, T et al 2002).
2.3.2 Clinical presentation

Patients with hepatocellular adenoma are more likely to present with symptomatic disease
than those with FNH. Epigastric or right upper quadrant pain is present in 25-50% of
patients (Buell, JF et al 2010). Spontaneous hemorrhage is also relatively common with these
lesions, occurring in over 20% of patients. These complications are more likely to occur in
men and with lesions greater than 5cm in diameter (Dokmak, S et al 2009). Perhaps the
most feared complication of hepatocellular adenoma is malignant degeneration. The risk has
been reported in the range of 8-10%(Dokmak, S et al 2009; Paradis, V 2010). Although 5cm
is the generally accepted size at which malignant degeneration becomes a concern, cases
have been reported in lesions as small as 4cm (Micchelli, ST et al 2008). There is also a
greater risk of malignant degeneration in males and in patients with the metabolic
syndrome. Malignancy within adenomas is typically discovered only after surgical
resection.
2.3.3 Management
In the case of small adenomas in the setting of oral contraceptive use, a period of
observation following the cessation of contraception is warranted. Surgical resection in this
setting is then reserved for lesions which fail to regress or continue to grow after stopping
the offending medication. As with other benign lesions, symptomatology that can clearly be
attributed to the adenoma is also an indication for surgical resection. The presence of
multiple adenomas, or adenomatosis, is an arbitrary distinction rather than a distinct
pathologic subtype, thus indications for resection are the same as for solitary adenoma.
Because of the well defined risk of malignant degeneration, there are also cases where
resection of asymptomatic lesions is warranted. Generally accepted criteria include
adenomas greater than 5cm in size, or any adenoma in a male, regardless of size (Dokmak, S
et al 2009).
2.4 Other benign lesions

2.4.1 Angiomyolipoma
Angiomyolipoma is a rare benign tumor of mesenchymal origin. They most commonly
occur in women and are discovered as incidental findings. Histologically, angiomyolipoma
is composed of fat cells, blood vessels, and smooth muscle. CT imaging will show early
enhancement that remains throughout the more delayed phases. Positive staining with
HMB-45, with negative staining for cytokeratins 18 and 19, help to secure the diagnosis
(Ding, GH et al 2011; Sturtz, CL & Dabbs, DJ 1994). Malignant degeneration is very rare, as
is rupture, with three cases reported in the world literature. Because of the rare nature of
serious complications, an initially conservative management strategy of imaging follow up
is recommended when the diagnosis is established. Recently proposed guidelines for
surgical resection of angiomyolipoma are as follows: symptomatic disease, tumors greater
than 6cm, tumors which grow on repeated imaging, tumors showing extrahepatic growth
with risk of rupture, and inability to make a definitive diagnosis on imaging or biopsy
(Ding, GH et al 2011).
2.4.2 Nodular regenerative hyperplasia

Nodular regenerative hyperplasia (NRH) is characterized by diffuse involvement of the
liver by multiple regenerative nodules in the absence of significant fibrosis. The incidence of
NRH in a large autopsy series has been reported at 2.6% (Wanless, IR 1990). The disease
typically manifests in the setting of systemic disorders such as Felty’s syndrome or with the
use of chemotherapeutic agents, of which azathioprine is the most common (Reshamwala,
PA et al 2006). Complications are rare, as demonstrated by Wanless’ series in which only 1
of 64 patients suffered any form of complication from NRH. Specific treatment for NRH is
not needed. Diagnosis is made on liver biopsy, with reticulin staining being particularly
helpful in identifying the changes of hyperplasia. Therapy, instead, is directed at treating
the underlying disorder or withdrawing the offending medication.
2.4.3 Inflammatory pseudotumor

Inflammatory pseudotumor of the liver is a benign reactive process, the pathogenesis of
which is unclear. In the majority of cases in the literature, an infectious agent was found to
be the causative agent. Symptoms, when present, are generally nonspecific including body
pain, fever, weight loss, leukocytosis, and elevated transaminases. CT findings are generally
not specific for the diagnosis, although spontaneous regression on followup imaging in 4-6
weeks is commonly reported to occur (Seki, S et al 2004). Histological features include
replacement of liver parenchyma by densely hylanized collagenous tissue and chronic
inflammatory infiltrates. These features are missed on FNA, making core needle biopsy
critical for accurate diagnosis (Tsou, YK et al 2007). In a review of eight cases, Tsou et al
have suggested that inflammatory pseudotumor may best be thought of as a variant of a
healing liver abscess. Thus, treatment consists of antibiotic therapy and nonsteroidal anti-
inflammatory drugs. With appropriate therapy, the lesion can be expected to spontaneously
regress. Surgical therapy is thus reserved for cases with severe symptoms or when
malignancy is unable to be reliably excluded.
2.5 Technical considerations for resection

The majority of benign liver lesions are asymptomatic, leaving surgical resection as an
appropriate therapy only in cases of symptomatic disease that is clearly attributable to the
lesion, or when the diagnosis remains in doubt following appropriate workup. The
exception is for hepatocellular adenoma, where the risk of malignant degeneration
mandates resection for lesions larger than 5cm or cases occurring in men.
2.5.1 Patient positioning

There are three commonly used patient positions employed in laparoscopic liver resection:
supine, lateral decubitus, and the so-called French position in which the patient is supine
with the legs in stirrups and the surgeon is positioned between the patient’s legs. The
appropriate position is determined based on the location of the tumor, and the surgical
technique to be employed. The French position has the advantage of allowing the surgeon to
operate with both hands while assistants can retract from either side of the table. The supine
position is best employed when approaching lesions on the left lobe or right anterior sector
of the liver. The lateral decubitus position places the patient recumbent on their left side at
an angle of sixty degrees. This position allows access to the posterior segments of the right
liver, as the left side down positioning prevents the liver from falling dependently into the
operative field. When a hand port is to be employed, it is generally placed in the right upper
quadrant as dictated by the position of the tumor being resected.
2.5.2 Anesthesia and intraoperative care

The use of low CVP anesthesia has been a critical factor in the improved safety of modern
hepatic surgery. This technique mandates the use of central venous catheters and arterial
lines for patient monitoring. During the parenchymal transection phase, central venous
pressure is lowered to between 2 and 4 mmHg with the use of nitrates, nitrous oxide, and
dieresis. Combined with the tamponade effect of pneumoperitoneum, this technique
minimizes blood loss from venous parenchymal bleeding (Tranchart, H et al 2010). Concern
has been raised over the possibility of carbon dioxide embolism during laparoscopic liver
surgery; however, extensive use of CO2 as an intravenous contrast agent in interventional
radiology procedures shows that these fears are probably overstated (Hawkins, IF & Caridi,
JG 1998). Argon embolism, on the other hand, is a legitimate fear, and we advocate against
the use of the argon beam coagulator on hepatic parenchymal veins. Furthermore, it is
prudent to lower insufflations pressures during use of the argon beam.
Minimization of blood product usage is another key component of intraoperative care. The
use of intraoperative thromboelastography (TEG) allows for near real time assessment of the
coagulation cascade with replacement of coagulation factors as appropriate. The cell saver is
well accepted as a means of minimizing blood transfusion requirements during operation
for benign indications. Cell saver use in the setting of malignancy is more controversial;
however, the employment of adjunctive measures such as leukocyte depletion filters may
minimize the burden of tumor cells in salvaged blood (Liang, TB et al 2008).
2.5.3 Parenchymal transection techniques

A number of parenchymal transection techniques have been described in the literature, with
none of them showing clear superiority over the others. Which technique is ultimately
chosen thus becomes dependent upon the individual surgeon’s comfort level with a given
technique. Here we describe two of the more common strategies: electrosurgical dissection
and stapler hepatectomy.
Electrosurgical transection techniques rely upon the surgeon’s ability to operate two devices
simultaneously. The surgeon should use a device such as the Harmonic Scalpel or Enseal
(Ethicon Endosurgery, Cincinnatti, OH) in the dominant hand. This device is used to incise
Glisson’s capsule and for the majority of parenchymal transection. The device should not be
fully introduced into the parenchyma to prevent tearing of large vessels. When active
bleeding is encountered, it is immediately controlled with bipolar cautery forceps which are
held in the surgeon’s other hand. Larger vessels require the use of laparoscopic clips. The
simultaneous use both devices is facilitated by sitting on a tall stool, which allows the
surgeon to operate the foot pedals independently.
Our group has favored the use of stapler hepatectomy. This technique provides the
advantage of more rapid parenchymal transection, without the need for prior control of
individual hepatic vessels. The first centimeter of parenchyma is relatively devoid of major
vessels, and is incised with electrosurgical devices as described above. The dissection then
proceeds using the thin blade of the stapler as a dissector. Care must be taken to avoid
inadvertent manipulation of the stapler during firing, which can lead to tearing of major
vessels and subsequent hemorrhage. The use of hand assistance is helpful in stabilizing the
stapler to prevent such complications. We have preferred the use of a 25 mm vascular staple
load for parenchymal transection.
When intraoperative hemorrhage is encountered, the presence of a hand in the abdomen is
highly beneficial in allowing digital control of bleeding vessels prior to attaining definitive
hemostasis. The “quick stitch” as described by Koffron has proven highly useful in
laparoscopic control of bleeding vessels. The quick stitch is a precut 10cm suture with two
vascular clips placed on the tail of the suture. After the suture is placed and hemostasis is
obtained, the closure is secured by additional clips place on the proximal end. Should
conversion be necessary during a pure laparoscopic procedure, it should initially be to a

hand assist method rather than to full laparotomy. In all cases, conversion should not be
viewed as a failure or complication, but rather as a measure of prudent judgment (Buell, JF
et al 2009a).
3. Laparoscopic liver surgery for malignancy

After becoming comfortable with resection of benign lesions, the logical progression in the
development of a laparoscopic liver program is the resection of malignant lesions. These
lesions require an increased degree of skill on the part of the surgeons in order to attain
adequate margins and maintain oncologic adequacy. The presence of cirrhosis in the setting
of HCC or steatohepatitis following neoadjuvant chemotherapy for colorectal metastasis
make proper patient selection and timing of operation critical. The consideration of
adjunctive techniques such as transarterial chemoemboliztion for preoperative downstaging
also becomes important. Here, we will discuss laparoscopic management of the two most
common malignant hepatic tumors: colorectal metastases and hepatocellular carcinoma.
3.1 Colorectal metastases

Colorectal metastases are the most common malignant hepatic tumor. Results following
open resection of these lesions have been excellent, with 5 year survival rates exceeding 50%
in many centers (House, MG et al 2010). Such outcomes have set a high standard by which
laparoscopic resection must be measured. The adoption of laparoscopy to this field has been
hindered by concerns of tumor seeding at port sates and the possibility of missing
extrahepatic lesions by inadequate inspection of the peritoneal cavity(Hsu, TC 2008;
Johnstone, PA et al 1996). These hurdles have slowly been brought down, and laparoscopic
resection is now a standard part of the therapeutic arsenal for hepatic malignancy.
3.1.2 Patient selection

Patient selection criteria for laparoscopic resection of colorectal metastases are similar to
those applied for open resection. Initial evaluation requires precise definition of tumor
anatomy and exclusion of extrahepatic disease. We favor triple phase CT as the initial
radiographic evaluation. When combined with digital arterial reconstruction, evaluation of
aberrant vascular anatomy, which can be present in nearly half of all patients, is afforded.
Evaluation of baseline liver function is performed with evaluation of bilirubin, INR, and
albumin. A thorough history and physical exam is necessary to assess general fitness for
major abdominal surgery. Tumor resectability is defined by the SSAT as an expected
negative margin resection with preservation of at least 2 contiguous hepatic segments with
adequate inflow, outflow, and biliary drainage and a future liver remnant of more than 20%
for normal parenchyma(Charnsangavej, C et al 2006).
3.1.3 Neoadjuvant therapy

The use of chemotherapy and chemoradiation for metastatic colon and rectal cancer has
become a mainstay of therapy. Modern chemotherapeutic regimens generally consist of 5-
fluorouracil combined with either oxaliplatin (FOLFOX) or irinotecan (FOLFIRI) have
produced excellent response rates, and have been able to render 10-30% of previously
unresectable disease amenable to surgical therapy. Agents such as cetuximab and
bevacizumab have shown even better response rates. This efficacy is not without a price,
however. Bevacizumab has a black box warning for spontaneous intestinal perforation.
Traditional chemotherapeutic combinations are hepatotoxic, leading to the phenomenon of
chemotherapy associated steatohepatitis (CASH). These considerations are important, as
patients are often referred for hepatic surgery after neoadjuvant therapy has been initiated.
3.1.4 Operative considerations and oncologic adequacy

The most critical factor to producing positive outcomes is the attainment of negative
operative margins (R0 resection). Facility with laparoscopic intraoperative ultrasound is a
must for surgeons approaching malignant liver lesions, allowing for precise definition of
tumor anatomy and planning of resection planes. As long as negative microscopic margins
are obtained, there does not appear to be a minimum necessary margin width (Pawlik, TM
et al 2005).
The approach to synchronous disease has received considerable attention, as it will be
present in up to 25% of patients with colorectal liver metastases (Martin, RC et al 2009).
There are three possible surgical strategies in this setting: the classic approach of colorectal
resection followed by hepatectomy, a simultaneous resection of colorectal and hepatic
disease, and a reverse strategy of metastasectomy followed by primary tumor resection. The
drawback of the classic strategy is the delay in metastasectomy while patients receive
adjuvant therapy. The combined strategy eliminates this delay, at the cost of greater surgical
insult with possibly higher morbidity. The reverse strategy was described to eliminate the
delay in metastasectomy while avoiding the surgical insult of the combined approach. With
appropriate patient selection, groups from MD Anderson and the University of Louisville
have demonstrated that the combined approach can be undertaken without increased
morbidity and mortality. Brouquet’s analysis of all three strategies found similar morbidity,
mortality, and survival across groups, showing that no approach is clearly superior for all
patients (Brouquet, A et al 2010).
With increasing worldwide experience of laparoscopic resection of colorectal metastases, the
oncologic integrity of laparoscopy compared with open techniques has been shown to be
comparable. Nguyen’s review of the world literature found only one case of port site
recurrence, which occurred in a case of metastatic renal cell carcinoma that ruptured prior to
resection (Nguyen, KT et al 2009). Castaing’s comparison of 60 patients undergoing
laparoscopic resection and 60 patients undergoing open resection provided the first
evidence of long term efficacy of laparoscopic resection for colorectal metastases. Five year
survival in the laparoscopic group in this series was 62%, which was comparable to the 56%
five year survival in the open group. There was no difference in width of resection margins
between groups, while the laparoscopic group included a greater percentage of patients
undergoing combined hepatic and colorectal resection (Castaing, D et al 2009). Such results
confirm that laparoscopic resection is a safe and effective alternative to open surgery for
hepatic colorectal metastases.
3.2 Hepatocellular carcinoma

Hepatocellular carcinoma (HCC) is the sixth most common malignancy and the third most
common cause of cancer death worldwide (Parkin, DM et al 2005). In the United States,
where chronic hepatitis C infection is the main risk factor, there has been an increase in the
incidence of HCC over the past several decades (El-Serag, HB & Mason, AC 1999). Most
patients present with relatively advanced disease, making curative treatment such as
resection and liver transplantation applicable in only 30-40% of patients in Western centers
(Bruix, J & Llovet, JM 2002). One of the major limiting factors in preventing resectability is
impaired hepatic function, with the vast majority of cases in Western patients developing in
the background of cirrhosis. Thus, appropriate patient selection becomes paramount in
achieving successful outcomes. Because of these limitations, the role of laparoscopic liver
resection has remained more limited than for other disease states.
3.2.1 Patient selection

Much of the patient selection process for resection of HCC centers around assessment of the
underlying liver parenchyma. The Child-Pugh classification system provides a rough
framework from which to base the selection process. In generally, Child A patients are able
to tolerate limited forms of resection, while Child B and C patients are typically referred for
more palliative procedures such as systemic therapy or transarterial chemoembolization. In
the West, assessment is directed at determining the presence of significant portal
hypertension. Generally, patients with hepatic-venous pressure gradient of less than 10,
esophageal varices of no greater than grade 1, and platelet counts of over 100,000 are
considered acceptable risk. In addition, bilirubin levels must be normal.
A common technique in Eastern centers is the assessment of indocyanine green clearance
rate (ICG). This technique involves the injection of an organic dye which is then measured in
the peripheral blood after a 15 minute interval. Clearance of the dye is used as a surrogate
for hepatic metabolic function. ICG retention of no more than 10-20% is considered to be
acceptable. Using this technique in 1056 consecutive patients with normal bilirubin and no
ascites, Imamura has been able to achieve hepatic resection with zero operative mortality
(Imamura, H et al 2003).
Advances in imaging technology have lead to the increasing use of systemic liver volumetry
as a preoperative risk assessment tool. A future liver remnant to standard liver volume ratio
of greater than 20% is considered safe in patients with healthy liver parenchyma, while
ratios of 30-40% are considered necessary for patients with compensated cirrhosis. An
insufficient future liver remnant may be addressed with the use of adjunctive techniques
such as portal vein embolization, which will be discussed in greater detail in the section on
resection in cirrhotics.
Tumor related factors that preclude surgical resection include extrahepatic disease and
invasion of the main portal vein, vena cava, and common hepatic artery. Multinodular
disease that can’t be resected with an adequate future liver remnant is also a relative
contraindication to resection, although there is a role for resection of the dominant lesion
with radiofrequency ablation of the remaining disease in highly selected cases. Although
size alone is not a criteria for resectability, there is a practical limit to the size of lesion that
can be safely approached laparoscopically. The recent international position statement for
laparoscopic liver surgery recommends limitation of the laparoscopic approach to tumors
<5cm in diameter for all but the most experienced of centers (Buell, JF et al 2009a).
3.2.2 Technical considerations and oncologic adequacy

Unlike the case of hepatic colorectal metastases, there does appear to be a benefit to wider
surgical margins in patients with HCC. For patients with solitary HCC lacking vascular
invasion, a margin of at least 2cm has proven beneficial in a randomized controlled trial
setting. Furthermore, the tendency of HCC to spread via the portal venous system favors the
use of planned anatomic resection in patients with adequate hepatic reserve. The inability to
perform anatomic resection should not be considered a contraindication, however, as more
limited resection as been shown to be beneficial in the setting of cirrhosis (Rahbari, NN et al

2011).
Despite the limitations imposed by the greater difficulties in technical resection and patient
selection, laparoscopic resection has proven to be a safe and effective alternative to open
surgery in appropriately selected patients. Lai has demonstrated 5 year survival of 50%,
with disease free survival of 36%, while Dagher has shown 5 year overall and disease free
survival of 64.9% and 32.2%, respectively (Dagher, I et al 2010; Lai, EC et al 2009). Others
have shown laparoscopic resection to be associated with lower morbidity and postoperative
ascites compared to open resection (Belli, G et al 2009b). Although hepatocellular carcinoma
in the setting of cirrhosis represents the most difficult of diseases to approach via
laparoscopy, these results show that the technique is safe and effective when performed in
centers that have acquired the appropriate experience.
4. Laparoscopic resection in cirrhotics

As noted above, the cirrhotic patient represents a unique challenge to the laparoscopic liver
surgeon. The possibility of postoperative liver failure resulting from inadequate remnant
liver function is a dreaded complication to be avoided at all costs. One technique that can
potentially prevent this problem is the use of preoperative portal vein embolization (PVE).
The effectiveness of PVE is based on the remarkable regenerative capacity of the liver. The
technique involves occlusion of the tumor bearing segments of the liver, which induces
hypertrophy in the remaining hepatic segments. Generally, reimaging 6 weeks after PVE is
performed to assess the adequacy of hypertrophy to provide an adequate future liver
remnant. Failure to achieve adequate hypertrophy indicates a severely diseased liver that is
not amenable to resection.
A meta-analysis of PVE has been found that the procedure is safe and able to induce
adequate hypertrophy to reduce post resection liver failure in a considerable proportion of
patients (Abulkhir, A et al 2008). Preoperative PVE is currently recommended in cirrhotic
patients with predicted future liver remnant of less than 40%. For centers using ICG
retention, values of 10-19% with a FLR of 40-60% also represents an indication for portal
vein embolization (Rahbari, NN et al 2011).
For cirrhotic patients able to undergo liver resection, laparoscopy provides a number of
unique benefits. The smaller incisions cause less disruption of the abdominal wall collateral
circulation. As complete evacuation of ascites is not necessary for a laparoscopic procedure,
intraoperative fluid shifts are lessened. This contributes to the reduction in postoperative
ascites seen with laparoscopy compared to open hepatectomy (Dagher, I et al 2009; Gigot,
JF et al 2002). Another unique benefit is the reduced adhesion formation following
laparoscopic surgery. For patients undergoing resection of HCC, salvage transplantation
remains an important option for recurrences that are within the Milan criteria. Laurent
found that liver transplants following laparoscopic compared to open resection were
performed in less time, with less blood loss and transfusion requirement (Laurent, A et al
2009). Similarly, Belli has found repeat hepatectomy following initial laparoscopic resection
to be faster and safer, with less blood loss and risk of visceral injury (Belli, G et al 2009a).
5. Development of a laparoscopic liver resection program

The recent international consensus conference on laparoscopic liver surgery has developed
guidelines for the establishment and credentialing of a laparoscopic liver surgery program
(Buell, JF et al 2009b). Prior to embarking upon beginning a program in laparoscopic liver

surgery, it is necessary to acquire experience with both advanced laparoscopy and open
hepatic surgery. These requirements have made the widespread adoption of laparoscopic
liver surgery appropriately slow. As advanced laparoscopy becomes an increasingly
important part of general surgery training programs, these prerequisites will become less of
a hurdle, with the expected more rapid acceptance of laparoscopic liver surgery.
After establishing the necessary expertise in laparoscopy and open hepatic surgery, the ideal
starting point is small, benign lesions in the periphery of the liver. Extensive use of hand
assistance is also critical in reducing the learning curve. Koffron has described the hybrid
technique, in which mobilization of the liver is performed laparoscopically, and
parenchymal transection is then performed in an open fashion through the hand port
incision (Koffron, AJ et al 2007). He has termed this approach “laparoscopic liver surgery
for everyone,” and we agree that this approach represents an ideal starting point for a
laparoscopic liver program.
Once comfortable with performing more limited resections, the next step in development is
the performance of major, anatomic resections. In this setting, the left lateral segmentectomy
is the ideal starting point. Although much attention is given to the parenchymal transection
phase, it should be noted that the greatest risk for vascular injury and subsequent
conversion to an open procedure is actually during the mobilization phase. The most
commonly injured vessel in this setting is the phrenic vein, which must be carefully
identified and avoided. Conversion, as we have emphasized previously, should not be
viewed as a failure or complication. Instead, the decision to convert to an open or hand
assisted procedure rather than continue with a potentially unsafe situation laparoscopically
is a mark of good surgical judgment.
Experience with resection of lesions located in the peripheral segments of the liver provides
a foundation of skills, including mobilization, transection, hemostasis, and laparoscopic
ultrasound. Once this fundamental skill set has been developed thoroughly, the surgeon is
then able to proceed to more difficult lesions. At this point, malignant and/or large lesions
located in the right and posterior segments of the liver can then be approached in the
culmination of programmatic development. We have found that facility with minor
resections can be achieved in 30 to 50 cases. More difficult resections such as formal
lobectomy and right posterior resection require an additional 60 to 80 cases to master. Thus,
the road to development of a laparoscopic liver resection program is long and often
arduous, but is highly rewarding to both the surgeon and the patient when properly
travelled.
6. Conclusion
Nearly 15 years after first being described, laparoscopic liver resection has been gradually
gaining acceptance in a number of centers worldwide. As the necessary skills in advanced
laparoscopy and hepatic surgery become more widespread, we anticipate that the further
adoption of laparoscopic liver resection will increase more rapidly. The maturation of long
term series have proven the oncologic adequacy of the laparoscopic approach in a variety of
settings. With the development of a greater number of surgeons who are proficient in
laparoscopic liver surgery, many more patients will benefit from decreased blood loss, less
postoperative pain, and shorter lengths of stay. From being a novel procedure practiced in
only a handful of centers worldwide, laparoscopic liver resection is now established as a
safe and effective technique in the therapeutic decision tree for patients with surgical disease
of the liver. We believe that this acceptance will continue to grow to the point that the
laparoscopic approach will, as has been seen with colon resection, eventually be adopted as
the standard of care in appropriately selected patients.
7. References
Abulkhir, A et al Preoperative portal vein embolization for major liver resection: a meta-
analysis Ann.Surg.2008;247(1):49-57
Belli, G et al Laparoscopic redo surgery for recurrent hepatocellular carcinoma in cirrhotic
patients: feasibility, safety, and results Surg.Endosc.2009a;23(8):1807-1811
Belli, G et al Laparoscopic and open treatment of hepatocellular carcinoma in patients with
cirrhosis Br.J.Surg.2009b;96(9):1041-1048
Brouquet, A et al Surgical strategies for synchronous colorectal liver metastases in 156
consecutive patients: classic, combined or reverse strategy? J.Am.Coll.Surg.2010;
210(6):934-941
Bruix, J & Llovet, JM Prognostic prediction and treatment strategy in hepatocellular
carcinoma Hepatology2002;35(3):519-524
Buell, JF et al The international position on laparoscopic liver surgery: The Louisville
Statement, 2008 Ann.Surg.2009a;250(5):825-830
Buell, JF et al The international position on laparoscopic liver surgery: The Louisville
Statement, 2008 Ann.Surg.2009b;250(5):825-830
Buell, JF et al Management of benign hepatic tumors Surg.Clin.North Am.2010;90(4):719-735
Castaing, D et al Oncologic results of laparoscopic versus open hepatectomy for colorectal
liver metastases in two specialized centers Ann.Surg.2009;250(5):849-855
Charnsangavej, C et al Selection of patients for resection of hepatic colorectal metastases:
expert consensus statement Ann.Surg.Oncol.2006;13(10):1261-1268
Cherqui, D et al Laparoscopic liver resections: a feasibility study in 30 patients
Ann.Surg.2000;232(6):753-762
Dagher, I et al Laparoscopic hepatectomy for hepatocellular carcinoma: a European
experience J.Am.Coll.Surg.2010;211(1):16-23
Dagher, I et al Laparoscopic versus open right hepatectomy: a comparative study
Am.J.Surg.2009;198(2):173-177
Di, SM et al Natural history of focal nodular hyperplasia of the liver: an ultrasound study
J.Clin.Ultrasound1996;24(7):345-350
Ding, GH et al Diagnosis and treatment of hepatic angiomyolipoma J.Surg.Oncol.2011
Dokmak, S et al A single-center surgical experience of 122 patients with single and multiple
hepatocellular adenomas Gastroenterology2009;137(5):1698-1705
El-Serag, HB & Mason, AC Rising incidence of hepatocellular carcinoma in the United States
N.Engl.J.Med.1999;340(10):745-750
Gaffey, MJ et al Clonal analysis of focal nodular hyperplasia of the liver
Am.J.Pathol.1996;148(4):1089-1096
Gigot, JF et al Laparoscopic liver resection for malignant liver tumors: preliminary results of
a multicenter European study Ann.Surg.2002;236(1):90-97
Hawkins, IF & Caridi, JG Carbon dioxide (CO2) digital subtraction angiography: 26-year
experience at the University of Florida Eur.Radiol.1998;8(3):391-402
House, MG et al Survival after hepatic resection for metastatic colorectal cancer: trends in
outcomes for 1,600 patients during two decades at a single institution
J.Am.Coll.Surg.2010; 210(5):744-745
Hsu, TC Intra-abdominal lesions could be missed by inadequate laparoscopy
Am.Surg.2008;74(9):824-826
Imamura, H et al One thousand fifty-six hepatectomies without mortality in 8 years
Arch.Surg.2003;138(11):1198-1206
Johnstone, PA et al Port site recurrences after laparoscopic and thoracoscopic procedures in
malignancy J.Clin.Oncol.1996;14(6):1950-1956
Koffron, AJ et al Laparoscopic liver surgery for everyone: the hybrid method Surgery2007;
142(4):463-468
Lai, EC et al Minimally invasive surgical treatment of hepatocellular carcinoma: long-term
outcome World J.Surg.2009;33(10):2150-2154
Laurent, A et al Laparoscopic liver resection facilitates salvage liver transplantation for
hepatocellular carcinoma J.Hepatobiliary.Pancreat.Surg.2009;16(3):310-314
Lefor, AT & Flowers, JL Laparoscopic wedge biopsy of the liver J.Am.Coll.Surg.1994;
178(3):307-308
Liang, TB et al Intraoperative blood salvage during liver transplantation in patients with
hepatocellular carcinoma: efficiency of leukocyte depletion filters in the removal of
tumor cells Transplantation2008;85(6):863-869
Martin, RC et al Simultaneous versus staged resection for synchronous colorectal cancer
liver metastases J.Am.Coll.Surg.2009;208(5):842-850
Micchelli, ST et al Malignant transformation of hepatic adenomas Mod.Pathol.2008;
21(4):491-497
Mortele, KJ & Ros, PR Benign liver neoplasms Clin.Liver Dis.2002;6(1):119-145
Motohara, T et al MR imaging of benign hepatic tumors Magn Reson.Imaging
Clin.N.Am.2002;10(1):1-14
Nguyen, KT et al World review of laparoscopic liver resection-2,804 patients Ann.Surg.2009;
250(5):831-841
Paradis, V Benign liver tumors: an update Clin.Liver Dis.2010;14(4):719-729
Parkin, DM et al Global cancer statistics, 2002 CA Cancer J.Clin.2005;55(2):74-108
Pawlik, TM et al Effect of surgical margin status on survival and site of recurrence after
hepatic resection for colorectal metastases Ann.Surg.2005;241(5):715-22, discussion
Rahbari, NN et al Hepatocellular carcinoma: current management and perspectives for the
future Ann.Surg.2011;253(3):453-469
Reshamwala, PA et al Nodular regenerative hyperplasia: not all nodules are created equal
Hepatology2006;44(1):7-14
Rooks, JB et al Epidemiology of hepatocellular adenoma. The role of oral contraceptive use
JAMA1979;242(7):644-648
Seki, S et al A clinicopathological study of inflammatory pseudotumors of the liver with
special reference to vessels Hepatogastroenterology2004;51(58):1140-1143
Semelka, RC et al Focal liver lesions: comparison of dual-phase CT and multisequence
multiplanar MR imaging including dynamic gadolinium enhancement J.Magn
Reson.Imaging2001;13(3):397-401
Sturtz, CL & Dabbs, DJ Angiomyolipomas: the nature and expression of the HMB45 antigen
Mod.Pathol.1994;7(8):842-845
Terkivatan, T et al Focal nodular hyperplasia: lesion characteristics on state-of-the-art MRI

including dynamic gadolinium-enhanced and superparamagnetic iron-oxide-
uptake sequences in a prospective study J.Magn Reson.Imaging2006;24(4):864-872
Tranchart, H et al Laparoscopic resection for hepatocellular carcinoma: a matched-pair
comparative study Surg.Endosc.2010;24(5):1170-1176
Trotter, JF & Everson, GT Benign focal lesions of the liver Clin.Liver Dis.2001;5(1):17-42, v
Tsou, YK et al Inflammatory pseudotumor of the liver: report of eight cases, including three
unusual cases, and a literature review J.Gastroenterol.Hepatol.2007; 22(12):2143-
2147
Wanless, IR Micronodular transformation (nodular regenerative hyperplasia) of the liver: a
report of 64 cases among 2,500 autopsies and a new classification of benign
hepatocellular nodules Hepatology1990;11(5):787-797
Wanless, IR et al On the pathogenesis of focal nodular hyperplasia of the liver
Hepatology1985; 5(6):1194-1200
6
Hilar Glissonean Access in

Laparoscopic Liver Resection
Akihiro Cho
Division of Gastroenterological Surgery, Chiba Cancer Center Hospital
Japan
1. Introduction
Laparoscopy for liver resection is a highly specialized field, as laparoscopic liver surgery
presents severe technical difficulties. However, the recent rapid development of technological
innovations, improvements in surgical skills and the accumulation of extensive experience by
surgeons have improved the feasibility and safety of a laparoscopic approach for properly
selected patients [1]. Since the first report of laparoscopic anatomical left lateral sectionectomy
in 1996 [2], increasing numbers of laparoscopic anatomical liver resections have been reported
[3-6]. However, laparoscopic anatomical resection has not been widely accepted because major
technical difficulties remain, such as hilar dissection and pedicle control. During open
anatomical liver resections, each Glissonean pedicle is often ligated and divided en bloc
extrahepatically [7, 8]. Using the same concept, we describe herein a novel technique by which
each Glissonean pedicle can be easily and safely encircled and divided en bloc extrahepatically
during laparoscopic anatomical liver resection.
2. Surgical technique
Laparoscopic encircling of the hepatoduodenal ligament is usually performed using an
Endo Retract Maxi (Fig. 1) or Endo Mini-Retract (Covidien Japan, Tokyo, Japan) to be used
as a tourniquet for complete interruption of blood inflow to the liver only if necessary [9].
Fig. 1. Endo Retract Maxi in activated position. Vessel tape is preliminarily fixed to the tip of
the metallic arch.
2.1 Encircling right-sided Glissonean pedicles, including the right, anterior, and
posterior pedicles
After dividing the cystic artery and duct and dissecting the gallbladder neck, the peritoneum
of the hepatoduodenal ligament is dissected at the hepatic hilum (Fig. 2). Retracting the round
ligament and gallbladder allows a good operative field of view, facilitating the encircling of
each Glissonean pedicle. The metallic arch of an Endo Retract Maxi or Endo Mini-Retract is
then meticulously extended between the hepatic parenchyma and the bifurcation of the right
and left Glissonean pedicles, so the tip of the metallic arch is visualized (Fig. 3). Although the
metallic arch is blindly deployed behind the Glissonean bifurcation, the tip can be safely
delivered into the dorsal side of the hepatoduodenal ligament because the blade is blunt. The
right Glisonean pedicle is encircled extrahepatically (Fig. 4). In the same way, the metallic arch
of Endo Mini-Retract is meticulously extended between the hepatic parenchyma and the
bifurcation of the anterior and posterior Glissonean pedicles, then the anterior or posterior
Glisonean pedicle is extrahepatically encircled (Fig. 5) [10, 11]. Hepatic parenchymal dissection
along the Cantle line facilitates inserting an endocopic stapler and dividing the right anterior
and posterior Glissonean pedicles respectively (Fig. 6).
B
Fig. 2. Dissection between the hepatic parenchyma and the Glissonean bifurcation is
performed from the ventral side (A) and dorsal side (B).
Hilar Glissonean Access in Laparoscopic Liver Resection 79
B
Fig. 3. An Endo Retract Maxi is introduced between the hepatic parenchyma and the
bifurcation of the right and left Glissonean pedicles, so the tip of the metallic arch is
visualized (A). The metallic arch is then meticulously extended (B).
Fig. 4. The right Glissonean pedicle is encircled with an Endo Retract Maxi from the ventral
side (A) and dorsal side (B).
B
Fig. 5. The metallic arch of Endo Mini-Retract is extended between the hepatic parenchyma
and the bifurcation of the anterior and posterior Glissonean pedicles, then the posterior (A)
or anterior (B) Glisonean pedicle is extrahepatically encircled.
Fig. 6. The posterior (A) and anterior (B) Glisonean pedicles are divided respectively using
an endocopic stapler.
Fig. 7. The ligamentum venosum is divided.
Fig. 8. The metallic arch of an Endo Retract Maxi is meticulously extended behind the
umbilical plate, so the left Glisonean pedicle is encircled extrahepatically.
Fig. 9. The medial Glissonean pedicle is encircled with an Endo Mini Retract.
Fig. 10. The medial Glissonean pedicle is divided using an endocopic stapler.
2.2 Encircling left-sided Glissonean pedicles, including the left, medial, and lateral
pedicles
Dividing the ligamentum venosum (Fig. 7) and retracting the round ligament upward
extends the umbilical portion, facilitating isolation of its root. A parenchymal bridge is
divided if present. Dissection between the hepatic parenchyma and umbilical plate is
performed. The metallic arch of an Endo Retract Maxi or Endo Mini-Retract is meticulously
extended behind the umbilical plate, so the left Glisonean pedicle is encircled
extrahepatically (Fig. 8). Hepatic parenchyma is divided along the main portal fissure,
which facilitates dividing the left Glissonean pedicle using an endoscopic stapler. A little
dissection of the hepatic parenchyma along the umbilical fissure facilitates isolation of the
root of the medial Glissonean pedicle (G4) or lateral Glissonean pedicles (G2, G3). Dissection
between the hepatic parenchyma and umbilical plate is performed, and G2, G3, or G4 is
extrahepatically encircled using Endo Mini-Retract (Fig. 9) and divided using an endoscopic
stapler based on resection type (Fig. 10).
3. Comments
Laparoscopic anatomical segmental resection has not been widely accepted due to technical
difficulties in controlling each Glissonean pedicle laparoscopically. Previous reports relating
to laparoscopic hemihepatectomy have described separate dissection and division of each of
the hepatic artery, duct and portal vein [3-6], or an intrahepatic Glissonean approach [12,
13]. The entire length of primary branches of the Glissonean pedicle and the origin of
secondary branches are located outside the liver and the trunks of the secondary and more
peripheral branches run inside the liver [8]. Therefore, the right, left, anterior, posterior,
medial, or lateral Glissonean pedicle can be encircled and divided en bloc extrahepatically.
Using an Endo Retract Maxi or Endo Mini-Retract, an extrahepatic Glissonean approach can
be safe and feasible. However, each Glissonean pedicles should be divided as distally as
possible to avoid biliary injury. The right Glissonean pedicle should not be transacted en
bloc but the right anterior and posterior Glissonean branches should be divided
respectively. The left Glissonean pedicle should be divided at the root of the umbilical
portion to avoid injury of the right hepatic duct. Therefore, the pedicle should be encircled
left to the Spiegel branch. In addition, each pedicles show shorter extrahepatic courses, and
thus are better divided after some amount of parenchymal dissection.
4. References
[1] Buell JF, Cherqui D, Geller DA, O'Rourke N, Iannitti D, Dagher I, Koffron AJ, Thomas M,
Gayet B, Han HS, Wakabayashi G, Belli G, Kaneko H, Ker CG, Scatton O, Laurent
A, Abdalla EK, Chaudhury P, Dutson E, Gamblin C, D'Angelica M, Nagorney D,
Testa G, Labow D, Manas D, Poon RT, Nelson H, Martin R, Clary B, Pinson WC,
Martinie J, Vauthey JN, Goldstein R, Roayaie S, Barlet D, Espat J, Abecassis M, Rees
M, Fong Y, McMasters KM, Broelsch C, Busuttil R, Belghiti J, Strasberg S, Chari RS;
World Consensus Conference on Laparoscopic Surgery: The international position
on laparoscopic liver surgery: The Louisville Statement, 2008. Ann Surg 2009; 250:
825-380.
[2] Azagra JS, Goergen M, Gilbart E, Jacobs D: Laparoscopic anatomical (hepatic) left lateral
segmentectomy-technical aspects. Surg Endosc.1996; 10: 758-761.
[3] O’Rourke N, Fielding G: Laparoscopic right hepatectomy: surgical technique. J

Gastrointest Surg2004; 8: 213-216.
[4] Dagher I, Di Giuro G, Lainas P, Franco D: Laparoscopic right hepatectomy with selective
vascular exclusion. J Gastrointest Surg2009; 13: 148-149.
[5] Han HS, Cho JY, Yoon YS: Techniques for performing laparoscopic liver resection in
various hepatic locations. J Hepatobiliary Pancreat Surg2009; 16: 427-432.
[6] Gayet B, Cavaliere D, Vibert E, Perniceni T, Levard H, Denet C, Christidis C, Blain A,
Mal F: Totally laparoscopic right hepatectomy. Am J Surg2007; 194: 685-689.
[7] Takasaki K, Kobayashi S, Tanaka S, Saito A, Yamamoto M, Hanyu F: Highly
anatomically systematized hepatic resection with Glissonean sheath code
transection at the hepatic hilus. Int Surg1990; 75: 73-77.
[8] Takasaki K: Glissonean pedicle transection method for hepatic resection: a new concept
of liver segmentation. J Hepatobiliary Pancreat Surg1998; 5: 286-291.
[9] Cho A, Yamamoto H, Nagata M, Takiguchi N, Shimada H, Kainuma O, Souda H, Gunji
H, Miyazaki A, Ikeda A, Matsumoto I: Safe and feasible inflow occlusion in
laparoscopic liver resection. Surg Endosc2009; 23: 906-908.
[10] Cho A, Asano T, Yamamoto H, Nagata M, Takiguchi N, Kainuma O, Souda H, Gunji H,
Miyazaki A, Nojima H, Ikeda A, Matsumoto I, Ryu M, Makino H, Okazumi S:
Laparoscopy-assisted hepatic lobectomy using hilar Glissonean pedicle transection.
Surg Endosc2007; 21: 1466-1468.
[11] Cho A, Yamamoto H, Kainuma O, Souda H, Ikeda A, Takiguchi N, Nagata M: Safe and
feasible extrahepatic Glissonean access in laparoscopic anatomical liver resection.
Surg Endosc2011; 25: 1333-1336.
[12] Machado MA, Makdissi FF, Galvão FH, Machado MC: Intrahepatic Glissonian
approach for laparoscopic right segmental liver resections. Am J Surg 2008; 196: 38-
42.
[13] Topal B, Aerts R, Penninckx F: Laparoscopic intrahepatic Glissonian approach for right
hepatectomy is safe, simple, and reproducible. Surg Endosc 2007; 21: 2111.
7
Laparoscopic Liver Surgery

Steven A. White, Rajesh Y. Satchidanand and Derek M. Manas
Department of Hepatobiliary and Transplant Surgery,
The Freeman Hospital, Newcastle upon Tyne, Tyne and Wear,
England
1. Introduction
Recent improvements in cross sectional imaging, chemotherapy and advances in the
techniques of liver resection have resulted in rates of 5 year survival approaching 60% for
patients with colorectal liver metastasis. Historically liver resection was perceived as a
formidable operation but now liver resection is safe and specialist centres should expect low
mortality rates in the region of 1-2%1,2. Consequently, many more patients are now referred
for liver resection and its indications are continually being revised and expanded.
At the same time there have been many advances in minimally invasive laparoscopic surgical
techniques so much so that laparoscopic liver resection (LLR) is becoming an increasingly
popular option amongst laparoscopic enthusiasts. Indeed the first laparoscopic liver resection
was described nearly 20 years ago for focal nodular hyperplasia3. In a recent review by
Nguyen and colleagues 4,5 over 3,000 laparoscopic liver resections have now been reported in
various series and meta-analyses 6 7 8. Despite this enthusiasm doubts still remain over its more
widespread application because of the risks of complications and whether there is any patient
benefit 9-11. The latter is still very difficult to demonstrate in the absence of any well designed
randomized controlled trials. Like laparoscopic cholecystectomy that came before, it is now
very unlikely that any well designed Randomised controlled trials (RCT) will ever be
performed. Perhaps the most important RCT that should have been done is outcome after
laparoscopic left lateral resection versus open resection. Yet for laparoscopic enthusiasts the
advantages are so obvious they would now be very reluctant to offer open resection in a trial
setting. The situation is very different for major resections e.g. right hepatectomy where any
advantage is still very difficult to demonstrate. In this situation a RCT would be difficult to
design as few centres regularly perform this operation and large numbers would be needed
because of high rates of conversion and recruiting patients with tumours distributed in such
away that they can be resected laparoscopically.
2. Indications and contra-indications

2.1 International consensus - The Louisville statement
In 2008 a consensus meeting was convened in Louisville to discuss the position of LLR
amongst some of the worlds leading hepatobiliary surgeons. This was a very important
development and the following guidelines were suggested as follows11:
1. LLR can be performed safely in specialized centres with results comparable to those
achieved after open resection
2. The main indications are for both symptomatic benign and malignant tumours the
latter being predominantly Hepatocellular carcinoma (HCC) and liver metastasis
(colorectal-CRLM) and in determinant liver lesions.
3. It is important that the indications for resection of benign liver tumours are not
expanded (e.g. asymptomatic tumours where there is no diagnostic doubt)
4. Harvested grafts for living donation should only be performed in very specialised
centres and should be scrutinized in a world registry 12 13-15.
Other areas of discussion focused on patient safety and contraindications with the following
guidelines being suggested
1. The contraindications for LLR should be the same as those for open resection.
2. Other contraindications include;
3. The presence of dense adhesions and failing to progress after prolonged dissection
4. Tumour adjacent to a major vascular structure
5. Tumour too large to manipulate
6. The need for a portal lymphadenectomy.
2.2 Benign liver tumours

Paired comparisons between laparoscopic and open resection for benign tumours have not
been frequently reported 16 17 18. A few series are dedicated to LLR for benign tumours only
but these can be subdivided into solid or cystic 19 20. Most studies report outcomes in series
mixed for both benign and malignant tumours 21. The largest series of LLR for benign
tumours have been reported by Koffron et al. (n=177) 22. Forty seven were hepatic adenomas
the others being made up of haemangiomas (n=37), FNH (n=23) and liver cysts (n=70). It is
not clear in this article what the indications for resection were. Most centres report
predominantly resection of malignant tumours. From the Newcastle series of 69 patients;
28% constitute benign lesions and 72% malignant. The most common benign lesions include
hepatic adenoma (Figure 1), symptomatic FNH (or where there was diagnostic doubt),
biliary cysts, angiomyolipoma, haemangioma, biliary haematoma and polycystic liver
disease. In our experience most of these lesions were resected in patients with a known
diagnosis of colorectal carcinoma where there was diagnostic doubt regarding a liver lesion
despite cross sectional imaging by CT and MRI and in some cases contrast enhanced
ultrasound. It is important not to expand the indications for resection just because it can be
done laparoscopically. In general for benign tumours most report less morbidity (including
incisional hernias), shorter hospital stay and faster time to oral intake 19.
2.3 Malignant liver tumours

Although there have been many reports of LLR for malignant tumours being resected
including hilar cholangiocarcinoma 23 and neuroendocrine/carcinoid tumours, for the
purposes of this chapter discussion will concentrate on the most commonly resected
malignant tumours e.g. CRLM and HCC.
2.4 Colorectal
One of the disadvantages of LLR for CRLM is that all patients have had previous surgery
and initial dissection can be tedious because of adhesions. Especially when patients have
had a previous right hemicolectomy or cholecystectomy. Indeed in one patient in the
authors series LLR was abandoned after 3 hours of dissection and failure to progress.
Laparoscopic Liver Surgery 89
Fig. 1. Hepatic Adenoma ideally placed for Laparoscopic resection

Surgery for LLR should be divided in two broad categories, a) Those patients with
metastasis confined to liver and b) those patients with concomitant extra-hepatic disease.
Essentially all patients with CRLM who have had radical treatment for their primary CRC
should be considered resectable and falls into one of the following groups;
A. Those patients with metastasis confined to liver
i. Unilobar or bilobar disease
ii. Single or multiple metastases
iii. Remnant liver is approximately 20-30%. Total liver volume (TLV) dependent on
remnant function or equivalent to at least two liver segments
B. Those patients with concomitant extra-hepatic disease
i. CRLM in the presence of resectable or ablatable pulmonary disease
ii. CRLM in the presence of resectable isolated extra-hepatic disease e.g. spleen, adrenal or
resectable local recurrence
iii. CRLM in the presence of resectable invasion of adjacent structures (e.g. diaphragm,
adrenal).
With respect to extra-hepatic disease. Elias et al. have reported overall 5-year crude survival
rates of 28% when hepatic and extra-hepatic disease are both resected in a curative manner,
however in this situation it must be accepted that an R0 resection will not be possible in 50%
of patients 24. More importantly, the presence of extra hepatic disease does not appear to
influence outcome when resection is complete along with the liver metastases 25 .
Nevertheless it cannot be denied that there are few long term survivors in the presence of
peritoneal disease 26. Certainly these types of patients should be carefully evaluated by open
surgery and not by LLR. The easiest patients to consider for LLR are those with disease
confined to a single segment who ideally have a solitary metastasis in the anterior segments
(IVb, V and in some cases VI) (Figure 2.) or in the left lateral segment (group Ai or Aii).
Laparoscopic posterior sectionectomy has been described but they are significantly more
challenging 27-29.
Fig. 2. Colorectal metastasis in segment VI for laparoscopic resection

Patients with extra-hepatic disease (group B) fall into a very difficult group as resection of
extra-heptic disease may require more advanced laparoscopic skills which could be more
easily dealt with by open surgery. The temptation to laparoscopically resect a single lesion
and then perhaps laparoscopically ablate a more difficult lesion should be avoided and open
surgery performed.
With respect to nodal disease, regional metastasis to peri-hepatic lymph nodes deposits
should not be regarded as a contraindication to open resection but does reduce long-term
outcome. Recent studies suggest up to 20% of patients will have hepatic nodal involvement
at the time of resection 30. It is very difficult to evaluate this laparoscopically. Resection of
nodes involving second tier nodes (i.e.celiac nodes) is far more controversial and offers no
survival benefit. Another problem highlighted by the MSKCC group is the ability to identify
which lymph nodes are involved during open surgery. Routine sampling of lymph node
stations and lymphadenectomy is unnecessary and time consuming, without any evidence
of benefit. The best approach is selective sampling based on intra-operative assessment and
pre-operative imaging 31. Again performing this laparoscopically would not be advisable.
One of the main advantages of LLR, in our experience, has been its use with synchronous
tumours (Figure 3). LLR can be performed at the same time with a laparoscopic colorectal
specialist who removes the primary in one sitting. Up to 25% of patients may present in this
way 32. Nonetheless there are no significant publications with any reasonable numbers to draw
on any useful conclusions as to whether there is any benefit with combined laparoscopic
procedures 33 34. Minimally invasive techniques have obvious advantages over two major
laparotomies in a short space of time. With advances in chemotherapy more patients are now
becoming operable with their primary still in situ as there liver disease can be controlled. This
cohort is becoming increasingly more common and challenging 35 36. Generally these patients
have either laparoscopic right hemicoloectomy or laparoscopic anterior resection with excision
of either a solitary or unilobar metastasis. A further group includes those patients who have
major colonic resection with clearing of a single lobe and then further downstaging
chemotherapy prior to definitive resection by a second open liver resection. Recent reports
have suggested no significant differences in post-operative morbidity or mortality or 5 year
survival rates in those patients with synchronous disease who need a minor hepatectomy with
colonic resection 37 38 . In patients who require a major hepatectomy, a test of time, to enable an
assessment of the biological behaviour of the disease and to provide adjuvant treatment, is still
sensible. Although simultaneous laparoscopic major liver resection e.g. right hepatectomy
along with major colonic resection e.g. anterior resection have been successfully described 39 40
the authors would not recommend this without a careful assessment of the patients fitness
because of the need for prolonged anaesthesia beyond 5 hours.
Fig. 3. Colorectal metastasis with the primary colonic tumour still in situ ideal for
simultaneous laparoscopic
Two-thirds of patients undergoing liver resection for CRLM will develop recurrence of their
disease within 2 years 32. One third will manifest with liver only disease and a small
proportion of them will be suitable for repeat liver resection 41. Technically repeat liver
resections are demanding. However long-term survival is similar to those following initial
liver resections for open resections 42 43 . In a series of 60 third hepatectomies 43 complication
rates were similar to those having first and second hepatectomies with no obvious survival
disadvantage. Five year survival rates of 32% have been reported after open resection.
Multivariate analysis suggests a curative resection (R0) as the most important predictor of
improved survival after open resection. There are no studies reporting repeat LLR but these
are likely to be technically more challenging. Further studies are needed to evaluate repeat
LLR in terms of survival rates and complications.
2.5 Hepatocellular carcinoma

The treatment of HCC covers a broad spectrum including surgical (Resection, Ablation or
Liver Transplant-LT) and non-surgical treatments (Sphere therapy, TACE, Sorafenib).
Mortality after liver resection in large series of non cirrhotics are now around 3%. Yet in
large volume centres in the east, mortality after resection for HCC in cirrhotics is now
approaching zero. Substantial refinements in the surgical techniques have played an
important role including the development of liver “hardware” such as ultrasonic dissectors,
low CVP anaesthesia, hepatoduodenal compression (Pringle’s manoeuvre) and vascular
staplers have all contributed to reducing blood loss, post-op morbidity and mortality 44.
There is no doubt that the results of LT for primary HCC have improved dramatically in the
last decade following the publication of the Milan criteria by Mazzaferro et al. in 1996 45.
Consequently more patients with HCC are being referred for consideration of LT and the
management of these patients on the ever expanding waiting list present an interesting
cohort of patients to discuss. With this in mind bridging treatments such as resection,
chemo-embolisation or ablation by RFA are becoming increasingly important The clinical
characteristics after such treatments are also important in terms of predicting overall
prognosis.
One of the disadvantages of resection is tumour recurrence as some suggest that this can
hinder subsequent LT 46 yet this has not been substantiated by others and in terms of
technical difficulty is no different to re-transplantation for other indications 47. To avoid this
problem there is a niche for the development of LLR which can reduce morbidity and have
an impact on curative intent as a potential bridging treatment. Resection can be useful as a
bridging treatment if patients are Childs A with a low MELD score, have a small tumour
<3cm without any obvious macroscopic tumour thrombus 44. Overall 3 year survival rates in
patients with Child’s A cirrhosis can be as high as 93% 48 for segmental resections.
Segmental resections are best performed given the risks of recurrence with non segmental
resections due to microscopic satellite nodules that are not easily visualised by intra-
operative ultrasound. Comparisons of LLR with open resection for HCC in cirrhotic patients
are favourable 49 50 51 52 but the main advantage of LLR is a shorter hospital stay and less
blood loss. LLR is also less likely to lead to problematic adhesions if LT is required at a later
date. Numerous single centre 49 50 53 54 and multi-centre series 55 have published their series
of LLR in patients with HCC and cirrhosis confirming it is safe and reproducible without
oncological compromise or survival.
3. Imaging
3.1 Computed tomography
This modality is the work-horse of all imaging techniques in the pre-operative planning
phase for LLR. Present generation triple phase multi-detector CT scanning technology
enables image acquisition during a single-breath hold, of the entire chest and abdomen and
pelvis. The improved resolution results in excellent detection of lesions in solid organs and
enables better local, regional and distant staging. The other advantage of CT scanning is the
high incidence of detection of lesions in the lung, liver and pelvis, when intravenous
contrast is used with arterial or venous phase scanning. Slice thickness or maximum
collimation should be 3- 5mm. The sensitivity for detecting a metastatic lesion approaches
80%, which increases to 90% when CT angiography is used, however lesions less than 1 cm
in size are liable to be missed 56. Contrast enhanced helical CT is the investigation of choice
in the initial evaluation of liver tumours assessing response to chemotherapeutic agents and
for post-operative surveillance for tumour recurrence.
3.2 Magnetic resonance imaging

