We know that undergoing any procedure is a scary experience. We understand the worry and anxiousness that is associated with surgeries and procedures and aim to walk the road to recovery with you every step of the way. We put this information together using the very helpful handbook, ‘Handbook of Surgical Consent” from Rajesh Nair and David J. Holroyd. We hope that the following information will answer all your questions and help you with the preparation phase for your procedure.
Laparoscopic surgery is a minimal-access surgical technique that involves insufflation of the abdominal cavity with carbon dioxide to allow diagnosis and treatment of intra-abdominal pathologies.
Laparoscopic surgery can be described as “keyhole surgery”. It is also important to break down the steps of the operation:
- The procedure is performed under general anaesthesia.
- Once asleep, a small cut is usually made in the region of the belly button (umbilicus).
- A small plastic sheath is inserted into the abdomen and gas is pumped into the abdominal cavity. (The gas used is carbon dioxide because it is highly soluble and rapidly excreted by the body).
- The gas pumped into the abdomen elevates the front of your abdominal wall away from the internal organs. This creates the necessary space for us to obtain good views and perform the operation.
- Further small incisions of 15 - 20mm are made through in which we place further plastic sheaths. Through these plastic sheaths, we insert our instruments.
- Most often two further incisions are made, however, this number can vary depending on the pathology identified and the intended operation. The location of these incisions depends on the indications for the procedure including the pathology identified.
- Conversion to an open procedure is often wrongly included as a risk when patients are being consented for laparoscopic operations. This is not a risk and should be included as part of the standard operation. The percentage rate of conversion depends on the procedure being undertaken and the experience of the surgeon performing the operation. The important point to emphasise is that if the operation cannot be safely completed laparoscopically, it will be necessary to convert to open.
Laparoscopic surgery is considered the gold standard technique for cholecystectomy and fundoplication. Laparoscopic appendicectomy is considered the standard technique for resection of the appendix in women of childbearing age. It is advocated, but not currently considered the standard for male patients, obese patients, and elderly patients. There have been mixed results reported with laparoscopic appendicectomy in pregnant women and the technique should be used with caution in this cohort of patients.
Major advantages of laparoscopic surgery over open surgery:
- Excellent visualisation of the abdomen and pelvis.
- Smaller scars/cosmetic benefit.
- Reduced rates of wound infection.
- Reduced postoperative pain.
- Reduced postoperative drug requirements.
- Shorter hospital stay.
- Earlier return to activities of daily living.
- Decreased postoperative ileus.
Complications of laparoscopic surgery are primarily related to the surgery or due to the secondary effects of the Pneumoperitoneum.
Potential risks / complications include:
- Adhesion formation
- Port site hernia formation
- Basal atelectasis/pneumonia
- Damage to surrounding structures/lactogenic injury
- Solid organ damage
- Small bowel/colon
- Major vascular injury
- Bile duct injuries
The injuries can occur during trocar insertion (increased risk with Veress needle), due to electrocautery conductivity or as a result of technical failure. Such injuries can go unrecognised at the time of laparoscopy, and therefore a high index of clinical suspicion is necessary in postoperatively unwell patients.
Complications due to Pneumoperitoneum
When absorbed, the systemic effects of carbon dioxide, the gas used for insufflation of the abdomen, include:
- Increase in PaCO2
- Increase in respiratory rate
- Myocardial instability / cardiac dysrhythmia
- Decrease in pH
Abdominal compartment syndrome is a rare, serious complication as a result of intra-abdominal hypertension. It is most commonly due to prolonged carbon dioxide insufflation, and is it is unrecognised, it can lead to severe organ dysfunction.
- Increased venous return
- Decreased cardiac output (CO)
- Increased systemic vascular resistance
- Increased risk of bradycardia (vagal stimulation)
- Gas embolism
- Ventilation / perfusion mismatching
- Displacement of the diaphragm
- Respiratory failure
Both the gallbladder and stones are removed. This can be done as a laparoscopic (keyhole) procedure under general anaesthetic (you are completely asleep), through four small holes, each 1-2cm in length, made in the tummy wall. Occasionally it is not possible to complete the operation by the keyhole method and a bigger incision (cut) is needed. The risk of the keyhole operation being converted to an open operation is about 2%.
