Minimal access surgery

Ideal minimal access surgery has:

Reduced trauma associated with access
No compromise of exposure of operative field

Surgery can be performed using the following approaches:

Laparoscopic
Thoracoscopic
Endoluminal
Intra-articular joint surgery
Combined approaches

Advantage of minimal access surgery

Less tissue trauma
Less postoperative pain
Faster recovery
Fewer postoperative complications
Better cosmesis

Disadvantages of minimal access surgery

Lack of tactile feedback
Increased technical expertise required
Possible longer duration of surgery
Increased risk of iatrogenic injuries
Difficult removal of bulky organs
More expensive

Established minimal access procedures

Laparoscopic cholecystectomy
Diagnostic laparoscopy
Laparoscopic appendicectomy
Laparoscopic fundoplication
Laparoscopic (or thoracoscopic) Heller's myotomy
Laparoscopic adrenalectomy
Laparoscopic splenectomy
Laparoscopic rectopexy

Minimal access procedures under evaluation

Laparoscopic hernia repair
Laparoscopic colectomy
Laparoscopic nephrectomy for living related donor
Parathyroidectomy
Laparoscopic surgery for perforated duodenal ulcer

Establishing pneumoperitoneum

Veress needle

Blind procedure with potential for complications
Major complication is visceral or vascular puncture
Usually inserted at umbilicus
Aimed towards the pelvis
Intraperitoneal placement can be checked by:
- Saline drop test
- Saline instillation test
- Low-flow gas insufflation
Insufflate at least 3.5 litres of CO2
Ensure maximum pressure is 10-12 mmHg
Insert primary port through umbilicus
Insert secondary ports under direct vision

Open (Hasson) technique

An attempt to reduce the rate of visceral injury
Cannula inserted using a 'cut-down' technique
Stay sutures inserted in linea alba as counter traction
Finger inserted through peritoneum to ensure that there are no adhesions
Primary port inserted under direct vision

Bibliography

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