Magnetic resonance imaging has an extremely high sensitivity in identifying and
characterizing small lesions within the liver. In addition patients are not exposed to
radiation but the procedure is far more expensive and labour intensive. One of its
limitations is the identification of extra hepatic disease. The technique is very sensitive to
respiratory artefact and this can limit its resolution in certain patients who are unable to
hold their breath for a sufficient length of time. Contrast agents such as gadolinium and the
liver specific super magnetic iron oxide result in very high sensitivities in diagnosing small
(less than 1 cm) liver metastases 57 and differentiating between potentially malignant and
benign liver lesions (e.g. FNH, adenoma etc). Usually MR imaging is utilised just prior to
resection, in order to identify small lesions not visualised by conventional CT scanning but
this is not universally routine.
3.3 Intra-operative ultrasound

Intra-operative ultrasound (IOUS) is an essential pre-requisite for assessment of the liver
prior to commencement of liver resection. IOUS allows for mapping of the major vascular
and ductal structures in relation to the metastasis and aids in planning the final approach to
resection. It also serves as a guide in confirming the accuracy of the plane of dissection.
However following chemotherapy, when fatty change supervenes and in the presence of
cirrhosis, identification of small iso-echoic masses becomes poor, decreasing the sensitivity
of IOUS. IOUS must be used before, during and at the end of resection in order to keep R1
resection rates as low as possible. It is also important to leave an adequate margin around
the tumour and to mark the margins prior to commencing parenchymal transaction. This is
also useful to avoid coning as it is very difficult to estimate the depth of a tumour without
measuring the dimensions.
4. Anaesthesia
One of the overlooked contra-indications for LLR is the patients inability to withstand a
prolonged pneumoperitoneum especially with major resections e.g. right hepatectomy.
Results of left lateral liver resection suggest that resection time can be comparable to open.
The median duration in the literature is around 2-3 hours 58 . In the authors experience
laparoscopic left lateral resection can be performed as quick laparoscopically as open once
the learning curve has been overcome. Transection time can be less than 1 hour as reported
in a recent meta-analysis 59. For major hepatectomy operative times are prolonged and the
duration of anaesthesia can be in excess of 5 hours compared to 3 hours for open surgery 60
61. This can be reduced by performing a hybrid resection or, using a hand-port as it is
generally the parenchymal transection and dealing with the right hepatic vein that causes
the prolonged pneumoperitoneum. In the UK most centres use epidural anaesthesia for
post-operative pain relief but for LLR the duration of anaesthesia can be significantly
reduced as an epidural and central venous pressure line are no longer required.
Few studies have reported the consequences of the prolonged peritoneum. There is no
doubt that increased intra-abdominal pressure reduces liver, renal lower limb and
mesenteric blood flow. It also increases cardiac output and arterial pressures . The presence
of obesity exacerbates these problems further. Careful consideration therefore needs to be
given to those patients with significant renal and cardiac disease. There is also experimental
evidence that prolonged peritoneum can impair post-operative liver regeneration, oxidative
stress and hepatocellular damage62. Sometimes the pneumoperitoneum can have
advantages in that during bleeding a careful increase in intra-abdominal pressure can
reduce bleeding and allow parenchymal transection without portal clamping. However
prolonged pneumoperitoneum with portal clamping can cause a significant reduction in
hepatic oxygen tensions, tissue hypoxia, with higher transaminase and increased tissue
necrosis 63. Gas embolism is also thought to be of concern in that it can cause haemodynamic
disturbance in 50% of episodes but usually has no clinical consequences as the solubility of
carbon dioxide is greater than nitrogen. It is important to avoid high intra-abdominal
pressures when dissecting the major venous structures in an effort to avoid this problem 64.
By controlling the differential pressures between the pneumoperitoneum and central venous
pressure the risk of air embolism can be reduced significantly.
5. Techniques of laparoscopic liver resection

Definitions of laparoscopic liver surgery have been standardised. There are 3 techniques,
totally laparoscopic, hand assisted and hybrid 11. Hand assisted can be used either at the
start of the operation or introduced at any time to aid dissection. This is most often
performed during right hepatectomy or major resection and to control bleeding. Hybrid
procedures comprise either totally laparoscopic converted to hand assisted and then the
operation is completed through a small incision usually this is for parenchymal transection
or to aid mobilisation of the right or left lobe after hilar dissection.
5.1 Patient positioning

During resection of the left lateral segment, and tumours within the anterior segments e.g.
IVb, V, VI the patient is positioned in the supine position with split legs with the surgeon
standing in between them and the assistants on each side (Figure 4). For tumours placed in
the posterior segments (VI and VII), patients are positioned in the left lateral decubitus
position. For those patients positioned supine with split legs, five ports (ENDO PATH Xcel
™, Ethicon Endosurgery, LLC, USA) are positioned; three 12 mm ports: the first at the
umbilicus (sometimes higher if distance between the xiphoid and umbilicus is greater than
15 cm), the second and third working ports in the right and left mid clavicular line; and two
5 mm ports in the right and left anterior axilliary line (Figure 5). For tumours positioned in
segments IVa and VIII, high up towards the dome of the right diaphragm a further 10mm
port is placed at the xiphisternum to allow for CUSA parenchymal division (Integra, Saint
Priest, France, USA)
Fig. 4. The surgeons preferred position for lap resection
Fig. 5. Port position for lap left lateral resection

Left hepatectomy can usually be performed using similar port positions to left lateral
resection. For right hepatectomy the surgeon stands between the patients legs with two
assistants on either side. The right side and right shoulder are slightly elevated. Ports are
shifted to the right and are placed as far across as the mid axillary line (Figures 7a and 7b).
A hand port, if required, is usually placed in the right iliac fossa (Figure 8). If it is placed too
high the hand will be over the liver, if it placed too low the surgeon has to stoop for
prolonged periods which can become uncomfortable. A laparoscopic port can also be placed
through the hand port to assist with totally laparoscopic dissection. Right hepatectomy
hepatectomy should only be performed if the tumour is located away from the hilum or the
RHV or IVC so as to give an oncologically sound resection.
5.2 Pringle’s manoeuvre

A staging laparoscopy is performed first to rule out the presence of significant extra-hepatic
disease although this is often limited due to dense pelvic adhesions. Laparoscopic
ultrasound (7.5 MHz, Aloka Co. Ltd, Tokyo, Japan) of the liver is then performed to define
the vascular anatomy and to confirm the location of metastases. The liver can be lifted by
two methods; early in our series a Nathanson hook was placed at the xiphisternum as
described for Nissen’s Fundiplication. This elevates the left lateral segment and the hepato-
duodenal ligament off the inferior vena cava thus ensuring good access through the foramen
of Winslow and giving fixed retraction for all hilar dissection. Now either a hand retractor
(fan), diamond flex or goldfinger retractor can be placed through a 5mm port to elevate the
LLS. The xiphisternal Nathanson Hook can then be replaced with a 5mm port after hilar
dissection to assist with tumours high on the dome of VIII.
An alternative method is to retract the falciform ligament towards the shoulder but this uses
an instrument through a 5 mm port. A better approach is to divide the falciform ligament
and then place an Endoloop ™ (Autosuture, Tyco Healthcare UK Ltd) around the free edge
of the ligamentum teres. This can be retracted superiorly by bringing this through the
anterior abdominal wall using an ‘Endo Close™’ (Autosuture, Tyco Healthcare UK Ltd)
device. The suture is then held in a haemostat thus holding the ligament against the anterior
abdominal wall. The gallbladder can also be used for retraction but some patients may have
already had this removed. Calot’s triangle should be dissected first and the cystic duct and
cystic artery divided.. Sometimes it is necessary to partially dissect the infundibulum of the
gallbladder prior to retraction over the liver. This elevates the liver and also assists with
access to the posterior surface of V and VI.
Once the liver has been retracted and the hepato-duodenal ligament has been lifted a tape
can then be placed. The pars lucida is opened, care being taken to look for an accessory left
hepatic artery. To place a tourniquet around the hepato-duodenal ligament a ‘Gold finger’
(Gold finger ™, Blunt Dissector and Suture Retrieval System, Ethicon Endo Surgery,
Johnson & Johnson, USA) is used. This is an endoscopic dissector previously developed for
laparoscopic bariatric surgery. The Gold finger is a long instrument with a versatile tip
which is used to help position laparoscopic gastric bands and creation of a retro-gastric
tunnel. The tip is blunt and includes a slot to snare and pull a pre-tied suture, and a keyhole
for multiple gastric bands. The tip can be set at varying degrees between the neutral position
and 90 degrees. It has multi-positional flexibility, is malleable and provides precise
articulation. The Gold finger has a one-handed, ergonomic operation which enables precise
dissection and controlled grasping and snaring. It is also disposable and ensures sterility
and consistent performance.
A nylon tape is passed through the snare in the tip of a Gold finger ™ (Ethicon Endo
Surgery, Johnson & Johnson, USA). As the tip of the Gold finger is blunt and atraumatic, it
can safely be introduced through a 10 mm working port in the right upper quadrant. It is
best to do this through the right sided port as the natural curvature of the liver from this
side avoids placing the tip into the caudate lobe and porta-hepatis if done from the left side.
The hepato-duodenal ligament is then cradled by the ‘Gold finger ™’ (Ethicon Endo
Surgery, Johnson & Johnson, USA). The Gold finger is then advanced beyond the porta-
hepatis until the tip with the nylon tape can be visualised on the left side of the hepato-
duodenal ligament. As the tip of the Gold finger is atraumatic, it can be safely deployed the
tip is then flexed and articulated to 90 degrees. The tape can then be grasped through the
port placed in the left upper quadrant in the mid-clavicular line (Figure 6). The two ends are
positioned through the port onto the anterior abdominal wall and placed through a
‘snugger’ using tubing (Suction tubing 10 cm, 7 mm, Pennine Healthcare Ltd, UK). The port
is removed and replaced with the tape lying adjacent to the side of the port.
Portal triad clamping (Pringle’s manoeuvre) is one of the methods used to reduce bleeding
from the hepatic transection plane. This manoeuvre of encircling the hepato-duodenal
ligament with a nylon tape is widely used and is easily performed during conventional open
surgery. However, this step can be difficult and technically challenging during laparoscopic
liver surgery and not all surgeons place a tape laparoscopically for fear of injury to the IVC
and structures within the porta hepatitis. For major laparoscopic resection it is a vital
adjunct to reduce haemorrhage. This is as a result of the two dimensional view during
laparoscopy and the ergonomics of most laparoscopic instruments make this manipulation
blind with the potential of injury to vital structures. Most of the literature on totally
laparoscopic liver resection mentions the placement of a tape or vascular sling around the
portal triad in the hepato-duodenal ligament in case a Pringle’s manoeuvre is necessary
during parenchymal division 21 although opinions differ 65 14 66 and once experience has
been gained for minor resections is often not necessary at all, even in some cirrhotic patients
67 Nonetheless it is our policy to always place a tape around the hepatoduodenal ligament
for training purposes.

Some surgeons use a tape around the hepato-duodenal ligament with intra-peritoneal
clamping. However, this uses up an extra port as an instrument clamps it on the inside.
Moreover laparoscopic instruments are not robust enough to give a satisfactory clamp. The
technique of using the Gold finger to facilitate placement of a tape around the hepato-
duodenal ligament for the Pringle manoeuvre is an easy, safe and efficient technique. This
manoeuvre is performed easily in a few minutes. Although this technique has evolved in a
small series we believe this to be a simplified technique that is much easier and safer for
laparoscopic liver resection.
6. Parenchymal transection and haemostasis

6.1 Hilar dissection
There are many preferences for hilar dissection for major resection e.g. right trisectionetomy,
right hepatectomy or left hepatectomy. Intra-hepatic 68 or extra-hepatic 69 (conventional or
anterior approach) division of major structures have both been described. It is the authors
practice to divide all major structures extra-hepatically with the exception of the hepatic bile
duct. This is divided last of all, within the liver parenchyma, using a suitable stapling
device. Fortunately the use of vascular staplers with roticulators has overcome most of the
problems relating to the management of major pedicles and vessels, these can be either 45 or
60mm varieties. When the bile duct is divided within the liver there is less risk of damaging
the remnant hepatic duct.
Fig. 6. Hepatoduodenal tape positioned lateral to the port for a Pringle manoeuvre
Fig. 7a. Port position for laporoscopic right hepatectomy with RIF incision
Fig. 7b. Pre-operative marking for hand assisted right hepatectomy

Fig. 8. Hand assisted liver resection

Hilar dissection can be tedious and difficult especially when there are extensive adhesions.
Major structures can be inadvertently injured and troublesome bleeding can be difficult to
deal with for the inexperienced surgeon. Extensive dissection in the hepatoduodenal
ligament is never necessary and can lead to devascularisation of the common hepatic duct or
remnant hepatic duct. For a right hepatectomy identification of major structures such as the
right hepatic artery (RHA), and right portal vein (RPV) can be approached either anteriorly
or laterally, posterior to the hepatic duct.. The author’s preference is to use locking clips
such as Weck Clips. The portal vein can be approached differently. This can be divided
using either a vascular stapler or Weck clips. However, care needs to be taken when
achieving vascular control as bleeding at the portal confluence can be difficult to stop.
Dividing the caudate process prior to this assists this manoeuvre by allowing more room.
Tiny venous tributaries supplying the true caudate lobe and caudate process may also be
encountered.
The posterior or Glissonian approach described by Launois and Jamieson 70 avoids hilar
dissection within the hepatoduodenal ligament. The basic concept is that the major right
sided structures such as RHA, RPV and RHD are enveloped in a tough fibrous Glissonian
sheath. This is more common for hand assisted procedures 71. Keeping very close, posterior
to the sheath a finger is used to encircle the right pedicle. If inflow to the remnant is
confirmed the whole pedicle is ligated using a vascular stapling device. There is certainly no
doubt that the posterior approach is the quickest way for inflow division 72,73.
Another technique for right hepatectomy is the anterior approach 68. This avoids the
potential hazard of major injury to the RHV with injudicious mobilization of liver and the
potential for hepatic ischaemia. Another problem that is avoided is IVC obstruction when
the liver is continually rotated to the left. It also has a theoretical advantage of less
propagation of tumour cells during the mobilisation phase as the liver is only mobilised
once the RHV has been disconnected. The anterior approach involves hilar dissection and
inflow control, complete parenchymal transection and division of the RHV only then is liver
mobilised. Survival appears to be better for the anterior approach ‘open procedures’, when
compared to the conventional mobilisation technique for patients with HCC74.
6.2 Parenchymal transection

Haemorrhage can be exsanguinating and unpredictable particularly after sustained use of
chemotherapy. However it is the constant steady bleeding sustained in the phase of
parenchymal transection that contributes most to the overall blood loss. A variety of
techniques and surgical adjuncts can be used to aid parenchymal transection. Most
experience is with the Cavitational ultrasonic aspirator (CUSA TM), bipolar sealing device
Tissue Link, The Habib x4 TM radiofrequency device or the Harmonic Scalpel ultrasonically
activated shears (now Harmonic ACE TM). The Harmonic Scalpel ® cuts and coagulates by
using ultrasound. Vessels are coapted (tamponaded) and sealed by a protein coagulum.
Coagulation occurs by means of protein denaturation when the blade, vibrating at 55,000
Hz, couples with protein, denaturing it to form a coagulum that seals small coapted vessels.
The newer Harmonic ACE version appears to be more effective in that it is faster and seals
vessels up to 5mm in diameter and seals up to twice systolic pressure. However after a 15
second application heat can be 140 oC 1cm away from the tip causing significant lateral
thermal damage away from the tissues being sealed 75. Their powerful compression forces
are directed at the tip of the device as well 76.
Newer generation devices include the LOTUS Torsion TM, which uses torsional ultrasound,
transfers less energy to adjacent structures. The torsional waveform is thought to be safer as
there are only weak frictional forces at the tip of the active blade and reduces’ distal drilling’
and tissue charring. The Ligasure TM device which utilises low voltage bi-polar
radiofrequency energy seals vessels up to 7mm in diameter up to 3 times systolic pressure
and monitors changes in tissue impedance and adjusts the energy output accordingly
causing less collateral tissue damage to within 1.5mm of the grasping jaws 77. Tissuelink
(Aquamantys TM) works using transcollation (transforming collagen) technology sealing
small biliary radicals, no charringand gives a bloodless operating field. This device delivers
radiofrequency energy and saline simultaneously to achieve temperatures of 100oC 78. The
major disadvantage is that is can be slower and is more expensive. A cheap and effective
time honoured method is bipolar diathermy giving good haemostasis on the liver
parenchyma using a power of up to 80 watts. There have been concerns regarding Argon
Beam Coagulation (ABC) and gas embolism79 because of the stream of argon gas when the
instrument is activated particularly on the liver bed when there are large open vessels. It is
strongly advisable not to use ABC in this situation.
There are no well designed controlled studies comparing different haemostatic techniques
during LLR but these have been reviewed in detail elsewhere 80 81. Attention to detail
regarding securing the bile ducts, identifying and ligating the medium and larger vascular
structures are important in ensuring minimal blood loss, bile leaks and achieving an
oncologically sound surgical procedure. To realize this, various techniques might be needed
at different stages of the operation and therefore a working knowledge of all available
techniques is useful.
7. Laparoscopic versus open liver resection - The evidence

7.1 The learning curve/patient benefit
Most studies reporting laparoscopic liver resection report a learning curve. How long that
learning curve is depends on the type of resection. Small resections less than 2cm require
little additional skill to that needed for a complex laparoscopic cholecystectomy when
positioned in the anterior segments V, IVb or left lateral segment on the proviso the surgeon
has completed a recognised training program in HPB surgery. For more major resections
e.g. right heptectomy, left hepatectomy the bar is significantly raised and should only be
attempted by surgeons who regularly perform complex laparoscopic procedures. The main
limiting factor is technical difficulty and access. Some would suggest that increasing size of
tumour is not a limiting factor 60 but this is not what has been recommended in the
Louisville guidelines 11.
It cannot be denied that not everyone is suitable for a laparoscopic liver resection. Most
centres suggest that up to 30% 68 29 are suitable although those centres performing more
major resections regularly report higher rates up to 80% but also report higher rates with
hand assisted techniques 82 4. One study suggests a learning curve of 60 cases is adequate to
demonstrate quicker operating times and a lower conversion rate 83. Indeed during our 4
year experience the conversion rate has decreased from 14% to 3%. The commonest reason
for conversion is usually technical or due to bleeding.
Most studies doing detailed analysis report reduced operating time when different era’s are
evaluated68. For example, laparoscopic left lateral resection can become significantly
quicker84 58 as in our experience, yet for major resection (e.g. right hepatectomy) there is still
some progress to be made to reduce operating times compared to open (5 hours versus 3
hours) 61,68 even procedures up to 10 hours have been reported 60. Also anatomical resections
are generally quicker than non anatomical wedge resections 68. Nonetheless the learning
curve is difficult to assess as it depends on the definition of success which to most would be
disease free survival which is rarely discussed. One study has addressed this in detail in a
non randomized study comparing 120 patients. There does not appear to be any difference
in overall 5 year survival in those having either LLR or open resection in terms of disease
free survival 85. Most studies report no difference in rates of R0 resection and no increased
risk of positive margins after LLR as reviewed elsewhere 10. Although a recent meta-analysis
suggests the risk of an R0 resection (<1cm) is twice as high after LLR than for open
resection86. Indeed R1 resection rates of up to 43% have been reported 18 and non segmental
resections may have the highest risk 87.
For left lateral resections and segmental resections blood loss and transfusion requirements
have improved significantly through eras and now most involved in the field would suggest
that with more minor resections blood loss is less when compared to open surgery 22,86,4.
However this is perhaps not the case for major resection and bleeding can be catastrophic
and problematic when it is from a major tributary such as the RHV or venous confluence 19
and this is why some prefer the safety of a hand port when they approach the RHV during
right hepatectomy.
The main advantage of LLR are the reported benefits which apply to all minimally invasive
procedures. These include reduced post-operative pain relief, reduced hospital stay, less
morbidity and mortality. Certainly a recent meta-analysis suggests patients have less blood
loss, shorter post-operative stay and a quicker return to activities of daily living for left
lateral resection or metastectomy7 6,86,4,10. Without randomized studies this will be difficult to
confirm as laparoscopic enthusiasts may have a tendency to send patients home earlier than
usual practise and may vary between centres. Generally the disadvantage of higher costs is
offset by the shorter stay 88,7,89,90.
8. Training in laparosopic liver surgery

An important consideration certainly in Europe is the recent introduction of the European
Working Time Directive (EWTD) which has threatened surgical training by a reduction in
working hours and doctor/patient contact. Surgical trainees are therefore not exposed to as
many opportunities to learn new or advanced techniques in laparoscopic surgery. There is
no doubt that laparoscopic training programs need to be developed to keep pace with the
introduction of new techniques and to allow surgical trainees adequate exposure and
applies to all surgical specialities.
A growth area in this field has been the introduction of various structured programs, virtual
reality systems and laparoscopic simulators which have been reviewed in detail elsewhere.
91 92. Alternative approaches to facilitate training has been the use of porcine or canine
simulators 93 . Nevertheless these can be expensive to implement and can be problematic for
licensing. An alternative approach which has not been widely reported is the use of a
Cadaver Lab Training Facility 94.
The Newcastle Surgical Training Centre (NSTC) based at the Freeman Hospital opened in
September 2007 (Figure 9). The laparoscopic training facility provides a specialist forum for
the development of advanced laparoscopic skills and is part of the national drive to improve
the delivery of near-patient technology. It is a unique, state of the art facility providing
advanced cadaveric education which enables surgeons to gain cadaveric training in a
unique and extremely high specification “wet lab” environment on fresh frozen cadavers.
This centre is one of the very first anatomical examination units of its kind in the UK to carry
a formal license from the Human Tissue Authority (HTA). The Human Tissue Act 2004
received Royal Assent in November 2004 and the act sets out standards and provides
guidance to clinicians carrying out education and training in using human cadaveric
materials.
Fig. 9. Laparoscopic cadaver training lab

A course has been designed by a faculty of experienced, advanced laparoscopic surgeons
providing an intensive 2 day course of lectures, debate, exchange and practical hands on
with a live link to clinical laparoscopic liver resection operations. All participants are given
an opportunity to perform 8 key tasks in order to develop their laparoscopic liver surgery
skills. These include the following;
1. Port Positioning for left lateral liver resection
2. Tape placement around the hepatoduodenal ligament for a safe Pringle’s manoeuvre
3. Dissection of hilar structures, portal vein, hepatic artery, and confluence of the hepatic
ducts and common bile duct.
4. Left lateral liver mobilisation.
5. Left lateral sectionectomy with an ultrasonic aspirator and stapling of the left hepatic
vein.
6. Right lobe mobilisation
7. Right hepatectomy with dissection of RHA, RPV, RHD and IVC dissection with
stapling of the RHV.
8. Use of hand ports for facilitating right hepatectomy.
Although safety, efficacy and reproducibility of LLS has been established, the same cannot
be said of the training and accreditation of junior surgeons. The specialist surgical societies
both at National and International levels are yet to establish guidelines for training and
mentoring.
With rapid progress in the field of electronics, computers and robotics, training of
residents/junior surgeons through surgical simulation is slowly gaining popularity as it
provides an opportunity for the trainee to develop the necessary skills for the clinical
situation. Furthermore with advanced software technologies, visual fidelity , manual
dexterity, hand eye co-ordination, real time response to emergency situations can now be
assessed. The down side of the virtual reality simulators is their computing power and the
initial set up costs. Oversimplification of complex reality isolates the trainee from the clinical
situation. As far as the authors are aware there are no virtual reality simulators for LLR
available for training.
Though basic psychomotor skills can be learnt on a surgical simulator or virtual reality
simulator, learning to use high energy devices like diathermy or dissectors, tissue handling
need a more realistic model like an animal or human cadaver. A synthetic model though
attractive in terms of cost benefit falls short in recreating training outcomes. Rodents have
been used extensively in both open and laparoscopic training models as they are well suited
for laboratory based research activities, are expensive to buy, breed and house in a
laboratory. Krahenbuhl et al. 95 have reported a safe technique of LLR in rats for liver
physiology research. Canine models have also been advocated but their major drawback are
anatomical constraints having multiple liver lobes but also stringent laws in the United
Kingdom which prevent their routine use in the laboratory for training 96 97. Porcine models
have been used extensively in Europe because of size and more favourable anatomy.
Unfortunately their overall cost and safety regulations prohibit their use in the UK. Sheep
have also been used for LLR because they are anatomically similar to human 98.
The use of a cadaver in a dissection laboratory for imparting anatomical knowledge is well
established 99. Cadaver training has also been used successfully in a workshop to train
residents in internal medicine to perform bedside procedures like thoracocentesis,
paracentesis, lumbar puncture and bone marrow biopsy 100. Fresh cadavers have also been
used for vascular surgery training 101.
Using cadavers for learning laparoscopic procedures holds immense potential. Katz et al. 102
described a cadaver model to be superior to porcine models for urological laparoscopic
training. Cadaver laparoscopic dissection has been used to enhance resident comprehension
of pelvic anatomy 103. In the UK with the introduction of the Human Tissue Act 2004, it is
possible to store and use cadavers for laparoscopic training. The advantages of using
cadavers are perfect for reproducing anatomical landmarks, tissue consistency and
flexibility, tactile feedback and tissue handling, use of gravity and retraction to make it more
realistic and almost near perfect reproduction of critical steps. Furthermore, the use of
proper instruments, patient positioning and an operation room setup helps the surgeon to
train in a more conducive atmosphere.
We have been conducting cadaver laparoscopic liver surgery courses for both practising and
training surgeons at NSTC since 2007. We have shown that the overall rating of the course
by the trainees attending has been very good.
9. References
[1] Jarnagin WR, Gonen M, Fong Y, Dematteo RP, Ben-Porat L, Little S et al. Improvement in
perioperative outcome after hepatic resection: analysis of 1,803 consecutive cases
over the past decade. Ann Surg 2002; 236(4):397-406.
[2] Rees M, Tekkis PP, Welsh FK, O'Rourke T, John TG. Evaluation of long-term survival
after hepatic resection for metastatic colorectal cancer: a multifactorial model of 929
patients. Ann Surg 2008; 247(1):125-135.
[3] Laparoscopic partial hepatectomy for liver tumour. Surg.Endosc. 6, 99. 1-9-1992. Gagner,
M., Rheault, M., and Dubuc, J. Ref Type: Generic
[4] Nguyen KT, Geller DA. Laparoscopic liver resection--current update. Surg Clin North Am
2010; 90(4):749-760.
[5] Nguyen KT, Gamblin TC, Geller DA. World review of laparoscopic liver resection-2,804
patients. Ann Surg 2009; 250(5):831-841.
[6] Simillis C, Constantinides VA, Tekkis PP, Darzi A, Lovegrove R, Jiao L et al.
Laparoscopic versus open hepatic resections for benign and malignant neoplasms--
a meta-analysis. Surgery 2007; 141(2):203-211.
[7] Rao A, Rao G, Ahmed I. Laparoscopic left lateral liver resection should be a standard
operation. Surg Endosc 2011; 25(5):1603-1610.
[8] Croome KP, Yamashita MH. Laparoscopic vs open hepatic resection for benign and
malignant tumors: An updated meta-analysis. Arch Surg 2010; 145(11):1109-1118.
[9] Vigano L, Tayar C, Laurent A, Cherqui D. Laparoscopic liver resection: a systematic
review. J Hepatobiliary Pancreat Surg 2009; 16(4):410-421.
[10] Nguyen KT, Marsh JW, Tsung A, Steel JJ, Gamblin TC, Geller DA. Comparative Benefits
of Laparoscopic vs Open Hepatic Resection: A Critical Appraisal. Arch Surg 2011;
146(3):348-356.
[11] Buell JF, Cherqui D, Geller DA, O'Rourke N, Iannitti D, Dagher I et al. The international
position on laparoscopic liver surgery: The Louisville Statement, 2008. Ann Surg
2009; 250(5):825-830.
[12] Soubrane O, Cherqui D, Scatton O, Stenard F, Bernard D, Branchereau S et al.
Laparoscopic left lateral sectionectomy in living donors: safety and reproducibility
of the technique in a single center. Ann Surg 2006; 244(5):815-820.
[13] Suh KS, Yi NJ, Kim T, Kim J, Shin WY, Lee HW et al. Laparoscopy-assisted donor right
hepatectomy using a hand port system preserving the middle hepatic vein
branches. World J Surg 2009; 33(3):526-533.
[14] Troisi RI, Van HJ, Berrevoet F, Vandenbossche B, Sainz-Barriga M, Vinci A et al.
Evolution of laparoscopic left lateral sectionectomy without the Pringle maneuver:
through resection of benign and malignant tumors to living liver donation. Surg
Endosc 2011; 25(1):79-87.
[15] Koffron AJ, Kung R, Baker T, Fryer J, Clark L, Abecassis M. Laparoscopic-assisted right
lobe donor hepatectomy. Am J Transplant 2006; 6(10):2522-2525.
[16] Farges O, Jagot P, Kirstetter P, Marty J, Belghiti J. Prospective assessment of the safety
and benefit of laparoscopic liver resections. J Hepatobiliary Pancreat Surg 2002;
9(2):242-248.
[17] Ardito F, Tayar C, Laurent A, Karoui M, Loriau J, Cherqui D. Laparoscopic liver
resection for benign disease. Arch Surg 2007; 142(12):1188-1193.
[18] Morino M, Morra I, Rosso E, Miglietta C, Garrone C. Laparoscopic vs open hepatic
resection: a comparative study. Surg Endosc 2003; 17(12):1914-1918.
[19] Troisi R, Montalti R, Smeets P, Van HJ, Van VH, Colle I et al. The value of laparoscopic
liver surgery for solid benign hepatic tumors. Surg Endosc 2008; 22(1):38-44.
[20] Katkhouda N, Hurwitz M, Gugenheim J, Mavor E, Mason RJ, Waldrep DJ et al.
Laparoscopic management of benign solid and cystic lesions of the liver. Ann Surg
1999; 229(4):460-466.
[21] Vibert E, Perniceni T, Levard H, Denet C, Shahri NK, Gayet B. Laparoscopic liver
resection. Br J Surg 2006; 93(1):67-72.
[22] Koffron AJ, Auffenberg G, Kung R, Abecassis M. Evaluation of 300 minimally invasive
liver resections at a single institution: less is more. Ann Surg 2007; 246(3):385-392.
[23] Giulianotti PC, Sbrana F, Bianco FM, Addeo P. Robot-assisted laparoscopic extended
right hepatectomy with biliary reconstruction. J Laparoendosc Adv Surg Tech A 2010;
20(2):159-163.
[24] Elias D, Sideris L, Pocard M, Ouellet JF, Boige V, Lasser P et al. Results of R0 resection
for colorectal liver metastases associated with extrahepatic disease. Ann Surg Oncol
2004; 11(3):274-280.
[25] Elias D, Liberale G, Vernerey D, Pocard M, Ducreux M, Boige V et al. Hepatic and
extrahepatic colorectal metastases: when resectable, their localization does not
matter, but their total number has a prognostic effect. Ann Surg Oncol 2005;
12(11):900-909.
[26] Elias D, Delperro JR, Sideris L, Benhamou E, Pocard M, Baton O et al. Treatment of
peritoneal carcinomatosis from colorectal cancer: impact of complete cytoreductive
surgery and difficulties in conducting randomized trials. Ann Surg Oncol 2004;
11(5):518-521.
[27] Gumbs AA, Gayet B. Video: the lateral laparoscopic approach to lesions in the posterior
segments. J Gastrointest Surg 2008; 12(7):1154.
[28] Costi R, Capelluto E, Sperduto N, Bruyns J, Himpens J, Cadiere GB. Laparoscopic right
posterior hepatic bisegmentectomy (Segments VII-VIII). Surg Endosc 2003; 17(1):162.
[29] Cho JY, Han HS, Yoon YS, Shin SH. Experiences of laparoscopic liver resection
including lesions in the posterosuperior segments of the liver. Surg Endosc 2008;
22(11):2344-2349.
[30] Jaeck D. The significance of hepatic pedicle lymph nodes metastases in surgical
management of colorectal liver metastases and of other liver malignancies. Ann
Surg Oncol 2003; 10(9):1007-1011.
[31] Grobmyer SR, Wang L, Gonen M, Fong Y, Klimstra D, D'Angelica M et al. Perihepatic
lymph node assessment in patients undergoing partial hepatectomy for
malignancy. Ann Surg 2006; 244(2):260-264.
[32] Lochan R, White SA, Manas DM. Liver resection for colorectal liver metastasis. Surg
Oncol 2007; 16(1):33-45.
[33] Kim SH, Lim SB, Ha YH, Han SS, Park SJ, Choi HS et al. Laparoscopic-assisted
combined colon and liver resection for primary colorectal cancer with synchronous
liver metastases: initial experience. World J Surg 2008; 32(12):2701-2706.
[34] Lee JS, Hong HT, Kim JH, Lee IK, Lee KH, Park IY et al. Simultaneous laparoscopic
resection of primary colorectal cancer and metastatic liver tumor: initial experience
of single institute. J Laparoendosc Adv Surg Tech A 2010; 20(8):683-687.
[35] Pathak S, Sarno G, Nunes QM, Poston GJ. Synchronous resection for colorectal liver
metastases: the future. Eur J Surg Oncol 2010; 36(11):1044-1046.
[36] Reddy SK, Pawlik TM, Zorzi D, Gleisner AL, Ribero D, Assumpcao L et al.
Simultaneous resections of colorectal cancer and synchronous liver metastases: a
multi-institutional analysis. Ann Surg Oncol 2007; 14(12):3481-3491.
[37] Tanaka K, Shimada H, Matsuo K, Nagano Y, Endo I, Sekido H et al. Outcome after
simultaneous colorectal and hepatic resection for colorectal cancer with
synchronous metastases. Surgery 2004; 136(3):650-659.
[38] de SE, Fernandez D, Vaccaro C, Quintana GO, Bonadeo F, Pekolj J et al. Short-term and
long-term outcomes after simultaneous resection of colorectal malignancies and
synchronous liver metastases. World J Surg 2010; 34(9):2133-2140.
[39] Tranchart H, Diop PS, Lainas P, Pourcher G, Catherine L, Franco D et al. Laparoscopic
major hepatectomy can be safely performed with colorectal surgery for
synchronous colorectal liver metastasis. HPB (Oxford) 2011; 13(1):46-50.
[40] Casaccia M, Famiglietti F, Andorno E, Di DS, Ferrari C, Valente U. Simultaneous
laparoscopic anterior resection and left hepatic lobectomy for stage IV rectal cancer.
JSLS 2010; 14(3):414-417.
[41] Khatri VP, Petrelli NJ, Belghiti J. Extending the frontiers of surgical therapy for hepatic
colorectal metastases: is there a limit? J Clin Oncol 2005; 23(33):8490-8499.
[42] Petrowsky H, Gonen M, Jarnagin W, Lorenz M, DeMatteo R, Heinrich S et al. Second
liver resections are safe and effective treatment for recurrent hepatic metastases
from colorectal cancer: a bi-institutional analysis. Ann Surg 2002; 235(6):863-871.
[43] Adam R, Pascal G, Azoulay D, Tanaka K, Castaing D, Bismuth H. Liver resection for
colorectal metastases: the third hepatectomy. Ann Surg 2003; 238(6):871-883.
[44] White SA, Manas DM, Farid SG, Prasad KR. Optimal treatment for hepatocellular
carcinoma in the cirrhotic liver. Ann R Coll Surg Engl 2009; 91(7):545-550.
[45] Mazzaferro V, Regalia E, Doci R, Andreola S, Pulvirenti A, Bozzetti F et al. Liver
transplantation for the treatment of small hepatocellular carcinomas in patients
with cirrhosis. N Engl J Med 1996; 334(11):693-699.
[46] Adam R, Azoulay D, Castaing D, Eshkenazy R, Pascal G, Hashizume K et al. Liver
resection as a bridge to transplantation for hepatocellular carcinoma on cirrhosis: a
reasonable strategy? Ann Surg 2003; 238(4):508-518.
[47] Belghiti J, Cortes A, Abdalla EK, Regimbeau JM, Prakash K, Durand F et al. Resection
prior to liver transplantation for hepatocellular carcinoma. Ann Surg 2003;
238(6):885-892.
[48] Cherqui D, Laurent A, Tayar C, Chang S, Van Nhieu JT, Loriau J et al. Laparoscopic
liver resection for peripheral hepatocellular carcinoma in patients with chronic liver
disease: midterm results and perspectives. Ann Surg 2006; 243(4):499-506.
[49] Tranchart H, Di GG, Lainas P, Roudie J, Agostini H, Franco D et al. Laparoscopic
resection for hepatocellular carcinoma: a matched-pair comparative study. Surg
Endosc 2010; 24(5):1170-1176.
[50] Sarpel U, Hefti MM, Wisnievsky JP, Roayaie S, Schwartz ME, Labow DM. Outcome for
patients treated with laparoscopic versus open resection of hepatocellular
carcinoma: case-matched analysis. Ann Surg Oncol 2009; 16(6):1572-1577.
[51] Lai EC, Tang CN, Ha JP, Li MK. Laparoscopic liver resection for hepatocellular
carcinoma: ten-year experience in a single center. Arch Surg 2009; 144(2):143-147.
[52] Belli G, Limongelli P, Fantini C, D'Agostino A, Cioffi L, Belli A et al. Laparoscopic and
open treatment of hepatocellular carcinoma in patients with cirrhosis. Br J Surg
2009; 96(9):1041-1048.
[53] Zhang L, Chen YJ, Shang CZ, Zhang HW, Huang ZJ. Total laparoscopic liver resection
in 78 patients. World J Gastroenterol 2009; 15(45):5727-5731.
[54] Belli G, Fantini C, Belli A, Limongelli P. Laparoscopic liver resection for hepatocellular
carcinoma in cirrhosis: long-term outcomes. Dig Surg 2011; 28(2):134-140.
[55] Dagher I, Belli G, Fantini C, Laurent A, Tayar C, Lainas P et al. Laparoscopic
hepatectomy for hepatocellular carcinoma: a European experience. J Am Coll Surg
2010; 211(1):16-23.
[56] Sahani DV, Kalva SP. Imaging the liver. Oncologist 2004; 9(4):385-397.
[57] Ward J, Robinson PJ, Guthrie JA, Downing S, Wilson D, Lodge JP et al. Liver metastases
in candidates for hepatic resection: comparison of helical CT and gadolinium- and
SPIO-enhanced MR imaging. Radiology 2005; 237(1):170-180.
[58] Abu HM, Pearce NW. Laparoscopic left lateral liver sectionectomy: a safe, efficient,
reproducible technique. Dig Surg 2008; 25(4):305-308.
[59] Rao A, Rao G, Ahmed I. Laparoscopic left lateral liver resection should be a standard
operation. Surg Endosc 2011; 25(5):1603-1610.
[60] Dagher I, O'Rourke N, Geller DA, Cherqui D, Belli G, Gamblin TC et al. Laparoscopic
major hepatectomy: an evolution in standard of care. Ann Surg 2009; 250(5):856-860.
[61] Abu HM, Di FF, Teng MJ, Lykoudis P, Primrose JN, Pearce NW. Single-Centre
Comparative Study of Laparoscopic Versus Open Right Hepatectomy. J Gastrointest
Surg 2011.
[62] Schmidt SC, Schumacher G, Klage N, Chopra S, Neuhaus P, Neumann U. The impact of
carbon dioxide pneumoperitoneum on liver regeneration after liver resection in a
rat model. Surg Endosc 2010; 24(1):1-8.
[63] Nsadi B, Gilson N, Pire E, Cheramy JP, Pincemail J, Scagnol I et al. Consequences of
pneumoperitoneum on liver ischemia during laparoscopic portal triad clamping in
a swine model. J Surg Res 2011; 166(1):e35-e43.
[64] Fors D, Eiriksson K, Arvidsson D, Rubertsson S. Gas embolism during laparoscopic
liver resection in a pig model: frequency and severity. Br J Anaesth 2010.
[65] Kazaryan AM, Pavlik M, I, Rosseland AR, Rosok BI, Mala T, Villanger O et al.
Laparoscopic liver resection for malignant and benign lesions: ten-year Norwegian
single-center experience. Arch Surg 2010; 145(1):34-40.
[66] Pulitano C, Catena M, Arru M, Guzzetti E, Comotti L, Ferla G et al. Laparoscopic liver
resection without portal clamping: a prospective evaluation. Surg Endosc 2008;
22(10):2196-2200.
[67] Belli G, Fantini C, D'Agostino A, Belli A, Russolillo N, Cioffi L. [Laparoscopic liver
resection without a Pringle maneuver for HCC in cirrhotic patients]. Chir Ital 2005;
57(1):15-25.
[68] Bryant R, Laurent A, Tayar C, Cherqui D. Laparoscopic liver resection-understanding

its role in current practice: the Henri Mondor Hospital experience. Ann Surg 2009;
250(1):103-111.
[69] Belli G, D'Agostino A, Fantini C, Belli A, Cioffi L, Limongelli P et al. Laparoscopic hand-
assisted right hemihepatectomy by ultrasound-directed intrahepatic approach. J
Hepatobiliary Pancreat Surg 2009; 16(6):781-785.
[70] Launois B, Jamieson GG. The posterior intrahepatic approach for hepatectomy or
removal of segments of the liver. Surg Gynecol Obstet 1992; 174(2):155-158.
[71] Belli G, D'Agostino A, Fantini C, Belli A, Cioffi L, Limongelli P et al. Laparoscopic hand-
assisted right hemihepatectomy by ultrasound-directed intrahepatic approach 21. J
Hepatobiliary Pancreat Surg 2009; 16(6):781-785.
[72] Machado MA, Makdissi FF, Herman P, Surjan RC. Intrahepatic Glissonian approach for
pure laparoscopic left hemihepatectomy. J Laparoendosc Adv Surg Tech A 2010;
20(2):141-142.
[73] Machado MA, Makdissi FF, Galvao FH, Machado MC. Intrahepatic Glissonian
approach for laparoscopic right segmental liver resections. Am J Surg 2008;
196(4):e38-e42.
[74] Liu CL, Fan ST, Cheung ST, Lo CM, Ng IO, Wong J. Anterior approach versus
conventional approach right hepatic resection for large hepatocellular carcinoma: a
prospective randomized controlled study. Ann Surg 2006; 244(2):194-203.
[75] Emam TA, Cuschieri A. How safe is high-power ultrasonic dissection? Ann Surg 2003;
237(2):186-191.
[76] Sutton PA, Awad S, Perkins AC, Lobo DN. Comparison of lateral thermal spread using
monopolar and bipolar diathermy, the Harmonic Scalpel and the Ligasure. Br J
Surg 2010; 97(3):428-433.
[77] Harold KL, Pollinger H, Matthews BD, Kercher KW, Sing RF, Heniford BT. Comparison
of ultrasonic energy, bipolar thermal energy, and vascular clips for the hemostasis
of small-, medium-, and large-sized arteries. Surg Endosc 2003; 17(8):1228-1230.
[78] Nissen NN, Grewal N, Lee J, Nawabi A, Korman J. Completely laparoscopic
nonanatomic hepatic resection using saline-cooled cautery and hydrodissection.
Am Surg 2007; 73(10):987-990.
[79] Kono M, Yahagi N, Kitahara M, Fujiwara Y, Sha M, Ohmura A. Cardiac arrest
associated with use of an argon beam coagulator during laparoscopic
cholecystectomy. Br J Anaesth 2001; 87(4):644-646.
[80] Abu HM, Underwood T, Taylor MG, Hamdan K, Elberm H, Pearce NW. Bleeding and
hemostasis in laparoscopic liver surgery. Surg Endosc 2010; 24(3):572-577.
[81] The use of fibrin sealants in laparoscopic liver surgery. Laparoscopic . 2011. saif, r. Ref
Type: Generic
[82] Buell JF, Thomas MT, Rudich S, Marvin M, Nagubandi R, Ravindra KV et al. Experience
with more than 500 minimally invasive hepatic procedures. Ann Surg 2008;
248(3):475-486.
[83] Vigano L, Laurent A, Tayar C, Tomatis M, Ponti A, Cherqui D. The learning curve in
laparoscopic liver resection: improved feasibility and reproducibility. Ann Surg
2009; 250(5):772-782.
[84] Lesurtel M, Cherqui D, Laurent A, Tayar C, Fagniez PL. Laparoscopic versus open left
lateral hepatic lobectomy: a case-control study. J Am Coll Surg 2003; 196(2):236-242.
[85] Castaing D, Vibert E, Ricca L, Azoulay D, Adam R, Gayet B. Oncologic results of
laparoscopic versus open hepatectomy for colorectal liver metastases in two
specialized centers. Ann Surg 2009; 250(5):849-855.
[86] Croome KP, Yamashita MH. Laparoscopic vs open hepatic resection for benign and
malignant tumors: An updated meta-analysis Arch Surg 2010; 145(11):1109-1118.
[87] Kazaryan AM, Marangos IP, Rosok BI, Rosseland AR, Villanger O, Fosse E et al.
Laparoscopic resection of colorectal liver metastases: surgical and long-term
oncologic outcome Ann Surg 2010; 252(6):1005-1012.
[88] Simillis C, Constantinides VA, Tekkis PP, Darzi A, Lovegrove R, Jiao L et al.
Laparoscopic versus open hepatic resections for benign and malignant neoplasms--
a meta-analysis. Surgery 2007; 141(2):203-211.
[89] Polignano FM, Quyn AJ, de Figueiredo RS, Henderson NA, Kulli C, Tait IS.
Laparoscopic versus open liver segmentectomy: prospective, case-matched,
intention-to-treat analysis of clinical outcomes and cost effectiveness. Surg Endosc
2008; 22(12):2564-2570.
[90] Vanounou T, Steel JL, Nguyen KT, Tsung A, Marsh JW, Geller DA et al. Comparing the
clinical and economic impact of laparoscopic versus open liver resection. Ann Surg
Oncol 2010; 17(4):998-1009.
[91] Fairhurst K, Strickland A, Maddern G. The LapSim virtual reality simulator: promising
but not yet proven. Surg Endosc 2010.
[92] Vassiliou MC, Dunkin BJ, Marks JM, Fried GM. FLS and FES: comprehensive models of
training and assessment. Surg Clin North Am 2010; 90(3):535-558.
[93] Fransson BA, Ragle CA. Assessment of laparoscopic skills before and after simulation
training with a canine abdominal model. J Am Vet Med Assoc 2010; 236(10):1079-
1084.
[94] Supe A, Dalvi A, Prabhu R, Kantharia C, Bhuiyan P. Cadaver as a model for
laparoscopic training. Indian J Gastroenterol 2005; 24(3):111-113.
[95] Krahenbuhl L, Feodorovici M, Renzulli P, Schafer M, Abou-Shady M, Baer HU.
Laparoscopic partial hepatectomy in the rat: a new resectional technique. Dig Surg
1998; 15(2):140-144.
[96] Frezza EE, Wachtel MS. A proposed canine model of laparoscopic nonanatomic liver
resection. J Laparoendosc Adv Surg Tech A 2006; 16(1):15-20.
[97] Machado MA, Galvao FH, Pompeu E, Ribeiro C, Bacchella T, Machado MC. A canine
model of laparoscopic segmental liver resection. J Laparoendosc Adv Surg Tech A
2004; 14(5):325-328.
[98] Teh SH, Hunter JG, Sheppard BC. A suitable animal model for laparoscopic hepatic
resection training. Surg Endosc 2007; 21(10):1738-1744.
[99] Parker LM. Anatomical dissection: why are we cutting it out? Dissection in
undergraduate teaching. ANZ J Surg 2002; 72(12):910-912.
[100] Oxentenko AS, Ebbert JO, Ward LE, Pankratz VS, Wood KE. A multidimensional
workshop using human cadavers to teach bedside procedures. Teach Learn Med
2003; 15(2):127-130.
[101] Reed AB, Crafton C, Giglia JS, Hutto JD. Back to basics: use of fresh cadavers in
vascular surgery training. Surgery 2009; 146(4):757-762.
[102] Katz R, Hoznek A, Antiphon P, Van VR, Delmas V, Abbou CC. Cadaveric versus
porcine models in urological laparoscopic training. Urol Int 2003; 71(3):310-315.
[103] Cundiff GW, Weidner AC, Visco AG. Effectiveness of laparoscopic cadaveric
dissection in enhancing resident comprehension of pelvic anatomy. J Am Coll Surg
2001; 192(4):492-497.
Part 3
Laparoscopic Appendectomy
8
Laparoscopic Appendectomy
Konstantinos M. Konstantinidis and Kornilia A. Anastasakou
Department of Surgery, Athens Medical Center
Greece
1. Introduction
Suspected acute appendicitis is the most frequent cause of emergency operations in visceral
surgery worldwide. Acute appendicitis is the reason for most urgent admissions and
unscheduled operations in general surgery. In the western world approximately 8% of the
population are appendectomised (Addis et al., 1990). The treatment for acute appendicitis
has been conventional appendectomy for more than a century. This procedure proved to be
safe and effective. However, a problem that remained is the high percentage -up to 47% in
women of child-bearing age- of negative appendectomies (Borgstein et. al, 1997).
Laparoscopic appendectomy counts almost 30 years of presence, and its introduction has
met with more hurdles than that of laparoscopic cholecystectomy. Especially during the last
two decades numerous studies tried to define the role of laparoscopic appendectomy in the
treatment of suspected acute appendicitis. In this chapter we aim to present our experience
with the laparoscopic approach for suspected appendicitis during the last almost twenty
years and discuss the diagnostic and therapeutic effects of laparoscopy in suspected
appendicitis. We will present our diagnostic approach, our surgical technique, and our
results, and will discuss the literature. The role of laparoscopy in fertile females will be
analysed. Also the place of laparoscopy in special groups such as the elderly, the employed
patients, the obese patients, the pregnant women, and the children will be discussed. Finally
we will refer briefly to newer techniques including the single port laparoscopic
appendectomy, the needlescopic procedure, and the incidental robotic appendectomy.
1.1 Background
1.1.1 Literature
Since the introduction of endoscopic appendectomy by Kurt Semm in 1983 (Semm, 1983)
the surgical community tried to determine its advantages and disadvantages compared to
the open procedure. Especially during the last twenty years there have been over 60
randomized controlled trials comparing laparoscopic and open appendectomy in adults
(Vettoretto et al., 2010) as well as many meta-analyses of randomized controlled trials
(Bennett et al., 2007; Chung et al, 1999; Fingerhut et al., 1999; Garbutt et al., 1999; Golub et
al., 1998; Liu et al., 2010; Sauerland et al., 1998, 2002, 2004, 2010). The number of publications
on laparoscopic appendectomy is still increasing, while publications on laparoscopic
cholecystectomy decline. The latter shows that the laparoscopic approach in suspected acute
appendicitis has not yet been fully accepted as the gold standard. There are still open issues
regarding the laparoscopic approach. These have to do with the indications, the results, the
costs, the standardisation of the surgical technique, the severity of leaving back a
macroscopically ‘innocent‘ appendix and the learning curve. Last but not least the debate
about the place of laparoscopy in complicated appendicitis, the incidence of intraabdominal
abscesses after laparoscopic appendectomy and its relationship to the severity of the disease,
the surgical technique, and the surgical expertise is still vivid.
In the last years it has become apparent that the laparoscopic approach does not have the
same value for all subpopulations. The investigators tried to determine the importance of
the laparoscopic method in several patient groups. So, one can maintain that recent studies
tend to clarify the issues regarding the worth of laparoscopy in the fertile female group, the
elderly, the obese and the employed patients. The debate is still ongoing about laparoscopy
in men, in complicated appendicitis, laparoscopy in pregnancy and in the paediatric
population.
1.1.2 Own experience

The first laparoscopic appendectomy in our department (surgical department specialized in
laparoscopy in a big private hospital in Athens) was performed in 1992. Since then we have
performed over 1800 laparoscopic appendectomies. We did not analyse all these cases, but
we performed a retrospective analysis in more than a thousand patients. Patients with
suspected appendicitis, who were treated in the Department of General, Laparoscopic, and
Robotic Surgery at the Athens Medical Center between April 1993 and March 2003 were
considered for our retrospective study on laparoscopic appendectomy published in 2008
(Konstantinidis et al, 2008). The study presented the results in 1026 patients and was not
comparative. Only laparoscopic patients were included as laparoscopy has been the
treatment of choice since the department was founded. Patients operated on during the
learning curve (100 pts.) and the few patients approached from the start by open technique
(15 pts.) were not included in the study. The inclusion criteria for our study on laparoscopic
appendectomy were suspected acute appendicitis (after clinical examination, laboratory
tests, and imaging tests) or chronic recurrent symptoms that could be attributed to
appendicitis, age 15 years or more and laparoscopy as first approach. All patients in whom
we performed a laparoscopic appendectomy or an appendectomy after conversion to an
open procedure were included in our analysis (908 pts). Also, diagnostic accuracy of
laparoscopy was analysed separately in the subgroup of fertile women (558 pts), and was
compared to diagnostic accuracy in the rest of the patients (468 pts).
After standardisation of our technique the latter did not actually change. New
developments were the single incision technique and the introduction of the DaVinci robotic
(TM- Intuitive Surgical Inc.) system in 2006. In this chapter we will refer to the results we
had between 1993 and 2003, as we measured and published them. With this exception we
will comment only on major complications and new developments.
2. Diagnostic approach, patient management and surgical technique

2.1 Diagnostic approach
We perform routine preoperative control in all patients. Women in whom differential
diagnosis includes gynaecological disorders are in many cases examined by the
gynaecologist and a transabdominal or transvaginal ultrasound or a CT scan is being
performed whenever indicated and possible. There are also some male patients, in whom
we might perform ultrasound or CT scan.
Laparoscopic Appendectomy 117
From the diagnostic point of view it has been suggested that active observation leads to a
consistently lower rate of negative laparotomies and laparoscopies (Jones, 2001). Several
scoring systems have also been proposed as diagnostic tools, but none of them has achieved
general acceptance. In the literature very low statistical association is reported between a
temperature >37° C and the presence of appendicitis (Cardal et al., 2004). An elevated WBC
count > 10.000 cells/mm, while statistically associated with the presence of appendicitis, is
reported to have very poor sensitivity and specificity and almost no clinical utility (Cardall
et al., 2004). On the other hand the combination of either leucocyte count and CRP value
(Gronroos JM & Groroos P, 1999) or leucocyte count, CRP value, and neutrophil percentage
(Yang et al., 2005) is considered very important in the exclusion of appendicitis. Finally
helical CT and graded compression US are reported to be useful instruments in the
diagnosis of acute appendicitis as they may lower the false negative rate (Balthazar et al,
1991, 1998; Birnbaum et al., 2000; Jones et al., 2001, Pacharn et al., 2010). CT is in most
studies found to be superior to US as it misses fewer cases; nonetheless, they are both
reliable in suspected acute appendicitis (van Randen et al., 2011). A diagnostic pathway
using routine US, limited CT, and clinical re-evaluation is proposed by Toorenvliet et al.
(Toorenvliet et al., 2010). US should be the first choice especially for pregnant patients
(Butala et al, 2010). Finally a multicenter study is ongoing to define the role of MRI instead
of CT in the diagnostic approach of acute appendicitis (Leeuwenburgh et al., 2010).
2.2 Patient management

Our patients are being given prophylactic antibiotics (1g cefotaxime and 500mg
metronidazole intravenously) and in complicated cases antibiotics are continued. Our policy
is to leave back a normal looking appendix, if another pathology is found at surgery, but to
remove a normal looking appendix, if there are no other findings. We normally release
patients in the first postoperative day. In complicated cases the hospital stay is prolonged.
Patients are examined on the tenth postoperative day as well as one month postoperatively.
2.3 Surgical team and surgical technique