The gallbladder is not an essential organ, and even today, only surgical removal of the gallbladder (cholecystectomy) guarantees that the patient will not suffer a recurrence of gallstones. This is one of the most common surgical procedures performed on women and can even be performed on pregnant women with low risk to the baby and mother. The primary advantages of surgical removal of the gallbladder over non-surgical treatment are both the elimination of gallstones, the prevention of gallbladder cancer and the freedom from pain which can be associated with pancreatitis.
A two-surgeon, four-cannula technique is used. In almost all patients, an abnormal presence of air or other gas can be identified with use of a closed technique. Cautery provides excellent haemostasis during dissection of the gallbladder from its attachments. Cholangiography through the gallbladder or the cystic duct is easily performed in selected patients.
What are the advantages of performing the procedure laparoscopically?
Rather than a ten to fifteen cm incision, the operation requires only four small openings in the abdomen. Patients usually have minimal post-operative pain. Patients usually experience faster recovery than open gallbladder surgery patients. Most patients go home after one day and enjoy a quicker return to normal activities.
What are the possible complications?
The operation is usually straightforward and you will usually be able to go home the following day. There are however risks with any operation and although they are rare, these are detailed below:
- Shoulder pain: This often happens after keyhole surgery, but tends to last less than 24-hours. It is due to the gas used to inflate the inside of the abdomen during the operation.
- Infection:This can occur in the wound(s), in the lungs, at the site of the intravenous drip, or at the position where the gallbladder was located.
- Bleeding:This can occur during or after the operation, as with any surgery.
- Bile leak: Bile can leak from tiny accessory ducts or the main bile duct after the operation. This may settle spontaneously, but in some cases may require further intervention.
- Damage to surrounding structures: Rarely, nearby structures can be damaged inadvertently during this operation, as with any operation. These structures include the bile duct, bowel, and the blood supply to the liver. A bile duct injury is potentially very serious but is rare, occurring in approximately 3 in every 1000 operations.
- Deep vein thrombosis (DVT)/Pulmonary embolus (PE): Clots forming in the veins can occur with any surgery, but the risk is increased with laparoscopic surgery. We give you a blood thinning agent to decrease this risk and ask you to wear compression stockings.
Retained stone: Before or during the operation a stone can move into the bile duct. This often causes no problem and passes into the bowel. However, if it does not pass, a second procedure may be necessary to remove it.
What about pain after the operation?
Keyhole surgery usually involves less pain than open surgery. Methods used to reduce the pain that may be experienced:
- Injecting the wounds with local anaesthetic while you are still asleep.
- Pain killing tablets are given to you before the operation which will continue to work after the operation, or, with your permission, long-lasting pain relief suppositories are given while you are still asleep.
- Pain relief tablets are given to you after the operation, as needed.You are also given pain relief tablets to take home.
Is there any after care for the wounds?
The four small holes are usually stitched with surgical clips. Each small hole should be kept covered with a shower-proof dressing and be kept dry for one week. As long as you have either a shower-proof dressing in place you will be able to shower immediately after the operation. The clips will be removed in the practice rooms at the first follow-up visit which would typically be in 10-14 days after the surgery. Clips offer several advantages over standard stitches; they are faster to apply, which saves time spent on the operating table, they are easier to remove. The removal of the clips may look daunting but is mostly painless.
It is quite usual for the bowels not to open for a day or two following surgery. Should you feel uncomfortable after this, consult or practice.
Returning to work
You will be able to go back to work fairly quickly depending upon how physically demanding your job is. The average is 2 weeks after keyhole surgery and 4 weeks after open surgery.
You may drive as soon as you are able to tolerate the seat belt and make an emergency stop without causing discomfort – usually after 1-2 weeks following keyhole surgery and 2-3 weeks following open surgery.