Abdominal Endoscopy: Laparoscopy

Laparoscopy (abdominal endoscopy) is an examination procedure in which the abdominal organs can be examined using an endoscope (called a laparoscope). In laparoscopy, the diagnostic procedure can be combined with a therapeutic procedure at the same time. Gynecologic laparoscopy is also called pelviscopy (pelvic endoscopy). Laparoscopy is used for inspection (viewing) and, if necessary, therapy for diseases of the following organs:

  • Liver
  • Gallbladder – laparoscopic cholecystectomy (gallbladder removal).
  • Spleen
  • Stomach
  • Small and large intestine
  • Omentum (abdominal network)
  • Urinary bladder
  • Female reproductive organs (uterus and adnexa; see indications for pelviscopy below).

Indications (areas of application) for pelviscopy

  • Suspicion of endometriosis – presence of endometrium outside the uterus.
  • Suspicion of tubal sterility (tubal occlusion).
  • For surgical treatment of tubes (fallopian tubes), ovaries (ovaries) and uterus (uterus) etc.
    • Loosening adhesions (adhesions).
  • To clarify recurrent (recurring) or chronic lower abdominal symptoms whose diagnosis cannot be clearly established by noninvasive methods such as sonography (ultrasound), computed tomography (CT) or magnetic resonance imaging (MRI).

Contraindications

  • Severe chronic obstructive pulmonary disease (COPD).
  • Severe heart failure (cardiac insufficiency)
  • Acute peritonitis
  • Ileus (intestinal obstruction)
  • Blood clotting disorders
  • Large aortic aneurysm (bulge (aneurysm) of the aorta).
  • Acute emergency (active bleeding)
  • Obesity per magna (obesity grade III; severe obesity).

The surgical procedure

During laparoscopy, the abdominal cavity is inspected (viewed) with the help of a special endoscope (laparoscope) connected to a video camera and a light source. Access is gained through small openings (0.3-2 cm long skin incisions) in the abdominal wall created by the surgeon. For this purpose, the abdomen (abdominal cavity) is previously filled with gas until a pneumoperitoneum (a gas-filled abdominal cavity) is created. For this purpose, a small skin incision (periumbilical incision) is made in the area of the navel. Then, a special insufflation cannula (Veres cannula) is used to pierce the abdominal wall so that its blunt tip is free in the abdomen (abdominal cavity). The hose of an insufflation pump is then connected to the Veres cannula and the intra-abdominal space (abdominal cavity) is “pumped up” with carbon dioxide (CO2) until a sufficient “working or examination space” has been created. The insufflation cannula can then be removed and a trocar (instrument used to create access to the abdominal cavity and held open by a tube) can be inserted “blindly”. The laparoscope is inserted through this trocar. The intra-abdominal space can then be viewed

In a diagnostic laparoscopy, after the inspection (viewing) of the abdomen (abdominal cavity), the instrument is removed again and the abdominal wall wound is closed with sutures. In an operative laparoscopy, additional instruments are inserted through further incisions in the skin, with the help of which the operation can be performed.

Laparoscopy versus lapartomy

The main advantages of laparoscopy over open abdominal surgery (laparotomy) are:

  • Small skin incisions
  • Faster recovery and discharge
  • Less pain
  • Lower risk of infection

In addition, there are also disadvantages of laparoscopy compared to laparotomy. These include:

  • More difficult technique (requires greater surgical experience).
  • Possibly longer surgery duration
  • Auxiliary incisions may be necessary
  • Possibly poorer spatial orientation (experienced surgeons have a good spatial overview even with laparoscopy)

Possible complications

  • Injury to the various organs during insertion of the instruments or during inspection of the organs
  • Pneumothorax – presence of air in the pleural space (actually airless space between the pleura and the lung).
  • Skin emphysema – excessive presence of air in the skin due to injury during laparoscopy.
  • Pneumomediastinum (synonym: mediastinal emphysema) – excessive occurrence of air in the mediastinum (space between the lung lobes) due to an injury during laparoscopy.
  • Wound healing disorders
  • Rupture of the abdominal suture (very rare)
  • Adhesions (adhesions) in the abdominal cavity. This can lead to ileus (intestinal obstruction) after a long time.
  • Hematoma (bruise)
  • Carryover of tumor cells
  • Postoperative pain
  • As after any surgical procedure, thrombosis (formation of a blood clot) can occur, with the possible consequence of embolism (occlusion of a blood vessel) and thus pulmonary embolism (danger to life). Thrombosis prophylaxis leads to a reduction in risk.
  • The use of electrical devices (e.g. electrocoagulation) can cause leakage currents, which can lead to skin and tissue damage.
  • Positioning on the operating table can cause positional damage (e.g., pressure damage to soft tissues or even nerves, resulting in sensory disturbances; in rare cases, this can also lead to paralysis of the affected limb).
  • In case of hypersensitivity or allergies (e.g. anesthetics/anesthetics, drugs, etc.), the following symptoms may temporarily occur: Swelling, rash, itching, sneezing, watery eyes, dizziness or vomiting.
  • Infections resulting in severe life-threatening complications in the area of vital functions (e.g., heart, circulation, respiration), permanent damage (e.g., paralysis) and life-threatening complications (e.g., sepsis/blood poisoning) are very rare.

Further notes

  • The risk of developing adhesions (adhesions) after laparoscopy is 32% lower than after open surgery (rate of new admissions after laparoscopy: 1.7%; after open surgery: 4.3%):Note: Patients who had colon (large intestine) or rectum (rectum) surgery were most frequently affected (10% and 11%, respectively); patients after cholecystectomy (gallbladder removal) were least frequently affected.
  • According to the results of a randomized trial, liver metastases (tumors in the liver that originate from cancer outside the liver) can be safely resected laparoscopically for colorectal cancer (cancer of the colon and rectum). The 5-year survival rates were not worse compared with open surgery. Prognostic factors for increased risk were:
    • Lymph node involvement at the site of the primary tumor.
    • Poorer ECOG performance status
    • Longer diameter of the largest liver metastasis
    • Presence of concomitant extrahepatic disease (“outside the liver“).