The surgical team involved in diagnosis and treatment consisted of specialized surgeons
trained in laparoscopy and working together over several years. The team grew with time.
The operating surgeon in most cases was the director of the department (K.M.K),
performing about several hundred laparoscopic procedures every year, many of them being
advanced procedures. The policy of the department is to approach patients laparoscopically
whenever possible. This is facilitated by the fact that almost all of the abdominal operations
in this department are performed by laparoscopy, over 50% of them being advanced
procedures. There are also scrub nurses and technicians with experience in laparoscopy
during the day as well as after hours.
Surgical technique evolved with time, experience and appearance of new technical devices.
Our technique went through several stages and has been described before (Konstantinidis et
al., 2008). The technique, which was performed in the last over 1600 patients will be
described here: Surgery is performed under general anesthesia with the patient lying in
supine position on a multi-positional operating table. There are two monitors. The surgeon
stands on the patient’s left side and the assistant on the right. The abdomen is entered at the
umbilicus using the open Hasson technique routinely. If there are dense adhesions another
approach can be used. A 10mm reusable port is placed at the umbilicus and the 30 degree
laparoscope is inserted. The abdominal cavity can now be visualized. Two further 5mm
reusable trocars are inserted in the suprapubic area and the left lower quadrant under visual
control. The surgeon operates with two hands and the assistant holds the laparoscope. The
small bowel is retracted away from the right lower quadrant with the patient lying in the
Trendelenburg position and right side up. Atraumatic forceps are used. The dissection
continues, sometimes using the Plasma Kinetics™ (Gyrus Medical, Cardiff, UK) bipolar
electrocautery, until the base of the cecum is visualized, and the appendix can be elevated.
The mesoappendix is managed in a retrograde fashion by lifting the apex of the appendix
and using the cutting bipolar electrocautery until the cecum is reached. Three ligating
Endoloops PDS II™(Ethicon, Sommerville, NJ, USA) are placed, the first one at the
appendicular base, the second one next to the first loop, and the third one in about 1cm
distance. The appendix is then transected using scissors. Before the transaction is complete
the remaining appendicular mucosa is first suctioned and then burned with caution using
the bipolar electrocautery. The laparoscope is changed from the 10 to the 5mm laparoscope
Fig. 1. Cauterisation of the mesoappendix Fig. 2. Cauterisation and cutting of the

mesoappendix
Fig. 3. Placement of the Endoloops PDS IITM Fig. 4. Cutting of the appendix
and placed through the LLQ port. If uncomplicated, the appendix is grasped and pulled
through a reducer at the umbilical port. If ruptured or gangraenous the appendix is put in a
retrieval bag and the bag grasped with a traumatic grasper and pulled through the umbilical
port. The site of appendectomy, right paracolic gutter, and pelvis are irrigated with about 3 to
5 liters of normal saline irrigation solution with presure. Fluid from the suprahepatic area and
the pouch of Douglas is suctioned. In cases of intraabdominal abscess a drain connected to a
closed suction system is placed in the abscess cavity and brought out through the subrapubic
trocar. The fascial incision at the umbilicus is closed with 2.0 Vicryl™ sutures. The skin is
closed with 4.0 or 5.0 absorbable subcuticular sutures, unless there is an intraabdominal
contamination, in which case the skin is closed with 4.0 interrupted nylon sutures.
Fig. 5. Not the whole lumen of the appendix Fig. 6. Cauterisation of the appendiceal
is beeing cut mucosa
Fig. 7. Cauterisation of the appendiceal Fig. 8. Cutting of the remaining appendix

mucosa with the bipolar.
Many surgeons prefer routine stapling of the appendiceal stump. The stapling is reported to
be quicker, easier, and lead to less postoperative infections (Kazemier et al., 2006). On the
other hand it means greater costs and the obligatory use of a 12- mm trocar. Other
investigators do not report a higher complication rate with the use of endoloops as is stated
in a recent review. The only difference between the two methods is considered to be
operating time (Sajid et al., 2009). A protocol recruitment is now running to investigate,
whether routine stapling of the stump can lead to less intraabdominal abscesses (Sauerland
& Kazemier, 2007). Peritoneal lavage is contradictory, as it may lead to spillage of infection
according to some investigators (Gupta, 2006) but may prevent infection if performed
copiously in all quadrants according to others (Hussain, 2008). We believe that a lavage with
3-5 liters of normal saline, as we described it, using a peristaltic pump is effective and saves
time. One could argue that it is more expensive, but our experience in over 1.800 patients
has been that it is worth the cost. Routine use of drains is not necessary, and may in some
patients lead to cecal fistulae (Petrowsky, 2004).
Finally, standardisation of surgical technique leads to reduction of operative time,
conversion rate, morbidity, and to a higher surgeon satisfaction in training centers (Ng et al.,
2004; Hsieh et al., 2009).
3. Results of laparoscopic appendectomy and discussion

3.1 Parameters examined in the literature
To evaluate the benefits of the laparoscopic approach in suspected appendicitis the scientific
community examines several parameters. Important issues in the study of laparoscopic
appendectomy are: intraoperative findings, conversion rate to open surgery, histological
findings and negative appendectomy rate, duration of operation, intra- and postoperative
complications (early and late), postoperative pain, time to bowel mobilization, time until
intake of solid food, duration of hospital stay, time until return to normal activities, full
activities and sports, reoperations, cosmesis, and costs. All of these parameters are dealt
with in the literature and most of them were measured in our published study
(Konstantinidis et al., 2008). In our patients we did not investigate the costs or the cosmetic
results.
3.2 Diagnostic and therapeutic outcomes of laparoscopic appendectomy

Conversion rate ranges in meta-analyses between 0% and 23% (Lippert et al, 2002;
Sauerland et al., 2004) but there are studies which report conversion rates as high as 39%
(Moberg et al., 1998). In everyday praxis conversion rate typically seems to range between
10 and 20%, while in centers of excellence it is lower than 2%. It is apparent that these
fluctuations are related with differences in laparoscopic experience. In most studies the
operator is a surgical trainee for about 80 to 95% of open appendectomies and for about 50
to 75% of laparoscopic procedures. In our study we had a conversion rate of 0,55% in the 908
patients, in whom an appendectomy was performed. The low conversion rate in our study
can be explained by the fact that we are not a teaching hospital but a private center. The
operating surgeon in most of our patients has been the director of the department (K.M.K).
But also the other surgeons belonging to the team are specialised and very experienced with
laparoscopy. A learning curve was apparent for the first 100 appendectomies, where we had
a conversion rate of 9%, but these patients were not included in the trial. Conversion rate is
reported to be increased in complicated appendicitis (Wullstein et al., 2001). The most
common reason for conversion is reported to be dense adhesions due to inflammation,
followed by localized perforation and diffuse peritonitis (Agresta et al., 2003; Liu et al.,
2002). The presence of significant fat stranding associated with fluid accumulation,
inflammatory mass or localized abscess in CT scan is also reported to significantly increase
the possibility of conversion (Liu et al., 2002). In our patients the reasons for conversion
were dense adhesions in two patients and excessive inflammation in 3 patients.
There were also some patients, who had to be converted because of other pathologies. In our
experience these were pelvic hemoperitoneum, inflammatory pelvic disease, ovarian cyst
torsion, ovarian mass, ruptured diverticulitis (of the sigmoid and of the cecum) and cecal
volvulus. Finally, we performed laparoscopic assisted procedures in a number of patients
with Meckelitis. The necessity to convert patients due to another pathology emphasises
the role of laparoscopy as a diagnostic tool.
There is a strong heterogeneity in operating time reported in the literature. Mean operating
times in meta-analyses of randomised trials range between 23,5 and 102,2 min (Sauerland et
al., 2004). Apart from differences in laparoscopic experience, this can be attributed to the
different definitions of operating time. Nevertheless, all meta-analyses agree that the
duration of surgery is longer in laparoscopic appendectomy (Benett, 2007; Chung et al.,
1999; Fingerhut et al, 1999; Garbutt et al., 1999; Golub et al, 1998; Sauerland et al., 2010;
Temple et al, 1999). It is nonetheless remarkable that - as laparoscopy evolves - the results of
meta-analyses performed by the same investigators show through the years a decreasing
difference in operating time between the two approaches (Sauerland et al., 1998, 2002, 2004,
2010). Sauerland et al. report in their most recent meta-analysis that laparoscopic
appendectomy is on the average 10 minutes longer than the open one (Sauerland et al.,
2010). The median operating time in our study was 26 minutes, which compares favourably
with most other studies (The time from cutting the skin at the umbilicus until putting the
last skin suture was defined as operating time). We believe that the short operating time is
due to the surgeon’s expertise, and the training of the surgical team. We also believe that it
has to do with the standardisation of the surgical technique.
It has been suggested, and seems logical, that surgical expertise has a great impact in
conversion rate and operating time. The latter one as well as the lack of precision in
manoeuvers by novices could affect complication rate and patients’ outcome.
In our study we had an overall complication rate of 5,7%, consisting mostly of minor
complications. At the beginning of our series we had to reoperate on a 28 year old female
patient 3 days after surgery because of persisting abdominal pain. We performed a
diagnostic laparoscopy. There were no findings. We attributed the pain to not properly
washed instruments, with remainings of Cidex™ (Johnson& Johnson, Cincinatti, Ohio,
USA) solution on them. We had no other reoperations or major complications except for one
intraabdominal abscess outside our published series.
The average wound infection rate for laparoscopic appendectomy is reported to be 2,8% in
the meta-analysis by Golub et al. (Golub, 1998) and 2,5% in a big prospective multi-center-
study (Lippert et al., 2002). Wound infection rate is reduced by a half after laparoscopic
appendectomy in the most recent meta-analysis (Sauerland et al., 2010) based on the study
of more than 6000 cases. This is consistent with the findings of a large data base analysis of
over 40.000 in the US (Guller, 2004). Wound infection rate in our study was measured
separately and was 1,1%.
Intraabdominal abscesses are reported in the older meta-analyses to be equally frequent as
in the open procedure (Chung et al., 1999; Garbutt et al., 1999; Temple et al.) or even
increased, but without reaching statistical significance (Golub, 1998). In the most recent
review intra-abdominal abscesses are reported to be nearly threefold after laparoscopic
appendectomy(Sauerland et al., 2010), and moderate heterogeneity was detectable. There
were no notable differences in the results of trials using staplers versus loop. The problem
with studies reporting higher incidence of intraabdominal abscesses with laparoscopic
appendectomy is that they lack standardization of the surgical technique, and also that they
do not uniformly describe the different grades of disease. A recent prospective randomised
study on 220 patients reports less intraabdominal abscesses with the laparoscopic approach
(Wei et al., 2010). Also, a very recent review on 2.264 patients (Asarias et al., 2011) did not
find a significant difference in intraabdominal abscesses between the open and the
laparoscopic approach. On the other hand a multivariate analysis from the American
College of Surgeons on almost 40.000 appendectomies (77% laparoscopic) found that
laparoscopy was associated with an increased risk for intraabdominal abscesses in the high
risk patients (12,3% vs. 8,9%) but not for the low risk patients (Fleming et al., 2010). We had
no intraabdominal abscesses after laparoscopic appendectomy in our study (Konstantinidis
et al., 2008). Our only experience with an intraabdominal abscess after laparoscopic
appendectomy was in a 59 year old man, in whom we performed one of the first operations
for a ruptured appendix in January 1993, and who was not included in our study, as
mentioned before. This patient was readmitted, and reoperated laparoscopically. A large
retrocecal abscess was drained without further problems in his postoperative course. We
believe that surgical expertise, precise manoeuvers during the operation, technique
standardisation, and irrigation with normal saline solution (5 ltrs., under presure) are very
important in order to avoid intraabdominal abscesses.
Most meta-analyses agree that postoperative pain is reduced after laparoscopy compared to
the open procedure (Chung, 1999, Chung et al., 1999; Garbutt et al., 1999; Golub et al., 1999,
Sauerland et al., 2010). Our patients required a median number of 4 minor drugs and 2
narcotics until their discharge.
There is consistent evidence that laparoscopy leads to a shorter hospital stay than the open
appendectomy (Garbutt, 1999, Liu et al., 2011, Sauerland et al., 2010), although there are
great fluctuations. We assume that this has to do with different discharge policies. Also,
return to normal activity, which was 7 days in our trial, seems to fluctuate very much
between most investigators, but is reported to be quicker with the laparoscopic approach
(Chung et al., 1999; Garbutt et al., 1999; Golub et al., 1998; Liu et al, 2010; Sauerland et al.,
2010; Temple et al., 1999) as is return to full activity and sport (Sauerland et al., 2010). In our
experience recovery as expressed through time until flatus (24 hours) and intake of solid
food (48 hours), as well as time until discharge (30 hours) was very satisfactory.
There is no other pathology in surgery where as high percentages for negative laparotomies
are tolerated as in suspected acute appendicitis. In the literature negative laparotomies in
suspected acute appendicitis typically range between 20-30%, while the typical range for
negative laparoscopies is 10-15% (Tate, 1996). Especially in the subgroup of fertile females
authors report a negative laparotomy rate between 22-40% and a negative laparoscopy rate
between 4-17% and (Sauerland et al., 2004). We assume that in experienced hands a negative
laparoscopy is truly negative - at least concerning the macroscopic findings- whereas a
negative laparotomy with a Mc Burney incision fails to diagnose the pathology in about half
of the cases as can be confirmed by the numbers. The long-term clinical course of these
patients with the missed pathology cannot always be concluded from the published
literature (Vettoretto&Agresta, 2010).
The superior visualization of the abdominal cavity is undoubtedly the great advantage of
laparoscopy and leads to a much higher diagnostic yield in comparison to the open
procedure. In the most recent meta-analysis laparoscopy reduced the rate of negative
appendectomies and the rate of un-established diagnoses, especially in fertile women
(Sauerland et al., 2010). Gynecological problems are found more frequently in laparoscopy
for suspected acute appendicitis than in laparotomy (Larsson, 2001). Hence, there is
consensus about laparoscopy being an invaluable tool in the management algorithm of
women in childbearing age (Agresta, 2003; Borgstein, 1997; Cox, 1995; Larsson, 2001;
Sauerland et al., 2010; van Dalen, 2003). A recent Cochrane Review about the role of
laparoscopy for the management of lower abdominal pain in women of childbearing age
found in the laparoscopic group higher rates of specific diagnoses been made, lower rates of
negative appendectomies and shorter hospital stays. Also, there was no evidence of an
increase of adverse events with either of the two approaches (Gaitan et al., 2010). In our
series laparoscopy alone could establish diagnosis in 89% of all patients, in 85,4% of fertile
women and in 93,1% in all other patients except fertile women. We had to face other surgical
problems than appendicitis in 11,5% of all patients. In the subgroup of fertile women we
were confronted with other diagnoses in 20,4% of all patients. Most of these conditions were
gynaecologic problems (19,2%), despite the fact that some of these patients were examined
by the gynaecologist –which is consistent with the literature (Borgstein, 1997)- and/or had
imaging studies performed. The laparoscopic approach gave us the opportunity to define
these problems, as well as to deal with most of them without having to convert to an open
procedure. So, even in therapeutic terms, laparoscopy offers the possibility to manage
unexpected problems, while a classical Mc Burney incision has many constraints in this
direction.
It has been questioned if one should remove a normal looking appendix, if there are no
other findings at laparoscopy, especially in fertile women. Investigators who chose not to
remove normal looking appendices report good results and almost no or few readmissions
both in the fertile women group and in all patients (Borgstein et al., 1997; Moberg et al.,
1998; Teh et al, 2000; van Dalen et al., 2003). That is why many investigators suggest not to
remove a normal looking appendix (van Brock, 2001; Morino, 2006). Their argument is that
removing all appendices diminishes the diagnostic value of laparoscopy, as well as beeing
accompanied by morbidity, mortality, and extra hospital costs (Benjamin et al, 2002; Binjen
et al, 2003; Sauerland et al., 2003). However, the assertion that mortality of incidental
appendectomy exceeds that of appendectomy for appendicitis (Benjamin, 2002) did not find
general acceptance (Howie, 2003). Howie reports that the estimated avoidable mortality
from missed appendicitis or negative appendectomy in Scotland was virtually identical at
1,13 and 1,07 patients per 10.000 admissions. Another argument against incidental
appendectomy is that it may have several adverse effects on fertility. Concerning this, a
large Swedish retrospective study on 10.000 women could not confirm negative effects of
appendectomy on fertility (Anderson et al, 1999). On the other hand incidental
appendectomy may increase morbidity, and diminishes the diagnostic value of laparoscopy.
We chose to remove all appendices if there were no other findings. This has to do with the
nature of our hospital. We are a private center, and cannot always afford to reexamine
patients, or, even worse, re-operate on them. It also has to do with the facilities, the
laparoscopic experience of our team and the absence of major complications or mortality up
to this point. In our study eighteen patients (2%) proved to have histological findings of
appendicitis without having macroscopic ones. We had a negative appendectomy rate of
11,6% in fertile women and 6,4% in the rest of the patients after histological examination. In
0,8% of all excised appendices the histological examination revealed a carcinoid tumor.
Removing a macroscopically innocent appendix surely diminishes the diagnostic
advantages of laparoscopy. On the other hand, the question whether or not to remove a
macroscopically normal appendix cannot be easily answered. Published data show a
discrepancy between the good clinical course of most patients in these series, were a
macroscopically innocent appendix was not removed and the histological findings in the
series were a normal appearing appendix was removed. It has been shown that a
macroscopically normal appendix is not always normal (Chiarugi et al., 2001), though the
literature is quite inhomogenous concerning the histological findings. It also has been
shown that a histologically normal appendix is not always normal (Wang et al, 1996) . Some
of these appendices in patients with acute pain in the right iliac fossa have an abnormal
content of neuropeptides. This could explain the pain relief after removal of a histologically
normal appendix (Di Sebastiano, 1999; Wang et al, 1996).
It seems that some patients suffer crises of endoappendicitis, that subsides with
conservative treatment. Endoappendicitis varies from 11to 26% and the reoperation rate for
the patients whose appendix was left in situ is reported to be 6%(Navez and Therasse, 2003).
So it might be that the great majority of these patients will not have any problems in the
future but for the individual patient the surgeon’s decision to leave the appendix behind
could mean a readmission, a peritonitis, a second operation, or the persistence of recurrent
symptoms. So we think that the decision to remove the appendix has to be individualized
and discussed with the patient prior to the operation. The experience of the laparoscopic
team is very important in this context. We generally agree with the algorithm proposed by
(Navez & Therasse, 2003) in the treatment of suspected acute appendicitis. The authors
propose to remove a macroscopically normal appendix if one suspects an appendicitis
clinically and there are no other findings. In cases of acute abdominal pain of uncertain
origin and negative laparoscopy the authors propose to perform only a diagnostic
laparoscopy and to avoid the terms of appendicitis or appendectomy. We also agree with
the investigators that the appendix should be removed if chronic recurrent symptoms exist,
and there are no other findings. We think there is enough evidence about this in the
literature (Chandler et al., 2002; Mussak et al., 2002), especially in young females (Chicolm
Mefire et al., 2011).
The debate on whether complicated appendicitis is a contraindication for the laparoscopic
approach is still ongoing. Sauerland et al. reported in an earlier review (Sauerland et al.,
2004) that laparoscopic approach for complicated appendicitis can probably lead to
increased complications, though there is not yet enough evidence to support this. On the
other hand many authors do not regard complicated appendicitis to be a contraindication
for laparoscopic appendectomy. On the contrary, laparoscopic appendectomy in
complicated appendicitis is reported to be safe (Ball et al., 2004; Kapischke et al., 2005;
Pedersen et al., 2001; Stolzing et al., 2000; Wullstein et al., 2001) and reduce complication
rate (Kapischke et al., 2005; Wullstein et al, 2001). Septic wound complications are reported
to be less (Piskun et al., 2001; Stolzing et al., 2000). Intraabdominal abscesses are reported to
be equally frequent (Asarias et al., 2011; Khalili et al., 1999; Wullstein et al., 2001) in the open
and the laparoscopic approach. Also laparoscopic appendectomy in complicated
appendicitis is supposed to lead to a shorter length of stay (Ball et al., 2004; Johnson et al.,
1998; Kapischke et al., 2005; Towfigh et al., 2006) and reduced hospital costs (Johnson et al.,
1998). The problem with some comparative studies is the existence of selection bias in
patients undergoing laparoscopic or open appendectomy and also the fact that statistical
analysis is not always done on an intention-to-treat-basis. Nevertheless Wullstein et al. in
their study on 299 patients with complicated appendicitis report that laparoscopic
appendectomy when compared with open appendectomy leads to a significant reduction of
early postoperative complications by itself and in an intention-to-treat view (Wullstein et al.,
2001). A recent systematic review with meta-analysis of 12 retrospective case-control studies
found less surgical site infections in laparoscopic appendectomy for complicated
appendicitis with no significant additional risk for intraabdominal abscesses (Makrides et
al., 2010). More prospective, randomized trials focusing on this question are needed in the
future. We did not study patients with complicated appendicitis separately in our series.
Nevertheless we had to face a ruptured or gangrenous appendix in 14,1% and, in spite of
that, had an overall wound infection rate of 1,1% and no intraabdominal abscesses. In our
experience complicated appendicitis is not a contraindication for the laparoscopic approach.
There is evidence supporting that cosmesis is superior with the laparoscopic approach
(Pedersen et al., 2001), and is difficult to improve (Ruiz de Angulo et al., 2011). We think
that this must be especially true in obese patients and complicated appendicitis, where
normally bigger incisions are needed. Also, in case of other findings that need an extension
of a Mc Burney incision or a new incision, laparoscopy is surely the best choice from the
cosmetic point of view.
Quality of life is also reported to be better with the laparoscopic approach, both in the early
and late period (Kaplan et al, 2009).
Cost- effectiveness is difficult to measure. From the institutional perspective laparoscopic
appendectomy is reported to be less cost- effective than the open procedure, even if in the
future the costs of the operation and the equipment (single- use vs. reusable; Endo-GIA vs.
Roeder loops) may decrease whereas from the societal perspective the laparoscopic
approach seems to be more cost- effective (Heikkinen et al., 1998; Macarulla et al., 1997;
Sauerland, 2010) if lost productivity is taken into consideration (Moore et al., 2004). In
middle- aged patients overall costs are reported to be lower with the laparoscopic procedure
(Lagares- Garcia et al., 2003). In our patients we try to reduce costs by applying reusable
instruments. We also prefer to use loops for the appendicular base instead of staplers and
can report excellent results and no complications.
It has been suggested that there may be fewer adhesions after laparoscopic appendectomy
compared to the open procedure (De Wilde, 1991; Gutt, 2004). We had no patients with
adhesion-related complications such as intestinal obstruction in our study. The incidence of
late readmitions (>30 days) after appendectomy is of particular interest. In the literature
there is increasing evidence that open appendectomy is related to late readmissions and, in
some cases, reoperations for SBO but there is an inhomogeneity in the results of different
studies (Anderson, 2001;Riber, 1997; Zbar, 1993). During a mean follow-up of 10 years the
authors of a retrospective study on 3,230 patients report 2,94% late readmissions after open
appendectomy. Almost half (45%) of readmissions were caused by nonspecific abdominal
pain with no signs of small bowel obstruction. SBO was seen in 1,24% of patients and was
surgically treated in 0,68%. Incisional hernias were seen in 0,4% of all appendectomies., as
did patients with complicated appendicitis or negative appendectomy (Tingstend et al.,
2004).
Our follow-up lasted 4 weeks. From the 63 patients operated on for chronic symptoms 5(8%)
continued to have abdominal pain one month after appendectomy. There were no
readmitions or reoperations for adhesion related complications or incisional hernias. We can
also report that no patient of this series was readmitted in our department with a late
complication such as small bowel ileus or an incisional hernia. More prospective,
randomized trials comparing the incidence of late complications with the laparoscopic and
open approach for suspected appendicitis in an intention-to-treat basis are needed. We also
think that late complications should be included in future cost-analyses.
Laparoscopic appendectomy is reported to be a safe and suitable procedure for surgical
training (Botha et al., 1995; Duff&Dixon, 2000; Scott-Conner et al., 1992). In our opinion it is
in many cases an ideal operation for a surgical trainee starting his/her training in
laparoscopy.
4. Special patient categories

4.1 Fertile females
Especially in the subgroup of fertile females authors report a negative laparotomy rate
between 22-40% and a negative laparoscopy rate between 4-17% and (Sauerland et al., 2004).
Females predominated among those readmitted (76%). Fertile females benefit from the
laparoscopic approach at a level Ia evidence and there was no inconsistency between studies
(Sauerland, 2010; Vettoretto & Agresta, 2010; Gaitan, 2011).
4.2 Obese patients

In the literature it is suggested that overweight patients seem to profit from laparoscopic
appendectomy in terms of postoperative pain, postoperative recovery (Enochson et al.,
2001), and septic wound complication rate (Stolzing et al., 2000, Corneille et al., 2007). In a
more recent comparative study no significant differences in terms of complications were
found between the two groups (Clarke et al., 2011). We did not perform a separate analysis
on overweight patients.
4.3 Employed patients

Employed patients profit from laparoscopic appendectomy as it is superior to open
appendectomy in terms of return to normal activities and full activity (Sauerland et al, 2010).
4.4 Elderly patients

Elderly patients have more overall complications after conventional appendectomy
(especially regarding pulmonary function impairment and return to normal activities), and
seem to benefit from laparoscopic appendectomy (Agresta et al., 2011; Guller et al, 2004;
Kim et al., 2011; Yeh et al. 2011).
Patient Population Level of Evidence

Women of childbearing age LOE Ia
Employed Patients LOE Ia
Elderly Patients LOE IIb
Obese Patients LOE III
Men LOE III
Table 1. Adult patient subpopulations that profit from laparoscopic appendectomy
4.5 Pregnant patients

Acute appendicitis is the most common cause of nonobstetric acute abdomen during
pregnancy. Some investigators report that the incidence is identical to that of the
nonpregnant population, while others suggest that it is less, with the third trimester being
particularly protective (Anderson & Lambe, 2001). Non the less, a perforation of the
appendix is reported to occur twice as often in the third trimester (69%) compared with the
first two (Weingold, 1983). The role of laparoscopic appendectomy during pregnancy
remains controversial. Laparoscopy for suspected appendicitis is considered to have less
complications and a higher diagnostic value compared to the open procedure. The ongoing
debate is whether the laparoscopic procedure leads to a higher percentage of fetal loss as is
reported in a systematic review from the UK (Walsh et al., 2008) or not, as is stated in a
review from the United States (Jackson et al., 2008). More recent studies consider the
laparoscopic approach to be safe and effective with a low rate of complications for the
mother and the fetus (Corneille et al., 2010; Jeing et al., 2011; Kirshtein et al., 2009; Lemieux
et al, 2009; Machado et al., 2009; Moreno-Sanz, 2007; Sadot et al.). It has to be stated that
long-term consequences of the pneumoperitoneum for the fetus have not yet been studied.
Also, one should stress the importance of a very good diagnostic work-up in order to avoid
unnecessary procedures without missing pathologic conditions. Walsh et al. report that the
negative appendectomy rate in their series was 27%, which is higher than in the
nonpregnant population. Regarding the diagnostic tools it has been reported that the
sensitivity of ultrasound is inversely correlated to the gestational age, while CT scan retains
a high sensitivity and specificity throughout pregnancy. It seems reasonable to perform an
ultrasound first, in order to exclude an obstetric pathology, and to proceed with a CT if
necessary (Butala, 2010).
4.6 Pediatric patients

Pediatric patients seem to benefit from the laparoscopic approach for suspected appendicitis
in the same ways adults do, and intraabdominal abscesses are not more frequent than with
the open approach. However, more RCTs are needed in order to come to final conclusions.
Especially in extremely obese children laparoscopy is considered to be the procedure of
choice both in complicated, and not complicated cases. The operative time is reported to be
shorter, there are less overall complications, and reduced analgesia requirements (Kutasy et
al., 2011).
5. Novel techniques and future research implications

5.1 Novel techniques
5.1.1 Single port appendectomy
Single-port-laparoscopy for acute appendicitis is reported to be safe and effective in children
(Tam et al., 2010) and adults, and may have advantages in terms of cosmetic results and
patient satisfaction (Barbaros et al.; 2010; Lee YS, 2009; Raakow et al.;Tsai & Selzer, 2010).
We tried this approach on two patients but could not really see the benefits. On the contrary,
we believe that the single port technique is much more appropriate and ergonomic in
robotic surgery. More comparative studies between the conventional technique and the
single port approach are needed in order to determine its role in laparoscopic
appendectomy, especially regarding long term morbidity (i.e. hernias) at the entrance site.
5.1.2 Needlescopic appendectomy

Needlescopic appendectomy can be safe and effective according to a recent review and is
supposed to reduce pain compared to conventional laparoscopy (Sajid et al., 2009; Sauerland
et al., 2010). Nevertheless it is associated with a longer operating time and a higher
conversion rate. Multicenter, randomized controlled trials are recommended before it can be
used routinely.
5.1.3 Robotic appendectomy

Incidental appendectomy is considered to eventually be necessary in women with ovarian
endometrioma and chronic pelvic pain, as the majority of the appendices are found to have
histopathologically confirmed pathology although being macroscopically normal (Wie et al.,
2008). Incidental robotic appendectomy is reported to be safe and effective in women
undergoing gynaecologic surgery, in women with chronic pelvic pain, and women with
ovarian malignancy (Akl et al., 2008). In the latter group three out of seven patients were
found to have appendicular metastasis. Our experience with the DaVinci (TM, Intuitive
Surgical Inc.) Robotic System started in 2006, and is today the everyday routine of the
department in advanced procedures. We performed incidental robotic appendectomy in

three patients who underwent gynecologic surgery for endometriosis for chronic pelvic pain
with good results. We believe that the robotic procedure has its place in complicated cases of
appendicitis with dense peritoneal adhesions.
5.2 Implications for future research

In our opinion future research should first of all determine the role of diagnostic
investigations (such as laboratory parameters, US, CT and MRI) which could lower the
percentage of negative laparoscopies, especially in pregnant women and high risk patients.
Also, a cost-benetit analysis of the routine appliance of US and CT in order to avoid negative
laparoscopies would be reasonable. Additionally, the importance of leaving back a
macroscopically innocent appendix in several patient categories (women of childbearing
age, patients with chronic pain, high-risk- patients, children) if no other pathology is found
should be further investigated. Another issue are intraabdominal abscesses. The role of the
patients characteristics, the surgeon’s expertise, the stump closure, the intraabdominal
lavage and the standardization of technique in abscess formation should be further
explored. The value of new techniques like the single port, the needlescopic and the robotic
procedure in special cases should be investigated, as should the place of laparoscopy in
obese patients and pregnant patients. Finally the late results of laparoscopic appendectomy
should be explored (adhesions, SBO).
6. Conclusion
In conclusion, laparoscopy seems to be as safe as open appendectomy for acute appendicitis.
Laparoscopy has many advantages, such as higher diagnostic yield, fewer postoperative
wound infections, less postoperative pain, shorter hospital stay, earlier return to normal and
full activity, better cosmesis, and probably decreased late complications such as adhesion
formation and incisional hernias. Also one cannot overemphasize the superior visualization
of the abdominal cavity and the possibility of not only diagnosing other pathologies but also
dealing with them without having to use a bigger incision. Fertile women can profit the
most from these advantages. But also elderly, overweight and employed patients seem to
profit from laparoscopy. If the safety of leaving a macroscopically innocent appendix in situ
is clarified by future studies the value of laparoscopy as a diagnostic tool will be enhanced.
One expects that the further expansion of laparoscopy will lead to much more experienced
surgeons, and that the progress in technology will facilitate this approach even more in the
future. The reported higher incidence of intraabdominal abscesses with laparoscopy in some
series could be experience- or technique-related and is likely to decrease with the evolution
of laparoscopic skills among surgeons that leads to more precise operative maneuvers, and
the standardisation of surgical technique. The higher operative costs in most institutions can
perhaps be outweighed by a shorter hospital stay, and quicker return to normal activities
with the laparoscopic approach, as well as by the possible decrease in late complications.
Operative costs themselves can be reduced by the application of reusable instruments,
application of loops instead of staplers, and further reduction of operating times. Finally it is
important to reduce negative laparoscopies. The exact role of imaging modalities,
inflammatory parameters and scoring systems in this purpose has yet to be defined.
7. Acknowledgements
The authors thank Mrs. Sofia Monastirioti for her assistance in editing the text of this
chapter. We also thank Dr. Petros Hiridis for his assistance with the illustrations.
8. References
Addis, DG.; Shaffer, N.; Fowler, BS. & Tauxe, RV. (1990). The epidemiology of appendicitis
and appendectomy in the United States. Am J Epidemiol , Vol. 8, No. 4, pp.910-925,
ISSN 0963-7486
Agresta, F.; De Simone, P.; Michelet, I. & Bedin, N.(2003). Laparoscopic Appendectomy:
why it should be done. JSLS, Vol. 16, No.1, pp. 347-352, ISSN 1679-1796
Akl, MN.; Magrina, JF.; Kho, RM.; Magtibay, PM. (2008). Robotic appendectomy in
gynaecological surgery: technique and pathological findings. Int J Med Robot, Vol. 4,
Issue 3, pp.210-213, ISSN 0029-7844
Andersson, E.; Lambe, M. & Bergstrom, R. (1999). Fertility patterns after appendicectomy:
historical cohort study. BMJ, Vol. 318, No. 7189 pp. 963-967, ISSN 1464-3685
Andersson, RE.(2001). Small bowel obstruction after appendicectomy. Br J Surg, Vol.26, No.
2, pp.1387-1391, ISSN 0003-4932
Andersson, RE. & Lambe, M. (2001). Incidence of appendicitis during pregnancy. Int J
Epidemiol, Vol., No., pp. 1281-1285, ISSN
Asarias, JR.; Schlussel, AT.; Cafasso, DE.; Carlson, TL.; Kasprenski, MC.; Washington, EN.;
Lustik, MB.; Yamamura, MS.; Matayoshi, EZ. & Zagorski, SM.(2011). Incidence of
postoperative intraabdominal abscesses in open versus laparoscopic
appendectomies. Surg Endosc, Vol.136, No.4, ISSN 003-4932
Ball, CG.; Kortbeek, JB.; Kirckpatrick, AW. & Mitchell, P. (2004). Laparoscopic
appendectomy for complicated appendicitis: an evaluation of postoperative
factors. Surg Endosc, Vol.8, No.1, pp.969-973, ISSN 0003-1348
Balthazar, EJ.; Megibow, ACCJ.; Sieger, SE.; & Birnbaum, BA. (1991). Appendicits:
prospective evaluation with high resolution CT. Radiology, Vol. 28(2), pp.21-24,
ISSN 0033-8419
Balthazar, EJ.; Rofsky, NM. & Zucker, R. (1998). Appendicitis: the impact of computer
tomography imaging on negative appendectomy and perforation rates. Am J
Gastroenterol, Vol.93, No.5, pp. 768-771, ISSN 1528-8404
Barbaros, U.; Sümer, A.; Tunca, F.; Gözkün, O.; Demirel, T.; Bilge, O.; Randazzo, V.; Dinççağ,
A.; Seven, R.; Mercan, S.; Budak, D. (2010). Our early experiences with single-
incision laparoscopic surgery: the first 32 patients. Surg Laparosc Endosc Percutan
Tech, Vol. 20, Issue 5, pp.306-311, ISSN 1072-7517
Benjamin, IS. & Patel, AG. (2002). Managing acute appendicitis: Laparoscopic surgery is
particularly useful for women. BMJ, Vol.22, No.2, pp.505-506, ISSN 0749-5161
Bennett, J; Boddy, A; Rhodes, M. (2007). Choice of approach in appendicectomy: a meta-
analysis of open versus laparoscopic appendicectomy. Surg Laparosc Endosc
Percutan Tech. Vol. 14. No. 4., pp: 245-255, ISSN 1130-0108
Bijnen, CL.; Van den Broek, WT.; Bijnen, AB.; De Ruiter, P. & Gouma DJ. (2003).
Implications of removing a normal appendix. Dig Surg, Vol.20, No.2, pp.215-219;
discussion pp. 220-221, ISSN 0303-5212
Birnbaum, BA. & Wilson, SR. (2000). Appendicitis at the Millenium. Radiology, Vol.215, No. 2
pp.337-348, ISSN 1528-8315
Borgstein, PJ.; Gordijn, RV.; Eijsbouts, QAJ. & Cuesta, MA. (1997). Acute appendicitis – a
clear-cut case in men, a guessing game in young women. Surg Endosc,Vol. 11 No.9,
pp. 923-927, ISSN 1130-0108
Botha, AJ.; Elton, C.; Moore, EE. & Sauven P. (1995). Laparoscopic appendicectomy: a
trainees perspective. Ann R Coll Surg Eng, Vol.3, No. 2, pp. 259-262, ISSN 1528-8242
Butala, P; Greenstein, AJ; Sur, MD; Mehta, N; Sadot, E; Divino,CM. (2010). Surgical
management of acute right lower-quadrant pain in pregnancy: a prospective cohort
study. Journal of the American College of Surgeons. Vol. 211, No.4, pp. 490-4, ISSN
1072-7515
Cardall, T.; Glasser, J. & Guss, DA. (2004). Clinical value of the total white blood cell count
and temperature in the evaluation of patients with suspected appendicitis. Acad
Emerg Med,Vol.14, No.2, pp.1021-7, ISSN 1007-9327
Chandler, B.; Beegle, M.; Elfrink, RJ. & Smith, WJ. (2002). To leave or not to leave? A
retrospective review of appendectomy during diagnostic laparoscopy for chronic
pelvic pain. Mo Med, Vol.13, No.5, pp.502-504, ISSN 1333-994
Chiarugi, M.; Buccianti, P.; Decanini, L.; Balestri, R.; Lerenzetti, L.; Franceschi, M. &
Cavina, E. (2001). “What you see is not what you get”. A plea to remove a “normal”
appendix during diagnostic laparoscopy. Acta Chir Belg,Vol.19, No.5, pp.243-245,
ISSN
Chichom Mefire, A; Tchounzou, R; Kuwong, PM; Atangana, JP; Lysinge, AC. & Malonga,
EE. (2011). Clinical, Ultrasonographic and Pathologic Characteristics of Patients
with Chronic Right-lower-quadrant Abdominal Pain that May Benefit from
Appendectomy. World Journal of Surgery.Vol.35, No.4, pp.723-30, ISSN 1069-6563583
Chung, R.; Rowland, D.; Li ,P. & Diaz, J A. (1999). Meta-analysis of Randomized Controlled
Trials of Laparoscopic Versus Conventional Appendectomy. Am J Surg, Vol.177,
No.3, pp. 250-256, ISSN 1007-9327
Clarke, T.; Katkhouda, N.; Mason, RJ.; Cheng, BC.; Olasky, J.; Sohn, HJ.; Moazzez, A.; Algra,
J.; Chaghouri, E. & Berne, TV. (2011). Laparoscopic versus open appendectomy for
the obese patient: a subset analysis from a prospective, randomized, double-blind
study. Surg Endosc, Vol.25, No.4, pp.1276-1280, ISSN 1432-2218
Corneille, MG.; Steigelman, MB.; Myers, JG.; Jundt, J.; Dent, DL.; Lopez, PP.; Cohn, SM. &
Stewart, RM. (2007). Laparoscopic appendectomy is superior to open
appendectomy in obese patients. Am J Surg, Vol.194, Issue 6, pp.877-880, ISSN 0803-
5253
Corneille, MG.; Gallup, TM.; Bening, T.; Wolf, SE.; Brougher, C.; Myers, JG.; Dent, DL.;
Medrano, G.; Xenakis, E & Stewart, RM.( 2010). The use of laparoscopic surgery in
pregnancy: evaluation of safety and efficacy. Am J Surg, Vol.20, Issue 6, pp.363-367,
ISSN 1879-1883
Cox, MR.; Mc Call, JR.; Padbury, RT.; Wilson, TG. & Wattchow, DA. (1995). Tooul.
Laparoscopic surgery in women with a clinical diagnosis of an appendicitis. Med J
Aust, Vol.8, No.3, pp. 130-2, ISSN 1007-9327
De Wilde RL. (1991). Goodbye to late bowel obstruction after appendicectomy. The Lancet,
Vol.73, No.11, ISSN 1421–9983
Di Sebastiano, P.; Fink, T. & Buchler MW. (1999). Neuroimune appendicitis. The Lancet, Vol.
354, No.9172, pp. 461-66, ISSN 1021–7401
Duff, SE. & Dixon, AR. (2000). Laparoscopic appendicectomy: safe and useful in training
Ann R Coll Surg Engl, Vol.172, No.1, pp. 388-391, ISSN 1469-0756
Enochson, L.; Hellberg, A.; Rudberg, C.; Fenyö; Gudbjartson, T.; Kullman, E.; Ringquist, I.;
Sörensen, S. & Wenner, J. (2001). Laparoscopic vs open appendectomy in
overweight patients. Surg Endoscopy, Vol.3, No.7, pp. 387-392, ISSN 0930-2794
Fingerhut, A.; Millat, B. & Borrie, F. (1999). Laparoscopic versus Open Appendectomy: Time
to Decide. Word J. Surg, Vol.23, No.8, pp. 835-845, ISSN 0003-4932
Fleming, FJ.; Kim, MJ.; Messing, S.; Gunzler, D.; Salloum, R. & Monson, JR. (2010). Balancing
the risk of postoperative surgical infections: a multivariate analysis of factors
associated with laparoscopic appendectomy from the NSQIP database. Ann Surg,
Vol.252, Issue 6, pp. 895-900, ISSN 0003-4932
Flum, DR.; McClure, TD.; Morris, A. & Koepsell, T. (2005). Misdiagnosis of appendicitis and
the use of diagnostic imaging. J Am Coll Surg, Vol.201, No.6, pp. 933-9, ISSN 1468-
3288
Gaitan, HG.; Ludovic Reveiz, &Cindy Farquhar (2010). Laparoscopy for the management of
acute lower abdominal pain in women of childbearing age. Cochrane Database of
systematic Reviews, Vol.1, Issue 1, ISSN 1464-780x
Gaitán HG, Reveiz L, Farquhar C.(2011). Laparoscopy for the management of acute lower
abdominal pain in women of childbearing age. Cochrane Database Syst Rev, Vol.22,
No.2, ISSN 1464-780X
Garbutt, JM.; Soper, NJ.; Shannon, WD.; Botero, A. & Littenberg, B. (1999). Meta-analysis of
randomized controlled trials comparing laparoscopic and open appendectomy.
Surg Laparosc Endosc, Vol.5, No.2, pp. 17-26, ISSN 1007-9327
Golub, R.; Siddiqui, F. & Pohl D. (1998). Laparoscopic versus open appendectomy: a
metaanalysis. J Am Coll Surg Vol.42, No.1, pp. 545-53, ISSN 1007-9327
Gronroos, JM. & Gronross, P. (1999). Leucocyte count and C-reactive protein in the
diagnosis of acute appendicitis. Br J Surg Vol.16, No.2, pp. 501-4, ISSN 0803-5253
Gupta, R.; Sample, C.; Bamehriz, F. & Birch, DW. (2006). Infectious complications following
laparoscopic appendectomy. Can J Surg, Vol.49, No.6, pp. 397-400, ISSN 1435-2451
Gutt, CN.; Oniu, T.; Schemer, P.; Mehrabi, A. & Buechler, MW. (2004). Fewer adhesions
induced by laparoscopic surgery? Surg Endosc., Vol18., No.6, pp. 898-906,
ISSN 0930-2794
Heikkinen TJ, Haukipuro H, Hulkko A. (1998). Cost-effective appendectomy. Open or
laparoscopic? A prospective randomized study. Surg Endosc, Vol.14, No.31
,pp.1204- 1208
Howie J BMJ (2003). 326,p49, ISSN 0253-4886
Hsieh, CS.; Chen, YL.; Lee, MH.; Chang, HC.; Chen, ST. & Kuo, SJ.(2009). A lower costly
laparoscopic appendectomy: our experience of more than 2000 cases. Int J Surg,
Vol.8, Issue 2, pp. 140-3, ISSN 1007-9327
Hussain, A.; Mahmood, H.; Nicholls, J. & El-Hasani, S. (2008). Prevention of intra-abdominal
abscess following laparoscopic appendicectomy for perforated appendicitis: a
prospective study. Int J Surg, Vol. 180, Issue 6, pp. 374-7, ISSN 1743-9159
Jackson, H.; Granger, S.; Price, R.; Rollins, M.; Earle, D.; Richardson, W. & Fanelli, R. (2008).
Diagnosis and laparoscopic treatment of surgical diseases during pregnancy: an
evidence-based review. Surg Endosc, Vol.22, No.9, pp. 1917-1927, ISSN 1432-2218
Jacob, DA.; Raakow, R. (2010). [Single-port transumbilical endoscopic cholecystectomy: a
new standard?]. Dtsch Med Wochenschr, Vol.22, No 1, pp1363-1367, ISSN 1528-8242
Jeong, JS.; Ryu, DH.; Yun, HY.; Jeong, EH.; Choi, JW. & Jang LC. (2011). Laparoscopic
appendectomy is a safe and beneficial procedure in pregnant women. Surg Laparosc
Endosc Percutan Tech, Vol.22, Issue 1, pp. 24-27, ISSN 1534-4908
Johnson AB, Peetz ME. (1998). Laparoscopic appendectomy is an acceptable alternative for
the treatment of perforated appendicitis. Surg Endosc, Vol.8, No.1, pp. 940-943, ISSN
0253–4886
Jones PF. (2001). Suspected acute appendicitis: trends in management over 30 years. Br J
Surg, Vol.88, Issue 1, pp.1570-1577, ISSN 1528-8242
Kapischke M, Bley K, Tempel J, Schulz T. (2005). Open versus laparoscopic appendectomy
for perforated appendicitis- a comparative study. Zentralbl Chir, Vol.10, No. 6,
pp.137-41, ISSN 1364-5706
Kaplan, M.; Salman, B.; Yilmaz, TU. & Oguz, M. (2009). A quality of life comparison of
laparoscopic and open approaches in acute appendicitis: a randomised prospective
study. Acta Chirurgica Belgica, Vol. 106, No. 3, pp. 356-63, ISSN 0001-5458
Kazemier, G.; Hof, KH.; Saad, S.; Bonjer, HJ. & Sauerland, S.; (2006). Securing the
appendiceal stump in laparoscopic appendectomy: evidence for routine stapling?
Surg Endosc, Vol.20, No.9, pp. 1473-6, ISSN 030
Khalili, TM.; Hiatt, JR.; Savar, A.; Lau, C. & Margulies DR. (1999).Perforeted appendicitis
is not a contraindication to laparoscopy. Am Surg, Vol.27, No.6, pp. 965- 967, ISSN
0253–4886
Kim, MJ.; Kim, MJ.; Fleming, FJ.; Gunzler, DD.; Messing, S.; Salloum, RM. & Monson, JR.
(2011). Laparoscopic appendectomy is safe and efficacious for the elderly: an
analysis using the National Surgical Quality Improvement Project database.Surgical
Endoscopy, Vol.1, No. 3, (Feb 7). [Epub ahead of print], ISSN 1432-2323
Kirshtein B, Perry ZH, Avinoach E, Mizrahi S, Lantsberg L. (2009). Safety of laparoscopic
appendectomy during pregnancy. World J Surg, Vol.21, Issue 1, pp.475-480, ISSN
0364
Kraemer, M.; Ohmann, C.; Leppert, R. & Yang, Q. (2000). Macroscopic assessment of the
appendix at diagnostc laparoscopy is reliable. Surg Endosc, Vol.19, Issue 5, pp. 625-
33, ISSN 0930-2794
Larsson, P-G.; Henriksson, G.; Olsson, M.; Boris, J.; Ströberg, P.; Tronstad, S-E. & Skullman,
S. (2001). Laparoscopy reduces unnecessary appendicectomies and improves
diagnosis in fertile women. Surg Endosc, Vol.15, No.2, pp. 200- 202, ISSN 1469-0756
Konstantinidis, KM.; Anastasakou, KA.; Vorias, KM.; Sambalis, GH.; Georgiou, MK.;
Xiarchos, AG. (2008). Journal of Laparoendoscopic and Advanced Surgical Techniques,
Vol. 18, No.2, pp. 248-258, ISSN 1492-6429
Kutasy, B.; Hunziker, M.; Laxamanadass, G.; Puri, P. (2011). Laparoscopic appendectomy is
associated with lower morbidity in extremely obese children. Pediatr Surg Int, Vol.
196, Issue 2,pp.533-536, ISSN 0179-0358
Lagares-Garcia, JA.; Bandsidhar, B. & Moore, RA. (2003). Benefits of laparoscopy in middle-
aged patients. Surg Endosc, Vol.7, No.2, pp. 68-72, ISSN 0798-0469
Lee, YS.; Kim, JH.; Moon, EJ.; Kim, JJ.; Lee, KH.; Oh, SJ.; Park, SM.; Hong, TH. (2009).
Comparative study on surgical outcomes and operative costs of transumbilical
single-port laparoscopic appendectomy versus conventional laparoscopic
appendectomy in adult patients. Surg Laparosc Endosc Percutan Tech,Vol. 19, Issue 6,
pp.493-496, PMID 2002-7094
Lee, SL.; Walsh, AJ. & Ho, HS. (2001). Computed tomography and ultrasonography do not
improve and may delay the diagnosis and treatment of acute appendicitis. Arch
Surg, Vol.136,No. 5, pp. 556- 562, ISSN 0014–312
Leeuwenburgh, MM.; Lameris, W.; Van Randen, A.; Bossyt, PM.; Boermeester, MA. &
Stoker, J. OPTIMAP study group. (2010). Optimizing imaging in suspected
appendicitis (OPTIMAP-study): a multicenter diagnostic accuracy study of MRI in
patients with suspected acute appendicitis. Study Protocol. BMC Emerg Med. Vol.7,
Issue 11, (Oct 20; 10:19), ISSN 1527-1323
Lemieux, P.; Rheaume, P.; Levesque, I.; Bujold, E. & Brochu, G.(2009). Laparoscopic
appendectomy in pregnant patients: a review of 45 cases. Surg Endosc, Vol. 23, Issue
8, pp. 1701-1705, ISSN 1432-2218
Lippert, H.; Koch, A.; Marutsch, F.; Wolff, S. & Gastinger, I. (2002).Offene versus
laparoskopische Appendektomie. Chirurg, Vol.101, Issue 8, pp.791-98, ISSN 723-
7065
Liu, SI.; Siewert, B.; Raptopoulos, V. & Hodin, RA. (2002). Factors associated with
conversion to laparotomy in patients undergoing laparoscopic appendectomy. J Am
Coll Surg, Vol.194, Issue 3, pp. 298-305, ISSN 1527-1315
Liu, Z.; Zhang, P.; Ma, Y.; Chen, H.; Zhou,Y.; Zhang,M.; Chu, Z. & Qin, H. (2010).
Laparoscopy or not: a meta- analysis of the surgical effects of lparoscopic versus
open appendectomy. Surg Laparosc Endosc Percutan Tech, Vol.20, No.6, pp.362-70,
ISSN 1471-230X
Macarulla, E.; Vallet, J.; Abad, JM.; Hussein, H.; Fernandez, E. & Nieto, B. (1997).
Laparoscopic versus open appendectomy: a prospective randomized trial. Surg
Laparosc Endosc, Vol.22, No.1, pp.335- 339, ISSN 1025 - 5583
Machado, NO.; Machado, LS. (2007). Laparoscopic cholecystectomy in the third trimester of
pregnancy: report of 3 cases. Surg Laparosc Endosc Percutan Tech,Vol. 19, No 6,
pp.439-441, ISSN 0972-2068
Markides. G.; Subar, D. & Riyad K.(2010). Laparoscopic versus open appendectomy in
adults with complicated appendicitis: systematic review and meta-analysis. World J
Surg, Vol.77, Issue 3, pp. 2026-40, ISSN 0003-1348
Moberg, AC.; Ahlberg, G.; Leijonmarck, CE.; Montgomery, A.; Reiertsen, Rosseland, AR. &
Stoerksson, R. (1998). Diagnostic laparoscopy in 1043 patients with suspected acute
appendicitis. Eur J. Surg, Vol.28, No.5, pp. 833- 840, ISSN 1102–4151
Moore, D.; Grogan, E.; Sperroff, T. & Holzman, M. (2004). Cost perspectives of laparoscopic
and open appendectomy. SAGES; Poster of distinction, Vol.18, No.2, ISSN 1366-
5278
Moore, CB.; Smith, RS.; Herbertson, R. &Toevs, C. (2011). Does Use of Intraoperative
Irrigation with Open or Laparoscopic Appendectomy Reduce Post-Operative Intra-
abdominal Abscess? Am. Surg, Vol.136, No.4, pp. 78-80, ISSN 1007-9327
Moreno-Sanz, C.; Pascual-Pedreño, A.; Picazo-Yeste, JS.; Seoane-Gonzalez, JB. (2009).

Laparoscopic appendectomy during pregnancy: between personal experiences and
scientific evidence. J Am Coll Surg, Vol. 205, Issue 1, pp.37-42, ISSN 1072-7515
Morino, M.; Pellegrino, L.; Castagna, E.; Farinella, E. & Mao. P.(2006). Acute nonspecific
abdominal pain: A randomized, controlled trial comparing early laparoscopy
versus clinical observation. Ann Surg, Vol.13, No.2, pp.886-888, ISSN 1528-8242
Mussack, T.; Schmidbauer, S.; Nerlich, A.; Schmidt, W. & Hallfeldt, KK. (2002). Chronic
appendicitis as an independent clinical entity. Chirurg, Vol.33, No.3, pp.710-715,
ISSN 0009-4722
Navez, B.; Therasse, A. (2003). Should every patient undergoing laparoscopy for clinical
diagnosis of appendicitis have an appendicectomy? Acta Chir Belg, Vol.91, Issue 4,
pp.87-89 ISSN 1007-9327
Neumeyer, L.; Kennedy, A. (2003). Imaging in appendicitis: a review with special emphasis
on the traetment of women. Obstet Gynecol, Vol,102, Issue 6,pp. 1404- 1409, ISSN
0001-6002
Ng, WT.; Lee, YK.; Hui, SK.; Sze, YS.; Chan, J.; Zeng, AG.; Wong, CH. & Wong, WH. (2004).
An optimal, cost-effective laparoscopic appendectomy technique for our surgical
residents. Surg Laparosc Endosc Percutan Tech, Vol. 14, No.3, pp. 125-9, ISSN 1681-
715X
Pedersen, AG.; Petersen, OB.; Wara, P.; Ronning, H.; Qvist, N. & Laurberg, S. (2001).
Randomized clinical trial of laparoscopic vs open appendicectomy. Br J Surg,
Vol.23, No. 3, pp. 200-205, ISSN 0007-1323
Piskun, G.; Kozik, D.; Rajpal, S.; Shaftan, G. & Fogler, R. (2001). Comparison of
laparoscopic, open, and converted appendectomy for perforated appendicitis. Surg
Endosc, Vol.10, No. 6, pp. 660- 662, ISSN 0972-2068
Pokala, N.; Sadhasivam, S.; Kiran, RP. & Parithivel, V.(2007). Complicated appendicitis--is
the laparoscopic approach appropriate? A comparative study with the open
approach: outcome in a community hospital setting. Am Surg, Vol.73, No.8, pp.741-
2, ISSN 0303-5212
Riber, C.; Soe, K.; Jorgensen, T. & Tonnesen, H. (1997). Intestinal obstruction after
appendicectomy. Scand J Gatroenterol, Vol.26, No.3, pp.1125- 1128, ISSN 0253–4886
Ruiz de Angulo, D.; Martínez de Haro, LF.; Ortiz, MA.; Munitiz, V.; Navas, D.; Abrisqueta, J.
& Parrilla, P.(2011). Evaluation of the aesthetic results perceived by patients after 3-
port laparoscopic appendectomy. Cir Esp, Vol.9, No.1, ISSN 1437-981
Sadot, E.; Telem, DA.; Arora, M.; Butala, P.; Nguyen, SQ. (2010). Divino CM Laparoscopy: a
safe approach to appendicitis during pregnancy. Surg Endosc, Vol.24, No 2, pp 383-
389, ISSN 0930-27
Sajid, MS.; Rimple, J.; Cheek, E. & Baig, MK. (2009). Use of endo-GIA versus endo-loop for
securing the appendicular stump in laparoscopic appendicectomy: a systematic
review. Sug Laparosc Endosc Perculan Tech, Vol.9, No.4, pp. 5-11, ISSN 1778-3852
Sauerland, S.; Lefering, R.; Holthausen, U. & Neugebauer EAM. (1998). Laparoscopic vs
conventional appendectomy – a meta-analysis of randomised controlled trials.
Langenbeck’s Arch Surg, Vol.127, Issue 3, pp. 289-295, ISSN 0253–4886
Sauerland, S.; Lefering, R. & Neugebauer EAM. (2002). Laparoscopic versus open surgery
for suspected appendicitis. Cochrane Review, The Cochrane Library, Vol.68, Issue 1
Cochrane Database Syst Rev. 2002;(1):CD001546, ISSN 1464-780
Sauerland, S.; Lefering, R. & Neugebauer EAM. (2004). Laparoscopic versus open
appendectomy for suspected appendicitis. The Cochrane Database of Systematic
Reviews,Vol.333,Issue 4.Art No.: CD001546.DOI:10.1002/14651858.CD001546.pub2,
ISSN 1538-3598
Sauerland, S. et al. EAM. (2010). Laparoscopic versus open appendectomy for suspected
appendicitis. The Cochrane Database of Systematic Reviews, Vol.19, No.6, CD001546,
ISSN 1538-3598
Sauerland S, Kazemier G. Appendix stump closure during laparoscopic appendectomy
(Protocol). Cochrane Database of Systematic Reviews 2007, Issue 2. Art. No.: CD006437.
DOI: 10.1002/14651858.CD006437, ISSN 1469-493
Semm K (1983). Endoscopic appendectomy. Endoscopy, Vol.21, Issue 1, pp.59-64, ISSN 1528-
8242
Scott-Conner, CE.; Hall, TJ.; Anglin, BL. & Muakassa FF. (1992). Laparoscopic
appendectomy. Initial experience in a teaching program. Ann Surg, Vol.20, No.1,
pp.660- 667, ISSN 1681-715
Stoltzing, H. & Thon, K. (2000). Perforated appendicitis: is laparoscopic operation advisable?
Dig Surg, Vol.17, No.6, pp.610-616, ISSN 1364-5706
Tate, J. J. T. (1996). Laparoscopic appendicectomy. Leading articles. Br J Surg, Vol.83, Issue 9,
pp. 1169-70 ISSN 2036-3605
Teh, SH.; O’Ceallaigh, Mckeon, JG.; O’Ceallaigh, S.; Mckeon. JG.; O’Donohoe, MK.; Tanner,
WA. & Keane, FB. (2000). Should an appendix that looks “normal” be removed at
diagnostic laparoscopy for acute right iliac fossa pain? Eur J Surg, Vol.166, Issue 5
pp.388- 389, ISSN 1102–4151
Temple, LK.; Litwin, DE. & Mc Leod, RS. (1999). A meta-analysis of laparoscopic versus
open appendectomy in patients suspected of having acute appendicitis. Can J Surg,
Vol.22, No.2, pp.377- 383, ISSN 1528-8242
Terasawa, T.; Blackmore, C.; Bent, S. & Kohlwes, J. (2004). Systematic Review: Computed
Tomography and Ultrasonography To Detect Acute Appendicitis in Adults and
Adolescents. Ann Intern Med, Vol.141, No.7, pp.537-546, ISSN 1748-880
Tingstedt, B.; Johansson, J.; Nehez, L.& Andersson, R. (2004). Late abdominal complaints
after appendectomy-readmissions during long-term follo-up. Dig Surg, Vol.21,
No.1, pp. 23-27, ISSN 1007-9327
Toorenvloiet, BR.; Wiersma, F.; Bakker, RF.; Merkus, JW.; Breslau, PJ. & Hamming, JF.
(2010). Routine ultrasound and limited computed tomography for the diagnosis of
acute appendicitis. World Journal of Surgery. Vol.34, No. 10, pp: 2278-85, ISSN 1432-
2323
Towfiigh, S.; Chen, F.; Mason, R.; Kathkouda, N.; Chan, L. & Berne, T. (2006). Laparoscopic
apppendectomy significantly reduces length of stay for perforated appendicitis.
Surg Endosc, Vol. 18, No. 2, pp. 495-499, ISSN 1007-9327
Tsai, AY.; Selzer, DJ. (2010). Single-port laparoscopic surgery. Adv Surg, Vol.23, Issue 1,
pp.1-27, ISSN 1528-8242
Van Randen, A.; Lameris, W.; Van Es, HW.; Van Heesewijk, HP.; Van Ramhorst, B.; Ten
Hove, W.; Bouma, WH.; Van Leeuwen, MS.; Van Keulen, EM.; Bossyt, PM.; Stoker,
J. & Boeremeester, MA; on behalf of the OPTIMA study group. (2011). Eur Radiol.
Vol.8, No.25, Mar 2 [Epub ahead of print]. ISSN 0033-8419
Van Dalen, R.; Bagshaw, PF.; Dobbs, BR.; Robertson, GM.; Lynch, AC. & Frizelle, FA. (2003).
The utility of laparoscopy in the diagnosis of acute appendicitis in women of
reproductive age. Surg Endosc, Vol.2, No.2, pp. 1311- 1313, ISSN 0930-2794
Van den Broeck, WT.; Bijnen, AB.; Van Eerten, PV.; De Ruiter P. & Gouma DJ. (2000).
Selective use of dignostic laparoscopy in patients with suspected appendicitis. Surg
Endosc, Vol.14, No.10, pp. 938- 941, ISSN 0930-2794
Vettoretto, N. & Agresta F. (2011). A brief review of laparoscopic appendectomy: the issues
and the evidence. Tech Coloproctol, Vol.15, No.1, pp.1-6, ISSN 1428-045X
Walsh, CA.; Tang, T. & Walsh SR. (2008). Laparoscopic versus open appendicectomy in
pregnancy: a systematic review. Int J Surg, Vol., No., pp. 339-344, ISSN
Wang, Y.; Reen, DJ. & Puri P. (1996). Is a histologically normal appendix following
emergency appendicectomy always normal? The Lancet, Vol.347, Issue 9008, pp.
1076-79, ISSN 1543-2165
Weston, AR.; Jackson, TJ. & Blamey, S.(2005). Diagnosis of appendicitis in adults by
ultrasonography or computed tomography: Asystemic review and meta-analysis.
International Journal of Technology Assessment in Health Care, Vol.21, No.3, pp. 368-
379, ISSN: 1948-5204
Wei, HB.; Huang, JL.; Zheng, ZH.; Wei, B.; Zheng, F.; Qiu, WS.; Guo, WP.; Chen, TF. &
Wang, TB.(2010). Laparoscopic versus open appendectomy: a prospective
randomized comparison. Surg Endosc, Vol.59, No.1, pp. 266-9, ISSN 0930-2794
Wie, HJ.; Lee, JH.; Kyung, MS.; Jung, US.; Choi, JS. (2008). Is incidental appendectomy
necessary in women with ovarian endometrioma? Aust N Z J Obstet Gynaecol,
Vol.48, No 1, pp.107-111, ISSN 0004-8666
Wullstein, C. Barkhausen, S. & Gross, E. (2001). Results of laparoscopic vs. conventional
appendectomy in complicated appendicitis. Dis Col Rectum, Vol.44, No.11, pp. 1700-
1705, ISSN 0100-6991
Yang, HR.; Wang, YC.; Chung, PK.; Chan, WK.; Jeng, LB. & Chen, RJ. (2005). Role of
leucocyte count, neutrophil percentage, and C-reactive protein in the diagnosis of
acute appendicitis in the elderly. Am Surg,Vol.2, No.1, pp. 344-7, ISSN 1681-715
Yeh, CC.; Wu, SC.; Liao, CC.; Su, LT.; Hsieh, CH. & Li, TC. (2011). Surgical Endoscopy, Mar
18, [epub ahead of print], Vol.17, No. 13, ISSN 1007-9327
Zbar, RI.; Crede, WB.; McKhann, CF. & Jekel, JF. (1993). The postoperative incidence of
small bowel obstruction following standard, open appendectomy and
cholecystectomy: a six year retrospective cohort study at Yale- New Haven
Hospital. Conn Med, 57, Vol.9, No.12, pp. 123- 127, ISSN 1715-5258
9
Appendicitis and Appendicectomy

Sami M. Shimi
Department of Surgery, Ninewells Hospital and Medical School,
University of Dundee
Scotland, United Kingdom
1. Introduction
The term appendicitis was first used by an epic publication by FITZ (Harvard Medical
School) in 1886. FITZ outlined the clinical diagnosis and suggested early removal of the
appendix. This new concept was not readily accepted. The first recorded appendicectomy
was reported from Australia and was done on a kitchen table in Toowoonba in 1893.
Appendicectomy in the UK did not gain early acceptance until 1902, when Sir Frederick
Treves operated on King Edward VII twelve days before his coronation.
2. Epidemiology
The epidemiology of appendicitis has caused a lot of intrigue. Although appendicitis was
unknown before the 18th Century, there was a striking increase in its prevalence from the
end of the 19th Century. There were suggestions that it was a side effect of modern western
life. Although evidence for this was lacking, the rapid emergence of appendicitis in
developed countries in the 20th Century and its rarity in rural areas and in undeveloped
countries was sited as evidence. By the mid 1920s appendicitis became sufficiently common.
Several theories have been advanced to account for the prevalence of the disease. One
theory suggested that diet was responsible for the geographical distribution of appendicitis.
It was however clear that diet could not fully explain the epidemiology of appendicitis. An
alternative hypothesis proposed that improved hygiene in developed countries reduced the
exposure of infants to enteric organisms would, modify the immune response to virus
infections which might then cause appendicitis. Although this theory was accepted for
many years, the hygiene hypothesis does not adequately explain the recent decline in the
frequency of appendicitis in the latter half of the 20th Century. It remains uncertain whether
there has been a real change in the incidence of appendicitis or whether the presentation and
course of the disease has indeed changed.
The current incidence of appendicitis is about 100 per 100,000 person-years in
Europe/America. Whereas the appendectomy rate is still decreasing, the incidence of
appendicitis is now nearly stable. During the last 30 years the incidence of perforated
appendicitis has not changed (approximately 20 per 100,000 person-years). Established risk
factors for acute appendicitis are age (peak: 10-19 years), sex, and ethnic group/race.
Classical theories (diet, hygiene) present illuminating models to explain the rise and fall of
incidence in the last century; however, from a contemporary perspective the evidence is
insufficient. The study of the epidemiology of appendicitis is complicated by the influence
of referral, infrastructure, and surgical treatment strategy on the incidence of acute

appendicitis. Therefore, there is a strong need for good prospective studies with high-
quality data.
3. Pathology
Several factors are claimed to predispose to acute inflammation of the appendix, including
faecolith, food residues, lymphoid hyperplasia (in children) and the presence of a carcinoid
tumour. Specific viral and bacterial inflammation can also affect the appendix. In addition
the appendix can be involved by ulcerative colitis and Crohn’s disease. In early acute
appendicitis there is acute inflammation of the mucosa which undergoes ulceration. Pus
may be present in the lumen. At this stage the patient experiences an ill defined central
abdominal pain. Microscopically, the appendix is usually swollen and the overlying vessels
are dilated and prominent. As the acute inflammation develops, it spreads through the full
thickness of the appendix wall to reach the serosal surface. This causes a localised acute
peritonitis, which is perceived as a sharp pain localised to the right iliac fossa. At this stage
the appendix microscopically shows dilated serosal vessels and a rough, yellow, fibrinous
exudate on the surface. By this stage the inflammation and the infection has spread to
involve all layers of the appendix wall. The build up of fluid exudate within the wall
increases tissue pressure and this, together with the toxic damage to blood vessels and
subsequent thrombosis can lead to superimposed ischemia. In addition the muscle layer is
replaced by an acute inflammatory infiltrate with degranulation of neutrophils contributing
to toxic damage. Both the ischemia, toxic products and infection contribute to weakness of
the wall of the appendix and the distal part of the appendix can become gangrenous and
perforate. This liberates bowel contents in to the peritoneal cavity and causes generalised
peritonitis which leads to severe deterioration in the clinical condition. If the general
condition of the patient is satisfactory, the omentum might cover the site of perforation and
local abscess formation follows. Infiltration into blood vessels and lymphatics leads to the
consequences of blood spread which is suppurative pylephlebitis (inflammation and
thrombosis of the portal vein), liver abscess and septicaemia. The inflammation can also
become chronic, or obstruction to the neck of the appendix may lead to mucus retention in
its lumen causing a mucocoele of the appendix. This does not often give rise to clinical
problems but on rare occasions may rupture and disseminate mucus secreting epithelial
cells in to the peritoneal cavity – pseudomyxoma peritonei.
The presence of gangrene or perforation seems to be associated with the presence of faecoliths.
These are intraluminal laminated appendiceal calculi. They result from dehydration and
compaction of faecal pellets. Approximately 50% of cases of gangrenous or perforated
appendicitis are associated with a faecolith in contrast with uncomplicated appendicitis in
which a faecolith is rarely present. It is thought that a faecolith increases the likelihood of
obstruction of the appendix and thereby allows the accumulation of pus. Overall about 20% of
all patients with acute appendicitis have perforation at the time of operation. At the extremes
of age (below 5 and above 60 years) the rate of perforation is in the region of 60%.
Perforation rates of 20% to 30% have been reported consistently over the past 70 years
despite the technologic advances over this interval. Recent evidence suggesting that
perforation precedes surgical evaluation in the majority of cases indicates that reduction of
perforation rates will have to be addressed through encouraging earlier evaluation and
greater access to care. However, modern surgical therapy has been responsible for reducing
Appendicitis and Appendicectomy 139
the mortality of appendicitis from 26% overall to less than 1% over the same period. The
mortality rate of 0.08% reported is testament to the benefits of advancing technology in
managing a persistent rate of perforation and its attendant complications. Perforation
continues to disproportionately affect those individuals at the extremes of age. This is most
likely due to delays in presentation and diagnosis related to an inability to communicate in
the younger population. In the older population, a combination of delayed presentation,
confounding medical conditions and a decreased index of suspicion may contribute to this
observation.
Emergency appendectomy was originally advocated because of the very high mortality of
perforated appendicitis and the assumption that acute appendicitis evolved to perforated
disease, a pathophysiologic hypothesis that has never been proven. This notion was first
proposed by Reginald Fitz, the originator of the term appendicitis, in 1886. Fitz was the first
to identify inflammation of the appendix as a cause for right lower quadrant infections,
previously known as thyphilitis. In making the argument that the appendix causes this
entity, however, Fitz incidentally noted that one-third of patients undergoing autopsy in the
pre-appendectomy era had evidence of prior appendiceal inflammation, suggesting that
appendicitis often resolved spontaneously without surgery. Later evidence from
submariners who developed appendicitis while at sea and received delayed surgical
therapy has shown that in most cases the acute disease can resolve with non-operative
antibiotic and supportive therapy.
Perforated and non-perforated appendicitis have followed radically different epidemiologic
trends over the past 2 decades. While perforated appendicitis slowly but steadily increased
in incidence, non-perforated appendicitis stabilised or declined. If perforated appendicitis
was simply the result of appendicitis that was not surgically treated early enough, the
trends should have been more nearly parallel throughout all the time periods studied. Time
series analysis showed that on a year-to-year basis, there was a significant positive
correlation between perforated and non-perforated appendicitis for men but not for women.
These unassociated epidemiologic trends suggest that the pathophysiology of these diseases
is different. If true, it might follow that many patients presenting with non-perforated
appendicitis might experience spontaneous resolution without perforation. There is
historical, clinical, and immunologic evidence to support this hypothesis.
An alternative hypothesis suggests that several factors (ie, prehospital time, availability of
operating room for emergency surgery, time of presentation) have been shown to be
significantly associated with perforated appendicitis. Compared with uncomplicated
appendicitis, perforated appendicitis is associated with a two- to tenfold increase in
mortality
4. Diagnosis
The diagnosis of appendicitis is predominantly a clinical one. The history and examination
are pivotal to determining the correct diagnosis. The pain can be a generalised colicky
abdominal pain that became more localised to the right iliac fossa over the course of three
days. Owing to the embryological origin of the appendix as a midline structure, the majority
of patients with acute appendicitis first notice a pain which starts in the region of the
umbilicus. This is usually a dull ache or it may be colicky pain when the appendix lumen is
obstructed. The pain may change from an intermittent pain to a constant localised sharp
pain. After a period of time the pain shifts to the right lower quadrant of the abdomen
owing to the inflamed appendix irritating the parietal peritoneum. Approximately 30% of
patients do not experience this shift of pain and their symptoms commence in the right iliac
fossa. Nausea and vomiting are common and anorexia is inevitable. About 20% of patients
will also have diarrhoea especially when the appendix lies in the pelvis.
There can be other features in the history suggestive of appendicitis. This includes episodes
of vomiting, fever and anorexia. Points to exclude in the history are changes to bowel habits
and urinary symptoms. In some cases the inflamed appendix can irritate the bladder due to
the close proximity. This however can be supported by a negative urinalysis. The possibility
of mesenteric adenitis should be considered in children. This is triggered by viral pathogens
and manifests initially as a respiratory tract infection or generalised malaise and fever prior
to the onset of abdominal symptoms. Although mesenteric adenitis is more common in
children, it still should be considered in young adults as such a diagnosis would not require
surgical intervention. It presents very similarly to acute appendicitis however subtle
differences do exist. Often the pain of mesenteric adenits can move location when the
patient moves whereas in appendicitis it is fixed to the right iliac fossa. Inflammatory bowel
disease such as Crohn’s often presents with ileocaecal disease and can present similarly to
appendicitis. In such cases a mass could be palpated in the right iliac fossa, without any
extraintestinal signs. The clinical history alone is not enough to diagnose the condition
therefore examination and investigation are essential.
Most patients with appendicitis have a low grade fever and some tachycardia. A very high
temperature (above 39 oC) indicates probable abscess formation or other cause of infection.
The site of maximum tenderness is usually at McBurney’s point. In patients with
inflammation of a retro-caecal appendix the pain may be considerably higher and more
lateral. Alternatively in pelvic appendicitis, the pain may be lower and almost midline. The
abdomen may show signs of guarding in 90% of patients with acute appendicitis. In patients
with perforation of the appendix they will have generalised peritonitis and the area of
guarding may extend beyond the right iliac fossa. Rebound tenderness is a useful sign. In
some patients an appendix mass could be felt on abdominal examination.
On general examination fever is an important sign indicative of an inflammatory condition.
A foetor is also detected in 50 % of patients. In children, general observation of discomfort
associated with movement or posture is also indicative. Abdominal examination should
reveal tenderness over the right iliac fossa with or without rebound tenderness or guarding
which indicates signs of peritonism. Specific signs of Appendicitis include McBurneys and
Rovsing’s signs. The appendix lies in the right iliac fossa and is attached to the
posteromedial wall of the caecum where the teniae coli unite. The surface marking for the
root of the appendix is relatively constant and is situated approximately one third of the
distance from the anterior superior iliac spine to the umbilicus. This is referred to as
McBurneys point as shown in the diagram (Figure 1).
In general, the clinical features of appendicitis can vary depending on the position of the
appendix. The commonest position of the appendix is retrocaecal. In this position, psoas
muscle irritation (exacerbation of pain on hip extension) can be evident. In the subcaecal and
pelvic position, supra pubic pain and urinary frequency may be the predominant symptoms
with right sided tenderness on rectal or vaginal examination. In the pre and post ileal
position, diarrhoea or vomiting may be the presenting features due to irritation of the ileum.
On examination for appendicitis it is important to determine if the pain is worst at
McBurneys point. Furthermore the patient may describe pain over this area on coughing.
Specific localisation of tenderness over this anatomical landmark is indicative that the
inflammation is no longer limited to the lumen of the appendix which poorly localises pain.
It is suggestive that there is irritation at the peritoneum where it comes into contact with the
appendix. Rovsing’s sign can be demonstrated by palpating the left iliac area which results
in stretching of the underlying peritoneum. This induces pain in the right iliac fossa due to
irritation of the inflamed peritoneum. Digital rectal examination can elicit tenderness on the
ipsilateral side to the appendix.
Fig. 1. Diagramatic illustration of McBurneys point (1) with regards to the umbilicus (2) and
the anterior superior iliac spine (3).
Fig. 2. Various positions of the vermiform appendix.

In females of child bearing age it is important to consider the possibility of pregnancy
particularly if the patient was sexually active. An ectopic pregnancy should be considered in
the potential differential diagnosis which can often present with pain in the lower
quadrants. The pain associated with ectopic pregnancies often radiates to the shoulder. A
history of the patient’s menstrual cycle and sexual activity and contraception can help in
elimination of this differential. It is important to assess beta HCG levels on admission as this
would determine further management. Ultasonography and CT scanning are the best non-
invasive means of investigating appendicitis. The scan may show an abnormal appendix or
an appendicolith with a diameter of over 6mm. The blood results will often have a rise in
the inflammatory markers including white cell count and C-Reactive protein (CRP).
It is important to ensure that the patient has received adequate analgesia and has had blood
tests to ensure clotting is normal before surgery. The patient would also require a ‘group
and save’ due to a small risk of bleeding during or after surgery. Antibiotics are often
prescribed as prophylaxis to help reduce the risk of wound infections. The patient may
require an NG tube if vomiting to prevent the risk of aspiration.
In order to make the diagnosis of appendicitis and at the same time avoid unnecessary
appendicectomies a variety of diagnostic modalities were advanced. A review of the
literature suggested that the clinical diagnosis of acute appendicitis based on symptoms,
physical findings, and serological tests is relatively inaccurate. Despite having high
sensitivity (up to 100%), clinical evaluation has relatively low specificity (73%). This means
that surgeons are likely to overestimate the presence of appendicitis in patients who present
acutely. Several reports have found the use and diagnostic accuracy (specificity and
sensitivity) of ultrasound and computed tomography (CT) to be limited in the preoperative
evaluation of patients with suspected appendicitis especially in the emergency setting.
The most common US technique used to examine patients with acute abdominal pain is the
graded-compression procedure. With this technique, interposing fat and bowel can be
displaced or compressed by means of gradual compression to show underlying structures.
Furthermore, if the bowel cannot be compressed, the noncompressibility itself is an
indication of inflammation. Curved (3.5–5.0-MHz) and linear (5.0–12.0-MHz) transducers
are used most commonly, with frequencies depending on the application and the patient's
stature. The reported sensitivity of ultrasonic detection of appendicitis lies between 55 and
98% and the specificity between 78 and 100%.
Computed Tomography (CT) has a higher sensitivity and specificity for the diagnosis of
appendicitis. The CT technique used to examine patients with acute abdominal pain
generally involves scanning of the entire abdomen after intravenous administration of an
iodinated contrast medium. Although abdominal CT can be performed without contrast
medium, the intravenous administration of contrast material facilitates good accuracy with a
positive predictive value of 95% reported for the diagnosis of appendicitis and a high level
of diagnostic confidence, especially in rendering diagnoses in thin patients, in whom fat
interfaces may be almost absent. Although rectal or oral contrast material may be helpful in
differentiating fluid-filled bowel loops from abscesses in some cases, the use of oral contrast
material can markedly increase the time to complete the test in the emergency setting and
may be contraindicated for patients who potentially may require anesthesia and surgery.
The lack of enteral contrast medium does not seem to hamper the accurate reading of CT
images obtained in patients with acute abdominal pain as it does in postoperative patients.
Exposure to ionizing radiation is a disadvantage of CT. This risk however should be
weighed against the direct diagnostic benefit. CT has been shown to reduce the negative-
finding appendectomy rate from 24% to 3%. However, only routine CT in comparison to
selective use of CT would achieve such results. CT seems to be more sensitive (96% vs. 76%)
and accurate (94% vs. 91%) than US in diagnosing acute appendicitis, whereas they are
almost equal when it comes to specificity (89% vs. 91%). CT imaging tailored to evaluate
acute appendicitis has proven to be particularly successful with a sensitivity of 100%,
specificity of 95%, positive predictive value of 97%, negative predictive value of 100%, and
accuracy of 98%.
Based on the clinical diagnosis, surgical exploration for suspected appendicitis is advocated
early to prevent progression or perforation with its associated morbidity and mortality.
Active observation is advocated for patients with equivocal symptoms, signs and laboratory
results. Surgical exploration has been accompanied by an incidental appendicectomy in a
considerable number of cases. Authors of large prospective studies report a 15%–32%
removal rate of normal appendices at surgery. The reported negative appendicectomy rate
for men varies from 7 % to 15 %, whereas that for women of child bearing age lies between
22 % and 47 % . This high rate of unnecessary appendicectomies has considerable morbidity
and high cost to the health care system. A large population based study found that patients
undergoing negative appendicectomy have prolonged hospitalisation, increased infectious
complications and higher rates of case fatality when compared with patients with
appendicitis. The national cost of hospitalisation was also higher. This may be due to
concomitant disease which necessitated the presentation of right iliac fossa pain which
otherwise remains undiagnosed after appendicectomy.
A number of studies have emphasised the value of laparoscopy as a diagnostic and
operative tool particularly in young women. Diagnostic laparoscopy has been found reliable
in the assessment of the appendix and has reduced the number of unnecessary
appendicectomies. In addition, it has been useful in the diagnosis of alternative pathology
when it exists.
In order to reduce total costs, some studies have suggested a selective approach in the use of
diagnostic laparoscopy. There is evidence however that unless diagnostic laparoscopy is
used routinely, the number of negative appendicectomies remains high.
5. Management
Historically we have seen progression in the management of right iliac fossa pain from
purgation to early appendicectomy. Early surgical dictum necessitated appendicectomy for
patients with right iliac fossa pain admitted to hospital with convincing signs and
symptoms. Appendicectomy was clearly overdone in the past as the delay in diagnosis of
appendicitis contributed to an increase in morbidity and mortality. Indeed delayed
diagnosis of appendicitis was the most common cause of litigation against emergency
surgeons. In regard to laparoscopic appendicectomy, early reports suggested a high rate of
complications particularly intra-abdominal abcess formation which was associated with
laparoscopic appendicectomy. A more recent Cochrane review however, has found an equal
rate of complications in open and laparoscopic appendicectomy. However, patients
operated on by laparoscopy, realised the benefits of laparoscopy in terms of less pain, early
discharge from hospital and return to normal activities.
Natural orifice translumenal endoscopic surgery (NOTES) has become an exciting area of
surgical development. Significant limitations to this surgical concept include lack of surgical
expertise and appropriate flexible instrumentation although both aspects are being
addressed. An alternative and competing technology to NOTES is single-incision
laparoscopic surgery (SILS). A number of reports have produced encouraging results for
single incision appendicectomy but this technique remains in its infancy. A number of
skeptics have expressed reservations about the applicability of these two techniques for
appendicectomy and it will be a matter for the surgical community uptake and adoption of
these two techniques over the next few years.
In terms of the cost of the utility of laparoscopic appendicectomy, the overall costs might be
justified since the use of laparoscopy can increase diagnostic power, provide less
postoperative pain and fewer wound infections, decrease hospital stay and return to normal
activities, and decrease the number of postoperative adhesions. At least six randomized
studies have addressed the cost issue. Some found that overall costs for laparoscopic
appendectomy were less (but not significantly so), most of the other studies have shown
consistently that laparoscopy is more expensive. There was however a wide range of costs.
One study found a mean difference of £148 in operating room charges, which does not
compensate the costs for the mean difference in analgesics requirement between
laparoscopic and open appendicectomy. On the other hand, there is no doubt in the
superiority of diagnostic laparoscopy and laparoscopic appendicectomy in terms of quality
but only if the incidence of post-operative complications could be reduced. The key to this
dilemma lies in separating simple appendicitis from complicated appendicitis. The former
will almost invariably have a low incidence of post-operative complications while those
with complicated appendicitis (perforation or abcess) seem to have a higher rate of
complications after laparoscopic appendicectomy.
5.1 Management of appendix abcess

Patients presenting with an appendix mass should be treated non-surgically in the first
instance. Once the abscess has been confirmed radiologically, percutaneous drainage is the
best treatment of choice. Occasionally this drainage can be followed by the development of a
faecal fistula but this is usually a low output fistula which normally heals spontaneously. If
percutaneous drainage is inadequate, it may be necessary to carry out operative drainage. In
patients who have had an appendix mass treated conservatively, about 15% will develop
recurrent appendicitis. An interval appendicectomy should be considered.
If appendix mass was found at laparoscopy or laparotomy an attempt should be made to
drain the abscess and leave the appendix in situ. Old surgical dogma which continues to
apply is that it is ‘fool hardy to remove the appendix in the presence of an appendix abcess’.
The main reasons for this is the generalised inflammation of the adjacent caecum and small
bowel. Attempts at appendicectomy in this scenario, invariably result with intra and post
operative complications. Such attempts usually result in a more extensive resection of the
adjacent small bowel and caecum. Given the emergency presentation of these patients, the
potential for complications is large.
5.2 Negative, incidental and elective appendicectomy

If a normal appendix was found at laparoscopy, most surgeons would leave the appendix
in-situ as an appendicectomy may carry some procedures specific complications. However
some skilled surgeons have excellent results with removing a normal appendix
laparoscopically. Based on the results of negative appendicectomies published, the
complication rate tends to be low. However, if a right iliac fossa incision has been made over
the appendix for open appendicectomy, it would seem reasonable to carry out an
appendicectomy. This is mainly due to a future assumption that appendicectomy has been
carried out when a patient presents at a later stage. It is also claimed that 20% of normal
looking appendices may have evidence of mucosal appendicitis. Further, although rare,
carcinoma of the appendix occurs in rare cases when the appendix looks microscopically
normal.
There is little evidence to support the concept of chronic appendicitis. A number of patients
mainly young females will have repeated acute presentations with right iliac fossa pain in
the absence of raised inflammatory markers. Labels such as chronic appendicitis and
‘grumbling appendix’ have been applied to these patients. However, there is no evidence to
support this diagnosis. In some of these patients a faecolith was found in the lumen of the
appendix which could in theory account for some of the symptoms without necessarily
causing full fledged appendicitis. However, elective appendicectomy does not necessarily
obviate the long term symptoms of many of these patients any more than a placebo effect.
Consequently, the concept of elective appendicectomy for chronic right iliac fossa pain
seems unjustified.
5.3 Non-operative management

Acute appendicitis is considered a surgical emergency. The incidence decreases with
increasing adult age, and the overall incidence in the general population has probably been
decreasing during the last 50 years. Classically, appendectomy is performed to avoid
perforation, which typically occurs within 48 hours. With the development of the preoperative
use of antibiotics, early investigators reported that the peritonitis associated with appendicitis
usually resolved before appendectomy. A number of publications have reported cases of
appendicitis treated conservatively with a small number of deaths, a further number requiring
abscess drainage, and a large number of failures requiring appendectomy. Several more recent
studies have shown that perforated appendicitis can be treated nonoperatively with IV
antibiotics with the performance of percutaneous drainage if an abscess is present. Success
rates have been reported as between 88% and 100%, with the incidence of recurrent
appendicitis 5% to 38%. The use of conservative (non-surgical) management of appendicitis is
currently reserved to situations where access to surgical management is limited such as on
board of ships, fishing vessels, submarines, space missions, polar and Antarctic expeditions .
Medical evacuation is performed when possible, and is expedited if improvement does not
occur. For some programs, prophylactic appendectomy has been considered. The benefits and
long term risks of performing a prophylactic appendectomy in an otherwise healthy
individual must however be carefully considered.
There are no studies that have looked at the complications associated with prophylactic
appendectomy.
5.4 Management of acute appendicitis

Based on current evidence, all patients presenting with convincing symptoms and signs of
appendicitis with raised serological markers of inflammation, should have a diagnostic
laparoscopy to confirm the diagnosis where possible. Patients found to have evidence of
appendicitis by virtue of serosal inflammation and / or the presence of fibrinous exudates
should be considered for appendicectomy. The consideration for open or laparoscopic
appendicectomy hinges on the experience of the surgeon, the availability of suitable
assistance and appropriate instruments and the express wishes of the patient if these have
been made in advance. In equivocal cases, all surgeons would search for an alternative
source to account for the patient’s symptoms and signs and in the absence of an alternative
source, appendicectomy should be considered.
In patients found to have perforated appendicitis surgeons should attempt to evaluate the
risks and benefits of laparoscopic surgery for the individual patient based on the amount of
contamination of the peritoneal cavity, the spread and intensity of inflammation against the
general condition of the patient together with surgical technical factors including the
experience of the surgeon and the availability of appropriate instruments.
In all patients undergoing appendicectomy, prophylactic antibiotics should be used. In

patients who have had a perforated appendix, appendicectomy should be followed by
peritoneal lavage. When perforation has occurred it is common practice to continue
intravenous antibiotics for a period postoperatively depending on the degree of infection
and contamination. Recent evidence suggests that metronidazole would be sufficient for
simple appendicitis. Additional broad-spectrum antibiotics may be necessary for
complicated appendicitis. If an adequate peritoneal lavage has been carried out, abdominal
drains do not confer any benefit.
5.4.1 Technique of open appendicectomy

An open procedure involves a muscle splitting gridiron incision at McBurneys point. The
muscle layers are separated along the line of the fibres allowing for the identification and
opening of the peritoneum. Upon entry into the peritoneum the caecum is identified and
appendix is located. This can be achieved through using the merging of the teniae coli as a
reference point. The vessels in the meso-appendix are ligated until the appendix is free. The
base of the appendix can then be ligated with two loops of absorbable sutures and the
appendix divided between the two loops. The appendix can then be removed. Some
surgeons invaginate the appendix stump either using a purstring absorbable suture or a Z
stitch. The majority of surgeons do not invaginate the appendix stump but use electro-
coagulation on the visible edge of the mucosa. After ensuring haemostasis, a thorough wash
is carried out. The wound is then closed in layers.
5.4.2 Laparoscopic appendicectomy

In 1983, Semm performed the first laparoscopic appendectomy. Ever since then, the
efficiency and superiority of laparoscopic approach compared to the open technique has
been the subject of much debate. The idea of minimal surgical trauma, resulting in
significantly shorter hospital stay, less postoperative pain, faster return to daily activities,
and better cosmetic outcome has made laparoscopic surgery for acute appendicitis very
attractive. However, several retrospective studies, several randomized trials and meta-
analyses comparing laparoscopic with open appendectomy have provided conflicting
results. Some of these studies have demonstrated better clinical outcomes with the
laparoscopic approach, while other studies have shown marginal or no clinical benefit and
higher surgical costs. The European Association of Endoscopic Surgeons have published
their guidelines on laparoscopic appendicectomy. In summary, the EAES have found that
laparoscopic appendicectomy is feasible and safe with a slightly longer operating time than
open appendicectomy. However, they expressly state that the safety of laparoscopic
appendicectomy during pregnancy is not established. Laparoscopic appendicectomy has
advantages over open appendicectomy but there is potential for serious injuries. EAES
recommends that at least 20 cases of laparoscopic appendicectomy should be done before
surgeon’s accreditation for this procedure.
5.4.3 Technique of laparoscopic appendicectomy

The patient is placed in a Trendelenburg position, with a slight rotation to the left. The
surgeon should stand on the patients left side and the primary monitor should be placed on
the right side of the patient (opposite the surgeon). The patients arms should be tucked at
the sides to allow sufficient room for the surgeon and camera operator to move cepahalad as
required. Pneumoperitoneum is produced by continuous pressure of 10-12 mmHg of carbon
dioxide via a Verres canula, positioned in the sub-umbilical area. Following gas insufflation,
a 12 mm canula for the 30 degree angled laparoscope should be placed in the periumbilical
area (preferably on the left). Alternatively, a 12 mm canula can be introduced by the
Hasson’s technique (introduction of first trocar into the peritoneum through a sub-umbilical
small incision) for initial insufflations of gas. Two additional canulae are required. A 12 mm
canula should be placed in the suprapubic area at the midline point to accommodate the
grasping or stapling device and/or to facilitate specimen extraction, and a third 5 mm
canula in the right (or left) lower abdominal quadrant is introduced under direct vision.
When the third cannula is placed on the right, it must be sufficiently far from the appendix
to allow a safe and comfortable working distance. The abdominal cavity is thoroughly
inspected in order to exclude other intra-abdominal or pelvic pathology. If the appendix is
normal, it is important to seek other sources to account for the patient’s presentation. If no
other cause is identified, it will be up to the discretion of the surgeon at the operating table
to decide on removing an apparently normal looking appendix. This has to be guided by
prior knowledge of the patient’s history, acute presentation, examination findings and
serological markers of inflammation.
The appendix should be identified at the base of the caecum. Atraumatic bowel graspers
should be used to lift the caecum. Part of the appendix should start coming to view. A second
pair of atraumatic graspers (or blunt suction probe) should be used to separate the appendix
from adherent tissue by blunt dissection. The mesoappendix should be identified and divided
with bipolar forceps (or mono-polar diathermy and scissors). Alternatively, the meso-
appendix could be divided using clips, Ligature, ultrasonic dissector or endoscopic stapler. The
base of the appendix should then be identified and secured with one or two ligating loops of
absorbable sutures placed at the base of the appendix close to the caecum. This is followed by
blunt dissection distal to the second loop using a curved dissector. The appendix should then
be divided between the 2 loops. The visible part of the mucosa is usually electro-coagulated.
There is no need to bury the appendix stump. Alternatively, the base of the appendix could be
stapled using one of the commercially available staplers. This achieves both closure and
division of the appendix. In all cases, the specimen should be removed through the trocar
without contact with the wound. Alternatively, if the appendix is too bulky, it should be
placed in an endobag (a variety are available on the market) which can be extracted through
one of the larger canulae sites. All removed tissue should be sent for histopathology. A
thorough wash is then carried out. Although this should centre on the operative site, it should
cover all sites of contamination encountered at the initial evaluation. Any faecoliths or necrotic
material which have escaped from a perforated appendix should be removed if encountered.
On occasion it may be necessary to look for inter-bowel fluid or pus collections and wash these
out as well. The procedure should terminate by abdominal desufflation and removal of all
cannulae. Patients should have two additional doses of antibiotics post operatively unless
widespread contamination and peritonitis was evident. In these cases, antibiotics coverage
should be continued for several days post operatively until the patient is no longer septic.
If bleeding is encountered during the procedure, an additional trocar may be required to
place a suction device while looking for the source of bleeding. Once this is identified,
control of bleeding may be achieved using clips or ligatures.
The use of staplers and more complex energy devices in appendicectomy saves time but
adds to the cost of the operation. In general, they are not recommended unless time is a
significant issue or these are used due to complexity or difficulty encountered during the
procedure.
Fig. 3. Operating room set-up for diagnostic Fig. 4. Trocar positions for appendicectomy.
laparoscopy and appendicectomy. Trocar 1 is used for the laparoscope. Trocars 2
and 3 are the main dissection sites. Trocar 4
can be added if necessary.
Fig. 5. Vesseles in the meso-appendix are Fig. 6. The appendix is freed by blunt
dissected and clipped. dissection to its base on the caecum.
Fig. 7. Two pre-tied loops of absorbable Fig. 8. The appendix is divided between loops
sutures are applied to the base of the and then delivered.
appendix.
5.5 Laparoscopic versus open appendicectomy

Despite numerous prospective randomised trials, systematic reviews and meta-analysis the
superiority of laparoscopic over open appendicectomy remains unclear particularly for
complicated appendicitis. Previous studies have produced conflicting conclusions regarding
the incidence of postoperative adverse events after laparoscopic and open appendicectomy.
Retrospective cohort studies, randomised controlled trials and meta-analysis have
demonstrated similar rates of overall morbidity. However, significant differences have been
demonstrated in a few studies. With regards to operating time, there is a clear trend of
extended operating time with laparoscopic appendicectomy in earlier studies with a further
trend towards parity between the two procedures. This is a reflection of the experience of
surgeons with the technique. With regards to hospital stay, the length of hospital stay after
surgery was shortened in laparoscopic appendicectomy by a fraction of a day. This
difference although numerically significant is of little practical significance.
Early return to full activity is accepted as an obvious advantage of laparoscopic
appendicectomy which is supported by a large scale meta-analysis conducted by the
Cochrane Colorectal Cancer Group. Clearly the smaller incisions of laparoscopic
appendicectomy contribute to reduce trauma to the abdominal wall and less pain allowing
faster recovery. Fast resumption of a normal diet following laparoscopic appendicectomy
was another appealing advantage, resulting from minimal manipulation of bowel. The
difference between laparoscopic and open appendicectomy in terms of resumption of
normal diet intake represents a fraction of a day. Although this is significant numerically it
is of doubtful practical significance. Reduced postoperative pain is another quality attribute
of laparoscopic surgery. Although difficult to assess, a number of meta-analysis found that
laparoscopic appendicectomy offered significant advantages in relieving postoperative pain
mainly due to its minimal abdominal wall trauma. Reduction of wound infection is a
significant advantage of laparoscopic appendicectomy. The chance of wound infection is
greater in open appendicectomy partly because the inflamed appendix is removed from the
abdominal cavity directly through the wound whereas in laparoscopic appendicectomy it is
extracted via a bag or trocar. In addition the port-site wounds in laparoscopic
appendicectomy are considerably smaller with less potential space and less interruption of
blood supply around wound.
Several explanations have been advanced for the reduction of ileus following laparoscopic
appendicectomy. Firstly, decreased handling of the bowel during the procedure leads to less
postoperative adhesion and such adhesions may be responsible for ileus. Secondly patients
after laparoscopic appendicectomy had less opiate analgesics which inhibited bowel
movements in the postoperative period. Thirdly earlier mobilisation after laparoscopic
appendicectomy may also contribute to the reduction of ileus. Several meta-analysis have
found that the incidence of intra-abdominal infections, intra-operative bleeding and urinary
tract infections after laparoscopic appendicectomy was higher compared with open
appendicectomy. It is not clear why intra-operative bleeding and urinary tract infections are
higher after laparoscopic appendicectomy. With regards to intra-abdominal infections and
abscess formation, there was suggestions that aggressive manipulation of the infected
appendix and increased use of irrigation fluid might have increased the incidence of intra-
abdominal infections after laparoscopic appendicectomy. The majority of studies however
have not separated the results for simple uncomplicated appendicitis. It does however
appear that patients with complicated appendicitis managed by laparoscopic
appendicectomy have a higher tendency for intra-abdominal abscess formation.
The conversion rate from laparoscopic to open appendicectomy is around 10%. This is not
surprising when considering the proportion of complicated appendicitis and the emergency
setting of the procedure.
Appendicectomy carries a fairly low risk of mortality. Consequently many studies do not
report mortality rates or multi-variate analysis on these rates. Amongst studies that do
report mortalities, the event rate ranges between 0.16 and 0.24.
During pregnancy, laparoscopic appendectomy was found to be safe and effective and at
least equivalent to open appendicectomy. Despite the raised intra-abdominal pressure
associated with pneumoperitoneum, laparoscopic appendicectomy is associated with good
maternal and fetal outcome. Further confirmatory studies are awaited before the safety of
laparoscopic appendicectomy can be accepted.
5.6 Long-term complications and implications

Both the acute inflammatory condition of appendicitis and the surgical operation carried out
to remove the appendix can potentially promote adhesion formation particularly around the
fallopian tubes which may lead to tubal dysfunction in females of child bearing age. There is
controversy surrounding the association between previous appendicectomy with
subsequent infertility in females. Some reports found perforated appendicitis in childhood is
not an appreciable cause of subsequent tubal infertility, while other reports found a high
incidence of tubal infertility in women previously treated for appendicitis complicated by
perforation, pelvic peritonitis or abscess. Three studies considered non-perforated
appendicitis as well as perforated appendicitis on subsequent infertility and their result
suggest that neither acute appendicitis nor perforation of the appendix was associated with
a significant risk of infertility. Other studies, considered the question of the association
between appendectomy and infertility. Some studies showed no association between a
history of appendicectomy and subsequent infertility while others found a higher incidence
of infertility in patients who have had a previous appendicectomy. One of these studies
analysed fertility after removal of a normal appendix. This study found that women whose
appendix was found to be normal at appendectomy in childhood seem to belong to a

subgroup with a higher fertility than the general population. The majority of these studies
suffer from small numbers, selected populations, design or analysis flaws. A recent
systematic review and appraisal of the evidence for evaluating if perforation of the
appendix was a risk factor for tubal infertility and ectopic pregnancy found 4 studies with
an appropriate epidemiological design with reasonable quality. It found that the risk of the
association for perforation of the appendix ranged from a high of 4.8 % for tubal infertility to
an insignificant association for ectopic pregnancy. The reviewed studies were consistent in
demonstrating a modest increase in risk, with all results in the same direction of increased
risk. Based on diagnostic tests for causation, the authors of the review did not accept a
causal relationship between perforation of the appendix and tubal infertility or ectopic
pregnancy although they have accepted the association and the risk of the exposure. A
subsequently published case control study did not provide substantial evidence that
perforation of the appendix was an important risk factor for female tubal infertility. A
further study examined fertility after appendectomy during pregnancy. This study found
that appendectomy during pregnancy of a normal, inflamed or perforated appendix did not
affect subsequent fertility. A recent epidemiological study concluded that appendicitis
appears to be low risk factor in subsequent infertility. However, Appendicectomy is
associated with increased fertility. On the basis of this data, a policy of liberal and prompt
laparoscopy used routinely on young women presenting with signs and symptoms of
appendicitis is encouraged. If the appendix is found to be inflamed or equivocal, then
appendicectomy is justified.
This epic study is likely to be cited for encouraging the practice of laparoscopic
appendicectomy for all cases presenting with right iliac fossa pain. This is based on the fact
that early mucosal appendicitis is thought to be a real entity and this is not apparent at the
time of laparoscopy. However, caution must be exercised due to apparent complications of
laparoscopic appendicectomy.
5.7 Post operative monitoring and management of complications

All patients require adequate post-operative monitoring. Those patients who had
percutaneous drainage of appendix abcess also require monitoring. In addition to vital
parameters, these patients require daily evaluation of the wound and abdomen by clinical
examination. Serial measurement of inflammatory parameters is also useful in showing
trends of improvement or otherwise. This should be continued until patients are discharged
from hospital.
Superficial wound infection can start to manifest 48 hours after surgery. Patients who show
signs of wound infection by virtue of inflammation of wound edges, should continue on
antibiotics treatment until the wound inflammation settles. As a marker of progress of the
inflammation, the area of cellulitis surrounding the wound should be marked on the skin
and monitored for progression or regression. In addition, palpation of the wound itself may
suggest accumulation of infected material under the wound, in the superficial tissues. In
such cases, the wound should be opened either fully or partially to allow drainage of the
infected material. In some cases, operative drainage under anaesthesia should be
considered.
Patients who do not show signs of improvement after appendicectomy or those who show
further deterioration, either clinically or serologically, should be considered for three
dimensional imaging. In these patients, the attending surgeon is looking for evidence of
intra-abdominal collection to account for the apparent lack of improvement. However, in
rare cases, there may be evidence of iatrogenic injury particularly during laparoscopic
appendicectomy or other missed diagnosis. In such patients, there should be a low
threshold for repeat laparoscopy or laparotomy. Any evidence of intra-abdominal collection
should be managed by drainage and peritoneal lavage. Iatrogenic injuries will require
expert surgical correction and appropriate post-operative management. A missed diagnosis
will require appropriate management.
Patients who had either percutaneous or laparoscopic drainage of an appendix abcess
require careful monitoring for resolution of the inflammation and regression of the abcess.
This is done clinically in the first instance but repeat three-dimensional imaging using
contrast enhanced CT is usually more accurate than clinical evaluation. Failure of resolution
of the inflammatory abcess or phelgmon associated with the abcess indicates either
insufficient drainage together with incomplete or inappropriate antibiotics treatment. In
such cases, the three dimensional imaging as well as bacteriological sensitivity testing of
retrieved purulent material will guide further management. In some patients, revision of
antibiotics requirement is necessary and in others revision of drainage is essential. In some
patients, operative intervention is necessary due to intra-abdominal spread or rupture of the
abcess. In these patients, the objective of operative intervention whether by laparotomy or
laparoscopy is adequate drainage of any collection together with peritoneal lavage. When
the abcess has been adequately drained, there is usually an accompanying improvement in
the general condition of the patient. The drain should be withdrawn when no further
purulent material is obtained. The patients can usually return to normal activity and can be
safely discharged from hospital. However, due to the relatively high incidence of recurrent
appendicitis, patients should be given a date for appendicectomy. This delayed
appendicectomy should be done when all signs of inflammation have disappeared and
should be attempted laparoscopically by an experienced surgeon.
6. Conclusion
Despite the recent decline in the incidence of appendicitis, it remains the commonest
surgical emergency. It is estimated that 10% of the population will have appendicitis during
their life time. Approximately 20 % of those will have complicated appendicitis. The
diagnosis of appendicitis remains clinical. However, reliance on clinical examination alone
will result in an unnecessary number of patients having exploratory surgery. Clinical
history and examination supplemented with routine inflammatory marker analysis
improves the diagnostic accuracy. Although ultrasound and computed tomography are
relatively accurate in the diagnosis of appendicitis, it is important to emphasise that CT is
more accurate than ultrasound but carries a radiation burden. The use of both radiological
investigations is limited in the emergency setting. The diagnosis of appendicitis is most
difficult at the extremes of age and it is in these patients that additional investigations may
be justified. In all other cases, if the history and examination is compatible with appendicitis
with raised inflammatory markers, patients (both males and females) should have a
diagnostic laparoscopy which can proceed to laparoscopic appendicectomy if the appendix
was found to be inflamed. If an appendix abcess was found, the abcess should be drained. If
the appendix was found to be perforated, conversion to open appendicectomy should be
considered. In all cases, adequate peritoneal lavage should be carried out. Post-operatively,
all patients should have antibiotics for different periods depending on the degree of
inflammation and contamination found at operation. Post-operatively, all patients should be
monitored for the emergence of adverse events. Patients who develop signs of peritoneal
infection or who fail to improve should have a CT in the first instance. Wound infections
should be managed by open drainage and antibiotics. Intra-abdominal infection should be
managed by laparoscopy/ laparotomy, drainage of collection and peritoneal lavage together
with systemic antibiotics.
Laparoscopic appendicectomy is safe for the majority of cases of simple appendicitis. If at
laparoscopy, the appendix is found to have perforated, the surgeon should make a careful
evaluation of whether to continue with laparoscopic surgery or convert to open surgery. In
either situation, the surgical objective is appendicectomy together with adequate peritoneal
lavage of all areas of the peritoneal cavity.
7. References
Ball CG, Kortbeek JB, Kirkpatrick AW, and Mitchell P. Laparoscopic appendectomy for
complicated appendicitis: an evaluation of postoperative factors. Surgical
Endoscopy. 2004; 18: 969-973.
Garbarino S, Shimi SM. Routine diagnostic laparoscopy reduces the rate of unnecessary
appendicectomies in young women. Surg Endosc. 2009 Mar;23(3):527-33. Epub 2008
Mar 26.
Hale DA, Molloy M, Pearl RH, Schutt DC, Jaques DP. Appendectomy: a contemporary
appraisal. Annals of Surgery 1997 Vol. 225, No. 3, 252-261
Ingraham AM, Cohen ME, Bilimoria KY, Pritts TA, Ko CY, and Esposito TJ. Comparison of
outcomes after laparoscopic versus open appendectomy for acute appendicitis at
222 ACS SQIP hospitals. Surgery 2010; 148: 625-37.
Livingston EH, Woodward WA, Sarosi GA, and Haley RW. Disconnect Between Incidence
of Nonperforated and Perforated Appendicitis: Implications for Pathophysiology
and Management. Ann Surg. 2007 June; 245(6): 886–892.
Stoker J, van Randen A, Lameris W, and Boermeester MA. Imaging patients with acute
abdominal pain. Radiology 2009; 253: 31-46.
Kirshtein B, Perry ZH, Avinoach E, Mizrahi S, Lantsberg L. Safety of laparoscopic
appendectomy during pregnancy. World J Surg. 2009 Mar;33(3):475-80.
Li X, Zhang J, Sang L, Zhang W, Chu Z, Li X, and Liu Y. Laparoscopic versus convential
appendectomy – a meta-analysis of randomised controlled trials. BMC
Gastroenterology 2010; 10: 129.
Markides G, Subar D, Riyad K. Laparoscopic versus open appendectomy in adults with
complicated appendicitis: systematic review and meta-analysis. World J Surg. 2010
Sep;34(9):2026-40. Review.
Needham PJ, Laughlan KA, Botterill ID, Ambrose NS. Laparoscopic appendicectomy:
calculating the cost. Ann R Coll Surg Engl. 2009 Oct;91(7):606-8.
Park HC, Yang DH, Lee BH. The laparoscopic approach for perforated appendicitis,
including cases complicated by abscess formation. J Laparoendosc Adv Surg Tech
A. 2009 Dec;19(6):727-30.
Sauerland S, Jaschinski T, Neugebauer EA. Laparoscopic versus open surgery for suspected
appendicitis. Cochrane Database Syst Rev. 2010 Oct 6;(10):CD001546. Review.
Part 4
Laparoscopic Hernia Repair Surgery

10
Laparoscopic Hernia Repair

Eva Deerenberg, Irene Mulder and Johan Lange
Erasmus University Medical Centre
The Netherlands
1. Introduction
A hernia is a protrusion of abdominal content (preperitoneal fat, omentum or abdominal
organs) through an abdominal wall defect. Anatomically the most important features of a
hernia are the hernial orifice and the hernia (peritoneal) sac, if present. The hernial orifice is
represented by the primary defect in the aponeurotic layer of the abdomen, and the hernial
sac by the bulging peritoneum. The neck of the hernial sac is located at the hernial orifice. As
the French anatomist Henri Fruchaud (1894-1960) already stated, hernias of the abdominal
wall occur in areas where aponeurosis and fascia are lacking the protective support of
muscles (Fruchaud, 1953). Most of these weak areas are anatomically present in the
abdominal wall congenitally, others may be acquired during life, for example by surgery.
The uncovered weak aponeurotic areas are subject to elevated intra-abdominal pressures
and give way if they deteriorate or represent anatomic varieties. The common sites of
herniation of the abdominal wall are the groin, the umbilicus, the linea alba, the semilunar
line of Spigel, the diaphragm and surgical incisions. In addition, more exceptionally
obturator hernias and hernias of the triangle of Petit are also encountered. Hernias can
broadly be classified into congenital and acquired types. Congenital hernias typically occur
at the groin, although they may be observed at other locations such as the umbilicus or
diaphragm.
Abdominal wall hernias represent a common issue in general surgical practice. The
definitive treatment of all hernias, regardless of their origin or type, is surgical repair. It is
suggested that a strategy of watchful waiting rather than surgery can be considered in
patients with asymptomatic or minimally symptomatic inguinal and incisional hernia. The
risks of delayed surgery are primarily related to the risks of incarceration and strangulation,
which necessities emergency surgery. Elective surgical repair should be considered if the
hernia is symptomatic, in case of an increased risk for incarceration or if the size of the
hernia complicates dressing or activities of daily living. Hernias that are less likely to
incarcerate include upper abdominal hernias, hernias with an abdominal wall defect larger
than 7-8cm and hernias less than 1 cm in diameter. The likelihood of incarceration decreases
as the hernia defect increases in size since it is less likely that intestinal or visceral contents
will become caught by a narrow neck of the hernia sac. In large incisional (‘giant’) hernias
more skin problems (ischemia, necrosis and ulcerations) are observed and represent an
indication for operation.
The surgical treatment of hernias is already performed since Hellenistic times when Celsus
performed hernial sac extirpations. The founder of modern hernia surgery is Bassini from
Padova (Italy), who performed the first anatomic hernia groin repair in 1887 (Bassini, 1887).
The results of anatomical hernia repair were a large step forward, however recurrences kept
frustrating surgeons since. Over de last decades it has become clear that prosthetic
reinforcement by a non-resorbable synthetic polymer mesh is required for most hernia
repairs. Abdominal wall hernias can be repaired with mesh reinforcement by open or
laparoscopic approach. The first report of the use of a laparoscope in the repair of an
abdominal wall hernia was made by Ger in 1982 (Ger, 1982). Bogojavalensky in 1989 was the
first to report on the use of a prosthetic mesh during laparoscopic hernia repair
(Bogojavalensky, 1989).
The objective of successful hernia repair is achieving a cost-effective repair with a low
recurrence rate, minimal operative and acute and chronic postoperative pain with a rapid
return to normal activities. Laparoscopic repair has the potential benefits of smaller wounds,
with less wound infections and better cosmetic results, and the possibility to perform the
procedure in the outpatient clinic. Patients are thought to experience less postoperative
discomfort and a faster recovery time. Additional benefit, especially in incisional hernia
surgery, is the possibility to diagnose and treat multiple hernias in one procedure. During
laparoscopic repair a mesh is placed intraperitoneally which makes contact between the
mesh and viscera inevitable. The contact with the viscera can lead to adhesion formation
and associated complications like small bowel obstruction, enterocutaneous fistula,
infertility and chronic pain. Other possible complications of the laparoscopic approach in
general are bowel and bladder injuries, artery laceration, neuralgia and trocar site
herniation. During laparoscopic hernia repair it is hardly ever possible to restore functional
anatomy of the abdominal wall and manage skin redundancy or the hernia sac.
The risk of recurrence is determined by surgical-technical factors (i.e. mesh use, choice and
placement), the experience of the surgeon, the occurrence of a wound infection and patient
related factors. Literature shows that recurrence rates are low in experienced hands. Several
co-morbidities have been identified that increase the risk of recurrence and wound infection
following hernia repair: smoking, diabetes, coronary artery disease, chronic obstructive
pulmonary disease (COPD), nutritional status, immunosuppression, chronic corticosteroid
use, low serum albumin, obesity and advanced age. A prolonged operative time and the use
of an absorbable synthetic mesh are also significant independent predictors of wound
infection and associated recurrences.
1.1 Mesh characteristics

The first prosthetic mesh for hernia repair, introduced in 1900, was a hand-made silver wire
filigrees. In the second half of the 20th century nylon, (expanding) PTFE, polypropylene and
polyester meshes were introduced. The current large diversity of synthetic polymer and
biologic materials available for the reinforcement of hernia repair, without high level
evidence for clinical use, complicates the selection of an appropriate prosthesis. The material
must be reactive enough to stimulate fibroblast ingrowth, yet inert enough to minimize
foreign body reaction, adhesion formation, allergic reaction and to avoid infection. The
mesh must have enough strength to prevent early recurrence but enough flexibility to
accommodate activity. The mesh should also have optimal laparoscopic handling
characteristics. Until now the ideal mesh does not exist and the location of implantation
(intra- or extraperitoneally) should be taken into account when choosing a mesh. When
choosing a synthetic mesh for laparoscopic hernia repair it is important to consider all
characteristics that generate the host response, like absorbability, pore size and weave.
Laparoscopic Hernia Repair 159
 Absorbability. Absorbable materials are less likely to become infected than non-
absorbable materials, and are less harmful to viscera. However the main disadvantage
of absorbable meshes is that the resultant scar tissue weakens after the mesh is absorbed
and the necessary long-term repair strength is not provided, in contrast with permanent
non-absorbable meshes. Partial absorbable meshes are thought to decrease the amount
of foreign material while maintaining mechanical strength, but data about the clinical
(long-term) performances are not available yet. Total non-absorbable meshes can be
more stiff and heavy, possibly causing discomfort for the patient.
 Pore size. Porosity of a mesh is the main determinant of tissue reaction. The space
between fibrils influences cellular infiltration, risk of infection, and mesh density and
flexibility. Meshes with large pores allow increased tissue ingrowth and are more
flexible than meshes with small pores. In a microporous mesh the granulomas around
individual fibrils can become confluent which leads to encapsulation of the mesh and
makes the mesh inflexible. Microporous meshes are more at risk of becoming infected,
as large immune cells cannot infiltrate to phagocytose bacteria. Due to the strong
chronic host response, macroporous meshes show good incorporation, but are more
likely to give rise to adhesions and erosions than microporous meshes when use intra-
abdominally. With increasing size of the pores, the chance of bulging of a macroporous
mesh used for bridging increases.
 Weave. Multifilament meshes are soft, flexible and resistant to wrinkling. They result in
strong integration in the host, but are more susceptible to infection. Monofilament
meshes are less susceptible to infection, but have the disadvantage of causing
significant adhesions when used intra-abdominally.
 Anti-bacterial of anti-adhesive treatment. Synthetic meshes with additional coatings
(i.e. silver or antiseptics) to reduce the risk of infection or adhesions (i.e. cellulose or
collagen layer) have been developed. The anti-adhesive layer functions as a barrier
between the viscera and the mesh and reduces the risk of adhesion formation.
Biological meshes made of donor collagen (porcine, bovine or human) are suggested to be
used especially in a contaminated or infected environment when closure is required. These
new developed collagen meshes are thought to be replaced by the patients own collagen in
time (remodelling), with an associated low adhesion formation and low infection risk.
They are less suitable for bridging; because due to gradual absorption, the risk of recurrence
is high. Unfortunately collagen meshes cannot be introduced through a laparoscopy port yet
and more research on outcome and recurrence rates should be done. Finally until now
surgeons and hospitals are also reluctant as costs of biological meshes are very high
compared to synthetic meshes.
1.2 Mesh fixation

During laparoscopic hernia repair the mesh can be placed intra- or extraperitoneally. For
extraperitoneally placed meshes, commonly used during groin hernia repair, minimal to no
fixation is required. This because when intraperitoneal pressure is evenly distributed over
the large peritoneal surface from the inside the mesh is kept in place without need for
fixation. However, some surgeons fixate the mesh in case of a direct inguinal hernia larger
than 2 cm. Fixation is then performed with tackers to the muscles and the periostal fascia of
the pubic bone. Care must be taken to avoid the lateral space as all three inguinal nerves are
located within.
An intraperitoneally implanted mesh, commonly used in ventral hernia repair, can be

fixated using different techniques. Proper fixation of the mesh is important to prevent
recurrence, but no consensus about the ideal fixation method exists. The ideal fixation
method would guarantee sufficient strength to withstand the pressures generated in the
abdomen during coughing and straining. The first used fixation method was represented by
stapling, using titanium staples with a penetration depth of 2 to 4.8 mm. These staples could
cause chronic pain by compression and twisting of tissue containing nerves. Currently, the
most frequently used techniques involve fixation with transabdominal sutures and tackers;
titanium helical coils with a maximal tissue penetration depth of 3.8 mm. Fixation with
tackers is fast and strong, but complications of adhesions to the tackers and nerve injury and
intestinal lesions have been observed. Transabdominal sutures penetrate all layers of the
abdominal wall, providing a significant stronger fixation than fixation with tackers only.
The disadvantages of transabdominal sutures are the time consuming procedure and the
increased risk of chronic postoperative pain by incorporating large bites of tissue.
When fixating a mesh it is important to use an appropriate amount of fixation points,
avoiding loosening and incarceration of omentum or bowel loops. Transabdominal sutures
should be placed no more than 5 cm apart. An overlap of 3 cm of the fascial defect is
sufficient when transabdominal sutures are used. If no sutures are used the minimal overlap
of the fascial defect should be 4 to 5 cm. The tackers or staples should be placed every 2 cm.
Newly developed are absorbable tackers that absorb within one year. These absorbable
tackers may lower the complication rate, but a tack is initially an invasive anchor that can
result in nerve damage and postoperative pain. Completely non-invasive mesh fixation,
such as with glue sealing, is gaining popularity in inguinal hernia repair, but use of glue in
laparoscopic ventral hernia repair is not a common procedure yet. This fixation technique
may be promising, but mesh dislocations, when positioned intraperitoneally, are reported.
2. Hernias of the groin region

The groin is the area of junction of the lower abdomen and the thigh at the myopectineal
orifice of Fruchaud. The myopectineal orifice is bounded by the oblique and transversus
abdominis muscles cranially, the iliopsoas muscles laterally, the rectus abdominis muscles
medially and the pubic pecten caudally. This orifice is the weak spot through which
neurovascular, muscular and testicular structures pass the abdominal wall during
embryologic development. Protruding through the abdominal wall occurs at this point of the
abdominal floor because no muscular covering reinforced by transversalis fascia is present.
The most common symptoms of a groin hernia are heaviness or a dull sense of discomfort in
the groin that is most pronounced when the intra-abdominal pressure is raised, for example
by straining or lifting. The pain is caused by the contents of the hernia pressing to the tight
ring at the neck of the hernia sac. As the intra-abdominal pressure increases, the contents of
the hernia are forced into the ring constricting them causing ischemia. Another cause of pain
may be from stretching of the ilioinguinal or iliohypogastric nerves hard enter. In case of
clinical suspicion of a groin hernia without palpable swelling herniography or MRI have the
highest sensitivity and specificity. In daily practice ultrasonography with Valsalva
manoeuvre is most often used.
The inguinal area is formed during embryologic development when the gubernaculum
develops. This ligament exists between the ovary or testis and labioscrotal swelling and
passes through the abdominal wall at the future inguinal canal. After twelve weeks of
gestation the ventral peritoneal processus vaginalis follows the gubernaculum, equally
piercing the abdominal wall. The processus vaginalis gives rise to the deep and superficial
inguinal rings and pushes up the scrotal skin, the subcutaneous layers and the different
investing layers of the spermatic cord. The spermatic cord consists of the internal spermatic
fascia, cremasteric fascia and external spermatic fascia as continuations of transversalis
fascia, internal and external oblique muscles, respectively. Thus, the cranial end of the
inguinal canal is the internal or deep inguinal ring, which is a normal defect of the
transversalis fascia. Its superior margin is represented by the transversus abdominis arch
and the inferior margins are formed by aponeurotic fibers from the iliopubic tract, the
inferior epigastric vessels, and the interfoveolar ligament of Hesselbach. The external or
superficial inguinal ring is a triangular opening in the aponeurosis of the external oblique
muscle. The superior and inferior crura, which form the margins of the ring, are held
together and reinforced by intercrural fibers.
2.1 Anatomy of the groin

In the male within the ‘triangle of doom’ between the testicular vessels and vas deferens, the
external iliac vessels are encountered. They are enveloped by lymphatic and fatty tissue. The
deep circumflex iliac artery and vein originate from the external iliac vessels and run
parallel to the iliopubic tract (ligament of Thomson), which is the thickened caudal margin
of the transversalis fascia. This structure, which extends from the anterior superior iliac
spine to the pubic tubercle, dorsally parallels the inguinal ligament. The latter is not visible
from the posterior view.
The inferior epigastric artery and (two) veins are, especially in the laparoscopic
extraperitoneal approach, the hallmark of safe exposure and entering of the ‘proper
preperitoneal space’. As the external iliac vessels are located within the endo-abdominal
fascia, the inferior epigastric vessels pass to the dorsal aspect of the rectus abdominis
muscles after perforation of the transversalis fascia, at the lateral boundaries of the rectus
abdominis muscles. The frequently occurring accessory obturator artery and vein (corona
mortis: ‘circle of death’), connecting the obturator and inferior epigastric vessels, cross the
superior pubic bone. They are at risk during dissection of the medial part of the pectineal
ligament of Cooper, especially in femoral hernia surgery.
The genital branch of the genitofemoral nerve innervates the ventral genital skin and the
cremaster muscle. After having accompanied the external iliac artery on the psoas muscle, it
enters the inguinal canal through the deep inguinal ring, running dorsally to the round
ligament of the uterus or the testicular vessels. Laterally to the deep inguinal ring, the lateral
femoral cutaneous nerve crosses dorsally to the iliopubic tract, innervating the skin at the
lateral side of the thigh. The femoral branch of the genitofemoral nerve and the lateral femoral
cutaneous nerve are observed within the ‘triangle of pain’, also known as Kathouda’s
‘quadrant of doom’. The triangle is located between the gonadal vessels and iliopubic tract, at
Bogros’ space. Bogros’ space is located between the transversalis fascia of ventral abdominal
wall and the iliopsoas muscles, laterally to the inferior epigastric and external iliac vessels. In
this area the application of staples for mesh prosthesis fixation is hazardous. The other nerves
from the lumbar plexus (iliophypogastric, ilio-inguinal, obturator and femoral nerves) are only
encountered if, inadvertently, dissection is performed between the transversus abdominis and
iliopsoas muscles and the transversalis fascia. The nerves encountered in the triangle of pain
from medial to lateral are the femoral branch of the genitofemoral nerve, the femoral nerve,
the cutaneous branch of the femoral nerve and the lateral femoral cutaneous nerve. The
anatomic landmarks and structures of importance are illustrated in the RISE (Rotterdam
Institute of Surgical Endoscopy)-circle, figure 1 (Lange & Kleinrensink, Surgical Anatomy of
the Abdomen, Elsevier gezondheidszorg, 2002).
Ventromedial quadrant (direct hernia): Ventrolateral quadrant (indirect hernia):

Base; iliopubic tract (of Thomson)(1) Deep inguinal ring
Conjoint tendon(2) Interfoveolar ligament (of Hesselbach)
Transeversalis fascia (caudal part of Transversus abdominis muscle(7)
Hesselbach’s triangle)(3)
Interfoveolar ligament (of Hesselbach)(4)
Branches of inferior epigastric vessels
Dorsomedial quadrant (femoral hernia at Dorsolateral quadrant (Kathouda’s quadrant of
femoral canal/lacuna vasorum): doom):
Pectineal ligament (of Cooper)(5) Nerves of triangle of pain:
Lacunar ligament (of Gimbernat)(6) Femoral branch of genitofemoral nerve(8)
Bladder Femoral nerve(9)
Corona mortis Cutaneous branch of femoral nerve(10)
External iliac vein Lateral femoral cutaneous nerve (11)
Prevesical space (of Retzius) Testicular vessels
Iliopectineal arch (ligament)
Vas deferens(12) or round ligament of uterus
Fig. 1. RISE (Rotterdam Institute of Surgical Endoscopy)-circle. Anatomic landmarks and

structures of importance in inguinal hernia repair (Lange & Kleinrensink, Surgical Anatomy
of the Abdomen, Elsevier gezondheidszorg, 2002).
The contents of the inguinal canal differ between male and female. In the male the spermatic
cord is surrounded by the cremasteric fascia and cremaster muscle. Within the cord, the
spermatic vessels and vas deferens are surrounded by the internal spermatic fascia. The
spermatic vessels are the internal spermatic (testicular) artery, the deferential artery and the
external spermatic (cremasteric) artery and vein, accompanied by the venous pampniform
plexus. Between the internal spermatic and cremasteric fascia, the genital branch of the
genitofemoral nerve and the cremasteric vessels are observed. The external spermatic fascia
envelops the cord caudally to the superficial inguinal ring. The contents of the inguinal
canal in the female include the round ligament of the uterus, the artery of the round
ligament of the uterus (Samson’s artery), the genital branch of the genitofemoral nerve, the
ilio-inguinal nerve and lymphatics.
2.2 Different types of groin hernia

Groin hernias are divided in inguinal and femoral hernias depending on their position in
relation to the inguinal ligament. This structure is formed by the external abdominal oblique
aponeurosis and the fascia lata of the thigh. It is located in between the anterior superior
iliac spine and the pubic tubercle of the pubic bone.
 Inguinal hernias are located cranially to the inguinal ligament. The occurrence of
inguinal hernias can be explained by the persistence of a processus vaginalis (indirect or
lateral hernia), by a deficient fascia transversalis (direct or medial hernia) or by a
combination of both.
 Femoral hernias occur through the opening located caudally to the ligament inguinal
and medially to the femoral vein.
 Scrotal hernias are sometimes classified separately but are in fact large indirect
inguinal hernias with a hernia sac reaching into the scrotum.
To distinguish an inguinal hernia from a femoral hernia clinically, or an indirect hernia from
a direct hernia, is often impossible and is of little importance since the operation is
nowadays the same.
2.3 Inguinal hernia

The inguinal hernia is one of the most frequently occurring hernias with an estimated 20
million hernias repair operations around the world. Estimated incidence rate in the UK is 13
per 10,000 population per year (Primatesta & Goldacre, 1996). Indications for laparoscopic
hernia repair are debatable. In case of a primary unilateral hernia an open mesh procedure is
currently recommended by the European Hernia Society because of lower recurrence rate,
costs and the possibility of local anaesthesia when compared with laparoscopic repair
(Simons et al., 2009; Neumayer et al., 2004). From a socio-economic perspective, an
endoscopic procedure is probably most cost-effective in patients participating in labour,
especially in bilateral hernia. Furthermore chronic postoperative inguinal pain seems to be
less generated by laparoscopic repair compared to conventional technique. All patients fit
for general surgery without significant contraindications, including extreme age or
significant cardiac, pulmonary or systemic illness, should be offered the option of a
laparoscopic hernia repair (Simons et al., 2009).
2.3.1 Classification
To date, there is a lack of consensus among general surgeons and hernia specialists on
classification systems for inguinal hernias. The traditional system classifies them into direct
and indirect inguinal hernias. The persistence of a processus vaginalis is often described as a
lateral or indirect hernia and a deficient transversalis fascia as a medial or direct hernia. In
general clinical distinguishing is often difficult and irrelevant because treatment does not
differ.
 Indirect inguinal hernias are the most common groin hernias in men and women. The
hernia develops at the internal ring laterally to the inferior epigastric artery, in contrast
to direct hernias which arise medially to the inferior epigastric vessels. Most indirect
inguinal hernias are congenital, even though they may not become symptomatic until
later in life (van Wessem et al., 2003). Indirect hernias develop more frequently on the
right, because the right testicle descends later to the scrotum than the left.
 Direct inguinal hernias occur through the transversalis fascia at (the caudal part of)
Hesselbach’s triangle, formed by the inguinal ligament inferiorly, the inferior epigastric
vessels laterally, and the rectus abdominis muscle medially. They occur as a result of a
weakness of this part of the transversalis fascia, representing the floor of the inguinal
canal. This weakness appears to be most often a congenitally diminished strength of
collagen.
To be able to compare results most researchers choose to classify hernias by the classification
of Nyhus (Nyhus, 1993):
 Type 1: Lateral/ indirect hernia with normal internal inguinal ring
 Type 2: Lateral/ indirect hernia with wide internal inguinal ring and normal
transversalis fascia
 Type 3a: Medial/ direct hernia
 Type 3b: Pantaloon- or combined hernia
 Type 4: Recurrent hernia
2.3.2 Laparoscopic repair

The two laparoscopic techniques that are currently most frequently performed are the
transabdominal preperitoneal repair (TAPP) and the total extraperitoneal repair (TEP). Both
TAPP and TEP use a mesh in the preperitoneal space as described by Stoppa to replace the
visceral sac. These laparoscopic techniques were originally developed for repair of difficult
and recurrent inguinal hernias, which were known to have high recurrence rates (Stoppa et
al., 1984). Performance of a laparoscopic repair may be technically challenging if the patient
has had prior prostatic surgery or lower abdominal radiotherapy. Currently no indications
exist in which TAPP is preferred over TEP.
One of the major challenges in learning laparoscopic hernia repair is the relative
unfamiliarity of most surgeons to the anterior abdominal wall anatomy from a posterior
view. This unfamiliarity is mainly responsible for the steep learning curve, which is
associated with an increased incidence of complications. Although peroperative
complications are rare in laparoscopic repair, they occur more often early during the
learning curve and are more critical. Reported complications include trocar injury to bowel
and bladder, vascular injury to the inferior epigastric and femoral vessels, nerve
entrapment, transection of vas deferens, and trocar site haemorrhage (Davis & Arregui,
2003). After 250 laparoscopic repairs the recurrence rate is half of the rate of surgeons who
have performed fewer repairs (Neumayer et al., 2004). If in future training would not be
only incidental but more structurally organised with emphasis on anatomy including a
defined proctorship it might be expected that learning curves will be much shorter.
2.3.3 TAPP
The TAPP approach was first described by Arregui and colleagues in 1992 (Arregui et al.,
1992). Performing a TAPP, firstly laparoscopic access into the peritoneal cavity is obtained.
After identification of the inguinal hernia the peritoneum is incised several centimetres
above the peritoneal defect. The peritoneum is incised from the edge of the median
umbilical ligament toward the anterior superior iliac spine. Repair of bilateral hernias can be
performed through two separate peritoneal incisions or one long transverse incision
between the superior iliac spines. Subsequently the preperitoneal avascular space between
the posterior and anterior fascia transversalis is dissected to provide visualization of the
myopectineal orifice of Fruchaud and size of the abdominal wall defect. In case of an
indirect hernia, the cord structures are isolated and dissected free from the surrounding
tissues. Simultaneously, the indirect hernia sac is identified on the anterolateral side and
adherent to the cord. The cord must be skeletonized with care to minimize trauma to the vas
deferens and the spermatic vessels. If the sac is sufficiently small, it can be reduced into the
peritoneal cavity. If the hernia sac is large it should be completely dissected and divided
beyond the internal ring, and the subsequent peritoneal defect closed with an endoloop
suture. The distal end of the transsected sac should be left open to avoid formation of a
hydrocèle. When reducing a direct hernia sac, a “pseudosac” may be present, which consists
of fascia transversalis that overlies and adheres to the peritoneum and invaginates into the
preperitoneal space during the dissection. This layer must be separated from the true hernia
sac in order for the peritoneum to be released back fully into the peritoneal cavity. Once the
pseudosac is freed, it will typically retract anteriorly into the direct hernia defect.
A large piece of mesh, of at least 15 x 10 cm, is used to cover the myopectineal orifice,
including the direct, indirect and femoral hernia spaces. It is important to dissect the
preperitoneal space to prevent folding of the edge of the mesh within this space. In addition
the mesh should be placed with a slight overlap of the midline to ensure adequate coverage
of the entire posterior floor of the groin. The intraperitoneal pressure that is evenly
distributed over the large surface of the mesh keeps it in place making fixation of the mesh
controversial provided that elimination of fixation does not lead to an increased rate of
recurrence. The use of tackers or sutures is associated with increased chronic inguinal pain,
use of postoperative narcotic analgesia, hospital length of stay and the development of
postoperative urinary retention (Koch et al., 2006; Taylor et al., 2008). Suitable structures for
fixation are the contralateral pubic tubercle and the symphysis pubis, Cooper’s ligament or
the tissue just above it and the posterior rectus sheath and transversalis fascia at least 2 cm
above the hernia defect. Fixation is never performed below the iliopubic tract laterally to the
internal spermatic vessels, to minimize the chance of damage to the lateral cutaneous nerve
of the thigh or the femoral branch of the genitofemoral nerve. Finally the mesh is covered by
securing the peritoneal flap back to its original position. The peritoneum should be closed to
eliminate the risk of formation of adhesions between the mesh and the intestine. The
configuration of the mesh is also important. A slit in the mesh, although attractive in
concept, can lead to constriction of the cord structures or allow herniation through the slit.
When using the TAPP technique, in addition to femoral hernias, especially sacless sliding
fatty inguinal hernias may be overlooked because of intact peritoneum. Therefore, in cases
of clinically diagnosed inguinal hernias, the preperitoneal space should be inspected
intraoperatively to avoid unsatisfactory results (Hollinsky & Sandberg, 2010). The main
drawback of the TAPP procedure is that it requires entering of the peritoneal cavity with
increased risk of injury to intra-abdominal organs. Further it requires subsequent incising

the peritoneum with eventually peritoneal closure. The TEP was developed to avoid
opening the peritoneal cavity with the associated risks.
2.3.4 TEP
The first to describe total extraperitoneal endoscopic repair of a inguinal hernias was Ferzli
in 1992 (Ferzli et al., 1992). The procedure is initiated with a subumbilical incision followed
by blunt dissection of the subcutaneous layer up to the anterior rectus sheath. The anterior
rectus sheath is horizontally incised and with retractors the rectus abdominis muscle is
searched and gently moved aside to bring the posterior rectus sheath in sight. The dissection
of the preperitoneal space up to the symphysis is continued with a balloon. When using a
balloon (‘space maker’) the thin fibrous layer of the posterior lamina of the fascia
transversalis will rupture automatically to expose the ‘proper preperitoneal space’.
Subsequently a blunt tipped trocar is inserted into the preperitoneal space and a
pneumoperitoneum is established. Additional trocars are inserted under direct vision.
Further identification and repair of the inguinal hernia is identical to TAPP repair.
2.3.5 Acute repair

Acute repair of inguinal hernia is necessary in case of incarceration or strangulation. The
cumulative probability of hernia getting strangulated after three months is 2.8% (Gallegos et
al., 1991). The risks of postoperative complications following emergency surgery are high,
and in elderly patients, mortality can be as high as 5% (Nilsson et al., 2007; Primatesta &
Goldacre, 1996). Mostly open surgery is performed is case of incarceration to reduce the
strangulated content, dissect the hernia sac and repair the abdominal wall defect. In 1993
Watson was the first to report acute laparoscopic reduction of the hernia with resection of
the bowel (Watson et al., 1993). This reluctance may be attributable to the technical
difficulties encountered in reducing the hernia sac and contents and the increased risk for
iatrogenic injuries. The overall rate of complication, recurrence and hospital stay are very
close to the rates documented in open repair for incarcerated hernias.
In case of a direct hernia, a releasing incision is made in the anteromedial aspect of the
defect to avoid the inferior epigastric vessels. In indirect henias, the vessels are controlled,
clipped and transected to facilitate the way for the releasing incision performed anteriorly in
the deep (internal) ring at the 12 o’clock position toward the superficial (external) ring
facilitating reduction of the incarcerated sac and its contents.
2.4 Laparoscopic repair of inguinal hernia in children

Laparoscopic repair of indirect hernia is nowadays one of the most frequently executed
paediatric surgical procedures. Laparoscopic repair has the same advantages in children as
in adults; less pain, faster recovery and better cosmesis. The overall incidence of inguinal
hernias in childhood ranges from 0.8% to 4.4% (Bronsther et al., 1972), with predominantly
indirect inguinal hernias. Incidence is higher in boys than in girls and in premature infants
weighing less than 1000 grams with an incidence between 5 and 30% (Harper et al., 1975;
Rajput et al., 1992). Inguinal hernias in children are mostly the result of a patent processus
vaginalis because of an arrest of embryologic development. The processus vaginalis closes
between the 36th and 40th week of gestation, which explains the increased incidence of
hernia in premature infants. Because the descend of the left testis takes place before the right
testicle the closure of the processus vaginalis is equally asymmetric, which results in 60% of
patent processus vaginalis occurrence on the right side. However only in 25-50% of patients
with a patent processus vaginalis a clinically significant hernia will become apparent (Lau et
al., 2007; van Veen et al., 2007). Diagnosis of inguinal hernia in children is often based on
anamnestic information from the parents or physical examination showing a bulge in the
groin with crying or coughing. For timing of elective surgery no evidence is available, but
surgical repair is usually performed as soon as possible after diagnosis even if the hernia is
asymptomatic. This because of fear of incarceration, although its exact risk has not been
studied in paediatric watchful waiting studies. Additionally between 24 and 30 % of
patients present with incarcerated inguinal hernia (Moss & Hatch, 1991; Puri et al., 1984).
Manual reduction is successful in a majority of patients (Moss & Hatch, 1991; Puri et al.,
1984; Stringer et al., 1991). Many paediatric surgeons hospitalize children after successful
manual reduction of incarcerated inguinal hernia and repair the hernia within 24-48 hours.
The short delay allows the involved tissues to return to their normal texture before surgery.
However some surgeons prefer immediate laparoscopy to inspect for vascular compromise
of bowel, testicular or ovarian tissue with repair of the hernia.
The laparoscopic technique of inguinal hernia repair in children involves a high ligation of
the indirect hernia sac without application of a mesh. First the spermatic cord is identified
followed by dividing and tracing the sac in the inguinal channel without mobilization of the
spermatic cord, with finally ligation of the hernia sac. In girls the surgeons must confirm
before ligation that the hernia sac does not contain ovary, fallopian tube, or uterus. In
addition to ligation and excision, plication of the floor of the inguinal canal may be
necessary when the inguinal ring has been enlarged by repetitive herniation. In paediatric
patients surgeons choose for primary repair because of the unknown effect of prosthesis
material and because paediatric tissues have greater elasticity making primary repair more
straightforward than in the adult population. A debate exists on exploration of the
contralateral processus vaginalis during surgery to diagnose and treat asymptomatic
contralateral hernia. The incidence of bilateral patent processus vaginalis has been described
in literature between 5 and 12% (Manoharan et al., 2005; Miltenburg et al., 1997; Tackett et
al., 1999). In open surgery routine contralateral exploration is not recommended, because
exploration increases the risk of testicular atrophy and infertility after cord injury. However
in laparoscopic hernia repair, evaluation and treatment of the contralateral processus
vaginalis is feasible without significant risk of injury to the vas and vessels. Additionally it
decreases the need for later contralateral surgery. Femoral hernias in children are rare,
occurring in less than 1% of children with groin hernia. They often present as recurrent
hernias after inguinal hernia repair, most likely because the surgeon was misled by the
findings of a processus vaginalis at the initial surgery and missed the femoral hernia defect.
2.5 Sportsmen hernia

The term sportsmen hernia describes a condition characterized by chronic groin pain,
without a demonstrable defect in the inguinal canal or abdominal wall, mostly observed in
athletes. The pain flares with activity and results from chronic, repetitive trauma or stress to
the musculotendinous portions of the groin. The exact pathophysiology is unclear and
various theories have emerged in literature considering the presences of an occult hernia, a
tear or microtears in the transversalis fascia or muscle strain. The theory that posterior
weakness in the inguinal wall is the prime cause of groin pain in athletes is supported by the
fact that reinforcement of the posterior wall often resolves the groin pain (Malycha & Lovell,
1992; Paajanen et al., 2004; van Veen et al., 2007; Ziprin et al., 2008).
Sportmen hernia are found almost exclusively in men and only sporadically in women
(Hackney, 1993; Moeller, 2007). For patients presenting with groin pain there are numerous
other potential causes for groin pain, including hip articulation problems, taking in
consideration the complex anatomy and biomechanics of the symphisis region. This makes
the sportsmen hernia largely a clinical diagnosis of exclusion by physical examination and
usage of radiological imaging. Sportsmen hernia can often be treated conservatively with
rest, anti-inflammatiory medication and physiotherapy. However when pain persist after
conservative treatment, laparoscopic mesh placement has shown to be a good option.
2.6 Femoral hernia

Femoral hernias account for 2 to 4% of groin hernias. Femoral hernia present more often in
women and account for 23% of groin hernia operations in women, as compared with 1% in
men (Dahlstrand et al., 2009). The reason for the higher incidence in women may relate to
comparatively less bulky musculature at baseline and weakness of the pelvic floor muscles
from previous childbirth. Additionally, the angle of the superior ramus of the pubic bone
with the inguinal ligament is less acute in women, explaining for a wider femoral canal.
Femoral hernias frequently present acutely with signs of incarceration and require
emergency surgery, with 40% emergency surgery in women and 28% in men. Subsequently
bowel resection is required more often than in elective repair, 23% in emergency repair
versus 0.6% in elective repair. Additionally, the risk for mortality is 5.4 times increased
when compared to elective operations. This highlights the importance of repairing femoral
hernias soon after presentation in an elective setting and suggests that there is no indication
for watchful waiting in patients with femoral hernias. Strangulated Richter’s type femoral
hernias occur relatively frequent and carry a significant morbidity and mortality. The
diagnosis of such strangulated femoral hernias is invariably delayed because they develop
without intestinal obstruction and with minimal local manifestation until the entrapped
knuckle of small bowel is gangrenous. A bruit over the femoral vein is an indication that the
adjacent femoral hernia is incarcerated or strangulated because the hernia compresses the
vein. Both open and laparoscopic approaches have been described for repair of femoral
hernia. If a large volume of intra-abdominal contents has protruded into the hernia sac, or if
there is bowel in the defect, laparoscopy is the operation of choice. Intra-abdominal contents
are best removed by preperitoneal approach. Additionally during laparoscopy the viability
of the bowel can be inspected.
3. Hernias of the ventral abdominal wall

Ventral hernias result from defects in the ventral abdominal wall and are typically classified
by etiology and location. They can develop as a result of prior surgery (incisional and trocar
site hernia) or at anatomical congenital weak locations (umbilical, epigastric and Spigelian
hernia). The abdominal wall exists of five muscles (external oblique, internal oblique,
transversus abdominis, rectus abdominis and pyramidal muscles) that protect the viscera.
Herniation of the abdominal wall during activity is prevented by the transverse abdominal
muscles. In adults the external oblique muscle is aponeurotic up to the level of the
umbilicus. The caudal boundary of the posterior layer of the rectus sheath is the linea
semicircularis, usually located 5 cm caudally to the umbilicus. Cranially to it, the medial
aponeuroses of the three lateral muscles give rise to the anterior and posterior layers of the
rectus sheath, enveloping the lateral border of the rectus sheath. Cranially to the umbilicus,
the muscular part of the transversus abdominis muscle extends more medially than the
muscular parts of the oblique muscles. Cranially to the umbilicus the abdominal cavity has
an integral muscular cover, except for the linea alba in the midline. Caudally to the
umbilicus, the medial borders of the external oblique and transversus abdominis muscles
decline laterally, and the medial border of the internal oblique muscle medially. The
transversus abdominis muscle is connected to the rectus sheath by its aponeurosis, the fascia
of Spigel, which is cutaneously represented by the linea semilunaris (Lange & Kleinrensink,
Surgical Anatomy of the Abdomen, Elsevier gezondheidszorg, 2002).
3.1 Technique of laparoscopic ventral hernia repair

After establishing a pneumoperitoneum and introducing trocars, laparoscopic ventral
hernia repair is started with lysis of intra-abdominal adhesions with caution to prevent
bowel injury. After reduction of the hernial content, the hernia sac is commonly left in situ.
In doing so seroma formation can occur. The fascial defect is measured and a piece of mesh
able to cover the defect with an overlap of at least 3 to 5 cm is cut in shape. The intra-
abdominal pressure should be lowered to make the abdominal wall more natural shaped
and to allow a flat placement of the mesh. The mesh is tension-free implanted and fixated
with tackers (every 2 cm) and possibly additional transabdominal sutures (at least every 5
cm). Tackers can be placed in one row or a double row (double-crown technique). Drains are
not typically used after laparoscopic hernia repair. Complications than can occur are related
to laparoscopy (i.e. bowel injury and subsequent enterotomy), nerve injury by tackers or
transabdominal sutures, adhesion formation to the mesh and fixation material, mesh
infection and mesh dislocation.
3.2 Incisional hernia

An incisional hernia develops when the fascial tissue fails to heal at the incision site of a
prior laparotomy. Incisional hernia is a common complication and represents about 80% of
all ventral hernias. The highest incidence of incisional hernias is observed after midline
laparotomy, the most common incision for abdominal surgery. In decreasing order of
incidence, incisional hernias are diagnosed after upper midline incisions, lower midline
incisions, transverse incisions and subcostal incisions. Incisional hernias are also described
after paramedian, McBurney, Pfannenstiel and flank incisions.
Conditions that impair wound healing make patients susceptible to the development of an
incisional hernia, such as wound infection, diabetes mellitus, obesity, immunosuppressive
drugs, aneurysm of the abdominal aorta, connective tissue disorders and smoking.
Approximately 15-20% of all patients will develop an incisional hernia after midline
laparotomy (Hoer et al., 2002; Millbourn et al., 2009; Mudge & Hughes, 1985). The incidence
rises up to 35% in patients with an aneurysm of the abdominal aorta (Adye & Luna, 1998;
Bevis et al., 2010). Besides patient co-morbidities, technical failure contributes to the
development of incisional hernia. After midline laparotomy the fascia should be closed with
a non absorbable or slowly-absorbable continuous suture in a suture length to wound length
ratio of 4:1 or more to lower the rate of incisional hernia (Hodgson et al., 2000; van 't Riet et
al., 2002).
Around 40% of incisional hernias are symptomatic and approximately 1 out of every 3
incisional hernias is repaired in an elective or emergency setting. In the United States,
approximately 4 to 5 million laparotomies are performed annually, leading to 400,000 to
500,000 incisional hernias, of which approximately 200,000 repairs are performed (Burger et
al., 2004).
3.2.1 Classification
Different classification systems for incisional hernias are available. The European Hernia
Society developed a classification for incisional hernias which takes in account the location,
size and possible recurrence of the incisional hernia (Muysoms et al., 2009). This
classification allows comparison of publications and future studies on treatment and
outcome of incisional hernia repair. Incisional hernias are classified by:
 Location:
 Midline: M1 (subxiphoidal), M2 (epigastric), M3 (umbilical), M4 (infraumbilical)
and M5 (suprapubic)
 Lateral: L1 (subcostal), L2 (flank), L3 (iliac) and L4 (lumbar)
 Width: W1 (smaller than 4 cm), W2 (4 to 10 cm), W3 (10 cm or more)
 Recurrence: yes or no
The Ventral Hernia Working Group (USA) developed a hernia grading system based on the
characteristics of the patient and the wound (Ventral Hernia Working et al., 2010). Using
this system a surgeon can assess the risk for surgical-site occurrences (infection, seroma,
wound dehiscence, and the formation of enterocutaneous fistulae) for individual patients
and thereby select the appropriate surgical technique, repair material, and overall clinical
approach for the patient. The grading system with assessment of risk for surgical site
occurrences:
 Grade 1, Low risk: patients without a history of wound infection and a low risk of
complications
 Grade 2, Co-morbid: patients with one or more co-morbidities of smoking, obesity,
diabetes mellitus, COPD, immunosuppression.
 Grade 3, Potentially contaminated: patients with a previous wound infection, stoma
present or operation with violation of the gastrointestinal tract.
 Grade 4, Infected: patients with an infected mesh or septic dehiscence.
3.2.2 Recurrence after laparoscopic repair

Luijendijk (2000) and Burger (2004) stressed the importance of mesh reinforcement for
incisional hernia repair, with long-term recurrence rates of 60% in the suture repair group
and 32% in the mesh group. Recurrence rates following laparoscopic and open ventral
hernia repair with prosthetic reinforcement are comparable (Bingener et al., 2007; Goodney
et al., 2002; Sajid et al., 2009). Wound infection is one of the main contributors to the
recurrence rate after laparoscopic ventral hernia repair, but surgical-technical failure is
underestimated. Technical failure (i.e. inadequate mesh fixation, mesh overlap and lateral
detachment) accounts for approximately 50% of the recurrences and infection for an
additional 25% (Awad et al., 2005). This explains the major decrease of recurrences in
experienced hands, compared to non-experts. By laparoscopic ventral hernia repair the
intraperitoneally placed mesh is pushed outward and held in place by the natural intra-
abdominal pressure. Another benefit of the laparoscopic approach is identifying small
fascial defects, known as ‘‘Swiss cheese’’ defects, which may be missed during open repair.
These small fascial defects are thought to be the major source of incisional hernia recurrence
and therefore identification is important for a successful hernia repair.
3.3 Trocar site heria

Trocar site hernias (TSH) have an overall low incidence of less than 1% in adults. The
incidence of TSH increases with the size of the used trocar. Almost all TSH develop from
trocars of 10 mm or above. Most TSH are located at the umbilical port site, where the largest
trocars are used and the fascia is expanded to remove surgical specimen. To prevent TSH
the fascia of trocar sites of 10 mm or above should be sutured with a non-absorbable or
slowly-absorbable suture, especially in the umbilical area. Co-morbidities as diabetes,
smoking and obesity might be risk factors for TSH (Helgstrand et al., 2010). The use of a
Veress Needle (instead of an open introduction technique) and a sharp trocar (compared to
a conical shaped trocar) are associated with a higher incidence of TSH. In young children the
reported incidence of TSH is higher than in adults (5% vs 1%). Herniation of the small sized
bowels through trocar ports of 3-5 mm is described, which shows the importance of closing
all trocar port fascias in paediatric patients.
3.4 Umbilical hernia

A congenital umbilical hernia develops when the umbilical scar fails to heal at birth. The
incidence of congenital umbilical hernia is 10-30%, with a higher incidence in African
American children than in Caucasian children. During the first 1.5 year of life most
umbilical hernias close and at the age of 5 almost all children have complete closure of the
umbilical ring. Repair should not be considered before an age of 3 years and only in children
with large hernias that do not decrease in size or are symptomatic. In the rare case of
incarceration, repair is necessary to avoid strangulation (Katz, 2001). Umbilical hernias in
adults are an acquired defect in over 90% and are three times more frequently seen in
women than in men. The development of an umbilical hernia is associated with obesity,
abdominal distension, ascites and pregnancy. In females umbilical hernias are more
frequent among multipara and are often easily reducible. Men often present with an
incarcerated umbilical hernia, most often containing herniated omentum or preperitoneal
fat. Laparoscopic umbilical hernia repair with an onlay patch is a safe and efficacious
technique, and compared to open repair has the advantages of a lower rate of wound
complications, reduced postoperative pain, shorter hospital stay and a diminished
morbidity rate (Lau & Patil, 2003; Toy et al., 1998). Hernia repair in the presence of ascites
due to cirrhosis should be considered elective, since emergency repair has an associated
morbidity of 70% and mortality of 5% (Telem et al., 2010). Even in patients with mild to
moderate cirrhosis correction can be safely performed (Heniford et al., 2000).
3.5 Epigastric hernia

An epigastric hernia is a defect in the linea alba located between the xyphoid process and
umbilicus. Epigastric hernias are comparable to umbilical hernias, but smaller in size, often
less than 1 cm (Lang et al., 2002). Epigastric hernias are acquired defects with an incidence of
3-5%, three times more frequent in men than in women and mostly diagnosed between 40-
60 years. Associated factors for the development of epigastric hernias are increased intra-
abdominal pressure and muscle or linea alba weakness. During laparoscopy an epigastric
hernia can be difficult to visualize due to lack of peritoneal involvement through the hernia
defect. Frequently epigastric hernias present incarcerated and in general only contain
omentum or preperitoneal fat. Because of the small defect the hernia defect mostly need to
be enlarged to reduce the hernial sac and its content.
3.6 Spigelian hernia

A Spigelian hernia is relatively rare, but more often diagnosed since the introduction of CT-
scan and laparoscopy. The Spigelian hernia occurs along the semilunar line at the level of
the absence of the posterior rectus sheath (semicircular line, below the umbilicus). Almost
all Spigelian hernias are interparietal due to the intact external oblique aponeurosis covering
the hernia. A large Spigelian hernia is most often found laterally and inferior to its defect in
the space directly posterior to the external oblique muscle.
The Spigelian hernia has different factors of etiology (Lange & Kleinrensink, Surgical
Anatomy of the Abdomen, Elsevier gezondheidszorg, 2002):
 Muscular gap between linea semilunaris and medial boundaries of oblique and
transversus abdominis muscles, caudally to umbilicus,
 Maximal width of aponeurosis of transversus abdominis muscle at crossing of
semicircular and semilunar lines.
 Parallelism of fibers of internal oblique and transversus abdominis muscles between
arcuate line and Hesselbach’s triangle.
 Blending of aponeuroses of internal oblique and transversus abdominis muscle into one
separate structure, caudally to arcuate line.
Clinical diagnosis of a Spigelian hernia is challenging, but imaging with ultrasonography or
CT-scan will confirm the presence of the hernia. Up to 20% of Spigelian hernias present
incarcerated and therefore elective repair is indicated when diagnosed. The technique of
laparoscopic repair is similar to other ventral hernia repairs. Compared to open repair,
laparoscopic repair of Spigelian hernias is associated with a decreased morbidity, shorter
hospital stay and low recurrence rate (Moreno-Egea et al., 2002).
4. Diaphragmatic or hiatal hernia

The diaphragm consists of striated muscle and has a collagenous central tendon, which is
cranially blended with the pericardium. The esophageal hiatus is a 2-3 cm long muscular
tunnel with a diameter of 3.5 cm, located 2-3 cm to the left at the peripheral muscular part of
the diaphragm. The right crus and dorsal median arcuate ligament encircle the esophagus.
Through the esophageal hiatus, besides the esophagus, pass the vagus trunks, sensory
phrenico-abdominal branch of left phrenic nerve to the pancreas and peritoneum,
esophageal vessels and retro-esophageal fat.
The natural anti-reflux mechanism is complex with several synergistic elements. A crucial
element in preventing reflux is the circular muscular lower esophageal sphincter (LES) of 3.5
cm, extending from the distal esophagus down to the angle of His. The LES is autonomically
controlled by vagal stimulation through intramural plexuses and enterohormones.
Normally at least 1 cm of the LES is held intra-abdominally by the circular bilaminar
phrenico-esophageal ligament. The ventral descending leaf connects the adventitia and
muscular coat of the distal esophagus to the hiatus and is continuous with the lesser
omentum at the right side of the esophagus. The supradiaphragmatic ascending leaf is
elastic and permits movement during swallowing and breathing. The extrinsic component
of the anti-reflux mechanism is the pinching action of the right crus of the diaphragm. The
right crus narrows the hiatus and increases the angle between the ventrally bended distal
esophagus and the cardia. The LES and crus normally supplement each other in preventing
acid reflux during swallowing or acute increased intra-abdominal pressure (Lange &
Kleinrensink, Surgical Anatomy of the Abdomen, Elsevier gezondheidszorg, 2002).
A diaphragmatic or hiatal hernia occurs after enlargement of the hiatus and is a common
disorder of the digestive tract. Cranial movement of the esophagus with protrusion of
abdominal content (stomach in general) into the thoracic cavity can occur through the
widened hiatus. This natural antireflux function is often disrupted by the presence of a
hiatal hernia and is strongly associated with gastro-esophageal reflux disease (GERD).
Hiatal hernias larger than 3 cm are a risk factor for erosive GERD and Barrett’s esophagus.
4.1 Classification
Anatomically four different types of hiatal hernias can be recognised:
 Type 1: Sliding hernia. The gastroesophageal junction migrates into the thoracic cavity.
 Type 2: Paraesophageal hernia. Herniation of the gastric fundus anterior to a normally
positioned gastroesophageal junction.
 Type 3: Mixed sliding and paraesophageal hernia.
 Type 4: Herniation of additional organs. The whole stomach and sometimes additional
visceral organs (i.e. colon, omentum or spleen) migrate into the thoracic cavity. This can
result in a stomach in upside-down position.
Up to 95% of all hiatal hernias can be classified as a type 1, sliding hernia. Type 3 and type 4
hiatal hernias tend to be large or giant hernias. Large or giant hernias are defined as at least
30%-50% of the stomach herniating into the thoracic cavity. Patients with hiatal hernia can
experience symptoms of GERD, as epigastric pain, dysphagia, heartburn, but in more severe
cases gastric hemorrhaging, vomiting and cardiopulmonary problems with dyspnea.
Paraesophageal hernias account for less than 5% of all hiatal hernias but can have
potentially life-threatening complications, such as obstruction, dilatation, necrosis with
perforation or bleeding of the stomach.
4.2 Laparoscopic repair

Patients with sliding hernias and GERD should be considered for elective surgical repair.
The objectives of hiatal hernia surgery for GERD are repair of the intrinsic component of the
anti-reflux mechanism by bringing back LES into the hiatal tunnel and repair of the extrinsic
component of the anti-reflux mechanism by narrowing the hiatus. Paraesophageal hernias
(type 2, 3 and 4) should be repaired when symptomatic, due to the associated possible life-
threatening complications. The laparoscopic approach to hiatal hernia repair has the benefit
of easy exposure of the hiatus area and a good vision into the mediastinum. To restore the
intrinsic component of anti-reflux mechanism a laparoscopic fundoplication is performed.
The laparoscopic Nissen fundoplication (360° wrap) is the most frequently applied
procedure. Other possible fundoplications are the posterior Toupet (270° wrap) and anterior
Dor (180° wrap). The laparoscopic Nissen fundoplication is equally effective in patients with
GERD or with paraesophageal hernia and is the preferred fundoplication procedure. The
failure rate of a Nissen fundoplication for GERD is between 2-30%, depending whether
failure is defined as resumption of conservative treatment or failure requiring reoperation.
The failure rate of a Nissen fundoplication for paraesophageal hernia is 7-33%, depending
whether failure is defined anatomically or symptomatically. Patient satisfaction after
laparoscopic Nissen fundoplication with 5-year follow-up is 86-96% (Lafullarde et al., 2001;
Smith et al., 2005). Complications associated with laparoscopic hiatal hernia surgery include
stenosis, pulmonary complications (pneumonia, pneumothorax, pulmonary edema) and
gastrointestinal complications (bleeding, perforation, dysphagia).
4.2.1 Laparoscopic fundoplication technique

The patient should be positioned supine on a split leg table with arms out and in a steep
reverse Trendelenburg position to help expose the hiatus. After establishing a
pneumoperitoneum five trocars are inserted. A liver retractor is used to retract the left liver
lobe and expose the anterior surface of the proximal stomach near the gastroesophageal
junction. The hepatogastric omentum should be opened over the caudate lobe of the liver,
just above the hepatic branch of the vagal nerve, exposing the right crus of the diaphragm.
Caution should be taken for an aberrant left hepatic artery in this area, present in
approximately 20% of patients. Over left, anteriorly the phrenoesophageal ligament can be
divided to its apex on the right. The right and left crus are dissected from its base to the
crural arch and the retroesophageal window is gently opened, protecting the posterior vagal
nerve. A penrose drain can be used to retract the esophagus during further dissecting, until
at least 2-3 cm of distal esophagus can be pulled below the diaphragm without tension.
During this dissection caution should be taken not to injure the anterior and posterior vagal
nerves, left or right pleura and aorta. The gastric fundus should be mobilized from 10-15 cm
inferior to the angle of His, isolating and dividing the short gastric vessels, working back to
the gastroesophageal junction. It is important to avoid excessive traction when dividing all
posterior gastric arteries and other attachments, to prevent tearing of the short gastric
arteries or splenic capsule. In some patients the proximal fundus and upper pole of the
spleen are closely attached, making this part of the dissection quite difficult. The mobilized
gastric fundus is brought through the retroesophageal window and around the distal
esophagus anteriorly to ensure adequate mobilization. If the gastric fundus is released and
exits the retroesophageal window, further mobilization is necessary. The fundoplication can
be completed around a 50-60 French dilator. The internal diameter of the wrap should
exceed the external diameter of the esophagus. Two or three non-absorbable sutures are
placed with bites taking full thickness gastric fundus and partial thickness anterior
esophageal wall, avoiding the anterior vagal nerve. When completed the wrap should be no
greater than 2 cm in length and optimally a bit of distal esophagus should be visible distally
to the wrap. Additional sutures from the wrap to the diaphragm can be placed. The crus can
be closed using non-absorbable stitches.
4.2.2 Paraesophageal hernia repair

Laparoscopic repair of a paraesophageal hernia consists of reduction of the stomach and
gastroesophageal junction into the abdominal cavity, complete excision of the peritoneal
hernia sac from the mediastinum, and repair of the esophageal hiatus. Following a Nissen
fundoplication, the crus should be closed using non-absorbable sutures. In case of a large
hiatus, additional anterior or lateral crural stitches can be added. An additional anterior
gastropexy can be performed in case of a very large or shortened esophagus. The anterior
stomach wall and the antrum should be sutured to the abdominal wall.
Laparoscopic repair of paraesophageal hernias is superior to open repair, with an associated

decreased length of hospital stay, complication rate and recurrence rate (Draaisma et al.,
2005). Long-term good functional results are observed in 75% and (symptomatic)
recurrences in 15% after large paraesophageal hernia repair (Poncet et al., 2010).
Postoperative complications associated with laparoscopic large paraesophageal hernia
repair are intrathoracal wrap migration, relative stenosis of the cardia, gastric volvulus or
strangulation, pneumothorax, pneumonia and dysphagia. A synthetic mesh can be used to
reinforce the hiatal repair, but is still controversial. A mesh might be associated with a
decreased recurrence rate, but may give rise to serious complications like prosthetic
migration, esophageal perforation, dysphagia and mesh infection. Since the majority of
paraesophageal hernias are mixed sliding and paraesophageal hernias, an insufficient LES
with GERD-symptoms may remain after surgery and antireflux medication is still required.
Esophagus (1)
Gastric fundus (2)
Splenic capsule (3)
Phrenico-esophageal ligament (4)
Abberant left hepatic artery (5)
Anterior vagus nerve (6)
Hepatic branch (7)
Posterior vagus nerve (8)
Fig. 2. Anatomic landmarks and structures of importance in hiatal hernia repair (Lange &
Kleinrensink, Surgical Anatomy of the Abdomen, Elsevier gezondheidszorg, 2002)
4.3 Treatment of recurrence

The reported failure following laparoscopic Nissen fundoplication for GERD and
paraesophageal hernia is between 2-33%. Although failure of fundoplication is unusual
when performed by an experienced surgeon, wrap herniation (‘slipped Nissen’) is the most
common mechanism of failure. Other causes of failure are represented by disrupted
fundoplication, slipped fundoplication, crural stenosis, too tight wrap, misplaced
fundoplication or twisted fundoplication. In carefully selected patients who have recurrent
or persistent symptoms (heartburn, dysphagia, chest pain, regurgitation, asthma, hoarsness
or laryngitis) after laparoscopic or open fundoplication a laparoscopic redo fundoplication
can be safely performed by an experienced surgeon. The overall conversion rate of redo
laparoscopic fundoplication is 10%. Complications occur in approximately 15%, slightly
increasing with multiple redos. After redo laparoscopic fundoplication 70% of patients is
GERD-related symptom free (Smith et al., 2005).
5. Parastomal hernia
Occurrence of parastomal herniation is a common complication after stoma formation. The
reported incidence of parastomal hernias varies from 28% in ileostomies to 56% in
colostomies (Carne et al., 2003; LeBlanc et al., 2005; Rieger et al., 2004). A parastomal hernia
is more likely to occur when the stoma emerges through the semilunar line rather than the
rectus sheath. Although most hernias become present within two years after stoma
construction, the risk of herniation extends up to 20 years.
5.1 Classification
Parastomal hernias can be classified in four types:
 Subcutaneous type: subcutaneous hernia sac
 Interstitial type: hernia sac within the aponeurotic layers of the abdomen
 Perstomal type: bowel prolapsing through a circumferential hernia sac enclosing the
stoma
 Intrastomal: hernia sac between the intestinal wall and the everted intestinal layer
Symptoms patients may experience are pain, poor fitting of stoma-material resulting in
leakage of stomal contents, obstruction, incarceration and cosmetic disfigurement.
Fortunately, most parastomal hernias can be treated conservatively and surgical
intervention is only indicated in 15% of patients with parastomal hernias (Hansson et al.,
2003). Recurrence rates after surgical repair are reported up to 76%, and can be explained by
the underlying defect in wound healing and collagen metabolism in most patients.
5.2 Laparoscopic repair

Parastomal hernia repair with prosthetic mesh is recommended, since recurrence rates are
unsatisfactory high after suture repair or relocation of the stoma. Complications that can
arise with mesh placement for parastomal hernia are mesh-infection, fistula formation and
adhesion formation. Laparoscopic repair is effective in correction of these hernias and has
the advantages of improved vision and definition of the fascial edges of the hernia.
Laparoscopic techniques for repair of parastomal hernia with prosthetic mesh can be
divided in ’keyhole techniques’ and modified ‘Sugarbaker techniques’. All involve
introduction of trocars, extensive adhesiolysis, and identifying and measuring the fascial
defect. A mesh should provide at least 5 cm of overlap of the fascial edges and should be
secured with tacks or constructed with transfascial sutures.
Several different ’keyhole techniques’ have been described, which have in common that a
mesh is placed with a central hole or slit in the mesh to allow the bowel to pass through the
mesh to the stoma site. One of the main drawbacks is shrinkage of the mesh that can result
in obstruction or recurrent herniation by enlargement of the hole. In the modified
Sugarbaker technique no hole is made in the mesh but the bowel to the stoma is lateralized
and covered by the mesh (Berger & Bientzle, 2007; Mancini et al., 2007; Sugarbaker, 1985).
The mesh is secured to the abdominal wall at the margin of the mesh at 5 cm intervals. A
second row of tackers is placed at the margin of the hernia defect with additional tackers at
each side of the colon. Both techniques are promising, however long term results are not yet
available. Perhaps prevention of development of parastomal hernia by placement of a
lightweight sublay mesh is the key (Janes et al., 2004).
6. References
Adye, B., & Luna, G. (1998). Incidence of abdominal wall hernia in aortic surgery. Am J Surg,
175(5), 400-402.
Arregui, M. E., Davis, C. J., Yucel, O., & Nagan, R. F. (1992). Laparoscopic mesh repair of
inguinal hernia using a preperitoneal approach: a preliminary report. Surg Laparosc
Endosc, 2(1), 53-58.
Awad, Z. T., Puri, V., LeBlanc, K., Stoppa, R., Fitzgibbons, R. J., Jr., Iqbal, A., et al. (2005).
Mechanisms of ventral hernia recurrence after mesh repair and a new proposed
classification. J Am Coll Surg, 201(1), 132-140.
Bassini, E. (1887). Sulla cura radicale dell'ernia inguinale. Arch Soc Ital Chir, 4, 380.
Berger, D., & Bientzle, M. (2007). Laparoscopic repair of parastomal hernias: a single
surgeon's experience in 66 patients. Dis Colon Rectum, 50(10), 1668-1673.
Bevis, P. M., Windhaber, R. A., Lear, P. A., Poskitt, K. R., Earnshaw, J. J., & Mitchell, D. C.
(2010). Randomized clinical trial of mesh versus sutured wound closure after open
abdominal aortic aneurysm surgery. Br J Surg, 97(10), 1497-1502.
Bingener, J., Buck, L., Richards, M., Michalek, J., Schwesinger, W., & Sirinek, K. (2007). Long-term
outcomes in laparoscopic vs open ventral hernia repair. Arch Surg, 142(6), 562-567.
Bogojavalensky, S. (1989). laparoscopic treatment of inguinal and femoral hernia (video
presentation). In: Proceedings of the 18th Annual Meeting of the American
Association of Gynecological Laparoscopists. Washington DC, USA.
Bronsther, B., Abrams, M. W., & Elboim, C. (1972). Inguinal hernias in children--a study of 1,000
cases and a review of the literature. J Am Med Womens Assoc, 27(10), 522-525 passim.
Burger, J. W., Luijendijk, R. W., Hop, W. C., Halm, J. A., Verdaasdonk, E. G., & Jeekel, J.
(2004). Long-term follow-up of a randomized controlled trial of suture versus mesh
repair of incisional hernia. Ann Surg, 240(4), 578-583; discussion 583-575.
Carne, P. W., Robertson, G. M., & Frizelle, F. A. (2003). Parastomal hernia. Br J Surg, 90(7),
784-793.
Dahlstrand, U., Wollert, S., Nordin, P., Sandblom, G., & Gunnarsson, U. (2009). Emergency
femoral hernia repair: a study based on a national register. Ann Surg, 249(4), 672-676.
Davis, C. J., & Arregui, M. E. (2003). Laparoscopic repair for groin hernias. Surg Clin North
Am, 83(5), 1141-1161.
Draaisma, W. A., Gooszen, H. G., Tournoij, E., & Broeders, I. A. (2005). Controversies in
paraesophageal hernia repair: a review of literature. Surg Endosc, 19(10), 1300-1308.
Ferzli, G. S., Massad, A., & Albert, P. (1992). Extraperitoneal endoscopic inguinal hernia
repair. J Laparoendosc Surg, 2(6), 281-286.
Fruchaud, H. (1953). [The effect of the upright position proper to man upon the anatomy of
the inguinal region: surgical consequences; anatomic bases of surgical treatment of
inguinal hernia]
Du retentissement de la position debout propre a l'homme sur l'anatomie de la region de
l'aine: consequences chirurgicales; les bases anatomiques du traitement chirurgical
des hernies de l'aine. Mem Acad Chir (Paris), 79(25-6), 652-661.
Gallegos, N. C., Dawson, J., Jarvis, M., & Hobsley, M. (1991). Risk of strangulation in groin
hernias. Br J Surg, 78(10), 1171-1173.
Ger, R. (1982). The management of certain abdominal herniae by intra-abdominal closure of
the neck of the sac. Preliminary communication. Ann R Coll Surg Engl, 64(5), 342-344.
Goodney, P. P., Birkmeyer, C. M., & Birkmeyer, J. D. (2002). Short-term outcomes of
laparoscopic and open ventral hernia repair: a meta-analysis. Arch Surg, 137(10),
1161-1165.
Hackney, R. G. (1993). The sports hernia: a cause of chronic groin pain. Br J Sports Med, 27(1),
58-62.
Hansson, B. M., van Nieuwenhoven, E. J., & Bleichrodt, R. P. (2003). Promising new
technique in the repair of parastomal hernia. Surg Endosc, 17(11), 1789-1791.
Harper, R. G., Garcia, A., & Sia, C. (1975). Inguinal hernia: a common problem of premature
infants weighing 1,000 grams or less at birth. Pediatrics, 56(1), 112-115.
Helgstrand, F., Rosenberg, J., & Bisgaard, T. (2010). Trocar site hernia after laparoscopic
surgery: a qualitative systematic review. Hernia.
Heniford, B. T., Park, A., Ramshaw, B. J., & Voeller, G. (2000). Laparoscopic ventral and
incisional hernia repair in 407 patients. J Am Coll Surg, 190(6), 645-650.
Hodgson, N. C., Malthaner, R. A., & Ostbye, T. (2000). The search for an ideal method of
abdominal fascial closure: a meta-analysis. Ann Surg, 231(3), 436-442.
Hoer, J., Lawong, G., Klinge, U., & Schumpelick, V. (2002). [Factors influencing the
development of incisional hernia. A retrospective study of 2,983 laparotomy
patients over a period of 10 years]
Einflussfaktoren der Narbenhernienentstehung. Retrospektive Untersuchung an 2.983
laparotomierten Patienten uber einen Zeitraum von 10 Jahren. Chirurg, 73(5), 474-480.
Hollinsky, C., & Sandberg, S. (2010). Clinically diagnosed groin hernias without a peritoneal
sac at laparoscopy--what to do? Am J Surg, 199(6), 730-735.
Janes, A., Cengiz, Y., & Israelsson, L. A. (2004). Randomized clinical trial of the use of a
prosthetic mesh to prevent parastomal hernia. Br J Surg, 91(3), 280-282.
Katz, D. A. (2001). Evaluation and management of inguinal and umbilical hernias. Pediatr
Ann, 30(12), 729-735.
Koch, C. A., Greenlee, S. M., Larson, D. R., Harrington, J. R., & Farley, D. R. (2006).
Randomized prospective study of totally extraperitoneal inguinal hernia repair:
fixation versus no fixation of mesh. JSLS, 10(4), 457-460.
Lafullarde, T., Watson, D. I., Jamieson, G. G., Myers, J. C., Game, P. A., & Devitt, P. G.
(2001). Laparoscopic Nissen fundoplication: five-year results and beyond. Arch
Surg, 136(2), 180-184.
Lang, B., Lau, H., & Lee, F. (2002). Epigastric hernia and its etiology. Hernia, 6(3), 148-150.
Lange & Kleinrensink, Surgical Anatomy of the Abdomen, Elsevier gezondheidszorg, 2002.
Lau, H., & Patil, N. G. (2003). Umbilical hernia in adults. Surg Endosc, 17(12), 2016-2020.
Lau, S. T., Lee, Y. H., & Caty, M. G. (2007). Current management of hernias and hydroceles.
Semin Pediatr Surg, 16(1), 50-57.
LeBlanc, K. A., Bellanger, D. E., Whitaker, J. M., & Hausmann, M. G. (2005). Laparoscopic
parastomal hernia repair. Hernia, 9(2), 140-144.
Luijendijk, R. W., Hop, W. C., van den Tol, M. P., de Lange, D. C., Braaksma, M. M., JN, I. J.,
et al. (2000). A comparison of suture repair with mesh repair for incisional hernia.
N Engl J Med, 343(6), 392-398.
Malycha, P., & Lovell, G. (1992). Inguinal surgery in athletes with chronic groin pain: the
'sportsman's' hernia. Aust N Z J Surg, 62(2), 123-125.
Mancini, G. J., McClusky, D. A., 3rd, Khaitan, L., Goldenberg, E. A., Heniford, B. T.,
Novitsky, Y. W., et al. (2007). Laparoscopic parastomal hernia repair using a nonslit
mesh technique. Surg Endosc, 21(9), 1487-1491.
Manoharan, S., Samarakkody, U., Kulkarni, M., Blakelock, R., & Brown, S. (2005). Evidence-
based change of practice in the management of unilateral inguinal hernia. J Pediatr
Surg, 40(7), 1163-1166.
Millbourn, D., Cengiz, Y., & Israelsson, L. A. (2009). Effect of stitch length on wound
complications after closure of midline incisions: a randomized controlled trial. Arch
Surg, 144(11), 1056-1059.
Miltenburg, D. M., Nuchtern, J. G., Jaksic, T., Kozinetz, C. A., & Brandt, M. L. (1997). Meta-
analysis of the risk of metachronous hernia in infants and children. Am J Surg,
174(6), 741-744.
Moeller, J. L. (2007). Sportsman's hernia. Curr Sports Med Rep, 6(2), 111-114.
Moreno-Egea, A., Carrasco, L., Girela, E., Martin, J. G., Aguayo, J. L., & Canteras, M. (2002).
Open vs laparoscopic repair of spigelian hernia: a prospective randomized trial.
Arch Surg, 137(11), 1266-1268.
Moss, R. L., & Hatch, E. I., Jr. (1991). Inguinal hernia repair in early infancy. Am J Surg,
161(5), 596-599.
Mudge, M., & Hughes, L. E. (1985). Incisional hernia: a 10 year prospective study of
incidence and attitudes. Br J Surg, 72(1), 70-71.
Muysoms, F. E., Miserez, M., Berrevoet, F., Campanelli, G., Champault, G. G., Chelala, E., et
al. (2009). Classification of primary and incisional abdominal wall hernias. Hernia,
13(4), 407-414.
Neumayer, L., Giobbie-Hurder, A., Jonasson, O., Fitzgibbons, R., Jr., Dunlop, D., Gibbs, J., et
al. (2004). Open mesh versus laparoscopic mesh repair of inguinal hernia. N Engl J
Med, 350(18), 1819-1827.
Nilsson, H., Stylianidis, G., Haapamaki, M., Nilsson, E., & Nordin, P. (2007). Mortality after
groin hernia surgery. Ann Surg, 245(4), 656-660.
Nyhus, L. M. (1993). Individualization of hernia repair: a new era. Surgery, 114(1), 1-2.
Paajanen, H., Syvahuoko, I., & Airo, I. (2004). Totally extraperitoneal endoscopic (TEP)
treatment of sportsman's hernia. Surg Laparosc Endosc Percutan Tech, 14(4), 215-218.
Poncet, G., Robert, M., Roman, S., & Boulez, J. C. (2010). Laparoscopic repair of large hiatal
hernia without prosthetic reinforcement: late results and relevance of anterior
gastropexy. J Gastrointest Surg, 14(12), 1910-1916.
Primatesta, P., & Goldacre, M. J. (1996). Inguinal hernia repair: incidence of elective and
emergency surgery, readmission and mortality. Int J Epidemiol, 25(4), 835-839.
Puri, P., Guiney, E. J., & O'Donnell, B. (1984). Inguinal hernia in infants: the fate of the testis
following incarceration. J Pediatr Surg, 19(1), 44-46.
Rajput, A., Gauderer, M. W., & Hack, M. (1992). Inguinal hernias in very low birth weight
infants: incidence and timing of repair. J Pediatr Surg, 27(10), 1322-1324.
Rieger, N., Moore, J., Hewett, P., Lee, S., & Stephens, J. (2004). Parastomal hernia repair.
Colorectal Dis, 6(3), 203-205.
Sajid, M. S., Bokhari, S. A., Mallick, A. S., Cheek, E., & Baig, M. K. (2009). Laparoscopic
versus open repair of incisional/ventral hernia: a meta-analysis. Am J Surg, 197(1),
64-72.
Simons, M. P., Aufenacker, T., Bay-Nielsen, M., Bouillot, J. L., Campanelli, G., Conze, J., et
al. (2009). European Hernia Society guidelines on the treatment of inguinal hernia
in adult patients. Hernia, 13(4), 343-403.
Smith, C. D., McClusky, D. A., Rajad, M. A., Lederman, A. B., & Hunter, J. G. (2005). When
fundoplication fails: redo? Ann Surg, 241(6), 861-869; discussion 869-871.
Stoppa, R. E., Rives, J. L., Warlaumont, C. R., Palot, J. P., Verhaeghe, P. J., & Delattre, J. F.
(1984). The use of Dacron in the repair of hernias of the groin. Surg Clin North Am,
64(2), 269-285.
Stringer, M. D., Higgins, M., Capps, S. N., & Holmes, S. J. (1991). Irreducible inguinal hernia.
Br J Surg, 78(4), 504-505.
Sugarbaker, P. H. (1985). Peritoneal approach to prosthetic mesh repair of paraostomy
hernias. Ann Surg, 201(3), 344-346.
Tackett, L. D., Breuer, C. K., Luks, F. I., Caldamone, A. A., Breuer, J. G., DeLuca, F. G., et al.
(1999). Incidence of contralateral inguinal hernia: a prospective analysis. J Pediatr
Surg, 34(5), 684-687; discussion 687-688.
Taylor, C., Layani, L., Liew, V., Ghusn, M., Crampton, N., & White, S. (2008). Laparoscopic
inguinal hernia repair without mesh fixation, early results of a large randomised
clinical trial. Surg Endosc, 22(3), 757-762.
Telem, D. A., Schiano, T., & Divino, C. M. (2010). Complicated hernia presentation in
patients with advanced cirrhosis and refractory ascites: management and outcome.
Surgery, 148(3), 538-543.
Toy, F. K., Bailey, R. W., Carey, S., Chappuis, C. W., Gagner, M., Josephs, L. G., et al. (1998).
Prospective, multicenter study of laparoscopic ventral hernioplasty. Preliminary
results. Surg Endosc, 12(7), 955-959.
van 't Riet, M., Steyerberg, E. W., Nellensteyn, J., Bonjer, H. J., & Jeekel, J. (2002). Meta-
analysis of techniques for closure of midline abdominal incisions. Br J Surg, 89(11),
1350-1356.
van Veen, R. N., van Wessem, K. J., Halm, J. A., Simons, M. P., Plaisier, P. W., Jeekel, J., et al.
(2007). Patent processus vaginalis in the adult as a risk factor for the occurrence of
indirect inguinal hernia. Surg Endosc, 21(2), 202-205.
van Wessem, K. J., Simons, M. P., Plaisier, P. W., & Lange, J. F. (2003). The etiology of
indirect inguinal hernias: congenital and/or acquired? Hernia, 7(2), 76-79.
Ventral Hernia Working, G., Breuing, K., Butler, C. E., Ferzoco, S., Franz, M., Hultman, C. S.,
et al. (2010). Incisional ventral hernias: review of the literature and
recommendations regarding the grading and technique of repair. Surgery, 148(3),
544-558.
Watson, S. D., Saye, W., & Hollier, P. A. (1993). Combined laparoscopic incarcerated
herniorrhaphy and small bowel resection. Surg Laparosc Endosc, 3(2), 106-108.
Ziprin, P., Prabhudesai, S. G., Abrahams, S., & Chadwick, S. J. (2008). Transabdominal
preperitoneal laparoscopic approach for the treatment of sportsman's hernia. J
Laparoendosc Adv Surg Tech A, 18(5), 669-672.
11
Laparoscopic Incisional Hernia Repair

Anita Kurmann and Guido Beldi
Department of Visceral Surgery and Medicine, Bern University Hospital
University of Bern, Bern
Switzerland
1. Introduction
An incisional hernia (Fig 1.) is defined as any abdominal wall gap with or without a bulge in
the area of a postoperative scar perceptible or palpable by clinical examination or imaging [1].
Incisional hernia is a common long-term complication following abdominal surgery and is
estimated to occur in 11-23% [2, 3]. Risk factors for incisional hernia are male gender, body
mass index, cancer, and previous laparotomy [4, 5].
Fig. 1. Clinical presentation of a patient with a large incisional hernia

Conventional hernia repair with tissue approximation was associated with a recurrence rate
of 60%. Theodore Billroths vision was the source of changes in hernia repair. Billroth told to
his pupil Cerny: “If we could artificially produce tissues of the density and toughness of
fascia and tendon the secret of the radical cure of hernia would be discovered”. This
statement appeard in the classic Beiträge zur Chirurgie in 1987. Francic C. Usher introduced
1957 a polypropylene based prosthesis to bridge the hernia defect and to reinforce the
abdominal wall without tension [6]. With the implantation of prosthesis the recurrence rate
in hernia repair was downsized [7].
Incisional hernia can be repaired by open or by laparoscopic approach and prosthetic

meshes are nowadays implanted in most procedures. The use of laparoscopy for the
treatment of incisional hernia was first reported in 1993 by LeBlanc and Booth [8]. With the
introduction of modern two-layered mesh, laparoscopic incisional hernia repair has become
an accepted therapeutic option. Feasibility and safety of laparoscopic incisional hernia repair
has been shown in various randomized controlled trials.
2. Incisional hernia classification

Developing a good classification for incisional hernias is much more difficult than for groin
hernias or for primary abdominal wall hernias because of their great diversity. The
classification as established and published by the consensus meeting of the European
Hernia Society held in Ghent, Belgium, 2008, (Tab 1.) comprises a division of subgroups for
incisional hernia, including localization, width, and length of the hernia [9]. The use of the
classification of the European Hernia Society is nowadays recommended. The analysis of
subgroups may define patients with high risk for recurrences and may lead to specific
treatment options. This classification is applicable in laparoscopic and open incisional hernia
repair.
Table 1. European Hernia Society classification for incisional abdominal wall hernia
Laparoscopic Incisional Hernia Repair 183
3. Symptoms
A swelling or protrusion with or without abdominal pain can be observed in a patient with
an incisional hernia when the patient sits up or coughs. In large incisional hernia peristaltic
bowel movements can be observed through a thin skin, sometimes already accompanied
with signs of a skin infection. Incisional hernias may occur along the full length of the
incision with one or multiple hernial orifices. Incarceration is the main complication of an
incisional hernia [10] and occurs in 1-3% of all hernias. Signs of incarceration are acute pain
and vomiting. Clinically there is a tense, tender irreducible hernia. In these cases an
emergency hernia repair is mandatory. Emergency hernia repair can also be performed by
laparoscopy with an additional mini-laparotomy if bowel resection is necessary.
Incisional hernia can be diagnosed by physical examination. Additional ultrasound or CT-
scan examination are recommended in cases of uncertainty (Fig 2).
Fig. 2. CT-Scan of a patient with a large incisional hernia. The hernia contains small and
large bowel.
4. Surgical technique of laparoscopic hernia repair

We routinely use a 30° camera. Scissors and two graspers have to be prepared for
laparoscopic hernia repair. The screen is placed at the opposite of the surgeon. The patient is
placed in a supine position with both arms unabducted under general anesthesia. A single
shot of antibiotics is given preoperatively. The site of trocar placing depends on the
localization of the hernia. If the hernia is localized in the right hemiabdomen, the trocars
should be placed on the left side. Using a limited open technique the pneumoperitoneum is
established and the optical trocar is inserted, and under direct vision, a minimum of two
additional trocars at a suitable distance from the hernial orifice are inserted. Alternatively
the pneumoperitoneum can be established using a Verres-Needle. After establishing the
pneumoperitoneum at 12mmHg a diagnostic laparoscopy is performed. Adhesions between
the omentum or intestine with the anterior wall surrounding the hernial orifice are divided,
and the content of the hernia is reduced completely (Fig. 3). Adhesiolysis has to be
performed with scissors and without electocoagulation under direct vision to avoid bowel
lesions. In cases of incarceration the necrotic tissue has to be resected. If there is not enough
working space or the trocars are not correctly placed an additional trocar can be helpful.
Fig. 3. Intraoperative laparoscopic view of the hernial orifice

In general, the hernial sac is left in situ. After completion of adhesiolysis, the
pneumoperitoneum is released, the maximal longitudinal and horizontal hernia diameter is
measured and marked on the skin (Fig. 4). An appropriate sized mesh is tailored in order to
Fig. 4. Patient with an incisional hernia in the upper part of the scar. The hernia and the size
of the mesh is marked on the patients skin.
overlap the hernia margins by at least 5 cm on each side. In addition, the mesh should
overlap the full length of the incision of the primary operation. Non absorbable
monofilament sutures are placed in 2-3 cm intervals along the mesh margin. The mesh is
rolled up and inserted into the abdomen through a 12mm trocar.
Then the mesh is rolled up and introduced into the abdominal cavity. After the mesh is
positioned correctly in the abdominal cavity, the suture ties are pulled through the
abdominal wall with a suture passer and the threats are knotted smoothly with the knots
buried in the subcutaneous tissue after reduction of the intraabdominal pressure to 8mmHg.
We use titanium tackers that are applied between the sutures every 1 to 2 cm between the
sutures and around the hernial orifice (Fig 5). If the skin is necrotic or to enhance cosmetic
results in large incisional hernia an additional open cutaneous excision is recommended.
Fig. 5. Intraoperative laparoscopic view after Mesh implantation.
5. Patient selection
5.1 General considerations
In general we plan the laparoscopic approach for all patients with incisional hernia.
Contraindications for laparoscopic hernia repair are the presence of anesthetic (severe
pulmonary disease) or technical contraindications (eviscerated organs) or patients unwilling
to undergo laparoscopic surgery.
5.2 Large incisional hernia

In our institution we prospectively evaluated 125 with a hernia diameter ≥5cm among 428
patients undergoing incisional hernia repair. We demonstrated that laparoscopic repair of
large incisional hernias is technical feasible and associated with less SSI and shorter hospital
stay but a comparable recurrence rate as open hernia repair (Table 2) [11].
Lap. group Open group P-Value

n = 69 n = 56
SSI 4 (5.8) 16 (26.8) 0.006
Intestinal fistula 0 (0) 1 (1.8) n.s.
Hospital stay (days)* 6 (1-23) 7 (1-67) 0.014
Recurrence 11 (15.9) 10 (17.9) n.s.
Return to work (weeks) 3 (0-50) 6 (0-28) n.s.
Pain at follow-up (VAS) 0.6 (0-6) 0.5 (0-5) n.s.
Values in parentheses are percentages unless indicated otherwise. * Values are median (range).
Table 2. Results of outcome parameters of large incisional hernia repair
5.3 Incisional hernia after liver transplantation

We showed that laparoscopic incisional hernia repair is feasible and safe even in patients
under immunosuppressive therapy [12].
6. Postoperative outcome
6.1 Conversion to open surgery
The conversion rate to open surgery depends on the surgeons experience, the surgical skills,
and intraoperative complications such as bowel lesions or bleeding. In the literature
conversion to open surgery is mostly due to adhesions, with an overall conversion rate of
10-15% [12, 13]. However, complete adhesiolysis is very important especially in large
incisional hernia to gain enough place for the mesh fixation and therefore to minimize the
recurrence rate.
6.2 Operation time

There is a wide range in duration of the operation comparing laparoscopic and open
incisional hernia repair. Most studies revealed that operation time in laparoscopic
incisional hernia repair is longer compared to open surgery [12-14]. However, there was
always a statistically difference in all these studies. Longer operation time can be
explained with the learning curve in laparoscopy. Furthermore the fixation technique of
the mesh can be time consuming especially in large incisional hernia repair. On the other
hand there are some studies with no difference or even a shorter operation time in
laparoscopic surgery [15, 16].
6.3 Sugical site infections

The definition of Surgical site infections (SSIs) according to the criteria developed by the
Centers for Disease Control and Prevention include every SSI up to 30 days after the
operation [17]. Infections are categorized as incisional (superficial or deep) infections or
organ–space infections. Superficial SSIs involve only skin and subcutaneous tissue and
exclude stitch abscesses. Deep SSIs involve deeper soft tissues at the site of incision. Organ–
space SSIs are defined as infections in any organ or space. In laparoscopic incisional hernia
repair the incidence of SSI is low. In a meta-analysis of 8 randomized controlled trials Forbes
et al. showed a significant reduced risk of surgical site infections in laparoscopic incisional
hernia repair compared to open surgery [18]. The extensive tissue dissection which is
associated with the open approach explains the significant higher infection rate in open
surgery. Mostly SSIs in laparoscopic surgery are superficial and can be treated
conservatively. Mesh removal due to an surgical site infection is very rare [19].
6.4 Enterotomy
In general the mortality rate of laparoscopic incisional hernia repair is low with 0.05% [8].
The most serious complication during laparoscopic incisional hernia repair is enterotomy
[8]. Enterotomy occurs during adhesiolysis or as a burning lesion with the electorcauter.
Therefore we avoid electrocauterisation during adhesiolysis to prevent bowel lesions and
perforation. The incidence of intraoperative bowel injuries has been reported to be 1.78%
[20] A recognized enterotomy during the operation is associated with a mortality rate of
1.7% [20]. However, if the enterotomy is not recognized during the operation the mortality
rate is increased up to 7.7% [20]. Enterotomy can be repaired by laparoscopic or open
approach with similar outcome result [20].
6.5 Enterocutaneous fistula

Enterocutaneous fistula after intraperitoneal non-resorbable mesh implantation was first
reported in by Kaufman et al. in 1981 [21]. An overview of the current literature shows that
enterocutaneous fistula after incisional hernia repair is a rare complication and occurs in up
to 1% [22]. There was no association of enterocutaneous fistula if the omentum was placed
between the mesh and bowel or not. In cases of enterocutaneous fistula the mesh has to be
resected partially around the fistula. Complete mesh removal is very rare and depends on
the surgeons experience [23]
6.6 Pain
Lomanto et al. showed that there is no difference in the amount of pain comparing
laparoscopic and open hernia repair at 24 and 48 hours postoperatively [24]. However,
patients undergoing laparoscopic repair had significantly less pain at 72 hours compared to
open surgery allowing earlier discharge and return to work [24].
The threshold for chronic pain is set at three months postoperatively according to the
International Association for the Study of Pain [25]. There is no meta-analysis investigating
chronic pain after laparoscopic incisional hernia repair. Postoperative pain after mesh
fixation with transfascial sutures is likely due to nerve irritation or entrapmen [26]. There is
a randomized controlled trial investigating pain comparing two different techniques of
mesh fixation [26]. Postoperative pain following suture fixation was significantly higher at 6
weeks postoperatively and two patients suffered from nerve irritation at sites of sutures.
However, after 6 months, no difference was seen between the two groups. Pain after mesh
fixation with transfascial sutures is likely due to nerve irritation or entrapment and the
relatively small distance between individual sutures used in this study. The significant
reduction of pain between 6 weeks and 6 months post operation in these patients could be in
response to desensitisation of entrapped nerve fibres or in response to resolution of local
inflammation [26]. Asencio et al. showed in their study that 22% of the laparoscopic group
and 7% of the open group reported significantly pain three months after the operation [13].
But all were pain free one year after the operation [13] . Therefore when pain persists a
surgical revisions due to nerve irritation is not recommended earlier than 6 months.
Alternatively a postoperative local injection of bupivacaine and steroids or removal of the
offending suture is recommended [27].
6.7 Recurrence rate

Recurrence rate is one of the most important long-term outcome parameters in laparoscopic
incisional hernia repair. Forbes et al. showed in their meta-analysis no difference in the
recurrence rate between laparoscopic and open incisional hernia repair [18]. The pooled
recurrence rate in the laparoscopic group was 3.4% and in the open group 3.5% in this
study. Such a low recurrence rate after either laparoscopic and open repair can be explained
with a relatively short follow-up and the small size of the hernias [18]. A follow-up of at
least three years is mandatory to evaluate correctly the real incidence of incisional hernia
due to the fact that incisional hernia can occur up to 5 years after the operation. With such a
long-term follow-up the incidence of recurrence has been reported to be up to 15-20% in
laparoscopic and open repair [11, 13].
Two technical details can minimize the recurrence rate. First a sufficient overlap of the mesh
and second the mesh fixation. We showed a significant decrease in horizontal mesh size
after tack fixation (mean difference -3.1% ±3.9%) versus fixation using sutures (-0.1% ±2.3%;
p=0.018) [26]. Mean vertical mesh size was not significantly different between the two
groups: tack fixation -2.8% ±6.1%, suture fixation -0.7% ±4.1% (p=0.16). Mean mesh area in
the tack fixation group was -12% and in the suture fixation group -2.9% at 6 months post
operatively when compared to post-op day 2 (p=0.061) [26]. Therefore a sufficient mesh-
overlap of the hernial orifice is mandatory in order to reduce recurrence rate.
Typical locations for hernia recurrences due to the mesh shrinkage are at the margin of the
mesh as shown in Fig. 6. Because the risk to gain a second incisional hernia or a recurrent
hernia along the full length of the incision, it is recommended to cover the whole length of
the incision during the first operation.
6.8 Seroma formation

The retained hernia sac is responsible for seroma formation. Seroma formation is classified
as a complication if it lasts more than 6 weeks after the operation. A randomized controlled
trial of Olmi et al. showed an incidence of seroma formation of 7% [15]. In most cases no
intervention is necessary. In cases of symptoms or if the seroma lasts longer than 8 weeks a
drainage is recommended. Potentially a compression dressing over a period of 7 days may
prevent seroma formation.
6.9 Hospitalisation time

Forbes et al. showed in their meta-analysis that duration of hospital stay is significantly
shorter in laparoscopic incisional hernia repair compared to open surgery [18]. Less amount
of pain [24] and a significantly lower rate of surgical site infections in laparoscopic repair
[18] are reflected in a shorter hospital stay. Influence of shorter hospital stay on overall costs
in laparoscopic hernia repair is discussed below.
6.10 Costs
On the one hand operative costs of laparoscopic incisional hernia repair compared to open
surgery are significantly higher due to expensive surgical tools in laparoscopy. On the other
hand in hospital costs are significantly lower in laparoscopic surgery due to shorter hospital
stay, lower infection rate and less postoperative pain. However, laparoscopic incisional
hernia repair is associated with significant lower overall costs. Therefore laparoscopic
incisional hernia repair is cost effective [15, 28].
Fig. 6. Intraoperative laparoscopic view of a recurrent hernia along the incision at the edge
of the mesh.
7. Conclusion
In conclusion laparoscopic incisional hernia repair is feasible and safe. Reduced SSI and
reduced hospital stay are the major short term advantages associated with laparoscopy most
likely as a consequence of reduced wound size [18, 27]. Recurrence rate are comparable in
laparoscopic and open incisional hernia repair [18].
8. References
[1] M. Korenkov and E. Neugebauer. (2001). Comments on the letter from S. Petersen and K.
Ludwig concerning our paper "Classification and surgical treatment of the
incisional hernia. Results of expert meeting." Langenbeck's Arch Surg 386:65-73.
Langenbecks Arch Surg, Vol. 386, No. 4, pp.310-311,
[2] K. Cassar and A. Munro. (2002). Surgical treatment of incisional hernia. Br J Surg, Vol.
89, No. 5, pp.534-545,
[3] M. Mudge and L. E. Hughes. (1985). Incisional hernia: a 10 year prospective study of
incidence and attitudes. Br J Surg, Vol. 72, No. 1, pp.70-71,
[4] J. Hoer, G. Lawong, U. Klinge and V. Schumpelick. (2002). [Factors influencing the
development of incisional hernia. A retrospective study of 2,983 laparotomy
patients over a period of 10 years]. Chirurg, Vol. 73, No. 5, pp.474-480,
[5] L. T. Sorensen, U. B. Hemmingsen, L. T. Kirkeby, F. Kallehave and L. N. Jorgensen.
(2005). Smoking is a risk factor for incisional hernia. Arch Surg, Vol. 140, No. 2,
pp.119-123,
[6] F. C. Usher. (1962). Hernia repair with Marlex mesh. An analysis of 541 cases. Arch Surg,
Vol. 84, No. pp.325-328,
[7] V. Schumpelick, J. Conze and U. Klinge. (1996). [Preperitoneal mesh-plasty in incisional
hernia repair. A comparative retrospective study of 272 operated incisional
hernias]. Chirurg, Vol. 67, No. 10, pp.1028-1035,
[8] K. A. LeBlanc. (2005). Incisional hernia repair: laparoscopic techniques. World J Surg, Vol.
29, No. 8, pp.1073-1079,
[9] F. E. Muysoms, M. Miserez, F. Berrevoet, G. Campanelli, G. G. Champault, E. Chelala,
U. A. Dietz, H. H. Eker, I. El Nakadi, P. Hauters, M. Hidalgo Pascual, A.
Hoeferlin, U. Klinge, A. Montgomery, R. K. Simmermacher, M. P. Simons, M.
Smietanski, C. Sommeling, T. Tollens, T. Vierendeels and A. Kingsnorth. (2009).
Classification of primary and incisional abdominal wall hernias. Hernia, Vol. 13,
No. 4, pp.407-414,
[10] J. Nieuwenhuizen, G. H. van Ramshorst, J. G. Ten Brinke, T. de Wit, E. van der Harst,
W. C. Hop, J. Jeekel and J. F. Lange. (2011). The use of mesh in acute hernia:
frequency and outcome in 99 cases. Hernia, Vol. No.
[11] A. Kurmann, E. Visth, D. Candinas and G. Beldi. (2011). Long-term follow-up of open
and laparoscopic repair of large incisional hernias. World J Surg, Vol. 35, No. 2,
pp.297-301,
[12] A. Kurmann, G. Beldi, S. A. Vorburger, C. A. Seiler and D. Candinas. (2010).
Laparoscopic incisional hernia repair is feasible and safe after liver transplantation.
Surg Endosc, Vol. 24, No. 6, pp.1451-1455,
[13] F. Asencio, J. Aguilo, S. Peiro, J. Carbo, R. Ferri, F. Caro and M. Ahmad. (2009). Open
randomized clinical trial of laparoscopic versus open incisional hernia repair. Surg
Endosc, Vol. 23, No. 7, pp.1441-1448,
[14] U. Barbaros, O. Asoglu, R. Seven, Y. Erbil, A. Dinccag, U. Deveci, S. Ozarmagan and S.
Mercan. (2007). The comparison of laparoscopic and open ventral hernia repairs: a
prospective randomized study. Hernia, Vol. 11, No. 1, pp.51-56,
[15] S. Olmi, A. Scaini, G. C. Cesana, L. Erba and E. Croce. (2007). Laparoscopic versus open
incisional hernia repair: an open randomized controlled study. Surg Endosc, Vol. 21,
No. 4, pp. 555-559,
[16] M. C. Misra, V. K. Bansal, M. P. Kulkarni and D. K. Pawar. (2006). Comparison of
laparoscopic and open repair of incisional and primary ventral hernia: results
of a prospective randomized study. Surg Endosc, Vol. 20, No. 12, pp.1839-1845,
[17] (2004). National Nosocomial Infections Surveillance (NNIS) System Report, data
summary from January 1992 through June 2004, issued October 2004. Am J Infect
Control, Vol. 32, No. 8, pp.470-485,
[18] S. S. Forbes, C. Eskicioglu, R. S. McLeod and A. Okrainec. (2009). Meta-analysis of
randomized controlled trials comparing open and laparoscopic ventral and
incisional hernia repair with mesh. Br J Surg, Vol. 96, No. 8, pp.851-858,
[19] U. A. Dietz, L. Spor and C. T. Germer. (2011). [Management of mesh-related infections.].
Chirurg, Vol. 82, No. 3, pp.208-217,
[20] K. A. LeBlanc, M. J. Elieson and J. M. Corder, 3rd. (2007). Enterotomy and mortality
rates of laparoscopic incisional and ventral hernia repair: a review of the literature.
Jsls, Vol. 11, No. 4, pp.408-414,
[21] Z. Kaufman, M. Engelberg and M. Zager. (1981). Fecal fistula: a late complication of
Marlex mesh repair. Dis Colon Rectum, Vol. 24, No. 7, pp.543-544,
[22] W. W. Vrijland, J. Jeekel, E. W. Steyerberg, P. T. Den Hoed and H. J. Bonjer. (2000).
Intraperitoneal polypropylene mesh repair of incisional hernia is not associated
with enterocutaneous fistula. Br J Surg, Vol. 87, No. 3, pp.348-352,
[23] S. Stremitzer, T. Bachleitner-Hofmann, B. Gradl, M. Gruenbeck, B. Bachleitner-
Hofmann, M. Mittlboeck and M. Bergmann. (2010). Mesh graft infection following
abdominal hernia repair: risk factor evaluation and strategies of mesh graft
preservation. A retrospective analysis of 476 operations. World J Surg, Vol. 34, No.
7, pp.1702-1709,
[24] D. Lomanto, S. G. Iyer, A. Shabbir and W. K. Cheah. (2006). Laparoscopic versus open
ventral hernia mesh repair: a prospective study. Surg Endosc, Vol. 20, No. 7, pp.
1030-1035,
[25] (1986). Classification of chronic pain. Descriptions of chronic pain syndromes and
definitions of pain terms. Prepared by the International Association for the Study of
Pain, Subcommittee on Taxonomy. Pain Suppl, Vol. 3, No. pp.S1-226,
[26] G. Beldi, M. Wagner, L. E. Bruegger, A. Kurmann and D. Candinas. (2010). Mesh
shrinkage and pain in laparoscopic ventral hernia repair: a randomized clinical
trial comparing suture versus tack mesh fixation. Surg Endosc, Vol. 25, No. 3,
pp.749-755,
[27] M. S. Sajid, S. A. Bokhari, A. S. Mallick, E. Cheek and M. K. Baig. (2009). Laparoscopic

versus open repair of incisional/ventral hernia: a meta-analysis. Am J Surg, Vol.
197, No. 1, pp.64-72,
[28] G. Beldi, R. Ipaktchi, M. Wagner, B. Gloor and D. Candinas. (2006). Laparoscopic
ventral hernia repair is safe and cost effective. Surg Endosc, Vol. 20, No. 1, pp.
92-95,
Part 5
Laparoscopic Solid Organ Surgery

12
Spleen Preserving Surgery and

Related Laparoscopic Techniques
Lianxin Liu, Dalong Yin and Hongchi Jiang
Department of Hepatic Surgery,
The First Affiliated Hospital of Harbin Medical University, Key Laboratory of
Hepatosplenic Surgery, Ministry of Education, Harbin, Heilongjiang Province
P.R. China
1. Introduction
“The spleen” whose weight once thought to have been hindering the speed of runners to its
role in cleansing process as its absence could result in the loss of laughing ability was called
the “mysteriipleniorganon”. Its biological function has been elusive for thousand of years
and also had been assumed to have no vitality in life. It’s been centuries since its existence
has been under tremendous perusal and it wasn’t until mid-twelfth century when the
concept of blood purifying function was emphasized. In early 1900, however, numerous
experiments have concluded its role in the host defense and immune function. Spleen
surgery dates back to 1549. Zaccaelli carried out the first splenectomy in this year. In 1952,
King and Schumaker reported the overwhelming postsplenectomy infection (OPSI) in
children with hereditary spherocytosis who had undergone splenectomies, which caused a
wide concern on the potential function of the spleen.
2. Splenic function
Immunity
The spleen richly contains T cells, B cells, K cells, macrophages/monocytes, natural killer
cells, killer cells, lymphokine-activated killer (LAK) cells, dendritic cells and so forth, and in
conjunction with a variety of immune factors to makes in vivo immune response. Tuftsin is
a tetrapeptide produced by the spleen to stimulatepha- gocytosis through the activation of
neutrophils, it is a typical anti-tumor substance in the spleen, and can reflect the spleen
function. Spleen tyrosine kinase (SYK) is a non-receptor tyrosine kinase, initially expressed
in the spleen hematopoietic cells. SYK plays an important role in the Fc-mediated
phagocytosis, B cell receptor signal transduction, cytokine secretion, and integrin-mediated
signal transduction.
Barrier function
Weiss first proposed in 1986 that there is a blood-spleen barrier (BSB) between the artery
and vein in the spleen, which is similar to blood-brain barrier and can filter Plasmodium
falciparum-infected red blood cells. Jiang and Zhu et al respectively made their study on rat
spleens and set up the concept and architecture of the BSB: The blood-spleen barrier (BSB) is
located in the marginal zone of the spleen, which lies at the periphery of the white pulp;
This is a biological barrier containing sinus-lining endothelial cells, basement membrane,

macrophages, reticular cells, reticular fibers (reticular tissue), and collagen fibers.
Endocrine function
As an important immune organ, the spleen also has an endocrine function, and is an
important part of the immuno–neuro–endocrine modulation system in the body. Normal
spleen may secrete erythropoietin, colony-stimulating factor, thyroid–stimulating hormone,
gonadotropin, growth hormone, etc.
Through the nineteenth and twentieth century splenectomy had been successfully performed
for trauma and hypersplenism. It was observed that the patients recovered to their usual
pursuits but the life-long probability of the infection, augmented rate of long-term
thromboembolic complications, enhanced arteriosclerosis, and late coronary artery disease
could not be ignored and the long-term survival seemed skeptic. It’s obvious that the
knowledge of spleen function is getting more apparent and deep. Its importance in the host
defense and immune function is absolutely undisputed. So the surgeons and researchers came
up with the notion of preserving the spleen. To the matter of fact this conception didn’t go in
vain as it has been established now that that the preservation of at least 25% of the splenic
parenchyma ensures an adequate short and long-term splenic function.
The anatomy of the spleen and its surrounding structures is indispensible. At the spleen
hilum, all the vascular structures enter and divide to the related poles. Sometimes in
patients the vessels divide into three branches thus any injury at the pedicle can result in the
ischemia to the part supplied by the other branches(figure 1). Since, there is an ample
amount of blood flow through the spleen. So, if the flow is interrupted to the part not being
dissected “reperfusion injury” should be well thought-out. If the crisis is in the superior or
inferior pole the dissection is not to difficult compared to the crisis at the hilum. The hilum
also has the pancreatic tail landing on it; therefore, the activities at the hilum must be with
care and precision so as not to injure pancreas. While draining the abscess there is an
increased risk of the content to leak and reach the peritoneal cavity that is probable to cause
sepsis around. Before starting the dissection of the splenic tissue, its abdominal adherence
should be resected with care and after the surgery the remenant spleen should be place
carefully to the left upper quadrantto avoid rotation, which further can re-open the cut
surface and vessels. The size, location of cysts, abscess, hemangioma and trauma plays an
essential role in the decision for choosing the best-suited technique.
Spleen injury scale
At present, there are dozens of methods for spleen injury scaling. Main methods include
Schackford Grade V (1981), Feliciano Grade V(1985), Gall & Scheele Grade IV(1986), Uranus
Grade V(1990), American Association for the Surgery of Trauma(AAST, 1994 Revision)
Grade V, and Patcher Grade IV(1998) and so on. These methods have different
characteristics, but sometimes cannot effectively guide clinical work and operation. The 6th
National Symposium on Spleen Surgery of China held in September 2000 in Tianjin adopted
the spleen injury scale criteria as below. Grade I: subcapsular splenic rupture whose length
≤ 5.0cm & depth ≤ 1.0cm shown in the surgery. Grade II: the length of the spleen
laceration≥5.0cm & depth ≥ 1.0cm, but the splenic hilum is not involved, or segmental
splenic vessels are injured. Grade III: splenic rupture involves into splenic hilum, or partial
spleen is broken apart, or spleen trabecular vessels are injured. Grade IV: extensive rupture
exists in the spleen, or there is an injury in splenic pedicle, and main veins and arteries. Such
scaling method helps to quickly determine the injury condition, but cannot cover all
Spleen Preserving Surgery and Related Laparoscopic Techniques 197
damages; so there is a need to make a revision and improvement according to actual

situation in clinical work to adjust the treatment.
a)
b)
c)
Fig. 1. a) spleen artery is divided four branches into different segment , b) the anatomic basis
of preseving spleen , c) model of spleen vessels
The spleen preserving surgeries of course was the remedy for many complications but with
the open nature of surgery came handful of post operative complication like infection,
delayed healing which at times altered the well being of the patients and “yes” the recovery.
It’s evident that the spleen preserving surgeries have been evolving through decades
(figure2). It’s apparent that the advents of novel laparoscopic techniques have opened new
gates to the spleen preserving surgeries. The dawn of nineteenth century could see the
concept of laparoscopic partial splenectomy blooming and by late nineties many centers
around the world adapted it as a routine procedure. Surgery is an evolving science and in
recent times there are several pioneering techniques that have minimized the technical flaws
and surgical outcomes.
a)
b)
Fig. 2. a) remnant spleen section after partial splenectomy , b)conservation of the spleen
with distal pancreatetomy
3. Laparoscopic surgery in spleen-preserving surgery

Carroll et al reported the laparoscopic splenectomy for the first time in 1992. Since then, the
laparoscopic surgery has extended to the traditional fields covered by laparotomy, e.g.
spleen adhesion, splenorrhaphy, artery ligation, partial splenectomy and the like, and has
been combined with such new techniques as LigaSure, splenic arterial embolization, CUSA,
radiofrequency ablation, thus adding a new vitality to the spleen-preserving surgery. The
laparoscopic spleen-preserving surgery is somehow difficult, time-consuming, and costly.
However, when compared to laparotomy, this surgery has more advantages, for example,
clear operative field, minimal invasion, rapid recovery, and short hospital stay.
Laparoscopic inspection: To determine the extent and scope for splenic injuries or lesions; to
understand injuries or lesions in the surrounding tissues or organs of spleen; to judge the
extent for the bleeding area and vascular injuries; to carry out the pathological examination
for the spleen or the surrounding tissues and organs under direct vision biopsy.
The laparoscopic spleen-preserving surgery has the following indications: Grade I-II splenic
injuries with hemodynamic and vital sign stability; local benign lesions in the spleen, e.g.
splenic cyst, splenichemangioma, echinococcosis, and etc.; hypersplenia, e.g. portal vein
hypertension, hereditary spherocytosis and etc.; perisplenic tumors, e.g. pancreatic tumor,
gastric cancer and etc.; splenic congenital diseases, e.g. splenectopia, accessory spleen and so
on. Contraindications: Grade IVsplenic injuries; severe portal hypertension; splenomeglia;
severe coagulopathy.
The spleen-preserving surgery is similar to the laparotomy:
1. For Grade I spleen injuries, the bleeding can be controlled by electric coagulation,
biological glue, fibrin and the like. For Grade II spleen injuries, the following methods
are adopted: splenorrhaphy, partialsplenectomy, splenic artery ligation and the like. For
Grade III spleen injuries, the following methods are adopted: partialsplenectomy, and
splenic artery ligation etc.
2. For splenic benign lesions, the laparoscopic resection is conducted.
3. For hypersplenia, the laparoscopic partial splenectomy is conducted.
4. The spleen can be conserved through laparoscopic resection for perisplenic tumors.
5. For splenectopia, the laparoscopic fixation can be conducted. For accessory spleen, the
laparoscopic resection can be conducted.
In the laparoscopic spleen-preserving surgery, the complications include hemorrhage,
visceral injury, infection, splenic vein thrombosis and so on.
The laparoscopic spleen-preserving surgery is still in trial stage, and its efficacy is uncertain.
Clinically, we should not blindly pursue new technology ignoring its efficacy; instead, we
should never forget the damage control principles for splenic surgery, always save life first,
and then deal with the injury.
In the current study, the spleen function is not very clear, but we begin to know it can play
an important role in human body. Spleen-preserving surgeries have been widely
implemented. Moreover, the extensive laparoscopic application has brought new
opportunities, making the future splenic surgery more scientific and reasonable.
4. Techniques
The laparoscopic surgery is classically done via four ports (trocars) through the abdominal
wall viz.12mm left umbilical trocar, 5mm trocar positioned 5cm distal to the xiphoid process
and slightly to the right of the midline, a 12 mm trocar positioned below the left costal arch
on the mammillary line and a 12mm trocar positioned below the left costal arch on the
anterior axillary linea. The surgery by this technique is quite efficient owing to the excellent
view of abdominal anatomical landmarks. The resection is very clean and efficient with
outstanding hemostasis from the cut surfaces. The 12 mm left umbilical trocar sometimes is
replaced by 15mm ones for the introduction of the linear staplers. Surgical adhesives and
meshes can be equally used with perfection if required. The surgery with spleen is
technically challenging, thus, the electro cautery must be used efficiently with minimizing
over use, because its overuse can cause the destruction of splenic parenchyma. The
manipulation of the instruments should be with care at the pedicle, which may permanently
disrupt the blood flow to the remenant spleen. The camera must be used in conjunction with
the operator’s maneuvers. The electro cautery can control the hemorrhage to some extent
but if the cut surface becomes large then many surgeries are probable of becoming total. The
eschar of electrocautery is a clinical concern as it may disrupt after surgery and cause future
complications. The eschars at the hilum are more prone to disrupt because of the pressure
in the blood vessels and rotation. The control of the suction is equally important as it may
sometimes disturb the meshes and eschar.
The use of harmonic scalpel has improved the lapraroscopic surgery, and because of the
greater precision near the vital structures it has bought wonders to the spleen preserving
surgeries. It has become an important tool in the surgical armamentarium. It doesn’t
produce noxious smoke plume, which makes the surgeons view even clearer. It also has the
additional benefit of minimal, if any, lateral thermal tissue damage that reduces the
postoperative sepsis and necrosis. It causes minimal charring and desiccation. The reduced
need for ligatures has contributed to the excellent recovery. There is no escharformation,
which makes this technique very advantageous as it clearly prevents its disruption, thus
preventing postoperative hemorrhage. The introduction of high definition cameras has
made the surgeries more vivid.
There is also a new widely adapted plasma scalpel and its use provides excellent results. Its
use has the benefit of giving a better precision, which makes this technique highly
promising. The comfort and ease with which it dissects the tissues is overwhelming. It
nearly gives the surgeon a blood less view of the surgery field. It causes minimum scarring
and has the advantage of faster healing which reduces the operating room time. Using
plasma scalpel minimizes the instrument changes that are good aspects for surgeons to
consider.
Radiofrequency (RF) ablation has recently evolved as a boon to the surgical world. It has
advantage over other techniques because it makes the surgery merely bloodless; hence
lesser post-operative complication, sepsis, and minimal hospital stay. Recently it was stated
that RF is used to coagualate not the tumor itself, but a thin zone of normal organ
parenchyma surrounding it, in order to achieve near bloodless division of the parenchyma.
However, only case reports and small series have been reported regarding RF-assisted
partial splenectomy. It is already successful on liver, brain and lungs and needs more effort,
trial and expertise corresponding spleen. The preservation of splenic parenchyma is the
requisite in spleen preserving surgeries and hemorrhage is yet another factor governing the
success of surgery. The use of laparoscope already has minimized the bleeding, scar, pain
and hospital stay and when used in symbiosis with RF ablation will undoubtedly bring
better outcome to spleen preserving surgeries.
The argon beam coagulator has good effect on solid organ surfaces such as the spleen.
Smoke is minimal as argon gas surrounds the target site. In a laparoscopic adaptation, 5 and
10mm diameter (disposable) probes are employed. It provides an optimum hemostasis.

Argon beam coagulator uses a no-touch technique, and the stream of argon gas, as it
conducts the electrical energy, simultaneously has a” blast” effect on the target tissues,
momentarily blowing away blood, fluid, and debris for more efficient coagulation. The
electrical generator is inexpensive but the electrode tips are relatively expensive, requiring
frequent replacement. However, the efficacy of the argon beam coagulator, with its potential
for a reduction of operating room time and its efficient achievement of (otherwise tedious)
hemostasis, may negate these expenses.
The laparoscopic techniques have bought about essential changes in the surgery and have
given a different vision and most importantly precision. The innovative robotic technologies
at some centers are used in conjunction with laparoscopy. The use of robotic cameras have
added the function of zoom in and zoom out and the 180 degree view have provided
surgeons with the desired angle to see splenic pedicle and surrounding landmarks. Robotic
cauteries, cameras can also be used with joysticks and voice activation so in delicate
moments like achieving hemostasis during pedicle dissection, The surgeons just have to
give a command to get the exact view thus saving time manpower and with ease. There are
many centers using the davinci system to perform procedures asdelicate as splenectomies.
Although, it will need more trial for this technique to be worldwide adopted.
Not only the tools to obtain optimum results during the surgeries are evolving but also the
laparoscopic surgery have also evolved. The minimal invasive is on a path of becoming even
more minimal. The technique like SILS (single incision laparoscopic surgery) has bought
revolution in the laparoscopic world. There are many literatures world wide showing the
use of SILS for partial splenectomies. This technique in particular draws lot of attention
owing to the fact that it’s used through single trocar introduced through a small umbilical
incision. From a single port three to four instruments as camera, scalpel, suction can be
introduced and operated. The instruments have a multiple operating and viewing angles so
the surgery doesn’t need many ports. The tips of the instruments are available with multiple
degree of rotation, which is the basic tenet of SILS. Partial splenectomies can be done with
intricate surgical maneuvers made easy. The reduced operating room time and the nearly
invisible scar also improve the pain, hospital stay and post operative complications.
During the laparoscopic surgeries there are many instances where accidents causes oozing
of blood and a condition of momentary panic because of either the unsuccessful clamping of
vessels or the spillage of resected spleen from the bag and also due to the deprived view of
the surgical site. The new idea of HALS (hand assisted laparoscopic surgery) prevents
momentary panic and also is an efficient and clever choice. In HALS there is a umbilical
incision where lap pad is fixed through which gloved hands are introduced into the
abdomen to improve depth perception, regain tactile sensation, aid in tissue extraction, and
reduce operative time. There are two to three additional incisions for the trocars. The other
hand operates the scalpel and suction. This technique can be considered as the hybrid of
laparoscopic and open surgery. The surgery as delicate as spleen has a major hemostatic and
technical issues. The direct introductions of hands in conjunction with the advanced
laparoscopic instruments have yielded good results. For instance, the panic due to the
uncontrolled hemorrhage can be stopped directly with the hands and the spleen remnant in
case spillage can easily be obtained. The exact texture of the spleen can be felt and the
desired amount retraction can be perfectly attained and not to forget the other hands
actively dissecting through the laparoscopic ports. In this technique lap pads are used so
that minimal incision is enough to introduce the hand in the abdominal cavity.
5. Discussion
As the splenic function mentioned above is better understood, spleen surgeries have
developed from the early stage of random splenectomy to the second stage of non-selective
spleen preserving, and to today’s stage of selective spleen preserving. The concept of spleen
preserving has become gradually popular, and various procedures to preserve the spleen
have been widely applied which has achieved aoptimal result. Current spleen- preserving
methods are mainly as follows:
1. Hemostasismethods, which involve hemostatic materials (such as gelatin sponge, fibrin
tissue adhesive), radiofrequency ablation, argon beam coagulator and other technical
equipment.
2. Suture repair for ruptured spleen.
3. Partial splenectomy.
4. Spleen autotransplantation.
5. Selective arterial embolization.
Partial splenectomies can be successfully performed for complication like splenic cyst,
splenichemangioma, splenic mass, blunt traumas and splenic cysts. Proper hemostasis and
uninterrupted view of the surgical site has always been a surgical concern. With the advent
of laparoscopic techniques many flaws have been obviated which makes partial
splenectomies more justifiable. The laparoscopic spleen surgeries, which once started with
classical four trocarsand electrocautery have evolved to have come long way. The assistance
of better HD cameras with robotic zoom in and zoom out function have given the surgeons
the most uninterrupted clear view of the surgical site which has bought the ease in locating
a structure and active hemostasis. The cameras once used by the fellow operator can now be
operated with voice commands and joysticks of the surgeon. The 180degree rotations of the
cameras have made the view extremely vivid circumventing accidents. The electro cautery
had drawbacks like the eschar formation that have been eliminated with the development of
harmonic and plasma scalpels. The harmonic and plasma scalpel and uses of laser prevents
escharformation, which prevents postoperative disruption and bleeding. These scalpels
works with better precision near the vital structures as the pedicle of spleen. There is
minimal thermal tissue damage, which is pivotal for postoperative recovery. The uses of
ligatures have become least and the charring and dissication have been minimized. The
postoperative healing, pain have also been greatly minimized with lesser hospital stay. A
surgeon should choose a specific way depending on experience, overall cost and the
simplicity in manipulating instruments. The robotic instruments, the use of harmonic and
plasma scalpels in other instance needs a constant technical assistance. Robotic instruments
are cumbersome and needs constant upgrading and high cost of compatible instruments
prevents worldwide adoption. There is also an operative time delay when using robotics
and it needs special training to surgeons.
Laser in the other hand has the advantage of checking blood loss, sealing the most small
blood vessels, ability to work in relatively dry field which facilitates visibility, minimum
tissue trauma less pain, edema (due to sealing of nerve endings and lymphatics) decreases
chance of malignant cells to spread, scarring due to precision and most importantly
decreases stenosis which is appropriate for splenic hemangiomas. The use of laser needs a
surgical technologist (ST) at all times as its failure during the surgery can cause panic. Strict
safety precautions must be enforced, eye protection for patients and all personnel in the
room is mandatory for most lasers and flammable prep solutions and other flammable
liquids should not be used in the area where the laser is used. All dry materials in or near
the operative field must be dampened with saline or water that makes the process more
tedious.
The argon beam coagulator has its advantages of its own in giving a competent hemostasis
with its “blast effect” which blows away the debris and coagulated blood for excellent
hemostasis. It has very good results for splenic abscess as it has a large oozing surface. The
major concern in this technique is the potential of gas embolism during the laparoscopic
surgery. So the ultrasonography and ECG is constantly needed to check if the embolism has
reached the heart and lungs to prevent further damages.
The minimal invasive surgery has become more minimal with SILS. The cameras,suction
and cutting shears all fit through one trocar. The single port for the trocar has laparosonic
cutting shears (LCS) and the cameras also have all round vision, which makes this method
promising. It has single small incision, therefore less invasive and traumatic. Like every
technique has its advantage and disadvantages. SILS is not very efficient if the tumor size is
large. It is a good option only for the spleens with normal size or only slightly enlarged.
Because of the single small incision the macerated spleen is liable to spillage. In case of
sudden bleeding it is difficult to control the hemostasis and still needs ergonomic
improvement. The fulcrum effect should be minimized to make this technique better so
robotic zoom in and zoom out cameras can be a good replacement. The hybrid technique as
HALS has eliminated many shortcomings from the laparoscopic surgery. Since, one hand is
inside the abdominal cavity it gives perfect retraction and uninterrupted view. The margin
of tumor can be felt so dissection margin can be precise without hampering the normal
spleen parenchyma. The bleeding site can be actively clamped with just a move of a finger.
The splenic parenchyma is frail and the use of hands directly to retract can certainly
circumvent bleeding and improper traction. There are many instances in spleen preserving
surgeries when the macerated spleen within the bag gets spilled in the abdominal cavity so
its recovery is quicker as the spleen gets implanted very soon. This technique can be very
efficient in blunt trauma cases when laparotomy is urgently required. The camera in the
other hand can work in conjunction with the hand to explore the abdominal cavity. This
technique is irrespective of the size of spleen because even the bigger spleen can be handled
with care and taken out without spillage and optimum safety. The pitfalls of HALS are the
air leakage from the lap pads and the hands getting tired in 20% of the surgeons.
6. Conclusion
A laparoscopic spleen preserving surgery as aforementioned is a technically demanding
procedure. The spleen parenchyma is frail and the tears or the parenchymal bleeding can
occur. Thus, from a surgeon’s point of view it requires exquisite care and control to avoid
parenchymal rupture and cell spillage. There are many techniques available to do the same
procedure in a logical and proficient way. The surgeons must be familiar with all the details
and complications before choosing for one. Every technique has a virtue of its own over the
other, so it is vital to discriminate techniques to choose the ideal one. The need of the
laparoscopic surgery must be understood with the operative time and cost in mind. The
postoperative outcome is the most important part of perioperative care and in the
abdominal surgeries as spleen; adhesion is serious complication that affects the motility of
abdominal structures later on. The complication as eschar formation, which may disrupt
postoperatively is capable of causing bleeding. Thus, the technique that offers minimum
adherence, eschar formation, sepsis, and necrosis should be employed.
7. References
[1] Barbaros U, Dinççağ A. Single incision laparoscopic splenectomy: the first two cases. J
Gastrointest Surg. 2009;13(8):1520-3.
[2] Carrara S, Arcidiacono PG, Albarello L, et al. Endoscopic ultrasound-guided application
of a new internally gas-cooled radiofrequency ablation probe in the liver and
spleen of an animal model: a preliminary study. Endoscopy. 2008;40(9):759-63.
[3] Targarona EM, Espert JJ, Balagué C, et al. Residual Splenic Function After Laparoscopic
Splenectomy. Arch Surg. 1998;133(1):56-60.
[4] Ghuliani D, Agarwal S, Thomas S, et al. Giant cavernous haemangioma of the spleen
presenting as massive splenomegaly and treated by partial splenectomy. Singapore
Med J. 2008;49(12) : e356.
[5] Ball, Kay. Lasers:ThePerioperative Challenge, ed III. Mosby, 1995. 86-120.
[6] Standards of Perioperative Clinical Practice in Laser Medicine and Surgery,
www.aslms.org/health/standards_perioperative.html
[7] Troust, D, et al. Surgical Laser Properties and Their Tissue Interaction.Mosby Year Book,
1992. 131–162
[8] Robotics and Technology. Wikipedia, Nov 2006,
http://en.wikipedia.org/wiki/ robotic_surgery.
[9] Hermes Intelligent Operating Room®,
www.trueforce.com/medical_ robotics/medical_robotics_ companies_hermes.htm
[10] Kaul, Sanjeev. Laparoscopic and Robotic Radical Prostectomy.eMedicine,Feb 28, 2005,
www.emedicine.com/med/topic3723.htm
[11] Lanfranco, Anthony, et al. Robotic Surgery. Annals of Surgery, 2004, 239:14
[12] Harmonic Scalpel®. Gateway Products Information and Ultrasonic Cutting and
Coagulation Devices. Johnson & Johnson, 2001–2006, Ethicon Endosurgery,Inc,
www.harmonicscalpel.com
[13] Harmonic Scalpel®. Intermedix International Experts, Inc,
www. armonicscalpelrepaircenter. com/harmonic.html
[14] Link, W. J. A Plasma Scalpel: Comparison of Tissue Damage and Wound Healing With
Electrosurgical and Steel Scalpels. Arch Surg, 1976,111(4):392–397,
[15] Marino, Ignazio RA. New Option for Patients Facing Liver ResectionSurgery. 2006
Plasma Surgical Limited, www.plasmasurgical.com/article–Marino.htm
[16] Jiang HC, Sun B, Qiao HQ, et al. Clinical application of serial operations with
preserving spleen. World J Gastroenterol. 2001,7(6):876-9.
[17] Reger,T. B., Janhke, M. E. Robotic Cardiac Surgery. AORN J, 2003,77:182
13
Laparoscopic Gastropexy for the Treatment

of Wandering Spleen With or Without
Gastric Volvulus
Caroline Francois-Fiquet1,Yohann Renard2,
Claude Avisse2, Hugues Ludot3,
Mohamed Belouadah and Marie-Laurence Poli-merol1
1
1Department
of Pediatric Surgery
2Department
of Anatomy
3Department of Anesthesiology
American Memorial Hospital CHU REIMS / REIMS

University of Medicine
France
1. Introduction
Wandering spleen is a rare condition. This congenital or acquired pathology is found in
children and adults alike. It is characterized by a hypermobile spleen causing in some cases
splenic torsion with ischemia.
We will successively look at the anatomy, etiologies, epidemiology, clinical pictures,
additional imaging examinations and surgical possibilities for this pathology.
2. Anatomy
Wandering spleen is caused by failed fusion of the dorsal peritoneum, or absence or
abnormal development of its suspensory ligaments that hold the spleen in its normal
position in the left upper quadrant of the abdomen.
The splenic ligaments are the gastrosplenic, splenorenal (splenopancreatic), splenophrenic,
splenocolic ligaments. (Couinaud, 1963)
Embryologically, the splenic ligaments develop in the coeliac artery territory, from the
primitive dorsal mesentery (mesogastrium), which is responsible for the formation of
peritoneum, the greater omentum and the several peritoneal folds. However, developmental
anomalies or variations may take place. These variations in the embryologic development of
the spleen’s primary supporting ligaments could explain the wandering spleen.
These ligaments may be absent, may be too long or too short, too wide or too narrow, or
abnormally fused.
3. Etiology
Wandering spleen can be a congenital or acquired condition.
3.1 Congenital form

Wandering spleen is in most cases a randomly distributed birth defect but in some cases it
can be part of a syndrome.
Fig. 1. Transverse section. Development of peritoneal reflexions of spleen during primitive

embryonic stage. Coeliac artery territory.
Fig. 2. Transverse section. Peritoneal reflexions of spleen are developed from dorsal
mesogastrium (primitive dorsal mesentery).
Laparoscopic Gastropexy
for the Treatment of Wandering Spleen With or Without Gastric Volvulus 207
Fig. 3. Frontal section showing the formation of splenocolic ligament and phrenicocolic
ligament
3.1.1 Association
3.1.1.1 Congenital diaphragmatic hernia
The first case of wandering spleen associated to congenital diaphragmatic hernia (CDH) was
described in the literature in 1940 by Bohrer. Several cases have been reported since then
(Yasuda et al, 2010; Fiquet-François et al, 2010; Yilmaz et al, 2008; De Foer et al, 1994). The
diagnosis of both pathologies can occur at the same time or the diagnosis of wandering
spleen can be secondary to CDH. With CDH wandering spleen can be a result of an
abnormal or absence of retroperitoneal fixation. Based on these data, all patients with CDH
should be considered as potential candidates for wandering spleen.
3.1.1.2 Omphalocele
Yilmaz reported the unusual case of wandering spleen associated to omphalocele. (Yilmaz et
al, 2008) As a possible cause for this association they listed defects on the abdominal walls
through which the organs were protruding, resulting in a restriction of the stomach and
spleen normal rotation or inefficient fusion after the rotation has been completed
3.1.2 Familial wandering spleen

Ben Ely described the first case of familial wandering spleen with two sisters diagnosed at a
3-year interval. (Ben Ely et al, 2008)
3.2 Acquired form

3.2.1 Postoperative (subtotal splenectomy)
Even if these data are not found in the literature, our multicenter study (Fiquet-François et
al, 2010) reported 4 cases of wandering spleen post subtotal splenectomy. They were in fact
excluded from the study that only focused on congenital forms. These cases are quite
interesting and probably unveil a technical defect. When the subtotal splenectomy involves
resection of the upper pole of the spleen, with the section of suspensory ligaments,
promoting acquired wandering spleen. To avoid this type of complications it is preferable to
preserve the upper pole of the spleen and promote resection of the lower pole. It is
important to bring up the possibility of wandering spleen in case of sudden or chronic
abdominal pain in a patient having a history of subtotal splenectomy.
Fig. 4. Sagittal section showing the Phrenogastric ligament. This ligament prolonge the
splenophrenic ligament to the right, and this splenophrenic ligament is an extension of the
splenorenal ligament.
3.2.2 Traumatic diaphragmatic hernia

As discussed above, CDH can be associated to wandering spleen; in fact traumatic
diaphragmatic hernia can also generate acquired wandering spleen.
3.2.3 Malarial infection

Malarial infection has not been clearly validated as responsible for the onset of secondary
wandering spleen, but it can clearly trigger the pathology, asymptomatic until then.
Cripps described the case of a patient who had a malarial infection at the age of 5 and the
CT-Scan done at the time validated a normally located spleen. (Cripps et al, 2010) However
at the age of 18 she developed clinical symptoms and the diagnosis concluded to wandering
spleen that could have resulted from a congenital fusion anomaly or attenuation of the
patient's suspensory ligaments caused by her previous malarial infection and splenomegaly.
However we can wonder if the malarial splenomegaly did not simply unveil an underlying
congenital abnormality.
Fig. 5. Frontal view. Peritoneal attachments of spleen. Stomach is retracted to the right
4. Epidemiology
The incidence of wandering spleen is uncertain and difficult to assess. The diagnosis is often
made following complications. The incidence of this pathology is probably dramatically
underestimated.
Romero and Barksdale evaluated the peak incidence for wandering spleen between the age
of 20 and 40 (Romero & Barksdale, 2003; Lin et al, 2005). Generally, 70–80% of the reported
cases occur in women of childbearing age. (Steinberg et al, 2002) Hormonal changes and
fluctuations explain this female predominance in adults. Furthermore the literature has
reported that potentially predisposing elements in this population include multiparity and
abdominal laxity thought to be secondary to pregnancy-induced hormonal effects on the
abdominal wall. (S. Zarrintan et al, 2007) Ghazeeri et al (Ghazeeri et al, 2010) reported the
case of splenic torsion on wandering spleen in a pregnant woman in her twelfth week of
twin pregnancy.
This pathology is also found in children seemingly affecting more boys than girls (Allen &
Andrews, 1989; François-Fiquet et al, 2009; Fiquet-François et al, 2010). This condition can
occur very early on as seen in neonatal cases (Balliu et al, 2004; Fiquet-François et al, 2010,
Arleo et al, 2010). During the first years of life the sex ratio is probably reversed. (Brown et
al, 2003)
5. Clinical pictures
The diagnosis of wandering spleen is extremely difficult since it is such a rare condition and
is clinically non-specific. In our recent multicenter study in children (Fiquet-François et al,
2010), we reported that the abdominal pain is at the forefront of all symptoms (93 % of
cases), and its severity brings 86% of all cases to Emergency Room care. Furthermore, in 57%
of all cases it was their first symptomatic episode of this type. The pain location is clinically
non-specific: diffuse, periumbilical, left side, pelvis, left hypochondrium… Vomiting can be
associated in 57% of cases. None of the diagnoses of wandering spleen were based on
clinical evidence only. Even if the diagnosis cannot solely be based on clinical observations,
it is important to note that the clinical presentation for wandering spleen can be either acute
or chronic pain (Fiquet-François et al, 2010). The acute clinical pictures require emergency
surgery because of the high risk of ischemia.
5.1 The acute clinical picture

The acute clinical picture can show two types of presentations: splenic torsion but also
gastric volvulus, associated or not to splenic torsion.
5.1.1 Splenic torsion

This is the main complication of wandering spleen, it usually reveals this abnormality. Pain
is at the forefront of the symptoms. Splenic torsion is an emergency situation as it can
quickly lead to irreversible splenic ischemia. In our series (François-Fiquet et al, 2010), 6
patients (43%) had splenectomy for splenic ischemia, but the torsion can complicate up to
65% of pediatrics cases (Romero & Barksdale, 2003).
5.1.2 Gastric volvulus +/- associated to splenic torsion

The clinical picture groups together painful symptoms associated to high occlusion with
vomiting. In some cases patients can be in a real state of shock.
Gastric volvulus associated to wandering spleen is a rare condition, and its quick clinical
improvement with a simple medical treatment often delays the diagnosis and access to
proper surgical care (Fiquet-François et al, 2010; François-Fiquet 2009; Spector & Chappell,
2000; Qazi & Awadalla, 2004). The semiological difficulty is quite real when faced with
complex clinical pictures associating gastric volvulus, wandering spleen and even in some
cases a diaphragmatic hernia (Liu & Lau, 2007).
The combination of wandering spleen and gastric volvulus should be explored by
additional imaging exams, and requires a quick and adapted therapeutic care.
5.2 Chronic clinical picture

Between 39% and 43% of children treated for wandering spleen had already presented
similar symptoms. (Brown et al, 2003; Fiquet-François et al, 2010). Most often these children
had been complaining about non-systematic recurrent but inconsistent abdominal pain for
the past months (even several years). Some children were even hospitalized several times
before making a proper diagnosis. This is mostly due to the quick clinical improvement
when the child was lying down (Fiquet-François et al, 2010; François-Fiquet et al, 2009).
The chronic clinical picture once again underlines the difficulty in making a proper
diagnosis when faced with an atypical clinical picture.
6. Additional imaging examinations

Additional imaging examinations are key elements for the diagnostic evaluation of
wandering spleen. The diagnosis cannot be made on non-specific clinical symptoms only.
6.1 Abdominal sonogram

An abdominal sonogram is the current diagnostic modality of choice for wandering spleen
since it can validate the diagnosis without using radiation. (Fiquet-François et al, 2010;
Brown et al, 2003; Di Crosta et al, 2009; Karmazyn et al, 2005).
It is essential to ask the radiologists to correctly evaluate the location and viability of the
spleen when faced with gastric volvulus, but also dull abdominal pain.
6.2 CT-scan and abdominal magnetic resonance imaging

The efficacy of contrast enhanced CT-scan imaging has been validated and can be quite
helpful in an emergency situation since it is not radiologist dependent and might sometimes
be faster to access. Thus, it remains a perfect choice for acute pictures such as diagnostic
evaluation of splenic torsion associated to a wandering spleen with a high risk of ischemia.
It is the whorled appearance of the splenic vessels and surrounding fat that is considered
pathognomonic of that condition. (Gomez et al, 2006). However even if this examination is
well indicated in adults, CT-scan should remain a last-resort examination in children
because of radiation exposure (Ben et al, 2006; Marinaccio et al, 2005). Abdominal magnetic
resonance imaging (MRI) (Fig 7-8-9), since it does not require any anesthesia seems to be a
good alternative to CT-scan for adults or older children with chronic pain. However,
because it is not available in all clinical settings, it can limit its indications. It can also be
recommended for uncomplicated chronic types.
6.3 Dynamic sonogram

Dynamic sonogram (on the side, standing up) is a simple examination that can help define
the splenic ptosis and be relevant for chronic and hard-to-identify cases. It is also properly
indicated for follow-up and monitoring exams.
6.4 Plain abdomen radiography

Plain abdomen radiography is still useful as first-line imaging examination. It allows for a
quick diagnosis of gastric volvulus (Fig 10).
A well-designed imaging check-up can usually validate the diagnosis. But in some cases the
diagnosis will only be validated during surgery.
7. Complications of wandering spleen

Splenic ischemia is the main complication of wandering spleen. It justifies in itself
emergency therapeutic care. Gastric volvulus is a well-known complication of wandering
spleen; however its incidence is lower than splenic torsion. Sometimes there can be a
pancreatitis and gastric outlet obstruction via direct external compression (sanchez et al,
2010) or even a pancreatic tail infarction (Dirican et al, 2009)
(a) (b)
Fig. 7. a-b Magnetic resonance imaging abdominal frontal view. Spleen in a low position
below the stomach, long pedicle, good vascularization
(a) (b)
Fig. 8. Magnetic resonance imaging abdominal transversal view. a : not visible on a view
going through both kidneys and b : well-vascularized spleen still visible in the left iliac fossa
Fig. 9. Magnetic resonance imaging abdominal frontal view. Long pedicle, good
vascularization
Fig. 10. Plain Abdomen: gastric volvulus

8. Surgery
Surgery is the only option to guarantee the viability of the spleen; however it should not
trigger any secondary ischemia. Its objective will be to restore the spleen in its anatomical
position as close to normal as possible to avoid the dangling effect of the spleen at the end of
its pedicle.
8.1 States of art

Surgery is the appropriate therapeutic choice, but many different approaches are available:
laparoscopic surgery, laparotomy, splenopexy, gastropexy, and splenectomy.
8.1.1 Surgical approaches

In the literature, we found that in 49% of the cases the diagnosis was made during surgery
(Brown et al, 2003). In this context, laparoscopic surgery is the procedure of choice. It allows
for an etiological diagnosis, a good evaluation of the surgical situation while offering several
therapeutic possibilities: splenectomy (Carmona et al, 2010), splenopexy (Hirose et al, 1998;
Kleiner et al, 2006), gastropexy (François-Fiquet et al, 2009; Fiquet-François et al, 2010) or
even a combination of several techniques such as gastropexy and splenopexy (Okazaki et al,
2010)
The choice for classic open surgery or laparoscopic surgery varies according to the different
surgical teams. When there is no history of abdominal surgery, laparoscopic procedure
seems to be the procedure of choice.
The risk of gastric perforation is an argument for laparotomy as the procedure of choice in
case of gastric volvulus, but it does not seem to be a limiting factor for an experienced
laparoscopic technician. (Mayo et al, 2001) The surgical treatment should only take place
after medical treatment has been administered. The gastric suction avoids the risk of
spontaneous or laparoscopy-induced gastric perforation.
8.1.2 Surgical procedures

Nowadays, it is commonly accepted to try and preserve the spleen, when viable, during the
procedure, to avoid post-splenectomy infectious complications.
It is necessary to be aware of this rare clinical pathology in order to avoid delaying surgical
care, which could lead to splenic ischemia or even gastric ischemia.
Nevertheless, splenic ischemia after torsion is quite common and the rate varies from 43% to
65% of cases according to the series (Fiquet-François 2010; Romero et al, 2003).
Splenectomy will be the gold standard for major splenic ischemia, when there is splenic
necrosis after torsion repair and the spleen is no longer viable.
Faced with a viable or almost viable spleen, the surgery should aim for splenic conservation.
The surgery should focus on a fixation technique that will:
- reposition the spleen properly in order to avoid any further risks of torsion. The goal is
to reconstruct the best possible physiological anatomy with surgical fixation.
- but also avoid gastric volvulus complication. This is why it is also recommended, as a
preventive measure, to perform a gastropexy on patients with a wandering spleen in
order to avoid any risk of developing a gastric volvulus. (Spector & Chappell, 2000;
Soleimani et al, 2007)
- while limiting spleen manipulation that could be responsible for secondary splenic
ischemia. (Fiquet-François et al, 2010)
Taking all these elements into account we have proposed an approach by Laparoscopic
Assisted Gastropexy (LAG)
8.2 Procedure: LAG laparoscopic assisted gastropexy

This technique can be used in adults and children alike and in both cases of congenital or
acquired wandering spleen. It can be done as an emergency procedure in case of splenic
ischemia or scheduled for uncomplicated chronic cases.
8.2.1 Installation
After gastric tube decompression (in case of gastric volvulus), the patient is positioned
supine on the surgical table.
A general anesthetic technique completed by bilateral Transversus Abdominis Plane Block
(TAPB) to allow for eviction curare substances.
Tracheal tube and positive pressure ventilation with O2-air (0.5,0.5) was used. The nitrous
oxide is formally cons indicated. (intestinal dilatation)
In children, the surgeon and assistant are at the right of the child. The laparoscopy column is
placed at the level of the patient’s left shoulder. (Fig 11) In adults, the French lover position
allows for the surgeon’s assistant to be perfectly positioned for this procedure.
Fig. 11. Diagram presenting the positions of: the patient, trocar entry sites, surgeon,
surgeon’s assistant and laparoscopic column.
8.2.2 Procedure
A 10-mm camera trocar was inserted in the sub-umbilical region using open laparoscopy.
A laparoscope (0° degree) was inserted through the umbilical port.
2 additional working ports (5mm) were inserted: below and above the umbilicus. A third
port can be inserted if necessary.
Laparoscopic exploration validated:
- the abnormal location of the spleen located in the lower left quadrant (in most of cases)
and its lack of supportive ligaments,
- the vascularization of the spleen with or without ischemia, the aspect of the stomach.
Normal or associated to gastric volvulus. In most of cases,during surgey we do not find
the gastric volvulus identified by abdominal X-rays, it became devolvulated non-
ischemic. However there is evidence of gastric distension with flaccid wall.
If the spleen is completely ischemic after de-torsion, we proposed a splenectomy.
Faced with splenic viability, we decided to perform a gastropexy. (Fig 12)
Fig. 12. Well-vascularized spleen in the left iliac fossa

The spleen was then moved freely from its abnormal location (left iliac fossa) to its normal
one (sub-diaphragmatic). (Fig 13)
Fig. 13. Repositioning the spleen at the level of the right hypochondrium
We created an extra peritoneal pocket. We performed a parietal peritoneal posterolateral

incision, opposite the large gastric curve, up to the diaphragm (7 cm). (Fig 14)
(a) (b)
Fig. 14. a - b Parietal peritoneal posterolateral incision
Fig. 15. Gastropexy by suturing the peritoneal wall to the greater curvature of the stomach
We proceeded to the gastropexy. (Fig 18) We fixed the anterior stomach lining with sutures
(Mersuture® 3/0; Johnson and Johnson, Somerville, NJ) on the free anterior peritoneum (Fig
15), in two planes. (Fig 16-17-18)
This suture can be done in separate stitches sutures or by two surgeons.
No drain was inserted. The nasogastric tube was removed at the end of the procedure.
Carbon dioxide gas was expelled, trocars removed, and incisions were are closed.
It is essential in case of splenectomy to ensure vaccination (pneumococcal, meningococcal,
and haemophilus) and prescribe the usual antibiotic course post-splenectomy. In case of
conservative splenic management, in spite of some signs of splenic suffering, it can be useful
in the immediate postoperative period to vaccinate as a precaution. Then, at 1-month

postoperative and according to imaging controls (Doppler sonogram or contrast CT-Scan)
showing the lack of spleen viability, an antibiotic course will be started.
Fig. 16. Gastropexy posterior wall suture done by one surgeon
Fig. 17. Final aspect of the posterior plane of the gastropexy

Fig. 18. Suture of the anterior plane (peritoneal-gastric) of the gastropexy
8.2.3 Postoperative care

The patient can drink on the day of the surgery after the legal delays post- anesthesia.
Eating can be started at D1. The patient will be kept laying down on this back the first 24
hours in order to limit shoulder pain.
The convalescence will last 10 days. The patient will be asked to stop all sport activities from
1 to 3 months according to patient’s age, clinical picture and type of sports.
8.2.4 Follow-up and monitoring imaging examination

Children will be seen again for a surgical consultation at M1, M4, M10, M24 and
postoperative follow-up then again every 3 years until adulthood. Doppler and dynamic
sonograms (on the side, standing up) are the key examinations for this follow-up. They can
assess the vascularization and viability of the spleen but also make sure the sutures are
adequate and discard any residual ptosis.
If there is a doubt on splenic vascularization, a contrast CT-Scan will be proposed.
9. Conclusion
The diagnosis of wandering spleen is extremely difficult to establish because it is such a rare
condition and is clinically nonspecific.
Early diagnosis and surgical care are the best guarantees for preserving the spleen.
Additional imaging examinations, especially abdominal sonogram as the imaging
examination of choice, can help establish a diagnosis when faced with an abnormal location
of the spleen. Splenopexy and gastropexy are two surgical fixation approaches aiming to
maintain the viable spleen in place.
The results of the gastropexy procedures seem encouraging, but faced with such a small
number of cases, no conclusion can be established. Gastropexy seems to avoid the risk of
gastric volvulus by restoring the best possible physiological anatomy while preserving the
spleen by lack of manipulation.
10. References
Allen, KB., Andrews, G. (1989). Pediatric wandering spleen. The case for splenopexy:
Review of 35 reported cases in the literature, J Pediatr Surg 24: 432–435.
Arleo, EK., Kovanlikaya, A., Mennitt, K., Acharya, S., Brill, PW. (2010). Multimodality
imaging of a neonatal wandering spleen, Clin Imaging 34.(4): 302-5.
Balliu, PR., Bregante, J., Pérez-Velasco, MC., Fiol, M., Galiana, C., Herrera, M., Mulet, J.
(2004). Splenic haemorrhage in a newborn as the first manifestation of wandering
spleen syndrome, J Pediatr Surg 39.(2): 240-2.
Ben Ely, A., Zissin, R., Copel, L. Vasserman, M., Hertz, M., Gottlieb, P., Gayer, G. (2006). The
wandering spleen: CT findings and possible pitfalls in diagnosis, Clin Radiol 61:
954-8.
Bohrer, JV. (1940). Torsion of a wandering spleen : complicated by diaphragmatic hernia,
Ann Surg. 111.(3): 416-26.
Brown, C., Virgilio, G., Vazquez, D. (2003). Wandering spleen and its complications in
children: A case series and review of the literature, J Pediatr Surg 38: 1676–1679.
Carmona, J., Lugo Vicente, H. (2010). Laparoscopic splenectomy for infarcted splenoptosis
in a child: a case report, Bol Asoc Med P R 102.(2): 47-9.
Cavazos, S., Ratzer, ER., Fenoglio, ME. (2004). Laparoscopic management of the wandering
spleen, J Laparoendosc Adv Surg Tech A 14: 227–229.
Couinaud, C. (1963). Anatomie de l'abdomen. Tome 1. Edition Doin. Paris.
Cripps, M., Svahn, J. (2010). Hand-assisted laparoscopy for wandering spleen, Surg Endosc.
25.(1): 312.
De Foer, B., Breysem, L., Smet, MH., Baert, AL. (1994). Late-onset Bochdalek hernia with a
rare postoperative complication: case report. Pediatr Radiol. 24.(4):306-7
Di Crosta, I., Inserra, A., Gil, CP., Pisani, M., Ponticelli, A. (2009). Abdominal pain and
wandering spleen in young children: the importance of an early diagnosis, J Pediatr
Surg 44: 1446-9.
Dirican, A., Burak, I., Ara, C., Unal, B., Ozgor, D., Meydanli, MM. (2009). Torsion of
wandering spleen, Bratisl Lek Listy 110.(11): 723-5.
François-Fiquet, C., Belouadah, M., Chauvet, P., Lefebvre, F., Lefort,G., Poli-Merol, ML.
(2009). Laparoscopic gastropexy for the treatment of gastric volvulus associated
with wandering spleen, J Laparoendosc Adv Surg Tech 19: 137-9.
Fiquet-Francois, C., Belouadah, M., Ludot, H., Defauw, B., Mcheik, JN., Bonnet, JP.,
Kanmegne, CU., Weil, D., Coupry, L., Fremont, B., Becmeur, F., Lacreuse, I.,
Montupet, P., Rahal, E., Botto, N., Cheikhelard, A., Sarnacki, S., Petit, T., Poli Merol,
ML. (2010). Wandering spleen in children: multicenter retrospective study, Journal
of Pediatric Surgery 45.(7): 1519–1524.
Ghazeeri, G., Nassar, AH., Taher, AT., Musallam, KM., Jamali, FR. (2010). The wanderer At
12 weeks' gestation, the patient presented with abdominal pain and a palpable
mass, Am J Obstet Gynecol 202.(6): 662 e1.
Gomez, D., Patel, R., Rahman, SH., Guthrie, JA., Menon, KV. (2006). Torsion Of A
Wandering Spleen Associated With Congenital Malrotation Of The Gastrointestinal
Tract, The Internet Journal of Radiology. Volume 5
Hirose, R., Kitano, S., Bando, T., Ueda, Y., Sato, K., Yoshida, T., Suenobu, S., Kawano, T.,
Izumi, T. (1998). Laparoscopic splenopexy for pediatric wandering spleen, J Pediatr
Surg 33: 1571-3.
Karmazyn, B., Steinberg, R., Gayer, G., Grozovski, S., Freud, E., Kornreich, L. (2005).
Wandering spleen—the challenge of ultrasound diagnosis: report of 7 cases, J Clin
Ultrasound 33: 433-8.
Kleiner, O., Newman, N., Cohen, Z. (2006). Pediatric wandering spleen successfully treated
by laparoscopic splenopexy, J Laparo- endosc Adv Surg Tech A 16: 328–330.
Lacreuse, I., Moog, R., Kauffmann, I., Méfat, L., Bailey, C., Becmeur, F. (2007). Laparoscopic
splenopexy for a wandering spleen in a child, J Laparoendosc Adv Surg Tech A 17:
255–257.
Lin, CH., Wu, SF., Lin, WC., Chen, AC. (2005). Wandering spleen with torsion and gastric
volvulus, J Formos Med Assoc 104: 755–758.
Liu, HT., Lau, KK. (2007). Wandering spleen: an unusual association with gastric volvulus,
AJR Am J Roentgenol. 188.(4): 328-30.
Lu, CC., Chen, HH., Hsieh, MJ. (2004). Wandering spleen presenting as gastric outlet
obstruction after repair of traumatic diaphragmatic hernia, J Trauma 56.(2): 431-2.
Marinaccio, F., Caldarulo, E., Nobili, M., Magistro, D., Marinaccio, M. (2005). Uncommon
etiology of acute abdomen in pediatric age: the torsion of spleen, G Chir 26: 34-6.
Mayo, A., Erez, I., Lazar, L., Rathaus, V., Konen, O., Freud, E. (2001). Volvulus of the
stomach in childhood: The spectrum of the disease, Pediatr Emerg Care 17: 344–348.
Okazaki, T., Ohata, R., Miyano, G., J.Lane, G., Takahashi, T. (2010). Laparoscopic splenopexy
and gastropexy for wandering spleen associated with gastric volvulus, Pediatr Surg
Int 26.(10): 1053-5.
Qazi, A., Awadalla, S. (2004). Wandering spleen: a rare cause of mesenteroaxial gastric
volvulus, Pediatr Surg Int 20: 878-80.
Romero, J., Barksdale, E. (2003). Wandering spleen: A rare cause of abdominal pain, Pediatr
Emerg Care 19: 412–414.
Sanchez, R., Lobert, P., Herman, R., O'Malley, R., Mychaliska, G. (2010). Wandering spleen
causing gastric outlet obstruction and pancreatitis, Pediatr Radiol. 40.(Suppl 1): S89-
91.
Soleimani, M., Mehrabi, A., Kashfi, A., Fonouni, H., Büchler, MW., Kraus, TW. (2007).
Surgical treatment of patients with wandering spleen: Report of six cases with a
review of the literature, Surg Today 37: 261–269.
Spector, JM., Chappell, J. (2000). Gastric volvulus associated with wandering spleen in a
child, J Pediatr Surg 35: 641-2.
Steinberg, R., Karmazyn, B., Dlugy, E., Freud, E., Horev, G., Zer, M. (2002). Clinical
presentation of wandering spleen, J Pediatr Surg 10: E30.
Yasuda, H., Inoue, M., Uchida, K., Otake, K., Koike, Y., Fujikawa, H., Miki, C., Kusunoki, M.
(2010). Wandering spleen causing intestinal obstruction after repair of congenital
diaphragmatic hernia, Eur J Pediatr Surg 20.(2): 121-3.
Yilmaz, O., Genc, A., Ozcan, T., Aygoren, RS., Taneli, C. (2008). Unusual association of
omphalocele and wandering spleen, Eur Surg Res 41.(4): 331-3.
Part 6
Miscellaneous Laparoscopic Procedures

14
Laparoscopic Approach to Abdominal Sepsis

José Sebastião Santos, Carlos A.M. Donadelli, Rafael Kemp,
Alberto Facury Gaspar and Wilson Salgado Jr.
Medical School, University of São Paulo, Ribeirão Preto, São Paulo
Brazil
1. Introduction
Diagnostic laparoscopy (DL) was introduced in surgical practice at the beginning of the 20th
century but its use was limited for about 80 years. During the second half of the 20th
century, laparoscopic access started to be used as a diagnostic resource in the traumatic and
non-traumatic acute abdomen (Llanio & Sarle, 1956). Over the last decades, with the advent
of new video systems, with the development of laparoscopic instruments and the improved
visualization of the entire abdominal cavity, DL achieved an excellent level (Geis & Kim,
1995). Within this context of progress, DL started to be successfully used in critically ill
patients in intensive care units, with a diagnostic accuracy of 96% and with no significant
changes in hemodynamic parameters during the procedure (Brandt et al., 1993; Forde &
Treat, 1992).
The easy identification of the types of organic fluids, the resources for the aspiration of pus,
blood, bile and the intestinal content and the increased surgical experience have contributed
to the therapeutic success of laparoscopy in an acute abdomen of surgical cause (Boyd &
Nord, 1992; Cueto et al., 1997; Easter et al., 1992; Geis & Kim, 1995).
With growing reports of its therapeutic efficacy, laparoscopy quickly became the
preferential route of access for the treatment of acute cholecystitis (Z’graggen et al., 1995;
Colonval et al., 1997) and was also standardized for the treatment of acute appendicitis,
adnexial diseases, and perforated gastric or duodenal ulcers (Branicki, 2002; Sauerland et al.,
2006). It also represents an alternative access route for the exploration of the the bile ducts
(Tagorona et al., 1995), necrosectomy and drainage of collection in acute pancreatitis
(Pamoukian & Gagner, 2001).
There is a growing use of laparoscopy in peritonitis secondary to the perforation of
diverticular disease of the colons as an option for cavity washing and drainage, and for the
resection of the segment involved, especially in elective procedures (Tonelli et al., 2009;
Chatzimavroudis et al.,2009). Selected cases of intestinal obstruction or perforation with
early intervention before the installation of sepsis or of circulatory shock can also benefit
from a laparoscopic access (Branicki, 2002).
2. Laparoscopy in peritonitis
Although DL represents a standard procedure for critically ill patients with an acute
abdomen (Pecoraro et al., 2001), there is controversy about its therapeutic use in the
presence of sepsis and of hemodynamic repercussions. The insufflation of CO2 into the
peritoneal cavity reduces the peritoneal immunity mediated by macrophages, with lower
production of inflammatory cytokines (IL-1, IL-6, TNF-α). However, laparoscopic surgery is
associated with a lower systemic inflammatory response compared to open surgery
(Buunen et al., 2004). Studies of the effect of laparoscopy in an animal model of severe
peritonitis have obtained conflicting results (Bloechle et al., 1998; Gurtner et al., 1995;
Salgado Jr et al., 2008; Wichterman et al., 1979).
There is experimental evidence that pneumoperitoneum predisposes to bacterial
translocation and increases the systemic inflammatory response (Bloechle et al., 1998), but
other studies have not confirmed this finding (Gurtner et al., 1995; Wichterman et al., 1979).
In a model of peritonitis induced by bacterial inoculation in rats subjected to laparoscopy,
elevation of the abdominal wall and laparotomy, the changes of the peritoneal immune
system in response to the abdominal infection were lower in the group treated by
laparoscopy (Targarona et al., 2006). In a similar study, the number of bacterial colonies
obtained in the peritoneal fluid, the rates of positive blood cultures and the peritoneal levels
of IL-1 and IL-6 were significantly lower after 24 and 72 hs in the groups subjected to
laparoscopy. CO2 did not appear to influence bacterial growth (Balague et al., 1999)
The incidence of bacteremia due to B. fragilis and E. faecalis was lower in secondary
experimental bacterial peritonitis submitted to washing of the cavity by laparoscopy
compared to laparotomy even when the duration of peritonitis exceeded 3 hs, suggesting
that laparoscopy produces a lower local trauma and preserves the intra-abdominal
conditions (Linhares et al., 2001)
In an experimental rat model of severe bacterial peritonitis (Figure 1) it was demonstrated
that antibiotic therapy and an early approach to the abdominal cavity by laparotomy or
laparoscopy had similar effects on survival. The approach to the abdominal cavity by
laparoscopy induces a greater elevation of the pro-inflammatory cytokines TNF-alpha and
IL-6 compared to laparotomy, but when the procedures are associated with the use of broad
spectrum antibiotic therapy (gentamicin and metronidazole) there is no difference between
them (Salgado Jr et al., 2008).
Fig. 1. Experimental model for bacterial peritonitis in rats. Cecal ligation against a rigid
mold and 17 gauge needle puncture (Salgado Jr et al., 2008).
Pneumoperitoneum induces an increase in circulating endotoxin but the survival of animals
treated by the laparoscopic route is greater than that of animals subjected to laparotomy,
Laparoscopic Approach to Abdominal Sepsis 227
indicating that the overall result of the laparoscopic method may be superior
(Chatzimavroudis et al.,2009).
Today, hemodynamic instability is still a limiting factor regarding the use of laparoscopy.
The lack of appropriate equipment and of a qualified team continues to be an absolute
contraindication of the method. Abdominal distention poses additional risks and reduces
the yield of this access route (Stefanidis et al., 2009).
The early use of laparoscopy in an acute abdomen is defended as an appropriate method to
prevent a delay in obtaining a definitive diagnosis. Diagnostic laparoscopy within 48 h of
hospital admission provided a definitive diagnosis in 90% of cases and modified the clinical
diagnosis in 30% of them. A significant portion of patients (83%) were submitted to the
laparoscopic procedure as the final treatment of their conditions, with a 7% rate of
conversion to open surgery. Peritonitis was present in 180 patients and there was one
postoperative death involving a patient with a perforated gastric neoplasia (Golash &
Willson, 2005).
An etiologic diagnosis of a non-traumatic acute abdomen by laparoscopy was obtained in
98.6% of cases. The surgical treatment was performed by the laparoscopic route in 75% of
the patients and by laparotomy directed by the laparoscopic diagnosis in 13%. Due to a
diagnostic error in 2 cases of intestinal obstruction in patients with no abdominal surgery, in
this situation the authors recommend laparotomy or investigation by means of other exams
(Kirshtein et al., 2003).
The 2005 Consensus of the European Association of Endoscopic Surgery recommends the
use of all non-surgical diagnostic means in order to obtain the etiologic diagnosis in patients
with a non-traumatic acute abdomen. If the etiology is not detected, DL should be indicated.
A perforated peptic ulcer, appendicitis, acute cholecystitis and pelvic inflammatory disease
should be treated by the laparoscopic route. The benefits regarding other etiologies have not
been sufficiently clarified (Sauerland et al., 2006).
3. Laparoscopy in nonspecific abdominal pain and abdominal sepsis

Nonspecific acute abdominal pain is characterized by a duration of less than 7 days and by
diagnostic uncertainty after basic clinical and laboratory evaluation. Under these
circumstances, DL is useful for establishing the etiology by means of direct inspection of
large areas of the surface of abdominal organs and for obtaining material for biopsy, culture
and aspirate, with complementation by laparoscopic ultrasonography. In most cases it is
also possible to perform a therapeutic intervention by the same route of access (Stefanidis et
al., 2009).
The accuracy of DL ranges from 70 to 99% and its use reduces the time of hospitalization
without interfering with morbidity when compared to expectant management of nonspecific
abdominal pain (Cueta et al., 1998; Cueto et al., 1997; Decadt et al.,1999; Fahel et al., 1999;
Gaita et al., 2002; Golash & Willson, 2005; Majewski, 2000; Navez et al., 1995; Ou &
Rowbotham, 2000; Poulin et al., 2000; Sanna et al., 2003; So¨zuër et al., 2000; Stefa’nson et
al., 1997).
DL is also useful in intensive care when the abdomen is the suspected source of sepsis, of
systemic inflammatory response syndrome (SIRS) or multiple organ failure. DL can be used
in critically ill patients who present abdominal pain with peritonism accompanied by some
signs and symptoms of an inflammatory process, but still without an indication of
laparotomy (Stefanidis et al., 2009).
DL can be performed by the bedside, a fact that avoids the risk associated with the
transportation of intensive care patients. The contraindications of DL are the same as those
for any laparoscopic intervention: hypercapnia, clotting disorder with no possibility of
correction, mutliple previous abdrominal surgeries with adhesions, and abdominal surgery
in the last 30 days. The use of pneumoperitoneum pressure of 8 to 12 mmHg is
recommended, although some authors have used pressures of up to 15 mm Hg with no
adverse consequences under these circumstances (Stefanidis et al., 2009).
The diagnostic accuracy of DL in intensive care patients is 90 to 100% (Almeida et al., 1995;
Brandt et al., 1993; Brandt et al., 1994; Gagne et al., 2002; Hackert et al., 2003; Jaramillo et al.,
2006; Kelly et al., 2000; Orlando & Crowell, 1997; Pecoraro et al., 2001; Walsh & Hoadley,
1998). These success rates are due to the more frequent abdominal diseases occurring in this
population (acalculous acute cholecystitis and mesenteric ischemia). The method may fail to
detect retroperitoneal processes such as pancreatitis (Stefanidis et al., 2009).
Several studies which evaluated the resolutive capacity of laparoscopy in different clinical
situations are summarized in Table 1.
Laparoscopy
Clinical Morbidity Mortality
Study N Study type Resolution
Setting (%) (%)
(%)
Acute Cueto et al.,
107 Review 87,9 14 4,6
abdomen 1997
Acute
Perri et al., 2002 221 Review 87% 3 0,5
abdomen
Acute Golash &
1320 Retrospective 83 0,9 0,07
Abdomen Willson, 2005
Brandt et al., Clinical series
ICU 25 8 0
1993 (retrospective)
Perforated
Druart et al.,
duodenal 100 Prospective 92 9 5
1997
ulcer
Acute Z’Graggen et
103 Prospective 95,1 10,7 0
Cholecystitis al., 1995
Acute Colonval et al. ,
Cholecystitis 1997
Small Bowel Kirshtein et al.,
Obstruction 2003
Diverticular Torenvliet et al.,
231 Review 95,7% 10,4 1,7
disease 2010
Table 1. Evidence for the use of laparoscopy for diagnosis and for some therapeutic
purposes in clinical practice.
4. Laparoscopy in acute appendicitis

Appropriate clinical history and physical examination are sufficient for the correct diagnosis
of acute appendicitis with typical clinical presentation, a context within which imaging
exams are of little value. Computed tomography (CT) is the most valuable exam when there
is a diagnostic doubt in acute appendicitis and its complications. CT has 94 to 98%
sensitivity, 83 to 100% specificity and 93 to 96% accuracy and can reduce the number of
unnecessary laparoscopiess and laparotomies (Spirit et al., 2010).
Appendectomy by the laparoscopic route yields better results than treatment by
laparotomy, especially in patients with disease in the gangrenous phase or with perforation
and localized peritonitis. There are isolated reports of the limitation of laparoscopic
appendectomy in patients with diffuse peritonitis due to the difficulty in cleaning the
peritoneal cavity, the debris and the infected secretion, whereas most reports emphasize the
resources of laparoscopic surgery in terms of providing a view of the peritoneal cavity and
its recesses, with similar or even more satisfactory conditions for washing the peritoneal
cavity compared to laparotomy (Saeurland et al., 2006).
For acute appendicitis, the laparoscopic approach reduces the levels of infection of the
surgical wound and favors a more rapid return to habitual activities for the patient
compared to laparotomy. Women of reproductive age benefit more from laparoscopy, but
other groups also experience this advantage. Laparoscopic treatment of acute appendicitis is
also recommended in cases of perforation and contamination of the cavity (Saeurland et al.,
2006).
A cohort study was conducted at various academic and private medical centers in the
United States to compare laparoscopy and laparotomy for appendectomy. There was no
difference in mortality between groups and the group subjected to laparoscopy had a lower
incidence of infection of the surgical wound and of episodes of sepsis. The group subjected
to laparotomy had a lower incidence of abdominal abscesses and, according to the authors,
the approaches yielded similar results (Hemmila et al., 2010).
Among the advantages of the laparoscopic method are the possibility of complete inspection
of the abdominal cavity, the preservation of the appendix when normal, and the
opportunity to also treat by the laparoscopic route or by guided laparotomy other
inflammatory processes or processes of varied characteristics detected on the occasion of
inspection (Saeurland et al.,2006).
5. Laparoscopy in abdominal sepsis due to affections of the small bowel

(mesenteric ischemia, intestinal obstruction and incarcerated hernias)
Peritonitis secondary to obstruction or ischemia of the small bowel is infrequent. According
to the most recent consensus about obstructive intestinal processes, conservative treatment
may be maintained for up to 72 hours as long as there is no evidence of strangulation or
incarceration. After 3 days of expectant treatment, whether or not these signs are present,
surgical exploration is obligatory (Catena et al., 2011).
Some evidence supports the use of the laparoscopic route in the lysis of abdominal
adhesions and in the treatment of incarcerated hernias before the onset of necrosis and
perforation of the intestinal loops. After the occurrence of these events, most authors
recommend surgery by laparotomy (Saeurland et al., 2006).
The lysis of adhesions by laparotomy, the universally accepted route of access for this
situation, leads to the later formation of new adhesions, to recurrent intestinal obstruction
and to a new laparotomy in 10 to 30% of cases (Landercasper et al., 1993).
In animal models, laparoscopy showed a lower incidence and a smaller number of
adhesions, as well as a less severe obstructive situation compared to open surgery. Thus, the
laparoscopic approach, when viable, can be considered to prevent obstruction due to
adhesions (Tittel et al., 2001). Other clinical and experimental studies have also shown
evidence of a lesser formation of adhesions at the surgical site and on the abdominal wall
when laparoscopy is used (Gadallah et al., 2001; Gamal et al., 2001).
The lysis of adhesions by the laparoscopic route has several theoretical advantages over
open surgery: 1) less intense postoperative pain, 2) more rapid resolution of the ileum, 3)
shorter hospitalization, 4) earlier return to daily activities, 5) lower incidence of
complications of the surgical wound, and 6) a reduced formation of postoperative adhesions
(Nagle et al., 2004). However, no randomized and controlled studies comparing adhesion
lysis by the laparoscopic and open route were detected. Thus, the indications and the results
of the less invasive procedure continue to be unclear (Catena et al., 2011).
Today laparoscopy should be reserved for well selected cases, with the use of an open
technique for the initiation of pneumoperitoneum, preferentially in the upper left quadrant
of the abdomen. It is preferable to use it in case of a first obstructive episode and also when
a single or a few adhesions are predicted (for example, when the previous surgery was an
appendectomy). A high rate of conversion is expected and the risk of damage to bowel is
higher compared to surgery by laparotomy. Findings of a bowel segment larger than 4 cm,
of multiple adhesions and of findings compatible with malignant neoplasias supports the
option for conversion (Catena et al., 2011).
The extent of release of adhesions is a matter of debate and divides the opinion of authors
between the option for lysis of all adhesions in the cavity in an attempt to prevent a new
obstructive event or sufficient release for the resolution of obstruction (Scott-Coombes et al.,
2003).
Treatment of abdominal wall hernias by laparoscopy has progressed considerably over the
last decades and in general this is considered to be the access route of choice in an elective
situation. However, it is not possible to transfer the knowledge acquired with this practice to
urgency situations such as incarceration, strangulation and bowel injury with contamination
of the cavity and infection. There are isolated reports of favorable results for properly
selected cases treated by experienced surgeons (Saeurland et al., 2006).
The contribution of laparoscopy to mesenteric ischemia is small. For this situation, DL is less
precise than angiography and CT and has not proved to be able to reduce the number of
unnecessary laparotomies. DL can detect ischemia when present but cannot rule out this
diagnosis when the intestinal loops have a normal appearance upon laparoscopy (Saeurland
et al., 2006).
6. Laparoscopy in peritonitis due to gynecological causes

Gynecological affections should always be part of the clinical reasoning in the evaluation of
abdominal pain in women. The more frequent causes of abdominal and pelvic pain are
ectopic pregnancy, salpingo-oophoritis, pelvic adhesions, endometriosis, and ovarian cysts.
In contrast to abdominal processes, CT is less valuable in these conditions. Transvaginal and
conventional ultrasonography with a pregnancy test for women of reproductive age are part
of the initial evaluation. DL is superior to all other tests and can correct the preoperative
diagnosis in up to 40% of cases (Saeurland et al., 2006).
7. Laparoscopy in trauma
DL has been indicated for victims of trauma with suspected intra-abdominal injuries in
order to reduce the rate of non-therapeutic laparotomies with their morbidity, mortality and
costs. The indications of DL include the suspicion of intra-abdominal injury maintained after
an initial negative workup in closed traumas, stab wounds with proven or possible
penetration of the cavity, gun-shot wounds with a possible intra-abdominal course, a
diagnosis of diaphragm perforation in penetrating wounds of the thoraco-abdominal region,
and the creation of a pericardiac transdiaphragmatic window to rule out heart injury
(Stefanidis et al., 2009).
Absolute contraindications of DL are hemodynamic instability due to hemorrhagic shock or
evisceration, and the relative contraindications include peritonitis, known or obvious intra-
abdominal injury, posterior penetrating trauma with a high probability of intestinal injury
and, of course, the lack of experienced professionals and of appropriate equipment
(Stefanidis et al., 2009).
The accuracy of DL in defining the need for laparotomy ranges from 75 to 100%. In a review,
DL prevented non-therapeutic laparotomy in 17 to 89% (median: 57%) of traumatized
patients. The procedure involved a 6% rate of false-positive results (0-44%). In addition to
providing an etiologic diagnosis, laparoscopy permits the appropriate treatment of
intracavity injuries in up to 83% of cases (Hori, 2008).
A review of 37 studies including more than 1900 patients revealed a rate of DL complication
of 1% (Villavicencio & Aucar, 1999). More recent reviews have revealed even lower rates
close to zero. Intraoperative complications may occur during the creation of the
pneumoperitoneum, the introduction of trochars, the occurrence of pneumothorax during
inspection due to an unidentified diaphragmatic injury, during the perforation of hollow
viscera, the laceration of solid viscera, during gas dissection in the subcutaneous layer of the
peritoneum and vascular injuries (more frequently of the epigastric or epiploic arteries)
(Hori, 2008).
8. Laparoscopy in the perforation of diverticular disease of the colon

Perforation of diverticular colon disease, generally in the sigmoid colon, with localized
contamination of the abdominal cavity can be treated with antibiotics during the early
stages, but abscesses larger than 5 cm must be approached surgically. Sigmoidectomy is
indicated in patients who have suffered at least 2 crises of diverticulitis and in patients
younger than 50 years who have suffered only one episode (Saeurland et al.,2006). Even
within an urgency context, this surgery can be performed by the laparoscopic route with a
surgical time and results comparable to those of laparotomy and has been performed with a
conversion rate of 10% (Tonelli et al., 2009).
Over the last few years, there has been an increased use of peritoneal washing and drainage
of the cavity by the laparoscopic route without resection, allied to antibiotic treatment
during the episode of peritonitis secondary to diverticular perforation. Definite treatment by
colectomy can be performed in an elective manner after the resolution of the inflammatory
process (Saeurland et al., 2006; Tonelli et al., 2009).
In a systematic literature review of 231 cases of acute diverticulitis with purulent peritonitis
treated in this manner, abdominal sepsis was effectively controlled in 95.7% of the patients.
Mortality was 1.7%, morbidity was 10.4% and 1.7% of the patients required a stoma. A long
recurrence-free period of time was observed in the patients not subjected to colon resection,
and later elective resection of the segment involved by the laparoscopic route was possible
in most cases (Toorenvliet et al., 2010).
Although most studies are retrospective, this conservative approach has a clear advantage.
However, there is a consensus on the fact that laparoscopic washing and drainage is not
recommended for cases of fecal peritonitis, and the results are unsatisfactory for cases of
formation of an abscess in the pelvis. Several prospective and randomized studies are being
conducted in order to better define in which clinical situations this approach should be
indicated (Toorenvliet et al., 2010).
9. Conclusion
Access by laparoscopy seems to be of advantage over laparotomy as a diagnostic and
therapeutic method in the approach to peritonitis and sepsis of abdominal origin by
involving a lower surgical trauma, by providing a good field of view of the peritoneal cavity
and by permitting to obtain tissue and fluid samples under direct vision. The rate of
unnecessary laparotomies can be reduced when laparoscopy is used for a diagnostic and
therapeutic approach in cases of acute abdomen, even in the presence of peritonitis or sepsis
of abdominal origin.
In the management of peritonitis by laparoscopy, the inflammatory response is milder
compared to management by laparotomy. The elevation of inflammatory cytokines is
moderate and macrophages present a better basal immunologic performance. In contrast to
what occurs with laparotomy, the acute phase of the inflammatory response associated with
perioperative sepsis is attenuated during laparoscopy, and the immune function seems to be
better preserved after the latter.
Despite the doubts about the feasibility and efficiency of laparoscopy compared to
laparotomy for the approach to peritonitis, minimally invasive surgery is gaining acceptance
among surgeons, especially regarding patients with abdominal sepsis.
10. Acknowledgments
Financial support: Fundação Waldemar Barnsley Pessoa
11. References
Almeida J, Sleeman D, Sosa JL, Puente I, McKenney M & MartinL. (1995). Acalculous
cholecystitis: the use of diagnostic laparoscopy. J Laparoendosc Surg, Vol. 5, pp. (227–
231).
Balague C, Targarona EM, Pujol M, Fillela X, Espert JJ & Trias M. (1999). Peritoneal response to
a septic challenge comparison between open laparotomy, pneumoperitoneum
laparoscopy, and wall lift laparoscopy. Surg Endosc, Vol.13, pp. (792–796).
Bloechle C, Emmermann A, Strate T, Scheurlen UJ,Schneider C, Achilles E, Wolf M, Mack D,
Zornig C & Broelsch CE (1998). Laparoscopic versus open repair of gastric
perforation and abdominal lavage of associated peritonitis in pigs. Surg Endosc, Vol.
12, pp. (212–218).
Boyd WP Jr & Nord HJ (2000). Diagnostic Laparoscopy. Endoscopy, Vol. 32, No.2, pp. (153-158)
Brandt CP, Priebe PP & Eckhauser ML. (1993). Diagnostic laparoscopy in the intensive care
patient. Avoiding the nontherapeutic laparotomy. Surg Endosc , Vol. 7, No.3, pp. (168-
172).
Brandt CP, Priebe PP, & Jacobs DG. (1994). Value of laparoscopy in trauma ICU patients with
suspected acute acalculous cholecystitis. Surg Endosc, Vol. 8, pp.(361–364).
Branicki FJ. Abdominal Emergencies: Diagnostic and Therapeutic Laparoscopy (2002). Surgical
Infections, Vol. 3, No.3, pp. (269-282).
Buunen M, Gholghesaei M, ET, Veldkamp R, Meijer DW, Bonjer HJ & Bouvy ND. (2004).
Stress response to laparoscopic surgery. Surg Endosc, Vol.18. pp. (1022-1028).
Catena F, Di Saverio S, Kelly MD, Biffi WL, Ansaloni L, Mandalá V, Velmahos GC, Sartelli M,
Tugnoli G, Lupo M, Mandalá S, Pinna AD, Sugarbaker PH, Van Goor H, Moore EE &
Jeekel J. (2011). Bologna Guidelines for Diagnosis and Management of Adhesive
Small Bowel Obstruction (ASBO): 2010 Evidence Based Guidelines of the World
Society of Emergency Surgery. World Journal of Emergency Surgery, Vol. 21, pp. (6.5).
Chatzimavroudis G, Pavlidis TE, Koutelidakis I, Giamarrelos-Borboulis EJ, Atmatzidis S,
Kountopoulo U, Marikis G & Atmatzidis Kl. (2009).CO2 Pneumoperitonium Prolongs
survival in an animal model of peritonitis compared to laparotomy. Journal of Surgical
Research, Vol. 152, pp. (69–75).
Colonval P, Navez B, Cambier E, Richir C, de Pierpont B, Scohy JJ & Guiot P. (1997). Is
laparoscopic cholecystectomy effective and reliable in acute cholecystitis? Results of a
prospective study of 221 pathologically documented cases. Arch Chir, Vol. 51, No. 7,
pp. (689-696).
Cuesta MA, Eijsbouts QA, Gordijn RV, Borgstein PJ & De Jong D. (1998). Diagnostic
laparoscopy in patients with an acute abdomen of uncertain etiology. Surg Endosc,
Vol. 12, pp. (915–917).
Cueto J, Díaz O, Garteiz D, Rodríguez M & Weber A. (1997). The efficacy of laparoscopic
surgery in the diagnosis and treatment of peritoniotis. Surg Endosc, Vol. 11, pp. ( 366-
370).
Decadt B, Sussman L, Lewis MP, Secker A, Cohen L, Rogers C, Patel A & Rhodes M. (1999).
Randomized clinical trial of early laparoscopy in the management of acute
nonspecific abdominal pain. Br J Surg, Vol. 86, pp. (1383–1386).
Easter DW, Cuschieri A, Nathanson LK & Lavelle-Jones M. (1992). The utility of diagnostic
laparoscopy for abdominal disorders. Audit of 120 patients. Arch Surg, Vol. 127, No.
4, pp. (379-383)
Fahel E, Amaral PC, Filho EM, Ettinger JE, Souza EL, Fortes MF, Alcaˆtara RS, Regis AB, Neto
MP, Sousa MM, Fogagnoli WG, Cunha AG, Castro MM & Santana PA Jr. (1999).
Nontraumatic acute abdomen: videolaparoscopic approach. JSLS, Vol. 3, pp. (187–
192).
Forde KA & Treat MR. (1992). The role of peritoneoscopy (laparoscopy) in the evaluation of
the acute abdomen in critically ill patients. Surg Endosc, Vol. 6, No.5, pp. (219-221).
Gadallah MF, Torres-Rivera C, Ramdeen G, Myrick S, Habashi S & Andrews G. (2001).
Relationship between intraperitoneal bleeding, adhesions, and peritoneal dialysis
catheter failure: a method of prevention. Adv Perit Dial, Vol. 17, pp.(127-129).
Gagne´ DJ, Malay MB, Hogle NJ & Fowler DL. (2002). Bedside diagnostic minilaparoscopy in
the intensive care patient. Surgery, Vol. 131, pp.(491–496).
Gaitań H, Angel E, Sańchez J, Go´mez I, Sańchez L & Agudelo C. (2002).Laparoscopic
diagnosis of acute lower abdominal pain in women of reproductive age. Int J Gynaecol
Obstet, Vol. 76, pp. (149–158).
Gamal EM, Metzger P, Szabo G, Brath E, Peto K, Olah A, Kiss J, Furka I & Mikó I. (2001). The
influence of intraoperative complications on adhesion formation during laparoscopic
and conventional cholecystectomy in an animal model. Surg Endosc, Vol. 15, pp.(873-
877).
Geis WP & Kim HC. (1995).Use of laparoscopy in the diagnosis and treatment of patients with
surgical abdominal sepsis. Surg Endosc, Vol.9, pp. (178–182).
Golash V, Willson PD. Early laparoscopy as a routine procedure in the management of acute
abdominal pain: a review of 1,320 patients. Surg Endosc. 2005;19(7):882–885
Gurtner GC, Robertson CS, Chung SCS, Ling TKW, Ip SM & Li AKC (1995). Effect of carbon
dioxide pneumoperitoneum on bacteraemia and endotoxaemia in an animal model of
peritonitis. Br J Surg, Vol. 82, pp. (844–848).
Hackert T, Kienle P, Weitz J, Werner J, Szabo G, Hagl S, Bu¨chlerMW & Schmidt J. (2003).
Accuracy of diagnostic laparoscopy for early diagnosis of abdominal complications
after cardiac surgery. Surg Endosc, Vol.17, pp. (1671–1674)
Hemmila MR, Birkmeyer NJ, Arbabi S, Osborne NH, Wahl WL & Dimick JB. (2010).
Introduction to Propensity Scores. A case study on the comparative effectiveness of
laparoscopic vs open appendectomy. Archives of Surgery, Vol. 145, No. 10, pp. (939-
945).
Hori Y. (2008). SAGES Guidelines Committee. Diagnostic laparoscopy guidelines: This
guideline was prepared by the SAGES Guidelines Committee and reviewed and
approved by the Board of Governors of the Society of American Gastrointestinal and
Endoscopic Surgeons (SAGES). Surg Endosc. Vol. 22, No. 5, pp. (1353-1383).
Jaramillo EJ, Trevino JM, Berghoff KR & Franklin ME Jr. (2006). Bedside diagnostic
laparoscopy in the intensive care unit: a 13-year experience. JSLS, Vol.10, pp. (155–
159).
Kelly JJ, Puyana JC, Callery MP, Yood SM, Sandor A & Litwin DE. (2000). The feasibility and
accuracy of diagnostic laparoscopy in the septic ICU patient. Surg Endosc, Vol. 14, pp.
(617–621).
Kirshtein B, Roy-Shapira A, Lantsberg L, Mandel S, Avinoach E & Mizrahi S. (2003). The use of
laparoscopy in abdominal emergencies. Surg Endosc, Vol. 17, pp. (1118–1124).
Landercasper J, Cogbill TH, Merry WH, Stolle RT & Strutt PJ. (1993). Long-term outcome after
hospitalization for small-bowel obstruction. Arch Surg, Vol. 128, pp.(765-770).
Linhares L, Jeanpierre H, Borie F, Fingerhut A & Millat B. (2001). Lavage by laparoscopy fares
better than lavage by laparotomy: experimental evidence. Surg Endosc, Vol. 15, No. 1,
pp. (85–89).
Llanio R & Sarle H. (1956). Interet de La peritoneoscope chez politraumatises. Marseille Chirurg,
Vol. 8, pp. (82-86).
M. L. Druart, R. Van Hee, J. Etienne, G. B. Cadie`re, J. F. Gigot, M. Legrand, J. M. Limbosch, B.
Navez, M. Tugilimana, E. Van Vyve, L. Vereecken,3 E & Wibin, J. P. (1997).
Yvergneaux Laparoscopic repair of perforated duodenal ulcer. A prospective
multicenter clinical trial. Surgical Endoscopy, Vol. 11, pp. (1017–1020)
Majewski W. (2000). Diagnostic laparoscopy for the acute abdomen and trauma. Surg Endosc,
Vol. 14, pp. (930–937).
Nagle A, Ujiki M, Denham W & Murayama K. (2004). Laparoscopic adhesiolysis for small
bowel obstruction. Am J Surg, Vol. 187, No. 4, pp. (464-470).
Navez B, d’Udekem Y, Cambier E, Richir C, de Pierpont B & Guiot P. (1995). Laparoscopy for
management of nontraumatic acute abdomen. World J Surg, Vol. 19, (382–386).
Orlando R III & Crowell KL. (1997). Laparoscopy in the critically ill. Surg Endosc, Vol. 11, pp.
(1072–1074)
Ou CS & Rowbotham R. (2000). Laparoscopic diagnosis and treatmentof nontraumatic acute
abdominal pain in women. J Laparoendosc Adv Surg Tech A, Vol.10, pp (41–45).
Pamoukian VN & Gagner M.(2001). Laparoscopic necrosectomy for acute necrotizing
pancreatitis. J Hepatobiliary Pancreatic Surg, Vol. 8, No. 3, pp. (221-223).
Pecoraro AP, Cacchione RN, Sayad P, Williams ME & Ferzli GS. (2001). The routine use of
diagnostic laparoscopy in the Intensive Care Unit. Surg Endosc, Vol. 15, pp. (638–641).
Perri SG, Altilia F, Pietrangeli F, Dalla Torre A, Gabbrielli F, Amendolara M, Nicita A, Nardi M
Jr, Lotti R & Citone G. (2002). Laparoscopy in abdominal emergencies. Indications
and limitations. Chir Ital, Vol. 54, No. 2, pp. (165-178).
Poulin EC, Schlachta CM & Mamazza J. (2000). Early laparoscopy to help diagnose acute
nonspecific abdominal pain. Lancet, Vol. 355, pp. (861–863).
Salgado Jr W, Santos JS &Cunha FQ (2008) The effect of laparoscopic Access and antibiotics on
the outcome of severe bacterial peritonitis in rats. Journal of Laparoscopy and Advanced
Surgery Techniques, Vol.18, No.1, pp.( 5-12).
Sanna A, Adani GL, Anania G & Donini A. (2003). The role of laparoscopy in patients with
suspected peritonitis: experience of a single institution. J Laparoendosc Adv Surg Tech
A, Vol.13, pp. (17–19).
Sauerland S, Agresta F, Bergamaschi R, Borzelino Z, Budzynski A, Champault G, Fingerhut A,
Isla A, Johansson M, Lundorff P, Navez B, Saad S & Neugebauer EA. (2006).
Laparoscopy for abdominal emergencies: evidence-based guidelines of the European
Association for Endoscopic Surgery (EAES). Surg Endosc, Vol. 20, pp.(14-29).
Scott-Coombes Dm, Vinpond MN & Thompson JM. (1993). General surgeons attidues to the
treatment and prevention of abdominal adhesions. Annals of the Royal College of
Surgeons of England, Vol. 75, pp. (123-128).
So¨zuër EM, Bedirli A, Ulusal M, Kayhan E &Yilmaz Z. (2000). Laparoscopy for diagnosis and
treatment of acute abdominal pain. J Laparoendosc Adv Surg Tech A, Vol. 10, pp. (203–
207).
Spirt MJ. (2010). Complicated intra-abdominal infeccions: a focus on appendicitis and
diverticulitis. Postgrad Med, Vol. 122, No.1, pp. (39-51).
Stefańsson T, Nyman R, Nilsson S, Ekbom A & Pa’hlman L. (1997). Diverticulitis of the
sigmoid colon: a comparison of CT, colonic enema, and laparoscopy. Acta Radiologica,
Vol. 38, pp. (313-319).
Stefanidis D, Richardson WS, Chang L, Earle DB & Fanelli RD. (2009). The role of diagnostic
laparoscopy for acute abdominal conditions: an evidence based review. Surg Endosc,
Vol. 23, pp. (16-23).
Targarona EM, Balagué C, Espert JJ, Pérez Ayuso RM, Ros E, Navarro S, Bordas J, Téres J, &
Trias M. (1995). Laparoscopic treatment of acute biliary pancreatitis. Int Surg , Vol. 80,
No. 4, pp. (365-368).
Targarona EM, Rodr´ıguez M, Camacho M, Balagué C, Gich I, Vila L & Trias M. (2006).
Immediate peritoneal response to bacterial contamination during laparoscopic
surgery. Surg Endosc, Vol. 20, No. 2, pp. (316–321).
Tittel A, Treutner KH, Titkova S, Ottinger A & Schumpelick V. (2001). Comparison of adhesion
reformation after laparoscopic and conventional adhesiolysis in an animal model.
Langenbeck’s. Arch Surg, Vol. 386, pp. (141-145).
Tonelli F, Di Carlo V, Liscia G &Serventi A. (2009) Diverticular disease of the colon: diagnosis
and treatment. Consensus Conference, 5th National Congress of the Italian Society of
Academic Surgeons. Ann Ital Chir, Vol. 80, No.1, pp. (3-8).
Toorenvliet BR, Swank H, Schoones JW, Hamming JF & Bemelman WA. Laparoscopic
peritoneal lavage for perforated colonic diverticulitis: a systematic review. Coloretal
disease, Vol. 12, pp. (862-867).
Villavicencio, RT & Aucar, JA. (1999). Analysis of Laparoscopy in Trauma. Review. Journal of
the American College of Surgeons, Vol. 189, No.1, pp. (11-20).
Walsh RM, Popovich MJ & Hoadley J. (1998). Bedside diagnostic laparoscopy and peritoneal
lavage in the Intensive Care Unit. Surg Endosc, Vol. 12, pp.(1405–1409).
Wichterman KA, Chaudry IH & Baue AE (1979). Studies of peripheral glucose uptake during
sepsis. Arch Surg, Vol. 114, pp (740–750).
Z’graggen K, Metzger A, Birrer S & Klaiber C (1995). Laparoscopic cholecystectomy as
standard therapy in acute cholecystitis. A prospective study. Chirurg, Vol. 66, No.4,
pp. (366-370).
15
Role of Endoscopy in
Laparoscopic Procedures
Mohamed O. Othman, Mihir Patel and Timothy Woodward
Mayo Clinic Jacksonville
USA
1. Introduction
Endoscopy is a viable tool in the diagnosis and management of various gastrointestinal
disorders. In this chapter we will discuss the role of Endoscopy in facilitating laparoscopic
procedures. Endoscopy can be done before, during or after the laparoscopic procedures and
can be an alternative management technique for laparoscopy. We will focus on the recent
advances in the frontier and what the future holds.
2. Endoscopy prior to laparoscopy

2.1 Tattooing prior to laparoscopic resection
Accurate localization of the surgical site is crucial prior to laparoscopic resection. Flat
colorectal polyps or cancer are often hard to localize by visualization of the colonic wall or
even by palpation. Measuring the distance of the lesion from the anal verge or correlating
with a barium enema is usually not accurate enough for localizing the segment prior to
colonic resection. Intra-operative colonoscopy is accurate in localizing the lesions, but it
might interfere with patient positioning or laparoscopic field by air insufflation; in addition
to prolonging the procedure time looking for the lesion.
Endoscopic tattooing of the lesion prior to laparoscopic resection has proven to be accurate
and efficient. Feingold et al in a retrospective study of 50 patients who underwent
endoscopic tattooing prior to laparoscopic resection found that 88% of these lesions were
accurately localized during the laparoscopic procedure; no complications were reported.[1]
Many agents have been studied for use in endoscopic tattooing. Methylene blue and indigo
carmine can successfully stain the serosa. However, these agents disappear in few days,
making it not suitable for endoscopic tattooing. [2,3] Indian ink, however, can stain the
serosa for years making it the ideal agent for tattooing [4]. Indian ink should be sterilized
and diluted prior to injection [5]. A prepackaged sterilized and already diluted Indian ink,
SPOT® (GI Supply, Camp Hill, Pennsylvania, USA) is currently used by many endoscopists
for endoscopic tattooing [6]. It is recommended to inject the tattoo in 3 circumferential sites
distal to lesion in case one of these sites is on the mesenteric side of the colon [4] The long-
term safety of Indian ink was evaluated in a study of 55 patients; no clinical complications
such as fever, infection or abdominal pain were reported. There was mild chronic
inflammation at the site of injection in 6 patients without clinical significance[7].
Intraperitoneal spillage of Indian ink can happen and it is usually without clinical
238
significance. There are a few case reports of peritonitis or peritoneal abscess as a result of
intraperitoneal spillage [8].
Preoperative endoscopic tattooing of pancreatic lesions prior to laparoscopic distal
pancreatectomy has been recently reported [9]. This technique utilizes endoscopic
ultrasound with the use of a fine needle for tattooing under endoscopic guidance. In a study
of 36 patients who underwent laparoscopic distal pancreatictomy, 10 patients had
preoperative endoscopic tattooing. Patients in the preoperative tattooing group had shorter
operation times compared to the control group [10]. Figure 1 Illustrate tattooing of duodenal
lesion prior to laparoscopic removal.
2.2 Endoscopic sphincterotomy prior to laparoscopic cholecystectomy

Common bile duct stones are found in 10% of patients undergoing elective cholecystectomy
[11]. In these patients, management of common bile duct stones includes endoscopic
sphincterotomy (ES) prior to or after laparoscopic cholecystectomy (LC) or LC with
intraoperative common bile duct exploration. Many studies evaluated both approaches with
controversial outcomes. A meta-analysis of 12 studies did not find any difference in
mortality, morbidity or in the need for an additional procedure between both approaches
[12]. However, a decision analysis published in 2008 suggested that LC with intraoperative
bile duct exploration is superior to ES with LC [13]. Most likely, these controversial results
could be explained by the difference in expertise among surgeons in performing
laparoscopic common bile duct exploration. Recently, Intraoperative Endoscopic
sphicnterotomy by Endoscopic Retrograde Cholangiopancreatography (ERCP) during LC
was introduced as an alternative technique for the management of Choledocholithiasis.
Enochsson et al. evaluated this technique in 37 patients with a 93.5% success rate and none
of the patients developed post ERCP pancreatitis [14]. Intraoperative ERCP was compared
to preoperative ERCP in patients with choledocholithiasis in a study by ElGeidie et al. The
study included 198 patients and it did not find any difference in the morbidity or in the
procedure time between the two approaches [15]. However, Intraoperative ERCP during LC
has the advantage of being able to perform the procedure and surgery in a single stage
procedure, making it an attractive option.
3. Endoscopy during laparoscopy (combined laparoscopic endoscopic

procedure)
3.1 Laparoscopic monitored colonoscopic polypectomy (LMCP) to avoid segmental
colon resection
The majority of large colonic polyps can be resected with colonoscopy. In few
circumstances, patients are referred to laparascopic segmental colonic resection either
because of the polyp size or because of the polyp location. Laparoscopic monitored
colonoscopic polypectomy was suggested as a new technique which can reduce the number
of segmental colonic resections. In this technique, the laparoscope can guide the endoscope
to the site of the polyp and mobilize the colon to achieve easier polypectomy. This technique
is particularly valuable in patients with angulated sigmoid colon from prior surgery and
adhesion. This technique was evaluated in a study by Grunhagen et al in which 11 patients
with difficult polypectomy were enrolled. Segmental colonic resection was avoided in 9
patients. No residual polyps were seen in the follow-up period [16]. Another trial included
47 patients who had LMCP and showed that 97% of the patients had a successful procedure
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Role of Endoscopy in Laparoscopic Procedures
without any complications[17]. In another trial from Germany that included 23 patients,
LMCP was successful in 17 patients [18]. In all previously mentioned trials, there was
minimal to no discomfort from the laparoscopic part of the procedure.
3.2 Endoscopy assisted laparoscopic wedge resection

Laparoscopic wedge resection is currently the standard of care for the removal of gastric
submucosal tumor and in particular Gastrointestinal Stromal Tumor (GIST). Laparoscopic
wedge resection is more feasible in tumors located at the anterior wall of the stomach
Tumors located in the posterior wall of the stomach or the gastro-esophageal junctions were
traditionally managed by surgery to ensure negative margins and to avoid excessive gastric
resection. Endoscopy assisted laparoscopic wedge resection was successfully performed in
gastric submucosal tumors located in the above mentioned area to spare open surgery. In
this technique, endoscopy is used simultaneously during laparoscopy to localize the tumor
and ensure negative margins. In a trial of 18 patients, this technique was proven successful
with a single complication (perforation) in one case [19]. A new technique described by Hiki
et al utilizes endoscopic submucosal dissection (ESD) of three–fourths of the circumference
around the submucosal tumor followed by seromuscular dissection of the exact three-
fourths of the circumference by laparoscopy then the tumor is removed by a laparoscopic
stapling device [20]. This technique is successful regardless of the tumor location and the
initial ESD done by endoscopy to ensure the exact margins of the tumor.
3.3 Combined colonoscopy and laparoscopy to close colonic perforation

Iatrogenic colonic perforation can be treated with segmental laparoscopic resection or with
laparoscopic suturing [21]. A new technique was proposed to close iatrogenic colonic
perforation with combined endoscopy and laparoscopy approach. This technique involves
mucosal closure using endoscopic clips, serosal closure using laparoscopy and a leak test
with air insufflations and water irrigation [22].
3.4 Combined laparoscopic-endoscopic approach for duodenal lesions

Endoscopic mucosal resection and endoscopic mucosal dissection of duodenal lesions is
feasible [23]. However, it is complicated with higher rates of bleeding, perforation and
tumor recurrence compared to EMR and ESD of colonic and stomach lesions [24]. Sakon et
al described a new technique utilizing ESD of the margins of the duodenal lesion followed
by laparoscopic resection. This promising technique was associated with less procedure
time and minimal bleeding [25].
3.5 Laparoscopy assisted foreign body removal

Most of ingested foreign body can be removed endoscopically. In few instances, sharp
foreign body can invade through the gastrointestinal wall to other organ and require
surgical assistance. Lanitis et al described a case in which a patient ingested two sharp
needles, one of them migrated to the liver and another one invaded into the abdominal wall.
Combined endoscopy and laparoscopy technique was successful in removing both lesions
[26]. Another case report described the removal of large dental bridge by the combined
approach. The foreign body was snared by the endoscopy in the stomach but it could not
pass through the overtube in the esophagus. Gastrostomy was done using laparoscope then
the snared foreign body was delivered to a laparoscopy grasper through the gastrostomy
240
[27]. This technique has many advantages in difficult cases of foreign body removal.
Endoscopy provides trans-illumination of the stomach and help to localize the foreign body
for laparoscopic removal. In addition, laparoscopy provides the opportunity to clean the
peritoneal spillage and ensure the closure of the abdominal wall [28].
4. Endoscopy after laparoscopy

4.1 Endoscopy in the treatment of bariatric surgery complications
Morbid obesity and its complications became an endemic problem in most developed
countries [29]. Laparoscopic bariatric surgery has gained popularity in the field of surgical
treatment of obesity. Laparoscopic gastric bypass and laparoscopic adjustable gastric
banding account for more than 50% of bariatric surgeries performed worldwide [30].
Endoscopy is a useful tool in assessing complications of bariatric surgeries in addition to its
role in the initial assessment of these patients prior to surgery.
Stomal stenosis is the one of the most frequent complications after Laparoscopic Roux en Y
Gastric Bypass ( RYGBP) [31]. Stomal stenosis occurs in 1-5% of patients undergoing
Laparoscopic RYGBP [32-34]. Endoscopic dilation of the stomal stenosis has proven to be
successful without the need of surgical revision. Ukleja et al performed endoscopic balloon
dilation of the stomal stricture in 61 patients. Dilation was done in 1 to 5 sessions and it was
successful in all patients without a need for surgical revision. However, the procedure was
complicated by perforation in 2.2% of all dilations (3 patients) [35]. In another series by Go
et al which included 38 patients with stomal stenosis after RYGBP, the success rate of
endoscopic balloon dilation was 95% with a 3% complication rate [36]. Similar results were
published by Peifer et al in their cohort of 43 patients, in which 2 endoscopic dilation
sessions up to 15 mm were successful in 93% of the patients without any perforations[34].
Laparoscopic gastric banding (LGB) can be complicated with band erosion and band
slippage in 1% and 4.9% of procedures performed, respectively [37]. Band erosion can be
seen by endoscopy as a white ring in retroflexion in the stomach. Removal of the gastric
band can be successfully done with endoscopy, especially if more than 50% of the band
eroded through the wall of the stomach. Expectant management is advisable when less than
50% of the gastric band eroded through the stomach wall [38]. Successful removal of gastric
bands was described in many case reports by cutting the thinnest part of the band using
papillotome, mixed current Argon Plasma Coagulation or with scissors [39-41].
Choleithiasis and its related billiary complications are common after bariatric surgery [42].
Occasionally, the endoscopists will face the challenge of accessing the bypassed intestinal
limb to the ampulla of vater in order to perform billiary procedures [43]. Many techniques
have been described in order to access the ampulla of vater in this circumstance. Wright et al
described their experience in 15 patients with RYGBP who underwent billiary interventions.
Initially, forward-viewing colonoscope was used to explore the afferent limb to find the
ampulla. Billiary cannulation with the use of the colonoscope was achieved in 2 patients. In
the rest of the patients, a guidewire was left and duodenoscope was advanced over the
guidewire to the ampulla. This technique was successful in two-thirds of the enrolled
patients [44]. Another described technique includes the use of the double balloon
enteroscopy for ERCP.The feasibility of this technique was illustrated in many case series
with a success rate of 80-90% in cannulating the common bile duct (CBD) and a more than
60% success rate in performing therapeutic intervention of the biliary tract [45-47]. The use
of double balloon enteroscopy offers the advantage of exploration of the afferent limb in less
241
time;, however, the lack of elevator could be problematic in gaining deep access of the CBD,
especially in patients with naive papilla. Another novel technique utilizes the creation of a
gastrostomy tube by an interventional radiologist in the excluded part of the stomach
followed by the use of an ERCP endoscope through the gastrostomy[48]. Although this
technique enables the use of an ERCP endoscope, it requires delaying the ERCP until
maturation of the gastrostomy tube. A new technique of laparoscopic-assisted ERCP was
proven to be successful in RYGBP patients [49]. Initially, a laparoscopic examination is done,
followed by identification of the stomach remnant to create gastrostomy as an access for the
ERCP endoscope. The endoscope is inserted through trochar from the abdominal wall to the
gastrostomy opening and then to the biliary tract. This technique was successful in 9 out of
10 patients included in the study by Lopes et al. These impressive results were confirmed by
Bertin et al, in which successful biliary cannulation was achieved in 94% of 21 RYGBP
patients who underwent laparoscopic assisted ERCP [50]. In conclusion, bariatric surgeries
are increasing due to the obesity epidemic. Endoscopists will have a major role in either
evaluating these patients prior to surgery or in treating post-surgical complications.
4.2 Endoscopy in treatment of post-surgical leaks and fistulas

Anastomotic leaks are one of the major complications after gastrointestinal surgery. After
laparoscopic RYGBP, anastomotic leaks can develop in 0.3 to 8% of patients[51].
Traditionally these leaks were managed surgically. The introduction of self-expandable
removable stents offered a less invasive approach for management of anastomotic leak. In a
retrospective study that included 5 patients with anastomotic leak and one patient with
chronic gastrocutaneous fistula; self-expandable plastic stent was successful in closing the
leak in all 5 patients but not in the patient with the fistula [52]. In another retrospective
study that included 11 patients with acute leak and 2 patients with chronic fistula as a
complication of bariatric surgery, self-expandable removal stents (metal and plastic) were
successful in healing the acute leak in 89% of patients and one of the two patients with
chronic fistula [53]. A new endoscopic device named “over the scope clip(OSC),” which
utilizes a combination of clip with grasper and large suction cap to ensure serosa to serosa
closure, was recently introduced to clinical practice. The new system has been evaluated in
12 patients with post-operative leaks or fistula with successful closure in 10 patients [54].
Currently, this system is approved in Europe but is not yet available for clinical use in
United States. The recently published experiences of the use of this new OSC in different
applications such as leaks, fistula and perforation are extremely encouraging [54-57].
5. Endoscopy as an alternative to laparoscopy

The recent advances in therapeutic endoscopy opened a new frontier for endoscopists to
manage complicated clinical scenarios that were only managed surgically in the past. In this
section we are going to discuss a few examples of the use of endoscopy in these clinical
scenarios where surgery is contraindicated or considered a more invasive approach.
5.1 Endoscopic gallbladder drainage

Cholecystectomy (mainly by laparoscopic approach) is the standard of care for management
of acute cholecystitis. In high risk patients for surgery percutaneous cholecystostomy is
advocated as a temporarizing measure [58]. However, this approach could be problematic in
patients with coagulopathy or due to anatomical reasons. In addition, an indwelling catheter
242
is predisposed to infection and it reduces the quality of life. Endoscopic transpapillary

drainage was introduced as a more attractive approach in this subset of patients. The
technique utilizes the ERCP endoscope to cannulate the billiary tree and the cystic duct
followed by placement of cystic duct stent or a nasocholecystic catheter in the gallbladder
[59, 60]. The outcome of this endoscopic approach was evaluated retrospectively in 35
surgically high-risk patients with acute cholecystitis. Nasocholecystic catheter was inserted
in 21 patients, plastic stent in 6 patients and combined approach in 2 patients. The procedure
was not successful in 6 of the 35 patients (17 %). Among the 29 patients with successful
gallbladder drainage, 24 patients clinically improved within 3 days, while 4 patients died of
septic complications. Although this technique was successful in 83 % of the patients, long-
term follow-up showed a 20% relapse rate for acute pancreatitis which emphasizes the role
of this approach as a bridge until the patient is surgically fit [61].
5.2 Endoscopic treatment of GERD

Endoscopic treatment of GERD has been an attractive topic for the last 15 years. Hope for a
successful cure of GERD with endoscopy has been a rollercoaster. In this section we will
briefly discuss various endoscopic modalities currently available for GERD treatment. One
of the earliest devices to treat GERD by endoscopic approach is the “Stretta Device”. This
device uses thermal coaogulation of the mucosa of the lower esophageal sphincter (LES) in
order to narrow the esophagus and prevent GERD. Although the device showed modest
success, its clinical use was hindered by the higher rate of complications such as esophageal
perforation and aspiration pneumonia. Currently this system is not commercially available
[62, 63]. Other devices utilize suturing techniques to produce endoscopic plication of the
LES in an effort to decrease GERD. There are more than five plicator devices available in the
market. There are multiple cases series and non-randomized trials investigating the
effectiveness of this technique. In summary, it showed a modest decrease in acid reflux but
the procedure is lengthy and there is an increased risk of complication [64-66]. Based on the
available data, it is premature to support incorporating these devices in clinical practice. A
third technique that involves injecting bulking agents at the LES to prevent GERD has been
recently introduced. The injected materials are either plexigal microsphere or ethylene vinyl
alcohol (biodegradable microsphere) as in the Enteryx device. Although the technique is
easy to use, the Enteryx device was recalled by the United States’ Food and Drug
Administration due to the associated complications such esophageal abscess, polymer
migration and death [67-69]. Although many of the above mentioned results are
disappointing, there are other devices currently being researched which could alter the
current grim look for use of endoscopy in GERD.
5.3 Endoscopic myotomy for esophageal achalasia

Traditionally, the endoscopy role in achalasia was limited to endoscopic dilation and
endoscopic injection of BOTOX [70]. A new technique involving creating a submucosal
tunnel in the lower esophagus followed by advancing the endoscope in the new created
space to the lower esophageal sphincter (LES) and electrocautery disruption of circular
muscle of LES was proven feasible in an animal model [71]. This technique was proven
successful in 17 patients with achalasia who underwent endoscopic myotomy in a tertiary
referral center in Japan. Patients had significant improvement of their dysphagia and in the
resting LES pressure. No major complications were reported [72]. The first case of
243
endoscopic myotomy in the United States was reported in December 2010 by Stavropoulos
et al; the procedure was successful with improvement in dysphagia in the follow-up period
[73]. This technique has many advantages including the minimally invasive nature of the
procedure, the lower incidence of reflux since only an incision of the circular muscle is done
and the option of performing laparoscopic myotomy if needed. However, long-term data
are not yet available for this new approach.
6. References
[1] Feingold, D.L., et al., Safety and reliability of tattooing colorectal neoplasms prior to
laparoscopic resection. J Gastrointest Surg, 2004. 8(5): p. 543-6.
[2] Lane, K.L., et al., Endoscopic tattoo agents in the colon. Tissue responses and clinical
implications. Am J Surg Pathol, 1996. 20(10): p. 1266-70.
[3] Price, N., et al., Safety and efficacy of India ink and indocyanine green as colonic tattooing
agents. Gastrointest Endosc, 2000. 51(4 Pt 1): p. 438-42.
[4] Yeung, J.M., C. Maxwell-Armstrong, and A.G. Acheson, Colonic tattooing in laparoscopic
surgery - making the mark? Colorectal Dis, 2009. 11(5): p. 527-30.
[5] Nizam, R., et al., Colonic tattooing with India ink: benefits, risks, and alternatives. Am J
Gastroenterol, 1996. 91(9): p. 1804-8.
[6] Askin, M.P., et al., Tattoo of colonic neoplasms in 113 patients with a new sterile carbon
compound. Gastrointest Endosc, 2002. 56(3): p. 339-42.
[7] Shatz, B.A., et al., Long-term safety of India ink tattoos in the colon. Gastrointest Endosc,
1997. 45(2): p. 153-6.
[8] Singh, S., et al., Complication after pre-operative India ink tattooing in a colonic lesion. Dig
Surg, 2006. 23(5-6): p. 303.
[9] Lennon, A.M., et al., EUS-guided tattooing before laparoscopic distal pancreatic resection (with
video). Gastrointest Endosc, 2010. 72(5): p. 1089-94.
[10] Newman, N.A., et al., Preoperative endoscopic tattooing of pancreatic body and tail lesions
decreases operative time for laparoscopic distal pancreatectomy. Surgery, 2010. 148(2): p.
371-7.
[11] Vezakis, A., et al., Intraoperative cholangiography during laparoscopic cholecystectomy. Surg
Endosc, 2000. 14(12): p. 1118-22.
[12] Clayton, E.S., et al., Meta-analysis of endoscopy and surgery versus surgery alone for common
bile duct stones with the gallbladder in situ. Br J Surg, 2006. 93(10): p. 1185-91.
[13] Kharbutli, B. and V. Velanovich, Management of preoperatively suspected choledocholithiasis:
a decision analysis. J Gastrointest Surg, 2008. 12(11): p. 1973-80.
[14] Enochsson, L., et al., Intraoperative endoscopic retrograde cholangiopancreatography (ERCP)
to remove common bile duct stones during routine laparoscopic cholecystectomy does not
prolong hospitalization: a 2-year experience. Surg Endosc, 2004. 18(3): p. 367-71.
[15] ElGeidie, A.A., G.K. ElEbidy, and Y.M. Naeem, Preoperative versus intraoperative
endoscopic sphincterotomy for management of common bile duct stones. Surg Endosc,
2011. 25(4): p. 1230-7.
[16] Grunhagen, D.J., et al., Laparoscopic-monitored colonoscopic polypectomy: a multimodality
method to avoid segmental colon resection. Colorectal Dis, 2010.
[17] Franklin, M.E., Jr., et al., Laparoscopic-assisted colonoscopic polypectomy: the Texas
Endosurgery Institute experience. Dis Colon Rectum, 2000. 43(9): p. 1246-9.
244
[18] Ommer, A., et al., [Laparoscopic-assisted colonoscopic polypectomy--indications and results].

Zentralbl Chir, 2003. 128(3): p. 195-8.
[19] Ludwig, K., et al., Laparoscopic-endoscopic rendezvous resection of gastric tumors. Surg
Endosc, 2002. 16(11): p. 1561-5.
[20] Hiki, N., et al., Laparoscopic and endoscopic cooperative surgery for gastrointestinal stromal
tumor dissection. Surg Endosc, 2008. 22(7): p. 1729-35.
[21] Coimbra, C., et al., Laparoscopic repair of colonoscopic perforation: a new standard? Surg
Endosc, 2010.
[22] Senadhi, V., et al., Combined colonoscopy and laparoscopy to close a colonic perforation.
Endoscopy, 2010. 42 Suppl 2: p. E213-4.
[23] Alexander, S., et al., EMR of large, sessile, sporadic nonampullary duodenal adenomas:
technical aspects and long-term outcome (with videos). Gastrointest Endosc, 2009. 69(1):
p. 66-73.
[24] Abbass, R., J. Rigaux, and F.H. Al-Kawas, Nonampullary duodenal polyps: characteristics
and endoscopic management. Gastrointest Endosc, 2010. 71(4): p. 754-9.
[25] Sakon, M., et al., A novel combined laparoscopic-endoscopic cooperative approach for duodenal
lesions. J Laparoendosc Adv Surg Tech A, 2010. 20(6): p. 555-8.
[26] Lanitis, S., et al., Combined laparoscopic and endoscopic approach for the management of two
ingested sewing needles: one migrated into the liver and one stuck in the duodenum. J
Laparoendosc Adv Surg Tech A, 2007. 17(3): p. 311-4.
[27] Olson, J.A., Jr., L.B. Weinstock, and L.M. Brunt, Combined endoscopic and laparoscopic
approach to remove a sharp gastric foreign body. Gastrointest Endosc, 2000. 51(4 Pt 1): p.
500-2.
[28] Iafrati, M.D., et al., A novel approach to the removal of sharp foreign bodies from the stomach
using a combined endoscopic and laparoscopic technique. Gastrointest Endosc, 1996.
43(1): p. 67-70.
[29] Padwal, R., S.K. Li, and D.C. Lau, Long-term pharmacotherapy for obesity and overweight.
Cochrane Database Syst Rev, 2004(3): p. CD004094.
[30] Buchwald, H. and S.E. Williams, Bariatric surgery worldwide 2003. Obes Surg, 2004. 14(9):
p. 1157-64.
[31] Podnos, Y.D., et al., Complications after laparoscopic gastric bypass: a review of 3464 cases.
Arch Surg, 2003. 138(9): p. 957-61.
[32] Msika, S., [Surgery for morbid obesity: 2. Complications. Results of a Technologic Evaluation
by the ANAES]. J Chir (Paris), 2003. 140(1): p. 4-21.
[33] Kothari, S.N., et al., Excellent laparoscopic gastric bypass outcomes can be achieved at a
community-based training hospital with moderate case volume. Ann Surg, 2010. 252(1): p.
43-9.
[34] Peifer, K.J., et al., Successful endoscopic management of gastrojejunal anastomotic strictures
after Roux-en-Y gastric bypass. Gastrointest Endosc, 2007. 66(2): p. 248-52.
[35] Ukleja, A., et al., Outcome of endoscopic balloon dilation of strictures after laparoscopic gastric
bypass. Surg Endosc, 2008. 22(8): p. 1746-50.
[36] Go, M.R., et al., Endoscopic management of stomal stenosis after Roux-en-Y gastric bypass.
Surg Endosc, 2004. 18(1): p. 56-9.
[37] Singhal, R., et al., Band slippage and erosion after laparoscopic gastric banding: a meta-
analysis. Surg Endosc, 2010. 24(12): p. 2980-6.
[38] Neto, M.P., et al., Endoscopic removal of eroded adjustable gastric band: lessons learned after 5
years and 78 cases. Surg Obes Relat Dis, 2010. 6(4): p. 423-7.
245
[39] Meyenberger, C., C. Gubler, and P.M. Hengstler, Endoscopic management of a penetrated
gastric band. Gastrointest Endosc, 2004. 60(3): p. 480-1.
[40] De Palma, G.D., et al., Endoscopic management of intragastric penetrated adjustable gastric
band for morbid obesity. World J Gastroenterol, 2006. 12(25): p. 4098-100.
[41] Weiss, H., et al., Gastroscopic band removal after intragastric migration of adjustable gastric
band: a new minimal invasive technique. Obes Surg, 2000. 10(2): p. 167-70.
[42] Caruana, J.A., et al., Incidence of symptomatic gallstones after gastric bypass: is prophylactic
treatment really necessary? Surg Obes Relat Dis, 2005. 1(6): p. 564-7; discussion 567-8.
[43] Lopes, T.L. and T.H. Baron, Endoscopic retrograde cholangiopancreatography in patients with
Roux-en-Y anatomy. J Hepatobiliary Pancreat Sci, 2010.
[44] Wright, B.E., O.W. Cass, and M.L. Freeman, ERCP in patients with long-limb Roux-en-Y
gastrojejunostomy and intact papilla. Gastrointest Endosc, 2002. 56(2): p. 225-32.
[45] Monkemuller, K., et al., ERCP with the double balloon enteroscope in patients with Roux-en-
Y anastomosis. Surg Endosc, 2009. 23(9): p. 1961-7.
[46] Parlak, E., et al., Endoscopic retrograde cholangiography by double balloon enteroscopy in
patients with Roux-en-Y hepaticojejunostomy. Surg Endosc, 2010. 24(2): p. 466-70.
[47] Moreels, T.G., et al., Diagnostic and therapeutic double-balloon enteroscopy after small bowel
Roux-en-Y reconstructive surgery. Digestion, 2009. 80(3): p. 141-7.
[48] Martinez, J., et al., Endoscopic retrograde cholangiopancreatography and gastroduodenoscopy
after Roux-en-Y gastric bypass. Surg Endosc, 2006. 20(10): p. 1548-50.
[49] Lopes, T.L., R.H. Clements, and C.M. Wilcox, Laparoscopy-assisted ERCP: experience of a
high-volume bariatric surgery center (with video). Gastrointest Endosc, 2009. 70(6): p.
1254-9.
[50] Bertin, P.M., K. Singh, and M.E. Arregui, Laparoscopic transgastric endoscopic retrograde
cholangiopancreatography (ERCP) after gastric bypass: case series and a description of
technique. Surg Endosc, 2011.
[51] Baker, R.S., et al., The science of stapling and leaks. Obes Surg, 2004. 14(10): p. 1290-8.
[52] Edwards, C.A., et al., Management of anastomotic leaks after Roux-en-Y bypass using self-
expanding polyester stents. Surg Obes Relat Dis, 2008. 4(5): p. 594-9; discussion 599-
600.
[53] Eubanks, S., et al., Use of endoscopic stents to treat anastomotic complications after bariatric
surgery. J Am Coll Surg, 2008. 206(5): p. 935-8; discussion 938-9.
[54] Manta, R., et al., Endoscopic treatment of gastrointestinal fistulas using an over-the-scope clip
(OTSC) device: Case series from a tertiary referral center. Endoscopy, 2011.
[55] Iacopini, F., et al., Over-the-scope clip closure of two chronic fistulas after gastric band
penetration. World J Gastroenterol, 2010. 16(13): p. 1665-9.
[56] von Renteln, D., M.C. Vassiliou, and R.I. Rothstein, Randomized controlled trial comparing
endoscopic clips and over-the-scope clips for closure of natural orifice transluminal
endoscopic surgery gastrotomies. Endoscopy, 2009. 41(12): p. 1056-61.
[57] Repici, A., et al., Clinical experience with a new endoscopic over-the-scope clip system for use
in the GI tract. Dig Liver Dis, 2009. 41(6): p. 406-10.
[58] Ito, K., et al., Percutaneous cholecystostomy versus gallbladder aspiration for acute
cholecystitis: a prospective randomized controlled trial. AJR Am J Roentgenol, 2004.
183(1): p. 193-6.
[59] Itoi, T., et al., Endoscopic transpapillary gallbladder drainage in patients with acute
cholecystitis in whom percutaneous transhepatic approach is contraindicated or
anatomically impossible (with video). Gastrointest Endosc, 2008. 68(3): p. 455-60.
246
[60] Comin, J.M., R.J. Cade, and A.F. Little, Percutaneous cystic duct stent placement in the
treatment of acute cholecystitis. J Med Imaging Radiat Oncol, 2010. 54(5): p. 457-61.
[61] Mutignani, M., et al., Endoscopic gallbladder drainage for acute cholecystitis: technical and
clinical results. Endoscopy, 2009. 41(6): p. 539-46.
[62] Chen, D., et al., Systematic review of endoscopic treatments for gastro-oesophageal reflux
disease. Br J Surg, 2009. 96(2): p. 128-36.
[63] Romagnuolo, J., Endoscopic "antireflux" procedures: not yet ready for prime time. Can J
Gastroenterol, 2004. 18(9): p. 573-7.
[64] Thomson, M., et al., Endoluminal gastroplication in children with significant gastro-
oesophageal reflux disease. Gut, 2004. 53(12): p. 1745-50.
[65] Chuttani, R., et al., A novel endoscopic full-thickness plicator for the treatment of GERD: A
pilot study. Gastrointest Endosc, 2003. 58(5): p. 770-6.
[66] Schiefke, I., et al., Use of an endoscopic suturing device (the "ESD") to treat patients with
gastroesophageal reflux disease, after unsuccessful EndoCinch endoluminal gastroplication:
another failure. Endoscopy, 2005. 37(8): p. 700-5.
[67] Wong, R.F., T.V. Davis, and K.A. Peterson, Complications involving the mediastinum after
injection of Enteryx for GERD. Gastrointest Endosc, 2005. 61(6): p. 753-6.
[68] Veerappan, G.R., J.M. Koff, and M.T. Smith, Enteryx polymer migration to lymph nodes and
beyond. Endoscopy, 2008. 40 Suppl 2: p. E10-1.
[69] Noh, K.W., et al., Pneumomediastinum following Enteryx injection for the treatment of
gastroesophageal reflux disease. Am J Gastroenterol, 2005. 100(3): p. 723-6.
[70] Urbach, D.R., et al., A decision analysis of the optimal initial approach to achalasia:
laparoscopic Heller myotomy with partial fundoplication, thoracoscopic Heller myotomy,
pneumatic dilatation, or botulinum toxin injection. J Gastrointest Surg, 2001. 5(2): p.
192-205.
[71] Pasricha, P.J., et al., Submucosal endoscopic esophageal myotomy: a novel experimental
approach for the treatment of achalasia. Endoscopy, 2007. 39(9): p. 761-4.
[72] Inoue, H., et al., Peroral endoscopic myotomy (POEM) for esophageal achalasia. Endoscopy,
2010. 42(4): p. 265-71.
[73] Stavropoulos, S.N., et al., Endoscopic submucosal myotomy for the treatment of achalasia
(with video). Gastrointest Endosc, 2010. 72(6): p. 1309-11.

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UPDATED TOPICS IN

Edited by Ahmed AbdelRaouf ElGeidie

Copyright © 2015 Second Edition

First published October, 2011, second - 2015

Published December 12, 2015

Part 1 Laparoscopic Biliary-Pancreatic Surgery 1

Chapter 1 Transcylindrical Cholecystectomy for

Chapter 2 Laparoscopic Cholecystectomy in High Risk Patients 27

Chapter 3 Gallbladder Surgery, Choice of Technique: An Overview 37

Chapter 4 Laparoscopy-Assisted Distal Pancreatectomy 53

Part 2 Laparoscopic Liver Surgery 61

Chapter 5 Laparoscopic Liver Resection 63

Chapter 6 Hilar Glissonean Access in Laparoscopic Liver Resection 77

Chapter 7 Laparoscopic Liver Surgery 87

Part 3 Laparoscopic Appendectomy 113

Chapter 8 Laparoscopic Appendectomy 115

Chapter 9 Appendicitis and Appendicectomy 137

Part 4 Laparoscopic Hernia Repair Surgery 155

Chapter 10 Laparoscopic Hernia Repair 157

Chapter 11 Laparoscopic Incisional Hernia Repair 181

Part 5 Laparoscopic Solid Organ Surgery 193

Chapter 12 Spleen Preserving Surgery and

Chapter 13 Laparoscopic Gastropexy for the Treatment of

Part 6 Miscellaneous Laparoscopic Procedures 223

Chapter 14 Laparoscopic Approach to Abdominal Sepsis 225

Chapter 15 Role of Endoscopy in Laparoscopic Procedures 237

We tried in this book to present evidence-based up-to-date information in laparoscopic

Ahmed AbdelRaouf ElGeidie

Laparoscopic Biliary-Pancreatic Surgery

Transcylindrical Cholecystectomy for the

1.2 Development of mini-lap (small-incision) cholecystectomy

see the savings produced by minilaparotomy, especially if applied to the 600,000

1.3 Laparoscopic cholecystectomy – Eric Mühe

2. Laparoscopic vs. small-incision cholecystectomy

In some studies, laparoscopic cholecystectomy has shown lower spirometric reductions

3. Treatment options in biliary lithiasis complications

- Laparoscopic cholecystectomy and, if necessary, laparoscopic common bile duct

4.1 Selection of patients for transcyndrical cholecystectomy in hospitalization and

4.2 The cylinders

Fig. 1. Cylinders used in Transcylindrical cholecystectomy

Fig. 2. Methacrylate cylinder, 2,8 cm in diameter

4.3 Technique and equipment

Fig. 3. Incision of 3,5 cm in length

Fig. 4. Cylinder bottom through the methacrylate plug

Fig. 5. View of the hepatocystic triangle through the plug

Fig. 7. Cystic duct with right angle dissector

4.4 Transcylindrical cholecystectomy under local anaesthesia plus sedation

Fig. 8. Local anesthesia on intercostals nerves IX-VII and incision planes

Fig. 9. Infiltration with mepivacaine 2% of the hepatocystic triangle

4.5 Surgical technique in acute cholecystitis and choledocholithiasis

Fig. 10. Cholangiography with cylinder in place

Total no. of patients 387

Completed transcylindrical 364

Ampliation to open cholecystectomy, no. (%) 23 (5.9)

Duration of simple cholecystectomy, mean (SD) 43,5 (13.3)

Length postoperative hospital stay mean (range), 2.0 (1-6)

Bile leakage, no. (%) 2 (0.5)

Reoperation for bleeding, no. (%) 2 (0.5)

Bile Duct injury, no. (%) 0

Death, no. (%) 11 (0.3)